Second power point for B24, Christine Dunn.

1. Nursing Management
during Labor and Birth
Christine Dunn

2. Healthy People 2020
Childbirth
• 1. Reduce maternal deaths
• 2. Reduce maternal illness and complications due
to pregnancy
• 3. Increase the proportion of pregnant women who
receive early and adequate prenatal care
• 4. Increase the proportion of pregnant women who
attend a series of prepared childbirth classes

3. Maternal Assessment
• Determine the woman’s response and her progress
in labor
• Maternal Vital Signs, uterine contractions
• Review the prenatal record
• Uteroplacental circulation
• Vaginal exam upon admission, then when necessary
to identify progress in labor ( Infection)
• Discomfort along with strategies at regular
intervals ( Pharm and nonpharm)
• Psychological status of patient and family

4. Leopold’s Maneuvers
• Method for determining the
presentation,position and lie of the
fetus using 4 steps.
• Each maneuver answers a question:
• See text.

5. Analysis of FHR
• One of the primary evaluation tools
used to determine fetal oxygen status
is the analysis of fetal heart rate.
• Fetoscope- intermittently
• Doppler- intermittently
• Electronic fetal monitor-continuously/
intermittently

6. Childbirth Discomfort
is Different WHY?
• Childbirth discomfort is part of the process of
labor, a physiologic process, not from an injury or
illness.
• The pregnant woman has several months to
prepare for the discomfort of labor and to acquire
skills to help cope.
• Labor discomfort has a foreseeable end; and the
firth of the newborn brings a rapid decrease in the
discomfort.
• Intermittent discomfort; labor ends with the birth
of a newborn this is an emotional signifcance that
affects the response to the discomfort.

7. Sources of Discomfort
• Tissue ischemia- Tissue hypoxia, uterus
• Cervical dilation- Causes discomfort, dilation and
stretching of the cervix. See text.
• Pelvic Structures- referred pain in back and legs
from pulling and pressure on pelvic structures.
• Distention of the vagina and perineum- As the fetus
descends into the pelvis distention of the vagina
and perineum occurs which causes discomfort.

8. Factors
• Influencing the Perception or tolerance of Pain:
• Intensity of labor
• Cervical readiness
• Fetal position
• Characteristics of the pelvis
• Fatigue
• Intervention of caregivers

9. Psychosocial Factors
• Culture- Influence how she perceives, interprets
and responds to pain during childbirth.
• Anxiety and Fear- Magnify sensitivity to pain and
impair a woman’s ability to tolerate it.
• Previous experiences with pain—Fear and
withdrawal natural reactions. Knowledge of the
normal sensations of labor helps her to suppress
her natural reactions of fear and withdrawal.
• Preparation and support- Reduces anxiety and fear
of the unknown, rehearse. Family and friends are
sources of comfort and assistance; realistic info.

10. Nonpharmacologic
Techniques
• Relaxation
• Cutaneous stimulation- Massage, thermal
stimulation, acupressure.
• Hydrotherapy
• Mental stimulation- imagery, breathing techniques
• Application of heat or cold
• Advantage: No side effects or risk to the fetus!!!

11. Pharmacologic
interventions during
labor
• Anesthesia- can be a combination of
analgesia, amnesia, relaxation and
reflex activity. Abolishes pain
perception by interrupting the nerve
impulses to the brain, may involve
loss of consciousness.
• Analgesia-Alleviation of the sensation
of pain or the raising of the threshold
for pain perception without loss of
consciousness

12. Pharmacologic Pain
Management
• Systemic Analgesia
• Side Effects to the fetus: Respiratory
Depression!!!
See textbook.

13. Pharmacologic Pain
Management
• Regional pain management- relief
without LOC.
Epidural
Intrathecal(Subarachnoid)
Local
Pudendal
General

16. I Want My Epidural!!
• Adverse Effects
 hypotension
 bladder distention
 catheter migration
 N/V
 Pruritus
 delayed resp depression
 prolonged second stage

17. I Want My Epidural !!
• Nursing Care
 preload with IV fluids(LR)
 assist anesthesiologist
 frequently assess FHR/MVS
 observe for bladder distention
 observe for side effects & report

18. Spinal Anesthesia
• Anesthesia of
choice for Cesarean
Section
• More rapid onset
than epidural for
C/S
• More complete
block than epidural
for C/S
• Requires much less
concentration of
drugs than epidural
• Potential spinal
headache
• Hypotension
• Bladder distention

19. Local Infiltration
• Injection of a local anesthetic such as lidocaine
into the superficial perineal nerves to nemb the
perineal area.
• Performed just before performing an episiotomy or
before suturing a laceration.
• Does not alter the discomfort of the uterine
contractions.
• No side effects to fetus! Or mother!

20. Pharmacologic Pain
Management
• Special considerations
effects on fetus
maternal physiologic alterations
effects on course of labor
effects of complications
interactions with other
substances.

21. Nursing Care during
the stages of labor
• First Stage- Key Nursing Interventions see text
• Summary of assessments during first stage:
• Latent
• Active
• Transition
• Positioning during the first stage of Labor:
• See text Teaching guidelines.

22. Nursing Care
• Second Stage : Supporting the woman and her
partner in making active decisions about her care
and labor management.
• Support her choice of pushing method
• Give feedback on her progress
• See Text summary.
• Perineal Lacerations
• Episiotomy

23. Nursing Care
• Third and Fourth stage
• Third- gradual decrease in the size of the uterus
this helps to shear the placenta away from its
attachment site. Immediate newborn
care/assessment, assist with the delivery of the
placenta inspect for intactness.
• Fourth- Observation for hemorrhage, comfort
measures, promotion of family attachment.

24. Application of the
Nursing Process
• Primary risks associated with
EPIDURAL analgesia…
Maternal hypotension with secondary
fetal hypoxia
Injury related to reduced sensation
and movement

25. NCLEX Questions
• A patient, age 22 is a G1 T1 P0 A0 L1.
During the 1st 24 hours after delivery, she
does not show consistent interest in her
neonate. How should the nurse interpret
this behavior?
• A. The patient is experiencing PPD (post
partum depression)
• B. The patient is questioning her role as a
mother
• C. The patient is showing expected
behaviors for the taking in period
• D. The patient is failing to attach to her

26. NCLEX Questions
• A pregnant patient arrives at the health
care facility stating that her bed linens
were wet when she woke up this AM. She
says no fluid is leaking but complains of
mild abdominal cramps and lower back
discomfort. Vaginal exam reveals 2 cm
dilated with positive ferning noted. What
stage of labor is this patient in?
• A. Latent
• B Active
• C. Transition
• D. Explosive stage

27. Questions
• A patient in labor tells the nurse –midwife that she
feels a strong urge to push. Vaginal exam reveals
that her cervix is not completely dilated. The
midwife tells her not to push yet. What is the
rationale for this instruction?
• A. Early pushing may cause edema and impede
fetal descent
• B. The nurse midwife is not ready to assist the
patient at this time
• C. The fetus has not rotated to the proper position
• D. Pushing at this time may cause ROM (rupture of
membranes)