1. Care of the Family in Childbirth
- Tie everything together
Care of the Family in Childbirth
Sue 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 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:

4. 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

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 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

6. . 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.

7. 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.

8. 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

9. 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.

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 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.

11. Assessments of First Stage
Latent Table 19-1, pg
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

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 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.

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, 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.

14. 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

15. 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.

16. 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.

17. 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 Nursing Assessment / Mother & Fetus
pp. 449
Key Facts to Remember – pp. 449

18. 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

19. 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.

20. 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

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

22. 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

23. 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

24. 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.

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. 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.

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 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.

27. 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.

28. 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

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 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

30. 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

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 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.

32. 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