Intrapartum Lesson 4 Assessment in the First, Second, Third, and Fourth Stage of Labor



in this lesson of your intrapartum unit we will discuss care of nursing care of the family during labor and birth in the first second third and fourth stage of labor for this lesson we will discuss these objectives please review these objectives assessment in the first stage of labour begins with the physical examination this includes a general systems assessment vital signs léopold maneuvers fetal heart rate and pattern uterine contractions in a vaginal exam the general assessment is brief it includes an assessment of the heart lungs and skin as well as examining the face hands sacrament and legs for edema the nurse should check deep tendon reflexes and for clonise the woman's current weight should be noted at this time vital signs should be assessed on admission the initial values are used as a baseline for all future measurements if blood pressure is elevated wait 30 minutes for the woman relax make sure that a second blood pressure reading is taken between contractions léopold maneuvers can be performed to assess for the number of fetuses the presenting part fetal lie and fetal attitude degree of descent into the pelvis of the presenting part and the expected point of maximum intensity of the fetal heart rate the procedure for performing léopold maneuvers is seen here and can be found in your book the fetal heart rate the fetal heart rate and pattern should be assessed the PMI are the point of maximum impulse of the heart fetal heart rate is a location on the maternal abdomen where the fetal heart rate has heard the loudest this is generally on the mothers abdomen below the umbilicus if the fetus is in a vertex presentation and above the umbilicus and a breech presentation and in these you can see the different points of the fetus where you would most likely find the point of maximal impulse depending on the fetal position whether it's left mentum anterior left occipital left occiput posterior this is where you would most likely feel to see the fetal heart rate vaginal exams are performed to determine the status of the cervix and whether membranes have been ruptured vaginal exams should be performed on admission prior to administering medications when there is a significant change in uterine activity when the mother feels pressure or the urge to bear down when the water breaks a vaginal exam is actually the second a nursing activity after the water breaks with the first being to check the fetal heart rate or when the notes nurse notes variable decelerations the reason and procedure for vaginal exam should be explained to the patient lab and diagnostic tests that are completed in labor include an analysis of a clean cat urine specimen a CBC a type and screen and if the woman has no prenatal care all of the labs that would have been drawn prenatal he may be drawn a rapid strep may be done if the Group B Strep Nauticus status is unknown if membranes are not ruptured it is this will likely be done some point during labor it is accomplished through an amniotic my physician or certified nurse midwife using a plastic a me hook or a surgical clamp it is important to monitor for infection once the bag of waters is ruptured temperature and vaginal discharge should be assessed every two hours once membranes have ruptured frequency assessments during the different phases of the first stage of labor can be found in your book and should be reviewed nursing care during the first stage of Labor and providing general hygiene measures nutrient in fluid intake both orally and intravenously and elimination clear liquids are the only oral intake recommended during labor in the United States related to the risk for having to have emergency c-section however this practice is being challenged as most patients use regional anesthesia reducing the risk of aspiration IV fluids are generally administered to maintain hydration and to ensure sufficient fluid if she is receiving epidural anesthesia or analgesia usually the fluids are lactated ringers or normal saline if maternal ketosis occurs d v lor may be administered to give the mother some glucose elimination needs it is important that the woman voids at least every two hours a distended bladder can impede the presenting part from descending into the pelvis or stop uterine contractions thus prolonging labor women who have an epidural are at risk of urine retention help the woman to voit along as long as possible if the woman is unable to avoid a catherine a catheter may be inserted in some facilities and with some healthcare providers it is a standing order to catheterize a woman who has an epidural most women do not have bowel movements and labor because of decreased intestinal motility however if she does have a bowel movement this increases the risk of infection and may embarrass the woman the nurse should take care to cleanse the perineal area immediately and explain to the woman that this is a natural occurrence positioning during labor if the woman does not change position on her own every 30 to 60 minutes it is important that the nurse encourage her to do so the side lying or lateral position is preferred as it released pressure from the abdominal aorta and promotes fetal oxygen through optimal blood flow to the placenta the woman should be allowed to sit if it does not affect the fetus your book discusses common maternal positions used during labor and birth in more detail support for the mother during labor and birth includes emotional support physical care comfort measures advice and information the presence of a person to provide continuous support is invaluable the nurse should provide support through helping the woman maintain control providing care that is called Trulli religiously respectful and non-judgmental meet her expected outcomes listen to her and encourage her act as her advocate help with energy comfort conservation help her control discomfort acknowledge her efforts and protecting her privacy the second stage of labor during the second stage of labor the infant is born the stage began when the woman is fully dilated at 10 centimeters and faced at 100% this stage ends with the birth of the baby the median duration for the second stage of labor is 20 to 30 minutes in the multiparous woman and 50 to 60 minutes in the nulliparous woman there are other influences on the length of time for the stage of labor and those are maternal size and fetal weight in position and ascent the upper limits for the length of time for the nulliparous woman are two hours without anesthesia and three hours with anesthesia for the melt appearance woman the limit is one hour without anesthesia and two hours with anesthesia the second stage of labor is composed of two phases the latent phase the latent phase is a period of rest and calm which the woman Labor's down during this phase the fetus continues to descend passively through the birth canal and rotate to the anterior position at this time the physician may choose to delay pushing in order to give the fetus time to move down this has been shown to reduce act as the act of pushing face if a decision has been made to delay pushing careful monitoring of the fetus should occur to ensure that the fetus maintains appropriate oxygenation status during the act of fish pushing step phase which is the second phase of the second stage of labor the woman has a strong urge to bear down at this point the fetus is usually at the plus one station in the anterior position the Ferguson reflex has been activated and oxytocin is released from the posterior pituitary gland the nurse should encourage the woman to listen to her body during the second stage of labor during the second stage of labor the nursery contender continued to monitor both mother and fetus according to the hospital and professional standards in your book is the information necessary if the nurse had to perform a delivery without a certified nurse midwife or physician present please review these guidelines the nurse most likely will need to assist with coaching the woman during the pushing vase encourage the woman to push as they feel like pushing monitor the woman's breathing to ensure that she does not hold her breath for more than six to eight seconds at a time followed by a slight exhale remind her to take the deep cleansing breath before and after each contraction monitor the fetal heart rate for decrease variability prolong late or variable decelerations if these occur take the appropriate interventions the mechanisms of birth the three phases of the spontaneous birth of a fetus in the vertex presentation are the birth of the head followed by the birth of the shoulders and finally the birth of the body and the extremities crowning occurs when the widest part of the head descends the vulva just before birth immediately before birth the perineal must musculature becomes greatly distended an episiotomy may be performed at this time if necessary to minimize soft tissue damage the physician or nurse midwife may use hands-on approach at this time to decrease tissue damage without an episiotomy immediately after birth there are assessments of the newborn that must be conducted these will be discussed in later lessons on newborn care perineal trauma may occur during the birth process the following are examples of perineal trauma perineal lacerations these occur as the fetal head is being born in are classified as first-degree which extends through the skin and structures superficial to the muscle as you see in the first illustration you see the small tear which is barely extends then the second degree which extends through the muscles of the perineum aadhi you see here as you get into the muscles of the perineum bobbing but not into the anal sphincter and the third degree which continues through anal sphincter muscle and you see that in illustration three and fourth-degree that also involves the interior rectal wall you see this actually in this fourth illustration vaginal and urethral last relate lacerations occur with perineal lacerations cervical injuries occur when the cervix retracts over the advancing fetal head most er shallow with minimal bleeding extensive lacerations follow hasty attempts to extend the cervical opening extensive lacerations can have effects on future pregnancies and births if an episiotomy is an incision made into the perineum to enlarge the vaginal outlet different types of episiotomy ZAR performed the midline appear episiotomy is the most common type the third stage of labor lasts from the birth of the baby until the placenta is expelled depending on preference the provider may use either a passive or an active approach to manage the stage of labor passive management involves patiently watching for signs that the placenta has separated lengthening of the umbilical cord in a small gush of blood are signs that the placenta has separated this is the common practice in the United States however active management is used in many countries around the world evidence has shown that active management of this staged decreases the incidence of postpartum hemorrhage once the signs of separations has occurred are apparent the woman is urged to push in the past it was thought that if the placenta delivered with the maternal side our Duncan side first that there was an increased chance of postpartum hemorrhage there is no creat increased incidence of postpartum hemorrhage if the placenta is delivered in this manner in your book is a box that lists the nursing care during the stage of labor please review this the first one to two hours after birth sometimes called the fourth stage of labor is a crucial time for the mother and the newborn both are justing to the physical process of birth but also are becoming acquainted with one another it is at this time that bonding against not only for the mother but the father and other family members it is during this crucial stage that the maternal organs begin the process of returning to a pre pregnant stay for more information on the nursing assessment during the fourth stage of labor please refer to your book this concludes lesson 4 of your intrapartum unit

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