everyone and this morning we are going to be talking about chapter 14 nursing management during labor and birth okay we're going to talk a bit about managing mom and baby during labor what things to look for and warning signs we have to constantly be assessing mom offering her emotional support updates keeping her as comfortable as possible and supporting whoever is supporting her so it is extremely important you do a thorough assessment and often you offer comfort measures often emotional support to mom and person with her information and instruction about how her labor's going about how the baby's doing how they're breathing you're an advocate so you're going to be an advocate between her and the health care system and again you're going to support the partner we're monitoring her vitals we're performing occasional vaginal exams to check for progress we're observing for rupture of membranes if they haven't already ruptured we're palpating her abdomen using leopold's maneuver to see how the baby's turning and what the presenting part is at that moment and that's in your book so make sure you go over that page and you know the different maneuvers what comes first second third and what you're feeling for when you do those maneuvers most importantly we're monitoring the patient we can't see the baby we can't see it we can't touch it so we have nothing to go on as far as monitoring except for the electronic fetal monitor so that strip that you run every so often is the only way you're telling if that baby is in good condition or something is going wrong also when you're monitoring uterine contractions you are checking cervical dilation when you do a vaginal exam and it should be 10 when they're ready to deliver a basement should be 100 when they're ready to deliver membrane status if they haven't ruptured already you will have to do um you have to rupture them um and if they are ruptured when they come into the hospital um you need to know the tom and what the characteristics look like of the the fluid because rupturing outside of the hospital is not ideal because it opens up the possibility to infection especially if they've stayed home for several hours before they come in after the membranes have ruptured okay key terms you need to remember what is successful fetal oxygenation well it requires several things it requires normal maternal blood flow and volume to the placenta it requires normal maternal oxygen saturation it requires adequate oxygen and carbon dioxide exchange in the placenta it requires an open good circulatory path between the placenta and the fetus which that path is the cord so the cord has to be open um normal fetal circulatory and oxygen carrying functions in maternal side complications that can affect this are hemorrhage vasodilation such as with an epidural block hypotension compression of the aorta and inferior vena cava hypertension and vasospasms can impede blood flow to the placenta and these are the things that you have to look for these are the things that can go wrong we talked earlier about how important it was for the uterus to have an adequate resting period i talked about that last week between contractions this allows blood exchange to and from the placenta so monitoring the duration and interval of contractions is very important placenta abruption is a catastrophic uh event and it does happen it's rare uh cord compression can also interfere with blood exchange to and from the placenta because if the cord is compressed blood isn't getting to the baby so these are two things that you look for when you're looking at contractions when you're looking at blood flow to mom from mom to baby and this is a picture that actually shows you you will as a nurse do frequent vaginal exams you're checking a basement you're checking dilation you're checking to see if you can feel the presenting part and looking at this picture you can tell at some point when the baby actually comes down and descends into the true pelvis the head is engaged hopefully it's the head you can actually feel it when you do a vaginal exam i talked about that last week in that you feel something soft but yet it's firm that's the baby's head during labor the nurse must monitor color amount clarity and odor of amniotic fluid mismonitor fetal heart tones either intermittent or continuous and this can be external with a toco or internal and what you're looking for is patterns patterns um warning signs and symptoms patterns and warning signs and symptoms and what you usually see you don't want to see you don't want to see decelerations you do want to see good accelerations that means the baby is adapting to the labor process and is headed your way fetal scalp sampling may be used to test for acidosis and fetal head stimulation and maternal pulse ox okay so these are some of the assessments that you're actually doing when i say you're doing assessments guidelines for the fetal heart rate these are guidelines for fetal heart rate during early labor if mom and baby are stable if there's any questions the fetal well-being continuous fetal monitoring is employed if mom and baby are stable then you can do intermittent monitoring the fetal heart rate is 110 to 160 beats per minute it's regular has good variability there are presence of accelerations or a cells absence of decelerations or what we commonly call d cells um the purpose of fetal monitoring during labor labor is to determine how well the baby is tolerating the stress of labor and to hopefully identify potential problems early so that they can be fixed an intervention can be used um because what you're hoping for with all your interventions and with your quick actions is a good outcome for mom and baby no amount of monitoring however can guarantee a good outcome uh you have to remember like i said you've got one patient you're monitoring that you see and touch you've got one that you can't see and touch um so it's it's to say what the outcome will be is 100 percent is totally impossible fetal heart rate below 100 is abnormal and will get the nurse's attention quickly but let it fall below 60 or below that and everyone in the unit snaps to attention and starts moving right away it's critical to find the problem and fix it asap because you only have minutes before brain and heart perfusion is affected and keep in mind also that a sustained tachycardia state is dangerous for the baby heart rates around 200 don't allow enough time for the ventricles to adequately fill so cardiac output is poor and so oxygen delivery is also going to be poor and this is a medical emergency when it happens so everybody moves very very quickly um when you're monitoring you have an initial 10 to 20 minute continuous fetal heart rate assessment on entry into the labor room and this is read on your strip uh you do a completion of prenatal and labor risk if you have time sometimes they come in and they're already crowning um intermittent osculation every 30 minutes during active labor for low-risk women and every 15 minutes for high risk women and during the second stage that's the first stage during the second stage intermittent musculation every 15 minutes for low risk low risk women and every five minutes for high-risk women external monitoring of contractions of course i talked about this mint ago uses a toco while internal monitor monitoring of contractions uses an internal catheter that's connected to the baby's presenting part um the fetal heart may have printed the system you're using may have a printed strip or it may be an electronic display either way each dark line is one minute and each lighter square is 10 seconds and you use this to time duration interval and other things for contractions keep in mind each dark line is one minute and each lighter square is 10 seconds i am going to bring in some um fetal monitoring strips next time in class face to face and let you look through them and get familiar with them and and be able to um look at the dark the lighter squares and the dark lines baseline this is another term you need to know the average heart rate measured over two minutes of a clear tracing within a ten minute period okay average heart rate measured over two minutes with a clear tracing within a 10 minute period and this will make more sense when you actually see the strip the normal you want to see is 110 to 160 and you do not want to see bradycardia which is less than 110 and persist for 10 minutes um usually brady for a baby uh may mean late fetal hypoxia uh head compression maternal hypotension and cord compression uh fetal heart blocks and uterine rupture may also be seen with bradycardia tachycardia is more than 160 beats per minute persisting for 10 minutes and what may be going on here is initial fetal hypoxia it may just be starting maternal fever and infection maternal drug use or fetal anemia um so these are things that you might see with bradycardia and tachycardia and they all are emergencies and have to be taken care of immediately so to reiterate you have a machine that produces a continuous tracing for your fetal heart rate it can be also electronic or it can be on paper your primary objectives are to provide information about fetal oxygenation and prevent injury and to detect fetal heart rate changes early before they are prolonged and profound so that you can intervene assessing the fetal heart tones some words that are extremely important acceleration you use the 15 by 15 rule an abrupt acceleration is an abrupt temporary increase in fetal heart rate that peaks 15 bpms above baseline and last 15 seconds often occurs with fetal movement or stimulation such as vaginal exam uterine contractions so it can be normal okay you want to see a cells and this is an abrupt temporary increase in fetal heart rate that peaks at 15 bpms above baseline and lasts for 15 seconds so it is something that you want to see um usually reassuring sign is the reassuring sign that reflects a responsive non-acidotic fetus so this is a good thing no intervention is needed d cells are deceleration this is a transient fall and fetal heart rate categorized and based on their shape and relationship to contractions you have different types you have early which is caused by fetal head compression icp vegal responses usually you just watch this requires no intervention this occurs during contractions and it mirrors contractions um you get a gradual decrease from baseline and it returns to baseline when the contraction is over so that's your early d cells variable reduce flow through the umbilical cord no uniform pattern no w or u um amnio infusion for the chord compression may be used because usually this is what's causing it you're having chord compression and you're trying to amnio infusion puts fluid up there to try to float the cord away from the baby or the baby away from the cord trying to get that cord free you have a fallen rise abruptly it's unrelated to contractions uh you have a decrease of 15 bpms lasting 15 seconds position change may help either side usually they start with the left oxygen trendelenburg or the knee chest position have them squatting apply upward pressure to the fetal uh presenting part and you're doing this in order to move the baby off the cord late d cells uteroplacental insufficiencies what causing is what's causing a late d cell fetus is in trouble not tolerating contractions this is always an ominous sign must intervene immediately um you have a delayed shift or a shift to the right of the contraction uh on the your strip you may begin it may begin after the peak and return to baseline after the contraction ends so this is something that requires immediate intervention and immediate call to your ob doc your variability may be marked moderate minimal or none okay so you're looking for a cells in d cells and variability in your contractions um interventions for late d cells troubleshooting put them on their left side oxygen to 8 to 10 liters per minute via mask increase the iv fluids stop the pitocin if they're on it because you want to relax the uterus and get help immediately the doctor should be on this way you want to determine the cause and fix it you want to troubleshoot the cause is the baby laying on the cord is mom hypotensive so you're going to be doing some troubleshooting and asking yourself some questions you want to stop the pitocin or oxytocin infusion if it's in use immediately you want to reposition and reposition mom again and again and again until hopefully you can find a way to stop these late d cells oxygenate again like i said 8 to 10 liters per minute an iv fluid bolus will help uh hydrate mom which can also help reposition and get the cord free initiate continuous monitoring this is a continuous monitoring phase on notify physician quickly as possible if not already done so and prepare for immediate delivery have the delivery nurse getting the delivery room if there is a delivery nurse uh getting the room uh ready for immediate delivery amnio infusion for variable d cells i talked about that where you're putting fluid up in the vagina to try to float the baby off of the cord um some things are very easily corrected if mom just received an epidural and is hypotensive which is what happens with an epidural a bolus of fluid may actually fix the hyper hypotension and it may fix the issue if she received pain medication um do you need to remember administer a reversal drug or just write it out till the effects wear off soon if it's not really bad uh you can perform a vaginal exam to see if mom has progressed quickly and is ready to push that will take care of the d cells did the membranes disrupt rupture and the cord prolapse question you need to ask ask yourself often all that is needed is to turn mom to one side of the other usually the left first to relieve cord compression uh you can also elevate her hips or she can do the squatting method and get on all fours all of this is basically being used to move that cord and of course the cord and the baby move with positions that the mom moves in so this hopefully will take care of the d cells if the mom is receiving oxytocin or pitocin uh to induce labor make sure that it is turned off because if you need the uterus to relax and it's not relaxing after the pit's turned off you can administer a tocolytic drug which will quiet the uterus down and you won't have the contractions um start on start oxygen instruct mom to take slow deep breaths um and get the things that need to be ready for the amnio infusion if it's going to be done so these are interventions for late d cells and this is a picture showing the monitoring it's uh this is internal monitoring and you see that it is connected to the scalp um and you have your catheter intrauterine pressure catheter this is usually done for continuous monitoring um there's some guidelines for internal fetal monitoring which i just showed you this uses an internal device and it's only used after the membrane's rupture only used after the membranes rupture because you can't get to it otherwise it includes a fetal scalp electrode that is attached to the head or buttocks whatever the presenting part is and reads signals from the fetal heart it's very accurate um you turn it clockwise when you want to remove it and you never pull on it never pull on it because this is connected to the baby so need i say more of what might happen um your lpc is a solid catheter with a pressure transducer in the tip and an infusion and infusion lumen um it slides inside the uterus along the side of the fetus and it monitors uterine contractions it can be used for amnioinfusion also if that needs to be done so that tells you what you use for your fetal monitoring and always remember if you're going to use internal those membranes have to be ruptured cervix has to be dilated at least two cms your fetal part your presenting part has to be low enough in order to get a scalp electrode on it and usually the physician is the one that does this um variability i mentioned variability a minute ago so variability minimal moderate marked or periodic okay variability is considered the fluctuations in the baseline fetal heart rate within a 10 minute window that gives you the print and sawtooth irregular pattern say that again variability is the fluctuations in the baseline fetal heart rate within a 10 minute window that gives the printout on your strip that's a sawtooth irregular pattern it assesses how the fetus is tolerating labor and it's also the best indicator of fetal oxygenation during labor evaluates the function of the fetal autonomic nervous system and the different types of variability poor or decreased variability you have fetal compromise and it can be caused by several things fetal sleep fetal anomalies hypoxia narcotic or sedative use alcohol drug use cns abnormalities maternal acidosis or fetal sepsis hypoxemia fetal tachycardia and it is it is seen um less than 28 weeks of gestation um your variability is termed as absent which is non minimal which is less than five beats per minute moderate which is 6 to 25 and marked which is 25 less than 25 beats per minute so that describes the variability and remember that's one of the things that you're looking for when you do your assessment um this table explains the terminology for labeling a fetal monitor strip you have category 1 which is essentially normal and can have intermittent monitoring you have category 2 which is indeterminate and fetal heart tones may be out of parameters there's iffy variability some d cells figure it out and fix it quickly category three endocrine indicates acidotic fetus bradycardia late d cells very ominous sign it needs to be looked at taken care of if possible immediately so make sure you look at this table box 14-1 these are nursing interventions for a category 3 strip bottom line is to find the cause and fix it and get the delivery room prepared immediately because usually the only thing that will totally fix the category three is delivery comfort and pain management pain is always an unpleasant sensation um it's distressful and with labor it's resulting from stimulation of sensory nerves pain is always subjective and personal so it's what the patient says it is pain is part of the normal labor process realistic preparation and education about the birth process helps the mom cope better with the pain and it's important that mom knows and remembers labor pain has an endpoint it's not going to last forever labor pain is intermittent so there is resting period and knowing that the baby's coming and that there is something at the end of all this pain allows the woman to cope better and it allows them to tolerate much more pain than they would ever be ever be able to do without the baby excessive pain is going to heighten their fear and anxiety um and it's also going to stimulate increased secretions of ketchicola means and these release this release reduces blood flow to and from the placenta so it affects the fetal oxygen and waste exchange and may reduce effectiveness of uterine contractions which is going to slow labor down you do not want that so keep mom as calm as possible and if she asks for pain medication then that should be given the maternal metabolic rate and oxygenate oxygen needs are in high demand from labor anyway pain and anxiety is going to increase some more um it's going to put increased demands on all systems for mom so it's important to monitor closely cultural difference every woman is going to handle pain different depending on their culture some women are very vocal others are very stoic and anxiety and fear is going to affect how they're going to cope if they're tense they're going to be less able to tolerate the rigors of labor and also previous labor experiences will affect how they deal with this labor if she's had a particularly difficult one before stillbirth the c-section these experiences are going to affect her and make her even more tense and anxious again preparation and education can be very helpful in helping the mother and partner cope with the rigorous labor period and then it this is the nurses the labor room nurse's responsibility keep that mom as calm as you possibly can help decrease anxiety by constantly telling her what's going on constantly reassuring her telling her what's happening with the baby and the same thing with the partner who's going to be anxious too and that can and the mom can feed on that so you need to keep both calm as possible non-pharmacologic medication management okay this is great because it doesn't affect the pace of the labor it doesn't have any effects on the fetus so this is what you always try first before you get in there and you just give a medicine relaxation will help blood flow to the placenta it promotes efficient uterine contractions um it helps relieve anxiety and there's all types to use there's imagery there's using a focal point proper breathing [Music] and this is really where education classes before um the delivery is important they prep the mom and the uh support person for all of this and give them information on how to do all of this so those prenatal classes are really good to have because you don't go in cold not knowing what to do or expect when non-pharmacologic measures don't work pharmacologic measures can be used pain management during labor can be delivered by systemic drugs regional pain relief or general anesthesia keep in mind that giving these meds to a pregnant woman requires special considerations because you're not just giving it to one patient you're giving it to two anything you give moms likely to cross the placenta barrier to the baby and will affect the baby drugs affect pregnant women differently than non-pregnant women sometimes they have a totally different reaction drug use can affect the length or progression of the labor any complications of pregnancy affects what drugs may be used okay so it will depend on what's going on as to what drugs can be used how do pain meds affect the fetus well most drugs given to mom as i said earlier caused a baby and the fetus is affected by the drug they may get sluggish they may get drowsy may have a decrease in oxygen respiratory depression so all of this has to be watched and thought of before you give mom any pharmacologic measures analgesia is another way to decrease pain this promotes a degree of pain relief anesthesia provides partial or complete loss of sensation sedatives and antimetics are used early and they allow mom to rest and decrease her anxiety so all of these can be used but used with caution and you need to know ahead of time what's going on with mom before you give them systemic analgesia systemic drugs most of the time the most commonly used is opioids um there's no loss of consciousness but there is a sedation they used to use demerol quite a lot denver also not used anymore very rarely now fentanyl state all new bain are your more common ones and of course you know fentanyl is something that can be very dangerous so it is used sparingly and very cautious you need to know mom's drug history before you administer these drugs especially now because you have such a big opioid addiction in the country so you need to know uh what's going on with her and her um her history her drug history primary side effects is respiratory depression um these often cause neonatal distress if given too close to delivery and they're given in small frequent doses what's used to rev reverse an opioid-induced respiratory depression is narcan so you need to have narcan nearby um you can resedate afterwards after you get reverse the the respiratory depression may use adjunct to adjunctive drugs such as antibiotics for nausea vomiting sedatives to enhance the effectiveness of the drugs use them with caution and you can if they're not used with caution get a severely respiratory depressed infant upon delivery analgesics shouldn't be given until labor is well established to avoid slowing the progression of labor um typically administered through an rv opioids are your most common promethazine hydroxyzine can be used and of course your benzos can also be used to cause some sedation and decrease anxiety regional energy analgesia and anesthesia your local infiltration anesthesia is infiltration of the perineum with local anesthetic and it can be done by physician or midwife just before delivery providing pain relief only in the immediate care area of the injection another regional anesthesia is the pudendal block this anesthetizes the lower vagina and part of the perineum it's injected by the physician or midwife at the pudendal nerve near each ischial spine subarachnoid or a spinal block is a fluid is put in a fluid filled area between the dura mater and the spinal cord and this is very commonly used is the spinal block it's a simpler quicker method immediate onset is one to two minutes um local anesthetic is injected in a single small dose knocking out sensory and motor function below the point 25 to 27 gauge spinal needle is placed cerebral spinal fluid is confirmed at the hub of the needle and then the anesthetic is injected and this is at the bottom of the back okay and you do get loss of sensation from that point all the way down to your toes some adverse effects hypotension decreased placental perfusion can occur with this type of anesthesia spinal headaches can occur when the cerebral spinal fluid leaks out of the site where you did the dural puncture it is worse when the woman sets up right so that is why is required the woman is lying flat even after delivery um in the recovery area you keep them flat for so long bed rest and iv hydration will help with that headache caffeine may help and sometimes they'll use a blood patch that will provide relief they take 10 to 20 milliliters of the blood from the mom and inject it into the epidural space and what this does is seal off the leakage which is causing the headache you're sealing off the leakage of the spinal leakage of the spinal fluid epidural block epidural space is outside the dura mater between the dura and the spinal canal um it's performed by injecting a local anesthetic agent combined with the opioid into the space level can be extended upward for a c-section or a btl if they're having that after delivery bilateral tubal ligation entry at l4 and l5 is done at the interspace a small catheter is placed a test dose is always done first to see if mom's going to have a reaction and it takes 20 to 30 minutes to take effect um any intravascular injection can cause rapid motor motor and sensory block you may get numbness to the tongue the lips dizziness and tinnitus uh drugs that they use for this are fentanyl morphine uh preservative free drugs only dural puncture can cause cerebral spinal fluid leakage and again producing a postural puncture spinal headache this is contraindicated in coagulation defects hypovolemia allergies mom's allergies infections mom's infections she has an infection um bladder distension can occur due to the decreased sensation and increased iv fluids so it's important that you're constantly asking or providing mom with um a bedpan if she doesn't have a catheter um a foley catheter the urge to push may be muted with this catheters may become displaced so you're constantly looking for placement there is an increased incidence of c-section with this type of anesthesia maternal fever can sometimes occur and this raises the fetal temp and causes tachycardia for fetus adverse effects such as nausea and vomiting itching or pueritis and delayed respiratory depression may occur fetal heart patterns must be monitored continuously and the patient may feel a brief electronic shock sensation when the catheter is placed it is a brief brief electronic shock sensation fetal heart rate maternal bp is measured every five minutes for the first 15 minutes then you need to follow a protocol of the facility that you're working in maternal hypertension that affects placental blood blood flow may occur in the first 15 minutes and women are given a bolus of 500 to 1 000 cc's of iv fluids some examples are lactated ringers or normal saline prior to the block to prevent the maternal hypotension because you want to keep that placental blood flow going fetal changes such as rise in fetal heart rate baseline tachycardia or late d cells may occur with maternal hypertension so you want to prevent that as much as you can intrathecal opio opioid analgesia which is another uh regional thing is injected into the subarachnoid space uh advantages of this are rapid onset no motor block patients can ambulate there are no hypertensive effects the disadvantages is limited duration of the action inadequate pain relief for the episiomotomy and laceration repair if it's needed and some side effects in nursing care is required the same side effects and nursing care that you give in all the other blocks is required for that particular type so this is some of the regional analgesian anesthesia that you can see i've went over each one of them make sure that you read about them in your book more closely general anesthesia sometimes they especially if there is a trouble with labor they will do general anesthesia this is systemic pain control that involves loss of consciousness and it's often needed for emergency procedures like an emergency c-section adverse effects include maternal aspiration of the gastric contents if mom if this is an emergency and she just ate or drank something right before respiratory depression of the mother or the infant it reaches the infant in two minutes general anesthesia does so you've got to move quickly uterine relaxation and increases the change of or increases the chance of postpartum hemorrhage afterwards after delivery how do you minimize these adverse effects well restrict intake to clear fluids administer drugs to raise the gastric ph some examples are victra zenec is was taken off the market it's no longer used in this country but there's tagamet pepcid on administering drugs to speed gastric emptying like reglan um use something called the circoid pressure to block the esophagus so the contents cannot come all the way up reduce timing uh from anesthesia induction to clamping of the cord um you know if you're going to give anesthesia you'll want to clamp that cord more quickly so it doesn't get to the baby keep sedating keep sedating drug used to a minimum until the cord is clamped so it doesn't get to the baby and this is general anesthesia not uh the first thing that you want to use but sometimes when especially an emergency c-section when labor has gone downhill sometimes you have no choice okay stages of labor first stage of labor women often hesitate to come to the hospital when they first start feeling pains because they feel like they're jumping the gun and if they've had braxton hicks before they think it's braxton hicks again and they're going to be sent home so they usually call and talk to the nurse usually there's patched into the delivery area or labor and delivery area the ob floor um or they may call their physician these are some of the questions you might want to ask them over the phone to gauge if they actually need to come in the bottom line is if anything sounds off you tell them to come in immediately um some questions estimated date of birth fetal movement uh and what's the frequency in the past few days if it's increased then that's telling the nurse that there's possibility that lightning is occurring and they are uh getting in position to uh fall down into the true pelvis other pre-monetary signs of labor that's being experienced back pain that nesting we talked about that energy spurt that you get that's a good sign check parity and grammar gravida uh what is this their third baby um in previous childbirth experiences with the others tom frame in previous labors laborers how long did it take for each delivery characteristics of the contractions are they coming in a pattern or are they random how long do they last bloody show in membrane status whether the membranes have ruptured or not if the mucus plug has been released and talked about that last week that's considered the bloody show when the mucous plug comes out then the membranes rupture usually with membrane rupture um you need to know what color it was was it clear which is what it should be or cloudy which indicates an infection was there any blood in it which would mean there is fetal compromise it should be clear and it should have just maybe a little vernix flowing through it as well and is there presence of someone in the household or is she alone these are all questions you need to ask over the phone um your administ admission assessments in your first stage if you've got time you want to do a maternal health history uh you want to do a physical assessment on all the body systems of mom vital signs heart and lung sounds height weight you want to do a fundal height measurement because this is going to tell you if lightning has already occurred if the fundus is still high up or it's lower uterine activity including your contraction frequency duration and intensity which we've talked about the status of the membranes which i just said um cervical dilation and degree of effacement fetal heart rate position in the station which we've discussed and their pain level okay when you're again status of membranes if they have uh ruptured at home when did they rupture approximately what time how long did they stay home before they came in after they ruptured uh vital signs temperature is very important because you want to anticipate there might might be some bacteria that was introduced and will cause an infection uh continuing with assessment fetal assessment is extremely important they are hooked up to external or internal usually external monitoring first and then if they need internal monitoring that's done after the membranes rupture lab studies they're going to have a routine urinalysis in cbc um if the mom hasn't already had this in prenatal care she's going to have syphilis screening gbs hiv hbs ag screening hiv has to be woman's consent and possible drug screening if it wasn't included in the prenatal history they also need an assessment of psychological status their anxiety level their education level did they have prenatal classes and it's also important to look at the partner yeah are they uh running around all over the place are they uh uh hyper are they so anxious that they're incoherent so it's important that you do an assessment of the partner that's with them as well um you also the women's knowledge vital signs vaginal exam you will be doing frequent vaginal exams throughout the labor process to monitor cervix cervical dilation uh and effacement and checking for presenting part a baby uh uterine contractions are monitored very closely uh pain level coping ability fetal heart rate you'll do a lot of tracing um and again the amniotic fluid make sure you look on table 14 3 it talks about the amniotic fluid and its characteristics um nursing management during the second stage of labor requires a lot of assessment it's a one-on-one assessment usually the nurse is with the mom all the time especially when they begin pushing you do not leave the patient evidence supports letting women tell you when they need to push or labor down allows mom to find a position comfortable for her offer her support get her in the position that's comfortable for her nursing management the second stage um continuing uh supporting the woman and the partner uh supporting involuntary bearing down efforts but no pushing until a very strong desire until you see a descent and rotation of the fetal head and it's well advanced providing instructions assistance pain relief again the positions to enhance descent and reduce pain and that you're taking your cues from the mom on that one and preparing for assistance with delivery some institutions deliver right in the labor and labor room they stay in the same room for delivery and that's their room after delivery some are taken to a labor suite and they deliver there so it will depend on your institution again nursing management uh after the baby comes cleansing of perineal area and vulva assisting with the birth birth suctioning with a bulb syringe is usually done by the person delivering the baby you then the immediate care of the newborn then requires drying the baby off putting skin-to-skin contact with mom for one hour if possible this does several things this increases baby's temperature which when they come out we're going to talk about this when we talk about the neonate they have a lot of problems with temperature regulation and they come out in an environment that's cold they're wet um so mom's mom is warm and so that skin to skin contact helps with temperature increase and it also helps with bonding between mom and baby and that's an important period for that bonding avgor scores are done on baby um they're done at one minute and then five minutes the rule of thumb is eight or higher um on the app core scores which means there's no intervention needed and the things that you're assessing for scoring is heart rate respiratory effort muscle tone color and reflex response and each of these five parameters is assessed and given a score of zero one or two and then it's for a total perfect score of 10. okay each of those five parameters i talked about is given a score of zero one or two to get a perfect score of ten um some of the things you'll see with this heart rate will be absent below 100 or above 100 that's one of your gauges another gauge is respiratory effort there's none slow weak cry or spontaneous respirations with strong cry you're looking for muscle tone is it limp sluggish or minimal or flexed and vigorous you're looking at reflexes you're gauging no response to suction or stimulation minimal response which is grimacing or active response which is crying you're looking at color of the infant are they polar or cyanotic cyanotic feet and hands only which is acrocyanosis and normal or are they pink are they cyanotic around their lips and that's a bad sign are they polar meaning they're not getting the blood flow they need um prevent hypothermia by drying them off and putting the baby in a warmer cap um this also doing all this helps stimulate breathing uh and crying uh skin to skin contact again is important if you can do it um identity identify bands are put on in the delivery room in direct site of the parents so that they can see delayed court clamping this is encouraged if you have not given drugs and anesthesia that's going to get to the baby quickly because you don't want that so delay chlor cord clamping uh you can do a minimum of one minute up to three minutes or when the cord stops pulsating you cut it in one to three minutes or when the cord stops pulsating what this does this delayed cord clamping allows for transfer of blood from the placenta to the baby so they get an extra extra boost of blood and this helps uh in neurodevelopment they have found better social skills fine motor skills uh and it lasts as long as um up to four years um there's also a decreased risk of anemia because they get a boost of iron stores more iron stores from mom about 27 to 47 milligrams more so this can prevent iron deficiency in baby during the first year life um you usually see about 80 to 100 milliliters of blood extra blood that's transferred so you have smoother cardiopulmonary transition at birth you have an increased platelet level count that's needed for clotting and you have a boost of fetal stem cells nearly a third of the stem cells are left in the placenta if the cord is cut too early a third so that's another reason to delay core clamping or cutting for one to three minutes nursing management during the third stage okay this is where you're back to caring for the mom observe for signs and symptoms of placental separation and what you're going to see what happens is there's a lengthening of the cord all of a sudden you'll see a movement in the cord and it'll be longer and there is a gush of blood and this gush of blood came from where the placenta has suddenly separated from the uterus okay um you need to examine it um assess the fundus and the perineum when you're examining the placenta in your book it talks about this you have dirty duncan and clean schultz the clean schultz is the baby infant side fetuses side when it was inside mom the dirty duncan was attached to the uterus you need to assess the fundus which is the uterus uh after delivery right after delivery is going to be uh two three finger breaths above above the umbilicus umbilicus okay above the belly button and as it's contracting it's hardening up and it's moving down so it starts to go down to the belly button and then um below the belly button one finger breath below two finger breaths below so you're constantly and this takes hours it's not something that happens immediately um make sure you also look at the placenta for intactness because sometimes when it separates from the uterus it leaves pieces and that's something you don't want to happen because it can cause a nasty infection with mom it causes a lot of postpartum hemorrhage um so make sure that you examine that after it's put in the it's a little pan for the antagonist and that's usually done by the nurse and assessing the fundus in the perineum is done by the nurse as well uh they may get pitocin after delivery of the placenta uh 10 to 20 units to help with contractions and bleeding this is given through the iv or they may get 10 units im so you need to assess this is why coagulation is important to know before mom goes into delivery so you'll know if you need to have all this stuff ready and on board to give and then of course the cleanup uh cleaning up the mom uh especially the perineum um and offering her if she wants to maybe wash off from being sweaty and hot vital signs every 15 minutes for the first hour you need to assess the locia every 15 minutes and prn um you can use cold pads to help with the bleeding if there is bleeding you also want to check for pooling because they're laying down blood is going to pool and then when they stand up it's going to just gush they may pass small clots um so it's important that you watch for small clots um with lokia you're going to assess the lokian in your book it talks about it starts out rubra very red uh and there can be anywhere from a minimal amount moderate and if it's a large amount you have you will have to do intervention um and that's where they get the pitocin to help the uterus contract and stop the bleeding um then you in your book it talks about it goes on in a few days to serosa and then alba so make sure that you know the toms for those and when they occur and that is in your book so make sure you read it you need to observe the perineum for hematomas lacerations uh appeasing episiotomies are not done as frequently as they used to be um but you still see them occasionally and this is where they actually cut below the perineum cut the perineum in order to allow the baby to come out without tearing mom and having a huge laceration ice can be applied for comfort to the perineal area uh methodogen or hemobait im may be given in addition to pitocin for bleeding so they may if pitocin doesn't work they may get meth methrigen or hemobait and they are both given i am um [Music] you move on to the fourth stage at that point and this is the stage of physical recovery for mom and infant this is from the delivery of placenta through the first one to two hours after birth and it is a time where you're assessing often fundal massage may be needed your fundus should be firm it should not be hard and it should not be boggy it should be firm uh it should be um located at the umbilicus um when or a little bit above right after delivery it's going to feel firm around mass and the way you write that is fundus firm at you which is umbilicus or firm at u plus one which may be umbilicus just above the umbilicus where it is when you first massage it right after delivery um the way you do that is support the base of the uterus during the massage um and just massage it like you would anything else support it at the base which is toward the mom's perineum and then massage uterus may be soft or boggy that means that you need to massage it that it's not firming up that the uterine contractions are not good enough to firm it up massage will firm it up usually um and it usually happens immediately some things that can cause the uh you cause it to feel soft and boggy and interfere with firming it up is a full bladder or retained clots these will increase uterine bleeding uh uterus may be displaced to the right or higher than expected if you've got a full bladder so you you know if you see that then have them offer them a bedpan and have them void and that should put the uterus right back where it needs to be vaginal discharge after birth uh and i just talked about this lokia it's gonna be rubra serosa alba small clots are also normal to have and you're going to see more lokia in a vaginal vaginal delivery than you are in a c-section c-sections many times you don't see hardly any rubra at all and then they don't go through the other two serosa and alba as as much as a vaginal delivery does postpartum chills are common so offer warm blankets uh localized pain from the birth trauma so you may need to offer us a mild analgesic or again ice to the perineum works well it numbs the area after pains uh intermittent contractions are more pronounced in women that have had babies before so those after pains hurt more in women who have had large babies so because you've got over distension and after pains hurt more with the full bladder and they hurt during breastfeeding because what breastfeeding is doing if mom tries to breastfeed right after delivery breastfeeding is helping firm up the uterus it's causing contractions so it also helps with uh postpartum bleeding as well um babies are usually very alert in the fourth stage so it's a prom tom for bonding and initiating breastfeeding so you get the double benefit there and you're helping contract the uterus as well vital signs are taken every five minutes and then every 15 on mom again assessment is very important in the third and fourth stage frequent assessment also nursing management vital signs fundus perineal area comfort level locia bladder status all important in the fourth stage um again to reiterate support and information information about the baby what's going on with mom's body uh the blood loss fundal checks very often perineal care hygiene bladder status offering bed pan and voiding often keeping a account of that amount of voiding and time how often they void comfort measures uh medication if needed parent newborn attachment very important happens because babies alert and this is a good time for that and teaching this is a good time maybe to have baby latch on and start teaching some um breastfeeding as well