N4441 Nursing of the Childbearing Family Labor and Delivery Student Name: LABOR AND DELIVERY Student name:

Delia Ramirez Terminology

Electronic Fetal Monitoring

Clinical Date

Date 09/25/2011 Definitions

Electronic fetal monitoring (EFM) is a method for examining the condition of a baby in the uterus by noting any unusual changes in its heart rate. Electronic fetal monitoring is performed late in pregnancy or continuously during labor to ensure normal delivery of a healthy baby. EFM can be utilized either externally or internally in the womb. Average FHR during a10-minute period that excludes periodic and episodic changes and period of marked variability. The baseline fetal heart rate is normally between 110 and 160 beats per minute. Normal irregularity of fetal cardiac rhythm or fluctuations from the baseline FHR of two cycles or more; the four possible categories are absent, minimal, moderate and marked. A visually apparent, abrupt (onset peak <30 seconds) increase in FHR above the baseline rate; the increase is 15 beats/min or greater and lasts 15 seconds or more, with the return to baseline less than 2 minutes from the beginning of the acceleration. Decelerations are defined according to their visual relation to the onset and end of a contraction and by their shape. A visually apparent gradual (onset to lowest point 30 seconds or more) decrease in and return to the baseline FHR associated with UCs; generally the onset, nadir, and recovery of the deceleration correspond to the beginning, peak, and end of the contraction. A visually apparent gradual (onset to lowest point 30 seconds or more) decrease in and return to baseline FHR associated with UCs; the deceleration begins after the contraction has started, and the lowest point of the deceleration occurs after the peak of the contraction; the deceleration usually does not return to baseline until after the contraction is over. A visually abrupt (onset to lowest point <30 seconds) decrease in FHR below the baseline; the decrease is 15 beats/min or more, lasts at least 15 seconds, and returns to baseline in less than 2 minures from the time of onset; variable decelerations are not necessarily associated with UCs; they have U, V, or W shape. The regular tightening of the uterus, working to push the baby down the birth canal. First Maneuver: Fundal Grip To determine fetal part lying in the fundus.To determine presentation. Using both hands, feel for the fetal part lying in the fundus. Findings: Head is more firm, hard and round that moves independently of the body. Breech is less well defined that moves only in conjunction with the body.
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Baseline Variability Periodic or Episodic Changes: Accelerations Decelerations: Early Late

Variable

Uterine contraction Leopolds Maneuvers (list all four and describe)

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N4441 Nursing of the Childbearing Family Labor and Delivery Student Name: Clinical Date
Second Maneuver: Umbilical Grip To identify location of fetal back. To determine position. One hand is used to steady the uterus on one side of the abdomen while the other hand moves slightly on a circular motion from top to the lower segment of the uterus to feel for the fetal back and small fetal parts. Use gentle but deep pressure. Findings: Fetal back is smooth, hard, and resistant surface Knees and elbows of fetus feel with a number of angular nodulation Third Maneuver: Pawliks Grip To determine engagement of presenting part. Using thumb and finger, grasp the lower portion of the abdomen above symphisis pubis, press in slightly and make gentle movements from side to side. Findings: The presenting part is not engaged if it is not movable. It is not yet engaged if it is still movable. Fourth Maneuver: Pelvic Grip To determine the degree of flexion of fetal head.To determine attitude or habitus. Facing foot part of the woman, palpate fetal head pressing downward about 2 inches above the inguinal ligament. Use both hands. Findings: Good attitude if brow correspond to the side (2nd maneuver) that contained the elbows and knees. Poor atitude if examining fingers will meet an obstruction on the same side as fetal back (hyperextended head) Also palpates infants anteroposterior position. If brow is very easily palpated, fetus is at posterior position (occiput pointing towards womans back) 1st Stage of Labor (3 phases) List centimeters and patient behaviors Latent Active

Dilation 0-3 cm; Contractions 30-45 sec long, 5-30 minutes apart, mild to moderate intensity; duration of phase about 6-8 hr) Excited, thoughts center on self, labor and baby, fairly confident, pain controlled fairly well, able to talk and walk thorugh contractions, open to instructions. Dilation 4-7 cm, contractions 40-70 sec long, 3-5 min apart, mild to moderate intensity; duration of phase about 3-6 hr. Becomes more serious, quiet, doubtful, desires companionship and encouragement, fatigued evidenced, malar (cheeks) flush, describes increasing discomfort.
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N4441 Nursing of the Childbearing Family Labor and Delivery Student Name:
Transition

Clinical Date
Dilation 8-10 com; contractions 45-90 sec long, 2-3 min apart, strong intensity; duration of phase about 20-40 min. Pain described as severe, with backache common, may voice frustration, expresses doubt, vague communications, writhing with contractions, shaking tremor in thighs, nausea, vomiting especially if hyperventilating, circumoral pallor, perspiration on forehead and upper lip, pressure on anus, amnesia between contractions. Consists of Latent and Active phase. Latent (10-30 minutes) spontaneous bearing down efforts slow down. Quiet concern over progress, fatigue and sleepy, feels sense of accomplishment, feels in control. Active (duration varies) Increase urge to bear down, vocalizations announcing contractions, expresses feeling of powerlessness, decrease ability to concentrate on anything but birth, frequent repositioning, shows excitement immediately after birth of head. Waiting to actively push until baby is crowning at the perineum; this may be an hour or more after you reach 10 cm dilation. Laboring down will lead to a longer second stage than a more active, directed pushing, but its not as exhausting, and some studies have shown that it leads to fewer instrumental deliveries. Labor is started or accelerated through intervention, such as placing prostaglandin gel on the cervix, using an IV drip of the hormone oxytocin (Pitocin), or by rupturing the membranes. Doing something to stimulate contractions. May decide to do this if contractions aren't coming frequently or forcefully enough to dilate your cervix or help move your baby down the birth canal. When the baby's head has passed through the birth canal and the top or crown stays visible at the vaginal opening. Women will experience a burning or stinging sensation, often referred to as the ring of fire, as your baby stretches the vaginal opening. Surgically planned incision on the perineum and the posterior vaginal wall during second stage of labor.

2nd Stage of Labor

Laboring down

Labor Induction Labor augmentation Crowning Episiotomy

Medications and the normal physical parameters are required to be completed prior to the clinical day. Please hand in a hard copy to your clinical instructor. It may not be graded at that time depending upon clinical instructor preference. Medication Dose Route Briefly State OB Nursing considerations and side effects use Pitocin (Oxytocin) 1-2 mU/min, IV Stimulation of Seizures, hypo/hypertension, dysrhythmias, N, V,abruption increase by 1-2 labor placentae, decreased uterine flow. mU q15-60 minutes until Assess: I&O ratio, Respirations, BP, FHT, for signs of water contractions intoxication occur; then decrease dose

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N4441 Nursing of the Childbearing Family Labor and Delivery Student Name:
Magnesium Sulfate 4-5 g IV inf; with 5 g IM in each gluteus, then 5 g q4 hr 0.5-2 g at 0.5 ml/min (10% solution); max IV dose is 3g -50-100 mg given when contractions are regularly spaced, repeat q1-3 hr prn - 0.5-2 mg q3-4 hr prn -0.3-3 mg/kg given over 1015 minutes -2.5-15 mg diluted in 4-5 ml H2O for inj, over 5 minutes -1-2 mg q4-6 hr prn 12.5-50 mg IV/IM Anticonvulsant in preeclampsia, eclampsia

Clinical Date
Muscle weakness, hypotension, N, V, anorexia, prolonged bleeding time Assess: I&O, for constipation, cramping, rectal bleeding (should be discontinued) Infuse over 3 hours. Give deep in gluteal site. Dysrhythmias, cardiac arrest, V, N, constipation, burning at IV site. Asses: ECG for shortened QT and T wave, cardiac status: rate and rhythm, remain recumbent hr after dose. Drowsiness, confusion, dizziness, headache, euphoria, sedation, respiratory depression. Assess: pain, location, type. I&Os. Respirations. CNS changes.

Calcium Gluconate

IV

Hypermagnesemia from magnesium sulfate Obstetric/regional analgesic

Analgesics (Demerol, Stadol, Nubain, Morphine, Dilaudid)

-IM/ SUBCUT -IV -IV IM/IV/ SUBCUT

Phenergan

IM/IV/PO

To reduce anxiety, increase sedation, and reduce N,V

Dizziness, drowsiness, constipation, urinary retention. Assess: I&O, Respiration status, Cardiac status: palpitations, BP

Epidural drugs: (lidocaine, bupivicaine, fentanyl/sufenta) Antibiotics for labor &

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N4441 Nursing of the Childbearing Family Labor and Delivery Student Name:
delivery: Penicillin Ampicillin Clindamycin Gentamycin Ancef (Cefazolin) Cytotec (Misoprostol) Cervidil (Dinoprostone)

Clinical Date

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Labor and Delivery Nursing Assessment Maternal History Prenatal risk factors or complications of pregnancy Previous OB history N4441 Nursing of the Childbearing Family Medical conditions and surgical history Labor and Delivery Psychological or mental health issues or history GPTPAL LNMP Student Name: Clinical Date EDC Physical Assessment/System Reference (normal findings for term laboring pregnant patient) Assessment Findings (your patient) Cardiovascular Heart rate increases slightly. Changes in BP occur (increases because of peripheral vascular resistance). During first stage uterine contractions cause systolic readings to rise about 10 mm Hg and second stage systolic by 30 diastolic by 25. WBC count can increase. Flushed cheeks, hot or cold feet, and eversion hemorrhoids. Neurological Respiratory Integumentary Muscoloskeletal GI Increased in RR from increased physical activity. Hyperventilation may cause respiratory alkalosis, hypoxia, hypocapnia Stretching of vaginal introitus. Minute tears in the skin around the vaginal introitus do occur. Backaches and joint aches occur as a result of increased joint laxity at term. Pointing toes can cause leg cramps. Motility and absorption is decreased, stomach-emptying time is slowed Nausea and vomiting of undigested food is common Nausea and belching is common - may occur in response to full cervical dilation Diarrhea may occur with onset of labor Possibly there will be hard impacted stool in rectum During delivery any stool that is present in the rectum will be pushed out by the pressure of the babys head moving through the vagina Diet restrictions for labor vary may be NPO, ice chips or clear liquids only during active labor as ordered by provider Note time of last solid food and oral fluids GU Anesthesia/Pain Management Epidural Spinal IV pain meds Comfort measures Natural Childbirth Other Reproductive Fundus (Uterine contractions) Fetal status (FHR) Cervix Membranes Psychosocial Maternal adjustment to labor 6 Labor & Delivery coping, pain (phase, behavior, management) Family interactions, support person Spontaneous voiding may be difficult : tissue edema, discomfort, analgesia, and embarrassment. Proteinuria of 1+ is normal.

Stage I: will be more open, confident, excited, then become increasingly uncomfortable. Stage II: Fatigue, powerlessness, quiet, concern over progress

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N4441 Nursing of the Childbearing Family Labor and Delivery Student Name: Clinical Date

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N4441 Nursing of the Childbearing Family Labor and Delivery Student Name:
Time VS Temp RR HR BP FHR Assessment Baseline Variability (1)* Periodic changes (2)** Reassuring or Nonreassuring (Category) Contraction Pattern Assessment (3)*** Frequency Duration Intensity KEY *(1) V=Variability; Abs=absent; M=minimal, Mo= moderate, Ma= marked **(2) A=acceleration; E=early decelerations; L=late decelerations V=variable decelerations ***(3) Mi=mild; Mo=moderate; F=firm

Clinical Date

Delivery Summary Time Weight Anesthesia Recovery Record Times VS Temp BP HR RR DTRs Fundal Height & Position Lochia Perineum

Sex Length Episiotomy/Lacerations

Delivery Type APGARS EBL

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N4441 Nursing of the Childbearing Family Labor and Delivery Student Name: Clinical Date

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N4441 Nursing of the Childbearing Family Patient Family Teaching Needs Identify and prioritize for your patient in nursing terms Primary teaching need must be related to #1 priority Labor and Delivery Nursing Diagnoses/Wellness Needs Student Name:
nursing diagnosis or wellness need Identify 3 priorities (nursing diagnoses) for one patient assigned: Rank and Classify All Priorities as: (U) Urgent, (A) ASAP. #1 Priority must be reflected in patient/family teaching and nursing interventions. 1. 2. 3.

Critical Thinking: Identify a Clinical Date

problem you encountered and how/what critical thinking helped you to a solution

Nursing Intervention: What nursing interventions did

you do related to your #1 priority need? 1.

Evaluation: What was the outcome of your nursing interventions? What goals were met or not met?
1.

Safety
Related to your patient

2.

2.

Comment here regarding additional history or concerns that need to be known but are not listed above: How will this experience affect your future practice of nursing (implications for future nursing practice)? Evaluate your nursing practice today- was it effective or not? What would you have done differently? State your justification if you would not change anything.

Briefly describe Creativity project presented to class (offline only students, see grading rubric):
References (at least two related to clinical area/diagnosis and individualized to patientonly ONE source may be a textbook):

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