Presentation on theme: "Care of the Family in Childbirth"— Presentation transcript:
1 Care of the Family in Childbirth - Tie everything togetherCare of the Family in ChildbirthSue Nesbitt, RN, MSN
2 Learning Outcomes Identify criteria for admission . Compare comfort measures that might be used for each stage of labor.Discuss the needs/physical assessment of the newborn following the birth.Describe the responsibility of the nurse in managing a precipitous birth.
3 Reasons to come to the Hospital Rupture of membranesRegular, frequent uterine contractionsPrimigravida – 5 minutes apart for 1 hourMultigravidas – 6-8 minutes apart for 1 hourAny vaginal bleedingDecreased fetal movementDuring her prenatal visits the woman is instructed to call her healthcare providerand come to the birthing unit if any of the following occur:
4 Admission Initial encounter sets tone Explanation of procedures and policiesInformed consent obtain at this time, and also done BEFORE any pain medsIntrapartal Assessment – vaginal exam, FHR, uterine contractions (to get a baseline and to know stage of labor)Urine - protein, glucose (is pt diabetic?), high keytones = vomiting, check for preeclampsiaLab – H&H, Blood type & crossmatch, platelets (to detect for bleeding problems)To answer any circulatory questionsID bandsNotify physician
5 The patient and her partner base the course of the hospital stay on the reception received from the admitting nurse. A calm, pleasant manner indicates to thewoman that she is important. Following the initial greeting, provide a quick yetthorough orientation to the facility such as the location of the restrooms andnurse call system. These simple steps can go along way in helping the couplefeel comfortable. The woman may be facing a number of unfamiliar proceduresthat may seem routine for healthcare providers.Informed consents should beobtained during this time (before pain medications are given and it allows thenurse an opportunity to explain upcoming procedures). Assessment of FHR,vaginal exam, and a measure of uterine contractions should take place nextto determine a baseline of where the patient is in relationship to which stageof labor she is in. For instance, if the FHR is less than 110 beats per minutesa fetal monitor should be placed immediately to obtain additional data. Assessthe woman’s BP once the FHR monitor is in place
6 . Then obtain lab specimens etc. Check urine for glucose, protein, ketones by using a dipstick before yousend the specimen to the lab. This is especially important if edema or elevatedblood pressure is present. Proteinuria of +1 or more may be a sign ofimpending preeclampsia. Glycosuria (elevated glucose) is found frequently inpregnant women because of the increased glomerular filtration rate in theproximal tubules and the inability of these tubules to increase reabsorptionof glucose. It may also be an indication of gestational diabetes and shouldnot be discounted. H/H values help determine the oxygen carrying capacityof the circulatory system and the woman’s ability to withstand blood loss atbirth. Elevation of the hematocrit indicates hemoconcentration of blood,which occurs with edema or dehydration. A low hemoglobin, in the absenceof other evidence of bleeding, suggests anemia. Blood may be typed andcross matched if the woman is in a high risk category. Platelets are evaluatedas well because low platelets can lead to bleeding problems. Low platelets arealso a contraindication for epidural anesthesia. A type and cross match isperformed in case the woman needs to get blood products in an emergency.
7 First Stage of Labor pgFirst Stage – From the beginning of labor to the full opening of the cervix to about 4 inches or 10 centimeters.Initial (Latent) Phase – Contractions become progressively stronger. Discomfort is minimal. Cervix thins and opens to about 4 cm. May last an average of 12 hours in first pregnancy and 5 hours in subsequent pregnancies.Active Phase– Cervix opens from 4 cm to 10 cm. The presenting part of the baby begins to descend into the woman’s pelvis. The woman begins to feel the urge to push. This phase lasts about 3 hrs in 1st pregnancy and 2 hrs in subsequent pregnancies.
8 Nursing Care – First Stage Integration of Family ExpectationsSafety of mom & babySpecific expectations – birth planNursing supportEmotional supportComfort measuresInformation and adviceAdvocacySupport of partnerCultural BeliefsModestyPain expressionSpecific Beliefs
9 Families sometimes come to the hospital with very specific plans regarding delivery. Sometimes the plans are unrealistic which lead to increased stressand anxiety, and in the end disappointment. Review the plan with the familyand try to accommodate when and if you can, but be aware of safety formom and baby.Cultural BeliefsWithin every culture, each person develops his or her own beliefs, values,and behaviors.Modesty – an important consideration. The nurse needs to be alert to thewoman’s responses to examinations and procedures and provide appropriatedraping and privacy. In particular, Middle Eastern woman are not accustomedto male physicians and attendants. Orthodox Jewish women may follow severalJewish laws during childbearing period. The law of Tznuit requires the womanto maintain modesty In order to preserve dignity. The woman may prefer agown that covers her elbows and knees. She may also wish a hair coveringsuch as a wig, scarf, or other form of head covering. The men typically do notobserve the woman while she is changing and should be given the opportunityto leave the room to maintain the woman’s dignity.
10 Pain Expression-Many Asian cultures – it is important for individuals to act in away that will not bring shame on the family. Therefore, Korean women maynot express pain outwardly for fear of shaming herself or her family.Filipina women may say it is best to lie quietly.Silence is valued in Chinese society, so a Chinese client may be quiet and stoic toavoid dishonoring herself or her family.Japanese women often prefer natural childbirth and prefer to eat during labor.
11 Assessments of First Stage Latent Table 19-1, pgVS, Temp Temp q4 hours unless ROMCheck to see if membranes have rupturedFHR, fetal activityQ 30min for low risk womenQ15min for high risk womenAssess Uterine contractionNPO – ice chipsActiveVS q 1 hour,Pain controlBladder statusFHRROM and increased bloody show, prolapse of cordFHR monitoringTransitionChanges in Mood (don’t be surprised)Assistance with breathing - monitor for hyperventilation
12 Latent – Check temperature more frequently than 4 hours if ROM has occurred because of the increased risk of infection. FHR every 60 minutes for low risk women and every30 minutes for high risk women.Active – BP, HR, Resp. every hour if in normal range. Uterine contractions palpatedevery 15 to 30 minutes. Empty bladder (a full bladder will delay the progression ofthe baby descending). FHR every 30 minutes for low risk women and every 15 minutesfor high risk women. During this phase, the cervix dilates from 4 – 7 cm, and vaginaldischarge and bloody show increase. If the membranes have not ruptured, they willduring this phase. The nurse needs to note the amount, color, odor, and consistencyof the amniotic fluid and the time of rupture, and immediately auscultates the FHR.The fluid should be clear with no odor. A concern at the time of ROM is prolapse ofthe umbilical cord. The concern is that the amniotic fluid coming through the cervixwill propel the umbilical cord through the cervix. The FHR is auscultated because adrop in the rate might indicate an undetected prolapsed cord. Immediate interventionin necessary to remove pressure on a prolapsed umbilical cord.
13 Transition – The contraction frequency is every 1 ½ to 2 minutes, duration is 60-90 seconds, and intensity is strong. Cervical dilatation increases from 8-10 cm, effacementis complete (100%) and there is usually a heavy amount of bloody show. Sterile vaginalexams may be done more frequently because this stage of labor usually is accompaniedby rapid change. Maternal BP,HR, Resp are monitored when the FHR is assessed (FHR isassessed every 30 min for low risk and 15 minutes for high risk women). A gentle reminderto slow down your breathing can help prevent hyperventilation. The woman will begin to feelpressure as the fetal presenting part moves down the birth canal. The nurses should encouragethe woman to refrain from pushing until the cervix is completely dilated. This will help preventcervical edema.
14 Promotion of Comfort: First stage pg441 Identify goalsGeneral comfort measuresPositions,…, full, bladder, fear- explain what to expectAnxietyWatch for tingling: lips fingers, toes. Control breathing, take shallow breathsClient teachingSupportive Relaxation techniquesBreathing techniques
15 In planning care, talk to the woman and her partner to identify goals. Usually a priority is concern with discomfort. Factors – uncomfortablepositions, infrequent position changes, diaphoresis, continual leaking ofamniotic fluid, a full bladder, a dry mouth, anxiety, and fear.General Comfort – The woman is encouraged to walk as long as thereare no contraindications, such as vaginal bleeding or rupture of membranesbefore the fetus is engaged in the pelvis. A side-lying position is generallyadvantageous, although frequent position changes seem to achieve moreefficient contractions. If the woman is more comfortable on her back, thehead of the bed should be elevated to relieve the pressure of the uterus onthe vena cava. Encourage the woman to empty her bladder every 1 to 2 hours.Anxiety – A moderate amount of anxiety about pain enhances the woman’sability to deal with it. Ways to decrease anxiety not related to pain are to giveinformation (which eases fear of the unknown), establish a rapport with thecouple (which helps them preserve their personal integrity), and expressconfidence in the couple’s ability to work with the labor process.Patient Teaching – Through orientation and explanation of surrounding,procedures, and equipment being used will decrease anxiety, thereby reducing pain.
16 Supportive Relaxation Techniques – Tense muscles increase resistance to the descent of the fetus and contribute to maternal fatigue. This fatigue increasespain perception and decreases the woman’s ability to cope with the pain.Comfort measures such as massage, techniques for decreasing anxiety andclient teaching can contribute to relaxation.Breathing Techniques – Used correctly, they increase the woman’s pain threshold,permit relaxation, enhance the woman’s ability to cope with contractions, providea sense of control, and allow the uterus to function more efficiently. Slow pacedbreathing is when the woman inhales slowly through the nose, moves her chestup and out during the inhalation, and exhales through pursed lips. The breathingrate is 6-9 breaths a minute. Modified paced breathing. The woman starts with acleansing breath and at the end of the breath she pushes out a short breath. Shethen inhales and exhales through the mouth at a rate of 4 breaths every 5 seconds.Pant blow breathing – It is similar to modified breathing except the breathing ispunctuated every few breaths by a forceful exhalation through pursed lips.Hyperventilation – is the result of an imbalance of oxygen and carbon dioxide(too much carbon dioxide and is exhaled and too much oxygen remains in the body).The signs and symptoms of hyperventilation are tingling or numbness in the tip ofthe nose, lips, fingers, or toes; dizziness; spots before the eyes; or spasms of thehands or feet. If this happens the woman should be encouraged to slow down herbreathing and take shallow breaths.
17 Second Stage of LaborFrom complete opening of the cervix to delivery of the baby. This stage averages about 45 to 60 minutes in the first pregnancy and 15 to 30 minutes in subsequent pregnanciesTable Nursing Assessment / Mother & Fetuspp. 449Key Facts to Remember – pp. 449
18 Nursing Care – Second Stage Provision of careComplete DilatationMore frequent VSAssist with positioning, breathing, & pushingPromotion of ComfortRest between UC’sGotta save energy for entire child birthAssisting during birthRoom preparedBirthing positionsCleansing the PerineumPreparation and to prevent infections
19 The second stage is reached when the cervix is completely dilated (10 cm). The uterine contractions continue as in the transition phase. Maternal pulseis assessed as the onset of the second stage. BP – every 30 min, but maybe done more frequently if fetal decelerations or bradycardia occur. FHRevery 15 min. in low risk women and every 5 min in high risk women.Promotion of comfort – Rest between contractions.Assist during birth – Birthing positionsUpright considered normal for most societies until modern times Squatting,kneeling standing and sitting positions for birth.Lithotomy – became common in the 20th century because of the convenienceif offered in applying new techniques.Evidenced based practice research has shown squatting results in fewerinstrumental deliveries, fewer episiotomy extensions and less perineal tears.Cleansing the perineum – After the woman has been positioned for birth,clean the perineal area to increase her comfort, to remove the bloodydischarge that is present before the actual birth, and to prevent infection.
20 Third Stage of LaborFrom delivery of the baby to delivery of the placenta. This stage usually lasts only a few minutes but may last up to 30 minutes
21 Apgar ScoringScore at 1minute than again at 5min.
22 Cord Blood Collection Banking Immediately after cord clamped & cut, Dr. withdraws blood from cord veinCord blood transferred to container from Cord Blood RegistryNurse follow directions for storage & pickupBlood can be used to treat childhood cancer, rare genetic disorders, cerebral palsyMain drawback is the cost
23 Nursing Care – Third Stage Initial Care of the NewbornPlaced on mother’s abdomen or under radiant warmerApgar at 1min and 5minAssess Umbilical cord for 3 vesselsCord blood bankingPractice for chance that infant may need stem cells laterPhysical assessmentNewborn IDMom, dad, and two for the newborn
24 Nursing care during the third and fourth stages focuses on initial care of the newborn, enhancing attachment, assisting with placenta delivery, andproviding care for the mother.Initial care of the newborn – the newborn is dried immediately and wetblankets are removed. The newborn’s nose and mouth are suctioned witha bulb syringe as needed.Apgar Scoring System – Apgar is used to evaluate the physical conditionof the newborn at birth. The newborn is rated 1 minute after birth andagain at 5 minutes and receives a total score ranging from 0 – 10 basedon the following assessments: Heart rate, respiratory effort, muscle tone,reflex irritability and skin color. If the Apgar score is less than 7 at 5minutes, the scoring should be repeated every 5 minutes up to 20 minutes.A score of 7 to 10 indicates a newborn in good condition who requires onlynasopharyngeal suctioning and perhaps some oxygen near the face. It thescore is below 7, resuscitative measures may need to beinstituted. Apgarscores of less than 3 at 5 minutes, post-birth may correlate with neonatal mortality.
25 Assess Umbilical cord for 3 vessels – When the cord is cut the nurse examines the cut end of the cord for the presence of two arteries and one vein. Theumbilical vein is the largest vessel, and the arteries are seen as smaller vessels.The number of vessels is recorded on the birth and newborn vessels. The mostcommon type of cord clamp is the plastic Hollister clamp. The Hollister clamp isremoved in the newborn nursery approximately 24 hours after the cord has dried.In recent years, the timing of umbilical cord clamping has been the focus ofdiscussion and research. In one study of preterm infants (equal to and less than 32gestational weeks), infants in the grouped with delayed cord clamping had fewerintraventricular hemorrhages and less late-onset sepsis.Cord Blood Collection for Banking – a blood sample is obtained from the umbilicalcord by inserting a large gauge needle into the umbilical vein. The needle allowsthe blood to be collected into a special container that parents receive from theCord Blood Registry and bring with them for the birth. The collected blood canthen be used to treat childhood cancers, rare genetic disorders, and cerebral palsy.The main drawback of cord blood banking remains the cost.
26 Newborn Physical Assessment by the Nurse – the nurse notes the size of the newborn and the contour and size of the head in relationship to the rest of thebody. The newborn’s posture and movements indicate tone and neurologicalfunctioning. Inspects the skin for discoloration, presence of vernix caseosa andlanugo, and evidence of trauma. Vernix is a white cheesy substance foundnormally on newborns. It is absorbed within 24 hours after birth. It is abundant onpreterm infants and absent on post term newborns. The nurse also observes thenares for flaring, inspects the palate for cleft palate, respiratory rate and presenceof retractions. A normal respiratory rate is 30 to 60 per minute. Absence of breathsounds on one side could indicate a pneumothorax.Newborn ID – Id bands typically come in a set of four, all preprinted with identicalnumbers. Two bands are placed on the newborn, one on the wrist and one on theankle. They must fit snugly to prevent their loss.
27 Birth of Placenta Uterus rises up in abdomen Umbilical cord lengthens Trickle of bloodUterus shape changes from a disk to a globeAfter birth, the physician prepares for the delivery of the placenta.The following signs suggest placental separation: pp. 456-Uterus rises up in the abdomen-Umbilical cord lengthens-Sudden trickle of blood appears-Uterus changes shapeWhile waiting for these signs, the nurse palpates the uterus to check forbogginess and fullness caused by uterine relaxation and subsequent bleedinginto the uterine cavity. Pitocin is frequently given at delivery of the placenta,so the uterus will contract and bleeding will be minimized.
28 Nursing Care – Fourth Stage Placenta – inspect for missing piecesEpisiotomy repairEpisiotomy- surgical incision of the perineum to enlarge the vagina and so facilitate delivery during childbirthUterus midline and firmCleanse perineum with warm H2O and place ice to perineumMonitor maternal VSWarm blanketsEnhancing attachment
29 Fourth Stage of Labor is aftercare. Pp.458 Recovery Period (1 – 4 hrs.)Earley interation (1st hr)> newborn in quiet state> can look at parents> can turn head, response to voice> early breast feedingPalpate fundus frequently – 1st 4 hr. after birthIf soft massage until firmSupport lower portionClean gownRemove soiled linenTable 19-9 – Maternal adaptation after birth – pp. 459Facts to Remember – Immediate Post birth danger signsDecreased B/PTachycardiaUterine atonyExcessive bleedingHematoma
30 Nurse Attended Birth – Precipitous Birth Precipitous- “hastly done”, when the birth occurs in 3hrs or lessRemain with patientAmniotic sac intact – must ruptureApply gentle pressure to head to prevent tears to perineumCheck for nuchal cord after head deliveredSuction mouth & noseGentle traction on anterior shoulder then upward pressure on the posterior shoulderHold securely and place on mother’s abdomenClamp cord and cutWatch for signs of placenta delivering
31 Occasionally labor progresses so rapidly that the nurse is faced with the task of managing the actual birth of the baby. A precipitous birth occurs when thelabor and birth occur in 3 hours or less. The amniotic sac must be rupturedso the newborn will not breathe in amniotic fluid with the first breath.Check of nuchal cord after head is delivered – (umbilical cord around the neck).If there is a nuchal cord, the nurse bends her fingers like a fish hook,grasps the cord, and pulls it over the baby’s head. It is important to checkthat the cord is not wrapped around the neck more than one time. If the cordis tightly looped and cannot be slipped over the baby’s head, two clamps areplaced on the cord, the cord is cut between the clamps, and the cord isunwound. Immediately after birth of the head, the nurse suctions the baby’smouth and nasal passages. The head will then rotate to one side or the other.The nurse then places one hand on each side of the head, over the fetal ears.Care should be taken to ensure that the hands are not exerting pressure on thefetal neck. The nurse then exerts gentle downward traction until the anteriorshoulder is seen, gentle upward traction is used to aid the birth of the posteriorshoulder. The nurse then instructs the woman to push gently so that the rest ofthe body can be born quickly. The newborn is held at the level of the uterus tofacilitate blood flow through the umbilical cord. The umbilical cord may now be cut.The nurse places two Kelly clamps approximately 1 to 3 in from the infants abdomen.The cord is cut between the Kelly clamps with sterile scissors.
32 Record in Birth Record Book Position of fetus at birthCord – neck, shoulderTime of birthApgar score, 1 & 5 minuteGenderDelivery time of placentaMethod of expulsionAppearance & intactnessMother conditionAny Medication given to mother or newborn