nursing responsibilities before, during and after delivery

7/30/2019 Nursing Responsibilities Before, During and After Delivery

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11/12/2011 paulmarkpilarrnman


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Labor is defined as the onset of rhythmic

contractions and the relaxation of the uterine smooth

muscles which results in effacement or progressive

thinning of the cervix, and dilation or widening of the

cervix.

This process culminates with the expulsion ofthe fetus and expulsion of the other products of

conception from the uterus.



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TRUE LABOR VS FALSE LABOR CONTRACTIONS

True Labor False LaborResult in progressive cervicaldilation and effacement

Do not result in progressivecervical dilation and effacement

Occur at regular intervals Occur at irregular intervals

Interval between contractions

decreases

Interval between contractions

remains the same or increases

Frequency, duration, and intensityincrease

Intensity decreases or remains thesame

Located mainly in back andabdomen

Located mainly in lower abdomenand groin

Generally intensified by walking Generally unaffected by walking

Not easily relieved by medications

Generally relieved by mildsedation11/12/2011 paulmarkpilarrnman


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TRUE LABOR VS FALSE LABOR

FACTOR TRUE LABOR FALSE LABOR

Show Present Absent

Cervix Becomes effaced and dilatesprogressively

Usually un-effaced andclosed

FetalMovement

No significant change eventhough the fetus continuesto move

May intensify for a shortperiod or stay the same



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FIRST STAGE OF LABOR

Latent or Prodromal Phase contractions - regular, q15-30 minutes x 15-40

seconds, mild to moderate intensity

Cervical effacement occurs

cervical dilatation 0 to 3 - 4 cm

Bloody show may be present

Woman can and should continue to walk about

mother may feel anticipation, excitement, betalkative & able to cope

Lasts approximately 6 hours in a nullipara and 4.5hours in a multipara



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Attitude of woman in labor:

Generally, women feel comfortable walking andsitting at this time

1. Upon admission, establish rapport with the womanand the support person accompanying the woman.

2. Encourage verbalization of fear and anxiety

regarding labor.

3. Provide woman and significant other healthteachings regarding labor process as needed.

4. Orient the patient and the significant others to the

surroundings

5. Explain all procedures before carrying them out



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6. Promote comfort and relief measures as needed.

- Provide information about pain relief options

-Encourage to ambulate if membranes have not yetruptured

- Assist to empty bladder every 2 hours

- Place pads under the buttocks to absorb

continuous drainage or show.- Teach positional changes, back rubs, sacral

pressure and relaxation and breathing techniquesthat help ease the pain and discomfort

-Provide frequent mouth care, perineal care,change pads, relaxing environment



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Active or Accelerated Phase contractions - regular, every 3-5 minutes x 30-60

seconds, moderate intensity

cervical dilatation 4 to 7 - 8 cm

effacement - 50 - 100%

increased bloody show

Spontaneous ROM may occur

mother becomes serious, concerned aboutprogress of labor; may ask for pain medication

or begin to use breathing techniques; becomesless receptive to instructions and may becomefatigued



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woman prefers to stay in bed, becomesincreasingly preoccupied with the sensation in herbody, withdraws from the environment and becomesless conversant.

1. Coach woman on breathing and relaxationtechniques

2. Provide ice chips or moisten lips and apply lip balmor let her gargle with NSS to moisten lips or mucusmembranes

3. Give short and direct answers to questions of patient

4. Inform the patient of the progress of labor andwellbeing of the fetus. Let her listen to the FHT asrequested



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5. Let the mother stay in bed if BOW has alreadyruptured.

6. Encourage to lie on left lateral position7. Provide relief measures as in latent phase



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Transient or Transitional Phase Contractions reach their peak of intensity, occurs

every 2-3 min and lasts for 60 90 seconds

cervical dilatation - 8 - 10 cm

effacement - 100%

presenting part continues descent

heavy bloody show

SROM, if not ruptured previously

mother becomes less able to cope, may becomeangry with nurse or partner, may lose control,thrash about in bed, groan or cry out; maydevelop nausea and vomiting; may have leg

tremors11/12/2011 paulmarkpilarrnman


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Woman may feel discouraged and asks thenurse repeatedly when labor will end. Woman feels not

in control of her emotions and the sensations in herbody that she is easily irritated and may not want to betouched. Woman feels the urge to push or bear down.

1. Reassure the woman that although this is the most

difficult period of labor, it is also the shortest.2. Reinforce breathing and relaxation techniques

3. Discourage bearing down if the woman feels theurge to do so since the cervix is not yet fully dilated.

4. If nausea and vomiting occurs let woman lie on herside to prevent aspiration



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1. Assess maternal condition:

A. Obstetric history:

a. Gravidity and parityb. Estimated date of confinement (EDC) or due date.

c. Duration of previous labors.

d. Problems with previous pregnancies/deliveries.

B. General condition:

a. Rh status.

b. Allergies.c. History of medical problems.



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C. Current pregnancy.

a. Onset of labor (contractions regular, 5 minutes or

less).b. Frequency, duration, and intensity of

contractions.

c. Membranes-ruptured or intact.

d. Amount and character of show or vaginalbleeding.

e. Vital signs.

f. Rate, location of fetal heart tones.

g. Any problems with this pregnancy.



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2. Vital Signs

Vital signs are taken upon admission

Latent Phase Take BP, PR and RR every 1-2 hours

Take temp every 4 hours. Assess every hourafter ROM due to increased risk to infection or

dehydration Take blood pressure between contractions not

during a contraction. After anesthesia isadministered, take every 15-20 mins

Active and Transition Phase: take every 30 min orevery hour



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Second stage: Take every 15 min to one hour

Vital Signs are taken more frequently in the

presence of complications and when certainprocedures are done.

3. Assess plans for newborn care:

Intend to breastfeedRooming-in preference

Circumcision preference if male infant

Choice of pediatrician



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4. Assess for the Duration, intensity, interval and frequencyof contractions

5. Assess for the show. In normal labor, only anincreasing amount of blood stained mucus discharge isexpected not actual bleeding

6. Perform IE to assess status of amniotic fluid,consistency of cervix, effacement, dilatation,

presentation and station.

7. Assess status of Amniotic fluid

Instruct woman and SO to report immediately anyleakage of fluid from the vagina

a. There is danger of cord prolapse if fetal head is notengaged

b. There is danger of serious intrauterine infection ifdelivery does not occur in 24 hours



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c. Immediately after ROM:

1) After rupture of BOW, assess FHR for one fullminute. If bradycardia is present, perform IE to

assess for cord prolapse and change theposition of the woman to relieve pressure on thecord.

2) Assess odor of amniotic fluid

3) Assess the amount and color of amniotic fluid.IT should be clear or straw colored with specksof vernix caseosa.

4) Record time of rupture, characteristics of fluid

and FHR



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8. Perform Leopolds Maneuver to determine fetalpresentation

9. Determine fundic height and correlate with AOG

10.Perform fetal assessment

Frequency:

a. Low Risk:

1) Latent Phase take FHT every hour2) Active Phase every 15 30 mins

3) Second stage take FHT evry 5-15 min

b. At risk: FHT is taken more frequently or

continuously1) Latent Phase take FHT 30 min

2) Active Phase every 15 min

3) Second stage take FHT every 5 min11/12/2011 paulmarkpilarrnman


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c. Take FHT immediately after the rupture of BOW,whether artificially or spontaneously

d. After any significant change in the uterinecontraction is noted



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1. Carry out doctors orders

2. Insert and administer IVF as ordered

a. Prevention of dehydration/fluid and electrolyteimbalance

b. Having a life-line for emergencies

c. Route of medication administration

3. Initiate labor progress notes: FHT, Uterinecontractions, vital signs

4. Notify patients attending physician upon request

5. Perform perineal preparation

6. Encourage to void frequently7. Clear liquids or ice chips may be provided in the

early stages of labor. NPO during active labor.

8. Encourage woman to ambulate



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9. Encourage ambulation during the latent phase

10.Administer enema as ordered and unlesscontraindicated

Contraindications:

a. Not given during active phase and rupturedBOW

b. Vaginal Bleeding

c. Abnormal fetal presentation and position

d. Fetus not yet engaged

e. Premature labor

f. Abnormal fetal heart rate11.Provide comfort measures



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12. Assess for danger signs of labor

a. Signs of fetal distress

b. Excessive bleeding

c. Cord prolapse

d. Maternal tachycardia, hypertension andhypotension

e. Pallor, cold clammy skinf. Fever, foul smelling vaginal discharge

g. Meconium staining

13.Transfer to delivery room as indicated

12.Primiparas are transferred to the DR when thecervix is fully dilated and perineum is bulging

13.Multiparas are moved to DR when cervix is 8 cmdilated



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SECOND STAGE OF LABOR

-

Refers to the period from full dilatation and cervicaleffacement to birth of infant

- Contractions change from the characteristiccrescendo-decrescendo pattern to an overwhelming,uncontrollable urge to push or bear down withcontractions.

- Need to push becomes so intense that she cannotstop herself

- Barely hears the conversation in the room aroundher



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1. Prepare delivery equipments

2. Position patient in a delivery position suited for thecondition of the patient

a. Lithotomy

b. Dorsal Recumbent

c. Side-lyingd. Squatting

3. Perform perineal preparation

a. Using gloved hand, cleanse perineum, anus and

upper thighs with antiseptic solution.b. Catheterize woman as necessary or as ordered

after perineal cleansing



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4. Prevent infection

a. Persons with infections or have been exposed to

infectious diseases are not allowed to enter DR.b. No one should be permitted in the DR without a

scrub suit, mask covering mouth and nose andcap that completely covers hair

c. Ideally, healthcare personnel attending deliverymust wear eye shields, gowns and gloves toprotect themselves

d. Proper hand washing after patient care andhandling of blood and body fluids

e. Wear gloves when there is the possibility ofhandling blood and body fluids



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5. Assist mother in the delivery room

1. Coach mother to push effectively and avoid the

valsalva maneuvera. Instruct to grasp below the knees or other

hard objects as she bears down

b. To push 3 to 5 times with each contraction but

push no longer than 5 to 6 seconds2. To avoid exhaustion, instruct the woman to pant

during some contractions

3. If the woman complains of leg cramps provide

relief by dorsiflexing the affected foot andstraightening the leg until the cramps disappear

4. Perform ironing on vaginal orifice to stretch andprepare soft tissues as the presenting partmoves towards the outlet



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5. When the head is crowning instruct mother not topant and not to push to prevent rapid expulsion ofthe baby and to avoid lacerations.

6. Ensure controlled delivery of the head:a. Keep one hand gently on the head as it advances

with contractions.

b. Support perineum with other hand and cover

anus with pad held in position by side of handduring delivery.

c. Leave the perineum visible

d. Ask the mother to breathe steadily and not to

push during delivery of the head.

e. Encourage rapid breathing with mouth open.



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7. Deliver the head slowly in between contractions.Immediately after delivery of the head:

a. wipe the nose and mouth of secretions

b. Insert fingers into vagina and feel for cord loopedaround the neck

8. Await spontaneous rotation of shoulders anddelivery within 1 2 minitues.

9. Apply gentle downward pressure to deliver topshoulder.

10.Then lift baby up, towards the mothers abdomen todeliver lower shoulder.

11.Place baby on abdomen or in mothers arms.

12. Note time of delivery.



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13.Thoroughly dry the baby immediately. Wipe eyes.Discard wet cloth.

14.Assess babys breathing while drying.

15.If the baby is not crying, observe breathing:

a. breathing well (chest rising)?

b. not breathing or gasping?

16.Exclude second baby.17.Palpate mothers abdomen.

18.Give 10 IU oxytocin IM to the mother.

19.Watch for vaginal bleeding.

20.Change gloves. If not possible, wash gloved hands.



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21.Clamp and cut the cord.

a. Put ties tightly around the cord at 2 cm and 5 cmfrom babys abdomen.

b. cut between ties with sterile instrument.

c. observe for oozing blood.

22.Leave baby on the mothers chest in skin-to-skin

contact. Place identification label.23.Cover the baby, cover the head with a hat.

24.Encourage initiation of breastfeeding

25.Record the delivery

a. Exact date and time of delivery

b. Sex of the infant

c. Condition of the infant (APGAR) after birth



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d. Type of episiotomy, lacerations

e. Spontaneous or forceps delivery

f. Use of oxygen and suction on the infantg. Number of vessels in the cord

h. Any other pertinent facts about the delivery



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1. Ensure 10-IU oxytocin IM is given.

2. Await strong uterine contraction (2-3 minutes) anddeliver placenta by controlled cord traction:

3. placenta does not descend during 30-40 seconds ofcontrolled cord traction, release both cord tractionand counter traction on the abdomen and wait untilthe uterus is well contracted again.

4. As the placenta is coming out, catch in both handsto prevent tearing of the membranes..

5. Check that placenta and membranes are complete.

6. Check that uterus is well contracted and there is noheavy bleeding.

Repeat check every 5 minutes.

7. Examine perineum, lower vagina and vulva fortears.



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8. Collect, estimate and record blood loss throughoutthird stage and immediately afterwards.

9. Clean the woman and the area beneath her. Put

sanitary pad or folded clean cloth under her

10.buttocks to collect blood. Help her to changeclothes if necessary.

11.Keep the mother and baby in delivery room for a

minimum of one hour after delivery of placenta.

12.Dispose of placenta in the correct, safe andculturally appropriate manner.

13.Record the following in the nurses notes

a. Time the placenta is delivered

b. How it is delivered

c. If the placenta is delivered complete and intact



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1. Assist in episioraphy

2. Cleanse the perineum with an antiseptic solutionand apply a sterile sanitary pad on the perineum

3. Lower legs from stirrups and remove soiled drapesand linens. Change mother into a clean gown

4. Provide extra blanket to keep patient warm

5. Monitor vital signs every 15 minutes for an hourthen every 30 min for the next hour then every hourdepending on patients condition

6. Examine the mother and the newborn 1 hour afterthe delivery of the placenta

7. Assess for lochia flow and post partum bleeding



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8. Transfer to recovery or private room

a. Suction machine and oxygen

b. Emergency drugs

c. IV remains patent for possible use ifcomplications develop

9. Accompany the mother and baby to ward.

10.Advise on Postpartum care and hygiene.11.Ensure the mother has sanitary napkins or clean

material to collect vaginal blood.

12.Encourage the mother to eat, drink and rest.

13.Ensure the room is warm (25C).14.Ask the mothers companion to watch her and call

for help if bleeding or pain increases, if mother feelsdizzy or has severe headaches, visual disturbance

or epigastric distress.11/12/2011 paulmarkpilarrnman


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15.Encourage the mother to empty her bladder andensure that she has passed urine.

16.Advise the mother on postpartum care and

nutrition.

17.Advise when to seek care.

18.Counsel on birth spacing and other family planningmethods.

19.Repeat examination of the mother before discharge



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CORE STEPS OF


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CORE STEPS OF

ESSENTIAL NEWBORN CARE

1. Immediate and thorough drying

2. Early skin-to-skin contact

3. Properly timed cord clamping

4. Non-separation of the newborn andmother for early initiation ofbreastfeeding


Ti B d Wi hi 1 30


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Time Band: Within 1st 30 sec

Immediate and Thorough Drying

1. Call out the time of birth

2. Dry the newborn thoroughly for at least 30 seconds

3. Wipe the eyes, face, head, front and back, arms andlegs

4. Remove the wet cloth

5. Do a quick check of breathing while drying

6. During the 1st secs:

a. Do not ventilate unless the baby is floppy/limpand not breathing

b. Do not suction unless the mouth/nose areblocked with secretions or other material


Ti B d Af 30 f d i


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Time Band: After 30 sec of drying

Early Skin-to-Skin Contact

1. If newborn is breathing or crying:

a. Position the newborn prone on the mothersabdomen or chest

b. Cover the newborns back with a dry blanket

c. Cover the newborns head with a bonnet

2. Avoid any manipulation

e.g. routine suctioning that may cause trauma or

infection3. Place identification band on ankle (not wrist)

4. Skin to skin contact is doable even for cesareansection newborns


Ti B d 1 3 i


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Time Band: 1 -3 min

Properly -timed cord clamping

1. Remove the first set of gloves

2. After the umbilical pulsations have stopped, clampthe cord using a sterile plastic clamp or tie at 2 cmfrom the umbilical base

3. Clamp again at 5 cm from the base

4. Cut the cord close to the plastic clamp

a. Do not milk the cord towards the baby

b. After the first clamp, you may strip the cord ofblood before applying the 2nd clamp

c. Cut the cord close to the plastic clamp

d. Do not apply any substance onto the cord


Ti B d Withi 90 i


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Time Band: Within 90 min

Non-separation of Newborn from

Mother for Early Breastfeeding1. Leave the newborn in skin-to-skin contact

2. Observe for feeding cues, including tonguing,

licking, rooting3. Point these out to the mother and encourage her to

nudge the newborn towards the breast

4. Counsel on positioning

1. Newborns neck is not flexed nor twisted2. Newborn is facing the breast

3. Newborns body is close to mothers body

4. Newborns whole body is supported11/12/2011 paulmarkpilarrnman

Ti B d Withi 90 i


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Mother for Early Breastfeeding5. Counsel on attachment and suckling

a. Mouth wide open

b. Lower lip turned outwardsc. Babys chin touching breast

d. Suckling is slow, deep with some pauses

6. Minimize handling by health workers

7. Do not give sugar water, formula or other liquids

8. Do not give bottles or pacifiers

9. Do not throw away colostrum


Ti B d Withi 90 i


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Mother for Early Breastfeeding5. Weighing, bathing, eye care, examinations,

injections should be done after the first full

breastfeed is completed6. Postpone washing until at least 6 hours



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1. Give preoperative teaching

a. Purpose

b. Clarify misconceptions

c. Breathing exercises

d. Early ambulation

2. Make sure that informed consent is signed

3. Follow up all lab works and refer as necessary

4. NPO 8 hours prior to surgery

5. Remove hairpins, nail polish, eyeglasses, contactlenses and dentures. Cover hair with cap

6. Insert IVF and retention catheter7. Administer atropine as ordered

8. Monitor maternal VS and FHT

9. Record and update nurses notes as necessary and

include pertinent findings11/12/2011 paulmarkpilarrnman


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1. Position patient in the OR table and assistanesthesiologist in the induction of anesthesia

2. Position the woman in supine position and drapeproperly

3. Perform skin prep. Cleansing and shavig is madefrom under the nipple line to the entire abdomenand perineal area

4. Cover patient appropriately with sterile drape, placescreen.

5. Assist OB during the entire operation whileobserving the principles of asepsis



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1 Maintain patent airway


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1. Maintain patent airway

a. Leave artificial airway in place until woman isawake

b. Maintain NPO until fully awake

c. Suction secretions PRN

d. Cough and deep breathe every 2 hours especiallywith general anesthesia

e. Use incentive spirometry

2. Watch for signs of hemorrhage

a. Falling blood pressure

b. Increased pulse and RRc. Restlessness

d. Cold, clammy skin

e. Decreased urinary output


3 Check perineal pad and fundus frequently


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3. Check perineal pad and fundus frequently

4. Monitor Vital signs q15 for the 1st hour then q 30 for the

next hour then q2 and q4 until stable

5. Put side rails up to ensure safety6. Encourage woman to ambulate on the first postpartum day

7. Introduce foods and fluids gradually when:

a. Fully awake

b. Bowel sounds have returned

c. Flatus is passed

8. Let mother hold and care for her baby as soon as possible

and follow the principles of essential newborn care

9. Remove urinary catheter as ordered

10. Remove or assist in the removal of sutures or clips and

change dressings as ordered



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nursing responsibilities before, during and after delivery

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