Nursing 6 Care of Mother and Infant During Labor and Birth
TEACHING FOCUS
In this chapter, students will have the opportunity to learn the admitting process for patients entering the maternity unit, including data collection. Students will be introduced to the types of settings for childbirth, the components of the birth process, admission procedures during the birthing process, monitoring of the patient during and after the birth, and monitoring the newborn. Students will also have the opportunity to learn the differences between true and false labor, the stages and phases of labor, and the nursing care required for vaginal births.
Lesson Plan
MATERIALS AND RESOURCES
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Anatomical models (Lesson 6.1) Computer and PowerPoint projector (all lessons) Videotapes, VCR, and projector (Lesson 6.1)
LESSON CHECKLIST
Preparations for this lesson include: Lecture Evaluation of student knowledge and skills needed to perform all entry-level activities related to nursing care during labor and birth, including: Different birth settings, methods of data collection, and admitting patients to the maternity unit Components of the birth process Stages and phases of labor Care of the mother and newborn immediately after delivery
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KEY TERMS
acrocyanosis (p. 150) adjustment (p. 138) amnioinfusion (p. 14036) amniotomy (p. 136) bloody show (p. 125) cold stress (p. 149) coping (p. 138) crowning (p. 142) dilate (p. 120) doula (p. 139) efface (p. 120) episiotomy (p. 130) fontanel (p. 122) leopold's maneuver (p. 130) lie (p. 122) molding (p. 122) neutral thermal environment (p. 149) nitrazine test (p. 136) nuchal cord (p. 135) ophthalmia neonatorum (p. 151) station (p. 126) suture (p. 122) uteroplacental insufficiency (p. 136) vaginal birth after cesarean (VBAC) (p. 142)
ADDITIONAL RESOURCES
PowerPoint slides (IER): 1-46
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LESSON 6.1 PRETEST
1. Which of the following is a reassuring pattern of contractions? a. frequency greater than every 1 minute and last less than 30 seconds b. frequency greater than every 2 minutes and last less than 90 seconds c. frequency greater than every 5 minutes or last longer than 30 seconds d. frequency greater than every hour or last longer than 90 seconds 2. Three signs of impending labor are a. ballottement, leg edema, and Braxton Hicks contractions. b. military presentation, tachycardia, and nausea. c. blurred vision, headache, and decreased fetal activity. d. bloody show, irregular contractions, and crowning. 3. The four stages of labor are a. quickening, labor, expulsion, and recovery. b. anticipation, activation, contractions, and resolution. c. dilation and effacement, expulsion, placental expulsion, and recovery. d. preparation, involvement, contractions, and recovery. 4. A pregnant woman should go to the hospital when she begins to experience a. frequent and intense contractions. c. lower back pain. b. frequent and urgent urination. d. effleurage accompanied by cravings. 5. The Apgar scoring system assesses a. fetal heart rate, respiratory effort, reflex irritability, muscle tone, and color. b. maternal heart rate, respiratory effort, reflex irritability, muscle tone, and color. c. fetal blood pressure, peripheral circulation, capillary refill, color, and alertness. d. maternal blood pressure, peripheral circulation, capillary refill, color, and alertness. 6. The newborn cannot be discharged until what has been passed? a. surfactant c. colostrum b. meconium d. placenta 7. What are the four interrelated components that make up the process of labor and birth? a. dilation, effacement, expulsion, and recovery b. membrane rupture, contractions, delivery, and recovery c. powers, passage, passenger, and psyche d. breathing, pushing, expelling, assessment 8. Spontaneous or artificial rupture of the amniotic membranes is a. Nitrazine test. c. Apgar. b. amnioinfusion. d. amniotomy. 9. Acrocyanosis in the newborn is a. the bluish color of the feet and hands. c. usually resolved after the first stool is passed. b. caused by a Vitamin K deficiency. d. caused by cold stress and can lead to hypothermia. 10. Which of the following is a characteristic of false labor? a. large amounts of bloody show c. cervix effacement gradually increases b. walking relieves contractions d. membranes must be artificially ruptured Answers 1. b 3. c 5. a 7. c 9. a 2. d 4. a 6. b 8. d 10. b
BACKGROUND ASSESSMENT
Question: The nurse notices that the fetal heart rate is variable and that the decelerations begin after the contraction starts and continue after the contraction is over. What does this pattern indicate? Answer: This patient is experiencing late decelerations, which are known as a nonreassuring pattern. Late decelerations occur when the baseline rate decreases, often indicating that the placenta is not delivering enough oxygen to the fetus (uteroplacental insufficiency).
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Question: How would you describe the nursing care of the newborn immediately after birth? Answer: The infant is dried with a towel, wrapped in warm blankets with a hat placed on the head, and placed in a radiant warmer to maintain a neutral thermal environment. Secretions are suctioned from the nose and mouth and a cord clamp is applied when the newborn is stabilized in the radiant warmer to maintain cardiorespiratory function. An Apgar score is given at one minute and five minutes after birth to evaluate the infant's condition and need for resuscitation.
CRITICAL THINKING QUESTION
A woman nearing her term date tells the nurse that she has decided to deliver at home because she doesn't want her baby to enter the world in an impersonal hospital setting. How should the nurse respond to this statement? Guidelines: There are some advantages of a home delivery: the patient has more control over who will or will not be present for the birth, there is no risk of acquiring infections or diseases from other patients, and the comfortable and familiar environment is relaxing and peaceful for the patient. There are also decided disadvantages that should not be overlooked: most physicians and nurse-midwives will not attend home deliveries, and lay midwives have varying levels of training and experience. Emergency care and technology is also not immediately available should an emergency arise, and there can be a significant delay in receiving appropriate emergency care. If the mother's chief reason for wanting a home delivery is the atmosphere, then the nurse should explain that most hospital birthing rooms are more home-like than institutional, with wood trim furniture that hides the utilitarian purposes. These types of birthing rooms provide the comfort and atmosphere of home, but with all the necessary medical equipment and personnel. Encourage the patient to research which local hospitals offer the most ideal birthing rooms for her and to begin making her preparations.
OBJECTIVES
Define each key term listed.
CONTENT
TEACHING RESOURCES
Crossword Puzzle (pp. 60-61) Discuss the importance of using proper terminology for nursing during birth and labor. Go around the room and have each student use one of the key terms in a sentence and explain its definition in his or her own words. Have the rest of the class evaluate the sentences and definitions.
Class Activity
Introduction (p. 115)
Discuss specific cultural beliefs the nurse may encounter when providing care to a woman in labor.
Cultural influence on birth practices (p. 115)
PPT 5 IER Alt TB IER Open-Book Quiz question 1 IER Related Activities 1 Table 6-1 Birth Practices of Selected Cultures (pp. 116, 117) Discuss how to take cultural differences into account when nursing during birth. Discuss how and why different cultures have approached the birthing process in different ways. Divide the class into small groups and have each group identify and discuss four areas of the birthing process that may be different from culture to culture. Have students give specific examples of cultural differences, explain nursing care and interventions for these
Class Activity
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OBJECTIVES
CONTENT
TEACHING RESOURCES
differences, and present their findings to the class for discussion.
Compare the advantages and disadvantages for each type of childbearing setting: hospital, freestanding birth center, and home.
Settings for childbirth (p. 116) Hospitals (p. 118) Freestanding birth centers (p. 119) Home (p. 119)
PPT 6 IER Open-Book Quiz question 2 IER Related Activities 2 Figure 6-1 (A) Typical labor, delivery, and recovery room (LDR); (B) When woman enters active phase of labor (p. 119) Discuss the different types of settings for childbirth. How do freestanding birth centers differ from hospitals? Discuss what a patient would need to successfully deliver a baby at home. Divide the class into small groups and assign each group one of the childbearing settings: hospital, freestanding birth center, and home. Have each group list the advantages and disadvantages of delivering in its assigned setting and explain which type of patient or pregnancy the setting is best suited for. Have each group share its findings with the class.
Class Activity
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Present the following scenario to the class for students to discuss: A diabetic patient insists on having a home delivery because she hates hospitals and she wants her baby to be born in its home surrounded by family. Is home delivery advisable or inadvisable for this patient? How should the nurse proceed from here?
Class Activity
Describe the four components ("four Ps") of the birth process: powers, passage, passenger, and psyche.
Components of the birth process (p. 119)
PPT 7-18 IER TB questions 1-4, 6 IER Alt TB IER Open-Book Quiz question 3 SG Learning Activities 1 (p. 51) Discuss which of the four Ps is the most crucial aspect of the birth process and why. Discuss the role the psyche plays in the birth process. Divide the class into small groups and assign each group one of the four Ps of the birth process. Have each group identify three areas about which patient teaching might be needed, make a brief teaching plan that addresses these areas, identify two specific nursing interventions, and present its plan to the class
Class Activity
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OBJECTIVES
CONTENT
TEACHING RESOURCES
for discussion.
Describe how the four Ps of labor interrelate to result in the birth of an infant.
Components of the birth process (p. 119) The powers (p. 119) Uterine contractions (p. 120) Maternal pushing (p. 122)
IER TB questions 1-7, 9 IER Related Activities 3 SG Learning Activities 2-6 (pp. 51, 52) SG Applying Knowledge 1 and 2 (p. 55) Figure 6-2 Cervical effacement and dilation (p. 120) Figure 6-3 Cervical dilation in centimeters (p. 121) Figure 6-4 Contraction cycle (p. 121) Nursing Tip (p. 122) Figure 6-5 The fetal skull (p. 123) Figure 6-6 Lie (p. 123) Figure 6-7 Fetal presentations (p. 124) Box 6-1 Classifications of Fetal Presentations and Positions (p. 125) Figure 6-8 Fetal position (p. 126) Review question 2 (p. 153) Discuss the nursing interventions and actions that can be taken to decrease the woman's fear and anxiety during labor. Divide the class into small groups and assign each group one of the Ps four of the birth process. Have each group identify the important elements of its component and explain how it relates to the other components of the birth process. Have groups share their findings with the class.
Class Activity
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The passage (p. 122) Bony pelvis (p. 122) Soft tissues (p. 122) The passenger (p. 122) Fetal head (p. 122) Lie (p. 122) Attitude (p. 122) Presentation (p. 123) Position (p. 124) The psyche (p. 125)
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6.1 Homework/Assignments:
6.1 Instructor's Notes/Student Feedback:
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LESSON 6.2 CRITICAL THINKING QUESTION
A woman in an outpatient clinic asks about false labor and says that she is hesitant to go to the hospital or call her physician unless she is certain that she is in labor. How should the nurse respond? Guidelines: The nurse should explain that true labor is characterized by cervical effacement and dilation, which can only be assessed by a physician. Other signs of false labor are irregular, infrequent, or mild intensity contractions that are relieved or lessened by walking; abdominal or groin discomfort; and little or no bloody show. The nurse should explain that false labor is very common and that it is often mistaken for true labor. The patient should never hesitate to go to the hospital or contact her physician; it is better to be mistaken and sent home than to wait too long and risk complications.
OBJECTIVES
Explain the normal processes of childbirth: premonitory signs, mechanisms of birth, and stages and phases of labor.
CONTENT
TEACHING RESOURCES
PPT 20-23 IER TB questions 8-12, 22 IER Alt TB IER Open-Book Quiz questions 4 and 5 IER Related Activities 4 SG Review Questions 1-11, 22 (pp. 55, 56, 58) Figure 6-9 Mechanisms of labor (p. 127) Figure 6-10 Station (p. 128) Review question 1 (p. 153) Discuss the various signs of impending labor and why the body reacts in such a manner shortly before delivery. Discuss what would happen if the fetus does not achieve the proper station prior to delivery. Divide the class into small groups and assign each group one of the following topics: normal processes of childbirth, premonitory signs, mechanisms of birth, and stages and phases of labor. Have students identify key points necessary to educate patients in their specific stages of labor and develop a teaching plan. Have each group present its plan to the class for discussion, and have the class discuss nursing interventions and possible complications or problems for each topic.
Class Activity
Normal childbirth (p. 125) Signs of impending labor (p. 125) Braxton Hicks contractions (p. 125) Increased vaginal discharge (p. 125) Bloody show (p. 125) Rupture of the membranes (p. 126) Energy spurt (p. 126) Weight loss (p. 126)
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Mechanisms of labor (p. 126) Descent (p. 126) Engagement (p. 128) Flexion (p. 128) Internal rotation (p. 128) Extension (p. 128) External rotation (p. 128) Expulsion (p. 13328)
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OBJECTIVES
Explain how false labor differs from true labor.
CONTENT
TEACHING RESOURCES
PPT 24-34 IER TB questions 7 and 8 IER Open-Book Quiz question 6 IER Related Activities 5 SG Learning Activities 7, 11-14 (pp. 52-53) SG Case Studies 1 and 2 (p. 54) SG Applying Knowledge 5 (p. 55) SG Review Questions 13-17, 23, 24 (pp. 57-58) Nursing Tip (pp. 122, 129, 131, 135, 137, 139) Skill 6-1 Assisting with an Emergency Birth (p. 129) Table 6-2 Comparison of True Labor and False Labor (p. 131) Figure 6-11 Leopold's maneuver (p. 131) Skill 6-1 Determining Fetal Heart Rate (p. 132) Box 6-2 When to Auscultate and Document Fetal Heart Rate (p. 133) Skill 6-3 External Electronic Fetal Monitoring (p. 133) Figure 6-12 Determining placement of fetoscope or sensor to assess FHR (p. 134) Figure 6-13 Recording of the FHR in the upper grid and the uterine contractions in the lower grid (p. 134) Figure 6-14 Variable decelerations, showing their typically abrupt onset and offset (p. 135) Figure 6-15 Late decelerations, showing their pattern of slowing, which persists after contraction ends (p. 135) Box 6-3 Reassuring and Nonreassuring Fetal Heart Rate and Uterine Activity Patterns (p. 136) Skill 6-4 Testing for the presence of amniotic fluid (Nitrazine paper test) (p. 136) Skill 6-5 Determining Contractions by Palpation (p. 137) Figure 6-16 The nurse helps the mother maintain control and use breathing techniques during active labor (p. 137) Figure 6-17 The nurse explains the external electronic fetal monitor to the woman (p. 138) Figure 6-18 The doula (p. 139) Discuss the admission process from beginning to end, as well as the role of the nurse in this process. Discuss the nursing interventions in counseling a
Admission to the hospital or birth center (p. 128) When to go to the hospital or birth center (p. 128) Admission data collection (p. 129) Fetal condition (p. 129) Maternal condition (p. 129) Impending birth (p. 129) Additional data collection (p. 130)
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Admission procedures (p. 130) Permits (p. 130) Laboratory tests (p. 130) Intravenous infusion (p. 130) Shave prep (p. 130) Determining fetal position and presentation (p. 135)
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Nursing care for the woman in false labor (p. 130)
Nursing care before birth (p. 132) Monitoring the fetus (p. 132) Fetal heart rate (p. 132) Intermittent auscultation (p. 132) Continuous electronic fetal monitoring (p. 133) Inspection of amniotic fluid
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6.2 Homework/Assignments:
6.2 Instructor's Notes/Student Feedback:
LESSON 6.3 CRITICAL THINKING QUESTION
The nurse is caring for a patient who will be moving through the third and fourth stages of labor. What are the nursing responsibilities during these stages of labor to provide care for the mother and the newborn? Guidelines: During the third and fourth stages of labor, which occur during the first few hours after birth, the biggest risks to the mother are hemorrhaging and infection. The nurse must monitor the vital signs, check the fundus, and observe for bleeding. It is essential for the nurse to minimize heat loss for the infant, ensure that the infant has a patent airway, and observe for the passage of urine or meconium.
OBJECTIVES
Determine appropriate nursing care for the intrapartum patient, including the woman in false labor and the woman having a vaginal birth after a cesarean birth (VBAC).
CONTENT
TEACHING RESOURCES
PPT 35 IER TB questions 5, 14-16, 19, and 20 IER Open-Book Quiz questions 7 and 8 IER Related Activities 6 SG Applying Knowledge 3 and 4 (p. 55) SG Review Question 18 (p. 58) SG Thinking Critically 1 (p. 54) CTQ (p. 153) Figure 6-19 Standing and walking during early labor and leaning on partner (p. 139) Table 6-3 The Labor Process and the Nurse (pp. 140, 141) Nursing Tip (pp. 142, 143) Review questions 3 and 5 (p. 153)
The labor process and the nurse (p. 140) Stages and phases of labor (p. 140) Vaginal birth after cesarean birth (p. 142)
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OBJECTIVES
CONTENT
TEACHING RESOURCES
Discuss how the nurse could involve the woman's partner in the labor process. Discuss how a woman having a vaginal birth after a cesarean delivery might feel. Divide the class into small groups and assign each group one of the following scenarios:
Class Activity
1. The woman in false labor 2. The woman in true labor 3. The woman who is VBAC Have each group identify the nursing interventions that need to be performed and discuss what special needs the patient may have. Have each group share its findings with the class and discuss ways the nurse could help the patient cope with her delivery status.
Explain common nursing responsibilities during the birth.
Nursing care during birth (p. 142) Nursing responsibilities during birth (p. 142) Immediate postpartum period: the third and fourth stages of labor (p. 148)
PPT 36-37 IER TB questions 13, 17, 18, and 23 IER Alt TB IER Open-Book Quiz question 9 SG Learning Activities 8-10 (p. 52) SG Applying Knowledge 5 (p. 55) SG Review questions 3, 7, 13, 16, 17, and 20 (pp. 56-58) Figure 6-20 The table contains the sterile instruments (p. 142) Figure 6-21 Perineal scrub preparation is done just before birth (p. 143) Nursing Tip (p. 143) Figure 6-22 The placenta after delivery (p. 144) Figure 6-23 Vaginal birth of a fetus in a vertex position (pp. 144-147) Review question 4 (p. 153) Discuss how the nurse could calm the patient if problems occur during delivery. Discuss ways the nurse could communicate with a distracted or upset patient during a difficult delivery. Write the following list of birthing responsibilities on the board and have students identify
Class Activity
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OBJECTIVES
CONTENT
TEACHING RESOURCES
which ones the nurse is responsible for: Preparing the multipara Transferring the patient to a delivery room Measuring cervix dilation and effacement Preparing delivery instruments Prep for perineal scrub Performing episiotomy Providing initial care of newborn Delivering placenta Examining placenta Have students identify and explain other nursing responsibilities during birth.
Describe the care of the newborn immediately after birth.
Nursing care immediately after birth (p. 148) Care of the mother (p. 148) Observing for hemorrhage (p. 148) Promoting comfort (p. 148)
PPT 3844 IER TB question 21 IER Open-Book Quiz question 10 SG Review Questions 8 and 25 (pp. 56, 59) SG Thinking Critically 2 (p. 54) Table 6-4 Apgar Scoring System (p. 143) Figure 6-24 The nurse applies the sensor and assesses the newborn in the radiant warmer (p. 149) Figure 6-25 The nurse assists the father in cutting the umbilical cord (p. 149) Skill 6-6 Administering Eye Ointment to the Newborn (p. 151) Skill 6-7 Administering Intramuscular Injections to the Newborn (p. 151) Discuss the Apgar scoring system. What does it determine? Divide the class into small groups and have each group develop a plan that outlines all of the nursing interventions related to care of the newborn immediately after birth. They should include specific assessments that are performed and their required frequency. Have each group present its plan to the class for discussion.
Class Activity
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Care of the infant (p. 148) Care of the newborn immediately after delivery (p. 148) Phase I (p. 149)
Divide the class into groups and have each group identify three key areas of concern for maintaining the health of the newborn. Also have groups identify one nursing intervention for those three areas.
Class Activity
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OBJECTIVES
Performance Evaluation
CONTENT
TEACHING RESOURCES
IER TB IER Related Activities IER Open-Book Quiz SG Learning Activities (pp. 51-53) SG Case Studies (p. 54) SG Applying Knowledge (p. 55) SG Review Questions (pp. 55-59) SG Thinking Critically (p. 54) CTQ (p. 153) Review Questions (p. 153)
6.3 Homework/Assignments:
6.3 Instructor's Notes/Student Feedback:
Introduction to Maternity & Pediatric Nursing, 5th ed. Elsevier items and derived items 2007, 2006 by Saunders, an imprint of Elsevier Inc. Leifer