Normal Labor and Delivery Nursing Care

Stage 1 -- Latent Phase Signs and Symptoms: Contraction: dilate 0-3 cm. Mild Duration – 30-45 seconds Frequency – 5-20 minutes Scant pinkish discharge, bloody show Mother’s response Surge of energy and excited Talkative, outgoing Anxiety low **Best time to do teaching!

Stage 1 – Latent Phase Nursing Care: Welcome to the hospital Assess goals for this labor Assess Psychological response Orient to common procedures Vital signs and FHT’s Enema IV NPO Assessment of Labor Progress – dilation, effacement, station, lie, etc.

What would you do? A woman is admitted to labor and delivery in latent labor. Upon reviewing her birth plan you recognize that you will not be able to honor the woman’s request to keep her baby with her at all times throughout the hospital stay.

Stage 1 – Active Phase Signs and Symptoms: Contractions – dilate 4-7 cm. Moderate Duration – 45-60 seconds Frequency – 2-5 minutes Mother’s Response More serious Determined, Dependent Restless Focuses on self

Stage 1 – Active Phase Nursing Care: Anticipate Needs: Sponge face with cool cloth Keep bed clean and dry- change chux Provide with mouth care – lip balm to lips Assess voiding Non-Pharmacological Measures Modified breathing Effleurage Music Analgesia and Anesthesia

Stage 1 – Transition Phase Signs and Symptoms: Contractions 7-10 cm Strong Irregular with multiple peaks Duration – 60-90 seconds Frequency – 2 minutes Mother’s response Withdrawn, drowsy, Nausea, trembling of legs Irritable, aggressive Urge to push

Stage 1- Transition Phase Nursing Care: Provide support- may need to breathe with the patient – get in her face Back rub Assist with pant-blow breathing Watch for hypervention – have breathe in mask and slow down the breathing Do NOT allow to push by having patient blow-blow-blow with urge. Do not be offended by irritability

Stage 2 of Labor Signs and Symptoms: Sudden Appearance of sweat on upper lip An episode of vomiting Increase in bloody show Shaking of extremities Increased restlessness Pressure on rectum; involuntary bearing down Bulging of perineum

Stage 2 of Labor Nursing Care: The key to care during this stage is to teach QUALITY PUSHING ! Keep perineum clean and dry Provide quiet environment Support with positive feedback Repeat doctors instructions Allow to hold the baby , Congratulate!!

Stage 2 – Mechanisms of Labor 1. Engagement and Descent 2. Flexion 3. Internal Rotation 4. Extension 5. Restitution ALSO known as Cardinal Movements. The fetus first descends into the pelvis is an oblique position because the pelvic inlet is widest from side to side. Flexion occurs as the fetal head descends and meets resistance from the soft tissue of the pelvis, the muscles of the pelvic floor and the cervix. Internal rotation occurs in the pelvic cavity as the widest diameter is not antero-posterior and the fetal head meets resistance from the levator ani muscles and their fascia. The head usually rotates from left to right. Extension occurs as the fetal head passes under the symphysis pubis allowing the occiput then the brow and face to emerge. Restitution – the shoulders of the fetus enter the pelvic inlet obliquely. External rotation – the shoulders rotate to the anteroposterior position of the pelvis Expulsion – the anterior shoulder meets the undersurface of the symphysis pubis and slips under it. 6. External Rotation 7. Expulsion

Episiotomy vs Laceration Episiotomy is the manual cutting of the perineum to increase room for delivery of fetus. Midline Mediolateral Laceration: tearing of the tissue of the perineum, vagninal wall, or periurethral.

Degree’s of Vaginal Tears/Episiotomy 1st - Extends only through the vaginal mucosa 2nd - Extends through the vaginal mucosa and submucosal tissue 3rd - Extends as a partial or complete transection of the anal sphincter muscle 4th - Extends through the anal sphincter and the lining of the rectum Degrees of vaginal tears: First Degree-The smallest or most simple episiotomy, extending only through the vaginal mucosa. It does not involve the underlying tissues. Second Degree-This is the most common type of episiotomy. It extends through the vaginal mucosa and into the submucosal tissues, but does not involve the rectal sphincter or mucosa. Third Degree-A third degree episiotomy involves the vaginal mucosa, submucosal tissues, and a partial or complete transection of the anal sphincter muscle. Fourth Degree-The most severe type of episiotomy includes incision of the vaginal mucosa, submucosal tissues, and anal sphincter, and it also involves of the lining of the rectum. The severity of the episiotomy is directly associated with the amount and seriousness of postpartum and long-term complications. As the degree of the episiotomy increases, there is more potential for infection, postpartum pain, and other complications, such as leakage of stool and development of recto-vaginal fistula. 13

Stage 3 of Labor Signs and Symptoms of Placental Separation: 1. A globular rise in the abdomen the placenta changes from a discoid to a globular shape 2. Sudden gush of blood 3. Lengthening of the cord

Stage 3 of Labor Nursing Care: Congratulate on delivery of baby Coach in relaxation for delivery of the placenta Initiate contact with the infant May allow to breast feed if desires

Test Yourself! The cardinal movement that facilitates the emergence of the fetal head is ____________. A. Flexion B. Extention C. External rotation Cardinal movement that allows the smallest diameter of the head to pass through the pelvis is__________________. B. Internal rotation C. Extension Cardinal movement that occurs as the fetal shoulders engage and descend through the pelvis is termed ______. A. Internal rotation B. External rotation

The End of Labor & Delivery & The Beginning of Pain in Labor RETURN

Causes of Pain in Labor Stage One Stretching of the cervix during dilation & effacement Uterine Anoxia Stage One Stretching of the uterine ligaments

Causes of Pain in Labor Stage Two Distention of the vagina and perineum Compression of the nerve ganglia in cervix & lower uterus Stage Two Pressure on urethra, bladder, rectum during fetal descent Traction on and stretching of the perineum

Factors affecting Mothers Response to Pain in Labor Knowledge and confidence gained through childbirth classes Cultural influences on expression of pain Maternal fatigue and anxiety Previous experiences with pain

Methods of Pain Relief Non-pharmacologic Childbirth methods Effleurage Breathing Techniques Relaxation Techniques Touch Focusing attention on one object Effleurage

Methods of Pain Relief Non-pharmacologic cont’d Sensory Stimulation Listening to music; subdued lighting Imagery Applying heat and cold Massage (lower back); Counter-pressure TENS Position Changes

Pain Relief in Labor Pharmacologic Methods Analgesia fentanyl morphine butorphinp; (Stadol) nalbuphine (Nubain) Naloxone (Narcan) – narcotic antagonist Tranquilizers Narcotic Poteniators hydroxyzine (Vistaril) promethazine (Phenergan) Stado & Nubain are synthetic agonist/antagonists narcotic analgesia – use caution administering to drug addicted pt. Can be given IM & IV. Side effects of systemic analgesia Naloxone used to reverse the side effects of narcotic opiods

Anesthesia Regional Local General Paracervical Epidural; Caudal Spinal Duramorph Pudendal Local Perineum General Used mainly in cesarean deliveries

Spinal Block

Epidural Block

Pudendal Block

Local Anesthesia 1% Lidocaine solution injected into the perineal tissue prior to an episiotomy or if tears are expected. 28

General Anesthesia Used for cesarean-section if: Spinal / Epidural ineffective Emergency situation – fetal distress Maternal conditions which contraindicated regional anesthesia Maternal refusal of regional anesthesia Fetal distress Significant coagulopathy - low platelets Acute maternal hypovolemia and Homodynamic instability Sepsis or local skin infection failed regional anesthesia Maternal refusal of regional anesthesia 29

True or False ? The anesthesia used for both labor and delivery is an epidural A. True B. False The anesthesia used for delivery and an episiotomy is pudendal A. True

True or False ? The nurse would be careful to keep the patient flat following delivery with a pudendal block A. True B. False The initial side effect of an epidural anesthesia is fetal bradycardia

The End Return to Module