Chapter 13: Nursing Care During Labor and Birth

Question 1

What are the nursing responsibilities during admission?

Answer 1

• establish a therapeutic relationship
• make family feel welcome
• determine family expectations
• convey confidence
• assign a primary nurse
• respect cultural values

Question 2

what is the focus assessment done at time of admission?

Answer 2

• performed first before broader database assessment:
  
  • FHR: should be regular at rate of 110-160 bpm
    
    • should have absence of decels and presence of accelerations
  • maternal V/S: important to identify HTN and infection
    
    • HTN: during pregnancy is over 140/90
    • infection: temp of 100.4 deg F or higher

Question 3

what signs suggest impending birth? what info should be gathered if birth is imminent on admission?

Answer 3

• Suggest impending birth: grunting sounds, bearing down, sitting on one buttock, saying “The baby’s coming”
• If birth is imminent, only minimal info can be gathered:
  
  • Name of mother and SO
  • Name of physician for prenatal care
  • Number of pregnancies and type of delivery
  • Status of membranes
  • Expected due date
  • Problems
  • Allergies
  • Time/type of last oral intake
  • Maternal vital signs/FHR
  • Pain

Question 4

What is the database assessment done on admission?

Answer 4

• obtain essential info from client
  
  • prenatal care, EDD, GTPAL, allergies, food intake, PMH, meds, use of tobacco/alcohol, support person
• fetal assessment
  
  • assess fetal presentation and position using Leopold’s and vaginal exam
  • FHR
  • document color and odor of amniotic fluid when ruptured
• labor status
  
  • assess contraction patterns, do vaginal exams, determine if ROM has occurred

Question 5

what admission procedures must be done?

Answer 5

• notify physician
• consent forms: for anesthesia, blood products, HIV test, consent for newborn care
• apply fetal monitor
• establish IV access: 18 G or larger
• lab tests: HCT, midstream urine specimen to assess protein and glucose

Question 6

fetal assessments done after admission

Answer 6

• FHR
  
  • freq of monitoring based on risk
  • if SROM occurs or amniotomy performed, assess for at least 1 min
• amniotic fluid
  
  • should be clear and contain bits of vernix
  • infection: cloudy, yellow, foul smelling
  • green: fetus passed meconium possibly due to transient hypoxia–>may need extra respiratory suctioning at birth

Question 7

maternal assessments done after admission

Answer 7

• V/S: temp, pulse, respirations, BP
• contractions
• labor progress: do vaginal exam to determine dilation, effacement, fetal descent
• I/O: encourage voiding every 2 hours
• response to labor: may become anxious or fearful b/c of pain, loss of control
  
  • assess pain and their desire to have help with pain
• support person’s response
  
  • he/she may be anxious, fearful, tired
  • feel responsibility to protect and support mom, but may feel unable to do so

Question 8

how often to assess maternal V/S in labor?

Answer 8

• reassess temp every 4 hours
  
  • every 2 hours if ROM has occurred
• reassess BP, pulse, and RR every hour

Question 9

how often to assess contractions?

Answer 9

• latent phase: every hour
• active or transition phase: every 15-30 min
• 2nd stage: every 5-15 min

Question 10

When to go to the birth facility?

Answer 10

• MUST review these with women who have come in with false labor
• Contractions: if they are inc in regularity, freq, duration, and intensity
• Nullipara: regular contractions, 5 min apart for 1 hour
• Multipara: regular contractions, 10 min apart for 1 hour
• Ruptured membranes: fluid flow from the vagina
• Bleeding: bright red blood
  
  • Normal bloody show is thicker, pink or dark red, mixed with mucus
• Dec fetal movement

Question 11

how to assest with an emergency birth?

Answer 11

• priorities:
  
  • prevent injury
  • provide warmth to infant
  • clear airway of newborn
• during birth:
  
  • stay with woman
  • put on sterile/clean gloves
  • call for help
• dry infant, suction, and place skin to skin
• put infant to breast

Question 12

What are comfort measures used to help with discomfort?

Answer 12

• soft lighting
• apply cool wash cloths to mother’s forehead
• temperature
• cleanliness
• bladder: empty every 2 hours
• positioning
• water: provide ice chips
• hunger

Question 13

Positioning of Laboring Mother

Answer 13

• movement and position changes dec pain, improve circulation, improve strength/effectiveness of contraction, dec length of labor, and encourage fetal descent
• encourage upright positions, frequent position changes, and a C shaped spine
• woman with epidural: assist with position changes every 30-45 min

Question 14

How to prevent injury

Answer 14

• allow labor to begin on its own
• freedom of movement in labor
• laboring down
• continuous labor support
• delay pushing until cervix fully dilated, effaced, +1 station, and internally rotated
• non-supine pushing
• no separation of mother and baby

Question 15

explain laboring down

Answer 15

• may last longer than 2 hours as long as no signs of compromise
• Pushes are most effective when the woman feels the natural urge to do so as the fetus descends
• Helps prevent maternal fatigue, decreases pushing time, dec instrument assistance, and higher Apgar scores

Question 16

Positioning of Mother for Pushing and Birth

Answer 16

• Upright positions are the best b/c promote effective pushing and take advantage of gravity
• Squatting ideal but limits access to perineum
• Best for woman to have upper body leaning forward over pelvis to promote expulsive efforts, direct fetus toward pelvic outlet, and inc diameter of pelvic outlet
  
  • upper torso should be in front of pelvis

Question 17

what can indicate fetal compromise?

Answer 17

• HR outside of 110-160
• amniotic fluid: meconium, foul smelling
• excessive freq or duration of contractions
  
  • less than 2 min apart or longer than 90-120 sec
• incomplete uterine relaxation
• maternal HTN/hypoTN
• maternal fever

Question 18

how to prevent infection in a laboring woman?

Answer 18

• good perineal hygiene
• document time and characteristics of ROM
• check temp q2h
• vag exam only when necessary
  
  • must use aseptic technique
• FHR: tachycardia is early indicator of maternal infection

Question 19

how to prevent fluid volume deficit in laboring mother?

Answer 19

• monitor hydration status
• V/S
  
  • temp inc: dehydration
  • inc pulse or dec BP: bleeding
• monitor FHR for signs of distress from uteroplacental insufficiency
• continuous/intermittent EFM
• I&O
• void q2h
• test urine for SG
• oral and IV fluids as needed

Question 20

Nursing Responsibilities during the 2nd Stage of Labor

Answer 20

• assist with breathing
• positions for birth
• perineal cleansing
• assist with delivery and equipment
• document time of delivery
• assist w/ cord clamping
  
  • 1 min delay in clamping inc amt of blood infant receives

Question 21

Nursing Responsibilities during the 3rd Stage

Answer 21

• administration of oxytocin to aid in uterine contraction
  
  • delivery of anterior shoulder
• care of infant
• monitor cardiopulmonary function of infant:
  
  • apgars at 1 & 5 min
  • suctioning
  • thermoregulation
  • identification
• watch for signs of placental separation
• document time and method of placenta delivery

Question 22

APGAR Score

Answer 22

• assess at 1 and 5 min
  
  • if 8 or higher, then no intervention necessary other than supporting thermoregulation and promoting normal respirations by bulb suctioning
  • 3-7: gently stimulate by rubbing infant’s back while administering O2; determine if mother had taken narcotics (have naloxone ready)
  • 0-2: infant needs resuscitation

Question 23

APGAR mnemonic and chart

Answer 23

• A: Appearance (color)
• P: Pulse (HR)
• G: Grimace (response to stimulation)
• A: Activity (Tone)
• R: Respirations

Question 24

Nursing Responsibilities during the 4th Stage: The Baby

Answer 24

• thermoregulation: can use skin to skin or warmer
  
  • also dry infant with warm towels (esp on head) to avoid evaporative heat loss
  • put cap on infant if not in warmer
• identification: arm and ankle band on baby that matches mom
• metabolism (feeding): during 1st hour
• medications:
  
  • Ilotycin, vitamin K
  • hepatitis B vaccine
• elimination
• attachment

Question 25

Nursing Responsibilities during 4th Stage: The Mother

Answer 25

• V/S
  
  • assess temp, BP, pulse, RR
• fundus
  
  • assess firmness, height, positioning with each V/S assessment
• lochia
  
  • assess
  • max flow: saturation of 1 std perineal pad w/in first hour
• bladder
  
  • full bladder suspected if fundus is above umbilicus or displaced from midline
• perineum
  
  • assess for hematoma formation
• pain
• promote early family attachment
• promote comfort

Question 26

how to assess V/S of mom after birth of baby

Answer 26

• assess BP, pulse, RR every 15 min for 1st hour
  
  • rising pulse is early sign of blood loss
  • BP falls as BV dec, but this is late sign of hypovolema

Question 27

What is the most common reason for postpartum bleeding?

Answer 27

uterus does not contract and compress vessels

Question 28

how should the uterus feel after delivery?

what to do if not normal?

Answer 28

• should be firm, midline, and below umbilicus
• if not firm (so it is boggy), then massage until firm

Question 29

How much should first 2 voidings be after delivery?

Answer 29

300-400 mL

Question 30

How to promote comfort in mom after delivery?

Answer 30

• Perineal trauma and uterine contractions (afterpains) can cause pain
• Postpartum chill often adds discomfort
• You can use:
  
  • Ice packs: to reduce edema and hematoma formation
  • Analgesics
  • Warmth: warm blankets and drinks

Question 31

how to promote early family attachment?

Answer 31

• First hour after labor is ideal for parent, infant attachment b/c a healthy neonate is alert and responsive
• Assess mom and baby while mom holds infant
• Assist mother to nurse if she plans to breastfeed
• Help family and other children see the newborn
• Normal parent infant attachment: tentative at first, then progress from fingertip touch to palm touch to enfolding of the infant; often make eye contact with infant and talk in higher pitched tones

Question 32

issues for new nurses

Answer 32

• Pain w/ birth: pain is expected
  
  • Some mothers want epidurals, and some do not
• Inexperience and negative experiences:
  
  • Nursing skills needed by intrapartum nurse: observation, critical thinking, problem solving, therapeutic communication, comfort promotion, empathy, and common sense
  • Should try not to convey negative attitudes to the laboring woman or family
• Unpredictability
• Intimacy

Question 33

Maternal Emotions during Latent Phase

Answer 33

–Elation

–Relief pregnancy at end

–Anticipation and apprehension

Question 34

Maternal Emotions During Active Phase

Answer 34

–More serious and introverted

–Vague fears: concern for self and baby

Question 35

Maternal Emotions During Transition Phase

Answer 35

–Irritability

–Rejection of support person

–Out of control and overwhelmed

–Desire to quit, give up

–Fearful of being left alone

Question 36

Maternal Emotions During Stage 2

Answer 36

• •Increased sense of control
• •Satisfaction and relief at progress
• •Fatigue
• •Exhaustion
• •Excitement that birth is imminent
• •Elation, relief, joy
• •Curiosity
• •Desire to see and feed baby

Question 37

emotional support of adolescents

Answer 37

• •Fewer coping mechanisms
• •Fewer problem solving skills
• •Establish a trusting relationship
• •Establish rapport without recrimination for inappropriate behavior
• •Positive reinforcement
• •Simple concrete explanations