Nursing Care of the Family During Labor and Birth

when to go to hospital

“nurses cannot give medical advice”

• call HCP or come to the hospital

• document what instructions/education given

• educate on true vs false labor

true vs false labor contractions 4

• true

regular, stronger, longer, close together

Become more intense with walking

Are usually felt in the lower back, radiating to the lower portion of the abdomen

continue despite use of comfort measures

false labor 4

Occur irregularly or become regular only temporarily

Often stop with walking or position change

Can be felt in the back or the abdomen above the umbilicus

Can often be stopped through the use of comfort measures

considerations false/true labor

for true labor: cervix has to dilate

false labor: often worsened with heat and dehydration

legal tip: emtala

The Emergency Medical Treatment and Active Labor Act

• protects pregnant women during an emergency regardless of their insurance status or ability to pay for care

presume true labor unless a provider certifies otherwise.

nursing care: first stage of labor

• priority

• why?

• what to do after?

priority is assessment (telephone or inperson)

determines health status of woman/the fetus and progress of labor

notify the HCP of the findings

INITIAL ASSESSMENT: SCREENING INTERVIEW 5,6,7

Chief complaint

Prenatal history (GTPAL, labs, OB complications)

last oral intake

Medical/surgical history/Allergies

Cultural/spiritual needs Support system and stressors

PHYSICAL ASSESSMENT 5

Maternal Vital Signs: Baseline temp, BP, HR, RR

Fetal Heart Rate (FHR): Baseline and variability

height and weight

Contractions: Frequency, duration, intensity (palpation or monitor)

fundal height

OB hx

gravidity; parity

potential comps

• hx of vaginal bleeding, gestational hypertension, anemia, pregestational or gestational diabetes, infections (e.g., bacterial, viral, sexually transmitted), and immunodeficiency status

EDB

fundal heiight

fhr

previous birth experience: pain relief, anesthesia, type of birth

tests for rupture membranes

nitrazine

fern test

nitrazine and fern

nitrazine: ph test: amniotic fluid is alkaline compared to urine/pus that is more acidic

fern test: collect specimen and put on clean glass slide. allow to dry; view under microscope for ferning (crystalline pattern)

bloody show 4

• not the same as

• looks/feels

• what increases it/lets it down more

• attributed to

not vaginal bleeding

pink and feels sticky (mucoid nature)

increases with effacement and dilation of the cervix

may be attributed to cervical trauma resulting from vaginal examination or coitus (intercourse) within the preceding 48 hours.

birth plan

should be assessed for mother’s preferences

• pain mt, care team, support person, clothing, culture, feeding method etc

If there is no written plan, the nurse helps the woman to formulate a birth plan by describing the options available and determining the woman’s wishes and preferences

UA assessment

• what parts

• watch for? why?

Frequency: From start of one contraction to start of the next (e.g., every 3-4 mins)

Duration: From start to end of the same contraction (e.g., 60-90 sec)

Intensity: Palpated as mild, moderate, or strong — or measured internally with IUPC

Resting tone: Should be soft between contractions

Watch for Tachysystole: >5 contractions in 10 minutes — may reduce oxygen to fetus and require interventions

Leopold maneuvers

• how?

• why 5

performed using abdominal palpation

estimate fetal size

answer four important questions

• (1) Which fetal part is in the uterine fundus?

• (2) Where is the fetal back located?

• (3) What is the presenting fetal part?

• fetal attitude?

Vaginal examination

• why does it do/why?

• when should it be done?

reveals whether the woman is in true labor

enables the examiner to determine whether the membranes have ruptured

performed only when indicated by the status of the woman and her fetus

bc of risk for infection, monitor

maternal temperature and vaginal discharge

Laboratory and diagnostic tests 4

covid test

urinalysis: clean catch

blood test: cbc, hiv, rh

GBS swap

signs of potential complications 6

Irregularities in FHR pattern

Meconium-stained or bloody amniotic fluid

Maternal temperature ≥38°C (100.4°F)

Foul-smelling vaginal discharge

Persistent bright or dark red vaginal bleeding

uterine and labor abnormalities

fhr irregularities 4

bradycardia or tachycardia

irregular fhr/arrythmias

late/variable/prolonged decels

minimal variability (not due to sleep cycle or medications)

uterine/labor abnormalities 5

More than 5 contractions in 10 minutes (tachysystole)

Contractions lasting ≥90 s

Relaxation between contractions <30 seconds

Intrauterine pressure ≥80 mm Hg or resting tone ≥20 mm Hg (via IUPC)

Arrest in progress of cervical dilation or effacement, descent of the fetus, or both

Nursing interventions/care mgt for women in first stage labor 5

general hygiene: showers, pericare, oral, hair, HH, gowns, linen

oral and IV hydration

elimination:

positioning

AMBULATION

elimination AND I/O

• FIVE TOTAL

voiding every 2 hrs

help ambulate to BR

• if membranes are not ruptured

bedpan

• sit upright

cath

monitor I+O; risk for hypervolemia

labor support by nurse

1. positive reinforcement and support her involvement in birth decisions.

2. Continuity of Care: Same nurse throughout shift if possible.

3. Emotional Support and advocacy

4. Comfort Measures: Help conserve energy and manage pain with accepted methods.

5. Protect Dignity: Maintain privacy and modesty.

Signs that suggest the onset of the second stage 7

• Increase in frequency and intensity of uterine contractions

• Urge to push or feeling need to have a bowel movement

• Involuntary bearing-down efforts

• Verbalizations of feeling out of control or unable to cope

• Increased bloody show

• An episode of vomiting

• Uncontrolled shivering

Nursing Care in Second-Stage Labor: assessment 4

• what are you charting and documenting

• one has 3 subpoints

every contraction and bearing-down effort.

maternal vs: every 5–30 min

fhr/pattern: 5–15 min

10–15 min:

• vaginal show

• signs of fetal descent;

• changes in maternal appearance, mood, affect, energy level, and involvement of partner/coach.

nursing role/interventions latent phase 2/4

help conserve energy

• position of comfort and relaxation

promote fetal descent and onset to bear down

• encouraging position changes, pelvic rock, ambulation, showering.

Active pushing phase 8

1:1 nursing care

conserve energy between contractions

Provide comfort and pain-relief measures as needed

calm env

coaching: pant down, pushing, change positions, etc

Provide emotional support, encouragement, and positive reinforcement of efforts

keep woman and family involved/informed

mirror to watch or touch fetal head

Immediate assessments and care of the newborn 4

skin to skin: most routine procedures can be done on mother’s chest/abdomen

apgar score

airway/respirations

prevent cold stress

if newborn is stable

further assessments can wait till stage 4

Perineal trauma related to birth

• stages and what is affected

• First degree: Skin only

• Second degree: Laceration that extends into the perineal body

• Third degree: Laceration that involves injury to the external anal sphincter muscle

• Fourth degree: Laceration that extends completely through the anal sphincter and the rectal mucosa

Vaginal and urethral lacerations

cervical injuries

episiotomy

L: spontaneous perineal tears

C: Happen when cervix pulls back over baby’s head; Small tears = little bleeding; Big tears = heavy bleeding, may affect future pregnancies

E: Cut in perineum to make more space for baby

Signs that suggest the onset of the third stage 6

Firmly contracting fundus

Uterus changes to globular/ovoid shape from discoid

Sudden dark blood gush from introitus

Umbilical cord appears to lengthen

Vaginal fullness (bc placenta is there) on exam/palpation

visible membranes (amniotic sac) at introitus

third stage nursing care 6

vs every 15 mm

check/assess for placental sep and bleeding

encourage bearing down to expel placenta

oxytocic medication: preventing hemorrhage.

nonpharmacologic and pharmacologic comfort and pain relief measures.

encourage bonding

• skin to skin. introduce parent, breastfeeding, etc

4th stage goal

stable pt in immmediate pp period (1-2 hrs)

nursing care

bp and hr every 15 mins/2 hrs

temp and then q4 X2, then 8

assess

• fundus

• bladder

• lochia

• perineum

fundus

should be fundus is firm (and bladder is empty), with uterus in midline, measure its position relative to woman’s umbilicus.

If the fundus is not firm, massage it gently to contract and expel any clots before measuring the distance from the umbilicus.

Perineum

Assess the episiotomy or laceration repair for redness (erythema), edema, ecchymosis (bruising), drainage, and approximation (REEDA).

• Assess for the presence of hemorrhoids.

nursin support in stage 3

allow bonding and rest

support feeding method

support relationship of family and newborn