Nursing Care During Stages of Labor ATI Chapter 14

FOURTH STAGE

Begins with the delivery of the placenta and includes at least the first 2 hr after birth

Active Phase (First Stage)

Cervical Dilation (4 to 7 cm) Contractions - more regular, moderate to strong -Frequency: 3 to 5 minutes -Duration: 40 to 70 Seconds Rapid dilation and effacement Some fetal descent Feelings of helplessness Anxiety and restlessness increase as contractions become stronger

Forth Stage

1-4 hours after placenta delivery Maternal Stabilization of Vital Signs -VS and BP watch closely -Fundal Height - Usually Midline around Umbilicus -Lochia: Watch amounts and clots -Bladder: Distension, Displaced Uterus to the Right Achievement of vital sign homeostasis Lochia scant to moderate rubra

Episiotomy

1st Degree - Skin 2nd Degree - Through Muscle 3rd Degree - Through Anal Sphincter 4th Degree - Through Anterior Rectal Wall

4th Stage Managment

Administer Pitocin Vital Signs Fundus Position -Consistency firm/boggy -Midline, Reference to Umbilicus -Lochia Amount -Bladder Status/Voiding -Bonding

Transition (First Stage)

Cervical Dilation (8 to 10 cm) Ends with Complete dilation Contractions - strong to very strong -Frequency: 2 to 3 minutes -Duration: 45 to 90 Seconds Tired, restless, and irritable Feeling out of control, client often states, "cannot continue" Can have N/V Urge to Push Increased rectal pressure and feelings of needing to have a bowel movement Increased bloody Show Most difficult part of labor

Stages of Labor

First stage (see Table 13.2) True labor to complete cervical dilatation (10 cm) Longest of all stages Three phases -Latent phase -Active phase -Transition phase Second stage: cervix 10 cm dilated to birth of baby Third stage: birth of infant to placental separation -Placental separation -Placental expulsion Fourth stage: 1 to 4 hours following delivery

Second Stage of Labor (5 min to 2hr)

Full dilation 10 cm - Birth of Newborn Progresses to intense contractions every 1 to 2 minutes Pelvic Phase- Fetal Descent Perineal Phase- Active Pushing Pushing results in birth of fetus

Culturally Competent Care

Hispanic: Prefer mother to be present rather than partner African American: Prefer female family members for support Asian American: Might prefer mother to be present; partner not an active participant; labor in silence; cesarean birth undesirable Native American: Prefer female nursing personnel; family involved in birth; use of herbs during labor; squatting position for birth European American: Birth is public concern; focus on technology; partner expected to be involved; provider seen as head of health care team

Latent Phase (1st Phase)

Onset of Labor Cervical Dilation (0 to 3 cm) Contractions - Irregular, mild to moderate -Frequency: 5 to 30 minutes -Duration: 30 to 45 Seconds Some dilation and effacement Talkative and eager

1st Stage Nursing Actions

Teach the client and her partner about what to expect during labor and implementing relaxation measures: breathing (deep cleansing breaths help divert focus away from contractions), effleurage (gentle circular stroking of the abdomen in rhythm with breathing during contractions), diversional activities (distraction, concentration on a focal point, or imagery). ● Encourage upright positions, application of warm/ cold packs, ambulation, or hydrotherapy if not contraindicated to promote comfort. ● Encourage voiding every 2 hr. DURING THE ACTIVE PHASE ● Provide client/fetal monitoring. ● Encourage frequent position changes. ● Encourage voiding at least every 2 hr. ● Encourage deep cleansing breaths before and after modified paced breathing. ● Encourage relaxation. ● Provide nonpharmacological comfort measures. ● Provide pharmacological pain relief as prescribed. DURING THE TRANSITION PHASE ● Continue to encourage voiding every 2 hr. ● Continue to monitor and support the client and fetus. ● Encourage a rapid pant-pant-blow breathing pattern if the client has not learned a particular breathing pattern. ● Discourage pushing efforts until the cervix is fully dilated. ● Listen for client statements expressing the need to have a bowel movement. This sensation is a finding of complete dilation and fetal descent. ● Prepare the client for the birth. ● Observe for perineal bulging or crowning (appearance of the fetal head at the perineum). ● Encourage the client to begin bearing down with contractions once the cervix is fully dilated. COHEN STUFF Support Client's expression of pain Watch for Cues for Comfort level Respect and Encourage Keep partner involved

Apgar Score

The Apgar test is done by a doctor, midwife, or nurse. The health care provider examines the baby's: Breathing effort Heart rate Muscle tone Reflexes Skin color Each category is scored with 0, 1, or 2, depending on the observed condition. If the infant is not breathing, the respiratory score is 0. If the respirations are slow or irregular, the infant scores 1 for respiratory effort. If the infant cries well, the respiratory score is 2. Heart rate is evaluated by stethoscope. This is the most important assessment: If there is no heartbeat, the infant scores 0 for heart rate. If heart rate is less than 100 beats per minute, the infant scores 1 for heart rate. If heart rate is greater than 100 beats per minute, the infant scores 2 for heart rate. Muscle tone: If muscles are loose and floppy, the infant scores 0 for muscle tone. If there is some muscle tone, the infant scores 1. If there is active motion, the infant scores 2 for muscle tone. Grimace response or reflex irritability is a term describing response to stimulation, such as a mild pinch: If there is no reaction, the infant scores 0 for reflex irritability. If there is grimacing, the infant scores 1 for reflex irritability. If there is grimacing and a cough, sneeze, or vigorous cry, the infant scores 2 for reflex irritability. Skin color: If the skin color is pale blue, the infant scores 0 for color. If the body is pink and the extremities are blue, the infant scores 1 for color. If the entire body is pink, the infant scores 2 for color.

Assessment

● Assess the client prior to admission to the birthing facility. ● Orient the client and her partner to the unit during admission. ◯ Conduct an admission history, review of antepartum care, and review of the birth plan. ◯ Obtain laboratory reports. ◯ Monitor baseline fetal heart tones and uterine contraction patterns for 20 to 30 min. ◯ Obtain maternal vital signs. ◯ Check the status of the amniotic membranes. ● Perform maternal and fetal assessments continuously throughout the labor process and immediately after birth. ● Avoid vaginal examinations in the presence of vaginal bleeding or until placenta previa or abruptio placentae is ruled out. If necessary, vaginal examinations should be done by the provider. ● Cervical dilation is the single most important indicator of the progress of labor. ● Progress of labor is affected by size of fetal head, fetal presentation, fetal lie, fetal attitude, and fetal position. ● The frequency, duration, and strength (intensity) of the uterine contractions cause fetal descent and cervical dilation.

3rd Stage Assessment

● Blood pressure, pulse, and respiration measurements every 15 min ● Clinical findings of placental separation from the uterus as indicated by ◯ Fundus firmly contracting ◯ Swift gush of dark blood from introitus ◯ Umbilical cord appears to lengthen as placenta descends ◯ Vaginal fullness on exam ● Assignment of 1 and 5 min Apgar scores to the neonat COHEN Assessment: -Watch for Placental separation -Placenta and fetal membranes examination; -Note and Document: perineal trauma; episiotomy; lacerations -Comfort Measures: Icepack to perineum, meds

2nd Stage Nursing Actions

● Continue to monitor the client/fetus. ● Assist in positioning the client for effective pushing. ● Assist in partner involvement with pushing efforts and in encouraging bearing down efforts during contractions. ● Promote rest between contractions. ● Provide comfort measures such as cold compresses. ● Cleanse the client's perineum as needed if fecal material is expelled during pushing. ● Prepare for episiotomy, if needed. ● Provide feedback on labor progress to the client. ● Prepare for care of neonate. A nurse trained in neonatal resuscitation should be present at delivery. ◯ Check oxygen flow and tank on warmer. ◯ Preheat radiant warmer. ◯ Lay out newborn stethoscope and bulb syringe. ◯ Have resuscitation equipment in working order (resuscitation bag, laryngoscope) and emergency medications available. ◯ Check suction apparatus COHEN Interventions -Support in Active Decision Making -Provide Instructions -Assist with Pain -Assist with Position -Prepare for Delivery Interventions with birth -Cleansing of perineal area and vulva -Assisting with birth, suctioning of newborn, and umbilical cord clamping, cord gases, cord blood sample -Providing immediate care of newborn ***Drying ***Apgar score ***Identification

3rd Stage Nursing Actions

● Instruct the client to push once findings of placental separation are present. Keep mother/parents informed of progress of placental expulsion and perineal repair if appropriate. ● Administer oxytocics expulsion of the placenta to occurs to stimulate the uterus to contract and thus prevent hemorrhage. ● Administer analgesics as prescribed. ● Gently cleanse the perineal area with warm water and apply a perineal pad or ice pack to the perineum. ● Promote baby-friendly activities between the family and the newborn, which facilitates the release of endogenous maternal oxytocin. Examples of such activities include introducing the parents to the baby and facilitating the attachment process by promoting skin-to-skin contact immediately following the birth. Allow private time and encourage breastfeeding. COHEN Interventions: -Instructing to push when separation apparent; -giving oxytocin if ordered -assisting woman to comfortable position; -providing warmth; -applying ice to perineum if episiotomy; explaining assessments to come; monitoring mother's physical status; recording birthing statistics;

4th Stage Assessment

● Maternal vital signs ● Fundus ● Lochia ● Urinary output ● Baby-friendly activities of the family COHEN Assessment: -Vital signs, fundus, perineal area, comfort level, lochia, bladder status

1st Stage Assessment

● Perform Leopold maneuvers. ● Perform a vaginal examination as indicated (if no evidence of progress) to allow the examiner to assess whether client is in true labor and whether membranes have ruptured. ◯ Encourage the client to take slow, deep breaths prior to the vaginal exam. ◯ Monitor cervical dilation and effacement. ◯ Monitor station and fetal presentation. ◯ Prepare for impending delivery as the presenting part moves into positive stations and begins to push against the pelvic floor (crowning). ● Assessments related to possible rupture of membranes ◯ When there is suspected rupture of membranes, the nurse should first assess the FHR to ensure there is no fetal distress from possible umbilical cord prolapse, which can occur with the gush of amniotic fluid. ◯ Verify presence of alkaline amniotic fluid using nitrazine paper (turns blue, pH 6.5 to 7.5). NOTE: nowadays they use Amnisure which is 99% accurate, more useful then nitrazine paper, which can not tell the difference between amniotic fluid and semen. ◯ A sample of the fluid may be obtained and viewed on a slide under a microscope. Amniotic fluid will exhibit a frond-like ferning pattern. Assess the amniotic fluid for color and odor. ■ Expected findings are clear, straw color, and free of odor. ■ Abnormal findings include the presence of meconium, abnormal color (yellow or port wine), and a foul odor. ● Perform bladder palpation on a regular basis to prevent bladder distention, which can impede fetal descent through the birth canal and cause trauma to the bladder. ◯ Clients might not feel the urge to void secondary to the labor process or anesthesia. ◯ Encourage the client to void frequently. ● Temperature assessment every 4 hr (every 1 to 2 hr if membranes have ruptured) COHEN STUFF Fetal Assessment Labs--U/A, CBC - Prenatal Labs if no PNC Psychological Status Review Childbirth Plans Contact Provider

Third Stage (5 to 30 min)

Ends with delivery of Placenta Placental Separation and expulsion Schultze presentation; shiny fetal surface of placenta emerges first Duncan presentation; dull maternal surface of placenta emerges first Signs of Placental Separation -The uterus rises upward -The umbilical cord lengthens -A sudden trickle of blood is released from the vaginal opening -The uterus changes its shape to globular

FIRST STAGE

Lasts from onset of regular uterine contractions to full effacement and dilation of cervix (longer than second and third stages combined)

THIRD STAGE

Lasts from the birth of the fetus until the placenta is delivered

SECOND STAGE

Lasts from the time the cervix is fully dilated to the birth of the fetus

Assessment in 1st Stage: Contraction monitoring

Latent Phase: q30-60 min. Active Phase: q15-30 min. Transitional Phase: q10-15 min.

Assessment in 1st Stage: FHR monitoring (normal range 110 to 160/min)

Latent Phase: q30-60 min. Active Phase: q15-30 min. Transitional Phase: q15-30 min.

Assessment in 1st Stage: Blood pressure, pulse, and respiration measurements

Latent Phase: q30-60 min. Active Phase: q30 min. Transitional Phase: q15-30 min.

2nd Stage Assessment

Begins with complete dilation and effacement ● Blood pressure, pulse, and respiration measurements every 5 to 30 min ● Uterine contractions ● Pushing efforts by client ● Increase in bloody show ● Shaking of extremities ● FHR every 15 min and immediately following birth Assessment for perineal lacerations, which usually occur as the fetal head is expulsed. Perineal lacerations are defined in terms of depth. ● First degree: Laceration extends through the skin of the perineum and does not involve the muscles. ● Second degree: Laceration extends through the skin and muscles into the perineum but not the anal sphincter. ● Third degree: Laceration extends through the skin, muscles, perineum, and external anal sphincter muscle. ● Fourth degree: Laceration extends through skin, muscles, anal sphincter, and the anterior rectal wall. COHEN Assessment -Typical signs of 2nd stage -Contraction frequency, duration, intensity -Maternal vital signs -Fetal response to labor via FHR -Coping status of woman and partner

4th Stage Nursing Actions

● Assess maternal blood pressure and pulse every 15 min for the first 2 hr and determine the temperature at the beginning of the recovery period, then assess every 4 hr for the first 8 hr after birth, then at least every 8 hr. ● Assess fundus and lochia every 15 min for the first hour and then according to facility protocol. ● Massage the uterine fundus and/or administer oxytocics as prescribed to maintain uterine tone and to prevent hemorrhage. ● Encourage voiding to prevent bladder distention. ● Assess episiotomy or laceration repair for erythema ● Promote an opportunity for parental-newborn bonding. ● After they have had a chance to bond with their baby and eat, most new mothers are ready for a nap or at least a quiet period of rest COHEN Interventions: -Support and information -Bladder status and voiding -Comfort measures -Parent-newborn attachment/Bonding -Teaching Administer Pitocin Vital Signs -Fundal checks; perineal care and hygiene Fundus Position -Consistency firm/boggy -Midline, Reference to Umbilicus -Lochia Amount -Bladder Status/Voiding