Chapter 5 - Labor and Delivery PDF

CARE OF MOTHER, CHILD, ADOLESCENT | NCM 107 CHAPTER 5: LABOR AND DELIVERY LABOR AND DELIVERY Woman experience: FIRST STAGE OF LABOR 1...

CARE OF MOTHER, CHILD, ADOLESCENT | NCM 107 CHAPTER 5: LABOR AND DELIVERY LABOR AND DELIVERY Woman experience: FIRST STAGE OF LABOR 1) Intense discomfort 1. LATENT PHASE 2) Nausea & vomiting 3) Feeling of loss of control ASSESSMENT 4) Anxiety, panic, or irritability Begins at the onset of regular uterine contractions and ends 5) She may resist being touched when rapid cervical dilatation begins. 6) Irresistible urge to push as woman reaches full cervical Contractions lasting 20- 40 sec. dilatation (10 cm.) Frequency: 15-30 min. IMPLEMENTATION Cervix dilates 0-3 cm 1. Encourage rest between contractions. Intensity: mild, 25 – 40 mmHg 2. Wake mother at beginning of contractions so she can begin Latent phase contractions cause minimal discomfort. breathing pattern A woman can continue to walk about and make preparations 3. Keep mother & partner informed of progress for birth. 4. Provide privacy This phase lasts 6 hrs. in nulliparas; 4.5 hrs. in multiparas 5. Offer fluids & ice chips, and ointments for dry lips IMPLEMENTATION 6. Encourage voiding every 1 – 2 hrs. 1. Encourage mother & partner to participate in care. GENERAL NURSING CARE INTRAPARTAL PERIOD 2. Assist with comfort measures, changes of position, and A. ASSESSMENT (ON ADMISSION) ambulation 1. Age, weight, height 3. Keep mother and partner informed of progress 2. Parity, gravidity, obstetric history 4. Offer fluids & ice chips 3. Allergies 5. Encourage voiding every 1- 2 hrs. 4. Urine specimen 2. ACTIVE PHASE LABOR 5. Time & type of last meal ASSESSMENT 6. Frequency, duration, intensity of contractions Cervical dilatation occurs more rapidly 7. Time of onset of contractions At least 4-7 cm dilated 8. Presence of bloody show Regular, frequent, usually painful contractions, lasting 40-60 9. Status of amniotic membrane sec. 10. Dilatation and effacement 11. Position of fetus (Leopold’s Maneuver) Frequency: every 3-5 min. 12. FHR & pattern Are not comfortable with talking or laughing during their 13. V/S and BP of mother contractions 14. Emotional response to labor Contractions grow so strong, last longer 15. Presence of support persons This phase lasts 3 hours in nullipara; and 2 hours in multipara. vaginal secretions (show) B. ANALYSIS/NURSING DX Spontaneous rupture of membranes may occur. 1. MOTHER Active stage of labor in a Friedman Graph can be subdivided 1) Altered cardiopulmonary tissue perfusion associated with into the following periods: hypovolemia r/t uterine relaxation following birth. 1) Acceleration (4-5 cm) 2) Ineffective individual coping r/t exhaustion 2) Maximum slope (5-9 cm) 3) Fear r/t lack of knowledge and unfamiliarity with labor process ‐ Very rapid cervical dilatation 4) Impaired gas exchange r/t hyperventilation ‐ 3.5 cm/hr (nulliparas) 5) Risk for injury r/t lack of control especially during transition ‐ 5-9 cm/hr (multiparas) phase, position during birth IMPLEMENTATION 6) Pain r/t labor process and episiotomy 7) Impaired physical mobility related to need for fetal 1. Encourage maintenance of effective breathing patterns monitoring, bed rest, or positioning 2. Provide a quiet environment 8) Altered urinary elimination r/t pressure of enlarged uterus, 3. Keep mother & partner informed of progress analgesia or anesthesia, and trauma of labor and birth 4. Promote comfort with backrubs, sacral pressure, pillow support, and position changes 2. INFANT 5. Instruct partner in effleurage 1) Ineffective thermoregulation r/t immature heat regulation, 6. Offer fluids & ice chips, and ointments for dry lips inability to shiver 7. Encourage voiding every 1 – 2 hrs. 2) Risk for injury r/t trauma of birth or maternal infection 3. TRANSITION PHASE 3) Ineffective airway clearance r/t excessive mucus, aspiration of meconium, or inability to clear airway ASSESSMENT C. PLANNING/IMPLEMENTATION Contractions reach their peak of intensity Frequency: every 2-3 min. 1. FIRST STAGE Duration: 60 – 90 sec. 1. ADMIT MOTHER AND LABOR COACH Maximum dilatation: 8 – 10 cm. a) Orient to unit By the end of this phase, both FULL DILATATION and b) Obtain history COMPLETE CERVICAL EFFACEMENT have occurred. 1. Parity & gravidity LAMAGON | BSN 2A  CARE OF MOTHER, CHILD, ADOLESCENT | NCM 107 CHAPTER 5: LABOR AND DELIVERY 2. EDB ▪ Fetal anemia 3. Onset of contractions ▪ Fetal arrythmia 4. Status of membranes c) BRADYCARDIA: FHR below 110 b/min. lasting longer than 10 5. Time & contents of last meal min. 6. Allergies Causes: 7. Intent to breast feed or bottlefeed o Fetal hypoxia as a result of: 8. Prenatal care a) Anesthetics used c) Obtain V/S b) Maternal hypotension d) Perform Leopold’s maneuver c) Prolonged umbilical cord compression e) Time & assess contractions d) Analgesics f) Assist with vaginal exam Nursing Intervention: g) Test urine for protein, glucose & ketones a) Position mother on her side h) Collect blood for CBC and cross match b) Assess for prolapsed cord i) Give emotional support to mother & labor coach c) Positioning to relieve pressure on cord 2. MAINTAIN ASEPSIS; USE UNIVERSAL PRECAUTION d) Elevate lower extremities e) Adm. O2 3. MONITOR FREQUENCY, DURATION AND STRENGTH OF Bradycardia CONTRACTIONS o Sustained