5/31/2018 chapter 17 Chapter 17 Stages of labor Khulod Barqawi,

Stages of Labor First Stage Latent phase Active phase Transition phase 5/31/2018 chapter 17 Stages of Labor First Stage Latent phase Active phase Transition phase Second Stage Third Stage Fourth Stage Khulod Barqawi,

First stage of labor:(Stage of Dialtion) 5/31/2018 chapter 17 First stage of labor:(Stage of Dialtion) It begins with the onset of true labor contractions and ends with complete dilation (10cm) and effacement (100%) of the cervix. It is the longest stage for both nulliparous and parous women. It has three phases: latent (early), active, and transition. Khulod Barqawi,

5/31/2018 chapter 17 1. Latent phase: Lasts from the beginning of labor until about 3cm of cervical dilation. The woman is usually sociable and excited during this phase of labor. Uterine contraction initially mild and infrequent progress to moderate strength every 5 min. Khulod Barqawi,

2. Active phase: The cervix dilates from 4 to 7 cm 5/31/2018 chapter 17 2. Active phase: The cervix dilates from 4 to 7 cm Effacement is completed The fetus descends to the pelvis Internal rotation begins Increase discomforts The woman becomes more anxious and feel helpless Serious inward focus Uterine contraction every 2-5 minute Khulod Barqawi,

3. Transition phase: - Short but intense phase 5/31/2018 chapter 17 3. Transition phase: - Short but intense phase The cervix dilate from 8 to 10cm The fetus descends further into the pelvis Bloody show increase Strong contractions The woman may have the urge to push down Leg tremors nausea and vomiting are common The woman is irritable and lose control Contraction every 1.5-2minute Khulod Barqawi,

Second stage of labor (expulsion): 5/31/2018 chapter 17 Second stage of labor (expulsion): Begins with complete dilation (10cm) and full effacement(100%) end with the birth of the baby. involuntary pushing response The mother may said that she needs to have a bowel movement or the baby is coming Crowning of the fetal head Feeling of stretching or splitting sensation Contractions are strong Woman exerts intense effort to push her baby May appear sleepy between contraction The word “labor” describe this phase Feels tremendous relief and excitement as the second stage ends with the birth of baby Khulod Barqawi,

Third stage of labor (placental) 5/31/2018 chapter 17 Third stage of labor (placental) Begins with the birth of the baby and ends with the expulsion of the placenta Length 5-10 min up to 30 min Four Signs suggest placental separation: 1.Spherical shape of uterus 2.The uterus rises upward in the abdomen 3.The cord descends further from the vagina 4.a gush of blood appears as blood trapped behind placenta is released Khulod Barqawi,

5/31/2018 chapter 17 The uterus must contract firmly and remain contracted after placenta is expelled to compress open vessels During this stage pain results from uterine contractions and brief stretching of cervix as placenta passes through it Khulod Barqawi,

Fourth stage of labor (physical recovery): 5/31/2018 chapter 17 Fourth stage of labor (physical recovery): It lasts from the delivery of the placenta through the first 1 to 4 hours after birth The uterus at or below the level of umbilicus ,firm contracted and rounded mass about 10 to 15cm in diameter Lochia is rubra Women may have chill lasts for 20 minutes, warm blanket or hot drink may be helpful Khulod Barqawi,

Ice packs on perineum decrease discomfort and limit hematoma formation 5/31/2018 chapter 17 After pains or birth trauma are the main causes of discomforts in this stage Ice packs on perineum decrease discomfort and limit hematoma formation After pains are more intense in multiparous or in women who breast feed, in women who have uterine over distention( large baby) and full bladder or clot that remain in uterus The woman is exhausted and need rest This stage is the ideal time for bonding and to start breast feeding Khulod Barqawi,

Nursing care during labor and birth 5/31/2018 chapter 17 Nursing care during labor and birth Assessment on admission Focused assessment 1. Fetal assessment Gestational age of the fetus Leopold’s maneuver Fetal movement and FHR Status of membrane( color ,odor and clarity of fluid) 2. Maternal assessment (vital signs) especially for infection or hypertension Khulod Barqawi,

Data base assessment Reason for coming to hospital Prenatal care EDD 5/31/2018 Data base assessment chapter 17 Reason for coming to hospital Prenatal care EDD # of pregnancies term and abortion Allergies Last time of food intake Medical surgical and pregnancy history Recent illness and treatment Medication, drug smoking and alcohol Mother subjective evaluation of labor Birth plan, pain management method and support person Khulod Barqawi,

3.Determine labor status 5/31/2018 chapter 17 2.Fetal assessment Presentation ,position and FHR Time of rupture membrane and characteristics of amniotic fluids 3.Determine labor status Assess contraction Cervix dilitation and effacement, station ,presentation and position Membrane status Khulod Barqawi,

4. Physical exame(brief) 5. Laboratory data 5/31/2018 chapter 17 4. Physical exame(brief) 5. Laboratory data Hematocrite and blood group and CBC Blood glucose levels Blood type and RH factor Midstream urine(protein and glucose) Syphilis ,hepatitis and HIV 6.IV access Continuous infusion prevent dehydration Isotonic electrolyte is preferable Glucose is avoided Khulod Barqawi,

Assessment after admission 5/31/2018 chapter 17 1.Fetal assessment FHR electronic or Doppler Amniotic fluid AROM OR SROM Assess FHR at least one min after rupture of membrane Record the time of rupture,FHR and character of fluid cloudy, yellow or foul odor suggest infection Green color suggest meconium passage (transient hypoxia) Amount more than 1000ml is large, between 500-1000 is moderate and scant if only trickle barely enough to detect Khulod Barqawi,

5/31/2018 chapter 17 2. Maternal assessment Vital signs( hyper or hypotension , increased pulse increased resp. increased temp are all abnormal Contraction Progress of labor , vaginal exam should be limited to prevent infection Intake and output ,check for bladder fullness every 2 hour LOOK AT THE MOTHER’S PERINIUM FOR CROWNING OF FETAL HEAD IF SHE EXPERIENCE A NEED TO DEFECATE Mother response to labor Khulod Barqawi,

Nursing care for woman in true labor 5/31/2018 chapter 17 Nursing care for woman in true labor 1. Fetal oxygenation Assessment of fetal well being include: FHR,contraction,aminiotic fluid and vital signs Intervention 1.promote placental function( position rather than supine) 2. observe for condition associated with fetal compromise Khulod Barqawi,

Conditions Associated with Fetal Compromise 5/31/2018 chapter 17 Fetal heart rate outside the normal range Little or no variability in heart rate Persistent slowing of heart rate after contractions Meconium-stained amniotic fluid Cloudy, yellowish, or foul odor to amniotic fluid Contractions longer than 90 seconds Incomplete uterine relaxation, intervals between contractions shorter than 60 seconds Maternal hypotension Maternal hypertension Maternal fever Khulod Barqawi,

1. providing comfort measures 5/31/2018 chapter 17 2. Discomfort Intervention 1. providing comfort measures Lightening: soft indirect lighting is soothing Temperature; Cool damp cloths on woman's face and neck promote comfort, an electric fan circulate air in the room is appropriate Cleanliness: change gown and linen when needed Khulod Barqawi,

Positioning: use any comfortable position but avoid supine 5/31/2018 chapter 17 Mouth care: ice chips and hard candy reduce discomfort of dry mouth, avoid excessive sugar and if oral intake is contraindicated brushing teeth or rinsing mouth Bladder emptying; Remined woman to empty bladder at least every 2 hours, catheterization is often needed Positioning: use any comfortable position but avoid supine Water( shower, tub, pool): enhance relaxation . Nipple stimulation by water current release oxytocin and make contraction more productive Khulod Barqawi,

5/31/2018 chapter 17 2. Teaching First stage Pushing in response only to her spontaneous urge Pushing without full dilitation leads to cervix become lacerated and edematous and progress is blocked Second stage Laboring down Position( curve body around uterus in C shape) Khulod Barqawi,

Breathing pattern: avoid holding breath more than 6-8 second 5/31/2018 Breathing pattern: avoid holding breath more than 6-8 second Provide encouragement Giving of self Pharmacologic management and support and care 3. Preventing injury assessment ; observe mother’s perineum to determine when to make final preparation Final preparation for primipara is done when crowning reach a diameter of 3-4cm but in multipara when cervix is fully dilated chapter 17 Khulod Barqawi,

Intervention 1. transfer to delivery room 2. positioning of birth 5/31/2018 chapter 17 Intervention 1. transfer to delivery room 2. positioning of birth 3. observing perineum Nursing care during Birth 1.Preparation of table 2.Perineal cleansing preparation 3.Initial care and assessment of newborn 4.Administration of medication such as oxytocin to control blood loss 5.Use universal precaution Khulod Barqawi,

Responsibilities after birth 5/31/2018 chapter 17 Care of infant 1. maintain cardiopulmonary function prepare neonatal resuscitation equipment Assess Apgar score Suctioning of secretion 2. supporting thermoregulation dry infant place under radiant warmer Skin to skin contact Khulod Barqawi,

Care of the mother 3. Identifying the infant Identifying band 5/31/2018 chapter 17 3. Identifying the infant Identifying band Care of the mother 1. observing for hemorrhage Vs,fundus,lochia,bladder Vital signs : assess temp. in recovery and before transfer to postpartum ward Assess other vital signs every 15 min for first hour and 30 min in the next hour Khulod Barqawi,

The first two or three voiding must be at least 300-400ml each voiding 5/31/2018 chapter 17 Fundus should be firm midline and at or below umbilicus .If not firm massage and encourage mother to breast feeding Bladder: full bladder is suspected when fundus is above umbilicus and or displaced to one side usually the right The first two or three voiding must be at least 300-400ml each voiding Lochia is rubra, small clot is okay but large clot is abnormal Saturation of one pad within the first hour is the maximum normal lochia flow Khulod Barqawi,

ice backs, analgesics , warmth 5/31/2018 chapter 17 2. Relieving discomfort ice backs, analgesics , warmth Ice packs: to reduce edema and limit hematoma formation Analgesics:after pain and perineal pain may relieved by mild analgesics. Regular urination reduce after pain because uterus contract effectively Warmth warm blanket is soothing and shorten the chills that is common after birth 3. promoting early family attachment : Khulod Barqawi,

Leopold's Maneuvers (1 of 4) 5/31/2018 chapter 17 Leopold's Maneuvers (1 of 4) Unn Fig. 17-1 Procedure 17-1 Khulod Barqawi,

Leopold's Maneuvers (2 of 4) 5/31/2018 chapter 17 Leopold's Maneuvers (2 of 4) Khulod Barqawi,

Leopold's Maneuvers (3 of 4) 5/31/2018 chapter 17 Leopold's Maneuvers (3 of 4) Unn Fig. 17-3 Procedure 17-1 Khulod Barqawi,

Leopold's Maneuvers (4 of 4) 5/31/2018 chapter 17 Leopold's Maneuvers (4 of 4) Khulod Barqawi,