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Chapter 6 Nursing Care of Mother and Infant During Labor and Birth Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. Settings for Childbirth (p. 116) Hospitals Advantages – access to emergency care, physician relationship Disadvantages – high cost Freestanding birth centers Advantages – lower cost Disadvantages – delay in emergency care Home Advantages - control Disadvantages – extended delay to emergency care Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 2 Components of the Birth Process (p. 116, 119-126) The Four “Ps” Powers - mother pushing, uterine contractions Passage – mother’s bony pelvis and soft tissues Passenger – fetus, placenta, amniotic membrane and amniotic fluid Psyche – the entire emotional, mental state of the mother Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 3 Factors that Influence the Progress of Labor (p. 116, 119-126) Preparation – attending prenatal classes Position – fetal presenting part within the mother’s pelvis Professional – nurses, coaches Place –setting of labor and delivery Procedures – internal exams People – supportive family members Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 4 Uterine Contractions (pp. 119-120) Effect of contractions on the cervix Efface - thin Dilate - open Phase of contractions Increment – increasing strength Peak – greatest strength Decrement – decreasing strength Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 5 Uterine Contractions (pp. 119-120) • Frequency – elapsed time between one contraction and the next • Duration - average number of seconds the contractions last – elapsed time from beginning of a contraction to the end of the same contraction • Intensity – mild- fundus easily indented, moderate – fundus can be indented, firm – fundus cannot be readily indented with fingertips Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 6 Safety Alert! (p. 122) Report to the RN any contractions that occur more frequently than every 2 minutes, last longer than 90 seconds, or have intervals shorter than 60 seconds Persistent contractions durations longer than 90 seconds may reduce fetal oxygen supply Contractions occurring more often than every 2 minutes may reduce fetal oxygen supply Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 7 Cervical Effacement - thinning and Dilation - opening(p. 120) Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 8 Contraction Cycle (p. 121) - Powers Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 9 Nursing Tip (p. 122) Provide emotional support to the laboring woman so she is less anxious and fearful. Excessive anxiety or fear can cause greater pain, inhibit the progress of labor, and reduce blood flow to the placenta and fetus. Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 10 The Passage (p. 122) Bony pelvis True Directly involved in childbirth False Flares Upper portion of pelvis Soft tissues – cervix, ligaments and fascia If previous delivery, will yield more readily to contractions and pushing efforts May not yield as readily in primiparas or older women Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 11 Passengers – page 122 Passengers are the fetus, the placenta, amniotic membrane and fluid Fetal head – composed of bones separated by tissue called sutures and fontanelles where the sutures meet Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 12 The Passenger—Fetal Skull (pp. 122-123) – two important fontanelles in obstetrics – the anterior and posterior fontanelles Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 13 The Passengers—Fetal Lie (pp. 122-123) – how the fetus is oriented to the mother’s spine Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 14 The Passengers—Presentation (pp. 123-124) – the fetal part that enters the pelvis first Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 15 Psyche (pp. 124-125) Mental state can influence the course of labor. The woman’s cultural and individual values influence how she will cope with childbirth. Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 16 Classifications of Fetal Presentations and Positions (p. 125) Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 17 Signs of Impending Labor (p. 126) Braxton Hicks contractions – irregular “false” labor Increased vaginal discharge Bloody show – thick mucus with blood Rupture of the membranes Energy spurt Weight loss Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 18 Mechanisms of Labor (p. 126) Descent – presenting part usually the fetus head Station – level of presenting part to the pelvis Engagement - when presenting part (head) reaches “0” station Flexion – flex of fetus head to chest Internal rotation – head turns swing anteriorly External rotation – head realigns with shoulders Expulsion – anterior shoulder, then posterior shoulder are born – then rest of body Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 19 Mechanisms of Labor (p. 126) Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 20 Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 21 Birth Station (pp. 126, 128) Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 22 When to Go to the Hospital or Birth Center (p. 128) Contractions – pattern of increasing frequency – 1st child…every 5 minutes for one hour. 2nd child…every 10 minutes for one hour Ruptured membranes Bleeding other than bloody show Decreased fetal movement Any other concern Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 23 Admission Data Collection (p. 128) Three major assessments performed promptly on admission Fetal condition – fetal heart rate Maternal condition – vital signs – assess for signs of infection or hypertension Impending birth – sitting on one buttock, making grunting sounds, bearing down with contractions, stating “the baby’s coming”, bulging of the perineum or fetal presenting part becomes visible Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 24 Admission Procedures (p. 130) Permits/consents Laboratory tests – hematocrit and urine Intravenous infusion – IV line started Perineal prep - cleansing Determining fetal position and presentationLeopold’s maneuvers helps to determine location of the fetal back Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 25 Comparison of False and True Labor False labor Contractions irregular Walking relieves contractions Bloody show usually not present No change in effacement/dilation of cervix True labor Contractions gradually develop a regular pattern Contractions become stronger and more effective with walking Discomfort in lower back/abdomen Bloody show often present Progressive effacement and dilation of cervix Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 26 Question 1 Which is a characteristic of true labor? 1) Contractions are regular, and the intensity remains the same. 2) Contractions are irregular, and the intensity remains the same. 3) Contractions are regular and are intensified by walking. 4) Contractions are regular and are not intensified by walking. Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 27 Nursing Care Before Birth (p. 131) After admission to the labor unit, nursing care consists of Monitoring the fetus – assessing fetal heart patterns to detect fetal hypoxia. Most hospitals use continuous EFM. Monitoring the laboring woman Helping the woman cope with labor Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 28 Monitoring the Fetus (p. 131) Fetal heart rate monitor by fetoscope or Doppler transducer Intermittent auscultation gives the mother greater freedom of movement Continuous electronic fetal monitoring used by hospitals- provides record for the chart The baseline fetal heart rate is the average FHR that occurs for 2 minutes during a 10minute period and averaged over 30 minutes. Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 29 FHR Outside of Normal Limits (p. 132) Any FHR outside the normal limits and any slowing of the FHR that persists after the contraction ends is promptly reported to the health care provider. Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 30 Evaluating Fetal Heart Rate Patterns (pp. 133-136) Baseline FHR 110-160 BPM Fetal bradycardia <110 BPM Fetal tachycardia >160 BPM Baseline variability – fluctuations showing intact nervous system and cardiac status of fetus Moderate variability change of 6 to 25 bpm from baseline Marked variability- more than 25 beats of fluctuation over the baseline – may be cord prolapse or maternal hypotension Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 31 Absent variability – is less than 6 beats/min change from baseline for a 10 minute period – caused by uteroplacental insufficiency or maternal hypotension, cord compression or fetal hypoxia Have patient lie on side, increase fluids, administer oxygen at 8 to 10L/min by mask, notify health care provider Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. Accelerations are temporary, abrupt rate increases of at least 15 beats/min above baseline that last 15 seconds but less than 2 minutes from onset to return to baseline This pattern suggests that fetus is well oxygenated and is known as a “reassuring” pattern. Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. Reassuring and Nonreassuring FHR and Uterine Activity Patterns (p. 135) Reassuring patterns Stable fetal heart rate (FHR) Moderate variability Accelerations Uterine contraction frequency greater than every 2 minutes; duration less than 90 seconds; relaxation interval of at least 60 seconds Nonreassuring patterns Tachycardia Bradycardia Decreased or absent variability; little fluctuation in rate Late decelerations Variable decelerations Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 34 Inspection of Amniotic Fluid (p. 137) Color Normal is clear fluid, may have flecks of white vernix Green-stained may indicate fetus passed meconium (first stool but before birth) • Can lead to fetal compromise Odor Should not smell • If it does, it may indicate infection Amount Scant—trickle Moderate— ~500 mL Large— ≥ 1,000 mL 35 Nitrazine paper test p 138 Nitrazine paper into fluid from vagina Blue-green – alkaline and is likely amniotic fluid Yellow to yellow –green – acidic and is most likely urine Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 36 Monitoring the Woman (p. 137) Vital signs – checked every 4 hours – temp of 100.4 or higher should be reported Contractions – monitor by EFM or palpation Progress of labor Intake and output Response to labor Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 37 Six Lamaze Institute Basic Practices for Maternity Care (p. 140) Labor should begin on its own. Woman should have freedom of movement. Woman should have a birth support person or doula. No routine interventions should be performed. Woman should be in non-supine positions. Woman should not be separated from infant. Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 38 Helping the Woman Cope with Labor (p. 140) Labor support Teaching Providing encouragement Supporting/teaching the partner Teach how labor pains affect the woman’s behavior/attitude How to adapt responses to the woman’s behavior What to expect in his/her own emotional responses Effects of epidural analgesia Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 39 Stages and Phases of Labor (p. 143) First stage—dilation and effacement (can last 4 to 6 hours) Second stage—expulsion of fetus (30 minutes to 2 hours) Third stage—expulsion of placenta (5 to 30 minutes) Fourth stage—recovery Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 40 Question 2 During which stage of labor does “crowning” occur? 1) 2) 3) 4) First Second Third Fourth Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 41 Vaginal Birth After Cesarean (p. 143) Main concern Uterine scar will rupture Can disrupt placental blood flow Lead to hemorrhage Woman may need more support than other laboring women Nurse provides empathy and support Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 42 Nursing Responsibilities During Birth (pp. 144-146) Preparing the delivery instruments and infant equipment Perineal scrub Administering medications Providing initial care to the infant Assessing Apgar score Assessing infant for obvious abnormalities Examining the placenta Identifying mother and infant Promoting parent-infant bonding Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 43 Immediate Postpartum Period: Third and Fourth Stages of Labor (p. 146) Third stage—expulsion of placenta Schulze or Duncan’s Fourth stage—nursing care includes Identifying and preventing hemorrhage Evaluating and intervening for pain Observing bladder function and urine output Evaluating recovery from anesthesia Providing initial care to the newborn infant Promoting bonding and attachment between the infant and family Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 44 Nursing Care Immediately After Birth (p. 147) Care of the mother Observing for hemorrhage • Vital signs • Skin color • Location and firmness of uterine fundus • Lochia • Pain Promoting comfort • Keep warm and dry • Ice to perineum to help reduce swelling and bruising Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 45 Nursing Care Immediately After Birth (cont.) (p. 147) Care of the newborn Phase 1 • Phase 2 • From birth to 1 hour (usually in delivery room) From 1 to 3 hours (usually in transition nursery or postpartum unit) Phase 3 • From 2 to 12 hours (usually in postpartum unit if roomingin with the mother) Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 46 Phase 1: Care of the Newborn (p. 147) Initial care includes Maintaining thermoregulation Maintaining cardiorespiratory function Observing for urination and/or passage of meconium Identifying the mother, father, and newborn Performing a brief assessment for major anomalies Encouraging bonding/breastfeeding Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 47 Apgar Scoring (pp. 151-152) Heart rate Respiratory effort Muscle tone Reflex response to suction or gentle stimulation on the soles of the feet Skin color Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 48 Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 49 Administering Medications to the Newborn (p. 152) Eye care Vitamin K (AquaMEPHYTON) Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 50 Question 4 What medication is most often used for neonatal eye care? 1) 2) 3) 4) Silver nitrate 1% Triple dye Silver nitrate 2% Erythromycin ophthalmic ointment Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 51 Observe for Major Anomalies (p. 153) Head trauma from delivery Symmetry and equality of extremities Are they of equal length? Do they move with same vigor on both sides? Assess digits of hands and feet Any evidence of webbing or abnormal number of digits Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 52 Umbilical Cord Blood Banking (p. 153) This type of blood is capable of regenerating stem cells that are able to replace diseased cells. Informed consent is essential. Collect blood after cord has been clamped. Blood must be transported within 48 hours of collection to blood banking facility. Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 53 Emerging Technologies and Practice (p. 154) C: type of waveform analysis that detects intrapartal changes in fetal ST waveforms, indicative of developing fetal metabolic acidosis. PERICALM-EFM: computerized interpretation of real-time FHR patterns that provides automatic analysis of fetal heart pattern to compliment clinical judgment as well as permanent documentation in EMR. Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 54