Care of the Client During Childbirth

Lecture Eight: Care of the Client During Childbirth

NURS 2208

T. Dennis RNC, MSN

   
Maternal Assessment

• Review prenatal Hx
• Present complaint
• Vital signs
• Weight
• Lungs
• Fundus
• Edema
• BP < 130 systolic and < 85 diastolic or no more than 15-20 mm Hg rise in systolic pressure over baseline BP in early pregnancy
• Pulse 60 – 90 bpm
• Respirations 14 – 22
• Hydration
• Perineum
• Labor/ Fetal status
• Laboratory evaluation
• Cultural assessment
• Preparation for childbirth
• Response to labor
• Anxiety
• Sounds during labor
• Support system

Prenatal Hx/ Present Complaint

• Present on the Labor and Delivery unit by 36 weeks
• Contains baseline assessment findings, lab values and any high risk indicators
• Review when patient arrives on the floor
• What is your EDB?
• Are you having any contractions?
• Are you having any pain? Where? On a scale of 1 – 10?
• Have you had any leaking of fluid or bleeding?
• What brought you to the hospital?

Vital signs

• BP < 130 systolic and < 85 diastolic or no more than 15-20 mm Hg rise in systolic pressure over baseline BP in early pregnancy
• Pulse 60 – 90 bpm
• Respirations 14 – 22
• Pulse ox 95% or greater
• Temperature 98 – 99.6 F
• Weight: 25 – 30 lbs greater than pre-pregnant weight (weight gain > 30 lbs edema, obesity)

 

System Assessment

• Lungs: auscultate, normal breath sounds clear and equal
• Fundus: Measure in cms, at 40 weeks’ gestation located just below xiphoid process
• Edema: Slight amount dependent edema
• Reflexes: Check deep tendon reflexes for hyperactivity, check clonus
• Hydration: Normal skin turgor

Labor Status

• Uterine contractions: palpate for frequency, duration and intensity toestablish pattern, explain & apply External Electronic Fetal Monitor (EFM) tocodynometer (TOCO) for permanent record.
• Document as mild, moderate or strong.
• Evaluate relaxation phase.

Sterile Vaginal Examination

• Perineum: Assess for leaking fluid or ruptured bag of water (BOW), vaginal bleeding, bloody show
• Assess cervical dilatation (fingertip to 10 cms), effacement (0% to 100%), station (-4 to +4), Ballotment, position (ROA, ROP, etc.).
• Assess membranes: Intact, leaking, or ruptured.

Assess Membranes

• If rupture BOW is suspected, do a nitrazine and fern test prior to vaginal examination.
• Nitrazine tape will not turn if not ruptured or leaking. Nitrazine will turn blue or blue green if fluid is leaking. Checks pH-amniotic fluid is alkaline. Ferning will appear under microscopic exam.
• Check color and odor: Green means meconium; foul odor means amnionitis

Fetal Status

• Leopold’s maneuvers to determine: the number of fetuses, the fetal lie, attitude, presenting part, degree of fetal descent, and fetal Point of Maximum Intensity (PMI) for FHR.
• Evaluate EFM strip to determine baseline, variability, periodic and nonperiodic patterns.
• Evaluate fetal activity.

Laboratory Evaluation

• CBC: Hgb…12-16 g/dL; Hct.. 38% - 47%
• RBC: 4.2 – 5.4
• WBC: 4500 – 11,000 ( may be 20,000)
• Platelets: 150,000 – 400,000
• Urinalysis: WNL
• Serologic testing: Positive may require follow-up titre
• Rh factor

Cultural Assessment

• Do you have a birth plan?
• Who would you like to remain with you during your labor and birth?
• What would you like to wear during labor?
• What activity would you like during labor?
• What position would you like for birth?
• Is there anything special you would like?
• Remember privacy.

Psychosocial Assessment

• Preparation for childbirth
• Response to labor
• Anxiety
• Sounds during labor
• Support system

First Stage of Labor:
LATENT Phase

• 0 – 3 cms dilation
• Q 3 – 30 min, contraction (ctx) frequency
• 20 – 40 sec, ctx duration
• Mild to moderate intensity on palpation; 25 – 40 mmHg with Intrauterine Pressure Catheter (IUPC)
• Baseline Sterile Vaginal Exam (SVE)

Care During the First Stage: Transition Phase

• Encourage side-lying position, pillows for support
• Evaluate physical parameters: BP, P & R every 30 min. If abnormal, increase monitoring and notify MD/CNM
• Evaluate FHR every 15 minutes.
• Encourage breathing patterns (first level and second level), back rubs, and sacralpressure.
• If hyperventilation occurs, have client breathe into cupped hands.
• Encourage to void every 1-2 hrs,
• Offer fluid in the form of ice chips, ointment for lips.
• Change chux frequently.
• Encouragement and assurance is important. Hyperesthesia may occur.
• A “bearing down” sensation is experienced.

The Second Stage of Labor

• 10 cms dilation (Complete)
• Pushing with contractions
• Q 1 1/2 – 2 min, contraction (ctx) frequency
• 60 – 90 sec, ctx duration
• Moderate to strong intensity on palpation; 70 – 90 mmHg with Intrauterine Pressure Catheter (IUPC)
• SVE increase to check progress
• Nullipara’s ready with a bulge, Multips sooner

Care During the Second Stage (pg.567- 568)

• Encourage side-lying position, pillows for support
• Evaluate physical parameters: BP, P & R every 5 - 15 min. If abnormal, increase monitoring and notify MD/CNM
• Evaluate FHR every 5 - 15 minutes.
• Assist with positioning ; Left lateral, Squatting, Semi Fowlers, & Hands and knees .
• May need straight catheterization
• Offer fluid in the form of ice chips, ointment for lips.
• Perineal massage with lubricant may be used.
• Encouragement and assurance is important.
• Pushing begins.

Care During the Second Stage (pg.567- 568)

• Assist in pushing, dry gown, ice chips, “cheer”.
• Prepare equipment and materials for delivery, turn on radiant warmer.
• Assist into birthing position.
• Wear protective clothing.
• Assist physician and/or midwife.
• Support significant other/family members .
• Prepare emergency medications.
• Keep informed of process and procedures.
• Panting exercise to prevent delivery of the head.
• During restitution and external rotation, the physician supports the perineum.
• Infant is delivered. Time is recorded.
• Football hold is used.
• Newborn’s mouth, then nose is suctioned. Cord is clamped/cut.

The Third Stage of Labor
(pg.573- 574)

• The uterus rises upward in the abdomen because the placenta settles downward into the lower uterine segment.
• Umbilical cord lengthens as placenta proceeds downward.
• A sudden trickle or spurt of blood appears.
• The uterus changes from discoid to globular shape.

Care During the Third Stage
(pg.573- 574)

• Palpate uterus to check for ballooning
• Client may push to aid in the expulsion of the placenta, cord traction applied, and/or fundal pressure.
• Encourage breathing to enhance relaxation
• After placenta is expelled, checked for “Shiny” Shultz or “Dirty” Duncan. Time is recorded.
• Examined by physician. May be sent to pathology for further inspection.
• Cord blood is obtained for Type, RH and Sickle cell testing.
• Different cultures have different beliefs about the afterbirth. “El companero” in Mexico. Buried in some societies. May be used for genetic testing, as well as cord blood studies done.

The Fourth Stage of Labor or The Recovery Period (pg. 574 – 576)

• Period immediately following the expulsion of the placenta.
• Lasts 1 to 4 hours.
• Episiotomy or lacerations are repaired.
• Uterus is palpated frequently to ensure it remains firmly contracted.
• Maternal and family bonding occurs during this period.
• Client may be wide awake, fatigued, usually very thirsty and hungry
• Infant is printed and banded.

Care During the Fourth Stage
(pg.575- 576)

• Change chux and linen after. episiotomy/laceration repair and perineal inspection by the physician.
• The perineum is cleansed and a maternity pad is applied.
• An ice pack may be applied to the repair site or to the perineum.
• If stirrups are used, both legs are removed from the stirrups at the same time.
• Parents are given time to bond with infant.
• Asses BP, P, R, firmness and position of fundus, and amount and character of vaginal blood flow every 15 minutes for the first 1 to 2 hours.
• Deviations from normal require more frequent checks.

Maternal Adaptations Following Birth (pg. 575)

• BP returns to pre-labor levels.
• Pulse is slightly lower than in labor
• Uterine fundus is in the midline at the umbilicus or 1 -2 fingerbreadths below the umbilicus.
• Lochia is rubra (red), small to moderate amount (from spotting on pads to ¼ to ½ of pad covered in 15 minutes.
• Bladder is nonpalpable.
• Perineum should be smooth, pink, without bruising or edema.
• Wide variations in emotional states may be experienced: excited, exhilaration, smiling, crying, fatigued, verbal, quiet, and/or sleepy.
• Tremors may occur.

Precipitous Birth (pg 577-579)

• Vertex presentation
• Breech presentation

Danger Signs during Fourth Stage (pg. 576)

• Hypotension
• Tachycardia
• Uterine atony
• Excessive bleeding
• Temperature >100

Assessment of the Client (pg 569-573)

• Initial care of the newborn
• Placed on Mother’s abdomen or under radiant warmer where parents can see the infant
• The first priority is respirations
• The newborn is placed in a Trendelenburg position to facilitate drainage of mucus from the nasopharynx and trachea
• Then suctioned with a Bulb syringe or a DeLee
• The second priority is to provide and maintain warmth
• The apgar score is rated at 1 minute and 5 minutes (see handout)
• Care of umbilical cord
• Cord blood collected
• Abbreviated assessment
• Infant Identification

Questions?

Ms. Brown has dilated to 5 cms. Her physician has just inserted and started her epidural. What is an appropriate nursing intervention for Ms. Brown at this time?

 a) Limit fluid intake

b) Monitor bladder status

c) Assist with ambulation

d) Observe for tetanic contractions

This female patient had experienced several episodes of false labor and as a result, she and her husband were well known to our staff. When she finally did give birth, I slipped into her room to congratulate her. There she sat, enthroned in the bed like a queen, with her husband beside her just finishing their lunch.

“So Anita,” I asked. “What did you have?”

Triumphantly, she announced, “I had the sphagetti.”

Medical Blooper for … A Chuckle A Day®…from the medical community

  DOWNLOAD PPT NOTES : Lecture 8

Source : Abraham Baldwin Agricultural College

About: ABAC Enrollment Fall 20113,248 students from 17 states, 22 countries, and 149 Georgia counties