CHAPTER13                  Nursing Care during                    Labor and Birth OBJECTIVES       After studying this cha...
Nursing Care during Labor and Birth CHAPTER 13             267Care of the woman and her family during labor and birth isa ...
268     PART III The Family during BirthEstablishing a Therapeutic RelationshipSandra Hall is a nursing student assigned t...
Nursing Care during Labor and Birth CHAPTER 13             269expect from each caregiver. For example, the primary nurse  ...
270     PART III The Family during BirthTABLE   13-1 Intrapartum Assessment GuideWomen who have had prenatal care have muc...
Nursing Care during Labor and Birth CHAPTER 13                    271 TABLE     13-1 Intrapartum Assessment Guide—cont’d A...
272      PART III The Family during BirthTABLE   13-1 Intrapartum Assessment Guide—cont’dAssessment, Method(Selected Ratio...
Nursing Care during Labor and Birth CHAPTER 13                   273 TABLE    13-1 Intrapartum Assessment Guide—cont’d Ass...
274     PART III The Family during BirthTABLE   13-1 Intrapartum Assessment Guide—cont’dAssessment, Method(Selected Ration...
Nursing Care during Labor and Birth CHAPTER 13               275                                                          ...
276        PART III The Family during Birth                                             CARE PATH FOR STAGES OF LABOR 1 & ...
Nursing Care during Labor and Birth CHAPTER 13                              277                                           ...
278        PART III The Family during Birth                                              CARE PATH FOR STAGES OF LABOR 1 &...
Nursing Care during Labor and Birth CHAPTER 13                           279                                              ...
280      PART III The Family during Birth PROCEDURE      13-1         Leopold’s Maneuvers      PURPOS E :   To determine p...
Nursing care of breech delivery
Nursing care of breech delivery
Nursing care of breech delivery
Nursing care of breech delivery
Nursing care of breech delivery
Nursing care of breech delivery
Nursing care of breech delivery
Nursing care of breech delivery
Nursing care of breech delivery
Nursing care of breech delivery
Nursing care of breech delivery
Nursing care of breech delivery
Nursing care of breech delivery
Nursing care of breech delivery
Nursing care of breech delivery
Nursing care of breech delivery
Nursing care of breech delivery
Nursing care of breech delivery
Nursing care of breech delivery
Nursing care of breech delivery
Nursing care of breech delivery
Nursing care of breech delivery
Nursing care of breech delivery
Nursing care of breech delivery
Nursing care of breech delivery
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Nursing care of breech delivery

  1. 1. CHAPTER13 Nursing Care during Labor and Birth OBJECTIVES After studying this chapter, you should be able to: 1. Analyze issues that may face the new nurse who cares for women during the intrapartum period. 2. Explain teaching guidelines for going to the hospital or birth center. 3. Describe admission and continuing intrapartum nursing assessments. 4. Describe common nursing procedures used when caring for women during the intrapartum period. 5. Identify nursing priorities when assisting the woman to give birth under emergency circumstances. 6. Relate therapeutic communication skills to care of the intrapartum woman and her significant others. 7. Apply the nursing process to care of the woman experiencing false or early labor. 8. Apply the nursing process to care of the woman and her significant others during the intra- partum period. Go to your Student CD-ROM for Review Questions keyed to these Objectives. DEFINITIONS Abortion A pregnancy that ends before 20 weeks’ ges- Multipara A woman who has given birth after two or more tation, either spontaneously (miscarriage) or electively. pregnancies of at least 20 weeks’ gestation; also informally Miscarriage is a lay term for spontaneous abortion that used to describe a pregnant woman before the birth of her is being more frequently used by health professionals. second child. Amniotomy Artificial rupture of the membranes (am- Nitrazine Paper Paper used to test pH; helps determine niotic sac). whether the amniotic sac has ruptured. Caput Succedaneum Area of edema over the pre- Nuchal Cord Umbilical cord around the fetal neck. senting part of the fetus or newborn that results from Nullipara A woman who has not completed a pregnancy to pressure against the cervix (usually called caput). at least 20 weeks’ gestation. Crowning Appearance of the fetal scalp or presenting Para A woman who has given birth after a pregnancy of at part at the vaginal opening. least 20 weeks’ gestation; also designates the number of a EDD Abbreviation for estimated date of delivery; also woman’s pregnancies that have ended after at least 20 weeks’ may be abbreviated EDB (estimated date of birth). gestation. (A multifetal gestation, such as twins, is considered Episiotomy Incision of the perineum to enlarge the one birth when calculating parity.) vaginal opening. Primipara A woman who has given birth after a pregnancy Ferning Microscopic appearance of amniotic fluid re- of at least 20 weeks’ gestation; also used informally to de- sembling fern leaves when the fluid is allowed to dry scribe a pregnant woman before the birth of her first child. on a microscope slide; also called fern test. Gravida A pregnant woman; also refers to a woman’s total number of pregnancies, including the one in progress, if applicable. 266
  2. 2. Nursing Care during Labor and Birth CHAPTER 13 267Care of the woman and her family during labor and birth isa rewarding yet demanding specialty within nursing. The Unpredictabilitybirth of a baby is more than a physical event. Birth has deep Birth follows its own timetable, even with efforts to “man-personal and social significance for the family, whose roles age” it. Some nurses find the uncertain nature of an intra-and relationships are forever altered by this event. partum area troubling, whereas others find it exciting. Some The nurse must support natural physical processes, pro- occurrences cannot be predicted or explained. In addition,mote a meaningful experience for the family, and be alert for the number of women needing care and the levels of carecomplications. Additionally, the nurse cares for two clients, they require can change quickly.one of whom—the fetus—cannot be observed directly. The intrapartum area is typically a happy place, and good Intimacyoutcomes for mothers and infants are usual. Most women The intimate nature of intrapartum care and its sexual over-have accepted their pregnancies and look forward to meet- tones make some nurses uncomfortable. They may feel thating their infants. Yet some women have had stressful preg- they are intruding on a private time.nancies because of physical and substance abuse, economic The male nurse often is anxious about this aspect of in-hardship, unsupportive personal relationships, and other trapartum care. Although he may have cared for other fe-problems (see Chapter 24). male clients, his care rarely has been so focused on the re- productive system. He often wonders whether a woman’s male partner will accept him as a care provider. ISSUES FOR NEW NURSES Both male nurses and female nurses should maintainNew nurses and nursing students often approach care of la- professional conduct and take cues from the couple. If theboring women with apprehension. They may face several couple wants privacy, the nurse should intervene only ascommon issues when caring for families during birth. needed to assess the woman and fetus. In more advanced la- bor, both partners often welcome the presence of a compe-Pain Associated with Birth tent, caring nurse of either gender.Working with people in pain is difficult, and most nurses feelcompelled to relieve pain promptly. Yet pain is expected in ADMISSION TO THE BIRTH CENTERlabor and cannot always be eliminated. Some women chooseto have unmedicated births. Helping the woman manage the The Decision to Go to the Hospital or Birth Centerpain of birth is a critical part of nursing care, and many During the last trimester, the woman needs to know whennurses find this to be the most creative aspect of their roles. she should go to the hospital or birth center. Factors to con- sider include:Inexperience and Negative Experiences Number and duration of any previous laborsThe nurse who has never given birth may feel inadequate to Distance from the hospitalcare for laboring women, even though the same nurse rarely Available transportationthinks that experiencing a fracture is necessary to care for Child care needssomeone with that problem. Nursing skills needed by the Nurses instruct women to distinguish between false andintrapartum nurse are basic: observation, critical thinking, true labor. Nurses teach guidelines for going to the birthproblem solving, therapeutic communication, comfort pro- center and reinforce those given by the physician or nurse-motion, empathy, and common sense. midwife (“Women Want to Know: When to Go to the Hos- Nurses also may be anxious because of their own difficult ex- pital or Birth Center”). Not everyone has a typical labor, soperiences during birth. They must be careful not to convey neg- a woman should be encouraged to go to the birth center ifative attitudes to the laboring woman and her significant other. she is uncertain or has other concerns. WOMEN When to Go to the Hospital or Birth Center These are guidelines for providing individualized instruction Bleeding—Bright-red bleeding should be evaluated to women about when to enter the hospital or birth center. promptly. Normal bloody show is thicker, pink or dark red, Contractions—A pattern of increasing regularity, frequency, and mixed with mucus. duration, and intensity. Decreased fetal movement—If you notice a substantial de- Nullipara—Regular contractions, 5 minutes apart, for crease in the baby’s movement, notify your physician or 1 hour nurse-midwife or come to the labor unit. Multipara—Regular contractions, 10 minutes apart, Other concerns—These guidelines cannot cover all situa- for 1 hour tions and do not replace specific instructions given to you Ruptured membranes—A gush or trickle of fluid from the by your birth attendant. Therefore please go to the hospi- vagina should be evaluated, regardless of whether con- tal for evaluation of any concerns and feelings that some- tractions are occurring. thing may be wrong.
  3. 3. 268 PART III The Family during BirthEstablishing a Therapeutic RelationshipSandra Hall is a nursing student assigned to the intrapartum Amy: Oh no . . . the monitor . . . .unit. A woman walks toward Sandra. The woman is leaning Sandra: You have a problem about the monitor? (Clarify-on a man and breathing rapidly. She says to Sandra, “I think ing the nonspecific remark that Amy made about the monitor.)I’m in labor, and my water broke on the way to the hospital.” Amy: I hated having that thing on with my last baby. I had Sandra: It sounds like today’s the day! Let’s find you a room. to lie the same way all the time or they couldn’t hear the Sandra asks the woman’s name (Amy James) and that of baby. I know it’s best for the baby, though.her birth attendant (Donna Moore, CNM, a nurse-midwife) as Sandra: You seem to have mixed feelings about the mon-they walk to a room. itor. (Reflecting what Amy seems to be feeling.) Sandra: I’m Sandra Hall, a nursing student. What names Amy: Yes, I didn’t like it, but I do feel better knowing thedo you want us to call each of you? (Questioning for infor- baby’s okay.mation. Shows respect by not assuming how the couple Sandra: We can usually find ways so it doesn’t bother youwants to be addressed.) so much. We don’t want you to feel tied down because that Amy: I’m Amy, and my husband is Jeff. will make you more uncomfortable. (Giving information with- Sandra: Is this your first baby, Amy, or have you had oth- out promising that Amy will be totally comfortable with theers? (Questioning in a way that avoids “yes” or “no” answers.) external fetal monitor.) Amy: It’s my second, and the first took forever! I’ve been Sandra observes that Amy’s contractions are every 3 min-having contractions off and on since midnight, but they didn’t utes and strong. She finds an experienced nurse to help eval-get regular till about 6:00 this morning. They are coming every uate Amy. Sandra uses critical thinking and wisely seeks help3 minutes now and starting to hurt a lot. from an experienced nurse because Amy seems to be in ac- Sandra helps Amy put a gown on and applies the exter- tive labor and this is her second baby. The fact that Amy’snal fetal monitor while they wait for the RN. She does not fol- first labor “took forever” does not necessarily mean that thislow up on Amy’s implied concern about having a long labor, labor will be long.however.Nursing Responsibilities during Admission DETERMINING FAMILY EXPECTATIONS ABOUTThe two nursing priorities when the woman arrives at the BIRTH. Regardless of their number of children, womenbirth center are to (1) establish a therapeutic relationship and their partners have expectations about the birth experi-and (2) assess the condition of the mother and fetus. ence. The partners may have studied their options exten- sively and planned a birth that best fits their ideals. ThoseESTABLISHING A THERAPEUTIC RELATIONSHIP who have not made specific plans also have expectationsThe nurse must quickly establish a therapeutic relationship shaped by contact with relatives and friends and previouswith the woman and her significant other. The woman’s first birth experiences. A couple may want to repeat a previousimpression influences her perception of the quality of her satisfying experience or avoid repeating a poor experience.entire birth experience. Sometimes one part of a past birth has negatively influ- MAKING THE FAMILY FEEL WELCOME. A warm enced the couple’s impression of the entire experience.greeting makes the woman and her significant other feel val- CONVEYING CONFIDENCE. From the first en-ued. Even if the unit is busy, the nurse should communicate counter, the nurse should convey confidence and optimisminterest, friendliness, caring, and competence. People un- in the woman’s ability to give birth and the ability of herderstand if the nurse is busy, but they do not understand significant other to support her. Women having their firstrudeness and insensitivity to their needs. baby may be overwhelmed by the power of normal labor Nurses often encounter women who speak a language contractions. The nurse can reassure these women that in-other than English. Arranging for a culturally acceptable in- tense contractions are normal in active labor while helpingterpreter who is fluent in the woman’s language makes the them manage contractions and watching for true problems.woman and her family feel welcome and promotes safety I Think about the different perspectives implied by the phrasesbecause it enhances understanding among the woman, her give birth and be delivered. The woman who gives birth is anfamily, and the nurse. active and able participant; she is the principal action figure. However, the language of be delivered implies that theI When caring for a woman who has not had prenatal care or woman is passive. The nurse might ask “Who will attend you childbirth classes, which are behaviors that most nurses as you give birth?” rather than “Who will deliver your baby?” value, the nurse must not be judgmental in either words or actions. The woman’s priorities and values may be different ASSIGNING A PRIMARY NURSE. Having one from those of the nurse, but she deserves the same respect, nurse give care during all of labor is ideal but often unreal- support, and care as the woman who made every prepara- istic. However, changes in caregivers should be as limited as tion for her baby’s birth. possible. The woman should know the name of and what to
  4. 4. Nursing Care during Labor and Birth CHAPTER 13 269expect from each caregiver. For example, the primary nurse FETAL HEART RATE. For assessment of a term fetusmight explain the role of a nursing student in the woman’s using intermittent auscultation, the following fetal heartcare. Common roles of nursing students in the intrapartum rate (FHR) guidelines are considered reassuring (Feinstein,area include promoting comfort, giving emotional support, Sprague, & Trépanier, 2000):and helping the primary nurse observe for maternal and fe- A lower limit of 110 beats per minute (bpm) and antal problems. upper limit of 160 bpm USING TOUCH FOR COMFORT. Touch can com- Regular rhythmmunicate acceptance and reassurance and provide physical Presence of accelerations in the FHRand emotional comfort to many laboring women. Women Absence of decelerations from the baselinewho usually do not welcome touch may appreciate it during These findings also would be reassuring in an electroni-labor. Cultural norms and personal history influence a cally monitored fetus (see Chapter 14).woman’s comfort with touch from an unrelated person. The MATERNAL VITAL SIGNS. Maternal vital signs arenurse should not assume that the woman desires touch but assessed to identify signs of hypertension and infection. Hy-instead ask her if she welcomes or benefits from touch. As pertension during pregnancy is defined as a sustained bloodlabor progresses, the woman’s desire for touch may change, pressure increase to 140 mm Hg systolic or 90 mm Hg dia-and touch may become irritating rather than comforting. stolic. The hypertension may be a disorder that is specific to RESPECTING CULTURAL VALUES. Cultural be- pregnancy or it may be chronic (American Academy of Pe-liefs and practices give structure, meaning, and richness to diatrics [AAP] & American College of Obstetricians and Gy-the birth experience. They influence the behavior of both necologists [ACOG], 2002; ACOG, 2001; ACOG, 2002)the childbearing family and the professional staff. Most cul- (see Chapter 25 for more information). A temperature oftural groups have specific practices related to childbearing. 38° C (100.4° F) or higher suggests infection.The nurse should incorporate a family’s beneficial and neu- IMPENDING BIRTH. Grunting sounds, bearingtral cultural practices into care as much as possible. down, sitting on one buttock, and saying urgently, “The baby’s coming” suggest imminent birth. The nurse abbrevi-I People naturally believe that their own cultural values are ates the initial assessment and collects other information best. The nurse should avoid using an attitude that is supe- after birth. While the nurse cares for the mother, the fol- rior or diminishes the validity of another person’s cultural be- lowing minimal information can be quickly gathered if liefs. Trust in technology is a common value of many care- birth is imminent: givers in the United States, but such reliance on technology Names of mother and support person(s) is considered unnecessary, odd, and even harmful by many other cultures. Name of her physician or nurse-midwife if she had prenatal care ✔ Number of pregnancies and prior births, including whether the birth was vaginal or cesarean CHECK YOUR READING Status of membranes1. What communication skills can the nurse use to establish Expected date of delivery a therapeutic relationship when the woman and her family Any problems during this or other pregnancies enter the hospital or birth center? Allergies to medications, foods, or other substances2. How can the nurse incorporate a couple’s cultural prac- Time and type of last oral intake tices into intrapartum care? Maternal vital signs and FHR Pain: location, intensity, factors that intensify or re- lieve, duration, whether constant or intermittent,MAKING ASSESSMENTS whether the pain is acceptable to the womanAT THE TIME OF ADMISSION If focused assessments of mother and fetus are normalA paper or computerized record of prenatal care is sent to and birth is not imminent, a more complete admission as-the center where the woman plans to give birth and added sessment is taken. If the initial assessments show that birthto her chart when she is admitted. Admission information is near or another urgent condition is identified, the physi-can be obtained from the prenatal record and verified or up- cian or nurse-midwife is notified promptly with essential as-dated as needed. Women who have not had prenatal care or sessment information. ✔who had care with a provider other than one who practicesat the facility she enters need more extensive assessment by CHECK YOUR READINGthe nurse and physician (Table 13-1). 3. What are the two assessment priorities when a womanFOCUSED ASSESSMENT comes to the intrapartum unit?A focused assessment is performed before the broader data- 4. What FHR characteristics (when auscultated) arebase assessment in the intrapartum unit, opposite of the usual reassuring? 5. What observations suggest that a woman is going to giveorder. Assessment priorities are to determine the condition of birth very soon? What should the nurse do in that case?the mother and fetus and whether birth is imminent.
  5. 5. 270 PART III The Family during BirthTABLE 13-1 Intrapartum Assessment GuideWomen who have had prenatal care have much of this information available on their prenatal record. The nurse need only verify itor update it as needed.Assessment, Method(Selected Rationales) Common Findings Significant Findings, Nursing ActionInterviewPurpose: To obtain information about the woman’s pregnancy, labor, and condi- tions that may affect her care. The in- terview is curtailed if she seems to be in late labor.Introduction: Introduce yourself, and ask Many women prefer to be addressed by The surname (family name) precedes the the woman how she wants to be ad- their first names during labor. given name in some cultures. Clarify dressed. Ask her if she wants her part- which name is used to properly ad- ner and/or family to remain during the dress the woman and to properly iden- interview and assessment. (Shows re- tify both mother and newborn. spect for the woman and gives her control over those she wants to remain with her.)Culture and language: If she is from an- Common non-English languages of Try to secure an interpreter fluent in the other culture, ask what her preferred women in the United States are Span- woman’s primary language. Ask her if language is and what language(s) she ish and some Asian dialects. The most there are people who are not accept- speaks, reads, or verbally understands. common non-English language varies able to her as interpreters (e.g., males (Identifies the need for an interpreter with location. or members of a group in conflict with and enables the most accurate data her culture). Family members may not collection.) be the best interpreters because they may interpret selectively, adding or subtracting information as they see fit. Telephone interpreters are available in many facilities. Hearing-impaired women may read lips well, or they may need sign-language interpreters or other assistance.Communication: Ask the woman to tell Women in active labor have difficulty an- If contractions are very frequent, assess you when she has a contraction, and swering questions or cooperating with the woman’s labor status promptly pause during the interview and physi- a physical examination while they are rather than continuing the interview. cal assessment. (Shows sensitivity to having a contraction. Ask only the most critical questions. her comfort and allows her to concen- trate more fully on the information the nurse requests.)Nonverbal cues: Observe the woman’s Latent phase: Sociable and mildly anx- The unprepared or extremely anxious behaviors and interactions with her ious. Active phase: Concentrating in- woman may breathe deeply and family and the nurse. (Permits estima- tently with contractions; often uses rapidly, displaying a tense facial and tion of her level of anxiety. Identifies prepared childbirth techniques. body posture during and between con- behaviors indicating that she should tractions. These behaviors suggest have a vaginal examination to deter- that birth is imminent: mine whether birth is imminent.) 1. Her statement that the baby is coming 2. Grunting sounds (low-pitched, gut- tural sounds) 3. Bearing down with abdominal mus- cles 4. Sitting on one buttock Euphoria, combativeness, or sedation suggests recent illicit drug ingestion.Reason for admission: “What brings you Labor contractions at term, induction of Bleeding, preterm labor, pain other than to the hospital/birth center today?” labor, or observation for false labor are labor contractions. Report these find- (Open-ended question promotes more common reasons for admission. ings to the physician or nurse-midwife complete answer.) promptly.Prenatal care: “Did you see a doctor or Early and regular prenatal care promotes No prenatal care or care that was irregu- nurse-midwife during your pregnancy?” maternal and fetal health. lar or begun in late pregnancy means “Who is your doctor or nurse-midwife?” that complications may not have been “How far along were you in your preg- identified. nancy when you saw the physician or nurse-midwife?” “Have you ever been admitted here before during this preg- nancy?” (Enables location of prenatal record and prior visit records.)
  6. 6. Nursing Care during Labor and Birth CHAPTER 13 271 TABLE 13-1 Intrapartum Assessment Guide—cont’d Assessment, Method (Selected Rationales) Common Findings Significant Findings, Nursing Action Interview—cont’d Estimated date of delivery (EDD): “When Term gestation: 38-42 wk. The woman’s Gestations earlier than the beginning of is your baby due?” (Determines if ges- gestation may have been confirmed or the 38th week (preterm) or later than tation is term.) “When did your last adjusted during pregnancy with an ul- the end of the 42nd week (postterm) menstrual period begin?” (For estima- trasound or other clinical examination. are associated with more fetal or tion of EDD if woman did not have pre- neonatal problems. The physician may natal care.) try to stop labor that occurs earlier than 36 weeks. Gravidity, parity, abortions: “How many Labor may be faster for the woman who Parity of 5 or more (grand multiparity) is times have you been pregnant?” “How has given birth before than for the nul- associated with placenta previa (see many babies have you had? Were they lipara. Miscarriage is used to describe Chapter 25) and postpartum hemor- full term or premature?” “How many a spontaneous abortion because many rhage (see Chapter 28). Women who children are now living?” “Have you lay people associate the term abortion have had several spontaneous abor- had any miscarriages or abortions?” with only induced abortions. tions or who have given birth to infants “Were there any problems with your with abnormalities may face a higher babies after they were born?” (Helps risk for an infant with a birth defect. estimate probable speed of labor and anticipate neonatal problems.) Pregnancy history (Identifies problems that may affect this birth.) Present pregnancy: “Have you had any Complications are not expected. Women who have diabetes or hyperten- problems during this pregnancy, sion may have poor placental blood such as high blood pressure, dia- flow, possibly resulting in fetal compro- betes, infections, or bleeding?” mise. Some complications of past pregnancies, such as gestational dia- betes, may recur in another pregnancy. The woman who plans a VBAC may need more support and reassurance to give birth vaginally. Past pregnancies: “Were there any Women who had previous cesarean Although the VBAC is less common, it problems with your other preg- birth(s) may have a trial of labor and may be chosen for a variety of rea- nancy(ies)?” “Were your other babies vaginal birth (VBAC). A woman who sons. The nurse should be aware of born vaginally or by cesarean birth?” previously had a difficult labor or a ce- the need for support and for complica- sarean birth may be more anxious than tions that may be more likely in the one who had an uncomplicated labor current pregnancy. and birth. Other: “Is there anything else you think This open-ended question gives the we should know so that we can bet- woman a chance to share information ter care for you?” that may not be elicited by other questions. Labor status: “When did your contrac- Varies among women. Many women go Women who say they have been “in la- tions become regular?” “What time did to the birth facility when contractions bor” for an unusual length of time you begin to think you might really be first begin. Others wait until they are (e.g., “for 2 days”) have probably had in labor?” (Facilitates a more accurate reasonably sure that they are really in false labor. These women may be very estimation of the time labor began.) labor. tired from the annoying, nonproductive contractions. Contractions: “How often are your con- Varies according to her stage and phase Irregular contractions or those that do tractions coming?” “How long do they of labor. Labor contractions are usually not increase in frequency, duration, or last?” “Are they getting stronger?” “Tell regular and show a pattern of increas- intensity are more likely to represent me if you have a contraction while we ing frequency, duration, and intensity. false labor. Contractions that are too are talking.” (Obtains the woman’s sub- frequent or too long can reduce pla- jective evaluation of her contractions. cental blood flow. Incomplete uterine Alerts the nurse to palpate contractions relaxation between contractions also that occur during the interview.) can reduce placental blood flow (see Chapter 14). Membrane status: “Has your water bro- Most women go to the birth facility for If the woman’s membranes have ruptured ken?” “What time did it break?” “What evaluation soon after their membranes and she is not in labor or if she is not did the fluid look like?” “About how rupture. If a woman is not already in la- at term, a vaginal examination is often much fluid did you lose—was it a big bor, contractions usually begin within a deferred. Labor may be induced if she gush or a trickle?” (Alerts the nurse of few hours after the membranes rupture is at term with ruptured membranes. the need to verify whether the mem- at term. branes have ruptured if it is not obvi- ous. Identifies possible prolonged rup- ture of membranes or preterm rupture.)VBAC, vaginal birth after cesarean. Continued
  7. 7. 272 PART III The Family during BirthTABLE 13-1 Intrapartum Assessment Guide—cont’dAssessment, Method(Selected Rationales) Common Findings Significant Findings, Nursing ActionInterview—cont’dAllergies: “Are you allergic to any foods, Record any known allergies to food, Allergy to seafood, iodized salt, or x-ray medicines, or other substances?” “Do medication, or other substances. As contrast media may indicate iodine al- you have an allergy to latex?” “What needed, describe how they affected lergy. Because iodine is used in many kind of reaction do you have?” “Have the woman. “prep” solutions, alternative ones you ever had a problem with anesthe- should be used. Allergy to latex is be- sia when you have had dental work?” coming more common. Allergy to den- (Determines possible sensitivity to tal anesthetics may indicate possible drugs that may be used.) allergy to the drugs used for local or regional anesthetics. These drugs usu- ally end in the suffix -caine.Food intake: “When was the last time you Record the time of the woman’s last food If the woman says she has not had any had something to eat or drink?” “What intake and what she ate. Include both intake for an unusual length of time, did you have?” (Provides information liquids and solids. question her more closely: “Is there needed to most safely administer gen- any food you may have forgotten, such eral anesthesia if required. Identifies as a snack or a drink of water or other possible fluid or energy deficit.) liquid?”Recent illness: “Have you been ill re- Most pregnant women are healthy. An Urinary tract infections are associated with cently?” “What was the problem?” occasional woman may have had a mi- preterm labor. The woman who has had “What did you do for it?” “Have you nor illness such as an upper respira- contact with someone having a com- been around anyone with a contagious tory tract infection. municable disease may become ill and illness recently?” possibly infect others in the facility.Medications: “What drugs do you take Prenatal vitamins and iron are commonly Drugs may interact with other medica- that your doctor or nurse-midwife has prescribed. Record all drugs the tions given during labor, especially prescribed?” “Are there any over-the- woman takes, including time and analgesics and anesthetics. Substance counter drugs that you use?” “I know amount of last ingestion. Women who abuse is associated with complications this may be uncomfortable to discuss, use illegal substances often conceal or for the mother and infant (see Chap- but we need to know about any illegal diminish the extent of their use be- ter 24). If the woman discloses that she substances that you use, to more cause they fear reprisals. uses illegal drugs, ask her what kind safely care for you and your baby.” and the last time she ingested them (Permits evaluation of the woman’s (often referred to as “taking a hit”). A drug intake and encourages her to dis- nonjudgmental approach is more likely close nonprescribed use.) to result in honest information.Tobacco or alcohol: “Do you smoke or use As in substance abuse, women may un- Infants of heavy smokers are often tobacco in any other form? About how derreport the extent of their use of to- smaller and may have reduced placen- many cigarettes a day?” “Do you use al- bacco or alcohol. tal blood flow during labor. Infants of cohol? About how many drinks do you women who use alcohol may show fe- have each day (or week)?” (Evaluates tal alcohol effects (see Chapter 30). use of these legal substances.)Birth plans (shows respect for the woman and her family as individuals and pro- motes achievement of their expecta- tions; enables more culturally appropri- ate care): Coach or primary support person: This is usually the woman’s husband or The woman who has little or no support “Who is the main person you want the baby’s father, but it may be her from significant others probably needs to be with you during labor?” Ask mother, her sister, or a friend, espe- more intense nursing support during that person how he or she wants to cially if she is single. labor and after the birth. These clients be addressed, such as “Mr. Ramos,” are more likely to have problems with or “Carlos.” parent-infant attachment. Other support: “Is there anyone else you Women often want another support per- would like to be present during labor?” son present. Preparation for childbirth: “Did you at- Ideally, the woman and a partner have The unprepared woman may need more tend prepared childbirth classes?” had some preparation in classes or support with simple relaxation and “Did someone go with you?” self-study. Women who attended breathing techniques during labor. Her classes during previous pregnancies partner may need to learn techniques do not always repeat the classes dur- to assist her. ing subsequent pregnancies. Preferences: “Are there any special Some women or couples have strong Conflict may arise if the woman has not plans you have for this birth?” “Is feelings regarding certain interventions. previously discussed her preferences there anything you want to avoid?” Common ones are (1) analgesia or with her physician or nurse-midwife or “Did you plan to record the birth anesthesia; (2) intravenous lines; if she is unaware of what services are with pictures or video?” (3) fetal monitoring; (4) use of epi- available where she gives birth. siotomy or forceps. Cultural needs: “Are there any special Women from Asian and Hispanic cultures Try to incorporate all positive or neutral cultural practices that you plan may subscribe to the “hot-and-cold” cultural practices. If a practice is harm- when you have your baby?” “How theory of illness and want specific ful, explain why and try to find a way can we best help you to fulfill these foods after birth, such as soft-boiled to work around it if the family does not practices?” eggs. They may not want their water or want to give it up. other fluids iced.
  8. 8. Nursing Care during Labor and Birth CHAPTER 13 273 TABLE 13-1 Intrapartum Assessment Guide—cont’d Assessment, Method (Selected Rationales) Common Findings Significant Findings, Nursing Action Fetal Evaluation Purpose: To determine if the fetus seems to be healthy and tolerating labor well. Fetal heart rate (FHR): Assess by inter- Average rate at term is 110-160 bpm. These signs may indicate fetal stress and mittent auscultation, or apply an exter- Rate usually increases when the fetus should be reported to the physician or nal fetal monitor if that is the facility’s moves and is reassuring. nurse-midwife: policy (most common in the United 1. Rate outside the normal limits States). Document FHR according to 2. Slowing of the rate that persists af- the risk status and stage of labor (see ter the contraction ends Chapter 14). 3. No increase in rate when the fetus Guidelines include: moves Low risk: q 1 h (latent phase), q 30 min 4. Irregular rhythm (active phase), q 15 min (2nd stage). More frequent assessments should be High risk: q 30 min (latent phase), q 15 made of the FHR and contractions if min (active phase), q 5 min (2nd stage). any finding is questionable. Labor Status Purpose: To identify whether the woman is in labor and if birth is imminent. If she displays signs of imminent birth, this assessment is done as soon as she is admitted. Contractions (yields objective information See interview section earlier in table. See interview section earlier in table. about labor status): In addition to ask- Women who have intense contractions ing the woman about her contraction or who are making rapid progress pattern, assess the contractions by should be assessed more frequently. palpation with the fingertips of one hand. Contractions should be as- sessed each time the FHR is assessed. Vaginal examination (Determines cervical Varies according to the stage and phase A vaginal examination is not performed if dilation and effacement; fetal presenta- of labor. It may not be possible to de- the woman reports or has evidence of tion, position, and station; bloody termine the fetal position by vaginal active bleeding (not bloody show) and show; and status of the membranes.) examination when membranes are in- may not be done if her gestation is tact and bulging over the presenting 36 weeks or less and she does not part. seem to be in active labor. Report rea- sons for omitting a vaginal examination to the physician or nurse-midwife. Status of membranes: During a vaginal Amniotic fluid should be clear, possibly A greenish color indicates meconium examination a flow of fluid suggests containing flecks of white vernix. Its staining, which may be associated with ruptured membranes. A nitrazine test odor is distinctive but not offensive. fetal compromise or postterm gesta- and/or fern test may be done, often The nitrazine test with a color change tion. Thick meconium with heavy par- using a sterile speculum exam. (Test is of blue-green to dark blue (pH >6.5) ticulate matter (“pea soup”) is most not needed if it is obvious that the suggests true rupture of the mem- significant (see Chapter 30). Thick membranes have ruptured.) branes but is not conclusive. The fern green-black meconium may be passed test is more diagnostic of true rupture by the fetus in a breech presentation of membranes because it is less likely and is not necessarily associated with to be affected by vaginal infections, re- fetal compromise. Cloudy, yellowish, cent intercourse, or other factors. strong-, or foul-smelling fluid suggests infection. Bloody fluid may indicate partial placental separation (see Chap- ter 25). Leopold’s maneuvers: Often done before A cephalic presentation with the head A hard, round, freely movable object in assessing the FHR to locate the best well flexed (vertex) is normal. The fetal the fundus suggests a fetal head, place for assessment. (Identifies fetal head is often easily displaced upward meaning the fetus is in a breech pre- presentation and position. Most accu- (“floating”) if the woman is not in labor. sentation. Less commonly, the fetus rate when combined with information When the head is engaged, it cannot may be crosswise in the uterus: a from vaginal examination.) be displaced upward with Leopold’s transverse lie. maneuvers. Pain: Note discomfort during and be- There may be verbal or nonverbal evi- Constant pain or a tender, rigid uterus tween contractions. Note tenderness dence of pain with contractions, but suggests a complication, such as when palpating contractions. (Distin- the woman should be relatively com- abruptio placentae (separated placenta) guishes between normal labor pain fortable between contractions. The skin (see Chapter 25) or, less commonly, and abnormal pain that may be associ- around the umbilicus is often sensitive. uterine rupture (see Chapter 27). ated with a complication.) Physical Examination Purpose: To evaluate the woman’s gen- eral health and identify conditions that may affect her intrapartum and post- partum care.bpm, Beats per minute. Continued
  9. 9. 274 PART III The Family during BirthTABLE 13-1 Intrapartum Assessment Guide—cont’dAssessment, Method(Selected Rationales) Common Findings Significant Findings, Nursing ActionPhysical Examination—cont’dGeneral appearance: Observe skin color Women are often fatigued if their sleep Pallor suggests anemia. Substantial and texture, nutritional state, and ap- has been interrupted by Braxton Hicks edema of the face and fingers or ex- pearance of rest or fatigue. Examine contractions, fetal activity, or frequent treme (pitting) edema of the lower ex- the woman’s face, fingers, and lower urination. Mild edema of the lower ex- tremities is associated with preeclamp- extremities for edema. Ask her if she tremities is common in late pregnancy. sia although it may occur in the can take her rings off and put them on. absence of this hypertensive disorder (see Chapter 25).Vital signs: Take the woman’s tempera- Temperature: 35.8°-37.3° C (96.4°-99.1° F). Report abnormalities to physician or ture, pulse, respirations, and blood Pulse: 60-100/min. nurse-midwife. Temperature of 38° C pressure. Reassess the temperature Respirations: 12-20/min, even and (100.4° F) or higher suggests infection. every 4 hr (every 2 hr after membranes unlabored. Pulse and respirations may also be el- rupture or if elevated); reassess blood Blood pressure near baseline levels es- evated. Pulse and blood pressure may pressure, pulse, and respirations every tablished during pregnancy. Transient be elevated if the woman is extremely hour. elevations of blood pressure are com- anxious or in pain. mon when the woman is first admitted, A blood pressure Ն140 mm Hg or but they return to baseline levels within Ն90 mm Hg diastolic or higher is con- about 1⁄2 hr. sidered hypertensive. For women who did not have prenatal care, there is no baseline for comparison.Heart and lung sounds: Auscultate all ar- Heart sounds should be clear with a dis- The woman who is breathing rapidly and eas with a stethoscope. tinct S1 and S2. A physiologic murmur deeply may have symptoms of hyper- is common because of the increased ventilation: tingling and spasm of the blood volume and cardiac output. fingers, numbness around the lips. Breath sounds should be clear, with respirations even and unlabored.Breasts: Palpate for a dominant mass. Breasts are full and nodular. Areola is darker, Report a dominant mass to the physician especially in dark-skinned women. or nurse-midwife. Breasts may leak colostrum (clear, sticky, straw-colored fluid) during labor.Abdomen: Observe for scars at the same Striae (stretch marks) are common. If Report a previous cesarean birth to the time Leopold’s maneuvers and the scars are noted, ask the woman what physician or nurse-midwife. Transverse FHR are assessed. It is usually suffi- surgery she had and when. The fundus uterine scars are least likely to rupture cient to assess the fundal height by at term is usually slightly below the if the woman is in labor (see Chap- observing its relation to the xiphoid xiphoid process but varies with mater- ter 27). Measure the fundal height (see process. nal height and fetal size and number. p. 132) if the fetus seems small or if the gestation is questionable.Deep tendon reflexes: Assess patellar re- A brisk jerk without spasm or sustained Report absent (uncommon unless the flex (see Chapter 25). Upper extremity muscle contraction is normal. Some woman is receiving magnesium sulfate) deep tendon reflexes should be used if women normally have hypoactive re- or hyperactive reflexes. Hyperactive re- epidural block analgesia is planned be- flexes, but at least a slight twitch is ex- flexes and clonus (repeated tapping cause they are normally not as strong pected. Obese women may appear to when the foot is dorsiflexed) are asso- as the patellar reflex. have diminished reflexes because of ciated with pregnancy-induced hyper- the fat tissue over the tendon. tension and often precede a seizure (see Chapter 25).Midstream urine specimen: Assess pro- Negative or trace of protein; negative glu- Proteinuria is associated with pregnancy- tein and glucose levels with a dipstick. cose and ketones. induced hypertension but may also be Follow instructions on the package for associated with urinary tract infections waiting times. Check for ketones if the or a specimen that is contaminated woman has not eaten for a prolonged with vaginal secretions. Glucosuria is period or has been vomiting. Send for associated with diabetes. Ketonuria is urinalysis if ordered. common in poorly controlled diabetes or if the woman does not eat adequate carbohydrates to meet her energy needs.Laboratory tests: Women who have had prenatal care may not need as many admission tests. Common tests include: 1. Complete blood cell count (or 1. Hemoglobin at least 11 g/dl; hemat- 1. Values lower than these reduce ma- hematocrit done on unit). ocrit at least 33%. ternal reserve for normal blood loss at birth. 2. Blood type and Rh factor. 2. The woman who is Rh-negative 2. Rh-negative mothers need Rh im- receives Rh immune globulin at mune globulin after birth if the infant 28 weeks’ gestation to prevent for- is Rh-positive. mation of anti-Rh antibodies if she has regular prenatal care. 3. Serologic tests for syphilis. 3. Negative. 3. A positive test indicates that the baby could be infected and needs treatment after birth. The mother should be treated if she has not been treated already.
  10. 10. Nursing Care during Labor and Birth CHAPTER 13 275 dure 13-1). The FHR is assessed by intermittent auscultation 13-1 and electronic monitoring (see Chapter 14). The nurse doc- uments the color and odor of the amniotic fluid and the During a labor admission assessment, a woman quickly de- nies her use of drugs and herbal preparations other than her time of rupture if the membranes ruptured before admission. prescribed prenatal vitamins. She becomes quiet, answer- Labor Status. The woman’s labor status is determined ing the nurse’s questions in a terse manner. by assessing her contraction pattern, performing vaginal ex- Questions amination if there are no contractions, and determining What might explain the woman’s change in behavior? whether her membranes have ruptured. Contractions are as- Should the nurse alter the assessment interview? sessed by palpation (Procedure 13-2), the fetal monitor, or both. Cervical dilation and effacement and the fetal station, presentation, and position are evaluated by vaginal exami- DATABASE ASSESSMENT. In addition to perform- nation. The vaginal examination may also reveal whethering the focused assessment, the nurse should assess the the membranes have ruptured if fluid is not obviously leak-mother, fetus, and available maternal support persons. ing from the vagina. Vaginal examination is not performed Basic Information. Intrapartum admission forms guide if the woman has active bleeding (other than bloody show)the nurse to obtain required information. Typical informa- because the procedure can increase bleeding.tion includes the following: Physical Examination. A brief physical examination The woman’s reason for coming to the hospital or evaluates the woman’s overall health. Other important ob- birth center (such as contractions, rupture of mem- servations relating to birth include the presence and loca- branes) tion of edema, abdominal scars, and height of the fundus. ✔ Prenatal care: when it began, her most recent visit, and her physician or nurse-midwife’s name CHECK YOUR READING Estimated date of delivery (EDD) Number of pregnancies, births, spontaneous preg- 6. Which tests may be done if the nurse is not certain nancy losses, and abortions whether the woman’s membranes have ruptured? (See Allergies: medications, food, other substances such as Table 13-1.) latex 7. Which characteristics of contractions may reduce blood flow to the placenta? (See Procedure 13-2.) Food intake: what food and when it was eaten Medical, surgical, and pregnancy history Recent illness, including treatment USING ADMISSION PROCEDURES Medications, including prescription and over-the- NOTIFYING THE BIRTH ATTENDANT. After assess- counter drugs, tobacco, alcohol and other substances ment the nurse notifies the woman’s birth attendant to re- of abuse port the woman’s status and obtain orders. The nurse in- Complementary or alternative therapy; use of herbal cludes the following data in the report: and botanical preparations and their purpose Gravidity, parity, abortions, and term and preterm Use of tobacco, alcohol, and illicit substances births Her subjective evaluation of her labor EDB and fundal height if it conflicts with the EDB Birth plans, including planned pain management Contraction pattern methods Results of vaginal examination Support persons: who they are and the role of each Cervical dilation and effacement Potential domestic violence (ask only when the Fetal presentation and position woman is alone) Station of the presenting part Fetal heart rate and patternI Women often bring several people with them to the birthing room and want them to stay during admission. However, be Maternal vital signs careful about asking for sensitive information, such as prior Any identified abnormalities and concerns about the pregnancies and births and potential abuse, when others are maternal or fetal condition present. A woman may have had an abortion or relinquished Pain, anxiety, or other reactions to labor a baby for adoption, and her family may not know about it. If the birth attendant admits the woman, any of several Even if her partner knows about previous pregnancies, her procedures may be performed. family or friends may not. Asking about domestic violence CONSENT FORMS. The woman signs consent for when the abuser is present will result in a quick denial and care during labor, such as anesthesia, vaginal birth and/or can be dangerous for the woman. Delay asking sensitive in- cesarean birth, blood transfusion, testing for human im- formation until the woman is alone for confidentiality, safety, munodeficiency virus (HIV). A separate consent for tubal and accuracy. ligation must be signed by the woman if she desires perma- Fetal Assessments. The fetal presentation and po- nent sterilization at the time of birth. Consent for newbornsition are assessed using a combination of vaginal exami- care and circumcision of male infants is often completed atnation and Leopold’s maneuvers (Figure 13-1 and Proce- this time. Text continued on page 280
  11. 11. 276 PART III The Family during Birth CARE PATH FOR STAGES OF LABOR 1 & 2 NANDA Problem LATENT PHASE Number PREADMIT ADMISSION (0-4 cm) LOCATION IV Assessments High risk screening with referrals prn: T, P, R, BP ෆ P, R, BP q 1 hr 5, 8, – MFM Deep tendon reflexes / clonus T ෆ 2 hr if rupture of membranes, q 9, 16 q ෆ – Homecare Labor status: 4 hr if bag of waters intact I 5, 6 – Genetic Counsel – admit for labor per protocol: ෆ BP, P q 15 min if epidural anesthetic III I I – Social Services CRITERIA FOR LABOR: ෆ Bladder status q 2 hr 1. complete effacement; or 2 cm Urine protein/ketones dip-stick prn in nullipara Deep tendon reflexes/clonus prn 2. cervical change Fetal monitoring: electronic fetal 3. rupture of membranes s labor ෆ monitor or electronic fetal 4. contractions at least 5 min apart monitoring while in bed or – cervix: sterile vaginal exam intermittent auscultation unless contraindicated Labor status: – uterine activity (toco / – frequency, duration, strength, palpation) resting tone of contractions – membrane status, color, ෆ 1 hr by toco/palpation or q amount, odor of fluid intrauterine pressure catheter Fetus: – membrane status; color, – presentation (ultrasound prn) amount and odor of fluid – FHR: 20 min or electronic fetal – sterile vaginal exam prn & monitoring strip (continue prior to meds as indicated electronic fetal monitoring if Fetus: non-reassuring pattern) ෆ – low risk: FHR q 30 min Urine – dip for protein & ketones – high risk: FHR ෆ 15 min q Level of childbirth preparation In and out catheterization Family interaction Beta-strep risk factors – preterm labor – rupture of membranes Ͻ 37 wk – previous baby c Beta-strep ෆ Progress to active phase c in 6° of admission verified __________________ IV 5, 6 Procedures/ CBC, VDRL, ABO-Rh stat on If intrauterine pressure catheter Tests admission labor pattern shows > 250 HBSAG if not on prenatal record Montevideo unit verified __________________ Treatments Initiate Labor Curve Consider amniotomy for prolonged Initiate “Active Management of Labor latent phase. Protocol” if criteria are met. Consider use of intrauterine Notify Special Care Nursery of pressure catheter if inadequate potential problems. cervical change. VI 3 Medication PAIN CONTROL: XI 5 Parenteral analgesia as ordered. (Consider Stadol or Nubain). If inadequate pain control, anesthesia consult, re-evaluate for epidural _______ Narcotic epidural _______ Anesthetic epidural Signatures / _______________________ / / _______________________ _______________________ / _______________________ / / _______________________ _______________________ BAYLOR UNIVERSITY MEDICAL CENTER MED REC NO. ______________________________________ DALLAS, TEXAS PATIENT ______________________________________ CARE PATH FOR STAGES OF LABOR 1 & 2 PHYSICIAN ______________________________________ PAGE 1 OF 4 Figure 13-1 I Care path for stages 1 and 2 of labor.
  12. 12. Nursing Care during Labor and Birth CHAPTER 13 277 CARE PATH FOR STAGES OF LABOR 1 & 2NANDAProblem LATENT PHASENumber PREADMIT ADMISSION (0-4 cm) LOCATIONIII 11 Elimination Encourage voiding q 2-3 hr ෆ In and out catheterization if unable to void & bladder is distended Bladder remains nondistendedII 7 Nutrition Clear liquids/ice chips, hard candy if Clear liquids/ice chips, hard candy if Hydration desired desired IV fluids prn and as ordered for T Ͼ 101 on 2 consecutive readings (notify attending MD) IV (18G) or heplock if VBAC Hydration status will be maintainedIV 11 Activity Bag of waters intact or rupture of membranes with presenting part engaged: encourage up ad lib; chair prn Ambulates frequentlyVI PT/Family At 1st OB appt, give info on: Ambulation & position changes2, 5, 6 Education – Labor warnings Electronic Fetal Monitor – Kick counts Breathing & Relaxation (B & R) – Prepared childbirth classes techniques – Optional classes: Analgesia & Anesthesia (A & A) VBAC options Baby care Labor progress & expectations Breastfeeding Advise in selection of a pediatrician Verbalizes understanding Appropriate B & R maintained Goal: By 28 wks, pt identifies when to call the doctor & describes verified __________________ verified __________________ when & how to do kick countsVIII 7, 8 Psycho Support person identified Support person identified Social Emotional verified __________________ Signatures Initials for these signatures will be / / _____________________ _____________________ found throughout the care path. / / _____________________ _____________________ BAYLOR UNIVERSITY MEDICAL CENTER MED REC NO. ______________________________________ DALLAS, TEXAS PATIENT ______________________________________ CARE PATH FOR STAGES OF LABOR 1 & 2 PHYSICIAN ______________________________________ PAGE 2 OF 4 Figure 13-1, cont’d I For legend see opposite page. Continued
  13. 13. 278 PART III The Family during Birth CARE PATH FOR STAGES OF LABOR 1 & 2 NANDA Problem ACTIVE PHASE SECOND STAGE Number (4-10 cm) (10 cm – Delivery) LOCATION IV Assessments T, q 4° if bag of waters intact; q 2° if ෆ ෆ T, q 4° if bag of waters intact; q 2° if rupture of membranes ෆ 5, 8, rupture of membranes BP, P, R, q 1 hr 9, 16 ෆ BP, P, R, q 1 hr ෆ BP, P q 15 min if epidural anesthetic ෆ I 5, 6 III I I BP, P q 15 min if epidural anesthetic ෆ Bladder status q 2 hr ෆ Bladder status q 2 hr ෆ Urine protein/ketones dipstick prn Urine protein/ketones dipstick prn Deep tendon reflexes/clonus prn Deep tendon reflexes/clonus prn Fetal monitoring: electronic fetal monitoring while in bed, or intermittent Fetal monitoring: electronic fetal auscultation monitoring while in bed, or Labor status: intermittent auscultation – frequency, duration, strength, resting tone of contraction q 1 hr by ෆ Labor status: toco/palpation or intrauterine pressure catheter – frequency, duration, strength, – membrane status; color, amount and odor of fluid resting tone of contraction – sterile vaginal exam prn & prior to meds ෆ 1 hr by toco/palpation or q Fetus: intrauterine pressure catheter – low risk: FHR q 15 min ෆ – membrane status; color, – high risk: FHR q 5 min ෆ amount and odor of fluid – VBAC continous electronic fetal monitor or electronic fetal monitoring – sterile vaginal exam prn & Effectiveness of expulsive efforts prior to meds – descent of presenting part Fetus: – position; document if abnormal presentation – low risk: FHR q 30 min ෆ – caput – high risk: FHR q 15 min ෆ In and out catheterization If intrauterine pressure catheter, labor pattern shows > 250 Montevideo units verified __________________ Cervix changes at a rate of > 1.2 cm/hr for nullips; > 1.5 cm/hr for multips verified __________________ IV 5, 6 Procedures / Tests Treatments Plot cervical dilation q 2 hours or ෆ per exam Consider use of intrauterine pressure catheter if inadequate cervical change VI 3 Medications PAIN CONTROL: XI 5 Parenteral analgesics as ordered. (Consider Stadol or Nubain). Anesthesia consult; epidural prn Oxytocin augmentation, if indicated per protocol If rupture of membranes Ͼ 24 hr antibiotics as ordered Maintains control; utilizes B & R Maintains control; techniques prn utilizes B & R techniques prn verified __________________ verified __________________ Signatures / / / _____________________ _____________________ _____________________ / / / _____________________ _____________________ _____________________ BAYLOR UNIVERSITY MEDICAL CENTER MED REC NO. ______________________________________ DALLAS, TEXAS PATIENT ______________________________________ CARE PATH FOR STAGES OF LABOR 1 & 2 PHYSICIAN ______________________________________ PAGE 3 OF 4 Figure 13-1, cont’d I Care paths for stages 1 and 2 of labor.
  14. 14. Nursing Care during Labor and Birth CHAPTER 13 279 CARE PATH FOR STAGES OF LABOR 1 & 2NANDAProblem ACTIVE PHASENumber (4-10 cm) SECOND STAGE LOCATIONIIII I I Elimination Encourage voiding q 2-3 hr ෆ Encourage voiding q 2-3 hr ෆ In and out catheterization if unable In and out catheterization if unable to void & bladder is distended to void & bladder is distended Bladder remains nondistended Bladder remains nondistendedII 7 Nutrition Clear liquids/ice chips Clear liquids/ice chips Hydration IV fluids prn and as ordered for T Ͼ IV fluids prn: and as ordered for T Ͼ 101 on 2 consecutive readings (notify 101 on 2 consecutive readings attending MD) (notify attending MD) IV (18G) or heplock if VBAC IV (18G) or heplock if VBAC Hydration status will be maintained Hydration status will be maintainedIV 11 Activity Bag of waters intact or rupture of Facilitate frequent position changes (q 1-2 hr) while in bed ෆ membranes with presenting part engaged: encourage up ad lib; chair prn Facilitate frequent position changes (q 1-2 hr) while in bed ෆVI PT/Family2, 5, 6 Education Appropriate B & R maintained Appropriate B & R maintained verified __________________ verified __________________ Psycho Support person identified Support person identified Social Emotional Signatures / / / _____________________ _____________________ _____________________ / / / _____________________ _____________________ _____________________ BAYLOR UNIVERSITY MEDICAL CENTER MED REC NO. ______________________________________ DALLAS, TEXAS PATIENT ______________________________________ CARE PATH FOR STAGES OF LABOR 1 & 2 PHYSICIAN ______________________________________ BILLING NO. ______________________________________ PAGE 4 OF 4 Figure 13-1, cont’d I For legend see opposite page.
  15. 15. 280 PART III The Family during Birth PROCEDURE 13-1 Leopold’s Maneuvers PURPOS E : To determine presentation and position of the fetus and aid in location of fetal heart sounds 1. Explain the procedure to the woman and the rationale 5. Palpate the uterine fundus. The breech (buttocks) is softer for each step as it is performed. Tell her what is found and more irregular in shape than the head. Moving the at each step. Gives information, teaches the woman, breech also moves the fetal trunk. The head is harder and and reassures her when the assessment findings are has a round, uniform shape. The head can be moved normal. without moving the entire fetal trunk. Distinguishes be- 2. Ask the woman to empty her bladder if she has not done tween a cephalic and breech presentation. If the fetus is so recently. Have her lie on her back with her knees in a cephalic presentation, the breech is felt in the fundus. flexed slightly. Place a small pillow or folded towel under If the presentation is breech, the head is felt in the fundus. one hip. Decreases discomfort of a full bladder during palpation and improves ability to feel fetal parts in the SECOND MANEUVER suprapubic area. Knee flexion helps the woman relax her abdominal muscles to enhance palpation. Uterine dis- placement prevents aortocaval compression, which could reduce blood flow to the placenta. 3. Wash your hands with warm water. Wear gloves if con- tact with secretions is likely. Prevents transmission of mi- croorganisms. Warm hands are more comfortable during palpation and prevent tensing of abdominal muscles. 4. Stand beside the woman, facing her head, with your dominant hand nearest her. The first three maneuvers are most easily performed in this position. FIRST MANEUVER 6. Hold the left hand steady on one side of the uterus while palpating the opposite side of the uterus with the right hand. Then hold the right hand steady while palpating the opposite side of the uterus with the left hand. The fetal back is a smooth, convex surface. The fetal arms and legs feel nodular, and the fetus often moves them during palpation. Determines on which side of the uterus is the back and on which side are the fetal arms and legs (“small parts”). LABORATORY TESTS. Women who had regular pre- INTRAVENOUS ACCESS. If used, intravenous (IV)natal care need laboratory tests only for specific indications, access is started with at least an 18-gauge catheter. A salinewhereas those who did not have prenatal care need more ex- lock may be used, or the woman may receive continuous in-tensive laboratory tests. Simple tests that are often per- fusion of fluids. The lock eases walking during early laborformed on the unit include the following: but provides quick access if fluids or drugs are needed. Con- Hematocrit obtained by finger stick tinuous fluid infusion prevents and relieves dehydration Midstream urine specimen to assess protein and glu- and is necessary if epidural block analgesia is used. IV solu- cose levels—usually obtained before notifying the birth tions containing electrolytes, such as lactated Ringer’s solu- attendant tion, are most common.

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