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Complete dilationii.Contractions:1.Strong to very strong2.Frequency: 2 to 3 min3.Duration: 45 to 90 secondsd.Assessments related to possible rupture of membranes:a.First assess FHR ensure there is no fetal distress from possible umbilical cord prolapsei.may occur with the gush of amniotic fluidb.Verify presence of alkaline amniotic fluid (pH 6.5 to 7.5)c.Assess the amniotic fluid for color and odor.:i.Normal findings:1.Clear2.Straw color3.Free of odorii.Abnormal findings:1.Presence of meconium2.Abnormal color (yellow or port wine)3.Foul odor.d.Perform bladder palpation on a regular basis to prevent bladder distention:i.Impede fetal descent through the birth canal and cause trauma to the bladderii.Clients might not feel the urge to void secondary to the labor process or anesthesia.iii.Encourage to void every 2 hrs.e.Temperature assessment every 4 hr (every 1 to 2 hr if membranes have ruptured)e.Nursing Actions:a.Educate pt on:i.What to expectii.Implementing relaxation measures:1.Deep cleansing breaths to divert focus away from contractions2.Effleurage - gentle circular stroking of the abdomen in rhythm with breathing during contractions3.diversional activities - distraction, concentration on a focal point, or imageryb.During active phase:i.Encourage pt to void ii.Implement relaxation techniquesc.During Transition phase:i.Listen for statements expressing the need to have a bowel movement indication of complete dilation and fetal descent ii.Prepare client for birth 1.Observe for perineal bulging or crowning (appearance of the fetal head at the perineum).Second Stage:a.Lasts from the time cervix is fully dilated to birthb.Begins with complete dilation and effacementi.Blood pressure, pulse, and respiration measurements every 5 to 30 minii.Increase in bloody showiii.Shaking of extremitiesiv.FHR every 15 min and immediately following birthb.Assessment for perineal lacerations:
i.First degree: 1.Extends through skin of perineum and does not involve the musclesii.Second degree:1.Extends through skin and muscles into the perineum but not anal sphincteriii.Third degree: 1.Extends through the skin, muscles, perineum, and external anal sphincter muscleiv.Fourth degree: 1.Extends through skin, muscles, anal sphincter, and the anterior rectal wallc.Nursing Actions:i.Promote rest between contractions.ii.Provide comfort measures such as cold compresses.iii.Cleanse the client’s perineum as needed if fecal material is expelled during pushing.iv.Prepare for episiotomy, if needed.v.Prepare for care of neonate:1.Check oxygen flow and tank on warmer.2.Preheat radiant warmer.3.Lay out newborn stethoscope and bulb syringe.4.Have resuscitation equipment in working order (resuscitation bag, laryngoscope) and emergency medications available5.Check suction apparatus.Third Stage:a.Lasts from the birth of the fetus until the placenta is deliveredb.Assessment:a.VS measurements every 15 minb.Placental separation from the uterus as indicated by:i.Fundus firmly contractingii.