Nursing Care of Family during Labour Flashcards
First Stage of Labour
- begins with regular uterine contractions
- ends with cervical effacement and dilation
- Obstetric triage
- Prenatal data (nurse reviews the prenatal record to identify the woman’s individual needs and risks)
First stage of Labour: Latent phase
up to 3 cm of dilation
First stage of Labour: Active phase
4-7 cm of dilation
First stage of Labour: Transition phase
8-10 cm of dilation
First stage of Labour: Assessment and nursing diagnosis
Determination of whether the woman is in true labor or false labor
- contractions
- cervix
- fetus
Obstetric triage
- a woman is considered to be in true labor until a qualified provider determines that she is not
Admission to the labour unit
Admission data
- prenatal data
- interview (SROM, bloody or pink show?)
Psychosocial factors
- women with history of sexual abuse
Stress in labour
Cultural factors
- woman may have a preconceived idea of the “right” way to behave
- culture and father participation
- non-english speaking woman in labour
True labor
rhythmic contractions, effacement, and the cervix is dilating. Fetus in engaged
First stage: Physical Examination
- General systems assessment
- Vital signs
- Leopold maneuvers (abdominal palpation)
- Assessment of FHR and patter
(check how many weeks by fingers between fundus and xiphoid. Check what is in the fundus (head or bum) , check fetal lie, check to see how engaged the head is in the true pelvis, check FHR again) - frequency of contractions
- intensity (mild, moderate, or strong)
- duration
- resting tone
- Vaginal exam: cervical effacement, dilation, fetal descent
First Stage: Laboratory and diagnostic tests
- analysis of urine specimen
- blood tests (CBC, HIV status, type and screen)
- Assessment of amniotic membranes and fluid
- other tests: BP, Temp, Pulse
- signs of potential problems
First Stage of Labour: Plan of care and interventions
Standards of care
Physical nursing care during labor
- general hygiene
- nutrient and fluid intake (oral intake, IV intake)
- elimination (voiding at least every 2 hours, catheterization, bowel elimination)
- ambulation and positioning
Supportive care during labour and birth: emotional support, physical care and comfort measures, and advice/information
- nurse, father/partner, doulas, grandparents, siblings during labor and birth
Emergency interventions: be ready and have tools ready
Second Stage of Labour: Infant is born
- fully dilated to when the baby is being born
- begins with full cervical dilation (10 cm)
- complete effacement
- the “pushing” stage
- ends with infant’s birth
Second Stage of Labour: latent phase
relatively calm with passive descent of baby through birth canal
Second Stage of Labour: Active
pushing and urge to bear down
- ferguson reflex: the urge to “bear down”
Care Management - Preparing for birth:
- Maternal position: supine, semi recumbent, or lithotomy positions are still widely used in Western societies despite evidence that an upright position shortens labor
- Bearing down Efforts: valsalva maneuver
- Fetal heart rate and pattern
- support of father or partner
- supplies, instruments, and equipment
Care Management: Birth in a delivery room or birthing room
- lithotomy position
- crowning
- nuchal cord
Care Management: use of final pressure
contraindicated
Care Management: assessment of newborn
immediate assessments and care of newborn
Care Management: Perineal Trauma related to childbirth. Perineal lacerations
First degree: laceration that extends through the skin and vaginal mucous membrane but not the underlying fascia and muscle
Second degree: laceration that extends through the fascia and muscles of the perineal body, but not the anal sphincter
Third degree: laceration that involves the external anal sphincter
Fourth degree: laceration that extends completely through the rectal mucosa, disrupting both the external and internal sphincters
Other perineal trauma
- vaginal and urethral lacerations
- cervical injuries
- episiotomy: an incision in the perineum used to enlarge the vaginal outlet. has steadily declined in recent years due to lack of sound, rigorous research to support its benefits
Third Stage of Labour: birth of the baby until the placenta is expelled
- the third stage is generally by far the shortest stage of labor
- usually expelled within 10 to 15 minutes after the birth; may be problematic if >30 minutes
- sudden gush of dark blood from the introitus
- apparent lengthening of the umbilical cord
- vaginal fullness
- placental examination and disposal: cultural preferences
Fourth Stage of Labour: Care Management
- first 1-2 hours after birth
- assessment of maternal physical status: physiologic changes to pre-pregnancy status
- signs of potential problems: excessive blood loss, alterations in vital signs and consciousness
- Care of the new mother
- care of the family: family-newborn relationships
