Nursing Care of Family during Labour

Question 1

First Stage of Labour

Answer 1

• 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)

Question 2

First stage of Labour: Latent phase

Answer 2

up to 3 cm of dilation

Question 3

First stage of Labour: Active phase

Answer 3

4-7 cm of dilation

Question 4

First stage of Labour: Transition phase

Answer 4

8-10 cm of dilation

Question 5

First stage of Labour: Assessment and nursing diagnosis

Answer 5

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

Question 6

True labor

Answer 6

rhythmic contractions, effacement, and the cervix is dilating. Fetus in engaged

Question 7

First stage: Physical Examination

Answer 7

• 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

Question 8

First Stage: Laboratory and diagnostic tests

Answer 8

• 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

Question 9

First Stage of Labour: Plan of care and interventions

Answer 9

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

Question 10

Second Stage of Labour: Infant is born

Answer 10

• 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

Question 11

Second Stage of Labour: latent phase

Answer 11

relatively calm with passive descent of baby through birth canal

Question 12

Second Stage of Labour: Active

Answer 12

pushing and urge to bear down
- ferguson reflex: the urge to “bear down”

Question 13

Care Management - Preparing for birth:

Answer 13

• 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

Question 14

Care Management: Birth in a delivery room or birthing room

Answer 14

• lithotomy position
• crowning
• nuchal cord

Question 15

Care Management: use of final pressure

Answer 15

contraindicated

Question 16

Care Management: assessment of newborn

Answer 16

immediate assessments and care of newborn

Question 17

Care Management: Perineal Trauma related to childbirth. Perineal lacerations

Answer 17

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

Question 18

Other perineal trauma

Answer 18

• 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

Question 19

Third Stage of Labour: birth of the baby until the placenta is expelled

Answer 19

• 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

Question 20

Fourth Stage of Labour: Care Management

Answer 20

• 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