Download Labor and Delivery Lecture Notes

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Nursing Responsibility During First Stage of Labor
J. Nursing Diagnoses for the Intrapartal Patient
I. Anxiety
1. R/T threat to health status
2. R/T role changes
II. Deficient Knowledge R/T lack of exposure to childbirth process
III. Fatigue
1. R/T stress
2. R/T sleep deprivation
3. R/T increased metabolic demands of pregnancy
IV. Activity Intolerance
1. R/T imbalance between oxygen demand and supply
2. R/T pain
V. Fear
1. R/T separation from support system
2. R/T lack of understanding of labor process
3. R/T language barrier
VI. Acute Pain
1. R/T uterine contractions
2. R/T birth process
VII. Ineffective Coping
1. R/T inadequate opportunity to prepare for stressor
2. R/T inadequate level in ability to cope
3. R/T uncertainty
4. R/T inadequate social support
VIII. Interrupted Family Processes
1. R/T gain of a family member
2. R/T change in roles
3. R/T economic changes
IX. Powerlessness R/T loss of privacy
X. Self-Care Deficit: Toileting
1. R/T bedrest status (epidural)
2. R/T impaired transfer ability
XI. Situational Low Self-Esteem R/T perceived loss of control
XII. Impaired Gas Exchange R/T ventilation-perfusion imbalance 2 hypovolemic shock
XIII. Ineffective Breathing Pattern
1. R/T decreased energy
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2. R/T body position
3. R/T pain
XIV. Risk for Injury R/T altered mobility
XV. Impaired Urinary Elimination
1. R/T decreased sensory motor function (epidural)
2. R/T increased stress to bladder
XVI. Risk for Impaired Skin Integrity
1. R/T increased moisture
2. R/T altered fluid status
3. R/T decreased sensation
4. R/T surgical incision of perineum
XVII. Impaired Tissue Integrity R/T tearing of perineum
XVIII. Risk for Infection
1. R/T break in primary defense
2. R/T invasive procedures
3. R/T rupture of amniotic membranes
I. Nursing Care in Normal Labor: Stage 1
A. Latent Phase (Early Phase)
I. Overview:
1.Up to 3 - 4 cm cervical dilation.
2. Average 8 - 20 hours (primipara).
3. Average 5 - 14 hours (multipara)
II. When to go to hospital
1. Contractions
a. Nullipara - regular, 5 minutes apart X 1 hour
b. Multipara - regular, 10 minutes apart X 1 hour
2. Ruptured Membranes - a gush or trickle of fluid from the vagina needs evaluating.
3. Bleeding - bright red blood not mixed with mucous needs immediate evaluation.
4. Decreased Fetal Movement - notify provider or go to hospital
III. Admission to Labor and Delivery
1. Establish a therapeutic relationship
a. Make the family welcome
1.) Take the time to show you care
2.) Arrange for an interpreter, if needed
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b. Determining family expectations about birth
1.) May have a written birth plan
2.) Be sure to include partner in assessment of expectations.
c. Convey confidence - use the term "give birth" instead of "deliver," the mother is in
control, reassure the woman that intense contractions are normal.
d. Assign a primary nurse (1:1 if possible, or 1:2).
e. Use touch for comfort:
1.) Be aware of cultural concerns (if touch is appropriate).
2.) Desire for touch may change as labor progresses (often does not like it in
transition).
f. Respect cultural values - Nurse should incorporate couple's cultural values (i.e.,
privacy) into the birth experience.
2. Impending Birth
a. Some may deliver shortly after coming to unit
b. Signs/ Symptoms of impending birth:
1.) Grunting
2.) Bearing down
3.) Saying, "The baby's coming!!!!"
c. Vital Information to Obtain:
1.) Mother's name
2.) Support person's name
3.) If she had prenatal care
4.) Physician/ midwife's name
5.) Gravida & Para status
6.) Vaginal or c-section (previous deliveries)
7.) Status of membranes
8.) EDC/ EDD/ EDB
9.) Any problems during pregnancy
10.) Allergies
11.) Time & type of last PO intake
12.) VS & fetal heart rate
d. History - if not in a hurry. Obtain from interview & woman's records:
1.) Woman's reason for coming to hospital (contractions? membranes?)
2.) Prenatal care history
3.) EDC/ EDD/ EDB
4.) Gravida, Para status
5.) Medical, surgical, & pregnancy hx
6.) Allergies
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7.) Food intake & when
8.) Any recent illness, including treatment
9.) Medications, alcohol, & tobacco use
10.) Blood type, Rh factor, Rhogam shots
e. Physical Assessment
1.) Brief head to toe
2.) Note especially:
a.) Edema
b.) Hydration status
c.) Oxygenation status
d.) Reflexes - deep tendon (patellar). If epidural, test upper extremity
e.) Weight
f.) Elimination pattern (last void & BM)
f. Lab Tests
1.) Hematocrit
2.) Urine for protein & glucose
3.) Blood type (if not on prenatal record)
4.) VDRL
5.) Beta strep status
g. Maternal Assessments
1.) Vital signs - compare with baseline or prenatal record.
a.) Temperature 100.4 or greater = ? infection
b.) BP sustained at 140/90 or greater = hypertension
c.) Temperature q4 unless increased or ruptured membranes, then q1
d.) Pulse, respiratory rate, and blood pressure q hour
2.) Contractions - if on external fetal monitor, must palpate to determine strength
of contractions. Factors that interfere with accuracy of determining duration and
interval:
a.) Abdominal fat
b.) Maternal position
c.) Fetal position
Assessment done:
a.) q hour - latent phase
b.) q 30 minutes - active & transition
c.) q 15 minutes - second stage
Note:
a.) Frequency - Beginning of one contraction to start of next
b.) Duration - Beginning to end of one contraction
c.) Interval - End of one contraction to start of next
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d.) Intensity - Mild (tip of nose); Moderate (chin); Firm (forehead)
Procedure: Use tips of fingers on fundus. Keep hand still. Monitor at least 3
contractions to get an accurate picture.
Report: Hypertonic contractions (decreased placental blood flow)
a.) Duration > 90 seconds
b.) Intervals < 60 seconds
c.) Frequency - closer than 2 minutes
d.) Incomplete relaxation between contractions
3.) Vaginal Bleeding
Assess: color, amount, odor. Bloody show & small amounts of vaginal bleeding
are normal due to rupture of small capillaries as mucus plug is expelled & cervix
dilates.
4.) Membrane Status
a.) Membranes rupture on their own - SROM (spontaneous rupture of
membranes)
b.) Rupture due to an amniotomy - AROM (artificial rupture of
membranes)
c.) Note:
i. FHR (fetal heart rate) X 1 minute (cord may prolapse or become
compressed.
ii. Color:
Clear or creamy: normal
Yellow, cloudy, or foul-smelling: infection
Green: meconium stool from transient hypoxia
iii. Amount:
>1000 ml - large
500-1000 - moderate
trickle - scant
iv. Time: when & how rupture occurred. Women may think it is
urine leaking due to pressure on bladder. Check with nitrazine
paper (sensitive to pH - turns blue with amniotic fluid).
h. Fetal Assessments
1.) FHR - Normal 110-160.
Ways to assess:
a.) Fetoscope
b.) Doppler
c.) External monitor
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Assess:
a.) Before, during & after a contraction
b.) Count baseline for 30-60 seconds between contractions
c.) Check maternal pulse to make sure you are truly hearing FHR
Good signs:
a.) Average rate 110-120 (lower) and 150 to 160 (higher)
b.) Accelerations of 15 bpm for 15 seconds with movement
c.) Variability (fluctuations in the fetal heart rate as it responds to labor
stress)
Bad signs:
a.) Heart rate outside of normal limits
b.) Decelerations (slowing of heart rate after the contraction ends)
c.) No increase in heart rate when baby moves
2.) Presentation - Leopold's Maneuvers
Have patient empty bladder. Position on back & raise head slightly - expose
abdomen. Stand at side of patient, facing her head (for the 1st through 3rd
maneuvers). Stand at side of patient facing feed (for 4th maneuver).
1st Maneuver: Using both hands, palpate the fundus to determine presenting part.
Head - round, hard - moves independently.
Buttocks - soft, irregular, moves with trunk, adjacent to small parts
2nd Maneuver: Place palms on either side of the abdomen with right hand first.
Exert deep, gentle pressure. Then use left hand. Determine where the fetal back is.
Back is a smooth continuous plane. Opposite side is nodular.
3rd Maneuver: Place thumb & fingers of one hand over symphysis pubis. Apply
pressure down and toward mother's back. Determine presenting part and degree of
descent: able to move it upward ("floating" - ballotable) or engaged (unable to
move.).
4th Maneuver: Turn to face feet. If breech presentation, omit. Place hands on
either side of uterus and slide fingers downward and pressing inward until fingers
feel an obstruction near the symphysis. If obstruction is felt on opposite side of
back of fetus, then head is flexed (you are feeling the forehead). If obstruction is
felt on the same side as the fetal back, then head is extended (you are feeling the
occiput).
i. Progress of Labor
I. Dilatation & effacement check. Done during and between contractions affected by contraction. Vaginal exam performed with a sterile lubricated gloved
hand. Frequency of exams depends on woman's parity, status of membranes, and
speed of labor. Should be limited to avoid introduction of pathogens.
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2. Station - Remember this is measured in relation to the maternal ischial spines.
j. Maternal Behavior Adaptation
Behavior changes as labor intensifies. During this phase, woman is often excited, some
apprehension, may be experiencing a sense of relief and anticipation.
k. Support Person's Adaptation
May become fearful, anxious, or tired as labor progresses. May feel responsibility to
protect woman. Some may become angry; others leave the room. Culture also plays a
part: some do not encourage the presence of father at the birth. Support person may be
friend, other relative, or a homosexual partner.
l. Nursing Measures
1.) Notify birth attendant (physician or nurse midwife). Include the following:
a.) Gravity, parity, & abortions
b.) EDD
c.) Contraction pattern
d.) Fetal presentation & position
e.) Cervical dilation, effacement, & station
f.) FHR
g.) Maternal VS
h.) Any abnormalities
i.) Response to labor (pain, anxiety)
2.) Consent forms: care during labor, anesthesia, vaginal birth & possible csection. Sometimes consent for newborn care.
3.) IV started. 18 or 20-gauge cath - lock or may receive continuous fluids
(usually LR). Dextrose is avoided as it may cause neonatal hypoglycemia.
4.) Perineal prep - few doctors still want the area shaved or clipped. Not full preps
anymore.
5.) Enema - Fleets may be given if stool is present to help with fetal descent (also
decreases likelihood of stool passing during pushing.)
6.) Comfort measures
a.) Lighting - soft, indirect lighting - avoid overhead glare.
b.) Temperature - cool cloths on forehead during labor, fan if possible.
May need socks for feet.
c.) Cleanliness - Change gown and underpads as needed. Let her desires
guide you; she may not wish to have gown changed in later stages.
d.) Mouth care -Ice chips, popsicles or hard candy help relieve dry mouth.
If NPO, moisten lips with washcloth or chapstick. May wish to rinse and
spit out.
e.) Bladder - Full bladder delays descent & intensifies labor. Have her
void at least q 2.
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f.) Positioning - Change positions frequently. Hands & knees or leaning
forward positions help with "back labor" (fetus' occiput is pressing on
mother's sacral promontory).
g.) Water - Shower or tub may help relaxation and water stimulates
nipples - release of oxytocin (from posterior pituitary) - increased
contractions.
7.) Teaching
Encourage mother not to push until fully dilated. If she pushes early, it may result
in edematous cervix (blocks progress) or lacerated cervix. 5 cm dilation is more
than half-way there because the last 5 cm will go quicker.
B. Active Phase
I. Overview:
Cervical dilation 4-7 cm
Effacement completed
Fetus descends & internal rotation begins
Pace of labor picks up
II. Maternal Assessments
1. Vital signs - P, R, BP hourly. T q hourly if membranes ruptured. Record & graph immediately.
2. Urine - Dip for protein (sign of developing PIH), ketones (maternal depletion or electrolyte
depletion). Fluid loss occurs through urine, emesis, respiration, and perspiration.
3. Bladder - Check for distention; may require I/O cath between contractions.
III. Progress of Labor
1. Vaginal exam (limit those if membranes have ruptured).
- Status of membranes intact? leaking? bulging?
- Status of cervix: soft/ firm? dilation? effacement?
- Fetal presentation: presenting part? fetal position?
- Fetal station
- Engagement
2. Contractions
- Pattern (frequency, duration, interval)
- Intensity
IV. Fetal Assessments
1. FHR - normal range: 110-160
2. Variability:  in variability = fetal distress
3. Changes in rate: accelerations, decelerations
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V. Behavioral Adaptation
1. Maternal: largely reflects how actual experience relates to expectations
a. Body posture/ movement: Look for cues of growing fatigue, tension, or pain. Look for
increased muscular tension.
b. Interactions with staff & partner: More focused inward; use short instructions.
c. Perceptions: May diminish; lose modesty; focused only on labor, not on what is going
on around.
d. Energy & fatigue level: Avoids unnecessary activity; may sleep between contractions.
e. Responses to disturbing stimuli: Increased irritability may push helping hands away, or
attempt to remove monitor, blood pressure cuff.
f. Expressions of discomfort or pain: Look for increased restlessness, muscular tension,
increased anxiety, fearfulness. These indicate increased pain & labor progression.
2. Support Person - Most experience:
a. Fear and concern over partner's and unborn child's well being.
b. Even if they are prepared, they usually feel uncomfortable and unsure due to all they
see & hear.
3. Nursing Diagnoses:
a. Acute Pain r/t uterine contractions AEB grimacing, expressed desire for pain relief
b. Deficient Fluid Volume r/t restriction of oral fluids and increased fluid loss AEB
increased urine concentration, expressed thirst
c. Impaired Physical Mobility r/t electronic fetal monitoring AEB inability to move due
to equipment
d. Impaired Gas Exchange r/t hyperventilation with contractions AEB c/o lightheadedness, tingling in hands & lips
e. Impaired Urinary Elimination r/t pressure of fetal descent AEB distended bladder,
inability to sense need to void
4. Nursing Interventions
a. Nutrition & Hydration - Some doctors/ midwives still require NPO status; others allow
food. It is important to maintain IV for hydration and nutrition. Monitor carefully for
fluid overload when oxytocin or other meds are being given. Monitor output and assess
for bladder distention.
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b. Comfort Measures:
1.) Massage
- Effleurage (light stroking) lower abdomen
- Kneading - shoulders, neck & back
- Counterpressure - sacrum (for back labor)
2.) Bath & showers - bath (when membranes are intact); shower (regardless of
membrane status).
Advantages: relaxation & pain relief; distraction; maintenance of upright position.
3.) Cold packs & hot compresses:
a.) Cold packs help: over sacral area; to refresh perspiring woman
b.) Hot compresses: over sacral area; lower abdomen
4.) Ambulation & position changes a.) If head of fetus is well applied to cervix, risk of cord prolapse with
ambulation is highly unlikely.
b.) If rupture of membranes occurs while ambulating, the nurse must
examine immediately & check FHR. Ambulation allows gravity to help
with descent & dilation.
c.) Positions (see McKinney & attachment):
- Standing
- Sitting upright
- Sitting, leaning forward with support
- Semi-sitting
- Side-lying
- Kneeling, leaning forward with support
- Hands & knees
5.) Relaxation & visualization (minds help body work with labor)
a.) Relaxation - Support mother and partner in exercises/ relaxing muscle
groups, and rhythmic breathing.
If no prenatal training, nurse can assist mother to relax muscle groups and
"breathe out tension."
b.) Visualization - Mental pictures of the events of labor (i.e., contractions,
opening the cervix [rather than just painful] or breathing bringing in
cleansing oxygen to the baby. Mother may wish to visualize her favorite
quiet, calming place.
6.) Promoting Self-Care: The nurse can assist the mother in maintaining a sense of
control by encouraging her to perform effleurage (if she thinks it helps), to urinate
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frequently, change positions frequently (especially upright positions to assist
with labor progress) and rest between contractions.
C. Transition Phase
I. Overview - Mother should never be left alone during this phase.
- Cervix dilate from 8-10 cm
- Bloody show increases
- Short, but intense phase (20-45 minutes)
II. Controlling the Urge to Push
Urge to push before complete dilation may be triggered due to a reflex action stimulated by the
presenting part descending. The stretch and pressure receptors in the lower uterine segment and vagina
are activated as the fetus descends. The dangers to fetus & mother of early pushing are:
1. Increased fetal head compression
2. Cervical laceration(s)
3. Cervical edema
4. Maternal exhaustion (due to ineffective pushing), and
5. Prolonged labor
Nursing Measures:
1. Explain importance of waiting for complete dilation
2. Encourage her to "blow out" short breaths of air through pursed lips during the urge to push.
Works better if nurse makes eye-contact and does this with her.
3. Change to a gravity-neutral position (like side-lying) to decrease downward pelvic pressure.
4. Refocus her attention to visualize the last rim of the cervix being retracted over the baby's
head with contractions.
III. Promoting Comfort
1. Problem:
a. Shaking, chills
Nursing measures: warm blankets, hold extremities
b. Perspiration, feeling hot
Nursing measures: fan, cool cloths, ice chips
c. Restlessness, irritability
Nursing measures: encouragement, relaxation techniques; avoid behaviors which irritate
patient
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d. Inability to focus, confusion
Nursing measures: firm but kind instruction; breathe with patient; use eye contact; sacral
counterpressure; ice or heat pack
e. Increased sacral pain
Nursing measures: sacral counterpressure; ice or heat pack
f. Inability to cope
Nursing measures: reassurance; physical presence; focus on shortness of phase
g. Exhaustion
Nursing measures: facilitate rest between contractions; alert patient to beginning of
contraction
h. Hiccoughing, burping, flatulence; nausea & vomiting
Nursing measures: assure patient that these are normal; cool cloth; provide emesis basin;
head elevated or on left side
IV. Managing Sensory Overload
Due to intensity of this phase, the woman may show apprehension, restlessness, and may appear
confused and unable to understand directions. She may experience panic and beg to be "put to sleep" or
"get this baby out."
1. Nursing Measures:
a. Refocus on breathing through contractions
b. Encourage support person (or nurse) to make eye contact.
c. Wake her up when next contraction is starting
d. Talk in a quiet, firm, reassuring tone
V. Monitoring for Potential Complications: Fetal Compromise
1. S/S meconium-stained fluid:
a. Late decelerations (start late in contraction, after peak, and end after contraction)
b. Variable decelerations (can occur any time during contraction & last 2 minutes or less)
c. Fetal bradycardia (<110 X 10 minutes or more)
d. Absent or decreased beat-to-beat variability
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VI. Hyperventilation:
1. Prone to hyperventilation due to:
a. Apprehension
b. Intense physiologic demands
c. Use of shallow, patterned breathing to cope with contractions
2. Cycle: rapid breathing  excess of CO2 blown off  respiratory alkalosis
3. Signs/ Symptoms:
a. Numbness & tingling to lips, fingers, & toes
b. Dizziness
c. Light headaches
d. Confusion
4. Treatment: breathing exhaled carbon dioxide in paper bag or cupped hands.