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Nursing Care of Mother and Infant During Labor and Birth

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1 Nursing Care of Mother and Infant During Labor and Birth
Chapter 6 Nursing Care of Mother and Infant During Labor and Birth Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

2 Cultural Influences on Birth Practices (p. 116)
Role of woman in labor and delivery Cultural preferences require flexibility Role of father/partner in labor and delivery May be driven by cultural practices Refer to Table 6-1 (pp ). Discuss the responsibilities of the nurse when interacting with families of different cultures. Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

3 Settings for Childbirth (p. 116)
Hospitals Advantages-preregistration, easy access to sophisticated resources, family centered care for complicated pregnancy Disadvantages Freestanding birth centers Advantages-home like settings, lower costs Disadvantages-immediate emergency access Home Advantages-control over persons around; no risk of cross contamination; low tech birth Disadvantages-limited choice of birth attendants; immediate emergency access Review the advantages and disadvantages of each setting. Does your community have a freestanding birth center? Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

4 Components of the Birth Process (p. 116, 119-126)
The Four “Ps” Powers Passage Passenger Psyche The powers that influence labor cause the cervix to dilate and move the fetus downward. Sources of power include uterine contractions and pushing efforts by the laboring woman. The passage refers to the patient’s pelvis. The passenger is the fetus. What impact can the patient’s psyche have on the labor’s progress and/or outcomes? Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

5 Factors that Influence the Progress of Labor (p. 116, 119-126)
Preparation Position Professional Place Procedures People-Table 6-1-***Birth Practices of Selected Cultural Groups*** Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

6 Uterine Contractions (pp. 119-120)
Effect of contractions on the cervix Efface Dilate Phase of contractions Increment Peak Decrement A uterine contraction results from involuntary smooth muscle contractions. The contractions assist in the effacement (thinning) of the cervix. During labor, one of the nurse’s roles is to monitor uterine contractions. Define frequency and duration. What are the differences among mild, moderate, and firm contractions? Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

7 Uterine Contractions (pp. 119-120)
Frequency elapsed time from the beginning of one contraction to the beginning of the next contraction Duration Elapsed time from the beginning to the end of same contraction Persistent contraction lasting longer than 90 sec reduce fetal oxygen supply It is important to have mother relax during contractions Intensity Mild Moderate Firm Maternal pushing A uterine contraction results from involuntary smooth muscle contractions. The contractions assist in the effacement (thinning) of the cervix. During labor, one of the nurse’s roles is to monitor uterine contractions. Define frequency and duration. What are the differences among mild, moderate, and firm contractions? Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

8 Safety Alert! (p. 122) Report to the RN any contractions that occur more frequently than every 2 minutes, last longer than 90 seconds, or have intervals shorter than 60 seconds Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

9 Cervical Effacement and Dilation (p. 120)
Cervical effacement and dilation can be likened to sucking on a Lifesaver. As the candy becomes thinner, the center opening becomes wider. Describe the differences between cervical effacement and dilation for the primigravida and multigravida woman. Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

10 Contraction Cycle (p. 121) Nurses must understand the components of the contraction cycle. Review the increments and peak of the contraction pattern. Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

11 Nursing Tip (p. 122) Provide emotional support to the laboring woman so she is less anxious and fearful. Excessive anxiety or fear can cause greater pain, inhibit the progress of labor, and reduce blood flow to the placenta and fetus. What interventions can the nurse implement to reduce anxiety and fear during labor? Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

12 The Passage (p. 122) Bony pelvis Soft tissues True False
Directly involved in childbirth Inlet Midpelvis Outlet False Flares Upper portion of pelvis Soft tissues If previous delivery, will yield more readily to contractions and pushing efforts May not yield as readily in primiparas or older women Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

13 The Passenger—Fetal Skull (pp. 122-123)
The bones in the fetal head are separated by connective tissue. What is the importance of this tissue in relation to the birthing process? Compare and contrast the fontanelles Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

14 The Passengers—Fetal Lie (pp. 122-123)
Fetal lie refers to the position of the fetus in relation to the maternal spine. Review the various fetal lie positions. Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

15 The Passengers—Presentation (pp. 123-124)
Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

16 The Passengers—Presentation (pp. 123-124)
Fetus Fetal Head-fontanelles (anterior/posterior) Lie-how the fetus is aligned with mother’s spine Attitude-normally one of flexion with the head flexed and arms and legs flexed Presentation-the fetal part that enters the pelvis 1st -Vertex-head is fully flexed-most favorable -Military head is neither flexed or extended -Brow head is partly extended -Face-head is fully flexed and face is presents -Breech-Frank, Full or complete, Footling Position- how a reference point on fetal presenting part within mother’s pelvis Occiput-how fetus is in cephalic vertex presentation Sacrum-how fetus is in a breech presentation Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

17 Psyche (pp. 124-125) Mental state can influence the course of labor.
The woman’s cultural and individual values influence how she will cope with childbirth. Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

18 Classifications of Fetal Presentations and Positions (p. 125)
Review the terminology used in each of the fetal presentations. Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

19 Signs of Impending Labor (p. 126)
Braxton Hicks contractions Increased vaginal discharge Bloody show Rupture of the membranes Energy spurt Weight loss Compare and contrast the clinical manifestations of Braxton Hicks contractions and true labor. Bloody show is a normal occurrence prior to the onset of labor. Describe the manifestations associated with bloody show. Rupture of membranes warrants evaluation of the pregnant woman at the health care facility. Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

20 Mechanisms of Labor (p. 126)
Descent Station-0 station at ischial spines above them minus stages below designated as plus stages; measured in cm Engagement Flexion Internal rotation Extension External rotation Expulsion Mechanisms of labor refer to those physiological changes in positioning which take place during a normal vaginal delivery. Describe each of these positions. Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

21 Birth Station (pp. 126, 128) Station refers to the position of the fetal head relative to the ischial spines. Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

22 Mechanisms of Labor (p. 126)
Also referred to as “cardinal movements.” Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

23 When to Go to the Hospital or Birth Center (p. 128)
Contractions Ruptured membranes Bleeding other than bloody show Decreased fetal movement Any other concern What is the timeline for patient education concerning how and when to seek care? Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

24 Admission Data Collection (p. 128-129)
Three major assessments performed promptly on admission Fetal condition-FHR w/fetoscope Maternal condition-V/S Impending birth-observing mother; making grunting noises, bearing down with contractions, stating “The baby is coming.”, Bulging of perineum or fetal presenting part at vaginal opening Discuss Skill 6-1, Assisting with an Emergency Birth (p. 129). Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

25 Admission Procedures (p. 130)
Permits/consents Laboratory tests Intravenous infusion Perineal prep Determining fetal position and presentation Discuss the actions required for each task listed. Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

26 Comparison of False and True Labor (p. 131)
False labor Contractions irregular Painless tightening of abdominal muscles Walking relieves contractions Bloody show usually not present No change in effacement/dilation of cervix True labor Contractions gradually develop a regular pattern Contractions become stronger and more effective with walking Discomfort in lower back/abdomen Bloody show often present Progressive effacement and dilation of cervix Refer to Table 6-2 (p. 131). What is the greatest difference between the types of labor? False labor does not result in cervical changes, while true labor causes changes in cervical dilation and effacement. At what point during the pregnancy should education be provided regarding false and true labor? Successful education should begin early in the pregnancy. This approach allows time for reinforcement throughout the pregnancy at each visit to the health care provider. Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

27 Nursing Care Before Birth (p. 131)
After admission to the labor unit, nursing care consists of Monitoring the fetus Monitoring the laboring woman Helping the woman cope with labor Fetal monitoring can be intermittent or continuous. Review factors which can determine the type of monitoring employed Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

28 Monitoring the Fetus (p. 131)
Fetal heart rate Intermittent auscultation Continuous electronic fetal monitoring Review Skill 6-2 on p. 132, Box 6-2 on p. 133, and Skill 6-3 on p. 134. Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

29 FHR Outside of Normal Limits (p. 132)
Any FHR outside the normal limits and any slowing of the FHR that persists after the contraction ends is promptly reported to the health care provider. Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

30 Evaluating Fetal Heart Rate Patterns (pp. 133-136)
Baseline FHR BPM Fetal bradycardia <110 BPM Fetal tachycardia >160 BPM Baseline variability Moderate variability Marked variability Absent variability Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

31 Evaluating Fetal Heart Rate Patterns (pp. 137)
Accelerations-temporary, abrupt rate increases at least 15 bpm above baseline and lasts 15 sec but less than 2 min-suggest well oxygenated fetus Early decelerations-FHR decreases no more than 40 bpm and return after contraction-U shape; compression of fetal head Variable decelerations-FHR decreases 15 bpm last 15 sec to 2 min-V or W shape-suggest umbilical cord compressed-due to be around fetal neck or inadequate amniotic fluid; reposition and monitor if they continue give oxygen Late decelerations-begin after contraction and do not return after contraction; suggest placenta not delivering enough oxygen (uteroplacental insufficiency)-nonreassuring-could indicate fetal hypoxia or fetal heart depresssion; reposition to prevent supine hypotension, administer O L/min, increase IV fluids; stop oxytocin; administer tocolytic drugs Prolonged decelerations-caused by cord compression or prolapse; maternal supine hypotension; or due to regional anesthesia Recurrent decelerations-occur more than 50% of uterine contractions Intermittent decelerations-occur in less than 50% of uterine contractions Sinusoidal pattern-may happen due to medication provided such as Demoral, or Stadol Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

32 Nonreassuring patterns
Reassuring and Nonreassuring FHR and Uterine Activity Patterns (p. 135) Reassuring patterns Nonreassuring patterns Stable fetal heart rate (FHR) Moderate variability Accelerations Uterine contraction frequency greater than every 2 minutes; duration less than 90 seconds; relaxation interval of at least 60 seconds Tachycardia Bradycardia Decreased or absent variability; little fluctuation in rate Late decelerations Variable decelerations See Box 6-3 on p. 135 for more details. A part of the nursing assessment is the evaluation of fetal heart patterns. Nonreassuring patterns need reported to the health care provider. Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

33 Late Decelerations (p. 135)
Review Box 6-3, p. 135. Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

34 Inspection of Amniotic Fluid (p. 137)
Amniotic Membranes-rupture spontaneously or artificially by Dr. by going an amniotomy-Priority-FHR will need to be assessed for at least 1 full minute and record and report. When membranes are ruptured will need to evaluate: Color Normal is clear fluid, may have flecks of white vernix Green-stained may indicate fetus passed meconium (first stool but before birth) Can lead to fetal compromise Odor Should not smell If it does, it may indicate infection Amount Scant—trickle Moderate— ~500 mL Large— ≥ 1,000 mL What nursing interventions would be needed for normal-appearing amniotic fluid, meconium-stained, and large quantities? Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

35 Monitoring the Woman (p. 137)
Vital signs Contractions Progress of labor Intake and output Response to labor Discuss the frequency of each of the items to be monitored. Closed glottis pushing decreases fetal oxygenation and should be avoided. Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

36 Six Lamaze Institute Basic Practices for Maternity Care (p. 140)
Labor should begin on its own. Woman should have freedom of movement. Woman should have a birth support person or doula. No routine interventions should be performed. Woman should be in non-supine positions. Woman should not be separated from infant. Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

37 Helping the Woman Cope with Labor (p. 140)
Labor support Teaching Positioning and breathing techniques Help to remind mother not to push before cervix fully dilated When cervix is fully dilated then take a deep breath & exhale at beginning of a contraction then take another deep breath and push while exhaling Providing encouragement Supporting/teaching the partner Teach how labor pains affect the woman’s behavior/attitude How to adapt responses to the woman’s behavior What to expect in his/her own emotional responses Effects of epidural analgesia Review the components of labor support with the class. What are the recommended positions of comfort for the laboring women? Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

38 Stages and Phases of Labor (p. 143)
First stage—dilation and effacement (can last 4 to 6 hours) Latent Phase-Cervix 1-4 cm; cooperative, alert Active Phase-Cervix 4-7 cm; apprehensive, anxious Transition Phase-Cervix 7-10 cm; irritable, rejects support Second stage—expulsion of fetus (30 minutes to 2 hours) Third stage—expulsion of placenta (5 to 30 minutes) Fourth stage—recovery The labor of the primigravida will last longer than that of a multigravida. What behaviors are associated with each of the stages of labor? Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

39 Vaginal Birth After Cesarean (p. 143)
Main concern Uterine scar will rupture Can disrupt placental blood flow Lead to hemorrhage Woman may need more support than other laboring women Nurse provides empathy and support Discuss some of the psychological barriers that may arise for a woman with VBAC. Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

40 Nursing Responsibilities During Birth (pp. 144-146)
Preparing the delivery instruments and infant equipment Perineal scrub Administering medications Providing initial care to the infant Assessing Apgar score Assessing infant for obvious abnormalities Examining the placenta Identifying mother and infant Promoting parent-infant bonding Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

41 Immediate Postpartum Period: Third and Fourth Stages of Labor (p. 146)
Third stage—expulsion of placenta Schulze or Duncan’s Fourth stage—nursing care includes Identifying and preventing hemorrhage Evaluating and intervening for pain Observing bladder function and urine output Evaluating recovery from anesthesia Providing initial care to the newborn infant Promoting bonding and attachment between the infant and family After the birth of the baby, the nurse continues to assess the mother. Review both normal and abnormal findings. Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

42 Nursing Care Immediately After Birth (p. 147)
Care of the mother Observing for hemorrhage Vital signs Skin color Location and firmness of uterine fundus Lochia Pain Promoting comfort Keep warm and dry Ice to perineum to help reduce swelling and bruising Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

43 Nursing Care Immediately After Birth (cont.) (p. 147)
Care of the newborn Phase 1 From birth to 1 hour (usually in delivery room) Phase 2 From 1 to 3 hours (usually in transition nursery or postpartum unit) Phase 3 From 2 to 12 hours (usually in postpartum unit if rooming-in with the mother) If the newborn does not experience any difficulty with adaptation to extrauterine life, the infant will often remain with the mother in the delivery room. Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

44 Phase 1: Care of the Newborn (p. 150)
Initial care includes Maintaining thermoregulation Maintaining cardiorespiratory function Observing for urination and/or passage of meconium Identifying the mother, father, and newborn Performing a brief assessment for major anomalies Encouraging bonding/breastfeeding Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

45 Care of the Newborn (p. 147) Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

46 Apgar Scoring (pp ) Scoring is done in the following 5 areas with scoring from 0-2 in each area Heart rate Respiratory effort Muscle tone Reflex response to suction or gentle stimulation on the soles of the feet Skin color The Apgar is performed twice. At what times is the scoring performed? A point-based system is used. Each of the parameters is given a score between 0 and 2 points. What are the implications of the score obtained? Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

47 Administering Medications to the Newborn (p. 152)
Eye care Vitamin K (AquaMEPHYTON) Review Skill 6-6 on p. 153 and Skill 6-7 on p. 154. Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

48 Observe for Major Anomalies (p. 153)
Head trauma from delivery Symmetry and equality of extremities Are they of equal length? Do they move with same vigor on both sides? Assess digits of hands and feet Any evidence of webbing or abnormal number of digits What else should be assessed in regard to major anomalies? Which anomalies require immediate notification to the RN or health care provider? Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

49 Umbilical Cord Blood Banking (p. 153)
This type of blood is capable of regenerating stem cells that are able to replace diseased cells. Informed consent is essential. Collect blood after cord has been clamped. Blood must be transported within 48 hours of collection to blood banking facility. Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

50 Emerging Technologies and Practice (p. 154)
STAN technology: type of waveform analysis that detects intrapartal changes in fetal ST waveforms, indicative of developing fetal metabolic acidosis. PERICALM-EFM: computerized interpretation of real-time FHR patterns that provides automatic analysis of fetal heart pattern to compliment clinical judgment as well as permanent documentation in EMR. Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.


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