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Lecture Eight: Care of the
Client During Childbirth
Maternal Assessment
- Review prenatal Hx
- Present complaint
- Vital signs
- Weight
- Lungs
- Fundus
- Edema
- Hydration
- Perineum
- Labor/ Fetal status
- Laboratory evaluation
- Cultural assessment
- Preparation for childbirth
- Response to labor
- Anxiety
- Sounds during labor
- Support system
Vital signs
- BP < 130 systolic and < 85 diastolic or no more than 15-20 mm Hg rise in systolic pressure over baseline BP in early pregnancy
- Pulse 60 – 90 bpm
- Respirations 14 – 22
- Pulse ox 95% or greater
- Temperature 98 – 99.6 F
- Weight: 25 – 30 lbs greater than pre- pregnant weight (weight gain > 30 lbs edema, obesity)
System Assessment
- Lungs: auscultate, normal breath sounds
clear and equal
- Fundus: Measure in cms, at 40 weeks’
gestation located just below xiphoid
process
- Edema: Slight amount dependent edema
- Reflexes: Check deep tendon reflexes for
hyperactivity, check clonus
- Hydration: Normal skin turgor
Sterile Vaginal Examination
- Perineum: Assess for leaking fluid or
ruptured bag of water (BOW), vaginal
bleeding, bloody show
- Assess cervical dilatation (fingertip to 10
cms), effacement (0% to 100%), station
(-4 to +4), Ballotment, position (ROA,
ROP, etc.).
- Assess membranes: Intact, leaking, or
ruptured.
Assess Membranes
- If rupture BOW is suspected, do a nitrazine and fern test prior to vaginal examination.
- Nitrazine tape will not turn if not ruptured or leaking. Nitrazine will turn blue or blue green if fluid is leaking. Checks pH-amniotic fluid is alkaline. Ferning will appear under microscopic exam.
- Check color and odor: Green means meconium; foul odor means amnionitis
Laboratory Evaluation
- CBC: Hgb…12-16 g/dL; Hct.. 38% - 47%
- RBC: 4.2 – 5.
- WBC: 4500 – 11,000 ( may be 20,000)
- Platelets: 150,000 – 400,
- Urinalysis: WNL
- Serologic testing: Positive may require
follow-up titre
Cultural Assessment
- Do you have a birth plan?
- Who would you like to remain with you
during your labor and birth?
- What would you like to wear during labor?
- What activity would you like during labor?
- What position would you like for birth?
- Is there anything special you would like?
- Remember privacy.
First Stage of Labor: LATENT Phase
- 0 – 3 cms dilation
- Q 3 – 30 min, contraction (ctx) frequency
- 20 – 40 sec, ctx duration
- Mild to moderate intensity on palpation;
25 – 40 mmHg with Intrauterine Pressure
Catheter (IUPC)
- Baseline Sterile Vaginal Exam (SVE)
Care During the First Stage: Latent Phase
- May ambulate if membranes intact
- Evaluate physical parameters: Maternal temperature every 4 hrs unless the temperature is > 99.6 or RBOW
- BP, P & R every 1 hr. If abnormal, increase monitoring and notify MD/CNM
- Evaluate FHR every 30-60 minutes
- Encourage frequent change of position
- Encourage to void every 2 hrs
- Offer fluid in the form of ice chips, clear liquids
Care During the First Stage: Active Phase
- Encourage side-lying position, pillows for support
- Evaluate physical parameters: Maternal temperature every 4 hrs unless the temperature is > 99.6 or RBOW.
- BP, P & R every 30 min - 1 hr. If abnormal, increase monitoring and notify MD/CNM
- Evaluate FHR every 30 minutes
- Encourage breathing patterns, back rubs, sacral pressure, effleurage.
- Encourage to void every 2 hrs
- Offer fluid in the form of ice chips, clear liquids
- Change chux frequently.
- Pharmacologic support may be administered.
First Stage of Labor: TRANSITION Phase
- 8 – 10 cms dilation
- Q 1 1/2 – 2 min, contraction (ctx)
frequency
- 60 – 90 sec, ctx duration
- Moderate to strong intensity on palpation;
70 – 90 mmHg with Intrauterine Pressure
Catheter (IUPC)
- If BOW ruptures, assess FHR
The Second Stage of Labor
- 10 cms dilation (Complete)
- Pushing with contractions
- Q 1 1/2 – 2 min, contraction (ctx) frequency
- 60 – 90 sec, ctx duration
- Moderate to strong intensity on palpation; 70 – 90 mmHg with Intrauterine Pressure Catheter (IUPC)
- SVE increase to check progress
- Nullipara’s ready with a bulge, Multips sooner
Care During the Second Stage (pg.567- 568)
- Encourage side-lying position, pillows for support
- Evaluate physical parameters: BP, P & R every 5 - 15 min. If abnormal, increase monitoring and notify MD/CNM
- Evaluate FHR every 5 - 15 minutes.
- Assist with positioning ; Left lateral, Squatting, Semi Fowlers, & Hands and knees.
- May need straight catheterization
- Offer fluid in the form of ice chips, ointment for lips.
- Perineal massage with lubricant may be used.
- Encouragement and assurance is important.
- Pushing begins.