Chapter 7 Nursing Care During Labor Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc....

Chapter 7

Nursing Care During Labor

Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 1

Birthing Centers and Nursing Care


Objectives

Define key terms listed. Describe three variations in cultural practices. Compare alternative birth settings. Outline three nursing assessments and

interventions during each stage of labor.


Objectives (cont.)

Discuss the significance of psychological support during labor.

Review ways to protect the woman from infection.


Goal of Nursing Care

Ensure best possible outcome for the mother and the newborn


Birth Settings

Traditional hospital Independent birthing centers Home birth services


In-Hospital Birthing Rooms Woman stays in the same room for labor,

delivery, and recovery (LDR room) Some settings have woman stay in same room

throughout entire stay; called LDRP—labor, delivery, recovery, postpartum


Freestanding Centers

Out-of-hospital birthing facilities Combine homelike environment with a short-

stay, ambulatory health facility with access to in-hospital obstetric and newborn care Advantage over a home birth: this type of setting

has quick access to a hospital Typically provide comprehensive prenatal,

birth, and postpartum care


Home Birth

Community-based nurse-midwife usually manages home births

Advantages Woman is in familiar, comfortable surroundings Less expensive

Risks Lack of emergency equipment May be too far from hospital or medical care if

complications arise


Cultural Considerations

Modesty Pain Position Female care provider Support person


Pain

Expressions vary based on cultural background Some women are stoic and silent to avoid bringing

shame on the family Others are expressive and loud


Position

Varies with culture Some prefer upright position Others prefer kneeling or squatting during

birth


Cultural Sensitivity

Will assist nurses in being nonjudgmental and less likely to impose their own values and beliefs on the women they care for


Care Management


When to Go to the Hospital or Birth Center


Contractions

Have a pattern of increasing frequency, duration, and intensity First child: comes when contractions have been

regular (every 5 minutes) for 1 hour Second or later child: comes when contractions

are regular and 10 minutes apart for 1 hour


Other Reasons to Goto the Hospital

Ruptured membranes Bleeding other than bloody show (e.g., active

bleeding that is not mixed with mucus) Decreased fetal movement Any other concern


Preadmission Forms

May have been completed before admission Prenatal record includes

Nursing and medical parameters Laboratory results Nutritional guidance already provided

• Psychosocial and cultural factors, including birth plan, may also be included


Care Plan

Reflects Where the labor and delivery process will take

place Degree to which the partner will participate

Teaching aspects Incorporates what the woman can expect


Data Collection and Admission Procedures

Three priority assessment questions should be completed when the woman is admitted to the labor and delivery unit What is the condition of the mother and fetus? Is the birth imminent? Does the labor appear to be uneventful?


On Presentation to L&D Unit

Women who have had prenatal care and have preregistered will likely require verification of information, including recent clinical laboratory results

Women who have not had prenatal care will require the nurse to obtain as much information as possible, depending on situation, and have clinical laboratory tests such as CBC, hematocrit, drug screen, STI, and others as indicated


Nursing Care of the Womanin False Labor

Prodromal labor Helps prepare woman’s body and fetus for

true labor Usually observed for 1 to 2 hours

Fetal monitoring is performed Woman usually can walk about when not

being monitored If it is true labor, walking often helps to

intensify contractions and aids in cervical effacement and dilation


Factors to Consider with False Labor

Number and duration of previous labors Distance from the health care facility Availability of transportation


Data Collection on Admission

What three priorities should the nurse’s data collection upon admission focus on? Condition of mother and fetus Whether birth is imminent Labor appears to be uneventful


Priority Assessment Questions

There are three priority assessment questions that should be answered when the woman is admitted to the labor and delivery unit. They are:1. What is the condition of the mother and fetus?

2. Is the birth imminent?

3. Does the labor appear to be uneventful?


Fetal Assessment and Monitoring


Objectives

Compare external and internal fetal monitoring during labor.

Compare the advantages and disadvantages of electronic fetal monitoring during labor.

Describe the cleansing of the woman’s perineum in preparation for birth.

Compare reassuring and nonreassuring fetal heart rates.


Objectives (cont.)

Relate the nurse’s role in fetal monitoring. Describe the purpose of amnioinfusion. Discuss the role of the doula in the delivery

room.


Focused Data Collection

First and Second Stages of Labor


Warning Signs: Potential Complications

Maternal fever greater than 38° C (100.4° F) Contractions lasting more than 90 seconds Contractions less than 2 minutes apart Meconium-stained amniotic fluid Foul-smelling vaginal discharge Excessive bleeding and hypotension Fetal bradycardia or tachycardia Loss of baseline variability on fetal monitor Fetal heart rate (FHR) <110 or >160 bpm


Monitoring Fetal Heart Rate

Assess by auscultation if woman not on electronic fetal monitoring Best heard over fetal back

FHR should be taken immediately after ROM FHR should also be taken after

Vaginal examination Administration of medications Notation of abnormal fetal activity


What are the advantagesof continuously

monitoring FHR?


Continuously Monitoring FHR

Continuously monitoring FHR allows the nurse to Evaluate FHR variability Identify abnormalities in FHR patterns


Signs of Fetal Distress

EFM signs to observe for and report, if they do not resolve after verifying placement of monitoring devices or repositioning woman, are A loss of baseline variability Variable or late decelerations that persist after

maternal position change Persistent fetal tachycardia


Other Signs of Fetal Distress

Meconium in amniotic fluid when fetus is in a vertex position

Requires immediate reporting to health care provider


Intermittent Fetal Heart Monitoring During Labor

Low-risk technology Intermittent auscultation with hand-held

Doppler or fetoscope Assess at 15-minute intervals during first stage Assess at 5-minute intervals during second stage


Reassessment of FHR

ROM Vaginal examination Ambulation (before and after) Change in infusion rate of oxytocin Administration of drugs (before and after) Urinary catheterization Expulsion of enema Recognition of abnormal uterine activity Decrease in fetal activity


Continuous EFM During Labor

Can detect changes in FHR May indicate inadequate oxygenation of fetus Allows for immediate interventions Provides visual display of FHR

Uterine activity measured and displayed Can be electronically transmitted to monitors at

nursing station so woman and fetus can be assessed even if nurse is not at bedside


Documentation of EFM

Some facilities still use paper to maintain medical records, whereas others now employ computerized charting called electronic medical record

Regardless of method, the EFM tracings are part of the medical record and must be correctly labeled with the woman’s name, date of birth, date of admission, date of tracings


Nurse’s Role in EFM

Continually assesses whether the FHR pattern is Reassuring: reflects adequate fetal oxygenation Nonreassuring: reflects fetal distress

• Appropriate interventions must be taken


Monitor Strips

It is important to document on the strip (or in the computer) each time anything is done, such as a vaginal examination, voiding, etc. This is important in the assessment of the tracing

strips and provides permanent documentation of care provided

Also important to record time EFM discontinued and restarted


Emergency Interventions

Nonreassuring heart rate Administer oxygen to woman

• 8 to 10 L/min by face mask

Turn woman to side-lying position Stop oxytocin infusion

• Keep IV line open

Notify health care provider


Types of Electronic Fetal Monitoring


External Fetal Monitoring

Ultrasound transducer and tocodynamometer to woman’s abdomen

Secured with elastic strips, belts, or stockinette

Sound waves are picked up by monitor Uterine contractions

Can be monitored for frequency and duration Cannot be monitored for uterine intensity


Internal Fetal Monitoring

Accuracy is main advantage Requires ruptured amniotic membranes Cervix must be dilated to at least 2 cm Spiral electrode is attached to fetal presenting

part Pressure transducer introduced into uterine

cavity


Reassuring and Nonreassuring

Fetal Heart Rate Patterns


The Normal Pattern

Heart rate 110 to 160 beats/min Beat-to-beat variability between 6 and 25

beats/min No decelerations but may see accelerations


Accelerations

Brief, temporary increases in FHR At least 15 beats/min above baseline

Usually occur with fetal movements May also occur with

Vaginal examinations Uterine contractions Fundal pressure Breech presentations


Decelerations

Transitory decreases in FHR from baseline Three types

Early Late Variable


Early Deceleration

Typically starts with contraction Ends when contraction is over

Stays within normal range of FHR Produces a V-shaped pattern

Common cause Compression of fetal head

No intervention necessary


Late Deceleration Usually begins at peak of contraction Ends after contraction has ended Often associated with uteroplacental

insufficiency Depth and time it takes to return to baseline is

important Persistence, or recurrence, usually indicates

hypoxia (lack of oxygen to fetus) A drop of 30 beats/min or change in baseline

variability is significant indicator of fetal distress


Cause of Late Deceleration

Maternal hypotension Excessive uterine activity Deficient placental perfusion


Repetitive Late Decelerations

Require immediate intervention Repositioning Administering oxygen Discontinuing oxytocin Increasing IV fluid Evaluating vital signs Prompt reporting to health care provider


Variable Decelerations

Transient drop in FHR before, during, or after uterine contraction Related to brief compression of umbilical cord

Decelerations are abrupt and often associated with accelerations before or after deceleration

Rare association with hypoxia Requires change in position of woman


Fetal Pulse Oximetry

Value remains controversial Transcervical catheter is positioned against

fetal cheek to measure oxygen saturation Amniotic membranes must have ruptured,

cervix dilated to at least 2 cm, fetus in vertex presentation at the cervix


Fetal Pulse Oximetry Readings

Normal term fetus during labor: 40% to 70% Levels less than 30% may indicate fetal

metabolic acidosis Would indicate hypoxia and require rapid

delivery of fetus Can be used to continue with labor and try to

avoid cesarean birth, especially if nonreassuring FHR is present in term fetus


Monitoring Uterine Contractions

20- to 30-minute baseline electronic monitoring of uterine contractions and FHR is usually performed

Palpating contractions Nurse places fingertips on woman’s abdomen over

uterine fundus


Determining Fetal Positionby Abdominal Palpation

Leopold’s maneuvers May reveal if multifetal pregnancy exists

(especially in woman without prenatal care) By doing this, can help locate best position for

auscultating FHR


Monitoring Status of Amniotic Fluid

If amniotic membrane is ruptured, assess for Time of rupture Color, amount, and odor

• Fluid that is clear and pale with little odor is normal

• Greenish suggests meconium

• Wine-colored indicates presence of blood with possible separation of placenta

• Foul or unpleasant odor indicates infection


Nitrazine Paper Test

Test strip is sensitive to pH Turns deep blue if amniotic fluid is present Turns yellow if urine is present


Ferning

Characteristic pattern of crystallization in amniotic fluid when it dries

Place fluid on glass slide, allow to dry, observe under microscope

Urine and other vaginal discharge will not show this type of pattern


Amnioinfusion

Infusion of warmed normal saline or lactated Ringer’s solution into uterine cavity after amniotic membranes have ruptured

Performed to Decrease compression of umbilical cord Increase fluid when oligohydramnios is present Dilute meconium in uterine cavity Decrease risk of fetus aspirating meconium


Contraindications to Amnioinfusion

Prolapsed cord Vaginal bleeding Severe fetal distress


Physical Care and Psychological Support During Labor and Birth


The Nurse’s Role

Documents progress of labor Reports abnormal findings Provides measures of support, prevention of

infection, and promotion of comfort


Vaginal Examinations

Performed with sterile gloves and a water-soluble lubricant Done to determine status of cervical dilation and

effacement Contraindicated if vaginal bleeding is present


Documentation

Vital signs every hour in latent phase and every 30 minutes in active phase of labor

FHR patterns are monitored Contractions are monitored, and nurse

documents in medical record the Frequency, intensity, and duration

Intake and output


Supporting the Partner

Some truly coach and take the lead in helping woman cope with labor

Others will assist if shown Some only want to provide encouragement

and support, but nothing more Partners should be permitted to provide the

type of support they’re comfortable with Should be encouraged to take a break Nurse remains available


Doula

A doula is a person other than a family member or friend who is trained to provide labor support

May be hired by mother to provide labor support, guidance, and encouragement to mother

Acts as an advocate for the family


Psychological Support

Goal is to Make the labor and delivery process a more

pleasant and satisfying experience Allow more family participation


Teaching

Ongoing tasks of intrapartum nurse Positions or breathing techniques different

from those learned in class may need to be taught to and tried by the laboring woman

Encourage her to try a change in technique or position for 2 or 3 contractions before abandoning it for another


Teaching (cont.)

Avoid pushing before cervix is fully dilated Teach to blow out in short puffs when urge to

push is strong If pushing done before dilation is complete,

can cause Maternal exhaustion Fetal hypoxia

Ultimately slows progress of laboring process


Pushing

Take deep breath and exhale it at beginning of each contraction

Take another deep breath and push with abdominal muscles while exhaling

Push for 4 to 6 seconds


Water Births

Experimental procedure that requires signed, informed consent


Discussion Question

What are the routine auscultations and documentation of fetal heart rate during the following phases and stages of labor? Latent phase Active phase of first stage of labor Second stage of labor


Nursing Care During Labor and After Delivery


Objectives

Explain the common nursing responsibilities during birth.

Identify nursing priorities when assisting in an emergency (precip) delivery.

List four items important to record about the infant’s birth.

Discuss the immediate care of the newborn. Explain the reason the neonate requires

administration of vitamin K at birth.


Objectives (cont.)

Describe the nursing assessments important in the woman’s recovery period after birth.

Illustrate two ways to encourage maternal-newborn bonding after birth.

Discuss fetal pulse oximetry.


Provision of Care During the Four Stages of Labor


Signs of Impending Birth

Sitting on one buttock Making grunting sounds Involuntarily bearing down with contractions States “the baby is coming” Bulging of the perineum Do not leave woman alone; prepare for

precipitate birth and summon help


Birth of the Baby

Cleansing breath before each contraction Keeps oxygen and carbon dioxide levels in

balance Use open-glottis method for pushing

After head delivered, woman is asked to stop pushing Baby’s nose and mouth are suctioned; health care

provider checks baby’s neck to ensure nothing is wrapped around it


Nursing Care During Delivery

Once positioned for delivery, cleanse vulva and perineum

Prepare delivery table Continue to monitor FHR every 5 to 15

minutes All health care team members don

appropriate personal protective equipment


Preparing for Delivery


Vaginal Delivery


Expulsion of Placenta

Third stage of labor begins after birth of baby and ends with expulsion of placenta

The uterus shrinks in size; the placenta does not

Placenta insertion site buckles, and it separates as uterus contracts

Usually takes place about 5 to 30 minutes after delivery


Signs of Imminent Delivery of Placenta

Lengthening of umbilical cord Gush of blood from vagina

May come after placenta delivered if fetal side of placenta is expelled first (Schultze mechanism)

May come just before delivery of placenta if maternal side is expelled first (Duncan mechanism)

Elevation of uterine fundus


Types of Placenta


Immediate Recovery Period

Sometimes referred to as fourth stage of labor

Physical recovery of mother Usually lasts between 1 and 4 hours

Vital signs are monitored Location and firmness of uterine fundus Massage fundus and assess for amount and

color of lochia Ice bag may need to be placed on perineum

Assess for bladder distentionCopyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 88

Third Stage of Labor Risks

Hemorrhage Therefore nursing assessment should include

Amount of bleeding Blood pressure Pulse rate


Phase 1: Immediate Care of the Newborn


Nursing Care of the Newbornin the Delivery Room

Divided into three phases Phase 1: birth to 1 hour of age Phase 2: 1 hour to 4 hours after birth Phase 3: from 4 hours after birth until discharge

from hospital


Phase 1 Care of the Newborn

Maintain thermoregulation Maintain cardiorespiratory function Identify mother, partner, and newborn Perform a brief assessment for anomalies Observe for and document passage of

meconium and urine Facilitate parent-newborn bonding Initiate first breastfeeding


Thermoregulation

Hypothermia forces newborn to use glucose to warm body

Hypoglycemia associated with development of neurologic problems

Cold stress increases basal metabolic rate Results in an increased need for oxygen

consumption; leads to hypoxia


Cardiorespiratory

Obligate nose breathers Bulb suctioning of mouth prevents aspiration

of mucus and amniotic fluid Once in radiant warmer, apply heart

monitoring leads If cyanotic, supplemental blow-by oxygen is

given


Cyanotic Newborn

If heart rate less than 100 beats/min Tactile stimulation is provided Suctioning Oxygen

If cyanosis does not resolve quickly Bag and mask resuscitation may be needed


Acrocyanosis

A blue color to the hands and feet due to sluggish peripheral circulation for the first few hours after birth


Apgar Scoring System

Numeric value (0, 1, 2) is given to Heart rate Respiratory effort Muscle tone Reflex irritability Color


Identification

In delivery room Mother, newborn, and partner are all given ID

bands that have the same number on them This band is checked whenever the baby is given

to or taken from the mother, and at discharge Some facilities even have an alarm device

attached to the bands to prevent infant abduction


Other Nursing Interventions

Document first urine and passage of meconium

Administer medications such as vitamin K (assist with blood clotting) and prophylactic eye ointment (to prevent ophthalmia neonatorum)

Observe for abnormalities Promote infant-parent bonding


Umbilical Cord Blood Banking

Umbilical cord Contains large amounts of stem cells that can help

treat assorted diseases or conditions Requires informed consent of mother and special

collection supplies Blood must arrive at storage center within 48

hours of collection


Emergency Delivery by the Nurse

Called precipitate delivery Major nursing interventions include

Remain calm and supportive Provide cleanliness as much as possible Control the birth of the baby Do not attempt to hold back the fetus’ head to

prevent the delivery


Audience Response SystemQuestion 1

During the fourth stage of labor, the postpartum woman has a soft, boggy uterus. The nurse knows this is likely due to:A. Full bladder displacing uterine fundus

B. Lochia flow needs 1 or more pads per hour

C. Poorly contracted uterus

D. Widening pulse rate and falling BP


Review Key Points


Chapter 7 Nursing Care During Labor Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc....

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Transcript of Chapter 7 Nursing Care During Labor Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc....