assessment and management

Question 1

 Maternal Assessment During Labor during 1st stage

Answer 1

 Check V/S q(every) 4hrs during the first stage
- temp q hour if membranes are already ruptured (risk of infection)
- BP b/n contractions, in left lateral pos, q 15 – 20 mins after giving anesthesia
- a rapid pulse indicates hemorrhage & dehydration
 Uterine contraction
Manual: fingers over fundus, you feel it about 5 secs before the client feels it
Techniques:
1. assess contraction (DIIF)
2. check contraction q 15 – 30 mins during the first stage
3. refer immediately if:
- duration more than 90 secs
- interval less than 30 secs
- uterus not relaxing completely after each contraction
 Show – slightly blood-tinged mucus discharge
 Internal Examination – to assess status of amniotic fluid, consistency of cervix, effacement/dilatation, presentation, station, and pelvic measurement.
- do it during relaxation
- less IE done once membrane have ruptured
- start with middle finger then index finger
 Status of Amniotic Fluid (if ruptured)
 Danger of cord prolapse if fetal head is not yet engaged.
 Danger of serious intrauterine infection if delivery does not occur in 24 hours

Question 2

When baby have Bradycardia what should do mgt?

Answer 2

MGT: 1. place mother on left side
2. assess for cord prolapse
3. administer oxygen

Question 3

When baby have tachycardia what should do mgt?

Answer 3

1. D/C oxytocin, position on LLP
2. give 02 at 8 – 10 lpm
3. prepare for birth if no improvement

Question 4

 Variable Pattern –
CAUSE:
MGT

Answer 4

CAUSE: sign of cord compression
MGT: release pressure on the cord

Question 5

 Sinusoidal Pattern
CAUSE:

Answer 5

hypoxia, fetal anemia & prematurity

Question 6

CARE OF THE PARTURIENT

1. LATENT PHASE
   Nursing Responsibilities:

Answer 6

1. Encourage walking - shorten 1st stage of labor
2. Encourage to void q 2 – 3 hrs. – full bladder inhibits contractions
3. Breathing – chest breathing

Question 7

CARE OF THE PARTURIENT

2. ACTIVE PHASE
   Nursing Responsibilities

Answer 7

Nursing Responsibilities:
1. M – edications – have meds ready
2. A – ssessment include: vital signs, cervical dilation and effacement, fetal monitor, etc.
3. D – dry lips – oral care (ointment) dry linens
4. B – abdominal breathing

Question 8

CARE OF THE PARTURIENT

3. TRANSITION PHASE
   Nursing Responsibilities

Answer 8

Nursing Responsibilities: RRE
1. Reassure woman that labor is nearing end & baby will be born soon
2. Reinforce breathing and relaxation techniques
3. Encourage fast-blow breathing to remove the urge to bear down
4. Emotional support

Question 9

 CARE OF THE BLADDER – encourage the woman to void q 2 hrs. to:

Answer 9

○ Delay fetal descent
○ Increases the discomfort of labor
○ Predispose to UTI
○ Can be traumatized during labor

Question 10

 FOODS & FLUIDS

Answer 10

• NPO (Nothing by mouth)on active phase
  ○ Clear fluids on latent phase

Question 11

 POSITIONING

Answer 11

– LLP - best position
○ Relieves pressure – IVC
○ Improves urinary function
○ Prevent hypotensive syndrome
○ Encourage anterior rotation of the fetal head
○ Squatting is ideal position – directs presenting part towards the cervix promoting dilatation

Question 12

 IV FLUIDS – reasons:

Answer 12

PLUA
○ Prevent dehydration/fluid & electrolyte imbalances
○ Life – line for emergencies
○ Usually required before administration of A/A
○ Administration of oxytocin after delivery to prevent atony

Question 13

 ENEMA – emptying the colon of fecal matters to:

Answer 13

○ Stimulate uterine contractions
○ Prevent infection
○ Facilitate descent of fetus

Question 14

 ENEMA ○ CONTRAINDICATIONS:

Answer 14

NIRVAA
 Not given during active phase
 If premature labor because of danger of cord prolapse
 Rupture of BOW
 Vaginal bleeding
 Abnormal fetal presentation & position
 Abnormal fetal heart rate pattern

Question 15

THIRD STAGE – PLACENTAL DELIVERY
Management

Answer 15

MANAGEMENT:
1. Watchful waiting.
a) Do not hurry the expulsion of the placenta by forcefully pulling out the cord or doing vigorous fundal push as this can cause uterine inversion. Just watch for the signs of placental separation.
b) Wait for signs of placental delivery
* Calkin’s sign – uterus is firm, globular & rising to the level of umbilicus; earliest sign of placental separation
* Sudden gush of blood from vagina
* Lengthening of the cord
c) Track the cord slowly, winding it around the clamp until the placenta spontaneously comes out, slowly rotating it so that no membranes are left inside the uterus, a method called Brandt – Andrew’s maneuver.
d) Inspect for completeness of cotyledons; any placental fragment retained can also cause severe bleeding and possible death.
e) Palpate the uterus to determine degree of contraction. If relaxed boggy or non - contracted, first nursing action is to massage gently and properly. An ice cap over the abdomen will also help contract the uterus since cold causes vasoconstriction.
2. Inject oxytocin (Methergine = 0.2 mg./ml. or Syntocinon = 10U/ml) IM to maintain uterine contractions, thus prevent hemorrhage. Note: oxytocins are not given before placental delivery.
4. Never leave the client unattended.
5. Oxygen & emergency equipment made available.

Question 16

THE FOURTH STAGE – PUERPERIUM

MANAGEMENT:

Answer 16

1. Repair of lacerations.
   CLASSIFICATION OF PERINEAL LACERATIONS

 First degree – involves the vaginal mucous membranes and perineal skin
 Second degree – involves not only the muscles, vaginal mucous membranes, and skin, but also the muscles.
 Third degree – involves not only the vaginal mucous membranes and skin, but also the external sphincter of the rectum
 Fourth degree – involves not only the external sphincter of the rectum, the muscles, vaginal mucous membranes, and skin, but also the m mucous membranes of the rectum.
2. Assist the doctor in doing episiorrhaphy repair of episiotomy or lacerations). In vaginal episiorrhaphy, packing is done to maintain pressure on the suture line, thus prevent further bleeding. Note: Vaginal packs must be removed after 24 – 48 hours
3. After repair of lacerations & episiotomy, perineum is cleansed, the legs are lowered from stirrups at the same time.
4. Make mother comfortable by perineal care and applying clean sanitary napkin snugly to prevent its moving forward from the anus to the vaginal opening. Soiled napkins should be removed from front to back.
5. Position the newly – delivered mother flat on bed without pillows to prevent dizziness due to decrease in intraabdominal pressure.
6. Check V/S of the mother every 15 mins for the first hour & every 30 mins for the next 2 hours until stable.
7. Check uterus & bladder q 15 mins. A full bladder is evidenced by a fundus which is to the right of the midline and dark – red bleeding with some clots. Will prevent adequate uterine contraction.
8. Fundus – should be checked every 15 minutes for 1 hour then every 30 minutes for the next 4 hours. Fundus should be firm, in the midline, and during the first 12 hours postpartum, is a little above the umbilicus. First nursing action for a non- contracted uterus: massage.
9. Perineum – is normally tender, discolored, and edematous. It should be clean, with intact sutures.
10. Blood pressure and pulse rate may be slightly increased from excitement and effort of delivery, but normalize within one hour.