Chapter 14 : Nursing Management During Labor and Birth - PowerPoint Presentation

Slide1

Chapter

14

:

Nursing Management During Labor and BirthSlide2

Nursing Management of Laboring Women

Assessment

Comfort measures

Emotional support

Information and instruction

Advocacy

Support for the partnerSlide3

Maternal Assessment During Labor and Birth

Maternal status (vital signs, pain, prenatal record review)

Vaginal examination (cervical dilation, effacement, membrane status, fetal descent and presentation)

Rupture of membranes

Uterine contractions

Leopold

maneuversSlide4
Slide5

Fetal Assessment During Labor and Birth

Amniotic fluid analysis

Fetal heart rate monitoring

Handheld

versus

electronic; intermittent

versus

continuous; external

versus

internal

Fetal heart rate patterns

Baseline, baseline variability, periodic changes (see Table 14.1)

Other assessment methods

Fetal scalp sampling, pulse oximetry, stimulationSlide6

Guidelines for Assessing Fetal Heart Rate

Initial

10-

to

20-minute

continuous FHR assessment on entry into labor/birth area

Completion of a prenatal and labor risk assessment on all clients

Intermittent auscultation every 30 minutes during active labor for low-risk women and every 15 minutes for high-risk women

During second stage of labor intermittent auscultation every 15 minutes for low-risk women and every 5 minutes for high-risk womenSlide7

Question

According to the ACOG, ICSI, and AWHONN guidelines, how often should the fetal heart rate be assessed for a high-risk laboring woman during the second stage of labor?

a. Every 5 minutes

b. Every 10 minutes

c. Every 15 minutes

d. Every 20 minutesSlide8

Answer

a. Every 5 minutes

During the second stage of labor, intermittent auscultation should be done every 5 minutes for the high-risk woman and every 15 minutes for the low-risk woman. (ACOG, ICSI, AWHONN guidelines)Slide9

Continuous Electronic Fetal Monitoring

Uses a machine to produce a continuous tracing of the FHR

Produce a graphic record of the FHR pattern

Primary objective

To provide information about fetal oxygenation and prevent fetal injury from impaired oxygenation

To detect fetal heart rate changes early before they are prolonged and profoundSlide10
Slide11

Criteria for Using Continuous Internal Monitoring of the FHR

Ruptured membranes

Cervical dilation of at least 2 cm

Present fetal part low enough to allow placement of the scalp electrode

Skilled practitioner available to insert spiral electrodeSlide12

Four

Categories of Baseline Variability

Absent: fluctuation range undetectable

Minimal: fluctuation range observed at <5 beats per minute

Moderate: (normal) fluctuation range from 6 to 25 beats per minute

Marked: fluctuation range >25 beats per minuteSlide13

Nursing Interventions

Average FHR

110 to 160

beats per minute

Fetal bradycardia

Fetal tachycardia

FHR variability an indicator of fetal statusSlide14

Typical Periodic Baseline Changes

Accelerations

Decelerations

Early

Late

Variable

ProlongedSlide15

Fetal Assessment

Nurse’s role

Additional methods to validate FHR

Fetal scalp sampling

Fetal pulse oximetry

Fetal stimulationSlide16

Comfort and Pain Management

Pain as universal experience; intensity highly variable

Mandate for pain assessment in all clients admitted to health care facility

Numerous nonpharmacologic and pharmacologic choices availableSlide17

Nonpharmacologic

Measures for Pain Management

Continuous labor support

Hydrotherapy

Ambulation and position changes

Acupuncture and acupressure

Attention focusing and imagery

Therapeutic touch and massage; effleurage

Breathing techniques (e.g., patterned-paced breathing)Slide18

Question

Is the following statement True or False?

Pain experienced by a woman in labor is fairly intense.

a. True

b. FalseSlide19

Answer

b. False

Pain during labor is a universal experience, but the intensity varies.Slide20

Pharmacologic Measures

Systemic analgesia

Regional or local anesthesia

Neuraxial analgesia/anesthesia techniques: use of analgesic or anesthetic, continuously or intermittently into epidural or intrathecal space

Shift in pain management: woman as an active participant during laborSlide21

Systemic Analgesia

Route: typically administered parenterally through existing IV line

Drugs

Opioids (butorphanol, nalbuphine, meperidine,

fentanyl)

Ataractics (hydroxyzine, promethazine)

Benzodiazepines (diazepam, midazolam)Slide22

Regional Analgesia/Anesthesia

Epidural block: continuous infusion or intermittent injection; usually started when dilation >5 cm

Combined

spinal–epidural

block (“walking epidural”)

Patient-controlled epidural

Local infiltration (usually for episiotomy or laceration repair)

Pudendal block (usually for

second

stage, episiotomy, or operative vaginal birth)

Intrathecal (spinal) analgesia/anesthesia (during labor and cesarean birth)Slide23

General Anesthesia

Emergency cesarean birth or woman with contraindication to use of regional anesthesia

IV injection, inhalation, or both

Commonly, first thiopental IV to produce unconsciousness

Next, muscle relaxant

Then intubation, followed by administration of nitrous oxide and oxygen; volatile halogenated agent also possible to produce amnesiaSlide24

Neuraxial Analgesia/Anesthesia

Rise in use

Does not interfere with progress of labor

Allows the woman to be an active participant in laborSlide25

First Stage of Labor: Phone Assessment

Estimated date of birth

Fetal movement; frequency in past few days

Other premonitory signs of labor experienced

Parity, gravida, and previous childbirth experiences

Time frame in previous labors

Characteristics of contractions

Bloody show and membrane status (whether ruptured or intact)

Presence of supportive adult in household or if she is aloneSlide26

Nursing Care During First Stage of Labor

General measures

Obtain admission history

Check results of routine laboratory tests and any special tests

Ask about childbirth plan

Complete a physical assessment

Initial contact either by phone or in person Slide27

First Stage of Labor: Admission Assessment

Maternal health history

Physical assessment (body systems, vital signs, heart and lung sounds, height and weight)

Fundal height measurement

Uterine activity, including contraction frequency, duration, and intensity

Status of membranes (intact or ruptured)

Cervical

dilation

and degree of effacement

Fetal heart rate, position, station

Pain level Slide28

First Stage of Labor: Admission Assessment (

cont.)

Fetal assessment

Lab studies

Routine: urinalysis, CBC

Syphilis screening, HbsAg screening, GBS, HIV (with woman’s consent), and possible drug screening if not included in prenatal history

Assessment of psychological status Slide29

Question

Is the following statement True or False?

If a pregnant woman in labor calls the health care facility, the nurse should strongly advise the woman to come to the facility to be evaluated.

a. True

b. FalseSlide30

Answer

b. False

If the initial contact is made by phone, the nurse needs to ask the woman about her signs and symptoms and what she is experiencing. The nurse would then instruct the woman to remain at home or come to the facility based on the woman’s responses.Slide31

First Stage of Labor: Continuing Assessment

Woman’s knowledge, experience, and expectations

Vital signs

Vaginal examinations

Uterine contractions

Pain level

Coping ability

FHR

Amniotic fluidSlide32

Nursing Management: Second Stage

Assessment

Typical signs of

second

stage

Contraction frequency, duration, intensity

Maternal vital signs

Fetal response to labor via FHR

Amniotic fluid with rupture of membranes

Coping status of woman and partnerSlide33

Question

During the second stage of labor, assessment would include which of the following?

a. Complaints of rectal or perineal pressure

b. Estimated date of birth

c. Fundal height

d. Fetal positionSlide34

Answer

a. Complaints of rectal or perineal pressure

During the second stage of labor, the nurse would assess for signs typical for this stage, such as complaints of rectal or perineal pressure. Assessment of estimated date of birth, fundal height, and fetal position are assessments for the first stage of labor. Slide35

Nursing Management: Second Stage

Interventions

Supporting woman

and

partner in active

decision-making

Supporting involuntary bearing-down efforts; encouraging no pushing until strong desire or until descent and rotation of fetal head well advanced

Providing instructions, assistance, pain relief

Using maternal positions to enhance descent and reduce pain

Preparing for assisting with deliverySlide36

Nursing Management: Second Stage (

cont.)

Interventions with birth

Cleansing of perineal area and vulva

Assisting with birth, suctioning of newborn, and umbilical cord clamping

Providing immediate care of newborn

Drying

Apgar score

IdentificationSlide37

Nursing Management: Third Stage

Assessment

Placental separation; placenta and fetal membranes examination; perineal trauma; episiotomy; lacerations

Interventions

Instructing to push when separation apparent; giving oxytocin if ordered; assisting woman to comfortable position; providing warmth; applying ice to perineum if episiotomy; explaining assessments to come; monitoring mother’s physical status; recording birthing statistics; documenting birth in birth bookSlide38

Nursing Management: Fourth Stage

Assessment

Vital signs, fundus, perineal area, comfort level, lochia, bladder status

Interventions

Support and information

Fundal checks; perineal care and hygiene

Bladder status and voiding

Comfort measures

Parent–newborn attachment

Teaching