NCP: Labor Stage 2 (expulsion)

8/14/2019 NCP: Labor Stage 2 (expulsion)

1/15

LABOR Stage II (Expulsion)

Stage II of labor, the stage of expulsion, begins with full cervical dilation (10 cm) and ends with the birth of thenewborn. Maternal efforts to bear down occur involuntarily during contractions that are 1.52 min apart, lasting 6090sec. The average rate of fetal descent is 1 cm/hr for nulliparas, 2 cm or more per hr for multiparas.

CLIENT ASSESSMENT DATA BASEActivity/RestReports of fatigueMay report inability to self-initiate pushing/relaxation techniquesLethargicDark circles under eyes

CirculationBP may rise 510 mm Hg in between contractions.

Ego IntegrityEmotional responses may range from feelings of fear/irritation to relief/joy.May feel a loss of control or the reverse as she is now actively involved in bearing down.

EliminationInvoluntary urge to defecate/push with contractions, combining intraabdominal pressure with uterine pressure.May have fecal discharge while bearing down.Bladder distension may be present, with urine expressed during pushing efforts.

Pain/DiscomfortMay moan/groan during contractions.Amnesia between contractions may be noted.Reports of burning/stretching sensation of the perineum.Legs may tremble during pushing efforts.Uterine contractions strong, occurring 1.52 min apart and lasting 6090 sec.

May fight contractions, especially if she did not participate in childbirth preparation classes.

RespiratoryRespiratory rate increases.

SafetyDiaphoresis often presentFetal bradycardia appearing as early decelerations on electric monitor during contractions (head compression) or

variables (cord compression)

SexualityCervix fully dilated (10 cm) and 100% effaced.Increased vaginal bloody show.Rectal/perineal bulging with fetal descent.Membranes may rupture at this point if still intact.Increased expulsion of amniotic fluid during contractions.Crowning occurs; caput is visible just before birth in vertex presentation.

NURSING PRIORITIES1. Facilitate normal progression of labor and fetal descent.2. Promote maternal and fetal well-being.3. Support clients/couples wishes regarding delivery experience, maintaining safety as a priority.


2/15

NURSING DIAGNOSIS: Pain [acute]

May Be Related To: Mechanical pressure of presenting part, tissue dilation/stretching,nerve compression, muscle hypoxia, intensified contractile pattern

Possibly Evidenced By: Verbalizations, distraction behavior (e.g., restlessness), facial mask of pain, narrowed focus, autonomic responses

DESIRED OUTCOMES/EVALUATION Verbalize reduction of pain.

CRITERIACLIENT WILL: Use appropriate techniques to maintain control.

Rest between contractions.

ACTIONS/INTERVENTIONS RATIONALE

Independent

Identify degree of discomfort and its sources. Clarifies needs; allows for appropriate intervention.

Provide comfort measures, such as mouth care; Promotes psychological and physical comfort,perineal care/massage; clean, dry linen and allowing client to focus on labor, and may reduceunderpads; cool environment (68F72F [20C22.1C]), the need for analgesia or anesthesia.cool, moist cloths to face and neck; or hot compressesto perineum, abdomen, or back, as desired.

Review information with client/couple about type Although client is under the stress of labor andof regional analgesia/anesthesia available at this discomfort levels may interfere with normalstage specific to the delivery setting (e.g., local, decision-making skills, she still needs to be inpudendal block, lumbar epidural reinforcement) control and make her own informed decisionsor use of transcutaneous electrical nerve stimulation regarding anesthesia. Note: The option of a nerve(TENS), acupressure/acupuncture. Review root block should be restricted to a hospital settingadvantages/disadvantages, as appropriate. where emergency equipment is available.

Monitor and record uterine activity with Provides information/legal documentation abouteach contraction. continued progress; helps identify abnormal

contractile pattern, allowing prompt assessment and intervention.(Refer to CP: DysfunctionalLabor/Dystocia.)

Provide information and support related to Keeps couple informed of proximity of delivery;progress of labor. reinforces that efforts are worthwhile and the end is in sight.

Encourage client/couple to manage efforts to Anesthetics may interfere with clients ability tobear down with spontaneous, rather than sustained, feel sensations associated with contractions,pushing during contractions. Stress importance of resulting in ineffective bearing down.using abdominal muscles and relaxing pelvic floor. Spontaneous, rather than sustained, efforts to bear

down avoid negative effects of Valsalvas maneuverassociated with reduced maternal and fetal oxygenlevels. Relaxation of the pelvic floor reduces resistanceto pushing efforts, maximizing effort to expel the fetus.

Observe for perineal and rectal bulging, opening Anal eversion and perineal bulging occur as theof vaginal introitus, and changes in fetal station. fetal vertex descends, indicating need to prepare for

delivery.


3/15

Assist client in assuming optimal position for Proper positioning with relaxation of perinealbearing down; (e.g., squatting or lateral recumbent, tissue optimizes bearing-down efforts, facilitatessemi-Fowlers position (elevated 3060 degrees). labor progress, reduces discomfort, and reducesAssess effectiveness of efforts to bear down. need for forceps application.(Refer to ND: Skin/Tissue Integrity, risk forimpaired.)

Encourage client to relax all muscles and rest Complete relaxation between contractionsbetween contractions. promotes rest and helps limit muscle strain/fatigue.

Monitor maternal BP and pulse, and FHR. Observe Maternal hypotension caused by decreasedunusual adverse reactions to medication, such as peripheral resistance as vascular tree dilates is theantigen-antibody reactions, respiratory paralysis, main adverse reaction to subarachnoid oror spinal blockage. Note adverse reactions such as peridural block. Fetal hypoxia or bradycardia isnausea/vomiting, urine retention, delayed respiratory possible, owing to decreased circulation within thedepression, and pruritus of face, eyes, or mouth. maternal portion of the placenta. Other adverse(Refer to ND: Gas Exchange, risk for impaired reactions may occur after administration of spinalfetal.) or peridural anesthetic especially when morphine is

used.

Collaborative

Assess bladder fullness. Catheterize between Promotes comfort, facilitates fetal descent, andcontractions if distension is noted and client is reduces risk of bladder trauma caused byunable to void. presenting part of fetus.

Assist with reinforcement of medication via Reduces discomfort associated with episiotomy,indwelling lumbar epidural catheter when forceps application, and fetal expulsion. Adversecaput is visible. Monitor vital signs and reactions include maternal hypotension, muscleadverse responses. (Refer to CP: Labor: Stage I twitching/convulsions, loss of consciousness,Active Phase; ND: Pain [acute].) reduced FHR, and beat-to-beat variability.

Position client in dorsal lithotomy position and Anesthetizes lower two-thirds of vagina andassist as necessary with administration of perineum during delivery and for episiotomypudendal anesthetic. repair. May interfere with efforts to bear down but

has no effect on maternal BP, FHR, or FHR

variability.

Assist as needed with administration of local Anesthetizes perineum tissue for incision/repairanesthetic just before episiotomy, if done. purposes.

Lumbar, Epidural, or Low Spinal Anesthesia

Administer IV fluid bolus of 5001000 ml Increases maternal circulating fluid as a means of lactated Ringers as indicated, before preventing adverse reactions of anesthetic such asadministration of agent. maternal hypotension, fetal hypoxia, and fetal

bradycardia.

Position client in sitting or lateral recumbent Proper alignment of vertebrae maximizes space forposition for insertion of drug/placement of needle/catheter placement.catheter for continuous infusion. Have clientflex head sharply on chest/arch back duringintrathecal administration.


4/15

Assist with administration of opiates (e.g., fentanyl Intraspinal narcotic, acting on opiate receptors[Sublimaze], morphine) into epidural space via within the spinal column, blocks pain for as longindwelling catheter. Have ephedrine, 10 mg, or as 11 hr. Literature reveals mixed results regardingnaloxone (Narcan), 0.4 mg, available as an antidote, use of morphine via indwelling catheter in stage IIdepending on agent used. labor (may be more effective in the active phase of

stage I labor). Note: Because of the potential for life-threatening complications, initial and subsequentbolus dosing should be done by anesthesia service orproviders specifically trained and certified.

Turn client side to side periodically during Promotes even distribution of drug tocontinuous infusions. prevent one-sided or unilateral block.

Monitor level of block per protocol. Migration of decreased sensation from belly button(dermatome T-10) to tip of breastbone(approximately T-6) increases risk of profoundhypotension. Necessitates evaluation of drugconcentration/infusion rate by anesthesia personnel.

Administer oxygen and increase plain IV fluid. Enhances venous return and circulating bloodIf hypotension occurs, displace uterus to the left volume, increasing placental perfusion andand elevate legs. oxygenation.

Administer diphenhydramine (Benadryl), May relieve pruritus, a side effect of morphinepromethazine hydrochloride (Phenergan), or administration.metoclopramide hydrochloride (Reglan) whenindicated.

Assist with administration of intrathecal Anesthetizes nerves at lumbar spaces L3L4 andsubarachnoid anesthetic. Identify beginning and L4L5. Administration of medication during aending of contractions. Administer anesthetic contraction may cause the level of the anestheticbetween contractions when fetal head is on to rise too high, anesthetizing the diaphragm.the perineum.

Transcutaneous Electrical Nerve Stimulation

Apply two pairs of electrodes on either side of Electrical stimulation of pain receptors (by TENSthoracic and sacral vertebrae. units) within the skin may block pain sensations by

causing release of endorphins. Has no adverse effecton client or fetus and may reduce need foranalgesia/anesthesia.

Encourage and assist client/couple with operation Ability to turn on mild electrical currents during aof control knobs on battery-operated device. contraction promotes a feeling of control for the

client.

Complimentary Therapy

Assist with acupressure/acupuncture, moxibustion. May be used to stimulate/regulate contractions torestore balance to labor and reduce perception of

pain.

General Anesthesia

Assist with general anesthesia (inhalation or Because of maternal and fetal side effects, generalIV administration), as indicated. anesthesia should only be used in obstetric

emergencies, such as hemorrhage, internal versionwith a second twin, or delivery of the aftercominghead in a breech presentation.


5/15

Assist with monitoring BP, pulse, respirations, General anesthesia has a depressant effect on theFHR, and variability. Watch for vomiting reaction. client and fetus, and poses a risk of maternal

aspiration.

NURSING DIAGNOSIS: Cardiac Output, altered [fluctuation]

May Be Related To: Fluctuation in venous return, changes in systemic vascular resistance

Possibly Evidenced By: Variations in blood pressure, changes in pulse rate, decreased urineoutput, fetal bradycardia

DESIRED OUTCOMES/EVALUATION Maintain vital signs appropriate for stage of labor.

CRITERIACLIENT WILL: Use appropriate techniques to sustain/enhance vascular return.

Display FHR and variability WNL.


Independent

Monitor BP and pulse frequently (every 515 min). Increases in cardiac output of 30%50% occur inNote amount and concentration of urine output; the expulsion stage, peaking at the acme of uterinetest for albuminuria. contractions and slowly returning to a precontractile

state as the contraction diminishes or ceases.Intrapartal toxemia due to stress, excess sodium andfluid retention, or oxytocin administration may bemanifested by increased BP, decreased urine output,

and increased concentration of urine.

Encourage client to inhale/exhale during bearing- Repeated, prolonged Valsalvas maneuversdown efforts, using an open glottis technique and (occurring when the client holds her breath whileholding breath no longer than 5 sec at a time. pushing against a closed glottis) eventually interruptInstruct client to push only when she feels the venous return and reduce cardiac output, BP, andurge to do so. Avoid forced pushing. pulse pressure. Avoiding Valsalvas maneuver

minimizes fall of maternal P O2 and rise in P CO 2 levels,which would have a negative impact on fetus.

Monitor FHR after every contraction or bearing- Detects fetal bradycardia and hypoxia associateddown effort. with reduction in maternal circulation and

reduced placental perfusion caused by anesthesia,Valsalvas maneuver, or incorrect positioning. (Referto ND: Gas Exchange, risk for impaired fetal.)

Encourage client/couple to select laboring position Upright and lateral recumbent positions preventthat optimizes circulation, such as the lateral occlusion of the inferior vena cava and obstructionrecumbent position, Fowler s position, or squatting. of the aorta, sustaining venous return and preventing

hypotension.

Monitor BP and pulse immediately after Hypotension is the most common adverse reactionadministration of anesthesia, and repeat until to lumbar epidural or subarachnoid (low spinal)client is stable. (Refer to ND: Pain [acute] for block as vascular dilation slows venous return andinformation about anesthesia and side effects.) reduces cardiac output.


6/15

Collaborative

Regulate IV infusion as indicated; monitor IV line (or saline lock access) should be availableoxytocin administration, and decrease rate in case the need to correct hypotension orif necessary. administer emergency drugs arises. Excess fluid

retention (a possible adverse reaction of oxytocin) maycontribute to development of intrapartal toxemia.

NURSING DIAGNOSIS: Gas Exchange, risk for impaired fetal

Risk Factors May Include: Mechanical compression of head/cord, reduced placental perfusion,prolonged labor, maternal hyperventilation

Possibly Evidenced By: [Not applicable; presence of signs/symptoms establishes an actualdiagnosis]

DESIRED OUTCOMES/EVALUATION Be free of variable or late decelerations with FHRCRITERIAFETUS WILL: WNL.

CLIENT WILL: Maintain control of respiratory pattern.Use positions promoting venous return/placental circulation.


Independent

Position client in lateral recumbent or upright Increases placental perfusion, prevents supineposition, or turn side to side as indicated. hypotensive syndrome, and takes pressure from

presenting part off cord, enhancing fetal oxygenationand improving FHR patterns.

Avoid placing client in dorsal recumbent position. Contributes to fetal hypoxia and acidosis; reducesbaseline variability and placental circulation.

Determine fetal station, presentation, and position. If During stage II labor, the fetus is most vulnerablefetus is in occiput posterior position, place client to bradycardia and hypoxia, which are associatedon her side. with vagal stimulation during head compression.

Malpresentations such as face, mentum (chin), orbrow may prolong labor and increase risk of hypoxiaand the likelihood of the need for a cesarean birth,whereas posterior position increases duration of stageII labor. Placing client in lateral recumbent positionfacilitates fetal rotation from occiput posterior (OP)position to occiput anterior (OA) position.

Assess clients breathing pattern. Note reports Identifies ineffective (inappropriate) respiratoryof tingling sensation of face or hands, dizziness, pattern. Initially, hyperventilation results inor carpopedal spasms. respiratory alkalosis and an increase in serum pH;

toward the end of labor, the pH falls and acidosisdevelops owing to lactic acid buildup frommyometrial activity.

Have client breathe into cupped hands or small Increases carbon dioxide levels and correctspaper bag, as indicated. respiratory alkalosis caused by hyperventilation.


7/15

Assist partner in helping with verbal coaching of Provides opportunity for couple to work togetherrespirations. Remind client to focus on an object/ to maintain/regain control of situation andmental picture. maintain state of relaxation during contractions.

Monitor client for fruity breath odor. Suggests acidosis associated with hyperventilation.As shifts in acid-base levels occur, fetal status can becompromised with resultant acidosis and hypoxia.

Encourage client/couple to inhale and exhale Helps maintain adequate oxygen levels. Exhalingevery 1020 sec during bearing-down efforts. while pushing minimizes physiological effects of Monitor response to pushing efforts. Valsalvas maneuver, which can decrease maternal

heart rate and P O2, and increases P CO 2, potentiallyresulting in placental and fetal hypoxia and acidosis.

Assess FHR, with fetoscope or fetal monitor, during Early decelerations due to vagal stimulation fromand after each contraction or pushing effort. head compression should return to baseline patterns

between contractions.

Monitor periodic changes in FHR for severe, Variable decelerations indicate hypoxia due tomoderate, or prolonged decelerations. Note possible cord entrapment or to nuchal or shortpresence of variable or late decelerations. cord. Late decelerations indicate uteroplacental

insufficiency, which should not be allowed to persist

for more than 30 min. Late decelerations are morelikely to occur in clients with pregnancy-inducedhypertension, diabetes, and kidney problems;placental aging; or following maternal anesthesia.

Note short- and long-term FHR variability. Average beat-to-beat changes should range from 6 to10 bpm, indicating integrity of fetal CNS.

Collaborative

Perform sterile vaginal examination, feeling for Elevation of vertex helps free umbilical cord,prolapse. If prolapse is present, lift vertex off cord. which may be compressed between presenting part

and birth canal.

Transfer to acute care setting, as indicated, if client is In cases of bradycardia or reduced FHR variability,in a free-standing birth center/home setting. more invasive monitoring, acute care equipment, or a

cesarean birth may be needed.

Monitor FHR electronically with internal lead. Electronic monitoring allows continued, accurateassessment. Direct scalp electrodes accuratelydetect abnormal fetal responses and reduction inbeat-to-beat variability.

If severe bradycardia, late decelerations, orprolonged variable decelerations appear:

Position client in lateral recumbent position; Increases maternal circulating blood volume andincrease plain IV fluid; placental perfusion.

Administer oxygen to client; Increases circulating oxygen available for fetaluptake. During this stage of labor, enhanced

metabolic processes increase oxygen consumption bytwice the normal level.

Assist as needed with intermittent fetal scalp Determines trends in fetal acid-base status, andsampling, if done; presence of fetal acidosis. The pH of fetal blood falls

rapidly during stage II labor, and prolonged hypoxiamay result in anaerobic metabolism with buildup of lactic acid.

Prepare for surgical intervention if spontaneous The fastest means of delivery must be implementedvaginal or low forceps delivery is not when the fetus has severe or irreversible hypoxia


8/15

immediately possible after approximately or acidosis.30 min, and fetal pH is 7.20 or less.

NURSING DIAGNOSIS: Skin/Tissue Integrity, risk for impaired

Risk Factors May Include: Precipitous labor, hypertonic contractile pattern, adolescence, largefetus, forceps application


DESIRED OUTCOMES/EVALUATION Relax perineal musculature during bearing-downCRITERIACLIENT WILL: efforts.

Be free of preventable lacerations.


Independent

Assist client/couple with proper positioning, Helps promote gradual stretching of perineal andbreathing, and efforts to relax. Ensure that client vaginal tissue. If maternal tissue within the birthrelaxes the perineal floor while using abdominal canal or perineum resists gradual stretching as themuscles in pushing. presenting part of the fetus descends, trauma or

lacerations of the cervix, vagina, perineum, uretha,and clitoris are possible.

Offer use of birthing bed in upright position. Upright positions reduce duration of labor,

Encourage squatting, Fowlers position, or standing enhance forces of gravity, reduce need forwhile pushing, if these positions are not episiotomy, and maximize uterine contractility.contraindicated.

Place client in left lateral Sims position for Reduces perineal tension, promotes gradualdelivery, if desired/comfortable. stretching, and reduces need for episiotomy.

Help client as needed in assuming position of Reduces risk of injury, especially if client is unablechoice/transfer to delivery table between to assist with transfer.contractions. Monitor safety, and support legs,especially if epidural (or caudal) catheter is in place.

Lift legs simultaneously, if leg supports/stirrups Reduces muscle strain; prevents pressure on calf are used, and place feet and legs properly in and popliteal space that could contribute tolow position, supporting feet. development of postpartal thrombophlebitis.

Collaborative

Assess for bladder fullness; catheterize prior to Reduces bladder trauma from presenting part.delivery, as appropriate. (Refer to CP: Labor:Stage IActive Phase; ND: Urinary Elimination,risk for altered.)


9/15

Assist as needed with hand maneuvers; apply Allows slow delivery once the fetal head haspressure to fetal chin through maternal perineum distended the perineum 5 cm; reduces trauma towhile exerting pressure on the occiput with the maternal tissues.other hand (modified Ritgen maneuver).

Assist with midline, or mediolateral episiotomy, Although controversial, episiotomy may preventif necessary. tearing of perineum in cases of a large infant, rapid

labor, and insufficient perineal relaxation. It mayshorten stage I of labor, especially when forceps areused. Note: Research suggests use of midlineepisiotomy is associated with a fourfold increase of major perineal trauma, including extensive tearing,whereas mediolateral episiotomy reduces likelihoodof severe perineal lacerations, the surgical repair ismore difficult, and problems with healing may occur.

Maintain accurate delivery records of location of Ensures proper documentation of events occurringepisiotomy and/or lacerations. Record type and during delivery process; identifies specific problemstiming of forceps if used. affecting postpartal recovery; e.g., maternal tissue

trauma is increased with forceps application, whichmay result in possible lacerations or extension of

episiotomy, increased level of postpartal discomfort.

NURSING DIAGNOSIS: Fluid Volume risk for deficit

Risk Factors May Include: Active loss, reduced intake, fluid shifts


DESIRED OUTCOMES/EVALUATION Maintain vital signs WNL, adequate urine output,CRITERIACLIENT WILL: moist mucous membranes.

Be free of thirst.


Independent

Measure intake/output and urine-specific gravity. In presence of dehydration, urine outputAssess skin turgor and production of mucus. decreases, specific gravity increases, and skinNote albuminuria. turgor and mucus production decrease. Proteinuria

may be caused by dehydration or exhaustion, or may

indicate preeclampsia.Monitor temperature, as indicated. Elevated temperature and pulse may indicate

dehydration or, on occasion, infection.

Assess FHR and baseline; note periodic changes Initially, FHR may become tachycardic withand variability (if internal scalp electrode is used). maternal dehydration and fluid losses. Prolonged

maternal acidosis may result in fetal acidosis andhypoxia. (Refer to ND: Gas Exchange, risk forimpaired fetal.)


10/15

Reduce excess clothing, cool body with wet cloths, Cools the body through evaporation; may reduceand maintain cool environment. Protect from chilling. diaphoretic losses. Muscle tremors associated with

chilling increase body temperature and generaldiscomfort. Note: Diaphoresis, blood loss at delivery,hyperventilation, reduced oral intake, and vomitingall contribute to possible alterations in maternal fluid-electrolyte balances.

Place client in upright or lateral recumbent position. Optimizes placental perfusion.

Collaborative

Administer fluids orally (sips of juices/broth or Replaces fluid losses. Solutions such as lactatedice chips), as allowed, or parenterally. Ringers administered intravenously help correct or

prevent electrolyte imbalances.

NURSING DIAGNOSIS: Infection, risk for maternal

Risk Factors May Include:Repeated invasive procedures, traumatized tissues, exposure topathogens, prolonged labor, or rupture of membranes


DESIRED OUTCOMES/EVALUATION Be free of infection.CRITERIACLIENT WILL:


Independent

Perform perineal care per protocol, using medical Helps promote cleanliness; prevents developmentasepsis. Remove fecal contaminants expelled of an ascending uterine infection and possibleduring pushing; change linens/underpad sepsis.as needed.

Note date and time of rupture of membranes. Within 4 hr after rupture of membranes, the client(Refer to CP: Prenatal Infection.) and fetus are at increased risk for ascending tract

infections and possible sepsis.

Perform vaginal examination only when Repeated vaginal examination increases the risk of absolutely necessary, using aseptic technique. endometrial infections.

Monitor temperature, pulse, and WBC count, Increased temperature or pulse greater than 100

as indicated. bpm may indicate infection. Normal protectiveleukocytosis with WBC count as high as 25,000/mm 3

must be differentiated from elevated WBC countcaused by infection.

Use surgical asepsis in preparing equipment. Reduces risk of contamination.Clean perineum with sterile water and soap orsurgical disinfectant just prior to delivery.


11/15

Assist partner with dressing in scrub apparel Reduces risk of infection resulting from cross-(if indicated), washing hands, and so forth, as contamination.required by setting. Reduce number of personspresent at delivery, depending on clients/careproviders wishes.

CollaborativeAdminister antibiotics, as indicated. Used only occasionally; prophylactic antibiotics are

controversial and must be used with caution becausethey may stimulate overgrowth of resistantorganisms.

Provide aseptic conditions for delivery. Helps prevent postpartal infection and endometritis.

NURSING DIAGNOSIS: Injury, risk for fetal

Risk Factors May Include: Malpresentations/positions, precipitous delivery, or cephalopelvic

disproportion (CPD)Possibly Evidenced By: [Not applicable; presence of signs/symptoms establishes an actual

diagnosis]

DESIRED OUTCOMES/EVALUATION Be free of preventable trauma or other

CRITERIAFETUS WILL: complications.


Independent

Assess fetal position, station, and presentation. Malpresentations such as face, mentum (chin), orbrow may prolong labor and increase the likelihoodthat cesarean delivery will be necessary, because lack of neck flexion increases the diameter of the fetalhead as it passes through the pelvic outlet. Breechpresentation usually necessitates surgicalintervention, owing to the high risk of spinal cordinjuries resulting from hyperextension of the fetalhead during vaginal delivery.

Monitor labor progress and rate of fetal descent. Precipitous labor increases the risk of fetal headtrauma because skull bones do not have adequatetime to adjust to dimensions of the birth canal.

Assess amount of amniotic fluid expelled at the Hydramnios is associated with fetal disorders suchtime membranes rupture and then during as anencephaly, disorders of the gastrointes tinalcontractions. tract, kidney dysfunction, and maternal diabetes.

Oligohydramnios is associated with postmaturityand intrauterine growth retardation secondary toplacental insufficiency.


12/15

Note color of amniotic fluid. Meconium-stained amniotic fluid, greenish in color,may indicate fetal distress caused by hypoxia in avertex presentation or to compression of fetalintestinal tract in breech presentation.

Transfer to delivery room, as appropriate, when If delivery is to occur in area separate from thevertex is visible at introitus in nullipara, or when labor setting, transfer at this time ensures that

multipara is 8 cm dilated. infant is born where emergency medications andequipment are available, if needed.

Remain with client and monitor pushing efforts as Ensures that trained personnel are present andhead emerges. Instruct client to pant during process. reduces possibility of trauma to fetal vertex; allows

gradual accommodation of skull bones to birth canaland overriding of sutures.

Obtain emergency delivery kit if delivery not Assures the availability of needed equipment andusually done in labor room. (Refer to CP: supplies in the event that labor progresses tooPrecipitous Labor/Delivery or Unplanned Out- rapidly for a planned delivery. When precipitousof-Hospital Delivery.) Verify proper functioning of delivery is imminent, transfer to the delivery roomequipment and availability of appropriate supplies. is postponed until the neonate is delivered and the

cord is clamped and cut.

Maintain record of events. Accurate documentation provides information aboutneonate/client status and postpartal needs.

Collaborative

Assist with vaginal delivery when fetus is in Posterior position increases possibility of fetalposterior position. trauma caused by neck injuries.

Assist with vertex rotation from OP to OA Manual or vacuum rotation from OP to OA is(Scanzoni maneuver). possible (if no CPD exists). Double application of

forceps to vertex may increase risk of fetal injury, yetOA position is preferred position for delivery.

Prepare for surgical intervention, if indicated. May be necessary in cases of CPD, persistent OP(Refer to CP: Cesarean Birth.) position, or deep transverse arrest of the head with

prolonged stage II labor or fetal distress, or with breechor shoulder presentation. Fetus with anencephaly maynot dilate maternal tissues effectively and maytherefore require surgical intervention.

NURSING DIAGNOSIS: Fatigue, risk for

Risk Factors May Include: Decreased metabolic energy production, increased energyrequirements, overwhelming psychological/emotional demands,presence of pain


DESIRED OUTCOMES/EVALUATION Effectively participate in bearing-down activities.

CRITERIACLIENT WILL: Relax/rest between efforts.


13/15


Independent

Assess fatigue level, and note activities/rest The amount of fatigue is cumulative, so that theimmediately before onset of labor. client who has experienced a longer-than-average

stage I labor, and/or one who was not rested at theonset of labor, may experience greater feelings of exhaustion.

Encourage rest/relaxation between contractions. Conserves energy needed for pushing efforts andProvide environment conducive to rest. delivery. Stage II can be extremely exhausting(Refer to ND: Pain [acute].) because of the muscular effort involved in bearing

down, the intensity of the emotional response to thebirth experience, inadequate rest, and/or length of labor.

Keep client/couple informed of progress. Helps provide needed psychological energy.Spontaneous efforts to bear down tend to lengthenstage II labor, but do not negatively affect the fetus.

Encourage use of relaxation techniques. Review Tense muscles increase feelings of exhaustion andthem with client/partner, as necessary. resistance to fetal descent and may prolong labor.

Monitor fetal descent, presentation, and position. Malposition and malpresentation may prolong(Refer to ND: Injury, risk for fetal.) labor and cause/increase fatigue.

Collaborative

Supply fluids with glucose orally as appropriate Replenishes reserves that may have been depletedor parenterally, if ordered. Test urine for ketones, in labor and possibly resulted in hypoglycemiaas indicated. or ketonuria.

Assist with anesthesia or use of forceps if clients Low forceps delivery may be necessary in theefforts do not rotate fetal vertex and promote event of extreme maternal feelings and/or whenfetal descent. maternal efforts to deliver are unsuccessful.

Midforceps delivery with rotation (Scanzonimaneuver) helps rotate fetus from OP to OA position.(Refer to ND: Injury, risk for fetal.)

Prepare for cesarean birth if vaginal delivery Maternal fatigue and lack of progress may resultis not possible. from CPD or fetal malposition.

NURSING DIAGNOSIS: Coping, Individual, risk for ineffective

Risk Factors May Include: Situational crisis, personal vulnerability, inadequate support system,unrealistic perceptions/expectations


DESIRED OUTCOMES/EVALUATION Verbalize feelings congruent with behavior.

CRITERIACLIENT WILL: Demonstrate effective coping skills by the use of self-directedtechniques for bearing-down efforts.


14/15


Independent

Determine clients/couples perception of behav- Helps nurse gain insight into couples feelings andioral response to labor. Encourage verbalization identify needs. Depending on ethnic background

of feelings. Note cultural influences. and childbirth preparation, involvement in the birthprocess can be ego-enhancing for the father orsupport person who desires active participation.Conversely, negative feelings or disappointmentabout performance arise if active involvement is notallowed or supported.

Discuss normal emotional and physical changes Understanding helps client cope with situationas well as variation in emotional responses. and cooperate with pushing efforts. Emotional

responses in this stage of labor vary from excitementat being able to participate more actively/control theforces of labor through pushing efforts, toembarrassment, irritability, or fear resulting from lossof control. This may be manifested by a lack of

cooperation or ineffective pushing duringcontractions.

Monitor response to contraction. Provide gentle Active involvement provides positive means of but firm instructions for efforts to bear down coping and assists in descent of the fetus. Negativewhen the urge to push arises. coping can result in prolonged labor and increases

the likelihood that anesthesia and/or forceps orvacuum may be needed for the delivery.

Discuss options for pain control/reduction. Client may require anesthesia or analgesia to(Refer to ND: Pain [acute].) promote relaxation and facilitate coping.

Support client/couple in their decision to use The clients perception of her performance may beanalgesia or anesthesia. influenced by her own goals for coping with pain. If

she has planned an unmedicated birth, she may feel a

sense of failure if she resorts to anesthesia as fatigueand pain become intense. The client may beconcerned about the support persons sense of failureas a coach if she resorts to medication. The nurse canreduce these feelings of failure by accepting thedecision in a nonjudgmental manner.

Point out tense or furrowed brow, clenched fists, and Helps client focus on tension reduction, and allowsso forth, and suggest that partner touch tense areas. couple to work together to regain control of situation.

Provide comfort measures (e.g., applying cool Reduction of discomforts and distractions allowscloths to face, neck, and extremities; eliminating couple to focus on labor efforts.excess clothing; positioning properly; providingperineal care; and providing a quiet, nonstimulatingenvironment).

Encourage client to rest between contractions with Conserves strength needed for pushing, therebyeyes closed. facilitating the coping process.

Facilitate partners participation in meeting clients Active participation fosters positive sense of self needs regarding comfort, pushing, and emotional and may actually strengthen and enhance couplessupport. future relationship and their relationship to the child.


15/15

Provide positive reinforcement; inform couple of Helps couple to feel positive about their participationlabor progress, appearance of fetal vertex, and that and rewarded for their cooperation. Encouragestheir efforts are helpful. Provide mirror for visual- continuation of efforts.ization of emerging infant or have client reach downand touch babys head as she pushes.

NCP: Labor Stage 2 (expulsion)

Documents

Transcript of NCP: Labor Stage 2 (expulsion)