CARE OF A WOMAN DURING THE FIRST STAGE OF LABOR

CONCEPTS:
1.

2.

3.

4.

Labor should begin on its own, not be artificially induced Women should be able to move about freely throughout labor, not be confined to bed Women should receive continuous support during labor No interventions such as intravenous fluids should be used routinely

5.

6.

Women should be allowed to assume a non-supine position for birth Mother and baby should be housed together after the birth, with unlimited opportunity for breastfeeding.

Management:
1. 2.

Respect contraction time Promote change of position
 

Reassure woman that she may move about as needed When rupture of membranes occur, women should lie on her side until she has been checked Full bladder can impede fetal descent Encourage woman to void every 2 – 4 hours If she cannot void, she may need to be catheterized

1.

Promote voiding and provide bladder care
  

4.

Halt/prevent hyperventilation
 

Have a paper bag nearby Teach proper breathing techniques Toalleviate anxiety

4.

Offer support

4.

5.

Respect and promote the support person’s activities Support woman’s pain management effort

8.

Provide comfort caused by decreased water intake

 

Apply cream to lips or suggest sucking on hard candy or ice chips Offer isotonic sports drinks if possible IV glucose solution as prescribed

Amniotomy
 

Artificial rupturing of membarnes Done if membrane does not rupture spontaneously Patient’s cervix must be dilated at least 3 cm Always measure the FHR immediately after the rupture of membranes

CARE OF A WOMAN DURING THE SECOND STAGE OF LABOR

PREPARING THE PLACE OF BIRTH

MULTIPARA
 Prepare

equipment when the cervix has dilated to 7 – 9 cm equipment when the has crowned

PRIMIPARA
 Prepare

Make sure that drapes and materials used for birth are sterile Prepare newborn care area

POSITIONING FOR BIRTH

Lithotomy position
Position woman into the table stirrups while the physician is scrubbing and donning a sterile mask, gown, and gloves  Raise both legs at the same time  Strap legs snugly but no too tight  Pad the stirrups to prevent thromboplebitis  Head part may be elevatedto promote effective pushing  Make sure that there is always someone at the foot of the table so that if birth should occur precipitously, the infant will not fall and be injured

    

Lateral/ sim’s position Dorsal recumbent position Semisitting position Squatting position standing

Promoting Effective Second Stage Pushing

Woman should push with contractions and rest between them Tell patient to prevent holding her breath during pushing. Urge her to breathe out during a pushing effort. For multipara, ask patient to pant with contractions

Perineal Cleaning

 

Clean perineum with a warmed antiseptic, and then rinse with a designated solution before birth. Always clean from the vagina outward If the patient defecates, clean/sponge the area as it occurs to prevent contamination of the birth cana (from front to back)

EPISIOTOMY

A surgical incision of the perineum that is made both to prevent tearing of the perineum and to release pressure on the fetal head with birth Advantage:
Substitutes a clean cut for a ragged tear  Minimizes pressure on the fetal head  Shorten the last portion of the second stage of labor

done without anesthesia

Types:
 Midline
  

episiotomy

 Advantages:

Heals easily Cause less blood loss Less postpartal discomfort

 Mediolateral
 Advantage:

episiotomy

If tearing occurs beyond the incision, it will be away from the rectum

BIRTH

RITGEN’S MANEUVER
 As

soon as the head of the fetus is prominent at the vaginal opening, place a sterile towel over the rectum and press forward on the fetal chin while the other had is press downward on the occiput  Helps fetus achieve extension  Do not apply pressure over the fundus because uterine rupture may occur

Suction out infant’s mouth immediately after the birth of the baby’s head and then check if there is a nuchal cord A child is considered born when the whole body is born – this the time that it should be noted and recorded as the time of birth

CUTTING AND CLAMPING THE CORD
 

Baby is laid on the abdominal drape of the mother while the cord is cut Best time to cut the cord:
 Depends

on the physician or the midwife’s preference  Delay cutting until pulsation ceases and maintaining the infant at uterine level
 Allows

as much as 100 mL of blood to pass from the placenta to the fetus  Danger: delay in clamping could cause overinfusion with placental blood  can cause polycythemia and hyperbilirubinemia

Cord is clamped with 2 kelly hemostats placed 8 – 10 inches from the infant’s umbilicus and then is cut between them Count the vessle cord to be certain that 3 are present Cutting the cord is part of the stimulus that initiates a first breath.

CARE OF THE WOMAN DURING THE THIRD AND FOURTH STAGES OF LABOR

OXYTOCIN

Given IM or IV or through IVF infusion
 IVF

infusion: 20 – 30 units/L

 

Increases uterine contractions Methylergonovine maleate (methergine)
 Semisyntheticc

derivative of ergonovine  Produces strong and effective contractions

Nursing Responsibilities:
 Give

only as prescribed  Be sure to obtain baseline blood pressure  Document administration

Placental Delivery

 

Through spontaneous delivery or manual extraction Inspect completeness of placenta Weight: 1/6th weight of the infant

Perineal Repair
 

Episiorrhapy Woman might need some type of medication to make her comfortable
 Pudendal

block

Immediate Postpartal Assessment and Nursing Care

Vital signs
 15

minutes for one hour then according to agency’s policy

Palpate the fundus for size, consistency, and position and observe the amount and characteristics of the lochia Perform perineal care and apply perineal pad

Offer clean gown and warm blanket
 Mother

often experiences chill and shaking sensation

NURSING CARE OF THE POSTPARTAL WOMAN AND FAMILY

Puerperium
  

Postpartal Period Fourth trimester of pregnancy Refers to the 6-week period after childbirth

PSYCHOLOGICAL CHANGES PF THE POSTPARTAL PERIOD

Phases of Puerperium (Reva Rubin)
A.

TAKING-IN PHASE
  
  

First 2 – 3 days Time of reflection for a woman Woman is largely passive and dependent
Physical discomfort Uncertainty Extreme exhaustion

B.

TAKING-HOLD PHASE
  

Woman begins to initiate action Strong interest in caring for her child Give the woman brief demonstration of baby care then allow her to care for her child herself

C.

LETTING-GO PHASE
 

Woman finally defines her new role Woman faces the reality of motherhood

PHYSIOLOGICAL CHANGES OF THE POSTPARTAL PERIOD

REPRODUCTIVE SYSTEM CHANGES

INVOLUTION
 Process

whereby the reproductive organ return to their nonpregnant state

Changes in the uterus, cervix, vagina, and perineum

The Uterus

Two processes of uterine involution:

area where the placenta was implanted is sealed off
 Rapid

contraction of uterus

 Organ

is reduced to its approximate pregestational

size
  

Immediately after birth uterus weighs 1000g End of first week uterus weighs 500 g After 6 weeks (involution has completed) uterus weighs 50 g (prepregnant state)

Uterine Involution

Immediately after birth uterus is at half-way between umbilicus and the symphysis pubis First few hours – 24 hours fundus can be palpated at the level of the umbilicus then decreases 1 fingerbreadth per day 9th – 10th day: uterus have already receded under the pubic bone and is no longer palpable

Causes of delayed involution
Multiple fetuses  Hydramnios  Exhaustion from prolonged or difficult labor  Grand multiparity  Excessive analgesia

First hour postpoartum is potentially the most dangerous time for the woman
 Uterine
 Uterus

atony

becoms relaxed  Patient will bleed very rapidly

Afterpains
 Intermittent

cramping after childbirth  Due to contraction of the uterus  Increase with breastfeeding

Lochia

Uterine flow consisting of blood, fragments of decidua, blood cells, mucus, and some bacteria

CHARACTERISTICS OF LOCHIA

TYPE OF LOCHIA

COLOR

DURATION 1 – 3 days

COMPOSITION Blood, fragments of decidua, and mucus

Lochia Rubra Red

Lochia Serosa Pink

3 – 10 days Blood, mucus, and invading leukocytes 10 – 14 days Largely mucus; leuckocyte count high

Lochia alba

White

CERVIX

By the end of 7 days, the external os is narrowed to the size of a pencil opening Cervix becomes firm and nongravid again External os now appears as slitlike or stellate (star-shaped)

VAGINA

Vaginal outlet will remain slightly distended than before Let woman perform Kegel Exercises to increase strength and tone of the vagina

Perineum

Edema and generalized tenderness after delvery Labia majora and labia minora typically remain atrophic, never returning to their prepregnant state

SYSTEMIC CHANGES

HORMONAL SYSTEM

Decrease of pregnancy hormones due to absence of placenta

URINARY SYSTEM

Difficult voiding
 Transient
 No

loss of bladder tone

sensation of having to void

 Edema

of the urethra

Assess woman’s abdomen frequently
 Full

bladder is felt as hard or firm area just above the symphysis pubis

Overdistended bladder can cause noncontraction of uterus
 Displaces

the uterus to the side

Extensive diuresis  to get rid of excess fluid in the body Urine tends to contain more nitrogen than normal

CIRCULATORY SYSTEM

Blood volume has returned to its prepregnancy level during the first to second week postpartum
 Due

to:

 Blood

loss a tbirth  Diuresis

High level of plasma fibrinogen
 Protective

measure against hemorrhage  Increase risk of thrombus formation

Leukocytosis
 Body’s

defense against infection and an aid to healing

 

Varicosities will recede Spider angiomas will fade slightly

GASTROINTESTINAL SYSTEM
 

Digestion and absorption begin to be active again Woman feels hungry and thirsty almost immediately after delivery Bowel evacuation may be difficult due to pain of episiotomy sutures or hemorrhoids

INTEGUMENTARY SYSTEM

Striae gravidarum still appears redenned
 Will

lighten in the next 3 – 6 months

Chloasma and linea nigra will disappear in 6 weeks time If diastasis recti occur, the area will appear slightly indented
 Abdominal

exercises to strengthen abdominal muscles

Vital Sign Changes

Temperature
 Slight

increase of temperature during the first 24 hours of peurperium due to dehydration during labor  Temperature above 100.4F (38C) after 24 hours is abnormal  may be a sign of postpartal infection

Pulse
 Slightly
 Due

slower than normal

to increase stroke volume

 By

end of first week, the pulse rate has returned to normal  Rapid and thready pulse during the postpartal period is a possible sign of hemorrhage

Blood Pressure
 Reading

above 140 mmHg systolic or 90 mmHg diastolic may indicate postpartal PIH  Oxytocin administration can also cause increase blood pressure  Orthostatic hypotension
 Dizziness

that occurs on standing  Due to acute blood loss

 Prevention
 Advise

of orthostatic hypotension

patient to sit up slowly and “dangle” on the side of her bed before attempting to walk

PROGRESSIVE CHANGES

LACTATION
 Formation

of breastmilk  Colostrum is continually excreted for the first 2 days postpartum  Breasts tends to become full and tense or tender as milk forms  Primary Engorgement
 Feeling

of tension in the breast on the third or fourth day postpartum  Fades as the infant begins effective sucking and empties the breast of milk

 Milk

production depends on:

 nipple

stimulation  the infant sucking at the breast  use of breast pump  ability of the milk to come forward in the breast (let-down relfex)

Return of Menstrual Flow

 

If woman is not breastfeeding 6 – 10 weeks after birth If breastfeeding  3 – 4 months Absence of lactation does not guarantee that a woman will not conceive during this time

POSTPARTUM ASSESSMENT

       

B – BREAST U – UTERUS B – BLADDER B – BOWEL L – LOCHIA E – EPISIOTOMY H – HOMAN’S SIGN E – EMOTIONAL STATUS

Breasts
   

Soft, firm, can be lumpy Secretion of Colostrum Engorgement Assessment of:

Breasts
Size, shape, color  Engorgement

 

Large and reddened with taut, shiny skin May feel hard, tense and painful

 Nipples

Assess for a crack, fissure, presence of caked milk

Nursing Responsibilities:
 Advise

woman to use well-fitting bra to support breast tissue  Avoid unecessary manipulation of the breast

Uterus
 

Process of Involution Height
 First

Day = at Umbilicus  Decreases 1 FB per Day

Consistency
 Firm,

Round, Smooth;  Not “Boggy”
 Atony  Retained

placenta  Presence of blood clots  Distended bladder

Location

Midline

Caution: Never palpate uterus without supporting the lower uterine segment  can cause uterine invertion How to keep uterus contracted:
 Massage

in a gentle rotating motion  Breastfeeding  Let the patient void/catheterize patient  Administration of oxytocin

Assess uterus every 10 – 15 minutes during the first hour after delivery

Bladder

Often times will be catheterized during labor and delivery Assess for Bladder Distention:
 Uterine  UTI

Atony

Recatheterize in 6 hours if not voided  if with Dr’s order Measure Urine Output

Bowel
   

Assessment for Bowel Sounds Complaints of Gas Pains Usually has Stool 2-3 days post delivery May need medication for gas pains, laxatives, stool softeners, enemas

Lochia
 

Duration: 2 – 6 weeks Amount
 Estimate

of Drainage  Number of Pads
Bleeding is excessive if perineal pad is soaked within 60 minutes

Color
 Rubra  Serosa  Alba

 

Odor Presence of any clots

Assess every 15 minutes for the first hour Encourage women to change perineal pads frequently Inform woman to avoid using tampons until she returns for her postpartal checkup to preven risk of infection

Episiotomy

Assessment for:
 Hematomas  Ecchymosis  Edema  Erythema  Intact

Suture Line  Signs of Infection

Homan’s Sign

Assessment for Thrombophlebitis
 Swelling  Reddness  Warmth  Pain

 

Unilateral Findings C/S Mother at Higher Risk

Emotional Status

Can have Mood Swings Observing Bonding Behavior & Ability to give Infant Care
 Rubin’s

Phases

NURSING INTERVENTIONS DURING POSTPARTAL STAGE

Provide Pain Relief for Afterpains
 

Assure woman that this is normal and rarely lasts more than 3 days Give Ibuprofen or Acetaminophen as ordered Do not place warm compress over the abdomen  can cause uterine relaxation

Relieve Muscular Aches
 

Give acitamenophen as prescribe Assess pain carefully
 Pain

in the calf when standing  suggests thrombophlebitis

Give Episiotomy Care

Assure woman that episiotomy pain does not usually last more than 5 – 6 days Cortisone-based cream or sitz-bath can reduce inflammation Explain to the woman that sutures are made of absorbable material that will not need to be removed, and usually dissolve within 10 days

Promote Perineal Exercises

Kegel Exercises
 Relieves

perineal discomfort  Improves circulation to the area  Decreases edema  Regain prepregnant muscle tone and form

Administer Hot and Cold Therapy

Ice pack to the perineum during the first 24 hours reduces perineal edema
 Wrap

ice first in a towel to decrease thermal injury

Ice pack after 24 hours is not advisable  delay healing; use hot packs or moist heat instead  increase blood flow to the area

Perineal Care

 

Should be done as part of daily bath and after each voiding or bowel movement Let the patient perform perineal care Caution women not to flush the toilet until she is standing upright

Promote Rest
 

Give analgesics as prescribed To regain strength

Promote Adequate Fluid Intake
 

To prevent dehydration At least 3 – 4 8-oz glasses of fluid a day

Promote urinary Elimination

A full bladder may interfere wtih effective uterine contraction An overdistended bladder may damage bladder function Encourage woman to walk to the batroom and void at the end of the first hour postpartum

Stimulate voiding:
 Provide

privacy  Running water at the sink  Offering woman a drink of water  Pour warm tap water over the vulva

Refer if patient has not voided 4 – 8 hours after birth

Prevent Constipation
    

Early ambulation High roughage diet Adequate fluid intake Stool softener may be necessary If woman has not moved her bowels by the third day a mild laxative may be ordered

Prevent/Alleviate Breast Engorgement

Encourage breastfeeing
 Main

treatment for relief of tenderness and soreness

 

Warm compress or standing under a warm show Wearing of bra with good support Oral analgesics may be needed

Promote Breast Hygiene
 

Wash breast daily with clear water Soaps should be avoided  can cause cracking and fissuring of the nipples Insert clean gauze squares or commercial nursing pads in bra to absorb moisture

Methods to Promote Uterine Involution

Lying on the abdomen gives support to abdominal muscles and ids in involution
 Place

a small pillow under the stomach to avoid too much pressure on the breast

Avoid knee-chest position until a postpartum examination has revealed a closed cervix

Sexual Activity

Coitus may be resumed as soon as lochia serosa has stopped  1 – 2 weeks after birth

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