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33 terms

2145 Nursing Care of the Laboring Woman

What do you do first with an emergent hospital admission - 3 areas of focus assessment?
3 Areas of Focus Assessment:
1. Impending birth- S/S of baby coming
2. FHR decels? Variability present? Baseline wnl? Accels?
3. Maternal VS. PIH? Shock?
How would you know if the baby is coming?
Increasing DIR of contractions, more bloody show, "I have to have a BM"
See crowning- not much time- be calm, gloves, get help. Mom bears down- hurry
Perineal bulging ok- have more time
-SROM w/ fetal presenting part- gloves- get help, be ready to support perineum and ease baby out
-Mom's behavior may be out of control- scary to her- calm voice, one word directions, may eye contract w/ her is possible
Hospital admission w/ possible SROM
1. 'My water broke', 'I feel wet all the time', 'I think I peed on myself'. clear might have white flecks
2. All need assessment ASAP to be sure the membranes are ruptured and assess fetal status
3. pelvic exam w/ speculum, hips elevated, light, pt coughs look at cx, pooling of fluid
4. Nitrazine paper will turn from yellow-green to dark blue pH >6.5 (alkaline). screening tool only b/c blood is also alkaline. urine is acidic.
5. dab on clothing if clothing is wet, otherwise use speculum and put on nitrazine paper and slide
6. slide fern pattern under microscope/ ultrasound exam for assessment for fluid
SROM/AROM how and what to assess (8)
PC: Fetal Distress Stat
1. Possibility of cord prolapse if fetal presenting part is not engaged
2. Note FHR pattern, is there distress?
3. IF bradycardia/distress: stat vaginal exam to rule out prolapsed cord
4. If cord present: push presenting part off cord until baby is born by ER C/S possibly place pt. in knee chest position
5. Amount of fluid
6. Color of Fluid
7. Clear w/ flecks of white- WNL
8. Green- meconium indicates possible fetal distress so use continious EFM, poss amnioinfusion of NS to thin mec to prevent meconium aspiration syndrome in newborn
Prolapse of umbilical cord - what to do (4)?
1. Stay calm
2. Call for help- MD, RN
3. Restore blood flow to fetus, move presenting part off umbilical cord
4. prep pt. and family for emergency C/S
SROM/AROM- "Heart Taco" (6)
1. Risk for Infection
2. Always note and chart:
FHR (Heart),(T) time of rupture, (A)amt. of fluid, (C)color of fluid, (O)odor, maternal rx, caregiver notified
3. Goal: Delivery before 24 hours
4. Some authorities concerned if 12-18 hours
5. Limit vaginal exams, use sterile gloves
6. Perineal care PRN to promote comfort
What to do for a regular admission (7)
1. Obtain and read prenatal hx- pt assessment starts
2. Greet pt, intro self- explain how you are there to help her birth, orient to enviornment, 'eyeball' assessment
3. What are the family/pt expectations? Birth plan?
4. Pt. gown, underwear off, urine specimen
5. EFM on for 20 minute strip is standard and maternal VS
6. Cervical check vs. pt admit record
7. Notify doctor, IV start, labs
What are the admission labs (4)?
1. Read prenatal hx- baseline info blood type and antibody screen, Hep B surface antigen, Rubella immune status- titer reading,
2. Group B strep + IV antibiotics stat (maybe do 1st)
3. CBC, type and screen if C/S, platelet, blood type & Rh
4. UA for protein and glucose
5. HIV and other STD results
Assessment of VS/EFM (5)?
1. Mom's Temperature: q2hr if ROM or q4hr if membranes intact
2. BP, Respirations: q 1 hour is WNL
3. Stage 1- FHR q15-30 mins, Mom's P, BP, RR q1 if WNL
4. Stage 2- FHR q5 mins, Mom's p, BP, RR q1hr if WNL
5. More VS if abnormal
Pitocin Augmentation/ Induction (5)
1. Follow hospital protocol
2. Always use EFM
3. Always use IVPB as IV route for labor
4. Dose: 1-2 mU/min can increase slowly to achieve effective pattern of labor
5. Max: 20mU/min
PURR through labor
P- position changes- use gravity and keep mom moving
U- urinate q2hrs
R- Relax, do what is needed to facilitate
R- Respiration- encourage mom to breath in a helpful manner
Squatting during labor advantages (5) & disadvantages (2)
1. gravity helps
2. straightens pelvis
3. increases pelvic diameter
4. promotes effective pushing
5. able to rub back
1. knees & hips may hurt
2. tiring
Use of Birth Ball (2)
1. Motivated pt
2. No epidural
Stage 2: Pushing (6)
1. Teach mother about pushing before she gets to 10 cm- what it will feel like (pressure, BM, bear down, breathe in & push down)
2. Discuss with her: positions, limit breathing holding only 6-8 seconds to limit fetal hypoxia, when to begin pushing, sounds she may make
3. Change maternal position q20-30 mins
4. Tell her when she needs to push (10cm)
5. Tell family that pushing is noisy business and the fetal head may look scary
6. Consider waiting until mom feel urge to push, labor down w/ epidural
7. squatting increases pelvic outlet by 23%
8. semi-sitting good for epidural
9. sidelying may help a posterior baby turn to anterior
Birth of Infant before & after (9)
1. Notify MD of immediate birth
2. Room set-up, warmer on, equipment set up
3. As baby crowns- possible perineal prep, support perineum and fetal head prn
4. Notify baby RN, peds and nursery (need 2 people to care 1 for mom, 1 for baby)
5. Assist w/ positioning of mother
After birth
6. Look at family- fainting?
7. Note time of birth, CAN, nuchal, meconium, vd? breathing? APGAR?
8. Promote attachment
9. Emotional support
Delivery of Placenta (5)
1. Assist Pt to push PRN, note time
2. Note intactness, to lab? Keep cord? Cord blood to lab? Cord blood saved by family?
3. Administer pitocin 10-20mU IV in 1000 LR- gravity flow about 20-40 gtts/min or Methergine, Hemabate prn to contract uterus, not WNL
4. Repair of lacerations, episotomy PRN
5. Palpate fundus, lochia check, correct count
When to go to the hospital Nullipara
regular UC, 5 minutes apart for 1 hour
When to go to the hospital Multipara
regular UC, 10 minutes apart for 1 hour
When to go to the hospital (5)?
1. contractions - increasing regularity & DIF
2. ROM = rupture of membranes
3. bleeding
4. decreased fetal movement
5. other concerns: trauma, infection
Reasons to use forceps and vacuum extraction (4)?
1. maternal exhaustion, inability to push
2. cardiac/pulmonary disease
3. non-reassuring FHR
4. failure of proper rotation
what is ferning (2)?
1. diagnostic tool to determine if fluid is amniotic
2. frosted pattern is only amniotic fluid
Admission assessment of baby (3)
1. intermittent auscultation
2. external fetal monitor
3. baseline, accels,decels, variability, reassuring?
How often to assess low risk baby during latent phase?
1. Q hour during latent phase (early 0-3cm)
How often to assess low risk baby during active & transition phase?
Q 30 minutes during active & transition phases
How often to assess low risk baby during 2nd phase (pushing/birth)?
Q 15 minutes during 2nd stage (pushing)
How often to assess high risk baby during active & transition phase?
Q 15 minutes
How often to assess low risk baby during 2nd phase (pushing/birth)?
Q 5 minutes
What is laboring down?
1. letting woman rest at 10cm until she has urge to push
2. decreases pushing time, maternal fatigue, operative/assisted deliveries, lacerations, swelling, fetal distress (especially 2/ nulliparas)
3. may decrease pushing time in primips to avg of 20 minutes, even w/epidural
upright/lateral position compared to supine for delivery decreases (5)? Increases (2)
1. length of 2nd stage
2. use of forceps
3. need for episiotomy
4. pain scores
5. abnormal FHR
1. maternal blood loss
2. risk of tears
Advantages (2) & disadvantages (2) of standing during labor
1. gravity
2. UC are less uncomfortable & more efficient
1. tiring
2. continuous EFM not possible w/o telemetry
Advantages (3) & disadvantages (2) of sitting during labor
1. gravity
2. can be used with EFM
3. can be done on side of bed
1. may increase suprapubic discomfort
2. UC are more effective when alternate sitting w/other positions
Advantages (4) & disadvantages (1) of side lying during labor
1. restful position
2. prevents supine hypotension
3. promotes effective UC
4. can be used with EFM
1. doesn't use gravity
Advantages (3) & disadvantages (3) of hand and knees during labor
1. reduces back pain
2. can use pelvic rock to ↓ back pain
3. caregivers can rub back
1. hands, wrists & knees can hurt (use pillows)
2. tiring
3. may be embarrassing (use 2 gowns)