Nursing Care During Labor and Birth Chapter 10

1. Nursing Care During Labor and Birth Chapter 10

2. Objectives 1.Discuss assessments and procedures the nurse performs during the woman’s admission to the hospital. 2. Describe external and internal methods for monitoring uterine contractions. 3. Compare and contrast advantages and disadvantages of intermittent auscultation of fetal heart rate with that of continuous electronic fetal monitoring. 4. Compare and contrast advantages and disadvantages of external fetal monitoring with that of internal fetal monitoring. 5. Explain how to apply the external fetal monitor. 6. Identify the role of the practical (vocational) nurse in the interpretation of fetal heart rate patterns. 7. Define three major deviations from the normal fetal heart rate baseline.

3. Objectives 8. Differentiate between early, variable, and late decelerations with regard to appearance, occurrence in relation to uterine contractions, causes, and whether or not the pattern is reassuring or nonreassuring. 9. Outline appropriate nursing interventions for each major periodic change: early, variable, and late deceleration patterns. 10. Discuss advantages and disadvantages of fetal stimulation, fetal scalp sampling, and fetal pulse oximetry for monitoring fetal status. 11. Determine data to collect when assessing a laboring woman for progress of labor and birth throughout each stage and phase of labor. 12. Identify common nursing diagnoses associated with each stage of labor and birth. 13. Choose appropriate nursing interventions for each stage of labor and birth to facilitate safe passage of the mother and fetus. 14. Evaluate the effectiveness of care given during each stage of labor and birth.

4. Role of the LPN/LVN During Labor and Delivery • Recognize and manage complications that may arise during the process • Give intensive support to the laboring woman and her partner or coach • Facilitate the labor process and ensure safe passage of the laboring woman and fetus through the event

5. The Nurse’s Role During Admission • Immediate assessments • Birth imminence • Fetal and maternal status • Risk factors • Additional assessments if birth is not imminent • Maternal health history and physical assessment (full-including weight, complete vitals, lungs, pain, deep tendon reflexes, clonus, amt. and location of any edema)-as time permits • Status of labor-contraction pattern, fetal lie, presentation, attitude, position, and station (pg. 207) • Labor and birth preferences-special requests: mobility during labor, IV fluids, episiotomy, presence of friends and family)

6. The Nurse’s Role During Admission(cont.) • Components of the admission health history • Obstetric history • Current status • Medical–surgical history • Social history • Desires/plans for labor and birth • Desires/plans for newborn

7. The Nurse’s Role During Admission(cont.) • Admission laboratory studies • Complete blood count (CBC) • Blood type and Rh factor • Serologic studies, such as VDRL or RPR to test for syphilis • Rubella titer (not done if prenatal record indicates the woman is immune) • ELISA to detect HIV antibodies (requires informed consent) • Vaginal or cervical cultures • Urinalysis (clean-catch specimen)

8. Question Mrs. Jones , a gravida 4 para 3, has just come in to the labor and delivery suite. She tells the admission nurse that her water broke 2 hours ago and she feels like pushing. What is the first assessment the nurse should make? a. Maternal vital signs b. Imminence of birth c. Take an obstetric history d. Find a good vein and start an IV

9. Answer b. Imminence of birth Rationale: Nursing assessment for signs that birth is imminent begins from the moment the woman arrives in the labor and delivery unit. If the woman is introverted and stops to breathe or pant with each contraction, you can infer that she is in an advanced stage of labor. In addition, if the woman makes statements such as, “I feel a lot of pressure,” or “The baby is coming,” or “I want to have a bowel movement,” it is likely the woman is in the second stage of labor, and the baby will be born soon.

10. The Nurse’s Role: Ongoing Assessment of Uterine Contractions and FHR • Monitoring uterine contractions • External Methods • Palpation to evaluate the contraction pattern • Mild contraction - fundus feels like the tip of your nose at the peak of a contraction • Moderate contraction – fundus feels like touching your chin • Strong contraction - feels like you are pushing on your forehead • Tocodynamometer (toco)-(belt) measures contraction frequency and duration LO2

11. The Nurse’s Role: Ongoing Assessment of Uterine Contractions and FHR (cont.) • Internal Methods • Intrauterine pressure catheter • Catheter tip placed above presenting part • Connected to fetal monitor • Records frequency, duration, and intensity of contractions LO2

12. The Nurse’s Role: Ongoing Assessment of Uterine Contractions and FHR (cont.) • Intermittent Auscultation of FHR • Acceptablemethod in low-risk pregnancy • Most common practice: place external fetal monitor for 20 minutes to get baseline data • If pattern is reassuring, then fetoscope or external monitor used intermittently • Auscultate fetal heart rate • Any concerns: attach continuous EFM LO3

13. The Nurse’s Role: Ongoing Assessment of Uterine Contractions and FHR (cont.) • Intermittent Auscultation of FHR • Advantages of IA • Woman has more freedom to move about • Nurses are encouraged to focus on the laboring woman and her support person, rather than on the technology • Associated with fewer medical interventions and fewer surgical deliveries LO3

14. The Nurse’s Role: Ongoing Assessment of Uterine Contractions and FHR (cont.) • Intermittent Auscultation of FHR • Disadvantages of IA • Takes more time • Requires higher nurse staffing levels • Many practitioners unaccustomed to using IA fear the potential of missing an ominous FHR pattern. LO3

15. The Nurse’s Role: Ongoing Assessment of Uterine Contractions and FHR (cont.) • Monitoring FHR • Continuous EFM • External EFM – indirect • Most common way to assess fetal status during labor • Works on the principle of ultrasound • Characteristics of the fetal heart rate pattern can then be monitored continuously via a video display and/or a continuous printout LO4

16. The Nurse’s Role: Ongoing Assessment of Uterine Contractions and FHR (cont.) External EFM – indirect • Toco monitors the contraction pattern • Helps screen for signs of fetal compromise • Sometimes it is difficult to get a consistent tracing if the fetus is small or extremely active, or if the woman is obese • Some manufacturers of fetal monitors have developed telemetry units LO4

17. The Nurse’s Role: Ongoing Assessment of Uterine Contractions and FHR (cont.) • Continuous EFM • Internal EFM • Invasive procedure • Spiral electrode is attached to the presenting part just under the skin • Records a graphic representation of FHR • Easier to obtain consistent tracing • Increases the risk of maternal and fetal infection and injury LO4

18. The Nurse’s Role: Ongoing Assessment of Uterine Contractions and FHR (cont.) • Evaluating FHR Patterns • Baseline fetal heart rate (FHR) • Measured between uterine contractions during a 10-minute period • Normally accepted baseline rate is between 110 beats per minute (bpm) and 160 bpm • Baseline variability • Fluctuations of the FHR from the baseline rate LO6

19. The Nurse’s Role: Ongoing Assessment of Uterine Contractions and FHR (cont.) • Baseline fetal heart rate (FHR) (cont.) • Evaluated visually as a unit • Normal if the fluctuations are greater than 6 bpm and less than 25 bpm • Reassuring sign that the fetal nervous system is intact LO6

20. The Nurse’s Role: Ongoing Assessment of Uterine Contractions and FHR (cont.) Baseline fetal heart rate (FHR) (cont.) • Three major deviations from a normal FHR baseline • Tachycardia • Baseline rate greater than 160 bpm • Bradycardia • Baseline FHR below 110 bpm • Absent or minimal variability • Non-reassuring pattern • Must continue for at least 2 minutes LO7

21. The Nurse’s Role: Ongoing Assessment of Uterine Contractions and FHR (cont.) • Evaluating FHR Patterns (cont.) • Periodic and episodic changes • Periodic changes are variations in the FHR pattern that occur in conjunction with uterine contractions, • Episodic changes are variations in the FHR pattern not associated with uterine contractions. LO8

22. The Nurse’s Role: Ongoing Assessment of Uterine Contractions and FHR (cont.) • Reassuring periodic changes • Accelerations - above the baseline by at least 15 bpm for at least 15 seconds (15 x 15 window) • Benign periodic changes • Early decelerations-looks like a “U” • Non-reassuring periodic changes • Variable decelerations indicating some type of acute umbilical cord compression • Late decelerations indicating utero-placental insufficiency (diminished or deficient blood flow to uterus or placenta)-grave situation LO8/9

23. The Nurse’s Role: Ongoing Assessment of Uterine Contractions and FHR (cont.) • Measures used to clarify non-reassuring FHR patterns • Fetal stimulation-indirectly w/ an acoustic vibrator through abdominal wall or directly with a gloved finger • Fetal scalp sampling-requires MD to take a small blood sample from fetus’ scalp-checks pH (if acidotic-will need delivered immediately • Fetal scalp pulse oximetry LO-10

24. Question Tell whether the following statement is true or false. Early decelerations are benign periodic changes.

25. Answer True Rationale: Sometimes instead of accelerations, there is a slowing of the FHR. If the dip in the FHR tracing occurs in conjunction with and mirrors a uterine contraction, it is an early deceleration. As long as the baseline remains within normal limits and the variability is good, early decelerations are benign.

26. Nursing Process During the First Stage of Labor: Dilation • Focus is on assessment • Providing physical care to the mother and fetus • Providing psychological care to the mother • And keeping the practitioner informed about labor progress

27. Nursing Interventions During the Latent Phase (Early Labor) • Assessment • Assess FHR and contractions at least once every hour • Assess maternal status • Assess status of fetal membranes • Assess the woman’s psychosocial state

28. Nursing Interventions During the Latent Phase (Early Labor) (cont.) • Nursing diagnosis • Risk of injury (fetal and maternal) related to possible complications of labor • Anxiety related to uncertainty of labor onset and insecurity regarding ability to cope • Acute pain related to contractions • Deficient Knowledge of labor process related to inadequate preparation for delivery or unexpected circumstances of labor

29. Nursing Interventions During the Latent Phase (Early Labor) (cont.) • Outcome identification and planning • Primary goals are maternal and fetal safety • Other goals and interventions are planned according to the individual needs of the laboring woman and her partner

30. Nursing Interventions During the Latent Phase (Early Labor) (cont.) • Implementation • Preventing fetal and maternal injury • Relieving anxiety • Promoting comfort • Providing patient teaching

31. Nursing Interventions During the Latent Phase (Early Labor) (cont.) • Goals and expected outcomes • Goal: The woman and fetus remain free from injury • Goal: The woman’s anxiety is reduced • Goal: The woman’s pain is manageable • Goal: The woman and her partner have adequate knowledge of the labor process

32. Question When planning care for a client in the latent phase of labor what is one primary goal? a. Mother’s pain is adequately controlled b. Mother’s anxiety is controlled c. Mother has adequate knowledge of labor process d. Mother is safe

33. Answer d. Mother is safe Rationale: Maintaining the safety of the laboring woman and her fetus throughout the latent phase of the first stage of labor are primary goals when planning care.

34. Nursing Interventions During Active Labor • Assessment • Assess woman’s psychosocial state • Assess labor progress • Assess fetal status • Assess maternal status

35. Nursing Interventions During Active Labor(cont.) • Selected nursing diagnoses • Risk for trauma to the woman or fetus related to intrapartum complications or a full bladder • Acute pain related to the process of labor • Anxiety related to fear of losing control • Ineffective coping related to situational crisis of labor • Ineffective breathing pattern: hyperventilation related to anxiety and/or inappropriate application of breathing techniques

36. Nursing Interventions During Active Labor(cont.) • Selected nursing diagnoses (cont.) • Impaired oral mucous membrane related to dehydration and/or mouth breathing • Risk for infection related to invasive procedures (e.g., vaginal examinations) and/or rupture of amniotic membranes • Outcome identification and planning • Primary goal remains maintaining maternal and fetal safety

37. Nursing Interventions During Active Labor (cont.) • Implementation • Preventing trauma during labor • Providing pain management • Reducing anxiety • Promoting effective coping strategies • Promoting effective breathing patterns • Maintaining integrity of the oral mucosa • Preventing infection

38. Nursing Interventions During the Transition Phase of Labor • Assessment • Assess for signs woman has reached transition phase • Assess woman’s ability to cope • Assess maternal status • Assess fetal status

39. Nursing Interventions During the Transition Phase of Labor (cont.) • Selected nursing diagnoses • Acute pain related to frequent, intense uterine contractions and pressure of the descending fetal head • Ineffective breathing pattern: hyperventilation related to intense uterine contraction pattern and loss of control of breathing techniques • Powerlessness related to intensity of the labor process • Fatigue related to energy expended coping with the intense labor

40. Nursing Interventions During the Transition Phase of Labor (cont.) • Outcome identification and planning • Major goals • The woman’s pain will be manageable • She will exhibit effective breathing patterns • She will maintain a sense of control • She will rest between uterine contractions.

41. Nursing Interventions During the Transition Phase of Labor (cont.) • Implementation • Managing pain • Promoting effective breathing patterns • Promoting a sense of control • Supporting the woman through fatigue • Preparing the room for delivery

42. Question Tell whether the following question is true or false. Your patient is in the transition phase of labor. One of your nursing interventions will be supporting the woman’s coach through the woman’s fatigue.

43. Answer False Rationale: Relaxing with contractions may be almost impossible; assist the woman to achieve relaxation or even sleep between contractions. Help her to find a comfortable position. Support her position with pillows. Placing a cool cloth to her forehead or giving her a back rub may help her relax between contractions.

44. Nursing Interventions During the Second Stage of Labor: Expulsion of the Fetus • Assessment • Monitor the blood pressure, pulse, and respirations every 15 to 30 minutes • Assess the contraction pattern every 15 minutes • Assess the woman’s report of an uncontrollable urge to push • Check the FHR every 15 minutes for the low-risk woman and every 5 minutes for the woman who is at risk for labor complications

45. Nursing Interventions During the Second Stage of Labor: Expulsion of the Fetus (cont.) • Selected nursing diagnoses • Fatigue related to length of labor and pushing efforts • Risk for trauma related to pushing techniques and positioning for delivery • Outcome identification and planning • Goals for the second stage of labor • The woman will push effectively despite fatigue • She will give birth with minimal or no trauma to the fetus or herself

46. Nursing Interventions During the Second Stage of Labor: Expulsion of the Fetus (cont.) • Implementation • Promoting effective pushing despite fatigue • Reducing the risk of trauma using effective pushing techniques and positions • Preparing for delivery of the newborn LO13

47. Nursing Process During the Third Stage of Labor: Delivery of the Placenta • Assessment • Assess the woman’s psychosocial state after she gives birth • Monitor for signs of placental separation • Selected nursing diagnoses • Risk of deficient fluid volume related to blood loss in the intrapartum period • Risk of trauma: hemorrhage, amniotic fluid embolism, retained placenta, or uterine inversion related to delivery of the placenta

48. Nursing Process During the Third Stage of Labor: Delivery of the Placenta (cont.) • Outcome identification and planning • Major goals during the third stage of labor • The new mother will maintain adequate fluid volume • She will remain free of trauma. • Implementation • Preventing fluid loss • Maintaining safety and preventing trauma-oxytocin given to prevent hemorrhage, deliver and intact placenta, keep blood loss <500ml LO13

49. Nursing Process During the Fourth Stage of Labor: Recovery • Assessment • Continue to assess the woman for hemorrhage • Assess the lochia (vaginal discharge after birth) • Monitor for signs of infection • Monitor for suprapubic distention • Assess the woman’s comfort level • Assess the mother’s psychosocial state during the fourth stage. • Assess initial bonding behaviors of the new family.

50. Nursing Process During the Fourth Stage of Labor: Recovery (cont.) • Selected nursing diagnoses • Risk of impaired parent–infant attachment related to disappointment regarding the gender of the newborn or an unwanted pregnancy • Risk of deficient fluid volume related to the possibility of hemorrhage from the former site of placenta attachment • Risk of infection related to invasive procedures and vaginal examinations during labor