Nursing Care During Labor & Birth

psychological birth

no epidural

labor triage

assess done prior to admission to "rule out" labor, admission

assessment done prior to admission to "rule out" labor

true vs false labor, ask pt (ctx/leaking fluid/vaginal bleeding/fetal movement), monitor FHR, SVE

admission

maternal health hx, physical/fetal assess, labs

maternal health hx

prenatal records, summary of visits, u/s+screening+dx tests, labs, chart review, ob/meds hx, current meds

physical assessment

vs, pain, safety, last po intake, uterine activity, fetal lie, sve

fetal assessment

EFM (assess fetal well being/baseline), continuous vs intermittent

labs

CBC, T/S (rh), UA, if not PNR: VDRL/RPR, HbaAg, HIV, GBS

induction/augmentation methods

induction, augmentation, soft cervix only, give meds when ending pregnancy, bishop score, cervical ripening, oxytocin, uterotonic

induction

"creates labor", starts labor process

augmentation

"changes labor", strenthen/modify labor

bishop score

determines cervical readiness, over 8

cervical ripening

ideal pt: solid cervix, mechanical methods, meds prostaglandins

cervical ripening mechanical methods

membrane sweep (not breaking water), amniotomy - AROM (water break w/crochet hook), foley bulb (60-120cc, dilates 3-4)

cervical ripening meds

dinoprostone (2 forms/vaginal insert/gel/1st), misoprostol (oral/gel), can cause tachysystole (requires frequent ctx/fetal assessment), cannot use if prior c/s

how long must you wait to administer oxytocin

dinoprostone 1 hr, misoprostol 4 hrs

oxytocin (pitocin)

stimulates uterine smooth muscle, high alert med, must obtain cat.1 tracing before using, monitor adverse s/s, contraindications

high alert meds

always use pump, port closest to pt, start slow/go slow, every 30mins-1 hr go up 1-2 mm when they have ctx 2-3 mins apart that last 40-60 sec

adverse effects

tachysytole/hypotension (early s/s), water intoxication (late s/s, 12-24 hrs/long term use)

contraindications

fetal malpresentation, placenta previa, prior classical c/s incision (vertical cut), tachysystole, fetal distress

uterotonic

ctx med, give after baby is born

nursing care during labor

support pt involvement, ongoing care/assessment

support pt involvement

room/unit orientation, assess level of edu, discuss monitor/strap/lines, encourage upright position, pt voids frequently

ongoing care/assessment

vs, cervical exams, fhr, ctx, rom (thin clear fluid), pain/coping

vs for latent phase

FHR (IA): q60 mins, ctx/vs:q30-60mins, temp: q4h until water breaks/q2h if rom

vs for active phase

FHR (IA)/ctx/vs: q15-30 mins, temp: q4h until water breaks/q2h if rom

labor pain: what to expect

understanding labor pain, types of pain, gate control theory

understanding labor pain

pain is subjective, influencing factors: fear/anxiety/past expereinces/prep/expectations

types of labor pain

visceral (organ pain/early stages), somatic (sharp/burnign/ring of fire/crowning, 2nd stage of labor), abnormal (constant pain)

a neural "gate" can block pain signals from reaching the brain

gate control theory of pain

visceral pain (1st stage)

uterine ctx, effacement/dilation, uterine ischemia during ctx, diffuse/cramping/difficult to localize

somatic pain (2nd stage)

fetal descent, stretching pelvic floor/vagina, perineal distention/crowning, sharp/localized pain

nonpharm strategies

continuous labor support, breathing/relaxation technique

pain management

pharm (local/inhaled/systemic/neuraxial)

local/regional

local (lidocaine), regional (pudendal nerve block/ring of fire pain), for sharp perineal pain (laceration repair)

inhaled analgesics

nitrous oxide, laughing gas, 30 sec before start of ctx, pt has to hold it

systemic

cross placenta, fentanyl, morphine, butorphanol

systemic shortest to longest acting

fentanyl (peak 30-60 mins), butorphanol (1-3 hrs), morphine (3-4hrs)

neuraxial

epidural (indwelling catheter says in back/cant walk), spinal (shot/c/s), CSE (combined spinal/edpidural, able to walk around)

nursing considerations: epidurals

procedure, complications

procedure

labs/iv, consent, prophylactic fluid bolus, positioning, vs q 5 mins, continous efm, bladder care

complications

n/v, hypotension, pruritus, urinary retention, dural puncture (wet tap), intravascular injection

intrauterine resuscitation interventions

stop uterotonics, reposition, iv fluids/o2, tocolytics

2nd stage of labor: 10 cm to 10 toes

best practice, labor down, core nursing role

best practice

spontaneous/non directed pushing, maternal choice of position

labor down

passive fetal descent, involuntary urge push

core nursing role

avoid aggressive "closed glottis" pushing, try every other ctx

2nd stage of labor laceration/episiotomy

perineal tears, defined by depth, increased risk (nulliparity/macrosomia/malpresentation/instrumented delivery/episiotomy)

episiotomy

incidion performed by hcp, routine episiotomies not recommended

superficial tear

1st degree

involves some pelvic floor musculature tear

2nd degree

involves anal sphincter musculature tear

3rd degree

complete tear of anal sphincter and partical tear of rectum

4th degree

2nd stage of labor: nursing care

s/s, pt centered pushing, delivery prep

s/s of 2nd stage

perineal bulging, labial separation, amniotic fluid changes, rectal pressure, involuntary bearing down

pt centered pushing

open glotting pushing (short 6-7 second pushes w/ exhalation laboring down 90m)

delivery prep

notify hcp, set up table, delivery time, dry/warm baby, sts

3rd stage newborn immediate care

dry/stimulate, apgars, security measures, skin to skin (natural oxytocin)

3rd stage of labor: delivery of placenta/membrane

s/s placental separation (hard/rounded shape, dark blood, lenghtening umbilical cord), after placenta separates (one last push, assess placenta/membrane intactness)

4th stage of labor: recovery

delivery of placenta=clincial stable (1-4 hrs), vs (1st hr:q15, 2nd hr:q30mins), fundus/lochia/perineum, pain, post anesthesia (motor/sensory fx, bladder/urinary retention), bonding