OB-CH_10-PPT (1)

Nursing Care During Labor and Birth Chapter 10

Nursing Care During Labor and Birth Chapter 10

1. Discuss assessments and procedures the nurse performs during the woman’s admission to the hospital.2. Describe external and internal methods for monitoring uterine contractions.3. Compare and contrast advantages and disadvantages of intermittent auscultation of fetal heart rate with that of continuous electronic fetal monitoring.4. Compare and contrast advantages and disadvantages of external fetal monitoring with that of internal fetal monitoring.5. Explain how to apply the external fetal monitor.6. Identify the role of the practical (vocational) nurse in the interpretation of fetal heart rate patterns.7. Define three major deviations from the normal fetal heart rate baseline.

Objectives

8. Differentiate between early, variable, and late decelerations with regard to appearance, occurrence in relation to uterine contractions, causes, and whether or not the pattern is reassuring or nonreassuring.9. Outline appropriate nursing interventions for each major periodic change: early, variable, and late deceleration patterns.10. Discuss advantages and disadvantages of fetal stimulation, fetal scalp sampling, and fetal pulse oximetry for monitoring fetal status.11. Determine data to collect when assessing a laboring woman for progress of labor and birth throughout each stage and phase of labor.12. Identify common nursing diagnoses associated with each stage of labor and birth.13. Choose appropriate nursing interventions for each stage of labor and birth to facilitate safe passage of the mother and fetus.14. Evaluate the effectiveness of care given during each stage of labor and birth.

Objectives

Recognize and manage complications that may arise during the process

Give intensive support to the laboring woman and her partner or coach

Facilitate the labor process and ensure safe passage of the laboring woman and fetus through the event

Role of the LPN/LVN During Labor and Delivery

Immediate assessments◦ Birth imminence◦ Fetal and maternal status◦ Risk factors

Additional assessments if birth is not imminent◦ Maternal health history and physical assessment (full-

including weight, complete vitals, lungs, pain, deep tendon reflexes, clonus, amt. and location of any edema)-as time permits

◦ Status of labor-contraction pattern, fetal lie, presentation, attitude, position, and station (pg. 207)

◦ Labor and birth preferences-special requests: mobility during labor, IV fluids, episiotomy, presence of friends and family)

LO1

THE NURSE’S ROLE DURING ADMISSION

Components of the admission health history◦ Obstetric history◦ Current status◦ Medical–surgical history◦ Social history◦ Desires/plans for labor and birth ◦ Desires/plans for newborn

THE NURSE’S ROLE DURING ADMISSION(CONT.)

Admission laboratory studies ◦ Complete blood count (CBC)◦ Blood type and Rh factor◦ Serologic studies, such as VDRL or RPR to test for syphilis◦ Rubella titer (not done if prenatal record indicates the

woman is immune)◦ ELISA to detect HIV antibodies (requires informed consent)◦ Vaginal or cervical cultures◦ Urinalysis (clean-catch specimen)

THE NURSE’S ROLE DURING ADMISSION(CONT.)

Mrs. Jones , a gravida 4 para 3, has just come in to the labor and delivery suite. She tells the admission nurse that her water broke 2 hours ago and she feels like pushing. What is the first assessment the nurse should make?

a. Maternal vital signsb. Imminence of birthc. Take an obstetric historyd. Find a good vein and start an IV

Question

b. Imminence of birth

Rationale: Nursing assessment for signs that birth is imminent begins from the moment the woman arrives in the labor and delivery unit. If the woman is introverted and stops to breathe or pant with each contraction, you can infer that she is in an advanced stage of labor. In addition, if the woman makes statements such as, “I feel a lot of pressure,” or “The baby is coming,” or “I want to have a bowel movement,” it is likely the woman is in the second stage of labor, and the baby will be born soon.

Answer

Monitoring uterine contractions◦ External Methods

Palpation to evaluate the contraction pattern‒ Mild contraction - fundus feels like the tip of your nose

at the peak of a contraction‒ Moderate contraction – fundus feels like touching

your chin‒ Strong contraction - feels like you are pushing on your

forehead Tocodynamometer (toco)-(belt) measures contraction

frequency and durationLO2

THE NURSE’S ROLE: ONGOING ASSESSMENT OF UTERINE CONTRACTIONS AND FHR

◦ Internal Methods Intrauterine pressure catheter

‒Catheter tip placed above presenting part‒Connected to fetal monitor‒Records frequency, duration, and intensity of

contractionsLO2

THE NURSE’S ROLE: ONGOING ASSESSMENT OF UTERINE CONTRACTIONS AND FHR (CONT.)

Intermittent Auscultation of FHR◦ Acceptable method in low-risk pregnancy◦ Most common practice: place external fetal monitor

for 20 minutes to get baseline data◦ If pattern is reassuring, then fetoscope or external

monitor used intermittently◦ Auscultate fetal heart rate◦ Any concerns: attach continuous EFMLO3


Intermittent Auscultation of FHR◦ Advantages of IA

Woman has more freedom to move about Nurses are encouraged to focus on the laboring

woman and her support person, rather than on the technology

Associated with fewer medical interventions and fewer surgical deliveries

LO3


Intermittent Auscultation of FHR◦ Disadvantages

Takes more time Requires higher nurse staffing levels Many practitioners unaccustomed to using IA

fear the potential of missing an ominous FHR pattern.

LO3


Monitoring FHR◦ Continuous EFM

External EFM – indirect‒Most common way to assess fetal status during

labor ‒Works on the principle of ultrasound‒Characteristics of the fetal heart rate pattern can

then be monitored continuously via a video display and/or a continuous printout

LO4


External EFM – indirect Toco monitors the contraction pattern Helps screen for signs of fetal compromise Sometimes it is difficult to get a consistent

tracing if the fetus is small or extremely active, or if the woman is obese

Some manufacturers of fetal monitors have developed telemetry units

LO4

THE NURSE’S ROLE: ONGOING ASSESSMENT OF UTERINE

CONTRACTIONS AND FHR (CONT.)

◦ Continuous EFM Internal EFM

‒Invasive procedure ‒Spiral electrode is attached to the presenting

part just under the skin‒Records a graphic representation of FHR‒Easier to obtain consistent tracing‒Increases the risk of maternal and fetal

infection and injuryLO4

THE NURSE’S ROLE: ONGOING ASSESSMENT OF UTERINE CONTRACTIONS

AND FHR (CONT.)

Evaluating FHR Patterns◦ Baseline fetal heart rate (FHR)

Measured between uterine contractions during a 10-minute period

Normally accepted baseline rate is between 110 beats per minute (bpm) and 160 bpm

Baseline variability‒Fluctuations of the FHR from the baseline rateLO6


◦ Baseline fetal heart rate (FHR) (cont.) Evaluated visually as a unit Normal if the fluctuations are greater than 6 bpm

and less than 25 bpm Reassuring sign that the fetal nervous system is

intact

LO6



Baseline fetal heart rate (FHR) (cont.) Three major deviations from a normal FHR

baseline‒Tachycardia

Baseline rate greater than 160 bpm‒Bradycardia

Baseline FHR below 110 bpm ‒Absent or minimal variability

Non-reassuring pattern Must continue for at least 2 minutesLO7



Evaluating FHR Patterns (cont.)◦ Periodic and episodic changes

Periodic changes are variations in the FHR pattern that occur in conjunction with uterine contractions,

Episodic changes are variations in the FHR pattern not associated with uterine contractions.

LO8



Reassuring periodic changes◦ Accelerations - above the baseline by at least 15 bpm

for at least 15 seconds (15 x 15 window) Benign periodic changes

◦ Early decelerations-looks like a “U” Non-reassuring periodic changes

◦ Variable decelerations indicating some type of acute umbilical cord compression

◦ Late decelerations indicating uteroplacental

insufficiency (diminished or deficient blood flow to uterus or placenta)-grave situation

LO8/9

THE NURSE’S ROLE: ONGOING ASSESSMENT OF UTERINE CONTRACTIONS AND FHR

(CONT.)

Measures used to clarify non-reassuring FHR patterns ◦Fetal stimulation-indirectly w/ an acoustic vibrator

through abdominal wall or directly with a gloved finger◦Fetal scalp sampling-requires MD to take a small

blood sample from fetus’ scalp-checks pH (if acidotic-will need delivered immediately

◦Fetal scalp pulse oximetry

LO-10

THE NURSE’S ROLE: ONGOING ASSESSMENT OF UTERINE CONTRACTIONS

AND FHR (CONT.)

Tell whether the following statement is true or false.

Early decelerations are benign periodic changes.

Question

True

Rationale: Sometimes instead of accelerations, there is a slowing of the FHR. If the dip in the FHR tracing occurs in conjunction with and mirrors a uterine contraction, it is an early deceleration. As long as the baseline remains within normal limits and the variability is good, early decelerations are benign.

Answer

Focus is on assessment Providing physical care to the mother and fetus Providing psychological care to the mother And keeping the practitioner informed about labor

progress

Nursing Process During the First Stage of Labor: Dilation

Assessment◦ Assess FHR and contractions at least once every

hour◦ Assess maternal status◦ Assess status of fetal membranes◦ Assess the woman’s psychosocial state

Nursing Interventions During the Latent Phase (Early Labor)

Nursing diagnosis◦ Risk of injury (fetal and maternal) related to

possible complications of labor◦ Anxiety related to uncertainty of labor onset

and insecurity regarding ability to cope◦ Acute pain related to contractions◦ Deficient Knowledge of labor process related to

inadequate preparation for delivery or unexpected circumstances of labor

Nursing Interventions During the Latent Phase (Early Labor) (cont.)

Outcome identification and planning◦ Primary goals are maternal and fetal safety◦ Other goals and interventions are planned according

to the individual needs of the laboring woman and her partner


Implementation◦ Preventing fetal and maternal injury ◦ Relieving anxiety◦ Promoting comfort ◦ Providing patient teaching


Goals and expected outcomes◦Goal: The woman and fetus remain free from

injury◦Goal: The woman’s anxiety is reduced◦Goal: The woman’s pain is manageable◦Goal: The woman and her partner have adequate

knowledge of the labor process


When planning care for a client in the latent phase of labor what is one primary goal?

a. Mother’s pain is adequately controlled

b. Mother’s anxiety is controlledc. Mother has adequate knowledge of

labor processd. Mother is safe

Question

d. Mother is safe

Rationale: Maintaining the safety of the laboring woman and her fetus throughout the latent phase of the first stage of labor are primary goals when planning care.

Answer

Assessment◦ Assess woman’s psychosocial state◦ Assess labor progress◦ Assess fetal status◦ Assess maternal status

Nursing Interventions During Active Labor

Selected nursing diagnoses◦ Risk for trauma to the woman or fetus related to

intrapartum complications or a full bladder◦ Acute pain related to the process of labor◦ Anxiety related to fear of losing control◦ Ineffective coping related to situational crisis of

labor◦ Ineffective breathing pattern: hyperventilation

related to anxiety and/or inappropriate application of breathing techniques

Nursing Interventions During Active Labor(cont.)

Selected nursing diagnoses (cont.)◦ Impaired oral mucous membrane related to

dehydration and/or mouth breathing◦ Risk for infection related to invasive procedures

(e.g., vaginal examinations) and/or rupture of amniotic membranes

Outcome identification and planning◦ Primary goal remains maintaining maternal and

fetal safety

Nursing Interventions During Active Labor(cont.)

Implementation◦ Preventing trauma during labor◦ Providing pain management ◦ Reducing anxiety ◦ Promoting effective coping strategies◦ Promoting effective breathing patterns◦ Maintaining integrity of the oral mucosa◦ Preventing infection

Nursing Interventions During Active Labor (cont.)

Assessment◦ Assess for signs woman has reached transition

phase◦ Assess woman’s ability to cope◦ Assess maternal status◦ Assess fetal status

Nursing Interventions During the Transition Phase of Labor

Selected nursing diagnoses◦ Acute pain related to frequent, intense uterine

contractions and pressure of the descending fetal head

◦ Ineffective breathing pattern: hyperventilation related to intense uterine contraction pattern and loss of control of breathing techniques

◦ Powerlessness related to intensity of the labor process

◦ Fatigue related to energy expended coping with the intense labor

Nursing Interventions During the Transition Phase of Labor (cont.)

Outcome identification and planning◦ Major goals

The woman’s pain will be manageable She will exhibit effective breathing patterns She will maintain a sense of control She will rest between uterine contractions.


Implementation◦ Managing pain ◦ Promoting effective breathing patterns ◦ Promoting a sense of control ◦ Supporting the woman through fatigue ◦ Preparing the room for delivery


Tell whether the following question is true or false.

Your patient is in the transition phase of labor. One of your nursing interventions will be supporting the woman’s coach through the woman’s fatigue.

Question

False

Rationale: Relaxing with contractions may be almost impossible; assist the woman to achieve relaxation or even sleep between contractions. Help her to find a comfortable position. Support her position with pillows. Placing a cool cloth to her forehead or giving her a back rub may help her relax between contractions.

Answer

Assessment◦ Monitor the blood pressure, pulse, and

respirations every 15 to 30 minutes◦ Assess the contraction pattern every 15

minutes◦ Assess the woman’s report of an uncontrollable

urge to push◦ Check the FHR every 15 minutes for the low-risk

woman and every 5 minutes for the woman who is at risk for labor complications

Nursing Interventions During the Second Stage of Labor: Expulsion of the Fetus

Selected nursing diagnoses◦ Fatigue related to length of labor and pushing

efforts◦ Risk for trauma related to pushing techniques and

positioning for delivery Outcome identification and planning

◦ Goals for the second stage of labor The woman will push effectively despite fatigue She will give birth with minimal or no trauma to

the fetus or herself

Nursing Interventions During the Second Stage of Labor: Expulsion of the

Fetus (cont.)

Implementation◦ Promoting effective pushing despite fatigue◦ Reducing the risk of trauma using effective pushing

techniques and positions◦ Preparing for delivery of the newborn

LO13

Nursing Interventions During the Second Stage of Labor: Expulsion of

the Fetus (cont.)

Assessment◦ Assess the woman’s psychosocial state after

she gives birth◦ Monitor for signs of placental separation

Selected nursing diagnoses◦ Risk of deficient fluid volume related to blood

loss in the intrapartum period◦ Risk of trauma: hemorrhage, amniotic fluid

embolism, retained placenta, or uterine inversion related to delivery of the placenta

Nursing Process During the Third Stage of Labor: Delivery of the Placenta

Outcome identification and planning◦ Major goals during the third stage of labor

The new mother will maintain adequate fluid volume

She will remain free of trauma. Implementation

◦ Preventing fluid loss◦ Maintaining safety and preventing trauma-oxytocin

given to prevent hemorrhage, deliver and intact placenta, keep blood loss <500ml

LO13

Nursing Process During the Third Stage of Labor: Delivery of the Placenta (cont.)

Assessment◦ Continue to assess the woman for hemorrhage ◦ Assess the lochia (vaginal discharge after birth)◦ Monitor for signs of infection◦ Monitor for suprapubic distention ◦ Assess the woman’s comfort level◦ Assess the mother’s psychosocial state during the

fourth stage.◦ Assess initial bonding behaviors of the new family.

Nursing Process During the Fourth Stage of Labor: Recovery

Selected nursing diagnoses◦ Risk of impaired parent–infant attachment

related to disappointment regarding the gender of the newborn or an unwanted pregnancy

◦ Risk of deficient fluid volume related to the possibility of hemorrhage from the former site of placenta attachment

◦ Risk of infection related to invasive procedures and vaginal examinations during labor

Nursing Process During the Fourth Stage of Labor: Recovery (cont.)

Selected nursing diagnoses (cont.)◦ Impaired urinary elimination related to perineal

trauma during delivery◦ Acute pain related to episiotomy, birth trauma,

and/or afterpains◦ Fatigue related to energy expended during labor


Outcome Identification and Planning◦ Appropriate goals

Parents will begin a positive bonding process with their newborn

Woman will ‒ Maintain adequate fluid volume‒ Still have no signs of infection‒ Maintain adequate voiding patterns‒ Not become extremely fatigued‒ Have her pain adequately managed

◦


Implementation◦ Providing care immediately after delivery◦ Promoting parent–newborn attachment◦ Maintaining adequate fluid volume◦ Preventing infection◦ Promoting urinary elimination◦ Minimizing pain◦ Reducing fatigue


OB-CH_10-PPT (1)

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