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Nursing Interventions during the third stage of labor

Describing the process of placental separation to the couple • Instructing the woman to push when signs of separation are apparent • Administering an oxytocic agent if ordered and indicated after placental expulsion • Providing support and information about episiotomy and/or laceration • Cleaning and assisting client into a comfortable position after birth, making sure to lift both legs out of stirrups (if used) simultaneously to prevent strain • Repositioning the birthing bed to serve as a recovery bed if applicable • Assisting with transfer to the recovery area if applicable • Providing warmth by replacing warmed blankets over the woman • Applying an ice pack to the perineal area to provide comfort to episiotomy if indicated • Explaining what assessments will be carried out over the next hour and offering positive reinforcement for actions • Ascertaining any needs • Monitoring maternal physical status by assessing: - Vaginal bleeding: amount, consistency, and color - Vital signs: blood pressure, pulse, and respirations taken every 15 minutes - Uterine fundus, which should be firm, in the mid-line, and at the level of the umbilicus • Recording all birthing statistics and securing primary caregiver's signature • Documenting birthing event in the birth book (official record of the facility that outlines every birth event)

Category I

• Baseline rate (110-160 bpm) • Baseline variability moderate • Present or absent accelerations • Present or absent early decelerations • No late or variable decelerations

Continuous Labor Support

• Involves offering a sustained presence to the laboring woman by providing emotional support, comfort measures, advocacy, information and advice, and support for the partner • A woman's family, a midwife, a nurse, a doula, or anyone else close to the woman can provide this continuous presence.

Patient-Controlled Epidural Analgesia

• (PCEA) involves the use of an indwelling epidural catheter with an infusion of medication and a programmed pump that allows the woman to control the dosing. • PCEA provides equivalent analgesia with lower anesthetic use, lower rates of supplementation, and higher client satisfaction • This method allows her to manage her pain at will without having to ask a staff member to provide pain relief.

Pudendal Nerve Block

• *Marty said not to worry about this*

Combined Spinal-Epidural Analgesia

• *Marty said that they don't use this method anymore*

Fetal Assessment During Labor and Birth

• A fetal assessment identifies well-being or signs that indicate compromise. • The character of the amniotic fluid is assessed, but the fetal assessment focuses primarily on determining the FHR pattern.

Guidelines for recording care include documenting:

• All care rendered, to prove that standards were met • Conversations with all providers, including notification times • Nursing interventions before and after notifying provider • Use of the chain of command and response at each level • All flow sheets and forms, to validate care given • All education given to client and response to it • Facts, not personal opinions • detailed descriptions of any adverse outcome • Initial nursing assessment, all encounters, and discharge plan • All telephone conversations

Opioids

• All opioids are lipophilic and cross the placental barrier, but do not affect labor progress in the active phase • Other systemic side effects include nausea, vomiting, pruritus, delayed gastric emptying, drowsiness, hypoventilation, and newborn depression. • *To reduce the incidence of new-born depression, birth should occur within 1 hour or after 4 hours of administration to prevent the fetus from receiving the peak concentration*

Analysis of Amniotic fluid

• Amniotic fluid should be clear when the membranes rupture. • Cloudy or foul-smelling amniotic fluid indicates infection. • Green fluid may indicate that the fetus has passed meconium secondary to transient hypoxia, prolonged pregnancy, cord compression, intrauterine growth restriction (IUGR), maternal hypertension, diabetes, or chorioamnionitis; *however, it is considered a normal occurrence if the fetus is in a breech presentation.* • Sterile normal saline or Ringer's lactate solution into the uterus) is used to dilute moderate to heavy meconium released in utero to assist in preventing meconium aspiration syndrome.

Cultural Pain Experience

• Appalachian women believe that placing a hatchet or knife under the bed of a laboring woman may help "cut the pain of childbirth," and a woman from this back-ground may wish to do so in the hospital setting. • Asian, Latino, and Orthodox Jewish women may request that their own mothers, not their husbands, attend their births; husbands do not actively participate in the birthing process. • Cherokee, Hmong, and Japanese women will often remain quiet during labor and birth and not complain of pain because outwardly expressing pain is not appropriate in their cultures. Never interpret their quietness as freedom from pain

Maternal assessment during labor and birth

• Assess maternal vital signs, including temperature, blood pressure, pulse, respiration, and pain, which are primary components of the physical examination and ongoing assessment. • Also review the prenatal record to identify risk factors that may con-tribute to a decrease in uteroplacental circulation during labor.

APGAR

• Assess the newborn by assigning an Apgar score at 1 and 5 minutes. • The Apgar score assesses five parameters—heart rate (absent, slow, or fast), respiratory effort (absent, weak cry, or good strong yell), muscle tone (limp, or lively and active), response to irritation stimulus, and color—that evaluate a newborn's cardiorespiratory adaptation after birth. • The parameters are arranged from the most important (heart rate) to the least important (color). • The newborn is assigned a score of 0 to 2 in each of the five parameters. • The purpose of the Apgar assessment is to evaluate the physiologic status of the newborn

Continuing Assessment During the First Stage of Labor

• Assess the woman's knowledge, experience, and expectations of labor. • Typically, blood pressure, pulse, and respirations are assessed every hour during the latent phase of labor unless the clinical situation dictates that vital signs be taken more frequently. During the active and transition phases, they are assessed every 30 minutes. • The temperature is taken every 4 hours throughout the first stage of labor and every 2 hours after membranes have ruptured to detect an elevation indicating an ascending infection. • Uterine contractions are monitored for frequency, duration, and intensity every 30 to 60 minutes during the latent phase, every 15 to 30 minutes during the active phase, and every 15 minutes during transition. • When the fetal membranes rupture, spontaneously or artificially, assess the FHR and check the amniotic fluid for color, odor, and amount. Assess the FHR intermittently or continuously via electronic monitoring. During the latent phase of labor, assess the FHR every 30 to 60 minutes; in the active phase, assess FHR at least every 15 to 30 minutes.

Acupuncture and Accupressure

• Can be used to relieve pain during labor. • Acupuncture involves stimulating key trigger points with needles. • The purpose of acupuncture is to restore qi, thus diminishing pain. • Stimulating the trigger points causes the release of endorphins, reducing the perception of pain. • Acupressure involves the application of a firm finger or massage used in acupuncture to reduce the pain sensation. • Some acupressure points are found along the spine, neck, shoulder, toes, and soles of the feet.

Interpreting FHR Patterns

• Category I: normal (Predictive of normal fetal acid-base status) • Category II: indeterminate (Not predictive of abnormal fetal acid-base status) • Category III: abnormal (Predictive of abnormal fetus acid-base status)

Marked Variability

• Causes of this include cord prolapse or compression, maternal hypoten-sion, uterine hyperstimulation, and abruptio placenta. *Interventions* • determining the cause if possible, lateral positioning • increasing IV fluid rate • administering oxygen at 8 to 10 L/min by mask • discontinuing oxytocin infusion • observing for changes in tracing • considering internal fetal monitoring • communicating an abnormal pattern to the health care provider, and preparing for a surgical birth if no change in pattern is noted

Analysis of FHR

• FHR assessment can be done intermittently using a fetoscope (a modified stethoscope attached to a headpiece) or a Doppler (ultrasound) device, or continuously with an electronic fetal monitor applied externally or internally.

Category III

• Fetal bradycardia (<110 bpm) • Recurrent late decelerations • Recurrent variable decelerations • Sinusoidal pattern (smooth, undulating baseline)

Category II

• Fetal tachycardia (>160 bpm) present • Bradycardia (<110 bpm) not accompanied by absent baseline variability • Absent baseline variability not accompanied by recurrent decelerations • Minimal or marked variability • Recurrent late decelerations with moderate baseline variability • Recurrent variable decelerations accompanied by minimal or moderate baseline variability; overshoots, or shoulders • Prolonged decelerations >2 min but <10 min

Nursing Care During the First Stage of Labor

• Identifying the estimated date of birth from the client and the prenatal chart • Validating the client's prenatal history to determine fetal risk status • Determining fundal height to validate dates and fetal growth • Performing Leopold's maneuvers to determine fetal position, lie, and presentation • Checking FHR •Performing a vaginal examination (as appropriate) to evaluate effacement and dilation progress • Instructing the client and her partner about monitoring techniques and equipment • Assessing fetal response and FHR to contractions and recovery time • Interpreting fetal monitoring strips • Checking FHR baseline for accelerations, variability, and decelerations • Repositioning the client to obtain an optimal FHR pattern • Recognizing FHR problems and initiating corrective measures • Checking amniotic fluid for meconium staining, odor, and amount • Comforting client throughout testing period and labor • Documenting times of notification for team members if problems arise • Knowing appropriate interventions when abnormal FHR patterns present • Supporting the client's decisions regarding intervention or avoidance of intervention • Assessing the client's support system and coping status frequently

Pharmacological Measures

• Include systemic analgesia and regional or local anesthesia.

Assessment During Second Stage of Labor

• Increase in apprehension or irritability • Spontaneous rupture of membranes • Sudden appearance of sweat on upper lip • Increase in blood-tinged show • Low grunting sounds from the woman • Complaints of rectal and perineal pressure • Beginning of involuntary bearing-down efforts • Other ongoing assessments include the contraction frequency, duration, and intensity; maternal vital signs every 5 to 15 minutes; fetal response to labor as indicated by FHR monitor strips; amniotic fluid for color, odor, and amount when membranes are ruptured; and the woman and her partner's coping status • Associated signs include bulging of the perineum, labial separation, advancing and retreating of the newborn's head during and between bearing-down efforts, and crowning (fetal head is visible at vaginal opening • Pushing is appropriate if the cervix has fully dilated to 10 cm and the woman feels the urge to do so.

Moderate Variability

• Indicates that the autonomic and central nervous systems of the fetus are well developed and well oxygenated. • It is considered a good sign of fetal well-being and correlates with the absence of significant metabolic acidosis

Assessing FHR

• Initial 10- to 20-minute continuous FHR assessment on entry into labor/birth area • Completion of a prenatal and labor risk assessment on all clients • Intermittent auscultation every 30 minutes during active labor for a low-risk woman and every 15 minutes for a high-risk woman • During the second stage of labor, every 15 minutes for the low-risk woman and every 5 minutes for the high-risk woman and during the pushing stage.

Hydrotherapy

• Involve showering or soaking in a regular tub or whirl-pool bath • When the woman enters the warm water, the warmth and buoyancy help to release muscle tension and can impart a sense of well-being • Contractions are usually less painful in warm water because the warmth and buoyancy of the water have a relaxing effect. • hydrotherapy is more commonly practiced in birthing centers managed by midwives. • *Recommendation for initiating hydrotherapy is that the woman be in active labor (more than 5 cm dilated) to prevent the slowing of labor contractions secondary to muscular relaxation.* • The woman's membranes can be intact or ruptured. • potential risks associated with hydrotherapy including hyperthermia, hypothermia, changes in maternal heart rate, fetal tachycardia, and unplanned underwater birth.

Intermittent FHR Monitoring

• Involves auscultation via a fetoscope or a handheld Doppler device that uses ultra-sound waves that bounce off the fetal heart, producing echoes or clicks that reflect the rate of the fetal heart. • allows the woman to be mobile in the first stage of labor. • does not document how the fetus responds to the stress of labor (unless listening is done during the contraction). • can be used to detect FHR baseline and rhythm and changes from baseline. • it cannot detect variability and types of decelerations, as electronic fetal monitoring can.

Systemic Analgesia

• Involves the use of one or more drugs administered orally, intramuscularly, or intravenously • The most important complication associated with the use of this class of drugs is respiratory depression • *Opioids given close to the time of birth can cause CNS depression in the newborn, necessitating the administration of naloxone (Narcan) to reverse the depressant effects of the opioids.* Classes of drugs given include: • Opioids, such as butorphanol (Stadol), nalbuphine (Nubain), meperidine (Demerol), morphine, or fentanyl (Sublimaze) • Ataractics, such as hydroxyzine (Vistaril), prometha-zine (Phenergan), or prochlorperazine (Compazine) • Benzodiazepines, such as diazepam (Valium) or midazolam (Versed) • *Nearly all medications given during labor cross the placenta and have a depressant effect on the fetus*

Assessment during the third stage of labor

• Monitoring placental separation by looking for the following signs: - Firmly contracting uterus - Change in uterine shape from discoid to globular ovoid - Sudden gush of dark blood from vaginal opening - Lengthening of umbilical cord protruding from vagina • Examining placenta and fetal membranes for intactness the second time (the health care provider assesses the placenta for intactness the first time) • Assessing for any perineal trauma, such as the follow-ing, before allowing the birth attendant to leave: - Firm fundus with bright-red blood trickling: laceration - Boggy fundus with red blood flowing: uterine atony - Boggy fundus with dark blood and clots: retained placenta • Inspecting the perineum for condition of episiotomy, if performed • Assessing for perineal lacerations and ensuring repair by birth attendant

Assessing Uterine Contractions

• Normal uterine contractions have a contraction (systole) and a relaxation (diastole) phase. • Each contraction starts with a building up (increment), gradually reaching an acme (peak intensity), and then a letting down (decrement). • Uterine contractions with an intensity of 30 mm Hg or greater initiate cervical dilation. During active labor, the intensity usually reaches 50 to 80 mm Hg. Resting tone is normally between 5 and 10 mm Hg in early labor and between 12 and 18 mm Hg in active labor. • To palpate the fundus for contraction intensity, place the pads of your fingers on the fundus and describe how it feels: *like the tip of the nose (mild), like the chin (moderate), or like the forehead (strong).*

Interventions for Category III Fetal Patterns

• Notify the health care provider about the pattern and obtain further orders, making sure to document all interventions and their effects on the FHR pattern. ( this should be done after all other interventions) • Reduce or discontinue oxytocin or other uterotonic agent as dictated by the facility's protocol, if it is being administered. • Turn the client on her left or right lateral, knee-chest, or hands and knees to increase placental per-fusion or relieve cord compression. • Administer oxygen via nonrebreather face mask to increase fetal oxygenation. • Increase the IV fluid rate to improve intravascular volume and correct maternal hypotension. • Assess the client for any underlying contributing causes • Provide reassurance that interventions are to effect pattern change. • Modify pushing in the second stage of labor to improve fetal oxygenation. • Document any and all interventions and any changes in FHR patterns. • Prepare for an expeditious surgical birth if the pat-tern is not corrected in 30 minutes.

Immediate Care of the Newborn

• Once birth takes place, the newborn is placed under a radiant warmer, dried, assessed, wrapped in warmed blankets, and placed on the woman's abdomen for warmth and closeness. • Drying the newborn and providing warmth to prevent heat loss by evaporation is essential to help support thermoregulation and provide stimulation.

Nursing Interventions During the second stage of labor

• Providing continuous comfort measures such as mouth care, encouraging position changes, changing bed linen and underpads, and providing a quiet, focused environment • Instructing the woman on the following bearing-down positions and techniques: - Pushing only when she feels an urge to do so - Delaying pushing for up to 90 minutes after complete dilation - Using abdominal muscles when bearing down - Using short pushes of 6 to 7 seconds - Focusing attention on the perineal area to visualize the newborn - Relaxing and conserving energy between contractions - Pushing several times with each contraction - Pushing with an open glottis and slight exhalation • Continuing to monitor contraction and FHR patterns to identify problems • Providing brief, explicit directions throughout this stage • Continuing to provide psychosocial support by reassuring and coaching • Facilitating the upright position to encourage the fetus to descend • Continuing to assess blood pressure, pulse, respirations, uterine contractions, bearing-down efforts, FHR, and coping status of the client and her partner • Providing pain management if needed • Providing a continuous nursing presence • Offering praise for the client's efforts • Preparing for and assisting with delivery by: - Notifying the health care provider of the estimated time frame for birth - Preparing the delivery bed and positioning client - Preparing the perineal area according to the facility's protocol - Offering a mirror and adjusting it so the woman can watch the birth - Explaining all procedures and equipment to the client and her partner - Setting up delivery instruments needed while maintaining sterility - Receiving newborn and transporting him or her to a warming environment, or covering the newborn with a warmed blanket on the woman's abdomen - Providing initial care and assessment of the newborn

Nursing interventions for the fourth stage of labor

• Providing support and information to the woman regarding episiotomy repair and related pain relief and self-care measures • Applying an ice pack to the perineum to promote comfort and reduce swelling • Assisting with hygiene and perineal care; teaching the woman how to use the perineal bottle after each pad change and voiding; helping the woman into a new gown • Monitoring for return of sensation and ability to void (if regional anesthesia was used) • Encouraging the woman to void by ambulating to the bathroom, listening to running water, or pouring warm water over the perineal area with the peribottle • Monitoring vital signs and fundal and lochia status every 15 minutes and documenting them • Promoting comfort by offering analgesia for afterpains and warm blankets to reduce chilling • Offering fluids and nourishment if desired • Encouraging parent-infant attachment by providing privacy for the family • Being knowledgeable about and sensitive to typical cultural practices after birth • Assisting the mother to nurse, if she chooses, during the recovery period to promote uterine firmness (the release of oxytocin from the posterior pituitary gland stimulates uterine contractions) • Teaching the woman how to assess her fundus for firmness periodically and to massage it if it is boggy • Describing the lochia flow and normal parameters to observe for postpartum • Teaching safety techniques to prevent newborn abduction • Demonstrating the use of the portable sitz bath as a comfort measure for her perineum if she had a laceration or an episiotomy repair • Explaining comfort/hygiene measures and when to use them • Assisting with ambulation when getting out of bed for the first time • Providing information about the routine on the mother-baby unit or nursery for her stay • Observing for signs of early parent-infant attachment: fingertip touch to palm touch to enfolding of the infant

Maternal Health History

• Should include typical bio-graphical data such as the woman's name and age and the name of the delivering health care provider. • Other information that is collected includes the prenatal record data, including the estimated date of birth, a history of the current pregnancy, and the results of any laboratory and diagnostic tests, such as blood type, Rh status, and group B streptococcal status; past pregnancy and obstetric history; past health history and family history; prenatal education; list of medications; risk factors such as diabetes, hypertension, and use of tobacco, alcohol, or illicit drugs; reason for admission, such as labor, cesarean birth, or observation for a complication; history of potential domestic violence; history of previous preterm births; allergies; time of last food ingestion; method chosen for infant feeding; name of birth attendant and pediatrician; and pain management plan.

Vaginal Examination

• The purpose of performing a vaginal examination is to assess the amount of cervical dilation, the percentage of cervical effacement, and the fetal membrane status and to gather information on presentation, position, station, degree of fetal head flexion, and presence of fetal skull swelling or molding

Birth

• The second stage of labor ends with the birth of the newborn. • Once the woman is positioned for birth, cleanse the vulva and perineal areas. • Once the fetal head has emerged, the primary care provider explores the fetal neck to see if the umbilical cord is wrapped around it. • As soon as the head emerges, the health care provider suctions the newborn's mouth first (because the newborn is an obligate nose breather) and then the nares with a bulb syringe to prevent aspiration of mucus, amniotic fluid, or meconium • The umbilical cord is double-clamped and cut between the clamps. With the first cries of the newborn, the second stage of labor ends

Continuous External Fetal Monitoring

• The tocotransducer is placed over the uterine fundus in the area of greatest contractility to monitor uterine contractions. • The other ultrasound transducer records the baseline FHR, long-term variability, accelerations, and decelerations. • Can be used while the membranes are still intact and the cervix is not yet dilated, but also can be used with ruptured membranes and a dilating cervix. • measures the approximate duration and frequency of contractions, providing a permanent record of FHR. • Can restrict the mother's movements. •* It also cannot detect short-term variability.*

Nitriazine Test

• To confirm that membranes have ruptured, a sample of fluid is taken from the vagina via a Nitrazine swab to determine the fluid's pH. • Vaginal fluid is acidic, whereas amniotic fluid is alkaline and turns a Nitrazine swab blue.

HIV

• To reduce perinatal transmission, women who are HIV positive are given zidovudine (ZDV) (2 mg/kg IV over an hour, and then a mainte-nance infusion of 1 mg/kg per hour until birth) or a single 200-mg oral dose of nevirapine at the onset of labor; the newborn is given ZDV orally (2 mg/kg body weight every 6 hours) and should be continued for 6 weeks. • women who are infected with HIV and have plasma viral loads of more than 1,000 copies per milliliter be counseled regarding the benefits of elective cesarean birth • Additional interventions to reduce the transmission risk would include avoiding use of a scalp electrode for fetal monitoring or doing a scalp blood sampling for fetal pH, delaying amniotomy, encouraging formula feeding after birth, and avoiding invasive procedures such as forceps or vacuum-assisted devices.

Absent/Minimal Variability

• Typically is caused by fetal acidemia secondary to uteroplacental insufficiency, cord compression, a preterm fetus, maternal hypotension, uterine hyperstimulation, abruptio placenta, or a fetal dysrhythmia. *Interventions* • include lateral positioning of the mother • increasing the IV fluid rate to improve maternal circulation, • administering oxygen at 8 to 10 L/min by mask, • considering internal fetal monitoring, documenting findings, and reporting to the health care provider.

General Anesthesia

• Typically reserved for emergency cesarean births when there is not enough time to provide spinal or epidural anesthesia or if the woman has a contraindication to the use of regional anesthesia. • can be administered by IV injection, inhalation of anesthetic agents, or both. • Commonly, thiopental, a short-acting barbiturate, is given IV to produce unconsciousness. • followed by administration of a muscle relaxant. • After the woman is intubated, nitrous oxide and oxygen are administered. • A volatile halogenated agent may also be administered to produce amnesia. • *primary complication with general anesthesia is fetal depression, along with uterine relaxation and potential maternal vomiting and aspiration.* • Ensure that the woman is NPO and has a patent IV. • administer a nonparticulate (clear) oral antacid (e.g., Bicitra or sodium citrate) or a proton pump inhibitor (Protonix) as ordered to reduce gastric acidity. • Assist with placement of a wedge under the woman's right hip to displace the gravid uterus and prevent vena cava compression in the supine position.

Continuous Internal Fetal Monitoring

• Usually indicated for women or fetuses considered to be at high risk. • multiple gestation, decreased fetal movement, abnormal FHR on auscultation, IUGR, maternal fever, preeclampsia, dysfunctional labor, preterm birth, or medical conditions such as diabetes or hypertension. • Involves the placement of a spiral electrode into the fetal presenting part, usually the head, to assess FHR, and a pressure transducer placed internally within the uterus to record uterine contractions. • fetal spiral electrode is considered the most accurate method of detecting fetal heart characteristics and patterns. • Four specific criteria must be met for this type of monitoring to be used: 1.Ruptured membranes 2. Cervical dilation of at least 2 cm 3. Presenting fetal part low enough to allow placement of the scalp electrode 4. Skilled practitioner available to insert spiral electrode

Early Decelerations

• Visually apparent, usually symmetrical, and characterized by a gradual decrease in the FHR in which the nadir (lowest point) occurs at the peak of the contraction. • They rarely decrease more than 30 to 40 bpm below the baseline. • They are most often seen during the active stage of any normal labor, during pushing, crowning, or vacuum extraction. • *are not indicative of fetal distress and do not require intervention.*

Physical Examination

• typically includes a generalized assessment of the woman's body systems, including hydration status, vital signs, auscultation of heart and lung sounds, and measurement of height and weight. • Fundal height measurement • Uterine activity, including contraction frequency, duration, and intensity • Status of membranes (intact or ruptured) • Cervical dilation and degree of effacement • Fetal status, including heart rate, position, and station • Pain level

Rupture of Membranes

• When membranes rupture, the priority focus should be on assessing fetal heart rate (FHR) first to identify a deceleration, which might indicate cord compression secondary to cord prolapse. • Prolonged ruptured membranes increase the risk of infection as a result of ascending vaginal organisms for both mother and fetus. • *Signs of intrauterine infection to be alert for include maternal fever, fetal and maternal tachycardia, foul odor of vaginal discharge, and an in-crease in white blood cell count.*

Ambulation and Position Changes

• Women should be encouraged to take up whatever position they find most comfortable in the first stage of labor. • Changing position frequently (every 30 minutes or so)—sitting, walking, kneeling, standing, lying down, get-ting on hands and knees, and using a birthing ball—helps relieve pain • may help to speed labor by adding the benefits of gravity and changing the shape of the pelvis. • Swaying from side to side, rocking, or other rhythmic movements may also be comforting. • *Supine positions should be avoided, since they may interfere with labor progress and can cause compression of the vena cava and decrease blood return to the heart.*

Fetal Tachycardia

• a baseline FHR greater than 160 bpm that lasts for 10 minutes or longer • causes include fetal hypoxia, maternal fever, maternal dehydration, amnionitis, drugs (e.g., cocaine, amphetamines, nicotine), maternal hyperthyroidism, maternal anxiety, fetal anemia, prematurity, fetal infection, chronic hypoxemia, congenital anomalies, fetal heart failure, and fetal arrhythmias.

Perineal lacerations

• a first-degree laceration extends through the skin • a second-degree laceration extends through the muscles of the perineal body • a third-degree laceration continues through the anal sphincter muscle • a fourth-degree laceration also involves the anterior rectal wall. • Special attention needs to be paid to third- and fourth-degree lacerations to prevent fecal incontinence. • Risks for third- or fourth-degree lacerations included nulliparity, being Asian or Pacific Islander, increased birth weight of newborn, operative vaginal birth, episiotomy, and longer second stage of labor.

Group B Streptococcus

• a gram-positive organism that colonizes in the female genital tract and rec-tum and is present in 10% to 30% of all healthy women • women are asymptomatic carriers but can cause GBS disease of the newborn through vertical transmission during labor and horizontal transmission after birth. • Risk factors for GBS include maternal intrapartum fever, prolonged ruptured membranes (>12 to 18 hours), previous birth of an infected newborn, and GBS bacteriuria in the present pregnancy. • Maternal infections associated with GBS include acute chorioamnion-itis, endometritis, and urinary tract infection. • Neonatal clinical manifestations include pneumonia and sepsis. • Identified GBS carriers receive IV antibiotic prophylaxis (penicillin G or ampicillin) at the onset of labor or ruptured membranes.

Fern Test

• a sample of vaginal fluid is obtained, applied to a microscope slide, and allowed to dry. • Using a microscope, the slide is examined for a characteristic fern pattern that indicates the presence of amniotic fluid.

Episiotomy

• an incision made in the perineum to enlarge the vaginal outlet and theoretically to shorten the second stage of labor. • midline episiotomy is the most commonly used one in the United States because it can be eas-ily repaired and causes the least amount of pain

Baseline Fetal Heart Rate

• average FHR that occurs during a 10-minute segment that excludes periodic or episodic rate changes, such as tachycardia or bradycardia. • It is assessed when the woman has no contractions and the fetus is not experiencing episodic FHR changes. • *The normal baseline FHR ranges between 110 and 160 beats per minute (bpm)*

Nursing Management During the Fourth Stage of Labor

• begins after the placenta is expelled and lasts up to 4 hours after birth, during which time recovery takes place. • The focus of nursing management during the fourth stage of labor involves frequent close observation for hemorrhage, provision of comfort measures, and promotion of family attachment.

Assessment during the fourth stage of labor

• center on the woman's vital signs, status of the uterine fundus and perineal area, comfort level, lochia amount, and bladder status. • During the first hour after birth, vital signs are taken every 15 minutes, then every 30 minutes for the next hour if needed. • The woman's blood pressure should remain stable and within normal range after giving birth. • *A decrease may indicate uterine hemorrhage; an elevation might suggest preeclampsia.* • The pulse usually is typically slower (60 to 70 bpm) than during labor • An elevated pulse rate may be an early sign of blood loss. • Fever is indicative of dehydration (less than 100.4° F or 38° C) or infection (above 101° F) • Respiratory rate is usually between 16 and 24 breaths per minute and regular. • Assess fundal height, position, and firmness every 15 minutes during the first hour following birth. • the fundus should be firm (feels like the size and consistency of a grapefruit), located in the midline and below the umbilicus. If it is not firm (boggy), gently massage it until it is firm • *If the fundus is displaced to the right of the midline, suspect a full bladder as the cause.* • Assess the perineum, including the episiotomy if present, for possible hematoma formation. • Assess vaginal discharge (lochia) every 15 minutes for the first hour and every 30 minutes for the next hour. Palpate the fundus at the same time to ascertain its firmness and help to estimate the amount of vaginal discharge

Nonpharmalogical Measures During Labor

• continuous labor support • hydrotherapy • ambulation and position changes • acupuncture and acupressure • attention focusing and imagery • therapeutic touch and massage • breathing techniques • effleurage.

Baseline Variability

• defined as irregular fluctuations in the baseline fetal heart rate, which is measured as the amplitude of the peak to trough in bpm. • Variability is described in four categories as follows: 1. Absent: fluctuation range undetectable 2. Minimal: fluctuation range observed at <5 bpm 3. Moderate (normal): fluctuation range from 6 to 25 bpm 4. Marked:fluctuation range >25 bpm

Attention Focusing and Imagery

• use many of the senses and the mind to focus on stimuli. • The woman can focus on tactile stimuli such as touch, massage, or stroking • Visual stimuli might be any object in the room, or the woman can imagine the beach, a mountaintop, a happy memory • Breathing, relaxation, positive thinking, and posi-tive visualization work well for mothers in labor

Breathing Techniques

• effective in producing relaxation and pain relief through the use of distraction • Controlled breathing helps reduce the pain experienced by using stimulus-response conditioning. • Benefits of practicing patterned breathing include: 1. Breathing becomes an automatic response to pain. 2. Breathing increases relaxation and can be used for deal with life's everyday stresses. 3. The steady rhythm of breathing is calming during labor. 4. Breathing provides a sense of well-being and a measure of control. 5. Breathing brings purpose to each contraction, making them more productive. 6. Breathing provides more oxygen for the mother and fetus

Nursing Management During the Second Stage of Labor

• focuses on supporting the woman and her partner in making active decisions about her care and labor management, implementing strategies to prolong the early passive phase of fetal descent, supporting involuntary bearing-down efforts, providing instruction and assistance, and using maternal positions that can enhance descent and reduce pain

FHR

• heard most clearly at the fetal back. • In a cephalic presentation, the FHR is best heard in the lower quadrant of the maternal abdomen. • In a breech presentation, it is heard at or above the level of the maternal umbilicus • As labor progresses, the FHR location will change accordingly as the fetus descends into the maternal pelvis for the birthing process.

Spinal (Intrathecal) Analgesia/Anesthesia

• involves injection of an anesthetic "caine" agent, with or without opioids, into the subarachnoid space to provide pain relief during labor or cesarean birth. • Adverse reactions for the woman include hypotension and spinal headache. • A narcotic is injected into the subarachnoid space, providing rapid pain relief while still maintaining motor function and sensation. • An intrathecal narcotic is given during the active phase (more than 5 cm of dilation) of labor.

Epidural Analgesia

• involves the injection of a local anesthetic agent (e.g., lidocaine or bupivacaine) and an opioid analgesic agent (e.g., morphine or fentanyl) into the lumbar epidural space. • A small catheter is then passed through the epidural needle to provide continuous access to the epidural space for maintenance of analgesia throughout labor and birth. • The epidural space is typically entered through the third and fourth lumbar vertebrae with a needle, and a catheter is threaded into the epidural space. • Can be used for both vaginal and cesarean births. • pain relief is balanced against other goals such as walking during the first stage of labor, pushing effectively in the second stage, and minimizing maternal and fetal side effects. • contraindicated for women with a previous history of spinal surgery or spinal abnormalities, coagulation defects, infections, and hypovolemia. • Complications include nausea and vomiting, hypo-tension, fever, pruritus, intravascular injection, maternal fever, allergic reaction, and respiratory depression. Effects on the fetus during labor include fetal distress secondary to maternal hypotension

Local Infiltration

• involves the injection of a local anesthetic, such as lidocaine, into the superficial perineal nerves to numb the perineal area. • This technique is done by the physician or midwife just before performing an episiotomy or before suturing a laceration.

Application of Heat

• is typically applied to the woman's back, lower abdomen, groin, and/or perineum. • sources include a hot water bottle, heated rice-filled sock, warm com-press (washcloth soaked in warm water and wrung out), electric heating pad, warm blanket, and warm bath or shower. • used to relieve chills or trembling, decrease joint stiffness, reduce muscle spasm, and increase connective tissue extensibility

Assessing the Woman Upon Admission

• nurse should ascertain whether the woman is in true or false labor and whether she should be admitted or sent home. • *Upon admission to the labor and birth suite, the highest priorities include assessing FHR, assessing cervical dilation/effacement, and determining whether membranes have ruptured or are intact.* • Do not do phone triage, tell the patient to come in if she suspects labor.

Fetal Bradycardia

• occurs when the FHR is below 110 bpm and lasts 10 minutes or longer • Causes include fetal hypoxia, prolonged maternal hypoglycemia, fetal acidosis, administration of analgesic drugs to the mother, hypothermia, anesthetic agents (epidural), maternal hypotension, fetal hypothermia, prolonged umbilical cord compression, and fetal congenital heart block

Regional Analgesia/ Anesthesia

• provides pain relief with-out loss of consciousness • Obstetric regional analgesia generally refers to a partial or complete loss of pain sensation below the T8 to T10 level of the spinal cord • The routes for regional pain relief include epidural block, combined spinal-epidural, local infiltration, pudendal block, and intrathecal (spinal) analgesia/ anesthesia.

Nursing Management During the Third Stage of Labor

• strong uterine contractions continue at regular intervals under the continuing influence of oxytocin. • The uterine muscle fibers shorten, or retract, with each contraction, leading to a gradual decrease in the size of the uterus, which helps shear the placenta away from its attachment site. • The third stage is complete when the placenta is delivered. • Nursing care during the third stage of labor primarily focuses on immediate newborn care and assessment and being available to assist with the delivery of the placenta and inspecting it for intactness.

Fetal Decelerations

• transient fall in FHR caused by stimulation of the parasympathetic nervous system. • described by their shape and association to a uterine contraction. • They are classified as early, late and variable only

Fetal Accelerations

• transitory abrupt increases in the FHR above the baseline that last <30 seconds from onset to peak • They are visually apparent, with elevations of FHR of more than 15 bpm above the baseline, and their duration is >15 seconds, but less than 2 minutes • *denote fetal movement and fetal well-being and are the basis for nonstress testing.*

Laboratory Studies

• typically are done to establish a baseline. • Include a urinalysis via clean-catch urine specimen and complete blood count (CBC). Blood typing and Rh factor analysis may be necessary if the results of these are unknown or unavailable. • syphilis screening, hepatitis B (HbsAg) screening, group B streptococcus, HIV testing (if woman gives consent), and possible drug screening if the history is positive.

Therapeutic Touch and Massage

• use the sense of touch to promote relaxation and pain relief. Massage works as a form of pain relief by increasing the production of endorphins in the body. • Massage involves manipulation of the body's soft tissues. It is commonly used to help relax tense muscles and to soothe and calm the individual. • Therapeutic touch is an energy therapy and is based on the premise that the body contains energy fields that lead to either good or ill health and that the hands can be used to redirect the energy fields that lead to pain • *Contraindications for massage include skin rashes, varicose veins, bruises, or infections* • Effleurage is a light, stroking, superficial touch of the abdomen, in rhythm with breathing during contractions.

Benzodiazepenes

• used for minor tranquilizing and sedative effects • Lorazepam (Ativan) can also be used for its tranquilizing effect, but increased sedation is experienced with this medication • Midazolam (Versed), also given IV, produces good amnesia but no analgesia. • Diazepam and midazolam cause CNS depression for both the woman and the newborn.

Antiemetics

• used in combination with an opioid to decrease nausea and vomiting and lessen anxiety • They may also be used to increase sedation. • Promethazine (Phenergan) can be given IV, but hydroxyzine (Vistaril) must be given by mouth or by intramuscular injection into a large muscle mass.

Application of Cold

• usually applied on the woman's back, chest, and/or face during labor. • Forms include a bag or surgical glove filled with ice, a frozen gel pack, camper's "ice," a hollow, plastic rolling pin or bottle filled with ice, a washcloth dipped n cold water, soda cans chilled in ice, and even a frozen bag of vegetables. • has the additional effects of relieving muscle spasms and reducing inflammation and edema

Late Decelerations

• visually apparent, usually symmetrical, transitory decreases in FHR that occur after the peak of the contraction. • *associated with uteroplacental insufficiency* • Conditions include maternal hypotension, gestational hypertension, placental aging secondary to diabetes and postmaturity, hyperstimulation via oxytocin infusion, maternal smoking, anemia, and cardiac disease. They imply some degree of fetal hypoxia

Continuous Fetal Monitoring (EFM)

•uses a machine to produce a continuous tracing of the FHR. • When the monitoring device is in place, a sound is produced with each heartbeat. • a graphic record of the FHR pattern is produced. • *The primary objective of EFM is to provide information about fetal oxygenation and prevent fetal injury that could result from impaired fetal oxygenation during labor.* • using continuous monitoring can limit maternal movement and encourages the woman to lie in the supine position, which reduces placental perfusion. • Continuous electronic fetal monitoring can be performed externally (indirectly), with the equipment attached to the maternal abdominal wall, or internally (directly), with the equipment attached to the fetus.