nursing management during labor and birth

when should a pregnant mom go to the hospital?

amniotic fluid leaking; intense contractions/pain/frequency; increase in bloody show or frank bleeding; decreased fetal movement; s/sx of preE or other complication

what is the initial assessment during the first stage of labor?

estimated DOB, GTPAL, maternal health history; fetal movement, frequency in past few days; other premonitory signs of labor experienced; time frame in previous labors; characteristics of contraction pattern; bloody show and membrane status; presence of supportive adult in household

what is the maternal admission assessment during the first stage of labor?

maternal health history, birth plan, physical assessment - fundal height measurement, uterine activity, status of membranes, cervical dilation and degree of effacement, station, FHR, position, pain level

what is PROM?

premature/passive rupture of membranes; at term and not in labor

what is PPROM?

premature rupture of membranes; not in labor

what is SROM?

spontaneous rupture of membranes; water breaking; membrane breaks naturally

what is AROM?

artificial rupture of membranes; dr has to break the amniotic sac manually

how to diagnose rupture of membranes?

nitrazine + pooling + fern test; speculum exam; cervical fluid collected and viewed under microscope

what is pooling?

visualization/collection of amniotic fluid on speculum exam

what is ferning?

crystallization of proteins + salt

what does the nitrazine testing for ROM indicate?

alkaline = membranes ruptured; blue-green = pH 6.5, Blue gray = pH 7.0, deep blue pH 7.5

acidic = not ruptured; yellow pH 5.0, olive-yellow pH 5.5, olive-green pH 6.0

what are some labs that are completed during the admission assessment?

urinalysis, CBC, blood type, syphilis screening, hepatitis screening, GBS, HIV

what are some signs of possible intrapartum complications?

increased IUP, contractions lasting > 90, tachysystole, abnormal fetal heart tracing, amniotic fluid: meconium-stained, cloudy, foul-smelling; labor dystocia, maternal temp > 38, foul smelling discharge, continuous bright red bleeding

what are some sources of pain during stage 1 of labor?

uterine anoxia, stretching of the cervix, stretching of the uterine ligaments

what are some sources of pain during stage 2 of labor?

distention of the vagina and perineum; pressure of the baby on tissue and organs

what are some sources of pain during stage 3 of labor?

cramping and lacerations

what are some factors that influence pain?

fear and anxiety, fatigue, individual pain tolerance, support, cultural expression of pain, psychosocial factors, preparation, previous experience

What are some clues that mom is coping during labor?

states she is coping, rhythmic activity during uterine contractions such as rocking and swaying, focused inward, rhythmic breathing, able to relax between uterine contractions, vocalization such as moaning and chanting

What are some clues that mom is NOT coping during labor?

states she is NOT coping, crying, tearfulness, tremulous voice, inability to focus or concentrate, panicked activity during contractions, jitteriness, trashing in bed, tense, sweaty

what are some nonpharmacologic measures for pain management?

continuous labor support, hydrotherapy, ambulation and position changes, acupuncture and accupressure, attention focusing and imagery, therapeutic touch and massage, effleurage, breathing techniques, application of hot and cold

what are some pharmacologic measures?

systemic analgesia, regional or local anesthesia, neuraxial analgesia/anesthesia techniques: use of analgesic or anesthetic, continuously or intermittently into epidural or intrathecal space

what is systemic analgesia?

typically administered parenterally through existing IV line; opioids, ataractics, benzodiazepines

what is the nursing care during pharmacological pain management?

assess labor progress, assess pain and coping, assess patient’s labor goals and expected outcomes, assess FHR, efficacy, document, naloxone

what are some precautions with nitrous oxide administration?

side effects of nausea, vomiting, dizziness; current vitamin B12 deficiency; non-reassuring FHR tracing; hemodynamic instability and/or impaired oxygenation

what are some reasons to discontinue N2O?

continued nausea, vomiting, dizziness; no longer desired; evidence of maternal/fetal compromise

what are the contraindications to N20?

acute drug or alcohol intoxication or impaired consciousness; inability to hold face mask; some medical conditions, such as pneumothorax or increased intracranial pressure

what is local anesthesia?

SQ infiltration of tissue

what is regional anesthesia?

spinal, epidural, combined spinal-epidural (CSE), pudendal; patient-controlled epidural, intrathecal (spinal) analgesia/anesthesia

epidural block

continuous infusion or intermittent injection; usually started when dilation > 5cm; affects a region of the body and/or blocks painful afferent (sensory) nerve fibers from transmitting pain stimuli to the cerebral cortex

what is spinal anesthesia?

imminent vaginal delivery or c/s, not suitable for labor; risk of spinal (post-dural) H/A, risk for decreased BP, rapid onset 5-10 min

combined spinal-epidural (CSE)

spinal/epidural administered during same procedure, provides rapid/continuous anesthesia/analgesia, labor or c/s

what are some advantages of epidural/cse?

pain relief, decreased aspiration, no altered LOC, continuous Rx

what are some disadvantages of epidural anesthesia?

decreased BP, urinary retention, immobility, may increase time of 2nd stage of labor, increase risk of low forceps or vacuum assisted

contraindications to regional anesthesia?

clotting disorders including thrombocytopenia, medication allergy, anatomical problems: scoliosis, spinal fusion/anomalies, unable to place

what is some nursing care pre-epidural placement?

educate patient, confirm consents completed, IV bolus/prevent hypotension, obtain medication/equipment, position patient/place BP cuff/pulse ox, continuous FM

what is the nursing care for epidural placement?

time out, position patient for epidural placement

what is the nursing care for post-epidural placement?

assess BP, assess fetal well being, assess pain relief, foley, lateral position, change patient position q 30-60 min, clear liquid diet; safety: independent double checks, pharmacy prepared meds, clearly label solutions and lines, patient monitoring; document

describe general anesthesia

emergency cesarean birth or woman with contraindication to use of regional anesthesia; IV injection, inhalation, or both; thiopental IV to produce unconsciousness → muscle relaxant → intubation, followed by administration of nitrous oxide and oxygen; volatile halogenated agent also possible to produce amnesia

what is some nursing assessment during the second stage of labor?

contraction frequency, duration, intensity; maternal vital signs; fetal response to labor via FHR; amniotic fluid with rupture of membranes; coping status of woman and partner; coping/pain, fetal descent

what are some nursing interventions during the second stage of labor?

supporting woman and partner in active decision making; supporting involuntary bearing-down efforts and encouraging no pushing until strong desire or until descent and rotation of fetal head well advanced; providing instructions, assistance, pain relief; using maternal positions to enhance descent and reduce pain; preparing for assisting with delivery; d/c foley; ensure adequate hydration

what are some nursing assessment during the third stage of labor?

placental separation, placental and fetal membranes examination, perineal trauma, episiotomy, lacerations

what is a first degree perineal tear?

superficial

what is a second degree perineal tear?

tear partially through perineal muscle tissue

what is a third degree perineal tear?

partially into rectal tissue

what is a fourth degree perineal tear?

through rectal tissue

what are the nursing interventions during the third stage of labor?

instructions to push when separation apparent; giving oxytocin if ordered; assisting woman to comfortable position; providing warmth; applying ice to perineum if episiotomy/laceration; explaining assessments to come; monitoring mother’s physical status; recording birthing statistics; documenting birth in birth book

what are some nursing assessments done in the third stage of labor?

v/s q 15 min, Apgars: 1 min, 5 min; observe for placental separation; assess fundus/lochia following delivery of placenta

what are some benefits of skin to skin contact?

thermoregulation, stabilization of vital signs, initiation of breastfeeding, transfer of good bacteria, pain control, improves bonding

what is the nursing care in the fourth stage of labor?

fundal check/lochia assessment, vitals, recovery, pain assessment, breastfeeding, rest, nutrition/hydration

what are some nursing interventions during the fourth stage of labor?

support and information, fundal checks, perineal care and hygiene, bladder status and voiding, comfort measures, parent-newborn attachment, teaching