Nursing Management during Labor and Birth

Christine Dunn

Healthy People 2020

Childbirth• 1. Reduce maternal deaths• 2. Reduce maternal illness and complications

due to pregnancy• 3. Increase the proportion of pregnant women

who receive early and adequate prenatal care• 4. Increase the proportion of pregnant women

who attend a series of prepared childbirth classes

Maternal Assessment

• Determine the woman’s response and her progress in labor

• Maternal Vital Signs, uterine contractions• Review the prenatal record• Uteroplacental circulation• Vaginal exam upon admission, then when

necessary to identify progress in labor ( Infection)• Discomfort along with strategies at regular

intervals ( Pharm and nonpharm)• Psychological status of patient and family

Leopold’s Maneuvers

• Method for determining the presentation,position and lie of the fetus using 4 steps.

• Each maneuver answers a question:

• See text.

Analysis of FHR

• One of the primary evaluation tools used to determine fetal oxygen status is the analysis of fetal heart rate.

• Fetoscope- intermittently• Doppler- intermittently• Electronic fetal monitor-

continuously/intermittently

Childbirth Discomfort is

Different WHY?• Childbirth discomfort is part of the process of labor,

a physiologic process, not from an injury or illness.• The pregnant woman has several months to

prepare for the discomfort of labor and to acquire skills to help cope.

• Labor discomfort has a foreseeable end; and the firth of the newborn brings a rapid decrease in the discomfort.

• Intermittent discomfort; labor ends with the birth of a newborn this is an emotional signifcance that affects the response to the discomfort.

Sources of Discomfort

• Tissue ischemia- Tissue hypoxia, uterus• Cervical dilation- Causes discomfort, dilation

and stretching of the cervix. See text.• Pelvic Structures- referred pain in back and

legs from pulling and pressure on pelvic structures.

• Distention of the vagina and perineum- As the fetus descends into the pelvis distention of the vagina and perineum occurs which causes discomfort.

Factors

• Influencing the Perception or tolerance of Pain:

• Intensity of labor• Cervical readiness• Fetal position• Characteristics of the pelvis• Fatigue• Intervention of caregivers

Psychosocial Factors

• Culture- Influence how she perceives, interprets and responds to pain during childbirth.

• Anxiety and Fear- Magnify sensitivity to pain and impair a woman’s ability to tolerate it.

• Previous experiences with pain—Fear and withdrawal natural reactions. Knowledge of the normal sensations of labor helps her to suppress her natural reactions of fear and withdrawal.

• Preparation and support- Reduces anxiety and fear of the unknown, rehearse. Family and friends are sources of comfort and assistance; realistic info.

Nonpharmacologic Techniques

• Relaxation• Cutaneous stimulation- Massage, thermal

stimulation, acupressure.• Hydrotherapy• Mental stimulation- imagery, breathing

techniques• Application of heat or cold• Advantage: No side effects or risk to the

fetus!!!

Pharmacologic interventions during

labor• Anesthesia- can be a combination of

analgesia, amnesia, relaxation and reflex activity. Abolishes pain perception by interrupting the nerve impulses to the brain, may involve loss of consciousness.

• Analgesia-Alleviation of the sensation of pain or the raising of the threshold for pain perception without loss of consciousness

Pharmacologic Pain Management

• Systemic Analgesia • Side Effects to the fetus:

Respiratory Depression!!! See textbook.

Pharmacologic Pain Management

• Regional pain management- relief without LOC.

Epidural Intrathecal(Subarachnoid) Local Pudendal General

I Want My Epidural!!

• Adverse Effects hypotension bladder distention catheter migration N/V Pruritus delayed resp depression prolonged second stage

I Want My Epidural !!

• Nursing Care preload with IV fluids(LR) assist anesthesiologist frequently assess FHR/MVS observe for bladder distention observe for side effects & report

Spinal Anesthesia

• Anesthesia of choice for Cesarean Section

• More rapid onset than epidural for C/S

• More complete block than epidural for C/S

• Requires much less concentration of drugs than epidural

• Potential spinal headache

• Hypotension• Bladder distention

Local Infiltration

• Injection of a local anesthetic such as lidocaine into the superficial perineal nerves to nemb the perineal area.

• Performed just before performing an episiotomy or before suturing a laceration.

• Does not alter the discomfort of the uterine contractions.

• No side effects to fetus! Or mother!

Pharmacologic Pain Management

• Special considerations effects on fetus maternal physiologic

alterations effects on course of labor effects of complications interactions with other

substances.

Nursing Care during the stages of labor

• First Stage- Key Nursing Interventions see text

• Summary of assessments during first stage:• Latent• Active• Transition• Positioning during the first stage of Labor:• See text Teaching guidelines.

Nursing Care

• Second Stage : Supporting the woman and her partner in making active decisions about her care and labor management.

• Support her choice of pushing method • Give feedback on her progress • See Text summary.• Perineal Lacerations• Episiotomy

Nursing Care

• Third and Fourth stage• Third- gradual decrease in the size of the

uterus this helps to shear the placenta away from its attachment site. Immediate newborn care/assessment, assist with the delivery of the placenta inspect for intactness.

• Fourth- Observation for hemorrhage, comfort measures, promotion of family attachment.

Application of theNursing Process

• Primary risks associated with EPIDURAL analgesia…

Maternal hypotension with secondary fetal hypoxia

Injury related to reduced sensation and movement

NCLEX Questions

• A patient, age 22 is a G1 T1 P0 A0 L1. During the 1st 24 hours after delivery, she does not show consistent interest in her neonate. How should the nurse interpret this behavior?

• A. The patient is experiencing PPD (post partum depression)

• B. The patient is questioning her role as a mother

• C. The patient is showing expected behaviors for the taking in period

• D. The patient is failing to attach to her neonate

NCLEX Questions

• A pregnant patient arrives at the health care facility stating that her bed linens were wet when she woke up this AM. She says no fluid is leaking but complains of mild abdominal cramps and lower back discomfort. Vaginal exam reveals 2 cm dilated with positive ferning noted. What stage of labor is this patient in?

• A. Latent• B Active • C. Transition• D. Explosive stage

Questions

• A patient in labor tells the nurse –midwife that she feels a strong urge to push. Vaginal exam reveals that her cervix is not completely dilated. The midwife tells her not to push yet. What is the rationale for this instruction?

• A. Early pushing may cause edema and impede fetal descent

• B. The nurse midwife is not ready to assist the patient at this time

• C. The fetus has not rotated to the proper position• D. Pushing at this time may cause ROM (rupture

of membranes)