NCLEX and CGFNS - MATERNITY NURSING

Forceps Birth

2011-07-11T17:31:00.002+03:00

Forceps birth is an assisted birth, sometimes called an instrumental or operative vaginal birth, uses instruments that are attached to baby’s head so that baby can be pulled out. Forceps are described as stainless steel that come in two intersecting parts and have curved end to cradle baby’s head. It can be used as low or outlet forceps or for mid-forceps procedures.
This procedure is done to provide traction or to assist in rotation of the fetus.

Advantages:

Provide assistance when laboring women is exhausted
May decrease need for cesarean birth

Disadvantages:

Maternal complication such as vaginal and perineal lacerations and postpartal hemorrhage
Neonatal complication such as facial bruising, edema and cerebral trauma.

Nursing care:

Explain the procedure to woman
Encourage her to relax perineum and breathe during forceps application
Advice physician when contraction is present
Assess newborn for facial bruising or edema.

Induction

2011-07-11T17:15:00.002+03:00

Induction labor is a procedure to stimulate uterine contraction during pregnancy before labor begins spontaneously. It is done for various reason, especially for mother and baby health reason. Elective induction may be accomplished by oxytocin infusion.

Advantages:

IV oxytocin induction is usually successful when labor readiness has been established, fetal maturity is established and Bishop score is 9 or more.
Maternal and fetal status can be monitored closely.

Disadvantages:
Induction is an invasive procedure.
Hypertonic labor, fetal distress, alterations in blood pressure, ruptured uterus.

Indications:

Postmaturity
Premature rupture of membranes
PIH
Presence of maternal disease such as diabetes mellitus
Fetal demise.

Contraindications:

Grand multiparity
Placental abdominalities
Previous uterine surgery
Fetal distress
Preterm fetus
Positive CST
Abnormal fetal presentation
Presenting part above inlet
Cephalopelvic disproportion (CPD).

Nursing Intervention:

Obtain baseline tracing of uterine contractions
Follow established protocols
Increase IV dosage only after assessing contractions, FHR, and maternal blood pressure and pulse.
Do not increase rate once desired contraction pattern is obtained.
Discontinue oxytocin if contraction frequency is less than 2 minutes of duration is more than 90 seconds, or if fetal distress is noted.

Amniotomy

2011-07-11T16:55:00.002+03:00

Amniotomy is the artificial rupture of membranes, sometimes called as AROM. It is done to stimulate labor.

Advantages:

Amniotomy can stimulate contractions
Amniotomy can evaluate the amniotic fluid

Disadvantages:

Birth must occur within 24 hour when amniotomy is done, and may be need cesarean birth.
Increased risk of prolapsed cord
Risk of Infection

Nursing Care:

Auscultate Fetal Heart Rate before and after amniotomy
Record the time of Amniotomy, Fetal Heart Rate, and characteristics of fluid (amount, color and odor).
Instruct woman to remain in bed unless fetal presentation part is well engaged. It is done to prevent prolapsed of umbilical cord.

Risks for Mother:

Increases the risk of infection.
Labor may become more aggressive
The mother increases her chances of having uneven dilation.

Risk for Baby:

Increase of umbilical cord compression
The pressure on the baby’s head causes swelling in some part.

Diabetes in Pregnancy

2011-07-10T15:53:00.002+03:00

Client with diabetes and their infants are at risk for complication during pregnancy. Infants of diabetic mother tent to be large for gestational age. It is caused by glucose that crosses the placenta, whereas insulin does not, these infants tend to gain weight. The problem is that high glucose environment impedes lung development and although the infants are large for gestational age, they are often premature.

Complication of infants from maternal diabetes:

Patent ductus arteriosus (PDA)
Polyhydramnions
Premature delivery
Respiratory distress syndrome

Complications of mother with diabetes pregnancy:

Hypertension
Renal disease
Ketoacidosis
Vascular compromise
Seizure activity related to hypoglycemia

Another problem in diabetes pregnancies is that the fluctuations in maternal blood sugar can result in fetal brain damage or sudden fetal death due to ketosis. That's why the client should be taught to check their blood glucose levels frequently during the day. Level over 120 mg/dL should be reported to the doctor for treatment.

Infants born to diabetic mothers might be delivered by cesarean section because of their large sizes and they should be assessed immediately after delivery for hypoglycemia by performing a dextrostix. The glucose level of 40 mg/dL or lower indicates hypoglycemia in the infant.

The blood is usually drawn from a heel stick and should be stuck on the lateral aspect of the heel. Blood test should be performed to detect hypocalcemia, hypokalemia and acidosis status.

Ectopic Pregnancy

2010-05-15T11:27:00.001+03:00

Ectopic pregnancy is the condition in which the ovum implants in area other than the endometrial lining of the uterus. This pregnancy is not commonly successful since the areas outside of the uterus cannot sustain for a full-term pregnancy. It’s studied that it usually happens when there is a tubal blockage that prevents the fertilized ovum from passing through the fallopian tubes.

Ectopic pregnancy can be happened at abdominal, tubal, myometrial or cervical.

Ectopic pregnancy at abdomen:
The abdomen is usually unable to sustain for embryo growth

Ectopic pregnancy at tubal:
This is the most common site of ectopic pregnancy. It can causes mother at risk for tubal rupture that can be a life threatening condition.

Ectopic pregnancy at myometrial:
We cannot recognize it until delivery that usually requires a hysterectomy to stop bleeding. Sometime it is called as placenta accrete.

Ectopic pregnancy at cervical:
It has relation with placenta previa

Precipitating Factors:

Pelvic Inflammatory Disease
Previous tubal surgery or tubal pregnancy
Endometriosis, and
Congenital anomalies of the fallopian tubes

Sign and Symptoms:

Sharp one-sided pain
Tenderness of adnexal, area over ovary and tube
Vaginal bleeding (may or may not seen)
Hard and rigid abdomen and signs of circulatory collapse when tubal is ruptured.

How to care patient with ectopic pregnancy:

Provide emotional support for whom undergoing surgical or medical treatment
Provide emergency resuscitation and emergency surgery
Teach mother about pre and post operative self care
Consider to refer mother to a Fetal Demise Support Group

Anesthesia in Labor and Delivery

2009-01-15T07:38:00.002+03:00

There are five types of anesthesia used in labor and delivery: local anesthesia, pudendal block, lumbar epidural block, subarachnoid (spinal) block, and general anesthesia.

Local Anesthesia:

It is used for blocking pain during episiotomy
It is administered just before the birth of the baby
The anesthetic has no effect on fetus

Pudendal Block:

It is administered just before the birth of the baby
The anesthetic is injected into the pudental nerve through a transvaginal route
It has effect last about 30 minutes
It blocks the perineal area for episiotomy
There is no effect on contraction or the fetus

Lumbar Epidural Block:

The anesthetic relieves pain from contractions and numbs the vagina and perineum
The anesthetic is injected in epidural space at L3 to L4 and may cause hypotension, so assess the maternal blood pressure
The anesthetic is administered after labor is established or just before a scheduled casarean birth
Keep mother in side-lying position or place a rolled blanket beneath the right hip to displace the uterus from the vena cava
Administer IV fluids if prescribed
Increase fluids if hypotension occurs

Subarachnoid (spinal) Block:

The anesthetic is injected into the spinal subarachnoid space at L3 to L5 and administered just before the birth
It relieves uterine and perineal pain and numbs the vagina, perineum, and lower extremities
The anesthetic can cause maternal hypotension and postpartum headache
Keep mother lie flat for 8 to 12 hours following spinal injection
Administer IV fluids as prescribed

General Anesthesia:

General anesthesia may be used for some surgical interventions
It might cause a danger of respiratory depression and vomiting
The mother is not awake

STAGES OF LABOR – Stage IV

2009-01-02T07:56:00.001+03:00

LAST STAGE

Last stage of labor begins with delivery of placenta and ends with postpartum stabilization
Duration: usually 1-2 hours after delivery (primipara or multipara)
Blood pressure returns to the pre-labor level
Pulse is slightly lower than during labor
Fundus remains contracted, in the midline, 1-2 fingerbeadths below the umbilicus

Nursing Interventions:

Maternal assessment every 15 minutes for 1 hours, every 30 minutes for 1 hours, and hourly for 2 hours
Administer oxytocin product if ordered
Assess fundus every 15 minutes, if soft, massage with side of hand
Assess lochia, checking peripad and under lower back
Assess bladder for distention because full bladder will prevent contractions and increase bleeding
Assess episiotomy for intactness and possible bleeding

STAGES OF LABOR – Stage III

2009-01-02T07:54:00.001+03:00

THIRD STAGE

Third stage of labor begins with delivery of infant and ends with delivery of placenta
Duration: up to 20 minutes (primipara or multipara)
Contractions occur until the placenta is born
Placental separation and expulsion occur
Birth of placenta occurs 5-30 minutes after birth the baby

Nursing Interventions:

Assess maternal signs and uterine status
Observe for placental separation
Observe mother for signs of altered LOC or altered respiration (indicate aneurysm or emboli)
Allow maternal-infant interaction as soon as possible

STAGES OF LABOR – Stage II

2009-01-02T07:44:00.004+03:00

SECOND STAGE

Second stage of labor begins with complete dilation and ends with delivery of infant
Duration: 30-90 minutes in primipara and 15-20 minutes in multipara
Cervical dilation complete
Uterine contractions occur every 2-3 minutes, lasting 60-75 seconds and the intensity is strong
Increase in bloody show
Mother feels urge to bear down

Nursing Interventions:

Assess fetal well-being continuously
Monitor maternal vital signs
Encourage pushing
Encourage deep-full breath (not to hold breath longer than 5 seconds when pushing)
Commend mother’s effort

STAGES OF LABOR – Stage I

2009-01-02T06:45:00.002+03:00

First Stage

The first stage consists of three phases: latent, active, and transition. This stage begins with the first true contraction and ends with complete effacement and dilation to 10 cm.

Latent Phase (Early Labor):

Duration: 10-12 hours in primipara and 8-10 hours in multipara
Cervical dilation is 1 to 4 cm
Uterine contractions occur every 15-30 minutes and are 15-30 seconds in duration and mild intensity
Mother is talk active
Encourage mother and partner to participate in care
Change position and ambulation to comfort mother
Offer fluids an ice chips
Inform the progress to mother and partner
Encourage voiding every 1-2 hours

Active Phase:

Duration: 2-4 hours in primipara and 2-4 in multipara
Cervical dilation is 4-7 cm
Uterine contractions occur every 3-5 minutes and are 30-60 seconds in duration and of moderate intensity
Mother becomes restless and anxious as contractions become stronger
Mother may experience feeling of helplessness
Encourage mother in maintenance of effective breathing
Provide a quiet environment
Inform the progress to mother and partner
Backrubs, sacral pressure, pillow support and position changes to promote comfort
Offer fluids and ice chips
Instruct partner in effleurage
Encourage voiding every 1-2 hours

Transition Phase:

Duration: 2-4 hours in primipara and 1-2 in multipara
Cervical dilation is 8-10 cm
Uterine contractions occur every 2-3 minutes and are 45-90 seconds in duration and strong intensity
Mother may becomes tired, restless, irritable, and feels out of control
Encourage rest between contraction
Inform the progress to mother and partner
Provide privacy
Offer fluids and ice chips
Encourage voiding every 1-2 hours

Special Nursing Interventions First Stage:

Monitor vital signs
Monitor fetal heart rate via ultrasound Doppler, fetoscope or electronic fetal monitor
Assess fetal heart rate before, during and after a contraction (normal FHR is 120-160 beats per minute)
Monitor uterine contractions by palpating, determining frequency, duration, and intensity of contraction
Assess status of cervical dilation and effacement
Assess fetal station presentation and position by Leopold’s maneuver
Assess the color of the amniotic fluid if the membranes have ruptured because meconium-stained fluid can indicate fetal distress

Fetal Distress

2008-12-11T07:21:00.002+03:00

Fetal distress is a compromise of the fetus during the antepartum period (before labor) or intrapartum period (birth process). It is commonly used to describe fetal hypoxia (low oxygen levels in the fetus).

Fetal distress can be detected due to abnormal slowing of labor, the presence of meconium (dark green fecal material from the fetus) or other abnormal substances in the amniotic fluid, or via fetal monitoring with an electronic device showing a fetal scalp pH of less than 7.2

Signs and Symptoms of Fetal Distress:

Fetal heart rate less than 120 or greater than 160 beats per minute
Fetal hyperactivity
Meconium-stained amniotic fluid
Progressive decrease in baseline variability
Late deceleration
Severe variable decelerations

Nursing Interventions:

Place patient in a lateral position, elevate legs
Administer oxygen at 8-10 L/min via face mask
Discontinue oxytocin (Pitocin) if infusing
Monitor maternal and fetal status
Prepare for emergency cesarean section

Supine Hypotensive Syndrome

2008-12-11T07:04:00.002+03:00

Supine hypotensive syndrome occurs when the venous return to the heart is impaired by the weight of the uterus. It results in partial occlusion of the vena cava and descending aorta and in reduced cardiac return, cardiac otuput, and blood pressure

Signs and Symptoms:

Hypotension
Fetal distress
Faintness, light-headedness, dizziness

Nursing Interventions:

Place patient in a lateral recumbent position
Monitor vital signs and fetal heart rate
Treat for shock if other signs of shock are present

Amniotic Fluid Embolism

2008-12-11T07:00:00.001+03:00

Amniotic fluid embolism is the condition in which the amniotic fluid is escaped into the maternal circulation. It is usually fatal to the mother because the debris containing amniotic fluid deposits in the pulmonary arterioles.

Signs and Symptoms:

Respiratory distress and chest pain
Seizures
Cyanosis
Heart failure and pulmonary edema
Fetal bradycardia and distress

Nursing Interventions:

Emergency action is performed to maintain life
Administer oxygen at 8-10 L/min by face mask or resuscitation bag
Position patient on side
Prepare for intubation and mechanical ventilation
Administer IV fluids, blood products, and coagulation therapy
Monitor fetal status
Prepare for emergency delivery
Provide emotional support for patient, partner and family

Uterine Inversion

2008-12-11T06:26:00.002+03:00

Uterine inversion is a condition that the uterus turns inside out completely or partly. It usually occurs during delivery or after delivery of placenta.

Signs and Symptoms of Uterine Inversion:

Severe pain
Hemorrhage
Depression in the fundal area
Interior of the uterus may be seen through the cervix or protruding the vagina

Nursing Interventions:

Monitor for signs of hemorrhage and shock and treat shock
Prepare patient to reposition the uterus to the correct position via the vagina or laparatomy if unsuccessful

Placenta Abruptio

2008-12-10T11:07:00.004+03:00

Placenta abruptio is premature separation of placenta from the uterine wall after 20 weeks of gestation and before the fetus is delivered.

Signs and Symptoms:

Painful vaginal bleeding (dark red)
Uterine rigidity and tenderness
Severe abdominal pain
Signs of maternal shock
Signs of fetal distress

Nursing Interventions:

Monitor maternal vital signs and fetal heart rate
Assess for excessive vaginal bleeding, abdominal pain, and increase in fundal height
Bed rest, oxygen, IV fluids, and blood products as prescribed
Monitor and report any uterine activity
Prepare for the delivery of the fetus as quickly as possible
Monitor for sings of disseminated intravascular coagulation in the postpartum period
Administer Rh immune globulin if the mother is Rh-negative and has not been given the injection at 28 weeks of gestation

Placenta Previa

2008-12-10T10:51:00.002+03:00

Placenta previa is a condition in which the placenta implanted improperly in the lower uterine segment near or over the internal cervical os.

Types of Placenta Previa:

Total: the internal os is covered entirely by the placenta when the cervix is dilated fully
Partial: the internal os is covered incompletely
Marginal: only an edge of the placenta extends to the internal os
Low-lying placenta: the placenta is implanted in the lower uterine segment but does not reach the internal os

Signs and Symptoms:

Painless red vaginal bleeding occur in the last half of pregnancy
Uterus is soft, relaxed, and non-tender
Fundal height may be greater than expected for gestational age

Nursing Interventions:

Interventions depend on the classification of the previa and gestational age of the fetus
Monitor maternal vital signs, fetal heart rate, and fetal activity
Prepare for ultrasound
Avoid vaginal examination
Bed rest in a left leteral position
Monitor amount of bleeding (shock)
Administer IV fluids, blood products, or tocolytic medication as prescribed
Cesarean section may be performed if bleeding is heavy
Administer Rh immune globulin if the mother is Rh-negative and has not been given the injection at 28 weeks of gestation

Rupture of Uterus

2008-12-10T10:43:00.002+03:00

Rupture of uterus is a separation of the uterine tissue, complete or incomplete. It is a result of a tear in the wall of the uterus from the stress of labor.

Signs and Symptoms - Rupture of Uterus:

Chest pain
Abdominal pain or tenderness
Contraction may stop or fail to progress
Rigid abdomen
Signs of maternal shock
Absent fetal heart rate
Fetus palpated outside the uterus (complete rupture)

Nursing Interventions - Rupture of Uterus:

Monitor and treat signs of shock (oxygen, IV fluids, blood products)
Prepare patient for cesarean section or hysterectomy
Provide emotional support for both of patient and partner

Preterm Labor

2008-12-07T17:32:00.001+03:00

Preterm labor means the labor that occurs after the 20th week but before 37th week. It may be associated with infection. The contractions occur more frequent than every 10 minutes and last 30 seconds or longer and persist.

Signs and Symptoms:

Abdominal cramping
Uterine contractions
Low back pain
Pelvic pressure or heaviness
Discharge may be thicker or thinner, bloody, brown or colorless and may be odorous
Amniotic membranes are ruptured

Nursing Interventions:

The interventions are focused on stopping the labor: treat infection, restrict activity, and hydration
Monitor fetal status
Bed rest and lateral position
Administer medications as prescribed: Ritodrin (Yutopar), Magnesium sulfate, Terbutaline (Brethine), Nifedipine (Procardia), Indomethacin (Indocin).

Precipitous Labor and Delivery

2008-12-07T17:30:00.001+03:00

Precipitous labor means the labor that lasting less than three hours.

Nursing Interventions:

Provide emotional support to calm mother
Stay with the mother
Encourage the mother to pant between contractions
Prepare for rupturing membranes when the head crowns
Do not try to keep fetus from being delivered

Interventions if Delivery is Necessary:

Apply gentle pressure to fetal head upward toward the vagina to prevent damage to the fetal head and vaginal lacerations
Support infant's body during delivery
Deliver the infant between contractions and check for the cord around the neck
Use restitution to deliver the posterior shoulder
Use gentle downward pressure to move the anterior shoulder under the pubic symphysis
Clear the infant's mouth
Dry and cover the infant to keep the body warm
Let the placenta separate naturally
Place the infant on the mother's abdomen or breast to induce uterine contractions

Propalse Cord

2008-12-07T16:17:00.003+03:00

Prolapse cord is displacement of umbilical cord between the presenting part and the amnion or protruding through the cervix. It causes compression of the cord and compromise fetal circulation.

Signs and Symptoms:

Umbilical cord is visible or palpable
Mother has feeling that something is coming through the vagina
Fetal heart rate is irregular and slow
Variable deceleration or bradycardia after rupture of the membranes
Violent fetal activity may occur and then cease if fetal hypoxia is severe

Nursing Interventions:

Relieve umbilical cord immediately
Reposition mother: turn her side to side or elevate her hips to shift the fetal presenting part toward her diaphragm
Apply finger pressure with a sterile glove hand to elevate fetal presenting part that is lying on the cord
Do not attempt to push the cord into the uterus
Assess fetus for hypoxia
Prepare for emergency cesarean birth
Administer oxygen by face mask to the mother as prescribed

Distocia

2008-12-04T21:17:00.002+03:00

Dystocia means prolonged or more painful labor. It can caused by uterine contractions, the fetus, or the bones and tissue of the maternal pelvis, large fetus, malpositioned, or abnormal presentation.

The contraction may be hypertonic or hypotonic. Dystocia can cause maternal dehydration, infection, and fetal injury or death.

Sign and Symptoms:

Contraction pattern is abnormal
Abdominal pain
Fetal distress
Lack of progress in labor
Maternal or fetal tachycardia

Nursing Intervention:

Assess and monitor fetal heart rate and fetal distress
Monitor maternal temperature and heart rate
Monitor uterine contraction
Assist with pelvic examination, measurement, ultrasound or other procedures
Administer antibiotic and IV fluid as prescribed
Monitor intake and output
Assess for dehydration
Monitor color of amniotic fluid
Teach mother in breathing and relaxing techniques
Provide good rest and comforts
Assess for prolapse of the cord

Fetal Heart Rate Monitoring

2008-10-04T20:05:00.006+03:00

Fetal monitoring is the way to displays the fetal heart rate (FHR). Fetal heart rate is monitored in relation to maternal contraction. The baseline FHR is measured between contraction and the normal FHR at term is 120-160 beats per minute. The device that monitors uterine activity can assess frequency, duration and intensity of contractions.

There are two types of fetal monitoring: external fetal monitoring and external fetal monitoring.

External Fetal Monitoring
It is noninvasive procedure and is performed using a tocotransducer or Doppler ultrasonic tranducer. The ultrasound transducer is placed over the area in which the fetal back is located and fasten with a belt. The tocotransducer is placed over the fundus of uterus where contractions feel stronger and fasten with a belt. This external fetal monitoring will allow the client to get position comfortably.

Internal Fetal Monitoring It is invasive procedure and requires rupturing of the membranes and the electrode is attached to the presenting part of the fetus. For being available of internal fetal monitoring, the mother must be dilated 2-3 cm.

FETAL HEART RATE PATTERN

Fetal Bradycardia:
The FHR is less than 120 beats per minute for 10 minutes of more

Fetal Tachycardia:
The FHR is greater than 160 beats per minute for 10 minutes or more.

Acceleration
Accelerations are temporary increases of FHR at least 15 beats greater than the baseline and lasting at least 15 seconds, reflect a responsive nonacidotic fetus. Acceleration may occur with fetal movement, uterine contraction, vaginal examinations, or when the fetus is in a breech presentation.

Early Decelerations
In early decelerations, the fetal heart rate is below baseline and return to the baseline by the end of the contraction. It usually occurs during contractions and not associated with fetal compromise and requires no interventions. A uniform shape and mirror image of uterine contraction are showed.

Late Decelerations
In late decelerations, the fetal heart rate looks similar to early deceleration but begin well after the contraction begins and return to baseline after the contraction ends. Late decelerations reflect impaired placental exchange or uteroplacental insufficiency. The intervention includes improving placental blood flow and fetal oxygenation by placing patient on side, administer oxygen by tight face mask, discontinue oxytocin (if any), hydration, and correct hypertension (if any).

Variable Deceleration
In variable decelerations, the fetal heart rate does not have the uniform appearance. Shape, duration and degree of FHR fall below baseline are variable. Variable decelerations are significant when the FHR repeatedly decreases to less than 7- beats per minutes and persists at the level for at least 60 seconds before returning to the baseline. The cause of variable decelerations is the conditions that restrict flow through the umbilical cord (compressed umbilical cord). Interventions include change position (trendelenburg may be helpful), discontinue oxytocin (if any), check for cord prolapsed or imminent delivery by vaginal exam, consider amnioinfusion, and administer 100% oxygen by tight face mask.

Breathing in Labor

2008-09-27T05:51:00.003+03:00

Breathing technique during labor and delivery will promote relaxation and oxygenation.

FIRST STAGE LABOR BREATHING

Cleancing Breath
Each contraction begins and ends with a deep inspiration and expiration.

Slow Paced Breathing
It is used as long as possible during labor, and promotes relaxation

Modified Paced Breathing
Breathing is shallow and fast, and it is used when slow paced breathing is no longer effective.
Pattern Paced Breathing (pant blow)
After a certain number of breaths, the client exhales with a slight emphasis or blow, and then begins the modified paced breathing.

Breathing to Prevent Pushing
Encourage client to blow repeatedly using short puffs when the urge to push is strong.

SECOND STAGE LABOR BREATHING

Traditional Pushing
The client takes on or more cleansing breaths at the beginning of a contraction and then hold it, pushing as hard as she can for as long as possible. Then quickly exhales, takes another breath and pushes again, repeating the process until the contraction is over.

Other Pushing Methods
The client exhales small amounts of air through an open glottis during pushing.
The client pushes in short bursts only when the urge is strong instead of using prolonged expulsive efforts.

Leopold’s Maneuvers

2008-08-10T19:54:00.004+03:00

Leopold’s Maneuvers are methods to determine position, presentation and engagement of fetus.

They will include:

Determination of what is in the fundus
Evaluation of the fetal back and extremities
Palpation of the presenting part above the symphysis, and
Determination of the direction and degree of flexion of the head.

How to Perform Leopold’s Maneuver

Before performing Leopold’s Maneuver, ask the mother to empty the bladder, warm hands, and apply them to the mother’s abdomen with firm and gently pressure.

First Leopold’s Maneuver:

It will determine which part of the fetus is in the fundus.
Place pals on each side of the upper abdomen and palpate around the fundus
You would feel a hard, round, movable object if the head is in the fundus
You would feel soft and have an irregular shape and are more difficult to move if the buttock is in the fundus

Second Leopold’s Maneuver:

Move hand downward over each side of the abdomen, applying firm, even pressure.
The fetus’s back which is a smooth, hard surface should be felt on one side of the abdomen.
The hands, feet, elbows, and knees which are as irregular knobs and lumps will be felt on the opposite side of the abdomen.

Third Leopold’s Maneuver:

It will determine fetal position
Place hand above the symphysis pubis
Bring thumb and fingers together and grasp the part of fetus between them that may be the head or the buttocks

Fourth Leopold’s Maneuver:

It is used in the late stage of pregnancy to determine how far the fetus has descended into the pelvic inlet.
Place hand on the sides of the lower abdomen close to the midline
Slide hands downward and press inward
If you have determined that the buttocks are in the fundus, then feel for the head
If you cannot feel the head, it probably has descended

Mechanism of Labor

2008-08-02T08:54:00.003+03:00

There are eight classical steps in the normal mechanism of labor as following here:

Engagement

This is also called lightening or dropping
The fetus nestles into the pelvis

Descent

This process starts from the time of engagement until birth and is assessed by the station.
The fetal head undergoes as it begins its journey through the pelvis.

Flexion

The fetal head’s nodding forward toward the fetal chest
While descending through the pelvis, the fetal head flexes so that the fetal chin is touching the fetal chest. This functionally creates a smaller structure to pass through the maternal pelvis

Internal Rotation

With further descent, the occiput rotates anteriorly and the fetal head assumes an oblique orientation. In some cases, the head may rotate completely to the occiput anterior position.

Extension

It begins after the head crowns
This means that the fetal chin is no longer touching the fetal chest.
It enables the head to emerge when the fetus is in a cephalic position
The extension of labor is completed when the head passes under the symphysis pubis and occiput and the anterior fontanel, brow, face and chin pass over the sacrum and coccyx and are over the perineum

Restitution

After the head emerges, the fetal head becomes in a realignment

External Rotation

The shoulder of fetus externally rotates after head emerging and restitution
The shoulder is in the anteroposterior diameter of the pelvis.

Expulsion

This is the birth of entire body.

Fetal Presentation

2008-07-17T02:46:00.004+03:00

Fetal position is defined as designation of landmark of fetal presenting part (occiput, mentum, sacrum, scapula) to right or left, and anterior, posterior, or transverse portion of the woman's pelvis.

A three-letter abbreviation is used to describe the relationship of the presenting part to the maternal pelvis.

Sides of presenting part facing in the pelvis are described as: R (right) or L (left).
Landmarks of presenting part are described as: O (occiput, or head), S (sacrum), Sc (scapula, or shoulders), M (mentum, or chin).
Directions of presenting part facing in the pelvis are descreibe as: A (anterior, or front), P (posterior, or back), or T (transverse).

The first and third letters relate to the pelvis, and the second letter relates to the fetus.

Common possible fetal presentations are :

VERTEX / OCCIPITAL PRESENTATION
LOA = Left Occipital Aterior
LOT = Left Occipital Transverse
LOP = Left Occipital Posterior
ROA = Right Occipital Anterior
ROT = Right Occipital Transverse
ROP = Right Occipital Posterior

FACE PRESENTATION
LMA = Left Mentum Anterior
LMT = Left Mentum Transverse
LMP = Left Mentum Posterior

BREECH PRESENTATIONS
LSA = Left Sacrum Anterior
LST = Left Sacrum Transverse
LSP = Left Sacrum Posterior

Here are images of fetal presentation :

click image to enlarge.

Labor: True and False

2008-06-27T11:05:00.004+03:00

There are pleliminary events to labor :

Backache
Cervix becomes soft and effaced and may begin to dilate
Braxton Hicks contraction increase
Lightening or dropping
Membranes may rupture spontaneously
Vaginal secretions increase
Urinary frequency increases
Passage of mucous plug occurs
Weight loss of 1 – 3 lb
“Bloody show” occurs
Mother has a sudden burst of energy

How to differentiate between true labor and false labor?

True Labor:

Contractions are in the back and abdomen
Contractions are regular with decreasing intervals
Contractions increase over time and increase with walking, and little or no effect from sedation
Cervical dilation and effacement are progressive

False Labor:

Contractions are in lower abdomen
Contractions are irregular with unchanging or increasing intervals
Contractions remain the same, unaffected by, or decrease with walking and relieved by sedation
No dilation or effacement or cervix

COMPLICATION OF PREGNANCY

2008-06-19T22:52:00.000+03:00

ABRUPTIO PLACENTAE
Abruptio Placentae is premature detachment of a normally situated placenta. Patient with abruption placentae will have bleeding, abdominal pain, boardlike uterus, maternal hypotension and tachycardia and fetal distress. Nursing managements will include: bed rest, monitor bleeding and shock, monitor fetal heart rate continuously.

ECLAMPSIA
Complication with seizures between 20th week of pregnancy and first postpartal week. Eclampsia can be happened with or following pregnancy-induced hypertension. Management of eclampsia will include giving magnesium sulfate, frequently assess vital signs, restrict fluid intake hourly to a total of 125 mL/h, and urinary output should be at least 30 mL/h.

GESTATIONAL DIABETES
Gestational diabetes occurs in 3–6% of all pregnancies, and although it typically resolves after delivery, it increases the risk of maternal pyelonephritis and of certain congenital anomalies, and is often associated with polyhydramnios and fetal macrosomia, with resultant dystocia. Patient will have polyuria, polydipsia and polyphagia. Gestational diabetes can be diagnosed with 3 hours Glucose Tolerance Test after 100 grams load. Management: exercise, dietary management, insulin (if needed), monitoring of weight, and teach and to assess glucose monitoring and diet.

PLACENTA PREVIA
Placenta previa is the condition in which the placenta is implanted in the lower segment of the uterus, extending to the margin of the internal os of the cervix or partially or completely obstructing the os. Clinical sign of placenta previa is painless vaginal bleeding. Management: monitor maternal vital signs, bed rest, monitor fetal heart rate, and not performing vaginal examination if placenta previa is suspected.

GROUP B STREPTOCOCCAL INFECTION
It would be 10-30% of pregnant women are colonized which are asymptomatic. It is recommended screening by rectovaginal swab at 37 weeks of gestation.

PREGNANCY-INDUCED HYPERTENSION (PIH)
PIH is a syndrome of hypertension, edema, and proteinuria that can occurs after 20th week of pregnancy. This patient will have headache, blood pressure of 140/90 or greater, or an increase of 30 mm Hg systolic or 15 mm Hg diastolic at two readings and edema that not relieved by bed rest, proteinuria, weight gain above 2 lb / weeks, visual disturbance, and epigastric pain. Patient who has pregnancy-induced hypertension will be managed by bed rest, control blood pressure, antihypertensive medicines, monitor intake and output, daily weight, and check urine for protein.

HELLP SYNDROME
This is a type of severe preeclampsia involving hemolysis, elevated liver function, and low platelets. Patient should delivery soon.

PRETERM LABOR
Preterm labor is a labor between 20 and 37 weeks of gestation.

Fundal Height Assessment - Prenatal Care

2008-05-25T23:21:00.000+03:00

Fundal Height assessment is measured to evaluate the fetus's gestational age. Fundal height is measured from the top of the symphysis pubis to the top of the fundus. Height is assessed in centimeters.

At 16 weeks, the fundus can be found halfway between the symphysis pubis and the umbilicus. At 20 - 22 weeks, the fundus will be at the umbilicus, and at 36 weeks, the fundus is at xyphoid process. During the second and third trimesters (weeks 18 to 30), fundal height in centimeters approximately equals the fetus's age in weeks plus or minus 2 centimeters.

Remember that picture as it maybe questioned in NCLEX - CGFNS test.

To Measure Fundal Height :
Place the pregnant woment in the supine position
Place the end of the tape measure at the level of the symphysis pubis.
Stretch the tape to the top of the uterine fundus, and
Record / document the measurement.

Maternity Nursing - Pregnancy, Signs and Symptoms

2008-05-20T00:37:00.000+03:00

Here the explanation of these signs and symptoms of pregnancy.

PRESUMPTIVE SIGNS OF PREGNANCY

Amenorrhea, more than 10 days elapsed since the time of expected onset of menstruation
Nausea and vomiting
Increase of urinary frequency
Fatigue and drowsiness
Breast changes : feeling of fullness, tenterness, enlargement, darkening of areola, prominence of veins, enlargement of montgomery's tubercles (it is a small gland around nipple)
Vaginal changes: bluish color (chadwick's sign)
Skin Changes : striae (stretch marks), dark pigmented vertical lines on abdomen (linea nigra), pigment formation on face (facial chloasma), and mother's perception of fetal movement (quickening)

PROBABLE SIGNS OF PREGNANCY

Uterine changes : Hegar's sign (softening of lower uterus), Goodell's sign (softening of cervix), and Braxton Hicks' Contraction (false labor)
Palpation of fetal body
Positive of horman test for pregnancy
Ballottement (rebounding of fetus in amniotic fluid)

POSITIVE SIGNS OF PREGNANCY

Fetal movement (felt by examiner)
Fetal heartbeat
Radiograph of fetus
Sonogram of fetus

These signs and symptoms of pregnancy always appears in NCLEX-CGFNS questions.