Care Scenario 2 Readings Baby Makes 5,100% CORRECT

Care Scenario 2 Readings Baby Makes 5 For September 30 - Chapter 13 and 18 Kara - Chapter 14: Nursing Management During Labour and Birth (page 409-448) For October 7 - Chapter 16 and 21 Kara - Chapter 19 select pa ...

Care Scenario 2 Readings Baby Makes 5 For September 30 - Chapter 13 and 18 Kara - Chapter 14: Nursing Management During Labour and Birth (page 409-448) For October 7 - Chapter 16 and 21 Kara - Chapter 19 select pages Chapter 14 Nurses must be respectful, available, encouraging, supportive and professional Promote positive birth experiences by responding to the needs of the labouring woman thru appropriate nursing interventions Goal to have all Canadian women have access to quality maternity care that is centred around women and family Maternal assessment during labour and birth: Vital signs, pain Review prenatal record to identify risk factors that can decrease uteroplacental circulation during labour Vaginal exam to assess cervical dilation and monitor this Vaginal examination: - Most nurses in community hospitals do this bc the physician isn’t usually there - Assess cervical dilation, the percentage of cervical effacement, and the fetal membrane status, gather info on presentation, position, station, degree of fetal head flexion, and presence of fetal skull swelling or molding - Women usually on their backs during this - Use water as a lubricant if it is the initial vaginal exam to check for membrane status - If membranes have already ruptured, use an antiseptic solution to prevent an ascending infection and use sterile gloves - Insert index and middle fingers into vagina and palpate the cervix for dilation, effacement and position (posterior or anterio) - If cervix is open to any degree, the presental fetal part, fetal position, station and presence of molding can be assessed - Membranes are either intact, bulging or ruptured - Then discuss the findings with woman and partner Cervical dilation and effacement is a key area to assess - Width of cervical opening determined dilation and length of cervix assesses effacement Fetal descent and presenting part: - Fetal descent = station - Palpate fetal skull (if vertex presentation) thru the opened cervix or palpate the bum if its breech - If the presenting part is palpated higher than the maternal ischial spines, a negative number is assigned - If the presenting fetal part is below the maternal ischial spines, a plus number is assigned - The number indicated cm and it goes from -5 to +4 Rupture of membranes: - If intact, membranes will be soft bulge that is more prominent during a contraction - If membranes have ruptured, may have had a sudden gush of fluid or even a slow trickle of fluid - When membranes rupture, assess fetal heart rate to assess for deceleration which might indicate cord compression secondary to cord prolapse - Prolonged ruptured membranes increase risk of infection - Signs of intrauterine infection: maternal fever, fetal and maternal tachycardia, foul odour of vaginal discharge, increase in WBCs - Confirmation of ruptured membranes: sample of fluid taken from vagina and tested to determine pH o Vaginal fluid is acidic o Amniotic fluid is alkaline Assessing uterine contractions: - Involuntary - Increase intrauterine pressure causing tension on the cervix leading to cervical dilation and thinning which forces fetus thru birth canal - Normal uterine contractios have systole (contraction) and diastole (relaxation) - Wave moving downward to cervix and upward to fundus of uterus - Starts with building up (increment), then peak (acme) then let down (decrement) - Contractions monitored by palpation, external fetal monitoring, or internal monitoring - Assess frequency, duration, intensity and uterine resting tone - Palpation: place the pads of your fingers on the fundus and describe how it feels (how hard it is) - Assessing using electronic fetal monitoring externally or internally but internal is more accurate Performing Leopold’s Manoeuvres: - Method for determining presentation, position and lie of the fetus thru 4 steps - Inspection and palpation of the maternal abdomen as a screening for malpresentation - Longitudinal lie is expected and the presentation can be cephalic, breech or shoulder - What fetal part (head or bum) is at the fundus - Which maternal side is the fetal back located - What is the presenting part - Is the fetal head flexed and engaged in the pelvis - See page 26 for a visual representation of the manoeuvres Fetal assessment during labour and birth Analysis of amniotic fluid: - Should be clear when membranes rupture - Cloudy or foul smelling indicates infection - Green fluid may mean fetus passed meconium secondary to transient hypoxia but it is normal if the fetus is breech - If it is determined that meconium stained amniotic fluid is due to fetal hypoxia, the maternity and pediatric teams work together to prevent meconium aspiration syndrome which would necessitate suctioning after head is born before infant takes a breath and maybe direct tracheal suctioning after birth if apgar score is low Analysis of FHR (Fetal heart rate) - Can determine fetal oxygen status indirectly - Intermittent FHR monitoring o Intermittent auscultation using a fetoscope or hand held doppler which uses ultrasound waves that bounce off the fetal heart producing echos or clicks that reflect fetal heart rate o This is preferred o This allows woman to be mobile in first stage of labour bcshes not attached to a stationary electronic fetal monitor o Doesn’t document how fetus responds to stress of labour bc its not continuous o Assess fetal wellbeing by listening to the FHR at the end of the contraction so late decelerations can be detected o Can be used to detect FHR baseline and changes from baseline o To assess for baseline listen for a full minute after a contraction o After that, sufficient to just listen for 30 seconds then x2 unless there is a problem o Check FHR regularly and after any invasive procedure, rupture of membranes, vaginal exam and admin of meds o FHR is heard best at fetal back o In cephalic presentation, FHR is best heard in lower quadrant of maternal abdomen o In breech presentation, heart at or above level of maternal umbilicus o Gel needed for the doppler device but not with a fetoscope o For high risk women, this may not be great bc there is no continual assessment, its just intermittent o Intermittent is recommended for healthy women without risk factors for adverse perinatal outcome o Assess FHR on admission and every hour in the latent phase of the first stage of labour o Assess every 15-30 mins during the active phase of the first stage of labour o Assess every 5 mins during the active second stage of labour - Continuous electronic fetal monitoring: cardiotocography o External monitor that records changes in the FHR with an aim to identify babies who may be hypoxic o Monitor produces a sound with each heartbeat and provides a visual graphic record of the FHR pattern o It also monitors the mothers contractions o This is associated withan increase in C section and instrumental vaginal births o Women with risk factors should receive this o Continuous record of FHR allows for early intervention but this can limit maternal movement and encourages woman to lie in supine position, which reduces placental perfusion and could contribute to problems o can be externally with equipment attached to maternal abdo wall or internally with equipment attached to fetus o continuous external monitoring; two ultrasound transducers are attached to a belt and applied around tummy  one over the fundus in the area of greatest contractility to monitor and record uterine contractions  the other records baseline FHR, long term variability, accelerations and decelerations – placed on abdo in midline between umbilicus and symphysis pubis  can be used while membranes are still intact and cervix isn’t dilated yet  restricts mothers movements and can’t detect short term variability  artefact: irregular variations or the absence of FHR on the fetal monitor record that result form mechanical limintations of the monitor or electrical interference o continuous internal monitoring:  for women or fetus considered high risk like multiple gestation, decreased fetal movement, abnormal FHR on auscultation, intrauterine growth restriction, maternal fever, preeclampsia, dysfunctional labour, preterm birth  place spiral electrode on fetal presenting part (usually head) and a pressure transducer placed internally within the uterus to record transactions  used if membranes ruptured, cervical dilation was at least 2cm, presenting fetal part low enough to identify correctly and allow placement of the scalp electrode and skilled practitioner available to insert spiral electrode (trained nurse can do this but can’t do the intrauterine thing)  can detect short (movement to movement) and long term (fluctuations within baseline) variations Determining FHR patterns: - FHR patterns give info on current acid-base status of fetus and require prompt ongoing evlaulation - Assessment parameters: baseline rate, baseline variability, periodic changes in the rate (accelerations and decelerations) - If pattern is normal – good fetal wellbeing - Atypical or indeterminate necessitated continued surveillance and re-evaluation - Abnormal indicates the need for immediate intervention Normal FHR signs: - Normal baseline (110-160 beats/min) - Moderate bradycardia (100-110) with good variability - Good beat to beat variability and fetal accelerations Atypical signs: - Tachycardia (over 160) - Moderate bradycardia (100-110) with lost variability - Absent beat to beat variability - Marked bradycardia (90-100) - Moderate variable decelerations Abnormal signs: - Fetal tachycardia with loss of variability - Prolonged marked bradycardia (less than 90) - Severe variable decelerations (under 70) - Persistent late decelerations Baseline fetal heart rate: - Avg FHR that occurs during a 10 minute segment thatexcludes periodic or episodic rate changes (like tachy or brady) and periods of marked variability - Assessed when the women has no contractions - Normal 110-160 – obtained by auscultation, ultrasound, doppler, or internal fetal spiral electrode - Fetal bradycardia: when FHR is below 110 and lasts 10 mins or longer – can be the initial response of a healthy baby to asphyxia - Causes of fetal bradycardia: fetal hypoxia, prolonged maternal hypoglycemia, fetal acidosis, viral infections, admin of drugs to the mother, maternal hypothermia, maternal hypotension, prolonged umbilical cord compression, fetal congenital heart block - Fetal tachycardia: baseline FHR greater than 160 lasting 10 mins or longer o Can represent compensatory response to asphyxia o Can be maternal or fetal in nature o Maternal causes: fever, meds, dehydration o Fetal hypoxia/acidosis, maternal anxiety, thyroid disease, fetal heart failure, fetal arrhythmia Baseline variability: normal physiologic variations in the time intervals that elapse between each fetal heartbeat observed along the baseline in the absence of contractions, decelerations and accelerations - Interplay between parasympathetic and sympathetic nervous systems producing movement to movement changes in FHR - Variability is the combined result of autonomic nervous system branch function so it implies that both branches are working and receiving adequate oxygen so variability is one of the most important characteristics of the FHR - Variability can be minimal, absent, moderate and marked - Minimal or absent: usually caused by uteroplacental insufficiency, cord compression, maternal hypotension, uterine hyperstimulation, abruptio placentae, or a fetal dysrhythmia o Improving uteroplacental blood flow can include laternal positioning of mother, increasing IV fluid rate to improve maternal circ, administering oxygen at 8-10L/min by mask, considering internal fetal monitoring, documenting findings, reporting to health care provider - Moderate variability: autonomic and CNS systems are well developed and well oxygenated - Marked variability: more than 25 beats of fluctuation in the FHR baseline o Causes: cord prolapse or compression, maternal hypotension, uterine hyperstimulation, abruptio placentae o Interventions: determine the cause, lateral positioning, increase IV fluid rate, admin O2, discontinue oxytocin infusion, consider internal fetal monitoring , prepare for surgerical birth if necessary - FHR variability is important clinical indicator predictive of fetal acid base balance and cerebral tissue perfusion - As CNS is desensitized by hypoxia and acidosis, FHR decreases until a smooth baseline pattern appears - Causes of decreased variability: fetal hypoxia/acidosis, drugs that depress the CNS, congenital abnormalities, fetal sleep, prematurity, fetal tachycardia Periodic baseline changes: temporary, recurrent changes made in response to a stimulus such as a contraction - Acceleration or deceleration in response to most stimuli - Accelerations; transitory increases in FHR above baseline associated with symp NS stimulation o Elevations more than 15 beats/minute above baseline and duration less than 2 mins - Deceleration: transiet fall in FHR caused by stimulation of parasympathetic NS o Early, late, variable and prolonged o Early: gradual decrease in FHR where the lowest point occurs at peak of contraction – usually no more than 30-40 beats per minute below baseline  Due to fetal head compression resulting in reflex vagal response with resultant slowing of FHR during conractions o Late: transitory decreases in FHR that occur after contraction begins and the FHR doesn’t return to baseline levels until well after the contraction has ended  Associated with uteroplacental insufficiency, causing hypoxemia from inadequate placental perfusion during contractions  Maternal hypotension, gestational hypertension, placental aging secondary to diabetes and postmaturity, uterine hyperstimulation via oxytocin infusion, maternal smoking, anemia, cardiac disease  Repetitive late decels and late decels with decr baseline variability are ominous signs so the fetal scalp pH should be obtained o Variable: present as visually apparent abrupt decreases in FHR below baseline and have unpredictable shape on the FHR baseline, possibly demonstrating no relationship with uterine contractions  Usually associated with cord compression but are uncomplicated usually  But if FHR goes below 70 beats per minut and persists for 60 seconds, can be abnormal o Prolonged: gradual or abrupt FHR declines of at least 15 beats per minut that last longer than 2 mins but less than 10  Rate usually drops to less than 90  Caused by disruption to oxygen supply like prolonged cord compression, abruptio placentae, cord prolapse, supine maternal position If patients gets atypical deceleration patterns like late or variable ones: - Notify health care provider, reduce or dc oxytocin, provide reassurance - With late decels, turn client on left side to increase placental perfusion, admin oxygen, increase iv fluid rate to improve intravascular volume - With variable decels, change clients position to relieve compression of cord, give oxygen and iv fluids as ordered, provide reassurance that interventions are to effect pattern change Other fetal assessments: - Fetal scalp blood sampling: measuring fetal distress in conjunction with EFM to make critical decisions about the management of labour o Assesses acid base status o Helps to prevent unnecessary surgical intervention o Woman must have ruptured membranes and enough cervical dilation to do this test and have vertex presentation o Not used much today - Fetal oxygen sat monitoring: can be used with EFM as an adjunct method of assessment when FHR pattern is abnormal or atypical o Soft sensor goes thru dilated cervix and placed on cheek, forehead or temple of fetus and held in place by uterine wall o Real time recording o Non invasive and safe but hasn’t been proven to be clinically useful in determining fetal status or reducing C section rates - Fetal stimulation: if the fetus doesn’t have adequate oxygen reserves, CO2 builds up leading to acidemia and hypoxemia which are reflected in abnormal FHR patterns and fetal inactivity o Fetal stimulation promotes movement with the hope that FHR accelerations will accompany the movement o Stimulate with a vibroacoustic stimulator applies to the womans lower abdomen – vibration and sound o Can also do it by tactile sitmulation via pelvic exam and stimulation of fetal scalp with gloved fingers o Well oxygenated fetus responds when stimulated by moving in conjunction with an acceleration of 15 beats per min above baseline that lasts over 15 seconds – this reflects a pH more than 7 and reflects an intact CNS o But the absence of response doesn’t indicate fetal compromise Promoting comfort and pain management during labour Acute pain of labour: primarlily physical, fixed duration, can be relieved by non pharm methods Pain can be influenced by personality, culture, anxiety, support, environment, social status Non pharm measures: - Continuous labour support - Hydrotherapy - Ambulation - Position changes - Acupuncture - Acupressure - Attention focusing and imagery - Therapeutic touch and massage - Breathing techniques - These can interfere with pain stimuli by closing a hypothetical gate in the spinal cord, blocking pain signals from reaching the brain - Unmanaged increased stress leads to release of cortisol and catecholamines, prolonging labour and impairing fetal blood flow - Maternal hyperventilation can lead to fetal resp alkalosis and metabolic acidosis Continuous labour support: offering a sustained presence to the labouring woman by providing emotional support, comfort measures, advocacy, info and advice and support from partner - Partner, midwife, nurse or doula or someone close to the woman can provide this - Support person can help with ambulating, respotiioning, breathing techniques, massage, therapeutic touch - Those who received continuous labour support were more likely to have a spontaneous vaginal delivery, had shorter labours, less likely to use pain meds and expressed more satisfaction with the birth experience Hydrotherapy: warm water for relaxation and relief of discomfort - Warm water releases endorphins and gives better circulation and oxygenation - Contractions usually less painful in water - Can shorten length of labour - Reduced pain and the use of epidural/spinal analgesia - No evidence of adverse outcomes - Still needs to be investigated for the second stage of labour - Bathtupbs, whirlpool baths, showers Ambulation and position changes: - Every 30 mins change position – sit, walk, kneel, stand, lie down, hands and knees, birthing ball - Walking helps make use of gravity to move baby down - Supine and sitting hshould be avoided Acupuncture and acupressure: to relieve pain - Acupuncture; trigger points with needles to release endorphins to reduce the perception of pain - Acupressure: apply firm finger or massage at the same trigger points – poits along spine, neck, shoulders, toes, wrists, lower back, hips, below kneecaps, ankles, along toenails o Can shorter length of labour Attention focusing and imagery: - Can focus on tactile stimuli like touch, massage, stroking - Auditory stimuli like music, huming - Guided imagery: distraction by viewing a pleasant image - Breathing, relaxation, positive thinking See page 39 for a graph of how the different positions can help in labour Therapeutic touch and massage: relax patients and distract from discomfort - Uses hands to promote relaxation and reduce pain and anxiety - Massage: some like light touch, some like more firm - Massage neck, shoulders, back, thighs, feet, hands - Skin problems like rashes, varicose veins, bruises or infections are contraindications for massage - Individualized approach to massage - Effleurage: form of massage using light, stroking, superficial touch of abdo in rhythm with breathing during contractions Breathing techniques: slow paced rhythmic breathing - Reduce pain thru a stimulus response conditioning - Select a focal point within her environment to stare at during the first sign of a contraction – this focus creates a visual stimulus that goes directly to her brain - Then take deep cleansing breath followed by rhythmic breathing - Increases confidence, sense of control, distract from pain, relax, even flow of O2 and CO2, relief of labour pain - Labour classes usually teach this - First pattern: slow paced breathing 0 breathing rate is half the number of breaths normally taken per minute o Following the cleansing breath, the woman inhales thru the nose to a count of 4, then exhales thru mouth to a count of 4, repeatingtill end of contraction when another cleansing breath is taken - Second pattern: modified paced breathing – rate slightly faster than normal but not more than twice the resting rate; then inhalation and exhalation done to the count of 2 following the procedure for slow paced breathing - Third pattern: pant blow breathing – same rate as the second one but the breathing is punctuated every few breaths by blowing softly thru puprsed lips o Pant- 2-3-4 blow or pant 2-3 blow - Encouraged to find a breathing style hat works for them Pharm measures: - Systemic and regional or local anesthesia - Neuraxial analgesia/anesthesia: admin of analgesic (opioids) or anesthetic (meds capable of producing loss of sensation in an area of the body) either continuously or intermittently, into the epidural or intrathecal space to relieve pain Systemic analgesia: - Use of 1+ drugs orally, IM or IV - Therapeutic effect can occur in minutes and last for hours - Complication: respiratory depression - Opioids given close to time of birth can cause CNS depression in newborn, necessitating the admin of naloxone to reverse the effects - Opioids, ataractics, benzodiazepines, barbiturates - See chart on page 42 for diff drugs and info on them - Usually parenterally thru an existing IV line - Often directly affects the baby so they are affected indirectly by the secondary physiologic or biochemical changes experienced by the mother - Increasing PCA – woman have sense of control over pain Opioids: - Moderate to severe pain - IV usually - Meperidine (demoerol) was once the most common - But meperidine metabolizes to normeperidine, leading to neurobehavioural depression in many women lasting for several days - Opioids can impact early breastfeeding, associated with newborn resp depression but they sometimes don’t achieve adequate maternal analgesia - All opioids are considered good analgescs but resp depression can occur depending on dose given - FHR pattern change usually transient - Side effects; nausea, vomiting, pruritus, delayed gastric emptying, drowsy, hypoventilation, newborn resp depression - To reduce risk of newborn resp depression, birth should occur within 1 hour or after 4 hours of admin to prevent fetus from receiving peak concentration Ataractics; in combo with opioids to decreases N and V and lessen anxiety Benzo: minor tranquilizing and sedative effects - Can stop seizures due to pregnancy induced hypertension but is not used in labour itself - Can be given to woman who is out of control so she relaxes long enough so she can participate effectively during labour rather than fighting against it - Midazolam givn IV produces amnesia – adjunct for anesthesia but small doesesbc of its amnesic effect - Can cause CNS in mom and baby Barbiturates: only in early labour to promote sleep when birth is unlikely for 12-24 hours - To promote therapeutic rest for a few hours to enhance woman’s ability to cope with active labour - Cross placenta and cause CNS depression in newborn Regional analgesia/anesthesia: - Unrivaled pain relief with minimal side effects - Into the lower neuraxis - Small doses needed bc it blocks pain pathways - Epidural block, CSE block, local infiltration, pudendal block, spinal (intrathecal) - Local and pudendal using during birth for episiotomies - Epidural and intrathecal for pain relief during active labour and birth - Woman can participate in birthing process but still have good pain control Epidural block: - Injection of a drug into the epidural space (located outside the dura mater between dura and spinal canal) - Entered thru 3rd and 4th lumbar vertebrae with a needle and catheter is threaded into epidural space - Needle removed and catheter is left to allow for continuous infusion or intermittent injections of the med - Can be used for both vaginal and c section births - Now its minimal blockade - Usually started after labour is well established and when cervical dilation is over 5cm - Pain relief is balanced against other goals like walking during first stage, pushing during second state, and minimizing side effects - Contraindicated for those with previous history of spinal surgery or spinal abnormalities, coagulation defects, infections and hypovolemia or those receiving anticoagulation therapy - Complications: N and V, hypotension, fever, pruritus, intravascular injection, resp depression - Effects on fetus: fetal distress secondary to maternal hypotension - Avoid supine position aftere epidural to help minimize hypotension Spinal analgesia/anesthesia: injection of anesthetic “caine” agent, with or without opioids into the subarachnoid space to provide pain relif during vag or c section birth - Contraindications similar to epidural ones - Adverse reation: hypotension and spinal headache Combined spinal-epidural analgesia: - CSE - Insert epidural needle into epidural space then inserting small gauge spinal needle thru the epidural needle into the subarachnoid space - Opioid put into spinal space - Spinal needle then removed and epidural catheter is inserted for later use - Rapid onset of pain relief that can last up to 3 hours - Superior pain control - Poor mobility and leg weakness reported with this - Complications: maternal hypotension leading to fetal distress, postdural puncture headache, inadequate or failed block, pruritus, urinary retention - Slows first stage of labour and or extend second stage - Hypotension associated with FHR changes are anaged with maternal positioning, IV hydration and oxygen - May need urinary catheter Ambulating during labour; can help pain control, shorter first stage, increase intensity of contractions, decrease possibility of operative vag or c section birth Patient controlled epidural analgesia: - Indwelling epidural catheter with an infusion of medication and programmed pump that allows woman to control dosing - Control over pain - Hand held device used to push button and bolus dose is given Local infiltration: inject local anesthetic like lidocaine into superficial perineal nerves to numb perineal area - By physician or midwife just before perfoming an episiotomy or before suturing a laceration Pudendal nerve block: inject local anesthetic agent into pudendal nerves near each ischial spine - Pain relief in lower vagina, vulva and perineum - Second stage of labour, episiotomy or operative vaginal birth with outlet forceps or vacuum delivery - Must be given 15 mins before its needed General anesthesia: for emergency C sections when not enough time for spinal or epidural anesthesia or if mum has contraindication to regional anesthesia - Quick bc rapid loss of consciousness - IV, inhalation or both - This then a muscle relaxant - Inubated, nitrous oxide and oxygen given - All anesthetic agent cross placenta and affect fetus - Fetal depression, uterine relaxation and potential maternal vomiting and aspiration - Ensure the woman is NPO and has a patent IV - Admin an antacid or PPI to reduce gastric acidity Nursing care during labour and birth: Important to give anticipatory guidance and explain each procedure (fetal monitoring, IV therapy, meds given, expected reactions) Acknowledge her support systems to help allay their fears and concerns Help to maintain control over pain, emotions, and actions Allow the woman time for discussion, offer companionship, listen to worries, pay attention to emotional needs Nursing care in the first stage of labour: - Determine assessment parameters and plan care accordingly j - High touch, low tech supportive nursing care - Get woman oriented to her birth suite - Take an admission history (review prenatal record), check results of routine la tests and any other special tests, ask about any birth plans, classes taken, coping mechanisms; complete a physical assessment to establish baseline values - Nursing interventions: o Identify estimated date of birth o Validate prenatal history to determine fetal risk status o Determine fundal height to validate dates and fetal growth o Perform leopolds manoeuvres to determine fetal position, lie and presentation o Check FHR o Vaginal exam o Assess fetal response and FHR against contrations and recovery time o Reposition client o Check amniotic fluid for meconium staining, odour and amount o Support clients decisions o Document care in a timely manner  ensure only factual and objective info on care is recorded  include communication with other health team members  document only clinically releant info  comprehensive date about mum baby status  record nursing interventions and patient response Assess the woman upon admission: - True or false labour - Assess FHR, cervical dilation, ruptured membranes or intact - If over the phone, be calm and caring and ask about estimated date of birth, fetal movement, parity, gravida and previous childbirth experiences, time from start of labour to birth in previous labours, characteristics of contractions including frequency, duration and intensity; appearance of any vaginal blood, membrane status, presence of a supportive adult in the house - Suggest positions for comfort and to increase placental perfusion - Ensure maternity care is patient centred and empowering for women - Invite the labouring woman to share her birth plan - Admission assessment: maternal health history, physical assessment, fetal assessment, lab studies, psychological status Maternal health history: - Name, age, etc - Prenatal record date (estimated DOB, history of current pregnancy, results of lab and diagnostic tests like Rh status, GBS status) - Past pregnancy history and obstetric history - Past health and family history - Prenatal education - Meds - Other risk factors like diabetes, hypertension, alcohol, tobacco or other drugs - Pain management plan - History of preterm births - Allergies - If diabetic, critical to monitor glucose levels during labour, to prepare for surgical birth if dystocia of labour occurs and to alert newborn nursery of potential hypoglycemia in the newborn after birth - Observe emotions, support system, verbal interaction, body language and posture, perceptual activity, energy level - Attitudes towards childbirth are heavily influenced by culture so pay attention to this See page 49 for admission assessment chart Physical exam: body systems, hydration status, VS, auscultate heart and lungs, measure height and weight - Fundal height measurement - Uterine activity, including contraction frequency duration and intensity - Status of membranes (intact or ruptured) - Cervical dilation and degree of effacement - Fetal status – HR, position, station - Pain level Lab studies; - Urinalysis via clean catch urine specimen - CBC - Blood typing and Rh factor analysis may be needed if not known yet - Syphilis screen, Hep B surface antigen screening, GBS testing, HIV testing, possible drug screening if history is positive - GBS: gram pos organism in vaginal and GI tract of some women – asymptomatic but can cause disease of newborn o Screening should be done at 35-37 weeks gestation o Antibiotic therapy for GBS carriers o Women at term whose membranes have ruptured more than 18 hours previously should receive treatment o Can affect newborn by causing pneumonia and sepsis o At onset of labour when membranes rupture, IV antibiotic prophylaxis (penicillin or ampicillin) is given - Elective C section is recommended at 38 weeks positive women – those who haven’t received any antiretroviral therapy or who have received monotherapy regardless of viral load and women with detectable viral load regardless of amount of therapy received and women with unknown viral load status and those who have received no prenatal care - Other interventions to reduce risk of transmission of HIV is avoiding the use of scalp electrode or doing scalp blood sampling, delaying amniotomy, avoiding invasive procedures like forcepts or vaccume delivery Continuing assessment during first stage: - BP pulse and RR are assessed every hour during latent phase of labour - During active and transition phases, assessed every 30 mins - Temp taken every 4 hours thru first stage - Vaginal exams periodically to track labour progress - Uterine contractions monitored for frequency, duration, intensity every 30 mins to 60 mins during latent phase; every 15-30 mins during active phase and every 15 mins during transition - Determine pain continually - When membranes rupture, assess FHR and check the amniotic fluid for colour, odour, and amount - During latent phase of labour, assess FHR every 3060 mins; in active phase, 15-30 mins and then also before ambulation, prior to procedures and before giving analgesia or anesthesia See page 51 for a table of summary of assessments Nursing interventions during admission: - Ask about expectations of birthing process - Info about labour, birth, pain, relaxation - Info about fetal monitoring equipment - Monitor FHR - Monitor mothers VS to get baseline - Reassure that labour progress is monitored closely Interventions during first stage: - Encourage partner to participate - Update on progress - Orient woman to labour and birth unit - Provide clear fluids - Maintain mums parenteral fluid intake at prescribed rate If she has IV - Give comfort measures - Encourage partners involvement with breathing techniues - Inform mum that discomfort is intermittent and of limited duration, urging her to rest between contrations and presever strength - Change bed linens and gown as needed - Keep perineal area clean and dry - Support decisions - Monitor VS - Ensure deep cleansing breaths before and after each contraction - Monitor FHR for baseline, accelerations, variability and decels - Check bladder status and encourage voiding every 2 hours to make room for birth - Reposition woan as needed to obtain optimal HR pattern - Respect privacy by covering when apprripriate - Offer human presence and don’t leave her alone for long periods Positioning during first stage: - Walking with partner support (gravity) - Slow dancing position with partner holding you (gravity) - Side lying with pillows between knees ( restful and gives more O2 to uterus) - Semi sitting (reduced back pain) - Sitting in chair with one foot on floor and one on chair (changes pelvic shape) - Kneeling over a birth ball (reduces back pain) - Sitting in rocking chair or birth ball and shifting weight back and forth (soothing rocking motion) - Lunge by rocking weight back and forth with fot up on chair during contraction See sample nursing care plan on page 53 Nursing management in the second stage: - Supporting woman and partner with interventions like assist with positioning and breathing techniques delaying pushing in this stage reduces the time spent in this stage, decreases the need ofr instrument assisted delivery and lessens postpartum fatigue - Encourage woman not to push until she has a strong desire to do so and until the descent and rotation of fetal head are well advanced - Sitting, semi recumbency, kneeling and squatting is associated with shorter birth intervals, less pain and perineal damage and fewer operative births - Perineal lacerations or tears can occur when fetal head emerges - First degres: extends thru skin - Second degree: extends thru muscles - Third degree: continues thru the anal sphincter - Fourth degree: involves anterior rectal wall - 3rd and 4th degrees need to be repaired carefully to retain fecal continence - Episiotomy: incision made in perineum to enlarge vaginal outlet and shorten the second stage of labour – can be midline or mediolateral (off to the side) - Midwives can perform and repair these but they usually use other measures when possible - Alternative measures: warm compress, continual massage with oil – can stretch perineal area to prevent cutting it See page 55 for summary of assessments in 2nd 3rd 4th stages of labour Assessment: - Continuous - Identify the signs of the second stage of labour like increase in apprehension or irritability, spontaneous rupture of membranes, sudden appearance of sweat on upper lip, low grunting sounds by woman, complaints of rectal and perineal pressure, beginning of involuntary bearing down efforts - Determine progress of labour like bulging of perineum, labial separation, advancing and retreating of newborns head during and between bearing down efforts and crowning (baby head visible at vaginal opening) - Vaginal exam is done to see if its appropriate for woman to push (when cervix is fully dilated to 10cm and when woman feels urge) Nursing interventions: - Focus on motivation and encouraging to put all her efforts into pushing the baby - Give feedback on her progress - If pushing isn’t doing much, tell woman to open eyes and look towards where baby will come out - Change positions every 20-30 mins - Position a mirror so woman can visualize the birthing process - Upright positioning benefits related to gravity – also improve fetal alignment - Positions: lithotomy with feet up in stirrups; semi sitting with pillows under knees, arms and back; laternal/side lying with curved back and upper leg supported by partner; sitting on birthing stool (opens pelvis and enhances pull of gravity); squatting; kneeling with hands on bed and knees apart - Comfort measures, position changes - Pushing only when feeling an urge; use abdo muscles when bearing down; short pushes of 6-7 seconds; focus attention on perineal area to see the baby; relax and conserve energy between contractions; pushing several times with each contraction - Continue to monitor contraction and FHR patterns - Psychological support - Asses BP, pulse, RR, uterine contractions, FHR, bearing down efforts, coping status of client and partner - Pain management - Praise for efforts - Notify HCP for estimated time frame for birth - Prepare delivery bed and position the client - Prepare perineal area - Offer ad mirror so woman can watch birth - Set up delivery instruments - Receive newborn and transport to warm environment and cover with warm blankets or put on mums tummy - Initial care and assessment of newborn Birth: - Second stage of labour ends with birth - Once the woman is positioned for birth, cleanses the vulva and perineal areas - Once head emerges, explore the neck to see if umbilcal cord is wrapped around it; if it is, slip the cord over the head to facilitate delivery - Suction the newborns mouth and then nares with a bulb syringe to prevent aspiration of mucus, amniotic fluid or meconium - Umbilical cord is double clamped and cut between the clamps - With the newborns first cries, the second stage of labour ends Immediate care of newborn: - Put baby under a warmer, dry him or her, assess, wrap in warm blankets, place on womans abdomen - In some places, the baby is placed on mothers tummy right away - Dry and provide warmth to prevent heat loss by evaporation - Assess the newborn by providing an apgar score at 1 and 5 mins - Apgar score assesses HR (absent, slow, fast); resp effort (absent, weak cry, good strong yell), muscle tone (limp or lively and active), response to irritation stimulus, and colour - Put identification bands on the baby – wrist and ankle to match the mothers band - Some places have additional security measures Nursing management in 3rd stage of labour: - Strong uterine contractions continue bc of oxytocin - Uterine muscle fibres shorter or retract and lead to a decrease in size of uterus to shear placenta away from attachment site - Complete when the placenta is delivered - Focus on newborn care and assist with delivery of placenta and assess for intactness - Hormones: o Oxytocin causing uterine contractions – peak levels here o Endorphins peak o Adrenaline fall - Skin to skin and first attempt at breastfeeding help keep oxytocin levels up and help the placenta separate and uterus to contract to prevent hemorrhage - Endorphins block out pain - Women start to feel cold with the fall of adrenaline Assessment: - Monitor placental separation by looking for a firmly contracting uterus, change in uterine shape form discoid to globular ovoid, suddent gush of dark blood from vaginal opening, lengthening of umbilical cord protruding from vagina - Examine placenta and fetal membranes for intactness the second time (HCP assesses the first time) - Assess for perineal trauma o If it’s a firm fundus with bright red blood trickling, it’s a laceration o Boggy fundus with red blood flowing: uterine atony o Boggy fundus with dark blood and clots: retained placenta - Inspect the episiotomy if done - Assess for lacerations and ensure repair is done Nursing interventions: - Describe the process of placental separation to couple - Tell woman to push when signs of separation are apparent - Give oxytocin if ordered - Support and info on laceration and/or episiotomy - Clean and assist client into a comfy position - Reposition birthing bed to serve as a recovery bed if applicable - Provide warmth - Apply ice pack to perineal area - Assess vaginal bleeding, vital signs every 15 mins; uterine fundus (firm and midline at level of umbilicus) - Document Nursing management in fourth stage: - After placenta is expelled and up to 4 hours after when recovery takes place - Close observation ofr hemorrhage - Assessment: vital signs, uterine fundus, perineal area, comfort level, lochia amount, bladder status - VS Q 15 mins for first hour; then Q30 mins for next hour if needed - Decrease in BP may indicate hemorrhage - Pulse is usually slower than during labour bc of decr in blood volume potentially - High pulse may be indicative of blood loss - Fever indicates dehydration or infection - Fundal height, position and firmness every 15 mins during first hour after birth – it has to be firm to prevent bleeding - If not firm, massage it till it is - Vagina and perinal areas are stretched and edematous after birth – assess for hematoma formation – heatoma if woman is in extreme pain, can’t void or is mass is noted in perineal area - Rate pain – should be less than 3 - Assess lochia Q15 misn for fist hour and Q 30 mins for next hour - Voiding should produce large amounts of urine each time Nursing interventions: - Support and info on episotomy repair and pain relief - Ice pack to perineum - Assist with hygiene and peri care – teach how to use peri bottls after each pad change and void - Monitor for return of sensation and ability to void - Encourage voiding - Monitor VS and fundal status - Provide warm blankets - Offer fluid and nourishment - Encourage mum baby attachment by providing privacy for family - Assist the mother to breastfeed - Teach how to assess fundus for firmness - Describe lochia - Explain comfort and hygiene methods - Assit with ambulation Key concepts on page 60