Labor and Birth Nursing Interventions PDF

Labor and Birth Nursing Interventions Frances McGill, RN, MD Deborah Nelson, MS, PHN, RNC-OB Spring 2022 Objectives Discuss normal labor and birth nursing assessments Identify nursing interventions for each stage of labor Identify nursing interventions during use of pharmacological agents The Nurse’...

Labor and Birth Nursing Interventions Frances McGill, RN, MD Deborah Nelson, MS, PHN, RNC-OB Spring 2022 Objectives Discuss normal labor and birth nursing assessments Identify nursing interventions for each stage of labor Identify nursing interventions during use of pharmacological agents The Nurse’s Role Caring for the Birthing Family Two Patients : Mother and Baby Normal vs abnormal labor Pain Patient safety Intimacy / privacy 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 Intrapartum Period Informed Consent. Standards of Practice – Monitoring – Intervening – Reporting – Delegation of duties Documentation Overview :Assessment of Labor Labor is the process of birth True vs False Labor – True labor - progressive dilation and effacement of the cervix in response to regular uterine contractions. – False labor - contractions at term that do not result in cervical change and are termed “Braxton-Hicks” contractions Initial evaluation of patient in labor – Establishment of gestational age by chart review – Review of medical history – Fetal Evaluation : Fetal Heart , position , ultrasound confirmation if indicated , fetal monitoring or intermittent cardiac auscultation – Full maternal evaluation : Vital Signs, Screening examination – Pelvic Examination : cervical effacement ( thinning out ) and dilatation , ,membranes ( intact or ruptured ) , uterine size , fetal position , – Contraction pattern – Analgesia if indicated Initial Assessment What are the most significant questions to ask? What next? Nursing Process-Assessments Maternal Age Gestational Age: Term 38 - 42 weeks gestation Prenatal Care Medical , Surgical History Family history particularly obstetric problems ( twins , preeclampsia ) Intimate Partner Violence Fetal Heart Rate (FHR) Fetal Movement Baseline Data Review Prenatal Record GP: Gravida= Number of pregnancies including present Parity pertains to outcome of pregnancy NOTE : There is one para per pregnancy EDC / EDD Estimated Date of Confinement /Delivery is established by date of Last Menstrual Period ( LMP ) or by first ultrasound Brief Systems Assessment Maternal Vital signs and Fetal Heart Rate 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) Baseline Data – Blood Pressure , baseline and trend – ( Question What happens to BP in normal pregnancy and why ? ) – Glucose Screen ( O’Sullivan Test ) – Glucose Tolerance Test if indicated / – HgbAIC and Glucose measurements if Gestational Diabetes – Blood Type, Rh – Antibody Screen – HBsAG, HIV, HTLV 1 &2, RPR ( syphilis screen) Rubella ,Chlamydia , Gonorrhea – other prenatal & biochemical tests CMV (AFP, Quad Screen ) – TB ( PPD) _ Admission Labs – Blood: CBC – Urinalysis: Protein, Glucose, Ketones - Blood type in Lab (Some hospitals repeat HIV ) - Repeat any pertinent labs Maternal Evaluation in Labor Review Prenatal Record and update Gestational age ( LMP and FIRST OB Ultrasound (US ) First US is most accurate. Do NOT change dating using later US Complications / Medical Problems in this /prior pregnancy Last meal Covid testing per protocol Elsevier items and derived items © 2009, 2005 by Saunders, an Clinical Evaluation of the Pregnant Uterus and Fetus FUNDAL HEIGHT Uterine Size approximates Weeks of Gestation when measured from symphysis pubis to the palpable fundus Leopold’s Maneuvers Place your hands on the borders of the uterus First Maneuver : Evaluates upper pole in fundus of uterus Second Maneuver : Position of fetal back Third Maneuver: Lower pole of fetus Fourth Maneuver: Confirm Presenting Portion /Part 14 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 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 Labor – Basics In Labor you are evaluating Passenger – fetus Passage: pelvic bones and vagina Power – contractions Myometrial cells express gene that encodes connexin 43 and oxytocin receptor>formation of gap junctions “Work of Labor” Effacement : the cervix thins out Dilatation: the cervix dilates from a small oval opening to 10 cm in order to > permit the fetal head to Descend through the open cervix through the vagina and permit Delivery of the fetus The placenta is then “expressed” Objective :Outline the management plan for patients under the following categories of care: continuing 18 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 Maternal Vital Signs BP , P, R , and Fetal Heart ; Interpret if electronic monitoring Normal Childbirth – “5 P’s” Powers Passage Passenger Position Psyche Mechanism of Labor Engagement Descent Flexion Internal Rotation Extension External rotation (restitution ) Expulsion / Delivery of Anterior , then posterior shoulder Elsevier items and derived items © 2009, 2005 by Saunders, an Pelvic Examination with Sterile Speculum and Sterile Gloves Status of Membranes Dilatation /Dilation Station The Cervix in Labor and Cervical Exam Elsevier items and derived items © 2009, 2005 by Saunders, an Assessment of Rupture of Membranes STERILE Speculum Examination 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 Correlate with gestational age : Term or Premature If Premature Rupture Of Membranes , inspect cervix , try to avoid pelvic exam to minimize ascending infection Cervical Dilatation/Dilation Cervical Dilation Nulliparous patient : dilates 1 cm per hour in active labor Multiparous Patient : dilates 1.5 cm / hour in active labor Fetal Monitoring Fetoscope or Doppler Heart Rate Normal 120-160 beats per minute May decrease with contractions Should recover quickly Electronic Fetal Heart Stages and phases of Labor Stage 1: onset of labor to full cervical dilation – Latent phase: onset of labor to active phase – Effacement : thinning of cervix , dilatation 0-4 cm – Active phase: period of rapid cervical dilation 4-10 cm , and descent Stage 2: complete dilation ( 10 cm , station to +3 )to delivery of infant Stage 3: delivery of infant to expulsion of placenta Stage 4: delivery of placenta plus 2 hours Elsevier items and derived items © 2013, 2009, 2005 by Saunders, an imprint of Elsevier Inc. 29 Labor Curve Elsevier items and derived items © 2009, 2005 by Saunders, an 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 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 48 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 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 Anesthesia Information for NCLEX as all not available in Grenada 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 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, screaming , – Bearing down – Check the perineum: look for head or presenting part Responsibilities During Birth Preparation of the sterile table Perineal cleansing preparation Assisting the midwife, physician Coaching the patient on when to push , when to relax Fetal heart in between contractions as directed 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 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 Delivery of head 2nd Stage Controlled delivery of head No episiotomy Or episiotomy if tissues thin and appear to be at risk of tear vertex anterior presentation + coaching--panting --don’t push fetus--final external extension and delivery Delivery of the Head Elsevier items and derived items © 2009, 2005 by Saunders, an 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 Assessment of the Newborn: 1 minute and 5 minutes post delivery ; may repeat at 10 minutes if depressed Most infants score 710 1Minute score determines need for resuscitation Moderate depression 4-7 Severe depression 0-4 Low 5 minute score may predict morbidity 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 Contraction of Uterus - firm , at level of umbilicus Amount of Bleeding 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. 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 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 Post- Partum Care Maternal Evaluation Neonatal Evaluation: Immediate : Blood pressure Bleeding Uterine contraction Bonding with Baby Later : Respiration Physical Assessment Swallowing Urination Meconium ( Early stool ) Lactation Home support Post- partum depression screening Objective :Outline the management plan for patients under the following categories of care: continuing 77 Obstetric Care in COVID 19 Pandemic 2020 Recommendations Space prenatal visits as clinically safe (max: q5-6 weeks if www.ACOG.org Obstetric Care and Recommendations 2021 References Elsevier items and derived items © 2009, 2005 by Saunders, an