Transcript Nursing Care of the Woman During Labor and Delivery

Intrapartum Nursing Care
On Admission
Induction/Cesarean Section
Care in 1st, 2nd, 3rd, and 4th Stages of Labor
Precipitous/Out-of-Hospital Delivery
When to go to Hospital
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Regular Contractions with  intensity
SROM
Vaginal Bleeding
Changes in Fetal Movement—especially a
 in fetal movement as described in the Daily
Fetal Movement Count
On Admission to Hospital
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Evaluate Is this True Labor?
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IMMINENCE OF DELIVERY
 Condition of mother
 Condition of fetus
 Previous experience with labor
 Childbirth education—Lamaze, Childbirth
preparation, breastfeeding, cesarean
section class
 Is there a BIRTH PLAN?Any plans for
anesthesia?
Identify Patient
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Note time of arrival/reason for admission
Pt’s name, MD-both Obstetrician and
pediatrician
Plans to breast or bottle feed
Assess when she last ate or drank
Assess support person and what they perceive
as their role in the labor process.
Remember to introduce yourself as the RN
and explain all assessment parameters and
interventions in simple terms
Review Prenatal History
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EDC/EDD Is baby term?
OB History: GTPAL status, previous labors
Medications taken during pregnancy including
Prenatal vitamins and Iron
Use of alcohol, illicit drugs, tobacco during pg
Labs (Blood Type & Rh, Rubella, Beta Strep, MSAFP,
VDRL/RPR, GC culture)
Diagnostic Tests (Amniocentesis, Ultrasound)
Allergies
Complications (Medical/OB)—chronic illnesses, BP,
dysuria, edema of hands and face, etc.
Physical Assessment on Admission
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Maternal Vital Signs—between contractions
Fetal Status—baseline FHR, accels/decels, fetal
movement and FHR response
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Labor Status
 Contractions—frequency, duration, intensity
 Vaginal Discharge (??SROM = NO GEL)—
bloody show?, color and odor of amniotic fluid
if SROM, use Nitrazine paper to assess SROM
 Vaginal Changes—dilatation, effacement
 Descent of Fetus– Presentation, Station,
Position
Physical Assessment, cont’d
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Abdominal Exam
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Chest
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Assess bowel sounds laterally
Assess fundal height
Perform Leopold’s Maneuvers
Assess heart and lung sounds
DTR’s
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Assess patellar reflexes bilaterally
Note hyperreflexia, if +3-+4, check for clonus
Psychosocial Assessment on Admission
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Mother’s Status—in early labor, pt is often
excited, teachable, and talkative. As labor progresses,
anxiety increases as pain increases & the ability of the pt
to focus decreases. Noting these variables helps the
nurse determine the progress of labor
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Support Persons—assess who they are & how
they expect to participate in the labor process e.g. active
labor coach vs. observer
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Nurse’s Role—support pt and significant others
and encourage to verbalize fears & concerns. Evaluate
how best to provide Family-Centered Care for this family
system
Admission/Diagnostics
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CBC (Hgb, Hct), Type/Rh (if unknown)
U/A
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Dipstick—often done in the lab
Glucose
 Albumin
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U/A if ordered
Blood Type and Cross-match for C/S only
Nursing Care On Admission
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Place EFM ASAP—Assess fetal status
Do Vag Exam—Assess Labor Status
Complete OB Paperwork
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Check Orders
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Assessment, Hx, Database, PG Hx, Vitals
Start IV, especially if pt wants epidural soon
Lab Work
Orient to Room
ALWAYS assess FHR
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AFTER AROM or SROM
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BEFORE starting Pitocin for Induction
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(risk of prolapsed cord)
Throughout induction
BEFORE & AFTER analgesia/anesthesia
Induction
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Definition: artificial initiation of labor before
spontaneous onset of contractions after the
period of viability.
Augmentation: Stimulation of contractions after labor has
begun to strengthen contractions
Indications: see p.744 Olds
Readiness
 FETAL: Fetal well-being (Reactive NST), Amniocentesis
L:S ratio >2:1, BPP >8, EDD
 MATERNAL: Use of Bishop’s Scale where the most
significant parameter is cervical readiness.
Bishop’s Scale for measuring Induction Readiness
Table 1. Bishop Scoring System
Factor
Score
Dilation (cm)
Effacement (%)
Station*
Cervical Consistency
Position of Cervix
0
Closed
0-30
-3
Firm
Posterior
1
1-2
40-50
-2
Medium
Midposition
2
3-4
60-70
-1,0
Soft
Anterior
3
5-6
80
+1,+2
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*Station reflects a . 3 to +3 scale.
Modified from Bishop EH. Pelvic scoring for elective induction. Obstet Gynecol 1964;24:267
Favorable cervix: in multipara, a score of >5
in primipara, a score of >7-9
Unfavorable cervix (low score) is associated with prolonged
labors and  risk of cesarean delivery.
Methods of Staged Induction–
especially used if cervix is not ripe
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Laminaria– seaweed is hydrophilic and
absorbs water thus swelling in the cx and
causing it to dilate. MD places these in
the external os of the cx and allows the
“tent” to swell overnight.
Prostaglandin– a variety of forms from
gels inserted transvaginally, to
suppositories, or vaginal inserts
Nurse’s Role in Prostaglandin E-2
(PGE-2) Monitoring
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Should have signed consent
NST to establish fetal well-being
Pt. Lies supine for insertion.
Pt remains in bed for 30-60min after gel and
2hrs after insert . Some moms stay in hospital
overnight and have Oxytocin induction in AM.
Monitor uterine and fetal activity continuously for
1st 1-2 hrs. post insertion.
Assess maternal VS hourly X 2, then q 4.
Nurse’s Role in Prostaglandin E-2
(PGE-2) Monitoring
Cervidil
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After 2 hours, pt is encouraged to walk. She may
be advised to go home if no active labor evident,
& instructed to return if BOW breaks, contractions
become more regular, or fetal movements
decrease.
RISKS: uterine hyperstimulation, but uncommon
if properly inserted.
Be prepared to remove excess gel
with gauze squares or remove
Cervidil insert in cases of hyperstimulation.
Methods of Induction-when Cervix is ripe and ready
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AROM/Amniotomy
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Potential complication:
a. Infection
b. Prolapsed cord
c. Fetal head or cord compression
Contraindications:
a. When presenting part is floating high
b. If fetus is in a breech or transverse lie
Methods of Induction-when Cervix is ripe and ready
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Nursing Care after AROM:
a. Assessment– FHT of baby immediately
-VS of mom a & p, Temp q 2h
-Assess color & odor of fluid
immediately after AROM
b. Intervention/Plan–
-Explain procedure to pt
-Prepare room: supine position, sterile gloves, for
MD, KY lubricant, Amniotome or Fetal Scalp Electrode
-Change waterproof pads under pt prn.
c. Evaluation—
-FHR remains stable, pt is comfortable
Methods of Induction-when Cervix is ripe and ready
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Oxytocin (Pitocin)
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Uses:*induce rhythmic uterine contractions
*augment weak or ineffective contr.
*promote uterine contraction in 4th
stage of labor
Oxytocin (Pitocin)
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Contraindications:
*any obstruction that interferes with fetal
descent
*any risk of uterine rupture(e.g..VBAC)
*hypertonic uterus
*existing fetal distress (e.g. positive CST)
*placenta previa
*genital herpes (active lesions)
Oxytocin (Pitocin)See box in text
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Mixed with D5LR, or D2NS(depends on MD)
Amount: your text adds 10U to 1000ml
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BRMC and St. Joseph adds 20U to 500ml
Rate: follow MD’s orders.
AWHONN guidelines recommend to begin
with .5-2mU/min and increase by 1-2mu q15-60
minutes until contractions are q2-3min in
frequency and 40-90 sec. duration. Maximum
dose: 20-40mU.min
Oxytocin (Pitocin)continued
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CALCULATING Pitocin rates:
10U added to 1000cc= 10U/1000cc
10U X 1000mU= 10000mU/1000cc=10mu/cc
Remember: you must convert mU/min to
cc/hr to set the rate on the IV pump
1cc/10mU X 60min/hr X 1mU/min=6cc/hr
So, 1mU/min= 6cc/hr
If you are to give the patient 5mU/min, at what
rate will you set the pump?
5mU/min X 1min/mU X 6cc/hr=30cc/hr
Oxytocin (Pitocin)—Nurse’s Role
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Assess & record FHT q15min, variability, accels
Assess & record Uterine activity q15
Assess & record Maternal BP q 15-30min
Assess & record Maternal I & O continuously.
IV Oxytocin can lead to water intoxication
Output should be 120cc/4hr or 30-35cc/hr.
Assess pt sensitivity and pain after initiation of
med.
Oxytocin (Pitocin)
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2 dangers with Oxytocin administration
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Increased strength, length, and frequency of
contractions may lead to uteroplacental insufficiency
2ndary to hypertonicity of uterus
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Birth injuries:
For fetus: rapid descent through pelvis may
cause fetal bruising, petechiae, injury
For mom: may predispose her to cervical
lacerations, uterine rupture, placenta abruptio, amniotic
fluid embolism.
Oxytocin (Pitocin)
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Nursing Care (see text )
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Monitor IV closely– Mainline and IV Pitocin
should generally equal 125cc/hr
Monitor contractions closely– If >90sec. In
duration or >frequent than q2min, D/C Pit.
Monitor FHR– Watch for late decels,
bradycardia <100 bpm, or
tachycardia>180 bpm
Monitor maternal VS and I & O regularly
Nursing Care-
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Stage of Labor
Frequency of Assessments—See next slide
Uterine Contraction- assess frequency,
duration, intensity
Vaginal Exams / “Bloody Show”
Fetal Position / Heart Rate
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st
1
Leopold Maneuvers
Location of FHT’s
Status of Membranes
Minimal Assessment of the Low-Risk Woman During the
1st Stage of Labor
Cervical
Dilatation
0-3cm
(latent)
4-7cm
(active)
8-10 cm
(transition)
BP, P, R
q 30-60 min.
q30 min
q 15-30 min
Temperature
q 4h
q 4h
q 4h
Uterine
activity
q 30-60 min
q 15-30 min
q 10-15 min
FHR
q 30-60 min
q15-30 min
q15-30
Vaginal Show
q 30-60 min
q 30 min
q 15 min
Behavior,
Appearance,
Energy Level
q 30 min
q 15 min
q 5 min
Vaginal Exam done only prn
to identify progress of labor
1. To confirm change in cervix when sx indicate
(e.g. strength, duration, or frequency of
contractions;  in amt of bloody show; ROM; or
woman feels pressure on her rectum)
2. To determine whether dilation and descent are
sufficient for administration of analgesic or
anesthetic
3. To reassess progress if labor takes longer than
expected
4. To determine station of presenting part
Signs of Transition
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 in bloody show
Nausea and vomiting
Increased rectal pressure
Desire to push
 ability to focus due to intensity and
frequency of contractions
Nursing Care / Psychosocial
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Confidentiality
Be Respectful
Supportive Care / Include Support Persons
Use of Touch
Reassurance / Gentle Coaching
Modesty
Nursing Care / Physical
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Positioning
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Hydration
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Bladder
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Dealing with Contractions
Signs of Potential Complications
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Rising Intrauterine Pressures
Cntx > 90 sec. Or < 2 minutes apart
Fetal bradycardia, tachycardia, decreased
variability
Meconium-stained, bloody or foul-smelling fluid
from vagina
Arrested progress of labor
Maternal temperature > 38 o C
Persistent bright or dark-red vaginal bleeding
Amnioinfusion
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Warmed, sterile NS or Ringer’s Lactate
infused INTO uterus via Intrauterine
Pressure Catheter (IUPC; 250 – 500 cc)
Increase Intrauterine Fluid Volume
Intrauterine Used to treat Problems related
to fetus
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Thick Meconium
Decelerations r/t Cord Compression
Contraindications for Amnioinfusion
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Omnious FHR
Umbilical Cord Prolapse
Significant Vaginal Bleeding
Uterine Hypertonia
Nursing Care during Amnioinfusion
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Note every 15 minutes
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Maternal B/P, Pulse
FHR
Contraction Pattern
Uterine Resting Tone
Strict Bedrest
Comfort, Reassure
DANGER  Rising Resting Tone  Uterine
Rupture
Nursing Care-2nd Stage of Labor
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Assessments -- See next slide
Signs of Fetal Descent
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Uncontrollable Urge to Push
Bulging of the Perineum
Anal Changes
Introitus Opens
Crowning
Burning/stretching sensation in perineum
Assessment during 2nd stage
BP, P, R
q 15 min.
Temperature*
Uterine activity
FHR
q 2h if ROM
q 5-15 min
Low-risk: q 15 min if EFM is not used &
continuously if it is used
High risk: q 5 min if EFM is not used &
continuously if it is used
Vaginal Show
Fetal Descent
q 5-15 min
q 5 min or continuous
Assessment in 2nd stage (cont’d)
Status of
bladder
especially in women who have an epidural
block
Behavior,
Appearance
Energy Level
Include assessment of emotional response of
woman and partner to 2nd stage.
Continuously
Signs of fetal descent
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Uncontrollable urge to push
Bulging of perineum
Anal changes—eversion,
passage of stool
Vaginal introitus opens
Crowning
Burning/stretching sensation on perineum
Nursing CarePsychosocial Assessments
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Less Irritated
VERY focused on work of Birth
More Cooperative
Doze off between Contractions
May be exhausted
Little modesty at this point
Nursing Care—
Physical/Psychological Support
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Positions for Pushing
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Lithotomy/semi-fowler’s
Sim’s/Side-lying
Squatting
Kneeling
Breathing
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Open glottis~groaning/grunting
Prolonged pushing~  O2 to baby
Cleansing breath & deep breath between
pushes
Physical/Psychological Support
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Environment
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Quiet between contractions to allow for rest
Massage legs if pt c/o of leg cramping
Psychological Support
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ENCOURAGE mom through each push
1 person give short, explicit instructions
Offer LOTS of praise for effort
Keep thinking with the end in mind!
Prepare for Delivery
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Continue Emotional Support of Mom & S.O.
Instrument Table (Tech usually does)
Infant Warmer, Resuscitation, ID
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Medical Support for Mom
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O2, DeLee & Suction, Meds, Laryngoscope Light,
Bulb Syringe,
O2,, Suction, Pitocin
“Break Bed” when Doctor is on the way or
present
Other Responsibilities
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Prep/wash perineum
Keep a watch on fetal status through each
contraction
Provide scalp stimulation prn
Pour mineral oil in and around perineum to
help stretch perineum and  need for epis
Note type of episiotomy/laceration
Note time of delivery
Other Elective Procedures
Episiotomies
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Definition: surgical incision of the
perineum performed more with primiparas
than multiparas. A controversial procedure
done more by MD’s than CNM’s.
Performed just prior to delivery when
the presenting part is crowning, usually
performed under regional or local
anesthesia.
Episiotomies
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Mediolateral: start at midline and extend
@ a 45 degree angle to the R or L.
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Advantage: avoids trauma to rectum, may
provide more room
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Disadvantage: increased blood loss,
longer time to heal, > discomfort during
early pp period.
Episiotomies
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Midline/median– begins at midline and
may extend down the midline through
the perineal body.
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Advantages: easy to repair, heals with less
discomfort for mom
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Disadvantage: if episiotomy extends, it
may tear through the rectum
Perineal Lacerations
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1st Degree: extends through the skin & structures
superficial to muscles
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2nd Degree: extends through muscles of
perineal body
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3rd Degree: tear extends through anal sphincter
muscle
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4th Degree: tear that involves the anterior
rectal wall
Nursing Role with Perineal Repair
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Assessment:
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Note type of episiotomy/laceration
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Note type of suture used and #
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Assess perineum for REEDA q shift in pp
period
Nursing Role with Perineal Repair
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Interventions:
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Encourage use of Topical Sprays (e.g. Dermoplast),
witch hazel pads (Tucks)
Offer ice bag to perineum in 1st 12 hours pp
Encourage use of Sitz bath or perineal shower for 20”
bid-tid, especially for 3rd & 4th Degree tears after 1st 12
hours
Offer donut pillow
Administer stool softener/laxative to prevent fear of
tearing sutures with BM
Offer analgesics prn
Cesarean Delivery
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Indications
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Cephalopelvic disproportion (CPD)
Malpresentations -- Breech, transverse lie, face
Preterm Baby -- only when chance of increased risk
to baby if delivered vaginally
Fetal Distress -- persistent late decelerations, poor
variability
Cord/Placental Problems -- prolonged severe
variable decelerations due to cord compression,
prolapsed cord, placenta previa, abruptio placenta
STD's -- genital herpes
Uterine Dystocia -- failed induction, reason for
induction persists, post-maturity
Pre-op Nursing Care
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IV fluids-- Usually warm Lactated Ringer’s
(LR) if spinal or epidural anesthesia
Labs--UA, CBC, type & crossmatch, Blood
Chemistry
Consent forms signed
Abdominal shave/clip (per dr.order)
Foley catheter
Keep dad present and involved/allow privacy
between couple when time allows
Explain all procedures--teach about return of
sensation to lower extremities, T,C, & DB &
pain management post-op
Pre-op Nursing Care (cont’d)
Remove all rings, jewelry, nail polish
 Monitor labor status - FHR &
contractions, till OR
 Always maintain calm attitude
 Administer an antacid e.g. Bicitra 30 cc.
po approx. 30 min before surgery
 Complete all admission hx and physical
assessment documentation
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Cesarean Section
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Skin Incisions
Uterine Incisions
Nursing Care During C/Section
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Reassure Mom during anesthesia induction.
Assess S.O. Coping
Care for Baby Immediately after Birth
Forceps
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web link on forceps and suction
Function: to provide traction, to rotate, or both
in the second stage of labor
Midforceps: when fetal head is at the level of
the ischial spines but above the +2 station
(Rarely used)
Outlet forceps: when the fetal head is visible
on the perineum without spreading the labia
apart. They shorten the length of 2nd stage.
Requirements for forceps: Cx dilated 10cm,
bladder empty, presenting part 0 station,
vertex presentation, membranes ruptured.
Vacuum Extractor
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A suction cap applied to fetal head traction is
applied to facilitate fetal descent in 2nd stage
of labor
Risks to fetus: cephalhematoma, scalp
lacerations, subdural hematoma
Risks to mom: perineal, vaginal,or cervical
lacerations
Requirements for vacuum: Cx dilated 10cm,
bladder empty, presenting part 0 station,
vertex presentation, membranes ruptured.
Indications for Forceps or Vacuum
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Prolonged second stage
Maternal condition precludes pushing:
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Fetal Distress–
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Heart disease, Pulmonary Edema
Exhaustion
Spinal, Epidural, Caudal Anesthesia– no sensation to
effectively push
late decels, poor variability. Bradycardia <100 for more
that 2-3 minutes
Threat to mother’s life
Immediate nursing actions
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Unwrap sterile packages and place onto
sterile field or in sterile basin with betadine
Assess maternal/fetal status
Teach mom that she may feel increased
pressure internally in vagina.
Coach mom through contractions to
effectively push with traction by forceps of
vacuum extractor
Nursing Actions after
Delivery with Forceps or Vacuum
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Check for sx of trauma to face, head, neck
of baby, lacerations or forceps face marks in
eye area
Check for increased ICP, lethargy, seizures,
paralysis (facial nerve palsy)
Answer parents’ questions about possible
trauma to their infant
Check mother for pp hemorrhage, vaginal
or labial hematoma
Nursing Care-3rd Stage of Labor
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Physical Assessments
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Signs of Placental Separation
Gush of Blood
 Cord Lengthens
 Fundus rises in abdomen
 Uterus becomes globular
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Psychosocial Assessments
Placental Separation
Shiny Schultz
Dirty Duncan
Nursing Care—3rd Stage of Labor
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Care of Mother – Physical
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Encourage her to push AFTER placenta
separates
Note time of Placental Expulsion
Add Pitocin to IV or Open Pitocin Drip
CHECK FUNDUS
Note how epis. Repair is going
Care of Mother – Emotional
Nursing Care – 3rd Stage of Labor
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Care of Newborn
Care after Episiotomy Repair
During C/Section
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Note time of Placental Separation
Emotional Support to Mom and S.O.
ESTIMATE BLOOD LOSS
Nursing Care- 4th Stage of Labor
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Greatest risk for Maternal Hemorrhage
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Physical Assessment
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At Risk for Hemorrhage (overhead)
Fundus (Firm, Soft, “Boggy”)
Lochia, Amount, Color
Perineum (Intact, Swelling, Approximation)
VS (B/P, P, R)
Frequency--q 15” x 4; q 30” x 2; q 60” x 2
4th Stage Nursing Care–C/Section
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Immediate Post-Op Care
Check the following every 15 minutes till stable
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V.S.—SaO2 , EKG pattern as well as TPR & BP
Lochia
Dressing
Fundus (very gently)
Foley—output appropriate
Return of sensation & mobility in toes & legs if spinal/epidural
Monitor IV with Pitocin infusing.
Offer O2 per mask prn
TCDB every 2 hrs. for 24 hr. (not as critical with epidural/spinal
anesthesia
Medicate prn for pain if general anesthetic, NO narcotics if
Duramorph
Facilitate attachment - bring baby back to mom while she is
recovering if possible; breastfeed baby
Post-op Care on Postpartum Unit
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V.S. every 4 hr. initially proceeding to tid after first 24
hours ( Hospital Policy )
Observe incision and need for dressing change
Provide pain control
Assess fundal height, lochia, bladder/bowel status,
hygiene
Perineal care: q 4 hr with indwelling catheter. Foley
may remain for 24 hrs, then give appropriate
instructions when d/c’ing
Mothering skills - help with positioning infant at
feedings due to incision; if breast-feeding, encourage
use of football hold or side-lying position with pillow on
abdomen
Encourage early ambulation to foster peripheral
circulation and  peristaltic activity
Other Elective Obstetrical Procedures
External Cephalic Version
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Definition: The alteration of fetal position by
abdominal or intrauterine manipulation to
accomplish a more favorable fetal position for
vaginal delivery.
Indications:
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Presenting part NOT engaged
Maternal abdominal wall thin enough to permit
good palpation
NO uterine irritability or contractions
Adequate amniotic fluid, intact membranes
NO known history of CPD
Version– Nursing Interventions
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Get consent for procedure and inform of possible
emergency C/S
Prepare for ultrasound to confirm fetal position
Close monitoring of fetus via fetal monitoring, NST
Follow MD orders if tocolytic ordered to relax uterus
Nurse may need to assist to head down position by
applying pressure over fetal head (pubic area) to
encourage fetus to stay in cephalic presentation.
Monitor maternal status for possible hemorrhage &
discomfort after procedure
Precipitous Delivery
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Definition = Labor < 3 hours
Assessment
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Vaginal Exam/Visualization
Precipitous Delivery-Nursing Care
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Don’t Break the Bed
Support Perineum, Deliver Fetal Head
Check for Nuchal Cord
Delivery Actions
Suction Baby’s mouth & nose
Clamp Cord, Wait for Placenta to come out
Dry Baby, Place on Mother’s Abdomen
Care -- Out-of Hospital Delivery
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Follow Precipitous Labor Actions
Try to be as clean as possible
Essential to protect infant from HEAT
LOSS (blankets, coats, newspaper)
BE CALM & CONFIDENT
THAT’S ALL FOLKS!
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Be sure to review
Handout “A”
“Cultural Influences During
Intrapartum Period”
as well!