NSG 401 OB EXAM ONE NOTES

NSG 401 OB EXAM ONE NOTES May 5, 2016 OB class notes How to take care of the laboring patient: ▪ Three stages of labor: 1. 0-10cm – first stage is divided into three phases (Early latent 0-3, active 4-7, trans 8-10cm) 2. Pushing (could take a couple of hours) 3. Placenta needs to be delivered (10-20mins- worried about hypovolemic shock) 4. Recovery stage (takes about 2 hours to make sure they are safe) ▪ Go through triage first-how do we know if they are in labor? Contractions (don’t go away)- helps cervix dilate. o Definition of labor: contraction that dilates the cervix. ▪ If water breaks doesn’t mean you’re in labor, but need to go to the hospital because the baby is at risk for infection. If the water breaks you may induce labor. ▪ SRON/AROM ▪ Benefits of breaking the water ▪ Is your baby moving? –Baby moving is good. Not moving could mean something is wrong. ▪ FIRST THING TO ASSESS on the pregnant women: baby’s heart rate/fetal monitor. RLQ/LLQ (you are listening to the baby's back) ▪ Safety for mom and baby (#1 goal) ▪ BURP your patient → breathing, urinate, relax, and position. ▪ Keep her out of bed→ Helps rotate the baby. ▪ Rocking chair ▪ After contraction take a cleansing breathe in and let it out (give baby more oxygen and save her strength). ▪ Vena Cava supplies blood to baby, therefore educate the patient to NOT lie on their back, this could decrease blood flow to the baby. ▪ The lady will lay on her back. The patient usually needs about four pillows. ▪ IV med (get an order for saline lock to help with movement) o Lactated ringers→ hydration/ 200ml/HR o Gauge 18 (if you need blood) o Forearm o Labs (type and cross, CBC –H&H, white blood cell, platelets less than 100, RPR (syphilis), o Narcotic- Push it slow. Is it safe for my baby? The best time to give it during the active stage of labor, so its not depressing the baby or getting rid of the contractions completely. o Bolus of lactated ringers prior to epidural so the blood pressure doesn’t become extremely low. ▪ Epidural ▪ Questions? o Am I going to paralyzed? o It will hurt, but not as much as contractions. o Take her blood pressure often now ▪ Water breaks→ color? Clear, maybe yellow from baby’s urine. o TACO o Clear or meconium stain? ▪ Peanut baby—helps transition the baby (peanut ball). ▪ Bladder full? Always empty the bladder→ after epidural? Straight cath. ▪ Place baby on moms abdomen ▪ Baby on skin-skin (golden hour)-BONDING ▪ Stage 3? Starts oxytocin, make sure she’s not bleeding, breast feed! ▪ Breast feed the first hour. ▪ Erthromycin, vitamin k, HEP B (meds for baby). May 5, 2016 OB class notes ▪ Maternity of childbearing women and families through all stages of pregnancy→ OR, NICU, labor, birth, recovery, antepartum. ▪ Maternal Mortality→ What actually causes it? What kills women in the US and world? *** o Hemorrhage (#1 U.S and world) o Hypertensive disorders (#3 in US and world) ▪ Preeclampsia o Infection (#1 in world) o Pulmonary embolism (#2 in the U.S) – Why are they prone to it? ▪ The body increases the blood factors to increases clotting to prevent hemorrhage, but that increases chance. ▪ Healthy People 2020 Mission – know OB stuff o To make sure postpartum relapse of smoking among women who quit smoking with pregnancy o Benefits of breast feeding→ Decrease the percentage of breastfed newborns who receive formula supplementation within the first 2 days of life o Reduce preterm birth o Reduce the rate of fetal and infants death ▪ Issues with the U.S Health Care System ▪ Foreign object retained after surgery (to prevent we count everything) ▪ Blood incompatibility (We are worried about that because hemorrhaging) o What 3 labs do you draw? CBC, RPR for syphilis, and type of cross. ▪ AWHONN → Association of Women’s Health, Obstetrics and Neonatal Nursing publishes standards and guidelines for perinatal nursing (Make the standards and are her “people”) ▪ Family nursing o Take in the values and beliefs of the family it impacts their care. o Culture and values are important. o What is a family? o Nuclear family: male and female partners with children. o Married parent families: o Extended family: o Married blended: formed from divorce and remarriage. o Single parent: o Homosexual: o No parent family: Family→ family is whoever they say they are ▪ Theories relevant to family nursing: o Family system theory family is viewed as a whole o Family stress theory*: ▪ Internal contexts ( we can change) ▪ External contexts (cant really change → time in history) ▪ Hands on support- its all about hands on support. ▪ Warmers in labor room ▪ Care providers choices o Obstetrical physician o Family practice physician (rural areas) o Nurse midwives o Doulas (support system- no medical interventions→ rub your head, get you ice chips/ employed by the parent) ▪ Birth settings o LDR or LDRP o Free standing birth centers o Home births ▪ Recent trends ** o Preconception and prenatal care o Decrease in VBACs o Increase in cesarean births 32.9% o More nurse midwives and doulas o Ethical concerns have increased → when does life begin? o Early discharge within 24 hours ▪ Childbirth satisfaction ▪ Lamaze philosophy of Birth o Birth is normal, natural, and healthy. o The experience of birth profoundly affects women and their families. o Women’s inner wisdom guides them through births. o Women have the right to give birth free from routine ▪ Birth plan o Identifies options and set priorities o May include: o Partners/family/friends involvement o Labor management o Birth specifies o Postpartum care ▪ Gravidity and Parity o Gravida: a woman who is pregnant o Parity- # of pregnancies in which the fetus have reached 20 weeks gestation o Grav 1/0 o Para 3/0 ▪ Obsterical History o GTPAL o G= Gravidity – pregnancy o T= Term births -37 weeks to 42 weeks gestation o P= Preterm births 20-37 gestation o A=Abortions-pregnancy ends prior to 20 weeks o L=Living children o KNOW how to do it ▪ Maternal Adaptions During labor * o Slight increaser in pulse o Slight increase in RR o Decrease in gastric motility which may lead to n/v o Increase in anxiety/fear o Blood glucose levels decrease o Hemorrhoids ▪ The labor and birth processes ▪ 5 factors affecting the process of labor o Passenger (baby) ▪ Head molds and bones overlap to get out of the canal ▪ The cone head is present ▪ The fetal head size affects birth. ▪ Fetal presentation- Vertex * we want/ Breech can be bottom or feet first. ▪ Breech is a risk because the head can get stuck. ▪ Breech doesn’t really deliver vaginally. ▪ External cephalic version→ Start IV, and sign consent in case of the emergency. The doctor will find the baby on the abdomen and move the baby into the vertex presentation. ▪ Fetal lie→ Two primary lies→ longitudinal or vertical ▪ Fetal attitude→ relation of fetal body to each other e.g. Flexion of chin → we don’t like baby’s with attitude ▪ Fetal position→ Right or left- is the baby on moms right or left side? ▪ Fetal presenting part→ • O=occiput (most of the time) • S= Sarcum • M= Mentum or chin • SC=Scapula or shoulder ▪ Third letter- location of presenting part in relation to a porition of material pelvis →A= anterior (baby looking at moms back), P= posterior (back against back), T= transverse. ▪ ROA/LOA ▪ We talk a lot about A and P. ▪ We are feeling for the fontanels so that’s how we can tell. ▪ Anterior fontanel closes at 18 months ▪ Posterior will have a lot of backache ▪ Anterior one looks like a diamond and way bigger ▪ Posterior one is a triangle and smaller. ▪ LOP= peanut ball or all fours ▪ Station- minus above/ positive is believe the ischical spine. ▪ Crowning is +3 ▪ Engagement- the baby is settle in the pelvis. Head in pelvis o Passageway (canal/uterus shape) ▪ True pelvis has 3 planes- inlet, midpelvis, or cavity, and outlet ▪ 4 basic types of shapes to pelvis ▪ Gynecoid/round (THE BEST) ▪ Android- heart ▪ Anthropoid-oval shaped ▪ Platypelloid-flat shaped ▪ The internal structure determines if you can deliver ▪ Bony pelvis- maternal pelvis plays a great role in the labor process because the fetus must succeffully accommodate ▪ Cervix- effaces (this) and dilates (open) ▪ Pelvis floor muscles – helps fetus rotate anteriorly ▪ Vaginal examination ▪ 2cm/80%/-2 • 2 cm dilated, it is 80% effaced, and the presenting part is 2 cm above the ischial spines. • 100%- effaced completely • Prostaglains – softens up cervix • Oxytocin –contractions o Powers (contractions/push) ▪ Primary force- Braxton hicks- contractions that are current contractions but doesn’t mean labor/involuntary contractions (oxytocin/ two nurse check→ don’t want to cause distress) ▪ Secondary force- voluntary pushing ▪ Spontaneous ▪ Open glottis → don’t hold breath! You want noises! ▪ Try other methods before Pitocin o Position of the mother (constantly changing position of mom) ▪ All fours→ best for rotating the baby when they are LOP—to turn it into anterior position ▪ o Psychological response (I CAN DO THIS!) ▪ Support ▪ Passed experience ▪ Pain tolerance and coping abilities ▪ Culture ▪ Emotional readiness ▪ Self-confidence ▪ Childbirth education ▪ Cardinal movements of Labor o They are dependent on the P’s ▪ Stages of labor –know ▪ 1 st stage- dilation ▪ HAS 3 PHASES – latent, active, and transition. ▪ Latent phase- slow chest breathing – smell the roses and blow out the birthday candle ▪ Active phase- rhythmic, shallow breathes. Panting ▪ 2nd stage- cervix is gone and start pushing ▪ 3rd stage- placenta delievered 5mins-1 hour ▪ 4th stage- recovery period ▪ True labor vs false labor o HURT NO MATTER WHAT IN TRUE LABOR ▪ Lightening o Baby drops/relief of pressure o Can breath easier ▪ Status of membranes o ASSESS COAT (TACO) o Color of fluid o Odor o Amount of amniotic fluid o Time of the rupture (MOST IMPORTANT→ the clock starts ticking when the rupture occurs, after the first 24 hours= INCREEASE infection o Always assess fetal heart tones-cord prolapse o When the bag of water breaks what is the number one intervention? Monitor the baby/make sure the baby is ok o If the cord prolapse→ emergency→ keep hand there to keep the head off the cord. ▪ Confirming ruptured membranes ▪ Fern test → when the amniotic fluid dries it crystalized and looks like a fern. Sometimes its urine or sperm (first=CHEAP) ▪ Amnisure test→ looks like a pregnancy test. ▪ Placenta ▪ 5 minutes to an hour ▪ Duncan on mom ▪ Third stage: ▪ After placenta/ Pitocin/ prevent hemorrhage o 40/500 Pitocin run at 150 ml/hr ▪ Baby distress? Bonding becomes second the baby should be sent to the warmer first to resituate. ▪ Perineum is between vagina and anus ▪ Episiotomy: incision made in the perineum to enlarge the vaginal opening. ▪ Squirt bottle as they pee so it doesn’t burn Pain management • Gate control theory → reducing or blocking the capacity of nerve pathways to transmits pain→ If you give pleasure signals it blocks the pain signal. o Epidurals • Nonphamacologic • Pharmacologic Measures o Sedatives – relieves anxiety and induce sleep o 2cm and always complaining—need rest→ Vistaril, Phenergan, and Ambien o Antiemetics – use big time, GI system slows down → INCREASE chance of n/v (Zofran 4mg, Phenergan, and reglan) o Antiemtics (Zofran) before C-section→ prevents aspiration and nausea, and give Reglan (helps move down if they do have food in stomach –STAT C-section) o BIcetric (neutralize acid incase they throw up) • Effects on fetus/newborn o Don’t give too early or too late • Narcan o Give for respiratory depression o *What certain drugs given for? • Regional blocks • Numb area • Numb the perineum (Local) • Pudendal block and paracervical (DON’T NEED TO KNOW) • Epidural*→ injection of local anesthetic into the epidural space. o It is connected to a pump o Advantages and disadvantages o BP drops→ we can prevent with a bolus of lactated ringers o D= Itchy, straight cath, limited movement (long second stage), increase use of Pitocin and forceps o A= remains alert, good relaxation o Maternal hypotension= POSION o Complications: Spinal headache they can fix it/inject blood o 1000 cc of bolus lactated ringers/ prophylactic = always worried about hypotension • Spinal- used for C-section o Don’t need the cath o Provides anesthesia frome the nipple to the feet • General Anesthesia o Necessary for emergency o Keep anesthesia time to a minimum • Education- always educate the patient! BURP