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Intrapartum DR Technique
Intrapartum DR Technique
Purposes
1. To strengthen woman’s coping with active labor and transition
2. To promote comfort.
3. To provide safe environment for the mother and new born.
4. To practice strict aseptic technique throughout the procedure.
5. To promote initial mother and child bonding.
Assessment
Assessment should focus on the following:
1. Assess if the patient is the transitional phase of the first stage of labor process.
2. Assess for fetal condition by auscultation of the fetal heart tone.
Nursing Diagnosis
Nursing Diagnosis may include the following:
MOTHER
1. Anxiety related to impending delivery
2. Acute pain related to uterine contraction/ descent of the fetus.
3. Ineffective coping related to discomfort
4. Impaired urinary elimination related to pressure of the fetus
5. Ineffective breathing patter related to pain and fatigue.
6. Risk for infection related to rupture of membranes/episiotomy and tissue trauma
7. Impaired tissue integrity related to placental separation.
8. Risk for injury related to potential hemorrhage
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NEWBORN
1. Ineffective airway clearance related to nasal and oral secretions from delivery.
2. Ineffective thermoregulation related to environment and immature ability for
adaptation.
3. Risk for injury related to immature defense of the neonate.
Desired Outcome
MOTHER
1. Client will verbalize positive statements about delivery outcome
2. Client will report pain is decreased from comfort strategies.
3. Client’s bladder will remain non-distended.
4. Client will remain free from signs of infection
5. Client will use breathing techniques during contraction
6. Client will deliver an intact placenta
7. Client’s blood loss will be controlled and hemorrhage prevented
8. Client’s vital signs will remain stable and uterus remain firm at midline
9. Client will interact with her newborn.
Implementation
Implementation
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4. Instructs to bear down properly, coaches to Promotes effective second-stage pushing; the
take deep breaths as soon as contraction birth process expense a great deal of energy.
begins (proper pushing and breathing Encouraging proper pushing and breathing
techniques). techniques conserves maternal energy.
5. Wipe mucous from face, mouth and nose, To remove secretion from the neonate’s mouth
establishes initial airway clearance using bulb and nose.
suction.
6. Using a sterile blanket, hold newborn To avoid slipping of the baby; prevent tension
firmly and close to the introitus with head in a to the cord and to allow secretion to drain from
slightly dependent position. the mouth and the nose.
7. Safely lay the infant on the radiant heart To facilitate thermoregulation.
warmer.
8. Provide immediate newborn care: Gentle suctioning removes secretions that may
A. Maintains airway by suctioning mouth collect in these areas. Suctioning mouth before
first then the nose. the nose prevents possible aspiration of oral
secretion.
B. Maintains body temperature Newborns have difficulty conserving body
- Dries the neonate immediately after delivery heat. Exposure to cold increases the metabolic
- Cover neonates head with towel or cap rate, increasing the need for oxygen and further
- Wrap neonate snugly with warm towel the respiratory rate.
C. Place Identical identification bracelets To prevent risk of switching babies and
on the mother and the neonate (follow agency kidnapping.
policy).
9. Performs immediate cord care and notes the To minimize bacterial colonization and
cord vessels. identify congenital anomalies.
10. Places ice pack over the uterine fundus. To promote uterine contraction and prevent
bleeding.
11. Monitors maternal vital signs every 15 To evaluate maternal post partum condition
min. for 1 hour until stable. and prevents complications.
12. Places adult diaper and change soiled To promote comfort.
gown.
13. Assists in the after care of the unit. To restore cleanliness and orderliness of the
unit.
14. Safely transfers mother to the stretcher per To prepare transport to post partum unit.
doctor’s order.
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Third Stage of Labor – Placenta
Evaluation
MOTHER
1. Client verbalizes positive statements about delivery outcome.
2. Client reports pain is minimized from comfort strategies.
3. Client’s bladder remained non-distended.
4. Client shows no signs of infection.
5. Client utilizes breathing techniques during contraction
6. Client delivers an intact placenta
7. Client’s blood loss was controlled and hemorrhage prevented.
8. Client’s vital signs remained stable and uterus is firm at midline.
9. Client bonds with her newborn.
NEWBORN
Document
1. Newborn transitions appropriately as evidenced by an APGAR score of 7 to 10.
2. Newborn’s temperature remained within normal limits.
3. Newborn has ID bracelet on and newborn care completed.
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The APGAR Scoring System
The APGAR Scoring System was developed by Dr. Virginia Apgar as a method of
assessing the newborn’s adjustment to extrauterine life. It is taken at one minute and five
minutes after birth. With depressed infants, repeat the scoring every five minutes as needed.
The one minute score indicates the necessity for resuscitation. The five minute score is more
reliable in predicting mortality and neurologic deficits. The most important is the heart rate,
then the respiratory rate, the muscle tone, reflex irritability and color follows in decreasing
order. A heart rate below 100 signifies an asphyxiated baby and a heart rate above 160
signifies distress.
Documentation
2. Neonate’s APGAR score, sex, time of delivery, time placenta was delivered.
Signs 0 1 2
Respiratory Slow, weak
Absent Good cry
Rate cry
Reflex No
Grimace Cry
Irritability Response
Pulse, Heart Slow
Absent >100
Rate (<100)
Body pink
Completely
Skin Color Blue Pale extremities
pink
blue
Some
Muscle
Flaccid flexion of Well flexed
Tone
extremities
References:
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Udan Q.J. (2004) Mastering Fundamentals of Nursing Concepts and Clinical
Application 2nd Edition. Educational Publishing House.
Engstrom, J. ( 2004). Maternal-Neonatal Nursing, Made Incredibly Easy. Lippingcott
Williams & Wilkins.
Fairchild S.S. Perioperative Nursing, Principles and Practice. Joans and Barlett
Publishers, Corporated.
Pilliteri A. (2007) Care of the Child Bearing and Child Rearing Family. 5 th Edition
Lippincott Williams & Wilkins.
Woodring B.C. (2005)Pediatric Nursing Made Incredibly Easy. Lippincott, Williams
& Wilkins.
Doenges, H. & M. ( 2006). Nurses Pocket Guide Diagnoses Prioritized Intervention
and Rationale 10th Edition.
Smith T., Jean & Johnson, Young, J. (2006). Nurses Guide to Clinical Procedures. 5 th
Edition. Philadelphia: Lippincott Williams & Wilkin.
Nettina, S.M. ( 2001) The Lippincott Manual of Nursing Practice. 7 th
Edition.Lippingcott: Williams & Wilkins.
Rating: _____________________
Date : _____________________
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