Nursing Management

during Labor and Birth

Shiella May P. Edquibal RN.
 Learning Outcome
Define Key Terms
Assessment of Data during admission
Measure and Evaluate Maternal Status during Labor and Birth
Address non-reassuring fetal heart rate patterns
Fetal Assessment
Comfort Promotion
Assessment in each stage of Labor
Nurses’ role throughout the labor and birth process
Wise nurses are not always silent, but they know when to be
during the miracle of birth.
 Admission Assessments
• Phone and Personal
• Estimated time of confinement (EDC or EDD)
• OB Scores
• Fetal Movement
• Signs of Labor
• Bloody Show
• Membrane Status
 Admission Assessment
• Maternal Health History
• Physical Examination
• Laboratory Status
• Culture and Traditions
 Evaluation of Labor Progress
• Vital Signs
• Vaginal Examination
• Cervical Dilatation and Effacement
• Fetal Descent and Presenting Part
• Rupture of Membranes
• Uterine Contractions
• Leopold's Maneuver
• Continuous Fetal Monitoring
• Fetal Heart Rate
 Fetal Heart Rate
• Reassuring FHR signs
• Non-reassuring signs
• Ominous signs
• https://www.youtube.com/watch?v=xsSQb_p21K4
 Baseline Variability
• Periodic Baseline Changes
• Acceleration
• Deceleration (Early, Variable and Late)
 Nursing Intervention for Non Reassuring
Decelerations
• Notify the physician
• Reduce or discontinue Oxytocin
• Reassurance
• Turn to left side
• Oxygen
• Increate IV fluids
 Comfort Promotion and Management
(Independent)
• Continuous Labor Support
• Ambulation and Position Changes
• Hydrotherapy
• Attention Focusing and Imagery (Doula)
• Massage and Breathing Techniques
 Medications
• Sedations
• Regional Anesthesia
• Epidural
• Spinal Anesthesia
• Combined Spinal and Epidural Anesthesia
• Patient Controlled Anesthesia (PCA)
• Local Infiltration
• General Anesthesia
 Nursing Management during the 3 Stages of
Labor
• 1st Stage of Labor
Time of onset of true labor until the cervix is completely dilated (10 Centimeters)
Early, Latent and transition phase
• 2nd Stage
The second stage of labor begins when the cervix is completely dilated (open), and ends with the birth of your
baby.
• 3rd Stage
Delivery of the baby till delivery of the placenta (5 to 15 minutes)
• 4th Stage
Recovery phase
https://www.youtube.com/watch?v=jFdXx35VR-o
https://www.youtube.com/watch?v=5naQCzDi6aA&list=PL8F9C02DA37A32E73&has_verified=1
 Nursing Intervention and Management
1st Stage of Labor
• Identify and validate Medical History
• Orient patient
• Vital Signs and Baseline FHR and Non Stress Test (NST)
• Carry out admitting orders
• Encourage, Educate, Respect and Listen
• Document
( Frequency of Assessment depends on the hospital protocol)
 Nursing Intervention and Management
2nd Stage of Labor
• Motivate (Push)
• Feedback on progress
• Offering Mirror
• Postioning
• Prepare equipment and instrument for delivery
• Maintain sterility of the field
• Position
• Document
 Nursing Intervention and Management
3rd Stage ( Placenta Delivery)
• Prepare Medication (Uterine Contraction)
• Examine Placenta, Disposal based on protocol
• Prepare for immediate care of newborn
 Case
Candice, a 23-year-old gravida 1, para 0 (G1,P0) is admitted to the labor and birth suite at 39 weeks’
gestation having contractions of moderate intensity every 5 to 6 minutes. A vaginal exam reveals her
cervix is 80% effaced and 5 cm dilated. The presenting part (vertex) is at 0 station and her membranes
ruptured spontaneously 4 hours ago at home. She is admitted and an IV is started for hydration and
vascular access. An external fetal monitor is applied. FHR is 140 bpm and regular. Her partner is present
at her bedside. Candice is now in the active phase of the first stage of labor, and her assessment findings are as
follows: cervix dilated 7 cm, 80% effaced; moderate to strong contractions occurring regularly, every 3 to
5 minutes, lasting 45 to 60 seconds; at 0 station on pelvic exam; FHR auscultated loudest below umbilicus
at 140 bpm; vaginal show—pink or bloody vaginal mucus; currently apprehensive, inwardly focused, with
increased dependency; voicing concern about ability to cope with pain; limited ability to follow directions.
 Activity
Nursing Care Plan
1. Identify at least 1 nursing diagnosis from the case provided
2. Create interventions with rationales
3. Outcome Identification and Evaluation
 Next Topic
• Immediate Newborn Care
• Breastfeeding