W 4: labor and delivery nursing care and complications

What is the simple most important indicator for the progress of labor?

Cervical dialation

What affects the progress of labor?

fetal head, presentation, lie, attitude, position

What causes fetal descent and cervical dialation within labor?

the frequency, duration, and strength (intensity) of uterine contractions

First stage of labor nursing actions

preform Leopold maneuvers
preform vaginal exam to assess if mom is in true labor, checking if membranes ruptured

Once membranes have ruptured, nursing actions indicate we

assess FHR → to determine possible umbilical cord prolapse
temp check every 4 hrs. 2 hrs if membranes have ruptured

Once membranes have ruptured, nursing actions specific to amniotic fluid indicate to

verify presence of amniotic fluid using a nitrazine paper → should turn deep blue with PH of 6.5-7.5
assess amniotic fluid for slight yellow tinge and no odor
AB findings include presence of meconium(baby’s BM), the color yellow or green or a foul odor

First stage nursing actions: Bladder

void frequently every 2 hours/ palpate bladder to prevent distension

Active phase of labor nursing actions

• Mom and FHR monitoring

• encourage frequent position changes/ deep cleansing baths

• provide non-pharm / and pharm

• discourage pushing until fully dilated

• listen to mom when she feels she is about to poop

  • observe for crowning/ once dilated, ask client to bear down

Second stage of labor: nursing assessments

• BP/HR/RR

• uterine contractions

• push efforts

• increase in bloody show

  • shaking in their extremities

• FHR every 5-15min → and following birth as well

nursing actions during the second stage, a neonatal resuscitation certifed nurse will

• check o2 flow and tank on warmer

• preheat radiant warmer. lay newborn stethoscope and bulb syringe

  • have resussitation equitment in this order (esuscitation bag, laryngoscope)

    and emergency medications available. Check suction apparatus.)

1st degree perineal Lacerations

Laceration extends through the skin of the perineum and does not involve the muscles

2nd degree perineal Lacerations

Laceration extends through the skin and muscles into the perineum, but not the anal sphincter

3rd degree perineal Lacerations

Laceration extends through the skin, muscles, perineum, and external anal sphincter muscle

4th degree perineal Lacerations

Laceration extends through skin, muscles, anal sphincter, and the anterior rectal wall

Nursing assessments for third stage of labor

• BP/HR/RR every 15 min

  • assignment of 1 and 5 Apgar scores to the newbron

Clinical findings of placental separation from uterus is indicate by

fundus firmly contracting, gush of dark blood from introitus, umbilical cord letghened as placenta decends

what can the nurse do pharm wise to contract the uterus to orevent hemorraging

admin oxytocic as prescribed

how long does the 4th stage of labor last?

first 2 hours after birth

4th stage assessment for BP/HR/RR

every 15 min for first two hours

4th stage assessment for temperature

every 4 hours first 8 hours then every 8 hours

4th stage assessement for the fundus and lochia

every 15 min for first hour

why should we massage the fundus during the 4th stage?

to maintain uterine tone and prevent hemorrhaging

External cephalic version

a procedure preformed at 37-38 weeks where an ultrasound-guided hands-on procedure to externally manipulate the fetus into a cephalic lie.

doing an external cephalic version puts high risk for

placental abruption, umbilical cord compression, emergency c-section

contraindications for an external cephalic version

uterine anomalies, previous cesarean birth, cephalopelvic disproportion(small pelvis for baby), placenta previa, multifetal gestation, oligohydramnios(low fluid), third-trimester bleeding, uteroplacental insufficiency, or nuchal cord.

nursing assessments done during an external cephalic version

Monitoring FHR during and for 1 hr after procedure for variable decelerations

Bishop score

used to determine maternal readiness for labor by evaluating whether the cervix is favorable for induction by rating the following.

• dilation

• effacement

• cervical consistency (firm, medium, soft)

• position

  • station of presenting part

what Bishop score should be calculated that results in a successfull induction?

8 or higher

cervical ripening

increases cervical readiness for labor through promotion of cervical softening, dilation, and effacement

Mechanic methods for cervical ripening

A ballon catheter is inserted into the intracervical canal to dilate the cervix

Chemical methods for cervical

Misoprostol: prostaglandin E1

Dinorostone: prostaglandin E2

At what point should you notify provider wen cervical ripening a being done

Tachysystole or fetal distress is occurring

What do you need before cervical ripening cold be done

informed consent

Nursing actions for mom during tachysystole

Admin sub Q of terbetaline

Nursing actins for a non-reassuring fetal status during tachysystole

Apply O2 via face mask 10L/min

Position the client on the left side

Increase rate of IV fluid administration

Notify the provider

At what weeks of gestation must a mom be to be induced into labor

39 weeks unless there is a medical indication

What would happen if a mom induced labor before 39 weeks?

Increased risk for infection, longer labor, need for c-section

What methods would be used to induce labor?

Mechanical or chemical, admin of IV oxytocin, nipple stimulation to trigger the release the endogenous oxytocin

What is a high risk medication

Oxytocin

What should be confirmed before admin of oxytocin

Fetal is engaged in the birth canal at minimum of 0

When to admin oxytocin after misoprostol

4 hours after

When do admi oxytocin after dinoprostone gel

6-12 hrs after

Through what port should IV Oxytocin should be connected to?

The port closest to the client . Usually the main IV line

Intrauterine pressure catheter (IUPC)

Monitor frequency, duration, and intensity of contractions

Once oxytocin is administered what assessments will the nurse perform

BP/HR/RR q30 to 60 min and with every change in dose

When oxytocin is administered what assessments does the nurse monitor for the baby

q15 min during first stage

q5 min during second stage and with every change in dose

What should frequency contractions be to maintain adequate dosage of oxytocin

2-3min.

What should contractions duration be to maintain adequate dosage of oxytocin

70 seconds

What should contraction intensity be to maintain adequate dosage of oxytocin

50mmHG on IUPC or strong on palpation

You see a frequency of 5-10 min and a single contraction lasting more than. 2 minutes. What is your priority action?

Stop oxytocin

What complication arises within the baby during oxytocin administration

Nonreassuring FHR

Augmentation of labor

the stimulation contractions once labor has spontaneously begun, but progress is inadequate.

Amniotomy

Artificial rupture of membranes through hook, clamp, or sharp instrument

When does labor begin after an AROM

12-24 hrs and can decrease duration of labor by 2 hrs

Amnioinfusion

Normal saline or LR instilled into the amniotic cavity through a transcervical catheter to supplement the amount of amniotic fluid

Fluid reduced severity of variable decelerations

Operative Vaginal Birth: Vacuum Extractor

The use of. Suction device to apply traction to fetal head and assist in birth of the head

What must be met before using a vacuum

Maternal exhaustion, fetal distress during second stage of labor, not used before 34 weeks of labor

Operative Vaginal Birth: Forceps

use of an instrument with two curved spoon-like blades to assist in the delivery of the fetal head. Traction is applied during contractions.

Report should look like after baby received an operative vaginal birth

Report that it happened and include the instrument used

Episiotomy

An incision made into the perineum to enlarge the vaginal opening to facilitate birth and minimize soft tissue damage

median (midline) episiotomy

extends from the vaginal outlet toward the rectum and is the most commonly used type

mediolateral episiotomy

Extends from the vaginal outlet posterlateral either to the left or right of midline and is used when 3rd degree laceration can occur, blood loss is greater, local anesthetic being administered to the perineum prior to incision

Indications for a C-section

• breech presentation

• Cephalopelvic disproportion

• Nonreassuring fetal status

• Placental AB

• Placenta previa

• Umbilical cord prolapse

• Congenital malformations

• High risk preg: + HIV status, HTN disorders, DM, active genital heroes lesions

• Previous C-section

• Dystopia

• Multiple gestations

• Maternal cardiac or resp disease

C-section post procedure

M for infection and excessive bleeding

Assess for uterine firmness

Assess lochia

Assess for manifestations of pneumonia

Assess for indications of thrombophlebitis

Apply SCDs

Monitor I& O’s

Selection criteria for a vaginal birth after a C-section

• No uterine scars or history of previous rupture

• One or two previous c-section

• Clinically adequate pelvis

No contraindications including: large gestational age newborn, mallresentation

Immediately recognizing a prolapse umbilical cord what should nurse do