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NCP: Labor Stage 2 (expulsion)

NCP: Labor Stage 2 (expulsion)

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Published by Javie

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Published by: Javie on Oct 03, 2009
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02/01/2013

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LABOR Stage II (Expulsion)
Stage II of labor, the stage of expulsion, begins with full cervical dilation (10 cm) and ends with the birth of thenewborn. Maternal efforts to bear down occur involuntarily during contractions that are 1.5–2 min apart, lasting 60–90sec. The average rate of fetal descent is 1 cm/hr for nulliparas, 2 cm or more per hr for multiparas.
CLIENT ASSESSMENT DATA BASEActivity/Rest
Reports of fatigueMay report inability to self-initiate pushing/relaxation techniquesLethargicDark circles under eyes
Circulation
BP may rise 5–10 mm Hg in between contractions.
Ego Integrity
Emotional responses may range from feelings of fear/irritation to relief/joy.May feel a loss of control or the reverse as she is now actively involved in bearing down.
Elimination
Involuntary urge to defecate/push with contractions, combining intraabdominal pressure with uterine pressure.May have fecal discharge while bearing down.Bladder distension may be present, with urine expressed during pushing efforts.
Pain/Discomfort
May moan/groan during contractions.Amnesia between contractions may be noted.Reports of burning/stretching sensation of the perineum.Legs may tremble during pushing efforts.Uterine contractions strong, occurring 1.5–2 min apart and lasting 60–90 sec.May fight contractions, especially if she did not participate in childbirth preparation classes.
Respiratory
Respiratory rate increases.
Safety
Diaphoresis often presentFetal bradycardia appearing as early decelerations on electric monitor during contractions (head compression) orvariables (cord compression)
Sexuality
Cervix fully dilated (10 cm) and 100% effaced.Increased vaginal bloody show.Rectal/perineal bulging with fetal descent.Membranes may rupture at this point if still intact.Increased expulsion of amniotic fluid during contractions.Crowning occurs; caput is visible just before birth in vertex presentation.
NURSING PRIORITIES
1.Facilitate normal progression of labor and fetal descent.2.Promote maternal and fetal well-being.3.Support client’s/couple’s wishes regarding delivery experience, maintaining safety as a priority.
 
NURSING DIAGNOSIS:Pain [acute]May Be Related To:
Mechanical pressure of presenting part, tissue dilation/stretching,nerve compression, muscle hypoxia, intensified contractile pattern
Possibly Evidenced By:
Verbalizations, distraction behavior (e.g., restlessness), facial mask of pain, narrowed focus, autonomic responses
DESIRED OUTCOMES/EVALUATION
Verbalize reduction of pain.
CRITERIA—CLIENT WILL:
Use appropriate techniques to maintain control.Rest between contractions.
ACTIONS/INTERVENTIONSRATIONALEIndependent
Identify degree of discomfort and its sources.Clarifies needs; allows for appropriate intervention.Provide comfort measures, such as mouth care; Promotes psychological and physical comfort,perineal care/massage; clean, dry linen and allowing client to focus on labor, and may reduceunderpads; cool environment (68°F–72°F [20°C–22.1°C]), the need for analgesia or anesthesia.cool, moist cloths to face and neck; or hot compressesto perineum, abdomen, or back, as desired.Review information with client/couple about type Although client is under the stress of labor andof regional analgesia/anesthesia available at this discomfort levels may interfere with normalstage specific to the delivery setting (e.g., local, decision-making skills, she still needs to be inpudendal block, lumbar epidural reinforcement) control and make her own informed decisionsor use of transcutaneous electrical nerve stimulation regarding anesthesia. Note: The option of a nerve(TENS), acupressure/acupuncture. Review root block should be restricted to a hospital settingadvantages/disadvantages, as appropriate.where emergency equipment is available.Monitor and record uterine activity with Provides information/legal documentation abouteach contraction. continued progress; helps identify abnormalcontractile pattern, allowing prompt assessment and intervention.(Refer to CP:
 
DysfunctionalLabor/Dystocia.)Provide information and support related to Keeps couple informed of proximity of delivery;progress of labor.reinforces that efforts are worthwhile and the end is in sight.Encourage client/couple to manage efforts to Anesthetics may interfere with client’s ability tobear down with spontaneous, rather than sustained, feel sensations associated with contractions,pushing during contractions. Stress importance of resulting in ineffective bearing down.using abdominal muscles and relaxing pelvic floor.Spontaneous, rather than sustained, efforts to beardown avoid negative effects of Valsalva’s maneuverassociated with reduced maternal and fetal oxygenlevels. Relaxation of the pelvic floor reduces resistanceto pushing efforts, maximizing effort to expel the fetus.Observe for perineal and rectal bulging, openingAnal eversion and perineal bulging occur as theof vaginal introitus, and changes in fetal station.fetal vertex descends, indicating need to prepare fordelivery.
 
Assist client in assuming optimal position for Proper positioning with relaxation of perinealbearing down; (e.g., squatting or lateral recumbent, tissue optimizes bearing-down efforts, facilitatessemi-Fowler’s position (elevated 30–60 degrees). labor progress, reduces discomfort, and reducesAssess effectiveness of efforts to bear down.need for forceps application.(Refer to ND: Skin/Tissue Integrity, risk forimpaired.)Encourage client to relax all muscles and rest Complete relaxation between contractionsbetween contractions.promotes rest and helps limit muscle strain/fatigue.Monitor maternal BP and pulse, and FHR. Observe Maternal hypotension caused by decreasedunusual adverse reactions to medication, such as peripheral resistance as vascular tree dilates is theantigen-antibody reactions, respiratory paralysis, main adverse reaction to subarachnoid oror spinal blockage. Note adverse reactions such as peridural block. Fetal hypoxia or bradycardia isnausea/vomiting, urine retention, delayed respiratory possible, owing to decreased circulation within thedepression, and pruritus of face, eyes, or mouth.maternal portion of the placenta. Other adverse(Refer to ND: Gas Exchange, risk for impaired reactions may occur after administration of spinalfetal.)or peridural anesthetic especially when morphine isused.
Collaborative
Assess bladder fullness. Catheterize between Promotes comfort, facilitates fetal descent, andcontractions if distension is noted and client is reduces risk of bladder trauma caused byunable to void.presenting part of fetus.Assist with reinforcement of medication via Reduces discomfort associated with episiotomy,indwelling lumbar epidural catheter whenforceps application, and fetal expulsion. Adversecaput is visible. Monitor vital signs and reactions include maternal hypotension, muscleadverse responses. (Refer to CP: Labor: Stage Itwitching/convulsions, loss of consciousness,Active Phase; ND: Pain [acute].)reduced FHR, and beat-to-beat variability.Position client in dorsal lithotomy position and Anesthetizes lower two-thirds of vagina andassist as necessary with administration of perineum during delivery and for episiotomypudendal anesthetic.repair. May interfere with efforts to bear down buthas no effect on maternal BP, FHR, or FHRvariability.Assist as needed with administration of local Anesthetizes perineum tissue for incision/repairanesthetic just before episiotomy, if done.purposes.
Lumbar, Epidural, or Low Spinal Anesthesia
Administer IV fluid bolus of 500–1000 ml Increases maternal circulating fluid as a means of lactated Ringer’s as indicated, before preventing adverse reactions of anesthetic such asadministration of agent.maternal hypotension, fetal hypoxia, and fetalbradycardia.Position client in sitting or lateral recumbent Proper alignment of vertebrae maximizes space forposition for insertion of drug/placement of needle/catheter placement.catheter for continuous infusion. Have clientflex head sharply on chest/arch back duringintrathecal administration.

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