1 / 77

Intrapartum Nursing Care

Intrapartum Nursing Care. On Admission Induction/Cesarean Section Care in 1 st , 2 nd , 3 rd , and 4 th Stages of Labor Precipitous/Out-of-Hospital Delivery. When to go to Hospital . Regular Contractions with  intensity SROM Vaginal Bleeding

jyates
Download Presentation

Intrapartum Nursing Care

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

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

  2. 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

  3. 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?

  4. 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

  5. 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.

  6. 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

  7. 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

  8. 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

  9. 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

  10. 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

  11. ALWAYS assess FHR • AFTER AROM or SROM • (risk of prolapsed cord) • BEFORE starting Pitocin for Induction • Throughout induction • BEFORE & AFTER analgesia/anesthesia

  12. 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 p.744 Olds • 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.

  13. 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 Bishop’s Scale for measuring Induction Readiness 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.

  14. 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. • Prostaglandin– a variety of forms from gels inserted transvaginally, to suppositories, or vaginal inserts

  15. 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.

  16. 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.

  17. Methods of Induction--when Cervix is ripe and ready • AROM/Amniotomy • Potential complication:a. Infectionb. Prolapsed cordc. Fetal head or cord compression • Contraindications:a. When presenting part is floating highb. If fetus is in a breech or transverse lie

  18. Methods of Induction--when Cervix is ripe and ready • Nursing Care after AROM:a. Assessment– FHT of baby immediately -VS of mom a & p, Temp q 2h -Assess color & odor of fluid immediately after AROMb. 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

  19. Methods of Induction--when Cervix is ripe and ready • Oxytocin (Pitocin) • Uses:*induce rhythmic uterine contractions *augment weak or ineffective contr. *promote uterine contraction in 4th stage of labor

  20. 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)

  21. Oxytocin (Pitocin)See box in text • Mixed with D5LR, or D2NS(depends on MD) • Amount: your text adds 10U to 1000ml • BRMC and St. Joseph adds 20U 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

  22. Oxytocin (Pitocin)continued • CALCULATING Pitocin rates: • 10U added to 1000cc= 10U/1000cc • 10U X 1000mU= 10000mU/1000cc=10mu/cc • Remember: you must convert mU/min to cc/hr to set the rate on the IV pump • 1cc/10mU X 60min/hr X 1mU/min=6cc/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

  23. Oxytocin (Pitocin)—Nurse’s Role • Assess & record FHT q15min, variability, accels • Assess & record Uterine activity q15 • Assess & record Maternal BP q 15-30min • Assess & record Maternal I & O continuously.IV Oxytocin can lead to water intoxicationOutput should be 120cc/4hr or 30-35cc/hr. • Assess pt sensitivity and pain after initiation of med.

  24. Oxytocin (Pitocin) • 2 dangers with Oxytocin administration • 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.

  25. Oxytocin (Pitocin) • Nursing Care (see text ) • Monitor IV closely– Mainline 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

  26. 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

  27. Minimal Assessment of the Low-Risk Woman During the 1st Stage of Labor Cervical Dilatation Vaginal exam prn to

  28. 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

  29. Signs of Transition •  in bloody show • Nausea and vomiting • Increased rectal pressure • Desire to push •  ability to focus due to intensity and frequency of contractions

  30. Nursing Care / Psychosocial • Confidentiality • Be Respectful • Supportive Care / Include Support Persons • Use of Touch • Reassurance / Gentle Coaching • Modesty

  31. Nursing Care / Physical • Positioning • Hydration • Bladder • Dealing with Contractions

  32. Signs of Potential Complications • Rising Intrauterine Pressures • Cntx > 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

  33. Amnioinfusion • Warmed, sterile NS or Ringer’s Lactate infused INTO uterus via Intrauterine Pressure Catheter (IUPC; 250 – 500 cc) • Increase Intrauterine Fluid Volume • Intrauterine Used to treat Problems related to fetus • Thick Meconium • Decelerations r/t Cord Compression

  34. Contraindications for Amnioinfusion • Omnious FHR • Umbilical Cord Prolapse • Significant Vaginal Bleeding • Uterine Hypertonia

  35. 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

  36. 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

  37. Assessment during 2nd stage

  38. Assessment in 2nd stage (cont’d)

  39. 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

  40. 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

  41. 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

  42. 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!

  43. 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

  44. 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

  45. Other Elective ProceduresEpisiotomies • 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.

  46. 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.

  47. 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

  48. Perineal Lacerations • 1st Degree: extends through the skin & structures superficial to muscles • 2nd Degree: extends throughmuscles of perineal body • 3rd Degree: tear extends through anal sphincter muscle • 4th Degree: tear that involves the anterior rectal wall

More Related