Nursing Management Labor and Birth

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Chapter 14

• Nursing Management Labor and Birth

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Admission Assessment Data

• Prioritize data
• What stage of labor?
• Assess for risks.
• Is fetus term? What is EDD?
• Age -G/P Pain- ROM-UCs FM
• Review PNC
• Culturally specific care

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Vaginal Examination

• Know placental site of attachment
• Dilation- opening of cervix 0-10 cms
• Effacement- thinning of cervix 2cm 0 effaced
  paper thin 100 effaced
• Station fetal head in relation to ischial spines
• Membranes- ruptured or intact

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Leopoldss Maneuver

• Used to determine presentation, position and lie.
• Feel fundus for buttocks
• Feel side of abdomen for back and small
  parts-position
• Feel for head in pelvis-position
• Palpate lower uterine segment to see if head is
  flexed or extended. May be engaged.

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Intermittent vs. Continuous Monitoring

• Intermittent- not attached to technology
• Can miss variations in heart tones
• Used more in birthing centers
• Continuous- cannot move
• May lead to unnecessary interventions
• Need skilled person to interpret

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Fetal Heart Tones

• Variabilitypush and pull of sympathetic and
  parasympathetic nervous system
• Variability fetal movement
• Normal FHT- 110-160
• Baseline average over 10 minutes
• Accelerations15 beat above baseline times 15
  seconds

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Variations in Fetal Heart Tones

• Early- Head Compression- start before uc- going
  to deliver
• Variable- mirror uterine contractions- cord
  compression
• Late Deceleration- uterine placental
  insufficiency-non reasuring

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Nursing Interventions

• Variables- Change positions, give oxygen,
  hydration
• Late deceleration-Change positions, give oxygen,
  hydration
• Turn off pitocin
• Inform MD- Document

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Evaluating Fetal Well Being

• Fetal scalp sampling- Evaluate fetal ph
• Pulse oximetry- evaluate O2 sat in utero
• Scalp Stimulation- noninvasive evaluate fetal
  reserve

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Comfort During Labor

• Non Pharmacological- used first
• Support- touch- breathing
• Hydrotherapy- vasodilation
• Acupuncture
• Pharmacological- Analgesia
• Goal is pain relief without compromising fetus

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Anesthesia

• Epidural- most common
• Spinal- more effective- shorter duration
• Side effects- Watch for hypotension
• NSG- Need to hydrate
• General- only used for emergency

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Comfort During Labor

• Promotion of Comfort-Position changes
• Keep clean
• Evaluate odor and color of fluid
• Void
• Provide- support, information, develop trusting
  relationship

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Nursing Assessment

• Continued evaluation of FHTs
• Latent- v/s every 30 minutes. Temp every four hrs
  after rupture every 2 hours
• Active-Every 30 minutes
• Transition every 15-30 minutes

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Active Management

• Become more uncomfortable
• May need pain meds
• Give reassurance and information
• Increase in vaginal secretions
• Ice chips
• Support

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Transition

• Shortest but most intense
• Stay with client
• May loose self confidence
• Refocus- use breathing
• C/O rectal pressure

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Second Stage

• Time to push
• Allow to use own urge to push
• Stay with client
• Support and give encouragement
• Get room ready- Gown support person
• Cleanse perineum

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Delivery

• Place newborn on warmer
• AIRWAY
• Dry
• Keep warm
• Assign APGARS (1-5 minutes)
• Initial newborn assessment

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Fourth Stage

• Evaluate for bleeding
• Bladder emptied?
• V/S every 15 minutes
• Transfer in 1 hr for vaginal 2hrs for C/S