Nursing Care Management During Labor and Delivery PDF

NUR C207 Care of Mother, Child and Adolescent (Midterm) By Gina M. Dumawal RN, MAN Intrapartal Care LABOR > the process by which the fetus and products of conception are expelled as the result of regular, progressive, frequent and strong uterine contraction. DELIVERY > the expu...

NUR C207 Care of Mother, Child and Adolescent (Midterm) By Gina M. Dumawal RN, MAN Intrapartal Care LABOR > the process by which the fetus and products of conception are expelled as the result of regular, progressive, frequent and strong uterine contraction. DELIVERY > the expulsion of the fetus and products of conception. 3  Theories of Labor Onset Uterine muscle stretching - results in release of prostaglandins. Pressure on the cervix - stimulates the release of oxytocin. Oxytocin stimulation, works together with prostaglandins to initiate uterine contractions. Change in the ratio of estrogen to progesterone (progesterone withdrawal). Placental age - triggers uterine contractions. Rising fetal cortisol levels - reduces progesterone formation & increases prostaglandin formation. Fetal membrane production of prostaglandin - stimulates uterine contractions. 4  Common Signs of Labor Preliminary Signs of Labor 1. Lightening - descent of the fetal presenting part into the pelvis. In primipara, occurs approximately 10 - 14 days before labor begins. In multipara, usually occurs on the day of labor or even after labor has begun. A woman may experience: > shooting leg pains from the increase pressure on her sciatic nerve. > increased amounts of vaginal discharge. > urinary frequency from pressure on her bladder. 2. Slight Loss of Weight As progesterone level falls, body fluid is more easily excreted from the body that can lead to a weight loss between 1 and 3 lbs. 6  Common Signs of Labor Preliminary Signs of Labor (cont.) 3. Increase in Level of Activity - related to an increase in epinephrine release initiated by a decrease in progesterone produced by the placenta. 4. Braxton Hicks Contractions – false labor contraction. 5. Ripening of the Cervix - internal sign seen only on pelvic exam. Throughout pregnancy, similar to the consistency of an earlobe (Goodell’s sign). At term, becomes still softer (as “butter-soft”). 7  Common Signs of Labor Signs of True Labor; involve uterine and cervical changes. 1. Uterine Contractions – the surest sign that labor has begun. Contractions are involuntary & come w/o warning. 2. Show “Bloody show” As the cervix softens & ripens, the mucus plug that filled the cervical canal during pregnancy (operculum) is expelled. The exposed cervical capillaries seep blood as a result of pressure exerted by the fetus. 3. Rupture of the Membranes Labor may begin with rupture of the membranes. Early rupture of the membranes can be advantageous as it can cause the fetal head to settle snugly into the pelvis. 8 9 Factors Affecting Labor and Delivery Process The Four Components (“P’s”) of Labor Essential Factors in Labor (Basic for Assessment) 1. Passage/passageway – pelvis and birth canal 2. Passenger – fetus and placenta 3. Powers – physiologic forces of labor 4. Psychological outlook / Psyche - response of the mother 10 Factors Affecting Labor and Delivery Process 1. PASSAGE / PASSAGEWAY - adequacy of the pelvis and birth canal in allowing fetal descent, involves the abilities of uterine segment to distend, cervix to dilate, vaginal canal and introitus to distend. Pelvis: Fusion of ilium, ischium, pubis & sacral bones – False pelvis: above pelvic inlet – True pelvis: inlet, midpelvis and outlet 11 Factors Affecting Labor and Delivery Process 1. PASSAGE / PASSAGEWAY (cont.) Types of Pelvis: a) Gynecoid: round, most common type, vaginal birth, b) Android: heart-shaped, usually have C/S, c) Anthropoid: oval, vaginal birth (often forceps), d) Platypelloid: flat, least common, vaginal birth 12 Factors Affecting Labor and Delivery Process 2. PASSENGER - widest diameter is the head, least likely to be able to pass through the pelvic ring. Whether a fetal skull can pass depends on its structures and its alignment with the pelvis: Structure of fetal skull Diameters of fetal skull Molding 13  Factors Affecting Labor and Delivery Process 2. PASSENGER (cont.) Structure of fetal skull The cranium, uppermost portion of the skull, composed of 8 bones: > The four superior bones – important in childbirth a.) frontal bone b.) two parietal bones c.) occipital bone > The other four bones of the skull a.) sphenoid b.) ethmoid c.) two temporal bones 14  Factors Affecting Labor and Delivery Process 2. PASSENGER (cont.) Structure of fetal skull Suture lines - bones of the skull meet/fused. > They allow the cranial bones to move and overlap, molding or diminishing the size of the skull. Fontanelle spaces compress during birth to aid in molding of the fetal head. Vertex - space between the 2 fontanelles. Sinciput - area over the frontal bone. Occiput - area over the occipital bone. 15  Factors Affecting Labor and Delivery Process 2. PASSENGER (Cont.) Diameters of the Fetal Skull Suboccipitobregmatic - narrowest diameter (approx 9.5 cm), measured from the inferior aspect of occiput to the center of anterior fontanelle. Occipitofrontal diameter (approx 12 cm), measured from occipital prominence to the bridge of the nose. Occipitomental diameter (approx 13.5 cm) - widest anteroposterior diameter, measured from the posterior fontanelle to chin. 16  Factors Affecting Labor and Delivery Process 2. PASSENGER (cont.) Molding - change in the shape of the fetal skull produced by the force of uterine contractions. > Bones of the fetal skull are not yet completely ossified, thus overlap and mold to facilitate passage through the rigid pelvis. > Molding is commonly seen in infants just after birth, lasts a day or two. 17 Factors Affecting Labor and Delivery Process 2. PASSENGER (cont.) Fetal presentation and position 18  Factors Affecting Labor and Delivery Process 2. PASSENGER (cont.) Fetal attitude a. Vertex (full flexion) – area between anterior and posterior fontanelles and between parietal eminencies. b. Sinciput (moderate flexion [military attitude]) – area lying in front of anterior fontanelle, and is subdivided into 2 parts = brow and face. c. Brow (partial extension) – area between anterior fontanelle and root of the nose. d. Face (poor flexion, complete extension) – area below the root of the nose. 19  Factors Affecting Labor and Delivery Process 2. PASSENGER (cont.) Fetal lie – whether the fetus is lying in a horizontal (transverse) or a vertical (longitudinal) position. Station- describes the location of the fetus on its descent down into the birth canal. 20  Factors Affecting Labor and Delivery Process 2. PASSENGER (cont.) ❖Placenta > weight - approx 500 g or 1/6 of the fetal weight. > size - 15 to 20 cm in diameter and 1.5 to 3.0 cm thick. > unusually enlarged in women with diabetes > if the uterus has scars or a septum, the placenta maybe wide in diameter because it is force to spread out to find implantation space. 21 Factors Affecting Labor and Delivery Process 3. POWERS Primary forces: uterine muscle contractions (causes dilation and effacement) Secondary forces: abdominal muscles (for 2nd stage) bearing down (pushing) Uterine contractions Origins Phases Contour changes Cervical changes Effacement and Dilatation The mark of effective uterine contractions is rhythmicity and progressive lengthening and intensity. 22  Factors Affecting Labor and Delivery Process 3. POWERS (cont.) Origins > Labor contractions begin at a “pacemaker” point located in the uterine myometrium then sweeps down over the uterus. > Uncoordinated contractions may slow labor and lead to failure to progress & fetal distress (inadequate placental filling). 23  Factors Affecting Labor and Delivery Process 3. POWERS (cont.) Phases; contraction consists of three phases: 1. Increment - intensity of the contraction increases 2. Acme - contraction is at its strongest 3. Decrement - intensity decreases Between contractions, uterus relaxes. As labor progresses, the relaxation intervals decreases from 10 minutes early in labor to 2-3 minutes. Duration of contractions also changes, increases from 20-30 seconds to a range of 60-90 seconds. 24  Factors Affecting Labor and Delivery Process 3. POWERS (cont.) Contour Changes: The uterus gradually differentiates itself into 2 distinct functioning areas. > The upper portion becomes thicker & active, preparing to exert strength necessary for expulsion. > The lower segment becomes thin walled so that the fetus can be easily pushed out of the uterus. The boundary between the 2 portions becomes marked by a ridge on the inner uterine surface, the physiologic retraction ring - prominent and observable as an abdominal indentation. 25  Factors Affecting Labor and Delivery Process 3. POWERS (cont.) Cervical Changes > Effacement - shortening and thinning of the cervical canal. Primiparas- accomplished before dilatation begins. Multiparas- dilatation may proceed before effacement is complete. > Dilatation - enlargement or widening of the cervical canal. Dilatation occurs for two reasons; > uterine contractions gradually increase the diameter of the cervical canal lumen. > the fluid-filled membranes press against the cervix. 26  Factors Affecting Labor and Delivery Process 4. Psyche - woman’s psychological state or feelings that bring into labor. The progress of labor and birth can be adversely affected maternal fear and tension. Anxiety can also increase pain perception and lead to an increased need for analgesia & anesthesia. Psychosocial Considerations Social support Past experience Knowledge 27  Mechanisms of Labor Position changes to keep the smallest diameter of the fetal head always presenting to the smallest diameter of the pelvis (cardinal movements of labor): 28  Mechanisms of Labor Descent - downward movement of the biparietal diameter of the fetal head to within the pelvic inlet. Full descent - fetal head extrudes beyond the dilated cervix and touches the posterior vaginal floor. Flexion - head bends forward onto the chest, making the smallest antero- posterior diameter present to the birth canal. Internal Rotation - the head flexes as it touches the pelvic floor and the occiput rotates to bring the head into the best relationship to the outlet of the pelvis. Extension - head extends & the foremost parts of the head to be born. External Rotation - shoulders engage & move similarly with the head. Expulsion - the rest of the baby is born, the end of the pelvic division of labor. 29  Phases of Labor 1. Latent Phase (preparatory phase) begins at the onset of regularly perceived uterine contractions and ends when rapid cervical dilatation begins. Contractions are mild and short, lasting 20 to 40 seconds. Cervical effacement occurs & cervix dilates from 0 to 3 cm. lasts approx 6 hours in a nullipara and 4.5 hours in a multipara. 2. Active Phase cervical dilatation increasing from 4 to 7 cm. Contractions grow stronger, lasting 40 to 60 seconds and occur approx every 3 to 5 minutes. lasts approx 3 hours in a nullipara and 2 hours in a multipara. Show and spontaneous rupture of the membranes may occur. contractions grow strong, last longer, causing true discomfort. 31  Phases of Labor 3. Transition Phase contractions reach their peak of intensity, occurring every 2 tothe membranes have not previously ruptured or been ruptured by amniotomy, they will rupture as a rule at full dilatation (10 cm). full dilatation (10 cm) and complete cervical effacement (obliteration of the cervix) have occurred. 32  Stages of Labor Second Stage Begins with the full dilation of the cervix and ends with the delivery of the fetus. Third Stage begins with the birth of the infant and ends with the delivery of the placenta. Two separate phases are involved: a.) placental separation b.) placental expulsion 33  Stages of Labor Placental Separation ❑Signs that placenta has loosened and is ready to deliver: Lengthening of the umbilical cord Sudden gush of vaginal blood Change in the shape of the uterus Firm contraction of the uterus Appearance of the placenta at the vaginal opening Schultze presentation - placenta separates first at its center and last at its edges, appearing shiny and glistening from the fetal membranes. Duncan presentation - placenta separates first at its edges, it looks raw, red, and irregular, with the ridges or cotyledons that separate blood collection spaces. 34  Stages of Labor Placental Expulsion After separation, the placenta is delivered either by the natural bearing- down effort of the mother or by gentle pressure on the contracted uterine fundus (Credé’s maneuver). Pressure must never be applied to a uterus in a noncontracted state, because doing so may cause the uterus to evert and hemorrhage. If the placenta does not deliver spontaneously, it can be removed manually. ❑The normal blood loss is 300 to 500 mL. 35 Discomforts During Labor and Delivery pain perineal tearing or the need for an episiotomy. dryness of the mouth cramping and muscle pain Nausea 36  Danger Signs of Labor and Delivery Maternal Danger Signs High or Low Blood Pressure - Normally, a woman’s blood pressure rises slightly in the 2nd stage of labor because of her pushing effort. > systolic pressure greater than 140 mm Hg and a diastolic pressure greater than 90 mm Hg or > increase in the systolic pressure of more than 30 mm Hg or in diastolic pressure of more than 15 mm Hg (the basic criteria for pregnancy-induced hypertension), should be reported. > falling BP should be reported because it may be the 1st sign of intrauterine hemorrhage, often associated with other clinical signs of shock (apprehension, increased PR and pallor). Abnormal Pulse. PR normally increases slightly during the 2nd stage of labor because of the exertion involved. A maternal pulse rate greater than 100 bpm during the normal course of labor is indication of hemorrhage. 37  Danger Signs of Labor and Delivery Maternal Danger Signs (Cont.) Inadequate or Prolonged Contractions. > contractions in less frequent, less intense, or shorter in duration - indicate uterine exhaustion (inertia). > A period of relaxation must be present between contractions > A uterine contractions lasting longer than 70 seconds should be reported. Pathologic Retraction Ring. An indentation across a woman’s abdomen (where the upper and lower segments of the uterus join), may be a sign of extreme uterine stress and possible impending uterine rupture. 38  Danger Signs of Labor & Delivery Maternal Danger Signs (cont.) Abnormal Lower Abdominal Contour. If a woman has a full bladder during labor, a round bulge on her lower anterior abdomen may appear. This is a danger signal for two reasons: > bladder may be injured by the pressure of a fetal head > pressure of full bladder may not allow the fetal head to descend. Increasing Apprehension - warnings of psychological danger during labor. > A woman who is becoming increasingly apprehensive despite clear explanations of unfolding events may only be approaching the second stage of labor. > Increasing apprehension needs to be investigated for physical reasons, because it can be a sign of O2 deprivation or internal hemorrhage. 39  Danger Signs of Labor and Delivery Fetal Danger Signs High or Low Fetal Heart Rate. > As a rule, an FHR of more than 160 bpm (fetal tachycardia) or less than 110 bpm (fetal bradycardia) is a sign of possible fetal distress. Meconium Staining. > It reveals that the fetus has had loss of rectal sphincter control. > It may indicate that a fetus has or is experiencing hypoxia, which stimulates the vagal reflex & leads to increased bowel motility. Hyperactivity. > Fetal hyperactivity - sign of fetal hypoxia, because frantic motion is a common reaction to the need for O2. Oxygen Saturation. > a low O2 saturation level suggests that fetal well-being is becoming compromised. > Oxygen saturation in a fetus is normally 40% to 70%. 40  Common Nursing Diagnoses Common nursing diagnoses pertinent to labor include: Pain related to labor contractions Anxiety related to process of labor and birth Health-seeking behaviors related to management of discomfort of labor Situational low self-esteem related to inability to use prepared childbirth method Powerlessness related to the unexpected duration and intensity of labor Anxiety related to lack of knowledge about “normal” labor process Risk for situational low self-esteem related to ineffectiveness of prepared childbirth breathing exercises 41  Care of a Woman During; 1st Stage of Labor ▪ Respect contraction time ▪ Promote change of position ▪ Promote voiding & provide bladder care (at least q 2 to 4hrs) ▪ Offer support ▪ Support a woman’s pain management needs ▪ Monitor progress of labor, FHT & V/S 2nd Stage of Labor ▪ Assess FHS at the beginning of the 2nd stage of labor. ▪ Prepare the place for birth (LR-DR) a) Open sterile packs of supplies on waiting table (cervix 7 to 9 cms). A table set with equipment can be left covered for up to 8 hours. b) Prepare the newborn care area. Turn on the radiant heat warmer in advance.  Care of a Woman During; 2nd Stage of Labor (cont.) ▪ Assess FHS at the beginning of the 2nd stage of labor. ▪ Prepare the place for birth (LR-DR) a) Open sterile packs of supplies on waiting table (cervix 7 to 9 cms). A table set with equipment can be left covered for up to 8 hours. b) Prepare the newborn care area. Turn on the radiant heat warmer in advance. ▪ Position patient for birth ▪ Promote effective 2nd stage pushing (the woman must push with contractions & rest between them) ▪ Perineal cleaning (from inner to outer) ▪ Note & record the time of birth. ▪ Note & record the sex of the newborn. ▪ Clamped the cord, count the blood vessels in the cord. ▪ Keep the newborn dry & wrap with a warm blanket.  Care of a Woman During; 3rd stage of labor ▪ Observes the signs of placental separation ▪ Checks characteristic & completeness of the placenta. 4th stage of labor ▪ Assesses amount of blood loss ▪ Assesses presence & degree of laceration (perineal, cervical and vaginal) ▪ Assists in episiorraphy ▪ Performs perineal care & applies pad correctly. ▪ Monitor V/S ▪ Check fundus frequently ▪ aftercare Physical Preparation of the Client Explanation of the procedure Securing informed consent Provision of safety, comfort and privacy > proper positioning > draping > constant feedback > therapeutic touch Psychological Preparation of the Client Factors Influencing a Positive Birth Experience Clear information on procedures Support, not being alone Sense of mastery, self-confidence Trust in staff caring for her Positive reaction to the pregnancy Personal control over breathing Preparation for the childbirth experience  Physical Preparation of the Client Explanation of the procedure Admission Procedures/Vital Assessment Data > When to enter the hospital or birth center? a) Contractions—regularity, frequency, duration & intensity. Nullipara—regular contractions, 5 minutes apart for 1 hour Multipara—regular contractions, 10 minutes apart for 1 hour b) Ruptured membranes c) Bleeding—bright-red bleeding should be evaluated promptly. d) Decreased fetal movement Orientation to a birthing room Baseline assessment of vital signs Recording of pregnancy history & PE Assessment of FHT Vaginal examination Urine and necessary blood samples obtained Explanation of fetal or uterine monitoring device to be used  Physical Preparation of the Client Initial Interview & Physical Examination 1.Description of labor 2.General physical condition 3.Preparedness for labor & birth Other information: - EDB/EDD, AOG - vital signs (between contractions) - time the woman last ate - any known drug allergies - past pregnancy & previous pregnancy outcome  Physical Preparation of the Client History Current pregnancy history a) gravida & para status b) description of pregnancy (planned or not, place of prenatal care, adequacy of nutrition & any complications) c) plans for labor (w/ or w/o anesthesia, breathing exercises) d) future childcare (breast-feed or not) Past Pregnancy History a) previous pregnancies (number, dates, types of birth, any complications or outcomes, gender & birth weights) b) current health of the children Past Health History a) document any previous surgeries & diseases. Family Medical History; heart or kidney disease, diabetes, cancer, allergies, seizures or congenital disorders.  Physical Preparation of the Client Physical Exam - overall appearance (tired or frightened, pale, presence of DHN, edema or varicosities ). a) Abdominal assessment - Leopold’s maneuver, assess for abdominal scars. b) Assessing rupture of membranes - time of rupture and characteristics of amniotic fluid. c) Vaginal exam - determine the cervical dilatation & effacement, confirm the fetal presentation, position and degree of descent. e) Sonography - to determine the diameter of the fetal skull, presentation, presenting part and degree of descent of a fetus. f) Vital signs g) Lab analysis - blood & urine exam h) Assessment of uterine contractions  Physical Preparation of the Client Initial Fetal Assessment Auscultation of the FHT- q 30 mins during beginning labor, every 15 minutes during active labor and every 5 mins on the 2nd stage of labor. - Breech - high in the uterus, at the woman’s umbilicus or above. - Cephalic - low in the abdomen - ROA position – RLQ, LOA position – LLQ - Posterior position (ROP or LOP) - on a woman’s side Physical and Psychological Preparation of the Client Informed Consent a. Patient decides to have a certain medical or surgical procedure, includes knowing and understanding what health care treatment is being undertaken. b. Point out information for them to decide whether or not to proceed with the course of treatment. c. Without proper consent, provider could be the subject of a lawsuit alleging assault, battery, negligence or a combination of actions.  Physical Preparation of the Client Provision of Safety, Comfort and Privacy > proper positioning and draping Physical and Psychological Preparation of the Client Provision of Safety, Comfort and Privacy (cont.) Constant feedback > make the family feel welcome > determine family expectations about birth > convey confidence > provide support > do not be offended by irritability > respect cultural values Therapeutic touch > use touch for comfort > back rub > assist with pant-blow breathing Monitoring and Management of Normal Labor Monitor maternal well-being > vital signs > uterine contractions > progress of labor > intake and output > response to labor Monitor fetal well-being > Fetal heart rate > Characteristic of amniotic fluid Monitoring and Management of Normal Labor Parameters in Assessing FHR Patterns 1. Baseline rate - determined by analyzing the range of FHR recorded on a 10-minute tracing obtained between contractions. (normal FHR 120-160 bpm.) - FHR fluctuates slightly (5 to 15 bpm) when a fetus moves or sleeps. Bradycardia because of vagal response elicited by compression of the fetal head during labor. Tachycardia caused by fetal hypoxia, maternal fever, drugs, fetal arrhythmia, or maternal anemia or hyperthyroidism. Monitoring and Management of Normal Labor Parameters in Assessing FHR Patterns 1. Baseline rate - determined by analyzing the range of FHR recorded on a 10-minute tracing obtained between contractions. (normal FHR 120-160 bpm.) - FHR fluctuates slightly (5 to 15 bpm) when a fetus moves or sleeps. Bradycardia because of vagal response elicited by compression of the fetal head during labor. Tachycardia caused by fetal hypoxia, maternal fever, drugs, fetal arrhythmia, or maternal anemia or hyperthyroidism. Monitoring and Management of Normal Labor Parameters in Assessing FHR Patterns (cont.) 2. Variabilities in the baseline rate (long term and short term) Baseline variability is the variation or differing rhythmicity in the heart rate over time reflected on the FHR tracing as a slight irregularity or “jitter” to the wave. Monitoring and Management of Normal Labor Parameters in Assessing FHR Patterns (cont.) 3. Periodic changes in the rate (acceleration and deceleration). - Periodic changes or fluctuations in FHR occur in response to contractions and fetal movement and are described in terms of accelerations or decelerations. - short term changes in rate rather than baseline; last from a few seconds to 1 or 2 minutes. - Four responses; a) acceleration, b) early deceleration, c) late deceleration, and d) variable deceleration. Monitoring and Management of Normal Labor Parameters in Assessing FHR Patterns (cont.) 3. Periodic changes in the rate (acceleration and deceleration). Periodic changes or fluctuations in FHR occur in response to contractions and fetal movement and are described in terms of accelerations or decelerations. Periodic changes are short term changes in rate rather than baseline; they last from a few seconds to 1 or 2 minutes. Four such responses are acceleration, early deceleration, late deceleration, and variable deceleration.  Monitoring and Management of Normal Labor Parameters in Assessing FHR Patterns (cont.) 3. Periodic changes in the rate (acceleration and deceleration). - Four responses; a) Accelerations. - Non-periodic accelerations are temporary normal increases in FHR caused by fetal movement, a change in maternal position or administration of an analgesic. b) Early Deceleration, - normal periodic decreases in FHR resulting from pressure on the fetal head during contractions. - occurs when the contraction begins and ending when the contraction ends, FHR returns quickly to between 120 and 160 beats at the end of the contraction. - normally occur late in labor, when the head has descended fairly low, if occur early in labor before the head has fully descended, the head compression causing the waveform change could be the result of CPD. Monitoring and Management of Normal Labor Parameters in Assessing FHR Patterns (cont.) 3. Periodic changes in the rate (acceleration and deceleration). - Four responses; (cont.) c) late deceleration, and - those delayed until 30 to 40 seconds after the onset of a contraction and continue beyond the end of a contraction. - may suggests decreased blood flow through the intervillous spaces of the uterus during uterine contractions. - lowest point of the deceleration (nadir) occurs near the end of the contraction instead of at its peak. - this pattern may occur with marked hypertonia caused by the administration of oxytocin.  Monitoring and Management of Normal Labor Parameters in Assessing FHR Patterns (cont.) 3. Periodic changes in the rate (acceleration and deceleration). - Four responses; (cont.) > Prolonged Decelerations - decelerations that last longer than 2 to 3 minutes but less than 10 minutes and may indicate cord compression or maternal hypotension. d) variable deceleration. - occur at unpredictable times in relation to contractions. - indicates cord compression which tends to occur more frequently after rupture of the membranes or with oligohydramnios in postterm pregnancy or with IUGR. Monitoring and Management of Normal Labor Monitor fetal well-being Electronic fetal monitoring External monitoring FHR—ultrasound transducer UCs—Toco transducer Monitoring and Management of Normal Labor Monitor the progress of labor > Contractions primary force a) Frequency b) Duration c) Intensity d) Interval/Resting tone > Pushing secondary force  Monitoring Progress of Labor and Delivery Uterine activity: Assess & record frequency, duration, intensity, and interval of uterine contraction q30-60 minutes by direct palpation or through interpretation of electronic fetal monitoring strips. Labor progress: Perform a vaginal exam to assess cervical effacement and dilatation, fetal position & station, & status of membranes. (use Friedman’s curve). Friedman's Curve describes progress of two variables over time: dilation of cervix and descent of baby. Dysfunctional labor when cervix stops dilating or fetal descent stops or both. FRIEDMAN’S CURVE  Providing Comfort Measures LIGHTING. Soft, indirect lighting is soothing, whereas needed. TEMPERATURE. Women in labor are often hot and perspiring. > Cool, damp washcloths on the woman’s face and neck promote comfort. CLEANLINESS. Bloody show and amniotic fluid leak from the woman’s vagina during labor. > Change the sheets & gown as needed. > Change the disposable under pad regularly to reduce microorganisms that may ascend into the vagina. MOUTH CARE. Ice chips and hard candy may reduce the discomfort of a dry mouth. > If oral intake is contraindicated, brushing the teeth and simply rinsing the mouth is helpful to the woman. > Many women appreciate a moist washcloth applied to their lips.  Providing Comfort Measures BLADDER. A full bladder intensifies pain during labor and can delay fetal descent. > Remind the woman to empty her bladder at least every 2 hours. POSITIONING. Encourage the woman to assume any position she finds comfortable and change positions frequently to: a) reduce discomfort from constant pressure b) help the fetus adapt to the pelvic contours c) promote fetal descent. > Upright positions benefit labor by adding the force of gravity to uterine contractions. WATER. Water in the form of a shower, tub, or whirlpool is relaxing for many women.  Preparing the Birthplace For a multipara, open the sterile packs of supplies on waiting tables when the cervix has dilated to 9 to 10 cm. For a primipara, delayed until full dilatation & descent (crowning). Prepare instrument table Adequate lighting Oxygen and suction equipment Radiant warmer, blankets, identification for newborn Gown, gloves, and protective equipment for personnel ❑A woman should be transferred early to avoid rushed, last-minute preparations that cause anxiety for everyone.  Observing the Perineum Position the mother for birth Cleanse the perineum Observe the perineum especially during late 2nd stage labor. Episiotomy * midline * mediolateral  Observing the Perineum Types of Episiotomy 1. Midline/median episiotomy - midline of the perineum, heals more easily, cause less blood loss & results in less postpartum discomfort. 2. Mediolateral episiotomy - midline but directed laterally away from rectum w/ less danger of complication from rectal mucosal tears. Types of Laceration (extent) ❖1st degree - fourchette, perineal skin and vaginal mucosa but not the fascia and muscle ❖2nd degree -skin, mucosa, fascia and muscle of the perineal body but not the anal sphincter ❖3rd degree - extend through the skin, mucosa, perineal body and the anal sphincter ❖4th degree - extension of the 3rd degree laceration through the rectal mucosa to expose the lumen of the rectum. Early Essential Newborn Care Early Essential Newborn Care End of Slides