Professional Documents
Culture Documents
Presented by:
Kristina Crisostomo
Abigail Buhayo
Rachelle Ann Mapue
Chiara Pascual
Kristelie Mae A. Tillain
BSN 1Y1 – 11/ Our Lady of Fatima University
Nursing Management
• Labor Process
• Methods of Prepared Childbirth
• True and False Labor Contractions
• Signs and Symptoms of Impending Labor
• Standards of Care Guidelines
• Stages of Labor
• Parenting Promotion
Labor Process
• Motivation
• Contraindications
• Alternatives
Motivation
•Located mainly in back and abdomen •Located mainly in lower abdomen and
groin
•Generally intensified by walking •Generally unaffected by walking
• Stage One
• Stage Two
• Stage Three
• Stage Four
Stage One
• Nursing Diagnoses
• Nursing Interventions
Nursing Diagnoses
• Controlling Pain
– Encourage ambulation as tolerated regardless of membrane status
as long as presenting part is engaged. (This may vary according to
health care provider.)
– Encourage diversional activities, such as reading, talking, watching
TV, playing cards, listening to music.
– Review, evaluate, and teach proper breathing techniques.
– Encourage a warm shower. Laboring woman can sit on a chair in the
shower with the water running continuously over her lower back.
– Encourage relaxation techniques.
– Provide comfort measures.
– Use of Jacuzzi or shower for relaxation if available.
– Reposition external monitors as needed.
Active Phase
• Nursing Diagnoses
• Nursing Interventions
Nursing Diagnoses
• Anxiety related to concern for self and fetus
• Acute Pain related to uterine contractions and
nausea and vomiting
• Impaired Urinary Elimination related to epidural
anesthesia or from pressure of the fetus
• Ineffective Coping related to discomfort
• Risk for Infection related to rupture of the
membranes
• Impaired Physical Mobility related to medical
interventions and discomfort
• Ineffective Breathing Pattern related to pain
and fatigue
Nursing Interventions
• Relieving Anxiety
– Monitor maternal vital signs and FHR, and keep the
woman/couple informed of thematernal and fetus status.
– Maternal temperature every 2 to 4 hours unless elevated or
membranes ruptured, then every 1 hour.
– Blood pressure, pulse, respirations usually every 30 to 60
minutes or as indicated by policy or maternal status.
– Evaluate FHR every 30 minutes if low-risk patient or every 15
minutes if highrisk patient regardless if monitoring is continuous
or intermittent.
– Provide encouragement and support.
– Involve the support person in the woman's care.
Cont.
• Minimizing Pain
– Encourage position changes for comfort.
– Assist the woman with breathing and relaxation
techniques as needed.
– Provide back, leg, and shoulder massage as needed.
– Assist with preparation for analgesia and anesthesia
Cont.
• Nursing Diagnoses
• Nursing Interventions
Nursing Diagnoses
• Promoting Comfort
– Assist the woman to a comfortable position.
– Left or right lateral, squatting, hand and knees, or
semisitting positions may be used.
• Assist the woman with pulling her legs back so her knees are
flexed.
• Teach the woman to put her chin to her chest so her body forms
and shape while pushing.
– Evaluate bladder fullness, and encourage voiding or
catheterize as needed.
– Evaluate effectiveness of anesthesia as indicated.
Cont.
• Preventing Infection and Promoting Safety
– Prepare the birthing room or delivery room using aseptic
technique, allowing ample time for setup before delivery.
– Prepare the infant resuscitation area for delivery.
– Prepare necessary items for neonatal care.
– Notify necessary personnel to prepare for delivery.
– If delivery room is to be used, transfer the primigravida to the
delivery room when the fetal head is crowning. The
multigravida is taken earlier depending on fetal size and speed
of fetal descent.
– Place all side rails up before moving. Instruct the woman to
keep her hands off the rails,and move from the bed to the
delivery table between contractions.
Cont.
• Nursing Diagnoses
• Nursing Interventions
Nursing Diagnoses
• Preventing Hemorrhage
– Ensure accurate measurement of intake and output
maintained throughout labor and delivery.
– Immediately after delivery of the placenta, administer
oxytocin (Pitocin 10 to 40 units/L at 100 mU/min) either
I.V. piggyback or I.M. as directed by facility policy and
provider.
– Infuse as bolus initially, then titrate to uterus (ie, if uterus
is firm, decrease the infusion; if boggy, leave as bolus).
Pitocin should never be administered I.V. push as it can
cause cardiac dysrhythmia and death.
Cont.
– Immediately after initiating Pitocin, massage uterine
fundus until firm. Uterine massage is done with two
hands, one anchored at the lower uterine segment above
the symphysis pubis and the other hand gently
massages the fundus.
– Check to see that the placenta and membranes are
complete.
– Evaluate and massage the uterine fundus until firm.
– If bleeding continues and uterus is firm, notify health care
provider for evaluation of lacerations or retained placental
fragments. Inspection and repair of lacerations of the
vagina and cervix are made by the health care provider.
Cont.
• Nursing Diagnoses
• Nursing Interventions
Nursing Diagnoses
• Promoting Thermoregulation
– Dry the neonate immediately after delivery, remove wet towels, and
place infant on warm dry towels. A wet, small neonate loses up to
200 cal/kg/min in the delivery room through evaporation, convection,
conduction, and radiation. Drying the infant cuts this heat loss in half.
– Cover the neonate's head with a cotton stocking cap to prevent heat
loss.
– Wrap the neonate in warm blankets.
– Place the neonate under a radiant heat warmer, or place the
neonate on the mother's abdomen with skin-to-skin contact.
– Provide a warm, draft-free environment for the neonate.
– Take the neonate's axillary temperature — a normal temperature is
between 97.5° and 99° F (36.4° and 37.2° C).
Cont.
• Nursing Diagnoses
• Nursing Interventions
Nursing Diagnoses
• Labor Room
• Delivery Room
Labor Room Lay-out
• A labor-delivery room in a
certain hospital.
Delivery Room Lay-out
• A mother breast-feeding
her twins.
• Mothers at Fabella after
delivery.
Recovery Room Lay-out
• A muti-patient post-
operative recovery room