Download It begins with the onset of regular uterine contractions

:
:
1. Uterine muscles are stretched leading to release of
prostaglandins that stimulate contractions.
2. Increased pressure on the cervix stimulates the nerve
plexus causing release of oxytocin which stimulates
myometrium contractions.
3. Estrogen increases, stimulating the uterine response.
4. Progesterone, which has a quieting effect on the uterus, is
withdrawn, allowing estrogen to stimulate contractions.
5. Oxytocin stimulates myometrium contractions.
6. The oxytocin level surges from stretching of the cervix.
1. Lightening: This refers to the descent of the
fetus into the true pelvis that occurs
approximately 2 weeks.
2. False uterine contractions (Braxton-Hicks ).
3. Effacement of cervix : is the shortening and
thinning of the cervix.
4. Frequency of micturition.
1.
2.
3.
4.
5.
The progress of labor
Cervical dilatation.
Engagement :When the greatest diameter of the
fetal head passes through the pelvic inlet; can occur
late in pregnancy or in early in labor
Increase uterine contractions.
Rupture of membrane (liquor).
Molding of the fetal skull.
Powers (the contractions)
Passage (the pelvis and birth canal)
Passenger (the fetus and placenta)
Position of mother.
Psychological (the response of the woman)
 It divided into 4 stages are:
1. 1st stage is called (dilating stage): from onset of
regular UC to full dilation of the cervix.
2. Duration of 1st stage in primigravida is
14-16 hours but in multigravida is
6hours.
** Divided into three phases:
Latent phase: mild contraction (0-3cm)
Active phase: moderate contraction (4-7cm)
Transition phase: severe contraction (8-10cm)
• Hospital Admission: include
1. Establish a rapport with the patient and significant
others & complete history as obstetric history, medical.
2. Explain all procedures or routines.
3. NPO except ice chips while in labor.
4. Activities allowed and disallowed according to ward
policies (i.e. bathroom).
5. Use of fetal monitors.
6. Progress reports.
7. Visitation policies.
8. Where patient's personal belongings will be
maintained & ask her for removal j.
9. Orient the patient to the surroundings (that is, room, call bell).
10. Initiate the patient's labor chart.
11. Review the information obtained originally in the exam room.
a. Obstetric history.
*GPTAL + Para.
*Estimated date of delivery (EDD).
*Duration of previous labors & Problems with previous pregnancies &deliveries.
b. General condition. { Rh status, Allergies, History of medical problems. }
c.
•
c. Current pregnancy:
*Onset of labor (contractions regular, 5 minutes or less).
*Frequency, duration, and intensity of contractions.
*Membranes-ruptured or intact.
*Amount and character of show or vaginal bleeding.
*Vital signs.
* Rate, location of fetal heart tones.
* Any problems with this pregnancy.
*perform Leopold's Maneuvers & fundal height.
12.Evaluate the patient's current emotional status.
FIRST MANEUVER
SECOND MANEUVER
THIRD MANEUVER
FOURTH MANEUVER
13. Evaluate for possible danger signs include:
(a) Increased pulse or temperature For mother.
(b) Excessive vaginal bleeding.
(c) Presence of meconium (fetal feces) in the amniotic fluid.
(d) Alteration in fetal heart tones (FHT's) above 160 or below 120.
(e) Change in the character of uterine contractions.
14. Perform the admission physician's orders to include
the following:
a. Administer and maintain intravenous fluids.
b. Draw lab work--CBC.
c. Assess uterine contractions (UC).
d. Perineal Preparation by Shaving of pubic hair to prevent infection of
perineal episiotomy/lacerations.
e. Cleansing Enema.
 Prevent fecal contamination of the perineum during delivery.
 Cleanse the bowel. This provides more room for fetal passage.
 Stimulate uterine contractions.
 Contraindications & complications:

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
Vaginal bleeding.
Premature labor.
Presenting part not engaged.
Abnormal presentation--breech or transverse.
Already rapid moving labor.
Membranes are ruptured or danger of prolapsed cord.
It is Graphic recording of the progress of
labor
*Uses
1. To detect labor that is not progressing normally
2. To indicate when augmentation of labor is
appropriate
 Fetal monitoring is done to detect presence of fetal life at time
of admission and to detect development of fetal distress
during labor.
 Normal fetal heart rate ranges from 120 to 160 b/m.
 The rate may increase or decrease by 30 b/m during a
contraction.
 Ultrasound to monitor FHR do at(5-6GWK).
 The FHTs should be checked and recorded :
1. On admission.
2. Every 15 minutes during the first stage of labor.
3. Every 5 minutes during the second stage of labor.
4. Immediately after rupture of membranes.
fetal monitor may be Internal
or External
A fetoscope or pinard
(19-20 GWK)
• There are 4 different ways to record the state of the
liquor on the partograph:
1. If the membranes are intact: "I" for intact.
2. If the membranes are ruptured and liquor is clear:
"C" for clear.
3. If the membranes are ruptured and liquor is
meconium-stained: "M" for meconium.
4. If the membranes are ruptured and liquor is absent:
"A" for absent
5. If the membranes are ruptured and liquor is Bloodstained: “B" for Blood
*There are 4 different ways to record the moulding on
the partograph:
1. If bones are separated and the sutures can
be felt easily: "O".
2. If bones are just touching each other: +1.
3. If bones are overlapping: +2.
4. If bones are overlapping severely: +3.
 Only the physician or a trained nurse performs this exam.
 Purposes :
1. To assess the percentage of cervical effacement &cervical
dilatation.
2. To evaluate status of membranes.
3. To evaluate station, position, presentation and degree of fetal
head flexion of fetal.
4. To assess presence of fetal skull swelling or molding.
Procedure of vaginal examination
Equipment:
Sterile gloves, lubricant and antiseptic solution.
1.Wash your hands, explain procedure & provide privacy.
2.Put the woman in dorsal recumbent position (woman turn
onto back with knees flexed)
3.Donning sterile gloves.
4.The examiner inserts his or her index and middle fingers into
the vaginal
5. The cervix is palpated to assess dilation, effacement, and
position (e.g., posterior or anterior). If
6.fetal position, station, and presence of molding.
7.Assessed the membranes and described as intact, bulging, or
ruptured.
• Uterine contractions are responsible for the dilation (opening) and
effacement (thinning) of the cervix in the first stage of labor.
• Uterine contractions are rhythmic and intermittent.
Each contraction has three phases:
1. Increment (buildup of the contraction)
2. Acme (peak or highest intensity)
3. Decrement (descent or relaxation of the uterine
muscle
Uterine contractions are monitored and assessed
according to three parameters:
1.Frequency refers to how often the contractions occur and is
measured from the increment of one contraction to the increment
of the next contraction
(the number of contractions in a 10-minutes.
2. Duration refers to how long a contraction lasts and is measured
from the beginning of the increment to the end of the decrement for
the same contraction.
3. Intensity refers to the strength of the contraction determined by
manual palpation or measured by an internal intrauterine catheter.
:
a. Hourly during latent phase.
b. Every 30 minutes during active phase and transition.
Monitor the patient's vital signs.
(1) On admission.
(2) Every hour during early labor.
(3) Blood pressure (BP), pulse (P), and respiratory rate
(R) every 30 minutes during active, transition, and
the second stage of labor, to include the
temperature every 4 hours.
(4) T take every 2hours if membrane ruptured.
(4) More frequently if complications arise.
Artificial Rupture of Membranes
 Rupture of the membranes is done by
the physician to induce labor.
Record the following information:
1.
2.
3.
4.
Time of the procedure (rupture of membranes).
Amount of fluid expelled (small, moderate, or large).
Color--clear or meconium stained .
Fetal heart rate immediately after the procedure and five
minutes after the procedure.
5. Instrument used, if other than an amnihook
(The amnihook is used to tear a small opening in the amniotic sac)
nd
2
stage of labor
NURSING CARE GIVEN IN THE DELIVERY
ROOM
1.Never leave the patient alone once she has been transferred to
the delivery room.
2.Encourage the patient to rest between contractions and to
push with contractions.
3.Position the patient's legs in the stirrups for the
lithotomy position.
1.Prep the patient's perineum by using a zig-zag motion ,A Beta
dine & 6 sponges to clean the perineum by washing the pubic
area, down each thigh, down each side of the labia, down the
perineum, and down the rectal area . Discard used sponges
after each step. Rinse area with the remaining solution.
For
mother
1. Sterile drapes for legs
and thighs .
2. Sterile towel to cover
abdomen.
3. Sterile sheet & pad to
go below buttocks &
on bed.
For episiotomy and
repair of perineal
wound:
Local anesthetic
syringe &needles &
medications.
Scissors for cutting.
Sutures & needles &
needle holder for
repair
For swabbing & wiping
clean:
• Bowels with lotions.
• Swabs & cotton wool.
• Gamgee pads.
For bleeding
controlling:
•
•
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Oxytocic drugs.
Syringe &needles.
Pressure forceps.
Bowel to collect
blood loss.
NURSING CARE GIVEN WHILE IN THE
DELIVERY ROOM
The activity of the normal birthing process :
1. Crowning: the appearance of the infant's head on
the perineum.
2. Delivery of the head. This includes suctioning of
the infants nose and mouth with a bulb syringe.
3. Delivery of the anterior shoulder and the
posterior shoulder.
4. Delivery of the trunk and lower body.
5. Clamping and cutting of the umbilical cord
INFORMATION TO BE RECORDED ABOUT
THE DELIVERY
1. Exact date and time of delivery.
2. Sex of the infant.
3. Condition of the infant (APGAR) after birth
4. Position of the infant at delivery.
5. Type of episiotomy, lacerations.
6. Spontaneous or forceps delivery.
7. Use of oxygen and suction on the infant.
8. Number of vessels in the cord.
9. Mother's name.
10.Any other pertinent facts about the delivery
It is the period from birth of the baby through
delivery of the placenta it is called placental stage.
Duration of 3rd stage in primigravida and
multigravida is 10 minutes.
 Signs of the placental separation are as
follows:
a. The uterus becomes globular in shape and firmer.
b. The uterus rises in the abdomen.
c. Increase the length of the umbilical cord descends
out of the vagina.
d. Sudden gush of blood.
NURSING CARE DURING THE THIRD STAGE
• Continue observation.
• Following delivery of the placenta, continue in
your observation of the fundus.
• Ensure that the fundus remains contracted.
Retention of the tissues in the uterus can lead to
uterine atony and cause hemorrhage.
• Massaging the fundus gently will ensure that it
remains contracted.
• Allow the mother to bond with the infant.
• Administer pain medications as per order.
Record the following information.
1. Time the placenta is delivered.
2. How delivered (spontaneously or
manually removed by the
physician).
3. Type, amount, time and route of
administration of Oxytocin.
4. If the placenta is delivered complete
and intact or in fragments.
FOURTH STAGE OF LABOR
• It is called recovery stage.
• It begins with delivery of placenta to 1-4
hours after delivery.
•.
NURSING CARE DURING THE FOURTH
STAGE OF LABOR
1. Transfer the patient from the delivery table.
2. Remove the drapes and soiled linen.
3.Remove both legs from the stirrups at the same
time and then lower both legs down at the same
time to prevent cramping.
4.Assist the patient to move from the table to the
bed
5.Provide care of the perineum. An ice pack may be
applied to the perineum to reduce swelling from
episiotomy.
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NURSING CARE DURING THE FOURTH
STAGE OF LABOR
place a clean gown on the patient.
Apply a clean perineal pad between the legs.
Transfer the patient to the recovery room
obtained a complete set of vital signs
evaluated the fundal height and firmness, and
evaluated the lochia
• Ensure emergency equipment is available in the
recovery room for possible complications
• IV remains patent for possible use if complications
develop.
NURSING CARE DURING THE FOURTH
STAGE OF LABOR
• Check the fundus:
1. Ensure the fundus remains firm.
2. Massage the fundus until it is firm if the
uterus should relax .
3. Massage the fundus every 15 minutes
during the first hour, every 30 minutes
during the next hour, and every hour until
the patient is ready for transfer.