Nur 312 Exam IINURSING CARE OF THE FAMILY DURING LABOR AND BIRTH

1. Review the factors included in the initial assessment of the woman in labor. – due date– ROM (Nitrazine paper)– bleeding– how far apart are the contractions False Labor– ctx irregular– ctx stop with comfort measures– cervix shows no significant change– fetus is usually not engaged in the

pelvis

True Labor– ctx become longer, stronger, closer– continue despite comfort measure– cervix show progressive change –

dilating – engagement of the fetus in pelvis

2. Describe the ongoing assessment of maternal progress during the first, second and third stages of labor.

– chart– what kind of birth– anesthesia– expectations– how many people in room – who– L&D experiences– prenatal care – FHR– vitals– descent

– presenting part– cervix– temp– uterine activity– vaginal show– behavior, appearance, mood, energy

level, condition of partner– vaginal examination– ctx

3. Recognize the physical and psychosocial findings indicative of maternal progress during labor. First Stage of Labor

– Latent (1-3 cm; ctx 30-45 sec, 5-30 min apart, mild to moderate)o alert, happy, excited, mild

anxietyo settles into labor room; selects

focal pointo rests or sleeps, if possibleo uses breathing techniqueso uses effleurage, focusing &

relaxation techniques– Active (4-7 cm, 40-70

sec, 3-5 min apart, moderate to strong)o seriously labor-oriented,

concentration and energy needed for ctx, alert, more demanding

o continues relaxation, focusing techniques

o uses breathing techiques– Transition (8-10 sec, ctx 45-90

sec, 2-3 min apart, strong)o irritable, intense concentrationo N/Vo continues relaxation, needs

greater concentration to do this o uses breathing techniqueso if needed, changes to pattern-

paced breathing (i.e., 4:1 breathing pattern) if using psychoprophylactic techniques

o uses panting to overcome urge to push if appropriate

Second Stage of Labor– Latent

o experiences a short period of peace and rest – Descent

o senses é urgency to bear down as Ferguson reflex activatedo notes é in intensity of uterine ctx; alters respiratory pattern: short 4- to 5- sec breath holds,

5-7x/ctxo making grunting sounds or expiratory vocalizations

Nur 312 Exam II– Transitional

o behaves in manner similar to behavior during transition in 1st stage (8-10 cm)

o experiences a sense of severe pain & powerlessness

o shows ê ability to listeno concentrates on birth of baby

until head is borno experiences ctx as

overwhelming in intensity

o reports feeling ring of fire as head crowns

o maintains respiratory pattern of 3-5 7-sec breath holds/ctx, followed by forced expiration

o eases head out with short expirations

o responds with excitement & relief after head is born

Third Stage of Labor– CO é rapidly as maternal circulation to

placenta ceases & pooled blood from lower extremities is mobilized

– pulse rate ê– BP returns to pre-pg levels

– express satisfaction with performance during labor & birth

– initiate, along with partner & family, process of bonding & attachment with newborn

Fourth Stage of Labor– intense tremors that resemble

shivering– pain

– lochia– fatigue

4. Describe fetal assessment during labor.– FHR and pattern– Leopold maneuvers– presentation– position

– point of maximal intensity (PMI) – auscultate FHR

– fetal descent– amniotic fluid

5. Analyze the influence of cultural and religious beliefs and practices on the process of labor and birth.

– South Korea o stoic response to labor pain o fathers usually not present

– Japan o natural childbirtho labor silento may eat during laboro father might be present

– China o stoic response to paino fathers usually not presento side-lying position preferred for

labor & birth b/c position is thought to reduce infant trauma

– India o natural childbirth methodso father usually not presento female relatives usually present

– Iran o father not presento prefers female support & female

caregivers– Mexico

o may be stoic about discomfort until 2nd stage, then may request pain relief

o fathers & female relatives may be present

– Laos o May use squatting position for

birtho Fathers may or may not be

preseto Prefer female attendants

6. Evaluate research findings on the importance of support (family, partner, doula, nurse) in facilitating maternal progress during labor and birth.

– provides labor support, incl: physical, emotional & informational support to women & partners during labor & birth

– sense of control with childbirth– education better experience, less pain, shorter labor– reduced rates of complications & surgical or obstetric interventions– enhanced self-esteem & satisfaction

7. Describe the role and responsibilities of the nurse in an emergency childbirth situation.

Nur 312 Exam II– put in lateral Sims position– keep mom calm– explain what is happening & how

being managed– provide O2 @ 8-10 L

– IV fluids– check temp– assisst with amniofusion– d/c oxytocin

8. Discuss ways the nurse can use evidence-based practices to enhance the quality of care a woman receives during labor and birth.

– reviews the prenatal record to ID individual needs & risks

– birth plan– past experiences

– confirm EDB– cultural beliefs– expectations

9. Use the nursing process to determine priorities of nursing care for the laboring client and family. – assess vitals – fetal monitoring

– pain level– stress level

10. Identify the responsibilities of the nurse during delivery.– inform the patient – assist doctor– praise & encourage

– use comfort measures– coach in breathing techniques

11. Describe nursing care for each phase of stages one and two. First Stage of Labor

– Latento provides encouragement,

feedback for relaxation, companionship

o assists woman to cope with ctxo encourages use of focusing

techniqueso helps to concentrate on

breathing techniques

o uses comfort measureso assists woman into comfortable

positiono informs woman of progress –

explain procedures & routineso give praiseo offers fluids, food, ice chips as

ordered– Active

o acts as buffer; limits assessment techniques to btwn ctx

o encourages woman prn to help maintain breathing techniques

o uses comfort measureso assists w/ frequent position

changes, emphasizing side-lying & upright positions

o encourages voluntary relaxation of muscles of back, buttocks,

thighs & perineum; performs effleurage

o applies counterpressure to sacrococcygeal area

o encourages & praiseso keeps woman aware of progresso offers analgesics as orderedo checks bladder; encourages

voidingo gives oral care; offer fluids, flood,

ice chips as ordered– Transition

o stays; provides constant supporto assists woman to cope w/ ctxo reminds, reassures, &

encourages woman to reestablish breathing pattern & conc prn

o alerts woman to begin breathing pattern before ctx becomes too intense

o prompts panting respirations if woman begins to push prematurely

o use comfort measureso accepts woman’s inability to

comply with instructionso accepts irritable response to

helping (i.e. counterpressure)o supports woman who has N/V;

gives oral care prn; gives reassurance regarding signs of end of 1st stage

o uses relaxation techniqueso keeps woman aware of progress

Second Stage of Labor

Nur 312 Exam II– Latent

o encourages woman to “listen” to her body

o continues to support measures allowing woman to rest

o suggests an upright position to encourage progression of descent if descent phase does not begin after 20 min

– Descento encourages respiratory pattern

of short breath holds and open-glottis pushing

o stresses normality & benefis of grunting sounds & expiratory vocalizations

o encourages bearing-down efforts with urge to push

o encourages or suggests maternal movement & position changes (upright, if descent is not occurring)

o encourages woman to “listen” to her body regarding movement &

position change if descent is occurring

o discourages long breath holds (no longer than 5-7 sec)

o if birth is to occur in a delivery room, transfers woman to delivery room early to avoid rushing or, if permitted, offers her option of walking to delivery room

o places woman in lateral recumbent position to slow descent if descent is too fast

– Transitional o encourages slow, gentle pushingo explains that “blowing away the

ctx” facilitates a slower birth of the head”

o provides mirror to help woman see or touch the emerging fetal head (best to extend over 2-3

ctx) to help her understand the perineal sensations

o coaches woman to relax mouth, throat, & neck to promote relaxation of pelvic floor

o applies warm compress to perineum to promote relaxation

12. Differentiate the stages and phases of labor. – First Stage of Labor

o begins with onset of regular contractions & ends with full cervical effacement & dilationo Latent Phase

0-3 cm 30-45 sec long

5-30 min apart mild to moderate

o Active Phase 4-7 cm 40-70 sec logn

3-5 min apart moderate to strong

o Transition Phase 8-10 cm 45-90 sec long

2-3 min apart strong

– Second Stage of Labor o begins with full cervical dilation and complete effacement & ends with baby’s birtho Latent Phase

experiences a short period of peace & resto Descent Phase

senses urgency to bear down as Ferguson reflex activated notes increase in intensity of uterine ctx; alters respiratory pattern; short 4- to 5- sec

breath holds – 5-7x/ctx makes grunting sounds or expiratory vocalizations

o Transitional Phase behaves in manner similar to behavior during transition in 1st stage experiences a sense of severe pain & powerlessness shows ability to listen concentrates on birth of baby until head is born

Nur 312 Exam II experiences ctx as overwhelming in intensity reports feeling ring of fire as head crowns maintains respiratory patter of 3-5, 7-sec breath holds/ctx, followed by forced expiration eases head out w/ short expirations responds w/ excitement & relief after head is born

– Third Stage of Labor o lasts from birth of baby until placenta is expelledo goal of mgmt is prompt separation & expulsion of placenta, achieved in easiest, safest

manner– Fourth Stage of Labor

o first 1-2 hr postpartumo crucial for mother & newborn

maternal organs undergo initial readjustment to non-pg state & fx of body systems begin to stabilize

newborn transition from intrauterine to extrauterine existence

LABOR AND BIRTH PROCESS

1. Explain the 5 major factors that affect the labor process.– passenger (fetus & placenta)

o size of fetal heado fetal presentationo fetal lie

o fetal attitude – relation of fetal body parts to each other

o fetal position– passageway (birth canal)

o size & shape of maternal pelvis o soft tissues = cervix, bladder & pelvic floor

– powers (ctx)o primary powers

responsible for effacement & dilation of cervix & descent of fetus effacement is shortening & thinning of cervix

o voluntary & involuntary voluntary = bearing-down involuntary = ctx

– position (of mother)o frequent changes in position relieve fatigue, comfort & improve circulationo upright position helps in descent of fetuso optimal CO in upright or side-lying position

– psychologic (tense = longer labor)o expectationso past experienceso support persons

o fatigueo knowledge base

2. Describe the anatomic structures of the bony pelvis.– Pelvic inlet: upper border of true pelvis – formed anteriorly by upper margins of pubic bone,

laterally by iliopectineal lines along innominate bones & posteriorly by anterior, upper margin of sacrum & sacral promontoryo ***smallest diameter is A/P***o upper aspect of symphysis pubis to sacral promitoryo estimated from lower edge of symphysis to sacral promontory

– Midpelvis: curved passage w/ short anterior wall & much longer concave posterior wall – bounded by posterior aspect of symphysis pubis, ischium, portion of ilium, sacrum & coccyxo ***smallest diameter is transverse***o distance btwn ischial spines = 10 cmo size is estimated – can’t measure

Nur 312 Exam II– Pelvic outlet: lower border of true pelvis – bounded by public arch anteriorly, ischial tubersities

laterally & tip of coccyx posteriorlyo ***smallest diameter is transverse***o measure distance btwn ischial tuberosities = 8-10 cm (fist btwn ischeal tuberosities)o angle of pubic arch inflences this distanceo coccyx able to move (unless broken & fused to sacrum during healing)

3. Recognize the normal measurements of the diameters of the pelvic inlet, cavity, and outlet. – Inlet

o Conjugates Diagonal 12.5 – 13 cm Obstetric 1.5 -2 cm < diagonal (radiographic)

Measurement that determines whether presenting part can engage or enter superior strait

True (vera) ≥ 11 cm (12.5) [radiographic]– Midplane

o 10.5 cmo largest plane & one of greatest diameter

– Outleto ≥ 8 cmo outlet presents smallest plane of pelvic canal

4. Explain the significance of the size and position of the fetal head during labor and birth.– sutures & fontanels make skull flexible to accommodate infant brain – cont. to grow – bones not firmly united, slight overlapping of bones – molding of shape of head occurs– head needs be tucked into chin = vertex presentation

o = 9.5 cm o = 9.25 cm– not tucked chin = sinciput presentation

o = 9.25 cm o = 12 cm– chin flexed up = brow presentation

o = 9.25 cm o = 13.5 cm5. Summarize the cardinal movements of the mechanism of labor for a vertex presentation.

– Engagemento ***engaged in pelvic inlet***o NULLIPAROUS PG – occurs before onset of active labor b/c firmer abdominal muscles direct

in presenting part into pelvis o MULTIPAROUS PG – head remains freely movable above pelvic brim until labor est

– Asynclitismo head engages in pelvic in a synclitic position – parallel to anteroposterior plane of pelviso ***oblique presentation of fetal head @ superior strait of pelvis; pelvic planes & those of fetal

head are NOT parallel***– Descent

o ***progress of presenting part though pelvis***o depends on:

pressure exerted by amniotic fluid direct pressure exerted by contracting fundus on fetus force of ctx of maternal diaphragm & abdominal muscles in 2nd stage of labor extension & straightening of fetal body

o degree measured by station of presenting parto accelerates in active phase & apparent when ROM

– Flexiono ***as soon as descending head meets resistance form cervix, pelvic wall, or pelvic floor –

flexes – so chin brought into closer contact with fetal chest***o permits smaller subocciitobregmatic diameter (9.5 cm) rather than larger diameters to present

in the outlet– Internal Rotation

Nur 312 Exam IIo pelvic inlet widest in transverse diameter fetal head passes inlet into true pelvis in

occipitotransverse positiono outlet widest in anteroposterior diameter – for fetus to exit, head must rotateo ***begins @ level of ischial spines but NOT completed until presenting part reaches lower

pelvis***

Nur 312 Exam II– Extension

o ***fetal head reaches perineum for birth – deflected anteriorly by perineum***o occiput passes under lower border of symphysis pubis 1st & emerges by extension

1st occiput, then face, & then chin– Restitution and External Rotation

o restitution: after head is born – rotates briefly to position occupied when engaged in inlet 45° turn realigns infant’s head w/ back & shoulders

o external rotation: shoulders engage & descent in maneuvers similar to those of head anterior shoulder descents 1st – reaches outlet, rotates to midline & delivered from

under pubic arch posterior shoulder guided over perineum until free of vaginal introitus

– Expulsiono after birth of shoulders – head & shoulders lifted up toward mother’s pubic bone & trunk of

baby born by flexing laterally in direction of symphysis pubiso baby completely emerged & 2nd stage of labor ends

6. Examine the maternal anatomic and physiologic adaptations to labor. – CO by 12-31% in 1st stage & 50% in 2nd stage– ***HR slightly***– BP

o blood flow redirected to peripheral vessels peripheral resistance & ***BP ***o 1st stage = 10 mm Hg systolico 2nd stage = 30 mm Hg systolic & 25 mm Hg diastolic

– WBC – hyperventilation may respiratory alkalosis, hypoxia & hypocapnia– proteinuria of 11 = normal finding d/t breakdown of muscle tissue from labor– gastrointestinal motility & absorption of solid fluids & slowing-emptying time slowed– metabolism & blood glucose levels may – ***redirection of blood flow to priority organs***– ***hypoxia of uterine muscles pain for mother***

MANAGEMENT OF DISCOMFORT

1. Describe the breathing techniques used with different types of childbirth education (i.e. Lamaze/Bradley)

– Lamae (psychoprohylaxis) method: requires practice @ home & coaching during labor & birtho goals = minimize fear & perception of pain & promote positive family relationships by using

both mental & physical preparation– Bradley method: husband-coached childbirth using breathing techniques– Dick-Read method: based on premise that fear of pain produces muscular tension – producing

pain & greater fear, teaching:o physiologic processes of laboro exercise to improve muscle toneo techniques to assist in relaxation o prevent or interrupt fear-tension-pain-mechanism

2. Describe the role and benefits of a doula compared to that of family members.– they are specially trained– provide continuous, one-on-one caring presence– focuses on laboring woman & provides physical & emotional support by using soft, reassuring

words of praise & encouragement– administer nonpharmacologic comfort measures to reduce pain & enhance relaxation & coping – provide info about labor progress & explain procedures & events– advocate for woman’s right to participate actively in mgmt of labor– ***help to anxiety & fear – make more confident & calm***

3. Discuss the mechanism of action of the non-pharmacologic methods of pain management used with laboring clients.

Nur 312 Exam II– gate-control theory & stress response = basis

o gate-control theory: pain sensations travel along sensory nerve pathways to brain but only limited # of sensations, or msgs, can travel through nerve pathways @ 1 time

distraction techniques block capacity of nerve pathways to transmit pain closing down hypothetic gate in spinal cord – preventing pain signals from reaching

brain pain diminished– distracts mother from pain

4. Define the difference between anesthesia and analgesia for labor and delivery.– anesthesia: abolishes pain perception by interrupting nerve impulses to brain – partial or complete

& sometimes w/ loss of consciousness ***loss of sensation***– analgesia: alleviation of sensation of pain or raising of threshold for pain perception w/o loss of

consciousness - ***pain relief***5. Identify the unique risks general anesthesia presents for pregnant women.

– crosses placental barrier – drugs in system respiratory depression– risk for aspiration

o slows GI emptying timeo gastric acidityo position for delivery

– ***must admin meds to neutralize gastric contents***– ***during intubation, cricoid pressure NEEDS to be apllied to risk for aspiration***

6. Compare the advantages, disadvantages, and NI for the major types of regional analgesia and anesthesia

– *** –caine***– spinal block – epidural

– pudenal nerve block– paracervcal block

– advantages o produce pain reliefo awakeo able to participateo protect own airway

– disadvantages o respiratory depressiono itching (esp. w/ Morphine) in face

usuallyo N/V (esp. w/ Morphine)o urinary retention

– NI o monitor urinary outputo be with mom 1st time gets up o monitor for effecto position to optimize distribution ***change position q10min***

7. Discuss the nursing role in client decision-making regarding analgesia and anesthesia in labor.– explain the advantages and disadvantages– inform of the side effects

8. Identify the optimal time for administration of systemic narcotic analgesia in labor.– 1st stage – active phase

9. Identify the drug classification, actions, side effects, toxic effects, route of administration and NI for the following medications used to provide pain management to clients in labor:

a. Morphinei. classification: opioid agonist/analgesicii. action: binds to opiate receptors in CNS; severity of painiii. side effects: confusion, sedation, hypotension, constipation iv. toxic effects: respiratory depressionv. route of admin: PO, Rect, IV, IM, subQvi. NI: assess LOC, BP, pulse & respirations

b. Fentanyli. classification: opioid agonist/analgesicii. action: binds to opiate receptors in CNS; painiii. side effects: dizziness, drowsiness, nauseaiv. toxic effects: respiratory depression

Nur 312 Exam IIv. route of admin: transmucosalvi. NI: assess BP, pulse, & respirations

c. Marcainei. classification: epidural local anestheticii. action: inhibit initiation & conduction of sensory nerve impulses by altering influx of Na & efflux

of K in neurons; *** pain & can cause motor blockade***iii. side effects: seizures, cardiovascular collapse, ***HYPOTENSION***iv. toxic effects: numbness, ringing in ears, metallic taste, slow speech, irritability, twitching,

seizures, cardiac dysrhythmiasv. route of admin: epiduralvi. NI: assess HR & BP – orthostatic hypotension

d. Epinepherinei. classification: adrenergic; antiasthmatic, bronchodilator, vasopressorii. action: maintenance of HR & BP; reverses respiratory depression, hypotension & other serious

adverse effects; localizes & intensifies effect of anesthesiaiii. side effects: nervousness, restlessness, tremor, angina, arrhythmias, HTN, tachyiv. toxic effects:v. route of admin: subQ, IM, IVvi. NI: give test dose – if HR 20-30% above baseline – catheter in vein & needs to reinserted

e. Ephedrinei. classification: vasopressorii. action: ***increases maternal BP***iii. side effects: HA, restlessness, tremors, respiratory difficultyiv. toxic effects: sharp rise in BP cerebral hemorrhagev. route of admin: subQ or IMvi. NI: measure BP

f. Demeroli. classification: opioid agonist analgesicii. action: stimulate both mu & kappa receptors; ***create feeling of well-being or euphoria NOT

amnesic effect***iii. side effects: brady, tachy, hypotension, respiratory depressioniv. toxic effects:v. route of admin: IV, IMvi. NI: monitor vitals

g. Nubaini. classification: opioid agonist-antagonist analgesicii. action: agonists @ kappa receptors & antagonists or weak agonists @ mu receptors;

***provide adequate analgesia w/o causing significant respiratory depression***iii. side effects: sedation (less likely to cause N/V)iv. toxic effects: v. route of admin: IM & IVvi. NI: not suitable for women w/ opioid dependence b/c antagonist activity can withdrawal sx in

mother & newbornh. Phenergan

i. classification: antiemeticii. action: ***diminishes N/V***iii. side effects: sedation, confusion, disorientation, neuroleptic malignant syndromeiv. toxic effects:v. route of admin: PO, IM, IV, Rectvi. NI: monitor vitals, level of sedation

Nur 312 Exam IIi. Narcan

i. classification: opioid antagonistii. action: reverses CNS depressant effects, esp. respiratory depression; counters effect of stress-

induced levels of endorphins; reverses pruritis from epidural opioidsiii. side effects: maternal hypo- & hypertension, tachy, hyperventilation, N/V, sweating,

tremulousnessiv. toxic effects:v. route of admin: IV or SubQvi. NI: pain will come back

COMPLICATIONS OF LABOR AND DELIVERY

1. Identify nursing care for the laboring client experiencing abnormal labor patterns.– change maternal position– administer 8-10 L of O2

– IV fluids

– uterine activity– call MD

– external cephalic version (ECV): attempt to turn fetus from breech or shoulder presentation to a vertex presentationo ULTRASOUND SCAN done to determine fetal position, locate umbilical cord, r/o placental

previa, evaluate adequacy of maternal pelvis, assess amt of amniotic fluid, fetal age & presence of any anomalies

o contraindications = uterine anomalies, previous c-section, CPD, placenta previa, multifetal gestation & oligohydramnios

– trial of labor (TOL): obervance of woman & fetus for 4-6 hr of spontaneous active labor to access safety of vaginal birth for mother & infant

– cervical ripening w/ prostaglandins– induction w/ oxytocin

– amniotomy– operative procedures

2. Describe the indications for use of forceps and/or vacuum extraction– macrosomia (>4000 g)– women w/ MG

– face & brow presentation

– need to shorten 2nd stage of labor – dystocia or to compensate for woman’s deficient expulsive efforts

– prevent worsening of dangerous condition (e.g. cardiac decompensation)– PREREQS

o vertex presentationo ruptured membranes

o absence of CPD

3. Describe the nursing actions necessary to care for a woman experiencing induction or augmentation of labor.

– observe uterine response– monitor fetal status– check dilation & effacement

– assess maternal vital signs, FHR & pattern

– HYPERSTIMULATIONo maintain woman in side-lying

positiono turn off oxytocin; keep

maintenance IV line open; rate

o admin O2

o notify MDo prepare terbutaline (Brethine) –

uterine activityo continue monitor FHR & pattern

& uterine activityo document

4. Describe NI for clients experiencing complications during childbirth:a. dystocia (based on the p’s)

i. provides encouragement & support to reduce anxiety & fearii. induceiii. admin oxytocic agents

Nur 312 Exam IIb. shoulder dystocia

i. suprapubic pressureii. maternal position changesiii. McRoberts maneuver: woman’s leg flexed apart w/ knees on abdomen

1. causes sacrum to straighten & symphysis pubis rotates toward mother’s headiv. Gaskin maneuver: squatting position or lateral recumbent positionv. provides encouragement & support to reduce anxiety & fear

c. prolapsed cordi. putting sterile gloved hand into vagina & holding presenting part off umbilical cordii. Sims position, Tredelenburg or knee-chest position – gravity keeps pressure of presenting

part off cordiii. forceps- or vacuum-assisted birth – if cervix dilatediv. ongoing assessment

d. postdates pregnancyi. provides encouragement & support to reduce anxiety & fearii. induce w/ cervical ripening agent followed by oxytociniii. monitor FHR & pattern

e. precipitous birthi. provide encouragement & support to reduce anxiety & fearii. provide opportunity to discuss their labor & birth w/ caregivers

f. uterine rupturei. start IV fluidsii. transfer blood productsiii. admin O2

iv. assist w/ prep for IMMEDIATE SURGERY

v. provide infog. unplanned cesarean

i. provide opportunity to discuss birth experience

ii. express feelings about what happened

iii. have questions answered

iv. address gaps in knowledge or understanding of events

v. connect event w/ emotions & behavior

vi. talk about future pgh. VBAC

i. provide comfort measures & emotional supportii. encouragement to express feelings about having cesarean birth if TOLAC fails

i. amniotic fluid embolismi. admin 8-10 L/min of O2

ii. prep for INTUBATION & MECHANICAL VENT

iii. initiate or assist w/ CPRiv. tilt mother 30° to side –

displaces uterus

v. admin IV fluidsvi. admin bloodvii. insert indwelling catheterviii. prep for emergency birth –

once stabilizedix. correct coag failure

5. Identify the drug classification, route of administration, dosages, actions, side effects, toxic effects, and NI for the following medications used for induction and augmentation of labor:

a. Prostaglandins (PGE2)i. classification: oxytocicii. action: ripens cervix, making softer & causes to dilate & efface; stimulates uterine

contractioniii. side effects: HA, N/V/D, fever, hypotension, tachysystole (12 or more uterine ctxx in 20 min

w/o alteration of FHR); fetal passage of meconiumiv. toxic effects:v. route of admin: intravaginally into posterior fornixvi. NI: assess vitals & health status; use caution if woman as hx of asthma, glaucoma, or renal,

hepatic or disorders; initiate oxytocin for induction of labor @ least 4 hr after last doseb. Cervidil

i. classification: oxytocicii. action: ripens cervix, making softer & causes to dilate & efface; stimulates uterine

contraction

Nur 312 Exam IIiii. side effects: HA, N/V/D, fever, hypotension, tachysystole (12 or more uterine ctxx in 20 min

w/o alteration of FHR); fetal passage of meconiumiv. toxic effects:v. route of admin: intravaginally into posterior fornixvi. NI: assess vitals & health status; use caution if woman as hx of asthma, glaucoma, or renal,

hepatic or disorders; initiate oxytocin for induction of labor @ least 4 hr after last dosec. Cytotec (Misoprostol)

i. classification: oxytocicii. action: ripens cervix, making softer & causing it to begin to dilate & efface; stimulates

uterine ctxiii. side effects: N/V/D, fever, tachysystole (12 or more uterine ctx in 20 min w/o alteration of

FHR); fetal passage of meconiumiv. toxic effects:v. dose/route: 25 mcg high in vaginavi. NI: assess vitals & health status; use caution if woman as hx of asthma, glaucoma, or renal,

hepatic or disorders; initiate oxytocin for induction of labor @ least 4 hr after last dose; ***watch for hypoerstimulation***

d. Oxytocini. classification: oxytocicii. action: stimulates uterine smooth muscle uterine ctx; stimulates mammary gland smooth

muscle; vasopressor & antidiuretic effectsiii. side effects: coma, seizure, uterine motility, painful ctx; intracranial hemorrage,

arrhythmias, asphyxia, hypoxiaiv. toxic effects: uterine ctx lasting >90 sec & occurring > 2 min; uterine resting tone > 20 mm

Hg; nonreassuring FHR; abnormal baseline; absent variability; repeated late decels or prolonged decels

v. route of admin: IV, piggybackvi. NI: maintain side-lying position; monitor vital signs

6. Use the nursing process to determine priorities of care for clients who experience an unexpected complication during labor.

– assess vitals– check FHR & pattern

– comfort & inform

THIRD AND FOURTH STAGES

1. Describe normal physiologic adaptation for a woman in the immediate postpartum period (systems review)

– involution: return of uterus to nonpregnant state after birth

– contractions– afterpains– vascular constriction & thromboses

reduce placental site to irregular nodular & elevated area; upward growth of endometrium – enables

endometrium to resume usual cycle of changes to permit implantation

– lochia: postchildbirth uterine discharge

– cervix soft– estrogen & progesterone after

expulsion of placenta

– CARDIOo elimination of uteroplacental circulation size of maternal vascular bed 10-15%o loss of placental endocrine fx removes stimulus for vasodilationo mobilization of extravascular water stored during pg

– BLOODo greater of plasma volume than # of blood cells

– NEUROLOGICo physiologic edemao postpartum HA

Nur 312 Exam II2. Discuss optimal nursing care for the client and family during the 3rd and 4th stages of labor.

(consider both physiologic and psychological needs)– physical assessments – MABUBBLE

HP– provide emotional support– answer questions– allow bonding time– ice pack for perineal pain or narcotics

– NSAIDS for cramping– clean up bleeding (1st 1-2 hr do

perineal care for mother)– new gown/sheets d/t sweating– clean room

3. Use the nursing process to determine priorities for the client in stage 4 for a vaginal and cesarean birth.

– physical assessments assessed every 15 min for 1 hr

– nutritional status assessed– maintain fluid balance (IV or PO)

– ID clients @ risk– keep bladder empty– gently massage uterus

4. Identify causes, signs and symptoms, and medical and nursing management of postpartum hemorrhage.

– uterine atony: marked hypotonia of uteruso ***most common cause of hemorrhage***o RISK FACTORS

over-distended uterus macrosomia multiple fetuses

hydraminos (extra fluid) distension w/ clots

anesthesia & analgesia conduction anesthesia

poor uterine contractility (over-tired) precipitous (< 3 hr) / prolonged labor (20-30 hr) induced or augmented labor (over works uterus) grand multiparity drugs (MgSO4) infection

placental separation problems uterine abnormality

– lacerations– hematomas– coagulation problems– placental problems

o retained

o abnormal implantation– traumatic birth– poor tissue integrity– hx of uterine & cervical surgeries– infectious process/ischemia

– MANAGEMENTo O: oxygenateo R: restore circulating volumeo D: drug therapyo E: evaluate responseo R: remedy the causeo pay attn to amt lost over time 1cc/ml = 1 g

5. Identify the significance of the four classes of postpartum blood loss. – Class I: < 900 ml (15% volume)

o no sx– Class II: 1200-1500 ml (20-25%)

o pulse & respirationso orthostatic BP changes

o perfusion of extremitieso narrowing pulse pressure

– Class III: 1800-2100 ml (30-35%)o hypotensiono cold clammy skin

o respirations (30-50 breaths/min)

o tachy (120-160)

Nur 312 Exam II

Nur 312 Exam IIClass IV: 2400 ml (40%)

o profound shocko no audible BPo oliguiric or anuric

o circulatory collapse/cardiac arrest

o volume not quickly restored6. Identify the drug classifications, route of administration, dosages, actions, side effects, toxic

effects, and NI of the following medications specifically for their use in postpartum hemorrhage:a. Methergine

i. classification: ergot alkaloidii. action: smooth muscle contractioniii. dose/route: 0.2mg IM q-2-4hiv. side effects: N/V, HTNv. NI: contraindicated in: hypertensive or cardiovascular disorders

b. Ergotratei. classification: oxytocicii. action: directly stimulates uterine & vascular smooth muscleiii. dose/route: 0.2-0.4mg q6-12h PO OR 200mcg q2-4h IM,IV up to 5 dosesiv. side effects: N/Vv. NI:

c. Oxytocini. classification: synthetic hormoneii. action: strength & freq of ctxiii. dose/route: 10U IM or 20-40U diluted in 500-1000Liv. side effects: N/V (antidiuretic effect – water intoxication)

d. Hemabatei. classification: prostaglandinii. action: smooth muscle ctxiii. dose/route: 0.25mg IM q15-90min for max of 8 dosesiv. side effects: N/V/D, bronchospasmv. NI: must be refrigerated; contraindications = pulmonary disease or asthma

e. Cytotec (Misopostol)i. classification: prostaglandinii. action: smooth muscle ctxiii. dose/route: 200-400ug PO OR 800-1000 ug Rect

7. Use the nursing process to determine priorities of care in the 4th stage for clients who experienced an unexpected complication during labor:

a. lacerationsi. assess bleeding for color & amt to determine possible source of bleedingii. check vital signsiii. rapid IV infusion of crystalloid sol’n @ 3ml for every 1 ml of estimated blood loss

b. hematomasi. admin pain medsii. assess site, sizeiii. assess vital signs

c. abnormal placental implantation or separationi. induce labor ii. assessment of size & tone of uterusiii. application of controlled cord traction when uterus contractediv. early cord clamping