Nursing Care during Labor and Birth - Ukiah Adult...

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Nursing Care Nursing Care during Labor during Labor and Birthand Birth

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Labor and BirthLabor and Birth

The woman in labor may present at any The woman in labor may present at any stage in the labor processstage in the labor process

Upon admission to the labor unit, a full Upon admission to the labor unit, a full health history is performedhealth history is performed

Important assessment items include the Important assessment items include the onset, frequency and duration of onset, frequency and duration of contractions, any leaking of fluid from the contractions, any leaking of fluid from the vagina, and if there is any bloody showvagina, and if there is any bloody show

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When the laboring mom presents in When the laboring mom presents in the final stages of labor, the nurse the final stages of labor, the nurse must move quicklymust move quickly

Believe her when she says her baby is Believe her when she says her baby is comingcoming

Don’t leave the mom, use the call light Don’t leave the mom, use the call light to notify other staffto notify other staff

Remain calm and reassure momRemain calm and reassure mom

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Fetal status – average FHR baseline is Fetal status – average FHR baseline is 110 to 160110 to 160

Moderate long term variability Moderate long term variability fluctuation is 6 to 25 bpmfluctuation is 6 to 25 bpm

Periodic changes are reassuring Periodic changes are reassuring accelerations with 15 X 15 increases accelerations with 15 X 15 increases from BL, indicate a well oxygenated from BL, indicate a well oxygenated babybaby

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Fetal MonitorFetal Monitor

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FHR changes that can be non-FHR changes that can be non-reassuring are variable and late reassuring are variable and late decelerationsdecelerations

Variables indicate some kind of cord Variables indicate some kind of cord compressioncompression

Assist the mother to change positions Assist the mother to change positions to relieve cord compressionto relieve cord compression

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FHR indications of possible hypoxiaFHR indications of possible hypoxia– Absent variabilityAbsent variability– Increasing BLIncreasing BL– Late decelsLate decels– Increasing decelsIncreasing decels– Persistent bradycardiaPersistent bradycardia– DeathDeath

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Late DecelerationsLate Decelerations

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BradycardiaBradycardia

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ROMROM Reports from mom of a gush or Reports from mom of a gush or

continued leakage of fluidcontinued leakage of fluid Nurse to check for pooling of fluid by Nurse to check for pooling of fluid by

SSESSE Nitrazine for alkaline fluid (blue)Nitrazine for alkaline fluid (blue) Fern testFern test AmniSure testAmniSure test

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Important to record the time of Important to record the time of rupture, color and odor of fluidrupture, color and odor of fluid

S/S of infection can include maternal S/S of infection can include maternal fever, cloudy/foul smelling fluid and fever, cloudy/foul smelling fluid and fetal tachycardiafetal tachycardia

Green fluid indicates presence of Green fluid indicates presence of meconium and possible fetal distressmeconium and possible fetal distress

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Assess for vaginal bleedingAssess for vaginal bleeding Blood pressure is the most critical Blood pressure is the most critical

immediate measurement of assess for immediate measurement of assess for VSVS

Assess contraction pattern – Assess contraction pattern – frequency, duration and intensityfrequency, duration and intensity

Determine fetal lie – Leopold’s Determine fetal lie – Leopold’s maneuvermaneuver

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If there is not heavy bleeding, a If there is not heavy bleeding, a vaginal exam is done to assess dilation vaginal exam is done to assess dilation and effacement of the cervixand effacement of the cervix

Confirm presenting part of the fetus, Confirm presenting part of the fetus, station and position, and engagementstation and position, and engagement

Determine if mom has a birth plan and Determine if mom has a birth plan and review birth plan with physician if review birth plan with physician if there is timethere is time

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Monitor uterine contractions noting Monitor uterine contractions noting contraction pattern and FHR response contraction pattern and FHR response to contractionsto contractions

Intermittent monitoring is leaving the Intermittent monitoring is leaving the mom on the monitor for 20 min., then mom on the monitor for 20 min., then allowing her to be off of the monitor allowing her to be off of the monitor for a period of time to walk aroundfor a period of time to walk around

Continuous monitoring is continuousContinuous monitoring is continuous

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External monitoring – contractions External monitoring – contractions only can tell when they happen and only can tell when they happen and how long they last – not strengthhow long they last – not strength

Internal monitoring – can determine Internal monitoring – can determine strength of contraction more strength of contraction more accuratelyaccurately

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Internal MonitoringInternal Monitoring

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Early labor (latent phase)Early labor (latent phase) Best time to teach patient and partner Best time to teach patient and partner

about the process of laborabout the process of labor She may be talkative, excited, and She may be talkative, excited, and

express feelings of confidenceexpress feelings of confidence Encourage her to express her fears Encourage her to express her fears

and ask her what most concerns her and ask her what most concerns her about laborabout labor

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Early laborEarly labor Discuss pain relief optionsDiscuss pain relief options Give a brief explanation of the labor processGive a brief explanation of the labor process Involve the partner in developing a plan for Involve the partner in developing a plan for

if the mom starts to lose controlif the mom starts to lose control Ask about coping behaviorsAsk about coping behaviors Provide supportive careProvide supportive care

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Review and reinforce breathing and Review and reinforce breathing and relaxation techniquesrelaxation techniques

Encourage mom to conserve energy in Encourage mom to conserve energy in laborlabor

Anxiety and fear are reduced and Anxiety and fear are reduced and labor process enhanced when the labor process enhanced when the woman knows what to expect and is woman knows what to expect and is supported during laborsupported during labor

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Danger signs in labor –Danger signs in labor –– Elevated BP above 140/90Elevated BP above 140/90– Sudden low BP below 90/50Sudden low BP below 90/50– Elevated maternal temp above 100.4Elevated maternal temp above 100.4– Green/cloudy/foul smelling amniotic fluidGreen/cloudy/foul smelling amniotic fluid– Non-reassuring FHRNon-reassuring FHR– Tetanic contractionsTetanic contractions– Heavy bleedingHeavy bleeding– Severe pain right upper quadrantSevere pain right upper quadrant

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A full bladder can interfere with the A full bladder can interfere with the decent of the fetus in labordecent of the fetus in labor

Check the bladder for fullness every 2 Check the bladder for fullness every 2 hourshours

Encourage voiding oftenEncourage voiding often If patient unable to void, do I&O cathIf patient unable to void, do I&O cath

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Preventing infection –Preventing infection –– Hand washing is the number one way to Hand washing is the number one way to

prevent the spread of infection.prevent the spread of infection.– Wash your hands thoroughly before and Wash your hands thoroughly before and

after providing careafter providing care– Encourage the woman and her partner to Encourage the woman and her partner to

wash their hands before and after wash their hands before and after contact with the perineum or after using contact with the perineum or after using the bathroomthe bathroom

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Transition phaseTransition phase Look for an increase in bloody show Look for an increase in bloody show

and a strong urge to pushand a strong urge to push The woman may experience irritability, The woman may experience irritability,

restlessness, anger, and feel out of restlessness, anger, and feel out of controlcontrol

She may tremble, vomit or cryShe may tremble, vomit or cry She may hyperventilateShe may hyperventilate

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TransitionTransition– N/V during this phase is common due to N/V during this phase is common due to

decreased gut peristalsis and delayed gastric decreased gut peristalsis and delayed gastric emptying.emptying.

– Assist the woman to her side if she is vomiting Assist the woman to her side if she is vomiting to help prevent aspirationto help prevent aspiration

– Do not give narcotics during this phase of laborDo not give narcotics during this phase of labor– Assist with position changes and breathingAssist with position changes and breathing– Provide short, brief instructions with Provide short, brief instructions with

demonstrationsdemonstrations

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PushingPushing– The hands and knees position The hands and knees position

encourages rotation of the fetal head, encourages rotation of the fetal head, enhances placental blood flow, decreases enhances placental blood flow, decreases fetal stress, and allows perineum to fetal stress, and allows perineum to stretch decreasing need for an stretch decreasing need for an episiotomyepisiotomy

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PushingPushing

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Fourth stage –Fourth stage –– Monitor for S/S of hemorrhage (increasing HR, Monitor for S/S of hemorrhage (increasing HR,

decreasing BP)decreasing BP)– Highest risk 2 to 4 hours postpartumHighest risk 2 to 4 hours postpartum– Monitor VSMonitor VS– Palpate fundus for position and firmnessPalpate fundus for position and firmness– Should be contracted and midline, one finger Should be contracted and midline, one finger

breath below the umbilicusbreath below the umbilicus– Bleeding should be dark read, small to Bleeding should be dark read, small to

moderatemoderate

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A temp of 100.4 or higher with foul A temp of 100.4 or higher with foul smelling vaginal discharge could smelling vaginal discharge could indicate an infectionindicate an infection

Mom should void within 6 hours after Mom should void within 6 hours after birthbirth

Urinary retention can cause a shift in Urinary retention can cause a shift in the fundus to the right, boggy uterus the fundus to the right, boggy uterus and increased bleedingand increased bleeding

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Mom is usually fatigued after birth and very Mom is usually fatigued after birth and very hungryhungry

She is self-absorbed and has an intense She is self-absorbed and has an intense need to talk about the labor and deliveryneed to talk about the labor and delivery

Assess initial bonding with infantAssess initial bonding with infant Turning away from the infant or making Turning away from the infant or making

disparaging comments about the infant can disparaging comments about the infant can indicate an attachment problemindicate an attachment problem

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Care immediately after birth –Care immediately after birth –– Inspect and cleanse the perineumInspect and cleanse the perineum– Place an absorbent pad under the buttocksPlace an absorbent pad under the buttocks– Ice pack to perineum for 12 hours, then Sitz Ice pack to perineum for 12 hours, then Sitz

bathbath– Promote parental bondingPromote parental bonding– Attempt to BF (helps uterus to contract)Attempt to BF (helps uterus to contract)– Place newborn skin to skin to promote bondingPlace newborn skin to skin to promote bonding

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Falling BP, increasing HR may indicate a Falling BP, increasing HR may indicate a fluid volume deficit or hemorrhagefluid volume deficit or hemorrhage

Inspect lochia for amount and colorInspect lochia for amount and color Fundus should be firmFundus should be firm Monitor perineum for hematomaMonitor perineum for hematoma May be shaky after birth (normal)May be shaky after birth (normal) Encourage restEncourage rest Provide rooming-in with infantProvide rooming-in with infant

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Newborn AssessmentNewborn Assessment

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NewbornNewborn

Keep baby warm to prevent heat lossKeep baby warm to prevent heat loss Given Vitamin K in Vastus Lateralis Given Vitamin K in Vastus Lateralis

and Erythromycin in both eyesand Erythromycin in both eyes If mom is Rh negative and baby is Rh If mom is Rh negative and baby is Rh

positive, mom will get Rhogam within positive, mom will get Rhogam within 72 hours after birth72 hours after birth

Encorage skin to skin and early breast Encorage skin to skin and early breast feeding (stimulate prolactin release feeding (stimulate prolactin release from anterior pituitary)from anterior pituitary) 3838

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Cool Surface

Draft

Wet skin Cold room

Nursing Care during Labor and Birth - Ukiah Adult...

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