NCM 107 Care of Mother, Child, Adolescent (Well-Client) PDF

NCM 107: Care of Mother, Child, Adolescent (Well-Client) DEFINITION OF TERMS 3. Duration 1. Labor - Length of a uterine contraction - A series of events by which uterine contraction...

NCM 107: Care of Mother, Child, Adolescent (Well-Client) DEFINITION OF TERMS 3. Duration 1. Labor - Length of a uterine contraction - A series of events by which uterine contraction - How long a contraction lasts and abdominal pressure expel a fetus and 4. Intensity placenta from the uterus - Begins within 37–42 weeks - Strength of a uterine contraction ➔ Considered the term age of pregnancy 5. Frequency - Primipara: 14–16 hours - Multipara: 6–8 hours - Measured from the beginning of one contraction to the beginning of the next However, this could be longer. Recently, research - As labor increases, the frequency also increases suggests that this could be longer. 6. Increment 2. Episiotomy - Building-up phase of the contraction - A surgical incision made at the opening of the vagina during childbirth to aid a difficult delivery 7. Acrement and prevent rupture of tissues - 2 kinds of Episiotomy: - Peak of the contraction A. Midline – lesser chance of bleeding, less 8. Decrement painful B. Mediolateral – less risk of greater - Letting down phase of the contraction laceration Interval - Allows the accommodation of the fetal head - In the perineum, as the mother is delivering her - Space between two contractions child, if the doctor sees that the fetal head The Augmentation of Labor and Induction of Labor needs some assistance in being delivered, the procedures help initiate or at least strengthen labor. doctor or obstetrician may opt to make a small cut at the perineal area 9. Augmentation of Labor - In order to facilitate the delivery of the fetus and at the same time prevent further injury - Assisting labor that has spontaneously started - One of the duties of a student nurse is to but is not effective or strong enough support the perineum using the hands and a - As the mother approaches true labor, there towel so that as the mother delivers the child, may be times wherein her labor contractions the perineal incision or the episiotomy won’t are not strong enough or not effective enough tear all the way down. and that could cause her to be prolonged in a ➔ Support the perineal area in order to certain stage prevent that from further lacerating - In order to enhance that labor, the obstetrician - Each kind of episiotomy have their pros and can administer oxytocin through IV fluids cons but in the end, it will be the obstetrician - Other way to augment the labor is through who will decide which one is the more amniotomy appropriate incision for the mother. ➔ Artificial rupture of membranes during labor ➔ The mother would experience bursting of the bag of waters. Sometimes, it doesn’t happen spontaneously during labor so the MODULE 3F: INTRA-NATAL CARE YUSON, DREA NCM 107: Care of Mother, Child, Adolescent (Well-Client) doctor can actually induce that using ➔ In that case if that is the reason why she forceps in order to rupture the bag of requires CS, there is a chance that in her waters so that labor can be triggered following delivery, she would still need to undergo CS 10. Induction of Labor ➔ But there are also some mothers whose - Applicable when the mother is already of term reason may not be the shape of the pelvis age. Around 37-40 weeks of gestation but has but other reasons and maybe this mother not yet initiated labor yet. The mother has not would want to try vaginal birth instead. So, felt any contractions. instead of going to vaginal birth directly, the - Labor started artificially mother would still have to undergo through - It can be inducted through oxytocin or trial of labor wherein the obstetrician will amniotomy as well. But amniotomy is the most observe and assess if the mother is ready common. for a normal spontaneous vaginal delivery. - Labor that is started by the obstetrician rather than the mother’s body itself THEORIES OF LABOR Progesterone levels will decrease slightly during the 11. Dysfunctional Labor later weeks of pregnancy especially as the mother approaches labor and delivery. - Prolonged labor due to the sluggishness of contractions - This is actually due to various factors and one of - Indication of augmentation of labor the theorized factors is actually due to the increase of estrogen and also the increase in 12. Eutocia prostaglandins. - Normal labor How Does Labor Start? 13. Dystocia LABOR - Difficult labor - Series of events by which uterine contractions 14. Amniotomy and abdominal pressure expel a fetus and placenta from uterus - Artificial rupture of membranes during labor - Normally begins between 37 and 42 weeks of 15. Trial of Labor pregnancy Many factors known to be responsible for the initiation - Full acronym is TOLAC (Trial of Labor after of spontaneous labor: Cesarean Delivery) - An attempt labor to determine whether labor 1. Uterine muscle stretching resulting in release of will progress normally especially for women prostaglandins who have experienced cesarean section As the fetus continues to grow, it also - For women post-cesarean section continues to expand the uterus - Ideally, if the mother has experienced cesarean One of the theories in labor that is the section in her previous delivery, she would uterus expands to a certain size, the body ideally still be in cesarean section in the recognizes it as the fetus being ready to be following delivery delivered therefore resulting in the release - The mother would need to undergo cesarean of prostaglandins in the uterine area delivery due to various reasons and one of that is the shape of her pelvis is not wide enough or not conducive enough for labor and delivery MODULE 3F: INTRA-NATAL CARE YUSON, DREA NCM 107: Care of Mother, Child, Adolescent (Well-Client) 2. Cervical pressure 5. Rising Fetal Cortisol Levels Fetus pressing on the cervix stimulates the Reduction of progesterone and increase in release of oxytocin from the posterior prostaglandins pituitary gland In the fetal area or the fetal side of the As the fetus becomes bigger, the fetal head pregnancy, the fetus will experience presses into the cervix so the fetus pressing secretion of rising fetal cortisol levels the cervix can stimulate the release of The fetal cortisol levels can stimulate the oxytocin from the posterior pituitary gland increase of prostaglandins in the mother Oxytocin is also known as labor hormone which will also inhibit or reduce progesterone Oxytocin stimulation + Prostaglandins 6. Fetal Membrane prostaglandin production - Oxytocin stimulation works together with The fetal membrane also continues to prostaglandins to initiate contractions secrete prostaglandins leading to labor and - Together, they are very much observed during delivery the initiation of true labor or labor itself 3. Estrogen – Progesterone Ratio PREPARATION FOR LABOR Progesterone withdrawal: Increasing - Where we observe the signs and symptoms of a estrogen in relation to progesterone can mother who is about to go through labor and trigger or initiate labor delivery Throughout pregnancy, we have there a Preliminary Signs of Labor stable ratio or sustained level of estrogen and progesterone, particularly - Subtle signs or symptoms progesterone. It’s actually the high levels of - Days or hours before labor begins. progesterone that prevents the initiation of - NOTE: These signs don’t occur on the same day uterine contractions. during delivery. They could occur as early as Near the end of the pregnancy, what days away from the labor happens is progesterone, the pregnancy - It is important that you, especially when you are hormone, decreases. In this case, there is an conducting your health teaching, it’s important increasing level of estrogen and that these to inform the mother of these signs, especially two have an inverse relationship. the first-time mother so that they will not panic As the estrogen increases, especially due to and instead, they will have a better experience the secretion of prostaglandins, in preparing themselves for the upcoming labor progesterone will reduce or decrease. Or and delivery rather the prostaglandins will overpower 1. Lightening the effects of progesterone, therefore leading to labor and delivery. - Sinking of fetal head into the true pelvis 4. Placental Degeneration - Changes in abdominal contours (“Decreasing” Placenta is thought to have a set age fundal height) So, if the placenta reaches around 37 to 40 - Causes relief from diaphragmatic pressure weeks of age, the placenta starts to ➔ Encourage deep breathing exercises for the degenerate because it has reached the peak mother in preparation for the labor and of maturity and therefore could lead to delivery labor and delivery - There’s a chance if you take your Leopold’s maneuver again, you might notice a decrease in the fundal height. So, do not panic if you observe that. MODULE 3F: INTRA-NATAL CARE YUSON, DREA NCM 107: Care of Mother, Child, Adolescent (Well-Client) ➔ That just means that the baby is sinking into 3. Excess energy the true pelvis or descended - Burst of adrenaline to provide energy for labor ➔ Because of this, there is lesser pressure in - The mother’s body actually recognizes that the the lungs and also in the abdominal area mother’s about to go and give birth. So, the - At the same time, the relief from the body also prepares by supplementing the diaphragmatic pressure and also from the mother with a burst of adrenaline especially abdomen, this may cause feelings of nausea. So, during delivery to provide energy for labor be mindful of that. At least you could explain it to the mother 4. Backache Primiparas: Approximately 10-14 days before labor - One of the most common complaints of mothers who are experiencing labor and Multiparas: On the day of labor/after the beginning delivery of true labor - Onset of true labor contractions - Intermittent, stronger than usual backache - Labor contractions begin in the back - Why backache? ➔ There’s the pressure because of the weight distribution and also more significantly is the location of your uterus ➔ In anatomy and physiology, the location of your uterus is retroperitoneal. So, the pain is actually strongest at the back and then it 2. Slight weight loss sweeps throughout the abdomen. - When a nurse or a student nurse is assigned to - 1-3 lbs. perform labor watch, what you can do is to ➔ Due to the decreasing levels of provide back rubs. progesterone which leads to increased fluid ➔ Not too deep pressure just back rubs in excretion, one of the effects of decreasing order to relieve the pressure and also progesterone, which then leads to provide for relief from pain increased urine production - Not the loss of fat but rather the loss of fluid 5. Cervical Ripening - Progesterone level decreases - Cervix feels very soft upon palpation during - Increased fluid excretion internal examination - Increased urine production ➔ In internal examination, what happens is the obstetrician will be inserting 2 of her fingers into the birth canal to both assess the cervical dilation and also the effacement ➔ The mother will be placed in a lithotomy position - “Butter soft” (usual assessment finding) - Goodell’s sign – earlobe consistency of cervix throughout pregnancy - Marks the beginning of true labor - Refers to the steady thinning of the cervix MODULE 3F: INTRA-NATAL CARE YUSON, DREA NCM 107: Care of Mother, Child, Adolescent (Well-Client) waters has already been ruptured, amniotic fluid still continues to be produced until delivery. ➔ At least there’s still some fluid that is buffering the baby and also ensuring that the baby will be delivered properly 6. Rupture of Membranes - Sudden gush or scanty, slow seeping of clear fluid from the vagina - Early rupture of membranes helps fetal head descent and engagement (engaged into the true pelvis) ➔ Therefore, the rupture of the bag of waters could lead to enhanced cervical dilation and labor progression - Amniotic fluid continues to be produced until 7. Show delivery of the membranes after the birth of the - Internal cervical mucus plug has been released child - “Bloody Show” – blood from cervical capillaries - Risks to need to watch out for mixed with mucus plug ➔ Intrauterine Infection – labor does not - As the mother approaches true labor, her cervix before spontaneously by 24h will get rid of the mucus plug. ◼ You need to observe for maternal or - The picture is what she may find in her pads. intrauterine infection Sometimes it may be bloody ➔ Umbilical Cord prolapse - Assure the mother that this is a normal finding ◼ What happens is the umbilical cord of because as the cervical mucus plug detaches the baby may be pushed downwards from the cervix, some of the capillaries of the and instead of the presenting head, that cervix will also rupture and will induce a slight is really directly presenting into the bleeding. The blood from these capillaries may cervix, you might find there an umbilical be mixed with the mucus plug. Therefore, cord. leading to a bloody show. ◼ This is very dangerous for the baby. ◼ You need to watch out for this as well. - Amniotic fluid is colloquially known as bag of water. - In movies, the pregnant mothers would say, “my water broke” ➔ This is actually the rupture of the bag of water - Maybe, you may encounter some mothers who may be concerned especially if they early rupture of membranes. They may be concerned if the delivery is “dry”. 8. Uterine Contractions ➔ One health teaching to give them is that it’s not possible because even if the bag of - Braxton Hicks MODULE 3F: INTRA-NATAL CARE YUSON, DREA NCM 107: Care of Mother, Child, Adolescent (Well-Client) ➔ Known as the trial contractions ➔ Because knowing this will help us create the ➔ Can start Last week or days before labor nursing care plan of a mother who is begins undergoing labor and delivery ➔ May be extremely strong for the mother ➔ It is really important not to just focus on the (but the frequency varies or there is no physiologic aspects but also focus on the change in strength) psyche of the mother, assist her as she experiences her uterine contractions, etc… ➔ Localized mostly in the abdomen ➔ All of these components has to be good in ◼ It does not radiate from the back or order to ensure both the survival of the towards the legs mother and the baby ➔ Triggered due to decreasing progesterone PASSAGE levels ➔ Primigravid mothers may not be able to - Mother’s pelvis distinguish between Braxton Hicks and true - Route a fetus must travel from the uterus contractions through the cervix ◼ Assure them and also give them - Fetopelvic disproportion – commonly caused adequate health teaching by the insufficient pelvic structure ➔ You know that this is not yet true labor ➔ One problem involving this factor because the contractions is relieved by rest, ➔ In some examinations, the fetal head may activity, or repositioning be a bit too big for the pelvis - True Labor ➔ If that’s the case, it is really not the fetal ➔ Begin at the back and sweeps forward head that is too big but rather the uterus is across abdomen and possibly legs not really conducive for labor and delivery ➔ Gradually increases in frequency and - Shape of Pelvis intensity Gynecoid (maternal pelvis) ➔ Painful, wavelike, building and receding Android ➔ Not relieved by rest Anthropoid ◼ It constantly increases Platypelloid ➔ Uterus becomes hard on palpation, indentation with fingers is not possible PASSENGER ◼ When you try to palpate the fundus, it - Refers to the fetus and its ability to move is hard and indentation cannot be done through the passage 3 Main Signs: - Affected by the following fetal features Fetal skull - Rupture of membranes Fetal Presentation (Cephalic) - Show or the bloody show Fetal Lie (Longitudinal) - Uterine contractions Fetal Attitude COMPONENTS OF THE BIRTHING PROCESS Fetal Position Successful labor depends on the 4 concepts or Fetal Station components: passage, passenger, powers, and psyche POWER or POWERS - A problem in one of these can significantly - Uterine contractions impact the progression of labor - Phases - Why do we need to review this again and again? Increment – building up phase (longest) Acrement or Acme – peak of contraction MODULE 3F: INTRA-NATAL CARE YUSON, DREA NCM 107: Care of Mother, Child, Adolescent (Well-Client) Decrement – letting down phase ◼ Can also contribute to the knowledge of - Characteristics the mother Duration Past experiences ◼ Beginning of increment to end of Accomplishment of pregnancy tasks decrement Feeling of control over situation ◼ Early labor: 30 seconds ◼ Late labor: 60-90 seconds Frequency STAGES OF LABOR ◼ Beginning of one contraction to the FIRST STAGE OF LABOR beginning of the next - From onset of true labor contractions until full ◼ Early labor: 5-30 mins apart cervical dilation ◼ Late labor: 2-3 mins apart or even lesser - Average – 12 hours Intensity Primipara: 6-18 hours ◼ Measured through palpation itself or Multipara: 2-10 hours through insertion of intrauterine - Recent research suggests that normal labor can catheter take longer Three Phases: 1. Latent Phase - Begins at onset of regularly perceived uterine contractions - Ends when rapid cervical dilatation begins - Cervical dilation: 0-3 cm - Mild and short contractions 20-40 seconds PSYCHE May be irregular Longer for women with “nonripe” cervix - Maternal psychological state - Primipara: around 6 hours - Feelings that the mother brings to the labor - Multipara: 4 ½ hours - Apprehension, fear, wonder, excitement Nursing Care: - Factors affecting psychological readiness Pain Management Presences of support system ❖ Analgesia may be given but if given too early, it ◼ Very crucial according to studies. may prolong the stage ◼ The mother is able to undergo effective ❖ Assist mother to prepare psychologically delivery with the presence of her ❖ Teach controlled and deep breathing exercises partner or support system ❖ Encourage activity, ambulation, and other non – ◼ In the local setting, our institutions pharmacotherapeutic measures don’t allow the partner to be physically ❖ Offer clear liquids or ice chips Involve partner, there for the mother. So, in lieu of the family, or support person ❖ Provide calm environment partner, we, nurses, get to be their Psychological Maternal Responses support system - Anticipation ◼ We need to keep the family and the - Excitement partner updated - Apprehension Degree of preparation from the mother’s side Childbirth education classes MODULE 3F: INTRA-NATAL CARE YUSON, DREA NCM 107: Care of Mother, Child, Adolescent (Well-Client) 2. Active Phase - Exhaustion - More rapid cervical dilatation (4-7 cm) Nursing Care: - Uncomfortable phase for the mother - Stronger contractions (40-60 seconds every 3-5 ❖ Assist with second stage pushing minutes) ❖ Prepare birthing area - Bloody show and spontaneous rupture of ❖ Assist mother in birthing position membranes may occur ❖ Be ready to assist in episiotomy - Primipara: around 3 hours ❖ Prepare for and assist with delivery - Multipara: around 2 hours Nursing Care Mother may feel: ❖ Frequent perineal care ❖ Encourage mothers to keep active and assume - Uncontrollable urge to push most comfortable position except flat on back - Nausea and vomiting (due to decrease in ❖ Pain management abdominal pressure) ❖ Anticipate mood swings and difficulty in coping (offer support) Cardinal Movements of Labor ❖ Continue to involve family and partner 1. Fetal Engagement, Descent, and Flexions ❖ Positioning 2. Internal Rotation Upright - Of the fetal head at the internal perineum Left side lying - Aligns fetal head in the most optimum position for descent (widest part at widest inlet area) - Perineum may appear bulging and tense 3. Transition Phase - Anus may be everted; stool may be expelled - Cervical Dilatation (8-10 cm) - Crowning – fetal scalp visible at the opening of - Contractions reach peak of intensity the vagina - Longer contractions (60-70 seconds every 2-3 3. Extension minutes) - Delivery of the head - Full cervical dilatation and effacement - Compression of presenting parts - ROM may occur at full cervical dilation 4. External Rotation - Strong urge to push - Head rotates to being the anterior shoulders Nursing Care: into the best line with the pelvis ❖ Mothers may experience intense discomfort, - Slight upward flexion needed to deliver nausea and vomiting, feeling of loss of control, posterior shoulder anxiety, panic, or irritability - Watch for: Shoulder dystocia in macrosomic ❖ Help direct maternal focus to birthing of baby babies ❖ Provide support 5. Expulsion of the baby ❖ Stay with the mother at all times - The baby is considered born once the entire body is already delivered and exposed to the extrauterine life SECOND STAGE OF LABOR - Complete cervical dilatation to delivery of the neonate - Lasts 2-60 minutes Primipara: 40 mins average - Multipara: 20 mins average - Fetus moved along the birth canal by the mechanisms of labor Psychological Maternal Responses: - Focus from discomfort to active pushing MODULE 3F: INTRA-NATAL CARE YUSON, DREA NCM 107: Care of Mother, Child, Adolescent (Well-Client) THIRD STAGE OF LABOR Fourth Degree Entire perineum, rectal sphincter, - Begins with the birth of the infant and ends and some of the mucous with the delivery of the placenta (1-30 mins) membrane of the rectum Two Phases: 1. Placental Separation - Placenta detaches from the uterine wall Signs: Lengthening of the umbilical cord Sudden gush of vaginal blood Placenta is visible at the vaginal opening Uterus contracts and feels firm Presentations: Schultze and Duncan 2. Placental Expulsion - Placenta is delivered through natural bearing FOURTH STAGE OF LABOR down or gentle pressure on the contracted - Time immediately after placental delivery uterine fundus (Crede’s Maneuver) - First hour after delivery (recovery period) - No pressure on noncontracted uterus – can cause uterine eversion and massive hemorrhage - Beginning of the postpartum period - Excessive hemorrhage with poor contraction – - Postpartum period: 6 weeks administer Hemabate or Methergine (Check BP - High risk for hemorrhage before administration) Psychological Maternal Responses: - Note time of placental delivery - Inspect intactness of placenta - Attention towards neonate - Inspect for placental remains (leads to - Adjusting to maternal role uncontracted uterus and bleeding) Psychological Maternal Responses: Nursing Care: - Concern for neonate’s condition ❖ Primary activity is stabilizing the status of the - Discomfort from uterine contractions before placental expulsion neonate and helping neonate get acclimated to Nursing Care: extrauterine life ❖ Assist with the delivery of the placenta ❖ Focus on maternal-neonatal bonding ❖ Assist with episiorrhaphy ❖ Obtain vital signs every 15 mins for the first ❖ Administer oxytocin as ordered (IV) hour ❖ Introduce neonate to the parents and allow ❖ Assess lochia, consistency and position of the breastfeeding fundus, episiotomy site ❖ Be prepared to initiate emergency procedures if mother’s or child’s condition do not stabilize Classification of Perineal Lacerations Classification Description of Involvement First Degree Vaginal mucous membrane and skin of the perineum to the fourchette Second Degree Vagina, perineal skin, fascia, levator ani muscle, and perineal body Third Degree Entire perineum, extending to reach the external sphincter of the rectum MODULE 3F: INTRA-NATAL CARE YUSON, DREA