1
Interventions for all other complications such as:
Tetany
Maternal HTN
Vena cava syndrome
uterine rupture
all treated with LION
Left side postion (mother left side)
IV
O2
Notify doc
STOP Pitocin if running (first thing to do)
2. High Fetal HR—HR >
• Document
• Take the
• Not a high
2. High Fetal HR—HR >160
• Document acceleration of fetal HR
• Take the mother’s temp
• Not a high priority ... Baby is WNL
Second stage of L&D (labor and delivery)
• Delivery of the fetus ... This is about
1.
2.
3.
4.
5.
Second stage of L&D (labor and delivery)
• Delivery of the fetus ... This is about order.
1. Deliver head ... The mother needs to stop pushing
2. Suction the mouth then the nose ... ABC order
3. Check for nuchal (around the neck) cord
4. Deliver the shoulders, next, the body
5. Make sure baby has ID band on before it leaves the delivery area
The height of the fundus after delivery should be at?
Fundus involutes ?
The location of the uterus should be?
Excessive lochia?
Moderate amount lochia?
the umblilicus or navel
2cn everyday postpartum
midline (if not the bladder is distended)
satruating a pad 15 mins
4-6 inches on pad in a hour
Blue discoloration of
the hands and feet in
the newborns during
the first few days after
birth
• Normal finding
and not indicative of poor oxygenation,
respiratory distress, or cold stress
are pink and easily blanched skin lesion that
appear on upper eyelid, nose, upper lip, lower occipital area, and nape of the neck
• No clinical significance
• Disappears by 2 years of age
Acrocyanosis
Navi (Telangiectatic nevi) aka stork bites
Do not adminster a systemic pain med to a woman in
labor if the baby is likely to be born the med is at its peak
Low Baseline Variability
• This is
• Fetal HR
• You do
Low Baseline Variability
• This is BAD
• Fetal HR stays the same—it doesn’t change
• You do “LION”
o Left side
o IV
o Oxygen
o Notify HCP
• Stop pit if it is running (first)
Third stage of L&D
• Delivery of the
• What do you check for with the delivery of the placenta?
Third stage of L&D
• Delivery of the placenta
• What do you check for with the delivery of the placenta?
o Make sure the placenta is complete and intact
o Check for 3-vessel cord—2 arteries and 1 vein, AVA
Best way to determine if pt has thrombophelebitis?
Bilateral calf circumference, homan sign is NOT the best answer
seen at birth and is composed of a plexus of newly
formed capillaries in the papillary layer of the corium
• Commonly found on the face and neck
• Red to purple, varies in size, shape and location
• Does not blanch on pressure
Port-wine stain or nevus flammeus
You have a primagravida at 5 cm who wants iv push pain med, what do you do?
You have a multigravida at 8cm what her IM pain what do you do?
hold the pain med, pt is primagravida and will deliver in about 13-30mins when med peaks
do not adminster pain med
4. High Baseline Variability
• Fetal heart rate is always changing—This is
•
High Baseline Variability
• Fetal heart rate is always changing—This is GOOD
• Document finding
Note
In utero, low variability of V/S is a bad sign but highly variable V/S is a good sign
Fourth Stage of L&D
• Recovery
• There are __ things you do in the 4th stage, __ times an hour (every __ minutes)
• There are 4 things you do in the 4th stage, 4 times an hour (every 15 minutes)
1. Vital signs: Assessing for shock ... Blood pressure goes down, HR goes up ... Pt looks
pale, cold, and clammy
2. Fundus: If it is boggy, massage it ... If displaced, catheterize it
3. Check perineal pads ... If there is excessive bleeding, the pad will saturate in 15
minutes or less
4. Roll pt over and check for bleeding underneath her
Recap
• 4 things to do every 15 minutes in the 4th stage of labor
o V/S , Fundus, Peri pads, Roll
Normal skin conditions in newborn
White, pinhead-size, distended sebaceous glands on the nose, cheek, chin, and
occasionally on the trunk. Usually disappear after a few week of bathing
• Palatal cysts of the newborn, which are small white or yellow cystic
vesicles
• Bluish discoloration in the sacral region of newborn usually seen in
African Americans ... Carefully document its presence as such action may prevent child
abuse charges against parents or caregiver
• Described as flee-bitten lesion ... pink rash with firm,
yellow-white papules or pustule on the face, chest, abdomen, back and buttocks of some
newborns. Usually appears 24 to 48 hours after birth and disappear in a few days
• An abnormal accumulation of blood vessels in the skin of the newborn. It is
one of the most common birthmarks associated with childhood and affect 10% of all children
Milia
• Epstein pearls
• Mongolian spot
• Erythema toxicum neoratorum
• Hemangioma
Tocolytics (Stop _, stop _)
• Tocolytics are given to women in
• Terbutaline (Brethine)
o S/E:
• Mag sulfate
o Treatment with Mag sulfate will induce
o HR will go , BP go Reflexes go , RR go , LOC go
Tocolytics (Stop contractions, stop labor)
• Tocolytics are given to women in premature labor that must be stopped
• Terbutaline (Brethine)
o S/E: maternal tachycardia (don’t give with cardiac disease)
• Mag sulfate
o Treatment with Mag sulfate will induce hypermagnesemia, which will cause everything to
go down
o HR will go down, BP go down, Reflexes go down, RR go down, LOC go down
There are 7 fetal monitoring patterns to learn ... The ones that start with the letter
“L” are bad
heart tracings. Use the mnemonic “LION” as the nursing intervention
5. Early Deceleration
• This is
•
6. Variable (VERY) Decelerations
• This is
• This indicates
• What is the nursing intervention?
7. Late Decelerations
• This is
• You do
5. Early Deceleration
• This is normal ... No big deal
• Document finding
6. Variable (VERY) Decelerations
• This is very BAD
• This indicates prolapsed cord
• What is the nursing intervention?
o PUSH and POSITION
7. Late Decelerations
• This is BAD
• You do “LION”
o Left side
o IV
o Oxygen
o Notify HCP
• Stop pit if it is running
Post partum assessment
assess every
assess for
assess q 4-8 hours
assess for BUBBLE HEAD
Cephalohematoma—A collection of blood between the
o Occurs in one or both sides of the
o Occasionally forms over the
o Develops within the first
• Caput succedaneum—An _____ of the neonate during birth from mechanical
trauma of the initial portion of scalp pushing through a
o The edema crosses the
o May involve wide areas of the head or it may just be a
o Caput Succedaneum (CS)—
Cephalohematoma—A collection of blood between the periosteum of a skull bone and the
bone itself
o Occurs in one or both sides of the head
o Occasionally forms over the occipital bone
o Develops within the first 24 to 48 hours after birth
• Caput succedaneum—An edema of the scalp of the neonate during birth from mechanical
trauma of the initial portion of scalp pushing through a narrowed cervix
o The edema crosses the suture lines
o May involve wide areas of the head or it may just be a size of a large egg
o Caput Succedaneum (CS)—Crosses Suture line, and Caput Symmetrical
So, what is the nursing intervention for hypermagnesemia due to mag sulfate treatment?
• Monitor
o If RR <12, decrease
• Assess for reflexes
o Normal reflex is
o If reflexes are 0 or 1+ ...
o If reflexes are 3+ or 4+ ...
• Monitor respiration
o If RR <12, decrease dose of Mag sulfate
• Assess for reflexes
o Normal reflex is 2+
o If reflexes are 0 or 1+ ... Decrease dose of mag sulfate
o If reflexes are 3+ or 4+ ... Increase dose of mag sulfate
Normal fetal heart rate =
1. Low Fetal HR (heart rate)—
• This is
• You do
Normal fetal heart rate = 120 to 160 beats per minutes
1. Low Fetal HR (heart rate)—HR <110
• This is BAD
• You do “LION”
o Left side (place mother on the left side)
o IV
o Oxygen
o Notify HCP
• Stop Pitocin (pit) if it was running
o Implement before “LION”
• Ace of spades means that this answer works every time
o Check
• Ace of spades means that this answer works every time
o Check the FHR
BUBBLE HEAD STANDS FOR
Breast
Uterine : fundus should be firm(important), massage fundus is boggy and midline and catherize pt if fundus is boggy and not midline
Bladder
Bowel
Lochia
Episiotomu
Hgb and Hct
Extremities (looking for thrombophebitis)
affect
discomforts
Fatty, whitish secretion
of the fetal sebaceous
gland to protect the skin
from amniotic fluid
exposure
Vernix Caseosa
Oxytocics (Stimulate and strengthen labor)
• Pitocin (Oxytocin)
o S/Es:
The nursing intervention is to l
• Methergine
o Causes
Oxytocics (Stimulate and strengthen labor)
• Pitocin (Oxytocin)
o S/Es: Uterine hyperstimulation (defined as longer than 90 seconds, closer than 2 minutes)
The nursing intervention is to lower the dose of pitocin in case of uterine
hyperstimulation
• Methergine
o Causes HTN—if it contracts blood vessels it makes sense that this increases BP