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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 True Labor
– ctx irregular – ctx become longer, stronger, closer
– ctx stop with comfort measures – continue despite comfort measure
– cervix shows no significant change – cervix show progressive change –
– fetus is usually not engaged in the dilating
pelvis – engagement of the fetus in pelvis
2. Describe the ongoing assessment of maternal progress during the first, second and third stages of
labor.
– chart – presenting part
– what kind of birth – cervix
– anesthesia – temp
– expectations – uterine activity
– how many people in room – who – vaginal show
– L&D experiences – behavior, appearance, mood, energy
– prenatal care level, condition of partner
– FHR – vaginal examination
– vitals – ctx
– descent
3. Recognize the physical and psychosocial findings indicative of maternal progress during labor.
First Stage of Labor
– Latent (1-3 cm; ctx 30- o continues relaxation, focusing
45 sec, 5-30 min apart, mild to techniques
moderate) o uses breathing techiques
o alert, happy, excited, mild – Transition (8-10 sec, ctx 45-90
anxiety sec, 2-3 min apart, strong)
o settles into labor room; selects o irritable, intense concentration
focal point o N/V
o rests or sleeps, if possible o continues relaxation, needs
o uses breathing techniques greater concentration to do this
o uses effleurage, focusing & o uses breathing techniques
relaxation techniques o if needed, changes to pattern-
– Active (4-7 cm, 40-70 paced breathing (i.e., 4:1
sec, 3-5 min apart, moderate to breathing pattern) if using
strong) psychoprophylactic techniques
o seriously labor-oriented, o uses panting to overcome urge
concentration and energy to push if appropriate
needed for ctx, alert, more
demanding
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 & birth
o 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 labor
o exercise to improve muscle tone
o 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***
Nur 312 Exam II
3. Discuss the mechanism of action of the non-pharmacologic methods of pain management used
with laboring clients.
– 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 time
o gastric acidity
o 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 – pudenal nerve block
– epidural – paracervcal block
– advantages – disadvantages
o produce pain relief o respiratory depression
o awake o itching (esp. w/ Morphine) in face
o able to participate usually
o protect own airway o N/V (esp. w/ Morphine)
o urinary retention
– NI
o monitor urinary output
o be with mom 1st time gets up
o monitor for effect
o 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. Morphine
i. classification: opioid agonist/analgesic
ii. action: binds to opiate receptors in CNS; severity of pain
iii. side effects: confusion, sedation, hypotension, constipation
iv. toxic effects: respiratory depression
v. route of admin: PO, Rect, IV, IM, subQ
vi. NI: assess LOC, BP, pulse & respirations
b. Fentanyl
Nur 312 Exam II
i. classification: opioid agonist/analgesic
ii. action: binds to opiate receptors in CNS; pain
iii. side effects: dizziness, drowsiness, nausea
iv. toxic effects: respiratory depression
v. route of admin: transmucosal
vi. NI: assess BP, pulse, & respirations
c. Marcaine
i. classification: epidural local anesthetic
ii. 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 dysrhythmias
v. route of admin: epidural
vi. NI: assess HR & BP – orthostatic hypotension
d. Epinepherine
i. classification: adrenergic; antiasthmatic, bronchodilator, vasopressor
ii. action: maintenance of HR & BP; reverses respiratory depression, hypotension & other serious
adverse effects; localizes & intensifies effect of anesthesia
iii. side effects: nervousness, restlessness, tremor, angina, arrhythmias, HTN, tachy
iv. toxic effects:
v. route of admin: subQ, IM, IV
vi. NI: give test dose – if HR 20-30% above baseline – catheter in vein & needs to reinserted
e. Ephedrine
i. classification: vasopressor
ii. action: ***increases maternal BP***
iii. side effects: HA, restlessness, tremors, respiratory difficulty
iv. toxic effects: sharp rise in BP cerebral hemorrhage
v. route of admin: subQ or IM
vi. NI: measure BP
f. Demerol
i. classification: opioid agonist analgesic
ii. action: stimulate both mu & kappa receptors; ***create feeling of well-being or euphoria NOT
amnesic effect***
iii. side effects: brady, tachy, hypotension, respiratory depression
iv. toxic effects:
v. route of admin: IV, IM
vi. NI: monitor vitals
g. Nubain
i. classification: opioid agonist-antagonist analgesic
ii. 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 & IV
vi. NI: not suitable for women w/ opioid dependence b/c antagonist activity can withdrawal sx in
mother & newborn
h. Phenergan
i. classification: antiemetic
ii. action: ***diminishes N/V***
iii. side effects: sedation, confusion, disorientation, neuroleptic malignant syndrome
Nur 312 Exam II
iv. toxic effects:
v. route of admin: PO, IM, IV, Rect
vi. NI: monitor vitals, level of sedation
Nur 312 Exam II
i. Narcan
i. classification: opioid antagonist
ii. action: reverses CNS depressant effects, esp. respiratory depression; counters effect of stress-
induced levels of endorphins; reverses pruritis from epidural opioids
iii. side effects: maternal hypo- & hypertension, tachy, hyperventilation, N/V, sweating,
tremulousness
iv. toxic effects:
v. route of admin: IV or SubQ
vi. NI: pain will come back
1. Identify nursing care for the laboring client experiencing abnormal labor patterns.
– change maternal position – uterine activity
– administer 8-10 L of O2 – call MD
– IV fluids
– external cephalic version (ECV): attempt to turn fetus from breech or shoulder presentation to a
vertex presentation
o 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 – amniotomy
– induction w/ oxytocin – operative procedures
2. Describe the indications for use of forceps and/or vacuum extraction
– macrosomia (>4000 g) – face & brow presentation
– women w/ MG
– 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 presentation o absence of CPD
o ruptured membranes
3. Describe the nursing actions necessary to care for a woman experiencing induction or
augmentation of labor.
– observe uterine response – assess maternal vital signs, FHR &
– monitor fetal status pattern
– check dilation & effacement
– HYPERSTIMULATION
o maintain woman in side-lying o notify MD
position o prepare terbutaline (Brethine) –
o turn off oxytocin; keep uterine activity
maintenance IV line open; o continue monitor FHR & pattern
rate & uterine activity
o admin O2 o document
4. Describe NI for clients experiencing complications during childbirth:
a. dystocia (based on the p’s)
i. provides encouragement & support to reduce anxiety & fear
ii. induce
iii. admin oxytocic agents
Nur 312 Exam II
b. shoulder dystocia
i. suprapubic pressure
ii. maternal position changes
iii. McRoberts maneuver: woman’s leg flexed apart w/ knees on abdomen
1. causes sacrum to straighten & symphysis pubis rotates toward mother’s head
iv. Gaskin maneuver: squatting position or lateral recumbent position
v. provides encouragement & support to reduce anxiety & fear
c. prolapsed cord
i. putting sterile gloved hand into vagina & holding presenting part off umbilical cord
ii. Sims position, Tredelenburg or knee-chest position – gravity keeps pressure of presenting
part off cord
iii. forceps- or vacuum-assisted birth – if cervix dilated
iv. ongoing assessment
d. postdates pregnancy
i. provides encouragement & support to reduce anxiety & fear
ii. induce w/ cervical ripening agent followed by oxytocin
iii. monitor FHR & pattern
e. precipitous birth
i. provide encouragement & support to reduce anxiety & fear
ii. provide opportunity to discuss their labor & birth w/ caregivers
f. uterine rupture
i. start IV fluids iv. assist w/ prep for IMMEDIATE
ii. transfer blood products SURGERY
iii. admin O2 v. provide info
g. unplanned cesarean
i. provide opportunity to discuss iv. address gaps in knowledge or
birth experience understanding of events
ii. express feelings about what v. connect event w/ emotions &
happened behavior
iii. have questions answered vi. talk about future pg
h. VBAC
i. provide comfort measures & emotional support
ii. encouragement to express feelings about having cesarean birth if TOLAC fails
i. amniotic fluid embolism
i. admin 8-10 L/min of O2 v. admin IV fluids
ii. prep for INTUBATION & vi. admin blood
MECHANICAL VENT vii. insert indwelling catheter
iii. initiate or assist w/ CPR viii. prep for emergency birth –
iv. tilt mother 30° to side – once stabilized
displaces uterus ix. 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: oxytocic
ii. action: ripens cervix, making softer & causes to dilate & efface; stimulates uterine
contraction
iii. 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 meconium
iv. toxic effects:
v. route of admin: intravaginally into posterior fornix
vi. 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
b. Cervidil
i. classification: oxytocic
Nur 312 Exam II
ii. action: ripens cervix, making softer & causes to dilate & efface; stimulates uterine
contraction
iii. 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 meconium
iv. toxic effects:
v. route of admin: intravaginally into posterior fornix
vi. 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
c. Cytotec (Misoprostol)
i. classification: oxytocic
ii. action: ripens cervix, making softer & causing it to begin to dilate & efface; stimulates
uterine ctx
iii. side effects: N/V/D, fever, tachysystole (12 or more uterine ctx in 20 min w/o alteration of
FHR); fetal passage of meconium
iv. toxic effects:
v. dose/route: 25 mcg high in vagina
vi. 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. Oxytocin
i. classification: oxytocic
ii. action: stimulates uterine smooth muscle uterine ctx; stimulates mammary gland smooth
muscle; vasopressor & antidiuretic effects
iii. side effects: coma, seizure, uterine motility, painful ctx; intracranial hemorrage,
arrhythmias, asphyxia, hypoxia
iv. 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, piggyback
vi. 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 – comfort & inform
– check FHR & pattern
1. Describe normal physiologic adaptation for a woman in the immediate postpartum period (systems
review)
– involution: return of uterus to endometrium to resume usual cycle of
nonpregnant state after birth changes to permit implantation
– contractions – lochia: postchildbirth uterine
– afterpains discharge
– vascular constriction & thromboses – cervix soft
reduce placental site to irregular – estrogen & progesterone after
nodular & elevated area; upward expulsion of placenta
growth of endometrium – enables
– CARDIO
o elimination of uteroplacental circulation size of maternal vascular bed 10-15%
o loss of placental endocrine fx removes stimulus for vasodilation
o mobilization of extravascular water stored during pg
– BLOOD
o greater of plasma volume than # of blood cells
Nur 312 Exam II
– NEUROLOGIC
o physiologic edema
o postpartum HA
2. 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 – NSAIDS for cramping
HP – clean up bleeding (1st 1-2 hr do
– provide emotional support perineal care for mother)
– answer questions – new gown/sheets d/t sweating
– allow bonding time – clean room
– ice pack for perineal pain or narcotics
3. Use the nursing process to determine priorities for the client in stage 4 for a vaginal and cesarean
birth.
– physical assessments assessed every – ID clients @ risk
15 min for 1 hr – keep bladder empty
– nutritional status assessed – gently massage uterus
– maintain fluid balance (IV or PO)
4. Identify causes, signs and symptoms, and medical and nursing management of postpartum
hemorrhage.
– uterine atony: marked hypotonia of uterus
o ***most common cause of hemorrhage***
o RISK FACTORS
over-distended uterus
• macrosomia (extra fluid)
• multiple fetuses • distension w/
• hydraminos 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 o abnormal implantation
– hematomas – traumatic birth
– coagulation problems – poor tissue integrity
– placental problems – hx of uterine & cervical surgeries
o retained – infectious process/ischemia
– MANAGEMENT
o O: oxygenate
o R: restore circulating volume
o D: drug therapy
o E: evaluate response
o R: remedy the cause
o 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%)
Nur 312 Exam II
o pulse & respirations o perfusion of extremities
o orthostatic BP changes o narrowing pulse pressure
– Class III: 1800-2100 ml (30-35%)
o hypotension o respirations (30-50
o cold clammy skin breaths/min)
o tachy (120-160)
Nur 312 Exam II
Class IV: 2400 ml (40%)
o profound shock o circulatory collapse/cardiac
o no audible BP arrest
o oliguiric or anuric o volume not quickly restored
6. 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 alkaloid
ii. action: smooth muscle contraction
iii. dose/route: 0.2mg IM q-2-4h
iv. side effects: N/V, HTN
v. NI: contraindicated in: hypertensive or cardiovascular disorders
b. Ergotrate
i. classification: oxytocic
ii. action: directly stimulates uterine & vascular smooth muscle
iii. dose/route: 0.2-0.4mg q6-12h PO OR 200mcg q2-4h IM,IV up to 5 doses
iv. side effects: N/V
v. NI:
c. Oxytocin
i. classification: synthetic hormone
ii. action: strength & freq of ctx
iii. dose/route: 10U IM or 20-40U diluted in 500-1000L
iv. side effects: N/V (antidiuretic effect – water intoxication)
d. Hemabate
i. classification: prostaglandin
ii. action: smooth muscle ctx
iii. dose/route: 0.25mg IM q15-90min for max of 8 doses
iv. side effects: N/V/D, bronchospasm
v. NI: must be refrigerated; contraindications = pulmonary disease or asthma
e. Cytotec (Misopostol)
i. classification: prostaglandin
ii. action: smooth muscle ctx
iii. 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. lacerations
i. assess bleeding for color & amt to determine possible source of bleeding
ii. check vital signs
iii. rapid IV infusion of crystalloid sol’n @ 3ml for every 1 ml of estimated blood loss
b. hematomas
i. admin pain meds
ii. assess site, size
iii. assess vital signs
c. abnormal placental implantation or separation
i. induce labor
ii. assessment of size & tone of uterus
iii. application of controlled cord traction when uterus contracted
iv. early cord clamping