Module 2 INTRAPARTUM - LECTURE 6 Flashcards
Nursing process?
Assessment: This is the first step in the nursing process. Nurses gather data about the patient’s health status, including their physical, emotional, social, and spiritual aspects. This information is collected through interviews, observations, physical examinations, and reviewing medical records.
Diagnosis/Analysis: Based on the data collected during the assessment, nurses analyze the information to identify the patient’s health problems and needs. Nursing diagnoses are different from medical diagnoses and focus on the patient’s response to their health issues.
Planning: After identifying the nursing diagnoses, nurses develop a plan of care. This plan outlines specific goals and interventions that are tailored to address the patient’s unique needs. It also involves setting priorities and establishing a timeline for care.
Implementation: In this step, nurses put the plan into action. They carry out the interventions and treatments outlined in the care plan, with a focus on promoting the patient’s health, preventing complications, and meeting their individual needs.
Evaluation: Continuous assessment and evaluation are crucial in nursing. Nurses assess the patient’s progress and determine whether the interventions are achieving the desired outcomes. If the outcomes are not met, the nurse may need to revise the care plan and make necessary adjustments.
Initial Assessment of Patient
Admit patient to triage: When a pregnant patient arrives at the healthcare facility in labor, they should be admitted to the triage area for initial assessment and evaluation.
POC (Point of Care): Urine dip: This involves conducting a point-of-care urine dipstick test to check for various parameters like protein, glucose, ketones, and signs of urinary tract infection. Abnormalities may indicate potential complications.
Initiate fetal monitoring: Fetal monitoring is crucial to assess the baby’s heart rate and monitor for signs of distress. This can be done externally using a fetal Doppler or internally with a fetal scalp electrode, depending on the clinical situation.
Obtain VS (Vital Signs): Measure the patient’s vital signs, including blood pressure, pulse rate, respiratory rate, and temperature. Monitoring vital signs helps in assessing the mother’s overall health and identifying any abnormalities.
Characteristics of Labor: Assess the characteristics of labor, including the frequency, duration, and intensity of contractions. This information helps determine the stage of labor and progression.
Assess for VB (Vaginal Bleeding): Check for any signs of vaginal bleeding, as it can be an alarming symptom during labor and may indicate complications.
Assess FM (Fetal Movement): Subjective: Ask the mother about fetal movement. Decreased or absent fetal movement can be a sign of fetal distress.
Check for Ruptured Membranes/Dilation: Examine the patient to determine if the amniotic membranes have ruptured (water has broken). Assess cervical dilation and effacement to gauge the progress of labor.
Prenatal Record: Review the patient’s prenatal record to gather information about the pregnancy history, any known medical conditions, previous pregnancies, and prenatal care history.
Physical Exam: Including high-risk s/sx (Signs and Symptoms): Perform a comprehensive physical examination, paying attention to any signs or symptoms that may indicate high-risk conditions or complications, such as pre-eclampsia, gestational diabetes, or infections.
Report to provider: Communicate the findings and assessment results to the healthcare provider (physician or midwife) responsible for the patient’s care. The provider can then make informed decisions regarding further management and interventions.
Admit or Send Home?
Is the patient in active labor?
Assess the characteristics of contractions, including their frequency, duration, and intensity.
Evaluate cervical dilation and effacement.
Active labor typically involves regular contractions, cervical dilation of at least 4 cm, and progressive effacement.
ROM (Rupture of Membranes)? GBS status (Group B Streptococcus (GBS) ?
Determine if the patient’s amniotic membranes have ruptured (water has broken).
Assess the patient’s Group B Streptococcus (GBS) status to determine if they require prophylactic antibiotics during labor.
Coping well?
Evaluate the patient’s ability to cope with pain and discomfort. This may include their pain management preferences and overall emotional well-being.
Labor History (Labor Hx)?
Consider the patient’s previous labor history, especially if there were complications or unique circumstances in prior pregnancies and deliveries.
High-risk diagnoses (High risk dx)?
Identify any high-risk conditions or complications that the patient may have, such as pre-eclampsia, gestational diabetes, or a history of preterm labor.
Fetal concerns?
Assess the well-being of the baby, which may include fetal heart rate monitoring.
Evaluate any concerns or signs of fetal distress.
Based on these considerations, you can make a decision regarding admission or discharge:
Earlier Admission: If the patient is in active labor, their water has broken (ROM), they are GBS positive, coping poorly, have a history of high-risk complications, or there are fetal concerns, earlier admission may be necessary. This could involve interventions such as pain management, administration of antibiotics for GBS, or close fetal monitoring.
Delayed Admission: If the patient is not yet in active labor, their membranes are intact, they are GBS negative, coping well, have a history of straightforward pregnancies, and there are no immediate fetal concerns, delayed admission may be considered. This approach allows for a more natural progression of labor without unnecessary interventions.
Diagnosing Rupture of Membranes
What’s the difference?
PROM (Preterm Rupture of Membranes): PROM occurs when the amniotic sac (membranes) ruptures before 37 weeks of gestation. This is a concern because it can lead to preterm birth, which carries risks for the baby. Diagnosing PROM involves a clinical assessment, which may include:
Confirming the presence of amniotic fluid leakage through a physical examination (e.g., sterile speculum exam, nitrazine paper or ferning test).
Ultrasound evaluation to assess the amniotic fluid volume and the status of the membranes.
PPROM (Preterm Premature Rupture of Membranes): PPROM is a specific subset of PROM that occurs before 37 weeks of gestation and before the onset of labor. PPROM is a concerning condition as it may lead to infection, premature birth, and other complications. Diagnosing PPROM involves the same methods as PROM.
SROM (Spontaneous Rupture of Membranes): SROM refers to the spontaneous rupture of membranes, typically during the course of labor when contractions have started. It can also occur in late pregnancy. In SROM, the amniotic sac breaks naturally without any external intervention. The diagnosis is often straightforward because there is usually a clear gush of amniotic fluid and other clinical signs.
AROM (Artificial Rupture of Membranes): AROM is the deliberate rupture of the amniotic sac by a healthcare provider using a sterile instrument, such as an amnihook, during labor. This procedure is often done to augment labor or facilitate internal monitoring of the baby’s status. AROM is different from SROM because it is intentionally initiated by a healthcare provider.
In summary, the key differences between these terms lie in the timing and circumstances of the membrane rupture:
PROM and PPROM both involve the rupture of membranes before 37 weeks of gestation, with PPROM specifically referring to preterm rupture before the onset of labor.
SROM refers to the spontaneous rupture of membranes during labor or late pregnancy, and it occurs naturally.
AROM is the artificial or medically induced rupture of membranes by a healthcare provider during labor or for specific medical reasons.
Diagnosing Rupture of Membranes
Nitrazine Test: The nitrazine test involves using nitrazine paper or strips to assess the pH level of vaginal secretions. Amniotic fluid has a pH level of around 7 to 7.5, which is more alkaline compared to the vaginal secretions. Therefore, if the nitrazine test strip turns blue (indicating alkalinity), it may suggest the presence of amniotic fluid. However, other factors, such as infections or semen, can also affect pH levels, so this test is often used in conjunction with other assessments.
Pooling: Pooling refers to the collection of amniotic fluid in the vaginal fornix. During a speculum exam, if a healthcare provider observes a visible pool of amniotic fluid in the vaginal canal, it is a strong indicator of ROM. Pooling is a visual sign of amniotic fluid leakage.
Fern Test (Ferning Test): The ferning test involves examining a sample of vaginal fluid under a microscope. When amniotic fluid dries on a glass slide, it forms a fern-like pattern due to the crystallization of proteins and salt present in the fluid. This unique ferning pattern is characteristic of amniotic fluid and can be observed under the microscope. It is a specific and reliable indicator of ROM.
Speculum Exam: A speculum exam is a physical examination performed by a healthcare provider using a speculum to visualize the cervix and vaginal canal. During this exam, the provider can assess for signs of amniotic fluid leakage, such as pooling and the presence of ferning.
Cervical Fluid Microscopic Examination: In some cases, cervical fluid collected with a swab may be viewed under a microscope to look for ferning patterns, which can further support the diagnosis of ROM.
vagina vs vaginal vault ?
Vagina: The vagina is the muscular, tubular structure that connects the external genitalia (vulva) to the cervix of the uterus. It serves several functions, including as the birth canal during childbirth and as a passageway for menstrual flow to exit the body. The vaginal walls are lined with mucous membranes and are capable of stretching to accommodate various activities, such as sexual intercourse.
Vaginal Vault: The vaginal vault is a specific anatomical term that refers to the upper portion or end of the vagina. After a hysterectomy, which is the surgical removal of the uterus, the lower part of the uterus is typically removed, leaving the upper part, which is sometimes referred to as the vaginal vault. In other words, the vaginal vault is the top part of the vagina where it connects to the cervix when the uterus is still intact.
The distinction between these terms is important in the context of gynecological procedures and surgery, especially when discussing the removal of the uterus. After a hysterectomy, the vaginal vault may be closed or sutured, depending on the type of surgery performed. It’s also relevant in discussions related to the anatomy of the female reproductive system and gynecological examinations.
Nitrazine Testing for ROM
The nitrazine test, also known as the nitrazine paper test, is a diagnostic tool used to determine whether the amniotic membranes (the sac surrounding the baby in the womb) have ruptured during pregnancy. The test relies on measuring the pH level of vaginal fluids to distinguish between amniotic fluid (which is alkaline) and other vaginal secretions (which are typically acidic). The color changes on the nitrazine paper correspond to different pH levels, as you’ve described:
For acidic pH (indicating that the membranes are likely not ruptured):
Yellow = pH 5.0
Olive-yellow = pH 5.5
Olive-green = pH 6.0
For alkaline pH (indicating that the membranes may have ruptured):
Blue-green = pH 6.5
Blue-gray = pH 7.0
Deep blue = pH 7.5
The principle behind this test is that amniotic fluid, when it comes into contact with the nitrazine paper, causes the paper to turn a color in the alkaline range (blue-green to deep blue), while vaginal secretions remain in the acidic pH range (yellow to olive-green).
A positive result (alkaline pH) suggests that the membranes may have ruptured, while a negative result (acidic pH) indicates that the membranes are likely intact. It’s important to note that while the nitrazine test can be a useful initial indicator of ruptured membranes, it may not always provide a definitive diagnosis. In cases where there is uncertainty or the clinical presentation is unclear, additional assessments, such as a ferning test or clinical examination, may be used to confirm the diagnosis of ruptured membranes.
What else has a ph of 7.4-7.5?
A pH range of 7.4 to 7.5 is slightly alkaline, and several biological fluids in the human body fall within this range. Here are some examples of bodily fluids and substances with a pH in this range:
Blood: Arterial blood in a healthy human typically has a pH of around 7.4, making it slightly alkaline. Maintaining this pH level is crucial for the normal functioning of enzymes and metabolic processes in the body.
Cerebrospinal Fluid (CSF): The pH of cerebrospinal fluid, which surrounds the brain and spinal cord, is generally around 7.4. This stable pH helps protect and maintain the health of the nervous system.
Intracellular Fluid: The pH inside most cells in the body is maintained close to 7.4. This is important for cellular processes and maintaining cellular health.
Interstitial Fluid: The fluid that surrounds cells in tissues, known as interstitial fluid, also typically has a pH around 7.4. This pH is important for the exchange of nutrients, gases, and waste products between cells and the bloodstream.
Saliva: Saliva in a healthy individual typically has a slightly alkaline pH, ranging from about 7.4 to 7.6. Saliva pH can vary slightly depending on factors like diet and hydration.
Urine: The pH of urine can vary depending on several factors, including diet and health. In a healthy individual, urine pH tends to be slightly acidic (around 6 to 6.5) but can become more alkaline (closer to 7.4) under certain conditions or with specific diets.
Semen: Semen, the fluid ejaculated during sexual activity, is typically alkaline, with a pH ranging from 7.2 to 8.0. This alkaline pH helps to neutralize the acidity of the vaginal environment, providing a more hospitable environment for sperm.
Sterile Vaginal Exam (SVE)
A Sterile Vaginal Exam (SVE), also known as a Sterile Speculum Exam, is a medical procedure performed by healthcare professionals to examine the vagina and cervix. It is called “sterile” because it involves the use of sterile instruments and techniques to minimize the risk of infection during the examination.
Here is an overview of the steps involved in a Sterile Vaginal Exam:
Preparation: The healthcare provider, often an obstetrician, gynecologist, or nurse, prepares for the exam by washing their hands thoroughly and wearing sterile gloves and a sterile gown. They also assemble the necessary sterile equipment, including a speculum and a light source.
Patient Preparation: The patient is typically asked to lie on their back on an examination table with their feet in stirrups, allowing for proper access and visibility. The patient may be covered with a drape for privacy.
External Examination: The healthcare provider may begin with an external examination, inspecting the vulva (external genitalia) for any abnormalities, signs of infection, or visible lesions.
Speculum Insertion: A sterile speculum, which is a metal or plastic instrument shaped like a duckbill, is inserted gently into the vagina. The speculum is gradually opened to allow a clear view of the cervix.
Cervical Examination: With the cervix visible through the speculum, the healthcare provider can assess various aspects of the cervix, including its position, size, color, and the presence of any discharge or abnormalities. They may also perform procedures like a Pap smear or collect samples for various tests if indicated.
Palpation (Optional): In some cases, the healthcare provider may use their gloved fingers to gently palpate (feel) the cervix and surrounding structures to assess for tenderness, masses, or other abnormalities.
Speculum Removal: Once the examination is complete, the speculum is carefully removed from the vagina.
Patient Education and Discussion: The healthcare provider may discuss their findings with the patient, answer any questions, and provide recommendations for further evaluation or treatment if necessary.
sve
During a Sterile Vaginal Exam (SVE), healthcare providers may assess three important aspects related to labor and childbirth: dilation, effacement, and station. These measurements help determine the progress of labor and the positioning of the baby in the birth canal.
Dilation: Dilation refers to the opening of the cervix. It is measured in centimeters (cm) and is an essential indicator of labor progress. The cervix starts out closed (0 cm) and needs to dilate to 10 cm or fully open for the baby to pass through the birth canal. Dilation typically occurs gradually during the active phase of labor, with each centimeter of dilation representing progress toward childbirth.
Effacement: Effacement, also known as cervical effacement or effacement of the cervix, describes the thinning and shortening of the cervix. Effacement is expressed as a percentage. For example, if the cervix is 50% effaced, it means that it is halfway thinned and shortened compared to its original length. Effacement typically occurs along with dilation as the cervix prepares for labor. A fully effaced cervix is often necessary for the baby’s head to descend and engage in the pelvis.
Station: Station refers to the position of the baby’s head (or presenting part) in relation to the mother’s pelvis. It is usually measured in relation to the ischial spines of the maternal pelvis. The ischial spines are bony landmarks in the pelvis, and their level is designated as “zero station.” A baby’s station can be described as negative (above the ischial spines) or positive (below the ischial spines). For example, a baby at -2 station means the baby’s head is 2 cm above the ischial spines, while a baby at +2 station means the head is 2 cm below the ischial spines. As labor progresses, the baby typically descends deeper into the pelvis (moves to a more positive station).
These measurements are crucial for healthcare providers to assess the progress of labor, determine the stage of labor, and make decisions regarding the management of labor and potential interventions. Monitoring dilation, effacement, and station helps ensure the safe and effective progression of labor and the well-being of both the mother and the baby.
Assessment ofVaginal bleeding
Assessing vaginal bleeding during pregnancy is a crucial aspect of prenatal care, labor, and delivery. Here are some key points to consider when assessing vaginal bleeding:
Bloody Show: The “bloody show” is a term used to describe the passage of a small amount of blood-tinged mucus from the vagina, often seen as a pink or brownish discharge. It can be a normal part of late pregnancy or early labor as the cervix begins to dilate and efface. It’s generally not a cause for concern unless accompanied by other concerning symptoms.
Scant Bleeding Normal After SVE: After a Sterile Vaginal Exam (SVE), it’s not uncommon for the patient to have a small amount of vaginal bleeding or spotting. This is usually due to the manipulation of the cervix during the examination and is generally considered normal.
Reporting Vaginal Bleeding to Healthcare Provider: Any vaginal bleeding during pregnancy should be reported to the healthcare provider (MD/CNM) promptly. While some bleeding can be normal (such as bloody show), it’s essential to rule out potentially serious causes.
Closely Monitoring Moderate to Heavy Bleeding: Any moderate to heavy vaginal bleeding during pregnancy is concerning and should be closely monitored. Healthcare providers may use pad counts or weights to quantify the amount of bleeding. Heavy bleeding can indicate a potential problem and requires immediate medical attention.
Sources of Abnormal Bleeding: Several serious conditions can cause abnormal vaginal bleeding during pregnancy, including:
Placenta Previa: This condition occurs when the placenta partially or completely covers the cervix. It can cause painless vaginal bleeding, often in the later stages of pregnancy. Placenta previa is a medical emergency and requires immediate attention.
Placental Abruption: Placental abruption is the premature separation of the placenta from the uterine wall. It can cause painful vaginal bleeding and can be life-threatening for both the mother and the baby. Immediate medical intervention is necessary.
Assessment of uterine activity
Subjective Assessment (Patient’s Report):
During labor, healthcare providers often start by asking the patient questions to obtain subjective information about uterine contractions. These questions can include:
“Can you describe the sensation or pain you’re feeling during contractions?”
“How frequent are your contractions?”
“How long do your contractions typically last?”
“Have you noticed any changes in the intensity of your contractions?”
“Are there any other sensations, such as back pain, associated with your contractions?”
The patient’s responses provide valuable information about their perception of uterine activity and can help healthcare providers gauge the progress of labor.
Objective Assessment:
Objective assessment involves clinical observations and measurements performed by healthcare providers. It includes:
Palpation: Healthcare providers use their hands to palpate the patient’s abdomen to assess the strength and frequency of uterine contractions. They may describe contractions as “mild,” “moderate,” or “strong.” This assessment can help determine the progress of labor and whether contractions are effective in cervical dilation and effacement.
Observation: Healthcare providers visually observe the patient for signs of uterine contractions. This can include noting the abdominal wall tightening and relaxation associated with contractions.
Tocometer: A tocometer is an external monitoring device that measures uterine contractions. It consists of sensors placed on the patient’s abdomen to detect changes in uterine activity. The tocometer provides continuous data on the frequency and duration of contractions.
IUPC (Intrauterine Pressure Catheter): In some cases, particularly when more precise monitoring is needed, an IUPC may be used. This is a thin catheter that is inserted through the cervix and placed inside the uterine cavity to directly measure the pressure generated by uterine contractions. It provides real-time data on the strength and frequency of contractions and is commonly used in situations like labor inductions or high-risk pregnancies.
uterine contractions during labor, specifically focusing on the assessment of contractions.
Contractions: Contractions refer to the rhythmic tightening and relaxing of the uterine muscles during labor, which help in the progress of labor and the eventual delivery of the baby.
Assessment of Contractions:
Increment: Building (longest phase): The increment phase of a contraction is when the uterine muscles start to tighten and build in intensity. It is the longest part of a contraction.
Acme: Peak: The acme phase is the peak or climax of a contraction. It’s when the uterine muscles are at their strongest and most intense.
Decrement: Ending: The decrement phase is the gradual relaxation and ending of the contraction. This is when the uterine muscles start to release their tension.
Describe contractions:
Frequency: Frequency refers to how often contractions occur, typically measured from the beginning of one contraction to the beginning of the next.
Duration: Duration is the length of time a contraction lasts, typically measured from the beginning of a contraction to its end.
Intensity: Intensity refers to the strength or palpation of contractions. Contractions can be categorized as mild, moderate, or strong based on how intense they feel when touched or palpated externally or internally using a uterine catheter.
Resting tone: Resting tone refers to the baseline tension in the uterine muscles between contractions. It’s the level of uterine muscle activity when no contractions are occurring. Monitoring resting tone is important to ensure that the uterus is relaxing adequately between contractions, allowing for proper blood flow to the baby and preventing excessive fatigue of the uterine muscles.
Location of fetal heart
RSA - Right Sacroanterior: This refers to a fetal position where the baby’s back is on the right side of the mother’s abdomen, and the baby is facing toward the front (anterior) with the sacrum (the lower part of the spine) positioned toward the mother’s anterior pelvis.
ROP - Right Occipitoposterior: This describes a fetal position where the baby’s occiput (the back of the head) is on the right side of the mother’s pelvis, and the baby is facing toward the back (posterior).
RMA - Right Mentoanterior: This refers to a fetal position where the baby’s chin (mentum) is on the right side of the mother’s pelvis, and the baby is facing toward the front (anterior).
ROA - Right Occipitoanterior: In this position, the baby’s occiput (the back of the head) is on the right side of the mother’s pelvis, and the baby is facing toward the front (anterior).
LSA - Left Sacroanterior: This position indicates that the baby’s back is on the left side of the mother’s abdomen, and the baby is facing toward the front (anterior) with the sacrum (the lower part of the spine) positioned toward the mother’s anterior pelvis.
LOP - Left Occipitoposterior: This describes a fetal position where the baby’s occiput (the back of the head) is on the left side of the mother’s pelvis, and the baby is facing toward the back (posterior).
LMA - Left Mentoanterior: In this position, the baby’s chin (mentum) is on the left side of the mother’s pelvis, and the baby is facing toward the front (anterior).
LOA - Left Occipitoanterior: This position indicates that the baby’s occiput (the back of the head) is on the left side of the mother’s pelvis, and the baby is facing toward the front (anterior).
Case Study:
Patient presents ambulatory to triage at 03:00 a.m. Reports this is her first baby and states she has never been pregnant before when questioned by RN. State, “the baby was due yesterday”. States Uterine Contractions (Ucs) started 4 hours ago and have increased in frequency/intensity. Reports UCs now q5, w/ intermittent, low abd pain 7/10 on pain scale. Pt stops conversation to focus on breathing during UCs. Reports small amount of mucous d/c per vagina streaked w/ blood x one hour ago, and sensation of “wetting pants” on car ride to hospital. Reports fm wnl.
Case study: Nursing Interventions:
Obtain weight/height:
Obtain the patient’s weight and height to assess baseline health parameters and calculate the patient’s body mass index (BMI). This information is useful for monitoring overall health during pregnancy.
Obtain urine specimen & perform POC (Point of Care):
Collect a urine specimen to perform a point-of-care test, such as a dipstick urinalysis. This can help assess for proteinuria (a possible sign of preeclampsia) and urinary tract infections, which can be common during pregnancy.
Assess VS (Vital Signs):
Monitor the patient’s vital signs, including blood pressure, pulse, respiratory rate, and temperature. Frequent monitoring is essential to detect any signs of maternal distress.
Assess labor signs/symptoms & fetal wellbeing:
Continuously monitor the patient’s uterine contractions (UCs) to assess their frequency, duration, and intensity.
Perform fetal heart rate monitoring to assess fetal wellbeing. Ensure that the fetal heart rate (fm) remains within the normal range (wnl).
Review hx (History):
Review the patient’s medical history and obstetric history, including any past medical conditions, surgeries, allergies, and prenatal care. This information can help in providing appropriate care.
Assess symptoms related to specific diagnosis:
Assess the patient’s specific symptoms, such as the reported uterine contractions, abdominal pain, mucous discharge streaked with blood, and the sensation of “wetting pants.” Document the findings accurately to monitor changes over time.
Report to provider:
Communicate all relevant findings and assessments to the healthcare provider or obstetrician. This includes the patient’s vital signs, fetal heart rate, cervical dilation if checked, and any concerning symptoms or complications. Prompt reporting ensures timely decision-making regarding the course of care, such as the need for admission, induction, or other interventions.
CASE STUDY:
ADDITIONAL DATA
Urine: The urine analysis results continue to show that all values are negative, and the specific gravity (SG) is 1.010, which is within the normal range. There are no signs of urinary tract infection or proteinuria.
VS (Vital Signs):
Blood Pressure (BP): 102/66 mmHg - Blood pressure remains within the normal range.
Respiratory Rate (RR): 18 breaths per minute - Normal respiratory rate.
Heart Rate (HR): 78 beats per minute - Normal heart rate.
Temperature (T): 37.0°C - Normal body temperature.
Oxygen Saturation (O2 sat): 98% - Normal oxygen saturation.
Height/Weight: The patient’s BMI of 23 is indicative of a healthy weight for her height.
Fetal Heart Rate (FHR): The fetal heart rate remains at 145 bpm, categorized as Category I, with accelerations (accels) x 2. This indicates a normal and reassuring fetal heart rate pattern.
Uterine Activity: Uterine contractions (UCs) occur approximately every 4-5 minutes, lasting 70 seconds each, with moderate palpation. These contractions continue to suggest active labor and progressive cervical dilation.
SVE (Sterile Vaginal Examination): Sterile vaginal examination has been deferred, meaning that a cervical check has not been performed at this time.
Leopold’s Maneuvers: Leopold’s maneuvers confirm a vertex (cephalic) presentation, with the baby’s occiput on the right (ROA). This confirms the position of the baby’s head, which is an important aspect of labor assessment.
Based on the provided data, the patient remains in active labor with reassuring signs of fetal well-being. Her vital signs, urine analysis, and fetal heart rate are all within normal limits. The Leopold’s maneuvers have confirmed the fetal presentation, which is cephalic.
Continued monitoring of contractions, fetal heart rate, and maternal comfort is essential. Communication with the healthcare provider should be maintained to determine the appropriate timing for a cervical examination and to discuss any potential interventions as labor progresses. Pain management options should also be considered and discussed with the patient to ensure her comfort during labor.
Report to Provider
S: Situation
Age: [Patient’s Age]
G_P_: [Patient’s Gravida and Para]
Gestational Age: [Patient’s Gestational Age]
Presenting Symptom: [Brief description of the patient’s complaint]
B: Background
Patient’s medical history: [Brief summary of the patient’s relevant medical history]
Obstetric history: [Brief summary of the patient’s obstetric history]
Current pregnancy status: [Brief summary of the current pregnancy status, if applicable]
A: Assessment Findings
Vital Signs: [Include vital signs such as blood pressure, heart rate, temperature, and respiratory rate, if available]
Physical Examination: [Describe any relevant physical findings, such as uterine contractions, fetal heart rate, cervical dilation, etc., as applicable]
Laboratory and Diagnostic Results: [Include any pertinent lab or diagnostic results, such as ultrasound findings, blood test results, etc., if available]
Obstetric Assessment: [Summarize the assessment related to the patient’s obstetric condition, including the condition of the fetus if applicable]
Pain Level: [Rate the patient’s pain level on a scale from 0-10, if applicable]
R: Recommendation
Plan: [Describe the proposed plan of care, including any interventions, treatments, or consultations needed]
Follow-up: [Indicate the recommended follow-up actions or monitoring]
Provider Orders: [Include any specific orders or medications prescribed]
Family/Patient Education: [Note any education provided to the patient or family]
Disposition: [Indicate the recommended disposition of the patient, such as admission, discharge, or transfer]
Signs of Possible
Intrapartum Complications
Increased Intrauterine Pressure (IUP): Elevated uterine pressure can indicate potential issues. Monitor closely for any significant rise in IUP.
Contractions Lasting > 90 Seconds: Contractions lasting longer than 90 seconds can lead to decreased fetal oxygenation and potential complications. Timely intervention may be necessary.
Tachysystole: (fast squeezing) Tachysystole, defined as more than 5 uterine contractions in 10 minutes, averaged over 30 minutes, can reduce fetal oxygen supply. Close monitoring and intervention may be required.
Abnormal Fetal Heart Tracing (Category II or III): Abnormal fetal heart rate tracings, categorized as II or III, indicate fetal distress. Immediate assessment and potential interventions are crucial to safeguard fetal well-being.
Amniotic Fluid Abnormalities: Meconium-stained, cloudy, or foul-smelling amniotic fluid can be indicative of fetal distress or infection. It requires careful monitoring and evaluation.
Labor Dystocia (Failure to Progress/FTP): Prolonged labor with failure to progress can lead to maternal and fetal complications. Consider interventions, such as augmentation or cesarean section, if appropriate.
Maternal Temperature > 38°C: Maternal fever during labor may suggest infection. It requires prompt evaluation, possible administration of antibiotics, and monitoring of fetal well-being.
Foul-Smelling Discharge: A foul-smelling discharge can be a sign of infection in the postpartum period. Immediate assessment and treatment are necessary.
Continuous Bright Red Bleeding: Continuous bright red bleeding during labor may indicate placental abruption or other significant bleeding issues. Rapid assessment and intervention are essential.
Common intrapartum NURSING DIAGNOSES
Impaired Communication: This diagnosis might apply when a pregnant person has difficulty expressing their needs, concerns, or understanding instructions due to factors like language barriers, pain, or anxiety.
Anxiety and Fear: Anxiety and fear can be common emotions during labor and delivery. Nurses assess and address these emotions to provide emotional support and reduce stress.
Risk for Injury: This diagnosis indicates that there is a risk that the pregnant person or the fetus may sustain an injury during labor and delivery. It may be due to factors such as difficult labor or the position of the fetus.
Pain: Pain management is a critical aspect of intrapartum care. Nurses assess the level of pain and implement pain relief strategies, which can include medications, relaxation techniques, or positioning.
Fluid Volume Deficit: This diagnosis is used when there is a risk or evidence of decreased fluid volume in the body. Maintaining adequate hydration is essential during labor and delivery.
Impaired Physical Mobility: During labor, a pregnant person’s mobility may be restricted due to monitoring equipment or epidural anesthesia. This diagnosis is relevant when mobility is limited, and interventions are needed to improve mobility and prevent complications.
Altered Pattern Urinary Elimination: Changes in urinary elimination patterns can occur during labor. Nurses monitor urinary output and address any issues, such as urinary retention or incontinence.
Risk of Infection: Infection is a concern during labor and delivery. Nurses assess for signs of infection and take measures to prevent its occurrence.
Impaired Gas Exchange, Fetal: This diagnosis is related to concerns about the exchange of oxygen and carbon dioxide between the mother and the fetus. It is closely monitored to ensure the well-being of the baby.
Ineffective Family Coping: Labor and delivery can be a stressful time for the family, and this diagnosis is used when family members are struggling to cope with the situation. Nurses provide support and education to help them manage their stress and emotions.
Knowledge Deficit: Some pregnant individuals may lack knowledge about the labor and delivery process or may have misconceptions. Nurses provide education and information to address any knowledge gaps and promote informed decision-making.
Common intrapartumNURSING interventions
Assessments/Monitoring: Continuous assessment and monitoring of the pregnant person’s vital signs, fetal heart rate, contractions, and cervical dilation are crucial. This information helps the healthcare team make informed decisions about the progress of labor and any necessary interventions.
Fluid Intake: Oral/IV: Maintaining proper hydration is important during labor. Nurses may encourage the pregnant person to drink clear fluids or provide intravenous (IV) fluids when necessary to prevent dehydration and ensure an adequate blood volume.
Bladder/Bowel Evacuations: Nurses assist with regular bladder and bowel evacuations to ensure the bladder is empty and there is less pressure on the uterus during contractions, which can help progress labor.
Pain Management: Providing pain relief options, such as medications (e.g., epidurals, analgesics), comfort measures (e.g., massage, breathing techniques), and positioning, is a critical nursing intervention to help the pregnant person manage pain and discomfort during labor.
Ambulation & Position Changes: Encouraging the pregnant person to change positions, walk, or use birthing balls can help facilitate labor progress and provide comfort. Different positions can also help relieve pressure and pain.
Nutritional Needs: Assessing and addressing the nutritional needs of the pregnant person, such as offering light snacks and clear fluids, helps maintain energy levels during labor, especially for those with long labors.
Emotional Support: Emotional support is essential throughout labor. Nurses provide reassurance, comfort, and encouragement, addressing the emotional needs of the pregnant person and their support system.
Integrating Care Team: Coordinating care with other healthcare providers, including obstetricians, midwives, and doulas, ensures a collaborative approach to intrapartum care. Involving family and friends as a source of support, per the pregnant person’s preferences, can also enhance the birthing experience.
Education and Informed Decision-Making: Nurses provide information and education about the labor process, interventions, and options to empower the pregnant person to make informed decisions about their care.
Fetal Monitoring: Continuous or intermittent fetal monitoring helps assess the well-being of the baby during labor. Nurses interpret and respond to fetal heart rate patterns and other indicators of fetal health.
Infection Control: Ensuring a sterile environment and practicing proper infection control measures helps reduce the risk of infection during labor and delivery.
Supporting Natural Labor Progression: Nurses encourage and support the natural progression of labor, avoiding unnecessary interventions when possible while keeping the healthcare team informed of any deviations from the normal course of labor.
Part 2 Nursing care in the first stage of labor
Components of Nursing care: stage 1
- Early Phase of Labor:
Monitoring the Labor Patient:
Vital Signs (VS): Regularly assess blood pressure, heart rate, respiratory rate, and temperature to monitor the patient’s overall condition.
Screenings and Assessments: Perform initial assessments, including cervical dilation, effacement, station, and fetal heart rate monitoring.
Fetal Assessment: Continuously monitor the fetal heart rate to ensure the baby’s well-being.
Pain Management/Labor Support: Assess the patient’s pain level and provide comfort measures such as relaxation techniques, breathing exercises, and positioning. Offer pain relief options as appropriate.
Communication with Team: Collaborate with the healthcare team, including obstetricians, midwives, and other support staff, to ensure coordinated care.
Consider Maslow’s Hierarchy: Address the patient’s physiological and safety needs by monitoring vital signs and providing pain relief.
2. Active Phase of Labor:
Monitoring the Labor Patient:
Continue monitoring vital signs, cervical dilation, effacement, and station. Assess for progression of labor.
Fetal Assessment: Maintain continuous fetal heart rate monitoring, paying close attention to any changes or signs of distress.
Pain Management/Labor Support: Continue to provide pain relief measures and support as labor intensifies.
Communication with Team: Update the healthcare team on the progress of labor and any changes in the patient’s condition.
Consider Maslow’s Hierarchy: Address the patient’s physiological and safety needs, ensuring their comfort and safety during active labor.
3. Transition Phase of Labor:
Monitoring the Labor Patient:
Frequent monitoring of vital signs, cervical dilation, effacement, and station is crucial during this intense phase.
Fetal Assessment: Maintain continuous fetal heart rate monitoring, as the baby’s well-being remains a top priority.
Pain Management/Labor Support: Provide strong pain relief measures and emotional support, as this phase is often the most challenging for the patient.
Communication with Team: Communicate effectively with the healthcare team to ensure a smooth transition phase and respond to any emergent situations promptly.
Consider Maslow’s Hierarchy: Address the patient’s physiological and emotional needs during this phase, focusing on pain relief and emotional support.
Nursing care in the first stage of labor:Pain management
Part of a Normal Process: Pain during the first stage of labor is a normal physiological response to uterine contractions as the cervix dilates and effaces. It’s important for healthcare providers to reassure the laboring person that this pain is a normal part of the birthing process and can be managed effectively.
Intensity Increases as Labor Progresses: Pain during the first stage of labor typically starts as mild discomfort and gradually intensifies as contractions become stronger and more frequent. Nursing care involves assessing and addressing the changing intensity of pain.
Occurs in a Predictable Pattern with Regular Respite (in a Normal Labor): Contractions in a normal labor follow a predictable pattern. They begin, peak in intensity, and then subside, providing periods of rest between contractions. Nurses assist the laboring person in recognizing this pattern and utilizing the rest periods for relaxation and recovery.
Ends with the Birth of the Baby: Pain during the first stage of labor ends when the cervix is fully dilated, and it’s time to push and give birth to the baby. Nursing care during this phase includes preparing the laboring person for the transition to the second stage of labor.
Nursing interventions for pain management during the first stage of labor can include:
Providing emotional support: Offering encouragement, reassurance, and a calming presence.
Teaching relaxation techniques: Guiding the laboring person in deep breathing, visualization, and progressive muscle relaxation exercises to help manage pain.
Position changes: Encouraging changes in position (e.g., walking, rocking, squatting) to optimize comfort and progress labor.
Medications: Administering pain relief medications as ordered, which may include epidurals, analgesics, or other pharmacological interventions.
Hydrotherapy: Offering the option of a warm shower or bath, which can help alleviate pain and provide relaxation.
Monitoring and reassessment: Continuously assessing pain levels and adjusting pain management strategies as needed.
Advocating for the patient: Ensuring that the patient’s preferences and comfort are prioritized in the birthing plan.
Providing information and consent: Explaining pain relief options, their risks and benefits, and obtaining informed consent for interventions.
Sources of Pain: Stage 1
Uterine Anoxia: Uterine anoxia refers to a temporary decrease in the oxygen supply to the uterine muscles during contractions. As the uterus contracts and tightens during labor, it can temporarily reduce blood flow to the uterine muscles. This decreased oxygen supply can result in pain and discomfort, often described as cramping or aching sensations. These contractions are responsible for cervical dilation and effacement, which are essential for the progress of labor.
Stretching of the Cervix: The cervix is the lower part of the uterus that needs to dilate (open) and efface (thin out) to allow the baby to pass through the birth canal. As the cervix gradually stretches and opens, it can cause pain and discomfort. This stretching sensation is often described as intense pressure or aching in the lower abdomen and pelvis.
Stretching of the Uterine Ligaments: The uterus is held in place by various ligaments that support its position in the pelvis. As the uterus contracts and the baby descends during labor, these ligaments are stretched and may cause pain. The stretching of uterine ligaments can lead to sensations of pulling or sharp discomfort in the lower abdomen and pelvic area.
