Module Four: Intrapartum Management Basic Skills 689. (1 point)



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Module Four: Intrapartum Management

Basic Skills
689. (1 point) Using Leopold’s maneuvers, I would determine fetal lie, presentation and position during labor. To help ascertain these in a confusing situation, I would also use a fetoscope to assess loudest fetal heart tone location and relate that to fetal position, and do an internal exam to assess a vertex presentation and suture lie to assess position.
690. (1 point) Vaginal exams to assess the progress of labor should be done according to Varney:


  • On admission, to establish an informational baseline.

  • Before deciding on the kind, amount, and route of any medication.

  • To verify complete dilatation in order to either encourage or discourage maternal pushing effort

  • After SROM if a prolapsed cord suspected or a possibility

  • To check for a prolapsed cord when fetal heart rate decels are not improved with the usual maneuvers

There is not set time schedule (such as every hour) that should be used.

(Varney, p 419)


691. (2 points)

Pelvic Structure

Changes in Labor

Cervix

Dilation and Effacement, movement to central in vagina from posterior

Uterus

Uterine contractions will cause hardness, check to see if coordinated action, muscle mass will migrate to top of uterus, after fetus and placenta are out, the uterus will contract and shrink in size

Bag of Waters


Assess for bulging of bag and rupture

Ischial spines

Assess ischial spines in relation to fetal presenting part to determine station

(Varney, p 389)
692. (5 points) The steps of a sterile speculum exam:

  1. Explain the procedure to the woman and have her empty her bladder

  2. Provide a drape and leave the room while the woman undresses from the waist down

  3. Assemble your equipment, making sure that your light source is at hand

  4. Assist the woman in a semi-sitting position, and do the following:

  5. encourage her to relax

  6. ask her to place her feet in the footrests, bring her hips to the end of the table and to let her knees fall out to the side

  7. Demonstrate sensitivity to the woman’s emotional well-being throughout the exam

  8. Wash your hands and put on sterile gloves

  9. Select the proper size speculum in a sterile pack and have assistant open the sterile pack and sterile lubricant, apply lubricant to the speculum.

  10. Let the woman know you are about to touch her to her.

  11. Examine the external genitalia, noting any condyloma, herpes lesions, lice and etc.

  12. Place your finger at the introitus, open your fingers into a peace sign and give posterior traction. This will expose the introitus.

  13. Let the woman know you will now insert the speculum.

  14. Introduce the speculum at a horizontal or slight oblique angle with the blades closed.
  15. Insert the speculum in a downward fashion towards the woman’s tailbone until the handle of the speculum is flush against the perineum.


  16. Carefully open the speculum until the cervix pops into view. If the cervix does not immediately pop into view, have the woman take a deep breath and encourage her to relax before trying to reposition the speculum. Often, the cervix, if given time, will come into view if you inserted the speculum posteriorly. This also helps to avoid any trauma to anterior structures.

  17. Once you have an adequate view of the cervix, tighten the blades of the speculum.

  18. Visualize the vagina and cervix noting:

  19. color

  20. integrity of the tissue

  21. presence of absence of discharge

  22. type of discharge, if present

  23. type of odor, if present

  24. Collect any specimens if needed, and explain each procedure to the woman. Have assistant help you as needed in order to maintain sterile technique.

  25. Loosen the speculum blades and begin to withdraw the speculum while maintaining pressure on the blade lever.

  26. Once the speculum clears the cervix (the cervix will move), remove your finger from the blade lever and let the vagina close the blades while you finish removing the speculum.

  27. Keep the speculum even when you remove it to prevent splattering of discharge.

  28. Place speculum in appropriate container.

  29. Remove and dispose of your gloves.

  30. Turn off you light source.

  31. Help the woman to a sitting position and offer her some tissue.

  32. Explain your findings.

  33. Leave the room while she dresses.

  34. Prepare specimens (if any).

  35. Document the results, including any significant emotional response to the exam.

(PSGM, p 47-48)

Sterile speculum exams are done to assess rupture of membranes, or if membranes were ruptured and an exam was needed to assess cervix, or to rule out placenta previa in the third trimester.

693. (3 points) Steps for urinary catheterization:


  1. Explain the procedure for catheterization to the woman.

  2. Assemble the necessary equipment.

  3. Wash and dry your hands. Put on sterile gloves.

  4. Prepare the woman by placing an underpad beneath her, placing a bowl between her legs, and washing the external genitalia.

  5. Have your assistant open the sterile catheterization try

  6. Remove your contaminated gloves and put on new sterile gloves

  7. Lubricate the catheter tip

  8. Prepare cotton balls (or povidine swabs) with antiseptic cleanser

  9. Separate the labia to expose the meatus

  10. Cleanse the meatus with prepared cotton balls (or povidine swabs)

  11. Cleanse the genitalia from the prepuce of the clitoris down

  12. Pick up the catheter from the end away from the side that will enter the woman

  13. Insert the tip of the catheter into the urethra to the proper depth (i.e. until flow of urine begins)

  14. Allow the urine to flow into the bowl

  15. Withdraw the catheter when urine flow is finished

  16. Wash and dry the genitalia

  17. Chart the output, the character of the urine and the time of the procedure.

(PSGM, p 165)

This should be done during labor if the woman’s bladder is full and bulging and she is not able to void on her own, or in this same situation after the baby is born and the bladder is obstructing full contraction of the uterus, or if a sterile sample of urine is needed and bloody show or other discharge would contaminate the specimen if collected any other way.

694. (1 point) Fetal heart tones should be evaluated every 30 minutes during active labor, more often (after every other contraction in second stage) as well as in the following situations:


  • when membranes rupture

  • after expulsion of an enema

  • whenever there is any sudden change in the contraction or labor pattern

  • after giving the woman medication and again at its peak action time

  • whenever there is any indication that an obstetric or medical complication is developing

To establish baseline FHT, the midwife should start to listen midway between two contractions and count the FHT for 6 seconds, break for 4 seconds, and count again for 6 seconds, and continue this pattern of listening through the contraction to midway between it and the following contraction. The rate and amount of irregularity should be noted, and correlations between uterine contractions and FHT should be noted.

(Varney, p 417)


695. (2 points) In assessing uterine contractions, the following should be evaluated:

  • frequency: the time between each contraction, usually as labors progresses contractions become more frequent

  • duration: the length of the actual contraction, usually as labor progresses the contractions get longer; active labor contractions are generally at least 45 seconds long, usually more like a minute

  • intensity: this can be assessed by how the woman handles the contractions as well as feeling her belly for hardness, or by the toco monitor if being externally or internally monitored

(Varney, p 418)

696. (2 points) All maternal vital signs are checked every time the woman presents for a diagnosis of labor and again for initial evaluation.

Maternal Vital Signs that are assessed during labor include:

BP: every hour

Pulse, Temperature, Respirations:


  • every 2 or 4 hours when the temp is normal and membranes are intact

  • every 1 or 2 hours after the membranes are ruptured

(Varney, p 415)
697. (1 point) Dipsticking Urine

  1. Instruct the woman to provide a mid-stream urine sample.

  2. Have her dip a chemical stick into the urine sample, fully covering the chemical squares.

  3. Compare, as directed on the dipstick container, within the time allowed to ascertain levels of glucose, ketones, protein, etc., if any.

  4. Note the following about the sample:

  • color

  • density

  • odor

  • clarity

  1. Instruct the woman to discard the urine sample, the dipstick and the container properly.

  2. Advise the woman of the results.

  3. Counsel the woman based on the results obtained from the dipstick and your observations.

  4. Document the results.

(PSGM, p 34)

698. (1 point) The best evaluation for anemia during labor is proper prenatal assessment of women at risk for anemia, or with anemia so that corrective measures can be taken and these woman can be watched closely during labor. During labor, pale fingernail beds, skin pallor, malaise, sore tongue, pale mucous membranes, drowsiness, fatigue, dizziness and weakness can also be assessed to determine anemia, although may of these s/sx are normally present for the laboring woman. Amount of blood loss should be evaluated and documented to assess risk for pp anemia. Capillary tube collection, or a CBC may be done as well to assess hematocrit, although the utility of knowing this at this time (unless the level of hemorrhage was so great as to require transfusion) is questionable.

699. (1 point) Assessment of Edema


  1. Explain the procedure to the woman.

  2. Expose the woman tibia and press the tissue against the bone, using the forefinger for 1-2 seconds.

  3. Begin pressing at the base of the tibia and repeat every three inches above if pitting is observed.

  4. Observe for the degree of pitting indentation

  • 2mm depression= +1 pitting edema

  • 4mm depression= +2 pitting edema

  • 6mm depression= +3 pitting edema

  • 8mm depression= +4 pitting edema

or,



  1. At mid-shin level press and hold for 5 seconds and grade according to the following:

  • slight impression in the skin and/or color returns rapidly= +1 pitting edema

  • obvious indentation which take 5 seconds to disappear and/or color to return= +2 pitting edema

  • 5-10 seconds for the indentation to disappear and/or 10 seconds for color to return= +3 pitting edema

  • indentation remains after 15 seconds and/or color does not return= +4 pitting edema




  1. Repeat if necessary on the hands and face of the woman.

  2. Inform the woman of the findings and counsel appropriately.

  3. Chart the results.

(PSGM, p 68)

700. (1 point) If indicated due to s/sx of preeclampsia or HELLP syndrome, hyperrelexivity should be assessed by evaluating for clonus:


  • position the woman so that her knee is partially flexed

  • support this position with one of your hands underneath the bend in the knee

  • with your other hand grasping her foot, sharply dorsiflex her foot and maintain pressure to keep it in dorsiflexion

  • you will be able to see and feel any beats of clonus, as the muscle contractions and relaxations will cause rhythmical alterations between dorsiflexion and plantar flexion-the muscles being stretched are the same as for the ankle-jerk reflex.

(Varney, p 751)
701. (2 points) In doing an amniotomy one should:

  • use sterile technique

  • do the amniotomy between contractions so that:

a. the force behind the rupture is not as strong

b. the membranes are not stretched tightly against the fetal head (which leaves too little room to safely grasp the membranes)



  • use an instrument that will be effective quickly and easily, such as an Allis clamp or hooks manufactured for that purpose

  • after rupturing the membranes, leave your fingers in the vagina through the next contraction:

a. evaluate the effect of the amniotomy on the cervix (dilation) and on the fetus (descent and rotation)

b. assure there was no prolapse of cord



  • have fetal heart tones evaluated during and after the AROM to assess the immediate effects on the wellbeing of the fetus

(Varney, p 420)
702. (2 points) The steps in performing an episiotomy:
  • Place your index and middle fingers into the vagina, palmar side down and facing you. Separate them slightly and exert outward pressure on the perineal body


  • The blades of the scissors are placed in a straight up-and-down position so that one blade is against the skin of the perineal body, with the point where the blades cross at the midline of the posterior fourchette.

  • With your fingers that are in the vagina, and the thumb of the same hand on the outside of the perineal body, palpate for and locate the external anal sphincter.

  • Adjust the length of the blades of the scissors on the perineal body to the projected length of the incision.

  • Cut.

  • Sponge, observe and palpate again for the external sphincter. Evaluate if another cut in this plane is needed.

  • Cut again, if needed.

  • Evaluate the extent of the incision into the vagina. Feel for a band of tight, restricting vaginal tissue just inside the introitus.

  • Extend the vaginal side of the incision, if needed, or if the band of tissue is there and needs to be incised. Extension is accomplished by now pressing downward with your two fingers in the vagina, holding them apart enough to splint the incision line and in far enough to extend beyond the projected lengthening of the incision line. Bring the scissors from above the back side of the hand to slide between the fingers and make the cut.

  • Apply pressure with 4x4 sponges to the incision.

(Varney, p 854)

Risk Screening
703. The history that needs to be taken at the initial labor assessment includes:

  • Age

  • Gravida and para

  • Time of onset of contractions and frequency and duration of contractions from the onset to present

  • Intensity of the contractions when lying down, in contrast to when walking around
  • Descriptions of the location of discomfort or pain felt with contractions


  • Length of previous labor

  • Number of years since last baby

  • Delivery methods of previous deliveries

  • Size of largest and smallest previous babies

  • EDD and present weeks of gestation

  • Absence, presence or increase in bloody show

  • Absence or presence of vaginal bleeding

  • Status of membranes

  • Any prenatal problems

  • Any general health issues

((Varney, p 387-88)
704.

False Labor

True Labor

contractions do not increase in frequency, duration and intensity

contractions are irregular and short duration



contractions increase in frequency, duration, and intensity

contractions rarely intensified and may be alleviated by walking

contractions intensified by walking

contractions felt in the lower abdomen and groin

contractions felt as radiating across the uterus from the fundus to the back

contractions are irregular and short duration

contractions may start as irregular and short duration, but become regular

(Varney, p 387)

705. It is not possible to distinguish between IUGR and SGA prior to delivery. The majority of SGA infants are small because of IUGR. Some babies can just be constitutionally small but be healthy.

IUGR babies:


  • show signs subcutaneous tissue wasting.

  • ability to gather large skin folds, especially around the shoulders and upper back.

  • dry skin

  • meconium

  • overalert appearance with prominent eyes, firm skulls

  • may have symmetric or asymmetric growth restriction

(Varney, p 616)
706. Progress and pelvic adequacy are indicated by:

  • Progressive effacement

  • Progressive dilation

  • Descent of the presenting part

  • Position of the presenting part, i.e. not asynclitic

707. In order to r/o ROM, it is necessary to do a sterile speculum exam (see above for steps), check for + nitrazine check and ferning, and for pooling of fluid in the speculum. It may also be possible to visualize a bulging bag of waters at the os, or to palpate the bag via a digital exam.

If ROM has occurred, very limited and sterile vaginal exams should take place. Also, the woman should not put anything in her vagina, no sex, and be impeccable about hygiene. Vitamin C and echinacea should be increased to help the immune system as well. If indicated due to symptomology, or if GBS+, IV antibiotics should be administered per protocol.

708. Parity effects both duration of labor and the incidence of complications. A multiparous cervix offers less resistance to labor, thereby shortening duration of the labor. Multiparas also have more relaxed pelvic floor, offering less resistance to the passage of the baby, also shortening the duration, and have more pronounced fundal dominance with their contractions. Duration of labor may increase with grand multiparas, as a result of changes in the uterine musculature, often called “exhaustion of the uterine muscle”, e.g. a woman having her eighth baby having a longer labor than her first.

Complications that rise in incidence with parity of 5 or above include abruptio placentae, placenta previa, uterine hemorrhage, maternal mortality, perinatal mortality, and double ovum twinning. (Varney, p 387)

709. Fetal positions that must be ruled out include: frank breech, complete breech, footling breech, brow, face, mentum, military, oblique or transverse.
710. Normal fetal positions that increase the duration of labor or rate of complications include: occiput posterior.
711. The qualities of the contraction that must be monitored to rule out complications are: coordination of effort, frequency, duration and intensity.
712. Vital signs and changes are used to rule out complications in the following ways:

Vital Signs

How to rule out complications

Blood Pressure

  • when checking BP during a contraction a rise of up to 15 systolic and 5-10 diastolic is WNL, it should return to prelabor levels between contractions. if rise is greater than above, check for other signs of preeclampsia

  • if elevated BP, put woman in LSL and check again

Temperature

  • elevation should not exceed 1-2 degrees F which is normal due to increased metabolism during labor

  • if higher, infection should be r/o

Pulse

  • a slightly elevated pulse is likely normal , other parameters should be checked to rule out infection

Respirations
  • a slight increase in respiratory rate is normal during labor and reflects the increase in metabolism that is occurring.


  • prolonged hyperventilation is abnormal and may result in alkalosis

(Varney, p 406-7)
713. Edema, especially pitting edema, may suggest preeclampsia or HELLP syndrome. Edema found in tandem with proteinuria, RUQ pain, headaches, elevated blood pressure would suggest preeclampsia. If edema is found and is not pitting or not in conjunction with previous symptoms, dehydration and inadequate electrolyte balance.
714. Estimated fetal weight of one or more pounds larger than previous baby or babies, alerts the midwife to the possibility of difficulty with delivery of the shoulders. (Varney, p 389)

Physical Assessment
715. The bones of the pelvis are the: illium, ischium, pubis, sacrum and coccyx.
716. The landmarks that are evaluated during pelivmetry are:


  • ischial spines

  • sacrum

  • coccyx

  • pubic arch

  • ischial tuberosity

the most important pelvic measurements are:

  • diagonal conjugate

  • bi-ischial diameter

  • angle of the pubic arch

  • bituberous diameter

  • angle of side walls

717. The muscles of the pelvic floor



Muscle

Description

Levator Ani:

a. pubococcygeous


b. iliococcygeous




  • supports and maintain position of pelvic viscera

  • resists increase intra-abdominal pressure during forced expiration, coughing, vomiting, defecation, urination

  • constricts the anus, urethra, and vagina

  • supports fetal head during childbirth

Coccygeous

  • supports and maintain position of pelvic viscera

  • resists increase intra-abdominal pressure during forced expiration, coughing, vomiting, defecation, urination

pulls coccyx anteriorly following defecation or childbirth




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