ch 19 intrapartum nursing care stages 1-4 Flashcards
status of 3 things in screening assessment intrapartum
-woman
-fetus
-labor
sources of data in screening assessment intrapartum (4)
-interview
-focused physical assessment
-lab results
-prenatal record
what is included in status of the woman in screening assessment
-general appearance
-use of breathing techniques, pain scale
-support person accompanying
-report of current and past medical and OB Hxs
-VS
-auscultate heart/lungs
-DTRs
-urine: dip for protein and glucose
-review for risk factors
what is included in status of the fetus in screening assessment
-report of EDB, current gestational age
-report of fetal movement (how often, changed?)
-size and shape maternal abdomen
-palpation for fetal movement and position
-FHR (20-30 min EFM tracing)
-review for risk factors
limits for protein and glucose in labor (dip test)
+1 protein
+1 glucose
what is included in status of labor in screening assessment
-membrane status (time, amount, color, odor)
-observation of vaginal fluid/bleeding
-report of contractions (frequency, duration, intensity, toco 20-30 mins)
-palpation of uterine activity
-vaginal exam (cervical status, fetal presentation and position, verification of membranes)
-review for risk factors
abnormal amniotic fluid
-malodorous
-actively bleeding
-green/brown color
when would you defer the vaginal exam in evaluating status of labor in screening assessment
if active bleeding (may have placenta previa)
2 tests for verification of membranes
-nitrazine: pH paper (amniotic fluid turns it blue)
-ferning: pattern seen under microscope, indicates amniotic fluid presence
what things besides amniotic fluid could turn the nitrazine paper blue (2)
-blood
-semen
when should complete admission assessment (after screening assessment) be completed and documented by RN
within first hour of admission
(unless active bleeding or delivery occurs)
can UAP help with admission assessment
-can do maternal VS
-can’t do fetal VS (which includes analyzing data)
-can’t put mom back on monitors
important consideration when obtaining obstetrical history
interview mom alone (no one else in room)
assessment of birth plan (5)
-EFM vs intermittent auscultation and palpation
-support person(s)/ birth attendant(s)
-pain management plan/ prep for labor and birth
-pediatric provider
-individual/cultural considerations
psych and emotional factors in patient interview of admission assessment
-language preference/barrier
-observation of general appearance and nonverbal comm
-domestic violence screen
-concerns/fears of labor and birth
-“ideal” birth experience
-learning needs of pt and family
what is included on physical exam in admission assessment
-heart, lungs
-skin
-edema (hands, face, sacrum, legs)
-DTRs
-FHR and uterine activity patterns
what labs are done for admission assessment
-urinalysis (possible culture and sensitivity)
-CBC (for Hct and Hgb)
-blood type and Rh
plan of care for stage 1 of labor
-ongoing assessments
-interventions (pain management, guidance)
what does stage 1 of labor include
dilation 1-10 cm
(latent 0-6 cm and active 6-10 cm)
how often to collect VS for laboring woman: low risk, latent phase (BP/P/R, T, FHR/UA, vag exam, psycho/emo)
-BP, P, R: q30-60mins
-T: q4h if BOWI, q2h if ROM, q1h if PROM
-FHR/UA: q30-60mins
-vag exam: PRN
-psycho/emo +partner: q30mins
what does the frequency of taking temperature in stage 1 labor depend on
membrane status
(monitors possibility of infection)
how often to collect VS for laboring woman: low risk, active phase (BP/P/R, T, FHR/UA, vag exam, psycho/emo)
-BP, P, R: q30mins
-T: q4h if BOWI, q2h if ROM, q1h if PROM
-FHR/UA: q15-30mins
-vag exam: PRN
-psycho/emo + partner: q15mins
when should you look at FHR
before and after contraction
-looking for early/late decels
1st nursing action after ROM
FHR (rapid decrease means prolapsed cord)
-then assess amniotic fluid
indications for additional FHR assessment during stage 1 labor (6)
-ROM (rule out prolapsed cord)
-sudden change in contraction pattern
-before and after maternal med and at peak of med
-any indication of complication
-listen to FHR through contraction
-consider EFM if periodic changes noted
what might hearing FHR above maternal umbilicus indicate
breech baby
3 ways to promote labor progress
-position changes and movement
-pain management/comfort
-adequacy of contraction pattern (2-5/10 mins)
graph for assessment of patterns of cervical dilation and fetal station over time
partogram
nurses role during AROM
-assess FHR before, during and after
-assess fluid
ongoing nursing care for mom during labor
-maintain cardiac output (position, hydration)
-control anxiety and fear
-control hyperventilation and adequate RR
-safety and comfort and regulation, sensation, perception (hygiene, oral care, pain management)
-infection control
-watch for Sx infection: fetal tachycardia, maternal T
-psych support and anticipatory guidance
-social: partner/support person
ongoing nursing care for baby during labor
-maintain maternal oxygenation (O2 to mom)
-fetus will show signs of decreased O2 before mom will
-ROM: assess for prolapsed cord
hygiene considerations for mom during labor
-clean linen and regular peri care
-showers, baths (if BOWI)
-socks/slippers
-elimination
-oral care: toothbrush, mouthwash, chapstick
comfort measures for laboring mom
-holding
-application of hot/cold
-giving ice chips, oral care, lip balm
-helping with personal hygiene (esp peri care)
-massage
-hydrotherapy
-helping with positioning
-assisting with ambulation
S+S intrauterine infection (chorioamnionitis/ IUI/ chorio)
-fetal tachycardia (>180)
-maternal fever
what IV fluids do you need to limit for mom during labor
IV fluids with 5% dextrose
can cause fetal hyperglycemia
emotional support measures for labor
-companionship
-eye contact
-praise
-distraction
-affirmation
-reassurance
-visualization
-attention focusing
-advocacy
-supporting husband/partner
-information/advice
signs of complications during stage 1 labor
-intrauterine pressure >80 mmHg
-resting tone >20 mmHg
-contractions >90 sec duration
->5 contractions in 10 mins
-relaxation time between contractions <30 sec
-FHR baseline <110 or >160
-FHR variability absent or minimal
-FHR late, variable, or prolonged decels
-irregular FHR (suspected fetal arrhythmias)
-MSF or bloody
-ceased cervical change and/or descent of fetus
-maternal temp >38 C (100.4 F)
-foul smelling vaginal discharge
-persistent bright/dark red vaginal bleeding
indicators of 2nd stage labor
-brief “lull” followed by increased frequency and intensity contractions
-urge to push, feel need to have bm, involuntary bearing down
-vomiting
-increased bloody show (not heavy. mixed with fluid and mucus)
-shaking/shivering
-restlessness, verbalizations
vaginal exam findings during “lull” of 2nd stage labor
-10 cm dilated
-100% effaced
-0 station
findings during active phase 2nd stage labor
-bloody show
-urge to push (fergusons reflex)
-grunting, expiratory vocalizations
-perineal bulging
maternal assessments during 2nd stage of labor
-BP and P: q5-15mins
-constantly palpate bladder for distention
-constantly evaluating contractions
-constantly observing perineal area
-constantly observing amniotic fluid for change
fetal assessments during 2nd stage of labor - how often?
latent: q15 mins
active pushing: q5-15mins
2 ways of pushing during labor
-spontaneous/ open glottis (*don’t push for more than 6-8 seconds at a time)
-directed/ closed glottis (10 seconds pushing, no sound)
2 types perineal trauma associated with labor
-tear: laceration
-incision: episiotomy
classifications of perineal trauma
1st degree: through skin and vaginal mucosa
2nd degree: through fascia and muscles
3rd degree: through external anal sphincter
4th degree: through anterior wall of rectum
risks for episiotomies
lateral: could extend to rectum
mediolateral: harder to heal, possibility of lifelong pain
immediate care of newborn (4)
-document exact time of birth
-immediate skin to skin
-delayed cord clamping (atleast 3 mins)
-immediate assessment and interventions (apgar, airway, resp effort support, thermoregulation support)
indicators of placental separation after birth
-firmly contracting fundus
-change in uterus from discoid to globular shape
-sudden gush dark blood
-apparent lengthening of umbilical
-finding of vaginal fullness on vaginal exam
nursing assessments 3rd stage labor
-before placental separation: BP, IV site
-BP, P, R: q15mins
what does 3rd stage labor include
delivery of placenta
nursing interventions 3rd stage labor
-gentle push
-administer oxytocin per protocol
-pain management
-ask hcp for blood loss and document
-collect umbilical cord blood for lab
-document assessments and interventions
-promote family attachment
what does 2nd stage labor include
delivery of baby
3 interventions for reducing risk PPH during 3rd stage labor
-early admin pitocin (most important)
-traction on umbilical cord
-early clamping and cutting umbilical cord
possible complications during 3rd stage labor (5)
-hemorrhage
-rupture of pre-existing cerebral aneurysm
-cardiac decompensation (if Hx of cardiac disorders)
-pulmonary embolism
-amniotic fluid embolism
risk factors for PPH (7)
-bladder distention
-uterine overdistention (multiple babies, big baby, polyhydramnios)
-regional anesthesia
-pitocin induction/augmentation
-uterine tachysystole (frequent contractions)
-magnesium sulfate therapy (smooth muscle relaxant)
-dystocia (difficult labor)
symptoms of uterine atony (3)
-soft, “boggy” fundus on palpation
-uterine fundus displaced above and to right of umbilicus
-excessive lochia rubra
within 12 hours of birth where should fundus be?
where is fundus every 24 hours after that?
-at umbilicus
-1 cm below umbilicus consistent with # days postpartum
nursing interventions for PPH
-perform fundal massage
-empty bladder (void or cath)
-recheck q15min for 1 hr, q30min for 2 hr
when do you stop fundal massage for PPH
once it contracts
assessment frequency 4th stage of labor
q15min for 1 hr, then q30min for 1 hr:
-P
-BP
-fundus
-bladder
-lochia
-perineum
-pain
-PAR
-add T at 1 hr and 2 hr
what does postanesthesia recovery score (PAR) include (5)
-activity
-respirations
-BP
-LOC
-color
when does 4th stage of labor begin
after placenta is delivered
immediate care of woman after placenta is born
-clean patient (bed and gown)
-PO fluids, food (if not C/S)
-assist woman to hold and position baby for eye-to-eye contact, assist with breastfeeding
-assess VS, fundus, lochia, pain, sensory and motor function q15mins
-promote elimination
-maintain comfort, safety, hygiene
-assess episiotomy or laceration repair, apply ice
-meet emotional needs
how to meet mom’s emotional needs during 4th stage labor
-listen to birth story/concerns
-encourage family members to visit
-support interactions with baby
-support feelings of shock, disbelief, grief
-promote family time with SO and baby
