NURSING CARE

FOR CLIENT
DURING
LABOR AND
DELIVERY
Establishing a Therapeutic
Relationship
❑Make the family feel
welcome.
❑Determine family
expectations about birth
❑Convey Confidence
❑Use touch for comfort
❑Respect cultural values
Immediate Assessment of a patient in
the first stage of labor

Ask about the following:

✔ EDB/EDD
✔ When contraction began
✔ Amount and character of any show
✔ Any recreational or prescription drugs used
✔ Past and present pregnancy history if the
prenatal record is not available.
✔ Birth plan
Immediate Assessment of a patient in
the first stage of labor

Assess about the following:

✔ Vital signs: Temperature, Pulse, Respiration,
Blood pressure
✔ Nature of Contraction (Frequency, Duration,
Intensity)
✔ Rating of pain on a 10-point scale
✔ What the patient has done to be prepared for
labor such as learning breathing exercise
✔ Position and presentation of the fetus
 The
Detailed
Assessmen
t During the
First Stage
of Labor
 THE HISTORY
CURRENT PREGNANCY PAST PREGNANCY
HISTORY HISTORY
✔ documentation of Gravida ✔ Document prior
and Parity status. pregnancies, abortions,
✔ description of the or miscarriages, including
pregnancy numbers, dates, types of
✔ plans for labor birth, any complication,
✔ plans for child care and outcomes, including
health, sex, and birth
weights of previous
children.
 THE HISTORY
PAST HEALTH HISTORY
✔ Document any previous
surgeries
✔ Heart disease or diabetes
✔ Anemia, Tuberculosis
✔ Kidney disease or
hypertension
✔ STI such as herpes
✔ Determine also if the patient
is at risk for prescription or
nonprescription drug abuse
or HIV exposure
FAMILY MEDICAL
HISTORY
✔ Ask if any family member has a
condition that could be
inherited such as cognitive
challenge, heart disease, blood
dyscrasia, diabetes, kidney
disease, allergies, seizures,
hearing loss, malignant
hyperthermia. If any of these
are present, adequate
preparation can then be made
for a child who might have
special needs at birth.
THE PHYSICAL EXAMINATION
Abdominal and Lower Leg Assessment
✔ Assessing a patient’s abdomen is important to estimate fetal size by fundal
height ( which should be at the level of xiphoid process at term).
✔ Palpate and percuss the bladder area ( over symphysis pubis) to detect a full
bladder.
✔ Assess for abdominal scars to reveal prev. Abdominal or pelvic surgery that
could have left adhesion.
✔ Inspect lower extremities for skin turgor to assess hydration and also for
edema and varicose veins.
THE PHYSICAL EXAMINATION
Determining Fetal Position, Presentation and Lie
Four methods can be used to determine if the fetus is in
an optimal position for birth.
✔ Determining the place of the patient’s abdomen where fetal heart tones are
heard the strongest
THE PHYSICAL EXAMINATION
Determining Fetal Position, Presentation and Lie
Four methods can be used to determine if the fetus is in
an optimal position for birth.
✔ Abdominal inspection and palpation: LEOPOLD’S
MANEUVER
THE PHYSICAL EXAMINATION
LEOPOLD’S
MANEUVER
THE PHYSICAL EXAMINATION
Determining Fetal Position, Presentation and Lie
Four methods can be used to determine if the fetus is in
an optimal position for birth.
✔ VAGINAL EXAMINATION
THE PHYSICAL EXAMINATION
Determining Fetal Position, Presentation and Lie
Four methods can be used to determine if the fetus is in
an optimal position for birth.
✔ SONOGRAPHY
Although not routine, sonography may be
used to determine the diameters of the fetal
skull and to determine presentation, position,
flexion, and degree of descent of a fetus at the
beginning of the labor. This is usually done by a
portable unit, but if it’s necessary for a patient
to be transported to another department to
have this done, be certain someone
accompanies them, so, if labor should become
more active, they can be returned quickly to
the labor or birth service for needed care.
ASSESSING RUPTURED MEMBRANES
✔ One out of every four labors begins with spontaneous rupture of the fetal membranes.
When this occurs a birthing parent feels a sudden gush or a slow trickle of amniotic
fluid from their vagina. If the fluid expelled was only a small amount, there may be a
question as to whether the membranes have ruptured.
✔ A sterile vaginal examination using a STERILE SPECULUM usually reveals whether
amniotic fluid is present in the vagina. After vaginal secretions are obtained with a
sterile, COTTON-TIP APPLICATOR, test them with a strip of NITRAZINE paper.
✔ VAGINAL SECRETION are acid; AMNIOTIC FLUID, in contrast, alkaline.
✔ If the patient membranes ruptured at home, ask them to describe the color of the
amniotic fluid, the amount, the odor, and the approximate time of rupture.
✔ Fetus with meconium staining needs immediate assessment. After birth, infant needs
continues close assessment to rule out possible meconium aspiration.
✔ If fluid is malodorous, there could be an infection.
✔ If membranes ruptured during labor, assess FHR immediately to be certain the umbilical
cord hasn’t prolapse and is now being compressed against the cervix by the fetal head.
✔ Time of rupture is important because potential time clock of an infection begins with
ruptured membranes. Preferably, baby is born within 24 hours of rupture to reduce risk
of infection.
ASSESSMENT OF PELVIC
ADEQUACY
✔ Evaluating pelvic adequacy using internal
conjugate and ischial tuberosity diameters
is generally done during pregnancy either
manually or by sonogram; so by 32 to 36
weeks of pregnancy, a primary care provider
can be alerted that cephalopelvic
disproportion could occur. Because the
diameter obtained during pregnancy have
not changed, they are not retaken if already
obtained.
 VITAL SIGNS
Vital signs are taken at the beginning and periodically during
labor.
TEMPERATURE
-Usually obtained every 4 hours during labor. Report temperature greater than 99F (37.2 C)
because it may indicate infection. Unless there are accompanying symptoms, however,
temperature elevation in patient who has taken in fluid by mouth usually reflects dehydration
(urge them to drink at least sips of water to maintain hydration).
PULSE AND RESPIRATION
- Should be measured and recorded at the same time intervals as temperature.
- A persistent pulse rate of more than 100bpm could be tachycardia from dehydration or
hemorrhage and so needs investigation.
-Do not count respiration during contraction because patients tend to breathe rapidly from pain.
Conversely, if a patient is using controlled breathing to decrease pain in labor , their RR during
contraction can be abnormally slow.
-Observe for hyperventilation (rapid, deep respiration) because prolonged hyperventilation can
cause a “blowing off” of CO2 and accompanying symptoms of dizziness and tingling of hands and
feet. Rebreathing into a paper bag and reassurance the feeling is normal help to reverse this
process.
 VITAL SIGNS
Vital signs are taken at the beginning and periodically during
labor.

BLOOD PRESSURE
-Measured and recorded every 4 hours as well and should be measured between contraction,
both for patient’s comfort and for accuracy, because maternal blood pressure tends to rise
5-15mmHg during contraction.
- If a patient received analgesic agent( meperidine) , which tend to cause hypotension, check the
BP every 15 mins after administration to be certain extreme hypotension did not occur.
 LABORATORY ANALYSIS

BLOOD
-blood is draw from Hemoglobin and Hematocrit, a serologic test for syphilis (Venereal Disease
Research Laboratory test), Hepatitis B antibodies, and blood typing to determine whether a
blood incompatibility is likely to exist in the newborn and what type of blood will need to be
supplied if the patient have an acute blood loss.

URINE
-Obtain a clean-catch urine specimen and test it at the point of care for protein and glucose, then
send it to laboratory for complete urinalysis.
 THE ASSESSMENT OF UTERINE
CONTRACTION
LENGTH OF CONTRACTION
Time the duration of the
contraction from the moment
the uterus first tenses until it
has relaxed again.
INTENSITY OF CONTRACTION FREQUENCY OF CONTRACTION
Refers to its strength. On the Time the frequency of
monitor this is the height of the contraction or how often they are
waveform .If you are assessing occurring. Frequency is timed from
manually, rate the contraction the beginning of contraction to the
according to: beginning of the next
❑ MILD, if the uterus does not feel
more than minimally tense.
❑ MODERATE, if the uterus feels
firm.
❑ STRONG, if the uterus feels as
hard as a wooden board or you
are unable to indent the uterus
with your fingertips at the peak of
the contraction.
 THE INITIAL FETAL ASSESSME
AUSCULTATION OF THE FETAL
HEART SOUNDS
Fetal heart sound are transmitted
best through the convex portion of the
fetus because that is the part that lies
in closest contact with the uterine
wall.
Hearing fetal heart sounds
confirms that the fetus is responding
well to labor but also provides
confirmatory information about fetal
position. Conversely, recognizing fetal
position aids in locating fetal heart
sounds. Illustrate where fetal heart sounds radiate best from various fetal position
 THE INITIAL FETAL ASSESSME
INITIAL ELECTRONIC MONITORING
Non invasive, easily applied, and
does not require cervical dilation or
fetal descent before it can be used so
that it can be introduced any time
during labor. The presence and
duration of UC is gained through a
pressure transducer or
tocodynamometer (toko is Greek for
“contraction”) strapped to the patient’s
abdomen or held in place by
stockinette.
External Electronic Monitoring in place. Two devices ( A transducer for the
uterus and an ultrasound sensor for the fetus) are strapped on the patient’s
abdomen
Nursing Care
related to
Stages of
Labor
 CARE OF PATIENT DURING FIRST
STAGE OF LABOR
Providing emotional support, encouraging communication
EMPOWER about their preference, and involving them in decision making.
BIRTHING PARENTS Educating them about labor process and offering coping
strategies can enhance their confidence. Additionally, promoting
positive birthing environment and respecting their choice
contribute to a more empowered experience.

Do not interrupt patient who is in the middle of breathing

exercises during labor to perform any procedures or ask
RESPECT
questions because, once their concentration is disrupted, they
CONTRACTION TIME
will feel the pain of the contraction.

A birthing sling or rebozo, is along piece of fabric that can be

slipped under the pregnant back as they lie supine or over the
abdomen if in a hand-and-knees position. A support person uses
HELP WITH FETAL the sling to gently rock the pregnant abdomen , a technique
ALIGNMENT which is advocate as also helping a fetus move into good
alignment with the pelvis
 CARE OF PATIENT DURING FIRST
STAGE OF LABOR
Encourage birthing parent to change positions regularly
HELP WITH FETAL because it can aid in optimal fetal positioning. Guiding the pelvic
ALIGNMENT tilts or suggesting specific position, such as hand and knees, may
also optimize baby’s alignment.

Full bladder or bowel can impede the fetal descent , so

PROMOTE VOIDING encourage the patient to void, if possible, at least every 2-4 hours
AND PROVIDE during labor. Remind your patient to void, because they may
BLADDER CARE mistakenly interpret the discomfort of a full bladder as part of
the sensation of labor.
 CARE OF PATIENT DURING SECOND
STAGE OF LABOR
Focus on creating a comfortable and safe environment for
PREPARING THE the delivery. Ensure the birthing area is clean, well-lit, and
PLACE OF BIRTH equipped with necessary supplies. Set up delivery bed with clean
lines, have medical instruments ready. Maintain a calm
atmosphere to support the birthing person, and be prepared to
assist as needed during delivery process.

More effective birth position include the lateral. Or Sim’s

position, dorsal recumbent position, semi –sitting, or squatting.
POSITIONING FOR
Using these positions plus warm compresses to the perineum
BIRTH
place less tension on the perineum and result in fewer perineal
tears.
A patient should wait to feel the urge to push even though a
pelvic exam has revealed they are fully dilated. Pushing is best
done from a semi-fowler position with leg raised against the
PROMOTING EFFECTIVE abdomen, squatting, or on all fours rather than lying flat to allow
SECOND-STAGE gravity to aid the effort. Make sure that the patient pushes with
PUSHING contraction and rest between them. They can use short pushes
or long, sustained ones, whichever feels more comfortable.
 CARE OF PATIENT DURING SECOND
STAGE OF LABOR
Massaging the perineum as the fetal head enlarges the
vaginal opening helps to keep it supple and prevent tearing. To
PERINEAL remove vaginal or rectal secretion, clean the perineum with a
CLEANING AND warmed antiseptic such as Iodophor (cold solution cause
MASSAGE cramping) and the rinse the area with sterile water. Always clean
from the vagina outward using a clean compress for each
stroke, be certain to include the wide area.

CUTTING AND Cutting the cord is part of the stimulus that initiate the first
CLAMPING THE CORD breath or marks the newborn’s most important transition into the
outside world, the establishment of independent respirations.

After the cord is cut, it is time for the new parents to spend
quality time with their newborn. Infant can remain on the birthing
parent’s abdomen for skin-to-skin contact. This initial contact is
INTRODUCING THE also an optimal time to begin breastfeeding because an infant
INFANT seems to be hungry at birth, and sucking at the breast stimulates
the release of endogenous oxytocin, encouraging UC and
involution, or the return of uterus to its prepregnant state.
Time intervals for nursing interventions during
second stage of labor
CARE OF PATIENT DURING THIRD &
FOURTH STAGE OF LABOR
After delivery, the placenta is inspected to be certain it is
THE DELIVERY OF intact without gross abnormalities and that no cotyledons remain
THE PLACENTA in the uterus. Normally, placenta is one-sixth the weight of the
infant.
After placenta inspection, if the birthing parent’s uterus has
not contracted firmly on its own, the primary care provider ill
massage the fundus to urge it to contract. Oxytocin(Pitocin 10
units) may be prescribe to be administered IM or per 1,000mL
IV fluid to also help contraction.

To be certain that the perineum did not tear from the

PERINEAL pressure of the fetal head, perineum is carefully inspected after
INSPECTION birth. Perineal tears are rated grade 1 to grade 4, grade 1 being
minimal and grade 4 extending to and including the rectum.
Most are small enough that no suturing is needed. If a tear is
large enough, a patient has enough natural perineal anesthesia
from pressure of the fetal head or enough epidural anesthesia
that they will not feel pain from suturing. If they do have pain, a
local anesthetic, usually lidocaine, can be given to make the
process pain- free.
 THE IMMEDIATE POSTPARTUM
ASSESSMENT AND NURSING CARE
✔ Obtain VS every 15 minutes for the first hour and then
according to agency policy or the patient’s condition.
✔ Wash the perineum with the agency-designated
solution and apply a perineal pad.
✔ Palpate the fundus for size, consistency, and position
and observe the amount and characteristic of lochia
each time you record vital sign.
✔ Offer a clean gown and a warm blanket because a
birthing parent often experiences chills and a shaking
sensation 10-15 minutes after birth.
Thank you

PREPARED BY:
CUAJAO, ANNAVERJOY,G.-BSN2A