CONDUCT OF NORMAL LABOR

Definition: A procedure done to monitor the progress of labor for the safe delivery
of the mother and the baby.

Purpose:
To monitor progress in labor
For safety of both mother and the baby
To promote comfort

Principles:
To provide privacy
Position patient properly
Explain the procedure to the patient

Equipments:
BP Apparatus Drapes Perineal Care Tray
Shaver Sterile Gloves
 CONDUCT OF NORMAL LABOR
1. Welcome the client and her partner, then introduce self.
- To show respect
2. Changes the client’s dress and place her personal belongings in a safe
place or give them to her partner.
- To prepare for delivery
3. Review her prenatal record and check the significant data.
- To have an idea on what to expect
4. Asses when the labor started, if the membranes have ruptured, if blood
has come out, if there are compilations that may require treatment,
and the client’s psychological response during this phase.
- To prepare and obtain significant data
5. Put the client to bed if the membranes have already ruptured.
- To prevent dry labor
6. Asses the progress of the labor.
A. Check the fetal presentation, position and engagement
- There are factors affecting success labor and delivery
B. Contractions: time begun, duration, intensity, frequency, and
regularity
- To check if contraction is normal
C. Check the vital signs
- To monitor patient’s condition
D. Complete the vaginal examination.
- To monitor patient’s condition
E. Recheck for allergies, edema
- To monitor patient’s condition
F. Check her dietary intake for the last 2 hours.
- To check if the mother eat something to complicate the delivery
G. Check for the bladder distention every 2 hours.
- To increase maternal comfort
H. Observe the character of amniotic fluid, discharges, and if the
rupture of the bag of water ( BOW ) has already occurred.
7. Provide the comfort measures.
A. Clean the vulva after the vaginal examination
- Prevents accumulation of any microorganisms.
B. Shave the perineum.
- Decrease possibility of any infection.
C. Give the enema based on the doctor’s order.
- Provide stimulation of bowel activity & cause emptying of lower
D. Check the lights in the labor room.
- Provide good lighting & promote better exposure and visualization
E. Provide touch.
- To provide non pharmacological pain management.
8. Teach ( coach ) the patient with the proper breathing techniques and
the bearing down efforts.
- To reduce pain contraction
9. Take note of the following indicating the beginning of the second
stage of labor.
A. Increase in bloody show
- Indicates the membrane has already rupture
B. Feeling of pressure in the perineum.
- Indicates the head is already at the pelvic inlet
C. Frequent regular close contractions.
- Indicates movements of fetus downward to the inlet
D. Increase in perspiration, client cries.
- Indicate pain
E. Complete dilatation of cervix
- Indicates that the cervix is ready for delivery
F. Bulging of the perineum
- Indicates the head of the fetus
10. Take / Transfer the client to the Delivery Room ( DR ) table when
signs above are noted. Call the physician.
- To prepare client for delivery
 Delivery Circulating Nurse
Definitions: The one who facilitates and prepare equipment, assist the
doctors clear all the equipment.

Purposes:
To facilitates successful delivery
to safeguard the mother and the baby

Principles:
Wash hands before and after the procedure
Never touch the sterile equipment

Equipment:

Gown Ice capsMask Methergin Bonnet

Shoulder Brace Stirrups BP set
 DELIVERY CIRCULATING NURSE
1. Put on gown, mask and bonnet.
- To protect yourself form spreading of microorganism
2. Assist the patient to the delivery table. Place on the Lithotomy
position
- To prepare the patient for delivery
3. Adjust the shoulder brace. Fasten the wristlets. Fasten the two
stirrups. Switch on the lights. Expose the perineum
- For the safety of the patient upon delivery
4. Do the perineal care
- To wash away any vaginal secretion
5. Drape the patient and expose only the necessary parts
- To provide comfort and privacy
6. Prepare instrument (if it’s not done by the handling nurse )
- To ready the equipment to be used
7. Intrapartum: check the blood pressure, observe the reactions,
anticipate the needs of the patient and the handling nurse
- To monitor the BP of the patient
8 After the delivery of the baby:
- For record purposes
A. Check the time of the delivery with the scrub nurse
- For accurate data
B. Check the baby’s sex with the scrub nurse who actually touched
the external genitalia
- For accurate data
C. Bring the newborn to the nursery. Endorse the baby to the nurse
for the immediate newborn care
9. Check the blood pressure immediately after the placental
explosion
- To monitor the BP of the patient
10. Inject the methergin 1 ampule intramuscularly
- To closed the cervix
11. Clean the perineum and apply the perineal pad. Apply the icecap
over the hypogastrium
- For good hygiene and for the constriction
12. Check the blood pressure. Then help in transferring the mother to
the stretcher
- To monitor the 4th BP and for the patient’s safety
13. chart: time, type of the delivery, time and mechanism of the
placenta explosion, completeness of the placenta, type of
perineal laceration, condition of the mother type of the IV fluid,
medication given of there are any and the condition of the uterus
- For documentation purposes
 BLOOD TRANSFUSION
Definition: The infusion of whole blood or blood component being
donated by a healthy person into a recipient vein.

Purposes:
To restore total blood volume
To restore the capacity of the blood
to provide plasma factor
Principle:
Observe sterility
Take and monitor vital signs
Verify client’s condition
Explain the procedure to the patient
Equipments:
Pack of RBC Blood Set
Plaster Towel
Tourniquet
Splint
 BLOOD TRANSFUSION
1. Check order and explain the procedure to the patient
- To prevent error and for correct administration of blood
2. Get blood in the laboratory and check for the blood type. cross-match,
Rh, serial number, amount and VDRL. Warm blood by wrapping with
towel. After it is warmed attached blood set into the blood pack and let
blood flow into the tubing only until 2 inches away from the tip of the
blood set
- To avoid adverse effect and injection during blood transfusion
3 Attach butterfly and bring equipment to bedside
- To save time and effort
4 Place patient flat on bed. Obtain and record baseline vital signs
- For proper injection and to know the reaction
5. Prepare infusion site. Select a large vein that allows patient some
degree of mobility
- For easy insertion
6. Assist doctor in venipuncture. ( Same as assisting the doctor in
intranenous infusion)
- For faster insertion
7. Regulate flow rate to 10 – 15 drops per minute for 15 – 30 minutes. If
there are no signs of adverse reactions or circulatory overloading
the infusion rate is regulated according to doctor’s order
- To determine adverse reaction
8 Observe patient closely and check vital signs every 15 minutes for
the first one hour and then hourly
- To monitor the condition of the patient
9 If any reaction is observed. close transfusion and report to the
physician immediately
- To avoid incident
10. Recheck the following information on the patient’s chart
- For proper documentation
A. Blood type and volume transfused
- To document all relevant data
B. Serial number
- To document all relevant data
C. Time transfusion started and ended
- To document all relevant data
D. Patient’s reaction or patient’s immediate response
- To document all relevant data
E. Physician who started the transfusion
- To document all relevant data
PREECLAMPSIA
&
ECLAMPSIA
 Mild Preeclampsia
• A woman is said to be mildly preeclamptic when her blood pressure
rises 30 mmHg or more systolic or 15 mmHg or more diastolic above
her prepregnancy level, taken on two occasions at least 6 hours apart.
The diastolic value of blood pressure is extremely important to note
because it is this pressure that best indicates the degree of peripheral
arterial spasm present.

• If a woman developed a blood pressure of 140/90 or over, she was

considered to have preeclampsia. This general rule is obviously less
meaningful than the comparison of an individual woman’s blood
pressure against her easrly pregnancy baseline.

• Edema also may be present. This develops because of the protein

loss, sodium retention, and a lowered glomerular filtration rate. Edema
begins to accumulate in the upper part of the body, rather than just a
normal ankle edema of pregnancy.
 Severe Preeclampsia
• A woman has passed from mild to severe preeclampsia when her
blood pressure has risen to 160 mmHg systolic and 110 mmHg
diastolic or above on at least two occasions 6 hours apart at bedrest
(the position in which blood pressure is lowest) or her diastolic
pressure is 30 mmHg above pregnancy level.
• Marked proteinuria, 3+ or 4+ on a random urine sample or more than 5
g in a 24 hour sample and extensive edema are also present.
• The extreme edema will be noticeable in the woman’s face and hands
as “puffiness’. It is most readily palpated over bony surfaces, such as
over the tibia on the anterior leg, the ulnar surface of the forearm, and
the cheekbones where the sponginess of fluid-filed tissue can be
palpated best.
 Nursing Diagnosis
• The nursing diagnosis used with hypertension of pregnancy are
numerous because the disease has such wide-ranging effects:
1. Altered tissue perfusion related to vasoconstriction of blood
vessels
2. Fluid volume deficit related to fluid loss to subcutaneous tissue
3. Risk of fetal injury related to reduced placental perfusion secondary
to vasospasm
4. Social isolation related to prescribed bedrest
 Nursing Intervention
for Mild Preeclampsia
• Promote Bedrest
When the human body is in a recumbent position, sodium tends to be
excreted at a more rapid rate than during activity. Bedrest, therefore, is the
best method of aiding increased evacuation of sodium and encouraging
diuresis.

Rest should always be in lateral recumbent position to avoid uterine

pressure on the vena cava and prevent supine hypotension syndrome.

• Promote Good Nutrition

Because the woman is losing protein in the urine, she needs a high-protein
diet. At one time, stringent restriction of salt was advised to reduce edema.
This is no longer true because stringent sodium restriction may activate the
renin-angiotensin-aldosterone system and result in increased blood pressure,
further compounding the problem.
 Nursing Intervention for Mild
Preeclampsia
• Provide Emotional Support
It is difficult for a woman with preeclampsia to appreciate the potential
seriousness of symptoms because they are still so vague. Neither high blood
pressure nor protein in urine is something she can see or feel. She may be
aware that edema is present, but it seems unrelated to the pregnancy. It is her
hands that are swollen, not a body area near her growing child.

The woman may have difficulty understanding the severity of the situation.
she may take instructions such as getting rest rather slightly. In addition, it is
not always easy to comply with an instruction such as get additional rest during
the day.
 Nursing Intervention for Severe
Preeclampsia
• Support Bedrest
1. The woman with severe preeclampsia should be admitted to a
private room so she can rest undisturbed by a roommate.
2. She should lie in lateral recumbent position as much as possible.
3. Be sure to minimize exposure to noise.
4. Place her in a room that is away from the sound of woman in labor
or the crying of infants on a postpartal unit.
5. Room should be darkened because a bright light can also trigger
convulsions.
6. Be certain the woman receives clear explanations of what is
happening and what is planned.
 Nursing Intervention for
Severe Preeclampsia
• Monitor Maternal Well-Being
The woman’s blood pressure should be taken frequently, at least 4
hours to detect any increase, which is a warning that her condition is
worsening. If blood pressure is fluctuating, it may need to be assessed hourly.
Obtain ordered blood studies (e.g. complete blood count, platelet count, liver
function, blood urea nitrogen, and creatine and fibrin degradation products) to
assess for renal and liver function and development of DIC, which often
accompanies severe vasospasm. Because she is at a high risk for premature
separation of the placenta and resulting hemorrhage, a type and cross match
or antibody screen for blood is usually drawn.
 Nursing Intervention for Severe
Preeclampsia
• Monitor Fetal Well-Being
Generally, single Doppler Auscultation are approximately 4-hour intervals
is sufficient at this stage of management. However, FHR may be assessed by
continuous fetal external monitor. The woman may have a nonstress test or
biophysical profile done daily to assess uteroplacental sufficiency. Oxygen
administration to the mother may be necessary to maintain adequate fetal
oxygenation and prevent bradycardia.

• Support a Nutritious Diet

The woman needs a moderate to high-protein, moderate-sodium to compensate
for the protein she is losing in urine. An IV fluid line should n\be initiated and
maintained to serve as an emergency route for drug administration as well as to
administer fluid to reduce hemoconcentration and hypovolemia.
 Nursing Intervention for Severe
Preeclampsia
• Administer Medications to Prevent Eclampsia
1. Hydralazine(Apresoline) – may be prescribed to reduce
hypertension. It acts to lower blood pressure by peripheral
dilatation without interfering with placental circulation. It can cause
tachycardia.
2. Diazoxide (Hyperstat) – may be used for its ability to produce a
rapid decrease in blood pressure. If vasopressors of this nature are
used, diastolic pressure should not be lowered below 80 to 90
mmHg or inadequate placental perfusion may occur.
3. Magnesium Sulfate – drug of choice to prevent eclampsia.
Classified as a cathartic, reduces edema by causing a shift in fluid
from the extra cellular spaces into the intestine. It also has a CNS
antidrepressant action, which lessens possibility of convulsions.
 Eclampsia
• This is the most severe classification of hypertension of pregnancy. A
woman has passed into this third stage when cerebral edema is so
acute that a convulsion or coma occurs. With eclampsia, maternal
mortality is as high as 20%.
• Eclampsia can result in death of the mother from cerebral
hemorrhage, circulatory collapse, or renal failure.
• Fetal prognosis in eclampsia is poor because of hypoxia and
consequent fetal acidosis. If premature separation of the placenta
from vasospasm occurs, the prognosis is even graver. If the fetus
must be delivered before term, all the risks of the immature infant will
be faced.
• In eclampsia, fetal mortality is approximately 10%. If eclampsia
develops, the mortality increases to as high as 25%.
 Nursing Diagnosis
• The nursing diagnosis used with hypertension of pregnancy are
numerous because the disease has such wide-ranging effects:
1. Altered tissue perfusion related to vasoconstriction of blood
vessels
2. Fluid volume deficit related to fluid loss to subcutaneous tissue
3. Risk of fetal injury related to reduced placental perfusion secondary
to vasospasm
4. Social isolation related to prescribed bedrest
 Nursing Intervention for
Eclampsia
• Tonic-clonic conculsioin
An eclamptic convulsion is a tonic-clonic convulsion that occurs in stages.
TONIC PHASE
After the preliminary signals, all the muscles of the woman’s body contract.
Her back arches, her arms and legs stiffen, and her jaw closes abruptly.
She may bite her tongue from the rapid closing of her jaw. Respirations will
be halted, because her thoracic muscles are held on contraction. Lasts
approximately 20 seconds. It may seem longer because the woman may
grow slightly cyanotic from the cessation of respirations.
INTERVENTION:
The priority of care for the woman with a convulsion is to maintain a patient
airway. Administer oxygen by face mask to protect the fetus during this
time of interval. Assess oxygen saturation via pulse oximeter. Apply an
external fetal heart monitor if not already in place to assess the condition of
the fetus. To prevent aspiration, turn the woman on her side to allow
secretions to drain from her mouth.
CLONIC PHASE
After the tonic phase of the convulsion, all the muscles of the
woman’s body begin to contract and relax, contract and relax, causing the
woman’s extremities to flail wildly (the clonic phase). She inhales and
exhales irregularly as her thoracic muscles contract and relaxes. She may
aspirate the saliva that collected in her mouth during the tonic phase if she
was not placed on her side or abdomen during this time. Her bladder and
bowel muscles contract and relax; incontinence of urine and feces may
occur. Although she begin to breathe during this stage, the breathing is
not entirely effective, her color may remain cyanotic and she may need
continued oxygen therapy, not for herself but for the fetus. The clonic
stage of a convulsion lasts up to 1 minute. Magnesium sulfate or diazepam
(valium) may be administered IV as an emergency measure at this time.
POSTICTAL STATE

The third stage of the convulsion is a postictal state. During

this stage, the woman is semi comatose and cannot be roused except
by painful stimuli for 1 to 4 hours. Extremely close observation is as
necessary during the postictal stage as it was during the first two
stages. If the convulsion caused premature separation of the placenta,
labor may begin during this period and the woman will be unable to
report the sensation of contractions. Also, the painful stimuli of
contractions may initiate another convulsion. Keep the woman on her
side so secretions can drain from her mouth. Give her nothing to eat or
drink by mouth. Remember that in coma hearing is the last sense lost
and her first one regained. Be aware that when talking at woman’s
bedside, she may be able to hear even though she does not respond.
Continuously assess fetal heart sound and uterine contractions. Check
for vaginal bleeding every 15 minutes. Evidence that placental
separation may have occurred will appear first on the fetal heart sound
record; vaginal bleeding will strengthen the presumption.
BIRTH

If the gestational age of the pregnancy is more than 24

weeks, a decision about delivery will be made as soon as a woman’s
condition stabilizes, usually 12-24 hours after the seizure. There is
some evidence that the fetus does not continue to grow after
eclampsia occurs. Thus, terminating the pregnancy at this point is
appropriate for both mother and child. For an unexplained reason,
fetal lung maturity appears to advance rapidly with hypertension of
pregnancy (possibly from the intrauterine stress), so even though the
fetus is younger than 36 weeks, the lecithin-sphingomyelin ratio may
indicate fetal lung maturity.
Cesarean birth is always more hazardous for the fetus because of
the association of retained lung fluid (see chapter26). Further, the
woman with eclampsia is not a good candidate for surgery. Becase
the vascular system is low in volume, the woman may become
hypotensive with regional anesthesia such as in epidural block.
The preferred method for birth, therefore, is vaginal. If labor does
not begin spontaneously, rupture of the membranes or induction
of labor with IV oxytocin may be instituted. If this is ineffective
and the fetus appears to be in imminent danger, the infant will be
delivered by cesarean birth.
POSTPARTAL HYPERTENSION

Pregnancy- include hypertension may occur up to 10 to 14

days after birth, although most postpartal hypertension accurs in
the first 48 hours after birth. Monitoring blood pressure in the
postpartal period is essential to detect residual hypertensive or
renal disease. Women who had elevation of blood pressure during
pregnancy need instruction about returning for a postpartal
checkup to have their post-pregnancy blood pressure evaluated to
be certain it has returned to normal.