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1 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 2 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 3 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 4 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 5 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 6 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. 7 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. 8 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 9 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. 10 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 11 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 12 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 13 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.