Вы находитесь на странице: 1из 7

Chap 7 Nursing care during labor

Labor and delivery process is an exciting, anxiety provoking, and


rewarding experience for the mother and the infant.

The primary goal of nursing is to ensure the best possible


outcome for the mother and infant.

Nursing care focuses on establishing a meaningful relationship


with the mother, determining fetal status, encouraging the
mother’ self direction, and proving support to the mother.

Birth settings

Independent birthing centers natural child birth is the emphasis


without drugs. Nurse midwife, delivery fetus.

Home birth; natural childbirth encouraged delivery done by nurse


midwife or MD

Traditional hospital setting.

Alternative births settings give the mother more control over the
birthing process

Limited when emergency occurs

Hospital more controlled setting and better able to deal with the
problems, however multiple rules to follow.

In hospital birthing rooms provide home like setting.

Freestanding centers out of hospital birthing centers home


setting at an ambulatory health facility.

Home birth midwife helps with that. This is less expensive but
involves risks.

Cultural considerations regarding modesty, pain, position,


female care provider, support person, if the patient’s wishes are
respected they will feel more comfortable. Avoid ethnocentrism.
When to go to the hospital

Admission to the hospital

• Onset of regular contraction that increase in frequency,


strength and duration
• Rom
• Bloody show/ mucous plug.

Preadmission forms; review and update

Care plans; is a major challenge for the nurse all care plans are
individualized

Data collection and admission procedures; record VS, record FHR


with monitor, ID bracelet, history done include allergies, last food
taken, assess uterine contraction determine if ROM has occurred,
obtain consents, check labs, orient pt to unit.

Physical exam

• 20-30 minutes baseline EFM is required


• Palpate uterine contraction at fundus
• Record duration, frequency and intensity of contraction.
• Leopolds maneuvers- used to palpate the abdomen to
determine position, presentation and engagement of the
fetus.
• Fetal heart rate is assessed by auscultation using Doppler or
fetoscope
• FHR <100 and >160 should be reported.
• Take FHR immediately after ROM to check for prolapsed cord
• FHR also taken post each vaginal exam, adm of meds, or
abnormal fetal activity.
• FHR tracings are part of the chart.
• Assess the membranes and fluid for color, amount, odor, and
time of rupture.

Nursing care of pt in false labor;


• EFM is done
• The mother is encouraged to walk so they can acess for
contractions
• Use nitrazipine paper to assess the fluid and determine as
amniotic, urine or vaginal secretions. If amniotic, paper will
turn blue
• may also check fluid under microscope when dry, will form a
fern pattern on slide known as ferning
• if membrane is ruptured the pt will be admitted to avoid
infection and prolapsed umbilical cord.

Focused data collection for first and second stages of labor

Monitoring fetal heart rate; should be between 110 and 160 bpm
if less or more the MD should be notified. The best way to
auscultate a fetal heart rate is thru it’s back. Do the leopolds
maneuver first to assess the position of the fetus. When you hear
the heart rate take that mother’s at the same time to see if they
synchronize if they do then you have to take the fetal heart rate
at a different site cause they should be different

Intermittent fetal heart rate monitoring during labor

Continuous electronic fetal monitoring during labor

Documenting electronic fetal monitoring;

• Reassuring and nonreassuring patterns


• Accelerations; when fetal heart rate accelerates
• Decelerations; when fetal heart rate decreases
• Fetal pulse oximetry normal value 40- 70%. Less than 30
means acidosis hypoxia and rapid delivery of baby

This info is now accessed on computer.

The nurse’s role;

• Document progress of labor


• Reports any abnormalities
• Provides support
• Prevent infection
• Promote comfort
• Assess cervical dilation via vaginal exam
• Keep pt NPO while in labor, ice chips only
• Keeping a close eye on the FHR for any abnormalities.

Mother may hire doula for labor process.

The birth; s/s of imminent birth. Sitting on buttock, making


grunting sounds involuntary bearing down with contraction.
Bulging of the perineum. If any of these s/s Do not leave patient,
summon help.

Types of electrical fetal monitoring

Enternal fetal monitoring the apparatus is attached to the


mother’s abdomen and it cannot measure uterine contraction
intensity.

Internal fetal monitoring; requires ruptured amniotic and cervix


dilation of at least 2 cm. it is inserted into vaginia and placed on
the part of the baby that is presenting most likely the head never
on face or fontanelles or genitalia. able to record uterine
contraction as well with a pressure tranducer.

In repeated late deceleration notify MD

Nursing; if on oxytocin discontinue, KVO, turn to left lateral sim’s,


and administer 8- 10 liters of oxygen

Monitoring uterine contraction; palpate fundus and record the


contraction.

Determining fetal position by abdominal palpation


Monitoring status of amniotic fluid; nitrazine paper to test.
Amniotic fluid should be clear. If green than presenceof
meconuim, if red/ pinkish than blood and if smelly than infection.

Amniofusion; is the infusion of warmed normal saline or ringer


lactate solution into uterine cavity after the amniotic membranes
have ruptured. Done to decrease the compression of the umbilical
cord, increase fluid when oligohydramnios, dilute meconium in
the uterine cavity and reduce risk of meconium aspiration.

The nurses role;

• Assist mother to position self, may be lithotomic, squatting


or side lying.
• Cleanse the perineum
• Prepare delivery table
• Continue EFM
• May need episiotomy
• MD or NM will deliver
• Assist as needed

Supporting the partner

The doula

Teaching

Water birth

Birth of the baby

Nursing care during the delivery

Expulsion of placenta

• The uterus will begin to shrink after the birth


• This will cause the buckling of the placenta and it will release
itself from the uterine wall
• As uterus contracts it is expelled
• Usually 15-30 minutes later/ post birth.

Signs of placenta delivery

• Cord lengthens
• Gush of blood
• Vagina
-Elevation of the fundus
• Risk for hemorrhage in this stage, monitor v/s
• Administer pitocin post delivery of placenta.

The immediate recovery period; last 1-4 hr post delivery

• Mother recovers physically


• Hemorrhage is greatest danger for 1st hour
• Check fundal height for position and firmness
• Check for uterine atony (bogy uterus)
• Massage uterus prn to maintain firmness
• Note color and amt of vaginal discharge
• Assessment is done q 15 min for one hour
• Encourage bonding
• Initiate breast feeding

Immediate care of the newborn;

Nursing care of the newborn in the delivery room

• Maintain thermoregulation
• Cardiorespiratory support
• Identification and clamping cord
• Doc urination and passage of meconium ( must be passed
within 24 hr of birth the first temperature on baby is rectal
to check for patency.)
• Perform brief assessment of newborn
• Place baby in radiant warmer
• Aspirate the mouth and nose
• Use blow by O2 if cyanotic
• Stimulate breathing by warming, manual stimulation
suction, or O2 adm bag/mask, rescucitate the infant
• Apgar score at one minute and five minutes.
• Administering vitamin K
• Prophylactic eye care
• Observing for abnormalities
• Umbilical cord blood bank
• Cord clamped is placed on umbilical stump and the stump
for 2 and 1 vein
• Erythromycin in eyes to protect against Chlamydia and
gonorhea

Phase 2 and phase 3 care of the newborn

Emergency delivery by the nurse;

• No MD or NM present
• Common in multipara women
• Sterility is not a priority
• Controlling the birth of the head no 1 priotity
• Will prevent maternal laceration and trauma to the head
• Mother to pant to control descent of head never push head
back
• Check to see where the cord is
• If around gently loosen and lift over
• If cord is tight clam in 2 places and cut
• Suction nose and mouth
• Major interventions stay calm and supportive provide
cleanliness, control birth of infant

Вам также может понравиться