Chapter 22--Processes & Stages of
Labor and Birth
Critical Factors In Labor
• The Four P’s: passage, passenger,
powers & psyche
• Passage:
• adequate pelvis?
• cephalopelvic disproportion (CPD)
• Suspect if presenting part does not engage in
pelvis (0 station)
Passenger
• The fetus: head is largest diameter
• Fetal head: 4 bones with 3 membranous
interspaces (sutures) that allow bones to move &
overlap to diminish size of skull
• Molding: head becomes narrower, longer,
sutures can overlap--normal--resolves 1-2 days
after birth
• Fontanelles: at junctures of skull bones
Fetal Attitude
Fetal Lie and Presentation
• Leopold's maneuvers/US
• Longitudinal lie: Vertical
• Presenting part:
• cephalic (head),
• vertex (occiput), chin (mentum)
• breech (buttocks or feet) (c-section)
• sacrum
• Transverse lie: Horizontal
(c-section)
• Presenting part: shoulder (acromion)
Fetal
position:
• mom’s
pelvis is
divided into
4 quadrants:
RA, RP, LA,
LP
•determine
which
quadrant
presenting
part (occiput)
is pointing
towards
Passenger
• Occiput Anterior (LOA & ROA): most
common positions & easiest for birth
• Occiput Posterior (LOP & ROP):
•
•
•
•
can prolong both 1st & 2nd stage of labor
back pain during UCs (back labor)
Instruct partner in sacral pressure during UC’s
Try “all fours,” knee-chest, or alternate sidelying positions to encourage baby to rotate to
anterior position
Powers
• Contractions: supplied by fundus of uterus
• Involuntary, become stronger as labor
progresses
• Abdominal muscles: “pushing” by mom
(2nd stage)
Psyche
• Psychological state & feelings of mom
• Coping skills
• Anxiety, fear, stress
• Labor support
Onset of labor
• Usually begins between 38 & 42 weeks
• Mechanism is unknown
• Upper uterus contracts downward pushing
presenting part on cervix causing effacement
and dilatation
• Premonitory signs of labor:
•
•
•
•
•
Lightening, Braxton-Hicks contractions (false labor),
cervical changes (ripening),
bloody show (mucous plug),
rupture of membranes (ROM),
sudden burst of energy
False vs True Labor:
Contractions
False Labor
• Benign and irregular
contractions
True Labor:
• Begin irregularly but
become regular and
predictable
• Felt first in lower back
• Felt first abdominally
and sweep around to the
and remain confined to
abdomen in a wave
the abdomen and groin
• Continue no matter what
• Often disappear with
the women’s level of
ambulation and sleep.
activity
• Do not increase in
duration, frequency or • Increase in duration,
frequency, and intensity
intensity
False vs True Labor:
Cervix
False Labor
True Labor
• No significant
change in dilation
or effacement
• Progressive change
in dilation and
effacement
• No significant
bloody show
• Bloody show
• Fetus- presenting
part is not engaged
in pelvis
• Presenting part
engages in pelvis
Critical Thinking
•
A primigravida client has just arrived in the birthing
unit. What steps would be most important for the nurse
to perform to gain an understanding of the physical
status of the client and her fetus?
A. Check for ruptured membranes, and apply a fetal scalp
electrode
B. Auscultate the fetal heart rate between and during contractions
C. Palpate contractions and resting uterine tone
D. Perform a vaginal exam for cervical dilation, and perform
Leopold's maneuvers
E. Determine gestational age of fetus
Stages of Labor: First Stage
• 0 to 10 cm: dilatation--opening of cervix)
• Latent: slowest part of the process--slow
dilation, mild contractions
• from onset of regular UCs to rapid dilatation
(about 3-4 cms)
• Active: labor “picks up steam”--period of more
rapid dilation
• from 4 cm to full dilatation: stronger UCs
• Transition: 7-10 cm--intense, N/V, shaking
Effacement
Thinning of cervix
(in %)
Station
Descent of fetal head
(in cm)
Descent of
fetal head:
Station
Floating
Engaged
At outlet/crowning
Dilatation & Effacement
Care of Laboring Patient
Early Labor
Couple excited, talkative, pain is manageable
• Initial physical
assessment & history
• Admission--rapport
• Fetal & UC
monitoring
• Vaginal exams, q 2
hours
• Vital signs
• Temperature q 4
hours-intact or q 2
hours ROM
• Educate regarding
labor
• Encourage comfort,
position changes,
bladder emptying
• Assess pain, pain
tolerance, preferred
type of labor/delivery
• Reassure regarding
what is normal,
reduce anxiety
Care of Laboring Patient
Active Labor
Couple quieter, discouraged, pain increasing
• Transition (7-10 cm): Yikes! “out of control”,
shaking, nausea/vomiting, sweating, pain is
intense
• Prepare for delivery
• Second stage (Pushing):
• Educate/instruct regarding pushing
• Assess urge to push and fetal descent
• Encourage/motivate patient, assess fatigue
• Monitor fetal/maternal response to pushing
bulge, crowning
• Signs of imminent birth: perineal bulging
Stages of Labor:
Second Stage
• Pushing & descent of baby (STATION)
• Full dilatation (10 cm) to birth
• Important NOT to push until full dilation
• Assessment: Urge to push? Rectal pressure?
• Push only with UC’s
• Crowning: baby’s head is visible at the
opening of vagina
• Cardinal movements of labor
youtube.com/watch?v=Xath6kOf0NE&feature
=related
youtube.com/watch?v=duPxBXN4qMg&featur
e=related
Mechanisms of labor. A, B, Descent. C, Internal rotation. D,
Extension. E, External rotation.
Head Rotation during Descent
Crowning
Crowning
Alternative settings
In the hospital
Stages of Labor: Third Stage
• Placental stage: from birth to delivery of placenta
• Placental separation from uterine wall (rise of fundus,
sudden gush of blood, lengthening of umbilical cord)
• Entire lining of uterus shed
• Expulsion of placenta
• Normal blood loss: 300-500 mL
• If placenta does not deliver spontaneously, can be
delivered manually
• Pitocin infusion started immediately post delivery
of placenta
Critical Thinking
•
A client is admitted to the labor unit with contractions 2 to 3
minutes apart and lasting 60 to 90 seconds. The client is
apprehensive and vomiting. This nurse understands this
information to indicate that the client is most likely in what
phase of labor?
•
•
•
•
•
A) Active
B) Transition
C) Latent
D) Second
Chapter 23
Intrapartal Nursing Assessment
Initial Intrapartum Assessment
Pages 608-612
•
•
•
•
•
•
•
•
Vital signs
Fetal heart rate pattern, fetal distress
Contraction pattern, intensity, pain
Membrane status--intact, ruptured, nitrizine test,
amniotic fluid: clear, meconium, foul odor
Prenatal records, history of pregnancy,
complications, previous pregnancies and
deliveries, maternal health problems
Psychosocial/family/cultural issues
Labs: CBC, dip urine for protein, glucose, ketones
Vaginal Exam--effacement/dilation/station, fetal
presentation/lie. Assesses LABOR PROGRESS
Intrauterine Fetal Resuscitation
•
•
•
•
•
•
*Stop pitocin
Reposition to left lateral, Trendelenberg if needed
Oxygen via mask at 8-10 L/min
Increase IV fluids
SQ terbutaline (0.25 mg) if uterus not relaxing
Vaginal exam for possible cause: prolapse, fetal
descent, rupture, abruption
• Amnioinfusion for variable decels
• Notify MD/midwife
Which strip shows signs that
Immediate intervention is needed?
Why?
What would you do?
B
A
Experiences of Pain
• Etiology
• Physiology
• Perception
• Factors influencing
Anxiety
Expectations
Psychological factors
Cultural factors
Support
Fetal position
Comfort and Pain Relief
• Support from doula or coach
• Alternative therapies
•
•
•
•
•
Relaxation/massage
Focusing and imagery
Breathing
Herbal preparations/aromatherapy
Hypnosis
Comfort and Pain Relief
• Pharmacological Measures
• Narcotic analgesics
• Nubain/Stadol/Demerol (pg. 689)
• Regional nerve blocks
• Epidural/spinal
• Local anesthetic blocks
• Pudendal/perineal
Systemic Analgesia
Table 25-3, pg 690
• Pre-medication Assessment:
• Pain level, VS, allergies, drug dependence
(withdrawal), vaginal exam/progress in labor,
UC pattern, fetal heart rate tracing
• Post-medication Assessment:
• VS, esp. RR, LOC, dizziness (bedpan), sedation,
FHR
• Reversal agent: Naloxone (Narcan)
• Competes with narcotic for opiate receptors.
Used in both mom and baby. (avoid with
narcotic dependence)
Regional Anesthesia
• Injection of local anesthesia to block
specific nerve pathways
• Epidural/spinal anesthesia
• Systemic toxicity: cardiovascular collapse
• Side effects: Hypotension (preload with IV
fluids), fetal distress on FHR tracing, spinal
HA
• Contradindications: coagulation disorders,
low platelet count (< 100), allergy, neurologic
disease, aspirin use
• Nursing care: Preload IV fluids (LR), monitor
BP, HR, anesthesia level, FHR, foley cath,
maternal positioning
Epidural Anesthesia
Medication for Pain Relief: Birth
• Local anesthesia
• Pudendal nerve block (2nd stage, episiotomy, repair)
• Local infiltration in perineum (episiotomy, repair)
• General anesthesia
• Regional contraindicated/emergency
• Preparation: hip wedge, preoxygenation, cricoid
pressure for intubation
• Complications: fetal depression, aspiration of vomitus
(Bicitra)
Local anesthesia for Episiotomy
Childbirth at Risk
(Ch. 26)
Complications of Labor or Delivery
Critical Thinking
The client in active labor is requesting pain relief. The
physician orders epidural anesthesia for the client.
Which of the following parameters should the nurse
be prepared to assess immediately after administration
of the epidural?
•
•
•
•
•
A) For headache.
B) For urinary retention.
C) The blood pressure.
D) The maternal pulse rate.
Precipitous Labor & Birth
• Labor in < 3 hours
• Risk factors:
• Multiparity, oxytocin or amniotomy,
hx of precipitate labor
• Risks for injury
• Maternal: cervical, vaginal & perineal
lacerations with possible hemorrhage, pain,
anxiety
• Fetal: Birth trauma (intracranial bleed,
brachial palsy), meconium-stained fluid, fetal
distress
• Management: close monitoring for cervical
changes, induction
Postterm Pregnancy
• > 42 weeks
• Maternal risks: trauma/hemorrhage due
to larger baby, ↑operative delivery/csection
• Fetal risks: placental changes that
↓oxygenation to baby and ↑mortality rate,
oligohydramnios (↑cord compression
during labor), LGA baby (↑birth trauma,
shoulder dystocia), meconium aspiration
• Management: > 40 wks, NST, BPP or
modified BPP (NST & AFI), induction
Malpresentations
• Occiput-posterior (OP)
• Prolonged labor, back labor (sacral nerve
compression), arrested dilatation/ descent,
perineal tears
• Usually vaginal, but may need C-Section if baby
doesn’t rotate
• Management: positioning (side-lying, knee-chest
or hand-knees), sacral pressure during UC’s
• Transverse Lie
• Associated with: pendulous abdomen, uterine
masses/fibroids, congenital abnormalities of
uterus, hydramnios
• Attempt External Cephalic Version, if
unsuccessful obligatory C-section
Malpresentations (cont)
• Breech presentation
Assessment: FHT heard high on the abdomen, Leopold’s,
vaginal exam & US.
• Higher risk of anoxia from prolapsed cord, traumatic injury to
the after coming head,
fracture of spine or arm,
dysfunctional labor
• Usually delivered by
C-section
External Version
• External cephalic version (37-38 wks): abdominal
manipulation to change fetal presentation
• Contraindications: multiple gestation, fetal
breech is engaged in pelvis, oligohydramnios,
nonreactive NST, nuchal cord, vaginal bleeding,
IUGR, ROM.
• Risks: immediate cesarean birth
• Nursing actions: NPO 8 hrs, NST, IV line,
terbutaline, continuous FHR, US used to guide
manipulations, assess for: labor, fetal distress.
O- moms need Rhogam following the procedure
Macrosomia/Shoulder Dystocia
• Wt. > 4500 gms (9-10 lbs)
• Associated with:
• DM, Gestational DM, Multiparity, Postdates, obesity
• Risks:
• Shoulder dystocia, difficulty delivering the shoulders after head
is delivered (obstetrical emergency)
• Maternal: vaginal/cervical tears, pp hemorrhage, rupture
• Fetal: compressed cord, fractured clavical, asphyxia & neurologic
damage, brachial plexus injury (Erb’sPalsy)
• S/S: Turtle sign
• Nursing interventions: McRoberts maneuvers, suprapubic
pressure. PP: assess for uterine atony/hemorrhage; trauma,
cerebral or neurologic damage to baby
Video: youtube.com/watch?v=jV6g427UMxY&feature=related
McRoberts Maneuvers Video
Multiple Gestation
• Monozygotic (identical) twins: can have 1 or 2 placentas,
chorions, or amnions (↑risk if all shared)
• Dizygotic (fraternal) twins: 2 of everything.
• Dx: faster than usual growth of uterus, ↑AFP, HCG,
Ultrasound
• Risks:
• Maternal: SAB, gestational DM, HTN/preeclampsia/HELLP,
hydramnios, PT labor & delivery
• Fetal: Preterm birth, twin-to-twin transfusion
Multiple Gestation (cont)
• Management:
• US to determine what type of twins
• Prevention of PT labor/routine cervical measurements
(US)
• NST surveillance
• Birth: depends on maternal & fetal complications and
fetal position/ presentation
• Examination of placenta
• Close monitoring PP for hemorrhage (atony)
Abruptio Placentae
• Premature separation of placenta from uterine wall
• S/S: sharp, stabbing pain high in fundus, heavy
bleeding (may be occult), hard, board-like uterus,
tense, painful uterus, signs of shock due to blood
loss, Port-Wine aminotic fluid if ROM.
• Predisposing fx: ↑parity, adv. maternal age, short
umbilical cord, chronic HTN, PIH, direct trauma,
vasoconstriction from cocaine or cigarette use
• Fetal distress on monitor. Can progress to DIC.
Abruptio Placentae (cont)
• Management:
• Emergency. Immediate c-section if birth
not imminent.
• Lg. gauge IV
• O2 via mask, fetal monitoring, maternal
VS, lateral positioning, labs, blood
transfusion (have 2 units avail)
• CBC (H&H), Fibrinogen levels, platelet
count, PT/PTT, fibrin degradation
products ( sx of DIC)
Placenta Previa
• Low implantation of placenta (1 in 200)
• abrupt, painless, bright red bleeding
• Associated with ↑parity, adv. maternal age, previous
c-section or uterine curettage, multiple gestation
• Dx: ultrasound. May resolve as pregnancy
progresses.
• Bleeding common around 30 wks: Bedrest, VS, IV
fluids, type & cross-match,
observe for bleeding
• Emergency: assess bleeding, hx, uc’s/labor,
•NEVER do vaginal exam !!!
C-Section delivery, possibly before 37 wks. Steroids for mom. Watch
for pp hemorrhage.
• Table 26-6, pg 746, differential dx: abruptio/previa
Placenta
Previas
Low-lying
Marginal
Partial
Complete
Prolapsed Cord
• Loop of umbilical cord slips down in front of the presenting
part
• S/S: deceleration of FHT: bradycardia, persistent
variable decels, cord palpatedor seen in vagina
• Associated with:
•
•
•
•
•
•
Premature rupture of membranes
Transverse or breech presentation
Multiple gestation
Placenta previa
Hydramnios
CPD (non-engagement of fetal head)
Prolapsed Cord
• Management: Hold fetal head off cord,
Trendelenburg or knee/chest position, immediate
emergency c-section
• Prevention
• Watch fetal heart tones after rupture of
membranes (SROM or AROM). Do VE if any
sign of fetal distress.
• If head not engaged, women with ruptured
membranes should not ambulate.
Birth Related Procedures
Chapter 27
Induction of labor
• The deliberate initiation of uterine contractions, by
chemical or mechanical means, to stimulate labor and birth
before spontaneous onset of labor
• Primary agent of induction: Pitocin by IV
• Pitocin is also used to augment labor
• If cervix not “ripe”, may need a preparatory stage of
cervical ripening before pitocin can be started → Cervidil
Methods of Induction
• Prostaglandins (Cervidil, prostin gel, Prepidil,
Cytotec) applied intravaginally for cervical
ripening
• Pitocin (oxytocin) by IV
• Amniotomy or stripping of membranes
• Sexual intercourse
• Nipple stimulation
• Herbal preparations
Indications for induction of labor
• Post-term pregnancy (≥ 42 weeks)
• Premature or prolonged rupture of membranes
• Maternal complications (Rh isoimmunization,
Diabetes, Pulmonary disease, Pregnancy-induced
hypertension)
• Chorioamnionitis
• Suspected fetal problems- Intrauterine Growth
restriction (IUGR) and hydrops (fetal hemolytic
disorder as result of Rh isoimmunization when
maternal immune system attacks fetal red blood
cells)
• Fetal demise
Contraindications to Induction
•
•
•
•
•
•
•
previous c-section
placenta previa or abruption
prolapsed cord
fetal bradycardia, nonreassuring fetal status
vaginal bleeding of unknown cause
cephalopelvic disproportion
active genital herpes
Cervical Ripening Assessment
• Bishop Score- rating that determines if the cervix
is ready for induction--Pg. 765
• Fetus must be in vertex position
• Baseline data on fetal and maternal well-being (at
least half an hour of monitoring)
• Fetal monitoring and uterine contraction
monitoring is imperative
• Notify MD if hyperstimulation or fetal heart rate
distress is noted
Oxytocin Induction
pg 767
• Confirmation that the baby is in a cephalic (vertex)
position (head down)
• V/S done at least every 30 minutes and when dose is
titrated
• FHTs and UCs assessed every 30 minutes
• Titration of oxytocin till UCs every 2-3 minutes
• Cervical dilation should be 2 cm/hr (ideally)
• Reassuring FHTs between 110-160 beats/min
When to Discontinue Oxytocin
Hyperstimulation-frequency of UCs less than 2
minutes apart
-Now being called tachysystole
-Inadequate uterine relaxation between contractions
<60 sec between UC’s
Fetal Distress -any decelerations or decreased
baseline variability
Operative Assisted Deliveries
• Forceps
• Indications: unable to push, arrested descent, need a
quick delivery, breech
• Associated with: maternal/fetal birth trauma, rectal
sphincter tear, urinary stress incontinence
• Vacuum extraction
• Advantages: fewer lacerations, less anesthesia needed,
• Disadvantages: marked caput, cephalhematomas, scalp
laceration/bruising
Cesarean Birth
Indications for:
Maternal Factors
Placenta Factors
•
•
•
•
•
•
•
•
• Placenta previa
• Placental abruption
• Umbilical cord prolapse
Active genital herpes
AIDS/HIV +
Cephalopelvic disproportion
Severe preeclampsia, diabetes
Obstructive tumor
Ruptured uterus
Previous c-section
Failed induction/fx to progress in
labor
• Elective?
Fetal Factors
•
•
•
•
•
•
Breech, transverse lie
Macrosomia
Extreme low birth wt
Fetal distress
Fetal anomalies
Multiple gestation
Cesarean Birth (cont)
• Mortality/morbidity
• 4 x higher than vaginal
birth in US. Most risk
assoc. with emergency
c-section
• Incision
• Skin vs. uterine
• Classical vs low
transverse
• Maternal Complications
•
•
•
•
•
•
Infection
Anesthesia reactions
DeepVeinThrombophebitis
Bleeding
Ureteral/bladder injury
Increase risk for subsequent
pregnancy
• Placenta Acreta/Previa,
Infertility
Cesarean Birth
•
•
•
•
Pre-op: CBC w/ platelets, hold clot,
bicitra/antacid
monitor baby
Teaching: pre & post-op, anesthesia,
recovery, breastfeeding
• Psychosocial issues:
• Fear
• Self-image/self-esteem
Post-Op Care
• Assess fundus/bleeding, vital signs, DVT.
• Antibiotics.
• Pain: Duramorph. Breakthrough pain
meds. Benadryl for itching. Zofran for
nausea.
• Clear liquids and advance as tolerated.
• Assess for GI function. Bowel sounds?
Passing flatus?
• Ambulation. Pre-medicate, teach splinting
with pillow.
• Stool softener
Critical Thinking
• A laboring multipara is having intense uterine
contractions with incomplete uterine relaxation
between contractions. Vaginal examinations reveal
rapid cervical dilation and fetal descent. What should
the nurse do first?
A) Notify the physician of these findings.
B) Place the woman in knee-chest position.
C) Turn off the lights to make it easier for the woman to
relax.
D) Assemble supplies to prepare for birth.
POSTPARTUM CARE
Postpartum Psychological Adaptations
Reva Rubin




Taking in: Mom wants to talk about her
experience of labor & birth, preoccupied with
her own needs
Taking hold: More ready to resume control of
her body, baby & taking on mothering role.
Needs reassurance if inexperienced.
Letting-go: by 5th week, total abandon to NB
Bonding: en face position, engrossement.
Encourage through early interaction & breastfeeding (within 1/2 hr of birth is best).
Maternal Responses to Newborn
Reva Rubin





Touch- progresses from fingertips →
palming →cuddling →
Voice- high-pitched & babies respond
Odor- mom’s respond to baby’s unique smell
Eye contact- en face position
delay eye ointment & bright lights
Nurse role- be able to answer ? About baby
Blues vs Dpression
 Postpartum/baby blues:
transient depression in first few days:
weepiness
mood swings
anorexia
difficulty sleeping
feeling of letdown
 Postpartum Depression
*If persists past 2 weeks, or worsens
Symptoms: very sad feelings
hopeless
worthless
anxiety
trouble caring for and bonding with your baby
Have trouble sleeping.
Not be able to concentrate.
Not feel hungry and may lose weight. (But some women feel
more hungry and gain weight)
 Postpartum Psychosis
A woman who has postpartum psychosis may feel cut off from her baby.
She may see and hear things that aren't there. Any woman who has
postpartum depression can have fleeting thoughts of suicide or of harming
her baby. But a woman with postpartum psychosis may feel like she has
to act on these thoughts.
Endocrine Adaptations

Hormones: drop after delivery of
placenta.
– hCG & hPL gone by 24 hours
– Estrogen & progesterone drop within 1 wk
– FSH remains low for 12 days, then rises
to begin new cycle
– Sex is ok once lochia is alba. Menstrual
period in 6-10 wks.
– Contraception necessary.
Physiological Adaptations

Uterine involution
– @ umbilicus first 24 hours--should feel firm
– Decreases 1 finger’s breadth per day
– By 10th day, no longer palpable


If high (3 or 4 fingers above U) and/or
deviated to right, have pt. void
Risk for delayed involution:
– Multiples, hydramnios, exhaustion, grand
multiparity, excessive analgesia

Afterpains

www.youtube.com/watch?v=EbItF_7KYCc&feature=related
Fundal Assessment




Every 10-15 mins in first hour. Supine position
Palpate: one hand at base of uterus & other at
umbilicus. Press inward and downward and feel for
firm globular mass.
Assess:
– Height (fingers above/below umbilicus)
– Position (midline, deviated to right or left)
– Consistency: firm, soft, boggy
If not firm, massage & should become firm. If still
boggy, notify MD/assess for clots, hemorrhage.
Administer oxytocin or other oxytocic (methergine,
hemabate).
Lochia





Rubra: Red, day 1-3, blood
Serosa: Pinkish or brownish, day 3-10,
blood, mucus, leukocytes
Alba: whitish, day 10-14 (may last 6 wks),
largely mucus & leukocytes
If flow increases, woman should rest more
Warning sign: if lochia returns to previous
type (alba to serosa, or serosa to rubra)
Lochia Assessment


Check q 15 mins in 1st hour.
Assessment:
– Color (rubra, serosa, alba), amount, odor,
presence of clots.
– Constant trickle of vaginal flow, or soaking pad
every 60 minutes is more than average. Can
weigh pads--1 gm = 1 ml of blood.

Lochia should not exceed a moderate
amount: 4 to 8 partially saturated pads/day
Lochia Assessment

Assessing Amounts:
– Scant: peripad has stain less than 1 inch
in length after 1 hour
– Small: stain less than 4 inches after 1
hour--10-25 mL
– Moderate: stain less than 6 inches after 1
hour--25-50 mL.

Instruct in perineal care: ∆ pad
frequently, hand washing, s/s of
infection & hemorrhage, no tampons
Cervix & Vagina


Cervix returns to firm, nongravid consistency
by about 7 days, but external os remains slitlike or stellate
Vagina involutes in 6 wk period, with return
of rugae.
– Kegel exercises for pelvic floor muscles.
 Isolate muscles to contract by stopping flow of
urine while urinating.
 Contract these muscles in sets of 10 or 20, 3
times per day.
Perineum

Assessment: turn pt to side in Sim’s
position. Lift upper buttock and assess
for:
– Ecchymosis, hematoma, erythema,
edema, intactness, approximation,
drainage or bleeding from stitches

Assess for hemorrhoids & document
number, appearance & size
Episiotomy


Midline or mediolateral
Nursing care:
– Assess for
approximation,
swelling, oozing,
infection
– Relief for pain: ice
pack in first 24
hours, then heat,
local analgesic
spray, witch hazel
pads (Tucks), sitz
bath, peri-bottle for
voiding, pain
medications
Other Assessments

Constipation: Give stool softeners as
ordered, prune juice, encourage ambulation,
adequate fluid intake, fiber in diet.

Homan’s sign: assess calves for redness,
warmth, pain, swelling.
-↑risk of DVT, thrombophlebitis.
-Occur in postpartum because:
– Fibrinogin level is elevated
– Dilatation of lower extremity veins
– Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling, stasis &
clotting of blood in lower extremities.
Thrombophlebitis

Superficial leg vein disease:
– S/s: tenderness in portion of vein, local heat &
redness, normal temperature or low-grade fever
– Tx: local heat, elevate limb, bed rest, analgesia,
elastic support hose

Deep Vein Thrombosis (DVT):
– S/s: edema of ankle, leg, initial low-grade fever,
then high temperature & chills, tenderness & pain,
changes in limb color & difference in
circumference
– Tx: IV heparin, bed rest, elevation of leg,
analgesics, warm moist heat, antibiotics
Urinary Retention



Diuresis begins p birth to rid extra fluid
(2000-3000 mL)
Trauma to bladder & urethra during
birth or anesthesia may cause loss of
tone, difficulty sensing need to void
Must assess abdomen frequently to
prevent permanent damage to bladder
from over distention. Check fundus to
see if bladder is full. If unable to void,
catheterize. Monitor for UTI.
Vital Signs



May have slight elevation of temp in 1st 24
hours--dehydration. If 100.4 or above,
suspect infection.
Rapid or thready pulse--sign of hemorrhage.
BP: monitor--still at risk of PIH. Methergine
(oxytocic) can ↑BP. ↓BP could be sign of
hemorrhage.
– Can have orthostatic hypotension due to blood
loss. Assist pt. with first trip to BR. Instruct pt to
dangle legs and sit first, before rising. If dizzy, do
not ambulate.
Breast Assessment

Breasts
– Soft: Soft on palpation, day 1 & 2
– Filling: firmer & warmth, day 3
– Engorged: appear large, reddened, taut,
shiny skin, warm, hard, tense &
tender/painful on palpation
– Mastitis (infection): only one part of
breast is warm/reddened--UNILATERAL

Nipples: look for cracking, fissures,
blisters, pain
Lactation

Engorgement: day 3 or 4.
– If breastfeeding:
 Encourage frequent breastfeeding.
 Warm compresses or warm shower.
– If not breastfeeding:
 Cold compresses/ice, snug bra or breast
binder, oral analgesics.

Breast care:
– Wash daily with water and air dry –NO SOAP
– Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy. Avoid underwires.
Use cotton nursing pads for leaking--keep
nipples dry.
Discharge Instructions






Avoid/limit heavy lifting, stairs.
Good diet, increase fluids if
breastfeeding.
Adequate rest, exercise/activity as
tolerated.
Report fever, foul smelling discharge,
increased pain or bleeding to MD.
Sex/contraception.
Follow up in 6 weeks with MD.
Postpartum Complications

Postpartum Hemorrhage
– CAUSES: Uterine atony, lacerations, retained
placental fragments

Risk factors:
– ↑ uterine distension: multiples, polyhydramnios,
macrosomia, fibroids
– Trauma: rapid or operative birth
– Placental problems: previa, accreta, abruptio,
retained placental fragments
– Atonic uterus: prolonged pitocin, magnesium
sulfate or labor; ↑ maternal age or parity; uterine
scar; chorioamnionitis; anemia; prior history
– Inadequate blood coagulation: fetal death or DIC
Hemorrhage

Interventions:
– Fundal massage, ensure
bladder emptying. If
uterus is firm but bleeding
persists, suspect
laceration.
– Administer oxtocics
(pitocin, methergine,
hemabate,
prostaglandins), blood
replacement.
– Frequent assessment of
bleeding, vital signs.
– MD: Bimanual massage,
manual exploration of
uterus, uterine packing,
D & C, hysterectomy.
Hemorrhage (cont.)

Lacerations: cervical, vaginal, perineal

Retained placental fragments:
– can occur well after delivery. Maternal serum
test for hCG or US. Possible D&C.
– May see symptoms even after 1 week

Subinvolution: retained placenta, infection,
fibroids
– PO methergine, antibiotic.
Hematomas

Cause:Trauma during the birth process

Puerperal hematomas occur in 1:300 to 1:1500 deliveries
Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy; however, a
hematoma may also result from injury to a blood vessel in the
absence of laceration/incision of the surrounding tissue





Most common locations for puerperal hematomas are the
vulva, vaginal/paravaginal area, and retroperitoneum
Women at increased risk of developing puerperal hematomas
include those who are nulliparous or who have an infant over
4000 grams, preeclampsia, prolonged second stage of labor,
multifetal pregnancy, vulvar varicosities, or clotting disorders
Assessment: location, size, vital signs, pain, H&H
Treatment: evacuation and repair of bleeding source by MD
Postpartum Infection



Puerperal Infection: Endometritis
infection of reproductive tract within 6 wks of
childbirth
Increased risk with:
–
–
–
–
–
–
–
C-section
Prolonged ROM, chorioamnionitis
Retained placental fragments
Preexisting anemia
Prolonged/difficult birth, instrumental birth
Internal fetal monitoring or IUPC
Uterus explored after birth/manual removal of
placenta
– Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection

Endometritis: infection of endometrium
– Associated with chorioamnionitis & Csection
– S/S: foul-smelling, bloody vaginal
discharge, fever (day 3 or 4), uterine
tenderness, tachycardia, chills. (Elevated
temp. in 1st 24 hours and elevated WBCs
are normal findings.)
– Can progress to pelvic cellulitis or
peritonitis.
Endometritis




TX: antibiotics as determined by culture of
lochia; oxytocics such as methergine, if
necessary, ↑ fluid intake, pain relief
Nursing considerations: Fowler’s position or
walking encourages drainage by gravity,
gloves, strict handwashing
Usual course is 7-10 days
May result in tubal scarring & interfere with
future fertility
Postpartum Infection

Nursing Interventions & Discharge Teaching
– Strict handwashing & instruction for pt & family
– Instruct re proper perineal care
 Wiping front to back, washing after voiding/
defecating, changing peripads frequently
– Well-balanced diet with adequate protein,
calories, vitamin C and fluids (2000 mL/day)
– Encourage sitz baths, early ambulation.
– Monitor vital signs and report s/s of infection
– Assess pain and administer analgesics
– Promote rest, relaxation, bonding with infant if
separated.
Post op C/Section Complications
1.Paralytic Ileus
2. Wound Dehiscence
3.Wound infection
1. A mother is experiencing shaking chills during
the hour following birth. What is the nurse’s
initial action?
A.
B.
C.
D.
Take a rectal temperature
Notify the physician or nurse-midwife
Cover the woman with warmed blankets
Review the order sheet for antibiotic orders
\
2.
The nurse assesses a postpartum client
and palpates the fundus at 2 cm above the
midline and deviated to the right. What is
the appropriate nursing action?
A. Encourage the client to breastfeed
B. Assist the client to empty her bladder
C. Assist the client to a prone position and
place
a small pillow under her abdomen
D. Massage the fundus
3.
A nurse is caring for a client who is 2 hours
postpartum who complains of severe, unremitting
vaginal pain and inability to void. The fundus is
firm at the umbilicus with moderate lochia rubra,
and the perineum appears edematous with
significant bruising. The nurse suspects the client
may have
A. A fourth-degree episiotomy.
B. Distended bladder.
C. Hematoma.
D. Endometritis.
4. A 6-day postoperative C-section client calls the clinic nurse
and complains of malaise and increased pain on the right side
of her incision with increased drainage. What should be the
nurse’s correct initial response?
A. Instruct the client to take her pain medication as prescribed
B. Notify the physician or nurse-midwife
C. Instruct the client to increase rest and seek assistance with
household tasks
D. Instruct the client to call the physician or nurse-midwife if her
temperature reaches 100.8.
5. A 6-day postpartum client complains of fatigue and
episodes of crying during the past two days. Which of
the following statements is a correct response by the
nurse?
A. “This must be very difficult for you.”
B. “This sounds like postpartum blues. It is a normal
response to birth.”
C. “You sound exhausted. Try and sleep when the baby
sleeps.”
D. “This sounds like postpartum depression; you should
contact your physician or nurse-midwife for a
referral to a counselor.”
6. A nurse is caring for a client with a
superficial thrombophlebitis. Which of the
following is the most appropriate nursing
action?
A. Administer anticoagulants per order
B. Elevate the affected limb
C. Apply ice packs to the affected limb
D. Administer antibiotics per order
Breastfeeding




www.youtube.com/watch?v=CIZ6rVzs4CE&feature=Pl
ayList&p=BD065FA5F03CD81A&index=38
(Breastfeeding Basics)
www.youtube.com/watch?v=RuvJZGFOHU&feature=P
layList&p=1330DE183266B0BC&playnext=1&playnext
_from=PL&index=3 (What’s the Big Deal?)
www.youtube.com/watch?v=Ox8htEVnQA&feature=PlayList&p=1330DE183266B0BC&in
dex=8 (latch-on 1)
www.youtube.com/watch?v=WOQzEN_dcPc&feature=
PlayList&p=1330DE183266B0BC&index=9 (latch-on
2)