Stages Of Labor Recap

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Stages Of Labor Recap

  1. 1. Prepared by : Ms. Shenell A. Delfin,RN THE LABOR PROCESS AND THE NURSE
  2. 2. <ul><li>CHARACTERISTICS PATIENT BEHAVIOR </li></ul>FIRST STAGE – STAGE OF DILATION AND EFFACEMENT Latent Phase ( 4 – 6 hours) Cervix dilation is 0-4 cm. Amniotic membranes may be intact. There may be “bloody show.” Contractions: q 20 minutes decreasing to q 5 minutes Duration: 15-40 seconds Intensity: mild to moderate <ul><li>Cooperative </li></ul><ul><li>Alert </li></ul><ul><li>Talkative </li></ul><ul><li>Welcomes diversions </li></ul><ul><li>Urinary frequency </li></ul><ul><li>Thirsty </li></ul>
  3. 3. <ul><li>NURSING INTERVENTIONS </li></ul><ul><li>Establish positive relationships </li></ul><ul><li>Encourage alternating ambulation </li></ul><ul><li>and rest </li></ul><ul><li>Assess fetal heart rate. </li></ul><ul><li>Time contractions </li></ul><ul><li>Document color of vaginal discharge </li></ul><ul><li>Assess for distended bladder </li></ul><ul><li>Provide lollipops for mother to hold and suck on between contractions for carbohydrate and fluid intake. </li></ul><ul><li>Assess vital signs q 2 hours </li></ul><ul><li>Woman may takes showers. </li></ul><ul><li>Teach what to expect as labor </li></ul><ul><li>progresses. </li></ul>
  4. 4. <ul><li>Active Phase (2-6 hours) </li></ul><ul><li>Cervix dilation is 4-8 cm. </li></ul><ul><li>Amniotic membranes may rupture. </li></ul><ul><li>Effacement of cervix occurs. </li></ul><ul><li>Contractions: 2-5 minutes apart </li></ul><ul><li>Duration: 40-60 seconds </li></ul><ul><li>Intensity: moderate to firm. </li></ul><ul><li>Apprehensive </li></ul><ul><li>Anxious </li></ul><ul><li>Introverted </li></ul><ul><li>Less social </li></ul><ul><li>Focused on breathing </li></ul><ul><li>Perspires </li></ul><ul><li>Facial flushing </li></ul><ul><li>Requests pain relief </li></ul><ul><li>Fears losing control </li></ul><ul><li>May need epidural analgesia at this time </li></ul>
  5. 5. <ul><li>NURSING INTERVENTIONS </li></ul><ul><li>Help coach apply coping strategies </li></ul><ul><li>learned in prenatal classes (breathing, relaxation). </li></ul><ul><li>Continue maternal and fetal </li></ul><ul><li>assessments </li></ul><ul><li>Reassure woman </li></ul><ul><li>Praise progress. </li></ul><ul><li>Provide back massage </li></ul><ul><li>facilitate position changes (avoid lying flat on back) </li></ul><ul><li>If taking nothing orally (NPO), moisten mouth </li></ul><ul><li>Monitor IV fluid intake </li></ul><ul><li>Watch for bladder distention. </li></ul><ul><li>Encourage voiding. </li></ul><ul><li>Report color, odor, amount of vaginal discharge' report if </li></ul><ul><li>meconium is seen. </li></ul><ul><li>Maintain warmth </li></ul><ul><li>provide general comfort measures. </li></ul>
  6. 6. <ul><li>Transition phase (30 minutes to 2 hours) </li></ul><ul><li>Cervix dilation is 8-10 cm; cervix fully effaced. </li></ul><ul><li>Amniotic membranes rupture. </li></ul><ul><li>Contractions: q 2-3 minutes </li></ul><ul><li>Duration: 60-90 seconds </li></ul><ul><li>Intensity: firm </li></ul><ul><li>Irritable </li></ul><ul><li>Rejects support person </li></ul><ul><li>Introverted </li></ul><ul><li>Wants to give up </li></ul><ul><li>Restless </li></ul><ul><li>Tremor of legs </li></ul><ul><li>Fears losing control </li></ul><ul><li>Requests medication </li></ul><ul><li>Hates it when someone is touching her abdomen </li></ul>
  7. 7. <ul><li>NURSING INTERVENTIONS </li></ul><ul><li>Provide firm coaching of breathing and relaxation techniques, focusing </li></ul><ul><li>Support coach </li></ul><ul><li>Praise and reassure woman. </li></ul><ul><li>Assess monitor strips of fetal heart rate and contractions. </li></ul><ul><li>Assess color of vaginal discharge. </li></ul><ul><li>Keep woman informed as to progress with each contraction. </li></ul><ul><li>Accept negative comments from woman. </li></ul><ul><li>Maintain positive approach. </li></ul>
  8. 8. <ul><li>SECOND STAGE – STAGE OF EXPULSION (30 MINUTES TO 2 HOURS) </li></ul><ul><li>Cervix dilation is 10 cm. </li></ul><ul><li>Contractions: q 1 ½ -3 minutes </li></ul><ul><li>Duration: 60 -80 seconds </li></ul><ul><li>Intensity: firm </li></ul><ul><li>Episiotomy may be performed by health care provider. </li></ul><ul><li>Second stage ends with birth of infant </li></ul><ul><li>Bulging perineum </li></ul><ul><li>Mother may pass stool </li></ul><ul><li>Uncontrollable urge to push </li></ul><ul><li>States “baby is coming” </li></ul><ul><li>Exhaustion after each contraction. </li></ul><ul><li>Unable to follow directions easily </li></ul><ul><li>Excitement concerning imminent birth. </li></ul>
  9. 9. <ul><li>NURSING INTERVENTIONS </li></ul><ul><li>Assist woman to assume position that helps her push. </li></ul><ul><li>Assist with open glottis pushing technique and coping strategies. </li></ul><ul><li>Support coach. </li></ul><ul><li>Maintain communication with health care provider. </li></ul><ul><li>Monitor contractions and fetal heart rate q 5 minutes. </li></ul><ul><li>Assess perineum and vaginal discharge </li></ul><ul><li>report bulging or crowning </li></ul><ul><li>Observe for bladder distention </li></ul><ul><li>Prepare sterile supplies for delivery </li></ul><ul><li>Prepare infant resuscitation equipment </li></ul><ul><li>provide feedback to woman and partner. </li></ul>
  10. 10. <ul><li>THIRD STAGE – EXPULSION OF PLACENTA </li></ul><ul><li>Duration: 5-30 minutes </li></ul><ul><li>Contractions: intermittent </li></ul><ul><li>Intensity: mild to moderate </li></ul><ul><li>Umbilical cord is cut </li></ul><ul><li>Signs of placental separation include the following </li></ul><ul><li>Lengthening of cord </li></ul><ul><li>Uterine fundus rises and becomes firm </li></ul><ul><li>Fresh blood expelled from vagina </li></ul><ul><li>Placenta is expelled by Schultz mechanism (shiny fetal side first) or by Duncan's mechanism (dull, rough maternal side first) </li></ul><ul><li>Uterus contracts to size or grapefruit. </li></ul><ul><li>Episiotomy is sutured by health care </li></ul><ul><li>Elation </li></ul><ul><li>Relief </li></ul><ul><li>Tremors </li></ul><ul><li>Increased physical energy </li></ul><ul><li>Curiosity about infant </li></ul><ul><li>Desire to nurse infant </li></ul><ul><li>Pain is minimal as placenta is expelled. </li></ul>
  11. 11. <ul><li>NURSING INTERVENTIONS </li></ul><ul><li>Observe and document blood loss. </li></ul><ul><li>Document delivery of placenta. </li></ul><ul><li>Examine placenta to determine if all of it was expelled (retained placenta causes hemorrhage because it prevents uterus from contracting). </li></ul><ul><li>Monitor mother's vital signs q 15 minutes. </li></ul><ul><li>Assess vaginal discharge. </li></ul><ul><li>Massage uterus until it is firm in midline at or below level of umbilicus. </li></ul><ul><li>Administer oxytocin to other as ordered </li></ul><ul><li>Obtain cord blood if needed. </li></ul><ul><li>Note parent/infant interaction. </li></ul><ul><li>Dry newborn and place in radiant warmer. </li></ul><ul><li>Attach heart and temperature monitor. </li></ul><ul><li>Assess and provide immediate newborn care </li></ul><ul><li>perform Apgar evaluation. </li></ul><ul><li>Apply proper identification to mother, infant, and partner. </li></ul>
  12. 12. <ul><li>FOURTH STAGE-RECOVERY </li></ul><ul><li>Uterus remain midline, firmly contracted at or below umbilicus level. </li></ul><ul><li>Lochia rubra saturates perineal pad (no more than one pad per hour). </li></ul><ul><li>Cramping may occur </li></ul><ul><li>Woman may have shaking chills that may be a thermoregulation response. </li></ul><ul><li>A get-acquainted period between woman, partner and infant </li></ul><ul><li>Mother breastfeeds infant </li></ul>
  13. 13. <ul><li>NURSING INTERVENTIONS </li></ul><ul><li>Provide proper identification of mother, partner, and newborn. </li></ul><ul><li>Obtain cord blood if needed. </li></ul><ul><li>Assess woman's vital signs q 15 minute. </li></ul><ul><li>Assess maternal voiding. </li></ul><ul><li>Monitor heart rate and temperature of newborn </li></ul><ul><li>Provide warmth to newborn. </li></ul><ul><li>Assess newborn for anomalies. </li></ul><ul><li>Assess fundus and massage to maintain firm contraction (a fundus that is displaced to the side indicates a full bladder is pressing against it). </li></ul>

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