Intrapartum 3164
self concept/ role/ interdependent after birth
(1) Needs vary. (repeat or a surprise?) (2) Common behaviors (feelings expressed) range from: fear, disappointment, frustration at having lost control, to anger ("why me") to lower esteem, or lower body image, or relief (3) Nursing Care: (a) use therapeutic communication (b) give information and repeat as necessary (c) emphasize the similarities and acknowledge the differences between vaginal and cesarean births. (d) provide family time to bond.
Vaginal Exam (VE)-
*Never do if questionable vaginal bleeding or known previa! -assess for: -cervical effacement (thins 0 to 100%) -cervical dilation (0 to 10 cm) -presenting part (vertex - feel posterior fontanel, military - feel anterior fontanel, breech - feel soft buttocks or leg) -station ( - 4 to +3) -position (anterior, posterior, left, right) -membrane status (I, SROM, AROM) -if ruptures: to bed immediately, check for prolapsed cord! -Assess FHR
midline or median episiotomy
-*most common -decreased pain -heals well -risk: extension into rectal wall
fetal heart rate patterns
-3 types
immediate infant care
-Airway & (APGAR) goal -Thermoregulation goal -ID bands -Cord clamp -always have bulb syringe by baby!! -cover them up after skin to skin time (hat and blanket) -Quick thorough assessment -Neonatal transition -Safety (positioning and holding of infant) -Hygienic measures, wear gloves until first bath -give prophylactic meds to baby
elimination assessment of laboring mom
-CCUA - dipstick for: -protein (pre-eclampsia) -Ketones (dehydration, starvation) -glucose (increased GFR in proximal tubules) -blood (infection) -leukocytes
stage 1 transition phase
-Endocrine (reproduction) - -assess contx. q 10-15 min., cx. -"urge to push" d/t pressure on perineum -perineal massage, warm moist compresses if ct. is trying to avoid episiotomy -Oxygenation (circulation) & Protection- -FHR q 5-15 min, vs q 30 min -leg tremors - apply warm blankets, socks DO NOT RUB -hyperventilation - assist breathing, paper bag -Activity & rest - conserve energy -nutrition - slow deep breathing, lift HOB, cool cloth, oral hygiene -elimination - -self-concept/interdependence mode - -senses very keen -fears "loss of control", irritable, "bark", "leave me alone" -support/encourage coach
stage 1 active phase assessment
-Endocrine (reproduction) - contrx q 15-30 min -Oxygenation (circulation) - -FHR q 15-30 min, vs q 1 hr., assess legs, promote circulation & warmth (increased restlessness leads to leg cramps - extend legs , dorsiflex foot) -Activity & rest - hang on S.O., exercise/ peanut ball opens up pelvis, freq. change in position gives more room for descent -nutrition - use proper breathing, ice, wet cloth, lip gloss, glycerine swabs, tongue behind upper teeth -elimination - -diaphoresis - sponge face, neck, body -self-concept/interdependence modes -fear being alone, -speak close to face (ear), -keep informed of progress, -"each contx. that much closer to having baby"
stage 1 of labor: latent phase
-Endocrine (reproductive) -notify Dr. of Contraction Cervix, changes, show Station, position -Friedman graph (evaluate uterine activity, cx. dilation, fetal descent) (pattern of progression) -assess contrx. & show every 30 min. to 1 hr.
actions upon admission
-Endocrine function assessment -feel Contractions: methods: 1) subjective 2) palpate fundus 3) external fetal monitor(EFM) -Perineum, Cervix: -Inspect -Status of fetal membranes 4) vaginal exam 5) Oxygenation (circulation) and Protection 6) paperwork 7) elimination assesment 8) perineal prep/ shave? 9) enema?
APGAR scoring
-Heart rate (pulse) **most important -Respiratory rate or effort (respiration) -Muscle tone (activity) -Reflex irritability (grimace) -Color (appearance) -score 0, 1, 2 points in 5 areas: 8-10 = good condition - routine obsv. 4-8 = fair condition - flow by, pat. airway 0-3 = extremely poor - immed. resuscitation -if less than 7 at 5 min then may do another in another 5 min
evaluation of fetal status
-Indications for EFM -Guidelines from governing bodies: AWHONN, TJC, DNV, Nurse Practice Act -hx: medical, ob problems: PTL, placenta previa (placenta delivered before baby), IUGR, post dates -treatment &/or response: labor induction, abnormal FHR pattern
admission paperwork
-Interview & History -age -ob. hx, g/p, EDC, -previous labor -allergies -last food -medical problems -Informed consents -Lab data: blood type, RH, serology, rubella -educational level -prepared childbirth coach/ s.o. -pediatrician -breast/bottle feeding -contract/birth plan -immunizations
oxygenation check of laboring mom
-Maternal vital signs -Heart, -lungs, -peripheral pulses, -edema, etc -Fetal heart rate (FHR)
pain management
-Non-pharmacological -Pharmacological: -Analgesics - IV (stadol) -Anesthesia - LOCAL - (xylocaine) REGIONAL: -pudendal (not often used) *spinal *epidural- first choice over spinal (Duramorph or Fentanyl)
stage 3 labor- birth of baby to birth of placenta
-Note & record: Time of birth, mode, sex, weight, placenta, ID # Apgar, time/type/mechanism of placenta del., put on babys bracelet -Assess infant & mother/family interaction -Note if infant eliminates -Administer meds (about 6 hr after birth) -baby most awake first two hours after born- best time for bonding and starting and establishing breast feeding
assessment during stage 2
-Notify dr -Assessment: -Endocrine (Reproduction) -contrx, dilation, effacement -Oxygenation (Circulation) -VS, FHR -Nutrition -NPO, IV -Elimination -n/v -Activity & Rest -labor down, pushing positions, breathing (not breathing too rapid, do open glottis breathing) -Self concept, Interdependence -Equipment check -Antiseptic prep
nursing management upon admission to birthing unit
-Orient -Psychosocial assessment (Role, Self Concept, & Interdependence Mode) -Anxious -Coping -plans -need to deal with the entire family - less stressful and smoother if use family systems approach
latent phase general checks
-Oxygenation (circulation) & Protection - -assess FHR, T, BP (no more than 15-20 mm Hg above pg. baseline), P (not greater than 100), R -Activity & Rest (dont lay on back- supine hypotension, try to keep on left side) no walking after membranes rupture -Nutrition- usually NPO except ice chips -Elimination - full bladder slows fetal descent; traumatized leads to cystitis -Self-Concept/Interdependence Modes
interventions of non-reassuring FHT (fetal heart tones)
-Position change -check for cord prolapse -correct hypotension (give fluids) -discontinue pit drip -make sure pushing where needs to be -notify Dr. -document -O2 -IV fluids -should correct within 10 min
FHR patterns: reassuring- type 1
-acceleration with contx. &/or FM -early decels -variable decels: -< 45 sec., -good variability, -stable baseline, -abrupt return to baseline
enema for labor mom
-fleets vs soap suds, assess FHR before & immediately after, assess contrx. after -evacuate lower bowel to: stimulate contractions, & prevent contamination of sterile field at delivery
words of encouragement
-have them say let go instead of no -have them say open and imagine cervix opening -instead of dont have them say dont -have them say out instead of oh and imagine baby coming out -have them say things that drop the jaw
fetal heart rate evaluation methods
-indirect (external) - non-invasive: -ultrasound, apply early in labor -only a rough measure of FHR, not as accurate variability, noisy, readjust freq., reapply gel -direct (internal) - invasive: -provides a continuous FHR recording, -membranes must be ruptured first, cx. must be partially dilated 2-3 cm, pp must be engaged
FHR patterns type 2 nonreassuring
-intermittent lates with good variability -variables - > 45 sec., slower return to baseline (baby having problems with oxygen reserve) -no FHR variability with decels
FHR pattern type 3 ominous
-lates with decreased FHR variability, persistent decels (stay down and dont come up) -variables - decreased variability, fetal tachycardia
stimuli for stage 2 (birth of baby)
-maternal age (older take longer), parity (#times delivery), fatigue -fetal (size, station) -psychological readiness
perineal prep
-mini vs complete, clean to dirty, between contrx., no soap or hair to enter vagina -not necessary, problems with knicks, increased infection
special procedures- episiotomy
-purpose: -shorten stage 2 -prevent laceration -prevent prolonged stretching of muscle supporting bladder or rectum -degree - first to fourth degree (1 - 4) from superficial tissue to into the rectal sphincter and up anterior wall of rectum
nursing actions during C section
-reassure ct/S.0; -position and drape client, -monitor client, -Monitor fetus, -assist physician
latent phase pain management
-relaxation+ breathing+ education+ support= synergistic effect -pain mostly lower back to abdomen -criteria to evaluate effective breathing: -relaxation focus -increased O2 -decreased pain perception -effleurage on tummy, imagery, music, rhythmic moving, positioning, breathing
nursing management of C section
-setup room, make sure equipment works 1) Preoperative preparation a) NPO after midnight and during labor b) informed written consent c) Lab-CBC, type and cross match for 2 units of packed RBC's, UA, serology, electrolytes d) U-S of placenta location e) IV-LR, may need to pre-hydrate f) Foley/indwelling catheter g) Abdominal and pubic shave/and sterile prep h) Pre-op meds - 1 hour before C-S, antacid - 15 minutes before anesth. i) Monitor maternal V.S. and FHR j) Monitor contrx, cx changes & fetal descent k) Emotional support and education to ct./family/S.0
cesarean birth
-stimuli: maternal or fetal -types: -transverse cut on skin called Pfannenstiel -transverse cut on uterus called transverse -vertical cut on skin called midline -vertical cut on uterus called classical or vertical
decel: late decels
-type II *non-reassuring, -as a result of decreased blood flow & O2 transfer to fetus through intervillious space during contx. - causes hypoxemia -stimuli: mom hypertension, placental path., strong freq. contx., supine position (sometimes) -always intervene - can lead to fetal hypoxia & acidosis -uniform in shape, occurs later in contraction cycle (starts at peak of contraction) -recovers after contraction -usually only drops 30-40 bpm -when start to have then have with every contraction -when oxygen supply goes down contributes to incomplete glucose metabolism which causes accumulation of lactic acid then HR goes up and have acidosis (takes 30 min or more)
variable Decels
-type II or III, non-reassuring -most common decel -stimuli: cord compression d/t: -abnormal fetal position, -amniotomy, -supine maternal position -pitocin induction, -oligohydramnios (little water, not enough in bag) -often altered by change in maternal position -can be V shape W shape or U shape -can happen at any time -have shoulders (goes up right before and after decel -drop about 60 beats -drop and return quickly -tend to happen late in labor or during second stage (pushing) -if happen in late phase then may do amnio infusion -can see change in ph of baby
mediolateral episiotomy
-uncommon -no 4th degree -maybe 3rd degree extension -increased blood loss -increased pain -more difficult to repair
prophylactic meds given to baby
-usually with in 1 hour -Erythromycin (Ilotycin)"eyes": -tx. N. gonarrheae & chlamydia -edema, inflammation for 24-48 hrs. -Vitamin K (Aqua-mephyton) "thighs": -IM Vastus lateralis, 0.5-1.0 mg -tx./prevent neonatal hemorrhage
fetal heart eval
-uterine activity -FHR - baseline and variability, want between 110-160: -sympathetic nerves - speed up -parasympathetic nerves - pulls down -the continuous opposition results in BTBV (beat to beat variability, minimal, mod, large) -Accelerations (always good) & decelerations (dont like)
fetal heart rate patterns- baseline
-variations: -tachycardia - > 160 for 10 min., marked is > 180 -bradycardia - < 110, marked if < 100 - associated with fetal acidosis -Baseline variability - stimuli: -maternal activity, uc's, & abdominal palpation will increase variability -analgesics, MgSO4, hypnotics; immature or sleeping fetus; anomalies will decrease variations
medical and nursing management of complications in labor/ birth
1. therapeutic communication 2. Trial of Labor 3. Induction: -Hygroscopic dilators (laminaria), PGE2 gel, mesoprestil, -Amniotomy "AROM", Oxytocin 4. Vacuum extraction or forceps
complications/ variations in labor/ birth
A. Assess client frequently and thoroughly (esp first hr) B. Collaborate closely with mom and SigO C. Medical and Nursing Management 1. Therapeutic communication
APGAR
Apgar - 1953, anesthesiologist A ppearance P ulse G rimace A ctivity R espiration -evaluate physical condition @ birth (to quickly identify those requiring resuscitative measures) -determine @ 1 & 5 minutes
Vaginal birth after cesarean (V.B.A.C.)
Indications for VBAC 1. previous low-segment incision 2. emergency surgical facilities available 3. physician readily available during labor
VEAL CHOP
Variable- Cord Early- Head Accel- Ok Late- Placenta
assessment in stage 4 after C section
a) Endocrine (Reproduction) - Stage IV Labor PLUS assess incisional area (dressing) 4 signs of excessive bleeding or formation of a hematoma, make sure fundus is firm b) Circulation (O2), Protection - see IX. c) Nutrition - see IX. C. PLUS (1) check doctor's orders on when to begin oral fluids and food. (2) always assess for the presence of bowel sounds before introducing oral fluids. d) Activity & Rest - see IX. PLUS (1) Turn, cough, deep breathe every 1-2 hours progress up to side of bed (dangle), to chair to ambulation. (2) Progressive exercises may be started after abdominal discomfort has eased, check with doctor's order. e) Elimination - see IX. PLUS (1) assess patency of foley catheter. (2) provide catheter care with pericare. (3) position catheter to promote drainage. (4) note and record characteristics and amount of drainage.
when should you not drink through straw
after surgery (bc swallow air)
pain management for C section
assess during first hour after Additional pain due to: (a) incision (b) manipulation and stretching of abdominal and uterine muscles/tissues during surgery (c) fatigue (d) flatus - from decreased or absent peristalsis (e) after pains (especially if a multipara)
what can pain inhibit when wanting to breastfeed
letdown reflex
delivery room board
patient name and info about them -G/P gravida (#times pregnant)/ pera (#times delivered) -EDC due date -SVE sterile vag exam: dilation, efacement, station -BOW: I, SROM, AROM -anesthesia: epidural or local or none
accels
reassuring
cord has what vessels
two arteries and one vein
decel: 3 types- early
type 1 reassuring, stimuli: increased ICP (intracranial pressure) leads to decreased cerebral blood flow, do no respond to O2 or position change -uniform in shape and mirrors contractions -start timing is early in contraction -usually stays above 100bpm -see when crowning, see when water breaks -typically well tolerated by baby