Chapter 14 nursing care during stages of labor

clinical findings of placental separation from uterus

fundus firmly contracting swift gush of dark blood from introitus umbilical cord appears to lengthen as placenta descends vaginal fullness on exam

Perineal Lacerations: 4th degree

laceration extends through skin, muscles, anal sphincter, anterior rectal wall

Perineal Lacerations: 3rd degree

laceration extends through skin, muscles, perineum, external sphincter muscle

Active Phase

more regular, moderate to strong Frequency Q3-5min duration 40-70 sec

Third stage assessments

-BP, HR, RR Q15min -clinical findings of placental separation from uterus -assignment of 1 and 5 min Apgar scores to neonate

Second stage assessment

-BP, HR, RR Q5-30min -Uterine contractions -pushing efforts by client -increase in bloody show shaking extremities FHR Q15min and after birth immediately. *assess for perineal lacerations, usually occur when fetal head is expulsed

assessment related to possible rupture of membranes

-First assess FHR to ensure no fetal distress from possible umbilical cord prolapse -Verify presence of alkaline amniotic fluid (use nitrazine paper) -Assess amniotic fluid color and odor (normal=clear, straw color, free of odor) (abnormal= yellow or port wine, foul odor ew) -Bladder palpation to prevent distension -Temp Q 4H (if membrane ruptured, Q1-2H)

Nursing actions during 3rd stage

-Instruct pt to push once findings of placental separation are present. -administer oxytocics expulsion of placenta, to prevent hemorrhage -administer analgesics as RX'd -cleanse perineal area with warm water, apply ice pack or perineal pad -promote baby friendly activities between family and newborn

1st stage of labor, nursing interventions

-Provide teaching to pt and partner of what to expect, relaxation measures. -encourage upright positions, apply warm/cold packs, ambulation, hydrotherapy if not contraindicated -encourage voiding Q 2 H

1st stage of labor (TRANSITION PHASE) nursing interventions

-continue voiding Q2H -continue monitoring pt and fetus -rapid pant-pant-blow breathing pattern, -pushing efforts until cervix fully dilated -listen for pt expressing need to BM, this - sign of complete dilation and fetal descent -prepare pt for birth -observe for perineal bulging/crowning (appearance of fetal head at perineum) -bearing down contractions once cervix is fully dilated

1. A nurse is caring for a client and her partner during the second stage of labor. The client's partner asks the nurse to explain how he will know when crowning occurs. Which of the following responses should the nurse make? A. "The placenta will protrude from the vagina." B. "Your partner will report a decrease in the intensity of contractions." C."The vaginal area will bulge as the baby's head appears." D."Your partner will report less rectal pressure."

1. A. The appearance of the placenta occurs after crowning and the birth of the neonate. B. Crowning occurs with an increase in the intensity of contractions and the urge to push. C. CORRECT: Crowning is bulging of the perineum and the appearance of the fetal head. D. Crowning occurs with an increase in rectal pressure as the fetal head descends onto the perineum.

What are the Leopold maneuvers?

1.Identifying the fetal part in the uterine fundus to determine fetal lie and the presenting part 2. Palpating the fetal back to identify fetal presentation 3. Determining which fetal part lies over the pelvic inlet to identify fetal attitude 4. Locating the fetal cephalic prominence to identify the attitude of the head

2. A nurse is caring for a client who is in the transition phase of labor and reports that she needs to have a bowel movement with the peak of contractions. Which of the following actions should the nurse make? A. Assist the client to the bathroom. B. Prepare for an impending delivery. C. Prepare to remove a fecal impaction. D. Encourage the client to take deep, cleansing breaths.

2. A. The urge to have a bowel movement indicates fetal descent and complete dilation. Assisting the client to the bathroom is not an appropriate action in view of the impending delivery. B. CORRECT: The urge to have a bowel movement indicates fetal descent and complete dilation. Preparing for an imminent delivery is appropriate. C. The nurse cleanses the perineal area to remove fecal matter that can be expelled due to the descent of the fetus. The nurse does not prepare to remove an impaction. D. Deep cleansing breaths are encouraged between contractions. The client will be encouraged to push because the sensation of a bowel movement indicates complete dilation and fetal descent.

3. A nurse is caring for a client in the third stage of labor. Which of the following findings indicate that placental separation? (Select all that apply.) A. Lengthening of the umbilical cord B. Swift gush of clear amniotic fluid C. Softening of the lower uterine segment D. Appearance of dark blood from the vagina E. Fundus firm upon palpation

3. A. CORRECT: The umbilical cord lengthens as the placenta is being expulsed. B. A sudden gush of clear amniotic fluid occurs when membranes rupture. C. Softening of the lower uterine segment is not an indication of placental separation. D. CORRECT: A gush of dark blood from the introitus is an indication of placental separation. E. CORRECT: The uterus contracts firmly with placental separation

4. A nurse in labor and delivery is planning care for a newly admitted client who reports she is in labor and has been having vaginal bleeding for 2 weeks. Which of the following should the nurse include in the plan of care? A. Inspect the introitus for a prolapsed cord. B. Perform a test to identify the ferning pattern. C. Monitor station of the presenting part. D. Defer vaginal examinations.

4. A. Active vaginal bleeding is not an indication of ruptured membranes. Therefore, the nurse should not anticipate cord prolapse. B. A test for ferning is performed if there is suspected amniotic fluid and there is no indication of ruptured membranes. C. Station is monitored by vaginal examination, which should not be performed if there is vaginal bleeding, which can be related to placenta previa or abruptio placentae. D. CORRECT: Vaginal examinations should not be performed until placenta previa or abruptio placentae has been ruled out as the cause of vaginal bleeding.

Fourth stage

Begins with the delivery of the placenta and includes at least the first 2hr after birth Delivery of placenta (maternal stabilization of vital signs)

Single most important indicator of progress of labor

Cervical dilation

What is the progress of labor affected by?

Fetal lie, presentation, attitude, and fetal size in relation to mother's pelvis

What causes fetal descent and cervical dilation?

Frequency, duration, and strength/intensity of uterine contractions

Perineal Lacerations: 2nd degree

laceration extends through skin and muscles into perineum, not anal sphincter

First stage

Lasts from onset of regular uterine contractions to full effacement and dilation of cervix Latent Phase-->Active Phase-->Transition (complete dilation)

Third Stage

Lasts from the birth of the fetus until the placenta is delivered Delivery of neonate (delivery of placenta)

Second Stage

Lasts from time the cervix is fully dilated to the birth of the fetus. Full Dilation Progresses to intense contractions Q1-2min(birth)

Culture preferences: Asian American

Might prefer mother to be present, partner not an active participant, labor in silence, cesarean birth undesirable

Perineal Lacerations: 1st degree

laceration extends through skin of perineum, no muscles

Culture preferences: Native American

Prefer female nursing personnel, family involved with birth, use herbs during labor, squatting position for birth

A nurse is caring for a client in the fourth stage of labor. What actions should the nurse take? Use the ATI Active Learning Template: Basic Concept to complete this item. UNDERLYING PRINCIPLES: Describe. NURSING INTERVENTIONS: Describe four.

UNDERLYING PRINCIPLES: The focus of care in the fourth stage is to maintain uterine tone and to prevent hemorrhage. NURSING INTERVENTIONS ● Assess vital signs, fundus, and lochia every 15 min for the first hour, then according to facility protocol. ● Massage the uterus. ● Encourage voiding to prevent bladder distention. ● Promote parental-newborn bonding.

1st stage of labor, nursing assessments

-Leopold maneuvers - Perform vaginal exam as indicated (if no evidence of progress) to allow examiner assess if pt in true labor and if membranes have ruptured -assessments related to possible rupture of membranes -perform bladder palpation on regular basis to prevent bladder distension (this may impede fetal descent through birth canal and cause bladder trauma) -BP, HR, RR; Temp Q4H -contraction monitoring -FHR monitoring

Initial pt assessment

-admission hx, review antepartum care, review of birth plan -obtain lab reports -monitor baseline fetal heart tones and uterine contraction patterns for 20-30min -obtain maternal v/s -check status of amniotic membranes

Fourth stage assesements

-maternal vital signs: Q15min for first 2 hours, then Q4 for first 8 hours after birth, then Q8 -fundus: assess Q15min for first hour massage to maintain uterine tone to avoid hemorrhage -lochia: assess Q 15min for first hour -urinary output, encourage voiding to prevent bladder distension -baby friendly activities of family -let mom nap -if applicable, assess episiotomy or laceration for erythema

2nd stage interventions

-monitor pt and fetus -assist in position changing for effective pushing -assist in partner involvement in bearing down during contractions -rest between contractions -comfort measures (cold compress) -cleanse perineum PRN fecal matter!! -prep for episiotomy PRN -provide feedback of labor to pt -prep for care of neonate

Nursing actions during transition phase

-monitor pt and fetus -void Q2H -rapid pant-pant-blow breathing pattern -discourage pushing until cervix is fully dilated -listen for pt expressing need for BM (=sensation of complete dilation and fetal descent) -prepare pt for birth! -observe perineal bulging/crowning (fetal head in perineum) -encourage pt to begin bearing down with contractions when fully dilated

Nursing actions during active phase

-provide client and fetal monitoring -encourage frequent position changes -encourage void Q2H -encourage deep cleansing breaths before and after modified paced breathing -encourage relaxation -provide nonpharm. comfort measures -provide pharm. pain relief as Rx'd

1st stage of labor (ACTIVE PHASE) nursing interventions

-pt and fetal monitoring -encourage frequent position changes -encourage voiding Q2H at least -deep cleansing breaths before and after modified paced breathing -relaxation -nonpharmaological comfort measures -pharmalogical pain relief as RX'd

5. A nurse is caring for a client who is in the first stage of labor and is encouraging the client to void every 2 hr. Which of the following statements should the nurse make? A. "A full bladder increases the risk for fetal trauma." B. "A full bladder increases the risk for bladder infections." C."A distended bladder will be traumatized by frequent pelvic exams." D."A distended bladder reduces pelvic space needed for birth."

5. A. A full bladder does not place the fetus at risk for trauma. B. Urinary stasis, which occurs due to long periods between voiding, increases the risk for bladder infections. C. The urethra can be traumatized by frequent pelvic exams. D. CORRECT: A distended bladder reduces pelvic space, impedes fetal descent, and places the bladder at risk for trauma during the labor process.

When to do vaginal examinations?

Avoid in presence of vaginal bleeding or until placenta previa or placenta abruptio is ruled out. If necessary, vaginal exam should be done by provider. During 1st stage of labor, OK to do if no evidence of progress to allow the examiner to determine whether pt in true labor and whether membranes have ruptured

Culture preferences: European American

Birth is public concern, focus on technology; partner expected to be involved, provider seen as head of health care team

What is bloody show

Bloody show is the passage of a small amount of blood or blood-tinged mucus through the vagina near the end of pregnancy. It can occur just before labor or in early labor as the cervix changes shape, freeing mucus and blood that occupied the cervical glands or cervical os.

Relaxation measures for pt in 1st stage

breathing (deep cleansing breaths to distract from contractions) effleurage (gentle circular stroking of abdomen in rhythm of breathing) diversional activities (concentration on focal point, imagery)

neonate preparation

check o2 flow and tank on warmer preheat radiant warmer lay out newborn stethoscope & bulb syringe resuscitation equipment ready check suction apparatus

Transition

contractions Strong to very strong frequency Q2-3min duration 45-90sec (complete dilation)

Latent Phase

onset of labor, contractions: Irregular, mild to moderate frequency Q5-30min duration 30-45 sec

Culture preferences: African American

prefers female family members for support

Culture preferences: Hispanic

prefers mother to be present instead of partner