Care of the Family in Childbirth - Tie everything together Care of the Family in Childbirth Sue Nesbitt, RN, MSN

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.

Reasons to come to the Hospital Rupture of membranes Regular, frequent uterine contractions Primigravida – 5 minutes apart for 1 hour Multigravidas – 6-8 minutes apart for 1 hour Any vaginal bleeding Decreased fetal movement During her prenatal visits the woman is instructed to call her healthcare provider and come to the birthing unit if any of the following occur:

Admission Initial encounter sets tone Explanation of procedures and policies Informed consent obtain at this time, and also done BEFORE any pain meds Intrapartal 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 preeclampsia Lab – H&H, Blood type & crossmatch, platelets (to detect for bleeding problems) To answer any circulatory questions ID bands Notify physician

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 the woman that she is important. Following the initial greeting, provide a quick yet thorough orientation to the facility such as the location of the restrooms and nurse call system. These simple steps can go along way in helping the couple feel comfortable. The woman may be facing a number of unfamiliar procedures that may seem routine for healthcare providers.Informed consents should be obtained during this time (before pain medications are given and it allows the nurse an opportunity to explain upcoming procedures). Assessment of FHR, vaginal exam, and a measure of uterine contractions should take place next to determine a baseline of where the patient is in relationship to which stage of labor she is in. For instance, if the FHR is less than 110 beats per minutes a fetal monitor should be placed immediately to obtain additional data. Assess the woman’s BP once the FHR monitor is in place

. Then obtain lab specimens etc. Check urine for glucose, protein, ketones by using a dipstick before you send the specimen to the lab. This is especially important if edema or elevated blood pressure is present. Proteinuria of +1 or more may be a sign of impending preeclampsia. Glycosuria (elevated glucose) is found frequently in pregnant women because of the increased glomerular filtration rate in the proximal tubules and the inability of these tubules to increase reabsorption of glucose. It may also be an indication of gestational diabetes and should not be discounted. H/H values help determine the oxygen carrying capacity of the circulatory system and the woman’s ability to withstand blood loss at birth. Elevation of the hematocrit indicates hemoconcentration of blood, which occurs with edema or dehydration. A low hemoglobin, in the absence of other evidence of bleeding, suggests anemia. Blood may be typed and cross matched if the woman is in a high risk category. Platelets are evaluated as well because low platelets can lead to bleeding problems. Low platelets are also a contraindication for epidural anesthesia. A type and cross match is performed in case the woman needs to get blood products in an emergency.

First Stage of Labor pg First 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.

Nursing Care – First Stage Integration of Family Expectations Safety of mom & baby Specific expectations – birth plan Nursing support Emotional support Comfort measures Information and advice Advocacy Support of partner Cultural Beliefs Modesty Pain expression Specific Beliefs

Families sometimes come to the hospital with very specific plans regarding delivery. Sometimes the plans are unrealistic which lead to increased stress and anxiety, and in the end disappointment. Review the plan with the family and try to accommodate when and if you can, but be aware of safety for mom and baby. Cultural Beliefs Within every culture, each person develops his or her own beliefs, values, and behaviors. Modesty – an important consideration. The nurse needs to be alert to the woman’s responses to examinations and procedures and provide appropriate draping and privacy. In particular, Middle Eastern woman are not accustomed to male physicians and attendants. Orthodox Jewish women may follow several Jewish laws during childbearing period. The law of Tznuit requires the woman to maintain modesty In order to preserve dignity. The woman may prefer a gown that covers her elbows and knees. She may also wish a hair covering such as a wig, scarf, or other form of head covering. The men typically do not observe the woman while she is changing and should be given the opportunity to leave the room to maintain the woman’s dignity.

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 may not 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 to avoid dishonoring herself or her family. Japanese women often prefer natural childbirth and prefer to eat during labor.

Assessments of First Stage Latent Table 19-1, pg 439-40 VS, Temp Temp q4 hours unless ROM Check to see if membranes have ruptured FHR, fetal activity Q 30min for low risk women Q15min for high risk women Assess Uterine contraction NPO – ice chips Active VS q 1 hour, Pain control Bladder status FHR ROM and increased bloody show, prolapse of cord FHR monitoring Transition Changes in Mood (don’t be surprised) Assistance with breathing - monitor for hyperventilation

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 every 30 minutes for high risk women. Active – BP, HR, Resp. every hour if in normal range. Uterine contractions palpated every 15 to 30 minutes. Empty bladder (a full bladder will delay the progression of the baby descending). FHR every 30 minutes for low risk women and every 15 minutes for high risk women. During this phase, the cervix dilates from 4 – 7 cm, and vaginal discharge and bloody show increase. If the membranes have not ruptured, they will during this phase. The nurse needs to note the amount, color, odor, and consistency of 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 of the umbilical cord. The concern is that the amniotic fluid coming through the cervix will propel the umbilical cord through the cervix. The FHR is auscultated because a drop in the rate might indicate an undetected prolapsed cord. Immediate intervention in necessary to remove pressure on a prolapsed umbilical cord.

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, effacement is complete (100%) and there is usually a heavy amount of bloody show. Sterile vaginal exams may be done more frequently because this stage of labor usually is accompanied by rapid change. Maternal BP,HR, Resp are monitored when the FHR is assessed (FHR is assessed every 30 min for low risk and 15 minutes for high risk women). A gentle reminder to slow down your breathing can help prevent hyperventilation. The woman will begin to feel pressure as the fetal presenting part moves down the birth canal. The nurses should encourage the woman to refrain from pushing until the cervix is completely dilated. This will help prevent cervical edema.

Promotion of Comfort: First stage pg441 Identify goals General comfort measures Positions,…, full, bladder, fear- explain what to expect Anxiety Watch for tingling: lips fingers, toes. Control breathing, take shallow breaths Client teaching Supportive Relaxation techniques Breathing techniques

In planning care, talk to the woman and her partner to identify goals. Usually a priority is concern with discomfort. Factors – uncomfortable positions, infrequent position changes, diaphoresis, continual leaking of amniotic fluid, a full bladder, a dry mouth, anxiety, and fear. General Comfort – The woman is encouraged to walk as long as there are no contraindications, such as vaginal bleeding or rupture of membranes before the fetus is engaged in the pelvis. A side-lying position is generally advantageous, although frequent position changes seem to achieve more efficient contractions. If the woman is more comfortable on her back, the head of the bed should be elevated to relieve the pressure of the uterus on the 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’s ability to deal with it. Ways to decrease anxiety not related to pain are to give information (which eases fear of the unknown), establish a rapport with the couple (which helps them preserve their personal integrity), and express confidence 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.

Supportive Relaxation Techniques – Tense muscles increase resistance to the descent of the fetus and contribute to maternal fatigue. This fatigue increases pain perception and decreases the woman’s ability to cope with the pain. Comfort measures such as massage, techniques for decreasing anxiety and client 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, provide a sense of control, and allow the uterus to function more efficiently. Slow paced breathing is when the woman inhales slowly through the nose, moves her chest up and out during the inhalation, and exhales through pursed lips. The breathing rate is 6-9 breaths a minute. Modified paced breathing. The woman starts with a cleansing breath and at the end of the breath she pushes out a short breath. She then 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 is punctuated 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 of the nose, lips, fingers, or toes; dizziness; spots before the eyes; or spasms of the hands or feet. If this happens the woman should be encouraged to slow down her breathing and take shallow breaths.

Second Stage of Labor From 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 pregnancies Table 19-5 Nursing Assessment / Mother & Fetus pp. 449 Key Facts to Remember – pp. 449

Nursing Care – Second Stage Provision of care Complete Dilatation More frequent VS Assist with positioning, breathing, & pushing Promotion of Comfort Rest between UC’s Gotta save energy for entire child birth Assisting during birth Room prepared Birthing positions Cleansing the Perineum Preparation and to prevent infections

The second stage is reached when the cervix is completely dilated (10 cm). The uterine contractions continue as in the transition phase. Maternal pulse is assessed as the onset of the second stage. BP – every 30 min, but may be done more frequently if fetal decelerations or bradycardia occur. FHR every 15 min. in low risk women and every 5 min in high risk women. Promotion of comfort – Rest between contractions. Assist during birth – Birthing positions Upright 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 convenience if offered in applying new techniques. Evidenced based practice research has shown squatting results in fewer instrumental 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 bloody discharge that is present before the actual birth, and to prevent infection.

Third Stage of Labor From delivery of the baby to delivery of the placenta. This stage usually lasts only a few minutes but may last up to 30 minutes

Apgar Scoring Score at 1minute than again at 5min.

Cord Blood Collection Banking Immediately after cord clamped & cut, Dr. withdraws blood from cord vein Cord blood transferred to container from Cord Blood Registry Nurse follow directions for storage & pickup Blood can be used to treat childhood cancer, rare genetic disorders, cerebral palsy Main drawback is the cost

Nursing Care – Third Stage Initial Care of the Newborn Placed on mother’s abdomen or under radiant warmer Apgar at 1min and 5min Assess Umbilical cord for 3 vessels Cord blood banking Practice for chance that infant may need stem cells later Physical assessment Newborn ID Mom, dad, and two for the newborn

Nursing care during the third and fourth stages focuses on initial care of the newborn, enhancing attachment, assisting with placenta delivery, and providing care for the mother. Initial care of the newborn – the newborn is dried immediately and wet blankets are removed. The newborn’s nose and mouth are suctioned with a bulb syringe as needed. Apgar Scoring System – Apgar is used to evaluate the physical condition of the newborn at birth. The newborn is rated 1 minute after birth and again at 5 minutes and receives a total score ranging from 0 – 10 based on the following assessments: Heart rate, respiratory effort, muscle tone, reflex irritability and skin color. If the Apgar score is less than 7 at 5 minutes, 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 only nasopharyngeal suctioning and perhaps some oxygen near the face. It the score is below 7, resuscitative measures may need to beinstituted. Apgar scores of less than 3 at 5 minutes, post-birth may correlate with neonatal mortality.

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. The umbilical 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 most common type of cord clamp is the plastic Hollister clamp. The Hollister clamp is removed 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 of discussion and research. In one study of preterm infants (equal to and less than 32 gestational weeks), infants in the grouped with delayed cord clamping had fewer intraventricular hemorrhages and less late-onset sepsis. Cord Blood Collection for Banking – a blood sample is obtained from the umbilical cord by inserting a large gauge needle into the umbilical vein. The needle allows the blood to be collected into a special container that parents receive from the Cord Blood Registry and bring with them for the birth. The collected blood can then be used to treat childhood cancers, rare genetic disorders, and cerebral palsy. The main drawback of cord blood banking remains the cost.

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 the body. The newborn’s posture and movements indicate tone and neurological functioning. Inspects the skin for discoloration, presence of vernix caseosa and lanugo, and evidence of trauma. Vernix is a white cheesy substance found normally on newborns. It is absorbed within 24 hours after birth. It is abundant on preterm infants and absent on post term newborns. The nurse also observes the nares for flaring, inspects the palate for cleft palate, respiratory rate and presence of retractions. A normal respiratory rate is 30 to 60 per minute. Absence of breath sounds on one side could indicate a pneumothorax. Newborn ID – Id bands typically come in a set of four, all preprinted with identical numbers. Two bands are placed on the newborn, one on the wrist and one on the ankle. They must fit snugly to prevent their loss.

Birth of Placenta Uterus rises up in abdomen Umbilical cord lengthens Trickle of blood Uterus shape changes from a disk to a globe After 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 shape While waiting for these signs, the nurse palpates the uterus to check for bogginess and fullness caused by uterine relaxation and subsequent bleeding into the uterine cavity. Pitocin is frequently given at delivery of the placenta, so the uterus will contract and bleeding will be minimized.

Nursing Care – Fourth Stage Placenta – inspect for missing pieces Episiotomy repair Episiotomy- surgical incision of the perineum to enlarge the vagina and so facilitate delivery during childbirth Uterus midline and firm Cleanse perineum with warm H2O and place ice to perineum Monitor maternal VS Warm blankets Enhancing attachment

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 feeding Palpate fundus frequently – 1st 4 hr. after birth If soft massage until firm Support lower portion Clean gown Remove soiled linen Table 19-9 – Maternal adaptation after birth – pp. 459 Facts to Remember – Immediate Post birth danger signs Decreased B/P Tachycardia Uterine atony Excessive bleeding Hematoma

Nurse Attended Birth – Precipitous Birth Precipitous- “hastly done”, when the birth occurs in 3hrs or less Remain with patient Amniotic sac intact – must rupture Apply gentle pressure to head to prevent tears to perineum Check for nuchal cord after head delivered Suction mouth & nose Gentle traction on anterior shoulder then upward pressure on the posterior shoulder Hold securely and place on mother’s abdomen Clamp cord and cut Watch for signs of placenta delivering

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 the labor and birth occur in 3 hours or less. The amniotic sac must be ruptured so 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 check that the cord is not wrapped around the neck more than one time. If the cord is tightly looped and cannot be slipped over the baby’s head, two clamps are placed on the cord, the cord is cut between the clamps, and the cord is unwound. Immediately after birth of the head, the nurse suctions the baby’s mouth 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 the fetal neck. The nurse then exerts gentle downward traction until the anterior shoulder is seen, gentle upward traction is used to aid the birth of the posterior shoulder. The nurse then instructs the woman to push gently so that the rest of the body can be born quickly. The newborn is held at the level of the uterus to facilitate 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.

Record in Birth Record Book Position of fetus at birth Cord – neck, shoulder Time of birth Apgar score, 1 & 5 minute Gender Delivery time of placenta Method of expulsion Appearance & intactness Mother condition Any Medication given to mother or newborn