[silence]
[music]
-The primary goal of family-orientedmaternity care is the maximum safety,
health and welfare of each mother and infant.
Within its framework, the nurse clinician promotes a safe environment
and provides care which supports the family as an open system,
thus enabling each parentto participate to the degree desired
during the childbearing experience.
[silence] The nurse's responsibilityto the family
during the first stage of labor involved physical comfort,
emotional support of both parentsand assessment of maternal
and fetal response to the labor process.
A plan of care for the Shimons was developed
from information gathered prenatallyon admission
and during the first stage of labor.
Mrs.Sandra Shimon is a 30-year-old Gravita 3, Para 2
admitted with ruptured membranes on March 18th at 7:30 AM.
Her blood type is O Rh negative.
All prenatal titers were negative.
Physical assessment findingswere within normal limits on admission.
During the first seven hoursof the latent phase of labor,
there was minimal change in the status of the cervix
and the descent of the fetus.
An IV solution containing oxytocicmedication was begun by Dr. Hendee
at 12:30, and there wasmarked acceleration of the dilatation
and descent patterns by 2:30 PM,indicating that the active phase had begun.
Mrs. Shimon received 25 milligrams of Demerol at four o'clock,
which allowed her to rest between contractions.
The Shimons expressed the desire for an awake delivery with a pudendal block,
and a plan of care was initiated to help them achieve this goal.
Mr. Shimon decided that he wanted to attend the delivery,
and the decision was supportedby the attending physician and the nurse.
Mrs. Shimon was transferred to the delivery room at 5:30
when the cervixwas eight centimeters dilated,
and the fetus was at plus two centimeters.
The second stage of labor began at 6 PMwhen the cervix reached full dilatation.
A cursory check of all equipmentprior to the delivery
should be made by the nursewho may need to use it.
The heat cradle, suction, oxygen, and resuscitation equipment
should be functional even thoughit may not be used for all deliveries.
Stock medications, light bulbsand batteries should be readily available.
A summary of pertinent data and identified problems
are recorded on the delivery record,as this information
will influence the managementof both the mother and the newborn.
A comprehensive delivery record can serve as a source of communication
between personnel and services.
Although there are many task to be accomplished
prior to the delivery of the infant,the nurse's primary responsibility
is the continued monitoringof the mother and fetus
as well as providing emotionalsupport to the Shimon's efforts
during the second stage of labor.
Coaching the awake mother involves
keeping in close contact both physically and verbally,
as most women withdraw inwardly in an effort to maintain control of their actions.
When the fetal partis pressing on the perineum,
the awake mother feels tremendous pressure and an uncontrollable desire to push.
A rapid second stage is often encountered in the multiparous,
thus careful coaching is necessary to prevent tearing as the fetus crowns.
-Keep panting, keep panting,keep panting.
Keep panting, keep panting, keep panting, keep panting.
You're doing beautiful.
Beautiful.
Keep panting, keep panting, keep panting, keep panting.
Easy.Keep panting.
That's right.
Contraction's [?].
Deep breath and relax.
[?] That's good.
I told you to play [?].
Just concentrate on it like a little puppy, [?] like a little puppy dog.
You're doing beautifully.
You're going to have that baby soon.
You're going to have plenty of [?] clean.
[?] the doctor, he's already scrubbed.
He's got [?].Everything's ready.
-[?].
-I know.This is as hard as [?].
It won't be any harder than it is right now.
It's all right.
It's all right.
Now if you can reach downthere and hold [?].
-Yes.
-I'm here.
-Please don't panic because I've already taken care of that.
-[chuckles]
-Okay, you two.- All right.
-I'm so sorry I left you [?].
One more thing, [?] going to feela little needle stick and that's all.
That's the [?]-- [crosstalk]
Mrs. Shimon is informed whenthe pudendal anesthesia is to be injected
so that she's preparedfor any momentary discomfort that may occur.
She should also be informedwhen the episiotomy is performed,
as there is sometimes discomfort even though anesthesia has been injected.
-[groans] [pants]
-Good.
Keep panting, keep panting, don't give up.
[?] Keep panting fast [?] like a puppy.
-[pants] [groans]
-[?] like a puppy.
That's right.
[?] [?].
Beautiful, beautiful, beautiful.
-[groans]
-Oh, I got you.-Hand me a towel, please.
-Between contractions,
encouragement and positive feedbackfrom the nurse and Mr. Shimon
help Mrs. Shimon prepare for the next contraction.
-You're doing great.-Beautiful job.
-[?], you're doing beautiful.
Doing beautiful.
-[?] I don't want you to push at all.
-Don't push.-No.
[?] Dr. Hendee's all ready.
-[groans]-[?]
-[groans]
-It's 6:30.
[?] little boy?
Looks like a boy.
[?].
It's a girl.
-Hallelujah.
-We got a girl.
-[?] listen to that cry.
Oh [?].
-The second stage of labor endswith the delivery of the infant,
and the third stage begins.
This stage brings added responsibilityto the nurse and delivery room staff,
as there are now two patients and care for each is going on concurrently.
-All right.
-[?] You'll have that one more pain.
You take about [?].
-Hi.
-We got a girl.
-She's beautiful.
What's with the white stuff?
[?] Oh, I'm going to move my arms up.-[?].
-She's about to be on her own.[?]
-She looks like a [?] baby.
-[?] Get ready for the [?].
-All right.
-[?].
-She's going to go over to a heated bath now.
[?].
-Oh, God.-I'm going to go over to the baby now, honey.
-Initial assessment of baby girl Shimon follows the Apgar format,
and has begun one minute after delivery.
Heart rate, respiratory rate, muscle tone, reflex irritability,
and color are evaluated on a scale from zero to two.
[baby crying]
The priorities of delivery room care to the newborn
are to establish respirations, to monitor the cardiovascular system,
and to provide temperature regulation and support.
Because Mrs. Shimon is Rh negative, blood for Rh typing
and Coombs tests are collected from the cord.
Care is taken to prevent mixing of the maternal blood
and fetal blood during this procedure.
An overall appraisal of the infant for anomalies
and birth injuries should be done immediately.
The number of cord vessels should be noted
and the cord stump checked for oozing.
The five-minute Apgar score is particularly important
as it quantitatively evaluates
how the infant is adapting to the extrauterine environment.
A decrease in Apgar score indicates that the infant
is encountering difficulty in this adaptation.
The third stage of labor is dangerous for the mother
because of the possibility of postpartum hemorrhage
and resultant hypovolemic shock.
The uterus continues to contract at regular intervals
after the baby has been delivered.
As it contracts, the area of placental attachment is reduced.
The maternal surface of the placenta folds and causes separation to take place.
Bleeding occurs in the placenta folds and facilitates further placental separation.
As the placenta moves downward into the lower uterine segment,
the uterus becomes firm and [?] in shape.
Expulsion of the placenta can usually be accomplished
by having the patient bear down in the same way she did
during the birth of the baby.
If the mother is unable to assist the physician,
the nurse may be requested to assist.
After expulsion of the placenta, the large vessels within the uterus,
especially those in the placental site are open and gapping.
The nurse must recognize the necessity
for the uterus to contract and stay contracted.
By ascertaining the consistency of the fundus
and its height in relation to the umbilicus,
the nurse can identify subtle changes in the uterus
and can inform the physician of these changes.
Postpartum hemorrhage is associated with uterine atony,
lacerations, or retained placental fragments.
The delivery of the placenta marks the end of the third stage of labor.
The type of oxytocic, the route of administration,
and the time at which it is to be given will vary with individual physicians.
The nurse should be familiar with the routine of the delivering physician
so that the drug or drugs are administered as he requests.
Each mother will respond to the delivery of her infant
in a very individualized way.
The nurse should recognize this individualism
and give feedback to the mother that will support her
as she sorts through the experience.
The fourth stage of labor begins after expulsion of the placenta
and terminates at the end of the next hour.
The nurse should be alert to signs
that indicate uterine relaxation or hemorrhage is occurring.
Changes in vital signs after expulsion of the placenta
may also indicate that bleeding is occurring.
Vital signs should be reported to the physician.
During delivery procedures,
the father can again provide both emotional and physical support.
This was the first time that Mr. and Mrs. Shimon
shared the experience of delivery.
Their apparent pleasure and excitement in the achievement of their goal
seem to have provided positive input into their family system.
-Wham, I could feel it.
I was scared though but I knew.
That's what I was always afraid of, [?].
[baby crying]
-The recording of the delivery data
should include pertinent information and evaluations.
Baby girl Shimon was delivered in the LOA position spontaneously.
There was no difficulty encountered
and there was minimal blood loss prior to delivery of the placenta.
The Apgar score at one minute was nine and at five minutes was 10.
Respirations occurred spontaneously.
The nose and mouth were aspirated.
No anomalies were noted and three cord vessels were present.
Admission procedures were then carried out.
The placenta was delivered spontaneously at 6:36,
making the length of the total labor 12 hours and six minutes.
A midline episiotomy was repaired and the cervix ascertained to be intact.
The uterus was explored for lacerations and retained placental fragments.
The blood loss was estimated at 250 ccs.
The placenta weighed 523 grams.
Cord blood specimens were obtained.
The blood pressure was stable at 120/70 with a pulse rate at 72.
The fundus was well contracted and firm.
Flow was minimal.
There was no apparent swelling or discoloration of the perineum,
nor was there bleeding from the suture line.
The nurse has a responsibility for facilitating early parent-infant interaction.
The condition of the mother and the infant
should be considered before allowing the parents
to hold their infant in the delivery room.
The parents have a need to establish the baby's identity as an individual
with a specific sex and to separate the real baby from the baby of prenatal fantasy.
Touching and holding the infant helps them identify this infant as their own.
[baby crying] [baby crying] [baby crying]
If there are maternal complications or the mother is sedated,
the nurse should make arrangements for maternal contact with the infant
as soon as the mother's condition allows.
The father should be allowed to hold the infant if he desires.
If the infant is small for gestational age, premature,
or is experiencing respiratory difficulties,
then the safety of the infant must take priority.
If the baby's condition prevents the parents from holding their infant,
the nurse must communicate this to the postpartum staff
so that arrangements can be made for the mother or father
to be taken to the infant as soon as possible.
If the infant has a defect,
the parents may wish to see or hold the infant,
and this should not be denied them.
They may imagine a defect to be many times worse than is actually present,
and a delay in showing them the infant may cause them unnecessary anguish.
When there is a complication present in the newborn that threatens life,
the parents are aware of what is happening in the delivery room
and their concerns cannot be overlooked.
The nurse can and must talk to the parent about what is happening
and what is being done.
This is particularly important
if the obstetrician is involved in caring for the infant.
Nursing care of the mother-infant unit may be carried on concurrently
if the mother and infant are allowed to remain
in the rooming-in situation through recovery.
In most situations, however,
the mother and infant are separated at this point
so that each may recover from the birth process
under close supervision of skilled nursing staff.
-Hi, Janice.
-Congratulations.
-Thank you.
-Did you have a chance to count all those things [?]?
-They're all right.
-[?] nurse for now.
Now check your band numbers to hers?
Why don't you read up your number?
[?] it's on her IV.
6722-
-722?
--6766.
-[?]
[baby crying]
19817 [?].
You can have her back in a little while.
[baby crying][?].
-[coughs]
-She'll be right around the corner, in nursery.
-Mrs. Shimon has requested rooming-in with plans to breastfeed,
so they will be reunited when Mrs. Shimon is settled in her room.
One of the primary goals of the recovery period,
is the promotion of rest, relaxation, and comfort.
When the mother has been made physically comfortable,
an assessment of her physical response to the labor process should be undertaken.
Vital signs take on an added dimension
during the fourth stage of labor as anesthesia, analgesia,
and oxytocic medications may cause the blood pressure and pulse to fluctuate.
The mother's abdomen, particularly the fundus, are very sensitive,
and the nurse should be gentle as possible when palpating or massaging the fundus.
The fundus should lie in the midline at, or slightly above the umbilicus.
If it lies to one side of the midline,
the bladder should be checked for signs of distension.
The perineum is inspected for evidence of swelling and discoloration.
A perineal or perineal vaginal hematoma
occurs when there is interstitial bleeding.
If a hematoma continues to swell,
the mother will have severe tenderness when the area is touched.
The physician should be notified immediately,
as hematomas can grow to the extent that the mother
will exhibit signs of circulatory shock.
-[?] bleeding now.
Could you turn on your side, and lift your hip just a little bit?
Little bit more.
That's right.
Oh, you're not having very much bleeding at all.
Everything's normal.
I'll clean you up a little bit and put a clean pad down.
[?]
You can lie on your back--
-The amount, color, consistency, and odor of the lochia should be checked.
The flow may tend to accumulate under the buttocks,
so turning the patient on the side may be necessary
for a thorough evaluation of the amount of flow.
-How do you two feel about that experience y'all just went through?
-Fantastic.
-Was it what you had expected?
-No.
Not really.
The last part was a lot more sudden than I expected.
-How do you feel about your decision then,
to have an awake delivery, now that it's over?
-Now that it's over, I think it was a good idea.
I wouldn't trade it for anything.
-An assessment of the Shimons' response to the delivery process indicates
that they are pleased with their accomplishment.
Both parents show signs of fatigue as well as excitement.
Their need for rest can be facilitated by the nurse.
Physical comfort, a quiet meal, and reassurance from the nurse
can set the stage that allows them to sort out the experience of childbirth,
which generally precedes relaxation and rest.
The nurse's responsibility to the family during the second stage
of labor involves observation for strict aseptic technique,
and provision of a safe environment within the delivery room.
She provides emotional support, physical comfort,
guidance, and information through the transition phase,
and continues to monitor maternal and fetal response to the labor processes.
The delivery of the infant marks the beginning of the third stage.
The nurse now has concurrent responsibilities.
She must often set priorities of care based on assessments
of the mother and the infant.
The nurse shares with the parents in their response to the delivery of the infant.
She continues to provide them with information
and emotional support as they respond to the delivery situation.
The nurse also provides any necessary assistance
with expulsion of the placenta and assesses the physiological response
for signs of uterine relaxation or bleeding.
Nursing responsibility to the newborn include establishment of respirations,
monitoring of the cardiovascular system, temperature regulation and support,
assessment of the infant's adaptation to extra-uterine life,
and assessment for anomalies and birth injuries.
She ensures the proper identification of the infant
and provides prophylactic eye care.
The expulsion of the placenta marks the end of the third stage
and the onset of the fourth and final stage of labor.
In the fourth stage, the nurse facilitates early parent-infant interaction,
if the parents desire,
and the mother and infant are recovering in a normal pattern.
She provides physical comfort and nourishment,
which establishes an atmosphere that promotes rest and relaxation.
The nurse monitors the mother's physiological
and behavioral responses as adaptation to the birth process continues.
This surveillance includes observation for signs of hemorrhage
and early indications of infection, excessive fatigue,
or emotional excitement that may inhibit rest.
Nursing responsibility to the childbearing family
continues during the postpartum period.
A plan of care that meets the parents'
and infant's needs during adaptation to the birth process
is the primary goal of nursing intervention.
[silence]