Nursing Care during Labor and Delivery
Establishing a Therapeutic Relationship • Make the family feel welcome • Determine family expectations about birth • Convey confidence • Use touch for Comfort • Respect cultural values
Health History • Once the woman has been admitted and labor progress has been assessed, the following additional information regarding health history is collected: • Personal data – blood type, allergies, etc. • History of previous illnesses • Problems with this pregnancy • Preferences for labor and delivery • Preparation for childbirth
Admission to Labor and Delivery • Assessments performed on admission include: • Vital signs • Physical exam with a vaginal exam • Contraction pattern • Membrane status • Fetal status • Psychosocial assessment, cultural assessment • Preparation for labor and delivery
Assessment of Labor Progress
PalpationLeopold’s Maneuver Start by: Stand on the Right side, face the woman and palpate with the palms of the hands. Step 1 - Start at upper fundus and palpate for the head or buttocks
Step 3- Gently grasp lower portion of uterus and feel for the head • Step 2- Go down each side and locate back
Auscultation Location of FHR in relation to the more commonly seen fetal positions
Ask Yourself? • If the fetal heart tones (FHT’s) are heard loudest (PMI) in the patient’s upper right quadrant of her abdomen, the fetus would be assessed for a breech presentation. A. True B. False
Vaginal Examination Information Obtained: • Presentation • Position • Condition of Membranes --ruptured or intact • Dilation - enlargement and widening of os ( cm.) • Effacement- thinning of the cervix (%) • Station • Engagement
Fetal Oxygenation • Main assessments related to fetal well-being are: • Fetal Heart Rate • Contractions • Characteristics of amniotic fluid • Maternal vital signs
Nursing Care related to stages of labor
Signs and Symptoms of the Stage 1 - Latent Phase • 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!
Nursing Care Stage 1 – Latent Phase • 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.
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 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 Two 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 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 – Nursing Care • Teach QUALITY Pushing • Support with delivery
Stage 3 – 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 ____________. A. Flexion B. Extention C. External rotation • Cardinal movement that allows the smallest diameter of the head to pass through the pelvis is__________________. A. Flexion 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
Promotion of Comfort and Pain Management
Causes of Pain in Labor Stretching of the cervix during dilation & effacement Stage One Uterine Anoxia Stretching of the uterine ligaments
Causes of Pain in Labor 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 • Preparation - Knowledge and confidence gained through childbirth classes • Cultural influences on expression of pain • Maternal fatigue, anxiety, sleep deprivation • Previous experiences with pain • Support
What is the Goal Of Pain Management?
Methods of Pain Relief • Nonpharmacologic • Childbirth methods • Breathing Techniques • Relaxation Techniques • Touch • Focusing attention on one object • Effleurage
Non-Pharmacological • Sensory Stimulation • Listening to music; subdued lighting • Imagery • Applying heat and cold • Massage (lower back); Counterpressure • TENS • Position Changes
Pain Relief in Labor • Pharmacologic Methods • Analgesia • Stadol • Barbiturates • Seconal; Nembutal • Tranquilizers • Vistaril
Pain Relief in Labor • Criteria for administering an analgesic: • Needs to be in active phase of labor • If give in latent phase – it may slow labor • If give in transition phase – can lead to neonatal respiratory depression
Anesthesia • Regional • Paracervical • Epidural; Caudal • Spinal • Pudendal • Local • General • Used mainly in cesarean deliveries
Epidural Anesthesia Injection of an anesthetic agent into the epidural space Provides pain relief during labor and delivery
Nursing Care related to an epidural • Preparation • Assess platelet count – must be normal • Empty bladder • Assess vital signs for baseline • IV fluids • Following • Assess V/S – especially the B/P because the main side effect is hypotension • Rotate position between right and left side-lying • Assess bladder and catheterize as needed • Assess for other side effects and intervene
Spinal Anesthesia A local anesthetic is injected directly into the spinal fluid in the spinal canal to provide anesthesia for cesarean birth and occasionally for vaginal birth
Pudendal Anesthesia Anesthesia administered transvaginally and intercepts pudendal nerve. Provides pain relief for episiotomy and delivery.
Local Anesthesia Local injection of anesthetic agent in the perineum for episiotomy and repair
General Anesthesia • Mainly used for emergency deliveries via cesarean birth • Used for delivery of the woman with active herpes who will require a cesarean delivery. Do not want fetus to go through the birth canal and risk contact.
True or False ? • The anesthesia used for both labor and delivery is an epidural A. True B. 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 A. True B. False