Management of Labor

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Management of Labor

  1. 1.  Evaluate volume of vaginal bleeding as stable or unstable per the patient’s vital signs and uterine response .  Stable : vital signs within 20% of patient’s average readings and uterus remains firm between assessment or quickly firms after fundal massage  Unstable : vital signs vary greater than 20% from the patient’s average readings or repetitive blood pressure readings below 90/60 mm Hg , pulse more than 110/min , respiration 24 to 26 / min accompanied by continuous bleeding and a boggy uterine tone  INCREASE PULSE RATE IS THE FIRST SIGN OF THE HYPOVOLUMIA AND VHYPOTENSION IS LATE .  If bleeding continues and uterus is firm , notify health care provider for evaluation of laceration or retained placental fragments .  AUTOTRANSFUSION 1
  2. 2. SEMINAR WHAT IS MEANT BY “ THE SEMINAR ” ? A SMALL GROUP OF ADVANCED STUDENTS IN A COLLEGE OR GRADUATE SCHOOL ENGAGED IN ORGINAL RESEARCH OR INTENSIVE STUDY UNDER THE GUIDANCE OF PROFESOR WHO MEET REGULARLY WITH THEM TO DISCUSS THEIR REPORTS AND FINDINGS . 2
  3. 3. MANAGEMENT OF PHASES OF LABOUR BHUSHAN RHISHIKESH JOSHI ( IIIRD B.BSC. NSG ) 3
  4. 4. CONTENTS  OBJECTIVES  INTRODUCTION TO TOPIC  PHASES OF LABOUR  MANAGEMENT OF FIRST STAGE  MANAGEMENT OF SECOND STAGE  CARE OF NEW BORN  MANAGEMENT OF THIRD STAGE 1. EXPECTANT 2. ACTIVE ( PREFERRED)  MANAGEMENT OF FOURTH STAGE  SUMMARY 4
  5. 5. OBJECTIVES  DEFINE LABOR .  DESCRIBE EVENTS OCCURING IN STAGES OF LABOR .  HIGHLIGHT PRINCIPLES AND OBJECTIIVES OF MANAGEMENT OF LABOR .  DISCUSS MANAGEMENT OF FIRST STAGE OF LABOUR  ELLABORATE MANAGEMENT OF SECOND STAGE OF LABOR .  EXPLAIN IMMEDIATE CARE OF NEW BORN .  DESCRIBE MANAGEMENT OF THIRD STAGE OF LABOR .  DISCUSS MANAGEMENT OF FOURTH STAGE OF LABOR  SUMMERIZATION OF TOPIC . 5
  6. 6. THE CHALLENGE IS, CAN YOU PROVIDE VIGILANCE WITHOUT INTERVENTION…. You are the only one , who can help you in best way . 6
  7. 7. DEFINING LABOR  SERIES OF EVENTS THAT TAKES PLACE IN THE GENITAL ORGANS IN AN EFFORT TO EXPEL THE VIABLE PRODUCT OF CONCEPTION OUT OF THE WOMB THROUGH VAGINA INTO THE OUTER WORLD IS CALLED AS LABOR .  NORMAL LABOR (EUTOCIA) LABOR IS CALLED AS NORMAL IF IT FULFILS FOLLOWING CRITERIA 1. SPONTANEOUS IN ONSET AND AT TERM 2. WITH VERTEX PRESENTATION 3. WITHOUT UNDUE PROLONG 4. NATURAL TERMINATION WITH MINIMAL AIDS 5. WITHOUT HAVING ANY COMPLICATIONS AFFECTING THE HEALTH OF THE MOTHER AND/OR THE BABY .  ABNORMAL LABOR (DYSTOCIA) ANY DEVIATION FROM THE DEFINATION OF NORMAL LABOR IS CALLED ABNORMAL LABOR 7
  8. 8.  FACTORS INITIATING LABOR THEORETICAL  MATERNAL FACTORS  PROGESTERONE  ESTROGEN  OXYTOCIN  PROSTAGLANDIN  PSYCHE  FETAL FACTORS  FETAL CORTISOL ARTIFICIAL  CERVICAL EXAM  STRIPPING OF MEMBRANES  PROSTAGLANDINS  ARTIFICIAL RUPTURE OF MEMBRANES  SEX  NIPPLE STIMULATION 8 EVENTS OCCURRING IN STAGES OF LABOR
  9. 9. EVENTS IN FIRST STAGE OF LABOR CHIEFLY CONCERNED WITH PREPARATION OF BIRTH CANAL SO AS TO FACILITATE EXPULSION OF FETUS IN SECOND STAGE .MAIN EVENTS THAT OCCURS IN THIS STAGE ARE : DILATION AND TAKING UP OF CERVIX THERE ARE DIFFERENT FEACTORS WHICH PREDISPOSE SMOOTH DILATION OF CERVIX : a) UTERINE CONTRACTION AND RETRACTION – CRVIX BECOMES SHORTENED AND RETRACTED IN BUCKET HOLDING FASHION . b) BAG OF MEMBRANE – EFFACEMENT OR TAKING UP OF THE CERVIX : IS A PROCESS OF THINNING OUT . NOTE THE FOLLOWING :  DILATION : HOW FAR THE CEVIX HAS BEEN OPENED ( IN CM )  EFFACEMENT : HOW THIN IS THE CERVIX ( IN CM OR % ) FULL FORMATION OF LOWER UTERINE SEGMENT 9 IN NULLIPARA THE FIRST STAGE MAY BE PROLONG UP TO 12 HOURS WHILE IN MULTIPARA IT GET COMPLETED IN 4 – 6 HOURS .
  10. 10. CERVICAL DILATION AND EFFACEMENT
  11. 11. EVEN TS IN SECOND STAGE OF LABOR THIS STAGE IS CONCERNED WITH THE DESCENT AND DELIVERY OF THE FETUS THROUGH THE BIRTH CANAL , CERVICAL DILATION CONTINUES , WITH FULL DILATION OF CERVIX , THE MEMBRANES USUALLY RUPTURE AND THERE IS ESCAPE OF GOOD AMOUNT OF LIQUOR AMNII . UTERINE CONTRACTION AND RETRACTION BECOMES MORE STRONGER EXPULSIVE FORCE OF UTERINE CONTRACTION IS ADDED BY CONTRACTION OF THE ABDOMINAL MUSCLES CALLED “ BEARING DOWN ” EFFORTS . THE SECOND STAGE MAY LAST FROM 1 TO 4 HOURS IN NULLIPARA AND LESS THAN 1 HOUR IN MULTIPARA . 11
  12. 12. EVENTS IN THIRD STAGE OF LABOR  THE THIRD STAGE OF LABOR COMPRISES THE PHASE OF PLACENTAL SEPARATION ITS DECENT TO LOWEAR SEGMENT AND FINALY ITS EXPULSION WITH MEMBRANES .  PLACENTAL SEPARATION : AFTER THE BIRTH SHAPE OF UTERUS BECOMES DISCOID AND CAVITY IS MUCH REDUCED(20CMX10CM) .  AS THE PLACENTA IS INELASTIC IT CAN NOT KEEP PACE WITH SUCH EXTENT OF RETRACTION AND RESULTS IN BUCKLING .  SEPARATION MAY BE MARGINAL MAY BE CENTRAL .  SEPARATION OF THE MEMBRANES  AFTER THE SEPARATION OF PLACENTA IT GET EXPELLED OUT .  THE THIRD STAGE MAY LAST FROM A FEW MINUTES TO 30 MINUTES . 12
  13. 13. PRINCIPLES AND OBJECTIIVES OF MANAGEMENT OF LABOR .  NON INTERFERENCE WITH WATCHFUL EXPECTANCY FOR NATURAL BIRTH .  MONITOR CAREFULLY SO AS TO DETECT ANY INTRAPARTUM COMPLICATION .  ASSIST IN THE NATURAL EXPULSION OF THE FETUS SLOWLY AND STEADILY .  TO PREVENT PERINEAL INJURIES .  IMMEDIATE CARE OF NEWBORN .  ENSURE STRICT VIGILANCE .  TO FOLLOW THE MANAGEMENT GUIDELINES STRICTLY IN PRACTICE 13
  14. 14. MANAGEMENT OF FIRST STAGE OF LABOR PRELIMINARIES BASIC EVALUATION OF CURRENT CLINICAL CONDITIONS. OBSTETRICAL AND GENERAL EXAMINATION INCLUDING VAGINAL EXAMINATION TO EXCLUDE ANY ABNORMALITIES. RECORDS OF ANTE NATAL VISITS , INVESTIGATION REPORTS AND ANY SPECIFIC TREATMENT GIVEN ARE TO BE REVIEWED .
  15. 15. ACTUAL MANAGEMENT General  ANTISEPTIC DRESSING  ENCOURAGEMENT , EMOTIONAL SUPPORT AND ASSURANCE  CONSTANT SUPERVISION REST AND AMBULATION BOWEL :ENEMA WITH SOAP AND WATER OR GLYCERINE SUPPOSITORY DIET: FOOD IS WITH HELD DURING ACTIVE LABOUR. BECAUSE DELAYED EMPTYING OF THE STOMACH AND LOW PH OF GASTRIC CONTAIN IS REAL DANGER IF ASPIRATED FOLLOWING GENERAL ANESTHESIA WHEN NEEDED UNEXPECTEDLY . BLADDER CARE : ENCOURAGED TO PASS URINE BY HERSELF . IF PATIENT FAILS TO PASS URINE SPECIALLY IN LATE FIRST STAGE , CATHETERIZATION SHOULD BE DONE WITH STRICT ASEPTIC PRECAUTIONS . 15
  16. 16. MANAGEMENT OF LABOR PAIN PAIN IS SUBJECTIVE , COMPLEX INTERACTION OF INFLUENCES : a. PHYSIOLOGIC b. PSYCHOSOCIAL c. CULTURAL d. ENVIRONMENTAL NATURE OF LABOR PAIN – 1ST STAGE VISCERAL PAIN DIFFUSE ABDOMINAL CRAMPING UTERINE CONTRACTIONS
  17. 17. NONPHARMACOLOGICAL PAIN RELIEF 1. CONTINUOUS LABOR SUPPORT INCREASINGLY AVAILABLE AT HOSPITALS & BIRTH CENTERS RECENT SURVEY (2002 - WHO) 6% OF WOMEN USED WARM WATER BATHS 49% FOUND THEM VERY HELPFUL 2. WARM WATER BATHS LABOR MAY SLOW IF USED IN EARLY LABOR LESS THAN 5CM DILATION 3. STERILE-WATER INJECTIONS INTRADERMAL INJECTIONS OF STERILE WATER IN THE SACRAL AREA CAUSES A BURNING SENSATION COUNTERIRRITATION DECREASES BACK PAIN FOR 45-90 MINS. 4 .POSITIONS, TOUCH, & MASSAGE
  18. 18. 18  NON-MEDICAL CARE BY A TRAINED PERSON  DIFFERENT DEFINITIONS/CRITERIA DEPENDING ON STUDIES: a) “MINIMUM OF 80%” PRESENCE b) PRESENCE “WITHOUT INTERRUPTION, EXCEPT FOR TOILETING”  VARIOUS TERMS: DOULA, LABOR ASSISTANT, BIRTH COMPANION, MONITRICE  MAY REFER TO HUSBAND OR UNTRAINED FEMALE COMPANION CONTINUOUS LABOR SUPPORT
  19. 19. EFFECTS OF PSYCHOLOGICAL SUPPORT DURING LABOUR Continuous Labor Support: Mechanism of Action from Hodnett (2007) Negative experiences may impede labor Negative experiences may impede adjustment to motherhood Mitigates potentially harsh environment Positive impact of companionship on mom woman uses gravity & position changes fetopelvic relationship is enhanced Mobility encouraged by support person fewer abnormal FHR patterns preserves uterine contractility stress hormones (epinephrine) may be reduced Support person decreases anxiety of mom Physiologic impact of continuous labor support 19
  20. 20. WHY ARE WE LOOKING TO DECREASE THE USE OF MEDICATION? THE THEORY “NATURAL BIRTH” : BODY PRODUCES ENDORPHINS TO COPE WITH PAIN . BABY‟S ENDORPHINS RAISE WHEN MOM‟S ENDORPHINS RAISE . MEDICATIONS DECREASE NATURAL ENDORPHINS FOR BOTH .IT ALSO STIMULATES THE BABY‟S ADRENAL GLANDS . “FIGHT OR FLIGHT” – HELPS TO ADAPT TO LIFE OUTSIDE OF THE UTERUS . IT INCREASES BLOOD FLOW TO BABY . STIMULATES IMMUNE SYSTEM (INCREASED WBC‟S) . MAKING BABY MORE ALERT – FACILITATES BONDING . OXYTOCIN PEAKS JUST AFTER AN UNMEDICATED BIRTH AND STIMULATES MATERNAL BEHAVIORS . OPIODS AND NARCOTICS CONTINUOUS LUMBAR EPIDURAL PARACERVICAL BLOCK 50 / 50 NITROUS / OXYGEN PSYCHOPROPHYLAXIS HYPNOSIS PHARMACOLOGICAL PAIN RELIEF
  21. 21. PARENTERAL OPIOIDS : MOTHER  LESS PAIN RELIEF AND SATISFACTION WITH PAIN RELIEF (ALL STAGES)  LOWER RATE OF OXYTOCIN AUGMENTATION  SHORTER STAGES OF LABOR  FEWER CASES OF MALPOSITION  FEWER INSTRUMENT-ASSISTED DELIVERIES PARENTERAL OPIOIDS - INFANT NEONATAL RESPIRATORY DEPRESSION DECREASED ALERTNESS INHIBITION OF SUCKING LOWER NEUROBEHARIORAL SCORES DELAY IN EFFECTIVE FEEDING LONG-TERM EFFECTS CANNOT BE EXCLUDED
  22. 22. EPIDURAL ANALGESIA  BALANCE BETWEEN PAIN RELIEF AND OTHER GOALS… 1. WALKING (1ST STAGE) 2. PUSHING EFFECTIVELY (2ND STAGE) 3. MINIMIZING SIDE EFFECTS MATERNAL AND NEONATAL “WALKING EPIDURAL” INTRATHECAL OPIOID INJECTION BEFORE CONTINUOUS EPIDURAL INFUSION  *OFTEN ARE UNABLE TO WALK… 1. SUBSTANTIAL MOTOR BLOCKADE 2. NEED CONTINUOUS FETAL MONITORING  ADVANTAGES: 1. RAPID ONSET OF PAIN RELIEF 2. POTENTIAL FOR THE INTRATHECAL MEDICATION TO SUFFICE 3. LIKELY TO DELIVER IN 2-3 HOURS
  23. 23. EPIDURAL ANALGESIA - EFFECTS  SLOWS LABOR (1ST AND 2ND STAGES)  INCREASES USE OF PITOCIN  OXYTOCIN AUGMENTATION  INCREASED PERINEAL TEARS  INCREASED INSTRUMENT-ASSISTED DELIVERY  FORCEPS/VACUUM EXTRACTION  INCREASED CESAREAN (?)  ESPECIALLY WHEN ADMINISTERED EARLY  MATERNAL FEVER EPIDURAL – SIDE EFFECTS COMMON:  HYPOTENSION  IMPAIRED MOTOR FUNCTION (INABILITY TO WALK)  NEED FOR CATHETERIZATION UNCOMMON (<10%):  PRURITIS  NAUSEA & VOMITING  SEDATION
  24. 24. NITROUS OXIDE  WIDELY USED IN MOST DEVELOPING COUNTRIES a) >60% FINLAND AND UNITED KINGDOM b) 50/50 BLEND NITROUS OXIDE AND OXYGEN FULL EFFECT 50 SECONDS AFTER INHALATION USUALLY SELF-ADMINISTERED AS NEEDED NITROUS OXIDE – SIDE EFFECTS  NAUSEA ,VOMITING ,POOR RECALL OF LABOR 1. NITRAZINE PAPER TURNS BLUE IN THE PRESENCE OF ALKALINE AMNIOTIC FLUID . 2. VAGINAL SECERITIONS ARE NITRAZINE NEGATIVE AS THEY ARE ACIDIC . 3. POOLING OF THE AMNIOTIC FLUID IN THE VAGINAL VAULT IS A RELIABLE SIGN . STATUS OF MEMBRANES
  25. 25. MONITORING FOR FETAL WELL-BEING: THE EVIDENCE 25 EARLY LABOR, FOR LOW RISK PATIENTS, NOTE THE FETAL HEART RATE EVERY 1-2 HOURS. DURING ACTIVE LABOR, EVALUATE THE FETAL HEART EVERY 30 MINUTES NORMAL FHR IS 120-160 BPM PERSISTENT TACHYCARDIA (>160) OR BRADYCARDIA (<120, PARTICULARLY <100) IS OF CONCERN
  26. 26.  TO NOTE THE PROGRESS OF LABOR : ABDOMINAL FINDINGS 1. UTERINE CONTRACTIONS- INTENSITY , FREQUENCY AND DURATION SHOULD ASSESSED . PROGRESSIVE INCREASE IN INTENSITY SIGNIFIES GOOD PROGRESS OF LABOR . 2. PELVIC GRIP – GRADUAL DISAPPEARANCE OF POLES OF HEAD . 3. SHIFTING OF MAXIMUM IMPULSE OF FETAL HEART BEAT DOWNWARDS AND MEDIALLY . VAGINAL EXAMINATIONS 1. DILATION OF CERVIX 2. POSITION OF HEAD AND DEGREE OF FLEXION FREQUENT VAGINAL EXAMINATIONS ARE STRICTLY CONDEMNED DUE TO MATERNAL UNCOMFORT AND RISK OF INFECTIONS . 26
  27. 27. NURSING DIAGNOSIS  DEFICIT FLUID VOLUME RELATED TO DECREASE ORAL INTAKE , DIETARY RESTRICTIONS AND ENERGY REQUIREMENT OF LABOR .  ACUTE PAIN RELATED TO UTERINE CONTRACTIONS OR POSITION OF THE FETUS AND NAUSEA AND VOMITING .  ANXIETY RELATED TO CONCERN FOR SELF AND THE FETUS .  IMPAIRED URINARY ELIMINATION RELATED TO EPIDURAL ANESTHESIA OR FROM PRESSURE OF THE FETUS .  INEFFECTIVE COPING RELATED DISCOMFORT .  RISK FOR INFECTION RELATED TO RUPTURE OF MEMBRANES .  IMPAIRED PHYSICAL MOBILITY RELATED TO MEDICAL INTERVENTIONS AND DISCOMFORTS .  INEFFECTIVE BREATHING PATTERN RELATED TO PAIN AND FATIGUE . 27
  28. 28. NURSING INTERVENTIONS MAINTAINING NUTRITION AND HYDRATION a) PROVIDING CLEAR LIQUID IN SMALL SIPS . b) EVALUATE URINE FOR KETONE AND GLUCOSE . c) ADMISTER I.V. FLUID AS INDICATED AND ORDERED RELIEVING ANXIETY a) PSYCHOLOGICAL SUPPORT . b) INFORM ABOUT THE MATERNAL STATUS FETAL STATUS AND LABOR PROGRESS PERIODICALY . c) ANSWER THE QUESTIONS AND OFFER THE SUPPORT . d) EXPLAIN THE PROCEDURE AND EQUIPMENTS USED DURING LABOR . 28
  29. 29. CONTROLLING PAIN 1. ENCOURAGE AMBULATION AS TOLERATED 2. ENCOURAGE DIVERSIONAL ACTIVITIES SREADING , TALKING , WATCHING T.V. PLAYING CARDS … 3. TEACH PROPER BREATHING TECHNIQUE SLOW CHEST BREATHING AVERAGE 10 TO 12 BREATHS PER MINUTE MODIFIED PACED BREATHING AS LABOR PROGRESS SLOW CHEST BREATHING IS NO LONGER EFFECTIVE THEN REGULAR SHALLOW BREATHS WHILE CONTRACTION SHOULD USED 4 PROVIDING COMFORT MEASURES . GIVE BACK AND FOOT RUB . ASSIST WOMAN IN CHANGING OF POSITION . 5 WARM SHOWER CAN BE ENCOURAGED SUCH LABORING WOMAN SITTING ON CHAIR AND WATER RUNNING OVER HER LOWER BACK . 29
  30. 30. ENCOURAGE BLADDER EMPTYING : 1. ENCOURAGE TO VOID EVERY 2 HOURS AT LEAST 100 ML IF POSSIBLE 2. PALPATE THE LOWER ABDOMEN AND EVALUATE FOR BLADDER DISTENTION . 3. PROVIDE PRIVACY TO PATIENT TO COMPLETE THE TASK . 4. CATHETERIZE THE PATIENT IF UNABLE TO VOID VOLUNTARILY . 5. MONITOR INTAKE OUTPUT AS PER THE FACILITY POLICY . PREVENTING INTRA- UTERINE INFECTIONS : 1. TAKE VITALS EVERY 2 HOURS 2. PERIODICALLY CHANGE PAD AND LINEN WHEN WET OR SOILED. 3. PROVIDE PERINEAL CARE AFTER VOIDING AND WHEN NEEDED . 4. MINIMIZE VAGINAL EXAMINATIONS . 5. OBSERVE FOR FETAL TACHYCARDIA AND WARMTH OF MATERNAL SKIN 6. ASSES THE COMPLETE BLOOD COUNT AS INDICATED AND AVAILABLE 30
  31. 31. SECOND STAGE OF LABOR TRANSITION FROM THE FIRST STAGE TO SECOND STAGE IS EVIDENCE BY FOLLOWING : 1. RUPTURE OF THE BAG OF MEMBRANES WITH ESCAPE OF LIQUOR AMNII 2. INCREASING INTENSITY OF UTERINE CONTRACTION 3. APPEARANCE OF BEARING DOWN EFFORTS . 4. COMPLETE DILATION OF CEVIX BIRTH 1. PERINEAL MANAGEMENT 2. ASK MOTHER TO FEEL THE BABY‟S HEAD 3. STAY FOCUSED ON WOMAN, NOT TASKS 31
  32. 32. PRELIMINARIES  ALL OBSERVATIONS SHOULD BE DOCUMENTED ON THE PARTOGRAM.  OBSERVATIONS BY A MIDWIFE OF A WOMAN IN THE SECOND STAGE OF LABOR INCLUDE: • HOURLY BLOOD PRESSURE AND PULSE • CONTINUED 4-HOURLY TEMPERATURE • VAGINAL EXAMINATION OFFERED HOURLY IN THE ACTIVE SECOND STAGE OR IN RESPONSE TO THE WOMAN‟S WISHES (AFTER ABDOMINAL PALPATION AND ASSESSMENT OF VAGINAL LOSS) • HALF-HOURLY DOCUMENTATION OF THE FREQUENCY OF CONTRACTIONS • FREQUENCY OF EMPTYING THE BLADDER • ONGOING CONSIDERATION OF THE WOMAN‟S EMOTIONAL AND PSYCHOLOGICAL NEEDS. 32
  33. 33. POSITIONING  IT IS MOST BENEFICIAL FOR THE PRACTITIONERS WHO OFFERS LABOR SUPPORT TO ENCOURAGE THE PATIENT TO UTILIZE POSITIONS IN ORDER TO FACILITATE FETAL DESCENT . RESEARCH SUPPORTS THAT THE MOST SUCCESSFUL POSITIONS IS THE SQUAT , ALTHOUGH OTHER POSITIONS EXISTS . ADVANCED IMAGING TECHNIQUE HAVE VERIFIED THAT DURING THE SQUAT POSITION THE PELVIC OUTLET INCREASES APPROXIMATELY BY 1-2 CM .  ADDITIONAL POSITIONING ARE AVAILABLE TO ENCOURAGE FETAL DESCENT : SIDE LYING , KNEE-CHEST , HANDS- AND- KNEE , AND FORWARD LEAN ACCOMPANIED BY PELVIC TILT OR PELVIC ROCKING .  SUPINE POSITION IS INAPPROPRIATE DURING LABOR – AT ALL STAGES – AS IT PROMOTES MATERNAL VENA CAVA COMPRESSION AND SUBSEQUENT DEOXYGENATION OF THE MOTHER AND FETUS . 33
  34. 34. PUSHING TECHNIQUE  FOR OPTIMAL SUCCESS THE PUSHING TECHNIQUES SHOULD BE INITIATED ONCE THE CERVIX IS FULLY DILATED , FETAL PRESENTING PART ON THE PELVIC FLOOR , AND PATIENT HAS SENSE TO PUSH / BEAR DOWN ( FERGUSON'S REFLEX )  TWO METHODS OF PUSHING EXIST : PASSIVE PUSHING AND ACTIVE PUSHING A . PASSIVE PUSHING : ( LABORING DOWN / REST AND DESCENT ) TECHNIQUE OFFERS NO ACTIVE PARTICIPATION FROM THE PATIENT TO FACILITATE DESCENT . THE NEED FOR THIS METHOD : 1. DUE TO EPIDURAL ANESTHESIA / ANALGESIA , THE WOMAN DOES NOT FEEL THE URGE TO PUSH . 2. MATERNAL CLINICAL CONDITION , SUCH AS CARDIAC DISEASE , TRAUMA . 3. FETAL CLINICAL CONDITIONS , SUCH AS NON REASSURING FHR . 4. LACK OF NURSING PERSONNEL TO PROVIDE 1:1 SUPPORT . 5. MATERNAL EXHAUSTION . 34
  35. 35. B. ACTIVE PUSHING  ACTIVE PARTICIPATION OF THE PATIENT AND THE PRACTITIONER TO ASSIST DESCENT OUT THE FETUS . IF PROLONGED THE TECHNIQUE MAY NEGATIVELY IMPACT ON THE FETAL WELL BEING . STRATEGIES THAT PROMOTE OXYGEN EXCHANGE IN THE MOTHER INCLUDE :  OPEN GLOTTIS PUSHING - THE TECHNIQUE ALLOW WOMAN TO MAINTAIN HER AIRWAY PATENT FOR GAS EXCHANGE WHILE ENHANCING BEARING DOWN EFFORTS WITH SEVERAL SHORTS , QUICK BREATHS FOR CONTRACTIONS (60-90SEC) . SHORT BREATHS 4 – 6 SEC FOLLOWED BY SLOW EXHALING WITH BEARING DOWN EFFORTS .  BIRTHING AIDS – BIRTHING BALLS , SQUAT BARS , BIRTHING STOOLS , AND CUSHION MAY BE UTILIZED TO SUPPORT THE WOMAN . 35
  36. 36. NURSING DIAGNOSIS A. FEAR OR ANXIETY RELATED TO IMPENDING DELIVERY . B. ACUTE PAIN RELATED TO DESCENT OF FETUS . C. RISK FOR INFECTION RELATED TO EPISIOTOMY AND TISSUE TRAUMA 36 NURSING INTERVENTION MINIMIZING FEAR AND ANXIETY 1. MONITOR MATERNAL VITAL SIGNS AS PER FACILITY POLICY . 2. MONITOR FHR AND UTERINE CONTRACTIONS EVERY 15 MINUTE IN LOW – RISK WOMAN AND EVERY 5 MINUTE IN HIGH – RISK WOMAN . 3. EXPLAIN PROCEDURE , BREATHING , AND EQUIPMENTS DURING THE DELIVERY PROCESS . 4. PERIODICALLY INFORM ABOUT THE PROGRESS OF LABOR TO WOMAN OR COUPLE . 5. PROVID FREQUEN POSITIVE ENCOURAGEMENT .
  37. 37. PROMOTING COMFORT 1. CHANGE POSITION FREQUENTLY TO INCREASE AND PROMOTE FETAL DESCENT . 2. EVALUATE BLADDER FULLNESS AND ENCOURAGE VOIDING OR CATHETERIZE AS NEEDED . 3. EVALUATE EFFECTIVENESS OF THE ANESTHESIA AS INDICATED : NOTIFY IF THE ALTERATION IN DOSING IS NEEDED . PREVENTING INFECTION AND PROMOTING SAFETY 1. PREPARE BIRTHING ROOM WITH STERILE TECHNIQUES , ALLOWING AMPLE TIME BEFORE THE DELIVERY . 2. PREPARE FETUS RESUSCITATION AREA : NOTIFY THE PEDIATRIC PERSONNEL , IF APPROPRIATE , PER FACILITY POLICY . 3. PLACE ALL SIDES RAIL UP BEFORE MOVING AND INSTRUCT THE WOMAN KEEP HER HANDS OFF THE RAILS MOVE BETWEEN CONTRACTIONS . 4. CLEAN THE VULVA AND PERINEAL AREA WHILE THE WOMAN IS POSITIONING FOR THE DELIVERY . 5. PRACTICE STANDARD PRECAUTIONS DURING THE DELIVERY . 37
  38. 38.  DELIVERY OF THE HEAD -”CROWNING: : ENCIRCLEMENT OF THE LARGEST HEAD DIAMETER BY THE VULVAR RING . -UNLESS EPISIOTOMY ; SPONTANEOUS LACERATION . -IT IS NOW CLEAR THAT AN EPISIOTOMY WILL INCREASE THE RISK OF A TEAR INTO THE EXTERNAL ANAL SPHINCTER AND THE RECTUM . -UNLESS EPISIOTOMY. ANTERIOR TEARS INVOLVING THE URETHRA AND LABIA ARE MUSH MORE COMMON . RITGEN MANEUVER - BY THE TIME THE HEAD DISTENDS THE VULVA AND PERINEUM ENOUGH TO OPEN THE VAGINAL INTROITUS TO A DIAMATER OF 5 CM OR MORE - ONE HAND: A TOWEL-DRAPED, GLOVED HAND MAY BE EXERT FORWARD PRESSURE ON THE CHIN OF THE FETUS THROUGH THE PERINEUM JUST IN FRONT OF THE COCCYX THE OTHER HAND: EXERTS PRESSURE SUPERIORLY AGAINST THE OCCIPUT CONDUCTION OF DELIVERY
  39. 39.  DELIVERY OF SHOULDER THE OCCIPUT : TURNS TOWARD ONE OF THE MATERNAL THIGH FETAL HEAD: TRANSVERSE POSITION EXTERNAL ROTATION: BISACROMIAL DIAMETER HAD ROTATED INTO THE ANTERIO-POSTERIOR DIMETER OF THE PELVIS . SUCKING THE NASOPHARINX OR CHECKING FOR A CORD DOWNWARD TRACTION : ANT. SHOULDER UNDER THE PUBIS UPWARD MOVEMENT: POST. SHOULDER IS DELIVERED  DELIVERY OF THE TRUNK THE REST OF THE BODY ALMOST ALWAYS FOLLOWS THE SHOULDER WITHOUT DIFFICULTY PROLONGED DELAY : MORE TRACTON PRESSURE ON THE FUNDUS TRACTION SHOULD BE EXERTED ONLY IN THE DIRECTION OF THE LONG AXIS OF THE INFANT .
  40. 40. IMMEDIATE CARE OF THE NEWBORN  SOON AFTER THE DELIVERY OF THE BABY PLACE IT ON THE TRAY COVERED WITH DRY LINEN WITH THE HEAD SLIGHTLY DOWNWARDS (15DEGREE) .  IT FACILITATE DRAINAGE OF THE MUCUS ACCUMULATED IN THE TRACHEO - BRONCHIAL TREE BY GRAVITY .  AIR PASSAGE SHOULD BE CLEARED IMMEDIATELY OF MUCUS AND LIQUOR BY GENTLE SUCTION  A P G A R RATING : 1 MIN AND 5 MIN 40
  41. 41. PROVISION OF INTIAL CARE  MAINTAIN RESPIRATION AND INITIATE LUNG EXPANSION a) POSITION- MODIFIED TRENDELENBERG b) SUCTION PM  SUPPORTING THERMO REGULATION a) WRAP INFANT BLANKET OR PLACE IN RADIANT WARMER b) SKIN TO SKIN CONTACT WITH MOTHER TO PROMOTE BONDING  PROPHYLAXIS WITH NEOMYCIN AND VIT. „K‟  CORD CUTTING AND DRESSING AND IDENTIFYING THE INFANT  TAKING ANTHROPOMETRIC MEASUREMENTS AND PRINTING  GIVING THE FIRST BATH 41
  42. 42. IMMEDIATE NEWBORN ASSESSMENT AND CARE (DELIVERY ROOM)  NURSING ASSESSMENT  MATERNAL HISTORY/LABOR DATA INDICATING POTENTIAL PROBLEMS WITH NEWBORN  APGAR SCORES  FINDINGS OF BRIEF PHYSICAL EXAMINATION PERFORMED IN THE DELIVERY ROOM 42 NURSING DIAGNOSES  INEFFECTIVE AIRWAY CLEARANCE RELATED TO NASAL AND ORAL SECRETIONS FROM DELIVERY  INEFFECTIVE THERMOREGULATION RELATED TO ENVIRONMENT AND IMMATURE ABILITY FOR ADAPTATION  RISK FOR INJURY RELATED TO IMMATURE DEFENSES OF THE NEWBORN
  43. 43. Plans and Interventions  WHEN THE HEAD IS DELIVERED BIRTH ATTENDANT IMMEDIATELY SUCTION SECRETIONS  WIPE MUCUS FROM FACE AND MOUTH AND NOSE  ASPIRATE/SUCTION MOUTH AND NOSE BULB SYRINGE  KEEP HEAD SLIGHTLY LOWER THAN THE BODY 43 1. SUCTIONING IMMEDIATELY CLEAN MUCOUS FROM THE FACE , MOUTH AND NOSE . ASPIRATION WITH BULB SYRINGE AS PER NECESSARY . NEONATAL RESUSCITATOR PROTOCOLS NO LONGER REQUIRE SUCTIONING ON THE PERINEUM IF MECONIUM IS PRESENT IN THE AMNIOTIC FLUID .  IF MECONIUM IS PRESENT AND BABY IS NOT VIGOROUS SUCTION THE TRACHEA BEFORE PROCEEDING WITH OTHER STEPS .
  44. 44. 2. ASSESSING RESPIRATORY STATUS A. ASSESS FOR 5 SYMPTOMS OF RESPIRATORY DISTRESS 1. RETRACTIONS 2. TACHYPNEA (RATE: >60 CPM) 3. DUSKY COLOR/CIRCUMORAL CYANOSIS 4. EXPIRATORY GRUNT 5. FLARING NARESB. B. DO NOT HYPEREXTEND NECK AT ANYTIME (MAY CLOSE GLOTTIS) 1. PLACE INFANT IN “SNIFF” POSITION 2. NECK SLIGHTLY EXTENDED AS IF SNIFFING AIR OPENS AIRWAY 44 3.PREVENT HEAT LOSS  IMMEDIATELY DRY INFANT UNDER A RADIANT WARMER OR SKIN TO SKIN CONTACT WITH THE MOTHER  KEEP NEONATES HEAD COVERED  INFANT TEMPERATURE SHOULD BE ABOVE 36.4°C.  INFANTS LOSE HEAT THROUGH EVAPORATION, RADIATION, CONDUCTION AND CONVECTION.
  45. 45. 4.APGAR SCORE OBTAIN APGAR SCORING AT 1 MIN AND 5 MIN  APGAR TEST IS A SCORING SYSTEM DESIGNED BY DR. VIRGINIA APGAR, AN ANESTHESIOLOGIST,  A SYSTEMATIC AND MEASURABLE METHOD TO ACCESS THE NEWBORN IN THE CRUCIAL MINUTES AFTER BIRTH.  PURPOSES: 1. IDENTIFY NEONATES EVALUATE THE CONDITIONS OF THE BABY AT BIRTH. 2. DETERMINE THE NEED FOR RESUSCITATION. 3. EVALUATE THE EFFECTIVENESS OF RESUSCITATIVE EFFORTS. 4. IDENTIFY NEONATE AT RISK FOR MORBIDITY AND MORTALITY. 45
  46. 46. TEST 0 POINTS 1 POINT 2 POINTS ACTIVITY (MUSCLE TONE) ABSENT ARMS & LEGS EXTENDED ACTIVE MOVEMENT WITH FLEXED ARMS & LEGS PULSE (HEART RATE) ABSENT BELOW 100 BPM ABOVE 100 BPM GRIMACE (RESPONSE STIMULATION OR REFLEX IRRITABILITY) NO RESPONSE FACIAL GRIMACE SNEEZE, COUGH, PULLS AWAY APPEARANCE (SKIN COLOR) BLUE-GRAY, PALE ALL OVER PINK BODY AND BLUE EXTREMITIES NORMAL OVER ENTIRE BODY – COMPLETELY PINK RESPIRATION (BREATHING) ABSENT SLOW, IRREGULAR GOOD, CRYING 46 APGAR SCORE
  47. 47. APGAR SCORE IF THERE ARE PROBLEMS WITH THE INFANT • AN ADDITIONAL SCORE MAY BE REPEATED AT A 10-MINUTE INTERVAL. • FOR A CESAREAN SECTION: • THE BABY IS ADDITIONALLY ASSESSED AT 15 MINUTES AFTER DELIVERY. SCORING • 7-9 = FREE FROM IMMEDIATE DISTRESS; NORMAL • 4-6 = MODERATELY DEPRESSED; MAY REQUIRE ADDITIONAL RESUSCITATIVE MEASURES • 0-3 = SEVERELY DEPRESSED; NECESSITATES IMMEDIATE MEDICAL ATTENTION NOTE: APGAR SCORE IS STRICTLY USED TO DETERMINE THE NEWBORN‟S IMMEDIATE CONDITION AT BIRTH AND DOES NOT NECESSARILY REFLECT THE FUTURE HEALTH OF YOUR BABY. 47
  48. 48. 48 CLAMPING AND LIGATURE OF THE CORD THE NEAR ONE IS PLACED 5 CM AWAY FROM THE UMBILICUS AND IS CUT IN BETWEEN . TWO SEPARATE CORD LIGATURE IS APPLIED WITH STERILE COTTON TREADS 1 CM APART USING REEF KNOT , THE PROXIMAL BEING PLACED 2.5 CM AWAY FROM THE NAVAL . SQUEEZING THE CORD WITH FINGERS PRIOR TO APPLYING LIGATURE . LEAVING BEHIND A LENGTH OF CORD ATTACHED TO THE NAVAL NOT ONLY PREVENTS INCLUSION OF THE EMBRYONIC STRUCTURES , IF PRESENT , BUT ALSO FACILITATE CONTROL OF PRIMARY HAEMORRHAGE DUE TO SLIPPED LIGATURE .THE CORD IS DIVIDED WITH SCISSOR 1 CM BEYOND THE LIGATURE TAKING ASEPTIC PRECAUTIONS SO AS TO PREVENT CORD SEPSIS .
  49. 49.  CLAMP THE CORD WITH TWO KOCHER‟S FORCEPS . THE CUT END IS THEN COVERED WITH STERILE GUAZE PIECE AFTER MAKING SURE THAT THERE IS NO BLEEDING. PURPOSE OF CLAMPING OF CORD ON MATERNAL END IS TO PREVENTING SOILING OF BED WITH BLOOD AND TO PREVENT FETAL BLOOD LOSS OF SECOND BABY IN UNDIAGNOSED MONOZYGOTIC TWIN .  DELAY IN CLAMPING FOR 2-3 MIN OR TILL CESSATION OF THE CORD PULSATION FACILITATES TRANSFER OF 80-100 ML BLOOD FROM COMPRESSED PLACENTA TO BABY WHEN PLACED BELOW THE LEVEL OF UTERUS .  QUICK CHECK IS MADE TO DETECT ANY ABNORMALITY AND THE BABY IS WRAPPED WITH DRY WARM TOWEL . THE IDENTIFICATION TAG IS TIED TO BOTH MOTHER AND BABY ON THE WRIST .  BABY WHEN PLACED BELOW LEVEL OF THE UTERUS . ITS BENEFICIAL FOR MATURE BABY BUT CAN BE DELETERIOUS TO A PRE-TERM BABY DUE TO HYPERVOLAEMIA . 49
  50. 50.  THE UMBILICAL STUMP NEEDS PARTICULAR ATTENTION AS THERE ARE RISKS OF BLEEDING AND INFECTION.  GOOD CORD CARE INCLUDES:  CUTTING CORD WITH STERILE EQUIPMENT OR A NEW RAZOR BLADE DEPENDING ON THE SETTING  LIGATION WITH A STERILE PLASTIC CLAMP OR CLEAN THREAD  KEEPING CORD STUMP EXPOSED, CLEAN (WITH 70% ALCOHOL, 4% CHLORHEXIDINE OR SIMPLE SOAP AND WATER) AND DRY 50 CORD CARE EXAMINE CORD FOR PRESENCE OF 3 VESSELS AND DOCUMENT 2 ARTERIES AND 1 VEIN.
  51. 51. CORD BLOOD COLLECTION MAKE SURE CORD BLOOD IS COLLECTED FOR ANALYSIS AND SENT TO LABORATORY FOR CHECKING : ◦ RH ◦ BLOOD TYPE ◦ HEMATOCRIT ◦ POSSIBLE CORD BLOOD GASES 51 FOOT PRINTING FOOTPRINTS ARE OFTEN TAKEN AND RECORDED IN THE MEDICAL RECORD.
  52. 52. NEWBORN VITAL SIGNS 52
  53. 53. VITAMIN K ADMINISTER A PROPHYLACTIC VITAMIN K ◦ PREVENT NEONATAL HEMORRHAGE DURING FIRST FEW DAYS OF LIFE BEFORE INFANT IS ABLE TO PRODUCE VIT. K ◦ RECOMMENDED ROUTE OF ADMINISTRATION: INTRAMUSCULAR ◦ DOSE:  1MG (OF KONAKION MM®, 2MG/0.2ML) BEING GIVEN AT BIRTH.  PRETERM INFANTS MAY RECEIVE 0.5MG. ◦ ALTERNATIVE ROUTE: ORAL ◦ DOSE:  2MG ORALLY AT BIRTH;  REPEAT DOSE (2MG) AT 3-5 DAYS AND AT 4-6 WEEKS OF AGE.  REPEAT DOSE IF THE INFANT VOMITS OR REGURGITATES WITHIN 1 HOUR 53
  54. 54. ANTHROPOMETRIC MEASUREMENTS MEASURE WEIGHT, LENGTH, AND HEAD CIRCUMFERENCE  HELPS DETERMINE IF A BABY'S WEIGHT AND MEASUREMENTS ARE NORMAL FOR THE NUMBER OF WEEKS OF PREGNANCY.  SMALL OR UNDERWEIGHT BABIES, AS WELL AS VERY LARGE BABIES, MAY NEED SPECIAL ATTENTION AND CARE. 54
  55. 55. LENGTH (FROM TOP OF HEAD TO THE HEEL WITH THE LEG FULLY EXTENDED 55 AVERAGE RANGE: 18-22 INCHES (46-56 CM) MEASURED FROM CROWN TO RUMP AND RUMP TO HEEL OR FROM CROWN TO HEEL AT BIRTH HEAD CIRCUMFERENCE (REPEAT AFTER MOLDING AND CAPUT SUCCEDANEUM ARE RESOLVED) AVERAGE RANGE: 33 TO 35 CM (13-14 INCHES) NORMALLY, 2 CM LARGER THAN CHEST CIRCUMFERENCE PLACE TAPE MEASURE ABOVE EYEBROWS AND STRETCH AROUND FULLEST PART OF OCCIPUT AT POSTERIOR FONTANELE
  56. 56. WEIGHT MEASUREMENT 56 CHEST CIRCUMFERENCE (AT THE NIPPLE LINE) AVERAGE RANGE: 30-33 CM (12-13 INCHES) NORMALLY, 2 CM SMALLER THAN HEAD CIRCUMFERENCE STRETCH TAPE MEASURE AROUND SCAPULAE AND OVER NIPPLE LINE
  57. 57. NEWBORN IDENTIFICATION  BEFORE A BABY LEAVES THE DELIVERY AREA, IDENTIFICATION BRACELETS WITH IDENTICAL NUMBERS ARE PLACED ON THE BABY AND MOTHER.  BABIES OFTEN HAVE TWO, ON THE WRIST AND ANKLE. 57 EXERCIESE :SAY TRUE OR FALSE a. NURSING A NEWBORN WITH THE MOTHER RATHER THAN IN THE NURSERY PREDISPOSES THE CHILD TO INFECTIONS b. HAND WASHING WITH SOAP AND WATER BEFORE HANDLING A NEWBORN SIGNIFICANTLY REDUCES THE RISK OF INFECTION IN THE BABY c. FORTIFIED INFANT FORMULA IS SUPERIOR TO MOTHER‟S BREAST MILK IN A SICK TERM NEWBORN . d. NEWBORN BABIES CANNOT BE KEPT WARM WITHOUT THE USE OF INCUBATORS
  58. 58. MANAGEMENT OF THIRD STAGE OF LABOR 58  ENSURE SRTICT VIGILANCE AND TO FOLLOW THE MANAGEMENT GUIDELINES SRICTLY IN PRACTICE IN ORDER TO PREVENT POST PARTUM COMPLICATIONS , THE IMPORTANT ONE BEING HEMORRHAGE . TWO METHODS OF MANAGEMENT ARE CURRENTLY IN PRACTICE : 1. WATCHFUL EXPECTANCY (15-20MIN) 2. ACTIVE MANAGEMENT (PREFERRED)
  59. 59. TWO METHODS OF THIRD STAGE MANAGEMENT PHYSIOLOGIC (“EXPECTANT”) MANAGEMENT OXYTOCICS ARE NOT USED PLACENTA IS DELIVERED BY GRAVITY AND MATERNAL EFFORTS SPONTANEOUSLY . CONSTANT WATCH IS MANDATORY AND PATIENT SHOULD NOT BE LEFT ALONE CATHETERIZE ONE MORE TIME IF THE BLADDER BECOMES FULL . A HAND PLACED OVER FUNDUS : a) TO RECOGNIZE THE SIGNS OF SEPARATION OF PLACENTA b) TO NOTE THE UTERINE ACTIVITY – CONTRACTION AND RELAXATION c) TO DETECT CUPPING OF FUNDUS , THOUGH RARE ,WHICH IS AN EARLY EVIDENCE OF INVERSION OF UTERUS . DESIRE TO FIDDLE WITH THE FUNDUS OR MASSAGE THE UTERUS IS ONLY TO MET DISASTER AND IS STRONGLY CONDEMNED . CORD IS CLAMPED AFTER DELIVERY OF THE PLACENTA . A WATCHFUL EXPECTANCY CAN BE EXTENDED UP TO 15-20 MIN . 59
  60. 60. ASSISTED EXPULSION ◦ FUNDAL PRESSURE FUNDUS IS PUSH DOWNWARD AND BACKWARD AFTER PLACING FOUR FINGERS BEHIND THE FUNDUS AND THE THUMB IN FRONT OF USING UTERUS AS SORT OF PISTON . THE PRESSURE MUST BE GIVEN ONLY WHEN UTERUS BECOMES HARD .IF IT IS NOT THEN MAKE IT BY GENTLY RUBBING .IF BABY IS MACERATED OR PREMATURE THIS METHOD IS PREFERABLE FOR CORD CONTRACTIONS TENSILE STRENGTH OF CORD IS MUCH REDUCED IN BOTH THE INSTANCES . ◦ PLACENTA DELIVERED BY CONTROLLED CORD TRACTION (CCT) ALSO CALLED MODIFIED BRANDT – ANDREWS METHOD WITH COUNTER-TRACTION ON THE FUNDUS THE PALMER SURFACE OF THE FINGERS OF THE LEFT HAND IS PLACED ABOVE APPROXIMATELY AT THE JUNCTION OF UPPER AND LOWER UTERINE SEGMENT . THE BODY OF UTERUS PUSHED UPWARD AND BACKWARD , TOWARDS THE UMBILICUS WHILE BY THE RIGHT HAND STEADY TENSION IS GIVEN IN DOWNWARD AND BACKWARD DIRECTION HOLDING THE CLAMP UNTIL THE PLACENTA COMES OUTSIDE THE INTROITS . 60
  61. 61. PLACENTAL SEPARATION 61 1. INCREASED BLEEDING 2. LENGTHENING OF CORD 3. UTERUS RISES , BECOMES GLOBULAR INSTEAD OF DISCOID 4. UTERUS ENLARGES , APPROACHING UMBILICUS  NORMALY SEPARATES WITHIN A FEW MINUTES AFTER DELIVERY OF FETUS . SIGNS OF SEPARATION FUNDAL MASSAGE AFTER DELIVERY OF PLACENTA WHICH FACILITATES THE EXPULSION OF RETAINED CLOTS IF ANY . NOTE THE FOLLOWING MAKE SURE IT IS COMPLETE LOOK FOR MISSING PIECES LOOK FOR MALFORMATION LOOK FOR AREA OF ADHERENT BLOOD CLOT
  62. 62. ACTIVE MANAGEMENT OF THIRD STAGE THE UNDERLYING PRINCIPLES  EXCITE POWERFUL UTERINE CONTRACTION WITHIN ONE MINUTE OF DELIVERY OF THE BABY BY GIVING PARENTERAL OXYTOCIC .  IT PRODUCE EARLY PLACENTAL SEPARATION AND ALSO PRODUCE EFFECTIVE UTERINE CONTRACTION . ADVANTAGES  MINIMIZE BLOOD LOSS UP TO 1/ 5 TH  SHORTEN DURATION OF THIRD STAGE TO HALF  ONLY DISADVANTAGE IS SLIGHTLY INCREASE INCIDENCE OF RETAINED PLACENTA AND CONSEQUENT INREASED INCIDENCE OF MANNUAL REMOVAL 62
  63. 63. OXYTOCIC(UTEROTONIC) DRUGS  COMBINED ERGOMETRINE AND OXYTOCIN  1ML AMPOULE CONTAINS 5 INTERNATIONAL UNITS OF OXYTOCIN AND 0.5 MG (500 MCG) OF ERGOMETRINE  INTRAMUSCULAR ADMINISTRATION OF 1ML AT DELIVERY OF ANTERIOR SHOULDER  NO MORE THAN 2 DOSES OF 0.5MG ERGOMETRINE SHOULD BE GIVEN .  OXYTOCIN COMPONENT ACTS ON OUTER REGION WITHIN 2-3 MINUTES AND PRODUCES STRONG „PHYSIOLOGICAL‟ CONTRACTIONS  ERGOMETRINE ACTS ON INNER REGION WITHIN 6-7 MINUTES AND PRODUCES A CONTINUOUS (TONIC) CONTRACTION LASTING UP TO 2 HOURS  COMBINED ACTION RESULTS IN A RAPID CONTRACTION ENHANCED BY A STRONGER, SUSTAINED CONTRACTION  DELIVERY OF PLACENTA TIMED TO TAKE PLACE WITH THE CONTRACTION CAUSED BY THE OXYTOCIN AND BEFORE ERGOMETRINE COMPONENT ACTS OTHERWISE IT MAY BE RETAINED
  64. 64. PREVENTING HEMORRHAGE 1. ENSURE ACCURATE MEASUREMENT OF INTAKE AND OUTPUT MAINTAINED THROUGH OUT THE LABOR AND DELIVERY . 2. IMMEDIATELY AFTER DELIVERY OF PLACENTA , ADMINISTER OXYTOCIN (PITOCINE) AS DIRECTED BY FACILITY POLICY AND PROVIDER . INFUSE AS BOLUS INITIALY , THEN TITRATE AS PER UTERINE RESPONSE ( I.E.. IF UTERUS IS FIRM , DECREASE THE INFUSION AND IF BOGGY , INCREASE INFUSION ) . OXYTOCINE SHOULD NEVER ADMINISTERED I.V. PUSH AS IT CAN CAUSE CARDIAC DYSRHYTHMIA AND DEATH . 3. IMMEDIATELY AFTER INITIATING OXYTOCINE , GENTLY MASSAGE UTERINE FUNDUS PERIODICALLY TO PROMOTE FIRMNESS . 4. EVALUATE THE UNDERSIDE OF PLACENTA . INTACT COTYLEDON , CLOT , MEMBRANE MAY ALSO STIMULATE THE BLEEDING . IF CLOT ARE NOT EXPELLED DURING PERIODIC EVALUATION DURING FIRST HOUR FOLLOWING DELIVERY , RISK OF HEMORRHAGE INCREASES . 64
  65. 65. 5. EVALUATE VOLUME OF VAGINAL BLEEDING AS STABLE OR UNSTABLE AS PER THE PATIENT‟S VITAL SIGNS AND UTERINE RESPONSE . STABLE : VITAL SIGNS WITHIN 20% OF PATIENT‟S AVERAGE READINGS AND UTERUS REMAINS FIRM BETWEEN ASSESSMENT OR QUICKLY FIRMS AFTER FUNDAL MASSAGE UNSTABLE : VITAL SIGNS VARY GREATER THAN 20% FROM THE PATIENT‟S AVERAGE READINGS OR REPETITIVE BLOOD PRESSURE READINGS BELOW 90/60 MM HG , PULSE MORE THAN 110/MIN , RESPIRATION 24 TO 26 / MIN ACCOMPANIED BY CONTINUOUS BLEEDING AND A BOGGY UTERINE TONE .  INCREASE PULSE RATE IS THE FIRST SIGN OF THE HYPOVOLUMIA AND VHYPOTENSION IS LATE . 6. IF BLEEDING CONTINUES AND UTERUS IS FIRM , NOTIFY HEALTH CARE PROVIDER FOR EVALUATION OF LACERATION OR RETAINED PLACENTAL FRAGMENTS . 7. AUTOTRANSFUSION
  66. 66. NURSING DIAGNOSIS  RISK FOR INJURY RELATED TO UTERINE ATONY AND HEMORRHAGE  DEFICIENT FLUID VOLUME RELATED TO DECREASE ORAL INTAKE , BLEEDING AND DIAPHORESIS .  ACUTE PAIN RELATED TO TISSUE TRAUMA AND BIRTH PROCEESS , INTENSIFIED BY FATIGUE .  IMPAIRED URINARY ELIMINATION RELATED TO EPIDURAL AND SPINAL ANESTHESIA AND TISSUE TRAUMA .  RISK OF IMPAIRED PARENTING RELATED TO INEXPERIENCE . 66 MANAGEMENT OF FORTH STAGE OF LABOR EVENTS IN FORTH STAGE OF LABOR LASTS FROM DELIVERY OF PLACENTA UNTIL POSTPARTUM CONDITION OF WOMAN HAS BECOME STABILIZED ( TYPICALLY 1TO 2 HOURS AFTER DELIVERY )
  67. 67. 67 NURSING INTERVENTIONS PROMOTING UTERINNE CONTRACTION AND CONTROLING BLEEDING 1. MONITOR VITAL SIGNS 2. SPECIALY TEMPERATURE SHOULD BE MONITOR EVERY 4 HOUR UNLESS ELEVATED . 3. EVALUATE UTERINE FUNDAL TONE , HEIGHT , AND POSITION . THE UTERUS SHOULD BE FIRM AROUND THE LEVEL OF THE UMBILICUS , AT THE MIDLINE 4 . AMOUNT OF VAGINAL BLEEDING (LOCHIA ) AT EACH INTERVAL OF ASSESSMENT : I. SCANT - BLOOD ONLY ON TISSUE WHEN WIPED OR LESS THAN 1 – INCH STAINED ON PERINEAL PAD . II. SMALL / LIGHT - LESS THAN 4 – INCH STAIN ON PAD . III. MODERATE - LESS THAN 6 – INCH STAINED ON PERINEAL PAD IV. HEAVY - SATURED PERINEAL PAD
  68. 68. 68 PERINEUM FOR EDEMA , DISCOLORATION , BLEEDING , ODOR OR HEMATOMA FORMATION . MAINTAINING FLUID VOLUME I. MAINTAINING I.V. FLUIDS AS INDICATED . II. PROVIDE ORAL FLUIDS AND SNACK OR MEAL AS TOLERATED IF VITALS ARE STABLE AND BLEEDING IS CONTROLLED . RELIEVING DISCOMFORT AND FATIGUE I. APPLY THE COVERED ICE PACK TO THE PERINEUM PERIODICALLY DURING FIRST 24 HOURS FOR EPISIOTOMY , PERINEAL LACERATION , OR EDEMA . II. ADMINISTER ANALGESIC AS PER INDICATED . III. ASSURE THAT EPIDURAL CATHETER HAS BEEN REMOVED . IV. ASSIST WOMAN IN FINDING COMFORTABLE POSITIONS .
  69. 69. ENCOURAGING BLADDER EMPTYING I. EVALUATE THE BLADDER FOR DISTENTION . II. ENCOURAGE THE WOMAN TO VOID . III. PROVIDE PRIVACY AND TIME. IV. THE RUNNING TAP WATER MAY STIMULATE VOIDING . V. CATHETER THE WOMAN IF THE BLADDER IS FULL AND SHE IS UNABLE TO VOID . PROMOTING PARENTING I. SHOW THE NEONATE TO MOTHER AND FATHER OR SUPPORT PERSON IMMEDIATELY AFTER THE BIRTH WHEN POSSIBLE . II. TEACH THE MOTHER AND FATHER TO HOLD THE INFANT AS SOON AS POSSIBLE . III. ASSIST THE MOTHER WITH BREAST – FEEDING DURING THE FIRST 30 MINUTE THEN 2 HOURS AFTER THE BIRTH . 69
  70. 70. 70 Partograph (Progress of labor )
  71. 71. REFERENCES  TEXT BOOK OF OBSTETRICS – D. C. DUTTA – FIF TH EDITION  LIPPINCOTT MANUAL OF NURSING PRACTICE – SECTION THREE – MATERNAL AND NEONATAL NURSING – NINTH EDITION  ESSENTIALS OF PEDIATRICS – O P GHAIS – SIXTH EDITION  INTERNET – www.nursingcrib.com ENCYCLOPEDIA- GOOGLE SEARCH  MYLES TEXTBOOK OF MIDWIFERY – FIFTINTH EDITION 71

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