Nursing Care of Mother and Infant During Labor and Birth
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Chapter 6Chapter 6
Nursing Care of Mother and Infant Nursing Care of Mother and Infant During Labor and Birth During Labor and Birth
• It is important to remember that every nursing intervention involves the welfare of two patients and the use of skills from:– Medical-surgical and pediatric nursing– Psychosocial and communication skills– OB care
Cultural Influences on Birth Cultural Influences on Birth PracticesPractices
• Role of woman in labor and delivery– Cultural preferences require flexibility
• Role of father/partner in labor and delivery– May be driven by cultural practices
Settings for childbirthSettings for childbirth
• Hospitals- LDR, LDRP
Birth Centers- CNM often attending- Advantages: homelike setting, lower costs- Disadvantages: delay in emergencies
• Home- Advantages: control, no risk of acquiring infection from others, low technology- Disadvantages: most MDs, CNMs won’t attend, delay in emergency, no doctor – patient relationship
Components of the Birth ProcessComponents of the Birth Process
• The Four “Ps”– Powers Contractions– Passage Pelvis– Passenger Fetus– Psyche:
Uterine ContractionsUterine Contractions
• Effect of contractions on the cervix– Efface (thin)– Dilate (open)
• Phase of contractions– Increment (increasing)– Peak (greatest)– Decrement
(decreasing)
• Frequency– Beginning of one to the next
• Duration – Beginning to end of same– > 90 sec. reduce fetal O2
• Intensity (strength)– Mild– Moderate– Firm
• Maternal pushing– When cervix is fully dilated
- analgesia
Four P’sFour P’s
• #1 P = PowersI. Contractions: primary powers of 1st stage of
laborI. Involuntary smooth muscle contractions
a. cause cervix to efface (thin) & dilate (open)b. frequency – time from beginning of one contraction to beginning of next*contractions closer than Q2min may reduce fetal O2 and should be reportedc. duration – time from beginning of contraction to end*persistent duration longer than 90 seconds may reduce fetal O2
Four P’sFour P’s
• Powers (cont.)d. Intensity – strength of contraction (mild,
moderate, firm)e. Interval – amount of time the uterus relaxes
- Blood flow from mom to placenta decreases during contractions & resumes during interval*persistent contraction intervals shorter than 60 seconds may reduce fetal O2
f. Duration of contractions increase while interval between contractions decreases
Contraction cycleContraction cycle
Increment: period of increasing strength
Peak or acme: period of greatest strength
Decrement: period of decreasing strength
Cervical Effacement and DilationCervical Effacement and Dilation
Cervical dilationCervical dilation
Four P’sFour P’s
• Pushing-When cervix is fully dilated and fetus starts to descend-Exhaustion or epidural may reduce or eliminate urge to push-Premature pushing should be discouraged
(increases exhaustion and fetal hypoxia)
Nursing Tip Nursing Tip
• Provide emotional support to the laboring woman so she is less anxious and fearful
• Excessive anxiety or fear can cause greater pain, inhibit the progress of labor, and reduce blood flow to the placenta and fetus
Four P’sFour P’s
• #2 P = Passage-consists of mother’s bony pelvis and soft tissues*measurements must be adequate to allow fetal head to pass through
Four P’sFour P’s
• # 3 P = Passenger: the fetus, placenta, membranes & amniotic fluida. Head – composed of several bones separated by connective tissue called sutures, plus 2 fontanels
*both allow fetal head to change shape as it passes through the pelvisb. Lie – describes how the fetus is oriented to mother’s spine
*99% are longitudinal (parallel to mom’s spine)
Four P’sFour P’s
• Passenger (cont.)c. attitude – normally flexion (most compact) “fetal position”d. presentation – fetal part that enters pelvis 1st
cephalic is most common 1. vertex presentation with head fully flexed is most favorable (smallest possible diameter enters pelvis – 96% of births) 2. breech – a) frank: legs flexed @ hips, extending toward shoulders – most common breech b) full: reverse of cephalic c) footling
e. position – how fetus is oriented in pelvisocciput: describes how head is oriented if fetus is in vertex presentation
The Passenger—PresentationThe Passenger—Presentation
Fetal positionFetal position
Four P’sFour P’s
• #4 P = Psyche • mental state can influence the course of labor
* Anxiety + fear = stress compounds (inhibit contractions, divert blood flow from placenta)* Reduces pain tolerance* Cultural and individual values influence point of view and coping with childbirth
Signs of Impending LaborSigns of Impending Labor
1) Braxton-Hicks contractions (false labor)- prepares cervix to dilate, adjusts fetal positioning
- Irregular contractions2) Increased vaginal discharge – from fetal
pressure. Should not cause irritation or itching
3) Bloody show – thick mucus + pink or dk. brown blood. May be a few days before labor or after labor starts
- Recent vaginal exams
Signs of Impending LaborSigns of Impending Labor
4) Rupture of membranes – infection can occur d/t break in amniotic sac seal, umbilical cord can become compressed. Woman should go to birth facility
5) Energy spurt – “nesting”N.I.: teach women to conserve their strength
6) Weight Loss – r/t loss of extra body water caused by hormonal changes. One to three pounds.
Mechanisms of Labor (Figure 6-9)Mechanisms of Labor (Figure 6-9)
• Also called Cardinal Movements – fetal position changes to adapt to pelvis*Know these in order!
1) Descent: required for all other mechanisms of labor and for birth
– Station describes level of presenting part in pelvis• minus stations above ischial spines, plus stations
below ischial spines • Pg. 129
Birth StationBirth Station
Ohhhh my!!!!Ohhhh my!!!!
Mechanisms of LaborMechanisms of Labor
2) Engagement: presenting part of fetal head is zero station or lower
Often happens before labor in nullipara
3) Flexion: contractions increase head flexion until the chin is on the chest
4) Internal Rotation: pelvic shape causes head to turn until occiput is directly under symphysis pubis-occiput anterior
• Fetus is pushed downward by contractions
Mechanisms of LaborMechanisms of Labor
5) Extension: fetal head must extend once it passes under the symphysis pubis– Must change from flexion to extension so it can
properly negotiate the turn6) External Rotation: head realigns with
shoulders and shoulders rotate to transversally align with AP pelvis
7) Expulsion: anterior, then posterior shoulder are born, quickly followed by the rest of the body
* See text pg. 128
Mechanisms of LaborMechanisms of Labor
When to Go to the Hospital When to Go to the Hospital or Birth Centeror Birth Center
• When contractions have a pattern of increased frequency, duration & intensitynullipara – Q5 min for 1 hourmultipara – Q10 min for 1 hour
• Ruptured membranes• Bleeding other than bloody show• Decreased fetal movement• Any other concern
False Vs. True LaborFalse Vs. True Labor
• False labor – Contractions irregular– Walking relieves
contractions– Bloody show usually not
present– No change in
effacement/dilation of cervix
• True labor– Contractions gradually
develop a regular pattern– Contractions become
stronger and more effective with walking
– Discomfort in lower back/abdomen
– Bloody show often present
– Progressive effacement and dilation of cervix
Nursing care of woman in False Nursing care of woman in False LaborLabor
• Often will observe for a few hours to see if there will be progression
• Often will run a fetal monitor strip to document fetal well-being
• Encourage woman to walk about, which may intensify contractions and bring about cervical effacement & dilation
• If no change, woman is usually sent home to await true labor
• Reassure pt. that symptoms will eventually change to true labor. Encourage pt. to return when she thinks she should.
Monitoring the FetusMonitoring the Fetus
• Normal FHR: 110-120 to 150-160 bpm• EFM: FHR & uterine contraction patterns are
continuously recorded-external or internal (membranes ruptured, dilated 1-2 cm)
Some Terms to Know:baseline rate: rate between contractionsvariability: describes fluctuations, or constant changes in baseline – is a reassuring sign!
• Changes in variab. “saw-tooth” pattern on monitor strip
More on Fetal MonitoringMore on Fetal Monitoring
• More terms to know:Accelerations: rate increases of at least 15 bpm over baseline that last approx 15 secs – reassuring sign (fetus well oxygenated)Early Decelerations: rate decreases during contractions that return to baseline by end – good (results from compression of fetal head)Variable Decelerations: begin & end abruptly, no pattern. Suggest umbilical cord compression or inadequate amniotic fluid.Late Decelerations: rate decrease that doesn’t return to baseline by end – nonreassuring
• Placenta is not delivering enough oxygen to the fetus (uteroplacental insufficiency)
Reassuring and Nonreassuring FHRReassuring and Nonreassuring FHRand Uterine Activity Patternsand Uterine Activity Patterns
• Reassuring patterns– Stable fetal heart rate (FHR) – Moderate variability– Accelerations– Uterine contraction frequency greater than every 2 minutes; duration
less than 90 seconds; relaxation interval of at least 60 seconds
• Nonreassuring patterns– Tachycardia– Bradycardia– Decreased or absent variability; little fluctuation in rate– Late decelerations– Variable decelerations
Nursing response to monitor Nursing response to monitor patternspatterns
• Accelerations & early decelerations are OK, require no response by nurse
• Variable decelerations – reposition the woman first! To relieve pressure on cord & improve blood flow through it.
• Late decelerations – repositioning, O2, increase IV fluid, stop oxytocin, give drugs to decrease contractions
Late DecelerationsLate Decelerations
AA
BB
CC
Amniotic FluidAmniotic Fluid
• Amniotomy – artificial rupture of membranes• Green-stained fluid may indicate fetus has
passed stool• Fetal compromise – respiratory problems at birth
• Cloudy or yellow fluid with bad odor may indicate infection
• Assess FHR for at least 1 minute after membranes rupture
• Nitrazine test: pH paper• Alkaline amniotic fluid turns it dark blue-green or dark
blue
Helping the Woman Cope with Helping the Woman Cope with LaborLabor
Labor support/CoachTeaching• Avoid pushing before cervix is fully dilated – teach
breathing techniques• Support effective pushing along with breathing Providing encouragement (OB team)Supporting/teaching the partner Pg.143
• Teach how labor pains affect the woman’s behavior/attitude• How to adapt responses to the woman’s behavior• What to expect in his/her own emotional responses • Encourage to take breaks and eat meals
Stages and Phases of LaborStages and Phases of Labor
• First stage—dilation and effacement (can last 4 to 6 hours)
• Second stage—expulsion of fetus (30 minutes to 2 hours)
• Third stage—expulsion of placenta (5 to 30 minutes)
• Fourth stage—recovery
Four Stages of LaborFour Stages of Labor
• First stage: dilation – Onset of labor to full 10-cm dilation– Subdivided into phases: latent, active, transitionLatent Phase: (4-6 hrs.)
1 to 4 cm dilation of cervix, mild to moderate contractions from Q20 min down to Q5 min.N.I.: review breathing & relaxation, assess FHR
Active Phase: (2-6 hrs.)4 to 7 cm dilation of cervix, moderate to firm contractions 2 to 5 minutes apart.N.I.: Help coach apply breathing & relaxation strategies.
Four Stages of LaborFour Stages of Labor
Transition: (30 min – 2 hours)dilation 7 to 10 cm, fully effaced; contractions Q 2 – 3 mins, firm. Pt. irritable, rejects support person.N.I.: Support coach, help with breathing & relaxation, focusing, provide praise & reassurance.
Second stage: expulsion (30 min-2 hrs.)Full cervical dilation to birth of infant
Four Stages of LaborFour Stages of Labor
• Third stage: placental stage (5 to 30 mins)– Expulsion of placentaN.I.: examine placenta for completeness
• Fourth stage: immediate postbirth recovery period- p. 148– 1 to 4 hours postbirth – Uterus midline & firmly contracted at or below
umbilicusN.I.: Assess for full bladder, VS Q 15 mins, assess
fundus & massage if needed, assess lochia- no more than 1 pad per hour, no large clots.
Ice pack may be placed on the perineum to reduce bruising & edema.
Vaginal Birth After CesareanVaginal Birth After Cesarean
• Main concern• Uterine scar will rupture• Can disrupt placental blood flow• Lead to hemorrhage• Woman may need more support than other
laboring women – anxious of ability to deliver• Nurse provides empathy and support
Nursing Responsibilities During Nursing Responsibilities During BirthBirth
• Preparing the delivery instruments and infant equipment
• Perineal scrub• Administering
medications• Providing initial
care to the infant
• Assessing Apgar score• Assessing infant for
obvious abnormalities• Examining the
placenta• Identifying mother and
infant• Promoting parent-
infant bonding
Nursing Care Immediately After Nursing Care Immediately After BirthBirth
• Care of the mother– Observing for hemorrhage
• Vital signs• Skin color• Location and firmness of uterine fundus• Lochia• Pain
– Promoting comfort• Keep warm and dry• Ice to perineum to help reduce swelling and bruising
Nursing Care Immediately After Nursing Care Immediately After Birth Birth (cont.)(cont.)
• Care of the infant– Phase 1
• From birth to 1 hour (usually in delivery room)– Phase 2
• From 1 to 3 hours (usually in transition nursery or postpartum unit)
– Phase 3• From 2 to 12 hours (usually in postpartum unit if
rooming-in with the mother)
Phase 1: Care of the NewbornPhase 1: Care of the Newborn
• 1st Phase- birth to 1 hour*Maintain thermoregulation by drying infant, warmer, hat, wrapping when out of warmer*Maintain cardiorespiratory function by wiping & suctioning nose & mouth, cord clampings/s resp. distress:persistent cyanosis, grunting, nostril flaring, retractions, resp. rate ^ 60/min, HR ^ 160 or below 110.*Apgar score: evaluates five factors at 1 min & 5 min*not a predictor of intelligence or abilities*8 to 10- continue to observe, 4 to 7- gentle stimulation.*Less than 3- active resuscitation
Newborn Care-Phase 1 cont.Newborn Care-Phase 1 cont.
• Meds – Erythromycin eye ointmentagainst gonorrhea, chlamydia - Vitamin K to assist in clotting
Assess for anomaliesInspect head & face for symmetry, trauma; look for obvious anomalies (cleft lip, spina bifida); fingers & toes, urination and/or meconium.
Umbilical Cord Blood BankingUmbilical Cord Blood Banking
• This type of blood is capable of regenerating stem cells that are able to replace diseased cells
• Informed consent is essential• Collect blood after cord has been clamped• Blood must be transported within 48 hours of
collection to blood banking facility
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