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Chapter 18

Chapter 18.docx

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NUR1 233
Sonia Elizabeth Semenic

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Chapter 18: Nursing Care During Labor and Birth First Stage of Labor  Beings with onset of regular uterine contractions and ends with compelte cervical effacement and dilation  Latent phase (3 cm of dilation)  Active phase (4-7cm of dilation)  Transition (8-10cm of dilation)  True labor o Contractions  Occur regularly, becoming stronger, lasting longer, and occuring closer together  Become more intesnse with walking  Fel tin lower back, radiating to lower portion of abdomen  Continue despite use of comfort measures o Cervix  Shows progressive change (softening, effacement and dilation – bloody show)  Moves to increasingly anterior position o Fetus  Presenting part usually becomes engaged in pelvis  Increased ease of breathing  Presenting part presses downward and compressess the bladder – urinary frequency  Warm baths: avoided until cervix 4-5cm dilated because water immersion in early labor can prolong labor process and increase use of oxytocin to stimulate uterine contractions and epidural analgesia for pain reduction  Admission to labor unit o Assessment top priority o Screening assessment: techniques of interview and physical assessment – review lab and diagnostic test findings to determine health status of woman and her fetus and progress of labor  Admission data o Prental record, intitial interview, physical examintaion to determine baseline physiological parameters, lab and diagnostic tests, expressed psychosocial and cultural factors, clinical evaluation of labor status  Prenatal data o Weight gain: greater than recommended can place woman at higher risk for cephalopelvic disproportion and cesarean birth – petite and gained 16kg or more o Confirm EDB o All other relevant information – previous births, vital signs, lab results, age, health history, pregnancy stuff  Interview o Primary reason for coming to hospital o To detemine onset of labor ask:  Time of onset of contractions and progress in terms of intensity, frequency, and duration  Location an character of discomfort from contractions  Persistence of contractions despite changes in maternal position and activity  Presence and character of vaginal discharge or show  Status of amniotic membranes such as gush or sepage of fluid o To determine if membranes ruptured: sterile speculum examination and a nitrazine (pH) or fern test  Ruptured – amniotic fluid which is alkaline o If general anesthesia required in an emergency, important to assess woman’s respiratory status – ask about allergies too o Type and time of woman’s last solid food and liquid intake o Help formulate a birth plan by describing options available and finds out woman’s wishes and preferences  Psychosocial factors o Note verbal interactions, body language, perceptual ability (language barrier?), discomfort level o Women with history of sexual abuse: memories can be triggered during vaginal examination, students watching, etc.  Cultural and religious preferences o The value and meaning placed on childbirth experience o View of childbirth as a wellness or illness experience and as a private or social event o Practices regarding diet, medications, activity, and emotional and physical support o Appropriate maternal and paternal behaviors o Birth companions o Views regarding the newborn and newborn care immediately after birth  Physical examination o General systems assessment, performance of Leopold’s maneuvers to determine fetal presentation, position, and point of maximal intensity for auscultation FHR, asssessment of fetal status, assessment of uterine contractions and vaginal examination to assesss cervical effacement and dilation, fetal descent, and amniotic membranes and fluid o Findings from vaginal examination more valid indicators of phase of labor than nature of contractions o General systems assessment: heart, lungs, skin – presence of edema of legs, face, hands, sacrum, and testing of deep tendon reflexes and for clonus o Vital signs: if BP elevated, should be reassessed 30 min later, between contractions o Encouraged to sleep on side instead of supine – prevent hypotension and fetal distress o Temperature: infection or fluid deficit o Intake and output: measured every 8 hours o Dipstick: to determine urinary and ketone levels  Leopold’s Maneuvers (Abdominal palpation) o Woman lying on back o Help to identify number of fetuses, presenting part, fetal lie and fetal attitude, degree of descent of presenting part into pelvis, expected location of the PMI of the FHR on woman’s abdomen  Assessment of FHR and pattern o PMI of FHR: location on maternal abdomen where the FHR is heard loudest – usually directly over fetal back  An aid in determining fetal presentation and position  Vertex presentation: FHR heard below mother’s umbilicus in either right of left lower quadrant of abdoment  Breech position: FHR heard over mother’s umbilicus  As fetus descends and rotates internally, FHR heard lower and closer to midline of maternal abdomen  PMI in right occipitoanterior position moves to midline just over symphysis pubis  Just before birth: fetal position occipitoanterior and fetal back is directly above the symphysis pubis o FHR and pattern assessed:  Immediately after ROM because this is most common time for umbilical cord to prolapse  After any change in the contraction pattern or maternal status  Before and after medicating woman or performing a procedure  Assessment of uterine contractions o General characteristic of effective labor: regular uteirne activity – but not directly related to labor progress o Uterine contractions: primary powers that act involuntarily to expel the fetus and placenta from uterus o Ways to evaluate uterine contactions: women’s subjective description, palpation and timing of contraction, and internal electronic monitoring o Each contraction wave like pattern – begins wiht slow increment gradually reaches an acme and then diminishes rapidly o Interval of rest ends when next contraction begins o Characteristics:  Frequency: how often uterine contractions occur, the time t
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