Labor and Nursing Interventions PDF

Labor and Birth Nursing Interventions Deborah Nelson, MS, PHN, RNC-OB *Adapted from Gonzalez, I., Goyal, D., & McNiesh, S. N126B Slides Objectives Discuss normal labor and birth nursing assessments Identify nursing interventions for each stage of labor Identify nursing interventions to during use of...

Labor and Birth Nursing Interventions Deborah Nelson, MS, PHN, RNC-OB *Adapted from Gonzalez, I., Goyal, D., & McNiesh, S. N126B Slides Objectives Discuss normal labor and birth nursing assessments Identify nursing interventions for each stage of labor Identify nursing interventions to during use of pharmacological agents The Nurse’s Role surrounding birth Pain Intimacy Inexperience Family dynamics Culture of hospital Personal beliefs Cultural Values A woman's culture gives her cues about how she should behave and react to labor and how she should interact with her newborn. Knowledge of the values and practices of cultural groups that the nurse encounters provides a framework to assess and care for the woman and her family. Legal/ Ethical Issues During the Intrapartal Period Informed Consent. Standards of Practice – Monitoring – Intervening – Reporting – Delegation of duties Documentation Initial Assessment What are the most significant questions to ask? What next? Nursing Process-Assessments Maternal Age Intimate Partner Violence Prenatal Care Gestational Age: Term 38 - 42 weeks gestation Fetal Heart Rate (FHR) & Fetal Movement Uterine Contractions Status of Membranes Baseline Data Review Prenatal Record – EDC/EDD – GP – BP – GTT/AIC – Blood Type, RH – Antibody Screen – HBsAG, HIV, TB, AFP Admission Labs – Blood: CBC – Urinalysis: Protein, Glucose, Ketones Assessment of Onset of Labor True Labor Contractions – Regular with increasing intensity and frequency – Enhanced by Walking Cervix – Progressive effacement and dilation Fetus – Movement to an anterior position False Labor Contractions – Irregular or temporary regularity – Usually resolve with walking/ position change Cervix – Soft, high, posterior, no progressive change Fetus – Engagement variable Brief Systems Assessment Maternal Vital signs Neuro: (LOC, affect, pain, headache, visual disturbances, reflexes) Cardiac (rate, rhythm, edema). Respiratory (rate, effort, breath sounds) GI ( Acute abdominal pain) Vaginal discharge (amniotic fluid, meconium, bleeding) Cervical Exam (deferred in some situations) Intrapartum Nursing Assessment Evaluating Labor progress Leopold’s Maneuvers –Position of fetus –Number of fetuses –Fetal Lie Bladder palpation –Check for bladder distention Leopold’s Maneuver Nursing Interventions Orient to environment Informed Consent Hydration Reassurance and information Encourage bladder emptying Assess for pain & implement comfort measures Position on L side to avoid supine hypotension Prepare emergency equipment Monitor for Maternal/ Fetal well-being Electronic Fetal Monitoring Assessment of Rupture of Membranes First: assess FHT’s Odor – Free from foul odor – Clear, straw colored Nitrazine paper/AmniSure test – Turns blue with amniotic fluid – pH 6.5 – 7.5 Fern test – Fern-like pattern under microscope Cervical Dilatation/Dilation Elsevier items and derived items © 2013, 2009, 2005 by Saunders, an imprint of Elsevier Inc. 17 Normal Childbirth – “5 P’s” Powers Passage Passenger Position Psyche Primary Forces of Labor Contractions Phases of Contractions – Increment – Acme – Decrement Assess for Characteristics of Contractions – Frequency – Duration – Intensity Contractions Passageway Mother’s pelvis shape Passenger – Fetal Presentation Fetal Position Anterior Fontanel Posterior Fontanel Fetal Position - Anterior Direct Occiput Anterior(OA) Left Occiput Anterior (LOA) Right Occiput Anterior (ROA) Fetal Position - Transverse Left Occiput Transverse - LOT Right Occiput Transverse - ROT Fetal Position - Posterior Direct Occiput Posterior (OP) Right Occiput Posterior (ROP) Left Occiput Posterior (LOP) Psyche The state of the mother’s psyche is a crucial aspect of childbirth. Marked anxiety, fear, or fatigue decreases a woman's ability to cope with labor pain. Maternal catecholamines are secreted in response to anxiety or fear. – They inhibit uterine contractility and placental blood flow. Relaxation augments the natural process of labor. Psyche Understand the role of psychological stress Management of Contractions Pain Management Support Educate STAGES OF LABOR Stage 2—100% effaced; 10 cm dilated to delivery of newborn Stage 1—0 - 100% effaced; 0 - 10 cm dilated Early (latent) phase 0-3-4cm Dilated Active phase ~ 4 cm – 7-8 cm Dilated Transition 7-8 cm-to complete (10 cm) Active Pushing Stage 3 Delivery of Placenta Stage 4 1-4 hours after Birth Stage I—Early or Latent Phase: Cervix: up to 3 cm dilation Duration: – Primipara: 8 – 12 hours – Multipara: 2 – 8 hours Prodromal labor = maternal exhaustion Contractions – – – – Irregular Strength: mild to moderate Frequency: 5 - 30 mins Duration: 30 - 40 secs Bloody Show: Scant, brownish or pale pink Affect: Anxiety, excitement common (or calm) Alert and Oriented Stage I--Active Phase Cervix: 4 - 7 cm dilation Failure to Progress = C/S delivery Contractions – More regular – Strength--moderate to strong – Frequency: 2 - 5 mins. – Duration: 40 - 60 secs Bloody Show: Scant to moderate, pink to bloody Affect: More serious, increased apprehension. Stage I -- Transition Phase Cervix: 8 - 10 cm dilation Duration: 20 - 40 mins Contractions – Strength--strong – Frequency: Every 1.5-2 mins – Duration: 45 - 90 secs Bloody Show: Copious, bloody Affect: c/o severe pain, backache, maternal frustration (exhaustion), irritable, amnesia between contractions Nursing Care During the Stages of Labor Management of Pain in the Intrapartum Period Non-pharmacologic management of pain Childbirth preparation methods Endorphins: Endogenous opiates secreted naturally by the pituitary gland in response to Intrapartum pain. Non-Pharmacological Pain Management Relaxation techniques Movement! Position changes Breathing techniques Effleurage Sacral counter pressure Hydrotherapy Massage Providing Comfort Measures Promotes the woman's ability to relax and cope with labor – Lighting and temperature – Cleanliness and mouth care – Bladder – Positioning – Providing encouragement – Pharmacologic pain relief 37 Labor--Pain ManagementAnesthesia Treatment of moderate to severe pain – When prolonged effect is desired – When analgesia is ineffective Risk of: – Systemic absorption – Maternal hypotension – Temporary or protracted loss of desired motor/sensory control – Spinal headache Emergency Interventions O2 (100%) at 8 - 10 L/ min. by mask IV Access/ Increase IV rate Maternal position change Stop Medications Get assistance Report to primary provider & immediate supervisor Anesthesia Types – Local – Sedation – Regional – Epidural – Spinal – General Local & Sedation Local – Infiltration anesthesia – Lidocaine injected into soft tissues of perineum for repair Sedation – Narcotics or tranquilizers – Administered as an injection or IV – Help reduce the pain of labor, will not eliminate pain entirely – Can also be used to lessen anxiety Regional Anesthesia Pudendal block – For 2nd stage perineal pain and perineal repair Labor-- Pharmacologic Pain Management Sedation Treatment of maternal exhaustion in absence of active labor – Barbituates – Narcotics: Morphine Sulfate – Risk of neonatal narcosis Analgesia Treatment of moderate to severe recurring pain – Narcotic Analgesics: CNS depression (i.e. Demerol, Fentanyl) – Risk of neonatal narcosis or labor suppression Epidural Anesthesia Major benefits – Patient can remain awake, alert, and almost totally pain-free – Can actively participate in the birth – Very effective at relieving labor pain Drawbacks – Take up to 20 minutes to administer and take effect – Must stay in bed – Can slow labor if given too soon – Can cause BP to drop Epidurals & Spinal Anesthesia Epidurals or spinals cannot be used if the patient – Uses blood thinners or has a bleeding tendency. – Is hemorrhaging or in shock. – Has an infection in the back or the blood. – Has an unusual anatomic condition or spinal abnormality General Anesthesia Light general anesthesia for Cesarean birth – Combination of thiopental, nitrous oxide, and succinylcholine Requires intubation Risk of neonatal suppression Used when regional anesthesia not possible Stage2 Pushing 10 cm dilation to delivery of neonate Descent – Movement of fetal presenting part through the maternal pelvis varies greatly Average Duration: Nullipara: 30 min - 3 hours Multipara: 5 - 30 minutes p41 Impending Birth The nurse must be alert for signs of impending births. – "The baby's coming" – Grunting sounds – Bearing down – Check the perineum Crowning 2nd Stage--Gentle pushing with each contraction, Vertex/anterior ü FHTs with doppler + Coaching to push & maintain control Fetus-external extension--variable decels and some tachycardia Responsibilities During Birth Preparation of the sterile table Perineal cleansing preparation Initial care and assessment of the newborn, including calling neonatal staff if indicated Administration of medication such as oxytocin to contract the uterus and control blood loss Delivery of head 2nd Stage Controlled delivery of head No episiotomy vertex anterior presentation + coaching--panting --don’t push fetus--final external extension and delivery Head Delivery Wipe secretions from mouth and nose. Suction mouth first then nose with bulb syringe or suction catheter if needed. + Coaching, gentle pushing Check for nuchal cord Delivery of Shoulders… Exterior rotation (shoulder rotation) Delivery of anterior shoulder, then posterior, then body. Expulsion of fetus End of Stage 2 Stage 3 Delivery of neonate to delivery of placenta Retained Placenta: defined as > 20 mins. Perineal Repair – Degree of Perineal interruption – Episiotomy Midline Mediolateral Perineal Laceration – Other Lacerations: Vaginal, Peri-urethral, Cervical Stage 4 Birth 1-2 hours Past Birth Immediate Post-birth Danger Signs—Report to CNM or Physician Immediately! Hypotension (> baseline) Tachycardia (mild is normal) Uterine Atony Excessive Bleeding (normals?) Hematoma During Stage 4 Check for ↓ BP, ↑Pulse, Boggy uterus Uterus = slightly above umbilicus, firm and midline! Teach self-massage to mom Lochia is rubra--? > 1 pad/15 min saturated? Begin newborn teaching—skin to skin positioning “golden hour”, breastfeeding, safety information, bulb suction, etc. References: American Academy of Pediatrics & The American College of Obstetrics and Gynecologist. (2017). Guidelines for Perinatal Care (eighth Edition). Washington D.C. Ward, S. & Hisley, S. (2016). Maternal child nursing care: Optimizing outcomes for mothers, children, and families. Philadelphia, PA: F.A.Davis