Scenario Presentation in Labor and Delivery Rooms

Presented by: Kristina Crisostomo Abigail Buhayo Rachelle Ann Mapue Chiara Pascual Kristelie Mae A. Tillain BSN 1Y1 – 11/ Our Lady of Fatima University

Nursing Management
• Labor Room and Delivery Room • Room Lay-Out • Tools and Equipment

Labor and Delivery Room
• • • • • • • Labor Process Methods of Prepared Childbirth True and False Labor Contractions Signs and Symptoms of Impending Labor Standards of Care Guidelines Stages of Labor Parenting Promotion

Labor Process
• From the initial prenatal visits, the nurse needs to emphasize to the mother that labor and delivery are normal physiologic process. • The pregnant woman typically approaches the time of delivery with major concerns in her personal well-being, of her unborn child, and a painful and difficult labor and delivery. • Addressing these concerns and minimizing her discomfort should be the paramount of importance of the nurse.

Methods of Prepared Childbirth
• • • • Grantly Dick-Read Method Psychoprophylactic or Lamaze Method Bradley Method of Delivery Home Delivery

Grantly Dick-Read Method
• This method is based on the idea that fear and anticipation of pain arouse natural protective tensions in the body, psychic as well as muscular. • Fear stimulates the sympathetic nervous system and causes the circular muscle of the cervix to contract. • The longitudinal muscles of the uterus then have to act against increased cervical resistance, causing tension and pain. • Tension and pain aggravate fear, which produces a vicious cycle of tension, pain, and fear.

Dick-Read Cont.
• A minor degree of pain, magnified by fear, becomes unbearable. • According to Dick-Read, prenatal courses and training reduce fear, overcome ignorance,and build a woman's self-confidence. • Click here for the included methods.

Dick-Read Methods
• Explanations of fetal development and childbirth. • Descriptions of methods available to relieve pain. • Exercises that strengthen certain muscles and relax others. • Breathing techniques that will enable the woman to relax in the first stage of labor and work effectively with muscles used during delivery. • Explanations of the value of improved physical health and emotional stability for childbirth.

Dick-Read Methods Cont.
• The woman is not told that labor and delivery will be painless; analgesia and anesthesia are available if needed or desired. • The woman is given empathic understanding and support during labor by her partner, the nurse, and the health care provider.

Psychoprophylactic or Lamaze Method
• Psychoprophylactic childbirth has a rationale based on Pavlov's concept of pain perception and his theory of conditioned reflexes (the substitution of favorable conditioned reflexes for unfavorable ones). The Lamaze method is an example of this technique. • The woman is taught to replace responses of restlessness, fear, and the loss of control with more useful activity. A high level of activity can excite the cerebral cortex efficiently to inhibit other stimuli such as pain in labor.

Lamaze Method Cont.
• The mother-to-be is taught exercises that strengthen the abdominal muscles and relax the perineum. • Breathing techniques to help the process of labor are practiced. • The woman is conditioned to respond with respiratory activity and disassociation or relaxation of the uninvolved muscles, while controlling her perception of the stimuli associated with labor.

Lamaze Method Cont.
• One method of control consists of breathing normally while silently mouthing the words to a song and simultaneously tapping the rhythm with the fingers.

Bradley Method of Delivery
• Commonly referred to as “husband-coached childbirth,” although the coach is not necessarily the husband of the woman. • Involves the concepts of leading, guiding, supporting, caring, and fostering specific skills and confidence. • Coaches attend classes and learn to help the woman long before labor begins. • The coach serves as a conditioned stimulus using the sound of his or her voice, use of particular words, and repetition of practice.

Bradley Method Cont.
• Medications are not encouraged for pain relief. Relaxation is the core component. • Increased tolerance to pain is accomplished by decreased mental anxiety and fear, which ultimately decreases the awareness of the pain stimulus. • Occurs with cognitive and physical rehearsal.

Home Delivery
• Motivation • Contraindications • Alternatives

• Belief that home birth has significant advantages for the family and the neonate. • Objection to the impersonal and authoritarian atmosphere of the hospital environment with enforced separation of woman and family. • Desire to avoid such practices as routine cesarean delivery for breech presentation, episiotomy, forceps delivery, oxytocin stimulation, routine monitoring of the fetal heart tones, and other practices associated with hospitals.

• Risk of in-hospital infections; belief that infant is immune to own-home bacteria. • Rising costs of hospitalization.

• High-risk indications for infant and mother. • Patient with history of premature or postdate delivery in previous pregnancy or previous cesarean delivery • Woman with medical or emotional complications. • Patient who cannot be quickly transported to a hospital.

• Alterations of hospital setting to a family-centered approach. • Birthing centers with adequate facilities for emergency care for low-risk women. • Properly educated and motivated support personnel.

True and False Labor Contractions
True Labor •Result in progressive cervical dilation and effacement • Occur at regular intervals •Interval between contractions decreases •Frequency, duration, and intensity increase •Located mainly in back and abdomen •Generally intensified by walking •Not easily disrupted by medications False Labor •Do not result in progressive cervical dilation and effacement • Occur at irregular intervals •Interval between contractions remains the same or increases •Intensity decreases or remains the same •Located mainly in lower abdomen and groin •Generally unaffected by walking •Generally relieved by mild sedation

Signs and Symptoms of Impending Labor
• Sudden burst of energy very soon before actual labor begins (nesting instinct) • Lightening or the feeling that the baby has dropped lower in abdomen. In this event, breathing becomes easier, lordosis of the spine increases, walking may begin to be difficult and leg cramps may occur often, and urination is more likely to occur often since of the pressure exerted in the abdomen. • Discharge of pinkish mucous plug or unusual vaginal discharge.

• Rupture of amniotic membrane (water breaks as a trickle or gush). Note color and any odor of amniotic fluid if not in hospital. If you even suspect your water has broken, go to the hospital. • Abdominal cramping, vaginal, thigh, or back pain or pressure. • Regular contractions with or without pain over more than one hour. • For contractions, monitor for length, regularity, and duration. Monitor by feeling abdomen with fingertips, feeling for tightening and loosening.

• Note for timing the contraction interval, time from beginning of one contraction to the beginning of another contraction. • Also for timing contraction duration, time from beginning of contraction to end of contraction.

Stages of Labor
• • • • Stage One Stage Two Stage Three Stage Four

Stage One
• Dilation from 0 to 10 cm. • Begins with the first true labor contractions and ends with complete effacement and dilation of the cervix (10 cm dilation). • The first stage of labor averages about 13½ hours for a nullipara and about 7½ hours for a multipara. • It has three phases: - Latent or Early - Active - Panting

Latent Phase (Early)
• Dilates from 0 to 3 cm. • Contractions are usually every 5 to 20 minutes, lasting 20 to 40 seconds, and of mild intensity. • The contractions progress to about every 5 minutes and establish a regular pattern.

Role of the Nurse (Latent Phase)
• Nursing Diagnoses • Nursing Interventions

Nursing Diagnoses
• Deficient Fluid Volume related to decreased oral intake, lack of eating, and the energy requirement of labor • Anxiety related to concern for self and the fetus • Acute Pain related to uterine contractions or position of the fetus

Nursing Interventions
• Maintaining Nutrition and Hydration
– Provide clear liquids and ice chips as allowed. – Evaluate urine for ketones and glucose. – Administer I.V. fluids as indicated.

• Relieving Anxiety
– Establish a relationship with the woman/support persons. – Provide information on the health care facility's policies and procedures. Inform the woman/support persons of maternal status and fetal status and labor progress. – Explain all procedures and equipment used during labor. – Answer any questions the woman/support persons have. – Review the birth plan and make appropriate revisions. – Monitor maternal vital signs. Remember the individual patient condition is used to determine frequency of vital signs and FHR assessment. Adjust as needed. – Monitor FHR

• Controlling Pain
– Encourage ambulation as tolerated regardless of membrane status as long as presenting part is engaged. (This may vary according to health care provider.) – Encourage diversional activities, such as reading, talking, watching TV, playing cards, listening to music. – Review, evaluate, and teach proper breathing techniques. – Encourage a warm shower. Laboring woman can sit on a chair in the shower with the water running continuously over her lower back. – Encourage relaxation techniques. – Provide comfort measures. – Use of Jacuzzi or shower for relaxation if available. – Reposition external monitors as needed.

Active Phase
• Dilates from 4 to 7 cm. • Contractions are usually every 2 to 5 minutes; lasting 30 to 50 seconds and of mild to moderate intensity. • After reaching the active phase, dilation averages 1.2 cm/hour in the nullipara and1.5 cm/hour in the multipara.

Transitional Phase
• Dilates from 8 to 10 cm. • Contractions are every 2 to 3 minutes, lasting 50 to 60 seconds and of moderate to strong intensity. Some contractions may last up to (but not exceed) 90 seconds.

Role of the Nurse (Active and Transitional)
• Nursing Diagnoses • Nursing Interventions

Nursing Diagnoses
• Anxiety related to concern for self and fetus • Acute Pain related to uterine contractions and nausea and vomiting • Impaired Urinary Elimination related to epidural anesthesia or from pressure of the fetus • Ineffective Coping related to discomfort • Risk for Infection related to rupture of the membranes • Impaired Physical Mobility related to medical interventions and discomfort • Ineffective Breathing Pattern related to pain and fatigue

Nursing Interventions
• Relieving Anxiety – Monitor maternal vital signs and FHR, and keep the woman/couple informed of thematernal and fetus status. – Maternal temperature every 2 to 4 hours unless elevated or membranes ruptured, then every 1 hour. – Blood pressure, pulse, respirations usually every 30 to 60 minutes or as indicated by policy or maternal status. – Evaluate FHR every 30 minutes if low-risk patient or every 15 minutes if highrisk patient regardless if monitoring is continuous or intermittent. – Provide encouragement and support. – Involve the support person in the woman's care.

• Minimizing Pain
– Encourage position changes for comfort. – Assist the woman with breathing and relaxation techniques as needed. – Provide back, leg, and shoulder massage as needed. – Assist with preparation for analgesia and anesthesia

• Monitor the woman following administration of analgesia/anesthesia.
– Monitor the woman's blood pressure, pulse, and respiratory rate after initiation or re-bolus of regional block every 5 minutes for the first 15 minutes. – Maintain uterine displacement with hip wedge, lateral decubitus position, or semi– Fowler's position with uterine displacement. – Intervene for maternal hypotension with lateral positioning, additional I.V. fluids as ordered, and administration of ephedrine per institutional protocol.

• Assess neonate for effects of maternal medication (neurobehavioral change, such as decreased motor tone and decreased respiratory rate). Initiate neonatal resuscitation as indicated in accordance with established guidelines. • Place patient in same position for removal of catheter as she was in during insertion.

Stage Two (Expulsion)
• Begins with complete dilation (10 cm cervix dilation) and ends with birth of the baby. • The second stage may last from 1 to 4 hours in the nullipara and from 20 to 45 minutes in the multipara.

Role of the Nurse
• Nursing Diagnoses • Nursing Interventions

Nursing Diagnoses
• Fear or Anxiety related to impending delivery • Acute Pain related to descent of the fetus • Risk for Infection related to episiotomy and tissue trauma

Nursing Interventions
• Minimizing Fear and Anxiety
– Monitor maternal vital signs as follows:
• Blood pressure — every 5 to 15 minutes depending on the woman's status. • Pulse and respirations — every 15 to 30 minutes. • Temperature — every 1 hour when membranes have ruptured.

– Monitor FHR and uterine contractions every 15 minutes in low-risk women and every 5 minutes in high-risk women. – Explain procedures and equipment during pushing and delivery. – Keep the woman or couple informed of their status.

• Promoting Comfort
– Assist the woman to a comfortable position. – Left or right lateral, squatting, hand and knees, or semisitting positions may be used.
• Assist the woman with pulling her legs back so her knees are flexed. • Teach the woman to put her chin to her chest so her body forms and shape while pushing.

– Evaluate bladder fullness, and encourage voiding or catheterize as needed. – Evaluate effectiveness of anesthesia as indicated.

• Preventing Infection and Promoting Safety – Prepare the birthing room or delivery room using aseptic technique, allowing ample time for setup before delivery. – Prepare the infant resuscitation area for delivery. – Prepare necessary items for neonatal care. – Notify necessary personnel to prepare for delivery. – If delivery room is to be used, transfer the primigravida to the delivery room when the fetal head is crowning. The multigravida is taken earlier depending on fetal size and speed of fetal descent. – Place all side rails up before moving. Instruct the woman to keep her hands off the rails,and move from the bed to the delivery table between contractions.

• If delivering in LDR (Labor, Delivery, Recovery) or LDRP (Labor, Delivery, Recovery, Postpartum) room, prepare labor bed for delivery in accordance with manufacturer's instructions. Prepare infant warmer and remainder of room for delivery. • Position the woman for delivery using a large cushion for her head, back, and shoulders. • Elevate the head of the bed. Stirrups or footrests may be used for foot support. Pad the stirrups. Place both legs in the stirrups at the same time to avoid ligament strain,backache, or injury.

– Clean the vulva and perineal areas when the woman is positioned for delivery. – Guide the woman step by step during the delivery process. – Practice standard precautions during labor and delivery.

Stage Three (Placental)
• Begins with delivery of the baby and ends with delivery of the placenta. • The third stage may last from a few minutes to 30 minutes.

Role of the Nurse
• Nursing Diagnoses • Nursing Interventions

Nursing Diagnoses
• Impaired Tissue Integrity related to placental separation • Risk for Injury related to potential hemorrhage

Nursing Interventions
• Promoting Tissue Integrity
– Ask the woman to bear down gently. Fundal pressure is never applied to facilitate delivery of the fetus or the placenta. Observe for the signs of placental separation.
• • • • The uterus rises upward in the abdomen. The umbilical cord lengthens. Trickle or spurt of blood appears. The uterus becomes globular in shape.

– Evaluate the placenta for size, shape, and cord site implantation. Evaluate placenta for Duncan or Schultze presentation.

• Preventing Hemorrhage
– Ensure accurate measurement of intake and output maintained throughout labor and delivery. – Immediately after delivery of the placenta, administer oxytocin (Pitocin 10 to 40 units/L at 100 mU/min) either I.V. piggyback or I.M. as directed by facility policy and provider. – Infuse as bolus initially, then titrate to uterus (ie, if uterus is firm, decrease the infusion; if boggy, leave as bolus). Pitocin should never be administered I.V. push as it can cause cardiac dysrhythmia and death.

– Immediately after initiating Pitocin, massage uterine fundus until firm. Uterine massage is done with two hands, one anchored at the lower uterine segment above the symphysis pubis and the other hand gently massages the fundus. – Check to see that the placenta and membranes are complete. – Evaluate and massage the uterine fundus until firm. – If bleeding continues and uterus is firm, notify health care provider for evaluation of lacerations or retained placental fragments. Inspection and repair of lacerations of the vagina and cervix are made by the health care provider.

– If still no relief, notify health care provider and prepare patient for possible surgery (dilation and curettage, Blynch suture, pelvic pressure packing, and selective arterial embolization). Autotransfusion (transfusion with one's own blood) is also a treatment available and approved for use by Jehovah's Witnesses.

Immediate Care for the Neonate
• Nursing Diagnoses • Nursing Interventions

Nursing Diagnoses
• Ineffective Airway Clearance related to nasal and oral secretions from delivery • Ineffective Thermoregulation related to environment and immature ability for adaptation • Risk for Injury related to immature defenses of the neonate

Nursing Interventions
• Promoting Airway Clearance and Transitioning of the Neonate
– Transitioning/close observation of the neonate is essential for at least 6 to 12 hours after birth. – Wipe mucus from the face and mouth and nose. Aspirate with a bulb syringe. – Clamp the umbilical cord approximately 1 inch (2.5 cm) from the abdominal wall with a cord clamp. – Evaluate the neonate's condition by the Apgar scoring system at 1 and 5 minutes after birth.

• Promoting Thermoregulation
– Dry the neonate immediately after delivery, remove wet towels, and place infant on warm dry towels. A wet, small neonate loses up to 200 cal/kg/min in the delivery room through evaporation, convection, conduction, and radiation. Drying the infant cuts this heat loss in half. – Cover the neonate's head with a cotton stocking cap to prevent heat loss. – Wrap the neonate in warm blankets. – Place the neonate under a radiant heat warmer, or place the neonate on the mother's abdomen with skin-to-skin contact. – Provide a warm, draft-free environment for the neonate. – Take the neonate's axillary temperature — a normal temperature is between 97.5° and 99° F (36.4° and 37.2° C).

• Preventing Injury and Infection
– Administer prophylactic treatment against ophthalmia neonatorum (gonorrheal or chlamydial). – Administer a single parental prophylactic injection of vitamin K within 1 hour of birth.
• This is done to prevent a vitamin K-dependent hemorrhagic disease of the neonate. • If the parents do not want the vitamin K administered, inform the parents that circumcision may not be performed. However, inform parents that the Vitamin K levels will reach their peak (without neonatal injection) at 8 days after birth.

– While in the delivery room (DR), place identical identification bracelets on the mother and the neonate. The nurse in the DR should be responsible for preparing and securely fastening the bands on the neonate.
• Information includes the mother's name, hospital/admission number, neonate's sex, race, and date and time of birth and other information specified in your facility's policy. • The father or significant other may also wear a bracelet matching the mother's. • Footprinting and fingerprinting the neonate are not adequate methods of patient identification. • Complete all identification procedures before the infant is taken from the delivery room.

– Weigh and measure the infant shortly after birth.
• Normal neonate weight is 6 to 9 lb (2,700 to 4,000 g). • Normal neonate length is 19 to 21 inches (48 to 53 cm).

– No later than 2 hours after birth, nursery/mother-baby personnel should evaluate theneonate's status and assess risks. – Administer hepatitis B vaccine according to your facility's policy.

• Issues regarding promoting airway clearance, transitioning the neonate, and promoting thermoregulation are essentially unchanged for home births, although Apgar scores are sometimes not given at home deliveries. • Eye prophylaxis is unchanged; parents may choose to not use prophylaxis. • Make sure attendants are familiar with neonatal resuscitation and that emergency numbers and procedures are readily available.

• Vitamin K administration is not a requirement for home deliveries. Vitamin K levels naturally increase at 8 days of life. If infant is a boy, and parents desire circumcision, the procedure is withheld until after day 8. • Identification procedures are not required for home births, although required state paperwork must be completed by the health care provider.

Stage Four
• Lasts from delivery of the placenta until the postpartum condition of the woman has become stabilized (usually 1 hour after delivery).

Role of the Nurse
• Nursing Diagnoses • Nursing Interventions

Nursing Diagnoses
• Risk for Injury related to uterine atony and hemorrhage • Deficient Fluid Volume related to decreased oral intake, bleeding, and diaphoresis • Acute Pain related to tissue trauma and birth process, intensified by fatigue • Impaired Urinary Elimination related to epidural or spinal anesthesia and tissue trauma • Disturbed Sensory Perception (tactile) related to effects of regional anesthesia • Risk for Impaired Parenting related to inexperience

Nursing Interventions
• Promoting Uterine Contraction and Controlling Bleeding
– Monitor blood pressure, pulse, and respirations every 15 minutes for 1 hour, then every – ½ hour to 1 hour until stable or transferred to the postpartum unit. Vital signs are taken more frequently if complications encountered. – Take temperature every 4 hours unless elevated, then every 1 to 2 hours.

• Maintaining Fluid Volume
– Maintain I.V. fluids as indicated. – Provide oral fluids and a snack or meal as tolerated. – Encourage drink and food before assisting the woman out of bed.

• Relieving Discomfort and Fatigue
– Apply a covered ice pack to the perineum during the first 24 hours for an episiotomy, perineal laceration, or edema. – Administer analgesics as indicated.

– Assure that epidural catheter has been removed. – Assist the woman in finding comfortable positions. – Assist the woman with a partial bath and perineal care, and change linens and pads as necessary. – Allow for privacy and rest periods between postpartum checks. – Provide warm blankets, and reassure the woman that tremors are common during this period.

• Encouraging Bladder Emptying
– Evaluate the bladder for distention. – Encourage the woman to void.
• Provide adequate time and privacy. • The sound from a running faucet may stimulate voiding. • Gently squirting tepid water against the perineum in a perineal bottle may help.

– Catheterize the woman (in and out) if the bladder is full and she is unable to void.
• Birth trauma, anesthesia, and pain from lacerations and episiotomy may reduce or alter the voiding reflex.

• Assessing return of sensation
– Evaluate mobility and sensation of the lower extremities. – Evaluate vital signs. – Remain with the woman, and assist her out of bed for the first time. Evaluate her ability to support her weight and ambulate. – Do not provide hot fluids if sensation is decreased.

Promoting Parenting
• Show the neonate to the mother and father or support person immediately after birth when possible. • Encourage the mother and father to hold the infant as soon as possible. • Teach the mother or parents to hold the neonate close to their faces, about 8 to 12 inches (20.5 to 30.5 cm), when talking to the baby. • Have the mother or parents look at and inspect the infant's body to familiarize themselves with their child.

• Assist the mother with breast-feeding during the first 30 minutes, then 2 hours, after birth. This is typically a period of quiet alert time for the neonate, and he or she will usually take to the breast. • Provide quiet alone time in a low-lighted room for the family to become acquainted. • Observe and record the reaction of the mother or parents to the neonate.

Standard of Care Guidelines
• Establish a baseline history for the woman in labor, including maternity history, labor events thus far, medications, herbal preparations, allergies, concerns, and availability of support systems. • Determine fetal status: fetal heart rate, variability, accelerations, decelerations, fetal movement, cervical status. Notify health care provider of abnormal findings. • Assess uterine contractions in accordance with established standards of care, facility • policy, and maternal and fetal condition.

• Monitor maternal and fetal status in accordance with established standards of care, facility policy, and maternal and fetal condition. • Make sure that appropriate medical personnel are available within the facility during the administration of oxytocin (Pitocin) and prostaglandins in accordance with ACOG guidelines. • Perform the following interventions: change mother's position, administer oxygen, intiate or increase I.V. fluids, administer tocolytics.

• Notify the healthcare provider for the following:
– – – – – Nonreassuring or repetitive variable decelerations Repetitive late decelerations Prolonged decelerations, bradycardia, or tachycardia. Abnormal maternal vital signs Nonreassuring fetal tracing.

• Assist the woman with breathing and pain control techniques during contractions.

Room Lay-out
• Labor Room • Delivery Room

Labor Room Lay-out
• Labor room in Fabella, a government-run hospital in the Philippines

Labor Room Lay-out
• Mother in the labor room.

Labor Room Lay-out
• A labor-delivery room in a certain hospital.

Delivery Room Lay-out
• Delivery room with necessary equipment.

Delivery Room Lay-out
• Delivery buzzer is present in some hospitals.

Delivery Room Lay-out
• Some hospitals have these equipment in their delivery rooms.

Delivery Room Lay-out
• Other women would like to give birth using birthing pools instead.

Delivery Room Lay-out
• Doctor and nurses in delivery room.

Delivery Room Lay-out
• Shot taken during delivery of a baby.

Delivery Room Lay-out
• Nurses in delivery room.

Recovery Room Lay-out
• A mother breast-feeding her twins.

• Mothers at Fabella after delivery.

Recovery Room Lay-out
• A muti-patient postoperative recovery room