NURSING MANAGEMENT OF THE CHILDBEARING FAMILY 1

INTRAPARTUM

Nursing Care During Labor and Birth

.

1. Differentiate between true and false labor

True False

Contractions
Frequency regular irregular
Intensity increasing no change
Duration increasing no change
Activity increases intensity often stop
Pain location lower back above U
Radiating to lower abd.

Cervix
Dilation progressive no change
Effacement progressive no change
Position anterior posterior

Baby
Engagement yes usually not

Comfort measures no effect stop

Care begins with the onset of labor or when the one of the following is
reported.
 Onset of progressive, regular uterine contractions
that increase in frequency, strength, and duration
 Blood-tinged mucoid vaginal discharge indicating
that mucous plug (operculum) has passed (could be a
prodromal sign if not accompanied by onset of
regualar contractions.)
 Fluid discharge from vagina (ROM may not be
accompanied by onset of regular contractions, but
care will begin when membranes are ruptured.)
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2. Describe important information that is available on

the prenatal record.
• Age
• Height & weight (update)
• Medical conditions
• OB hx and complications
• EDB
• Maternal wt. gain
• Labs: blood type and Rh, CBC, rubella, serology
(VDRL), HBsAG, Group B Strep, UA, HIV, drug
screening

3. Discuss information to be collected during the

admission interview.

• Confirm EDB

• Chief complaint
• onset of contractions
• frequency
• duration
• intensity
• changes

• bloody show
• description

• ROM
• What time did this happen
Description of Fluid

• Last meal
• Birth Plan
• Infant feeding method
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• Pediatrician
• Psychosocial factors
• Abuse
• Address concerns about labor
• Cultural Factors

5. Describe the general care of the family during each stage

of labor.

First Stage of Labor

 Assessment and nursing diagnosis
 Determination of true or false labor
 Contractions
 Cervix
 Fetus
 Physical examination
 General systems assessment
 Vital signs
 Leopold’s maneuvers
 Assessment of FHR and pattern
 Admission to labor unit
 Admission data
 Prenatal record
 Interview
 Psychosocial factors
 Women with a history of sexual abuse
 Stress in labor
 Cultural factors
 Assessment of uterine contractions
 Determine effectiveness. Are they
powerful enough to expel the contents of
the uterus?
 Frequency
 Intensity
 Duration
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 Resting tone
 Report to provider

 Vaginal examination
 Cervical effacement, dilation, fetal descent
 Determines true labor
 Status of membranes
 Dilation and effacement
 Presenting part
 Position
 Station

 Perform a Vaginal Exam When:

• There is significant change in UA
• Urge to push
• Membranes Rupture
• Variable Decelerations
• Admission
• Medication
It is a sterile procedure!!!!!!!!!!!!

 Laboratory and diagnostic tests

• Analysis of urine specimen
• Blood tests

 Assessment of amniotic membranes and fluid

• SROM or AROM will induce labor
• Assess color, viscosity/odor, amount, S&S of
infection (Table 18-3 page 510)
• Document on labor record and report Abnormal
findings.

Always assess FHR when membranes

rupture ASAP!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
• Signs of potential problems (Box 18-6)
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 Plan of care and interventions

 Standards of care are the same that we use for any
patient

 Physical nursing care during labor (Table 18-4 page

513)
• General hygiene
• Nutrient and fluid intake
• Elimination-Carefully monitor I&0 especially
with epidural.
• Ambulation and positioning

 Supportive care during labor (Table 18-5)

• Nurse
• Father or partner
• Grandparents
• Doulas
• Siblings during labor and birth

 Emergency interventions (Page 523)

Second Stage of Labor

 Infant is born
 Begins with full cervical dilation (10 cm)
 Complete effacement
 Ends with baby’s birth
 Table 18-6
 Preparing for birth
 Maternal position
 Bearing-down efforts
• Valsalva maneuver

 Fetal heart rate (FHR) and pattern

Location of the FHR will change at this point in labor
due to internal rotation. For example a baby at ROA will
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turn OA for birth. PMI will move down and toward

center.

 Support of father or partner

 Supplies, instruments, and equipment
 Birth in a delivery room or birthing room
 Birth in LDR or LDRP room
 Mechanism of birth: vertex presentation
 Prevention of meconium aspiration
 Use of fundal pressure
 Immediate assessment and care of newborn
 Perineal trauma related to childbirth
 Lacerations
 Perineal lacerations
 Vaginal and urethral lacerations
 Cervical injuries
 Episiotomy
 Emergency childbirth (Box 18-9)

Third Stage of Labor

 Placental separation and expulsion
 Firmly contracting fundus
 Change in uterus
 Sudden gush of dark blood from introitus
 Apparent lengthening of umbilical cord
 Vaginal fullness
 Collaborative care
 Placental examination and disposal
 Cultural preferences
 Maternal physical status
 Physiologic changes to prepregnancy status
 Signs of potential problems
 Excessive blood loss
 Alteration in vital signs and consciousness
 Care after placental delivery
 Care of family during the third stage
 Family-newborn relationships
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