Normal Labor

CONDUCT OF NORMAL LABOR

Definition: A procedure done to monitor the progress of labor for the safe delivery of the mother and the baby.

Purpose:

To monitor progress in labor

For safety of both mother and the baby

To promote comfort

Principles:

To provide privacy

Position patient properly

Explain the procedure to the patient

Equipments:

BP Apparatus Drapes Perineal Care Tray

Shaver Sterile Gloves

CONDUCT OF NORMAL LABOR

1. Welcome the client and her partner, then introduce self.- To show respect 2. Changes the client’s dress and place her personal belongings in a safe

place or give them to her partner. - To prepare for delivery3. Review her prenatal record and check the significant data.- To have an idea on what to expect4. Asses when the labor started, if the membranes have ruptured, if blood

has come out, if there are compilations that may require treatment, and the client’s psychological response during this phase.

- To prepare and obtain significant data5. Put the client to bed if the membranes have already ruptured. - To prevent dry labor

6. Asses the progress of the labor.A. Check the fetal presentation, position and engagement- There are factors affecting success labor and deliveryB. Contractions: time begun, duration, intensity, frequency, and

regularity- To check if contraction is normalC. Check the vital signs- To monitor patient’s conditionD. Complete the vaginal examination.- To monitor patient’s conditionE. Recheck for allergies, edema- To monitor patient’s conditionF. Check her dietary intake for the last 2 hours.- To check if the mother eat something to complicate the deliveryG. Check for the bladder distention every 2 hours.- To increase maternal comfort H. Observe the character of amniotic fluid, discharges, and if the

rupture of the bag of water ( BOW ) has already occurred.

7. Provide the comfort measures.

A. Clean the vulva after the vaginal examination

- Prevents accumulation of any microorganisms.

B. Shave the perineum.

- Decrease possibility of any infection.

C. Give the enema based on the doctor’s order.

- Provide stimulation of bowel activity & cause emptying of lower

D. Check the lights in the labor room.

- Provide good lighting & promote better exposure and visualization

E. Provide touch.

- To provide non pharmacological pain management.

8. Teach ( coach ) the patient with the proper breathing techniques and the bearing down efforts.

- To reduce pain contraction

9. Take note of the following indicating the beginning of the second stage of labor.

A. Increase in bloody show

- Indicates the membrane has already rupture

B. Feeling of pressure in the perineum.

- Indicates the head is already at the pelvic inlet

C. Frequent regular close contractions.

- Indicates movements of fetus downward to the inlet

D. Increase in perspiration, client cries.

- Indicate pain

E. Complete dilatation of cervix

- Indicates that the cervix is ready for delivery

F. Bulging of the perineum

- Indicates the head of the fetus

10. Take / Transfer the client to the Delivery Room ( DR ) table when signs above are noted. Call the physician.

- To prepare client for delivery

Delivery Circulating Nurse Definitions: The one who facilitates and prepare equipment, assist the

doctors clear all the equipment.

Purposes: To facilitates successful delivery

to safeguard the mother and the baby Principles:

Wash hands before and after the procedure Never touch the sterile equipment

Equipment:

Gown Ice capsMask Methergin Bonnet Shoulder Brace Stirrups BP set

DELIVERY CIRCULATING NURSE

1. Put on gown, mask and bonnet.- To protect yourself form spreading of microorganism 2. Assist the patient to the delivery table. Place on the Lithotomy

position- To prepare the patient for delivery3. Adjust the shoulder brace. Fasten the wristlets. Fasten the two

stirrups. Switch on the lights. Expose the perineum - For the safety of the patient upon delivery4. Do the perineal care- To wash away any vaginal secretion5. Drape the patient and expose only the necessary parts- To provide comfort and privacy6. Prepare instrument (if it’s not done by the handling nurse )- To ready the equipment to be used

7. Intrapartum: check the blood pressure, observe the reactions, anticipate the needs of the patient and the handling nurse

- To monitor the BP of the patient 8 After the delivery of the baby:- For record purposesA. Check the time of the delivery with the scrub nurse- For accurate dataB. Check the baby’s sex with the scrub nurse who actually touched

the external genitalia - For accurate dataC. Bring the newborn to the nursery. Endorse the baby to the nurse

for the immediate newborn care9. Check the blood pressure immediately after the placental

explosion - To monitor the BP of the patient10. Inject the methergin 1 ampule intramuscularly - To closed the cervix

11. Clean the perineum and apply the perineal pad. Apply the icecap over the hypogastrium

- For good hygiene and for the constriction

12. Check the blood pressure. Then help in transferring the mother to the stretcher

- To monitor the 4th BP and for the patient’s safety

13. chart: time, type of the delivery, time and mechanism of the placenta explosion, completeness of the placenta, type of perineal laceration, condition of the mother type of the IV fluid, medication given of there are any and the condition of the uterus

- For documentation purposes

BLOOD TRANSFUSION

Definition: The infusion of whole blood or blood component being donated by a healthy person into a recipient vein.

Purposes: To restore total blood volumeTo restore the capacity of the bloodto provide plasma factor

Principle:Observe sterilityTake and monitor vital signs Verify client’s condition Explain the procedure to the patient

Equipments:Pack of RBC Blood Set Plaster TowelTourniquet Splint

BLOOD TRANSFUSION

1. Check order and explain the procedure to the patient- To prevent error and for correct administration of blood

2. Get blood in the laboratory and check for the blood type. cross-match, Rh, serial number, amount and VDRL. Warm blood by wrapping with towel. After it is warmed attached blood set into the blood pack and let blood flow into the tubing only until 2 inches away from the tip of the blood set

- To avoid adverse effect and injection during blood transfusion

3 Attach butterfly and bring equipment to bedside- To save time and effort

4 Place patient flat on bed. Obtain and record baseline vital signs- For proper injection and to know the reaction

5. Prepare infusion site. Select a large vein that allows patient some degree of mobility

- For easy insertion

6. Assist doctor in venipuncture. ( Same as assisting the doctor in intranenous infusion)

- For faster insertion

7. Regulate flow rate to 10 – 15 drops per minute for 15 – 30 minutes. If there are no signs of adverse reactions or circulatory overloading the infusion rate is regulated according to doctor’s order

- To determine adverse reaction

8 Observe patient closely and check vital signs every 15 minutes for the first one hour and then hourly

- To monitor the condition of the patient

9 If any reaction is observed. close transfusion and report to the physician immediately

- To avoid incident

10. Recheck the following information on the patient’s chart

- For proper documentation

A. Blood type and volume transfused

- To document all relevant data

B. Serial number


C. Time transfusion started and ended


D. Patient’s reaction or patient’s immediate response


E. Physician who started the transfusion


PREECLAMPSIA &

ECLAMPSIA

Mild Preeclampsia• A woman is said to be mildly preeclamptic when her blood pressure

rises 30 mmHg or more systolic or 15 mmHg or more diastolic above her prepregnancy level, taken on two occasions at least 6 hours apart. The diastolic value of blood pressure is extremely important to note because it is this pressure that best indicates the degree of peripheral arterial spasm present.

• If a woman developed a blood pressure of 140/90 or over, she was considered to have preeclampsia. This general rule is obviously less meaningful than the comparison of an individual woman’s blood pressure against her easrly pregnancy baseline.

• Edema also may be present. This develops because of the protein loss, sodium retention, and a lowered glomerular filtration rate. Edema begins to accumulate in the upper part of the body, rather than just a normal ankle edema of pregnancy.

Severe Preeclampsia• A woman has passed from mild to severe preeclampsia when her

blood pressure has risen to 160 mmHg systolic and 110 mmHg diastolic or above on at least two occasions 6 hours apart at bedrest (the position in which blood pressure is lowest) or her diastolic pressure is 30 mmHg above pregnancy level.

• Marked proteinuria, 3+ or 4+ on a random urine sample or more than 5 g in a 24 hour sample and extensive edema are also present.

• The extreme edema will be noticeable in the woman’s face and hands as “puffiness’. It is most readily palpated over bony surfaces, such as over the tibia on the anterior leg, the ulnar surface of the forearm, and the cheekbones where the sponginess of fluid-filed tissue can be palpated best.

Nursing Diagnosis• The nursing diagnosis used with hypertension of pregnancy are

numerous because the disease has such wide-ranging effects:

1. Altered tissue perfusion related to vasoconstriction of blood vessels

2. Fluid volume deficit related to fluid loss to subcutaneous tissue

3. Risk of fetal injury related to reduced placental perfusion secondary to vasospasm

4. Social isolation related to prescribed bedrest

Nursing Interventionfor Mild Preeclampsia

• Promote Bedrest

When the human body is in a recumbent position, sodium tends to be

excreted at a more rapid rate than during activity. Bedrest, therefore, is the

best method of aiding increased evacuation of sodium and encouraging

diuresis.

Rest should always be in lateral recumbent position to avoid uterine

pressure on the vena cava and prevent supine hypotension syndrome.

• Promote Good Nutrition

Because the woman is losing protein in the urine, she needs a high-protein

diet. At one time, stringent restriction of salt was advised to reduce edema.

This is no longer true because stringent sodium restriction may activate the

renin-angiotensin-aldosterone system and result in increased blood pressure,

further compounding the problem.

Nursing Intervention for Mild Preeclampsia

• Provide Emotional Support

It is difficult for a woman with preeclampsia to appreciate the potential

seriousness of symptoms because they are still so vague. Neither high blood

pressure nor protein in urine is something she can see or feel. She may be

aware that edema is present, but it seems unrelated to the pregnancy. It is her

hands that are swollen, not a body area near her growing child.

The woman may have difficulty understanding the severity of the situation.

she may take instructions such as getting rest rather slightly. In addition, it is

not always easy to comply with an instruction such as get additional rest during

the day.

Nursing Intervention for Severe Preeclampsia

• Support Bedrest

1. The woman with severe preeclampsia should be admitted to a private room so she can rest undisturbed by a roommate.

2. She should lie in lateral recumbent position as much as possible.

3. Be sure to minimize exposure to noise.

4. Place her in a room that is away from the sound of woman in labor or the crying of infants on a postpartal unit.

5. Room should be darkened because a bright light can also trigger convulsions.

6. Be certain the woman receives clear explanations of what is happening and what is planned.


• Monitor Maternal Well-Being

The woman’s blood pressure should be taken frequently, at least 4

hours to detect any increase, which is a warning that her condition is

worsening. If blood pressure is fluctuating, it may need to be assessed hourly.

Obtain ordered blood studies (e.g. complete blood count, platelet count, liver

function, blood urea nitrogen, and creatine and fibrin degradation products) to

assess for renal and liver function and development of DIC, which often

accompanies severe vasospasm. Because she is at a high risk for premature

separation of the placenta and resulting hemorrhage, a type and cross match

or antibody screen for blood is usually drawn.


• Monitor Fetal Well-BeingGenerally, single Doppler Auscultation are approximately 4-hour intervals

is sufficient at this stage of management. However, FHR may be assessed by

continuous fetal external monitor. The woman may have a nonstress test or

biophysical profile done daily to assess uteroplacental sufficiency. Oxygen

administration to the mother may be necessary to maintain adequate fetal

oxygenation and prevent bradycardia.

• Support a Nutritious DietThe woman needs a moderate to high-protein, moderate-sodium to compensate for the protein she is losing in urine. An IV fluid line should n\be initiated and maintained to serve as an emergency route for drug administration as well as to administer fluid to reduce hemoconcentration and hypovolemia.


• Administer Medications to Prevent Eclampsia

1. Hydralazine(Apresoline) – may be prescribed to reduce hypertension. It acts to lower blood pressure by peripheral dilatation without interfering with placental circulation. It can cause tachycardia.

2. Diazoxide (Hyperstat) – may be used for its ability to produce a rapid decrease in blood pressure. If vasopressors of this nature are used, diastolic pressure should not be lowered below 80 to 90 mmHg or inadequate placental perfusion may occur.

3. Magnesium Sulfate – drug of choice to prevent eclampsia. Classified as a cathartic, reduces edema by causing a shift in fluid from the extra cellular spaces into the intestine. It also has a CNS antidrepressant action, which lessens possibility of convulsions.

Eclampsia• This is the most severe classification of hypertension of pregnancy. A

woman has passed into this third stage when cerebral edema is so acute that a convulsion or coma occurs. With eclampsia, maternal mortality is as high as 20%.

• Eclampsia can result in death of the mother from cerebral hemorrhage, circulatory collapse, or renal failure.

• Fetal prognosis in eclampsia is poor because of hypoxia and consequent fetal acidosis. If premature separation of the placenta from vasospasm occurs, the prognosis is even graver. If the fetus must be delivered before term, all the risks of the immature infant will be faced.

• In eclampsia, fetal mortality is approximately 10%. If eclampsia develops, the mortality increases to as high as 25%.

Nursing Diagnosis

• The nursing diagnosis used with hypertension of pregnancy are numerous because the disease has such wide-ranging effects:

1. Altered tissue perfusion related to vasoconstriction of blood vessels

2. Fluid volume deficit related to fluid loss to subcutaneous tissue

3. Risk of fetal injury related to reduced placental perfusion secondary to vasospasm

4. Social isolation related to prescribed bedrest

Nursing Intervention for Eclampsia

• Tonic-clonic conculsioin

An eclamptic convulsion is a tonic-clonic convulsion that occurs in stages.

TONIC PHASE

After the preliminary signals, all the muscles of the woman’s body contract. Her back arches, her arms and legs stiffen, and her jaw closes abruptly. She may bite her tongue from the rapid closing of her jaw. Respirations will be halted, because her thoracic muscles are held on contraction. Lasts approximately 20 seconds. It may seem longer because the woman may grow slightly cyanotic from the cessation of respirations.

INTERVENTION:

The priority of care for the woman with a convulsion is to maintain a patient airway. Administer oxygen by face mask to protect the fetus during this time of interval. Assess oxygen saturation via pulse oximeter. Apply an external fetal heart monitor if not already in place to assess the condition of the fetus. To prevent aspiration, turn the woman on her side to allow secretions to drain from her mouth.

CLONIC PHASE

After the tonic phase of the convulsion, all the muscles of the After the tonic phase of the convulsion, all the muscles of the woman’s body begin to contract and relax, contract and relax, causing the woman’s body begin to contract and relax, contract and relax, causing the woman’s extremities to flail wildly (the clonic phase). She inhales and woman’s extremities to flail wildly (the clonic phase). She inhales and exhales irregularly as her thoracic muscles contract and relaxes. She may exhales irregularly as her thoracic muscles contract and relaxes. She may aspirate the saliva that collected in her mouth during the tonic phase if she aspirate the saliva that collected in her mouth during the tonic phase if she was not placed on her side or abdomen during this time. Her bladder and was not placed on her side or abdomen during this time. Her bladder and bowel muscles contract and relax; incontinence of urine and feces may bowel muscles contract and relax; incontinence of urine and feces may occur. Although she begin to breathe during this stage, the breathing is occur. Although she begin to breathe during this stage, the breathing is not entirely effective, her color may remain cyanotic and she may need not entirely effective, her color may remain cyanotic and she may need continued oxygen therapy, not for herself but for the fetus. The clonic continued oxygen therapy, not for herself but for the fetus. The clonic stage of a convulsion lasts up to 1 minute. Magnesium sulfate or diazepam stage of a convulsion lasts up to 1 minute. Magnesium sulfate or diazepam (valium) may be administered IV as an emergency measure at this time.(valium) may be administered IV as an emergency measure at this time.

The third stage of the convulsion is a postictal state. During The third stage of the convulsion is a postictal state. During this stage, the woman is semi comatose and cannot be roused except this stage, the woman is semi comatose and cannot be roused except by painful stimuli for 1 to 4 hours. Extremely close observation is as by painful stimuli for 1 to 4 hours. Extremely close observation is as necessary during the postictal stage as it was during the first two necessary during the postictal stage as it was during the first two stages. If the convulsion caused premature separation of the placenta, stages. If the convulsion caused premature separation of the placenta, labor may begin during this period and the woman will be unable to labor may begin during this period and the woman will be unable to report the sensation of contractions. Also, the painful stimuli of report the sensation of contractions. Also, the painful stimuli of contractions may initiate another convulsion. Keep the woman on her contractions may initiate another convulsion. Keep the woman on her side so secretions can drain from her mouth. Give her nothing to eat or side so secretions can drain from her mouth. Give her nothing to eat or drink by mouth. Remember that in coma hearing is the last sense lost drink by mouth. Remember that in coma hearing is the last sense lost and her first one regained. Be aware that when talking at woman’s and her first one regained. Be aware that when talking at woman’s bedside, she may be able to hear even though she does not respond. bedside, she may be able to hear even though she does not respond. Continuously assess fetal heart sound and uterine contractions. Check Continuously assess fetal heart sound and uterine contractions. Check for vaginal bleeding every 15 minutes. Evidence that placental for vaginal bleeding every 15 minutes. Evidence that placental separation may have occurred will appear first on the fetal heart sound separation may have occurred will appear first on the fetal heart sound record; vaginal bleeding will strengthen the presumption.record; vaginal bleeding will strengthen the presumption.

POSTICTAL STATEPOSTICTAL STATE

If the gestational age of the pregnancy is more than 24 If the gestational age of the pregnancy is more than 24 weeks, a decision about delivery will be made as soon as a woman’s weeks, a decision about delivery will be made as soon as a woman’s condition stabilizes, usually 12-24 hours after the seizure. There is condition stabilizes, usually 12-24 hours after the seizure. There is some evidence that the fetus does not continue to grow after some evidence that the fetus does not continue to grow after eclampsia occurs. Thus, terminating the pregnancy at this point is eclampsia occurs. Thus, terminating the pregnancy at this point is appropriate for both mother and child. For an unexplained reason, appropriate for both mother and child. For an unexplained reason, fetal lung maturity appears to advance rapidly with hypertension of fetal lung maturity appears to advance rapidly with hypertension of pregnancy (possibly from the intrauterine stress), so even though the pregnancy (possibly from the intrauterine stress), so even though the fetus is younger than 36 weeks, the lecithin-sphingomyelin ratio may fetus is younger than 36 weeks, the lecithin-sphingomyelin ratio may indicate fetal lung maturity.indicate fetal lung maturity.

BIRTHBIRTH

Cesarean birth is always more hazardous for the fetus Cesarean birth is always more hazardous for the fetus because of the association of retained lung fluid (see because of the association of retained lung fluid (see chapter26). Further, the woman with eclampsia is not a chapter26). Further, the woman with eclampsia is not a good candidate for surgery. Becase the vascular system is good candidate for surgery. Becase the vascular system is low in volume, the woman may become hypotensive with low in volume, the woman may become hypotensive with regional anesthesia such as in epidural block. The regional anesthesia such as in epidural block. The preferred method for birth, therefore, is vaginal. If labor preferred method for birth, therefore, is vaginal. If labor does not begin spontaneously, rupture of the membranes does not begin spontaneously, rupture of the membranes or induction of labor with IV oxytocin may be instituted. If or induction of labor with IV oxytocin may be instituted. If this is ineffective and the fetus appears to be in imminent this is ineffective and the fetus appears to be in imminent danger, the infant will be delivered by cesarean birth.danger, the infant will be delivered by cesarean birth.

Pregnancy- include hypertension may occur up to 10 to 14 Pregnancy- include hypertension may occur up to 10 to 14 days after birth, although most postpartal hypertension accurs in days after birth, although most postpartal hypertension accurs in the first 48 hours after birth. Monitoring blood pressure in the the first 48 hours after birth. Monitoring blood pressure in the postpartal period is essential to detect residual hypertensive or postpartal period is essential to detect residual hypertensive or renal disease. Women who had elevation of blood pressure during renal disease. Women who had elevation of blood pressure during pregnancy need instruction about returning for a postpartal pregnancy need instruction about returning for a postpartal checkup to have their post-pregnancy blood pressure evaluated to checkup to have their post-pregnancy blood pressure evaluated to be certain it has returned to normal. be certain it has returned to normal.

POSTPARTAL HYPERTENSIONPOSTPARTAL HYPERTENSION

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Normal Labor