family-nursing-ob-exam-2-blueprint-answers.pdf

lOMoARcPSD|23524095 Family Nursing OB Exam 2 Blueprint Answers Family Nursing (Herzing University) Scan to open on Studocu Studocu is not sponsored or endorsed by any college or university Downloaded by Tierra Earl ([email protected]) lOMoARcPSD|23524095 Braxton Hicks contractions, True versus False labor NSG222.03.01.01 Braxton Hicks Contractions ○ which the woman may have been experiencing throughout the pregnancy, may become stronger and more frequent ○ typically felt as a tightening or pulling sensation of the top of the uterus ○ occur primarily in the abdomen and groin and gradually spread downward before relaxing ○ true labor contractions are more commonly felt in the lower back ○ aid in moving the cervix from a posterior position to an anterior position ○ help in ripening and softening the cervix ○ irregular and can be decreased by walking, voiding, eating, increasing fluid intake, or changing position. ○ usually last about 30 seconds but can persist for as long as 2 minutes ○ As birth draws near and the uterus becomes more sensitive to oxytocin, the frequency and intensity increase if the contractions last longer than 30 seconds and occur more often than 4-6x an hour, advise the woman to contact her health care provider so she can be evaluated for possible preterm labor, especially if she is less than 38 weeks pregnant True Versus False Labor Not all contractions indicate labor ○ False labor is a condition occurring during the latter weeks of some pregnancies when irregular uterine contractions are felt, but the cervix is not affected true labor is characterized by contractions occurring at regular intervals that increase in frequency, duration, and intensity ○ contractions bring about progressive cervical dilation and effacement False labor, prodromal labor, and Braxton Hicks contractions are all names for contractions that do not contribute in a measurable way toward the goal of birth Distinguishing between true and false labor is an essential nursing assessment skill and one that develops with experience Passenger NSG222.03.01.02 fetus (with placenta) is the passenger fetal head (size and presence of molding), fetal attitude (degree of body flexion), fetal lie (relationship of body parts), fetal presentation (first body part), fetal position (relationship to maternal pelvis), fetal station, and fetal engagement are all important factors that have an impact on the ultimate outcome in the birthing process Fetal Head 1 Downloaded by Tierra Earl ([email protected]) lOMoARcPSD|23524095 ○ ○ ○ ○ ○ ○ ○ ○ largest fetal structure, making it an important factor in labor and birth There is considerable variation in the size and diameter of the fetal skull large in proportion to the rest of the body, usually about 1/3 of the body length bones that make up the face and cranial base are fused and essentially fixed 5 bones that make up the rest of the cranium (2 frontal bones, 2 parietal bones, and the occipital bone are soft and pliable, with gaps between the plates of bone ○ The gaps, membranous spaces between cranial bones, are called sutures, and the intersections of these sutures are called fontanelles Sutures are important as they allow cranial bones to overlap in order for the head to adjust in shape (elongate) when pressure is exerted on it by uterine contractions or the maternal bony pelvis Some diameters shorten, while others lengthen as the head is molded during the labor and birthing process malleability of the fetal skull may decrease fetal skull dimensions by 0.5 to 1 cm After birth, the sutures close as the bones grow and the brain reaches its full growth newborn may occasionally endure minor physical injury during the childbirth process involving structural or tissue impairment Most are temporary and self-limiting with full recovery changed (elongated) shape of the fetal skull at birth as a result of overlapping of the cranial bones is known as molding Along with molding, fluid can collect in the scalp (caput succedaneum) or blood can collect beneath the scalp (cephalohematoma), further distorting the shape and appearance of the fetal head ○ Caput succedaneum can be described as edema of the scalp at the presenting part swelling crosses suture lines and disappears within 3-4 days ○ Cephalohematoma is a collection of blood between the periosteum and the bone that occurs 7 hours after birth does not cross suture lines generally reabsorbed over the next 6-8 weeks Parents may become concerned about the distortion of their newborn's head reassurance that the oblong shape is only temporary is usually all that is needed to reduce their anxiety Sutures also play a role in helping to identify the position of the fetal head during a vaginal examination Duringexamination, palpation of these sutures by the examiner reveals the position of the fetal head and the degree of rotation that has occurred anterior and posterior fontanelles are also useful in helping to identify the position of the fetal head 2 Downloaded by Tierra Earl ([email protected]) lOMoARcPSD|23524095 allow for molding, and are important when evaluating the newborn ○ anterior fontanelle is the famous “soft spot” of the newborn’s head is a diamond-shaped space that measures from 1-4 cm remains open for 12-18 months after birth to allow for growth of the brain posterior fontanelle corresponds to the anterior one but is located at the back of the fetal head ○ is triangular ○ closes within 8-12 weeks after birth and on average ○ measures 1-2 cm at its widest diameter Fetal Attitude ○ refers to the posturing (flexion or extension) of the joints and the relationship of fetal parts to one another ○ most common fetal attitude when labor begins is with all joints flexed— fetal back is rounded, the chin is on the chest, the thighs are flexed on the abdomen, and the legs are flexed at the knees most favorable for vaginal birth, presenting the smallest fetal skull diameters to the pelvis ○ When the fetus presents to the pelvis with abnormal attitudes (no flexion or extension), their non-flexed position can increase the diameter of the presenting part as it passes through the pelvis, increasing the difficulty of birth ○ attitude of extension tends to present larger fetal skull diameters, which may make birth difficult Fetal Lie ○ refers to the relationship of the long axis (spine) of the fetus to the long axis (spine) of the mother ○ 3 possible lies: longitudinal (most common) occurs when the long axis of the fetus is parallel to that of the mother (fetal spine to maternal spine side-by-side) Transverse occurs when the long axis of the fetus is perpendicular to the long axis of the mother (fetal spine lies across the maternal abdomen and crosses her spine) Oblique fetal long axis is at an angle to the bony inlet, and no palpable fetal part is presenting usually transitory and occurs during fetal conversion between other lies ○ A fetus in a transverse or oblique lie position cannot be delivered vaginally Fetal Presentation ○ refers to the body part of the fetus that enters the pelvic inlet first (“presenting part”) is the fetal part that lies over the inlet of the pelvis or the cervical os Knowing which fetal part is coming first at birth is critical for planning and 3 Downloaded by Tierra Earl ([email protected]) lOMoARcPSD|23524095 ○ ○ initiating appropriate interventions determined by abdominal palpation 3 main presentations cephalic (head first) majority of term newborns (95%) enter this world in this presentation presenting part is usually the occipital portion of the fetal head also referred to as a vertex (A) presentation Variations in a vertex presentation include the military (B), brow (C), and facial (D) presentations breech (pelvis first) occurs when the fetal buttocks or feet enter the maternal pelvis first and the fetal skull enters last abnormal presentation poses 7 challenges at birth ○ largest part of the fetus (skull) is born last and may become “hung up” or stuck in the pelvis ○ umbilical cord can become compressed between the fetal skull and the maternal pelvis after the fetal chest is born because the head is the last to exit ○ buttocks are soft and are not as effective as a cervical dilator during labor compared with a cephalic presentation ○ possibility of trauma to the head as a result of the lack of opportunity for molding. types of breech presentations are determined by the positioning of the fetal legs ○ frank breech (50-70%), the buttocks present first with both legs extended up toward the face can result in a vaginal birth Image A ○ full or complete breech (510%), the fetus sits crossed-legged above the cervix generally necessitate a cesarean birth Image B ○ footling or incomplete breech (10-30%), one or both legs are presenting generally necessitate a cesarean birth Image C and D associated with prematurity, placenta previa, multiparity, uterine abnormalities (fibroids), and some congenital anomalies such as hydrocephaly shoulder (scapula first) approximately 2% 4 Downloaded by Tierra Earl ([email protected]) lOMoARcPSD|23524095 shoulder presentation or shoulder dystocia occurs when the fetal shoulders present first with the head tucked inside signs of shoulder dystocia appear while the woman is pushing as the neonate’s head slowly extends and emerges over the perineum but then retracts back into the vagina, commonly referred to as the “turtle sign.” Odds of a shoulder presentation are 1 in 300 births fetus is in a transverse lie with the shoulder as the presenting part Conditions associated include placenta previa, prematurity, high parity, premature rupture of membranes, multiple gestation, or fetal anomalies cesarean birth is usually necessary if identified before labor begins but will be evaluated based on the length of gestation, size of the fetus, position of the placenta, and whether the membranes have ruptured Fetal Position ○ describes the relationship of a given point on the presenting part of the fetus to a designated point of the maternal pelvis ○ landmark fetal presenting parts include occipital bone (O), which designates a vertex presentation chin (mentum [M]), which designates a face presentation buttocks (sacrum [S]), which designate a breech presentation scapula (acromion process [A]), which designates a shoulder presentation ○ maternal pelvis is divided into 4 quadrants: right anterior left anterior right posterior left posterior quadrants designate whether the presenting part is directed toward the front, back, left, or right side of the pelvis ○ determined by identifying first the presenting part and then the maternal quadrant the presenting part is facing ○ Position is indicated by a 3-letter abbreviation as follows: first letter defines whether the presenting part is tilted toward the left (L) or the right (R) side of the maternal pelvis. second letter represents the particular presenting part of the fetus: O for occiput S for sacrum (buttocks) M for mentum (chin) A for acromion process D for dorsal (refers to the fetal back) when denoting the fetal position in shoulder presentations third letter defines the location of the presenting part in relation to the anterior (A) portion of the maternal pelvis or the posterior (P) portion of the maternal pelvis If the presenting part is directed to the side of the maternal pelvis, the fetal presentation is designated as transverse (T) LOA is currently the most common (and most favorable) fetal position for birthing today, followed by right occiput anterior (ROA) positioning of the fetus allows the fetal head to contour to the diameters of the maternal pelvis. LOA and ROA are optimal positions for a vaginal birth 5 Downloaded by Tierra Earl ([email protected]) lOMoARcPSD|23524095 An occiput posterior position may lead to a long and difficult birth, and other positions may or may not be compatible with vaginal birth Fetal Station refers to the relationship of the presenting part to the level of the maternal pelvic ischial spines measured in centimeters and is referred to as a minus or plus, depending on its location above or below the ischial spines ○ Typically, ischial spines are the narrowest part of the pelvis and are the natural measuring point for the birth progress ○ Zero (0) station is designated when the presenting part is at the level of the maternal ischial spines ○ When the presenting part is above the ischial spines, the distance is recorded as minus stations presenting part is above the ischial spines by 1 cm, it is documented as being a −1 ○ When the presenting part is below the ischial spines, the distance is recorded as plus stations presenting part is below the ischial spines by 1 cm, it is documented as being a +1 station. easy way to understand this concept is to think in terms of meeting the goal, which is birth ○ If the fetus is descending downward (past the ischial spines) and moving toward meeting the goal of birth, then the station is positive and the centimeter numbers grow bigger from +1 to +4 The closer the presenting part of the fetus is to the outside, the larger the positive number (+4 cm) ○ If the fetus is not descending past the ischial spines, the station is negative and the centimeter numbers grow from −1 to −4 The farther away the presenting part from the outside, the larger the negative number (−4 cm) Fetal Engagement signifies the entrance of the largest diameter of the fetal presenting part (usually the fetal head) into the 6 Downloaded by Tierra Earl ([email protected]) lOMoARcPSD|23524095 smallest diameter of the maternal pelvis ○ fetus is said to be engaged in the pelvis when the presenting part reaches 0 station determined by pelvic examination. largest diameter of the fetal head is the biparietal diameter ○ extends from one parietal prominence to the other ○ is an important factor in the navigation through the maternal pelvis typically occurs in primigravidas 2 weeks before term multiparas may experience engagement 7 weeks before the onset of labor or not until labor begins Position (Maternal) NSG222.03.01.03 Positioning for normal labor and birth has evolved sitting upright with flexed hips, squatting, or less commonly standing or kneeling during the childbirth ○ maintain flexion at the hip joint and somewhat straighten the pelvis Childbirth medicalization has reduced laboring women’s opportunity in a spontaneous position of choice to a recumbent one Scientific evidence has shown that nonmoving, back-lying positions during labor are not healthy ○ With an upright position, gravity can help in bringing the fetus down, and there is less risk of compressing the maternal aorta which supplies oxygen to the fetus many women continue to lie flat on their backs during labor Some of the reasons why this continues include the beliefs that: ○ laboring women need to conserve their energy and not tire themselves. ○ nurses cannot keep track of the whereabouts of ambulating women. ○ it is the preference of the health care provider. ○ the fetus can be monitored better in this position. ○ the supine position facilitates vaginal examinations and external belt adjustment. ○ a bed is “where one is supposed to be” in a hospital setting. ○ the position is more convenient for the delivering health care provider. ○ laboring women are connected to medical equipment that impedes movement Women should be encouraged to assume any position of comfort for them recent randomized controlled study, the use of a peanut-shaped ball that is placed between the woman’s legs during labor decreased the length of labor and increased the rate of vaginal births ○ associated with a significantly lower incidence of cesarean births ○ can be a potentially successful nursing intervention to help progress labor and support vaginal birth, along with position changes, for women laboring under epidural analgesia If the only furniture provided is a bed, this is what the woman will use ○ Furnishing rooms with comfortable chairs, beanbags, and other birth props allows a woman to choose from a variety of positions and to be free to move around during labor Changing positions and moving around during labor and birth offer 7 benefits ○ Maternal position can influence pelvic size and contours ○ Changing position and walking affect the pelvis joints, which may facilitate fetal descent and rotation ○ Squatting enlarges the pelvic inlet and outlet diameters ○ kneeling position removes pressure on the maternal vena cava and helps rotate the fetus from a posterior position to an anterior one to facilitate birth use of any upright or lateral position compared to supine or lithotomy positions may: ○ reduce the length of the first stage of labor. 7 Downloaded by Tierra Earl ([email protected]) lOMoARcPSD|23524095 ○ reduce the duration of the second stage of labor. ○ reduce the number of assisted deliveries (vacuum and forceps). ○ reduce episiotomies and perineal tears. ○ contribute to fewer abnormal fetal heart rate patterns. ○ increase comfort and reduce requests for pain medication. ○ enhance a sense of control by the mother. ○ alter the shape and size of the pelvis, which assists in descent. ○ assist gravity to move the fetus downward National Institute for Health and Care Excellence (NICE) guidelines recommend discouraging women from lying supine or semi-supine during labor and encourage them to adapt to any other position that they find comfortable since lying on the back is associated with longer labor, increase in surgical births, increased pain, and a higher incidence of fetal heart rate abnormalities Partners NSG222.03.01.04 Women desire support and attentive care during labor and birth ○ Caregivers can convey emotional support by offering their continued presence and words of encouragement emotional, physical, and/or spiritual support during labor is the norm for most cultures A caring partner can use massage, light touch, acupressure, hand-holding, stroking, and relaxation can help the woman communicate her wishes to the staff; and can provide a continuous, reassuring presence, all of which bring some degree of comfort presence of the mother’s significant other at the birth provides special emotional support, a partner can be anyone who is present to support the woman throughout the experience ○ many women, the essential ingredients for a safe and satisfying birth include a sense of empowerment and success in coping with or transcending the experience in addition to having solid, positive encouragement from a support companion Worldwide, women usually support other women in childbirth ○ Doula is a Greek word meaning woman servant or caregiver now commonly refers to a woman who offers emotional and practical support to a mother or couple before, during, and after childbirth believes in “mothering the mother,” and clinical support remains the job of the midwife or medical staff The continuous presence of a trained female support person reduces the need for medication for pain relief, use of vacuum or forceps delivery, and need for cesarean births been associated with a slight reduction in the length of labor is an experienced labor companion, provides the woman and her partner with emotional and physical support and information throughout the entire labor and birth experience Continuous support by nurses includes reassurance, encouragement, praise, and explanation Nursing care of women during labor should incorporate finding a way to connect with her and to understand what she is experiencing (knowing); spending time with her (presence); protecting her and preserving her dignity (doing for); providing information and explanations in a clear methodical manner (enabling); and ensuring a safe childbirth experience laboring women should always have the option to receive partner support, whether from nurses, doulas, significant others, or family ○ the support partner should provide the mother with continuous presence and hands-on comfort and encouragement overall objective of providing support for women during childbirth is to create a positive experience for 8 Downloaded by Tierra Earl ([email protected]) lOMoARcPSD|23524095 her while preserving her physical and psychological health Basic client preparation NSG222.03.01.05 Basic prenatal education can help women manage the labor process and feel in control of the birthing experience ○ literature indicates that if a woman is prepared before the labor and birth experience, labor is more likely to remain natural without the need for medical intervention ○ evidence indicates that well-prepared women with good labor support is less likely to need analgesia or anesthesia and is less likely to require cesarean birth Prenatal education teaches the woman about the childbirth experience and increases her sense of control ○ Is able to work as an active participant during the labor and birth experience ○ research suggests that prenatal preparation may affect intra- and postpartum psychosocial outcomes Ex. prenatal education covering parenting communication classes had a significant effect on postpartum anxiety and postpartum adjustment ○ Special consideration of each woman’s culture, age, cognitive skills, access to health information, and health literacy all impact her understanding of the content presented ○ Nurses play an essential role in providing evidence-based education throughout the prenatal period Learning about labor and birth allows women and couples to express their needs and preferences ahead of time, enhance their confidence, and improve communication between themselves and staff Pain Management ○ perception of pain can be influenced by a number of factors past experiences of pain culture and beliefs Stoicism anxiety and depression ○ To manage a client’s plan, nurses need to understand what it is and provide support to the laboring client to enable her to deal with the pain and challenges of labor ○ Labor and birth, though a normal physiologic process, can produce significant pain Pain during labor is a nearly universal experience ○ Controlling the uterine discomfort without harm to the fetus or labor process is the major focus of pain management during childbirth ○ Pain is a subjective experience involving a complex interaction of physiologic, spiritual, psychosocial, cultural, and environmental influences Cultural values and learned behaviors influence perception and response to pain, as do anxiety and fear, both of which tend to heighten the sense of pain ○ challenge for care providers is to find the right combination of pain management methods to keep the discomfort manageable while minimizing the negative effect on the fetus, the normal physiology of labor, maternal–infant bonding, breastfeeding, and a woman’s perception of the labor itself Table 13.2 Stages and phases of labor NSG222.03.01.06 Stages of Labor Labor is typically divided into 4 stages: ○ Dilation first stage is the longest 9 Downloaded by Tierra Earl ([email protected]) lOMoARcPSD|23524095 ○ ○ ○ begins with the first true contraction and ends with full dilation (opening) of the cervix. divided into 2 phases, latent and active, each corresponding to the progressive dilation of the cervix Expulsive second stage begins when the cervix is completely dilated and ends with the birth of the newborn can last from minutes to hours contractions typically occur every 2-3 minutes, lasting 60-90 seconds and are strong by palpation women are usually intent on the work of pushing Placental third stage starts after the newborn is born and ends with the separation and birth of the placenta Continued uterine contractions typically cause the placenta to be expelled within 5-30 minutes If the newborn is stable, bonding of infant and mother takes place through touching, holding, and skin-to-skin contact Restorative fourth stage Also called immediate postpartum period lasts from 1-4 hours after birth mother’s body begins to stabilize after the hard work of labor and the loss of the products of conception often not recognized as a true stage of labor, but it is a critical period for maternal physiologic transition as well as new family attachment Close monitoring of mother and her newborn are done First Stage fundamental change underlying the process is progressive dilation of the cervix ○ Cervical dilation is gauged subjectively by vaginal examination and is expressed in centimeters ends when the cervix is dilated to 10 cm in diameter and is large enough to permit the passage of a fetal head of average size fetal membranes usually rupture during this stage, but they may have burst earlier or may even remain intact until birth primigravida, this stage of labor can last up to 20 hours without being considered prolonged ○ time can vary widely multiparous woman, it can last up to 14 hours women usually perceive the visceral pain of diffuse abdominal cramping and uterine contractions Pain is primarily a result of the dilation of the cervix and lower uterine segment, and the distention (stretching) of these structures during contractions divided into 2 phases: ○ Latent/Early (0-6cm) gives rise to the familiar signs and symptoms of labor begins with the start of regular contractions and ends when rapid cervical dilation begins cervix dilates slowly to approximately 6 cm Sedation can increase the duration of this phase. Contractions usually occur every 5-10 minutes, last 30-45 seconds, and are described as mild by palpation by the nurse 10 Downloaded by Tierra Earl ([email protected]) lOMoARcPSD|23524095 ○ Assessment of intensity is evaluated by pressing down on the fundus during a contraction to see if it can be dented with the nurse’s fingers ○ ability to indent the fundus at the peak of the contraction would typically indicate a mild contraction Effacement of the cervix is from 0-40% Many remain talkative during this period, perceiving their contractions to be similar to menstrual cramps Women may remain at home during this phase, contacting their health care provider about the onset of labor. women are apprehensive but excited about the start of labor after the long gestational period Active encompasses the time from an increase in the rate of cervical dilation (end of latent phase of labor) until completion of cervical dilation Cervical dilation begins to occur more rapidly and predictably until it reaches 10 cm and cervical dilation and effacement are complete more rapid cervical dilation generally dilates at a rate of 1.2-1.5 cm per hour fetus descends farther in the pelvis Contractions become more frequent (every 2-5 minutes) and increase in duration (45-60 seconds) women’s discomfort intensifies (moderate to strong by palpation) becomes more intense and inwardly focused, absorbed in the serious work of her labor ○ limits interactions with those in the room If she and partner have attended childbirth education classes, she will begin to use the relaxation and paced breathing techniques they learned to cope with the contractions Second Stage begins with complete cervical dilation (10 cm) and effacement and ends with the birth of the newborn previous stage of labor primarily involved the thinning and opening of the cervix, this stage involves moving the fetus through the birth canal and out of the body cardinal movements of labor occur during the early phase of passive descent Contractions occur every 2-3 minutes, last 60-90 seconds, and are described as strong by palpation Parity, delayed pushing, use of epidural analgesia, maternal body mass index, birth weight, pelvis shape, occiput posterior position, and fetal station at complete dilation all have been shown to affect the length of the second stage of labor. ○ A longer duration is associated with adverse maternal outcomes ex. higher rates of puerperal infection, third- and fourth-degree perineal lacerations, and postpartum hemorrhage mother usually feels more in control and less irritable and agitated ○ focused on the work of pushing maternal urge to push is generally felt when there is direct contact of the fetus to the pelvic floor Stretch receptors in the wall of the vagina, rectum, and perineum communicate the pressure of the fetus descending in the birth canal that, along with increased abdominal pressure, causes the overwhelming urge to push described by laboring women Pushing 11 Downloaded by Tierra Earl ([email protected]) lOMoARcPSD|23524095 ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ active pushing is the time in which the laboring mother is feeling rectal pressure by the fetal presenting part and physiologically feels the urge to push If the mother has an epidural in place, this sensation to push is dulled perineum bulges, and there is an increase in bloody show fetal head becomes apparent at the vaginal opening but disappears between contractions When the top of the head no longer regresses between contractions, it is said to have crowned fetus rotates as it maneuvers out may last up to 3 hours in a first labor and up to 2 hours in subsequent ones Spontaneous VS Directed Pushing 2 ways of conducting the second stage of labor: spontaneous pushing (following the mother’s spontaneous urge) ○ represents a natural way of managing the second stage of labor directed pushing (pushing directed by the caregiver) ○ as a result of epidural analgesia, health care providers frequently resort to directed pushing without taking into account the negative repercussions it has on the woman and her fetus physiologic approach focuses on spontaneous pushing as the mother feels the need rather than when she is directed, which can reduce fetal oxygenation Evidence is mounting that the management of the second stage, particularly pushing, is a modifiable risk factor in long-term perinatal outcomes Traditionally, women have been taught to hold their breath to the count of 10, inhale again, push again, and repeat the process 7 times during a contraction linked to hemodynamic changes in the mother and interferes with oxygen exchange between the mother and the fetus associated with pelvic floor damage ○ longer the push, the more damage to the pelvic floor health care providers sometimes resist delaying the onset of pushing after the second stage of labor has begun because of a belief that it will increase labor time Delaying maternal bearing-down efforts during the second stage until the woman feels the urge to push (laboring down) allows for optimal use of maternal energy, has no detrimental maternal effects, and results in improved fetal oxygenation delaying pushing for up to 90 minutes after complete cervical dilation resulted in a significant decrease in the time mothers spend pushing without a significant increase in total time in second stage of labor World Health Organization (WHO) has recommended that during the second stage of labor, nurses should encourage and support women to follow their own urge to push and not direct it Using an open-glottis method (involuntary pushing with expiratory grunting and vocalization) to push supports the mother’s involuntary bearing-down efforts Behaviors demonstrated by laboring women during this time include pushing at the onset of the urge to bear down using their own patterns and techniques of bearing down in response to sensations they experience using open-glottis bearing down with contractions pushing with variations in strength and duration pushing down with progressive intensity using multiple positions to increase progress and comfort Labor nurses need to develop an evidence-based approach that acknowledges and reinforces 12 Downloaded by Tierra Earl ([email protected]) lOMoARcPSD|23524095 ○ women’s innate ability to give birth and refrain from trying to direct women’s pushing behaviors Laboring down (promotion of passive descent) is an alternative strategy for second-stage management in women with epidurals fetus descends and is born without coached maternal pushing Third Stage begins with the birth of the newborn and ends with the separation and birth of the placenta ideal placement for the newborn immediately following the birth is on the mother’s abdomen, in skin-toskin contact which promotes a positive transition from intrauterine to extrauterine life consists of 2 phases: ○ placental separation After the infant is born, the uterus continues to contract strongly and can now retract, decreasing markedly in size contractions cause the placenta to pull away from the uterine wall ○ The following signs of separation indicate that the placenta is ready to deliver The uterus rises upward. The umbilical cord lengthens. A sudden trickle of blood is released from the vaginal opening. The uterus changes its shape to globular Spontaneous birth of the placenta occurs in 1 of 2 ways: the fetal side (shiny gray side) presenting first (called Schultz's mechanism or more commonly called “shiny Schultz”) maternal side (red raw side) presenting first (termed Duncan mechanism or “dirty Duncan”). ○ placental expulsion After separation of the placenta from the uterine wall, continued uterine contractions cause the placenta to be expelled within 2-30 minutes unless there is gentle external traction to assist After the placenta is expelled, the uterus is massaged briefly by the attending physician or midwife until it is firm so that uterine blood vessels constrict, minimizing the possibility of hemorrhage Normal blood loss is approximately 500 mL for a vaginal birth and up to 1,000 mL for a cesarean birth loss of over 1,000 mL is considered severe If the placenta does not spontaneously deliver, the health care provider assists with its removal by manual extraction On expulsion, the placenta is inspected for its intactness by the health care provider and the nurse to make sure all sections are present If any piece is still attached to the uterine wall, it places the woman at risk for postpartum hemorrhage because it becomes a space-occupying object that interferes with the ability of the uterus to contract fully and effectively Worldwide, approximately 800 women die each day from preventable causes related to childbirth ○ single most common cause is severe bleeding, which can kill a woman within hours if care is delayed Postpartum hemorrhage occurs mostly during the third stage of labor, and active management of it can prevent its occurrence Active management includes: 13 Downloaded by Tierra Earl ([email protected]) lOMoARcPSD|23524095 ○ administration of a uterotonic agent after the birth ○ expulsion of the placenta with controlled traction of the cord ○ uterine fundal message after placental expulsion Prompt and effective management is paramount to saving the lives of these women, and prevention measures can be initiated in the third stage of labor Fourth Stage begins with completion of the expulsion of the placenta and membranes and ends with the initial physiologic adjustment and stabilization of the mother (1-4 hours after birth) initiates the postpartum period mother usually feels a sense of peace and excitement, is wide awake, and is initially talkative attachment process begins with her inspecting her newborn and desiring to cuddle and breastfeed them mother’s fundus should be firm and well contracted ○ Typically it is located at the midline between the umbilicus and the symphysis, but it then slowly rises to the level of the umbilicus during the first hour after birth ○ If the uterus becomes boggy, it is massaged to keep it firm lochia (vaginal discharge) is red, mixed with small clots, and of moderate flow ○ If the woman has had an episiotomy during the second stage of labor, it should be intact with the edges approximated and clean and no redness or edema present. focus during this stage is to monitor the mother closely to prevent hemorrhage, bladder distention, and venous thrombosis Usually the mother is thirsty and hungry during this time and may request food and drink Her bladder is hypotonic, and she has limited sensation to acknowledge a full bladder or to void Vital signs, the amount and consistency of the lochia, and the uterine fundus are usually monitored every 15 minutes for at least 1 hour women will be feeling cramp-like discomfort during this time due to the contracting uterus 14 Downloaded by Tierra Earl ([email protected]) lOMoARcPSD|23524095 Vaginal examination NSG222.03.02.01 purpose is to assess the amount of cervical dilation, percentage of cervical effacement, and fetal membrane status and to gather information on presentation, position, station, degree of fetal head flexion, and presence of fetal skull swelling or molding Prepare the woman by informing her about the procedure, what information will be obtained from it, how she can assist with the procedure, how it will be performed, and who will be performing it woman is typically on her back is performed gently with concern for the woman’s comfort ○ If it is the initial vaginal examination to check for membrane status, water is used as a lubricant. After donning sterile gloves, examiner inserts their index and middle fingers into the vaginal introitus Next, the cervix is palpated to assess dilation, effacement, and position (posterior or anterior) ○ If the cervix is open to any degree, presenting fetal part, fetal position, station, and presence of molding can be assessed ○ membranes can be evaluated and described as intact, bulging, or ruptured. conclusion of the vaginal examination, findings are discussed with the woman and her partner to bring them up to date about labor progress ○ findings are documented either electronically or in writing and reported to the primary health care provider in charge of the woman’s care Cervical Dilation and Effacement ○ first stage of labor, the cervix opens and thins to allow descent of the fetus into the birth canal ○ amount of cervical dilation (opening) and the degree of cervical effacement (thinning) are key areas assessed during the vaginal examination as the cervix is palpated with the gloved index finger finding is somewhat subjective, experienced examiners typically come up with similar findings ○ The width of the cervical opening determines dilation, and the length of the cervix assesses effacement Effacement and dilation are used to assess cervical changes as follows Effacement: 15 Downloaded by Tierra Earl ([email protected]) lOMoARcPSD|23524095 ○ 0%: cervical canal is 2 cm long ○ 50%: cervical canal is 1 cm long ○ 100%: cervical canal is obliterated Dilation: ○ 0 cm: external cervical os is closed ○ 5 cm: external cervical os is halfway dilated ○ 10 cm: external os is fully dilated and ready for birth passage ○ information yielded by this examination serves as a basis for determining which stage of labor the woman is in and what her ongoing care should be Fetal Descent and Presenting Part ○ vaginal examination or ultrasound can determine fetal descent (station) and presenting part ○ gloved index finger is used to palpate the fetal skull (if vertex presentation) through the opened cervix or the buttocks in the case of a breech presentation ○ Station is assessed in relation to the maternal ischial spines and the presenting fetal part spines are not sharp protrusions but rather blunted prominences at the midpelvis ischial spines serve as landmarks and have been designated as zero station If presenting part is palpated higher than maternal ischial spines, a negative number is assigned if presenting fetal part is felt below maternal ischial spines, a positive number is assigned, denoting how many centimeters below zero station Progressive fetal descent (−5 to +4) is the expected norm during labor moving downward from the negative stations to zero station to the positive stations in a timely manner If progressive fetal descent does not occur, a disproportion between the maternal pelvis and the fetus might exist and needs to be investigated Rupture of Membranes ○ integrity of the membranes can be determined during vaginal examination ○ Typically, if intact, membranes will be felt as a soft bulge that is more prominent during a contraction ○ If the membranes have ruptured, the woman may have reported a sudden gush of fluid may occur as a slow trickle of fluid When membranes rupture, the priority focus should be on assessing fetal heart rate (FHR) first to identify a deceleration, which might indicate cord compression secondary to cord prolapse ○ If the membranes are ruptured when the woman comes to the hospital, the health care provider should ascertain when this occurred ○ Prolonged ruptured membranes increase the risk of infection as a result of ascending vaginal pathologic organisms for both mother and fetus Signs of intrauterine infection to be alert for maternal fever fetal and maternal tachycardia foul odor of vaginal discharge increase in white blood cell count ○ fetal membranes usually rupture during the first stage of labor To confirm if they have ruptured, a sample of fluid is taken from the vagina via a nitrazine yellow dye swab to determine the fluid’s pH Vaginal fluid is acidic, while amniotic fluid is alkaline and turns a nitrazine swab blue 16 Downloaded by Tierra Earl ([email protected]) lOMoARcPSD|23524095 ○ Sometimes, false-positive results can occur, especially in women experiencing a large amount of bloody show because blood is alkaline membranes are most likely intact if the nitrazine swab remains yellow to olive green with pH between 5 and 6 membranes are probably ruptured if the nitrazine swab turns a blue-green to deep blue with pH ranging from 6.5-7.5 Many bedside tests are available to determine a change in vaginal pH or the presence of amniotic components insulin-like growth factor–binding protein 1 (a gene that may predict placental dysfunction, gestational diabetes, and preterm labor) or alpha-fetoprotein (AFP) in the vaginal fluid should be part of an overall clinical assessment and not rely exclusively on one test Performing Leopold maneuvers NSG222.03.02.02 x 2 are a method for determining the presentation, position, and lie of the fetus through the use of 4 specific steps involves inspection and palpation of the maternal abdomen as a screening assessment for malpresentation flat palmar surfaces of the nurse’s hands with the fingers together palpate the uterus ○ longitudinal lie is expected, and the presentation can be cephalic, breech, or shoulder. ○ Each maneuver answers a question: Maneuver 1: What fetal part (head or buttocks) is located in the fundus (top of the uterus)? Maneuver 2: On which maternal side is the fetal back located? (Fetal heart tones are best auscultated through the back of the fetus.) Maneuver 3: What is the presenting part? Maneuver 4: Is the fetal head flexed and engaged in the pelvis? Fetal assessment during labor and birth NSG222.03.02.02 x 2 Analysis of amniotic fluid ○ Amniotic fluid should be clear when the membranes rupture Rupturing of membranes is either spontaneous or artificial by means of an amniotomy amniotomy, a disposable plastic hook (an Amnihook) is used to perforate the amniotic sac Cloudy or foul-smelling amniotic fluid indicates infection Green fluid may indicate that the fetus has passed meconium (first feces, or stool, of the newborn) secondary to transient hypoxia, prolonged pregnancy, cord compression, intrauterine growth restriction (IUGR), maternal hypertension, diabetes, or chorioamnionitis (infection of the placenta and the amniotic fluid) is considered a normal occurrence if the fetus is in a breech presentation If determined that meconium-stained amniotic fluid is due to fetal hypoxia, maternity and pediatric teams work together to prevent meconium aspiration syndrome, which can lead to respiratory distress ○ would necessitate suctioning after the head is born before the infant takes a breath and perhaps direct tracheal suctioning after birth if the Apgar score is low some cases, an amnioinfusion (introduction of warmed, sterile normal saline or Ringer’s lactate solution into the uterus) is used to dilute moderate to heavy meconium released in utero to assist 17 Downloaded by Tierra Earl ([email protected]) lOMoARcPSD|23524095 in preventing meconium aspiration syndrome Analysis of fetal heart rate ○ Monitoring of the fetal heart rate throughout labor and birth is essential to assure fetal well-being to optimize neonatal outcomes ○ is one of the primary evaluation tools used to determine fetal oxygen status indirectly ○ assessment can be done intermittently using a fetoscope (a modified stethoscope attached to a headpiece) or a Doppler (ultrasound) device, or continuously with an electronic fetal monitor applied externally or internally ○ objective of monitoring is to reduce mortality and morbidity by ensuring that all fetal hypoxic insults are identified in time to allow removal or alteration of the reason for them, or to enable a safe birth of the fetus before irreversible asphyxia damage occurs ○ Intermittent FHR Monitoring is a primary method of fetal surveillance in labor practice of using a handheld Doppler or fetoscope for periodic assessment of the FHR handheld Doppler device uses ultrasound waves that bounce off the fetal heart, producing echoes or clicks that reflect the rate of the fetal heart is an acceptable option for low-risk laboring women, but is underutilized in the hospital setting nurse listens for short periods of time at regular intervals Intermittent monitoring allows the woman to be mobile during the first stage of labor is free to move around and change position at will since she is not attached to a stationary electronic fetal monitor does not provide a continuous recording and does not document how the fetus responds to the stress of labor (unless listening is done during the contraction) ○ best way to assess fetal well-being would be to start listening to the FHR at the end of the contraction (not after one) so that late decelerations could be detected pressure of the device during a contraction is uncomfortable and can distract the woman from using her paced-breathing patterns can be used to detect fetal heart rate baseline and rhythm and changes from baseline. ○ Can’t detect variability and types of decelerations, as electronic fetal monitoring (EFM) can ○ During intermittent auscultation to establish a baseline, the FHR is assessed for a full minute after a contraction ○ Next, unless there is a problem, listening for 30 seconds and multiplying the value by 2 is sufficient ○ If the woman experiences a change in condition during labor, auscultation assessments should be more frequent Changes in condition include ruptured membranes or the onset of bleeding ○ more frequent assessments occur after periods of ambulation, a vaginal examination, administration of pain medications, or other clinically important events FHR is heard most clearly at the fetal back cephalic presentation, the FHR is best heard in the lower quadrant of the maternal abdomen breech presentation, it is heard at or above the level of the maternal umbilicus 18 Downloaded by Tierra Earl ([email protected]) lOMoARcPSD|23524095 ○ As labor progresses, FHR location will change accordingly as the fetus descends into the maternal pelvis for the birthing process ○ To ensure that the maternal heart rate is not confused with the FHR, palpate the client’s radial pulse simultaneously while the FHR is being auscultated through the abdomen Image: A. Left occiput anterior (LOA). B. Right occiput anterior (ROA). C. Left occiput posterior (LOP). D. Right occiput posterior (ROP). E. Left sacral anterior (LSA) For low-risk women, the FHR and contraction characteristics should be assessed every 15-30 minutes in active labor every 5-15 minutes while pushing, as well as before and after any digital vaginal examinations, membrane rupture, medication administered, and ambulation to the restroom using a Doppler device to assess FHR a small amount of water-soluble gel is applied to the woman’s abdomen or ultrasound device before auscultation to promote sound wave transmission Usually the FHR is best heard in the woman’s lower abdominal quadrants ○ if the FHR is not found quickly, it may help locate the fetal back by performing Leopold maneuvers intermittent method of FHR assessment allows the client to move during labor, information obtained doesn’t provide a complete picture of the well-being of the fetus from moment to moment leads to the question of what the fetal status is during the times that are not assessed ○ women who are considered at low risk for complications, these periods without assessment is not a problem ○ undiagnosed high-risk woman, it might prove unpromising Continuous Electronic Fetal Monitoring Electronic fetal monitoring (EFM) detects the fetal pulse by sensing and analyzing tissue movements via Doppler ultrasound uses a transducer that is capable of both sending and receiving ultrasound waves waves travel through the ultrasound gel, then body tissues, and are eventually reflected by any tissue fast reflections are analyzed and software in the machine determines the FHR is the recommended method of intrapartum fetal surveillance for high-risk pregnancies continuous cardiotocography (CTG) remains the predominant method of fetal monitoring today Despite the questions about its efficacy and controversy regarding increased rates of surgical births associated with its use is not a substitute for appropriate, professional nursing care and support of women in labor indications for offering women continuous fetal monitoring in labor are documented in the include women receiving oxytocin infusing women who have epidural analgesia when there are a variety of problems related to a compromise in either fetal or maternal health like prolonged rupture of membranes (longer than 24 hours), moderate hypertension (higher than 150/100 mm Hg), confirmed delay in the first 19 Downloaded by Tierra Earl ([email protected]) lOMoARcPSD|23524095 ○ ○ or second stage of labor, and the presence of meconium uses a machine to produce a continuous tracing of the FHR When the monitoring device is in place, a sound is produced with each heartbeat a graphic record of the FHR pattern is produced primary objective of EFM is to provide information about fetal oxygenation and prevent fetal injury that could result from impaired fetal oxygenation during labor purpose of EFM is to detect FHR changes early before they are prolonged and profound ○ Fetal hypoxia is demonstrated in a heart rate pattern change and is by far the most common cause of fetal injury and death that can be prevented with optimal fetal surveillance during labor and early interventions Continuous External Monitoring external or indirect monitoring, 2 ultrasound transducers, each of is attached to a belt, are applied around the woman’s abdomen similar to the handheld Doppler device 1 transducer is called a tocotransducer, a pressure-sensitive device that is applied against the uterine fundus ○ detects changes in uterine pressure and converts the pressure registered into an electronic signal that is recorded on graph paper ○ placed over the uterine fundus in the area of greatest contractility to monitor uterine contractions The other ultrasound transducer records the baseline FHR, long-term variability, accelerations, and decelerations ○ positioned on the maternal abdomen in the midline between the umbilicus and symphysis pubis ○ diaphragm of the ultrasound transducer is moved to either side of the abdomen to obtain a stronger sound and is then attached to the second elastic belt ○ converts the fetal heart movements into beeping sounds and records them on graph paper Good continuous data are provided on the FHR External monitoring can be used while the membranes are still intact and the cervix is not yet dilated and can be used with ruptured membranes and a dilating cervix noninvasive and can detect relative changes in abdominal pressure between uterine resting tone and contractions measures the approximate duration and frequency of contractions, providing a permanent record of FHR can restrict the mother’s movements cannot detect short-term variability Signal disruptions can occur due to maternal obesity, fetal malpresentation, and fetal movement as well as by artifact ○ term artifact is used to describe irregular variations or absence of the FHR on the fetal monitor record that result from mechanical limitations of the monitor or electrical interference ○ gaps in the monitor strip can occur periodically without explanation Continuous Internal Monitoring usually indicated for women or fetuses considered to be at high risk Possible conditions might include 20 Downloaded by Tierra Earl ([email protected]) lOMoARcPSD|23524095 multiple gestation decreased fetal movement abnormal FHR on auscultation IUGR maternal fever Preeclampsia dysfunctional labor preterm birth medical conditions such as diabetes or hypertension involves the placement of a spiral electrode into the fetal presenting part, usually the parietal bone on the head, to assess FHR, and a pressure transducer placed internally within the uterus to record uterine contractions fetal spiral electrode is considered the most accurate method of detecting fetal heart characteristics and patterns as it involves receiving a signal directly from the fetus Specially trained labor and birth nurses are permitted to place the spiral electrode on the fetal head when the membranes rupture to assess the FHR in some health care facilities, but they do not place the intrauterine pressure catheter in the uterus does not have to include both an intrauterine pressure catheter and a scalp electrode fetal scalp electrode can be used to monitor the fetal heartbeat without monitoring the maternal intrauterine pressure. FHR and the duration and interval of uterine contractions are recorded on the graph paper allows evaluation of baseline heart rate and changes in rate and pattern 4 specific criteria must be met for this type of monitoring to be used: Ruptured membranes Cervical dilation of at least 2 cm Presenting fetal part low enough to allow placement of the scalp electrode Skilled practitioner available to insert spiral electrode can accurately detect both short-term (moment-to-moment) changes and variability (fluctuations within the baseline) and FHR dysrhythmias maternal position changes and movement do not interfere with the quality of the tracing Table 14.1 Interpreting Fetal Heart Rate Patterns NSG222.03.02.03 nurse must be able to interpret the various parameters to determine if the FHR pattern is a category I (strongly predictive of normal fetal acid–base status at the time of observation and needs no intervention); a category II (not predictive of abnormal fetal acid–base status but does require evaluation and continued monitoring) or a category III (predictive of abnormal fetal acid–base status at the time of observation and requires prompt evaluation and interventions, such as giving maternal oxygen, changing maternal position, discontinuing labor augmentation medication, and/or treating maternal hypotension) Category 1: Normal ○ Predictive of normal fetal acid-base status and doesn’t require intervention ○ Baseline 110-160 bpm ○ Baseline variability moderate ○ Present or absent accelerations ○ Present or absent early decelerations 21 Downloaded by Tierra Earl ([email protected]) lOMoARcPSD|23524095 ○ No late or variable decelerations ○ Can be monitored with intermittent auscultation during labor Category 2: Indeterminate ○ Not predictive of abnormal fetal acid-base status, but requires evaluation and continued surveillance ○ Fetal tachycardia (over 160) ○ Fetal bradycardia (less than 110) not accompanied by absent baseline variability ○ Absent baseline variability not accompanied by recurrent decelerations ○ Minimal or marked variability ○ Recurrent late decelerations with moderate baseline variability ○ Recurrent variable decelerations accompanied by minimal or moderate baseline variability, overshot, or shoulders ○ Prolonged decelerations over 2 min but less than 10 min Category 3: Abnormal ○ Predictive of abnormal fetus acid-base status and requires intervention ○ Fetal bradycardia (less than 110) ○ Recurrent late decelerations ○ Recurrent variable decelerations (absent or declining) ○ Sinusoidal Pattern (smooth, undulating baseline) Non pharmacologic measures NSG222.03.03.01 are usually simple, safe, and inexpensive to use Many are taught in childbirth classes ○ women should be encouraged to try a variety of methods prior to the real labor Many need to be practiced for best results and coordinated with the partner or coach nurse provides support and encouragement for the woman and her partner Although women can’t consciously direct the labor contractions, they can control how they respond to them, enhancing their feelings of control Continuous Labor Support ○ involves offering a sustained presence to the laboring woman by providing emotional support, comfort measures, advocacy, information and advice, and support for the partner ○ It is a evidence-based strategy associated with reduced cesarean rates ○ strong evidence that having a companion present throughout the childbirth process reduces the need for pain relief measures A woman’s family, a midwife, a nurse, a doula, or anyone else close to the woman can provide this continuous presence ○ A support person can assist the woman with ambulating, repositioning herself, and using breathing techniques can aid with the use of acupressure, massage, music therapy, or therapeutic touch ○ During the natural course of childbirth, a laboring woman’s functional ability is limited secondary to pain, and she often has trouble making decisions A support person can help make them based on their knowledge of the woman’s birth plan and personal wishes ○ Good interpersonal relationships can reduce fear associated with childbirth and subsequently contribute to a satisfactory birth experience ○ has been shown to have beneficial effects on the mother and the newborn primarily due to the reduction in anxiety during the laboring experience ○ human presence is of immeasurable value to make the laboring woman feel secure 22 Downloaded by Tierra Earl ([email protected]) lOMoARcPSD|23524095 Hydrotherapy ○ is the external use of any form of water for health promotion ○ may involve showering or soaking in a regular tub or whirlpool bath ○ When showering is the selected method, the woman stands or sits in a shower chair in a warm shower and allows the water to gently glide over her abdomen and back ○ If a tub or whirlpool is chosen, the woman immerses herself in warm water for relaxation and relief of discomfort ○ is an effective pain management option for many ○ Women who are experiencing a healthy pregnancy can be offered this option ○ potential risks associated with hydrotherapy: hyperthermia hypothermia changes in maternal heart rate fetal tachycardia unplanned underwater birth ○ benefits reducing pain relieving anxiety promoting a sense of control during labor Ambulation and Position Changes ○ Positioning during labor is influenced by cultural factors, obstetric practices, place of childbirth, technology, and the preferences of the mother and health care providers ○ are extremely useful comfort measure ○ women adopted a variety of positions during labor, rarely using the recumbent position until during the first half of the 20th century medical profession has favored recumbent positions during labor ○ there is evidence that walking and upright positions in the first stage of labor reduce the length of labor and do not seem to be associated with increased intervention or negative effects on mothers’ and babies’ well-being upright posture, gravity directs the weight of the fetus and amniotic fluid downward, successively dilating the cervix and the birth canal Uterine contractions have been shown to be better spaced, stronger, and more efficient in dilating the cervix when the mother is in an upright position than when supine ○ Women should be encouraged to use whatever position they find most comfortable in the first stage of labor ○ Changing position frequently (every 30 minutes or so), sitting, walking, kneeling, standing, lying down, getting on hands and knees, and using a birthing ball, helps relieve pain ○ Position changes may help speed labor by adding the benefits of gravity and changing the shape of the pelvis ○ Allowing the woman to obtain a position of comfort frequently facilitates a favorable fetal rotation by altering the alignment of the presenting part with the pelvis As the mother continues to change position based on comfort, the optimal presentation is afforded upright position during the second stage has been associated with a decrease in surgical births and a reduction in labor duration Supine positions should be avoided, since they may interfere with labor progress and can cause compression of the vena cava and decrease blood return to the heart ○ Swaying from side to side, rocking, or other rhythmic movements may be comforting 23 Downloaded by Tierra Earl ([email protected]) lOMoARcPSD|23524095 ○ If labor is progressing slowly, ambulating may speed it up again Upright positions such as walking, kneeling forward, or doing a lunge on the birthing ball give most women a greater sense of control and active movement than just lying down Application of Heat and Cold ○ Superficial applications of heat and/or cold in various forms are popular ○ are easy to use, inexpensive, require no prior practice, and have minimal negative side effects when used properly ○ Heat is typically applied to the woman’s back, lower abdomen, groin, and/or perineum sources include: hot water bottle heated rice-filled sock warm compress (washcloth soaked in warm water and wrung out) electric heating pad warm blanket warm bath or shower ○ heat is used to relieve chills or trembling, decrease joint stiffness, reduce muscle spasm, and increase connective tissue extensibility ○ Cold therapy, or cryotherapy, is usually applied on the woman’s back, chest, and/or face during labor Attention Focusing and Imagery ○ Visualization or guided imagery uses many of the senses and the mind to focus on stimuli ○ women can focus on tactile stimuli ex. touch, massage, or stroking ○ may focus on auditory stimuli ex. music, humming, or verbal encouragement ○ Visual stimuli might be any object in the room, or the woman can imagine the beach, a mountaintop, a happy memory, or even the contractions of the uterine muscle pulling the cervix open and the fetus pressing downward to open the cervix ○ Some focus on a particular mental activity ex. song, a chant, counting backward, or a religious verse ○ Breathing, relaxation, positive thinking, and positive visualization work well ○ use of these techniques keeps the sensory input perceived during the contraction from reaching the pain center in the cortex of the brain Effleurage and Massage ○ Effleurage is a light, stroking, superficial touch of the abdomen, in rhythm with breathing during contractions used as a relaxation and distraction technique from discomfort External fetal monitor belts may interfere with the ability to accomplish ○ use the sense of touch to promote relaxation and pain relief ○ Massage works as a form of pain relief by increasing the production of endorphins in the body Endorphins reduce the transmission of signals between nerve cells and lower the perception of pain touch receptors go to the brain faster than pain receptors, massage—anywhere on the body—can block the pain message to the brain light touch has been found to release endorphins and induce a relaxed state touching and massage distract women from discomfort involves manipulation of the body’s soft tissues. commonly used to help relax tense muscles and to soothe and calm the individual may help relieve pain by assisting with relaxation, inhibiting sensory transmission in the pain pathways, or improving blood flow and oxygenation of tissues 24 Downloaded by Tierra Earl ([email protected]) lOMoARcPSD|23524095 Research indicates the duration of labor is shorter and Apgar scores were higher when massage techniques were used during labor to promote maternal relaxation Breathing Techniques ○ Conscious use of breath by the woman has the power to profoundly influence her labor and how she engages with it ○ breath affects the lungs, immediately cueing the nervous system nervous system responds by sending messages, which impact the entire psychophysiologic system Messages sent from the nervous system affect us physically, emotionally, and mentally ○ If we alter how we breathe, we alter the constellation of messages and reactions in our entire mind–body experience ○ are effective in producing relaxation and pain relief through the use of distraction ○ Controlled breathing helps reduce the pain experienced by using stimulus–response conditioning women select a focal point within her environment to stare at during the first sign of a contraction focus creates a visual stimulus that goes directly to her brain takes a deep cleansing breath, which is followed by rhythmic breathing Verbal commands from partner supply an ongoing auditory stimulus to her brain Benefits of practicing patterned breathing include breathing that becomes an automatic response to pain. increases relaxation and can be used to deal with life’s everyday stresses. is calming during labor. provides a sense of well-being and a measure of control. brings purpose to each contraction, making them more productive. provides more oxygen for the mother and fetus ○ Many couples learn patterned-paced breathing during childbirth education classes 3 levels may be taught, each beginning and ending with a cleansing breath or sigh after each contraction first pattern, known as slow-paced breathing, women inhales slowly through her nose and exhales through pursed lips ○ breathing rate is typically 6-9 breaths per minute second pattern, women inhale and exhale through her mouth at a rate of 4 breaths every 5 seconds ○ rate can be accelerated to 2 breaths per second to assist her to relax third pattern is similar to the second pattern except that the breathing is punctuated every few breaths by a forceful exhalation through pursed lips ○ All breaths are kept equal and rhythmic and can increase as contractions increase in intensity ○ Many childbirth educators don’t recommend specific breathing techniques or try to teach parents to breathe the “right” way during labor and birth Women are encouraged to find breathing styles that enhance their relaxation and use them Pharmacologic measures NSG222.03.03.02 Opioids ○ butorphanol (Stadol) 25 Downloaded by Tierra Earl ([email protected]) lOMoARcPSD|23524095 ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ nalbuphine (Nubain) meperidine (Demerol) morphine, or fentanyl (Sublimaze) morphine-like medications that are most effective for the relief of moderate to severe pain typically are administered IV All opioids are lipophilic and cross the placental barrier but do not affect labor progress in the active phase are associated with newborn respiratory depression, decreased alertness, inhibited sucking, and a delay in effective feeding decrease the transmission of pain impulses by binding to receptor site pathways that transmit pain signals to the brain effect is increased tolerance to pain and respiratory depression related to a decrease in sensitivity to carbon dioxide All opioids are considered good analgesics respiratory depression can occur in the mother and fetus depending on the dose given may cause a decrease in FHR variability identified on the fetal monitor strip This FHR pattern change is usually transient systemic side effects include nausea, vomiting, pruritus, delayed gastric emptying, drowsiness, hypoventilation, and newborn depression To reduce the incidence of newborn depression, birth should occur within 1 hour or after 4 hours of administration to prevent the fetus from receiving the peak concentration A recent study reported that parenteral opioids provide some relief from pain in labor but are associated with neonatal respiratory distress Maternal satisfaction with opioid analgesia appeared moderate at best Opioid antagonists such as naloxone (Narcan) are given to reverse the effects of the CNS depression, including respiratory depression, caused by opioids. also used to reverse the side effects of neuraxial opioids, such as pruritus, urinary retention, nausea, and vomiting, without significantly decreasing analgesia Continuing assessment during first stage of labor NSG222.03.03.03 After the admission assessment is complete and the woman and her support person have been oriented to the room, equipment, and procedures, assessment continues for changes that would indicate that labor is progressing as expected Assess the woman’s knowledge, experience, and expectations of labor Typically, blood pressure, pulse, and respirations are assessed every hour during the latent phase of labor unless clinical situation dictates that vital signs be taken more frequently active phase of labor, vital signs are assessed every 30 minutes Temperature is taken every 4 hours throughout the first stage of labor ○ every 2 hours after membranes have ruptured to detect an elevation indicating an ascending infection Vaginal examinations are performed periodically to track labor progress ○ assessment information is shared with the woman to reinforce that she is making progress toward the goal of birth ○ Uterine contractions are monitored for frequency, duration, and intensity every 30-60 minutes during the latent phase every 15 to 30 minutes during active phase ○ Note changes in the character of contractions as labor progresses, and inform the woman of her progress 26 Downloaded by Tierra Earl ([email protected]) lOMoARcPSD|23524095 ○ Continually determine the woman’s level of pain and her ability to cope and use relaxation techniques effectively When the fetal membranes rupture, spontaneously or artificially, assess FHR and check amniotic fluid for color, odor, and amount ○ Assess FHR intermittently or continuously via electronic monitoring ○ During the latent phase of labor, assess the FHR every 30-60 minutes ○ active phase, assess the FHR at least every 15-30 minutes ○ be sure to assess the FHR before ambulation, before any procedure, and before administering analgesia or anesthesia to the mother Nursing interventions-Birth NSG222.03.03.04 The second stage of labor ends with the birth of the newborn maternal position for birth varies from the standard lithotomy position to side-lying to squatting to standing or kneeling depending on the birthing location, woman’s preference, and standard protocols ○ Once the woman is positioned for birth, cleanse the vulva and perineal areas primary health care provider then takes charge after donning protective eyewear, masks, gowns, and gloves and performing hand hygiene Once fetal head has emerged, the primary care provider explores the fetal neck to see if the umbilical cord is wrapped around it ○ If it is, the cord is slipped over the head to facilitate delivery ○ As soon as the head emerges, the health care provider suctions the newborn’s mouth first (newborn is an obligate nose breather) and then the nares with a bulb syringe to prevent aspiration of mucus, amniotic fluid, or meconium umbilical cord is double-clamped and cut between the clamps by the birth attendant or the woman’s partner if desired With the first cries of the newborn, the second stage of labor ends Nursing Management During the Third Stage of Labor, up to continuing assessment NSG222.03.03.05 During the third stage of labor, strong uterine contractions continue at regular intervals under the continuing influence of oxytocin ○ uterine muscle fibers shorten, or retract, with each contraction, leading to a gradual decrease in the size of the uterus, which helps shear the placenta away from its attachment site third stage is complete when the placenta is delivered Nursing care during the third stage of labor primarily focuses on ○ immediate newborn care ○ assessment and observing for signs of placental separation ○ being available to assist with the delivery of the placenta ○ recording the time of expulsion ○ inspecting the placenta for intactness ○ nurse should be assessing the mother by palpating the uterus before and after placental expulsion 3 hormones play important roles in the 3 stage ○ During this stage, women experience peak levels of oxytocin and endorphins, while the high adrenaline levels that occurred during the 2nd stage of labor to aid with pushing begin falling hormone oxytocin causes uterine contractions and helps the woman enact instinctive mothering behaviors ex. holding the newborn close to her body and cuddling the baby ○ Skin-to-skin contact immediately after birth and the newborn’s first attempt at breastfeeding further augment maternal oxytocin levels, strengthening the uterine contractions that will help 27 Downloaded by Tierra Earl ([email protected]) lOMoARcPSD|23524095 the placenta separate and the uterus contract to prevent hemorrhage ○ Endorphins, the body’s natural opiates, produce an altered state of consciousness and aid in blocking out pain ○ drop in adrenaline level from the 2nd stage, which had kept the mother and baby alert at first contact, causes most women to shiver and feel cold shortly after giving birth A crucial role for nurses during the 3rd stage of labor is to protect the natural hormonal process by ensuring unhurried and uninterrupted contact between mother and newborn after birth, providing warmed blankets to prevent shivering, and allowing skin-to-skin contact with initial breastfeeding Uterine involution NSG222.04.01.01 uterus returns to its normal size through a gradual process of involution ○ involves retrogressive changes that return it to its non-pregnant size and condition involves 3 retrogressive processes: ○ Contraction of muscle fibers to reduce those previously stretched during pregnancy ○ Catabolism, which shrinks enlarged, individual myometrial cells ○ Regeneration of uterine epithelium from the lower layer of the decidua after the upper layers have been sloughed off and shed during lochial discharge uterus, which weighs approximately 1,000 g (2.2 lb) soon after birth, undergoes physiologic involution as it returns to its nonpregnant state ○ Approximately 1 week after birth, the uterus shrinks in size by 50% and weighs about 500 g (1 lb) ○ end of 6 weeks, it weighs approximately 60 g (2 oz), about the weight it was before the pregnancy During the first 12 hours postpartum, the fundus of the uterus is located at the level of the umbilicus ○ Over the first few days after birth, the uterus typically descends from the level of the umbilicus at a rate of 1 cm (1 fingerbreadth) per day ○ By 3 days, the fundus lies 2-3 fingerbreadths below the umbilicus (or slightly higher in multiparous women) ○ By the end of 10 days, the fundus usually cannot be palpated because it has descended into the true pelvis If these retrogressive changes don’t occur as a result of retained placental fragments or infection, then subinvolution of the uterus typically results (delayed or absent involution) ○ Subinvolution is generally responsive to early diagnosis and treatment Factors that facilitate uterine involution ○ complete expulsion of amniotic membranes and placenta at birth ○ complication-free labor and birth process ○ Breastfeeding ○ early ambulation Factors that inhibit involution ○ prolonged labor and difficult birth ○ incomplete expulsion of amniotic membranes and placenta ○ uterine infection ○ overdistention of uterine muscles (multiple gestation, hydramnios, or a large singleton fetus) ○ a full bladder (displaces the uterus and interferes with contractions) ○ anesthesia (relaxes uterine muscles) ○ close childbirth spacing (frequent and repeated distention decreases tone and causes muscular relaxation) 28 Downloaded by Tierra Earl ([email protected]) lOMoARcPSD|23524095 Urinary system adaptations NSG222.04.01.02 x 2 Pregnancy and birth can have profound effects on the urinary system During pregnancy, glomerular filtration rate and renal plasma flow increase significantly ○ usually return to normal by 6 weeks after birth There is a gradual return of bladder tone and normal size and function of the bladder, ureters, and renal pelvis, all of which were dilated during pregnancy Many women have difficulty feeling the sensation to void after giving birth if they received an anesthetic block during labor (inhibits neural functioning of the bladder) or if they received oxytocin to induce or augment labor (antidiuretic effect) ○ will be at risk for incomplete emptying, bladder distention, difficulty voiding, and urinary retention urination may be impeded by ○ perineal lacerations. ○ generalized swelling and bruising of the perineum and tissues surrounding the urinary meatus. ○ hematomas. ○ decreased bladder tone as a result of regional anesthesia. ○ diminished sensation of bladder pressure as a result of swelling, poor bladder tone, and numbing effects of regional anesthesia used during labor Difficulty voiding can lead to urinary retention, bladder distention, and urinary tract infection Urinary retention and bladder distention can cause displacement of the uterus from the midline to the right and can inhibit the uterus from contracting properly, which increases the risk of postpartum hemorrhage Urinary retention is a major cause of uterine atony, which allows excessive bleeding ○ Frequent voiding of small amounts (less than 150 mL) suggests urinary retention with overflow, and catheterization may be necessary to empty the bladder to restore tone Postpartum diuresis occurs as a result of 7 mechanisms: ○ the large amounts of intravenous fluids given during labor ○ a decreasing antidiuretic effect of oxytocin as its level declines ○ the buildup and retention of extra fluids during pregnancy ○ decreasing production of aldosterone, the hormone that decreases sodium retention and increases urine production ○ All factors contribute to rapid filling of the bladder within 12 hours of birth ○ Diuresis begins within 12 hours after childbirth and continues throughout the first week postpartum Normal function returns within a month after birth Integumentary system adaptations NSG222.04.01.02 x 2 experiences lasting effects of pregnancy As estrogen and progesterone levels decrease, darkened pigmentation on the abdomen (linea nigra), face (melasma), and nipples gradually fades Some experience hair loss during pregnancy and the postpartum periods Approximately 90% of hairs are growing at any one time, with the other 10% entering a resting phase. ○ high estrogen levels present during pregnancy, an increased number of hairs go into the resting phase, which is part of the normal hair loss cycle ○ most common period for hair loss is within 3 months after birth, when estrogen returns to normal levels and more hairs are allowed to fall out hair loss is temporary, and regrowth generally returns to normal levels in 4-6 months in two thirds of women and by 15 months in the remainder, though hair may be less abundant than before pregnancy 29 Downloaded by Tierra Earl ([email protected]) lOMoARcPSD|23524095 Striae gravidarum (stretch marks) developed during pregnancy on the breasts, abdomen, and hips gradually fade to silvery lines ○ lines do not disappear completely profuse diaphoresis (sweating) that is common during the early postpartum period is one of the most noticeable adaptations ○ Many women will wake up drenched with perspiration during the puerperium ○ postpartum diaphoresis is a mechanism to reduce the amount of fluids retained during pregnancy and restore prepregnant body fluid levels ○ It can be profuse at times ○ common, especially at night during the first week after birth Reassure the client that this is normal and encourage her to change her night clothes to prevent chilling Breastfeeding NSG222.04.01.03 is a dynamic process, which requires coupling between periodic motions of the infant’s jaws, undulation of the tongue, and breast milk ejection reflex ○ All mechanisms must be coordinated to be successful All major health organizations recommend breastfeeding ○ American Academy of Pediatrics (AAP) recommends exclusive breastfeeding for 6 months followed by the introduction of appropriate complementary foods and continued breastfeeding to 1 year and beyond considered to be the standard of care Nurses have an important role in promoting, supporting, and protecting breastfeeding ○ must have the necessary knowledge and skills to provide breastfeeding education to all mothers Proper positioning, latching-on, sucking, and swallowing are the foundation for successful breastfeeding is recommended by international and national organizations, the nurse must respect and support all mothers in either of the infant feeding methods chosen During pregnancy, the breasts increase in size and functional ability in preparation for breastfeeding. ○ Estrogen stimulates growth of the milk collection (ductal) system ○ progesterone stimulates growth of the milk production system ○ Within the first month of gestation, the ducts of the mammary glands grow branches, forming more lobules and alveoli structural changes make the breasts larger, more tender, and heavy Each breast gains nearly 1 lb in weight by term glandular cells fill with secretions, blood vessels increase in number, and the amount of connective tissue and fat cells increase Prolactin from the anterior pituitary gland, secreted in increasing levels throughout pregnancy, triggers the synthesis and secretion of milk after the woman gives birth During pregnancy, prolactin, estrogen, and progesterone cause synthesis and secretion of colostrum, which contains protein and carbohydrate but no milk fat ○ only after birth takes place, when the high levels of estrogen and progesterone are abruptly withdrawn, that prolactin is able to stimulate the glandular cells to secrete milk instead of colostrum takes place within 4-5 days after giving birth Oxytocin acts so that milk can be ejected from the alveoli to the nipple ○ sucking by the newborn will release milk A decrease in the quality of stimulation causes a decrease in prolactin surges and a decrease in milk 30 Downloaded by Tierra Earl ([email protected]) lOMoARcPSD|23524095 production ○ Prolactin levels increase in response to nipple stimulation during feedings ○ Prolactin and oxytocin result in milk production if stimulated by sucking If the stimulus (sucking) is not present, as with a woman who is not breastfeeding, breast engorgement and milk production will subside within days postpartum Skin-to-skin contact during the first hour following birth is the gold standard to initiate breastfeeding if the mother decides this is the method of feeding for her newborn ○ newborn’s instinct is to seek nourishment after birth newborn moves on their mother’s abdomen up to her breast instinctively Researchers term this movement the breast crawl that helps initiate breastfeeding immediately after childbirth occurs when a newborn, left undisturbed and skin-to-skin on the mother’s trunk following birth, moves toward the mother’s breast for the purpose of locating and self-attaching for the first feeding From there, the newborn uses leg and arm movements to propel toward the breast Upon reaching the sternum, the newborn will bounce the head up and down and side to side ○ As the newborn approaches the nipple, the mouth opens and after 7 attempts, latch-on and suckling take place ○ Newborns have senses and skills that enable early initiation of feeding at the breast Nurses can help facilitate the breast crawl as a continuation of the birthing process Nurses have a responsibility to promote the health of their childbearing families and provide evidencebased care ○ Encouraging use of the breast crawl can be the first step in health promotion for every newborn Breast milk production can be summarized as follows: ○ Prolactin levels increase at term with a decrease in estrogen and progesterone levels. ○ Estrogen and progesterone levels decrease after the placenta is delivered. ○ Prolactin is released from the anterior pituitary gland and initiates milk production. ○ Oxytocin is released from the posterior pituitary gland to promote milk let-down. ○ Infant sucking at each feeding provides continuous stimulus for prolactin and oxytocin release Typically, during the first 2 days after birth, the breasts are soft and non-tender ○ may report a tingling sensation in both breasts, which is the “let-down reflex” that occurs immediately before or during breastfeeding ○ After this time, breast changes depend on whether the mother is breastfeeding or taking measures to prevent lactation Engorgement is a postnatal physiologic painful condition in which distention and swelling of the breast tissue occurs as a result of an increase in blood and lymph supply as a precursor to lactation ○ Breast engorgement usually peaks in 3-5 days postpartum and usually subsides within the following 24-36 hours ○ If milk is not removed as it is formed, the alveolar space can become overdistended, causing tender, swollen, and painful breasts ○ can occur from infrequent feeding or ineffective emptying of the breasts and typically lasts about 24 hours ○ Breasts increase in vascularity and swell in response to prolactin 2-4 days after birth ○ If engorged, the breasts will be hard and tender to touch ○ temporarily full, tender, and uncomfortable until the milk supply is ready ○ Frequent emptying of the breasts helps minimize discomfort and resolve engorgement 31 Downloaded by Tierra Earl ([email protected]) lOMoARcPSD|23524095 ○ ○ ○ ○ ○ Standing in a warm shower or applying warm compresses immediately before feedings will help to soften the breasts and nipples in order to allow the newborn to latch on more easily Treatments to reduce the pain include heat or cold applications cabbage leaf compresses breast massage milk expression Ultrasound breast pumping antiinflammatory agents nonprescription antiinflammatory medication can be taken for the breast discomfort and swelling resulting from engorgement Treatment measures will enhance the let-down reflex Between feedings, applying cold compresses to the breasts helps reduce swelling To maintain milk supply, the breasts need to be stimulated by a nursing infant, a breast pump, or manual expression of the milk Mood disorders NSG222.04.01.04 x 2 it is common for women to experience changes in their mood during this time may include being fatigued, irritable, and worried ○ frequently feelings become severe enough to require medical intervention Perinatal mood disorders are one of the most common complications to occur during the postpartum period, impairing maternal caregiving skills postpartum period, mood disorders can be divided into 3 distinct entities in ascending order (least severity to most severity) of severity: ○ “maternal (baby) blues” ○ postpartum depression ○ Psychosis ○ Disorders have not been clearly separated, and it is a matter of much debate whether they are discrete disorders or a single disorder that ranges along a continuum of severity Up to 85% of new mothers suffer from the short-lived postpartum mood disorder commonly called the “baby blues” or “maternal blues,” ○ characterized by mild depressive symptoms, anxiety, irritability, mood swings, loss of appetite, trouble sleeping, tearfulness (often for no discernible reason), increased sensitivity, and fatigue ○ symptoms typically peak on postpartum days 4 and 5, may last hours to days, and usually resolve by day 10 ○ symptoms may be distressing, they do not reflect psychopathology, and they typically do not affect the mother’s ability to function and care for her child Stages of becoming a mother NSG222.04.01.04 x 2 Nurses have recognized the importance of the process of becoming a mother (BAM) to maternal–infant nursing since Rubin’s report on maternal role attainment (MRA) ○ Mothers’ perceptions of their competence and/or confidence in mothering and their expressions of love for their infants are affected by age, relationship with the father or partner, socioeconomic status, birth experience, stress, available support, personality traits, selfconcept, child-rearing attitudes, role strain, health status, preparation during pregnancy, relationships with their own mothers, depression, and anxiety ○ Infant variables identified as influencing MRA/BAM include appearance, responsiveness, 32 Downloaded by Tierra Earl ([email protected]) lOMoARcPSD|23524095 temperament, and health status More current research has led to renaming the 4 stages a woman progresses through in establishing a maternal identity in BAM: ○ Commitment, attachment to the unborn baby, and preparation for delivery and motherhood during pregnancy woman’s work is to make a commitment to the pregnancy and to the safe birth and care of her unborn child associated with a positive adaptation to motherhood. ○ Acquaintance/attachment to the infant, learning to care for the infant, and physical restoration during the first 2 to 6 weeks following birth while the mother is placing the infant in her family context and learning how to care for her infant, her attachment and attitude toward her infant, and her self-confidence and/or sense of competence in mothering consistently indicate an interdependence of these two variables ○ Moving toward a new normal ○ Achievement of a maternal identity through redefining self to incorporate motherhood (around 4 months); the mother feels self-confident and competent in her mothering and expresses love for and pleasure interacting with her infant nursing care provided during the first 2 stages is especially important in assisting mothers as they begin to mother Follow-up is needed as mothers move toward a new normal and recognizing a transformation of themselves can continue to reinforce their capabilities Nursing assessment in the postpartum period NSG222.04.02.01 x 2 Postpartum assessment ○ Many adaptations and adjustments must be made to accommodate the new family member Nurses need to carry out a thorough assessment of maternal discomfort and attempt to implement both preventive and therapeutic measures to reduce any discomfort to improve the mother’s quality of life in one of the most complex phases of her life ○ nurse’s focus is on assistance for families to maximize their adjustment, surveillance for maladaptation, education, consultation, and collaboration as needed ○ Comprehensive nursing assessment begins within an hour after the woman gives birth and continues through discharge ○ Nurses need a firm grasp of normal findings to be able to recognize abnormal findings and intervene appropriately ○ postpartum assessment includes vital signs physical and psychosocial assessments assessing the parents and other family members ex. siblings and grandparents, for attachment and bonding with the newborn ○ exact protocol may vary among facilities, postpartum assessment typically is performed as follows: During the first hour: every 15 minutes During the second hour: every 30 minutes During the first 24 hours: every 4 hours After 24 hours: every 8 hours ○ During each assessment, keep in mind risk factors that may lead to complications ex. infection or hemorrhage, during the recovery period 33 Downloaded by Tierra Earl ([email protected]) lOMoARcPSD|23524095 ○ ○ ○ ○ ○ Early identification is critical to ensure prompt intervention Risk Factors for Postpartum Infection Operative procedure (forceps, cesarean birth, vacuum extraction) History of diabetes, including gestational-onset diabetes Prolonged labor (more than 24 hours) Use of indwelling urinary catheter Anemia (hemoglobin < 10.5 mg/dL) Multiple vaginal examinations during labor Prolonged rupture of membranes (>24 hours) Manual extraction of placenta Compromised immune system (HIV positive) Risk Factors for Postpartum Hemorrhage Precipitous labor (less than 3 hours) Uterine atony Placenta previa or abruptio placenta Labor induction or augmentation Operative procedures (vacuum extraction, forceps, cesarean birth) Retained placental fragments Prolonged third stage of labor (more than 30 minutes) Multiparity, more than 3 births closely spaced Uterine overdistention (large infant, twins, hydramnios) postpartum period is a time of transition for women end of the pregnancy and childbirth initiates physiologic changes as many body systems return to their nonpregnant states Nurses need to be aware of the normal physiologic and psychological changes that take place in clients’ bodies and minds in order to provide comprehensive care during the postpartum period In addition to client and family teaching, one of the most significant responsibilities of the postpartum nurse is to recognize potential complications after childbirth always review the woman’s medical record for information about her pregnancy, labor, and birth Note any preexisting conditions, any complications that occurred during pregnancy, labor, birth, and immediately afterward, and any treatments provided Postpartum assessment of the mother typically includes vital signs pain level epidural site inspection for infection systematic head-to-toe review of body systems acronym BUBBLE-EE—breasts, uterus, bladder, bowels, lochia, episiotomy/perineum/epidural site, extremities, and emotional status—can be used as a guide for this head-to-toe review While assessing the woman and her family during the postpartum period, be alert for danger signs Notify the primary health care provider immediately if any are noted Fever more than 100.4°F (38°C) Foul-smelling lochia or an unexpected change in color or amount Large blood clots, or bleeding that saturates a peripad in an hour Severe headaches or blurred vision 34 Downloaded by Tierra Earl ([email protected]) lOMoARcPSD|23524095 Visual changes, such as blurred vision or spots, or headaches Calf pain with dorsiflexion of the foot Swelling, redness, or discharge at the episiotomy, epidural, or abdominal sites Dysuria, burning, or incomplete emptying of the bladder Shortness of breath or difficulty breathing without exertion Depression or extreme mood swings Vital Signs Assessment Obtain vital signs and compare them with the previous values, noting and reporting any deviations ○ changes can be an early indicator of complications Temperature ○ Use a consistent measurement technique (oral, axillary, or tympanic) to get the most accurate readings ○ Typically, the new mother’s temperature during the first 24 hours postpartum is within the normal range or a low-grade elevation Some experience a slight fever, up to 100.4°F (38°C), during the first 24 hours elevation may be the result of dehydration because of fluid loss during labor. Temperature should be normal after 24 hours with replacement of fluids lost during labor and birth ○ temperature above 100.4°F (38°C) at any time or an abnormal temperature after the first 24 hours may indicate infection and must be reported Abnormal temperature readings warrant continued monitoring until an infection can be ruled out through cultures or blood studies elevated temperature can identify maternal sepsis, which results in significant maternal morbidity and mortality worldwide To improve the outcome, it is essential that nurses be vigilant in obtaining accurate values and monitoring their clients’ temperatures Pulse ○ rates of 60-80 beats per minute (bpm) at rest are normal during the first week after birth pulse rate is called puerperal bradycardia During pregnancy, the heavy gravid uterus causes a decreased flow of venous blood to the heart After birth, there is an increase in intravascular volume ○ cardiac output is most likely caused by an increased stroke volume from the venous return now elevated stroke volume leads to a decreased heart rate Tachycardia in the postpartum woman can suggest anxiety, excitement, fatigue, pain, excessive blood loss or delayed hemorrhage, infection, or underlying cardiac problems Any pulse rate higher than 100 bpm warrants further investigation to rule out complications Respirations ○ rates in the postpartum woman should be within the normal range of 12-20 breaths per minute at rest ○ Pulmonary function typically returns to the prepregnant state after childbirth when the diaphragm descends and the organs revert to their normal positions ○ Any change in respiratory rate out of the normal range might indicate pulmonary edema, atelectasis (a side effect of epidural anesthesia), or pulmonary embolism and must be reported ○ Lungs should be clear on auscultation 35 Downloaded by Tierra Earl ([email protected]) lOMoARcPSD|23524095 Blood Pressure ○ Assess the woman’s blood pressure and compare it with her usual range Report any deviation from this range ○ Immediately after childbirth, the blood pressure should remain the same as during labor An increase in blood pressure could indicate gestational hypertension decrease could indicate shock or orthostatic hypotension or dehydration, a side effect of epidural anesthesia ○ Blood pressure readings shouldn’t be higher than 140/90 mm Hg or lower than 85/60 mm Hg ○ Blood pressure may vary based on the woman’s position, so assess blood pressure with the woman in the same position every time ○ Be alert for orthostatic hypotension, which can occur when the woman moves rapidly from a lying or sitting position to a standing one Pain ○ the 5th vital sign, is assessed along with the other 4 parameters ○ Question the woman about the type of pain and its location and severity ○ Have the woman rate the pain using a numeric scale from 0-10 ○ Nursing care should focus on providing comfort measures to ease pain perineal care clean gown mouth care providing warm blankets ensuring adequate fluid intake to facilitate healing repositioning frequently encouraging rest between assessments ○ Many postpartum orders will have the nurse premedicate the woman routinely for afterbirth pains rather than waiting for her to experience them first goal of pain management is to have the woman’s pain scale rating maintained between 0 and 2 at all times, especially after breastfeeding can be accomplished by assessing the woman’s pain level frequently and preventing pain by administering analgesics If the woman has severe pain in the perineal region despite use of physical comfort measures, check for a hematoma by inspecting and palpating the area ○ If one is found, notify the health care provider immediately Postpartum danger signs ○ While assessing the woman and her family during the postpartum period, be alert for danger signs Notify the primary health care provider immediately if any are noted Fever more than 100.4°F (38°C) Foul-smelling lochia or an unexpected change in color or amount Large blood clots,

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