Scribd
Upload
279 views18 pages

Intrapartum Care and Labor Guidelines

This document outlines the objectives and factors affecting labor and delivery. It describes the stages of labor and the nursing care responsibilities during each stage, including establishing rapport, monitoring vital signs, assisting with positioning, encouraging breathing and pushing techniques, and preparing for and assisting with delivery. Postpartum care such as perineal care, monitoring for hemorrhage and allowing rest is also summarized. Key aspects of care include communication, support, safety and promoting a healthy delivery process.

Uploaded by

MICHELLE FACTO
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
279 views18 pages

Intrapartum Care and Labor Guidelines

This document outlines the objectives and factors affecting labor and delivery. It describes the stages of labor and the nursing care responsibilities during each stage, including establishing rapport, monitoring vital signs, assisting with positioning, encouraging breathing and pushing techniques, and preparing for and assisting with delivery. Postpartum care such as perineal care, monitoring for hemorrhage and allowing rest is also summarized. Key aspects of care include communication, support, safety and promoting a healthy delivery process.

Uploaded by

MICHELLE FACTO
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

INTRAPARTUM

CARE
OBJECTIVES

• Identify factors affecting labor


• Assess a woman for health practices and concerns during pregnancy
• Formulate a nursing diagnosis concerned with healthy pregnancy
• Plan and implement care to promote positive health practices
• Evaluate outcomes for achievement and effectiveness of care
Danger Signs of Pregnancy
◼ Visual Changes
◼ Sudden, severe, continuous Headaches
◼ Edema- non dependent
◼ Rapid weight gain
◼ Abdominal or epigastric pain
◼ S & S of Infection
◼ Vaginal Bleeding/ Drainage
◼ Persistent Vomiting
◼ Muscular irritability/ Seizures
◼ Absence or decrease in fetal movements
```````````````````
FACTORS AFFECTING LABOR & DELIVERY
PROCESS
• COMPONENTS:
1. PASSAGE (WOMAN’S PELVIS)
2. PASSENGER ( FETUS)
3. POWER (UTERINE CONTRACTIONS)
4. PLACENTA
5. PSYCHE
STAGES OF LABOR
Nursing care and responsibilities during first stage of labor

• > establish rapport


• > Explain all procedures or routines, which will be carried out prior to
performing them. These include:
• (a) NPO except ice chips while in labor.
• (b) Activities allowed and disallowed according to ward policies (i.e.
bathroom privileges).
• (c) Use of fetal monitors.
• (d) Visitation policies.
• (e) Where patient’s personal belongings will be maintained.
• > VS monitoring, perineal care provided
• > Conduct health teaching on breastfeeding, newborn care, and
effective bearing down because during this time, patient’s anxiety is
controlled and she is able to focus on nurse’s instructions.
• >instruct not to push – prevent cervical edema/tearing
What to do when “bag of water” ruptured?

• Do not allow patient to ambulate after the


rupture/leak of BOW
• Check if fetal part is evident on the vaginal opening
• Monitor for the fetal heart tone and contractions
• Attached to EFM
• Observe for the color of amniotic fluid ( yellow,
greenish = meconium stained)
Nursing care & responsibilities during 2nd stage
of labor
• Continue monitoring the FHT, uterine contractions and refer
• Assist patient’s needs, continue to give support, offer encouragement
• Assist patient in assuming her position of comfort.
• Reinforce breathing techniques, encourage to concentrate and push
when uterine contraction is at its peak. (count 1-10 with woman as she
pushes)
• Prepare the sterile table ready with instruments use in the normal
spontaneous delivery ( kidney basin, clamps/forceps, umbilical cord clip,
surgical scissor, linen and sponges)
• Call out the time, gender of the baby when delivered
• Secure baby’s name tag ( place ankle area)
Nursing care & responsibilities for 3rd stage
• Administer Oxytocin as ordered
• Early cord clamping and controlled cord traction to deliver the placenta (do
not vigorously pull the cord of the placenta- prevent uterine inversion)
• Catch the placenta, count the number of cotyledons
• Assist physician if there is repair of episiotomy or lacerations
Nursing care & responsibilities
• Do perineal care, wash and cleanse the mother, attached adult diaper
• Change soiled gown with new one
• Assist in transfer to Recovery room, place side rails up
• Hooked to Cardiac monitoring; check the VS every 15 minutes for two hours, every
30 minutes for two hours, every 1 hour for 2 times, then every 4 hours
• Monitor for a firm contracted uterus, check the diaper for hemorrhage and refer
• Allow patient to rest or sleep after the event of birthing

You might also like