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NURS 319 OB/Maternity Exam Guide
NURS 319 OB/Maternity Exam Guide
First
Stage of Labor
Begins with regular uterine contractions
Ends with full cervical effacement and dilation
Three phases: if the patient has an epidural the 3 phases wont
occur.
(1) Latent phase: up to 3 cm of dilation. She is fairly comfortable, may
be able to hide it
(2) Active phase: 4-7 cm of dilation. She is uncomfortable, crabby, and
doesnt want to talk to anyone.
(3) Transition phase: 8-10 cm of dilation. She is mad and in pain and
beyond ready to give birth. Sometime she will have vomiting.
Plan
o
o
o
Monitoring Techniques
Intermittent auscultation (IA)
o Listening to fetal heart sounds at periodic intervals to
assess FHR
o IA of the fetal heart can be performed with:
Leff scope
DeLee-Hillis fetoscope
Ultrasound device
o Easy to use, inexpensive, less invasive then EFM
o Difficult to perform on women who are obese
o Does not provide a permanent record if needed for a
lawsuit!
Electronic fetal monitoring (EFM) to measure how strong
the contractions are
o External monitoringfirst line! If theres ANY doubt, use an
internal device
FHR: ultrasound transducer
UCs: tocotransducer
o Internal monitoring
Spiral electrode
IUPC
o Display
Monitor paper
Computer screen
Fetal Heart Rate Patterns
Baseline FHR
o Average rate during a 10-minutes segment that excludes:
Periodic or episodic changes
Periods of marked variability
Segments of the baseline that differ by more than 25
bpm
Must be at least 2 minutes of interpretable data
o Variability
Irregular fluctuations in FHR of two cycles per minute
or greater
Care
Key Points
Fetal well-being during labor is gauged by response of the FHR to
UCs
Standardized definitions for common FHR patterns have been
adopted by ACNM, ACOG, AWHONN
Five essential components include baseline FHR, variability,
accelerations, decelerations, and changes in FHR over time
firm object or the fist or heel of the hand. Pressure can also be
applied to both hips, or to the knees.
Music
Water therapy (hydrotherapy): with warm water
Transcutaneous electrical nerve stimulation: 2 pairs of flat
electrodes on either side of the womens thoracic and sacral
spine to provide continuous low-intensity electrical
impulses/stimuli.
Acupressure of heat and cold: not acceptable for some
cultures. Acupressure on certain points in the hand and feet can
be used to relieve pain.
Acupuncture: used more in Eastern than Western area.
Touch and massage
o Therapeutic touch
Hypnosis: deep relaxation, similar to daydreaming or
meditation
o
o
Care Management
Informed consent for anesthesia: 3 essential components;
(1) the procedure and its advantages and disadvantages must be
thoroughly explained (2) the woman must agree with the plan of
labor pain care as explained to her and (3) her consent must be
given freely without coercion or manipulation from her HCP.
Timing of administration: can be given at any time
Preparation for procedures
Administration of medication
IV route: preferred route because (1) onset of pain relief is
rapid and more predictable, (2) pain relief is obtained with
small doses, and (3) duration of effect is more predictable.
IM route: although it allows quick administration without an
IV site, it is not preferred because (1) onset of pain relief is
Key Points
Nonpharmacologic pain and stress management strategies alone
or in combination with pharmacologic methods help manage
discomfort
The Gate-control theory of pain and the stress response are basis
for many nonpharmacologic methods of pain relief
Type of analgesic or anesthetic is determined in part by the stage
of labor and method of birth
Sedatives may be appropriate for women in prolonged early
labor to decrease anxiety or promote sleep or therapeutic rest
Naloxone (Narcan) is an opioid antagonist that can reverse opioid
effects
Pharmacologic control of discomfort requires collaboration
among health care providers and the laboring woman
Nurse must understand medications, expected effects, potential
adverse reactions, and methods of administration
Maintenance of maternal fluid balance is essential during spinal
and epidural nerve blocks
Maternal analgesia or anesthesia can affect neonatal
neurobehavioral response
Opioid analgesics with preexisting opioid dependence may cause
symptoms of abstinence syndrome
Epidural anesthesia is the most effective pharmacologic pain
relief methods for labor
General anesthesia rarely used for vaginal birth but may be used
for cesarean birth or when rapid anesthesia is needed in an
emergency
Chapter 23 Physiologic and Behavioral Adaptations of the Newborn
Physiologic Adaptations
Cardiovascular system
o Heart rateasleep, awake, and crying
o BP60-80/40-50
o Blood volumearound 80 mL/kg; immediately after birth it
can increase as much as 100 mL or more with delaying
cord clamping.
Hematopoietic system
o RBCshigher RBCs and HGB & HCT than in an adult
o Leukocytesinitial increase after birth, then decreases
o Plateletssimilar to adults
Thermogenic system
o Thermoregulationmaintenance of balance between heat
loss and heat production
o Heat loss
Convection: flow of heat from the body surface to
cooler ambient air.
Radiation: the loss of heat from the body surface to a
cooler solid surface not in direct contact but in
relative proximity.
Evaporation: loss of heat that occurs when a liquid is
converted to a vapor. Ensure baby is completely dry
after bathing.
Conduction: the loss of heat from the body surface to
cooler surfaces in direct contact.
o Thermogenesisneonate attempts to generate heat in
response to the cold by increasing muscle activity.
o Cold stressexcessive heat loss that results in increased
respirations and non-shivering thermogenesis to maintain
core body temperature.
o Hyperthermialess frequently occurring than hypothermia,
and can occur due to excess heat production r/t sepsis or a
decrease in heat loss.
o Brown fat helps baby maintain heat
Hepatic system
o Carbohydrate metabolism-hypoglycemiaafter birth when
the newborn is cut off from maternal glucose supply, the
glucose level can drop between 30 and 90 minutes after
birth then gradualy rise.
o Conjugation of bilirubin
o Physiologic jaundice
Kernicterus: a very serious problem, bilirubin
deposits in the brain. Refers to the irreversible, longterm consequences of bilirubin toxicity such as
hypotonia (aka floppy baby syndrome from reduced
muscle strength), delayed motor skills, hearing loss,
cerebral palsy, and gaze abnormalities.
o Jaundice associated with breatfeeding
o Coagulation deficiencies can be developed by infants, so
circumsized males must be obsereved closely. Hemorrhage
can also be caused be a clotting defect indicated
hemophilia. Babies lack vitamin K which we get from the 3
pounds of bacteria that we carry, so they have a weak ability
to coagulate.
Immune System
o Risk for infection is high within the first months of life.
Lethargy, irritability, poor feeding, vomiting, diarrhea,
decreased reflexes, and pale or mottled skin color are some
s/s that suggest infection. Respiratory symptoms include
apnea, tachypnea, grunting, or retracting can be associated
with infection such as pneumonia.
Integumentary system
o Vernix caseosaa cheeselike, whitish substance that is
fused with the epidermis and serves as a protective covering
after 35 weeks of gestation.
o Sweat glandsinfants dont sweat in the first 24 hours, but
by day 3 sweating begins on the face and progresses to the
palms.
o Desquamation(peeling) of the skin of the term infant does
not occur until a few days after birth.
o Mongolian spotsbluish black areas of pigmentation can
appear over any part of the exterior surface of the body.
They should be documented careful to prevent confusion
with bruises.
o Nevialso known as salmon patches, are the result of
superficial capillary defect and commonly found on upper
Key Points
Uterus involutes rapidly after birth, returning to true pelvis within
2 weeks
Rapid decrease in estrogen and progesterone levels after
expulsion of the placenta is responsible for triggering anatomic
and physiologic changes in puerperium
Return of ovulation and menses determined in part by whether
the woman breastfeeds her infant
Assessment of lochia and fundal height is essential to monitor
progress of normal involution and to identify potential problems
Under normal circumstances, few alterations in vital signs are
seen after childbirth
Hypercoagulability, vessel damage, and immobility predispose
woman to thromboembolism
Marked diuresis, decreased bladder sensitivity, and
overdistention of bladder can lead to problems with urinary
elimination
Pregnancy physiologic changes allow woman to tolerate
considerable blood loss at birth