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Title: REIMBURSEMENT ISSUES Last modified by: barbmeyer Created Date: 8/26/2003 11:52:41 AM Document presentation format: On-screen Show Other titles – PowerPoint PPT presentation

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Nursing Care During Intrapartum
Normal Labor
  • In most pregnancies, the fetus reaches maturity
    and the uterus begins the process of labor at
    exactly the right time.
  • Researchers are still trying to discover the
    exact cause for the onset of labor.
  • Prostaglandin E2 and F2 alpha from the amnion and
    decidua are the final pathways to stimulation of
    uterine contractions. Prostaglandin synthesis
    results from a mix of hormonal events in the
    fetal brain, pituitary gland ,adrenal glands, and

Normal Labor
  • Theories
  • Mechanical Theory
  • Uterine stretching
  • Once this hollow organ reaches a certain state of
    distention, it will spontaneously contract and
  • Hormonal theory
  • Oxytocin stimulation
  • Progesterone withdrawal
  • Estrogen stimulation
  • Fetal cortisol

Normal Labor
  • Signs of Impending Labor (continued)
  • Lightening
  • As early as 2 weeks before the onset of labor,
    the woman may notice that the fetus seems to have
    settled, or dropped into the pelvis
  • This is seen most often in nulliparas.
  • Once lightening has occurred, urinary frequency
    often returns.
  • The woman may be able to breathe more normally.

Normal Labor
  • Signs of Impending Labor (continued)
  • Seepage or Sudden Outflow of Fluid
  • It may be urine or it may be amniotic fluid,
    indicating rupture of membranes.
  • Test with Nitrazine paper. Without washing area,
    the paper is moistened with discharge if it
    turns blue, it is amniotic fluid. Dr. can do fern
    test to test ROM.
  • Amnisure test test for ROM
  • The amniotic sac generally ruptures after labor
    has begun. Rupture of the bag of water (BOW)
    leads to increased risk for infection.
  • Delivery should occur within 18 to 24 hours after
    membranes rupture.

Normal Labor
  • Signs of Impending Labor (continued)
  • Bloody Show
  • There is an increase in the amount of vaginal
    discharge and a blood-tinged mucus.
  • This show is the mucus that occluded the
    opening of the cervix during pregnancy (mucous
  • Vaginal examination may show the cervix has begun
    to change consistency softens, thins (effaces),
    and opens (dilates).

Normal Labor
  • Signs of Impending Labor (continued)
  • Braxton-Hicks Contractions
  • This is irregular tightening of the pregnant
    uterus that increases in frequency, duration, and
    intensity as pregnancy progresses.
  • They vary from mild to moderate in severity.
  • Do not dilate the cervix.
  • Backache
  • Weight loss (a few days before onset of labor)
  • Burst of energy

Normal Labor
  • Signs of Impending Labor (continued)
  • True Labor
  • Regular, rhythmic contractions that cause
    progressive dilation and effacement (thinning and
    shortening or obliteration of the cervix that
    occurs late in pregnancy or labor or both) of the
  • False Labor versus True Labor
  • Because many women fear that they will go to the
    hospital at the wrong time, nurses should explain
    how true labor differs from false labor.

Normal Labor
  • Contractions rarely follow a pattern
  • Vary in length and intensity
  • Most noticeable in the fundus
  • Stop with relaxation interventions
  • No effacement/dilation
  • No change in fetal position
  • Contractions are regular
  • Become closer together, stronger, and last longer
  • Get stronger with walking
  • Usually start in lower back and travel to lower
  • Do not stop with relaxation techniques
  • Fetus continues descent into the pelvis

Guidelines for when to go to the hospital or
birthing center
  • Contractions demonstrate pattern of increasing
    frequency, duration, intensity
  • 1st child 5 min. apart for 1 hr.
  • Multiple children 10 min. apart for 1 hr.
  • Membranes rupture
  • Bleeding other than bloody show
  • Decreased fetal movement
  • Any other concerns

Labor and Delivery
  • Alternative Labor and Delivery Sites
  • A plan for delivery should have been established
    during the pregnancy.
  • Traditional Hospital Settings
  • Sterile, limit visitors, delivery room to
    recovery room to postpartum room
  • Birthing Centers
  • Located within the hospital but structured to be
    more homelike attitude of the staff more open
    and welcoming to the spouse and significant others

Labor and Delivery
  • Alternative Labor and Delivery Sites (continued)
  • Home
  • Must be agreed on by the physician or
    nurse-midwife permitted only when an
    uncomplicated delivery is expected and the
    primary care practitioner has reasonable
    confidence that no harm will come to either the
    mother or the infant

Labor and Delivery
  • Process of Labor and Delivery
  • Passageway the pelvis and soft tissue
  • Passengers the fetus and placenta
  • Powers contractions
  • Position of mother standing, walking, side
    lying, squatting, on hands and knees
  • Psyche psychologic response

Pelvic Types
Important pelvic diameters
Labor and Delivery
  • Passageway
  • Pelvis
  • Superior portion of the pelvis functions as
    support for the uterus and fetus during the late
    months of pregnancy.
  • These bones aid in directing the fetus into the
    inferior portion of the pelvis, the true pelvis.
  • The two sections are divided by an imaginary line
    called the linea terminalis or pelvic inlet.

Figure 26-1
(From Lowdermilk, D.L., Perry, S., Bobak, I.M.
1997. Maternity womens health care. 6th
ed.. St. Louis Mosby.)
A, Pelvic brim (inlet, linea terminalis, or
iliopectineal line) from above. B, Pelvic outlet
from below.
Labor and Delivery
  • Passageway (continued)
  • Pelvis
  • Size and shape of the true pelvis are more
    important than the false pelvis, because the
    fetal head must be able to pass through this
    section of the pelvis for vaginal delivery.
  • The true pelvis is divided into three segments
  • Inlet cavity, or midpelvis outlet
  • Evaluation of the size of the true pelvis
  • Palpation pelvimetry and ultrasonography

Labor and Delivery
  • Passageway (continued)
  • Soft Tissue
  • Uterine tissues upper section musculature
    provides the force during contractions lower
    section becomes thin acts as a passive tube
  • Cervical tissues effaces dilates d/t pressure
    of presenting part moving downward w/contractions
  • Vagina stretches to allow passage of fetus
  • Perineum muscles of pelvic floor stretched
    thinned by pressure of the presenting part

Effacement dilation of the cervix
Cervical dilation
Labor and Delivery
  • Passengers
  • Fetus
  • Fetal skull
  • This is usually largest part of the body
    delivery of the head poses the greatest concern.
  • Bones of the skull are not rigidly joined
    (fused) this allows the bony plates to overlap
    at suture lines as the fetus progresses through
    the maternal pelvis this is called molding.
  • Fontanels anterior is the larger and
    diamond-shaped posterior is smaller and

Figure 26-3
(A, B, From Lowdermilk, D.L., Perry, S., Bobak,
I.M. 1997. Maternity womens health care.
6th ed.. St. Louis Mosby. C, from Lowdermilk,
D.L., Perry, S., Bobak, I.M. 1999. Maternity
nursing. 5th ed.. St. Louis Mosby.)
Fetal head at term. A, Bones. B, Fontanelles. C,
Labor and Delivery
  • Passengers (continued)
  • Fetus
  • Fetal attitude
  • The relationship of fetal body parts to one
    another- want flexed
  • Fetal position
  • The relationship of the occiput of the fetus to
    the front, back, or sides to the mothers pelvis
  • Anterior or Posterior or Transverse. Can be
    direct, right,or left. Best is LOA or ROA

Fetal positions
Labor and Delivery
  • Passengers (continued)
  • Fetus
  • Fetal lie
  • The relationship of the cephalocaudal
    (head-to-buttocks) axis of the fetus to the
    cephalocaudal axis of the mother
  • Longitudinal spine of the fetus parallel to the
    spine of the mother
  • Transverse spine of the fetus perpendicular to
    that of the mother
  • Oblique lying at an angle in utero

Labor and Delivery
  • Passengers (continued)
  • Fetus
  • Fetal presentation
  • That part of the fetus that first enters the
    pelvis and lies over the inlet
  • Head, face, breech, or shoulder
  • Cephalic (96) head (vertex)
  • Breech (3) buttocks (Complete or Frank) or legs
  • ( Footling)
  • Another body part (1) shoulder, hand, elbow, or
    iliac crest

Labor and Delivery
  • Passengers (continued)
  • Fetus
  • Fetal position
  • Relationship of the presenting fetal part to a
    quadrant of the maternal pelvis
  • A longitudinal lie, well-flexed attitude, with
    vertex presentation is the ideal.
  • If a part other than the vertex presents, labor
    is generally longer, more tiring to the mother,
    and more likely to require surgical intervention.

Labor and Delivery
  • Passengers (continued)
  • Fetus
  • Monitoring fetal status
  • Fetal heart rate (FHR)
  • Auscultate using a fetoscope or a Doppler
  • Normal FHR range is 110 to 160 beats per minute.
  • An baseline increase or decrease of 30 beats per
    minute may indicate fetal distress and should be
    reported immediately.
  • Decelerations and /or lack of accelerations
    indicate fetal distress and must be reported

Labor and Delivery
  • Passengers (continued)
  • Fetus
  • Monitoring fetal status
  • Continuous electronic monitors
  • May be internal or external
  • More accurate in detecting subtle changes of
  • Monitor variability, accelerations,
    decelerations, and baseline on graph

Figure 26-9
(From Lowdermilk, D.L., Perry, S., Bobak, I.M.
1999. Maternity nursing. 5th ed.. St. Louis
Diagram of internal invasive fetal monitoring
with intrauterine catheter and spiral electrode
in place.
Figure 26-7
(From Lowdermilk, D.L., Perry, S., Bobak, I.M.
1999. Maternity nursing. 5th ed.. St. Louis
Diagram of external noninvasive fetal monitoring
with tocotransducer and ultrasound transducer
  • Periodic decrease in FHR in response to
  • Early caused by pressure on fetal skull from
    vagal response
  • Late caused by decreased O2 blood flow
    through the placenta
  • Variable caused by compression on umbilical cord

Nursing Interventions
  • Change maternal position
  • Give IV bolus
  • Turn off Pitocin
  • O2 via nonrebreather mask
  • Call physician

Labor and Delivery
  • Passengers (continued)
  • Fetus
  • Signs of Fetal distress
  • Nonreassuring FHR patterns
  • Change in baseline or variability,
    tachycardia, bradycardia, decelerations, lack of
  • Meconium staining
  • Stool released from the rectum of the fetus in
    response to hypoxia
  • Must report to physician when noted
  • Placenta must be functioning properly during
    pregancy and labor. Must be delivered after

Labor and Delivery
  • Powers
  • Uterine Contractions
  • During labor, the muscles in the upper uterine
    segment, the fundus, thicken and contract at
  • Early labor
  • Are 15 to 30 minutes apart last 20 to 35 seconds
  • Later labor
  • Are 2 to 3 minutes apart last 60 to 80 seconds

Labor and Delivery
  • Powers (continued)
  • Uterine Contractions
  • These contractions are involuntary and originate
    at pacemaker points near the uterotubal junction
  • When the contraction occurs, the uterine cavity
    becomes smaller, and this forces the presenting
    fetal part or the bag of waters against the
  • The upper segment retracts, pulling the lower
    segment upward around the presenting part.
  • Measure frequency, duration, intensity, and

Phases measurement of contractions
  • FREQUECY Elapsed time from beginning of 1
    contraction to beginning of next contraction.
    Measured in a range of minutes. Should not be any
    more frequent than every 2 minutes.
  • DURATION Elapsed time from the beginning of a
    contraction until the end of the same
    contraction. Measured in a range of seconds.
  • INTENSITY Approximate strength of a contraction.
    Palpated as MILD, MODERATE, STRONG.
  • INTERVAL Elapsed time that the uterus is resting
    between contractions. Should be at least 60

What to report regarding contractions
  • Contractions occurring more often than Q 2
  • Persistent contraction durations longer than 90
  • Persistent contraction intervals shorter than 60

Labor and Delivery
  • Powers (continued)
  • Uterine Contractions
  • Voluntary Pushing
  • When the presenting part reaches the pelvic
    floor, the woman typically experiences the urge
    to bear down or push.
  • Once the cervix is fully effaced and dilated, the
    woman can assist in the progress of labor.
  • When she feels the urge, she pushes down on the
    pelvic floor with open glottis and not in supine
  • Encourage laboring down if comfortable and stable

Labor and Delivery
  • Position of the Mother
  • Position allows gravity to assist womans
  • Squatting or using a semiseated position is more
    effective than a supine position.
  • Abdominal muscles work in greater synchrony with
    uterine contractions during bearing-down efforts.

Labor and Delivery
  • Psyche
  • Mothers psychologic state
  • Anxiety, fear, fatigue, ability to cope with pain
  • Good support system

Labor and Delivery
  • Mechanisms of Labor
  • Descent change in station
  • Engagement
  • Flexion
  • Internal rotation
  • Extension
  • External rotation
  • Expulsion

Nursing Assessment and Interventions
  • Health Perception and Health Management
  • It is important to know how well-prepared the
    woman is for childbirth.
  • If a hospital delivery is planned, physician will
    be notified when pt admitted
  • Prospective parents should pack a suitcase with
    necessary items well in advance of the date of

Nursing Assessment and Interventions
  • Vitals
  • P, R, and BP at least q 1 hr while in labor
  • Temp q 2 hr if ROM, q 4 h if no ROM
  • Contractions frequency, duration, intensity,
  • FHTs baseline, accelerations, decelerations,
  • PAIN
  • VAGINAL EXAMS dilation, effacement, station,
    presenting part, ROM

Nursing Assessment and Interventions
  • Nutritional and Metabolic Pattern
  • GI motility and absorption decrease during labor
    and delivery.
  • Food eaten before labor may remain in the
    digestive tract and lead to complaints of nausea
    and vomiting.
  • Once labor begins, solid foods are generally
  • It is important to know when the last food was
    consumed in case general anesthesia becomes
  • Orders for intravenous fluids to prevent
    dehydration are common. LR 125 ml/hr

Nursing Assessment and Interventions
  • Activity and Exercise
  • Ambulation is generally encouraged so long as the
    membranes are not ruptured and fhts are stable
  • Walking provides distraction and tends to
    strengthen the effectiveness of labor.
  • After the woman becomes uncomfortable or has been
    given analgesics, she is usually encouraged to
  • Low back pain is common.
  • Changing position may help with discomfort-should
    not be supine
  • Warm shower is given for low back pain.

Nursing Assessment and Interventions
  • Elimination
  • Urine output may be normal or decreased.
  • Voiding every 2 hours is desirable.
  • A full bladder can interfere with the progress of
  • Some women experience diarrhea with the onset of
    labor careful hygiene technique is important to
    reduce the possibility of contamination.

Nursing Assessment and Interventions
  • Sexuality and Reproductive Issues
  • Vaginal Examination
  • Assessment of vaginal drainage continues through
  • Moderate amounts of discharge are common, and
    linens should be changed to provide comfort.
  • Vaginal examination to assess the progress of
    labor continues throughout labor dilation,
    effacement, station, presenting part, membranes

Nursing Assessment and Interventions
  • Psychosocial Assessment
  • Coping and Stress Tolerance
  • Many women have unrealistic expectations for
    themselves and feel they should be able to be in
    control of labor.
  • Encouragement and support in breathing exercises
  • Fatigue and pain lower the womans ability to
  • It is important to understand the cultural and
    religious background of each woman because they
    may strongly influence her behavior.

Nursing Assessment and Interventions
  • Psychosocial Assessment (continued)
  • Roles and Relationships
  • Many women want their spouse or significant other
    to be with them during the labor and delivery.
  • Often this person works as the coach to remind
    the woman of breathing techniques and to provide
  • If the mother is alone, the nursing staff must
    provide extra support.

Nursing Assessment and Interventions
  • Psychosocial Assessment (continued)
  • Self-Perception
  • The prepared mother generally feels more able to
    deal with labor and delivery than does the
    unprepared one.
  • Multigravidas generally have more confidence.
  • Women who have experienced problems during
    pregnancy or in past labors and deliveries may
    need reassurance that they can be successful.

Nursing Assessment and Interventions
  • Psychosocial Assessment (continued)
  • Father or Partner During Labor
  • Father or partner needs to be included in the
    circle of communication.
  • The father or partner is usually able to
    interpret the womans needs and convey her
    desires to staff members.
  • Assess for level of comfort in asking questions
    and in being present and involved during the
    second stage of labor and birth.
  • A well-informed father can make a significant
    contribution to the health and well-being of the
    mother and child.

Nursing Assessment and Interventions
  • Psychosocial Assessment (continued)
  • Doulas
  • A trained, experienced woman who is present
    throughout labor
  • Has been found to not only reduce the pain and
    duration of labor but also enhance the laboring
    womans satisfaction with her experience and to
    improve outcomes in terms of a decreased rate of
    operative delivery and childbirth complications

Labor and Delivery
  • Stages of Labor and Delivery
  • First stage dilation effacement
  • Latent phase
  • Active phase
  • Transition phase
  • Second stage delivery/expulsion
  • Third stage delivery of the placenta
  • Fourth stage recovery/stabilization

  • LATENT PHASE 0-3 CM Dilation, contractions 5-8
    min apart, 20-35 secs. Talkative, receptiive to
    teaching. Pain mild. Better to stay at home.
    Encourage walking. BOW usually intact. Anxious.
  • ACTIVE PHASE 4-7 CM Dilation, contractions 3-5
    min apart, 40-60 secs. Less talkative, focus on
    breathing techniques. Best time for epidural.
    Usually membranes ruptured.
  • TRANSITION PHASE 7-10 CM Dilation, contractions
    2-3 min apart, 60-80 secs. Not talkative,
    breathing techniques, pain meds, nausea/vomiting,
    yelling at s.o./nurse.

    in nullips. 20-90 min in multips. Assist with
    pushing. Episiotomy.

  • From delivery of infant til delivery of placenta.
  • Should be no longer than ½ hour. Can hemorrhage.
  • EBL should be 200-300 ml blood.
  • Examine placenta for intactness.
  • Pt. receive IV Pitocin for uterus.
  • Must ID infant with mother.
  • Infant stabilized. Apgar scores. RHL.

  • RECOVERY/ STABILIZATION over next 2-4 hrs after
  • Assess mom and infant q 15 min over next hour
    vital signs, uterine tone, vaginal drainage,
    perineum, pain.
  • Allow to eat. (mom and infant)
  • Infant to NBN within 1 hour of delivery if

Nursing Responsibilities during after birth
  • Prepare delivery instruments infant equipment
  • Appropriate staff for delivery
  • Administer medications
  • Assess mother infant
  • Provide initial infant care
  • ID mother, infant
  • Promote parent-infant bonding

Assessments immediately after birth
  • Mother
  • VS
  • BUBBLE-HE Breasts, Uterus, Bladder, Bowel,
    Lochia, Episiotomy, Homans, Emotional status
  • Pain
  • Ice to perineum
  • Warm blankets
  • Dressing if C-section
  • Level of sensation LE movement if
  • Newborn make sure ID with mom
  • Thermoregulation warmer, hat, warm blankets
  • Cardiorespiratory status
  • Anomalies
  • Passage of urine meconium
  • Breastfeed

Labor and Delivery
  • Response of the Newborn to Birth
  • Apgar Score
  • Score taken at 1 and 5 minutes of age.
  • Score can range from 0 to 10.
  • The criteria used include heart rate, respiratory
    effort, muscle tone, reflex irritability, and
  • A low score indicates serious problems that may
    require resuscitation.
  • A high score indicates good condition, requiring
    only routine care.

Nursing Assessment and Interventions
  • Psychosocial Assessment (continued)
  • Values and Beliefs
  • The values and beliefs of women in labor should
    be respected.
  • The nurse should seek information about specific
    cultural practices, values, and beliefs and
    incorporate these into the plan of care.
  • American Indians
  • Hispanic
  • Iran
  • India
  • Laos
  • Southeast Asia
  • Native Americans

Nursing Assessment and Interventions
  • Psychosocial Assessment (continued)
  • Non-EnglishSpeaking Women in Labor
  • A womans level of anxiety in labor arises when
    she does not understand what is happening to her
    or what is being said. She may feel a complete
    loss of control over her situation.
  • She can panic and withdraw or become physically
    abusive when someone tries to do something she
    perceives might harm her baby.
  • Ideally, a bilingual nurse will care for the
    woman if not, use a translator.

Nursing Process
  • Nursing Diagnoses
  • Pain, acute
  • Fatigue
  • Infection, risk for
  • Tissue perfusion, ineffective
  • Fluid volume, risk for deficient
  • Urinary elimination, impaired
  • Injury, risk for
  • Knowledge, deficient
  • Anxiety fear
  • Coping, ineffective

Medical Interventions
  • Induction
  • An attempt to start labor at a time other than
    when it begins spontaneously
  • May be necessary when membranes have been
    ruptured for longer than a few hours, in cases of
    severe pregnancy-induced hypertension, or in a
    post-term pregnancy. Should have medical
    necessity. Must be 39 weeks for elective
  • Amniotomy
  • Prostaglandin gel application
  • Oxytocin stimulation
  • Cervidil
  • Foley balloon

Medical Interventions
  • Forceps Delivery
  • Forceps are a pair of spoon-like devices that fit
    around the fetal head to aid in expulsion of the
  • Vacuum Extraction
  • This involves attachment of a vacuum cup to the
    fetal head and application of negative pressure.
  • Cesarean Delivery
  • Delivery is made through an abdominal and uterine
  • VBAC Vaginal birth after Cesarean
  • TOLAC Trial of Labor after Ceserean

Indications for Cesarean Section
  • Cephalopelvic disproportion (CPD)
  • Previous c-section
  • Breech or Mal presentation
  • Abnormal condition of placenta
  • Infections of vaginal canal- ex active genital
  • Pelvic abnormalities
  • Medical conditions that would endanger mothers
  • Nonreassuring FHT
  • Prolapsed Cord
  • Congenital anomalies
  • Elective

Pain Management
  • Factors contributing to pain during labor
  • Dilation stretching of uterus and cervix
  • Reduced uterine blood supply during contractions
  • Pressure of fetus on pelvic structures
  • Stretching of vagina perineum

Nonpharmacological pain management
  • Advantages
  • Do not harm mother or fetus
  • Do not slow labor if they provide adequate pain
  • Carry no risk for allergies or adverse drug
  • Limitations
  • Should be rehearsed before labor begins
  • Can slow labor if pain not adequately controlled

Nonpharmacological pain management
  • Relaxation techniques
  • Skin stimulation
  • Effleurage
  • Sacral pressure
  • Thermal stimulation
  • Positioning
  • Diversion/distraction
  • Breathing techniques
  • 1st stage breathing
  • 2nd stage breathing