OB-Semis 1st Semester Nursing PDF

lOMoARcPSD|47543927 OB-Semis - 1st semester Nursing (Lyceum-Northwestern University) Scan to open on Studocu Studocu is not sponsored or endorsed by any college or university Downloaded by Manamtam Daniella ([email protected]) ...

lOMoARcPSD|47543927 OB-Semis - 1st semester Nursing (Lyceum-Northwestern University) Scan to open on Studocu Studocu is not sponsored or endorsed by any college or university Downloaded by Manamtam Daniella ([email protected])  lOMoARcPSD|47543927 THEORIES OF LABOR DR. JUDITH M. MANUEL - FACULTY OF NURSING NCM_107 1ST SEMESTER I A.Y. 2022 - 2023 Transcribe by: Ryan Laurence P. Inigo THE LABOR PHENOMENA I. LABOR AND DELIVERY Also known as parturition, childbirth, birthing Is the process by which the fetus and the placenta are expelled from the uterus and the vagina into the external environment o Parturient- is a woman in labor o Toco- and toko- (Gr)- are combining forms meaning childbirth o Eutocia- normal labor o Dystocia - difficult labor The trigger that converts the random, painless Braxton- Hick’s contraction, into strong coordinated labor contractions is unknown Normally labor begins when the fetus is sufficiently mature, yet not too large to cause difficulties in delivery Figure: Fetal Skull In some instances, labor begins before the fetus is mature (premature birth); in others labor is delayed (postmature birth). It is unknown why this occurs II. THEORIES PROPOSED WHY LABOR BEGINS 1. Uterine Stretch Theory – Any hollow body organ when stretched to capacity will necessarily contract and empty because of pressure on nerve endings and increased Irritability of the uterine musculature. 2. Oxytocin Stimulation Theory – Because labor is considered a stressful event, the hypophysis is stimulated to initiate production of oxytocin. Oxytocin is known to stimulate uterine contractions 3. Progesterone Deprivation Theory – Progesterone Is believed to inhibit uterine motility. A decrease in the amount of the hormone, therefore, results in uterine contractions. 4. Prostaglandin Theory – The relative progesterone deprivation and estrogen predominance set off production of cortical steroids which act on lipid precursors to release Figure: Fetal Skull arachidonic acid and, in turn, increase the synthesis of prostaglandins III. MEASUREMENT OF FETAL HEAD 5. Theory of Aging Placenta – The decrease of nutrients 1. Transverse diameter- 9.25 cm. and blood supply in the aging placenta causes uterine o Biparietal- largest transverse contractions.FACTORS AFFECTING, 2. Bimastoid 7 cm (smallest transverse) LABOR & DELIVERY (5 P'S) A. SUTURES 1. Passenger 2. Passageway 3. Power 4. Person (Psyche) 5. Placenta A. PASSENGER The passage of the fetus through the birth canal is influenced by: o Size of the fetal head and shoulder o Dimensions of the pelvic girdle o Fetal presentation o Fetal position Fetal head – is the largest presenting part- common presenting part: ¼ of its length o Bones – 6 bones 1. ▪ S- sphenoid Figure: Suture ▪ F- frontal- sinciput ▪ B. MOLDINGS E- ethmoid ▪ The overlapping of the sutures of the skull to permit P- parietal (2) passage to fetal head during delivery ▪ T- temporal ▪ O- occipital/occiput 1 Downloaded by Manamtam Daniella ([email protected])  lOMoARcPSD|47543927 [NCM_107] THEORIES OF LABOR - Dr. Judith M. Manuel Figure: Molding C. FONTANELS 1. Anterior fontanel- bregma, diamond shape o 3x4 cm (>5 cm-hydrocephalus) 2. Posterior fontanel or lambda (vertex) - triangular shape: 1x1 cm: Figure: Fetal Lie D. ANTEROPOSTERIOR DIAMETER Suboccipitobregmatic- 9.5 cm, complete flexion, B. PASSAGES smallest AP Pelvis- 4 bones Occipitofrontal- 12 cm, partial flexion Pelvic brim- False pelvis that supports the uterus Occiptomental- 13.5 cm hyperextension Linea Terminals- imaginary line that separates the false Submentobregmatic- face presentation & true pelvis Figure: Anteroposterior Diameter E. SHAPES OF PELVIS 1. Gynecoid- round shape 2. Android- describe as male pelvis, heart shape 3. Anthropoid- apelike pelvis: diamond shape narrowed transverse diameter Figure: Pelvis 4. Platypelloid- widen transverse, narrow antero- posterior, flat in front & back, oval shape/pear shape Figure: Shape of Pelvis Figure: True Pelvis IV. FETAL LIE PELVIC INLET- where the baby passes first o Diagonal conjugate - posterior border of the pubis ▪ anterior portion of sacral promontory. Ave. 12.5-13 cm 2 Downloaded by Manamtam Daniella ([email protected])  lOMoARcPSD|47543927 [NCM_107] THEORIES OF LABOR - Dr. Judith M. Manuel epinephrine in response to the stress brought about by the approaching delivery. The pregnant woman should be cautioned not to use this energy to carry out household chores because it is meant to prepare the body for the "labor" ahead. 4. Braxton Hicks Contraction – these are painless, irregular ad intermittent uterine Contractions are also known as practice contractions. 5. Ripening of the cervix – The cervix becomes even softer, now described as "butter-soft" 6. Rupture of the membranes – Also known as the bag of waters, its rupture may be seen as a sudden gush, or a scanty, slow sleeping, of amniotic fluid from the vagina. The color of the amniotic fluid should always be noted. o At term, it is clear, almost colorless, and contains white specks of vernix caseosa. Greer staining means the amniotic fluid has been A. Conjugate vera (true) - anterior border of the pubis contaminated with meconium, a sign of fetal o anterior portion of sacral promontory. distress if the fetus is in non-breech o 11.0 cm. presentation. Yellow staining may mean blood o Can be measured only thru radiographic films incompatibility, while pink staining may indicate B. Obstetric conjugate- shortest bleeding. o Estimating by subtracting 1.5 to 2 cm the 7. Show – This is the blood-tinged mucus discharged from diagonal conjugate Measures 10 cm or more the vagina because of pressure of the descending fetal o Ex.: DC= 12.5cm - 1.5= 11 cm part on the cervical capillaries causing their rupture. Transverse diameter- line between the points farthest from the ileopectineal line VI. SIGNS OF TRUE LABOR o 13 cm True labor is said to occur when the following signs are PELVIC OUTLET observed: o Antero posterior- lower border of the A. UTERINE CONTRACTIONS symphysis pubis to the sacro coccygeal points. The surest sign that labor has begun is the initiation of o Transverse diameter- be the 2 ischial spines effective, productive, and involuntary aterine contractions. Narrower diameter is much important than the wider There are three phases of uterine contractions: diameter o Crescendo/Increment- intensity of the contraction increases. This phase is longer than the other two phases combined o Acme/Apex- the height or peak of this contraction o Decrescendo Decrement- intensity of the contraction decreases Figure: Uterine Contraction B. SHOW Capillary blood mixes with mucus when operculum is released, that is why show is no more than a pinkish vaginal discharge. Show should be distinguished from bright red vaginal bleeding because the latter is a danger sign during this phase of pregnancy. FALSE LABOR PAINS TRUE LABOR PAINS Remain irregular May be slightly irregular at first V. PREMONITORY/ PRELIMINARY/ PRODROMAL nut become regular and SIGNS OF LABOR predictable within a matter of 1. Lightening – This is defined as the settling of the fetal hours. head into the pelvic brim which occurs 2-3 weeks before Generally confined to the First felt in the lower back and labor onset. Lightening causes relief of abdominal abdomen sweep around to the abdomen tightness and diaphragmatic pressure so that respiration in a girdle-like fashion. becomes easier. No increase in duration, Increase in duration, o Lightening should not be confused with frequency and intensity. frequency and intensity. engagement since engagement is defined as Often disappear if the woman Continue no matter what the that paint when the biparietal diameter of the ambulates. woman's level of activity fetal head has passed the pelvic inlet Absent cervical changes Accompanied by cervical 2. Loss of weight – There is loss of weight of about 2-3 lbs, effacement and dilatation. one to two days before labor onset, due to loss of appetite Table: there are several differences between false and true labor pains and decrease in progesterone level. Progesterone is DILATATION- This is the process by which the external known to cause fluid retention. Its decrease, therefore is cervical is enlarges from a few millimeters wide to 10 cm known to cause fluid excretion, thus causing loss of full dilatation. weight. 3. Increase level of activity ("nesting behavior") – The sudden burst of energy is believed to be due to increase in 3 Downloaded by Manamtam Daniella ([email protected])  lOMoARcPSD|47543927 [NCM_107] THEORIES OF LABOR - Dr. Judith M. Manuel o In primigravidas- effacement occurs before m dilatation; in multigravidas, however, dilatation may precede effacement Table: Stages of Labor EFFACEMENT-thinning/shortening of the cervical canal Table: Phases of the 1st stage of labor PHASES DILAXN DURAXN INTERVAL INTENSITY o Cervix = 1 inch thick; during labor, paper thin Latent 0-4 cm 30-40 sec 15 min Mild ▪ ½ inch cervix = 50% effaced ▪ ¼ - inch cervix = 75% effaced Active 4-8 cm 45-60 sec 5 min Mid strong ▪ ¾ - inch cervix = 25% effaced Transition 8-10 cm 60-90 sec 2-3 min Very strong IX. THE FIRST STAGE OF LABOR The first stage of labor, otherwise known as the Stage of Dilatation, is a very important stage in so far as assessment of fetal and maternal well-being is concerned. The following are discussions of this stage of labor. A. PHASES Latent Phase- The phase begins with onset of regular contraction and ends with complete effacement (100%) and cervical dilatation of about 4 cm. Figure: Effacement and Dilatation o Mild uterine contractions occur regularly o 10-20 minutes apart and are of short duration o (10-30 seconds). The woman usually experiences low backaches and abdominal cramps and is generally excited, alert, talkative, and in control. Active or Accelerated Phase- This begins with complete effacement and cervical dilatation of about 2-3 cm and ends with cervical dilatation of approximately 8 cm. o Moderate uterine contractions occur at 2–5- minute intervals and last 30-45 seconds. the woman experiences moderately increased o pain, may be more apprehensive, and fears losing control. B. NURSING MANAGEMENT Nursing care of the woman in her first stage of labor Figure: Effacement and Dilation includes the following considerations: Hospital Admission. VII. UTERINE CHANGES Privacy and reassurance are both very important at this time and throughout the other stages of labor. Establishing The uterus is gradually differentiated into two distinct the maintaining rapport with the woman in labor will go a portions. These are distinguished by a ridge formed in the long way towards alleviating fear and apprehension. inner uterine surface, the physiological retraction ring Keeping her informed of the progress of labor is the best 1. Upper uterine segment is the portion from the isthmus way of giving emotional support. for the physiological retraction ring) up to the fundus. Such important data as the expected date of confinement 2. Lower uterine segment is the portion from the isthmus (EDC), the condition of the membranes, and the show (or the physiological traction ring) down to the cervix should be elicited at the onset on order to determine the kind of management to be given to the particular patient. VIII. LENGTH OF LABOR Physical Assessment- General physical examination. In general multigravidas deliver 6 hours earlier than Leopold's maneuvers and/or internal examination are primigravidas. Labor which is completed in more than 18 done to determine the following: hours in primigravidas or more than 12 hours in o Effacement, dilatation, and condition of the multigravidas called prolonged labor. membranes. Labor which is completed in less than 3 hours is termed o Lie or presentation - the relation of the long precipitate delivery. axis of the fetus to the long axis of the mother. ▪ Lie may either be vertical or Table: Comparison of Length of Labor in Primigravidas and Multigravidas horizontal. STAGE OF PRIMIGRAVIDA MULTIGRAVIDA o Location of the fetal heart tone in relation to the LABOR S S presentation. First Stage 12½ hours 7 hours, 20 minutes Second Stage 80 minutes 30 minutes Third Stage 10 minutes 10 minutes TOTAL 14 hours 8 hours DURATIO STAGES START- END N Stage 1 Cervical P-10-14 Hrs True labor – full Dilation M-6-8 Hrs dilation Figure: Fetal Presentation Stage 2 Fetus P-1.5 Hrs Full dilation – fetal X. OUTLINE OF VARIOUS PRESENTATION AND THEIR M-30-45 Min. expulsion PRESENTATIONS PARTS Stage 3 Placenta 5-30 Min. Fetal expulsion – 1. VERTICAL LIE Placental delivery Cephalic Presentation- head is the presenting part Stage 4 Recovery/ 1-2 Hrs. Watch out for sign Vertex - head is sharply flexed, making the parietal bones Immediate of hemorrhage the presenting part Postpartu 4 Downloaded by Manamtam Daniella ([email protected])  lOMoARcPSD|47543927 [NCM_107] THEORIES OF LABOR - Dr. Judith M. Manuel Breech Presentation- buttocks are the presenting parts o Scapula - in shoulder presentations. The word Footling "dorso" is added to indicate the position of the o Double- legs unflexed and extended, feet are fetal back. presenting parts o Single - one leg unflexed and extended; one foot is the presenting part 2. Horizontal Lie- Shoulder Presentation (transverse) Figure: Fetal Position A. OUTLINE OF POSSIBLE FETAL POSITIONS Vertex Presentation o LOA left occipitoanterior o LOP-left occipitoposterior o LOT-left occipitotransverse o ROA right occipitoanterior o ROP right occipitoposterior o ROT right occipitotransverse Breech Presentation o LSA left sacroanterior o LSP-left sacroposterior XI. STATION o LST-left sacrotransverse The relation of the fetal presenting part to the level of the o RSA right sacroanterior ischial spines are explained below: o RSP-right sacroposterior o Station 0- when the fetal presenting part is at o RST-right sacrotransverse the level of the ischial spines. Face Presentation ▪ Station 0 is synonymous to o LMA-left mentoanterior engagement. o LMP-left mentoposterior o Station - 1 or -2 - when the fetal presenting part o LMT-left mentotransverse is above the level of the ischial spines o RMA-right mentoanterior o Station +1 or +2-when the fetal presenting part o RMP-right mentoposterior is 1 cm or 2 cm below the level of the ischial o RMT-right mentotransverse spines. Shoulder Presentation o Station +3 or +4- is synonymous to crowning. o LADA - left acromiodorsoanterior Crowning is defined as the encirclement of the o LADP-left acromiodorsoposterior largest diameter of the fetal head by the vulvar o RADA-right acromiodorsoabterior ring. o RADP-right acromiodorsoposterior BATH- is advisable if contractions are still tolerable or are not too close to one another. Bathing will not only ensure cleanliness but will also provide comfort and relaxation. XIII. PERINEAL PREPARATION The perineum is cleansed from front to back using the No. 7 stroke in order to disinfect the area surrounding the vagina, this procedure helps to prevent contamination of the birth canal and reduce possibilities of postpartum infection. Perineal shaving is no longer a routine procedure nowadays but if and when it is ordered, the techniques vary from one hospital to the other. The basic steps are as follows: Figure: Station o The perineal hair is first lathered well. o The skin from above is stretched and kept taut XII. POSITION and with the use of a safety razor, hair is shaved The relation of the fetal presenting part of a specific downward from the mons veneris, using long quadrant of the woman's pelvis. The woman's pelvis is single strokes running along the growth of the divided into four quadrants: hair. o Right anterior o The perineum is again washed thoroughly after o Right posterior shaving. o Left anterior o The woman is instructed not to touch the o Left posterior genitals afterwards to keep the area as clean as possible during labor. Four parts of the fetus have been chosen as points of direction: o Occiput - in vertex presentations o Chin (mentum) - in face presentations o Sacrum - in breech presentations 5 Downloaded by Manamtam Daniella ([email protected])  lOMoARcPSD|47543927 [NCM_107] THEORIES OF LABOR - Dr. Judith M. Manuel Blood Pressure (BP) and Fetal Heart Rate (FHR) are taken every hour during the latent phase and every 30 minutes during the active phase. Definitely, BP and FHR should never be taken during contraction. During uterine contractions, no blood goes to the placenta. The blood is pooled to the peripheral blood vessels which results in increased blood pressure. Therefore, the blood pressure should be taken in between contractions and Figure: Perineal Skin Prep whenever the mother in labor complains of a headache. A. AMBULATION FHR, on the other hands, tends to decrease during a Ambulation is advised during the latent phase of labor in contraction because of the compression of the fetal head. order to help shorten the first stage of labor. When the fetal head is compressed by the contracting uterus, the vagus nerve is stimulated, thus causing B. DIET bradycardia, FHR normally 120-160 per minute. It should Solid or liquid foods are avoided for the following reasons: not be mistaken for the uterine soufflé the sound which Digestion is delayed during labor. results when the uterine blood vessels refill with blood. A full stomach interferes with proper bearing down. Uterine soufflé synchronizer with maternal heartbeat. For Aspiration may occur during the reflex nausea and any abnormality in FHR the initial nursing action is to change the mothers in position because the abnormality vomiting of the transition phase or when anesthesia is may just be due to Supine Hypotensive Syndrome. If the used. rate does not change despite positioning the attending physician should be informed. C. ENEMA ADMINISTRATION Enema is not a routine procedure for all women in labor XIV. DANGER SIGNALS but may be done for the following reasons: The nurse must be aware of the following danger signals A full bowel hinders labor progress, enema increases the labor and delivery. Signs fetal and maternal distress are space available for passage of the fetus and improves given below. frequency and intensity of uterine contractions. The effectiveness of enema administration is therefore, shown A. SIGNS OF FETAL DISTRESS by evaluating the change in uterine tone and the amount Tachycardia (FHR more than 180) Bradycardia (FHR less of show. than 100) Enema decreases the possibility of fecal contamination of Meconium- stained amniotic fluid in non-breech the perineum during the second stage of labor. presentation A full bowel can add to the discomfort of the immediate Fetal thrashing or hyperactivity due to feta struggling for postpartum period. more oxygen. Table: The Procedure of Enema Administration During Labor Consists of The Following Considerations XV. ADMINISTRATION OF ANALGESICS Soapsuds for Fleet enema is usually given Narcotics are the most commonly used analgesics, The optimal temperature of the solution is 105- 115 F specifically Demerol (meperidine hydrochloride). Its (40.5- 54.6 C). dosage is based on the patient's weight the status of labor, The patient is placed on side-lying position and the size and stage of gestation. Demerol acts to suppress the sensory portion of the cerebral cortex. A dose of 25-100 mg is given and it takes effect within 20 D. VOIDING minutes when the patient experiences a sense of well- The woman in labor should be encourage to empty her being and euphoria. Demerol, being also an bladder every to 2-3 hours because: antispasmodic, should not be given very early in labor o Full bladder retards fetal descent. because it will retard labor progress. It should not also be o Urinary stasis can lead to urinary tract infection given when delivery is less than an hour away because it o A full bladder may be traumatized during can cause respiratory depression in the newborn. It is, 52 delivery. therefore, preferably given when cervical dilatation is around 5-8cm. E. BREATHING TECHNIQUE The woman in the first stage of labor should be instructed XVI. ADMINISTRATION OF ANESTHETICS not to push or beat down during contractions because it Regional anesthesia is preferred over any other form will not only lead to maternal exhaustions but, more because it does not enter maternal circulation and importantly, unnecessary bearing down can lead to therefore does not retard labor contractions nor cause cervical edema because of the excessive pounding of the respiratory depression in the newborn. The patient is fetal presenting part on the pelvic floor, thus interfering completely awake and aware of what happening, but since with labor progress. To minimize bearing down, the patient there is loss of coordination between contractions and should be advised to do abdominal breathing during pushing, the baby will have to be delivered with the aid of contractions. forceps. One of the more commonly used anesthesia is the low spinal, specially saddle block. Xylocaine is injected F. POSITION into the 5th lumbar space, causing anesthesia into the Encourage the woman in labor to assume Sim's position parts of the body that come in contract with a saddle, e.g., because the inferior vena cave is caught between the the perineum, the upper thighs, and lower pelvis. gravid uterus and the spinal column, causing a drop in Postspinal headaches, however, may occur because of arterial blood pressure. which leads the woman to leakage of cerebrospinal fluid (CSF) or air at the time of complain of dizziness. needle insertion. The patient should be kept flat on bed for o It favors anterior rotation of the head 13 hours and her fluid intake increased to prevent pospinal o It promotes relaxation between contractions. headaches. o It prevents supine hypotensive syndrome A. TRANSFER OF PATIENTS G. CONTRACTIONS A sure sign that the baby is about to be born is the bulging Uterine contractions are monitored every hour during the of the perineum. latent phase of labor and every 30 minutes during the active phase by spreading the fingers lightly over the XVII. THE TRANSITION PHASE OF LABOR fundus. A. NURSING MANAGEMENT H. VITAL SIGNS XVIII. THE SECOND STAGE OF LABOR 6 Downloaded by Manamtam Daniella ([email protected])  lOMoARcPSD|47543927 [NCM_107] THEORIES OF LABOR - Dr. Judith M. Manuel The second stage begins with complete dilatation of the Median – begun in the midline of the perineum and cervix and ends with delivery of the infant. directed toward rectum Mediolateral – begun in the midline of the perineum but XIX. MECHANISMS OF LABOR/FETAL POSITION directed laterally away from the rectum. CHANGES As the fetus passes through the birth canal for delivery, it goes F. BREATHING TECHNIQUE through different position changes so that the smallest diameter of As soon as the head crowns, woman is instructed not to the fetal head (in cephalic presentation) will fit through the pelvic push any longer because it causes rapid expulsion of the inlet and outlet. fetus.. Descent- The fetus goes down the birth canal. Descent either follows or includes engagement. XXI. THE THRID STAGE OF LABOR Flexion- As the fetus descends down the birth canal, The third stage, also know as the Placenta Stage, begins pressure from the pelvic floor causes the fetal heard to be with the delivery of the infant and ends with the delivery of flexed, so that the chin touches the chest. This brings the the placenta. smallest diameter of the fetal head into a good position, which is termed attitude. Attitude, therefore, is the degree A. PHASES of flexion that the fetus assumes prior to delivery. B. PLACENTAL SEPARATION PHASE Internal Rotation- The wider anteroposterior (AP) Separation of the placenta results from the disproportion diameter of the fetal head enters the wider transverse between the size of the placenta and the reduced size of diameter of the pelvic inlet and will rotate so that fetal head the site of placental attachment after the delivery of the is positioned at the wide AP diameter of the pelvic outlet. baby. The signs of placental separation are the following: Extension- As the head comes out, the back of the neck o The uterus becomes more firm and round in stops beneath the public arch. The head then extends and shape again and rising high to the level of the the head, face, and chin are born. umbilicus. External Rotation- After the head has been delivered, it rotates 45 to the left so that the anterior shoulder is just C. PLACENTAL EXPULSION PHASE below the public arch This phase is effected by the mother's bearing down or by gentle pressure on the fundus. There are two mechanisms by which the placenta is separated and expelled from uterus. o Schultz- clear type of placenta, "aw-separation in "center" shiny, reddish in color. o Duncan - dark, dirty "dweg” - edges (separation) D. NURSING MANAGEMENT Method of placental delivery- Do not hurry the delivery of the placental by forcefully pulling out the cord or by vigorous fundal push as this can lead to uterine inversion. Time of placental delivery- 10 minutes immediately notified as it could be a sign of uterine atony. Uterine "atony" never contact to massage Ŏ uterus Figure: Mechanism of Labor E. CARE AFTER PLACENTAL DELIVERY A. NURSING MANAGEMENT The following aspects are important: The care of the woman during the second stage of labor, Inspection of placenta for completeness of cotyledons which is focused on the delivery of the baby, consists of the following: The initial nursing action for a non-contracted or boggy uterus is gentle massage of the fundus. An ice cap may B. POSITIONING ON THE DELIVERY TABLE also help. Oxytocic agents may be administered as ordered to When positioning the woman on lithotomy on the delivery table, the legs should be put up slowly at the same time on ensure uterine contractions, thus preventing hemorrhage o Methergine (0.2mg) and Syntocinon (10U) are the stirrups in order to prevent trauma to the uterine ligaments and back aches or leg cramps. two of the more commonly given oxytocics o Common side effect of oxytocins is hypertension. Monitor the blood pressure. C. BEARING DOWN TECHNIQUES Lacerations are rugged edged which heal more slowly and This is the best time to encourage strong pushing with therefore predispose infection, if healing process in contractions. At the beginning of a contraction, the woman prolonged is asked to take two short breaths, then to hold her breath and bear down at the peak of the contraction. F. CARE DURING AND AFTER PERINEAL REPAIR D. CARE OF THE EPISIOTOMY WOUND A local anesthetic, usually Xylocaine, is given in order to minimize pain during episiorrhaphy. In vaginal Episiotomy- a perennial incision done to facilitate the episiorrhaphy, packing is done to maintain pressure on the birth of the baby is made by the doctor primarily to prevent suture line and, therefore, prevent bleeding. The nurse lacerations. Other reasons for doing episiotomy are to: o should be aware that this packing is usually removed after Prevent prolonged and serve stretching of the 24 or 48 hours. muscles supporting the bladder or rectum, which can later lead to stress incontinence of Estimation of blood loss: 250-300cc-N 500cc hemorrhage. urine or even vaginal prolapse. Reduce duration of the second stage of labor in cases of XXII. THE FOURTH STAGE OF LABOR maternal hypertension of fetal distress. Enlarge Fourth stage first one- or two-hours vital signs of the the vaginal outlet in breech presentation or mother are quite unstable. forceps delivery. Spare the infant's head from having brain damage prolonged pressure which G. NURSING MANAGEMENT may result in brain damage, especially in the Nursing interventions during the fourth stage of labor are focused premature baby. mainly: 1. Assessment E. THE TWO TYPES OF EPISIOTOMY ARE: 7 Downloaded by Manamtam Daniella ([email protected])  lOMoARcPSD|47543927 [NCM_107] THEORIES OF LABOR - Dr. Judith M. Manuel a. Fundus - should be palpated every 15 minutes during the body breaks down fats because there are not enough first hour postpartum and then every 30 minutes for the next carbohydrates and proteins available. Ketones may be 4 hours. deleterious to fetus. b. Bladder-checked every 2 hours during the first 8 hours Abdominal examination- An abdominal examination postpartum and then every 8 hours for 3 days. Suspect a full should include a measurement of fundal height as well urinary bladder if the fundus is not well contracted and is as an assessment of fetal size (estimated fetal weight), shifted to the right. A full urinary bladder prevents good presentation and position using Leopold's maneuvers. contraction of the uterus and therefore may cause o Inspect: Scars, linea, striae, symmetry hemorrhage. o Palpate: fundal height, fetal position c. Vaginal discharge - the amount of blood flow should be o Osculate: fetal heart tones checked every 15 minutes and should be moderate. It is said o Determine and palpate contractions that if a newly-delivered woman saturates a sanitary napkin more often than every 30 minutes, the flow is excessive B. INSPECT AND PALPATE LOWER EXTREMITIES necessitating immediate referral to the doctor. Press firmly with thumbs about 5 seconds over shin d. Blood pressure and pulse rate- should be checked every 15 minutes during the first hour postpartum and then every If any signs of elevated blood pressure, elicit DTR 30 minutes until stable. BP and pulse rate are slightly If reflexes are hyperactive, check for clonus increased from excitement and the effort of delivery but normally stabilizes within one hour. e. Perineum - should be inspected every 8 hours for 3 days. Take note of the condition of the episiorrhaphy: H. BLADDER ASSESSMENT Voiding pattern, complete emptying, pain burning on urination Record first three voids with the amount and times voided A full bladder displaces the uterus upwards and laterally and prevents contraction of the uterus = UTERINE ATONY => risk of postpartum hemorrhage. Figure: Fetal Position Comfort Measures- Helping the mother feel comfortable after delivery can be effective by the following measures: C. MEASURING FUNDAL HEIGHT Perineal care gently Place the zero line of the tape measure on the Position her flat on bed without pillows to prevent anterior border of the symphysis pubis and stretch dizziness due to sudden release intraabdominal pressure tape over midline of abdomen to top of fundus Mother a soothing sponge bath change her soiled The tape should be brought over the curve of the gown/dress and dirty linens. fundus. Additional blankets if the mother suddenly complains e. The height of the fundus in centimeters equals the Mother initial nourishment of coffee, tea or milk. number of weeks gestation plus or minus 2. Mother to sleep in order to regain lost energy. After 32 weeks the relationship is less accurate. D. ABDOMINAL EXAMINATION FOR CONTRACTIONS An initial abdominal examination is carried out on timber admission by laying a hand on the uterus and palpating, noting the degree of hardness during a contraction and timing its length. This should be repeated at intervals throughout labor in order to assess the length, strength and frequency of contractions and the descent of the presenting part. The uterus should always feel softer between contractions. XXIII. PHYSICAL EXAMINATION OF THE LABORING WOMAN Steps you should take to prepare for the examination: Ask woman to empty bladder (collect urine for testing). Prepare to follow a logical order. Prepare to chart logically immediately after exam (make notes). Figure: Abdominal Examination for Contractions Remember to use all your senses during assessment. The monitor should never be relied on; the mother's Remember to explain everything you are doing. abdomen should be regularly palpated by hand. Exam should be carried out immediately and as quickly as possible. A. URINE TESTS USED DURING INTRAPARTUM pH- Measures acidity/alkalinity of the urine, Levels below normal indicate high fluid intake, levels above the norm indicate inadequate fluids & dehydration. Protein - Normal = Negative, Small amounts may be in urine from vaginal secretions & dehydration, Amounts of 2+ to 4+ may indicate be one indicator of possible UTI, Kidney, Infection or PIH. Figure: Frequency and Duration of Contractions Glucose- Normal = Negative or +1. High levels of glucose may be one indicator of high blood sugar, gestational diabetes or diabetes mellitus. Always ask what woman has recently eaten if her BS is high Ketones - Normal = Negative Ketones are products of the breakdown of fatty acids caused by fasting. The 8 Downloaded by Manamtam Daniella ([email protected])  lOMoARcPSD|47543927 [NCM_107] THEORIES OF LABOR - Dr. Judith M. Manuel posterior fornix for pooling of fluid and by obtaining a sample of the fluid with a sterile applicator and applying the fluid to a glass slide. The glass slide is allowed to air dry and is subsequently inspected for an arborization pattern ("ferning"). XXIV. STAGES OF LABOR CHART Figure: The Segment of a Contration The first stage of labor begins when uterine contractions of sufficient frequency, intensity and duration result in effacement and dilation of the cervix. The first stage is completed when the cervix reaches 10 cm. The second stage involves descent of the fetus and its eventual expulsion from the vagina. It begins with complete cervical dilation (10 cm) and ends with delivery of the infant. The third stage of labor involves delivery of the placenta. It begins with the completion of the infants' delivery and ends with delivery of the placenta and membranes. Table: Stages of Labor Chart There is no place for routine vaginal examinations in any FIRST STAGE ACTIVE LABOR labor. Vaginal examination should only be done when LATENT-EARLY LABOR LATENT (4-8 cm) there is doubt about the clinical situation or symptoms, LABOR (0-3 cm.) Pre-labor and the information gathered is necessary or likely to be of Ripening and Contractions: 5-20 Contractions: 2-5 use in making a clinical decision. o effacement of the minutes apart minutes apart Significant vaginal bleeding of unknown etiology cervix (delay examination until placenta previa has 30-45 seconds long 45-60 seconds long been ruled out by ultrasonography), o Presence of placenta previa, o Mild, feel like cramps, Stronger and more Ruptured membranes in patients who are not in back pain, pressure intense labor and for whom immediate induction of labor is not anticipated, o Presence of active HSV lesions in a patient with ruptured membranes TRANSITION SECOND STAGE THIRD STAGE Figure: LABOR -10 cm) LABOR (10 cm Delivery of the A, Birth) Placenta Vaginal Contractions: 1-2 Contractions: 3-5 Contractions: View B, minutes apart minutes apart Irregular 45-90 seconds long 60-120 seconds long A feeling of fulness Abdominal View (Normal Flexed Head) and cramping as placenta separates E. HOW TO PALPATE THE PRESENTING PART: Palpate the hard skull; palpate for sagital suture; follow to The strongest they Less aware of the A time for mom to will get contractions, more hold and enjoy anterior or posterior fontanel aware of the urge to baby. If what you feel is soft it may be breech or face. push and fullness in vagina as baby moves down Figure: Suture and Fontanelles F. ASSESSING CERVICAL EFFACEMENT Cervical effacement: Palpate degree of thickness; normal cervix about 1 inch thick Figure: A, cervix before effacement begins B, Effacement in its early phase C, Effacement with some dilation D, Complete effacement and dilatation G. SPECULUM EXAMINATION A speculum examination will be necessary in cases of suspected "leaking" or ruptured membranes. The presence of leaking or ruptured membranes can be confirmed by performing a nitrazine test, inspecting the 9 Downloaded by Manamtam Daniella ([email protected])