Nursing Care During Labor

NURSING CARE
DURING LABOR
Marie Agnes Baniwas
At your Service
ASSESSMENT Premonitory Signs of Labor
Lightening – primis – 10-14 days before labor; multis: with onset of labor
Braxton-Hick’s contractions increase and may become annoying --
sleeplessness
2 to 3 lb weight loss may occur 3 to 4 days before labor
Increased vaginal mucus discharge
Spurt of energy may occur 1-2 days before labor – allows the woman to
make final preparations for delivery
Initial Assessment should answer the following questions

Is she in labor?
How far has she progressed?
Have the membranes ruptured?
Are there complications that may require treatment?
What is her psychologic response to the beginning of labor?
Check vital signs.
 If BP is elevated, repeat procedure 30 minutes later to obtain a true reading when the
woman is relaxed.
 BP should be checked at least every hour between contractions. BP may rise 5 to 10
mmHg during a contraction.
 Cardiac output is increased due to:
 Uterine contraction causes the shift of about 300-500 ml of blood to the central
blood volume ---» inc. BP
 Anxiety and pain ---» stress response ---» inc. BP
 TPR monitoring is done q 4 hours, or more frequently if indicated
 Temperature & respiration should be normal. Closer observation is
needed when the membranes have ruptured and in the presence of fetal
tachycardia.
 Pulse rarely exceeds 100 /minute. A persistent pulse of over 100 is
suggestive of exhaustion or dehydration.
 Check for edema of the legs, face, hands or sacrum
 Obtain a specimen of urine for routine urinalysis to check for presence of protein, glucose
or acetone
 Inquire regarding symptoms of infection (diarrhea, cold, cough, sore throat)
 Recheck for allergies
 Check the woman’s dietary intake for the last 4 hours.
 Perform Leopold’s to determine the fetal presentation, lie, position and engagement
 Assess FHT for rate & regularity: note the area of maximal intensity.
Methods of determining the degree of fetal distress throughout
labor
Assessment of the rate & rhythm of the fetal heart.
Fetoscope monitoring
Electronic FHR monitoring
External monitoring
Internal monitoring
Telemetry
Fetal Blood Sampling
Non Stress test
Contraction Stress Test
ABNORMAL FHR PATTERNS
 Tachycardia – fetal distress
 Bradycardia – fetal hypoxia
 Late Deceleration
 Decelerations that are delayed until 30-40 seconds after the onset
of contraction and continues beyond the end of contraction;
 Suggests uteroplacental insufficiency or decreased blood flow
through the intervillous spaces of the uterus during contractions, as
in marked hypotonia or abnormal uterine tonus caused by oxytocin
administration.
Management:
o slow rate of administration of oxytocin or stop it
o Change woman’s position from supine to lateral
o Administer IV fluids or oxygen to woman
 Variable pattern
 Indicates compression of the cord
Management
o Change position from supine to lateral or
Trendelenburg
o Administer O2 to woman
o CS delivery
 Sinusoidal pattern
 FHR pattern resembles a frequently undulating wave; fetus is severely
anemic or hypoxic
SPECIAL CONSIDERATIONS : ASEPSIS & ANTISEPSIS
Personnel should wear caps, masks; those who will participate in the delivery
should be in sterile attire.
People with communicable disease (upper respiratory infection, open skin
lesions, diarrhea) should not be allowed into the delivery room
Only sterile instruments should be used.
ASEPSIS-the absence of bacteria, viruses, and other microorganisms.
ANTISEPSIS-the practice of using antiseptics to eliminate the microorganisms
that cause disease

AMNIOTOMY
Artificial rupturing of the membranes. It allows the fetal head to contact the
cervix ---»more efficient contractions.
This may be done with a hemostat. Take FHR after (danger: escape of loop cord
with fluid).

 OTHER NURSING MEASURES
Coach the woman on bearing down efforts.
Short pushes of no longer than 6-7 seconds
Physiological pushing: pushing only with the urge to push (3-5 times
with each contraction) and resting in between
Pushing with an open glottis and slight exhalation
(Valsalva maneuver impedes return flow of blood to the heart
because of increased intrathoracic pressure)
Positioning – lithotomy, lateral sims, dorsal recumbent
Psychosocial support
Preparation of the DR and instruments (forceps, scissors, needle,
needle holder, bowl/kidney basins, sutures, sponges)

Nursing Interventions
1. Afterthe delivery of the placenta, oxytocin (Methergine) is given IM and/or Pitocin (Syntocinon)
maybe given as a drip up to 8 hours after delivery.
2. Suturing of the episiotomy usually requires local anesthesia, unless the woman had a pudendal
block or epidural anesthesia
Assessment:
Vital signs: BP, pulse, Temperature
Uterus: degree of contraction; fundal height
Lochia: amount, presence of clots
3. Perineum/episiotomy
4. Bladder/distention
5. Family interaction
6. Potential Complications:
7. Hypothermic reactions
8.Chilling accompanied by uncontrollable shaking;
Exact etiology: unknown; possible explanations: sudden release of intraabdominal pressure,
exhaustion, disequilibrium in the internal & external body temperatures
Management:
Clean, dry warm gowns, blankets
Avoid drafts
Warm fluids

Promoting Nutrional Health During Pregnancy

Recommended weight gain during Pregnancy
Average woman should gain 11.3 to 15.8 kg ( 25-35 lb. )
During pregnancy

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NURSING CARE

Initial Assessment should answer the following questions

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