WEBVTT

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[silence]

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[music]

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-The primary goal of family-oriented
maternity care is the maximum safety,

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health and welfare of each mother and infant.

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Within its framework, the nurse
clinician promotes a safe environment

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and provides care which supports
the family as an open system,

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thus enabling each parent
to participate to the degree desired

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during the childbearing experience.

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[silence] The nurse's responsibility
to the family

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during the first stage of labor
involved physical comfort,

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emotional support of both parents
and assessment of maternal

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and fetal response to the labor process.

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A plan of care for the Shimons was developed

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from information gathered prenatally
on admission

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and during the first stage of labor.

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Mrs.Sandra Shimon
is a 30-year-old Gravita 3, Para 2

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admitted with ruptured membranes
on March 18th at 7:30 AM.

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Her blood type is O Rh negative.

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All prenatal titers were negative.

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Physical assessment findings
were within normal limits on admission.

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During the first seven hours
of the latent phase of labor,

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there was minimal change
in the status of the cervix

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and the descent of the fetus.

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An IV solution containing oxytocic
medication was begun by Dr. Hendee

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at 12:30, and there was
marked acceleration of the dilatation

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and descent patterns by 2:30 PM,
indicating that the active phase had begun.

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Mrs. Shimon received 25 milligrams
of Demerol at four o'clock,

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which allowed her to rest
between contractions.

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The Shimons expressed the desire
for an awake delivery with a pudendal block,

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and a plan of care was initiated
to help them achieve this goal.

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Mr. Shimon decided
that he wanted to attend the delivery,

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and the decision was supported
by the attending physician and the nurse.

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Mrs. Shimon was transferred
to the delivery room at 5:30

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when the cervix
was eight centimeters dilated,

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and the fetus was at plus two centimeters.

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The second stage of labor began at 6 PM
when the cervix reached full dilatation.

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A cursory check of all equipment
prior to the delivery

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should be made by the nurse
who may need to use it.

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The heat cradle, suction, oxygen,
and resuscitation equipment

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should be functional even though
it may not be used for all deliveries.

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Stock medications, light bulbs
and batteries should be readily available.

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A summary of pertinent data
and identified problems

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are recorded on the delivery record,
as this information

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will influence the management
of both the mother and the newborn.

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A comprehensive delivery record
can serve as a source of communication

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between personnel and services.

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Although there are many task
to be accomplished

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prior to the delivery of the infant,
the nurse's primary responsibility

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is the continued monitoring
of the mother and fetus

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as well as providing emotional
support to the Shimon's efforts

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during the second stage of labor.

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Coaching the awake mother involves

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keeping in close contact
both physically and verbally,

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as most women withdraw inwardly in an effort
to maintain control of their actions.

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When the fetal part
is pressing on the perineum,

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the awake mother feels tremendous pressure
and an uncontrollable desire to push.

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A rapid second stage
is often encountered in the multiparous,

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thus careful coaching is necessary
to prevent tearing as the fetus crowns.

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-Keep panting, keep panting,
keep panting.

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Keep panting, keep panting,
keep panting, keep panting.

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You're doing beautiful.

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Beautiful.

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Keep panting, keep panting, keep panting, keep panting.

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Easy.
Keep panting.

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That's right.

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Contraction's [?].

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Deep breath and relax.

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[?] That's good.

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I told you to play [?].

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Just concentrate on it like a little puppy,
[?] like a little puppy dog.

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You're doing beautifully.

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You're going to have that baby soon.

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You're going to have plenty of [?] clean.

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[?] the doctor, he's already scrubbed.

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He's got [?].
Everything's ready.

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-[?].

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-I know.
This is as hard as [?].

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It won't be any harder than it is right now.

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It's all right.

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It's all right.

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Now if you can reach down
there and hold [?].

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-Yes.

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-I'm here.

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-Please don't panic
because I've already taken care of that.

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-[chuckles]

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-Okay, you two.
- All right.

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-I'm so sorry I left you [?].

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One more thing, [?] going to feel
a little needle stick and that's all.

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That's the [?]-- [crosstalk]

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Mrs. Shimon is informed when
the pudendal anesthesia is to be injected

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so that she's prepared
for any momentary discomfort that may occur.

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She should also be informed
when the episiotomy is performed,

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as there is sometimes discomfort
even though anesthesia has been injected.

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-[groans] [pants]

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-Good.

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Keep panting, keep panting, don't give up.

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[?] Keep panting fast [?] like a puppy.

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-[pants] [groans]

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-[?] like a puppy.

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That's right.
That's right.

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[?] [?].

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Beautiful, beautiful, beautiful.

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-[groans]

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-Oh, I got you.
-Hand me a towel, please.

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-Between contractions,

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encouragement and positive feedback
from the nurse and Mr. Shimon

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help Mrs. Shimon prepare
for the next contraction.

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-You're doing great.
-Beautiful job.

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-[?], you're doing beautiful.

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Doing beautiful.

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-[?] I don't want you to push at all.

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-Don't push.
-No.

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[?] Dr. Hendee's all ready.

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-[groans]
-[?]

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-[groans]

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-It's 6:30.

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[?] little boy?

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Looks like a boy.

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[?].

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It's a girl.

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-Hallelujah.

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-We got a girl.

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-[?] listen to that cry.

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Oh [?].

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-The second stage of labor ends
with the delivery of the infant,

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and the third stage begins.

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This stage brings added responsibility
to the nurse and delivery room staff,

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as there are now two patients
and care for each is going on concurrently.

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-All right.

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-[?] You'll have that one more pain.

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You take about [?].

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-Hi.

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-We got a girl.

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-She's beautiful.

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What's with the white stuff?

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[?] Oh, I'm going to move my arms up.
-[?].

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-She's about to be on her own.
[?]

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-She looks like a [?] baby.

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-[?] Get ready for the [?].

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-All right.

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-[?].

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-She's going to go over to a heated bath now.

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[?].

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-Oh, God.
-I'm going to go over to the baby now, honey.

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-Initial assessment of baby girl Shimon
follows the Apgar format,

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and has begun one minute after delivery.

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Heart rate, respiratory rate,
muscle tone, reflex irritability,

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and color are evaluated on a scale
from zero to two.

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[baby crying]

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The priorities of delivery room care
to the newborn

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are to establish respirations,
to monitor the cardiovascular system,

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and to provide temperature regulation
and support.

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Because Mrs. Shimon is Rh negative,
blood for Rh typing

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and Coombs tests
are collected from the cord.

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Care is taken to prevent mixing
of the maternal blood

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and fetal blood during this procedure.

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An overall appraisal
of the infant for anomalies

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and birth injuries
should be done immediately.

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The number of cord vessels should be noted

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and the cord stump checked for oozing.

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The five-minute Apgar score
is particularly important

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as it quantitatively evaluates

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how the infant is adapting
to the extrauterine environment.

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A decrease in Apgar score indicates
that the infant

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is encountering difficulty
in this adaptation.

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The third stage of labor
is dangerous for the mother

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because of the possibility
of postpartum hemorrhage

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and resultant hypovolemic shock.

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The uterus continues to contract
at regular intervals

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after the baby has been delivered.

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As it contracts, the area
of placental attachment is reduced.

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The maternal surface of the placenta folds
and causes separation to take place.

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Bleeding occurs in the placenta folds
and facilitates further placental separation.

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As the placenta moves downward
into the lower uterine segment,

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the uterus becomes firm and [?] in shape.

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Expulsion of the placenta
can usually be accomplished

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by having the patient bear down
in the same way she did

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during the birth of the baby.

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If the mother is unable
to assist the physician,

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the nurse may be requested to assist.

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After expulsion of the placenta,
the large vessels within the uterus,

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especially those in the placental site
are open and gapping.

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The nurse must recognize the necessity

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for the uterus to contract
and stay contracted.

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By ascertaining the consistency of the fundus

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and its height in relation to the umbilicus,

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the nurse can identify subtle changes
in the uterus

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and can inform the physician of these changes.

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Postpartum hemorrhage
is associated with uterine atony,

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lacerations, or retained placental fragments.

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The delivery of the placenta marks the end
of the third stage of labor.

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The type of oxytocic,
the route of administration,

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and the time at which it is to be given
will vary with individual physicians.

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The nurse should be familiar
with the routine of the delivering physician

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so that the drug or drugs
are administered as he requests.

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Each mother will respond
to the delivery of her infant

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in a very individualized way.

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The nurse should recognize this individualism

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and give feedback to the mother
that will support her

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as she sorts through the experience.

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The fourth stage of labor begins
after expulsion of the placenta

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and terminates at the end of the next hour.

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The nurse should be alert to signs

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that indicate uterine relaxation
or hemorrhage is occurring.

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Changes in vital signs
after expulsion of the placenta

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may also indicate that bleeding is occurring.

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Vital signs
should be reported to the physician.

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During delivery procedures,

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the father can again provide
both emotional and physical support.

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This was the first time
that Mr. and Mrs. Shimon

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shared the experience of delivery.

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Their apparent pleasure and excitement
in the achievement of their goal

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seem to have provided positive input
into their family system.

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-Wham, I could feel it.

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I was scared though but I knew.

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That's what I was always afraid of, [?].

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[baby crying]

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-The recording of the delivery data

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should include pertinent information
and evaluations.

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Baby girl Shimon was delivered
in the LOA position spontaneously.

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There was no difficulty encountered

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and there was minimal blood loss
prior to delivery of the placenta.

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The Apgar score at one minute
was nine and at five minutes was 10.

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Respirations occurred spontaneously.

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The nose and mouth were aspirated.

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No anomalies were noted
and three cord vessels were present.

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Admission procedures were then carried out.

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The placenta
was delivered spontaneously at 6:36,

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making the length of the total labor
12 hours and six minutes.

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A midline episiotomy was repaired
and the cervix ascertained to be intact.

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The uterus was explored for lacerations
and retained placental fragments.

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The blood loss was estimated at 250 ccs.

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The placenta weighed 523 grams.

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Cord blood specimens were obtained.

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The blood pressure was stable
at 120/70 with a pulse rate at 72.

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The fundus was well contracted and firm.

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Flow was minimal.

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There was no apparent swelling
or discoloration of the perineum,

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nor was there bleeding from the suture line.

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The nurse has a responsibility for facilitating
early parent-infant interaction.

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The condition of the mother and the infant

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should be considered
before allowing the parents

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to hold their infant in the delivery room.

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The parents have a need to establish
the baby's identity as an individual

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with a specific sex and to separate
the real baby from the baby of prenatal fantasy.

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Touching and holding the infant
helps them identify this infant as their own.

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[baby crying] [baby crying] [baby crying]

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If there are maternal complications
or the mother is sedated,

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the nurse should make arrangements
for maternal contact with the infant

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as soon as the mother's condition allows.

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The father should be allowed
to hold the infant if he desires.

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If the infant is small for gestational age,
premature,

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or is experiencing respiratory difficulties,

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then the safety of the infant
must take priority.

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If the baby's condition prevents
the parents from holding their infant,

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the nurse must communicate
this to the postpartum staff

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so that arrangements can be made for
the mother or father

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to be taken to the infant as soon as possible.

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If the infant has a defect,

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the parents may wish to see or hold the infant,

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and this should not be denied them.

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They may imagine a defect to be many times
worse than is actually present,

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and a delay in showing them the infant
may cause them unnecessary anguish.

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When there is a complication present
in the newborn that threatens life,

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the parents are aware of what is happening
in the delivery room

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and their concerns cannot be overlooked.

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The nurse can and must talk to the parent
about what is happening

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and what is being done.

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This is particularly important

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if the obstetrician
is involved in caring for the infant.

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Nursing care of the mother-infant
unit may be carried on concurrently

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if the mother and infant are allowed to remain

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in the rooming-in situation through recovery.

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In most situations, however,

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the mother and infant
are separated at this point

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so that each may recover
from the birth process

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under close supervision
of skilled nursing staff.

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-Hi, Janice.

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-Congratulations.

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-Thank you.

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-Did you have a chance
to count all those things [?]?

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-They're all right.

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-[?] nurse for now.

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Now check your band numbers to hers?

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Why don't you read up your number?

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[?] it's on her IV.

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6722-

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-722?

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--6766.

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-[?]

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[baby crying]

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19817 [?].

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You can have her back in a little while.

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[baby crying]
[?].

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-[coughs]

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-She'll be right around the corner,
in nursery.

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-Mrs. Shimon has requested rooming-in
with plans to breastfeed,

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so they will be reunited when
Mrs. Shimon is settled in her room.

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One of the primary
goals of the recovery period,

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is the promotion of rest,
relaxation, and comfort.

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When the mother has been
made physically comfortable,

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an assessment of her physical response
to the labor process should be undertaken.

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Vital signs take on an added dimension

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during the fourth stage
of labor as anesthesia, analgesia,

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and oxytocic medications may cause
the blood pressure and pulse to fluctuate.

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The mother's abdomen, particularly the fundus,
are very sensitive,

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and the nurse should be gentle as possible
when palpating or massaging the fundus.

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The fundus should lie in the midline at,
or slightly above the umbilicus.

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If it lies to one side of the midline,

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the bladder should be checked
for signs of distension.

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The perineum is inspected for evidence
of swelling and discoloration.

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A perineal or perineal vaginal hematoma

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occurs when there is interstitial bleeding.

21:15.687 --> 21:17.854
If a hematoma continues to swell,

21:17.937 --> 21:21.312
the mother will have severe tenderness
when the area is touched.

21:21.604 --> 21:23.854
The physician
should be notified immediately,

21:23.937 --> 21:26.271
as hematomas can grow
to the extent that the mother

21:26.354 --> 21:29.062
will exhibit signs of circulatory shock.

21:31.687 --> 21:33.062
-[?] bleeding now.

21:33.146 --> 21:38.312
Could you turn on your side,
and lift your hip just a little bit?

21:38.396 --> 21:39.979
Little bit more.

21:40.354 --> 21:41.812
That's right.

21:42.521 --> 21:45.021
Oh, you're not having
very much bleeding at all.

21:45.104 --> 21:46.187
Everything's normal.

21:46.354 --> 21:49.312
I'll clean you up a little bit
and put a clean pad down.

21:49.437 --> 22:13.646
[?]

22:13.729 --> 22:14.687
You can lie on your back--

22:14.729 --> 22:19.187
-The amount, color, consistency,
and odor of the lochia should be checked.

22:19.812 --> 22:22.854
The flow may tend to accumulate
under the buttocks,

22:22.937 --> 22:25.562
so turning the patient on the side
may be necessary

22:25.604 --> 22:28.646
for a thorough evaluation
of the amount of flow.

22:32.271 --> 22:35.604
-How do you two feel about that
experience y'all just went through?

22:35.729 --> 22:37.187
-Fantastic.

22:37.729 --> 22:39.521
-Was it what you had expected?

22:40.187 --> 22:41.437
-No.

22:42.146 --> 22:43.312
Not really.

22:44.854 --> 22:48.646
The last part was a lot more sudden
than I expected.

22:51.229 --> 22:52.771
-How do you feel about your decision then,

22:52.812 --> 22:54.646
to have an awake delivery,
now that it's over?

22:55.479 --> 22:57.687
-Now that it's over,
I think it was a good idea.

22:57.896 --> 22:59.812
I wouldn't trade it for anything.

23:00.396 --> 23:04.646
-An assessment of the Shimons' response
to the delivery process indicates

23:04.687 --> 23:06.812
that they are pleased
with their accomplishment.

23:07.521 --> 23:10.896
Both parents show signs of fatigue
as well as excitement.

23:11.396 --> 23:14.396
Their need for rest
can be facilitated by the nurse.

23:15.021 --> 23:19.104
Physical comfort, a quiet meal,
and reassurance from the nurse

23:19.187 --> 23:23.479
can set the stage that allows them
to sort out the experience of childbirth,

23:23.604 --> 23:26.479
which generally precedes relaxation
and rest.

23:28.687 --> 23:32.396
The nurse's responsibility
to the family during the second stage

23:32.479 --> 23:36.479
of labor involves observation
for strict aseptic technique,

23:36.562 --> 23:40.146
and provision of a safe environment
within the delivery room.

23:40.604 --> 23:43.771
She provides emotional support,
physical comfort,

23:43.896 --> 23:47.187
guidance, and information
through the transition phase,

23:47.354 --> 23:52.146
and continues to monitor maternal
and fetal response to the labor processes.

23:54.104 --> 23:57.729
The delivery of the infant marks
the beginning of the third stage.

23:57.979 --> 24:00.604
The nurse now
has concurrent responsibilities.

24:01.104 --> 24:04.562
She must often set priorities of care
based on assessments

24:04.646 --> 24:06.479
of the mother and the infant.

24:06.521 --> 24:10.312
The nurse shares with the parents in their
response to the delivery of the infant.

24:10.479 --> 24:12.896
She continues to provide them
with information

24:12.979 --> 24:17.021
and emotional support as they respond
to the delivery situation.

24:18.562 --> 24:21.187
The nurse also provides
any necessary assistance

24:21.229 --> 24:25.229
with expulsion of the placenta
and assesses the physiological response

24:25.271 --> 24:27.937
for signs of uterine relaxation or bleeding.

24:30.396 --> 24:34.812
Nursing responsibility to the newborn
include establishment of respirations,

24:35.271 --> 24:40.312
monitoring of the cardiovascular system,
temperature regulation and support,

24:40.812 --> 24:43.979
assessment of the infant's adaptation
to extra-uterine life,

24:44.062 --> 24:46.896
and assessment for anomalies
and birth injuries.

24:47.562 --> 24:50.437
She ensures the proper identification
of the infant

24:50.521 --> 24:52.854
and provides prophylactic eye care.

24:53.354 --> 24:56.687
The expulsion of the placenta marks
the end of the third stage

24:56.771 --> 25:00.229
and the onset of the fourth
and final stage of labor.

25:00.896 --> 25:05.437
In the fourth stage, the nurse facilitates
early parent-infant interaction,

25:05.562 --> 25:06.937
if the parents desire,

25:07.021 --> 25:10.062
and the mother and infant
are recovering in a normal pattern.

25:10.854 --> 25:13.229
She provides physical comfort
and nourishment,

25:13.312 --> 25:17.479
which establishes an atmosphere
that promotes rest and relaxation.

25:19.146 --> 25:21.396
The nurse monitors the mother's physiological

25:21.479 --> 25:25.562
and behavioral responses as adaptation
to the birth process continues.

25:25.896 --> 25:29.271
This surveillance includes observation
for signs of hemorrhage

25:29.396 --> 25:33.104
and early indications of infection,
excessive fatigue,

25:33.187 --> 25:35.354
or emotional excitement that may inhibit rest.

25:37.146 --> 25:40.229
Nursing responsibility
to the childbearing family

25:40.354 --> 25:42.854
continues during the postpartum period.

25:43.104 --> 25:45.229
A plan of care that meets the parents'

25:45.271 --> 25:48.396
and infant's needs during adaptation
to the birth process

25:48.521 --> 25:51.562
is the primary goal
of nursing intervention.

25:51.646 --> 26:30.646
[silence]