Nursing Care during Labor and Birth Chapter 18-Part 1 Nursing Care during Labor and Birth Mosby items and derived items © 2006 by Mosby, Inc.

Nursing Care during Labor and Birth Labor begins with first uterine contraction, continues during cervical dilation and birth, and ends as woman and family begin attachment process with infant Mosby items and derived items © 2006 by Mosby, Inc.

Mosby items and derived items © 2006 by Mosby, Inc. First Stage of Labor Begins with onset of regular uterine contractions Ends with full cervical effacement and dilation Mosby items and derived items © 2006 by Mosby, Inc.

Mosby items and derived items © 2006 by Mosby, Inc. First Stage of Labor Three phases Latent phase: up to 3 cm of dilation Active phase: 4 to 7 cm of dilation Transition phase: 8 to 10 cm of dilation Mosby items and derived items © 2006 by Mosby, Inc.

Mosby items and derived items © 2006 by Mosby, Inc. First Stage of Labor Care begins when woman reports one or more of following: Onset of progressive, regular uterine contractions that increase in frequency, strength, and duration Blood-tinged mucoid vaginal discharge indicating that mucous plug (operculum) has passed Fluid discharge from vagina Mosby items and derived items © 2006 by Mosby, Inc.

Mosby items and derived items © 2006 by Mosby, Inc. First Stage of Labor Assessment and nursing diagnosis Determination of true or false labor Contractions Cervix Fetus Mosby items and derived items © 2006 by Mosby, Inc.

Mosby items and derived items © 2006 by Mosby, Inc. First Stage of Labor Assessment and nursing diagnosis (cont’d) Admission to labor unit Admission data Prenatal record Interview Psychosocial factors Women with a history of sexual abuse Stress in labor Cultural factors Mosby items and derived items © 2006 by Mosby, Inc.

Mosby items and derived items © 2006 by Mosby, Inc. First Stage of Labor Assessment and nursing diagnosis (cont’d) Physical examination General systems assessment Vital signs Leopold’s maneuvers Assessment of FHR and pattern Mosby items and derived items © 2006 by Mosby, Inc.

Mosby items and derived items © 2006 by Mosby, Inc. First Stage of Labor Assessment and nursing diagnosis Physical examination (cont’d) Assessment of uterine contractions Frequency Intensity Duration Resting tone Cervical effacement, dilation, fetal descent Vaginal examination Mosby items and derived items © 2006 by Mosby, Inc.

Mosby items and derived items © 2006 by Mosby, Inc. First Stage of Labor Assessment and nursing diagnosis (cont’d) Laboratory and diagnostic tests Analysis of urine specimen Blood tests Assessment of amniotic membranes and fluid Signs of potential problems Mosby items and derived items © 2006 by Mosby, Inc.

Mosby items and derived items © 2006 by Mosby, Inc. First Stage of Labor Plan of care and interventions Standards of care Physical nursing care during labor General hygiene Nutrient and fluid intake Elimination Ambulation and positioning Mosby items and derived items © 2006 by Mosby, Inc.

Mosby items and derived items © 2006 by Mosby, Inc. First Stage of Labor Plan of care and interventions (cont’d) Supportive care during labor Nurse Father or partner Grandparents Doulas Siblings during labor and birth Emergency interventions Mosby items and derived items © 2006 by Mosby, Inc.

Mosby items and derived items © 2006 by Mosby, Inc. Second Stage of Labor Infant is born Begins with full cervical dilation (10 cm) Complete effacement Ends with baby’s birth Mosby items and derived items © 2006 by Mosby, Inc.

Mosby items and derived items © 2006 by Mosby, Inc. Second Stage of Labor Three phases Latent: relatively calm with passive descent of baby through birth canal Descent: active pushing and urges to bear down Ferguson reflex Transition: presenting part is on perineum, and bearing-down efforts are most effective for promoting birth Mosby items and derived items © 2006 by Mosby, Inc.

Mosby items and derived items © 2006 by Mosby, Inc. Second Stage of Labor Preparing for birth Maternal position Bearing-down efforts Valsalva maneuver Fetal heart rate (FHR) and pattern Support of father or partner Supplies, instruments, and equipment Mosby items and derived items © 2006 by Mosby, Inc.

Mosby items and derived items © 2006 by Mosby, Inc. Supine hypotension. C, Compression of aorta and inferior vena cava with woman in supine position. D, Relieved by use of a wedge pillow placed under woman’s right side Inferior vena cava Mosby items and derived items © 2006 by Mosby, Inc.

Mosby items and derived items © 2006 by Mosby, Inc. Second Stage of Labor Preparing for birth (cont’d) Birth in a delivery room or birthing room Birth in LDR or LDRP room Mechanism of birth: vertex presentation Prevention of meconium aspiration Use of fundal pressure Immediate assessment and care of newborn Mosby items and derived items © 2006 by Mosby, Inc.

Mosby items and derived items © 2006 by Mosby, Inc. Second Stage of Labor Perineal trauma related to childbirth Lacerations Perineal lacerations Vaginal and urethral lacerations Cervical injuries Episiotomy Emergency childbirth Mosby items and derived items © 2006 by Mosby, Inc.

Mosby items and derived items © 2006 by Mosby, Inc. Types of Episiotomies Mediolateral Median (or midline) Mosby items and derived items © 2006 by Mosby, Inc.

Mosby items and derived items © 2006 by Mosby, Inc. Ch. 18-Part 2 Mosby items and derived items © 2006 by Mosby, Inc.

Mosby items and derived items © 2006 by Mosby, Inc. Third Stage of Labor Placental separation and expulsion Firmly contracting fundus Change in uterus Sudden gush of dark blood from introitus Apparent lengthening of umbilical cord Vaginal fullness Mosby items and derived items © 2006 by Mosby, Inc.

Mosby items and derived items © 2006 by Mosby, Inc. Third Stage of Labor Collaborative care Placental examination and disposal Cultural preferences Maternal physical status Physiologic changes to prepregnancy status Signs of potential problems Excessive blood loss Alteration in vital signs and consciousness Mosby items and derived items © 2006 by Mosby, Inc.

Mosby items and derived items © 2006 by Mosby, Inc. Third Stage of Labor Collaborative care (cont’d) Care after placental delivery Care of family during the third stage Family-newborn relationships Mosby items and derived items © 2006 by Mosby, Inc.

Mosby items and derived items © 2006 by Mosby, Inc. Key Points Onset of labor may be difficult to determine for both nulliparous and multiparous women The home is most often the ideal place for a woman during the latent phase of first stage of labor Mosby items and derived items © 2006 by Mosby, Inc.

Mosby items and derived items © 2006 by Mosby, Inc. Key Points Nurse assumes much of the responsibility for: Assessing progress of labor Keeping primary health care provider informed about progress in labor Deviations from expected findings FHR and pattern reveal fetal response to stress of labor process Mosby items and derived items © 2006 by Mosby, Inc.

Mosby items and derived items © 2006 by Mosby, Inc. Key Points Meconium-stained amniotic fluid is not always indicative of fetal distress associated with hypoxia Assessment of laboring woman’s urinary output and bladder is critical to ensure her progress and to prevent injury to the bladder Mosby items and derived items © 2006 by Mosby, Inc.

Mosby items and derived items © 2006 by Mosby, Inc. Key Points Woman’s or couple’s perception of birth experience is likely to be positive when events and performances are consistent with expectations Especially in terms of maintaining control and adequacy of pain relief Woman’s level of anxiety may increase when she does not understand medical terminology used or because of a language barrier Mosby items and derived items © 2006 by Mosby, Inc.

Mosby items and derived items © 2006 by Mosby, Inc. Key Points Coaching, emotional support, and comfort measures assist woman to use energy constructively in relaxing and working with contractions Progress of labor is enhanced when a woman changes position frequently during first stage of labor Mosby items and derived items © 2006 by Mosby, Inc.

Mosby items and derived items © 2006 by Mosby, Inc. Key Points Doulas provide continuous supportive presence during labor that can have positive effect on childbirth Cultural beliefs and practices of a woman and her significant others can have a profound influence on their approach to labor and birth Nurse who is aware of particular sociocultural aspects of helping and coping is an advocate for the woman or couple during labor Mosby items and derived items © 2006 by Mosby, Inc.

Mosby items and derived items © 2006 by Mosby, Inc. Key Points Quality of the nurse-client relationship is a factor in the woman’s ability to cope with stressors of the labor process Women with history of sexual abuse often experience profound stress and anxiety during childbirth Mosby items and derived items © 2006 by Mosby, Inc.

Mosby items and derived items © 2006 by Mosby, Inc. Key Points Inability to palpate the cervix during vaginal exam indicates complete effacement and full dilation and is the only certain, objective sign that the second stage has begun Women may have an urge to bear down at various times during labor before the cervix is fully dilated or may not occur until active phase of second stage of labor Mosby items and derived items © 2006 by Mosby, Inc.

Mosby items and derived items © 2006 by Mosby, Inc. Key Points When responding to rhythmic nature of the second stage of labor, the woman normally: Changes body positions Bears down spontaneously Vocalizes (open-glottis pushing) when she perceives the urge to push (Ferguson reflex) Mosby items and derived items © 2006 by Mosby, Inc.

Mosby items and derived items © 2006 by Mosby, Inc. Key Points Women should bear down several times during a contraction using the open-glottis pushing method Sustained closed-glottis pushing should be avoided because oxygen transport to fetus will be inhibited Mosby items and derived items © 2006 by Mosby, Inc.

Mosby items and derived items © 2006 by Mosby, Inc. Key Points Nurses can use the role of advocate to prevent routine use of episiotomy and to reduce the incidence of lacerations by: Empowering women to take an active role in their birth Educating health care providers about approaches to managing childbirth that reduce the incidence of perineal trauma Mosby items and derived items © 2006 by Mosby, Inc.

Mosby items and derived items © 2006 by Mosby, Inc. Key Points Objective signs indicate that the placenta has separated and is ready to be expelled Excessive traction on umbilical cord, before placenta has separated, can result in maternal injury Siblings present for labor and birth need preparation and support for the event Mosby items and derived items © 2006 by Mosby, Inc.

Mosby items and derived items © 2006 by Mosby, Inc. Key Points Nurses observe progress in development of parent-child relationships and are alert for warning signs during immediate postpartum period Mosby items and derived items © 2006 by Mosby, Inc.

Mosby items and derived items © 2006 by Mosby, Inc. Key Points After emergency childbirth out of the hospital, stimulation of mother’s nipple manually or by infant’s suckling stimulates release of oxytocin from maternal posterior pituitary gland Oxytocin helps uterus to contract and thereby prevents hemorrhage Mosby items and derived items © 2006 by Mosby, Inc.

Mosby items and derived items © 2006 by Mosby, Inc. Key Points Woman benefits from reviewing her childbirth experience with nurse who managed her care during labor and birth Mosby items and derived items © 2006 by Mosby, Inc.