NCLEX: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

Health Promotion and Maintenance; Nursing Care of the Childbearing Family: THE INTRAPARTUM EXPERIENCE

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

General overview: This review of the anatomical and physiological determinants of successful labor provides baseline data against which the nurse compares findings of an ongoing assessment of the woman in labor. Nursing actions are planned and implemented to meet the present and emerging needs of the woman in labor.

I. BIOLOGICAL FOUNDATIONS OF LABOR

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

A. Premonitory signs

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

1. Lightening—process in which the fetus “drops” into the pelvic inlet.

a. Characteristics

  • Nullipara—usually occurs 2 to 3 weeks before onset of labor.
  • Multipara—commonly occurs with onset of labor.

b. Effects

  • Relieves pressure on diaphragm—breathing is easier.
  • Increases pelvic pressure.
    (a) Urinary frequency returns. (b) Increased pressure on thighs. (c) Increased tendency to vulvar, vaginal, perianal, and leg varicosities.

2. Braxton Hicks contractions—may become more uncomfortable.

B. Etiology: unknown. Theories include:

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

1. Uterine overdistention.

2. Placental aging—declining estrogen/progesterone levels.

3. Rising prostaglandin level.

4. Fetal cortisol secretion.

5. Maternal/fetal oxytocin secretion.

C. Overview of labor process—forces of labor (involuntary uterine contractions) overcome cervical resistance; cervix thins (effacement) and opens (0–10 cm dilation) (First Stage of Labor). Voluntary contraction of secondary abdominal muscles during the second stage (e.g., pushing, bearing-down) forces fetal descent. Changing pelvic dimensions force fetal head to accommodate to the birth canal by molding (cranial bones overlap to decrease head size).

Stages of labor:

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

1. First—begins with establishment of regular, rhythmic contractions; ends with complete effacement and dilation (10 cm); divided into three phases:

a. Latent and early active.

b. Active.

c. Transitional.

2. Second—begins with complete dilation and ends with birth of infant.

3. Third—begins with birth of infant and ends with expulsion of placenta.

4. Fourth—begins with expulsion of placenta; ends when maternal status is stable (usually 1–2 hours postpartum).

 

Health Promotion and Maintenance; Nursing Care of the Childbearing FamilyHealth Promotion and Maintenance; Nursing Care of the Childbearing Family

 

D. Anatomical/physiological determinants

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

1. Maternal

a. Uterine contractions—involuntary; birth; begin process of involution.

  • Characteristics: rhythmic; increasing tone (increment), peak (acme), relaxation (decrement).
  • Effects:
    (a) Decreases blood flow to uterus and placenta. (b) Dilates cervix during first stage of labor. (c) Raises maternal blood pressure during contractions. (d) With voluntary bearing-down efforts (abdominal muscles), expels fetus (second stage) and placenta (third stage). (e) Begins involution.
  • Assessment:
    (a) Frequency—time from beginning of one contraction to beginning of the next. (b) Duration—time from beginning of contraction to its relaxation. (c) Strength (intensity)—resistance to indentation. (d)False/true labor—differentiation (Assessment: Differentiation of False/True Labor). (e) Signs of dystocia (dysfunctional labor).

b. Pelvic structures and configuration:

  • False pelvis—above linea terminalis (line travels across top of symphysis pubis around to sacral promontory); supports gravid uterus during pregnancy.
  • True pelvis—below linea terminalis; divided into:
    (a) Inlet—“brim,” demarcated by linea terminalis.
    (i) Widest diameter: transverse.
    (ii) Narrowest diameter: anteriorposterior (true conjugate).
    (b) Midplane—pelvic cavity.
    (c) Outlet.
    (i) Widest diameter: anterior-posterior (requires internal rotation of fetal head for entry).
    (ii) Narrowest diameter: transverse (intertuberous); facilitates birth in occipitoanterior (OA) position.
  • Classifications
    (a) Gynecoid—normal female pelvis; rounded oval. (b) Android—normal male pelvis; funnel shaped. (c) Anthropoid—oval. (d)Platypelloid—flattened, transverse oval.

2. Fetal

a. Fetal head (The fetal head).

  • Bones—one occipital, two frontal, two parietals, two temporals.
  • Suture—line of junction or closure between bones; sagittal (longitudinal), coronal (anterior), and lambdoid (posterior, frontal); permit molding to accommodate head to birth canal.
  • Fontanels—membranous space between cranial bones during fetal life and infancy.
    (a) Anterior “soft spot”—diamond shaped; junction of coronal and sagittal sutures; closes (ossifies) by 18 months. (b) Posterior—triangular; junction of sagittal and lambdoid sutures; closes by 4 months of age.

 

Health Promotion and Maintenance; Nursing Care of the Childbearing Family

 

b. Fetal lie—relationship of fetal long axis to maternal long axis (spine).

  • Transverse—shoulder presents.
  • Longitudinal—vertex or breech presents.

c. Presentation—fetal part entering inlet first (Categories of fetal presentation).

  • Cephalic—vertex (most common); face, brow.
  • Breech
    (a) Complete—feet and legs flexed on thighs; buttocks and feet presenting.
    (b) Frank—legs extended on torso, feet up by shoulders; buttocks presenting.
    (c) Footling—single (one foot), double (both feet) presenting.

d. Attitude—relationship of fetal parts to one another (e.g., head flexed on chest).

e. Position—relationship of presenting fetal part to quadrants of maternal pelvis; vertex most common, occiput anterior on maternal left side (LOA) (see Categories of fetal presentation).

 

Health Promotion and Maintenance; Nursing Care of the Childbearing Family

 

3. Assessment: determine presentation and position.

a. Leopold’s maneuver—abdominal palpation.

  • First—palms over fundus, breech feels softer, not as round as head would be.
  • Second—palms on either side of abdomen, locates fetal back and small parts.
  • Third—fingers just above pubic symphysis, grasp lower abdomen; if un-engaged, presenting part is mobile.
  • Fourth—facing mother’s feet, run palms down sides of abdomen to symphysis; check for cephalic prominence (usually on right side), and if head is floating or engaged.

b. Location of fetal heart tones (FHTs)—heard best through fetal back or chest.

  •  Breech presentation—usually most audible above maternal umbilicus.
  • Vertex presentation—usually most audible below maternal umbilicus.
  • Changing location of most audible FHTs—useful indicator of fetal descent.
  • Factors affecting audibility:
    (a) Obesity. (b) Maternal position. (c) Polyhydramnios. (d) Maternal gastrointestinal activity. (e) Loud uterine bruit—origin: hissing of blood through maternal uterine arteries; synchronous with maternal pulse. (f) Loud funic souffle—origin: hissing of blood through umbilical arteries; synchronous with fetal heart rate (FHR). (g) External noise, faulty equipment.

c. Vaginal examination: palpable sutures, fontanels (triangular-shaped superior, diamond-shaped inferior = vertex presentation, OA position).

4. Cardinal movements of the mechanisms of normal labor—vertex presentation, positional changes of fetal head accommodate to changing diameters of maternal pelvis (Cardinal movements in the mechanism of labor with the fetus in vertex presentation).

a. Descent—head engages and proceeds down birth canal.

b. Flexion—head bent to chest; presents smallest diameter of vertex (suboccipital-bregmatic).

c. Internal rotation—during second stage of labor, transverse diameter of fetal head enters pelvis; occiput rotates 90 degrees to bring back of neck under symphysis (e.g., left occipitotransverse [LOT] to LOA to OA); presents smallest diameter (biparietal) to smallest diameter of outlet (intertuberous).

d. Extension—back of neck pivots under symphysis, allows head to be born by extension.

e. Restitution—head returns to normal alignment with shoulders (with LOA, results in head facing right thigh), presents smallest diameter of shoulders to outlet.

f. Delivery of head—shoulders in anteriorposterior position.

g. Expulsion—birth of neonate completed.

 

Health Promotion and Maintenance; Nursing Care of the Childbearing Family

 

5. Assessment: relationship of fetal head to ischial spines (degree of descent).

a. Engagement—widest diameter of presenting part has passed through pelvic inlet (e.g., biparietal diameter of fetal head).

b. Station—relationship of presenting part to ischial spines (IS).

  • Floating—presenting part above inlet, in false pelvis.
  • Station –5 is at inlet (presenting part well above IS).
  • Station 0—presenting part at IS (engaged).
  • Station +4—presenting part at the outlet.

E.Warning signs during labor

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

1. Contraction—hypertonic, poor relaxation, or tetanic (greater than 90 seconds long and ≤2 minutes apart).

2. Abdominal pain—sharp, rigid abdomen.

3. Vaginal bleeding—profuse.

4. FHR—late decelerations, prolonged variable decelerations, bradycardia, tachycardia (Fetal heart rate (FHR) decelerations and nursing interventions), decreased variability.

5. Maternal hypertension.

6. Meconium-stained amniotic fluid (MSAF).

7. Prolonged ROM.

 

Health Promotion and Maintenance; Nursing Care of the Childbearing Family

Health Promotion and Maintenance; Nursing Care of the Childbearing Family

 

II. PARTICIPATORY CHILDBIRTH TECHNIQUES

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

A. Psychoprophylaxis—Lamaze method

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

1. Premise—conditioned responses to stimuli occupy nerve pathways, reducing perception of pain. Emphasis is on childbirth as a natural event, with a woman who is informed as the active participant. The ability to relax effectively reduces the perception of pain, and the involvement of the coach fosters the family concept.

2. Childbirth partners are taught:

a. Anatomy and physiology of labor.

b. Psychology of man and woman.

c. What to expect in the birthing setting.

d. Conditioned responses to labor stimuli.

  • Concentration on focal point.
  • Breathing techniques.
  • Need for active coaching to enable woman to:
    (a) Use techniques appropriate to present stage of labor. (b) Avoid hyperventilation.

e. Specific stage—appropriate techniques:

  • First stage of labor—early: slow, deep chest breathing; active: patterned breathing.
  • Transition (8–10 cm)—rapid, shallow breathing pattern, to prevent pushing prematurely.
    (a) Panting. (b) Pant-blow. (c) “He-he” pattern.
  • Second stage of labor
    (a) Pushing (or bearing-down)—aids fetal descent through birth canal. (b) Panting—aids relaxation between contractions; prevents explosive birth of head.

f. Effects on labor behaviors/coping:

  • Helps mother cope with and assist contractions.
  • Prevents premature bearing-down efforts; reduces possibility of cervical lacerations, edema due to pushing on incompletely dilated cervix.
  • When appropriate, improves efficiency of bearing-down efforts.

B. Other methods—include parent classes, classes for siblings, multiparas, and those who plan cesarean birth.

III. NURSING ACTIONS DURING FIRST STAGE OF LABOR

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

A. Assessment: careful evaluation of:

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

1. Antepartal history

a. EDD

b. Genetic and familial problems.

c. Preexisting and coexisting medical disorders, allergies.

d. Pregnancy-related health problems (hyperemesis, bleeding, etc.).

e. Infectious diseases (past and present herpes, etc.).

f. Past obstetric history, if any.

g. Pelvic size estimation.

h. Height.

i. Weight gain.

j. Laboratory results:

  • Blood type and Rh factor.
  • Serology.
  • Urinalysis.
  • Hepatitis.
  • Rubella.

k. Prenatal care history.

l. Use of medications.

2. Admission findings

a. Emotional status.

b. Vital signs.

c. Present weight.

d. Fundal height.

e. Estimated fetal weight.

f. Edema.

g. Urinalysis (for protein and glucose).

3. FHR—normal, 110 to 160 beats/min (see Fetal heart rate (FHR) decelerations and nursing interventions).

a. Check and record every 15 to 30 minutes—monitor fetal response to physiological stress of labor.

b. Bradycardia (mild, 100–110 beats/min, or 30 beats/min lower than baseline reading).

c. Tachycardia (moderate, 160–179 beats/min, or 30 beats/min above baseline reading lasting 5 or more minutes).

4. Contractions—every 15 to 30 minutes.

a. Place fingertips over fundus, use gentle pressure; contraction felt as hardening or tensing.

b. Time: frequency and duration.

c. Intensity/strength at acme:

  • Weak—easily indent fundus with fingers.
  • Moderate—some tension felt, fundus indents slightly with finger pressure.
  • Strong—unable to indent fundus.

5. Maternal response to labor—assess for effective coping, cooperation, and using effective breathing techniques.

6. Maternal vital signs—between contractions.

a. Response to pain or use of special breathing techniques alters pulse and respirations.

b. BP, P, RR—if normotensive: on admission, and then every hour and prn; after regional anesthesia: every 30 minutes (every 5 minutes first 20 minutes).

c. Temperature—if within normal range: on admission, and then every 4 hours and prn. Every 2 hours after rupture of membranes.

d. Before and after analgesia/anesthesia.

e. After rupture of membranes.

7. Character and amount of bloody show.

8. Bladder status: encourage voiding every 1 to 2 hours, monitor output.

a. Determine bladder distention—palpate just above symphysis (full bladder may impede labor progress or result in trauma to bladder).

b. Admission urinalysis—check for protein and glucose.

9. Signs of deviations from normal patterns.

10. Status of membranes:

a. Intact.

b. Ruptured (nitrazine paper turns blue on contact with alkaline amniotic fluid). Fluid may be placed on a glass slide to dry; a fern-like crystallization of sodium chloride will appear. Note, record, and report:

  • Time—danger of infection if ruptured more than 24 hours.
  • FHR stat and 10 minutes later—to check for prolapsed cord.
  • Character and color of fluid.

11. Amniotic fluid.

a. Amount—polyhydramnios (>2000 mL)—associated with congenital anomalies/poorly controlled diabetes.

b. Character—thick consistency or odor associated with infection.

c. Color—normally clear with white specks.

  • Yellow—presence of bilirubin; Rh or ABO incompatibility.
  • Green or meconium stained; if fetus in vertex position, indicates recent fetal hypoxia secondary to respiratory distress in fetus.
  • Port wine—may indicate abruptio placentae.

12. Labor progress:

a. Effacement.

b. Dilation.

c. Station.

d. Bulging membranes.

e.Molding of fetal head.

13. Perineum—observe for bulging.

B. Analysis/nursing diagnosis:

1. Anxiety, fear related to uncertain outcome, pain.

2. Ineffective individual coping related to lack of preparation for childbirth or poor support from coach.

3. Altered nutrition: less than body requirements related to physiological stress of labor.

4. Altered urinary elimination related to pressure of presenting part.

5. Altered thought processes related to sleep deprivation, transition, analgesia.

6. Fluid volume deficit related to anemia, excessive blood loss.

7. Impaired (fetal) gas exchange related to impaired placental perfusion.

C. Nursing care plan/implementation:

1. Goal: comfort measures.

a. Maintain hydration of oral mucosa. Encourage sucking on cool washcloth, ice chips, lollipops, clear liquids (if ordered).

b. Reduce dryness of lips. Apply lip balm.

c. Relieve backache. Apply sacral counter-pressure (particularly with occipitoposterior [OP] presentation).

d. Encourage significant other to participate.

e. Encourage ambulation when presenting part engaged.

2. Goal: management of physical needs.

a. Encourage frequent voiding to prevent full bladder from impeding oncoming head.

b. Encourage ambulation throughout labor; lateral Sims’ position with head elevated to:

  • Encourage relaxation.
  • Allow gravity to assist in anterior rotation of fetal head.
  • Prevent compression of inferior vena cava and descending aorta (supine hypotensive syndrome).
  • Promote placental perfusion.

c. Perineal prep, if ordered to promote cleanliness.

d. Fleet’s enema, if ordered—to stimulate peristalsis, evacuate lower bowel. Note: contraindicated if:

  • Cervical dilation (4 cm or more) with unengaged head—due to possibility of cord prolapse.
  • Fetal malpresentation/malposition—due to possible fetal distress.
  • Preterm labor—may stimulate contractions.
  • Painless vaginal bleeding—due to possible placenta previa.

3. Goal: management of psychosocial needs. Emotional support:

a. Encourage verbalization of feelings, fears, concerns.

b. Explain all procedures.

c. Reinforce self-concept (“You’re doing well!”).

4. Goal: management of discomfort.

a. Analgesia or anesthesia—may be required or desired—to facilitate safe, comfortable birth.

b. Support/enhance/teach childbirth techniques.

  • Reinforce appropriate breathing techniques for current labor status.
    (a) If woman is hyperventilating, to increase [latex]PaCO_2[/latex], minimize fetal acidosis, and relieve symptoms of vertigo and syncope, suggest:
    (i) Breathe into paper bag.
    (ii) Breathe into cupped hands.
    (b) Demonstrate appropriate breathing for several contractions—to reestablish rate and rhythm.

5. Goal: sustain motivation.

a. Offer support, encouragement, and praise, as appropriate.

b. Keep informed of status and progress.

c. Reassure that irritability is normal.

d. Serve as surrogate coach when necessary (if no partner, before partner arrives, while partner changes clothes, during needed breaks); assist with effleurage, breathing, focusing.

e. Discourage bearing-down efforts by pant-blow until complete (10-cm) dilation to avoid cervical edema/laceration.

f. Facilitate informed decision making regarding medication for relaxation or pain relief.

g. Minimize distractions: quiet, relaxed environment; privacy.

D. Evaluation/outcome criteria:

1. Woman manages own labor discomfort effectively.

2. Woman maintains control over own behavior.

3. Woman successfully completes first stage of labor without incident.

IV. NURSING ACTIONS DURING SECOND STAGE OF LABOR

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

A. Assessment:

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

1. Maternal (or couple’s) response to labor.

2. FHR—continuous electronic monitoring, or after each contraction with fetoscope, Doppler.

3. Vital signs.

4. Time elapsed—average: 2 minutes to 1 hour; prolonged second stage increases risk of: fetal distress, maternal exhaustion, psychological stress, intrauterine infection.

5. Contraction pattern—average every 1 1/2 to 3 minutes, lasting 60 to 90 seconds.

6. Vaginal discharge—increases.

7. Nausea, vomiting, disorientation, tremors, amnesia between contractions, panic.

8. Response to regional anesthesia, if administered.

a. Signs of hypotension—reduces placental perfusion, increases risk of fetal hypoxia.

b. Effect on contractions—note and report any slowing of labor progress.

9. Efforts to bear down—increases expulsive effects of uterine contractions.

10. Perineal bulging with contractions—fetal head distends perineum, crowns; head born by extension.

B. Analysis/nursing diagnosis:

1. Pain related to strong uterine contractions, pressure of fetal descent, stretching of perineum.

2. High risk for injury:

a. Infection related to ruptured membranes, repeated vaginal examinations.

b. Laceration related to pressure of fetal head exceeding perineal elasticity.

3. Impaired skin integrity related to laceration, episiotomy.

4. Fluid volume deficit related to hypotension secondary to regional anesthesia.

5. Anxiety related to imminent birth of fetus.

6. Ineffective individual coping related to prolonged sensory stimulation (contractions) and anxiety.

7. Altered urinary elimination related to anesthesia and contractions, descent of fetal head.

8. Sleep pattern disturbance.

C. Nursing care plan/implementation:

1. Goal: emotional support.

a. To sustain motivation/control:

  • Never leave mother and significant other alone during second stage.
  • Keep informed of progress.
  • Direct bearing-down efforts (pushing) without holding breath* while pushing. Encourage pushing “out through vagina” and encourage mother to touch crowning head; position mirror so woman can see perineal bulging with effective efforts; minimize distractions.

b. To allay significant other’s anxiety: reassure regarding mother’s behavior if she is not anesthetized.

c. Support family choices.

2. Goal: safeguard status.

a. Precautions when putting legs in stirrups:

  • If varicosities, do not put legs in stirrups.
  • Avoid pressure to popliteal veins; pad stirrups.
  • Ensure proper, even alignment by adjusting stirrups.
  • Move legs simultaneously into or out of stirrups—to avoid nerve, ligament, and muscle strain.
  • Provide proper support to woman not using stirrups. Do not hold legs (can cause back injury).

b. Support woman in whatever position selected for birth (e.g., side-lying position).

c. Cleanse perineum, thighs as ordered.

3. Goal: maintain a comfortable environment.

a. Free of unnecessary noise, light.

b. Comfortable temperature (warm).

4. Medical management:

a. Episiotomy may be performed to facilitate birth.

b. Forceps may be applied to exert traction and expedite birth.

c. Vacuum extraction also used to assist birth.

5. Birthing room birth with alternative positions (squat).

D. Evaluation/outcome criteria:

1. Cooperative, actively participates in birth; maintains control over own behavior.

2. Successful, uncomplicated birth of viable infant.

3. All assessment findings within normal limits (vital signs, emotional status, response to birth).

4. Presence of significant other.

V. NURSING ACTIONS DURING THIRD STAGE OF LABOR

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

A. Assessment:

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

1. Time elapsed—average: 5 minutes; prolonged third stage (greater than 25 minutes) may indicate complications (placenta accreta).

2. Signs of placental separation:

a. Increase in bleeding from the vagina.

b. Cord lengthens.

c. Uterus rises in abdomen, assumes globular shape.

3. Assess mother’s level of consciousness.

4. Examine placenta for intactness and number of vessels in umbilical cord (normal: three. Note: two vessels only—associated with increased incidence of congenital anomalies); condition of placenta for calcification, infarcts, etc.

B. Analysis/nursing diagnosis:

1. Family coping: potential for growth related to bonding, beginning achievement of developmental tasks.

2. Fluid volume deficit related to blood loss during third stage.

C. Nursing care plan/implementation:

1. Goal: prevent uterine atony. Administer oxytocin, as ordered.

2. Goal: facilitate parent-child bonding.

a. While protecting neonate from cold stress, encourage parents to see, hold, touch neonate.

b. Comment about neonate’s individuality, characteristics, and behaviors.

c. After neonate is assessed for congenital anomalies (e.g., cleft palate, esophageal atresia), encourage breastfeeding, if desired.

3. Goal: health teaching.

a. Describe, discuss common neonatal behavior in transitional period (periods of reactivity, sleep, hyperactivity).

b. Demonstrate removal of mucus by aspiration with bulb syringe.

c. Demonstrate ways of facilitating breastfeeding.

D. Evaluation/outcome criteria:

1. Woman has a successful, uneventful completion of labor.

a. Minimal blood loss.

b. Vital signs within normal limits.

c. Fundus well contracted at level of umbilicus.

2. Parents express satisfaction with outcome, demonstrate infant attachment.

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VI. NURSING ACTIONS DURING THE FOURTH STAGE OF LABOR—1 TO 2 HOURS POSTPARTUM

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

A. Assessment—every 15 minutes four times; then, every 30 minutes two times—or until stable—to monitor response to physiological stress of labor/birth.

1. Vital signs:

a. Temperature taken once; if elevated, requires follow-up—may indicate infection, dehydration, excessive blood loss. Note, record, report temperature of 100.4°F (38°C).

b. Blood pressure—every 15 minutes × 4.

  • Returns to prelabor level—due to loss of placental circulation and increased circulating blood volume.
  • Elevation may be in response to use of oxytocic drugs or preeclampsia (first 48 hours).
  • Lowered blood pressure—may reflect significant blood loss during labor/birth, or occult bleeding.

c. Pulse—every 15 minutes × 4.

  • Physiological bradycardia—due to normal vagal response.
  • Tachycardia—may indicate excessive blood loss during labor/birth, dehydration, exhaustion, maternal fever, or occult bleeding.

2. Location and tone of fundus—every 15 minutes × 4 to ensure continuing contraction; prevent blood loss due to uterine relaxation.

a. Fundus—firm; at or slightly lower than the umbilicus; in mid-line.

b.May be displaced by distended bladder—due to normal diuresis; common cause of bleeding in immediate postpartum, uterine atony.

3. Character and amount of vaginal flow.

a.Moderate lochia rubra.

b. Excessive loss: if perineal pad saturated in 15 minutes, or blood pools under buttocks.

c. Bright red bleeding may indicate cervical or vaginal laceration.

4. Perineum.

a. Edema.

b. Bruising—due to trauma.

c. Distention/hematoma, rectal pain.

5. Bladder fullness/voiding—to prevent distention.

6. Rate of IV, if present; response to added medication, if any.

7. Intake and output—to evaluate hydration.

8. Recovery from analgesia/anesthesia.

9. Energy level.

10. Verbal, nonverbal interaction between woman and significant other.

a. Dialogue.

b. Posture.

c. Facial expressions.

d. Touching.

11. Interactions between parent(s) and newborn; signs of bonding (culturally appropriate).

a. Eye contact with newborn.

b. Calls by name.

c. Explores with fingertips, strokes, cuddles.

12. Signs of postpartum emergencies:

a. Uterine atony, hemorrhage.

b. Vaginal hematoma.

B. Analysis/nursing diagnosis:

1. Fluid volume deficit related to excessive intrapartum blood loss, dehydration.

2. Altered urinary elimination related to intrapartum bladder trauma, dehydration, blood loss.

3. Impaired skin integrity related to episiotomy, lacerations, cesarean birth.

4. Altered family processes related to role change.

5. Altered parenting related to interruption in bonding secondary to:

a. Compromised maternal status.

b. Compromised neonatal status.

6. Knowledge deficit related to self-care procedures, infant care.

7. Fatigue related to sleep disturbances and anxiety.

8. Anxiety regarding status of self and infant.

9. Altered nutrition, less than body requirements, related to decreased food and fluid intake during labor.

C. Nursing care plan/implementation:

1. Goal: comfort measures.

a. Position, pad change.

b. Perineal care—to promote healing; to reduce possibility of infection.

c. Ice pack to perineum; as ordered—to reduce edema, discomfort, and pain related to hemorrhoids.

2. Goal: nutrition/hydration. Offer fluids, foods as tolerated.

3. Goal: urinary elimination.

a. Encourage voiding—to avoid bladder distention.

b. Record: time, amount, character.

c. Anticipatory guidance related to nocturnal diuresis and increased output.

4. Goal: promote bonding.

a. Provide privacy, quiet; encourage sustained contact with newborn.

b. Encourage: touching, holding baby; breastfeeding (also promotes involution).

5. Goal: health teaching.

a. Perineal care—front to back, labia closed (after each void/bowel movement).

b. Hand washing—before and after each pad change; after voiding, defecating; before and after baby care.

c. Signs to report:

  • Uterine cramping/ ↑ pain.
  • Increased vaginal bleeding, passage of large clots.
  • Nausea, dizziness.

D. Evaluation/outcome criteria:

1. Expresses comfort, satisfaction in fourth stage.

2. Vital signs stable, fundus contracted, moderate lochia rubra, perineum undistended.

3. Tolerates food and fluids well.

4. Voids an adequate amount.

5. Demonstrates culturally appropriate contact with infant.

6. Verbalizes abnormal signs to report to physician.

7. Returns demonstration of appropriate perineal care.

8. Ambulates without pain, dizziness, numbness of legs.

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