NUR 2421 Maternity Nursing Exam 4 Labor (Completed A)

Keiser University NUR 2421 Maternity Nursing Exam 4 Labor Stages / Phases of Labor – First stage: Latent (early): onset of regular contractions. Nullipara about 8.6 hours, but no more than 20. Multipara 5.3 hours but no more than 14. Mild contractions 20-40 seconds long every 3-30 minutes. Active: Anxiety and contraction intensity increases. Cervix dilates from about 4-7 cm. Fetal decent is progressive. Cervical dilatation at least 1.2 cm per hour for nullipara, 1.5 cm/hour for multiparas. Transition: Last part of first stage. Often inner directed and tired. Nurse should reassure patient she will not be left alone. Dilatation from 8-10 cm (slows down) Rate of fetal decent increases-average is 1cm/hr in nulliparas, 2 cm/hour for multiparas. This phase should be no longer than 3 hours for nulliparas, 1 hour for multiparas. First stage may be increased by 1 hour if epidural anesthesia is used. Contractions become more frequent, longer, and increase in intensity. Every 1 ½ - 2 minutes, 60- 90 seconds long and strong. Increased rectal pressure, urge to bear down, increased bloody show and ROM. Second stage: Starts after 10 cm dilated and ends with the birth of the child. Usually within 2 hours after fully dilated for primigravidas (multipara about 15 minutes). Epidural may increase the time an extra hour. Contractions continue at 1 ½ - 2 minutes, 60-90 seconds long and strong. Decent continues until it reaches perineal floor. As head decends, woman has urge to push because of pressure of fetal head on sacral and obturator nerves. Bloody show may increase. Crowning occurs when the fetal head is encircled by the external opening of the vagina (introitus) and means birth is imminent. “Push through the pain and burning” Stage 3: Involves placental descent and delivery. The placenta normal descends naturally with minor assistance from the clinician. Assessment of the mother and inspection of the placenta is crucial as this may be a dangerous time if any placental fragments remain, which can lead to hemorrhage. Stage 4: Recovery is the final stage of labor. Recovery begins with the delivery of the placenta and ends 3-4 hours later. Nursing assessment is important during this phase to monitor the wellbeing of the newborn and the stays of the mother.SROM - spontaneous rupture of membranes. The breaking of the “water” or membranes marked by the expulsion of amniotic fluid from the vagina. AROM - artificial rupture of membranes. Use of a device such as an amnihook or allis forceps to rupture the amniotic membrane. PROM - premature rupture of membranes. Spontaneous rupture of membranes and the leakage of amniotic fluid before the onset of labor at any gestational age. PPROM – preterm premature rupture of membranes. When the membranes rupture and the leakage of amniotic fluid from the vagina occurs before 37 weeks of gestation. True labor – the contractions produce progressive dilatation and effacement of the cervix. They occur regularly and increase in frequency, duration and intensity. The discomfort of true labor contractions usually starts in the back and radiate around to the abdomen. Pain is not relieved by ambulation (walking may increase pain) or resting. False labor – contractions of the uterus, regular or irregular, that may be strong enough to be interpreted as true labor but that do not dilate the cervix. Contractions hardening or “balling up” without discomfort. Epidural analgesia / anesthesia – lumbar epidural block involves injection of a local anesthetic agent into the epidural space (potential space between the dura mater and the ligamentum flavum, extending from the base of the skull to the end of the sacral canal). Produces good analgesia that alters maternal physiologic responses to pain. Most common complication is hypotension. General anesthesia – a state of induced unconsciousness that may be achieved through IV injection, inhalation of anesthetic agents, or a combination of both methods. Stations / Engagement – (Cardinal Movements of Labor Mnemonic: EDFIEEE)E: Every = Engagement D: Darn = Descent F: Fetus = Flexion I: Is = Internal rotation E: Extremely = Extension E: Eager to = External rotation E: Exit = Expulsion Engagement: Passage of the widest diameter fetal presenting part below the plane of the pelvic inlet. The head is said to be engaged if the leading edge is at the level of the ishial spines. Descent: Refers to the downward passage of the presenting part through the bony pelvis. Not steady process. Greatest at deceleration phase of first stage and during 2nd stage of labor. Flexion: Occurs passively as the head descends due to the shape of the bony pelvis. Partial flexion occurs naturally but complete flexion usually occurs only in the labor process. Complete flexion places the fetal head in optimal smallest diameter to fit through the pelvis. Internal Rotation: Rotation of the fetal head from occiput transverse to occiput either in anterior or posterior position. Occurs passively due to the shape of the bony pelvis. Extension: Occurs when the fetus has descended to the level of the vaginal introitus. When occiput is just past the level of the symphysis, the angle of the birth canal changes to upward position. External Rotation/Restitution: As the head is delivered, it rotates back to its original position prior to internal rotation. It aligns anatomically with the fetal torso. The release of the passive forces on the fetal head allows it to return to appropriate position. Expulsion: Delivery of the fetus. After delivery of the fetal head, descent and intraabdominal pressure by mother brings shoulder to the level of the symphysis. Downward traction allows release of the shoulder and the fetus is delivered. Early decelerations – periodic change in fetal heart rate pattern caused by head compression; deceleration has a uniform appearance and early onset in relation to maternal contraction. Variable decelerations – periodic change in fetal heart rate caused by umbilical cord compression; decelerations vary in onset, occurrence and waveform.Late decelerations – symmetrical decrease in fetal heart rate beginning at or after the peak of the contraction and returning to baseline only after the contraction has ended, indicating possible uteroplacental insufficiency and potential that the fetus is not receiving adequate oxygenation. Cervical Dilatation – process in which the cervical os and the cervical canal widen from less than 1 cm to more than 10 cm, allowing birth of the fetus. Cervical Effacement – thinning and shortening of the cervix that occurs late in pregnancy or during labor. Lightening – moving of the fetus and uterus downward into the pelvic cavity. Elimination during labor – Episiotomy – incision of the perineum to facilitate birth and to avoid laceration of the perineum. “Back labor” Contraction assessment – Vital sign assessment of the laboring client – Labor Induction – the stimulation of uterine contractions when spontaneous onset of labor, with or without ruptured fetal membranes, for the purpose of accomplishing birth. Cesarean Section – Medication administration during labor:Pitocin/ Stadol Narcan Terbutaline Pitocin Cervidil antacid Duramorph