Intrapartum Nursing Care

On Admission
Induction/Cesarean Section
Care in 1st, 2nd, 3rd, and 4th Stages of Labor
Precipitous/Out-of-Hospital Delivery
When to go to Hospital

 Regular Contractions with  intensity

 SROM
 Vaginal Bleeding
 Changes in Fetal Movement—especially a
 in fetal movement as described in the Daily
Fetal Movement Count
On Admission to Hospital
 Evaluate Is this True Labor?
 IMMINENCE OF DELIVERY
 Condition of mother

 Condition of fetus

 Previous experience with labor

 Childbirth education—Lamaze, Childbirth

preparation, breastfeeding, cesarean
section class
 Is there a BIRTH PLAN?Any plans for
anesthesia?
Identify Patient
 Note time of arrival/reason for admission
 Pt’s name, MD-both Obstetrician and
pediatrician
 Plans to breast or bottle feed
 Assess when she last ate or drank
 Assess support person and what they perceive
as their role in the labor process.
 Remember to introduce yourself as the RN
and explain all assessment parameters and
interventions in simple terms
Review Prenatal History
 EDC/EDD Is baby term?
 OB History: GTPAL status, previous labors
 Medications taken during pregnancy including
Prenatal vitamins and Iron
 Use of alcohol, illicit drugs, tobacco during pg
 Labs (Blood Type & Rh, Rubella, Beta Strep, MSAFP,
VDRL/RPR, GC culture)
 Diagnostic Tests (Amniocentesis, Ultrasound)
 Allergies
 Complications (Medical/OB)—chronic illnesses, BP,
dysuria, edema of hands and face, etc.
Physical Assessment on Admission
 Maternal Vital Signs—between contractions
 Fetal Status—baseline FHR, accels/decels, fetal
movement and FHR response
 Labor Status
 Contractions—frequency, duration, intensity

 Vaginal Discharge (??SROM = NO GEL)—

bloody show?, color and odor of amniotic fluid
if SROM, use Nitrazine paper to assess SROM
 Vaginal Changes—dilatation, effacement

 Descent of Fetus– Presentation, Station,

Position
Physical Assessment, cont’d

 Abdominal Exam
 Assess bowel sounds laterally
 Assess fundal height
 Perform Leopold’s Maneuvers
 Chest
 Assess heart and lung sounds
 DTR’s
 Assess patellar reflexes bilaterally
 Note hyperreflexia, if +3-+4, check for clonus
Psychosocial Assessment on Admission

 Mother’s Status—in early labor, pt is often

excited, teachable, and talkative. As labor progresses,
anxiety increases as pain increases & the ability of the pt
to focus decreases. Noting these variables helps the
nurse determine the progress of labor
 Support Persons—assess who they are & how
they expect to participate in the labor process e.g. active
labor coach vs. observer
 Nurse’s Role—support pt and significant others
and encourage to verbalize fears & concerns. Evaluate
how best to provide Family-Centered Care for this family
system
Admission/Diagnostics
 CBC (Hgb, Hct), Type/Rh (if unknown)
 U/A
 Dipstick—often done in the lab
 Glucose
 Albumin

 U/A if ordered
 Blood Type and Cross-match for C/S only
Nursing Care On Admission
 Place EFM ASAP—Assess fetal status
 Do Vag Exam—Assess Labor Status
 Complete OB Paperwork
 Assessment, Hx, Database, PG Hx, Vitals
 Check Orders
 Start IV, especially if pt wants epidural soon
 Lab Work
 Orient to Room
ALWAYS assess FHR
 AFTER AROM or SROM
 (risk of prolapsed cord)
 BEFORE starting Pitocin for Induction
 Throughout induction
 BEFORE & AFTER analgesia/anesthesia
Induction
 Definition: artificial initiation of labor before
spontaneous onset of contractions after the
period of viability.
 Augmentation: Stimulation of contractions after labor has
begun to strengthen contractions
 Indications: see pg 628; 10th edition
 Readiness
 FETAL: Fetal well-being (Reactive NST), Amniocentesis
L:S ratio >2:1, BPP >8, EDD
 MATERNAL: Use of Bishop’s Scale where the most
significant parameter is cervical readiness.
 Bishop’s Scale for measuring Induction Readiness
Table 1. Bishop Scoring System

Factor

Score Dilation (cm) Effacement (%) Station* Cervical Consistency Position of Cervix

0 Closed 0-30 -3 Firm Posterior

1 1-2 40-50 -2 Medium Midposition

2 3-4 60-70 -1,0 Soft Anterior

3 5-6 80 +1,+2 -- --

*Station reflects a . 3 to +3 scale.

Modified from Bishop EH. Pelvic scoring for elective induction. Obstet Gynecol 1964;24:267

Favorable cervix: in multipara, a score of >5

in primipara, a score of >7-9
Unfavorable cervix (low score) is associated with prolonged
labors and  risk of cesarean delivery.
Methods of Staged Induction–
especially used if cervix is not ripe

 Laminaria– seaweed is hydrophilic and absorbs water

thus swelling in the cx and causing it to dilate. MD places
these in the external os of the cx and allows the “tent” to
swell overnight.
 Transcervical Balloon—mechanical method of dilating cx.
 Prostaglandin–(PGE2, PGF2)a a variety of forms from
gels inserted transvaginally, to suppositories, or vaginal
inserts help soften the cervix and initiate contractions.
 Dinoprostone (Cervidil) 10mg vaginal insert inserted once.
 Misoprostol (Cytotec) 25mcg tab inserted into the cervical os q4h.
Nurse’s Role in Prostaglandin E-2
(PGE-2) Monitoring

 Should have signed consent

 NST to establish fetal well-being
 Pt. Lies supine for insertion.
 Pt remains in bed for 30-60min after gel and
2hrs after insert . Some moms stay in hospital
overnight and have Oxytocin induction in AM.
 Monitor uterine and fetal activity continuously for
1st 1-2 hrs. post insertion.
 Assess maternal VS hourly X 2, then q 4.
 Nurse’s Role in Prostaglandin E-2
(PGE-2) Monitoring
Cervidil

 After 2 hours, pt is encouraged to walk. She may

be advised to go home if no active labor evident,
& instructed to return if BOW breaks, contractions
become more regular, or fetal movements
decrease.
 RISKS: uterine hyperstimulation, but
uncommon if properly inserted.
 Be prepared to remove excess gel with gauze squares
or remove Cervidil insert in cases of hyperstimulation.
Methods of Induction--
when Cervix is ripe and ready

 AROM/Amniotomy
 Potential complication:
a. Infection
b. Prolapsed cord
c. Fetal head or cord compression
 Contraindications:
a. When presenting part is floating high
b. If fetus is in a breech or transverse lie
Methods of Induction--
when Cervix is ripe and ready

 Nursing Care after AROM:

a. Assessment– FHT of baby immediately
-VS of mom before & after, Temp q 2h thereafter
-Assess color & odor of fluid immediately
b. Intervention/Plan–
-Explain procedure to pt
-Prepare room: supine position, sterile gloves, for
MD, KY lubricant, Amniotome or Fetal Scalp Electrode
-Change waterproof pads under pt prn.
c. Evaluation—
-FHR remains stable, pt is comfortable
Methods of Induction--
when Cervix is ripe and ready

 Oxytocin (Pitocin)
 Uses:
 induce rhythmic uterine
contractions
 augment weak or ineffective
contractions.
 promote uterine contraction in
4th stage of labor
Oxytocin (Pitocin)
 Contraindications:
*any obstruction that interferes with fetal
descent
*any risk of uterine rupture(e.g..VBAC)
*hypertonic uterus
*existing fetal distress (e.g. positive CST)
*placenta previa
*genital herpes (active lesions)
Oxytocin (Pitocin)See box in text
 Mixed with LR, D5LR, or D2NS(depends on MD)
 Amount: your text adds 10U to 1000ml
 BRMC and St. Joseph adds 30U to 500ml

 Rate: follow MD’s orders.

AWHONN guidelines recommend to begin
with .5-2mU/min and increase by 1-2mu q15-60
minutes until contractions are q2-3min in
frequency and 40-90 sec. duration. Maximum
dose: 20-40mU./min
Oxytocin (Pitocin)continued
MD Order:
Start Oxytocin 1mU/min and increase by 1mU/min q 20minutes

 CALCULATING Pitocin rates:

 10U added to 1000ml= 10U/1000ml
 10U X 1000mU= 10000mU/1000ml=10mu/ml
 Remember: you must convert mU/min to
ml/hr to set the rate on the IV pump
 1ml/10mU X 60min/hr X 1mU/min=6ml/hr
So, 1mU/min= 6cc/hr
 If you are to give the patient 5mU/min, at what
rate will you set the pump?
 5mU/min X 1min/mU X 6cc/hr=30cc/hr
 IF the Oxytocin bag has 30U in 500ml, and you have the
same MD order, this is the formula:

 500ml X 1U X 1mU X 60min = 1ml

30U 1000mU min 1hr hr

 If the IV pump reads 12 ml/hr , how much Oxytocin is the patient

receiving?
 Oxytocin (Pitocin)—Nurse’s Role

 Assess & record FHR q15min if Oxytocin, variability,

accels
 Assess & record Uterine activity q15-30min.
 Assess & record Maternal BP q 15-30min.
 Assess & record Maternal I & O continuously.
IV Oxytocin can lead to water intoxication
Output should be 120cc/4hr or 30-35cc/hr.
 Assess pt sensitivity and pain after initiation of med.
Oxytocin (Pitocin)
 2 dangers with Oxytocin administration
 Tachysystole: Increased strength, length, and
frequency of contractions may lead to uteroplacental
insufficiency 2ndary to hypertonicity of uterus

 Birth injuries:
For fetus: rapid descent through pelvis may
cause fetal bruising, petechiae, injury
For mom: may predispose her to cervical
lacerations, uterine rupture, placenta abruptio, amniotic
fluid embolism.
Oxytocin (Pitocin)
 Nursing Care (see text )
 Monitor IV closely– Mainline LR and
IV Pitocin should generally equal 125cc/hr
 Monitor contractions closely– If >90sec. In
duration or >frequent than q2min, D/C Pit.
 Monitor FHR– Watch for late decels,
bradycardia <100 bpm, or
tachycardia>180 bpm
 Monitor maternal VS and I & O regularly
Nursing Care-- 1st Stage of Labor
 Frequency of Assessments—See next slide
 Uterine Contraction- assess frequency,
duration, intensity
 Vaginal Exams / “Bloody Show”
 Fetal Position / Heart Rate
 Leopold Maneuvers
 Location of FHT’s
 Status of Membranes
 Minimal Assessment of the Low-Risk Woman During the
1st Stage of Labor

Cervical Dilatation

0-3cm 4-7cm 8-10 cm

(latent) (active) (transition)
BP, P, R q 30-60 min. q30 min q 15-30 min
Temperature q 4h q 4h q 4h
Uterine q 30-60 min q 15-30 min q 10-15 min
activity
FHR q 30-60 min q15-30 min q15-30
Vaginal Show q 30-60 min q 30 min q 15 min
Behavior, q 30 min q 15 min q 5 min
Appearance,
Energy Level
 Vaginal Exam done only prn
to identify progress of labor

1. To confirm change in cervix when sx indicate

(e.g. strength, duration, or frequency of
contractions;  in amt of bloody show; ROM; or
woman feels pressure on her rectum)
2. To determine whether dilation and descent are
sufficient for administration of analgesic or
anesthetic
3. To reassess progress if labor takes longer than
expected
4. To determine station of presenting part
Signs of Transition (8-10cm)
  in bloody show
 Nausea and vomiting
 Increased rectal pressure
 Desire to push
  ability to focus due to intensity and
frequency of contractions
Nursing Care / Psychosocial

 Confidentiality
 Be Respectful
 Supportive Care / Include Support Persons
 Use of Touch
 Reassurance / Gentle Coaching
 Modesty
Nursing Care / Physical
 Positioning

 Hydration

 Bladder

 Dealing with Contractions

Signs of Potential Complications
 Rising Intrauterine Pressures
 Contractions > 90 sec. Or < 2 minutes apart
 Fetal bradycardia, tachycardia, decreased
variability
 Meconium-stained, bloody or foul-smelling fluid
from vagina
 Arrested progress of labor
 Maternal temperature > 38 o C
 Persistent bright or dark-red vaginal bleeding
Amnioinfusion
 Warmed, sterile NS or Ringer’s Lactate
infused INTO uterus via Intrauterine
Pressure Catheter (IUPC; 250 – 500 cc)
 Increase Intrauterine Fluid Volume
 Intrauterine infusion may be used to treat
problems related to fetus
 Thick Meconium
 Decelerations r/t Cord Compression
Contraindications for Amnioinfusion

 Omnious FHR
 Umbilical Cord Prolapse
 Significant Vaginal Bleeding
 Uterine Hypertonia
Nursing Care during Amnioinfusion
 Note every 15 minutes
 Maternal B/P, Pulse
 FHR
 Contraction Pattern
 Uterine Resting Tone
 Strict Bedrest
 Comfort, Reassure
 DANGER  Rising Resting Tone  Uterine
Rupture
Nursing Care-2nd Stage of Labor

 Assessments -- See next slide

 Signs of Fetal Descent
 Uncontrollable Urge to Push
 Bulging of the Perineum
 Anal Changes
 Introitus Opens
 Crowning
 Burning/stretching sensation in perineum
 Assessment during 2nd stage

BP, P, R q 15 min.

Temperature* q 2h if ROM
Uterine activity q 5-15 min
FHR Low-risk: q 15 min if EFM is not used &
continuously if it is used
High risk: q 5 min if EFM is not used &
continuously if it is used
Vaginal Show q 5-15 min
Fetal Descent q 5 min or continuous
Assessment in 2nd stage (cont’d)
Status of especially in women who have an epidural
bladder block

Behavior, Include assessment of emotional response of

Appearance woman and partner to 2nd stage.
Energy Level Continuously
Signs of fetal descent

 Uncontrollable urge to push

 Bulging of perineum
 Anal changes—eversion,
passage of stool
 Vaginal introitus opens
 Crowning
 Burning/stretching sensation on perineum
Nursing Care-
Psychosocial Assessments
 Less Irritated
 VERY focused on work of Birth
 More Cooperative
 Doze off between Contractions
 May be exhausted
 Little modesty at this point
Nursing Care—
Physical/Psychological Support
 Positions for Pushing
 Lithotomy/semi-fowler’s
 Sim’s/Side-lying
 Squatting
 Kneeling
 Breathing
 Open glottis~groaning/grunting
 Prolonged pushing~  O2 to baby
 Cleansing breath & deep breath between
pushes
Physical/Psychological Support
 Environment
 Quiet between contractions to allow for rest
 Massage legs if pt c/o of leg cramping
 Psychological Support
 ENCOURAGE mom through each push
 1 person give short, explicit instructions
 Offer LOTS of praise for effort
 Keep thinking with the end in mind!
Prepare for Delivery
 Continue Emotional Support of Mom & S.O.
 Instrument Table (Tech usually does)
 Infant Warmer, Resuscitation, ID
 O2, DeLee & Suction, Meds, Laryngoscope Light,
Bulb Syringe,
 Medical Support for Mom
 O2,, Suction, Pitocin
 “Break Bed” when Doctor is on the way or
present
Other Responsibilities
 Prep/wash perineum
 Keep a watch on fetal status through each
contraction
 Provide scalp stimulation prn
 Pour mineral oil in and around perineum to
help stretch perineum and  need for epis
 Note type of episiotomy/laceration
 Note time of delivery
Other Elective Procedures
Episiotomies

 Definition: surgical incision of the

perineum performed more with primiparas
than multiparas. A controversial procedure
done more by MD’s than CNM’s.
Performed just prior to delivery when
the presenting part is crowning, usually
performed under regional or local
anesthesia.
Episiotomies

 Mediolateral: start at midline and extend

@ a 45 degree angle to the R or L.
 Advantage: avoids trauma to rectum, may
provide more room

 Disadvantage: increased blood loss,

longer time to heal, > discomfort during
early pp period.
Episiotomies

 Midline/median– begins at midline and

may extend down the midline through
the perineal body.
 Advantages: easy to repair, heals with less
discomfort for mom

 Disadvantage: if episiotomy extends, it

may tear through the rectum
Perineal Lacerations
 1st Degree: extends through the skin & structures
superficial to muscles
 2nd Degree: extends through muscles of
perineal body
 3rd Degree: tear extends through anal sphincter
muscle
 4th Degree: tear that involves the anterior
rectal wall
Nursing Role with Perineal Repair

 Assessment:
 Note type of episiotomy/laceration

 Note type of suture used and #

 Assess perineum for REEDA q shift in pp

period
Nursing Role with Perineal Repair
 Interventions:
 Encourage use of Topical Anesthetic Sprays (e.g.
Benzocaine[Dermoplast]), witch hazel pads (Tucks)
 Offer ice bag to perineum in 1st 12 hours pp
 Encourage use of Sitz bath or perineal shower for 20”
bid-tid, especially for 3rd & 4th Degree tears after 1st 12
hours
 Offer donut pillow
 Administer stool softener/laxative to prevent fear of
tearing sutures with BM
 Offer analgesics prn
Cesarean Delivery
 Indications
 Cephalopelvic disproportion (CPD)
 Malpresentations -- Breech, transverse lie, face
 Preterm Baby -- only when chance of increased risk
to baby if delivered vaginally
 Fetal Distress -- persistent late decelerations, poor
variability
 Cord/Placental Problems -- prolonged severe
variable decelerations due to cord compression,
prolapsed cord, placenta previa, abruptio placenta
 STD's -- genital herpes
 Uterine Dystocia -- failed induction, reason for
induction persists, post-maturity
Pre-op Nursing Care
 IV fluids-- Usually warm Lactated Ringer’s
(LR) if spinal or epidural anesthesia
 Labs--UA, CBC, type & crossmatch, Blood
Chemistry
 Consent forms signed
 Abdominal shave/clip (per dr.order)
 Foley catheter
 Keep dad present and involved/allow privacy
between couple when time allows
 Explain all procedures--teach about return of
sensation to lower extremities, T,C, & DB &
pain management post-op
Pre-op Nursing Care (cont’d)

 Remove all rings, jewelry, nail polish

 Monitor labor status - FHR & contractions, till OR
 Always maintain calm attitude
 Administer an antacid e.g. Bicitra 30 cc. po approx.
30 min before surgery
 Administer a prophylactic IV antibiotic (cefotaxime 1g)
 Complete all admission hx and physical assessment
documentation
Cesarean Section
 Skin Incisions
 Uterine Incisions
 Nursing Care During C/Section
 Reassure Mom during anesthesia induction.

 Assess S.O. Coping

 Care for Baby Immediately after Birth

Forceps web link on forceps and suction

 Function: to provide traction, to rotate, or both

in the second stage of labor
 Midforceps: when fetal head is at the level of
the ischial spines but above the +2 station
(Rarely used)
 Outlet forceps: when the fetal head is visible
on the perineum without spreading the labia
apart. They shorten the length of 2nd stage.
 Requirements for forceps: Cx dilated 10cm,
bladder empty, presenting part 0 station,
vertex presentation, membranes ruptured.
Vacuum Extractor
 A suction cap applied to fetal head traction is
applied to facilitate fetal descent in 2nd stage
of labor
 Risks to fetus: cephalhematoma, scalp
lacerations, subdural hematoma
 Risks to mom: perineal, vaginal,or cervical
lacerations
 Requirements for vacuum: Cx dilated 10cm,
bladder empty, presenting part 0 station,
vertex presentation, membranes ruptured.
Indications for Forceps or Vacuum
 Prolonged second stage
 Maternal condition precludes pushing:
 Heart disease, Pulmonary Edema
 Exhaustion
 Spinal, Epidural, Caudal Anesthesia– no sensation to
effectively push
 Fetal Distress–
 late decels, poor variability. Bradycardia <100 for more
that 2-3 minutes
 Threat to mother’s life
Immediate nursing actions
 Unwrap sterile packages and place onto
sterile field or in sterile basin with betadine
 Assess maternal/fetal status
 Teach mom that she may feel increased
pressure internally in vagina.
 Coach mom through contractions to
effectively push with traction by forceps of
vacuum extractor
Nursing Actions after
Delivery with Forceps or Vacuum

 Check for sx of trauma to face, head, neck

of baby, lacerations or forceps face marks in
eye area
 Check for increased ICP, lethargy, seizures,
paralysis (facial nerve palsy)
 Answer parents’ questions about possible
trauma to their infant
 Check mother for pp hemorrhage, vaginal
or labial hematoma
Nursing Care-3rd Stage of Labor
 Physical Assessments
 Signs of Placental Separation
 Gush of Blood
 Cord Lengthens

 Fundus rises in abdomen

 Uterus becomes globular

 Psychosocial Assessments
Placental Separation
Shiny Schultz
Dirty Duncan
Nursing Care—3rd Stage of Labor

 Care of Mother – Physical

 Encourage her to push AFTER placenta
separates
 Note time of Placental Expulsion
 Add Oxytocin to IV or Open Oxytocin Drip
 CHECK FUNDUS
 Note how episiotomy repair is going
 Care of Mother – Emotional
Nursing Care – 3rd Stage of Labor

 Care of Newborn
 Care after Episiotomy Repair
 During C/Section
 Note time of Placental Separation
 Emotional Support to Mom and S.O.
 ESTIMATE BLOOD LOSS
Nursing Care- 4th Stage of Labor

 Greatest risk for Maternal Hemorrhage

 At Risk for Hemorrhage
 Physical Assessment
 Fundus (Firm, Soft, “Boggy”)
 Lochia, Amount, Color
 Perineum (Intact, Swelling, Approximation)
 VS (B/P, P, R)
 Frequency--q 15” x 4; q 30” x 2; q 60” x 2
 4th Stage Nursing Care–C/Section
 Immediate Post-Op Care
 Check the following every 15 minutes till stable
 V.S.—SaO2 , EKG pattern as well as TPR & BP
 Lochia
 Dressing
 Fundus (very gently)
 Foley—output appropriate
 Return of sensation & mobility in toes & legs if spinal/epidural
 Monitor IV with Pitocin infusing.
 Offer O2 per mask prn
 TCDB every 2 hrs. for 24 hr. (not as critical with epidural/spinal
anesthesia
 Medicate prn for pain if general anesthetic-Ketoralac 30mg IV q6h.
NO narcotics if intrathecal morphine was administered.
 Facilitate attachment - bring baby back to mom while she is
recovering if possible; breastfeed baby
Post-op Care on Postpartum Unit
 V.S. every 4 hr. initially proceeding to tid after first 24
hours ( Hospital Policy )
 Observe incision and need for dressing change
 Provide pain control
 Assess fundal height, lochia, bladder/bowel status,
hygiene
 Perineal care: q 4 hr with indwelling catheter. Foley
may remain for 12-24 hrs, then give appropriate
instructions when d/c’ing
 Mothering skills - help with positioning infant at
feedings due to incision; if breast-feeding, encourage
use of football hold or side-lying position with pillow on
abdomen
 Encourage early ambulation to foster peripheral
circulation and  peristaltic activity
Other Elective Obstetrical Procedures
External Cephalic Version
 Definition: The alteration of fetal position by
abdominal or intrauterine manipulation to
accomplish a more favorable fetal position for
vaginal delivery.
 Indications:
 Presenting part NOT engaged
 Maternal abdominal wall thin enough to permit
good palpation
 NO uterine irritability or contractions
 Adequate amniotic fluid, intact membranes
 NO known history of CPD
 Version– Nursing Interventions

 Get consent for procedure and inform of possible

emergency C/S
 Prepare for ultrasound to confirm fetal position
 Close monitoring of fetus via fetal monitoring, NST
 Follow MD orders if tocolytic ordered to relax uterus
 Nurse may need to assist to head down position by
applying pressure over fetal head (pubic area) to
encourage fetus to stay in cephalic presentation.
 Monitor maternal status for possible hemorrhage &
discomfort after procedure
Precipitous Delivery
 Definition = Labor < 3 hours
 Assessment
 Vaginal Exam/Visualization
Precipitous Delivery-Nursing Care
 Don’t Break the Bed
 Support Perineum, Deliver Fetal Head
 Check for Nuchal Cord
 Delivery Actions
 Suction Baby’s mouth & nose
 Clamp Cord, Wait for Placenta to come out
 Dry Baby, Place on Mother’s Abdomen
Care -- Out-of Hospital Delivery

 Follow Precipitous Labor Actions

 Try to be as clean as possible
 Essential to protect infant from HEAT
LOSS (blankets, coats, newspaper)
 BE CALM & CONFIDENT
THAT’S ALL FOLKS!

 Be sure to review
Handout “A”
“Cultural Influences During
Intrapartum Period”
as well!