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Labor and Birth: Nursing Management Flashcards

1
Q

Factors influencing onset of labor

A

-Uterine stretch
-During last trimester, estrogen increases and progesterone decreases
-Increased oxytocin sensitivity
-Increased release of prostaglandins

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2
Q

Premonitory signs of labor

A

-Cervical changes (softening or dilation 1 hr - 1 m before labor)
-Lightening (baby drops into pelvis, uterus lowers, breathing is easier, decrease in gastric reflux, increased pelvic pressure, cramping, and edema; occurs 2 weeks or more before labor in primis and at time labor in multis)
-Increased energy level (nesting, spending more time on household chores and w/ children at home; 24-48 hrs before labor, increase in EPI)
-Bloody show (mucus plug expels as result of cervical softening; mixes w/ blood to produce pink-tinged secretions)
-Braxton hicks contractions (stronger and more frequent, pulling sensation at top of uterus; last abt 30 sec - 2 min; if it occurs more than 4-6x/hr –> call doctor)
-Spontaneous rupture of membranes (loss of amniotic fluid aka PROM, labor begins within 24 hrs, infection is possible, danger of cord prolapse)

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3
Q

Late preterm

A

-Infant born between 34-36 weeks gestation
-Experiences same health issues as other preemies

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4
Q

True labor

A

-Timing: regular (4-6 min apart, lasting 30-60 sec)
-Strength: stronger w/ time
-Discomfort: starts in back radiates around front of abdomen
-Activity: contractions continue no matter what positional change is made
-Stay or go: stay home until contractions are 5 min apart, last 45-60 sec, strong enough that convo is not possible

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5
Q

False labor

A

-Timing: irregular, not occurring close together
-Strength: weak, not getting stronger w/ time
-Discomfort: felt in front of abdomen
-Activity: contractions slow down w/ activity or position change
-Stay or go: drink fluids and walk around to diminish the contractions

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6
Q

Critical factors affecting labor and birth

A

-Passageway (birth canal: pelvis and soft tissues)
-Passenger (fetus and placenta)
-Powers (contractions
-Position (maternal: lying down slows labor)
-Psychological response (mom and partner to get more control of labor)

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7
Q

Additional factors affecting labor process

A

-Philosophy (low tech, high touch)
-Partners (support caregivers)
-Patience (natural timing)
-Pt preparation (childbirth knowledge base)
-Pain control (comfort measures)

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8
Q

Linea terminalis

A

-Division of false and true pelvis
-Thru sacral prominence at back of superior aspect of symphysis pubis at front of pelvis

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9
Q

True pelvis

A

-Below linea terminalis
-Bony passageway in which fetus must travel
-Inlet
-Mid pelvis
-Outlet

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10
Q

False pelvis

A

-Above linea terminalis
-Upper flared parts of 2 iliac bones and concavities
-Wings of base of sacrum

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11
Q

Pelvis shape

A

-Gynecoid: favorable for vaginal delivery, inlet is round and outlet is roomy
-Android: common in male, not favorable, prognosis for labor is poor –> C-section
-Anthropoid: usually adequate, common in men and white women, sacrum is long, producing a deep pelvis
-Platypelloid: not favorable, flat shape

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12
Q

Passageway: soft tissues

A

-Cervix: thins thru effacement to allow presenting part to descend into vagina
-Pelvic floor muscles
-Vagina
-Similar to pulling turtleneck sweater over head

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13
Q

Passenger

A

-Fetal skull (largest and least compressible structure)
-Fetal attitude (degree of body flexion and relationship of body parts with one another)
-Fetal lie (relationship of fetal spine to maternal spine)
-Fetal presentation (1st body part)
-Fetal position (relationship to maternal pelvis)
-Fetal station
-Fetal engagement

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14
Q

Sutures

A

-Allow for overlapping and changes in shape (molding)
-Help identify position of fetus
-Will close as baby develops to allow room for brain to grow

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15
Q

Fontanelles

A

-Intersections of sutures
-Help in identifying position of fetal head and in molding
-Anterior fontanelle is the famous “soft spot” (diamond shaped space 1-4 cm that closes 12-18 m after birth)
-Posterior fontanelle closes 8-12 weeks after birth (1-2 cm)

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16
Q

Diameters

A

-Occipitofrontal
-Occipitomental
-Suboccipitobregmatic (important, 9.5 cm, measured from base of occiput to center of anterior fontanelle, smallest anteroposterior diameter of skulls)
-Biparietal (important, 9.25 cm, largest transverse diameter of fetal skull, distance between 2 parietal bones)

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17
Q

Fetal attitude

A

-Body parts in relation to each other during labor
-Fetal position: head tucked into chest, arms and legs drawn in toward center of chest

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18
Q

Fetal lie

A

-Relationship of long axis (spine) of fetus to long axis (spine of mother)
-Longitudinal (ideal for vaginal delivery)
-Transverse (breech, needs C-section)
-Oblique (needs C-section)

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19
Q

Fetal presentation

A

-Cephalic (vertex), military, brow, face
-Breech: frank (buttocks), full or complete (foot/leg), footling or incomplete; risk of umbilical cord compression
-Shoulder

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20
Q

Fetal position

A

-Relationship of a given point on presenting part of fetus to a designated point of the maternal pelvis
-Occipital bone (O): vertex
-Chin (mentum): face
-Buttocks (sacrum): breech
-Scapula (acrominion): shoulder
-3 letter abbreviation: 1st letter defines whether presenting part is tilted toward L or R of maternal pelvis, 2nd letter defines particular presenting part of fetus such as occiput or sacrum, 3rd letter defines location of presenting part in relation to the anterior or posterior portion of the maternal pelvis (A, P, T)
-LOA is most common and most favorable, followed by ROA

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21
Q

Fetal station

A

-0: good
- Negative 4 to positive 4
-Negative: lightening hasn’t occurred
-Positive: lightening has occurred
-Mother not ready for delivery

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22
Q

Fetal engagement

A

-Presenting part reaching 0 station
-Floating: no engagement (cervix is dilated, C-section needed), presenting part freely movable about pelvic inlet
-Biparietal diameter is important factor in navigation thru maternal pelvis

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23
Q

Cardinal movements during labor

A

-Engagement: greatest transverse diameter of head in vertex (biparietal diameter) passes thru pelvis inlet (0 station)
-Descent: downward movement of head into pelvic inlet (pressure of amniotic fluid and fundus d/t fetus’s buttocks or head), contractions of abdominal muscles, extension of fetal body)
-Flexion: vertex meets resistance from cervix, walls of pelvis, or pelvic floor; chin is brought into contact w/ fetal thorax and presenting diameter is changed from occipitofrontal to suboccipitobregmatic
-Internal rotation: as head descends, lower portion of head meets resistance from one side of pelvic floor, head rotates 45 degrees)
-Extension: nucha (base of occiput) becomes impinged under symphysis, occurs after internal rotation is complete, anterior fontanelle, brow, nose, mouth, chin are born
-External rotation: after head is born, it untwists, causing occiput to move 45 degrees to its original L or R position (restitution); allows shoulders to rotate internally to fit thru pelvis
-Expulsion: rest of body occurs more smoothly after birth of head and shoulders

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24
Q

Powers

A

-Uterine contractions (primary stimulus)
-Intra-abdominal pressure from mother pushing and bearing down
-Contractions: involuntary, thin and dilate cervix
-Parameters: frequency, duration, intensity

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25
Uterine contractions
-Responsible for thinning and dilating cervix -Cervical canal 2 cm --> 0% effaced -Cervical canal 1 cm --> 50% effaced -Cervical canal 0 cm --> 100% effaced -Cervix is no longer palpable when fully dilated (10 cm) -External cervical os closed --> 0 cm dilated -External cervical os half open --> 5 cm dilated -External cervical os fully open --> 10 cm dilated
26
Uterine contraction parameters
-Frequency: how often contractions occur, beginning of 1 contraction to beginning of next -Duration: how long contraction lasts, beginning of 1 contraction to end of same contraction -Intensity: strength of contraction determined by manual palpation or measured by internal intrauterine pressure catheter
27
Factors influencing a positive birth experience
-Clear information on procedures -Support, not being alone -Sense of mastery, self-confidence -Trust in staff caring for her -Positive rxn to pregnancy -Personal control over breathing -Preparation for childbirth experience
28
Physiologic responses to labor: maternal
-Increased HR, CO, BP (during contractions) -Increased WBC -Increased RR and O2 consumption -Decreased gas motility and food absorption -Decreased gastric emptying and gastric pH -Slight temp elevation -Muscle aches/cramps -Increased BMR -Decreased blood glucose levels
29
Physiologic responses to labor: fetal
-Periodic FHR accelerations and slight decelerations -Decrease in circulation and perfusion -Increase in arterial CO2 pressure -Decrease in fetal breathing movements -Decrease in fetal O2 pressure, decrease in partial pressure of O2 -Helps prepare fetus for extrauterine respiration immediately after birth
30
1st stage of labor
-True labor to complete cervical dilatation (10 cm) -Longest of all stages -3 phases: latent phase, active phase, transition phase
31
1st stage of labor: stages
-Latent: 0-6 cm, contractions every 5-10 min, lasting 30-45 sec, intensity mild -Active: 6-10 cm, contractions every 2-5 min, 45-60 sec, intensity moderate
32
2nd stage of labor
-Cervix 10 cm dilated to birth of baby -Lasts up to 3 hours
33
2nd stage of labor: stages
-Pelvis phase: period of fetal descent -Perineal phase: period of active pushing, contractions every 2-3 min, 60-90 sec, intensity strong
34
3rd stage of labor
-Birth of infant to placental separation -Placental separation: detaching from uterine wall -Placental expulsion: coming outside of vaginal opening -Takes 5-10 min, may take up to 30
35
4th stage of labor (not true labor)
-1-4 hrs following surgery or birth of newborn -Maternal physiologic adjustment -Mother is wide awake and initially talkative -Uterus becomes boggy, massaged to be kept firm -Lochia is red w/ clots and of moderate flow -Mother needs food and water -Bladder is hypotonic -Cramps -VS monitored q15m - 1 hr
36
Signs of placental separation
-Uterus rises upward -Umbilical cord lengthens -Sudden trickle of blood is released from the vaginal opening -Uterus changes its shape to globular
37
Placental expulsion
-Expelled 2-30 min after separation from uterine wall -After expulsion, uterus is massaged by physician or midwife until it is firm so that blood vessels constrict, minimizing possibility of hemorrhage -Normal blood loss is 500 mL for vaginal birth and 1,000 mL for C-section -Risk for postpartum hemorrhage is any piece is still attached to uterine wall
38
Factors influencing pain during labor and birth
-Physiologic -Spiritual -Psychosocial -Cultural -Environmental
39
Key terms r/t FHR
-Accelerations -Artifact -Baseline FHR -Baseline variability -Deceleration -Electronic fetal monitoring -Periodic baseline changes
40
Nursing management of laboring women
-Assessment -Comfort measures -Emotional support -Info and instruction -Advocacy -Support for partner
41
Maternal assessment during labor and birth
-Status (VS, pain, prenatal record review) -Vaginal exam -Rupture of membranes -Uterine contractions -Leopold maneuvers
42
Vaginal exam
-Takes time and experience to develop -Assesses progress of labor -Highly invasive and can be painful -Assess amount of cervical dilation, percentage of effacement, fetal membrane status and to gather info on presentation, position, station, degree of fetal head flexion, presence of fetal skull swelling or molding -Sterile procedure
43
Uterine contractions
-During active labor: intensity reaches 50-80 mmHg -During rest: 5-10 mmH in early labor and 12-18 mmHg in active labor -Palpate fundus w/ pads of fingers and feeling for tip of nose (mild), chin (moderate), forehead (strong) -Mild, moderate, strong -Frequent clinical experience is needed to gain accuracy in assessing intensity of uterine contractions
44
Leopold manuevers
-Determines presentation, position, lie of fetus -Place woman in supine position 1: what fetal part (head or buttocks) is located in fundus (top of uterus) 2: on which maternal side is fetal back located (fetal heart tones are best auscultated thru back of fetus) 3: what is the presenting part 4: is the fetal head flexed and engaged in the pelvis
45
Fetal assessment during labor and birth
-Amniotic fluid analysis -FHR monitoring: handheld vs electronic; intermittent vs continuous; external vs internal -FHR patterns: baseline and variability, periodic changes, fetal scalp sampling, pulse ox, stimulation
46
Analysis of amniotic fluid
-Clear when ruptured -Spontaneous or artificial by means of amniotomy (amnihook) -Cloudy or foul-smelling amniotic fluid indicates infection -Green fluid indicates fetus has passed meconium secondary to transient hypoxia, prolonged pregnancy, cord compression, IUGR, maternal HTN, DM, chorioamnionitis (normal if fetus is breeched) -Prevent meconium aspiration syndrome, which can lead to respiratory distress -Necessitates suctioning after head is born and infant takes a breath, trach suctioning if apgar score is low -Amnioinfusion (sterile water or LR's)
47
Analysis of FHR
-Determines fetal oxygen status -Intermittently using fetoscope or a doppler or continuously w/ EFHR
48
Guidelines for assessing FHR
-Initial 10-20 min continuous FHR assessment on entry into labor/birth area -Completion of prenatal and labor risk assessment on all clients -Intermittent auscultation q30 min during active labor for low-risk women and q15 min for high-risk women -During 2nd stage of labor intermittent auscultation q15 min for low-risk women and q5 min for high-risk women
49
Intermittent FHR monitoring
-Auscultation using doppler or fetoscope -For low-risk women -Low in cost and used routinely -Does not document fetal distress during labor -Start listening to FHR at end of contraction so that late decelerations could be detected -Pressure of device is uncomfortable -Auscultation for full min after contraction; from then on, unless there is a problem, listen for 30 sec and multiply value by 2 -Heard best at fetal back or at lower quadrant of maternal abdomen
50
Continuous electronic FHR monitoring
-Uses machine (EFM) to produce continuous tracing of FHR -Recommended for high-risk babies -For women w/ oxytocin finusing, epidural analgesia, HTN, presence of meconium -Produce graphic record of FHR pattern -Primary objective: provide info abt fetal oxygenation and prevent fetal injury from impaired oxygenation, to detect FHR changes early before they are prolonged and profound
51
Continuous external monitoring
-Attached to belt around woman's abdomen -2 ultrasound transducers -Used when membranes intact and cervix is not yet dilated -Measures uterine contractions -Artifact: describes irregular variation or absence of FHR that results from mechanical limitation of monitor or electrical interferance
52
Continuous internal monitoring
-For women or fetuses at high-risk -Multiple gestation, decreased fetal mvmt, abnormal FHR on auscultation, IUGR, maternal fever, preeclampsia, dysfunctional labor, preterm birth, DM, HTN -Spiral electrodes into fetal presenting part (usually head) -Most accurate method -Unlike external monitoring, it detects both short-term changes and variability and FHR dysrhythmias -Also, maternal position changes don't interfere w/ quality of tracing
53
Criteria for using continuous internal monitoring of FHR
-Ruptured membranes -Cervical dilation of at least 2 cm -Present fetal part low enough to allow placement of the scalp electrode -Skilled practitioner available to insert spiral electrode
54
4 categories of baseline variability
-Absent -Minimal -Moderate -Marked
55
Absent
Fluctuation range undetectable
56
Minimal
Fluctuation range observed at < 5 BPM
57
Moderate
Normal fluctuation range from 6-25 BPM
58
Marked
Fluctuation range > 25 BPM
59
Baseline FHR
-Average FHR that occurs during 10-min segment that excludes tachy or brady -Normal: 110-160 BPM
60
Category 1 FHR pattern
-Normal -Predictive of normal fetal acid-base status -No intervention required -FHR 110-160 BPM -Can be monitored via intermittent auscultation
61
Category 2 FHR pattern
-Indeterminate -Not predictive of abnormal fetal acid-base status -Requires evaluation and continued surveillance -FHR > 160 or < 110 BPM -prolonged decelerations > 2 min but < 10 min
62
Category 3 FHR pattern
-Abnormal -Predictive of abnormal fetus acid-base status -Requires intervention -FHR < 110 BPM -Sinusoidal pattern (smooth, undulating baseline)
63
Interventions for category 3 patterns
-Discontinue oxytocin and any other uterotonic agents -Turn client on her L or R lateral, knee-chest, or hands and knees to increase placental perfusion or relieve cord compression -Administer O2 via nonrebreather face mask to increase fetal oxygenation -Increase IV fluid rate to improve intravascular volume and correct maternal hypotension -Assess client for underlying causes -Provide reassurance that interventions are to affect pattern change -Modify pushing in the 2nd stage of labor to improve fetal oxygenation -Document any and all intervention and any changes in FHR patterns -Prepare for an expeditious surgical birth if the pattern is not corrected within 30 min
64
Fetal bradycardia
-Lasts 10 min or more -Caused by fetal hypoxia, prolonged maternal hypoglycemia, fetal acidosis, analgesic drugs, hypothermia, maternal hypotension, fetal hypothermia, prolonged umbilical cord compression, congenital heart block -May be benign if an isolated event, but ominous sign if accompanied by baseline variability and late decelerations
65
Fetal tachycardia
-10 min or more -Early compensatory response to asphyxia -Caused by fetal hypoxia, maternal fever, maternal dehydration, amnionitis, drugs (cocaine, nicotine), maternal anxiety, fetal anemia, maternal hyperthyroidism, prematurity, fetal infection, chronic hypoxemia, congenital anomalies, fetal heart failure, fetal arrhythmias -Ominous sign if accompanied by decrease in variability and late decelerations
66
Baseline variability
-Irregular fluctuations in baseline FHR -Categories: fluctuation range undetectable, range observed at < 5 BPM, range from 6-25 BPM, range > 25 BPM) -Absent or minimal is caused by fetal acidemia --> improve uteroplacental perfusion --> increase IV fluids, oxygen at 8-10 L/min by mask -Moderate indicates CNS is well developed and fetus is oxygenated (good sign of well-being) -Marked variability (> 25 BPM) caused by cord prolapse or compression, uterine hypotension, uterine hyperstimulation, abruptio placenta --> lateral positioning, increased IV fluids, administer oxygen 8-10 L/min by mask, discontinue oxytocin -External monitoring can't assess variability accurately (use an internal monitor instead)
67
Periodic baseline changes
-Temporary, recurrent changes made in response to a stimulus such as a contraction -Accelerations -Decelerations -Sinusoidal pattern
68
Accelerations
-Abrupt increase of FHR > 15 BPM above baseline that lasts > 15 sec but < 2 min from onset to peak -Sympathetic nervous system -Normal, no interventions required
69
Decelerations
-Fall in FHR caused by stimulation of parasympathetic nervous system -Early: symmetrical, apparent, nadir (lowest point) occurs at peak of contraction during active labor; no fetal distress -Late: apparent, symmetrical, occurs after peak of contraction, gradual waveform, FHR doesn't return to baseline well after contraction ends; associated w/ uteroplacental insufficiency; category 2 or 3 FHR; moderate variability can be corrected, chronic episodes are harder to correct -Variable: visually abrupt decreases in FHR below baseline and unpredictable shape (U, V, or W); most common and occur w/ cord compression; category 2 or 3 FHR -Prolonged: abrupt FHR declines > 15 BPM that are > 2 min but < 10 min; drops < 90 BPM; correct underlying cause
70
Sinusoidal pattern
-Visually apparent, smooth, sinewave-like pattern in FHR baseline w/ cycle frequency of 3-6 BPM that persists for > 20 min -True pattern is rare -d/t derangement of CNS control of FHR and occurs when severe degree of hypoxia secondary to fetal anemia and hypovolemia is present -Category 3 FHR -Fetal intrauterine transfusion is needed -Fetus is in marked jeopardy
71
Fetal scalp sampling
-Decreased d/t being replaced by other techniques -Shown to have poor positive predictive value for intrapartum hypoxia -No benefit in reducing C-section rates
72
Umbilical cord blood analysis
-Cerebral palsy often attributed to fetal acidosis d/t low cord pH at birth -Normal range is 7.2-7.3
73
Fetal scalp stimulation
-Indirect method used to eval fetal oxygenation and acid-base balance to identify fetal hypoxia -Vibroacoustic stimulator (artifical larynx) applied to women's lower abdomen and turned on for 3-5 sec to produce sound or vibration or by placing globed finger on fetal scalp and applying firm pressure -Well oxygenated fetus will respond when stimulated by moving in conjunction w/ acceleration of 15 BPM above baseline FHR (pH > 7) -Not done if fetus is preterm or if woman has intrauterine infection, placenta previa, fever
74
Comfort and pain management
-Pain as universal experience; intensity highly variable -Mandate for pain assessment in all clients admitted to health care facility
75
Nonpharmacologic measures for pain management
-Based on the gate control theory of pain -Continuous labor support -Hydrotherapy (stands or sits in shower chair w/ warm water running, whirlpool baths; should be 6 cm dilated) -Ambulation and position changes (walking , changing position q30 min, birthing ball) -Acupuncture and acupressure (stimulating key trigger points w/ needles, releases endorphins) -Attention focusing and imagery (song, music, visual stimuli) -Therapeutic touch and massage (effleurage: light, stroking touch of abdomen, in rhythm w/ breathing during contractions) -Breathing techniques (patterned-paced breathing: slow-paced breathing for 6-9 breaths/min) -Heat or cold
76
Pharmacologic measures
-Systemic analgesia (1 or more drugs orally, IM, or IV; distributed thruout entire body) -Regional or local anesthesia -Neuraxial analgesia (opioids)/anesthesia techniques; use of analgesic or anesthetic, continuously or intermittently into epidural or intrathecal space -Shift in pain management: woman as an active participant during labor
77
Systemic analgesia agents
-Opioids: butorphanol, nalbuphine, meperidine, morphine, fentanyl -Ataractics/antiemetics: hydroxyzine, promethazine, prochlorperazine -Benzodiazepines: diazepam, midazolam -PCA
78
Opioids
-Moderate to severe pain -IV -Cross placental barrier and don't affect labor progress -Newborn respiratory depression, decreased alertness, inhibited sucking, delay in effective feeding -Naloxone given to reverse effects of CNS depression
79
Antiemetics
-Combo w/ opioids to decrease N/V and lessen anxiety -Used to increase sedation -Promethazine IV -Prochlorperazine IV or IM w/ morphine sulfate for sleep during prolonged latent phase -Hydroxyzine PO or IM -No affect on labor progress -May cause a decrease in FHR variability and possible newborn depression
80
Benzodiazepines
-Minor sedative effects -Diazepam IV to stop seizures from eclampsia, causes CNS depression -Calm woman out of control -Lorazepam for tranquilizing effect but increases sedation -Midazolam IV produces good amnesia but no analgesia (adjunct for anesthesia), causes CNS depression
81
Systemic analgesia
-Route: typically parenterally thru existing IV line -Drugs: opioids (butorphanol, nalbuphine), ataractics/antiemetics (hydroxyzine, promethazine), benzodiazepines (diazepam, midazolam)
82
Regional analgesia
-Epidural block: continuous infusion or intermittent injection; usually started when dilation > 5 cm -Below T8 or T10 level of spinal cord -Combined spinal-epidural block ("walking epidural") -Patient-controlled epidural -Local infiltration (usually for episiotomy or laceration repair) -Pudendal block (usually for 2nd stage, episiotomy, or operative vaginal birth) -Intrathecal (spinal) analgesia: during labor and C-section
83
General anesthesia
-Emergency C-section birth or woman w/ contraindication to use of regional anesthesia -IV injection, inhalation, or borth -Commonly, 1st thiopental, propofol IV to produce unconsciousness -Next, muscle relaxant -Then, intubation, followed by administration of nitrous oxide and O2; volatile halogenated agent also possible to produce amnesia -Fetal depression -Administer nonparticulate (clear) oral antacid (bicitra or sodium citrate) or PPI (protonix) to reduce gastric acidity -Wedge under R hip to displace gravid uterus and prevent vena cava compression in supine position
84
1st stage of labor: phone assessment
-Estimated DOB -Fetal movement: frequency in past few days -Other premonitory signs of labor experienced -Parity, gravida, previous childbirth experiences -Time frame in previous labors -Characteristics of contractions -Bloody show and membrane status (whether ruptured or intact) -Presence of supportive adult in household or if she is alone -FHR strips -Checking amniotic fluid for meconium staining, odor, amt -Vaginal exam -Fundal height -Leopold maneuvers
85
Nursing care during 1st stage of labor
-General measures: obtain admission hx, check results of routine lab tests and any special test, ask abt childbirth plan, complete physical assessment -Initial contact either by phone or in person
86
1st stage of labor: admission assessment
-Maternal health hx: physical exam, fundal height, uterine activity, status of membranes, cervical dilatation, FHR, pain level -Fetal assessment -Lab studies: routine (urinalysis, CBC), syphilis screening, HbsAg screening, GBS, HIV (w/ woman's consent), drug screening -Psychological status assessment
87
1st stage of labor: continuing assessment
-Woman's knowledge, experience, expectations -VS -Uterine contractions -Pain level -Coping ability -FHR -Episiotomy has been restricted d/t risk of procedure and unclear benefits of use -Increase in apprehension or irritability -Spontaneous rupture of membranes -Sudden appearance of sweat on upper lip -Increase in blood-tinged show -Low grunting sounds -Complaints of rectal and perineal pressure -Beginning of involuntary bearing-down efforts
88
Nursing management: 2nd stage assessment
-Typical signs of 2nd stage -Contraction frequency, duration, intensity -Maternal VS q5-15 min -Fetal response to labor via FHR q 5-15 min -Amniotic fluid w/ rupture of membranes -Vaginal discharge -Coping status of woman and partner
89
Nursing management: 2nd stage interventions
-Supporting woman and partner in active decision making -Supporting involuntary bearing-down efforts; encouraging no pushing until strong desire or until descent and rotation of fetal head well advanced -Providing instructions, assistance, pain relief -Using maternal positions to enhance descent and reduce pain -Preparing for assisting w/ delivery
90
Nursing management: 2nd stage birthing interventions
-Cleansing of perineal area and vulva -Assisting w/ birth, suctioning of newborn, and umbilical cord clamping -Providing immediate care of newborn: drying, apgar score, identification
91
2nd stage of labor: birthing techniques
-Pushing only when feels an urge to do so -Delaying pushing up for up to 90 min after complete dilation -Using abdominal muscles when bearing down -Short pushes of 6-7 sec -Focusing attention of perineal area to visualize newborn -Relaxing and conserving energy between contractions -Pushing w/ open glottis and slight exhalation
92
2nd stage of labor: immediate care of newborn
-Dry and provide warmth -Some places immediately place baby on mother's abdomen -APGAR score at 1 and 5 min -Appearance (skin color), pulse (HR), grimace (reflex irritability), activity (muscle tone), respiration (breathing) -7 or up is good
93
Nursing management: 3rd stage of labor assessment
-Placental separation (3rd stage is complete when placenta is delivered): firmly contracting uterus, changing in uterine shape from discoid to globular, sudden gush of dark blood, lengthening of umbilical cord -High levels of oxytocin and endorphins and adrenaline -Protect natural hormonal process by ensuring unhurried and uninterrupted contact between mother and newborn after birth -Placenta and fetal membranes exam -Perineal trauma: firm fundus w/ bright red blood trickling --> laceration, boggy fundus w/ red blood flowing --> uterine atony, boggy fundus w/ dark blood and clots --> retained placenta -Episiotomy -Lacerations
94
Nursing management: 3rd stage of labor interventions
-Instructing to push when separation apparent -Giving oxytocin if ordered -Assisting woman to comfortable position -Providing warmth -Applying ice to perineum if episiotomy -Explaining assessments to come -Monitoring mother's physical status -Recording birthing statistics -Documenting birth in birth book
95
Nursing management: 4th stage assessment
-VS stable (q15m during 1st hour then q30m for next hour if needed): pulse 60-70 BPM, fever indicates dehydration (<100.4) or infection (>101) during labor, RR 16-24/min, BP returns to prepregnancy level -Fundus needs to remain firm to prevent excessive hemorrhage (feels like grapefruit, located in midline and below umbilicus), gently massage if boggy -If fundus is displaced to R of midline, suspect full bladder as cause; could cause uterine hemorrhage secondary to bogginess -Perineal area -Comfort level (pain < 3) -Lochia -Bladder status (diuresis should occur)
96
Nursing management: 4th stage interventions
-Support and information -Fundal checks; perineal care and hygiene -Bladder status and voiding -Comfort measures -Parent-newborn attachment -Monitor ability to void -Teach mother how to assess her own fundus -Safety technique education to prevent newborn abduction -Apply ice pack to perineum to reduce -Observe for early parent-infant attachment

Maternity (15 decks)

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