Nursing Care During Labor Birth PDF

Preview

Summary

Lecture notes...

Description

NURSING CARE DURING LABOR & BIRTH Is it real? When a patient comes in thinking they are in labor, it is important to monitor those pts for Black – ppt a little awhile. We put them in monitor. We watch the contractions pattern, watch what the baby is Yellow – voiceover doing while the pt is having contractions, we do cervical exams to see what the cervix is doing. When Red – lecture the pt comes into the hospital thinking they might be in labor, one of the first thing they do is put a Purple – book set of vitals, put the baby on a monitor and do a cervical exam so we know the cervix is like as soon as they get there. Then, monitor the pt for about an hour watching their contractions and we’ll check them again if there are any change in the cervix either in effacement or in Discuss nursing care, indications, maternal and fetal risk factors for the their cervical dilation. Effacement – thinning and shortening of the cervix

False Labor 



Irregular contractions 

Sometimes they can seem they are regular contraction.



Are the contractions regular? We would like them to see in the hospital if contractions are 5 mins apart and they have been that way for an hour.

Contractions go away when hydrated 



People don’t realized if they get dehydrated, they will get contractions but they are just irritable contractions, they are not making cervical change



False labor vs. true labor



Maternal admission and focused labor assessments



Cervical ripening and labor induction



Instrument assisted birth



Episiotomy



Cesarean section

Contractions get milder when changing positions 



following:

Contractions get lighter and don’t get stronger.

Ruptured membranes vs. urine 

Sometimes, we think that their water is broken because we notice a bit of moisture. When we test them, it might actually be urine rather than actual amniotic fluid

True labor – patient that are in actual labor will show cervical changes; their discomfort level will change – it will get worse for them. Their effacement will also increase. 

Water breaks – fluid continues to leak 

If a pt comes in and saying that they think their water broke. We can do a diff test to determine if it’s amniotic fluid. If it is amniotic fluid, they stay, and we can’t send them home if their water broke. They are at increase risk for infection, and increase for cord compression with leaking of fluid



Contractions regulate and get stronger



Walking intensifies the contractions



Hydration does not make a difference in the pain



Bloody show with contractions

Maternal admission for labor onset *once we determine that the pt is in actual labor and we are going to admit them for actual labor, it is important to start the whole admission process. P381 – priorities. What is importance to do first and why? 

Perform physical exam 

Is pt dilated? What are v/s? Water broken or intact? Position (lie) of the baby





NURSING CARE DURING LABOR & BIRTH Is the baby breech? C-section



Is the baby in a transverse lie – C-section



Is the baby is down? Prepare for vaginal delivery

Obtain obstetric history as well as medical and surgical 



Does the patient have medical problems, clotting factor problems, severe scoliosis that possibly may inhibit labor, broken pelvis that may inhibit labor, infectious problems such as herpes or something of that nature (to determine if we should do a vaginal delivery or C-section)

Does the patient have a birth plan for the delivery? 

They don’t want continuous fetal monitoring and only want to be monitored every 15 mins per hour while they are in active labor



Don’t want continuous IV fluid. Agreed with IV lock but not with continuous fluid



Want to get up and walk around



Todd relaxation labor rather than being in bed



Important to know what type of labor they have. Many birth plans in hospitals must be approved by their physician since sometimes physicians’ orders are different than patient’s birth plans. Patients are encouraged to bring their birth plans to their physician’s office so that they can get that approved and the hospital knows to work with that specific things in their birth plan



Obtain patient’s prenatal record from physician



Perform assessment of the fetus and contractions through use a toco and us transducer 

Getting the mom on the monitor so we can the toco to trace the contractions pattern and the ultrasound to trace the baby heart rate. It is important to have that on so we see what’s happening to the baby when the mom is having contractions

Amniotomy (AROM) https://www.youtube.com/watch?v=6aA1lAvQj6w&has_verified=1 

What is an amniotomy? o

Artificially rupture of the membrane. A doctor will go in during an induction or augmentation of labor and they break the water since the water hasn’t break it yet. It can bring the baby down to put more pressure down the cervix – to help cervix dilation. It is always ARIOM.



What to chart after the amniotomy o



Time rupture happen, FHR, the color, odor, and amount of fluid

What should the fluid look like? o

Usually clear and sometimes might see little flex of vernix (creamy white skin lubricant skin particles). As baby matures, the vernix starts to sloughs off. Protects the baby skin while floating in amniotic fluid. Mature baby will see a little amount of vernix. Large amounts of vernix in the fluid means the baby is premature.

o

NURSING CARE DURING LABOR & BIRTH We want to note that the fluid is clear. Green – meconium stain; bowel movement inside the uterus, can be seen due to fetal stress. When the baby is stress out in utero, they can sometimes have a bowel in the utero. It’s also seen in response to fetal hypoxia which is also a distress in utero or a postterm gestation if the baby too far posstate

o

Foul strong odor, cloudy, yellow – sign of infection = Chorioamnionitis, inflammation of the amniotic sac and that is usually caused by bacterial or viral infection. Prepare for this since we can have a very sick baby



How do we describe the fluid in terms of volume? o

We have to know if we have large amounts of fluid or a small amounts of fluid. Moderate amount is 500 to 1000 mL. If the baby head is well applied on the cervix, only scant amount of fluid if you rupture the bag because of the head has such a pressure there. It is barely opening and trying to fill a liquid in that jar out. That lid on that jar keeps the liquid from coming out.



What is considered Polyhydramnios o



What is oligohydramnios? o



Excessive amounts of fluid

Minimal amount of fluid; small quantity

What is SROM and how does it differ from AROM? o

SROM – Spontaneous Rupture of Membrane – water breaks on its own

o

AROM – Artificial Spontaneous of Membrane



What are the safety considerations?



Possible complications? *read the process on how to address it o

Prolapse of the umbilical cord. If baby is extremely high in utero and we break the water and the cord is down above the baby’s head – between baby’s head and cervix; cord can come out with the fluid and can cut off oxygen to the baby

o

As the cord comes down and the cord prolapse and the water depletes, the baby’s head is gonna come down and it can put pressure trapping the cord between the cervix and the baby’s head. Umbilical cord provides oxygen to the baby. If that happens, baby’s oxygen is completely cut off. Take the pressure off the cord by doing vaginal exam and pushing that baby’s head up and putting the mom in Trendelenburg position to get that baby to come back higher and up the uterus and up the cervix and that’s an emergent situation for a C-section

o

Worry about infection – open pad for bacteria. Can cause infection the longer the mom is ruptured

o

Very rare situation – placental abruption, if there is enough of water that can rapidly come rushing out. It can create a suction and pull the placenta out of the uterine lining

o

ALWAYS MONITOR FHR



NURSING CARE DURING LABOR & BIRTH Interventions after an amniotomy? o

Keep mom clean and dry; change the chalks pad, dry under her so she can stay dry. Changing them frequently minimize bacteria

Induction or Augmentation of labor •

Induction are more done more frequently because they do not want to wait till their due date

•

Augmentation is early stages of labor, but their water is broken, or contractions is regular. But there are not as much change in cervix as we want to so we are giving them medications to help speed the labor up and get contractions closer – Pitocin

•

Why induce? •

They are tired of being pregnant – not an indication but allows it

•

In the event of entering an environment of hostility of the fetus as being, that’s when you have a baby with IUGR – Interno Uterine Growth Restriction or a maternal blood incompatibility – sickle cell attacking it or oligoro

•

Gestational diabetes – induce a wk earlier since babies get larger and larger – macrosomia is a serious problem

•

•

Water breaks without labor is starting then it is a premature rupture of the membranes

•

Postdate – if a baby goes too past postdate , it can have mecronium stain fluid

•

Infection in the amniotic fluid

•

Preeclampsia and pressure is continuing to rise and get worse

•

Placenta abruption

•

Sometimes, fetal may die in the utero – fetal demise – not C-section

Contraindications? •

Placenta privia – put the mom at risk of hemorrhage so C-section is done then

•

Umbilical cord prolapse – not induce and try the baby to come on their own and see if the cord move out of the way

•

Abnormal fetal presentation – if the baby is in a transverse lie where it is lying across the cervix; there is no reason to induce a patient like that cause we know that the baby cant deliver that way

•

NURSING CARE DURING LABOR & BIRTH Two or more C-section – most physician will not allow an induction for vaginal delivery. They can attempt to have vaginal delivery with only 1 C-section depending on the incision into the uterus.

• •

•

Mother’s overall health

What are the risks? •

Hyperstimulation – too much uterine cavity

•

Proticin – we don’t know if they can handle it; monitor

•

Excessive urine activity can wind up causing damage to the body by hypoxia or it can rupture the uterus

•

Possible hemorrhage after the delivery because mother has uterus has been saturated with that poticin.

What methods can be used? •

Cervical tightening – done with a medication called Cytotec – that is where medication is placed on the side of the cervix. Medication is absorbed into the cervix so the cervix will respond to the Pitocin to get a cervical change

• •

Administration of Pitocin or oxytocin – causes contraction of the uterus

Nursing considerations? •

Making sure that we are watching the baby’s FHR, mom’s contraction pattern, and mom’s pain

Operative Vaginal Birth (forceps) 

Why use forceps: o

Forceps is not use usually, it is use as last resort. It can cause a tissue damage

o

It is a last resort, if the m om is pushing for a while and the baby is stuck and hasn’t rotated around to make the delivery easy, and the mom is exhausted and not giving effective pushing

o

Seeing some deep decelerations on the baby’s HR then the doctor will intervene with forceps or a vacuum



Contraindications? o

If the baby is not far enough down, don’t use a forcep just use C-section

o

Only use if we know that we can get a rapid delivery with minimal pulse to the baby

o 

NURSING CARE DURING LABOR & BIRTH Worried / careful when using

Risks? o

Tissue damage

o

It can also bone damage – it can crush a baby’s cheek bone and part of the skull; concern about laceration and abrasion



o

Cephalohepatoma

o

Facial nerve injury

Technique? o

Forceps handle go in and they lock together; it wraps around the baby’s heads.

o

They can’t really see where they are going so they will look for suture lines and position baby’s head. Pull when mom is having contractions



Nursing considerations? o

Watching the amount of times that the different attemtps are being made to delivery the baby

o

Make sure the bladder is empty so the bladder does not keep the baby out from coming down the pelvis

o

Help physician in whatever they need

o

Be there for their mom since it is painful and traumatic

Operative Vaginal Birth (vacuum) 







Why use a vacuum? o Vacuums are use more commonly than forceps are. It is use often in vaginal delivery and C-section sometimes o The baby is stuck, it is a mouth presentation with the way the face is position, mom is exhausted and not giving enough push Contraindications? o If the baby is not low enough, just go for a C-section o Same as forceps Risks? o Same as forceps o Cause severe bruising o Use suction and sometimes they pop off and physician will reapply and pull again o Laceration to the scalp; cephalohepatoma o Jaundice for the baby – all the blood that pulls there now has to break down and go somewhere else Technique? o Vacuums work via vacuum seal. Yellow is a sponge. Hard wire plastic part and the sponge goes against the baby’s scalp and then the words Kiwi, as the doctor pushes that to tube like structure, that forms a suction between the sponge and baby’s scalp. The doctor will use the entire Kiwi and pull and the only thing pulling is the suction in that scalp. Pulling baby’s skin into that sponge and trying to bring the baby down into a vaginal canal

NURSING CARE DURING LABOR & BIRTH

Obstetrical Surgical Incisions: Episiotomy  







Episiotomy – Surgical incision of the perineum to enlarge the vaginal opening just before birth

Not as done as often they are used to be, but study shows that 10 to 20% of births today even have an episiotomy whether they need them or not Indications: o Rapid resolution of shoulder dystorsia, if you have a large baby in there and you need to make more room to get them out, episiotomy would be needed to allow more room. o If a vacuum extraction or a forcep birth is being used, you want to allow as much room as possible to bring that baby in. if a baby is being born face up – auxiput posterior . we want to allow more room to bring the baby in o Macrosomia – extremely large baby Types: p413. o Median/Midline – cuts from the bottom of the vaginal opening , straight down toward the rectum in a perineal space o Mideolateral – cuts off to the side either right or left o Depends on the physician and how to do it. Midline is more common Nursing Care: o Care begin before episiotomy, when a patient is pushing, a nurse will help perineal massage and stretching during their pushing process. It can help stretch out the perineum a little and allow more room and leads to a patient not needing an episiotomy. o If a patient is sitting up when you are leaning a little instead of lying flat, it can put more pressure at the perineum and stretch the perineum as well. The care after they already have the episiotomy – make sure to keep the area clean to decrease risk of infection Maternal Risks: o Number 1 maternal risk is infection from episiotomy o Perineal pain – mom’s is gonna have perineal pain after delivering a baby but now when you cut them and suture them up , they also don’t have the swelling from the delivery but they have that pain from an incision – help them with pain with ice pack , cool water, and pain medication

Cesarean Section read up CH 15 from pg 414 

Indications: o A baby that is too large into mom’s pelvis – celphlopelvic disproportion then you definitely need to do a C-section, the baby cannot do labor all day and the baby is not just gonna come down , the pelvis is not big enough to accommodate the size of the baby o Baby with extremely large shoulder that can cause a shoulder distortion and get the baby stuck and ended up having a C-section. you need to be aware of the size of the baby before the mom goes into labor to know whether we should be considering a C-section









NURSING CARE DURING LABOR & BIRTH o If a mom has something going on that forces an immediate delivery such as abruption or severe preeclampsia, or HELLP o Gestational diabetes or regular diabetes – they have macrosomac babies so doctor will consider Csection o If the patient has active general herpes, we cannot deliver them vaginally because of the transfer of the disease to the baby through the delivery o Baby with fetal distress, when we see in their heart tones that they are not tolerating labor then we need to get the baby out. If the mother had a previous C-section and they choose not to do a vaginal delivery. But Ii they had 2 C-section, we automatically do it because of the risk of your uterine rupture o If there is a malpresentation – breech or a transverse lie of the baby o Any type of previous medical illness, previous stroke (we don’t want them pushing during labor), brain surgery, heart condition Incision Types: o External incision o External incision  Transverse (Pfannenstiel– baciny cut – most common – scheduled C-section will almost always have this type  Vertical – up and down from the belly button to the pubic symphysis o *what truly matter is the uterine incision is  Vertical urine incision indicates it’s an emergency C-section as well as vertical skin incision. That incision is more at risk for uterine rupture, if it has to undergo contraction. If someone has a previous vertical urine incision, they will not be allowed to have a delivery vaginally o Fenistil or transverse – allows C-section with their 2nd delivery if they wanna try Maternal risks: o Hemorrhage o Internal damage to organs. The most common organ damage is next to the bladder or the bowel as they are making the incision o The risks is the same of any type of abdomen surgery – hemorrhage, infection, UTI, blood clots, ileus (everything slows down during surgery) o increase risk for endometriosis because of the scarring o com...