NURSING CARE DURING LABOR

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NURSING CARE DURING LABOR

• CHAPTER 8

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BIRTH SETTINGS

• In -Hospital Birthing Rooms
• LDR
• LDRP
• woman has less control over procedures, but
  easier to control emergency situations
• Out-of-hospital birthing centers (Freestanding
  Centers)
• woman has more control over what is done
• more difficult to care for emergencies
• Home Birth
• in familiar surroundings
• more risk if emergency arises

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COMMUNICATION CULTURAL BELIEFS

• FOCUS ON WOMANS FEELINGS PERCEPTIONS AND
  RESPOND TO HER CONCERNS. ESTABLISH TRUST.
  COMMUNICATION IS VERBAL NONVERBAL
• MODESTY PAIN ARE EXPRESSED DIFFERENTLY IN
  DIFFERENT CULTURES
• BIRTH POSITION SUPPORT PERSONS DIFFER
• SEE TABLE 8-1

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CARE MANAGEMENT

• Most women come to the hospital
• onset of regular uterine contractions
• fluid discharge from vagina
• bloody show

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ASSESSMENT ADMISSION PROCEDURES

• BOX 8-1 ADMISSION PROCEDURES
• ID, INFO, V/S, CONTRACTIONS, FHR, LABOR, LAB,
  IVs, PREP, PERSONAL ITEMS
• REVIEW ALL NURSING CARE PLANS
• WARNING SIGNS OF POTENTIAL COMPLICATIONS, FAST
  FOCUS 8-1

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NURSING ASSESSMENT ADMISSION PROCEDURES

• STANDARD PRECAUTIONS
• OBTAIN PRENATAL RECORD/ INFO
• V/SREPORT Tgt100.4 B/Pgt140/80 PIH
• ASSESS WHEN CONTRACTIONS BEGAN, FREQUENCY,
  DURATION, INTENSITY
• Rupture Of Membranes ( ROM)?? WHEN??
• COLOR, AMT, ODOR??

• MONITOR FHR 110-160 BPM-EXTERNAL MONITOR/DOPPLER
• LAST FOOD, FLUIDS
• ALLERGIES
• SVE- VAGINAL EXAM-- OF CERVICAL DILATION
  EFFACEMENT
• IV, ENEMA, PREP
• DOULA

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FAST FOCUS 8-2 REASSESS FETAL HEART RATE AFTER

• ROM
• spontaneous (SROM) or artificially by care
  provider (AROM)
• VAGINAL EXAM
• AMBULATION
• CHANGE IN IV RATE OF OXYTOCIN
• CATHERIZATION
• ADMINISTRATION OF DRUGS

• ENEMA
• ABNORMAL UTERINE ACTIVITY
• DECREASE IN FETAL ACTIVITY FELT BY MOM
• ALWAYS RECORD ACTIVITY ON MONITOR STRIP

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STAGES PHASES OF LABOR Table 8-2

• STAGE 1 LATENT PHASE- 0-3 CM
• ACTIVE PHASE- 4-7CM
• TRANSITION- 8-10 CM

• STAGE 2 EXPULSION OF FETUS
• STAGE 3 EXPULSION OF PLACENTA
• STAGE 4 IMMEDIATE RECOVERY

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SOURCES OF PAIN

• CAUSES
• UTERINE CONTRACTIONS
• DILATATION EFFACEMENT OF CERVIX
• PRESSURE PULLING OF PELVIC STRUCTURES
• DISTENTION STRETCHING OF VAGINA PERINEUM

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GATE CONTROL THEORY

• GATE -LIKE MECHANISM INVOLVED IN THE SIGNAL OF
  PAIN TO CEREBRAL CORTEX. CUTANEOUS STIMULI SUCH
  AS TOUCHING, RUBBING, FINGERTIP MASSAGE, MAY
  CLOSE THE GATE
• ONLY ONE IMPULSE CAN TRAVEL UP OR DOWN THE NERVE
  PATHWAY AT A TIME
• FOCUSING, STIMULATION, BREATHING, KNOWLEDGE CAN
  ALSO CLOSE THE GATE

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CHEMICAL FACTORS

• BODY MAKES NATURAL PAIN KILLERS CALLED ENDORPHINS
• ENDORPHINS ARE MORPHINE LIKE SUBSTANCES FOUND IN
  THE BRAIN
• PRODUCED IN RESPONSE TO STRESS
• MAKE THE WOMAN SLEEPY DROWSY

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METHODS TO MANAGE PAIN

• KNOWLEDGE DECREASES PHARMACOLOGICAL
  INTERVENTIONS, AND INCREASES SATISFACTION WITH
  CHILDBIRTH EXPERIENCE
• RELAXATION TECHNIQUES, MAY INTERFERE WITH PAIN
  TRANSMISSION

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PAIN MANAGEMENT CONT...

• CONDITIONING TO RELAX WITH THE CONTRACTION
• VISUALIZATION, IMAGERY
• FOCUSED CONCENTRATION
• EFFLEURAGE, SACRAL PRESSURE

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PAIN MANAGEMENT INTERVENTIONS

• NONPHARMACOLOGIC
• Relaxation/ Breathing
• Position changes--Sims
• Showering, before ROM
• Back support/ Back rub
• Abdominal massage
• Cool cloth to forehead
• Distraction/ Hypnosis

• PHARMACOLOGIC
• ANALGESICS--Demerol, Nubain
• SEDATIVES/ BENZODIAZEPINES relieve anxiety, not
  pain, rarely used
• PHENOTHIAZINE-- Phenergan, Vistaril relieve
  nausea/anxiety

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ANESTHESIA

• See Table 8-3
• Anesthetic injected into
• PUDENDAL BLOCK space in front of pudendal
  nerve--transavaginally
• EPIDURAL BLOCK epidural space
• SPINAL BLOCK spinal fluid
• PARACERVICAL NERVE BLOCK cervical mucus

• GENERAL
• Rarely used, only in emergency
• Loss of consciousness
• At risk for aspiration, infant also under its
  effects
• Apgar low, risk for neurological damage high

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BIRTH OF THE BABY

• Signs of impending birth, box 8-3
• Help with pushing, positioning of pt
• Preparation of delivery table, fig 8-2
• Preparation of perineum, fig 8-11
• Assessment documentation of FHR, contractions

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EXPULSION OF PLACENTA

• Usually expelled within 15 30 minutes after
  delivery
• Records time of delivery of placenta whether
  expelled spontaneously or manually removed
• Oxytocin or Pitocin usually administered
  immediately after placenta delivers to help
  uterine muscles contract reduce blood loss

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IMMEDIATE RECOVERY PERIOD

• Lasts from placenta delivery until about 1-4
  hours later or until mother is stable
• Greatest danger is hemorrhage within 1st hour
  after delivery
• Nursing assessment performed every 15 minutes for
  at least 1 hour
• location firmness of fundus
• amount color of lochia
• pulse BP

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INITIAL CARE OF THE NEWBORN

• SUCTION MOUTH THEN NOSE
• KEEP WARM
• ASSESS CORD
• APGAR SCORE
• KEEP INFANT DRY
• IDENTIFICATION
• OBSERVE FOR ABNORMALITIES

• ENCOURAGE PARENT/NEWBORN BONDING
• WITHIN 1 HOUR
• PROPHYLACTIC EYE CARE
• VITAMIN K INJECTION

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THE APGAR SCORING SYSTEM TABLE 8-4

• COLOR
• HEART RATE
• RESPIRATORY EFFORT
• MUSCLE TONE
• REFLEX IRRITABILITY

• VALUE OF 0-2 IS GIVEN FOR EACH OBSERVATION
• GOOD 9-10
• ACROCYNOSIS BLUE HANDS FEET

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UMBILICAL CORD BANKING

• Traditionally collected only for babys blood
  type then discarded
• Contains stem cells
• Possibility of stem cell transplants
• Can be collected stored for future use if needed

• Cord blood collection procedure
• consent
• cleanse cord stump
• 70 80 ml blood collected prior to placenta
  being expelled
• sample transported to cord blood bank within
  48 hrs
• cryopreserved at -196 degrees Centigrade
• no expiration date

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EMERGENCY DELIVERY BY THE NURSE

• ALSO CALLED A PRECIPITATE DELIVERY CAN OCCUR
  WITH MULTIPARA, OXYTOCIN STIMULATION, PRETERM
• MAJOR CONCERNS
• REMAIN CALM HELPS MOTHER AND NURSE
• PROVIDE CLEANLINESSSTERILE GLOVES

• CONTROL BIRTH ENCOURAGE MOTHER TO OPEN MOUTH
  PANT TO KEEP FROM PUSHING
• APPLY GENTLE PRESSURE TO PERINEUM
• DELIVER HEAD BETWEEN CONTRACTIONS

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PRECIPITATE CONTD

• NEVER HOLD HEAD BACK TO PREVENT BIRTH!!!
• SUCTION MUCUS FROM MOUTH NOSE WITH BULB SYRINGE
• CK FOR NUCHAL CORDSLIP OVER HEAD OR CLAMP X2 AND
  CUT

• DELIVER ANTERIOR THEN POSTERIOR SHOULDERS
• REPEAT SUCTION AFTER REST OF BODY DELIVERED
• KEEP WARM
• DELIVER PLACENTA
• V/S Q 15 X 1 HR
• NOTIFY PHYSICIAN