PBL Care Scenario #2 "Anticipation and Baby Makes Five" Reading: "Chapter 14: Nursing Management During Labour and Birth pp. 409-448"

infection

Analysis of Amniotic Fluid • Amniotic fluid should be clear when the membranes rupture • Cloudy or foul smelling amniotic fluid indicates ______________ • Green fluid may indicate that the fetus has passed meconium secondary transient hypoxia; this is considered normal if the fetus is in a breech presentation o Maternity and pediatric teams work together to prevent meconium aspiration syndrome o Necessitate suctioning after birth if the Apgar score is low • In some cases, an amnioinfusion is used to dilute moderate to heavy meconium released in utero to assist in preventing meconium aspiration

160

Analysis of the FHR • Determining FHR Patterns o Baseline FHR ♣ Atypical Signs • Fetal tachycardia (>______ beats/min); lost variability o Considered ominous when accompanied by a decrease in variability and late decelerations • Absent beat-to-beat variability • Marked bradycardia (90-100 beats/min) o Can be ominous sign when accompanied by decrease in long-term variability and late deceleration • Moderate variable decelerations

110-160

Analysis of the FHR • Determining FHR Patterns o Baseline FHR ♣ Normal FHR Signs • Normal baseline (_____-_____ beats/min) • Moderate bradycardia (100-110 beats/min); good variability o Can be the initial response of a healthy fetus to aphyxia • Good beat-to-beat variability and fetal accelerations

variability

Analysis of the FHR • Determining FHR Patterns o Baseline FHR ♣ Abnormal Signs • Fetal tachycardia with loss of _____________ • Prolonged marked bradycardia (<90 beats/min) • Severe variable decelerations (<70 beats/min) • Persistent late decelerations

IV fluid

Analysis of the FHR • Determining FHR Patterns o Baseline Variability ♣ Determined in three ways: • Marked Variability o Occurs when there are more than 25 beats of fluctuation in the FHR baseline o Causes include cord prolapse or compression, maternal hypotension, uterine hyperstimulation, and abruptio placentae o Interventions include determining the cause, lateral positioning, increasing the ____ _________ 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 HCP, and preparing for possible surgical birth

lateral

Analysis of the FHR • Determining FHR Patterns o Baseline Variability ♣ Determined in three ways: • Minimal or Absent o Typically is caused by uteroplacental insufficiency, cord compression, maternal hypotension, uterine hyperstimulation, abruptio placentae, or fetal dysrhythmia o Interventions to improve uteroplacental blood flow and perfusion through the umbilical cord include ___________ positioning, of the mother, increasing IV fluid rate to improve maternal circulation, administering oxygen at 8 to 10 L/min by mask, considering reporting to the HCP o Prep for a surgical birth may be required

Moderate

Analysis of the FHR • Determining FHR Patterns o Baseline Variability ♣ Determined in three ways: • ______________ Variability o Indicates that the autonomic and central nervous systems of the fetus are well developed and well oxygenated o It is considered a good sign of fetal well-being and correlates with the absence of significant metabolic acidosis

time intervals

Analysis of the FHR • Determining FHR Patterns o Baseline Variability ♣ Defined as normal physiologic variations in the ___________ _________________ that elapse between each fetal heartbeat observed along the baseline in the absence of contractions, decelerations, and accelerations

intact

Analysis of the FHR • FHR assessment can be done intermittently using a fetoscope or a Doppler (ultrasound) deice, or continuously with an electronic fetal monitor applied internally or externally o Continuous Electronic Fetal Monitoring (Cardiotocography or CTG) ♣ Uses external monitor to record changes in the FHR with an aim to identify babies who may be short of oxygen ♣ Produces sound and visual graphic record of the FHR pattern ♣ More precise because it also monitors the mother's contractions ♣ Purpose is to identify fetal hypoxemia and academia in order to allow early intervention in an effort to prevent fetal morbidity and mortality ♣ SOGC guidelines state that women with risk factors for adverse perinatal outcomes should receive EFM ♣ The use increased use of EFM has be known to be associated with steadily increased rates of cesarean births in Canada ♣ With EFM, there is a continuous record of the FHR: no gaps exist, as they do with intermittent FHR • This has a downside as it encourages the mother to lie still in a supine position, which reduces placental perfusion ♣ Continuous External Monitoring • Two ultrasounds transducers, each of which is attached to a belt, are applied around the woman's abdomen • Good continuous data are provided on the FHR • Can be used while the membranes are still __________ and the cervix is not yet dilated • Can detect relative changes in abdominal pressure between uterine resting tone and contractions • Also measure the approximate duration and frequency of contractions • Can restrict the mothers movements • Signal disruption can occur • Artefact describes irregular variations or the absence of FHR on the fetal monitor record that result from mechanical limitations for the monitor or electrical interference ♣ Continuous Internal Monitoring • Usually indicated for women or fetuses considered to be at high risk • Possible conditions might include multiple gestation, decreased fetal movement, abnormal FHR on auscultation, intrauterine growth restriction (IUGR), maternal fever, pre-eclampsia, dysfunctional labour, preterm birth, or medical conditions such as diabetes or hypertension • Fetal spiral electrode is placed, considered the most accurate method of detecting fetal heart characteristics and patterns because it involves receiving a signal directly from the fetus • Both FHR and the duration and interval of uterine contractions are recorded on the graph paper • Four specific criteria must be met for this type of monitoring to be used: o Ruptured membranes o Cervical dilation of at least 2 cm o Presenting fetal part low enough to identify correctly and allow placement of the scalp electrode o Skilled practitioner available to insert spiral electrode • Can detect both short-term changes and long-term variations as well as FHR dysrhythmias • Maternal position changes and movement do not interfere with the quality of tracing

dilation

Analysis of the FHR • FHR assessment can be done intermittently using a fetoscope or a Doppler (ultrasound) deice, or continuously with an electronic fetal monitor applied internally or externally o Continuous Electronic Fetal Monitoring (Cardiotocography or CTG) ♣ Uses external monitor to record changes in the FHR with an aim to identify babies who may be short of oxygen ♣ Produces sound and visual graphic record of the FHR pattern ♣ More precise because it also monitors the mother's contractions ♣ Purpose is to identify fetal hypoxemia and academia in order to allow early intervention in an effort to prevent fetal morbidity and mortality ♣ SOGC guidelines state that women with risk factors for adverse perinatal outcomes should receive EFM ♣ The use increased use of EFM has be known to be associated with steadily increased rates of cesarean births in Canada ♣ With EFM, there is a continuous record of the FHR: no gaps exist, as they do with intermittent FHR • This has a downside as it encourages the mother to lie still in a supine position, which reduces placental perfusion ♣ Continuous External Monitoring • Two ultrasounds transducers, each of which is attached to a belt, are applied around the woman's abdomen • Good continuous data are provided on the FHR • Can be used while the membranes are still intact and the cervix is not yet dilated • Can detect relative changes in abdominal pressure between uterine resting tone and contractions • Also measure the approximate duration and frequency of contractions • Can restrict the mothers movements • Signal disruption can occur • Artefact describes irregular variations or the absence of FHR on the fetal monitor record that result from mechanical limitations for the monitor or electrical interference ♣ Continuous Internal Monitoring • Usually indicated for women or fetuses considered to be at high risk • Possible conditions might include multiple gestation, decreased fetal movement, abnormal FHR on auscultation, intrauterine growth restriction (IUGR), maternal fever, pre-eclampsia, dysfunctional labour, preterm birth, or medical conditions such as diabetes or hypertension • Fetal spiral electrode is placed, considered the most accurate method of detecting fetal heart characteristics and patterns because it involves receiving a signal directly from the fetus • Both FHR and the duration and interval of uterine contractions are recorded on the graph paper • Four specific criteria must be met for this type of monitoring to be used: o Ruptured membranes o Cervical ____________ of at least 2 cm o Presenting fetal part low enough to identify correctly and allow placement of the scalp electrode o Skilled practitioner available to insert spiral electrode • Can detect both short-term changes and long-term variations as well as FHR dysrhythmias • Maternal position changes and movement do not interfere with the quality of tracing

cervical dilation

Maternal Assessment During Labour and Birth • Assess maternal vital signs, including temperature, blood pressure, pulse, respiration, and pain • Review the prenatal record to identify risk factors that may contribute to a decrease in uteroplacental circulation during labour • If there is no vaginal bleeding on admission, a vaginal examination is performed to assess ______________ _____________ • Evaluate maternal pain and the effectiveness of pain management strategies at regular intervals during labour and birth

lochia

Nursing Care During Labour and Birth • Nursing Management During the Fourth Stage of Labour o Assessment ♣ Assess vaginal discharge (__________) 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

lochia

Nursing Care During Labour and Birth • Nursing Management During the Fourth Stage of Labour o Assessment ♣ Assessments during the fourth stage centre on the woman's vital signs, status of the uterine fundus and perineal area, comfort level, __________ amount, and bladder status

presentation

Performing Leopold's Manoeuvres • Steps o 4. Perform the third manoeuvre to confirm ___________________ ♣ a. Move hands down the sides of the abdomen to grasp the lower uterine segment and palpate the area just above the symphysis pubis ♣ b. Place thumb and fingers of one hand apart and grasp the presenting part by bringing fingers together ♣ c. Feel for the presenting part. If the presenting part is the head, it will be round, firm, and ballottable; if it is the buttocks, it will feel soft and irregular

attitude

o 5. Perform the fourth manoeuvre to determine ____________. ♣ a. Turn to face the client's feet and use the tips of the first three finger of each hand to palpate the abdomen ♣ b. Move fingers toward each other while applying downward pressure in the direction of the symphysis pubis. If you palpate a hard area on the side opposite the fetal back, the fetus in flexion, because you have palpated the chin. If the hard area is on the same side as the back, the fetus is in extension, because the area palpated is the occiput

5

Analysis of the FHR • FHR assessment can be done intermittently using a fetoscope or a Doppler (ultrasound) deice, or continuously with an electronic fetal monitor applied internally or externally o Intermittent FHR Monitoring ♣ Involves using a fetoscope or a hand held Doppler device that uses ultrasound waves that bounce off the fetal heart, producing echoes or clicks that reflects the rate of the fetal heart ♣ Intermittent FHR allows the mother to move around but does not provide continuous FHR recording and does not document how the fetus responds to the stress of labour ♣ Best way is to listen to FHR at the end of a contraction (not after one) so that late decelerations can be detected ♣ Can be used to detect FHR baseline and rhythm and changes fram baseline ♣ First assessment is for a minute after contraction, then 30 seconds on subsequent assessments ♣ If a woman experiences a change in condition during labour, auscultation assessments should be more frequent ♣ Should also be checked after any invasive procedure, rupture of membranes, vaginal examinations, and administration of meds ♣ To ensure that the maternal heart rate is not confused with the FHR, palpate the client's radial pulse simultaneously while the FHR is being auscultated through the abdomen ♣ Procedure for using fetoscope or Doppler device to assess FHR is similar • The main difference is that a small amount of water-soluble gel is applied to the woman's abdomen or ultrasound device before auscultation with the Doppler device to promote sound wave transition ♣ Intermittent FHR Guidelines from the SOGC • Admission fetal hear tracings are not recommended for healthy women at term in labour in the absence of risk factors for adverse perinatal outcome, as there is no evident benefit • Intensive fetal surveillance by intermittent auscultation or EFM requires the continuous presence of nursing or midwifery staff o Assess FHR on admission and every hour in the latent phase of the first stage of labour o Assess FHR every 15 to 30 minutes during the active phase of the first stage of labour o Assess FHR every ___ minutes during the active second stage of labour

palpation

Assessing Uterine Contractions • Primary power of labour that is involuntary • Normal uterine contractions have a contraction and then relaxation period o Contraction resembles a wave • Starts with building up (increment), gradually reaching an acme (peak intensity), and then a letting down (decrement) • Monitored by _____________ or external fetal monitoring • Assessment includes frequency, duration, intensity, and uterine resting tone • 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) • Subjective judgement of the indentibility of the uterine wall; a descriptive term assigned (mild, moderate, or strong) • Electronic fetal monitoring can be done either externally or internally, internal is more accurate o For women at risk for preterm birth, home uterine activity monitoring can be used to screen for prelabour uterine contractility so that escalating contractility can be identified, allowing earlier intervention to prevent preterm birth o Uterine activity usually recorded by the woman for 1 hour twice daily

Electronic fetal monitoring

Assessing Uterine Contractions • Primary power of labour that is involuntary • Normal uterine contractions have a contraction and then relaxation period o Contraction resembles a wave • Starts with building up (increment), gradually reaching an acme (peak intensity), and then a letting down (decrement) • Monitored by palpation or external fetal monitoring • Assessment includes frequency, duration, intensity, and uterine resting tone • 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) • Subjective judgement of the indentibility of the uterine wall; a descriptive term assigned (mild, moderate, or strong) • _______________ ____________ ________________ can be done either externally or internally, internal is more accurate o For women at risk for preterm birth, home uterine activity monitoring can be used to screen for prelabour uterine contractility so that escalating contractility can be identified, allowing earlier intervention to prevent preterm birth o Uterine activity usually recorded by the woman for 1 hour twice daily

antiseptic

Maternal Assessment During Labour and Birth • Vaginal Examination o Purpose 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 o Woman is typically lying on her back o Performed gently with concern for comfort o If it is the initial vaginal examination to check for membrane status, water is used as a lubricant o If the membranes have already ruptured, an _____________ solution is used to prevent an ascending infection o After donning sterile gloves, the examiner inserts his or her index and middle fingers into the vaginal introitus o Next, the cervix is palpated to assess dilation, effacement, and position (e.g. posterior or anterior) o If the cervix is open to any degree, the presenting fetal part, fetal position, station, and presence of molding can be assessed o In addition, the membranes can be evaluated and described as intact, bulging, or ruptured o Patient and/or partner updated at end, and documentation completed

width/length

Maternal Assessment During Labour and Birth • Vaginal Examination ♣ Cervical Dilation and Effacement • The ___________ of the cervical opening determines dilation, and the ___________ of the cervix assesses effacement • The information yielded by this examination serves as a basis for determining which stage of labour the woman is in and what her ongoing care should be

Station

Maternal Assessment During Labour and Birth • Vaginal Examination ♣ Fetal Descent and Fetal Presenting Part • During the vaginal examination, the gloved index finger is used to palpate the fetal skull through the opened cervix or the buttocks in the case of a breech position • ____________ is assessed in relation to the maternal ischial spines and the presenting fetal part • The ischial spines serve as landmarks and have been designated as zero ____________ • If the presenting part is palpated higher than the maternal ischial spines, a negative number is assigned; if the presenting fetal part is felt below the maternal ischial spines, a plus number is assigned, denoting how many centimeters below zero ____________ • Progressive fetal descent is the expected norm during labour - moving downward from the negative ____________ to zero ____________ to the positive stations in a timely manner • If progressive fetal descent does not occur, a disproportion between the maternal pelvis and the fetus might exist and needs to be investigated

fetal heart rate (FHR)

Maternal Assessment During Labour and Birth ♣ Rupture of Membranes • If intact, the membrane will be felt as a soft bulge that is more prominent during a contraction • If the membranes have ruptured, the woman may have reported a sudden gush or slow trickle of fluid • If membranes rupture the priority assessment should be __________ ___________ __________ (_______) to identify a deceleration, which might indicate cord compression secondary to cord collapse • Important to ascertain when they ruptured o Prolonged ruptured membrane can increase risk of infection o Signs include maternal fever, fetal and maternal tachycardia, foul odour of vaginal discharge, and an increase in white blood cell count • To conform membrane rupture a sample of fluid is taken from the vagina and tested with nitrazine paper to determine the fluid's pH o Vaginal fluid is acidic while amniotic fluid is alkaline o Membranes are most likely intact if the paper remains yellow to olive green o The membranes are probably ruptured if the paper turns a blue-green to deep blue • If paper test is inconclusive a fern test can be ordered o A sample of fluid is obtained and assessed with a microscope to examine a characteristic fern pattern that indicates the presence of amniotic fluid

acidic/alkaline

Maternal Assessment During Labour and Birth ♣ Rupture of Membranes • If intact, the membrane will be felt as a soft bulge that is more prominent during a contraction • If the membranes have ruptured, the woman may have reported a sudden gush or slow trickle of fluid • If membranes rupture the priority assessment should be fetal heart rate (FHR) to identify a deceleration, which might indicate cord compression secondary to cord collapse • Important to ascertain when they ruptured o Prolonged ruptured membrane can increase risk of infection o Signs include maternal fever, fetal and maternal tachycardia, foul odour of vaginal discharge, and an increase in white blood cell count • To conform membrane rupture a sample of fluid is taken from the vagina and tested with nitrazine paper to determine the fluid's pH o Vaginal fluid is __________ while amniotic fluid is ____________ o Membranes are most likely intact if the paper remains yellow to olive green o The membranes are probably ruptured if the paper turns a blue-green to deep blue • If paper test is inconclusive a fern test can be ordered o A sample of fluid is obtained and assessed with a microscope to examine a characteristic fern pattern that indicates the presence of amniotic fluid

Prolonged

Maternal Assessment During Labour and Birth ♣ Rupture of Membranes • If intact, the membrane will be felt as a soft bulge that is more prominent during a contraction • If the membranes have ruptured, the woman may have reported a sudden gush or slow trickle of fluid • If membranes rupture the priority assessment should be fetal heart rate (FHR) to identify a deceleration, which might indicate cord compression secondary to cord collapse • Important to ascertain when they ruptured o ________________ ruptured membrane can increase risk of infection o Signs include maternal fever, fetal and maternal tachycardia, foul odour of vaginal discharge, and an increase in white blood cell count • To conform membrane rupture a sample of fluid is taken from the vagina and tested with nitrazine paper to determine the fluid's pH o Vaginal fluid is acidic while amniotic fluid is alkaline o Membranes are most likely intact if the paper remains yellow to olive green o The membranes are probably ruptured if the paper turns a blue-green to deep blue • If paper test is inconclusive a fern test can be ordered o A sample of fluid is obtained and assessed with a microscope to examine a characteristic fern pattern that indicates the presence of amniotic fluid

cleansing

Nursing Care During Labour and Birth • Nursing Care During the First Stage of Labour o As the woman progresses through the first stage of labour, nursing interventions include: ♣ Encouraging the woman's partner to participate ♣ Keeping the woman and her partner up to date on the progress of labour ♣ Orienting the woman and her partner to the labour and birth unit and explaining all of the birthing procedures ♣ Providing clear fluids (e.g. ice chips) as needed or requested ♣ Maintaining the woman's parenteral fluid intake at the prescribed rate if she has an IV ♣ Initiating or encouraging comfort measures, such as backrubs, cool cloths to the forehead, frequent position changes, ambulation, showers, slow dancing, leaning over a birth ball, sidelying, or counterpressure on lower back ♣ Encouraging the partner's involvement with breathing techniques ♣ Assisting the woman and her partner to focus on breathing techniques ♣ Informing the woman that the discomfort will be intermittent and of limited duration; urging her to rest between contractions to preserve her strength; and encouraging her to use distracting activities to lessen the focus on contractions ♣ Changing bed linens and gown as needed ♣ Keeping the perineal area clean and dry ♣ Supporting the woman's decision about pain management ♣ Monitoring maternal vital signs frequently and reporting any abnormal values ♣ Ensuring that the woman takes deep __________________ breaths before and after each contraction to enhance gas exchange and oxygen to the fetus ♣ Educating the woman and her partner about the need for rest and helping them plan strategies to conserve strength ♣ Monitoring FHR for baseline, accelerations, variability, and decelerations ♣ Checking on bladder status and encouraging voiding at least every 2 hours to make room for birth ♣ Repositioning the woman as needed to obtain optimal heat rate pattern ♣ Communicating requests from the woman to appropriate personnel ♣ Respecting the woman's sense of privacy by covering her when appropriate ♣ Offering human presence by being present with the woman, not leaving her alone for long periods ♣ Being patient with the natural labour pattern to allow time for change ♣ Reporting any deviations from normal to the health care professional so that interventions can be initiated early to be effective

FHR

Nursing Care During Labour and Birth • Nursing Care During the First Stage of Labour o Key Nursing Interventions: ♣ Identifying the estimated date of birth from the client and prenatal chart ♣ Validating the client's prenatal history to determine fetal risk status ♣ Determining fundal height to validate dates and fetal growth ♣ Performing a vaginal examination (as appropriate) to evaluate effacement and dilation progress ♣ Performing Leopold's manoeuvers to determine fetal position, lie, and presentation ♣ Checking _______ ♣ Instructing the client and her partner about monitoring techniques and equipment ♣ Assessing fetal response and _______ against contractions and recovery time ♣ Interpreting fetal monitoring strips ♣ Checking _______ baseline for accelerations, variability and decelerations ♣ Repositioning the client to obtain an optimal _______ pattern ♣ Recognizing _______ problems and initiating corrective measures ♣ Checking amniotic fluid for meconium staining, odour and amount ♣ Comforting the client throughout the testing period and labour ♣ Supporting the client's decisions regarding intervention or avoidance of intervention ♣ Assessing the client's support system and coping status frequently

touch/tech

Nursing Care During Labour and Birth • Nursing Care During the First Stage of Labour o The nurse will provide high-__________, low-________ supportive nursing care during the first stage of labour when admitting the woman and orienting her to the labour and birth suite o Nursing car during this stage will include taking an admission history (reviewing prenatal record); checking the results of routine laboratory tests and any special tests such as chorionic villi sampling, genetic studies, and biophysical profile done during pregnancy; asking the woman about her childbirth preparation (birth plan, classes taken, coping skills); and completing a physical assessment of the woman to establish baseline of values for future comparison

group B streptococcus (GBS)

Nursing Care During Labour and Birth • Nursing Care During the First Stage of Labour • Assessing the Woman Upon Admission ♣ Laboratory Studies • Tests include urinalysis via clean-catch urine specimen and complete blood count (CBC) • Blood typing an Rh factor analysis may be necessary if the results of these are unknown • May be necessary to perform syphilis screening, hepatitis B surface antigen (HBsAg) screening, ____________ ____ _________________ (______) testing, human immunodeficiency virus (HIV) testing (if the woman gives consent), and possible drug screening if the history is positive • ______ is a gram-positive organism that is present and the vaginal and gastrointestinal tract of 15% to 45% of women o These woman are asymptomatic carriers but can cause ______ disease of the newborn through vertical transmission o Risk factors for ______ include maternal intrapartum fever, prolonged ruptured membranes, previous birth of an infected newborn, and ______ bacteriuria in the present pregnancy o SOGC issued guidelines that advised universal screening of pregnant women at 35 to 37 weeks' gestation for ______ and intrapartum antibiotic therapy for ______ carriers o Identified ______ carriers receive IV antibiotic prophylaxis (penicillin G or ampicillin) at the onset of labour or when membranes rupture • The SOGC recommends elective cesarean section at 38 weeks for HIV-positive women who meet one of the following criteria: women who have not received any anti-retroviral therapy, women receiving anti-retroviral monotherapy regardless of the viral load, women with detectable viral load regardless of the amount of therapy they have received, women with unknown viral load status, and woman who have received no prenatal care

Rh factor

Nursing Care During Labour and Birth • Nursing Care During the First Stage of Labour • Assessing the Woman Upon Admission ♣ Laboratory Studies • Tests include urinalysis via clean-catch urine specimen and complete blood count (CBC) • Blood typing an _____ ___________ analysis may be necessary if the results of these are unknown • May be necessary to perform syphilis screening, hepatitis B surface antigen (HBsAg) screening, group B streptococcus (GBS) testing, human immunodeficiency virus (HIV) testing (if the woman gives consent), and possible drug screening if the history is positive • GBS is a gram-positive organism that is present and the vaginal and gastrointestinal tract of 15% to 45% of women o These woman are asymptomatic carriers but can cause GBS disease of the newborn through vertical transmission o Risk factors for GBS include maternal intrapartum fever, prolonged ruptured membranes, previous birth of an infected newborn, and GBS bacteriuria in the present pregnancy o SOGC issued guidelines that advised universal screening of pregnant women at 35 to 37 weeks' gestation for GBS and intrapartum antibiotic therapy for GBS carriers o Identified GBS carriers receive IV antibiotic prophylaxis (penicillin G or ampicillin) at the onset of labour or when membranes rupture • The SOGC recommends elective cesarean section at 38 weeks for HIV-positive women who meet one of the following criteria: women who have not received any anti-retroviral therapy, women receiving anti-retroviral monotherapy regardless of the viral load, women with detectable viral load regardless of the amount of therapy they have received, women with unknown viral load status, and woman who have received no prenatal care

massage

Nursing Care During Labour and Birth • Nursing Management During the Fourth Stage of Labour o Assessment ♣ Assess fundal height, position, and firmness every 15 minutes during the first hour following birth • The fundus needs to remain firm to prevent excessive post-partum bleeding • The fundus should be firm, located in the midline and below the umbilicus • If it is not firm (boggy) gently ______________ it until it is firm and once firmness is obtained, stop massaging

height

Nursing Care During Labour and Birth • Nursing Care During the First Stage of Labour • Assessing the Woman Upon Admission ♣ 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 • The physical examination also includes the following assessments: o Fundal ____________ measurement o Uterine activity, including contraction frequency, duration and intensity o Status of membranes (intact or ruptured) o Cervical dilation and degree of effacement o Fetal status, including heart rate, position, and station o Pain level • These findings should be similar to those of the woman's prepregnancy and pregnancy findings, with exception of her pulse rate, which might be elevated secondary to her anxious state with beginning labour

frequency/duration/intensity

Nursing Care During Labour and Birth • Nursing Care During the First Stage of Labour • Assessing the Woman Upon Admission ♣ 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 • The physical examination also includes the following assessments: o Fundal height measurement o Uterine activity, including contraction ________________, _____________ and _____________ o Status of membranes (intact or ruptured) o Cervical dilation and degree of effacement o Fetal status, including heart rate, position, and station o Pain level • These findings should be similar to those of the woman's prepregnancy and pregnancy findings, with exception of her pulse rate, which might be elevated secondary to her anxious state with beginning labour

ruptured/intact

Nursing Care During Labour and Birth • Nursing Care During the First Stage of Labour • Assessing the Woman Upon Admission o It is important to ascertain whether the woman is in true or false labour and whether she should be admitted or sent home o Upon admission to the birth suite, the highest priorities include assessing FHR, assessing cervical dilation/effacement, and determining whether membranes have _______________ or are ___________ o If the initial contact is by phone, establish a therapeutic relationship with the woman

Prenatal

Nursing Care During Labour and Birth • Nursing Care During the First Stage of Labour • Assessing the Woman Upon Admission ♣ Maternal Health History • Should include typical biographical data such as the woman's name and age, and the name of the delivering health care provider • Other information includes: o _____________ record, including estimated date of birth, a history of current pregnancy, and the results of any laboratory and diagnostic tests, such as blood type, Rh status, and group B streptococcal status o Past pregnancy and obstetric history o List of medications o Risk factors such as diabetes, hypertensions, and use of tobacco, alcohol or illicit drugs o Reason for admission, such as labour, cesarean birth, or observations for a complication o History of potential domestic violence o History of previous pattern births o Allergies o Time of last food ingestion o Method chosen for infant feeding o Name of birth attendant and pediatrician o Pain management plan

amniotic fluid

Nursing Care During Labour and Birth • Nursing Care During the First Stage of Labour • Continuing Assessment During the First Stage of Labour o Assess the woman's knowledge, experience and expectations of labour o Typically, blood pressure, pulse, and respirations are assessed every hour during the latent phase of labour 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 labour unless the clinical situation dictates more frequent measurement (maternal fever) o Vaginal examinations are performed periodically to track labour progress ♣ The assessment information is shard with the woman to reinforce that she is making progress towards the goal of birth ♣ Uterine contractions are monitored for frequency, duration, and intensity every 30 to 60 minutes during the latent phase, and every 15 minutes during transition ♣ Note the changes in the character of the contractions as labour progresses, and inform the woman of her progress o Continually determine the woman's level of pain and her ability to cope and use relaxation techniques effectively o When the fetal membranes rupture, assess the FHR and check the _____________ __________ for colour, odour, and amount ♣ During the latent phase of labour, assess the FHR every 30 to 60 minutes; in the active phase, assess FHR at least every 15 to 30 minutes ♣ Also be sure to assess FHR before ambulation, prior to any procedure, and before administering analgesia or anesthesia to the mother

30

Nursing Care During Labour and Birth • Nursing Care During the First Stage of Labour • Continuing Assessment During the First Stage of Labour o Assess the woman's knowledge, experience and expectations of labour o Typically, blood pressure, pulse, and respirations are assessed every hour during the latent phase of labour unless the clinical situation dictates that vital signs be taken more frequently ♣ During the active and transition phases, they are assessed every ____ minutes ♣ The temperature is taken every 4 hours throughout the first stage of labour unless the clinical situation dictates more frequent measurement (maternal fever) o Vaginal examinations are performed periodically to track labour progress ♣ The assessment information is shard with the woman to reinforce that she is making progress towards the goal of birth ♣ Uterine contractions are monitored for frequency, duration, and intensity every 30 to 60 minutes during the latent phase, and every 15 minutes during transition ♣ Note the changes in the character of the contractions as labour progresses, and inform the woman of her progress o Continually determine the woman's level of pain ad her ability to cope and use relaxation techniques effectively o When the fetal membranes rupture, assess the FHR and check the amniotic fluid for colour, odour, and amount ♣ During the latent phase of labour, assess the FHR every 30 to 60 minutes; in the active phase, assess FHR at least every 15 to 30 minutes ♣ Also be sure to assess FHR before ambulation, prior to any procedure, and before administering analgesia or anesthesia to the mother

FHR

Nursing Care During Labour and Birth • Nursing Care During the First Stage of Labour • Nursing Interventions During the Admission Process o Nursing interventions during the admission process should include: ♣ Assessing the client's expectations of the birthing process ♣ Providing information about labour, birth, pain-management options, and relaxation techniques ♣ Presenting information about fetal monitoring equipment and the procedures needed ♣ Monitoring _______ and identifying patterns that need further intervention ♣ Monitoring the mother's vital signs to obtain a baseline for later comparison ♣ Reassuring the client that her labour progress will be monitored closely and nursing care will focus on ensuing fetal and maternal well-being throughout

slower

Nursing Care During Labour and Birth • Nursing Management During the Fourth Stage of Labour o Assessment ♣ 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 BP should remain stable and within normal range after giving birth • A decrease may indicate uterine hemorrhage; an elevation might suggest pre-eclampsia ♣ The pulse is typically ___________ (60 to 70 BPM) than during labour • This may be associated with a decrease in blood volume following placental separation • An elevated pulse rate may be an early sign of blood loss ♣ Fever is indicative of dehydration (<38C) or infection (>38.3C), which may involve the genitourinary tract ♣ Respiratory rate is usually between 16 and 24 breaths per minute and regular • Reparations should be unlaboured unless there is an underlying pre-existing respiratory condition

dehydration/infection

Nursing Care During Labour and Birth • Nursing Management During the Fourth Stage of Labour o Assessment ♣ 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 BP should remain stable and within normal range after giving birth • A decrease may indicate uterine hemorrhage; an elevation might suggest pre-eclampsia ♣ The pulse is typically slower (60 to 70 BPM) than during labour • This may be associated with a decrease in blood volume following placental separation • An elevated pulse rate may be an early sign of blood loss ♣ Fever is indicative of _________________ (<38C) or _____________ (>38.3C), which may involve the genitourinary tract ♣ Respiratory rate is usually between 16 and 24 breaths per minute and regular • Reparations should be unlaboured unless there is an underlying pre-existing respiratory condition

bladder

Nursing Care During Labour and Birth • Nursing Management During the Fourth Stage of Labour o Assessment ♣ In addition palpate the ____________ for fullness, since many women receiving an epidural block experience limited sensation in the ____________ region • Voiding should produce large amounts of urine (diuresis) each time • Palpation of the woman's ____________ after each voiding helps to ensure complete emptying • A full ____________ will displace the uterus to either side of the midline and potentiate uterine hemorrhage secondary to bogginess

hematoma

Nursing Care During Labour and Birth • Nursing Management During the Fourth Stage of Labour o Assessment ♣ The vagina and perineal areas are quite stretched and edematous following a vaginal birth • Asses the perineum, including episiotomy if present, for possible __________________ formation • Suspect a __________________ if the woman reports excruciating pain or cannot void or if a mass is noted in the perineal area • Also asses for hemorrhoids

perineum

Nursing Care During Labour and Birth • Nursing Management During the Fourth Stage of Labour o Nursing Interventions ♣ Providing support and information to the woman regarding episiotomy repair and related pain-relief and self-care measures ♣ Applying an ice pack to the ________________ 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 bathroom, listening to running water, or pouring warm water over the perineal area with the peri bottle ♣ Monitoring vital signs every 15 minutes and documenting them ♣ Promoting comfort by offering analgesia for afterpains and war, 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 ♣ 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 ♣ Explain 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 ♣ Assessing for signs of early parent-infant attachment: provides touch at times other than during feedings, meets all of the baby's physical needs

ambulating

Nursing Care During Labour and Birth • Nursing Management During the Fourth Stage of Labour o Nursing Interventions ♣ 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 _________________ to bathroom, listening to running water, or pouring warm water over the perineal area with the peri bottle ♣ Monitoring vital signs every 15 minutes and documenting them ♣ Promoting comfort by offering analgesia for afterpains and war, 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 ♣ 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 ♣ Explain 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 ♣ Assessing for signs of early parent-infant attachment: provides touch at times other than during feedings, meets all of the baby's physical needs

sitz bath

Nursing Care During Labour and Birth • Nursing Management During the Fourth Stage of Labour o Nursing Interventions ♣ 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 bathroom, listening to running water, or pouring warm water over the perineal area with the peri bottle ♣ Monitoring vital signs every 15 minutes and documenting them ♣ Promoting comfort by offering analgesia for afterpains and war, 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 ♣ 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 _______ ________ as a comfort measure for her perineum if she had a laceration or an episiotomy repair ♣ Explain 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 ♣ Assessing for signs of early parent-infant attachment: provides touch at times other than during feedings, meets all of the baby's physical needs

3

Nursing Care During Labour and Birth • Nursing Management During the Fourth Stage of Labour o Assessment ♣ Assess the woman's comfort level frequently to determine the need for analgesia • Woman's pain should be less than ___ on the pain scale

bearing down

Nursing Care During Labour and Birth • Nursing Management During the Second Stage of Labour o Assessment ♣ Assessment involves identifying the signs typical of the second stage of labour, including: • 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 ______________ __________ efforts ♣ Other ongoing assessments include the contraction frequency, duration, and intensity; maternal vital signs every 5 to 15 minutes; fetal response to labour as indicated by FHR monitoring strips; amniotic fluid for colour, odour, and amount when membranes are ruptured; and the coping status of the woman and her partner ♣ Assessment also focuses on determining the progress of labour • Associated signs include bulging of the perineum, labial separation, advancing and retreating of the newborn's head during and between bearing-down

5/15

Nursing Care During Labour and Birth • Nursing Management During the Second Stage of Labour o Assessment ♣ Assessment involves identifying the signs typical of the second stage of labour, including: • 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 ___ to ____ minutes; fetal response to labour as indicated by FHR monitoring strips; amniotic fluid for colour, odour, and amount when membranes are ruptured; and the coping status of the woman and her partner ♣ Assessment also focuses on determining the progress of labour • Associated signs include bulging of the perineum, labial separation, advancing and retreating of the newborn's head during and between bearing-down

mouth/nares

Nursing Care During Labour and Birth • Nursing Management During the Second Stage of Labour o Birth ♣ Once the woman is positioned for birth, cleanse the vulva and perineal areas ♣ Once the fetal head has emerged, the primary HCP explores the fetal neck to see if the umbilical cord is wrapped around it • If it is, the cord is slipped over the head to facilitate delivery ♣ As soon as the head emerges, the HCP suctions the newborn's ___________ first and then the ___________ with a bulb syringe to prevent aspiration of mucus, amniotic fluid, or meconium ♣ The umbilical is double-clamped and cut between the clamps ♣ With the first cries of the newborn, the second stage of labour ends

cries

Nursing Care During Labour and Birth • Nursing Management During the Second Stage of Labour o Birth ♣ Once the woman is positioned for birth, cleanse the vulva and perineal areas ♣ Once the fetal head has emerged, the primary HCP explores the fetal neck to see if the umbilical cord is wrapped around it • If it is, the cord is slipped over the head to facilitate delivery ♣ As soon as the head emerges, the HCP suctions the newborn's mouth first and then the nares with a bulb syringe to prevent aspiration of mucus, amniotic fluid, or meconium ♣ The umbilical is double-clamped and cut between the clamps ♣ With the first _________ of the newborn, the second stage of labour ends

muscle

Nursing Care During Labour and Birth • Nursing Management During the Second Stage of Labour o Immediate Care of the Newborn ♣ Assess the newborn by assigning an Apgar score at 1 and 5 minutes ♣ The Apgar score assess five parameters: • Heart rate (absent, slow, or fast) • Respiratory effort (absent, weak cry, or good strong yell), _____________ tone (limp, or lively and active), response to irritation stimulus, and colour - that evaluate a newborn's cardiorespiratory adaptation after birth • The parameters are arranged from the most important (heart rate) to the least important (colour) • 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

Respiratory

Nursing Care During Labour and Birth • Nursing Management During the Second Stage of Labour o Immediate Care of the Newborn ♣ Assess the newborn by assigning an Apgar score at 1 and 5 minutes ♣ The Apgar score assess five parameters: • Heart rate (absent, slow, or fast) • __________________ effort (absent, weak cry, or good strong yell), muscle tone (limp, or lively and active), response to irritation stimulus, and colour - that evaluate a newborn's cardiorespiratory adaptation after birth • The parameters are arranged from the most important (heart rate) to the least important (colour) • 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

Heart rate

Nursing Care During Labour and Birth • Nursing Management During the Second Stage of Labour o Immediate Care of the Newborn ♣ Assess the newborn by assigning an Apgar score at 1 and 5 minutes ♣ The Apgar score assess five parameters: • ___________ __________ (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 colour - that evaluate a newborn's cardiorespiratory adaptation after birth • The parameters are arranged from the most important (___________ __________) to the least important (colour) • 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

radiant warmer

Nursing Care During Labour and Birth • Nursing Management During the Second Stage of Labour o Immediate Care of the Newborn ♣ Once the infant is born, place him or her under the _____________ ____________, dry him or her, assess him or her, wrap him or her in warmed blankets, and place him or her on the woman's abdomen for warmth and closeness ♣ The nurse can also assist the mother with breastfeeding her newborn for the first time ♣ Drying the newborn and providing warmth to prevent heat loss by evaporation is essential to help support thermoregulation and provide stimulation • Placing the newborn under a radiant heat source and putting on a stockinet cap will further reduce heat loss after drying ♣ Assess the newborn by assigning an Apgar score at 1 and 5 minutes ♣ The Apgar score assess 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 colour - that evaluate a newborn's cardiorespiratory adaptation after birth • The parameters are arranged from the most important (heart rate) to the least important (colour) • 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 ♣ To verify his or her identity, secure two identification bands on the newborn, one on the wrist on eon the ankle, that match the band on the mother's wrist

Apgar

Nursing Care During Labour and Birth • Nursing Management During the Second Stage of Labour o Immediate Care of the Newborn ♣ Once the infant is born, place him or her under the radiant warmer, dry him or her, assess him or her, wrap him or her in warmed blankets, and place him or her on the woman's abdomen for warmth and closeness ♣ The nurse can also assist the mother with breastfeeding her newborn for the first time ♣ Drying the newborn and providing warmth to prevent heat loss by evaporation is essential to help support thermoregulation and provide stimulation • Placing the newborn under a radiant heat source and putting on a stockinet cap will further reduce heat loss after drying ♣ Assess the newborn by assigning an ____________ score at 1 and 5 minutes ♣ The ____________ score assess 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 colour - that evaluate a newborn's cardiorespiratory adaptation after birth • The parameters are arranged from the most important (heart rate) to the least important (colour) • The newborn is assigned a score of 0 to 2 in each of the five parameters • The purpose of the ____________ assessment is to evaluate the physiologic status of the newborn ♣ To verify his or her identity, secure two identification bands on the newborn, one on the wrist on eon the ankle, that match the band on the mother's wrist

warming

Nursing Care During Labour and Birth • Nursing Management During the Second Stage of Labour o Nursing Interventions • 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, 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: o Notifying HCP of the estimated time frame for birth o Preparing the delivery bed and positioning the client o Preparing the perineal area according to the facilities protocol o Offering a mirror and adjusting it so the woman can watch the birth o Explaining all the procedures and equipment to the client and her partner o Setting up delivery instruments needed while maintaining sterility o Receiving newborn and transporting him or her to a _______________ environment, or covering the newborn with a warmed blanket on the woman's abdomen o Providing the initial care and assessment of the newborn

mirror

Nursing Care During Labour and Birth • Nursing Management During the Second Stage of Labour o Nursing Interventions ♣ Focus on motivating the woman, encouraging her to put all her efforts to pushing this newborn to the outside world, and giving her feedback on her progress ♣ If the woman is not pushing and not making progress, suggest that she keep her eyes open during the contractions and look toward where the infant is coming out ♣ Changing positions every 20 to 30 minutes will also help in making progress ♣ Positioning a __________ so the woman can visualize the birthing process and how successful her pushing efforts are can help motivate her ♣ The benefits of upright positioning during the second stage of labour are related to gravity with less aortovagal compression, improved fetal alignment, and larger anterior-posterior and transverse pelvic outlets

upright

Nursing Care During Labour and Birth • Nursing Management During the Second Stage of Labour o Nursing Interventions ♣ Focus on motivating the woman, encouraging her to put all her efforts to pushing this newborn to the outside world, and giving her feedback on her progress ♣ If the woman is not pushing and not making progress, suggest that she keep her eyes open during the contractions and look toward where the infant is coming out ♣ Changing positions every 20 to 30 minutes will also help in making progress ♣ Positioning a mirror so the woman can visualize the birthing process and how successful her pushing efforts are can help motivate her ♣ The benefits of ___________ positioning during the second stage of labour are related to gravity with less aortovagal compression, improved fetal alignment, and larger anterior-posterior and transverse pelvic outlets

abdominal

Nursing Care During Labour and Birth • Nursing Management During the Second Stage of Labour o Nursing Interventions ♣ Other important nursing interventions during the second stage include: • Providing continuous comfort measures such as mouth care, position changes, changing bed linen and underpads, and providing a quiet, focused environment • Instructing the woman on the following bearing-down positions techniques: o Pushing only when she feels the urge to do so o Using ________________ muscles when bearing down o Using short pushes of 6 to 7 seconds o Focusing attention on the perineal area to visualize the newborn o Relaxing and conserving energy between contractions o Pushing several times with each contraction

descent/rotation

Nursing Care During Labour and Birth • Nursing Management During the Second Stage of Labour o Research suggests that delaying pushing in the second stage of labour reduces the time spent in this stage, decreases the need for instrument-assisted delivery, and lessens postpartum fatigue o Shortening the phase of active pushing and lengthening the early phase of passive descent can be achieved by encouraging the woman not to push until she has a strong desire to do so and until the ____________ and ____________ of the fetal head are well advanced o Upright positions such as sitting, semi-recumbency, kneeling, and squatting to be associated with shorter birth intervals, less pain, and perineal damage, and fewer operative births o Perineal lacerations or tears can occur during the second stage when the fetal head emerges through the vaginal introitus ♣ The primary care provider should repair any lacerations during the third stage of labour o An episiotomy is an incision made in the perineum to enlarge the vaginal outlet and theoretically shorten the second stage of labour ♣ Alternative measure such as warm compresses and continual massage with oil have been successful in stretching the perineal area to prevent cutting it

Stimulation

Other Fetal Assessments • Fetal __________________ o Indirect method used to evaluate fetal oxygenation and acid-base balance to identify fetal hypoxia o If the fetus does not have adequate oxygen reserves, carbon dioxide builds up, leading to academia and hypoxemia o Fetal __________________ is performed to promote fetal movement with the hope that FHR accelerations will accompany movement o Fetal movement can be stimulated with a vibro-acoustic stimulator applied to the woman's lower abdomen o A well-oxygenated fetus will respond when stimulated by moving in conjunction with an acceleration of 15 beats/minute above baseline heart rate the lasts at least 15 seconds o The FHR acceleration reflects a pH of more than 7 and a fetus with an intact central nervous system o Absence of response does not necessarily indicate fetal compromise

Upright

Nursing Care During Labour and Birth • Nursing Management During the Second Stage of Labour o Research suggests that delaying pushing in the second stage of labour reduces the time spent in this stage, decreases the need for instrument-assisted delivery, and lessens postpartum fatigue o Shortening the phase of active pushing and lengthening the early phase of passive descent can be achieved by encouraging the woman not to push until she has a strong desire to do so and until the descent and rotation of the fetal head are well advanced o _____________ positions such as sitting, semi-recumbency, kneeling, and squatting to be associated with shorter birth intervals, less pain, and perineal damage, and fewer operative births o Perineal lacerations or tears can occur during the second stage when the fetal head emerges through the vaginal introitus ♣ The primary care provider should repair any lacerations during the third stage of labour o An episiotomy is an incision made in the perineum to enlarge the vaginal outlet and theoretically shorten the second stage of labour ♣ Alternative measure such as warm compresses and continual massage with oil have been successful in stretching the perineal area to prevent cutting it

uterus

Nursing Care During Labour and Birth • Nursing Management During the Third Stage of Labour o Assessment ♣ Assessment during the third stage of labour includes: • Monitoring placental separation by looking for the following signs: o Firmly contracting _________ o Change in uterine shape from discoid to globular ovoid o Sudden gush of dark blood from vaginal opening o Lengthening of umbilical cord protruding from vagina • Examining placenta and fetal membranes for intactness the second time • Assessing for any perineal trauma, such as the following, before allowing the birth attendant to leave: o Firm fundus with bright-red blood trickling: laceration o Boggy fundus with red blood flowing: uterine atony o Boggy fundus with dark blood clots: retained placenta • Inspecting the perineum for condition of episiotomy, if performed • Assessing for perineal lacerations and ensuring repair by birth attendant

uterine atony

Nursing Care During Labour and Birth • Nursing Management During the Third Stage of Labour o Assessment ♣ Assessment during the third stage of labour includes: • Monitoring placental separation by looking for the following signs: o Firmly contracting uterus o Change in uterine shape from discoid to globular ovoid o Sudden gush of dark blood from vaginal opening o Lengthening of umbilical cord protruding from vagina • Examining placenta and fetal membranes for intactness the second time • Assessing for any perineal trauma, such as the following, before allowing the birth attendant to leave: o Firm fundus with bright-red blood trickling: laceration o Boggy fundus with red blood flowing: ___________ _________ o Boggy fundus with dark blood clots: retained placenta • Inspecting the perineum for condition of episiotomy, if performed • Assessing for perineal lacerations and ensuring repair by birth attendant

oxytocin

Nursing Care During Labour and Birth • Nursing Management During the Third Stage of Labour o Nursing Interventions ♣ Interventions during the third stage of labour include: • Describing the process of placental separation to the couple • Instructing woman to push when signs of separation are apparent • Administering _______________ if ordered and indicated after placental expulsion • Providing support and information about episiotomy and/or laceration • Cleaning and assisting the 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 warm blankets over woman • Applying ice pack to the perineal area to provide comfort to episiotomy if indicated • Explaining what assessments will be carried out over the net hour and offering positive reinforcement for actions • Ascertaining any needs • Monitoring maternal physical status by assessing: o Vaginal bleeding: amount, consistency, and colour o Vital signs: blood pressure, pulse, and respirations taken every 15 minutes o Uterine fundus, which should be firm, in the midline, and at the level of the umbilicus • Recording all the birthing statistics and securing the primary caregiver's signature • Documenting birthing even in the birth book (official record of the facility that outlines every birth event), detailing any deviations

episiotomy

Nursing Care During Labour and Birth • Nursing Management During the Third Stage of Labour o Nursing Interventions ♣ Interventions during the third stage of labour include: • Describing the process of placental separation to the couple • Instructing woman to push when signs of separation are apparent • Administering oxytocin if ordered and indicated after placental expulsion • Providing support and information about ________________ and/or laceration • Cleaning and assisting the 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 warm blankets over woman • Applying ice pack to the perineal area to provide comfort to ________________ if indicated • Explaining what assessments will be carried out over the net hour and offering positive reinforcement for actions • Ascertaining any needs • Monitoring maternal physical status by assessing: o Vaginal bleeding: amount, consistency, and colour o Vital signs: blood pressure, pulse, and respirations taken every 15 minutes o Uterine fundus, which should be firm, in the midline, and at the level of the umbilicus • Recording all the birthing statistics and securing the primary caregiver's signature • Documenting birthing even in the birth book (official record of the facility that outlines every birth event), detailing any deviations

vertex/breech

Performing Leopold's Manoeuvres • Steps o . Perform the first manoeuvre to determine presentation ♣ a. Facing the woman's head, place both hands on the abdomen to determine fetal position in the uterine fundus ♣ b. Feel the buttocks, which will feel soft and irregular (indicates ___________ presentation); feel for the head, which will feel hard, smooth, and round (indicates a ____________ presentation)

supine

Performing Leopold's Manoeuvres • Steps o 1. Place the woman in the ___________ position and stand beside her

position

Performing Leopold's Manoeuvres • Steps o 3. Complete the second manoeuvre to determine ______________ ♣ a. While still facing the woman, move hands down the lateral sides of the abdomen to palpate on which side the back is located (feels hard and smooth) ♣ b. Continue to palpate to determine in which side the limbs are located (irregular nodules with kicking and movement)

bleeding

Nursing Care During Labour and Birth • Nursing Management During the Third Stage of Labour o Nursing Interventions ♣ Interventions during the third stage of labour include: • Describing the process of placental separation to the couple • Instructing woman to push when signs of separation are apparent • Administering oxytocin if ordered and indicated after placental expulsion • Providing support and information about episiotomy and/or laceration • Cleaning and assisting the 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 warm blankets over woman • Applying ice pack to the perineal area to provide comfort to episiotomy if indicated • Explaining what assessments will be carried out over the net hour and offering positive reinforcement for actions • Ascertaining any needs • Monitoring maternal physical status by assessing: o Vaginal ______________: amount, consistency, and colour o Vital signs: blood pressure, pulse, and respirations taken every 15 minutes o Uterine fundus, which should be firm, in the midline, and at the level of the umbilicus • Recording all the birthing statistics and securing the primary caregiver's signature • Documenting birthing even in the birth book (official record of the facility that outlines every birth event), detailing any deviations

firm/midline/umbilicus

Nursing Care During Labour and Birth • Nursing Management During the Third Stage of Labour o Nursing Interventions ♣ Interventions during the third stage of labour include: • Describing the process of placental separation to the couple • Instructing woman to push when signs of separation are apparent • Administering oxytocin if ordered and indicated after placental expulsion • Providing support and information about episiotomy and/or laceration • Cleaning and assisting the 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 warm blankets over woman • Applying ice pack to the perineal area to provide comfort to episiotomy if indicated • Explaining what assessments will be carried out over the net hour and offering positive reinforcement for actions • Ascertaining any needs • Monitoring maternal physical status by assessing: o Vaginal bleeding: amount, consistency, and colour o Vital signs: blood pressure, pulse, and respirations taken every 15 minutes o Uterine fundus, which should be _______, in the ____________, and at the level of the ______________ • Recording all the birthing statistics and securing the primary caregiver's signature • Documenting birthing even in the birth book (official record of the facility that outlines every birth event), detailing any deviations

placenta

Nursing Care During Labour and Birth • Nursing Management During the Third Stage of Labour o The third stage is complete when the ______________ is delivered o Nursing care during the third stage of labour focuses primarily on immediate newborn care and assessment and being available to assist with the delivery of the placenta and inspecting it for intactness o Three hormones play important roles in the third stage ♣ During this stage, the woman experiences peak levels of oxytocin and endorphins, while the high adrenaline levels that occurred during the second stage of labour to aid with pushing begin falling ♣ The hormone oxytocin causes uterine contractions and helps the woman to enact instinctive mothering behaviours such as holding the newborn close to her body and cuddling the baby o Skin-to-skin contact immediately after birth and the newborn's first attempt at breastfeeding further augment maternal oxytocin levels, strengthening the uterine contractions that will help the placenta to separate and the uterus to contract to prevent hemorrhage o The drop in adrenaline level from the second stage, which had kept the mother and baby alert at first contact, cause most women to shiver and feel cold shortly after giving birth

Skin-to-skin

Nursing Care During Labour and Birth • Nursing Management During the Third Stage of Labour o The third stage is complete when the placenta is delivered o Nursing care during the third stage of labour focuses primarily on immediate newborn care and assessment and being available to assist with the delivery of the placenta and inspecting it for intactness o Three hormones play important roles in the third stage ♣ During this stage, the woman experiences peak levels of oxytocin and endorphins, while the high adrenaline levels that occurred during the second stage of labour to aid with pushing begin falling ♣ The hormone oxytocin causes uterine contractions and helps the woman to enact instinctive mothering behaviours such as holding the newborn close to her body and cuddling the baby o ________-___-________ contact immediately after birth and the newborn's first attempt at breastfeeding further augment maternal oxytocin levels, strengthening the uterine contractions that will help the placenta to separate and the uterus to contract to prevent hemorrhage o The drop in adrenaline level from the second stage, which had kept the mother and baby alert at first contact, cause most women to shiver and feel cold shortly after giving birth

Scalp Blood

Other Fetal Assessments • Fetal __________ __________ Sampling o Developed as a means of measuring fetal distress in conjunction with EFM to make critical decisions about the management of labour and to prevent unnecessary operative interventions resulting from the use of EFM alone o A sample is obtained to measure pH o Woman must have ruptured membranes, have me the requirement for cervical dilation, and have a vertex presentation o Seldom used but still recommended by SOGC to assess acid-base balance when gestational age is greater than 34 weeks, delivery is not imminent, and the FHR tracing is considered atypical or abnormal

Oxygen Saturation

Other Fetal Assessments • Fetal ______________ __________________ Monitoring (Fetal Pulse Oximetry) o Can be used with EFM as an adjunct method of assessment when the FHR pattern is abnormal or atypical o Placed on the check, forehead, or temple of the fetus and is held in place by uterine wall o Non-invasive and safe method to measure fetal oxygenation

Spine/sitting

Promoting Comfort and Pain During Labour Non-Pharmacological Measures ♣ Ambulation and Position Changes • Changing position frequently (every 30 minutes or so) - sitting, walking, kneeling, standing, lying down, getting on hands and knees, and using a birthing ball - helps relieve pain • Walking, moving round, and changing positions throughout labour make use of gravity to facilitate movement of the baby downward, helping to increase pelvic diameter and promote fetal rotation, thereby shortening the length of the first stage of labour • __________ and ___________ positions for a prolonged time should be avoided because they may interfere with the progress of labour and can cause compression of the vena cava and decreased blood return to the heart • "Ambient Rooms", rooms in which the hospital bed is removed and additional equipment was added to promote relaxation, mobility, and a calm atmosphere were associated with favourable outcomes • Swaying from side to side, rocking, or other rhythmic movements may also be comforting • Ambulation may speed up slowed labour

distraction

Promoting Comfort and Pain During Labour Non-Pharmacological Measures ♣ Attention Focusing and Imagery • Attention focusing or ________________ and imagery use many of the senses and the mind to focus on stimuli • ________________ includes use of a visual focal point, guided imagery, visualization, hypnosis or rituals • Breathing, relaxation, positive thinking, and positive visualization work well for mothers in labour and are examples of labour support behaviours

slow-paced

Promoting Comfort and Pain During Labour Non-Pharmacological Measures ♣ Breathing Techniques • Effective in producing relaxation and pain relief through the use of distraction • If the woman is concentrating on _________-_____________ rhythmic breathing, she isn't likely to fully focus on contraction pain • Benefits include increased confidence, enhanced sense of control, distraction from pain, enhanced relaxation, an even flow of oxygen and carbon dioxide, prevention of breath holding during contractions, and relif from labour pain • Each breath ends and begins with a cleansing breath that involves inhaling through the nose with the shoulder relaxed and exhaling through the mouth and releasing all tension • _________-_____________ Breathing o The breathing rate is half the number of breaths normally taken in one minute o Following a cleansing breath, the woman inhales through the nose to a count of four and then exhales through the mouth to a count a four, repeating until the end of contraction when another cleansing breath is taken

Support

Promoting Comfort and Pain During Labour Non-Pharmacological Measures ♣ Continuous Labour _____________ • Involves offering a sustained presence to the labouring woman by providing emotional _____________, comfort measures, advocacy, information and advice, and _____________ for the partner • A woman's family, a midwife, a nurse, a doula, or anyone else close to the woman con provide this continuous presence • A _____________ person can assist the woman to ambulate, reposition herself, and use berthing techniques • Can also aid with the use of acupressure, massage, music therapy, or therapeutic touch • The support person can help her make decisions based on his or her knowledge of the woman's birth plan and personal wishes A recent review found that woman who received continuous labour _____________ were more likely to give birth spontaneously (vaginally), had shorter labours, were less likely to used pain medications and expressed more satisfaction with the birth

Touch/Massage

Promoting Comfort and Pain During Labour Non-Pharmacological Measures ♣ Therapeutic ___________ or ________________ • Both therapeutic ___________ and ________________ can serve to relax patients and distract them from discomfort • Therapeutic ___________ is an intentionally directed process of energy exchange that uses the hands to promote relaxation and reduce pain and anxiety without actually touching the physical body of the patient o Must be learned and practiced • Through ________________, the use of firm counterpressure in the lower back or sacrum is especially helpful for back pain during contractions

Ambulation

Promoting Comfort and Pain During Labour Non-Pharmacological Measures ♣ _________________ and Position Changes • Changing position frequently (every 30 minutes or so) - sitting, walking, kneeling, standing, lying down, getting on hands and knees, and using a birthing ball - helps relieve pain • Walking, moving round, and changing positions throughout labour make use of gravity to facilitate movement of the baby downward, helping to increase pelvic diameter and promote fetal rotation, thereby shortening the length of the first stage of labour • Spine and sitting positions for a prolonged time should be avoided because they may interfere with the progress of labour and can cause compression of the vena cava and decreased blood return to the heart • "Ambient Rooms", rooms in which the hospital bed is removed and additional equipment was added to promote relaxation, mobility, and a calm atmosphere were associated with favourable outcomes • Swaying from side to side, rocking, or other rhythmic movements may also be comforting • _________________ may speed up slowed labour

Hydrotherapy

Promoting Comfort and Pain During Labour Non-Pharmacological Measures ♣ __________________ • A measure in which a woman immerses herself in warm water for relaxation and relief of discomfort • The warm water releases endorphins and provides better circulation and oxygenation • Contractions are usually less painful in warm water because the warmth and buoyancy of the water have a relaxing effect • __________________ may shorten the length of labour and enhance coping by encouraging ab upright position and increased movements • Evidence indicates that water immersion in the first stage of labour reduces pain and the use of epidural/spinal analgesia • More commonly practiced in birthing centres managed by midwives

Acupuncture/Acupressure

Promoting Comfort and Pain During Labour Non-Pharmacological Measures ♣ ___________________ and ____________________ • Classic Chinese teaching holds that throughout the body there are meridians or channels of energy (qi) that when in balance regulate functions • Pain represents an imbalance or obstruction of the flow of energy • Stimulating the trigger points causes the release of endorphins, reducing the perception of pain • Acupressure involves the application of a firm finger or massage at the same trigger points to reduce the pain sensation • Holding and squeezing the hand of a woman in labour may trigger the point most commonly used for both techniques

Naloxone

Promoting Comfort and Pain During Labour Pharmacological Methods ♣ Opioids • Typically administered IV • Opioids can impact early breastfeeding and are associated with newborn respiratory depression, yet they do not achieve adequate maternal analgesia • They also a decrease in FHR variability and the FHR pattern change I usually transient • Other systemic side effects include nausea, vomiting, pruritis, delayed gastric emptying, drowsiness, hypoventilation, and newborn respiratory depression • To reduce the incidence of newborn respiratory depression, birth should occur within 1 hour or after 4 hours of administration to prevent the fetus from receiving peak concentration • _______________ duration is very short so if it is given the mother should be monitored for relapse respiratory depression

birthing process

Promoting Comfort and Pain During Labour Pharmacological Methods ♣ Regional Analgesia/Anesthesia • Also referred to as neuraxial analgesia/anesthesia, provide unrivaled pain relief in labour with minimal side effects • Routes include epidural block, CSE block, local infiltration, pudendal block, and intrathecal (spinal) analgesia/anesthesia • Local and pudendal routes are used during birth for episiotomies; epidural and intrathecal routes are used for pain relief during active labour and birth • The major advantage of regional pain-management techniques is that the woman can participate in the ________________ ________________ and still have good pain control

lumbar

Promoting Comfort and Pain During Labour Pharmacological Methods ♣ Regional Analgesia/Anesthesia • Epidural Block o There has been a significant increase in epidural use o Involve the injection of a drug into the epidural space, which is located outside the dura matter between the dura and the spinal canal o An epidural block provides analgesia and anesthesia and can be used for both vaginal and cesarean births o Usually started well after labour is established, typically when cervix dilation is greater than 5 cm o Epidural is contraindicated for women with a previous history of spinal surgery or spinal abnormalities, coagulation defects, infections, and hypovolemia o Also contraindicated for the woman who is receiving anticoagulation therapy o Complications may include nausea and vomiting, hypotension, fever, pruritus, intravascular injection, and respiratory depression o Effects on the fetus during labour include fetal distress secondary to maternal hypotension o Ensuring that the woman avoids a supine position after an epidural catheter has been placed will help to minimize hypotension o Today many women receive a continuous _____________ epidural infusion of a local anesthetic as well as an opioid o The addition of opioids, such as fentanyl or morphine, to the local anesthetic helps decrease the amount of motor block obtained o Continuous infusion pumps are often used to administer the epidural analgesia, allowing the woman to be in control and administer a bolus dose on demand

NPO

Promoting Comfort and Pain During Labour Pharmacological Methods ♣ Regional Analgesia/Anesthesia • General Anesthesia o 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 o All anesthetic agents cross the placenta and affect the fetus o The primary complication with general anesthesia is fetal depression, along with uterine relaxation and potential maternal vomiting and aspiration o For the nurse, ensure that the woman is _________ and has a patent IV, administer a nonparticulate antacid or a proton pump inhibitor, 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, and assist in the perinatal team in providing supportive care once the newborn has been removed from the uterus

hypotension

Promoting Comfort and Pain During Labour Pharmacological Methods ♣ Regional Analgesia/Anesthesia • Spinal (Intrathecal) Analgesia/Anesthesia o This involves the injection of an anesthetic "caine" agent, with or without opioids, into the subarachnoid space to provide pain relief during labour or cesarean birth o Contraindications are similar to epidural block o Potential adverse reactions for the woman include ____________________ and spinal headache

Pudendal

Promoting Comfort and Pain During Labour Pharmacological Methods ♣ Regional Analgesia/Anesthesia • _______________ Nerve Block o Refers to the injection of a local anesthetic agent into the _______________ nerves near each ischial spine o It provides pain relief in the lower vagina, vulva, and perineum o Used for the second stage of labour, an episiotomy, or an operative vaginal birth with outlet forceps or vacuum extractor o It must be administered about 15 minutes before it is needed to ensure its full effect o Neither maternal or fetal side effects are common

Patient-Controlled Epidural Analgesia

Promoting Comfort and Pain During Labour Pharmacological Methods ♣ Regional Analgesia/Anesthesia • _______________ ___________________ _________________ ________________ o This method allows the woman to have a sense of control over her pain and reach her own individually acceptable analgesia level

central nervous system

Promoting Comfort and Pain During Labour Pharmacological Methods ♣ Systemic Analgesia • Most common complication is respiratory depression • Woman given this method are required careful monitoring • Opioids given close to the time of birth can cause _______________ ________________ _______________ depression in the newborn, necessitating the administration of naloxone to reverse depressant effects of the opioids • Several drug categories can be used such as opioids, ataractics, benzodiazepines, and barbiturates • Systemic analgesics are typically administered parenterally, usually through an existing IV line • Maternal analgesia during labour often directly affects the baby because of placental transfer of drugs administered to the mother; the baby is also affected indirectly by the secondary physiologic or biochemical changes experienced by the mother • In the past decade there has been increasing use of client-controlled IV analgesia

Barbiturates

Promoting Comfort and Pain During Labour Pharmacological Methods ♣ _____________________ • Are used only in early labour to promote sleep when birth is unlikely for 12 to 24 hours • The goal is to promote therapeutic rest for a few hours to enhance the woman's ability to cope with active labour • These drugs cross the placenta and cause central nervous system depression in the newborn

Benzodiazepines

Promoting Comfort and Pain During Labour Pharmacological Methods ♣ ________________________ • Used for minor tranquilizing and sedative effects • Diazepam is given IV to stop seizures due to pregnancy-induced hypertension • It is NOT used during labour itself • Lorazepam can also be used for its tranquilizing effect, but increased sedation is experienced with this medication • Midazolam, also given IV, produces amnesia but no analgesia • Diazepam and midazolam cause central nervous system depression in both the woman and the newborn

niddah

Promoting Comfort and Pain During Labour • Can vary according to geography and culture o At the beginning of regular-onset uterine contractions, the appearance of bloody show, or membrane rupture, Orthodox Jewish women observe the law of ____________ ♣ At this point, the husband will no longer touch his wife but may remain in the room providing spiritual support ♣ He may or may not look at his wife during the birth o Korean women will not express pain outwardly in fear of shaming the family o Chinese culture values silence o Aboriginal tradition is sacred and involves the family and community ♣ Can be distressing when the individual has to leave the community to give birth alone and can also be limited in the number of support people who are allowed to attend the birth