Labor and Delivery Processes - ATI CH 11

Labor and Delivery Processes - ATI CH 11 Labor and Delivery Processes - ATI CH 11 Labor and Delivery Processes - ATI CH 11 Who are the 3 clients an intrapartum nurse should care for during each labor and delivery? ◯ Fetus ◯ Mother ◯ Family unit What are the physiologic changes that can precede labor? - ◯ Backache - a constant low, dull backache, caused by pelvic muscle relaxation ◯ Weight loss - a 0.5 to 1.4 kg (1 to 3 lb) weight loss ◯ Lightening - fetal head descends into true pelvis about 14 days before labor; feeling that the fetus has "dropped;" easier breathing, but more pressure on bladder, resulting in urinary frequency; more pronounced in clients who are primigravida ◯ Bloody show - brownish or blood-tinged mucus discharge caused by expulsion of the cervical mucus plug resulting from the onset of cervical dilation and effacement ◯ Energy burst - sometimes called "nesting" response When does a woman's water break? - Spontaneous ROM can initiate labor or can occur anytime during labor, most commonly during the transition phase. ■ Labor usually occurs within 24 hr of the rupture of membranes. ■ Prolonged rupture of membranes greater than 24 hr before delivery of fetus may lead to an infection. ■ Immediately following the rupture of membranes, a nurse should assess the FHR for abrupt decelerations, which are indicative of fetal distress to rule out umbilical cord prolapse. When does the nurse assess the amniotic fluid and what are the characteristics that should be observed? - ◯ Assessment of amniotic fluid is completed once the membranes rupture ■ Should be watery, clear, and pale- to straw-yellow in color. ■ Odor should not be foul. ■ Volume is between 500 and 1,200 mL. ■ Nitrazine paper should be used by a nurse to confirm that amniotic fluid is present. When using Nitrazine paper to confirm ROM, how would the nurse differentiate between urine and amniotic fluid? - ☐ Amniotic fluid is alkaline: Nitrazine paper should be deep blue, indicating pH of 6.5 to 7.5. Urine is slightly acidic: Nitrazine paper remains yellow. What are the 5 "P's" of labor and delivery? - Passenger, Passageway Powers Position Psychological response 1 PASSENGER - Passenger - consists of the fetus and the placenta. The size of the fetal head, fetal presentation, lie, attitude, and position affect the ability of the fetus to navigate the birth canal. The placenta can be considered a passenger because it also must pass through the canal. 2 PASSAGEWAY - Passageway - the birth canal that is composed of the bony pelvis, cervix, pelvic floor, vagina, and introitus (vaginal opening). The size and shape of the bony pelvis must be adequate to allow the fetus to pass through it. The cervix must dilate and efface in response to contractions and fetal descent. 3 POWERS - Powers - uterine contractions cause effacement and dilation of the cervix and descent of the fetus. Involuntary urge to push and voluntary bearing down in the second stage of labor helps in the expulsion of the fetus. 4 POSITION - Position - of the woman who is in labor. The client should engage in frequent position changes during labor to increase comfort, relieve fatigue, and promote circulation. Position during the second stage is determined by maternal preference, provider preference, and the condition of the mother and the fetus. ■ Gravity can aid in the fetal descent in upright, sitting, kneeling, and squatting positions. 5 PSYCHOLOGICAL RESPONSE - Psychological response - maternal stress, tension, and anxiety can produce physiological changes that impair the progress of labor. Presentation - Presentation - the part of the fetus that is entering the pelvic inlet first. It can be the back of the head (occiput), chin (mentum), shoulder (scapula), or breech (sacrum or feet). Lie - ■ Lie - the relationship of the maternal longitudinal axis (spine) to the fetal longitudinal axis (spine). Transverse - fetal long axis is horizontal and forms a right angle to maternal axis and will not accommodate vaginal birth. The shoulder is the presenting part and may require delivery by cesarean birth if the fetus does not rotate spontaneously. Parallel or longitudinal - fetal long axis is parallel to maternal long axis, either a cephalic or breech presentation. .............