1. Intrapartum Nursing Care
On Admission
Induction/Cesarean Section
Care in 1st, 2nd, 3rd, and 4th Stages of Labor
Precipitous/Out-of-Hospital Delivery

2. When to go to Hospital Regular Contractions with  intensity SROM
Vaginal Bleeding
Changes in Fetal Movement—especially a  in fetal movement as described in the Daily Fetal Movement Count

3. On Admission to Hospital
Evaluate Is this True Labor?
IMMINENCE OF DELIVERY
Condition of mother
Condition of fetus
Previous experience with labor
Childbirth education—Lamaze, Childbirth preparation, breastfeeding, cesarean section class
Is there a BIRTH PLAN?Any plans for anesthesia?

4. Identify Patient Note time of arrival/reason for admission
Pt’s name, MD-both Obstetrician and pediatrician
Plans to breast or bottle feed
Assess when she last ate or drank
Assess support person and what they perceive as their role in the labor process.
Remember to introduce yourself as the RN and explain all assessment parameters and interventions in simple terms

5. Review Prenatal History
EDC/EDD Is baby term?
OB History: GTPAL status, previous labors
Medications taken during pregnancy including Prenatal vitamins and Iron
Use of alcohol, illicit drugs, tobacco during pg
Labs (Blood Type & Rh, Rubella, Beta Strep, MSAFP, VDRL/RPR, GC culture)
Diagnostic Tests (Amniocentesis, Ultrasound)
Allergies
Complications (Medical/OB)—chronic illnesses, BP, dysuria, edema of hands and face, etc.

6. Physical Assessment on Admission
Maternal Vital Signs—between contractions
Fetal Status—baseline FHR, accels/decels, fetal movement and FHR response
Labor Status
Contractions—frequency, duration, intensity
Vaginal Discharge (??SROM = NO GEL)—bloody show?, color and odor of amniotic fluid if SROM, use Nitrazine paper to assess SROM
Vaginal Changes—dilatation, effacement
Descent of Fetus– Presentation, Station, Position

7. Physical Assessment, cont’d
Abdominal Exam
Assess bowel sounds laterally
Assess fundal height
Perform Leopold’s Maneuvers
Chest
Assess heart and lung sounds
DTR’s
Assess patellar reflexes bilaterally
Note hyperreflexia, if +3-+4, check for clonus

8. Psychosocial Assessment on Admission
Mother’s Status—in early labor, pt is often excited, teachable, and talkative. As labor progresses, anxiety increases as pain increases & the ability of the pt to focus decreases. Noting these variables helps the nurse determine the progress of labor
Support Persons—assess who they are & how they expect to participate in the labor process e.g. active labor coach vs. observer
Nurse’s Role—support pt and significant others and encourage to verbalize fears & concerns. Evaluate how best to provide Family-Centered Care for this family system

9. Admission/Diagnostics
CBC (Hgb, Hct), Type/Rh (if unknown)
U/A
Dipstick—often done in the lab
Glucose
Albumin
U/A if ordered
Blood Type and Cross-match for C/S only

10. Nursing Care On Admission
Place EFM ASAP—Assess fetal status
Do Vag Exam—Assess Labor Status
Complete OB Paperwork
Assessment, Hx, Database, PG Hx, Vitals
Check Orders
Start IV, especially if pt wants epidural soon
Lab Work
Orient to Room

11. ALWAYS assess FHR AFTER AROM or SROM
(risk of prolapsed cord)
BEFORE starting Pitocin for Induction
Throughout induction
BEFORE & AFTER analgesia/anesthesia

12. Induction
Definition: artificial initiation of labor before spontaneous onset of contractions after the period of viability.
Augmentation: Stimulation of contractions after labor has begun to strengthen contractions
Indications: see pg 628; 10th edition
Readiness
FETAL: Fetal well-being (Reactive NST), Amniocentesis L:S ratio >2:1, BPP >8, EDD
MATERNAL: Use of Bishop’s Scale where the most significant parameter is cervical readiness.

13. Bishop’s Scale for measuring Induction Readiness
Table 1. Bishop Scoring System
Factor
Score
Dilation (cm)
Effacement (%)
Station*
Cervical Consistency
Position of Cervix
Closed
0-30 -3
Firm
Posterior 1
1-2
40-50 -2
Medium
Midposition 2
3-4
60-70
-1,0
Soft
Anterior 3
5-6 80
+1,+2 --
*Station reflects a . 3 to +3 scale.
Modified from Bishop EH. Pelvic scoring for elective induction. Obstet Gynecol 1964;24:267
Favorable cervix: in multipara, a score of >5
in primipara, a score of >7-9
Unfavorable cervix (low score) is associated with prolonged
labors and  risk of cesarean delivery.

14. Methods of Staged Induction–especially used if cervix is not ripe
Laminaria– seaweed is hydrophilic and absorbs water thus swelling in the cx and causing it to dilate. MD places these in the external os of the cx and allows the “tent” to swell overnight.
Transcervical Balloon—mechanical method of dilating cx.
Prostaglandin–(PGE2, PGF2)a a variety of forms from gels inserted transvaginally, to suppositories, or vaginal inserts help soften the cervix and initiate contractions.
Dinoprostone (Cervidil) 10mg vaginal insert inserted once.
Misoprostol (Cytotec) 25mcg tab inserted into the cervical os q4h.

15. Nurse’s Role in Prostaglandin E-2 (PGE-2) Monitoring
Should have signed consent
NST to establish fetal well-being
Pt. Lies supine for insertion.
Pt remains in bed for 30-60min after gel and 2hrs after insert . Some moms stay in hospital overnight and have Oxytocin induction in AM.
Monitor uterine and fetal activity continuously for 1st 1-2 hrs. post insertion.
Assess maternal VS hourly X 2, then q 4.

16. Nurse’s Role in Prostaglandin E-2 (PGE-2) Monitoring
Cervidil
After 2 hours, pt is encouraged to walk. She may be advised to go home if no active labor evident, & instructed to return if BOW breaks, contractions become more regular, or fetal movements decrease.
RISKS: uterine hyperstimulation, but uncommon if properly inserted.
Be prepared to remove excess gel with gauze squares or remove Cervidil insert in cases of hyperstimulation.

17. Methods of Induction-- when Cervix is ripe and ready
AROM/Amniotomy
Potential complication: a. Infection b. Prolapsed cord c. Fetal head or cord compression
Contraindications: a. When presenting part is floating high b. If fetus is in a breech or transverse lie

18. Methods of Induction-- when Cervix is ripe and ready
Nursing Care after AROM: a. Assessment– FHT of baby immediately VS of mom before & after, Temp q 2h thereafter Assess color & odor of fluid immediately b. Intervention/Plan– -Explain procedure to pt -Prepare room: supine position, sterile gloves, for MD, KY lubricant, Amniotome or Fetal Scalp Electrode -Change waterproof pads under pt prn.
c. Evaluation— FHR remains stable, pt is comfortable

19. Methods of Induction-- when Cervix is ripe and ready
Oxytocin (Pitocin)
Uses:
induce rhythmic uterine contractions
augment weak or ineffective contractions.
promote uterine contraction in 4th stage of labor

20. Oxytocin (Pitocin)
Contraindications: *any obstruction that interferes with fetal
descent *any risk of uterine rupture(e.g..VBAC) *hypertonic uterus *existing fetal distress (e.g. positive CST) *placenta previa *genital herpes (active lesions)

21. Oxytocin (Pitocin)See box in text
Mixed with LR, D5LR, or D2NS(depends on MD)
Amount: your text adds 10U to 1000ml
BRMC and St. Joseph adds 30U to 500ml
Rate: follow MD’s orders. AWHONN guidelines recommend to begin with .5-2mU/min and increase by 1-2mu q15-60 minutes until contractions are q2-3min in frequency and sec. duration. Maximum dose: 20-40mU./min

22. CALCULATING Pitocin rates: 10U added to 1000ml= 10U/1000ml
Oxytocin (Pitocin)continued MD Order: Start Oxytocin 1mU/min and increase by 1mU/min q 20minutes
CALCULATING Pitocin rates:
10U added to 1000ml= 10U/1000ml
10U X 1000mU= 10000mU/1000ml=10mu/ml
Remember: you must convert mU/min to ml/hr to set the rate on the IV pump
1ml/10mU X 60min/hr X 1mU/min=6ml/hr So, 1mU/min= 6cc/hr
If you are to give the patient 5mU/min, at what rate will you set the pump?
5mU/min X 1min/mU X 6cc/hr=30cc/hr

23. IF the Oxytocin bag has 30U in 500ml, and you have the same MD order, this is the formula:
500ml X U X 1mU X 60min = 1ml 30U mU min hr hr
If the IV pump reads 12 ml/hr , how much Oxytocin is the patient receiving?

24. Oxytocin (Pitocin)—Nurse’s Role
Assess & record FHR q15min if Oxytocin, variability, accels
Assess & record Uterine activity q15-30min.
Assess & record Maternal BP q 15-30min.
Assess & record Maternal I & O continuously. IV Oxytocin can lead to water intoxication Output should be 120cc/4hr or 30-35cc/hr.
Assess pt sensitivity and pain after initiation of med.

25. Oxytocin (Pitocin) 2 dangers with Oxytocin administration
Tachysystole: Increased strength, length, and frequency of contractions may lead to uteroplacental insufficiency 2ndary to hypertonicity of uterus
Birth injuries: For fetus: rapid descent through pelvis may cause fetal bruising, petechiae, injury
For mom: may predispose her to cervical lacerations, uterine rupture, placenta abruptio, amniotic fluid embolism.

26. Oxytocin (Pitocin) Nursing Care (see text )
Monitor IV closely– Mainline LR and IV Pitocin should generally equal 125cc/hr
Monitor contractions closely– If >90sec. In duration or >frequent than q2min, D/C Pit.
Monitor FHR– Watch for late decels, bradycardia <100 bpm, or tachycardia>180 bpm
Monitor maternal VS and I & O regularly

27. Nursing Care-- 1st Stage of Labor
Frequency of Assessments—See next slide
Uterine Contraction- assess frequency, duration, intensity
Vaginal Exams / “Bloody Show”
Fetal Position / Heart Rate
Leopold Maneuvers
Location of FHT’s
Status of Membranes

28. Minimal Assessment of the Low-Risk Woman During the
1st Stage of Labor
Cervical Dilatation
0-3cm (latent)
4-7cm (active)
8-10 cm (transition)
BP, P, R
q min.
q30 min
q min
Temperature
q 4h
Uterine activity
q min
q min
q min
FHR
q15-30 min
q15-30
Vaginal Show
q 30 min
q 15 min
Behavior, Appearance,
Energy Level
q 5 min
Vaginal exam prn to

29. Vaginal Exam done only prn to identify progress of labor
1. To confirm change in cervix when sx indicate (e.g. strength, duration, or frequency of contractions;  in amt of bloody show; ROM; or woman feels pressure on her rectum)
2. To determine whether dilation and descent are sufficient for administration of analgesic or anesthetic
3. To reassess progress if labor takes longer than expected
4. To determine station of presenting part

30. Signs of Transition (8-10cm)
 in bloody show
Nausea and vomiting
Increased rectal pressure
Desire to push
 ability to focus due to intensity and frequency of contractions

31. Nursing Care / Psychosocial
Confidentiality
Be Respectful
Supportive Care / Include Support Persons
Use of Touch
Reassurance / Gentle Coaching
Modesty

32. Nursing Care / Physical
Positioning
Hydration
Bladder
Dealing with Contractions

33. Signs of Potential Complications
Rising Intrauterine Pressures
Contractions > 90 sec. Or < 2 minutes apart
Fetal bradycardia, tachycardia, decreased variability
Meconium-stained, bloody or foul-smelling fluid from vagina
Arrested progress of labor
Maternal temperature > 38 o C
Persistent bright or dark-red vaginal bleeding

34. Amnioinfusion
Warmed, sterile NS or Ringer’s Lactate infused INTO uterus via Intrauterine Pressure Catheter (IUPC; 250 – 500 cc)
Increase Intrauterine Fluid Volume
Intrauterine infusion may be used to treat problems related to fetus
Thick Meconium
Decelerations r/t Cord Compression

35. Contraindications for Amnioinfusion
Omnious FHR
Umbilical Cord Prolapse
Significant Vaginal Bleeding
Uterine Hypertonia

36. Nursing Care during Amnioinfusion
Note every 15 minutes
Maternal B/P, Pulse
FHR
Contraction Pattern
Uterine Resting Tone
Strict Bedrest
Comfort, Reassure
DANGER  Rising Resting Tone  Uterine Rupture

37. Nursing Care-2nd Stage of Labor
Assessments -- See next slide
Signs of Fetal Descent
Uncontrollable Urge to Push
Bulging of the Perineum
Anal Changes
Introitus Opens
Crowning
Burning/stretching sensation in perineum

38. Assessment during 2nd stage
BP, P, R
q 15 min.
Temperature*
q 2h if ROM
Uterine activity
q 5-15 min
FHR
Low-risk: q 15 min if EFM is not used & continuously if it is used
High risk: q 5 min if EFM is not used & continuously if it is used
Vaginal Show
Fetal Descent
q 5 min or continuous

39. Assessment in 2nd stage (cont’d)
Status of bladder
especially in women who have an epidural block
Behavior, Appearance
Energy Level
Include assessment of emotional response of woman and partner to 2nd stage.
Continuously

40. Signs of fetal descent Uncontrollable urge to push Bulging of perineum
Anal changes—eversion, passage of stool
Vaginal introitus opens
Crowning
Burning/stretching sensation on perineum

41. Nursing Care- Psychosocial Assessments
Less Irritated
VERY focused on work of Birth
More Cooperative
Doze off between Contractions
May be exhausted
Little modesty at this point

42. Nursing Care—Physical/Psychological Support
Positions for Pushing
Lithotomy/semi-fowler’s
Sim’s/Side-lying
Squatting
Kneeling
Breathing
Open glottis~groaning/grunting
Prolonged pushing~  O2 to baby
Cleansing breath & deep breath between pushes

43. Physical/Psychological Support
Environment
Quiet between contractions to allow for rest
Massage legs if pt c/o of leg cramping
Psychological Support
ENCOURAGE mom through each push
1 person give short, explicit instructions
Offer LOTS of praise for effort
Keep thinking with the end in mind!

44. Prepare for Delivery Continue Emotional Support of Mom & S.O.
Instrument Table (Tech usually does)
Infant Warmer, Resuscitation, ID
O2, DeLee & Suction, Meds, Laryngoscope Light, Bulb Syringe,
Medical Support for Mom
O2,, Suction, Pitocin
“Break Bed” when Doctor is on the way or present

45. Other Responsibilities
Prep/wash perineum
Keep a watch on fetal status through each contraction
Provide scalp stimulation prn
Pour mineral oil in and around perineum to help stretch perineum and  need for epis
Note type of episiotomy/laceration
Note time of delivery

46. Other Elective Procedures Episiotomies
Definition: surgical incision of the perineum performed more with primiparas than multiparas. A controversial procedure done more by MD’s than CNM’s. Performed just prior to delivery when the presenting part is crowning, usually performed under regional or local anesthesia.

47. Episiotomies
Mediolateral: start at midline and a 45 degree angle to the R or L.
Advantage: avoids trauma to rectum, may provide more room
Disadvantage: increased blood loss, longer time to heal, > discomfort during early pp period.

48. Episiotomies
Midline/median– begins at midline and may extend down the midline through the perineal body.
Advantages: easy to repair, heals with less discomfort for mom
Disadvantage: if episiotomy extends, it may tear through the rectum

51. Perineal Lacerations
1st Degree: extends through the skin & structures superficial to muscles
2nd Degree: extends through muscles of perineal body
3rd Degree: tear extends through anal sphincter muscle
4th Degree: tear that involves the anterior rectal wall

52. Nursing Role with Perineal Repair
Assessment:
Note type of episiotomy/laceration
Note type of suture used and #
Assess perineum for REEDA q shift in pp period

53. Nursing Role with Perineal Repair
Interventions:
Encourage use of Topical Anesthetic Sprays (e.g. Benzocaine[Dermoplast]), witch hazel pads (Tucks)
Offer ice bag to perineum in 1st 12 hours pp
Encourage use of Sitz bath or perineal shower for 20” bid-tid, especially for 3rd & 4th Degree tears after 1st 12 hours
Offer donut pillow
Administer stool softener/laxative to prevent fear of tearing sutures with BM
Offer analgesics prn

54. Cesarean Delivery Indications Cephalopelvic disproportion (CPD)
Malpresentations -- Breech, transverse lie, face
Preterm Baby -- only when chance of increased risk to baby if delivered vaginally
Fetal Distress -- persistent late decelerations, poor variability
Cord/Placental Problems -- prolonged severe variable decelerations due to cord compression, prolapsed cord, placenta previa, abruptio placenta
STD's -- genital herpes
Uterine Dystocia -- failed induction, reason for induction persists, post-maturity

55. Pre-op Nursing Care
IV fluids-- Usually warm Lactated Ringer’s (LR) if spinal or epidural anesthesia
Labs--UA, CBC, type & crossmatch, Blood Chemistry
Consent forms signed
Abdominal shave/clip (per dr.order)
Foley catheter
Keep dad present and involved/allow privacy between couple when time allows
Explain all procedures--teach about return of sensation to lower extremities, T,C, & DB & pain management post-op

56. Pre-op Nursing Care (cont’d)
Remove all rings, jewelry, nail polish
Monitor labor status - FHR & contractions, till OR
Always maintain calm attitude
Administer an antacid e.g. Bicitra 30 cc. po approx. 30 min before surgery
Administer a prophylactic IV antibiotic (cefotaxime 1g)
Complete all admission hx and physical assessment documentation

57. Cesarean Section Skin Incisions Uterine Incisions
Nursing Care During C/Section
Reassure Mom during anesthesia induction.
Assess S.O. Coping
Care for Baby Immediately after Birth

58. Forceps web link on forceps and suction
Function: to provide traction, to rotate, or both in the second stage of labor
Midforceps: when fetal head is at the level of the ischial spines but above the +2 station (Rarely used)
Outlet forceps: when the fetal head is visible on the perineum without spreading the labia apart. They shorten the length of 2nd stage.
Requirements for forceps: Cx dilated 10cm, bladder empty, presenting part 0 station, vertex presentation, membranes ruptured.

59. Vacuum Extractor
A suction cap applied to fetal head traction is applied to facilitate fetal descent in 2nd stage of labor
Risks to fetus: cephalhematoma, scalp lacerations, subdural hematoma
Risks to mom: perineal, vaginal,or cervical lacerations
Requirements for vacuum: Cx dilated 10cm, bladder empty, presenting part 0 station, vertex presentation, membranes ruptured.

60. Indications for Forceps or Vacuum
Prolonged second stage
Maternal condition precludes pushing:
Heart disease, Pulmonary Edema
Exhaustion
Spinal, Epidural, Caudal Anesthesia– no sensation to effectively push
Fetal Distress–
late decels, poor variability. Bradycardia <100 for more that 2-3 minutes
Threat to mother’s life

61. Immediate nursing actions
Unwrap sterile packages and place onto sterile field or in sterile basin with betadine
Assess maternal/fetal status
Teach mom that she may feel increased pressure internally in vagina.
Coach mom through contractions to effectively push with traction by forceps of vacuum extractor

62. Nursing Actions after Delivery with Forceps or Vacuum
Check for sx of trauma to face, head, neck of baby, lacerations or forceps face marks in eye area
Check for increased ICP, lethargy, seizures, paralysis (facial nerve palsy)
Answer parents’ questions about possible trauma to their infant
Check mother for pp hemorrhage, vaginal or labial hematoma

63. Nursing Care-3rd Stage of Labor
Physical Assessments
Signs of Placental Separation
Gush of Blood
Cord Lengthens
Fundus rises in abdomen
Uterus becomes globular
Psychosocial Assessments

64. Placental Separation Uterus must contract firmly
Change in shape from a discoid to a globular ovoid shape as the placenta moves down into the lower uterine segment
Sudden gush of dark blood from introitus
More umbilical cord showing as it gets closer to the introitus
ON vaginal or rectal exam noticing fullness or seeing fetal membranes at the introitus

65. Shiny Schultz Shiny shultz indicates fetal surface appears first
Dirty Duncan means the maternal surface is delivering first
Of no clinical importance
Must be examined for intactness.
Make sure that no placental fragments or fetal membranes have been left behind.
Fourth stage will be discussed later.
Expected outcomes are that blood loss will be less than 500 ml.
Placenta will be expelled within 20 minutes.
Mother will be prepared for the sensations.

66. Dirty Duncan

67. Nursing Care—3rd Stage of Labor
Care of Mother – Physical
Encourage her to push AFTER placenta separates
Note time of Placental Expulsion
Add Oxytocin to IV or Open Oxytocin Drip
CHECK FUNDUS
Note how episiotomy repair is going
Care of Mother – Emotional

68. Nursing Care – 3rd Stage of Labor
Care of Newborn
Care after Episiotomy Repair
During C/Section
Note time of Placental Separation
Emotional Support to Mom and S.O.
ESTIMATE BLOOD LOSS

69. Nursing Care- 4th Stage of Labor
Greatest risk for Maternal Hemorrhage
At Risk for Hemorrhage
Physical Assessment
Fundus (Firm, Soft, “Boggy”)
Lochia, Amount, Color
Perineum (Intact, Swelling, Approximation)
VS (B/P, P, R)
Frequency--q 15” x 4; q 30” x 2; q 60” x 2

70. 4th Stage Nursing Care–C/Section
Immediate Post-Op Care
Check the following every 15 minutes till stable
V.S.—SaO2 , EKG pattern as well as TPR & BP
Lochia
Dressing
Fundus (very gently)
Foley—output appropriate
Return of sensation & mobility in toes & legs if spinal/epidural
Monitor IV with Pitocin infusing.
Offer O2 per mask prn
TCDB every 2 hrs. for 24 hr. (not as critical with epidural/spinal anesthesia
Medicate prn for pain if general anesthetic-Ketoralac 30mg IV q6h. NO narcotics if intrathecal morphine was administered.
Facilitate attachment - bring baby back to mom while she is recovering if possible; breastfeed baby

71. Post-op Care on Postpartum Unit
V.S. every 4 hr. initially proceeding to tid after first 24 hours ( Hospital Policy )
Observe incision and need for dressing change
Provide pain control
Assess fundal height, lochia, bladder/bowel status, hygiene
Perineal care: q 4 hr with indwelling catheter. Foley may remain for hrs, then give appropriate instructions when d/c’ing
Mothering skills - help with positioning infant at feedings due to incision; if breast-feeding, encourage use of football hold or side-lying position with pillow on abdomen
Encourage early ambulation to foster peripheral circulation and  peristaltic activity

72. Other Elective Obstetrical Procedures

73. External Cephalic Version
Definition: The alteration of fetal position by abdominal or intrauterine manipulation to accomplish a more favorable fetal position for vaginal delivery.
Indications:
Presenting part NOT engaged
Maternal abdominal wall thin enough to permit good palpation
NO uterine irritability or contractions
Adequate amniotic fluid, intact membranes
NO known history of CPD

74. Version– Nursing Interventions
Get consent for procedure and inform of possible emergency C/S
Prepare for ultrasound to confirm fetal position
Close monitoring of fetus via fetal monitoring, NST
Follow MD orders if tocolytic ordered to relax uterus
Nurse may need to assist to head down position by applying pressure over fetal head (pubic area) to encourage fetus to stay in cephalic presentation.
Monitor maternal status for possible hemorrhage & discomfort after procedure

75. Precipitous Delivery Definition = Labor < 3 hours Assessment
Vaginal Exam/Visualization

76. Precipitous Delivery-Nursing Care
Don’t Break the Bed
Support Perineum, Deliver Fetal Head
Check for Nuchal Cord
Delivery Actions
Suction Baby’s mouth & nose
Clamp Cord, Wait for Placenta to come out
Dry Baby, Place on Mother’s Abdomen

77. Care -- Out-of Hospital Delivery
Follow Precipitous Labor Actions
Try to be as clean as possible
Essential to protect infant from HEAT LOSS (blankets, coats, newspaper)
BE CALM & CONFIDENT

78. THAT’S ALL FOLKS! Be sure to review Handout “A”
“Cultural Influences During Intrapartum Period”
as well!