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Nur 312 Exam II

NURSING 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 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

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 activated
o notes é in intensity of uterine ctx; alters respiratory pattern: short 4- to 5- sec breath holds,
5-7x/ctx
o making grunting sounds or expiratory vocalizations
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– Transitional
o behaves in manner similar to overwhelming in intensity
behavior during transition in 1st o reports feeling ring of fire as
stage (8-10 cm) head crowns
o experiences a sense of severe o maintains respiratory pattern of
pain & powerlessness 3-5 7-sec breath holds/ctx,
o shows ê ability to listen followed by forced expiration
o concentrates on birth of baby o eases head out with short
until head is born expirations
o experiences ctx as o responds with excitement & relief
after head is born
Third Stage of Labor
– CO é rapidly as maternal circulation to – express satisfaction with performance
placenta ceases & pooled blood from during labor & birth
lower extremities is mobilized – initiate, along with partner & family,
– pulse rate ê process of bonding & attachment with
– BP returns to pre-pg levels newborn
Fourth Stage of Labor
– intense tremors that resemble – lochia
shivering – fatigue
– pain
4. Describe fetal assessment during labor.
– FHR and pattern – point of maximal intensity (PMI) –
– Leopold maneuvers auscultate FHR
– presentation – fetal descent
– position – amniotic fluid
5. Analyze the influence of cultural and religious beliefs and practices on the process of labor and
birth.
– South Korea – Iran
o stoic response to labor pain o father not present
o fathers usually not present o prefers female support & female
– Japan caregivers
o natural childbirth – Mexico
o labor silent o may be stoic about discomfort
o may eat during labor until 2nd stage, then may request
o father might be present pain relief
– China o fathers & female relatives may
o stoic response to pain be present
o fathers usually not present – Laos
o side-lying position preferred for o May use squatting position for
labor & birth b/c position is birth
thought to reduce infant trauma o Fathers may or may not be
– India preset
o natural childbirth methods o Prefer female attendants
o father usually not present
o female relatives usually present
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
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7. Describe the role and responsibilities of the nurse in an emergency childbirth situation.
– put in lateral Sims position –  IV fluids
– keep mom calm – check temp
– explain what is happening & how – assisst with amniofusion
being managed – d/c oxytocin
– provide O2 @ 8-10 L
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 – confirm EDB
individual needs & risks – cultural beliefs
– birth plan – expectations
– past experiences
9. Use the nursing process to determine priorities of nursing care for the laboring client and family.
– assess vitals – pain level
– fetal monitoring – stress level
10. Identify the responsibilities of the nurse during delivery.
– inform the patient – use comfort measures
– assist doctor – coach in breathing techniques
– praise & encourage
11. Describe nursing care for each phase of stages one and two.
First Stage of Labor
– Latent
o provides encouragement, o uses comfort measures
feedback for relaxation, o assists woman into comfortable
companionship position
o assists woman to cope with ctx o informs woman of progress –
o encourages use of focusing explain procedures & routines
techniques o give praise
o helps to concentrate on o offers fluids, food, ice chips as
breathing techniques ordered
– Active
o acts as buffer; limits assessment effleurage
techniques to btwn ctx o applies counterpressure to
o encourages woman prn to help sacrococcygeal area
maintain breathing techniques o encourages & praises
o uses comfort measures o keeps woman aware of progress
o assists w/ frequent position o offers analgesics as ordered
changes, emphasizing side-lying o checks bladder; encourages
& upright positions voiding
o encourages voluntary relaxation o gives oral care; offer fluids, flood,
of muscles of back, buttocks, ice chips as ordered
thighs & perineum; performs
– Transition
o stays; provides constant support o use comfort measures
o assists woman to cope w/ ctx o accepts woman’s inability to
o reminds, reassures, & comply with instructions
encourages woman to o accepts irritable response to
reestablish breathing pattern & helping (i.e. counterpressure)
conc prn o supports woman who has N/V;
o alerts woman to begin breathing gives oral care prn; gives
pattern before ctx becomes too reassurance regarding signs of
intense end of 1st stage
o prompts panting respirations if o uses relaxation techniques
woman begins to push o keeps woman aware of progress
prematurely
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Second Stage of Labor
– Latent
o encourages woman to “listen” to o suggests an upright position to
her body encourage progression of
o continues to support measures descent if descent phase does
allowing woman to rest not begin after 20 min
– Descent
o encourages respiratory pattern her body regarding movement &
of short breath holds and open- position change if descent is
glottis pushing occurring
o stresses normality & benefis of o discourages long breath holds
grunting sounds & expiratory (no longer than 5-7 sec)
vocalizations o if birth is to occur in a delivery
o encourages bearing-down efforts room, transfers woman to
with urge to push delivery room early to avoid
o encourages or suggests rushing or, if permitted, offers
maternal movement & position her option of walking to delivery
changes (upright, if descent is room
not occurring) o places woman in lateral
o encourages woman to “listen” to recumbent position to slow
descent if descent is too fast
– Transitional
o encourages slow, gentle pushing ctx) to help her understand the
o explains that “blowing away the perineal sensations
ctx” facilitates a slower birth of o coaches woman to relax mouth,
the head” throat, & neck to promote
o provides mirror to help woman relaxation of pelvic floor
see or touch the emerging fetal o applies warm compress to
head (best to extend over 2-3 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 & dilation
o Latent Phase
 0-3 cm  5-30 min apart
 30-45 sec long  mild to moderate
o Active Phase
 4-7 cm  3-5 min apart
 40-70 sec logn  moderate to strong
o Transition Phase
 8-10 cm  2-3 min apart
 45-90 sec long  strong
– Second Stage of Labor
o begins with full cervical dilation and complete effacement & ends with baby’s birth
o Latent Phase
 experiences a short period of peace & rest
o 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
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 shows  ability to listen
 concentrates on birth of baby until head is born
 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 expelled
o goal of mgmt is prompt separation & expulsion of placenta, achieved in easiest, safest
manner
– Fourth Stage of Labor
o first 1-2 hr postpartum
o 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 head o fetal attitude – relation of fetal
o fetal presentation body parts to each other
o fetal lie 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 circulation
o upright position helps in descent of fetus
o optimal CO in upright or side-lying position
– psychologic (tense = longer labor)
o expectations o fatigue
o past experiences o knowledge base
o support persons
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 promontory
o ***smallest diameter is A/P***
o upper aspect of symphysis pubis to sacral promitory
o 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 & coccyx
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o ***smallest diameter is transverse***
o distance btwn ischial spines = 10 cm
o size is estimated – can’t measure
– Pelvic outlet: lower border of true pelvis – bounded by public arch anteriorly, ischial tubersities
laterally & tip of coccyx posteriorly
o ***smallest diameter is transverse***
o measure distance btwn ischial tuberosities = 8-10 cm (fist btwn ischeal tuberosities)
o angle of pubic arch inflences this distance
o 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 cm
o largest plane & one of greatest diameter
– Outlet
o ≥ 8 cm
o 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 cm
5. Summarize the cardinal movements of the mechanism of labor for a vertex presentation.
– Engagement
o ***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
– Asynclitism
o head engages in pelvic in a synclitic position – parallel to anteroposterior plane of pelvis
o ***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 part
o accelerates in active phase & apparent when ROM
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– Flexion
o ***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
o pelvic inlet widest in transverse diameter ∴ fetal head passes inlet into true pelvis in
occipitotransverse position
o outlet widest in anteroposterior diameter – for fetus to exit, head must rotate
o ***begins @ level of ischial spines but NOT completed until presenting part reaches lower
pelvis***
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– 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
– Expulsion
o after birth of shoulders – head & shoulders lifted up toward mother’s pubic bone & trunk of
baby born by flexing laterally in direction of symphysis pubis
o 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 systolic
o 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 & 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***
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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
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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
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iv. toxic effects:
v. route of admin: PO, IM, IV, Rect
vi. NI: monitor vitals, level of sedation
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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

COMPLICATIONS OF LABOR AND DELIVERY

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
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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
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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

THIRD AND FOURTH STAGES

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