STRUCTURE OF FEMALE PELVIS (FIGURE 1)
The pelvis is a skeletal ring often referred to as pelvic girdle formed by two innominate bones, the sacrum and the coccyx.
Innominate Bones
Each innominate bone is made up of three bones, the ilium, the ischium and the pubis.
Sacrum
The sacrum is a wedge-shaped bone consisting of five fused vertebrae and lies between the ilia. The prominent upper margin of the first sacral vertebra is called the sacral promontory. The anterior surface of the sacrum is concave from above downward and from side to side. There are four pairs of foramina through which the sacral nerves pass.
Coccyx
The coccyx is a small triangular bone which articulates with the lower end of the sacrum.
Pelvic Joints
- Sacroiliac joints: These are two slightly movable joints formed where the ilium joins with the first two sacral vertebrae on either side.
- Symphysis Pubis: It is a cartilaginous joint between the two pubic bones.
- Sacrococcygeal joint: It is a hinge joint between the sacrum and the coccyx.
Pelvic Ligaments
The pelvic girdle requires great strength and stability in order to fulfill its function of support. The pelvic joints are reinforced by powerful ligaments.
- Sacroiliac ligaments: These ligaments pass in front of and behind each sacroiliac joint.
- Pubic ligaments: The superior pubic ligament connects the top portion of the pubic bones. The arcuate pubic ligament runs under the symphysis pubis and connects the lower portion.
- Sacrotuberous ligaments: These run between the posterior superior iliac spine, sacrum and coccyx at one end and the ischial tuberosity at the other on each side.
- Sacrospinous ligaments: One ligament on each side runs between the sacrum and ischial spine.
Division of the Pelvis
- True pelvis: Lies below the linia terminalis or pelvic brim. It is the bony canal through which the fetus must pass. It is divided into three planes (Figure 2).
- Brim or inletIt is the upper boundary of true pelvis. The brim is bounded by upper margin of symphysis pubis in front, linia terminali's on sides and sacral promontory in the back. Largest diameter of the inlet is transverse and smallest diameter is anteroposterior.
- Anteroposterior diameter of the inlet is measured clinically by diagonal conjugate the distance from the lower margin of symphysis pubis to the sacral promontory and usually measures 13.5 cm.Obstetric or true conjugate is the distance between the inner surface of symphysis and sacral promontory. The measurement is obtained by subtracting 1.5-2.0 cm (thickness of symphysis pubis) from diagonal conjugate. Adequate diameter is usually 11.5 cm.
- Oblique diameters: Right and left oblique diameters are measured from the sacroiliac joint on the one side to the iliopectineal eminence on the opposite side. It is named in relation to the mother's anatomical position.Right oblique is from right sacroiliac joint and measures 12 cm.
- Transverse diameter: It is the maximum distance between two farthest points of pelvic brim. This diameter is nearest the sacrum than the pubis. It measures 13 cm.
- CavityCavity is circular in shape and is the space between the plane of brim and that of outlet. It is a curved canal with shallow anterior and deep posterior wall. Anterior wall measures 4 cm and posterior wall 12 cm and curved- diameters of the inlet cannot be measured clinically. Clinical evaluation of adequacy is made by noting the ischial spines. All the diameters are considered to be 12 cm.
- OutletOutlet is diamond shaped, bounded by lower margin of symphysis pubis in front, ischial tuberosities on sides and tip of sacrum posteriorly.
- Anteroposterior diameter extends from the apex of the pubic arch to the tip of the coccyx. This diameter increases by half an inch during labor by the coccyx being displaced backwards as the head descends, and measures 13 cm.
- Transverse diameters: There are two transverse diameters bi-spinous 10 cm, at the upper boundary of outlet and inter tuberischial 11 cm at the lower border of outlet, distance between the inner borders of ischial tuberosities.
Shapes of the Pelvis (Figure 3)
There are four types of pelvic shapes based essentially on the shape of the brim.
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FEATURES OF THE FOUR TYPES OF PELVIS Plane of pelvisFeaturesGynecoidAndroidAnthropoidPlatypelloidBrimFore pelvisBrimWideRoundedNarrowHeart shapedNarrowOval anteroposteriorlyWideOval transversely (kidney shaped)CavitySide wallsSacrumStraightWell-curvedConvergentStraightStraightDeep concaveDivergentFlatOutletIschial spinesSubpubic archBluntWide, 90 degreeProminentNarrow, < 90 degreeBluntWide > 90 degreeBluntWide > 90 degreeBone structureMediumHeavyMediumMediumIncidence50%20%25%5% - Android (normal male pelvis): Posterior segments are decreased in all three planes. Deep transverse arrest and failure of rotation of the fetus are common. Seen in 20% of all women.
- Anthropoid (apelike pelvis): Anteroposterior diameter is longer, may allow for easy delivery of an occiput posterior presentation of fetus. Seen in 25% of all women.
- Platypelloid (flat female pelvis with wide transverse diameter): Arrest of fetal descend at the pelvic inlet is common. This type of pelvis is seen in 5% of all women.
THE FETAL SKULL (Figure 5)
The fetal skull is ovoid in shape. At term it is larger in proportion to the other parts of the skeleton. The skull may be divided into three parts: vault, base and face.
- The vault which contains the brain is composed of 5 bones: 2 frontal, 2 parietal and 1 occipital. These are united by membranes known as sutures and fontanelles. The sutures and fontanelles may be felt on vaginal examination during labor and indicate the position of the occiput and degree of flexion of the head.
- The base of the skull is composed of 5 bones: 2 temporal, 1 ethmoid, 1 sphenoid and part of the occipital bone. These are firmly fused together. At the base of the skull is an opening known as the foramen magnum, through which passes the spinal cord.
- The face is composed of 14 bones, all fused together.
Sutures (Figure 4)
There are four sutures of obstetrical importance. They are composed of soft, fibrous tissue and allow mobility between the cranial bones. Sutures are very useful landmarks while making a vaginal examination.
- Sagittal suture: Between two parietal bones
- Frontal suture: Between two frontal bones
- Coronal suture: Between the frontal bone on one side and the parietal bones on the other side.
- Lambdoidal suture: Between the parietal and occipital bones.
Fontanelles
Membraneous spaces between the cranial bones of the fetus or newborn baby. There are six fontanelles on the skull, but only two are of obstetrical importance, the anterior and the posterior.
- Anterior fontanelle: The largest fontanelle. It is the junction of the sagittal, frontal and coronal sutures. It is diamond shaped, 2.5 cm long and 1.5 cm wide. Pulsations of the cerebral vessels can be felt through it. The fontanelle closes by 18 months of age.
- Posterior fontanelle: This is located where the sagittal suture meets the lambdoidal suture. It is triangle shaped and smaller than anterior fontanelle. This fontanelle can be recognized as the junction of three sutures in vaginal examination during labor. It closes by six weeks of age.
Regions of Fetal Skull (Figure 5)
- Vertex: It is a quadrilateral area bounded by the anterior fontanelle and the coronal suture in front, the posterior fontanelle and the lambdoidal suture behind, and longitudinal lines through the parietal eminences laterally.
- Brow or Sinciput: It is the area bounded by the supraorbital ridges in front, the anterior fontanelle and the coronal sutures behind and longitudinal lines passing through the frontal eminences laterally.
- Face: It is the area bounded by the orbital ridges and the root of the nose to the junction of the chin and neck.
- Occiput: This is the region that lies between the foramen magnum and the posterior fontanelle. The part below the occipital protuberance is known as the suboccipital region.
Diameters of the Fetal Skull (Figure 6)
The engaging diameter of the fetal skull depends on the degree of flexion present.
Diameters of the fetal skull |
Sl. No. | Diameter | Measurement | Presentation |
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1. | Suboccipitobregmatic Measured from below the occipital protuberance to the center of the anterior fontanelle or bregma. | 9. 5 cm | Vertex well flexed |
2. | Suboccipitofrontal Measured from below the suboccipital protuberance to the center of the frontal suture | 10 cm | Vertex deflexed |
3. | Occipitofrontal Measured from the occipital protuberance to the root of the nose (glabella) | 11.5 cm | Vertex extremely deflexed in occipitoposterior position |
4. | Submentobregmatic Measured from the point where the chin joins the neck to the center of the bregma | 9.5 cm | Face completely extended |
5. | Submentovertical Measured from the point where the chin joins the neck to the highest point on the vertex. | 11.5 cm | Faceincompletely extended |
6. | Mentovertical Measured from midpoint of the chin to the highest point on the vertex, slightly nearer to the posterior than to the anterior fontanelle. | 13.5 cm | Brow midway between flexion and extension |
7. | Biparietal Transverse diameter, measured between the two parietal eminences. | 9.5 cm | |
8. | Bitemporal Transverse diameter, measured between the farthest points of the coronal suture at the temples. | 8.2 cm |
Relationship of the Fetus to the Uterus and Pelvis
Relationship of the fetus to the uterus and pelvis are expressed using certain terms. These determine which part of the fetus enters the pelvic brim first and governs the mechanism of labor.
- Lie—The lie of the fetus is the relationship between the long axis of the fetus to the long axis of the uterus. Lie may be longitudinal, transverse or oblique.
- Attitude –Attitude is the relationship of the fetal head and limbs to its trunk and should be one of flexion. The fetus is curled up with chin on chest and arms and legs flexed, forming a compact mass. If the head is well flexed, the smallest diameters will be presenting.
- Presentation—Presentation refers to the part of the fetus that lies at the pelvic brim or in the lower pole of the uterus. Presentations can be vertex, breech, shoulder, face or brow. Vertex, face and brow are cephalic or head presentations.Breech is podalic presentation and depending on the degree of flexion, complete breech, footling, knee or extended breech may present.In transverse presentation, the fetus lies across the pelvis and there may be shoulder, arm or any part of the trunk presenting.
- DenominatorDenominator is the part of presentation that indicates or determines the position. Each presentation has different denominator and these are as follows:
- PositionPosition is the relationship between the denominator of the presentation and six areas of the pelvic brim:Right anteriorLeft anteriorRight posteriorLeft posteriorRight lateralLeft lateral
In addition, when the denominator is found in the midline either anteriorly or posteriorly, it is described as direct anterior or direct posterior.
Engagement of the Fetal Head
Engagement of the fetal head is said to have occurred when the widest presenting transverse diameter has passed through the brim of the pelvis.
A head is not engaged when its greatest diameter is still above the plane of inlet. If freely movable, it is called a floating head. A head is said to be deeply engaged when the largest diameter has passed into the cavity. A head is at the outlet when the largest diameter is lying at the bony outlet and the perineum is beginning to bulge.
Presenting Part
The presenting part of the fetus is the part that lies over the cervical os during labor and on which the caput succedaneum forms and thus first to be felt per vagina during internal examination.
PREGNANCY
Pregnancy is the state of a female after conception and until the termination of gestation. Conception is the act of conceiving—the implantation of a blastocyte in the endometrium. The human conceptus from fertilization through eight weeks of pregnancy is termed as an embryo, from 9th week till delivery, it is called a fetus.
The duration of pregnancy is approximately 280 days or 40 weeks. Gestational age is expressed in completed weeks. Fertilization takes place at the time of ovulation, approximately 14 days after the first day of last menstrual period (in a 28 day cycle) and the period of gestation is thus 266 days or 38 weeks.
Gravidity is the total number of pregnancies regardless of their duration. Parity is the number of viable newborns live or dead that woman has delivered regardless of the number of children involved. (e.g. the birth of twins or triplets increases the parity only by one).
Calculation of the Expected Date of Delivery (EDD) and Duration of Pregnancy
The expected date of delivery is calculated from the first day of the last menstrual period (LMP) by counting 9 calendar months and adding 7 days to it. The number of days counted from the first day of the last menstrual period to the date of examination will give the duration of pregnancy at that particular date.
Estimation of Gestational Period from the Height of the Fundus of Uterus
The fundus assumes different heights in the abdomen at different periods of gestation (Figure 7).
12 weeks | Level of symphysis pubis |
16 weeks | Half-way between symphysis pubis and umbilicus |
20 weeks | 1-2 fingers breadth below the umbilicus |
24 weeks | Level of umbilicus |
28 weeks | 1/3rd of the way between umbilicus and xiphoid process. (3 fingers breadth above the umbilicus) |
32 weeks | 2/3rd of the way between umbilicus and xiphoid process. (6 fingers breadth above umbilicus) |
36 weeks | Level of the xiphoid process |
40 weeks | Slightly below the level at 36th week if lightening occurs. |
Diagnosis of Pregnancy
Pregnancy may be diagnosed by the woman herself even before she has missed a period because she feels different. Changes in breasts can occur as early as 5 to 6 weeks after conception.
Diagnosis of pregnancy in the first trimester and early second trimester is based on a combination of presumptive and probable signs of pregnancy. Pregnancy is self-evident later in gestation when the positive signs are readily observed.
Presumptive Signs of Pregnancy
These are the maternal physiological changes which the woman experiences.
- Amenorrhea at 4th week. (cessation of menstruation)
- Nausea and vomiting (morning sickness) from 4th to 14th week
- Tingling, tenseness and enlargement of breasts from 3rd to 4th week.
- Frequency of micturition—6th to 12th weeks
- Fatigue
- Breast changes—Darkening of nipples, primary and secondary areolar changes and appearance of Montgomery's tubercles
- Presence of cholostrum in the nipples
- Excessive salivation
- Quickening—the first movement of fetus felt by the mother around 18th to 20th week
- Skin pigmentation and conditions such as chloasma, breast and abdominal striae, linea nigra and palmar erythema
Probable Signs
Probable signs of pregnancy are maternal physiological changes other than presumptive signs which are detected upon examination and documented by the examiner.
- Enlargement of the uterus
- Presence of human chorionic gonadotrophin (hCG) in blood from 6th to 12th week
- Vaginal discharge—Copious non-irritating mucoid discharge which appears at 6th week
- Hegar's sign—Softening and compressibility of the isthmus from 6th to 10th week
- Jacquemiers sign/Chadwick's sign—Violet-Blue discoloration of the vaginal membrane due to increased vascularity by about 8th week
- Osiander's sign—Increased pulsation felt in the lateral fornices from 8th week onwards
- Palmer's sign—Regular and rhythmic uterine contractions resembling systole and diastole of heart that can be elicited during bimanual examination as early as 48 weeks
- Goodell's sign—Softening of the cervix from a nonpregnant state of firmness similar to the tip of a nose to the softness of lips of mouth in the pregnant state by sixth week.
- Globular enlargement of uterus with a soft feel.
- Palpation of Braxton Hick's contractions
- Ballotment of fetus from 16th to 28th week.
Positive Signs
Positive signs are those directly attributable to the fetus as detected and documented by the examiner.
- Visualization of fetus by ultrasound from 6th week onwards
- Visualization of fetal skeleton by 16th week.
- Fetal heart sounds by ultrasound from 6th week onwards
- Palpable fetal movements from 22nd week onwards
- Visible fetal movements late in pregnancy
Pregnancy Tests
- Immunologic testThis test is based on the production of chorionic gonadotrophin (hCG) by the syncytiotrophoblastic cells during early pregnancy. hCG is secreted into the maternal bloodstream and then excreted in mother's urine.Specific antisera are mixed with urine from the woman suspected of being pregnant. If the urine contains hCG, it will neutralize the antibodies in the antiserum and inhibit agglutination indicating a positive pregnancy test.If the urine does not contain hCG, agglutination will occur—a negative pregnancy test.
- Radioimmunoassay testBlood is tested to detected the hCG beta subunit. These are extremely sensitive tests, able to detect hCG at far lower levels than other tests. The test known as betapreg can be used as early as one week after conception, if laboratory facilities are available.
- Biological tests of pregnancyBiological tests were done in the past using mice and frogs. The tests included Aschheim Zondek test, Friedman test, Frank test and Hogben test.
ANTENATAL CARE
Antenatal care refers to the care given to an expectant mother from the time the conception is confirmed until the beginning of labor.
Objectives
The objectives of prenatal care are to:
- Promote, protect and maintain the health of the mother during pregnancy
- Detect high risk pregnancies and give special attention
- Forsee complications and take preventive measures
- Remove anxiety and fear associated with pregnancy
- Reduce maternal and infant morbidity and mortality
- Teach the mother elements of nutrition, personal hygiene and newborn care
- Sensitize the mother to the need of family planning.
The importance of regular visits to the prenatal clinic must be emphasized to help the mother have an optimum outcome of pregnancy that is “ healthy mother and healthy baby”.
Frequency of Visits to the Antenatal Clinic
Ideally the mother should visit the antenatal clinic once a month during the first seven months (28 weeks) twice a month during the eight month (upto 32 weeks) and thereafter once a week if everything is normal.
Antenatal Examination
The first visit irrespective of when it occurs should include the client's health history obstetric history, physical and pelvic examinations and laboratory examinations.
- Health history
- Personal history: Patient Name, Age, Religion and OccupationSpouse: Name, Age, Occupation, Family income and Address
- Medical history: Medical conditions that require special care
- Family history: History of conditions that are genetic in origin, familial or racial
- Diabetes in first degree relative
- Hypertension
- Multiple pregnancies
- Sickle cell anemia, thalassemia
- Congenital anomalies
- Menstrual history
- Age at menarche
- Frequency, duration and amount of menstrual flow
- Dysfunctional uterine bleeding.
- Obstetric history
- Past pregnancy: Prenatal health
- Labor and delivery: Mode of delivery, duration of labor, PPH
- Puerperium: Sepsis, mastitis, hypertension
- Babies: Condition at birth, sex, weight
- Lactation: Breastfeeding, any complication
- Present pregnancy
- Duration of amenorrhea
- Eating and sleeping habits
- Bowel and bladder pattern
- Minor disorders.
- Physical examinationA complete screening physical examination is done during the initial antepartal examination in order to ascertain if the woman has any medical disease or abnormalities.The components of physical examination are:
- Physical measurements: Temperature, pulse, respirations and blood pressure.
- General observations: Appearance, emotional state, posture and apparent state of health
- Review of systems
- Assessments and laboratory tests
- Height and weight
- Urinalysis
- Blood tests—ABO blood group and Rh factor, hemoglobin and hematocrit, VDRL, HIV and Rubella immune status.
- Abdominal examinationAn abdominal examination of the pregnant woman should be done in addition to the physical examination and assessment. The examination includes inspection, palpation and auscultation.
- Inspection is done to note
- Skin condition of abdomen
- Incisional scars
- Contour of abdomen which give clue to lie of the fetus presenting part and to determine if it is engaged or floating.
- Size of abdomen
- Palpation is done using Leopold's maneuvers
- First maneuver (Fundal palpation) is performed to detect the height of fundus and presentation.
- Second maneuver (Lateral palpation) helps to identify the position, lie and variety
- Third maneuver (Pawlick's grip / second pelvic grip) is done to identify the presenting part and to determine if it is engaged or floating.
- Auscultation of fetal heart sounds helps in the diagnosis of a live fetus and its location of maximum intensity which provides information about the presentation.
- Vaginal examinationVaginal examination is performed in early pregnancy to detect the condition of vagina, presence of scars, prolapse of uterus or cervical fibroids. In late pregnancy the examination is done to make pelvic assessment.
Ultrasonography
Ultrasonographic examination has almost replaced the radiological examination during pregnancy. This painless procedure is useful for detecting and confirming
- The pregnancy
- Gestational age
- Abnormalities of pregnancy
- Fetal anomalies
- Fetal well-being
Prenatal Education
Every mother needs advice regarding the importance of regular prenatal check-ups and measures to be taken to maintain or improve her health status during pregnancy in order to have a normal delivery and healthy baby.
In order to remove the fear of unknown and to help them approach the event of childbirth without undue anxiety, ‘child birth preparation’ through explanation of physiological changes and methods of coping during labor and delivery and puerperium must be explained.
Rest and Sleep
Pregnant women may continue her usual activities throughout pregnancy.
Hard and strenuous activities should be avoided in the first trimester and last six weeks. The woman should have an average of 10 hours of sleep (8 hours at night and 2 hours at noon) especially in the last trimester.
In late pregnancy, lateral position in bed would be more comfortable.
Diet
The diet during pregnancy should be adequate to maintain maternal health, meet the needs of growing fetus and provide strength during labor. During pregnancy the calorie requirement is increased by about 300. The diet should be light, nutritious, easily digestable and rich in protein, minerals and vitamins. In addition to the principal food, the mother needs additional quantity of milk, egg, green vegetables and fruits. 2400 calories is generally recommended.
Exercise
Day-to-day domestic and social activities to be continued during pregnancy. Brisk walk in the morning and evening and specific antenatal exercises to prepare the mother's body for labor and delivery are recommended.
Bathing and Clothing
Daily bath and wearing loose comfortable clothes are advised for the comfort of pregnant women. Wearing high heeled shoes should be avoided in late pregnancy when the center of balance alters.
Care of Breasts and Nipples
If the nipples are anatomically normal, nothing beyond ordinary cleaning is needed. If the nipples are flat or retracted, rolling of the nipples and drawing them out between thumb and forefinger, twice daily for 5 minutes must be explained. Drawing the nipples and rolling them between fingers is recommended after cleansing.12
Dental Care
Tendency to dental caries is high in pregnancy and consulting a dentist and taking required treatment must be emphasized.
Alcohol and smoking—should be avoided in pregnancy since nicotine is harmful for the growing fetus and mother. Growth retardation and maldevelopment of fetus are the possible complications to be prevented.
Care of Bowels
Regulation of diet to include food containing roughage, fluids and vegetables as well as extra quantity of water are to be explained to mother.
Coitus—should be avoided in the first three months to prevent abortion and in the 3rd trimester to prevent premature labor and puerperal infection.
Travel—by vehicles having jerks are better avoided in first trimester and last six weeks. Rail journey is preferable to bus travel and travel by aircraft offers no risk.
Immunization—against tetanus is essential for mothers in developing countries to protect them as well as their neonates. Two doses of tetanus toxoid between 16 and 24 weeks are generally recommended.
General Advice
The mother should be instructed to go to the hospital in the following circumstances:
- Active vaginal bleeding even if small amount
- Severe and continuous headache
- Swelling of face, fingers and toes
- Persistent vomiting
- Dimness or blurred vision
- Painful uterine contractions at interval of about 10 minutes or less for at least one hour
- Sudden gush of watery fluid per vagina
- Pain in abdomen
- Fever with chills.
MINOR DISORDERS OF PREGNANCY
At various times during the course of pregnancy, women will experience problems due to physiological changes occurring in their body.
- Nausea and vomitingNausea and vomiting upon getting up in the morning are experienced by some women, especially primigravidae in their first trimester. Advice to stay in bed longer, avoiding fatty foods and fluids in empty stomach are generally sufficient to relieve symptoms.
- BackacheA problem experienced in the last trimester by some women. Relaxation of pelvic joints, faulty posture, muscle spasm and urinary infection are some of the causes for backache.Advice regarding more rest in hard bed, massaging back muscles and wearing a well—fitting pelvic girdle belt while walking may be given.
- ConstipationThis is a common problem in pregnancy due to the effect of progesterone on the gut and diminished physical activity.Regular bowel habits, taking fluids and including vegetables and fruits in diet are to be explained to mothers having problem of constipation.
- HeartburnRestriction of greasy and spicy foods and avoiding fats often help to reduce the problem. Remaining upright for 1 to 2 hours after meals reduces the possibility acid reflux. Taking small, frequent meals to avoid overloading the stomach is helpful. Antacids if prescribed by the physician can be taken for relief of symptoms.13
- Leg crampsLeg cramps often occur due to deficiency of serum calcium and elevation of serum phosphorus. Instruct patient to elevate her legs periodically and avoid lying with toes pointed. Increasing milk intake, taking warm baths at bedtime and regular exercises prevent the occurrence of leg cramps.
- Urinary frequency and dysuriaTaking more fluids during day time, avoiding distension of bladder and early treatment for any urinary tract infection are the measures to help women with urinary problems in pregnancy.
- Varicose veinsVaricose veins in the legs, vulva or rectum appear in the later months of pregnancy. Elevation of legs while resting and elastic crepe bandage during movements can give symptomatic relief. For hemorrhoids, local application of hydrocortisone ointment and prescribed laxatives to keep the bowels soft are recommended.
LABOR
A process that involves a series of integrated uterine contractions that occur over time, and work to propel the products of conception (fetus, placenta and amniotic fluid) out of the uterus through the birth canal.
Normal Labor or Eutocia
Labor is normal when a fetus of 38 to 42 weeks presenting by the vertex, is delivered within 24 hours, spontaneously, uncomplicated and with minimal aid in case of both mother and baby.
Causes of Onset of Labor
The precise mechanism of initiation of labor is still unclear. Some of the hypotheses are as listed below.
- Uterine distension. The stretching effect on the myometrium by the growing fetus and liquor amni.
- Pressure of the presenting part on the nerve endings in the cervix. Pressure stimulates a nerve plexus known as the cervical ganglion. Labor is more likely to start on time when the head is engaged.
- Over distension of uterus in case of multiple pregnancy and hydramnios, over distension tends to induce premature labor.
- Oxytocin stimulation theory—The uterus becomes increasingly sensitive to oxytocin as pregnancy progresses.
- Progesterone withdrawal theory—A decrease in progesterone production may stimulate prostaglandin synthesis and enhance the effect of estrogen which has a stimulating effect on uterine muscle.
- Estrogen stimulation theory—Estrogen stimulates irritability of uterine muscles and enhances uterine contractions.
- Fetal cortisol theory—Estrogen level increases due to the effects of fetal cortisol in late pregnancy.
- Prostaglandin stimulation theory—Initiation and maintenance of labor due to synthesis of prostaglandins in late pregnancy.
SIGNS OF LABOR
- Prelabor or premonitory signs of labor may begin two to three weeks prior to the onset of true labor in primigravidae and a few days before in multiparae.
- Lightening—In primigravidae the presenting part sinks into the true pelvis due to active pulling up of the lower segment of the uterus around the presenting part. This minimizes the fundal height and hence relieves the pressure on diaphragm making breathing easier for the mother.
- Frequency of micturition and constipation—The mother may experience urinary frequency and constipation due to pressure from the engaged presenting part.
- Cervical changes—The cervix becomes ripe. A ripe cervix is soft, less than 1.3 cm in length, admits one finger and is dilatable.
- Taking up of cervix—The cervix becomes shorter as it gets drawn up and merged into the lower uterine segment.
- True laborThe features of true labor pains are:
- Painful, rhythmic uterine contractions with hardening of uterus.
- Progressive dilatation and effacement of cervix
- Appearance of “show”—blood stained mucoid discharge
- Formation of the bag of waters.
Features of True and False Labor Pains
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STAGES OF LABOR AND PHYSIOLOGICAL CHANGES DURING THE DIFFERENT STAGES
- First Stage—Stage of DilatationFirst stage of labor begins with regular, rhythmic contractions and completes when the cervix is fully dilated.Average duration is 12 hours in primigravida and 8 hours in multigravida.Physiological changes
- Contraction and retraction of uterine muscle
- Formation of upper and lower segments
- Development of the retraction ring
- Polarity neuromuscular harmony between the two poles or segments of uterus
- Dilatation and effacement of cervix
- Fetal axis pressure
- Formation of bag of water
- Rupture of membranes.
- Second Stage—Stage of ExpulsionSecond stage of labor begins with the complete dilatation of the cervix and ends with the expulsion of the fetus through the birth canal. Average duration is 1-1½ hours in primigravida and ½ hour in multigravida.Physiological changes
- Stronger, frequent contractions
- Voluntary contractions of the abdominal muscles–bearing down efforts
- Expulsive, downward force of uterine contractions
- Displacement of pelvic floor (soft tissue displacement)
THE MECHANISM OF NORMAL LABORDefinitionThe mechanisms of labor are the positional movements that the fetus undergoes to accommodate itself to the maternal pelvis as it negotiates the birth canal.Positional movementsThere are several basic movements which take place when the fetus is in a cephalic, vertex presentation.- Engagement
- Descend throughout
- Flexion
- Internal rotation of the head
- Crowning
- Birth of the head by extension
- Restitution
- Internal rotation of the shoulders
- External rotation of the head as the shoulders rotate internally
- Birth of the shoulders and body by lateral flexion.
PrinciplesThe principles are common to all mechanisms.- Descend occurs throughout
- The part that leads and first meets the resistance of the pelvic floor will rotate forwards until it comes under the symphysis pubis
- The part that escapes under the symphysis pubis will pivot around the pubic bone
- During the mechanism, the fetus turns slightly to take advantage of the widest available space in each plane of the pelvis, i.e. transverse at the brim and anteroposterior at the outlet.
Summary of mechanisms in left occipitoanterior position- The lie is longitudinal
- The presentation is cephalic
- The position is left occipitoanterior
- The attitude is one of flexion
- The denominator is occiput
- The presenting part is the posterior part of the anterior parietal bone
- Engagement takes place with sagittal suture of the fetal head in the right oblique diameter of the pelvic inlet and the biparietal diameter in the left oblique. The occiput points to the left ileopectineal eminence and sinciput to the right sacroiliac joint.
- Descend occurs throughout.
- Flexion substitutes the suboccipitobregmatic diameter for the suboccipitofrontal which entered the pelvic inlet
- Internal rotation takes place as the occiput turns 1/8th of a circle (45 degrees) to the right and sagittal suture comes to the anteroposterior diameter of the pelvis (outlet).
- The occiput escapes under the symphysis pubis and crowning occurs when the head no longer recedes between contractions.
- The head is born by extension, pivoting on the suboccipital-region around the pubic arch
- Restitution-the occiput turns 1/8th of circle (45 degrees) to the left to undo the twist on the neck
- Internal rotation of the shoulders.The anterior shoulder reaches the pelvic floor and rotates anteriorly to lie under the symphysis pubis. This movement can be seen as the head turns at the same time of external rotation of the head.
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The head turns 1/8th of a circle (45 degrees) to the mother's left. The bisacromial diameter comes into the anteroposterior diameter of the maternal pelvis. This occurs in the same direction as restitution and at the same time as internal rotation of shoulders.
- The anterior shoulder escapes under the symphysis pubis and the body is born by lateral flexion.
- Third Stage—Stage of Placental DeliveryThird stage of labor comprises the phase of placental separation, its descend to the lower segment and finally its expulsion with the membranes. The time begins upon completion of the birth of the baby and ends with the expulsion of placenta. Average duration of third stage is 30 minutes in both primigravidae and multipara.Physiological changes
- Contraction and retraction of uterus
- Expulsion of placenta and membranes.
Signs of placental separation:- Sudden trickle or gush of blood
- Lengthening of the umbilical cord visible on the introitus
- Change in the shape of the uterus from discard to globular
- Change in the position of the uterus as it rises in the abdomen
Method of separation of the placenta may be central (Schultz method) or marginal (Mathews Duncan method). - Fourth StageFourth stage of labor begins with the birth of the placenta and ends one hour later. The first postpartal hour is a critical time of initial recovery from the stress of labor and delivery and requires close observation of the mother.Physiological changes
- Uterus becomes firm and retracted (hard to touch)
- When contracted, the entwining muscle fibers of the myometrium serve as ligatures to the open blood vessels at the placental site and bleeding is controlled naturally.
- Thrombi form in the distal blood vessels in the decidua from where it does not get released into systemic circulation.
NURSING MANAGEMENT DURING LABOR AND DELIVERY
First Stage of Labor
- Admit the mother in labor room and complete procedures such as changing to hospital gown, applying identification band, obtaining history and completing chart forms
- Orient patient to labor and delivery rooms
- Explain admission protocol, labor process and management plans
- Carry out perineal shave and administer enema if not contraindicated
- Start an I.V. line if indicated and adminster fluids
- Provide bodily care and attend to comfort needs
- Monitor and evaluate maternal well-being, fetal well-being and progress of labor (vital signs of mother, fetal heart sounds, utrine contractions, cervical dilation and fetal descend)
- Encourage to use coping skills such as breathing, relaxation and positioning
- During latent phase (1-4 cm dilation) review breathing teachnique she can use as labor progress and encourage ambulation and comfortable position.
- During active phase (4-8 cm dilation) provide comfortable position, assist with breathing exercises, provide backup and sacral pressure and analgesia.
- During transitional phase (8-10 cm dilation), assist with deep breathing during contractions and shallow breathing and relaxation between contractions.
Second Stage of Labor
- Continue to monitor maternal well-being including vital signs, bladder care, hydration and analgesia
- Encourage maternal pushing efforts
- Evaluate perineal integrity and perform episiotomy if appropriate
- Deliver the baby and reassure mother about neonate's condition.
Third Stage of Labor
- Encourage patient to maintain position to facilitate delivery of placenta
- Allow mother to hold and feed the baby if she desires
- Deliver placenta and membranes
- Monitor maternal vital signs, bleeding and consistency of uterus
- Administer oxytocin if required
- Examine placenta and membranes for completeness
- Perform episiotomy suturing if one was made.
Fourth Stage of Labor
- Provide clean gown, perineal pads and comfortable position
- Check vital signs regularly
- Palpate fundus of uterus for contractility
- Massage the fundus and express any clots present
- Inspect the perineum, bladder and change pads
- Offer food and fluids if not contraindicated
ABNORMAL LABOR (DYSTOCIA)
Dystocia means abnormal or difficult labor or delivery.
Difficulty in labor and delivery may be due to
- Fetal causes such as fault in
- Attitude e.g. deficient flexion
- Position e.g. posterior positions
- Presentation e.g. breech, shoulder
- Maternal causes such as
- Fault in the force e.g. abnormal uterine action
- Fault in passage e.g. Pelvic abnormalities
- Poor maternal health e.g. poor general condition
MAL POSITIONS AND PRESENTATIONS
1. Occipitoposterior Position
An abnormal position of the vertex which gives rise to difficulty in delivery of the fetus with a normal gynecoid pelvis
Causes:
- Shape of the pelvic inlet. Android or anthropoid pelvis with wide posterior segment favors occipitoposterior position
- Deflexion of the fetal head—Factors affecting flexion of the head are high pelvic inclination and attachment of placenta in the anterior wall of the uterus.
- Abnormal uterine contraction—This could be the cause or effect of deflexion.
Possible difficulties in occipitoposterior position
- Difficulty in engagement of head
- Premature rupture of membranes
- Prolonged labor with increased risk of fetal asphyxia
- Extension of head resulting in brow or face presentation
- Excessive moulding.
Possible outcomes of labor
Favorable outcome
- Long anterior rotation of the head (3/8th of a circle/135 degree) and delivery as in an anterior position.
- Short posterior rotation and vaginal delivery as face to pubis.
Unfavorable outcomes
- Arrested occipitoposterior position
- Arrest in occipitotransverse or oblique position.
Alternative methods of delivery
- Rotation of head and extraction using Keilland's forceps if the pelvis is adequate and the obstetrician is skilled.
- Application of ventouse. In cases where the pelvis is adequate and nonrotation is due to weak contractions, ventouse is applied to promote flexion, achieve rotation and to extract the head.
Special needs during labor and nursing care
- Occipitoposterior position may lead to disorganized labor especially in primigravidae.
- Monitor the uterine contractions, maternal vital signs, fetal heart sounds and maternal condition at regular intervals.
- Prolonged labor accompanied by marked backache.
- Analgesia, back rub and comfort measures need to be provided.
- Encourage mother to lie on the side, which the fetus faces and to walk about.
- Retention of urine: Catheterization may be required.
- The urge to bear down may present before second stageExamination to confirm dilatation and instructions for appropriate action are indicated.
2. Brow Presentation
Brow presents when the head is midway between full flexion and full extension. The engaging diameter is mentovertical 13.0 cm and is the longest diameter of fetal head.
Causes:
- Faults in passage such as contracted pelvis, obliquity of uterus, pendulous abdomen and tumors of the lower uterine segment.
- Faults in the passenger—tumor on the neck of the fetus, cord round the neck, anencephaly.
Outcome of labor
If the position is unstable it may get converted to either vertex or face presentation.
If no conversion occurs, there is no mechanism of labor for an average size baby with normal pelvis.
Management:
- If brow presentation is diagnosed during pregnancy and there is no contraindications such as contracted pelvis and congenital malformation of the fetus, one may wait for spontaneous correction to occur until one week prior to the expected date of delivery.
- Elective cesarean section, if brow presentation persists with complicating factors such as elderly primigravida and contracted pelvis.
- If diagnosed during labor, with mother and baby in good condition, cesarean section is the best method.
- If obstructed labor with dead baby, craniotomy may be choice for management.
3. Face Presentation
A cephalic presentation where the presenting part is the face. The attitude of the fetus shows complete flexion of the limbs with extension of the spine. There is complete extension of the head so that the occiput is in contact with the back. The denominator is mentum.19
Causes
Maternal
- Minor degree of disproportion particularly in flat type of pelvis
- Multiparity with pendulous abdomen
- Lateral obliquity of the uterus.
Fetal
- Anencephaly
- Congenital goiter
- Dolichocephalic head with long anteroposterior diameter
- Short umbilical cord round the neck of the fetus several times
- Increased tone of the extensor group of neck muscles.
Diagnosis
- Antenatal diagnosis is seldom made
- Intranatal diagnosis—mentoposterior is easier to diagnose
- Vaginal examination –Early in labor—diagnosis is difficult as the head is high and the parts are difficult to feel through the bulging membranes.Late in labor—after rupture of membranes the following features can be palpated
- Mouth and malar eminences
- Sucking effect of mouth
- Hard alveolar margins
- Absence of meconium staining on the examining finger
However, the parts are often obscured due to edema. The findings must be clearly distinguished from those of breech presentation in which case- Ischial tuberosities can be felt in line with the anus
- Absence of alveolar margins
- Meconium is always present on the examining finger
- Grip of the anal sphincter may be felt on the finger
Management
- Sonography should be done to confirm the diagnosis, to exclude bony, congenital malformation of the fetus and to note the size of the baby
- If the pelvis is normal and adequate, labor is allowed to proceed, taking care to prevent exhaustion from prolonged labor
- If the pelvis is contracted and the patient is an elderly primigravida or multigravida with bad obstetric history, treatment is cesarean section.
4. Transverse or Shoulder Presentation
When the long axis of the fetus lies perpendicular to the maternal spine, it is called a transverse lie. The shoulder is most likely to present over the cervical opening during labor.
Shoulder presentation is about 5 times greater in multigravidae than in primigravidae
Causes
- Contracted pelvis
- Uterine deformities
- Prematurity
- Lax abdomen in multigravidae
- Hydramnios
- Hydrocephalus and anencephalus
- Placenta previa
Types
- Dorsoanterior
- Dorsoposterior
Diagnosis
- Inspection: The uterus appears broader and asymmetrical with the height of fundus less than the period of amenorrhea
- Transverse bulging of the abdomen with bulging of flanks.
Palpation
- Hard, ballotable, rounded head on one iliac fossa, at a lower level than breech
- Soft, broad and irregular breech to one side of midline
- The back is felt anteriorly across the long axis in dorsoanterior or irregular, small parts are felt anteriorly in dorsoposterior.
- The lower pole of the uterus is found empty in the prenatal period, (During labor, it may be occupied by the shoulder).
Auscultation
Fetal heart sounds are heard much below the umbilicus. It is quite distinct in dorsoanterior position and indistinct in dorsoposterior.
Vaginal examination (During labor)
Elongated bag of membranes can be felt if it does not rupture prematurely.Presenting part may be high up and floating.
After rupture of membranes, the shoulder can be identified by palpating the following parts—the acromion process, the scapula, the clavicle and axilla. Palpating the ribs and intercostal spaces is the characteristic landmark.
Occasionally an arm is found prolapsed. Hand can be differentiated from a foot and an elbow from a knee.
Ultrasonography can diagnose transverse lie and position of placenta.
Management
There is no mechanism of labor in transverse lie/shoulder presentation and an average size baby fails to pass through an average size pelvis. If diagnosed early and the fetus is alive, cesarean section is done.
If labor is advanced with FHS absent and mother exhausted, resuscitation of mother is done with IV fluids. When her condition improves, destructive operations such as decapitation or eviceration is done depending upon the position of the neck. If the fetus is large, even cesarean section is done for maternal safety.
5. Breech Presentation (Figure 8)
It is the presentation in which the lie of the fetus is longitudinal and the podalic pole presents at the pelvic brim.
Varieties
- Complete breech (Flexed breech)The normal attitude of full flexion is present. The thighs are flexed at the hips, legs are flexed at the knees, and arms flexed over chest. The presenting part consists of the two buttocks and external genitalia and two feet. It is commonly present in multiparae.
- Incomplete breechOccurs due to varying degrees of extension of thighs or legs at the podalic pole. Three varieties are possible.
- Breech with extended legs or frank breechIn this condition the thighs are flexed on the trunk and the legs are extended at the knee joints. The presenting part consists of the two buttocks and external genitalia only.It is commonly present in primigravidae.
- Footling presentationOne or both feet present because neither hips nor knees are fully flexed. The feet are lower than the buttocks.
- Knee presentationThighs are extended but the knees are flexed, bringing the knees down to present at the brim.
Clinical varieties
- Uncomplicated breechBreech presentation with no other associated obstetric complications.
- Complicated breechThe presentation is associated with conditions which adversely influence the prognosis such as prematurity, twins, contracted pelvis, placenta previa etc.
Causes
- PrematurityThere is higher incidence of breech in earlier weeks of pregnancy. Smaller size of the fetus and comparatively larger volume of amniotic fluid allow the fetus to undergo spontaneous version by kicking movements until 36th week when the position becomes stabilized.
- Factors preventing spontaneous version such as
- Breech with extended legs
- Twins
- Oligohydramnios
- Congenital malformation of the uterus such as septate or bicornuate uterus
- Short cord
- Intrauterine death of fetus.
- Favorable adaptation in cases like
- Hydrocephalus—big head can be well accommodated in the wide fundus
- Placenta previa
- Contracted pelvis
- Cornufundal insertion of placenta.
Diagnosis
- Abdominal palpation reveals the cephalic pole at the fundus and podalic pole below
- Auscultation—FHS is heard above the umbilicus
- Ultrasonography—diagnosis can be confirmed by sonography
- Vaginal examinationIn early labor, vaginal examination will reveal the following:
Management
Delivery of fetus in breech presentation occurs in three phases
- Delivery of the breech or buttocks
- Delivery of the shoulder
- Delivery of the head.
Selection for vaginal delivery or elective cesarean section is done at term. The woman is admitted into hospital at 39 to 40 weeks for cesarean section.
Women with breech in labor anticipating vaginal delivery requires special attention.
- Enema is restricted to reduce the chance of rupture of membranes
- Mother is kept in bed to preserve the membranes intact and to allow the cervix to dilate fully
- Hydration is maintained with IV fluids
- Arrangements to be made for forceps application and resuscitation of newborn
- Oxytocics to be kept ready to treat possible postpartum hemorrhage.
Management of Arrest of Breech
- Arrest of after coming headThe after coming head can get arrested due to:
- Hydrocephalus
- Contracted pelvis
- Deflexed head
- Posteriorly rotated head
- Contraction ring around neck
- Rigid perineum (arrest at the outlet)
Methods of delivering the after coming head
- Burns Marshall's method
- Mauriceau Smellie Veit method (Jaw flexion and shoulder traction)
- Pinard's maneuver for extended legs
- Extraction using forceps.
If the head is arrested and the fetus dead, craniotomy may be done.
Principles involved in the delivery of after coming head
- Cervix should be fully dilated
- Head should be in flexed position
- Effective suprapubic pressure should be provided
- The head should be delivered within 5 to 8 minutes, after the delivery of the trunk.
6. Compound Presentation
Presence of a hand or foot or both alongside the head or both hands by the side of the breech is called compound presentation.
The commonest compound presentation is head with the hand
The rarest is the head with a hand and foot.
Causes
Conditions preventing engagement of the head where a hand or foot slips by the side of the head.
- Prematurity
- Contracted pelvis
- Multiple pregnancy
- Macerated fetus
- High head with early rupture of membranes
- Hydramnios.
Diagnosis
Feeling the limb alongside head when cervix is sufficiently dilated.
Management
Management depends on the stage of labor, maturity of the fetus, number of fetuses, (singleton or twins) pelvic adequacy and associated cord prolapse. In cases of single, live fetus with contracted pelvis or cord prolapse delivery by cesarean section is the choice. In uncomplicated cases, if there is a favorable sign of elevation of prolapsed limb during uterine contraction in the first stage and the condition of fetus is good, replacement of the prolapsed limb is done under general anesthesia in the second stage followed by forceps delivery.
7. Cord Prolapse
Abnormal descend of the umbilical cord by the side of the presenting part.
Types of cord prolapse
- Occult prolapse—The cord lies alongside but not in front of the presenting part and is not felt by the fingers on internal examination.
- Cord presentation—The cord is slipped down below the presenting part and lies in front of it in the intact bag of membranes.
- Cord prolapse—The cord lies in front of the presenting part inside the vagina or outside the vulva following rupture of the membranes.
Predisposing factors:
Any situation where the presenting part is neither well applied to the lower uterine segment nor well down in the pelvis allowing a loop of cord to slip down in front of the presenting part. These include:
- Malpresentations
- Prematurity
- Multiple pregnancy
- Polyhydramnios
- High head
- High parity.
Diagnosis
Occult prolapse:
- Peristence of variable deceleration of fetal heart rate pattern on continuous fetal monitoring in an otherwise normal labor.
- Persistent funic soufflé with irregular heart sounds.
Cord presentation
- Feeling the pulsation of the cord through the intact membranes
- Evidence of decelerations in fetal heart monitoring.
Cord prolapse
- The cord is felt below or beside the presenting part on vaginal examination
- A loop of cord visible at the vulva
- Cord is felt at the cervical os if the presenting part is high
- Pulsation can be felt between contractions if the fetus is alive.
Management
- Obtain continuous or frequent fetal heart sounds
- Keep patient in exaggerated Sim's position to minimize cord compression
- Cesarean section is the most likely method of delivery.
FORCEPS DELIVERY
Forceps delivery is a means of extracting the fetus with the aid of obstetric forceps when it is inadvisable or impossible for the mother to complete the delivery by her own efforts.
Forceps are also used to assist the delivery of the after coming head of the breech and on occasion to withdraw the head up and out of the pelvis at cesarean section.
Types of Obstetric Forceps Currently Used
Three varieties are commonly used in present day obstetric practice
- Long curved forceps with or without axis traction device
- Short curved forceps
- Kielland's forceps.
Classification According to Level of Application
- High forceps operationApplication of forceps on a fetal head where the biparietal diameter has not yet passed the pelvic brim that is a nonengaged head. In present day practice, cesarean is preferred to this type of forceps application.
- Midforceps operationApplication of the forceps on a head the biparietal diameter of which has passed the pelvic brim but not reached the level of ischial spines.
- Low forceps operationApplication of the forceps on a head, the biparietal diameter of which has passed the level of ischial spines.
- Outlet forcepsApplication on a fetal head lying on the perineum and is visible at the introitus between contractions.
Indications of Forceps Application
Maternal indications:
Delay in the second stage that is head on the perineum for 20 to 30 minutes without advancement as in following conditions:
- Maternal distress
- Preeclampsia or eclampsia
- Heart disease
- Failure to bear down due to regional blocks, paraplegia or psychiatric disorders
- Vaginal birth after cesarean delivery (VBAC)
Fetal indications
- Fetal distress in the second stage
- Cord prolapse
- Aftercoming head of breech
- Low birth weight baby
- Postmaturity.
Prerequisites for forceps delivery
- Cervix fully dilated and effaced
- Membranes ruptured
- Fetal head engaged
- No appreciable CPD
- Bladder emptied
- Good uterine contractions.
Preparation of the mother
- Adequate explanation of the procedure and the need for it
- Adequate and appropriate analgesia
- Lithotomy position as the obstetrician gets ready to apply the forceps.
Preparation to receive the baby
- Resuscitation equipment and medications
- Presence of pediatrician.
VACUUM EXTRACTION (VENTOUSE DELIVERY)
Ventouse is an instrumental device designed to assist the delivery by creating a vacuum between it and the fetal scalp.
Indications
- Deep transverse arrest with adequate pelvis
- Delay in descend of the second twin baby
- Occiput posterior or occiput lateral position
- Delay in the second stage or late first stage
- As an alternative to forceps operation except in face presentation, aftercoming head of breech, fetal distress and prematurity.
- Maternal exhaustion.
Conditions to be Fulfilled
- No bony resistance below the head.
- Engaged head of a singleton baby.
- Cervix dialated at least 6 cm.
Preparation of the Mother and Articles
- Adequate explanation to mother.
- Preparation and position as for forceps delivery.
- Appropriate size cup for application on fetal head.
- Pudendal block or perineal infiltration.
- Ventous in good working condition.
NORMAL PUERPERIUM
Puerperium is the period following childbirth during which the body tissues especially the pelvic organs revert back approximately to the prepregnant state both anatomically and physiologically. Retrogressive changes occur in reproductive organs with the exception of mammary glands which show features of activity.
Involution is the process whereby genital organs revert back approximately to the state as they were before pregnancy.
Duration of Puerperium
Puerperium begins as soon as the placenta is expelled and lasts for approximately six weeks. The postpartum period is divided into:
The remote puerperium includes the period of involution. Majority of nonlactating women resume menstrual cycles at this time or soon thereafter.
Anatomical and Physiological Changes during Puerperium
Uterus
Immediately following delivery, the uterus weighs about 1 kg and its size approximately 20 weeks of pregnancy. Height of fundus is about 5″ from the symphysis pubis. Daily, the height of uterus comes down by ½ an inch. By 12th day the fundus is at the level of symphysis pubis. Uterine involution is complete by 6 weeks at which time the organ weighs less than 100 gm, slightly larger following pregnancy. The placental site contracts rapidly to a size less than half the diameter of placenta. This contraction causes constriction and permits occlusion of underlying blood vessels. The resulting hemostasis leads to endometrial necrosis. Endometrial regeneration is completed by 6 to 8 weeks.
Lower uterine segment
Immediately following delivery, the lower segment becomes a thin, flabby, collapsed structure. It reverts back to normal size and shape in few weeks.
Cervix
The cervix contracts slowly, the external os admits two fingers for a few days and narrows down to admit the tip of a finger by the end of first week. The external os never reverts back to nulliparous state.
Vagina
The distensible vagina seen soon after birth takes 4 to 8 weeks to involute. It regains its tone but never to the virginal state. The rugae reappear partially by 3rd week, but not to the prepregnant state. Hymen is lacerated and is represented by nodular rags called the caranculae myrtiformes. Broad ligaments and round ligaments recover from stretching and laxation after several weeks. Pelvic floor and pelvic fascia also take long time to involute from the stretching effect during delivery.
Lochia
Lochia is the vaginal discharge during puerperium containing blood, mucus, shreds of epithelium, decidual membranes and cholestrin crystals and is usually present for two weeks. It has a peculiar offensive, fishy smell and is alkaline in reaction.
Depending on the variation of color, it is named as:
- Lochia rubra—red in color and contains shreds of epithelium and blood. Its duration is 3 to 4 days
- Lochia serosa—serous color discharge (yellowish or pink or pale brownish) which contains mostly WBC. Its duration is 5 to 9 days.
- Lochia alba—pale white in color contains decidual cells, leukocytes and granular epithelial cells. Its duration is 10 to 15 days.Normal duration may extend upto 3 weeks.Excessive lochia discharge is due to retained products of conception, infection, defective suckling of baby.The discharge may be excessive following cesarean delivery, twin delivery and hydramnios. It may be scanty following premature labor.Persistence of red color beyond the normal limit indicates subinvolution or retained bits of conceptus.Duration of the lochia alba beyond 3 weeks suggests local genital lesion.
General Physiological Changes
Temperature
There may be slight reactionary rise of temperature following delivery by 0.5 degree F.
Temperature normally comes down within 12 hours. On the 3rd day there may be slight rise of temperature due to breast engorgement which usually does not last for more than 24 hours. If the temperature stays high for longer period, genitourinary tract infection should be ruled out.27
Pulse
Pulse rate is likely to be raised for few hours after normal delivery and settles down to normal by second postpartum day. The pulse rate is quite unstable during puerperium—it may be raised when the mother gets excited or has after pains and may be lowered due to rest and increased fluid excretion.
Urinary tract
The bladder may be over distended without any desire to pass urine. Stagnation of urine along with devitalized bladder wall contribute to urinary tract infection in puerperium.
The insensitivity of bladder resulting from trauma during labor and dilatation of ureters and renal pelvis return to normal by 8 weeks.
Gastrointestinal tract
In early puerperium, women experience increased thirst due to loss of fluid during labor (diuresis, perspiration and bleeding). Constipation may be present due to slight intestinal paresis. Lack of tone of the perineal and abdominal muscles and pain in the perineal region are common.
Weight loss
In addition to the weight loss as a consequence of the expulsion of the uterine contents, a further loss of about 2 kg occurs during puerperium because of diuresis.
Blood values
Immediately following delivery, there is slight decrease in blood volume due to dehydration and blood loss. The blood volume returns to the nonpregnant level by the second week. RBC count, hematocrit level and platelet count are decreased and WBC count is elevated until second week. ESR remains elevated and a state of hypercoagulability persists for a week after delivery.
Menstruation and Ovulation
Menstruation returns by 6th week in 40% and by 12th week in 80% of nonbreastfeeding mothers.
In breastfeeding mothers, menstruation may be suspended until the baby stops breastfeeding in about 70% and for others it may start earlier. Ovulation may occur as early as 4 weeks in non-lactating mothers and about 10 weeks after delivery in lactating mothers.
Ovulation may precede the first menstrual period in about 1/3rd and it is possible for the woman to become pregnant before she menstruated following her delivery.
Lactation
Preparation for lactation starts during pregnancy although lactation starts following delivery.
The physiological basis of lactation is divided into 4 phases
- Preparation of breasts—mammogenesis
- Synthesis and secretion from the breast alveoli-lactogenesis
- Ejection of milk galactokinesis
- Maintenance of lactation—galactopoiesis
In the first postpartum week, the total amount of milk yield in 24 hours is calculated to be 60 multiplied by the number of postpartum days and is expressed in milliliters. Thus, the milk yield on 3rd postpartum day will be about 180 ml. By the end of second week the milk yield per feeding will become 120 to 180 ml.
NURSING MANAGEMENT OF POSTPARTAL CLIENTS
The principles in management of postpartal clients are to:
- Restore the health of mother
- Prevent infection
- Promote and maintain lactation
- Help the mother take care of the baby
Immediate Attention
In the immediate hours following delivery, the mother's temperature, pulse, respiration and blood pressure must be checked regularly to monitor her general condition.
She may be given a drink or something to eat if she is hungry. Measures to promote sleep must be instituted.
Rest and Ambulation
Physician's order for rest and ambulation may depend on the intrapartal course, the mother's condition and the type of analgesia and anesthesia used. A woman who had a long, difficult labor, is exhausted. Those who are hemorrhaged or groggy from medication may need rest for several hours.
A woman who entered labor rested, progressed normally and is alert may be ambulated as required with assistance at first. Early ambulation provides a sense of wellbeing, promotes better drainage of lochia and hastens involution of uterus.
Additional benefits of early ambulation include faster healing of episiotomy, regular bowel movement and reduced chance of postpartum thrombophlebitis and urinary tract infection. The range of activities should be increased gradually.
Eight hours sleep during night and two hours afternoon are recommended.
Diet
The woman must be given regular diet and plenty of fluids after delivery. For a woman who hemorrhaged, high protein diet and iron suppliments are recommended. Women who breastfeed require high calories, adequate protein, plenty of fluids, minerals and vitamins.
Perineal Care
Immediately after delivery, cold compress may be applied to the perineum to decrease traumatic edema and discomfort. Perineal area should be gently cleaned with plain soap or antiseptic solution 2 to 3 times a day and after voiding and defecation.
Episiotomy wound should be inspected daily. Instructions regarding handwashing, cleansing of perineum and careful application and removal of perineal pads must be given.
Care of Bladder and Bowel
The woman should be encouraged to pass urine 6 to 8 hours following delivery and thereafter at 4 to 6 hours interval. Failure to empty the bladder 8 hours after delivery or incomplete emptying evidenced by presence of residual urine of more than 60 ml requires evacuation of the bladder by catheterization.
Constipation may occur in most women following delivery. For those who do not move their bowels, stool softeners or tap water enema may be prescribed on the 2nd postpartum day.
Care of Breasts
The breasts should be examined daily regardless of the feeding method. Presence of redness or soreness to be noted and mother given instructions regarding handwashing, cleaning of breasts before and after feeding and wearing of wellfitting brassiers for comfort and support.
Postpartum Immunization for Rh Negative Mothers
For Rh negative mothers who deliver Rh positive babies, if the coombs test on cord blood is negative, 1 ml (300 mg) Rh (D) immunoglobulin is given after cross matching. (Mother's RBCs are crossmatched with 1:1000 dilution of Rh immunoglobulin before preparing the injection).
The injection is given intramuscularly within 72 hours after delivery.
Postpartum Exercises
Postnatal exercises should be started as soon after delivery as possible in order to improve circulation, strengthen pelvic floor and abdominal muscles.29
Circulatory Exercises
Foot and leg exercises must be performed very frequently in the immediate postpartum period to improve circulation, reduce edema and prevent deep vein thrombosis.
Pelvic Floor Exercises
Mothers should be encouraged to do perineal exercises as often as possible in order to regain full bladder control, prevent uterine prolapse and ensure normal sexual satisfaction in future. For this exercise the mother may sit, stand or halflie with legs slightly apart. Close and draw up around the anal passage as though preventing a bowel action, then repeat for front passages (vagina and urethra) as if to stop the flow of urine in midstream. Hold for as long as possible upto 10 seconds,(to a count of six) breathing normally, then relax. Repeat upto ten times. Pelvic floor exercises should be continued for 2 to 3 months.
Abdominal Exercises
These help abdominal muscles to regain tone as soon as possible after delivery in order to prevent backache and regain former figure. Abdominal exercises include abdominal breathing, head and shoulder raising, leg raising, pelvic tilt, knee rolling, hip hitching and sit ups.
Mothers who had cesarean deliveries can start abdominal, tightening, pelvic tilting and knee rolling exercises gently after 24 hours. Pelvic floor exercises, head raising and hip hitching can be started after 4 to 5 days.
Health Education
Mothers should receive the following instructions before they leave the hospital.
- Postpartum check-up six weeks later
- Problems to be reported to physician in the postpartum period
- Methods of contraception
- Physiology of puerperium and return of menstruation
- Diet for lactating mothers
- Breastfeeding
- Immunization for the baby
- Management of minor newborn problems
- Care of eyes and umbilical cord
- Diet in postpartum period and for lactation.
NATIONAL IMMUNIZATION SCHEDULE |
Age | Vaccine | Dosage | Route of Administration |
---|---|---|---|
At Birth | BCG (For institutional deliveries) OPU zero dose (For institutional deliveries) | 0.05 ml 2 drops | Intradermal Oral |
6 weeks | BCG if not given at birth DPT1 and OPV1 | 0.05 ml 0.5 ml 2 drops/0.5 ml | Intradermal Deep intramuscular Oral |
10 weeks | DPT2 OPV2 | 0.5 ml 2 drops | Deep IM Oral |
14 weeks | DPT3 | 0.5 ml | Deep IM |
OPV3 | 2 drops | Oral | |
9 months | M M R | 0.5 ml | Subcutaneous |
16-24 months | DPT (Booster dose) | 0.5 ml | Deep IM |
OPV –(Booster dose) | 2 drops | Oral | |
5 to 6 years | DT | 0.5 ml | Deep IM |
(A second dose of DT after 4 weeks if no evidence of previous immunization with DPT) | |||
10-16 years | Tetanus Toxoid | 0.5 ml | Deep IM |
(A second dose of TT after 4 weeks if no evidence of previous immunization with DPT, DT or TT) | |||
For pregnant women | TT1 in early pregnancy TT2 after 4 weeks | 0.5 ml | Intramuscular |
THE NEWBORN BABY
Definitions and Terms
- Newborn/NeonateThe term used for a baby from birth through the first 28 days of life.
- Term babyA baby born at term (between 38-42 weeks), has an average birth weight for the country, has breathed and cried immediately following birth, established independent rhythmic respiration and adapted quickly to the extrauterine environment.
- Low birth weight babyA newborn weighing less than 2.5 kg (normal birth weight in India) at birth irrespective of gestational age.
- Very–low birth weight babyNewborns weighing 1500 gm or less at birth
- Extremely–low birth weight babyNewborns weighing 1000 gm or less at birth
- Preterm babyA baby born before 37 completed weeks of gestation (calculating from the first day of last menstruation).
- Small for gestational age (SGA) babyA newborn with low birth weight for its gestational age
- Post-term babyA baby born after 42 weeks of gestation
- Stillborn babyA baby born after 28th completed week of gestation with no sign of life and absence of breathing.
Immediate Care of the Newborn
The primary concern for the baby at the time of delivery is the establishment of respiration. Prompt onset of breathing is essential to subsequent mental and physical development. When the head is delivered, suctioning of the mouth and nares is done with a bulb syringe or mucus sucker to prevent aspiration of mucus or amniotic fluid.
Soon after birth rubbing of the back or flicking of the sole of the foot is done to provide stimulation for respiration. The newborn must be dried and wet linen removed at the earliest followed by wrapping in warm blanket to prevent heat loss.
Apgar scoring at 1 minute and at 5 minutes to be recorded.
The cord is to be clamped and cut as soon as convenient following birth of the baby. Early clamping should be done in case of Rh incompatibility, to prevent antibody transfer from the mother to baby.
If a radiant warmer is available the newborn may be placed under the warmer until temperature stabilizes.
A quick check must be made at this stage to detect any gross abnormality. Identification tags are to be tied on the wrists of mother and newborn.
- Apgar scoringSixty seconds after the complete birth of the baby the following five objective signs are evaluated and each given a score of 0, 1 or 2. A score of 10 indicates that the baby is in best possible condition. A normal infant in good condition at birth will achieve an Apgar score of 7 to 10.If the score is less than 7 medical aid is necessary.
THE APGAR SCORE |
Sign | Score | ||
---|---|---|---|
0 | 1 | 2 | |
1. Heart rate | Absent | Less than 100 bpm | More than 100 bpm |
2. Respiratory effort | Absent | Slow, irregular | Good, crying |
3. Muscle tone | Limp | Some flexion of limbs | Active |
4. Reflex response to stimulus (to catheter in nostrils) | None | Minimal grimace | Cough or sneeze |
5. Color | Blue, Pale | Body pink, extremities blue | Completely pink |
FEATURES OF A NORMAL NEWBORN
Posture
A newborn baby assumes a posture of general flexion
- flexion of limbs, spine and head resembling the posture during intrauterine life.
Head
- The shape of the head depends on the mode of presentation and moulding of the head during labor. Head circumference varies from 33 to 35 cm. Moulding and caput succedaneum disappears within a day or two after birth.
- Temperature, respiration, heart rate and blood pressure. The temperature shows variations as the heat regulation mechanism is not well developed in newborn. The rectal temperature varies from 97 to 99 °F.Breathing varies from 40 to 60 per minute with an average of 44 per minute and regular.Heart rate varies from 120 to 140 per minute.The blood pressure varies from systolic 60 to 80 and diastolic below 50 mm of Hg.
Skin
The skin color is pinkish red. Lanugo present at birth gradually disappears. Non-specific rashes may appear. The skin may show yellowish tinge on 2nd or 3rd day and gradually disappears by 7th day. This is the physiological jaundice which appears in about 10% of newborns and is due to excessive bilirubin production following rapid breakdown of red cells and imperfect excretion of bile pigments by the neonatal liver.
Abdomen
The cord becomes dry and shriveled up by 5th day and falls off by 7th day by a process of dry gangrene that sets in it.
Genitalia
Vulval engorgement, leucorrhea or at times, slight vaginal bleeding may occur during the first week in female newborns. It is due to the withdrawal of maternal estrogen from the newborn.
Urine
The baby usually passes urine during or immediately after delivery. During the first week urinary output is very low to the extent of 60 ml in 24 hours and thereafter the amount increases. The color is at first dark and soon becomes colorless with low specific gravity.
Stools
Meconium is normally passed 3 to 4 times a day for 2 to 3 days. A delay in the initial passage of meconium for more than 12 hours after birth requires observation to rule out obstruction in the alimentary tract. Meconium is sticky, dark 32green and odorless. Transitional stool occurs gradually from 3rd day and is yellowish brown in color with a characteristic smell due to the development of bacterial flora in the lower intestine. Milk stools are passed by the end of first week.
In breast-fed babies, the stools are soft and golden yellow in color, sour smelling and acid in reaction. In bottle-fed babies, the stools are hard, pale in color, foul smelling and alkaline in reaction. Stool frequency varies from one or two to 5 to 6 in 24 hours.
Weight
In normal full term babies, there is a loss of approximately 10% of body weight in the first 4 to 5 days. The loss is due to loss of water through the skin, lungs, urine and bowel while intake is very little. In bigger babies the loss is more. After the first week, the baby makes a regular gain of 40 to 60 gm per day. After the second week, the rate of weight gain is about 25 to 30 gm per day for the first three months.
Measurements
Variations in measurements may be seen, but relationships are consistent. Average newborn measurements are–head circumference 35 cm, chest circumference 32 cm, crown–rump length 35 cm and crown–heel length 51 cm.
Behavior and Reflexes of Neonates
- Crying and sleepingA healthy newborn baby usually sleeps during most part of the day and night. The baby usually cries when hungry or wet.
- Sucking and swallowing reflexes are present at birth. Yawning and sneezing at intervals may be present in the neonatal period.
- Rooting reflex–it is the movement of the mouth for sucking of the nipple when corner of the infant's mouth is lightly touched.
- The grasp reflex–when any object like finger or pencil is grasped by the flexed palm of the infant, it is called palmar reflex. This reflex is present in a healthy term baby and weak in a preterm baby.
- The moro reflex/startle reflexThis reflex is elicited by sudden jerking of the cot or even a loud noise. The newborn suddenly throws his arms upwards and outwards with the hands and fingers extended with a vigorous extensor tremor of the forelimbs which rapidly subsides.
- Tonic neck reflexThe baby is placed on his or her back and the head is turned to one side. The arm and leg on the same side extend and the opposite arm and leg flex and the baby assumes a fencing position. If the head is turned to the opposite side, same reaction occurs. This reflex is present for 2 to 3 months. If it persists longer than this time. It usually indicates neurological dysfunction.
- Walking/stepping reflexThe baby is held so that the soles of the feet touches a flat surface. This stimulates the baby to a stepping or dancing movement with both legs. This reflex is present at birth and disappears after 3 to 4 weeks.
- Traction response/head lag reflexWhen pulled to an upright position by the wrists to a sitting position, the head will lag initially and then right itself momentarily before falling forward on to the chest.
- Ventral SuspensionWhen held prone suspended over the examiner's arm the baby shortly holds his head level with his body and flexes his limbs.
- Babinski reflexThe lateral aspect of the sole of the infant's foot is scratched, going from heel to toes. The reflex shows a dorsal flexion of the big toe. The reflex is present until 9th or 10th month. Poor response may be due to nervous system immaturity and absence may be due to defects in the lower spinal cord.33
Daily Care and Observation of the Newborn
Daily assessment is important for identification of early problems. For a normal newborn, the following care and observations should be carried out every day.
- Vital signs checkRespirations are to be regular, smooth and quiet with a rate about 40 per minute.Temperature by axilla or groin to be within normal range.
- WeightWeight to be checked and evaluated daily. Loss of 10% of body weight in the first week is normal. Most babies regain their birth weight in 7 to 10 days.
- ColorAny cyanosis should be reported to the pediatrician immediately. Jaundice may be noted from the third day. It is abnormal if jaundice appears earlier, deepens or persists beyond 7th day.
- The headAssessment of the anterior fontanelle which should be level with the scalp (not bulging or depressed), resolution of caput succedaneum and moulding are important. Appearance of any swelling such as cephalhematoma should also be noted.
- The mouthMouth should be clean and moist. Adherent white patch indicates oral thrush.
- Umbilical cordThe base of umbilical cord is inspected and cleaned with alcohol daily.
- EliminationThe stools are observed and compared with expected normal in relation to the neonate's age and feeding. Constipation, loose stools or sore buttocks to be noted. The frequency of passing urine in 24 hours should be noted.
- BathCleansing the skin may be done daily or as frequently as required especially the face, skin flexures and napkin area to prevent excoriation. Daily bath is recommended if the baby is at home. As the baby is undressed skin is inspected for rashes, septic spots or abrasions.
INFANT FEEDING
Majority of women decide when they conceive that they want to breastfeed their babies. Some may not take a decision early. However, it is important to teach all pregnant women about the benefits of breastfeeding. Preparation for breastfeeding must begin when pregnancy starts altering the breasts and nipples. All pregnant women must be given the following instructions:
- Wear a comfortable brassier that does not compress the breasts and support the increasing weight.
- Cleanse the breasts daily with water and wipe with a soft clean cloth followed by careful cleansing.
- If the nipples are flat or inverted, nipple rolling to be done to bring them out with lightly lubricated thumb and index fingers. Roll the nipple of each breast for approximately 30 seconds every day in the 9th month.
- The importance and benefits of breast milk and exclusive breastfeeding.
Benefits of Breastfeeding
- It is always available at right temperature
- It is free of bacterial contamination
- It is easily digestable and nourishing. Breastfed babies thrive much better and are less susceptible to infection.
- Breastfed infants become less obese
- Breast milk contains the essential vitamins and necessary food factors in proper proportion.
- Mother gets more opportunity to bond with the baby and baby gets a feeling of security
- Milk allergy is very rare with breast milk
- Breast milk is a more effective rehydration fluid than plain water
- In the immediate postpartum period frequent sucking at the breasts, is the best stimulus for milk production
- Breast milk offers protection against infection and deficiency states as it contains:
- Vitamin D which offers protection against rickets
- Lactoferrin which hinders the growth of E. coli and provides protection against gastroenteritis
- Bifidus factor which promotes lactobacillus and inhibits growth of E. coli
- Lysozyme which offers protection against infection
- Breast milk gives passive immunity to the baby as it contains protective antibodies
- Breast milk has a laxative action and offers no danger of allergy.
Hormonal Control of Milk Production and Ejection
When the placenta is delivered, estrogen and progesterone levels fall and cause prolactin levels to rise in the mother. Prolactin which is secreted from the anterior pituitary gland stimulates the production of milk in the alveoli cells of the breasts. The ‘let down’ reflex occurs when the baby begins to suckle at the breast.
As the baby sucks, the nerve endings in the nipple and areola stimulate the posterior pituitary which in turn secretes oxytocin. Oxytocin causes the myoepithelial cells in the alveoli and lactiferous sinuses to contract and eject milk. The hind milk that is ejected after the let down is rich in fats and nutrients. The pituitary gland is controlled by the hypothalamus and hence the let down reflex is influenced by emotions such as fear, pain, anxiety and environment.
Management of Breastfeeding
- Time of first feedingThe baby can be put to mother's breast within an hour after birth. The sucking reflex is strongest in the first half hour after birth.
- Feeding scheduleThe baby should be permitted to suck freely at the breast frequently and without any fixed time table (demand feeding).This will ensure that the newborn has the full benefit of colostrum. The baby takes feed frequently in the beginning but gradually settles to a 3 to 4 hour schedule.As regards night feeds, it is desirable that at least one feed is given for first three months. Later the baby may not need night feeds.
- Duration of each feedOn the first day 2 to 3 minutes on each breast may be sufficient and the duration may be increased by a minute per breast per day. After the initial week the baby should be fed for 7 to 10 minutes at each breast when he indicates he is hungry. Most babies will settle down to feeding every 3 to 4 hours and gain weight satisfactorily.
- Beginning breastfeeding
- Instruct mother to clean her nipple and areola with wet swab or soft cloth before and after each feed.
- Advice mother to keep clean hands, short nails and wear clean clothes.
- Teach the technique of breastfeeding:
- Assume comfortable position–sitting or lying in bed
- Place the nipple and areola into baby's mouth
- Relax and give full attention to baby while feeding and keep the baby awake while feeding.
- Rotate breasts as the starting and ending breast to provide for complete emptying of both breasts.
- Burping (breaking the wind)At the end of feeding from each breast, burping is done for five minutes to prevent regurgitation and vomiting. Burping helps the baby to bring out swallowed air from stomach. For burping, hold the baby in upright position either on the shoulder or lap and gently pat the back upwards until the swallowed air is expelled.35
- Identifying the baby who is well-fedA baby who takes adequate quantity of milk will:
- Not cry after feeding
- Fall asleep and have uninterrupted sleep
- Refuse to drink any more milk
- Not have constipation
- Have progressive weight gain
- The baby-friendly hospital initiativeIn 1992, UNICEF and WHO launched the baby-friendly initiative to promote, protect and support breastfeeding. The objective is to establish the superiority of breastfeeding in order to protect the newborn's health by becoming baby friendly. The steps of the initiative laid down are:
- There must be a written breastfeeding policy
- All pregnant women must be informed about the benefits of breastfeeding
- Mothers must be helped to initiate breastfeeding within half an hour of birth
- Mothers must be taught the correct technique of breastfeeding
- Unless medically indicated, the newborn should be given no food or drink other than breast milk.
- To practice rooming in by allowing mothers and babies to remain together 24 hours a day
- To encourage breastfeeding on demand
- To encourage exclusive breastfeeding
- No artificial teats should be given to babies
- Breastfeeding support groups are to be established and mothers must be referred to them on discharge.
- A babyfriendly hospital should also provide other preventive care services such as immunization, rehydration salts against diarrheal dehydration and baby's growth and development surveillance.
- Contraindications to breastfeeding
- Mothers on drugs that can be harmful to baby such as cytotoxics, certain hormones and radioactive isotopes
- Infectious diseases such as typhoid fever, human immune deficiency infection and pulmonary tuberculosis
- Chronic medical illnesses such as heart disease, severe anemia and poorly controlled epilepsy
- Puerperal psychosis
- Mothers taking high doses of antiepileptic, anticoagulant and antithyroid drugs
- Babies with harelip and cleft palate
- Preterm and very ill babies.
NURSING DIAGNOSES FOR MATERNAL - NEONATAL CLIENTS
Nursing diagnosis is a clinical judgment about individual, family or community responses to actual or potential health problems/life processes. Nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable (NANDA).
Use of Nursing Diagnosis
- Nursing diagnosis is used as the second step of the nursing process. In the second step, the data collected during the assessment of the client's health status is analyzed and problems are identified. Some of the conclusions resulting from data analysis will lead to nursing diagnoses.
- Nursing diagnoses are used as diagnostic labels which describe health states that a nurse could legally diagnose and treat. These labels are concise descriptors of a cluster of signs and symptoms.
Types of Nursing Diagnoses
- Actual Nursing DiagnosesAn actual nursing diagnosis represents a state that has been clinically validated by identifiable, major, defining characteristics. The actual nursing diagnosis statement begins with a precise qualifier such as ‘altered’, ‘impaired’, ‘deficit’, or ‘ineffective’.The defining characteristics refer to clinical cues—subjective and objective signs or symptoms that point to the nursing diagnoses. Example: Impaired skin integrity related to immobility as evidenced by erythematous sacral lesions.
- High Risk Nursing DiagnosesA high risk nursing diagnosis is a clinical judgment that an individual, family or community is more vulnerable to develop the problem than others in the same or similar situation. The statement of nursing diagnosis will begin with ‘High risk for’. Example: A postoperative high risk nursing diagnosis statement could be as ‘High risk for impaired skin integrity related to immobility secondary to pain’.
- Possible Nursing DiagnosesA possible nursing diagnosis is a statement describing a suspected problem for which additional data are needed. The word possible is used to describe problems that may be present but that require additional data to be confirmed or ruled out. The word possibly serves to alert nurses to the need for additional data. Possible nursing diagnoses are two-part statements.Example: Possible feeding self-care deficit related to fatigue and IV in right hand.
- Wellness Nursing DiagnosesA wellness nursing diagnosis is a clinical judgment about an individual, group or community in transition from a specific level of wellness to a higher level of wellness. For such a nursing diagnosis, two cues should be present.
- Desire for a higher level of wellness.
- Effective present status or function.
These are one part statements containing the label only. The label begins with ‘potential for enhanced’ followed by the higher level of wellness that the individual or group desires.Example:Potential for enhanced family process.Potential for enhanced marital relationship.Potential for enhanced parenting. - Syndrome Nursing DiagnosesA syndrome diagnosis comprises a cluster of actual or high risk nursing diagnoses that are predicted to be present because of a certain event or situation. Syndrome nursing diagnoses are one part diagnostic statements because the etiology or contributing factors for the diagnosis are contained in the diagnostic label.Example:Rape trauma syndrome.Disuse syndrome.
Types of Diagnostic Statements
Diagnostic statements can have one, two or three parts. One part statements contain only the diagnostic label. Wellness and syndrome nursing diagnoses are written as one part statements.
Two part statements contain the label and factors that have contributed or could contribute to a health status change. Possible nursing diagnoses and high-risk nursing diagnoses are written as two part statements.
For writing actual nursing diagnoses, three part statements are used. They contain the label, the contributing factors and the defining characteristics (signs and symptoms) of the health state alteration.
Three part statements
Actual nursing diagnoses statements consist of three parts.
Diagnostic label + contributing factors + defining characteristics.
Gordon identified the PES format for recording the three part diagnosis. Problem, etiology and signs and symptoms (PES).37
The format cannot be used for highrisk or possible diagnoses because signs and symptoms are not present in those instances.
Writing Actual and High Risk Diagnostic Statements
- Ineffective coping related to labor and delivery as evidenced by fatigue and expressed inability to cope. ‘I cannot go on anymore’.
- Hypothermia related to cold stress as evidenced by body temperature below normal, cool pale skin and achrocyanosis.
- Deficient fluid volume related to postpartum hemorrhage as evidenced by decreased pulse volume and pressure, increased pulse rate and decreased urinary output.
- Risk for infection related to neonate's immature immune system.
- Risk for infection related to labor and delivery.
NURSING DIAGNOSES FOR PRENATAL CLIENTS
1. Deficient Knowledge Related to Self-care Activities during Pregnancy
Definition
Inadequate understanding of information needed to practice health-related behaviors during pregnancy.
Assessment
- Age of patient
- Psychosocial aspects such as health beliefs, knowledge regarding pregnancy, learning ability, previous obstetric history, support system and coping pattern
- Mental status and orientation and memory.
Defining characteristics
- Inability to follow through with instructions
- Inappropriate or exaggerated behaviors such as hostility, apathy and agitation
- Inadequate knowledge of care to be taken during pregnancy
- Verbalization of problems.
Expected outcomes
- Patient will communicate need for more information
- Patient will demonstrate understanding of information taught
- Patient will demonstrate ability to perform new bahaviors learned
- Patient will continue to practice appropriate health-related behaviors after pregnancy
Nursing interventions
- Establish a trusting relationship and respect so that patient will relax and be receptive to learning
- Communicate and negotiate realistic learning goals with the patient
- Assess patient's knowledge of pregnancy to establish a basis for nursing care plans
- Provide information/teaching tailoring the content to suit the patient's level of understating
- Provide instructions to seek appropriate resource persons for obtaining comprehensive care during pregnancy
- Review dietary intake during pregnancy based on physician's recommendations. Explain to patient that she needs an extra 300 calories per day, for a total of 2100 to 2400 calories per day.
- Instruct patient to avoid wearing constrictive clothing, using high-heeled shoes and taking nonprescription drugs. Constrictive clothing can obstruct venous circulation and high-heeled shoes can increase the likelihood of back strain.
- Discuss dangers of exposure to toxic chemicals or gases to avoid possible teratogenic effects on fetus
- Instruct the woman to contact physician or go to hospital if she experiences any danger sign or symptom
- Severe vomiting
- Frequent and severe headache
- Epigastric pain
- Vision disturbances
- Swelling of fingers and face
- Altered or absent fetal movements after quickening
- Signs of vaginal tract or urinary infection
- Unusual or severe abdominal pain
- Fluid discharge from vagina
- Vaginal bleeding
Evaluations for expected outcomes
- Patient express need for more information about self-care
- Patient establishes realistic goals
- Patient demonstrates understanding of matters taught
- Follows appropriate exercises
- Limits or stops smoking and/or consumption of alcohol if indicated
- Obtains sufficient rest
- Avoids areas that may contain toxic chemicals or gases
- Stops wearing constrictive clothing and high-heeled shoes
- Reports danger signals to physician promptly
- Takes prenatal vitamins as prescribed
- Patient demonstrates ability to perform health related behaviors learned
- Patient continues to practice health related behaviors after pregnancy.
Documentation
- Patient's knowledge of self-care activities
- Expressions indicating motivation to learn
- Teaching carried out and methods of teaching used
- Dietary intake reported or seen
- Demonstration or return demonstration of skills
2. Nausea and Vomiting Related to Physiological Changes of Pregnancy
Definition
A minor disorder of pregnancy experienced by pregnant women between 4th and 16th week of gestation.
Assessment
- Characteristics and pattern of occurrence of nausea and vomiting
- Types of food and smell to which patient has intolerance
- Physical health status
- Patient's understanding of the physiological changes of pregnancy
- Support system available.
Defining characteristics
- Change in appetite and pattern of eating
- Vomiting in the morning and/or later in the day
- Increased salivation
- Inability to retain food and fluids
- Fatigue and signs of dehydration.
Expected outcomes
- Patient will identify the factors that aggravate vomiting
- Patient will appreciate the physiological changes of pregnancy that cause vomiting
- Patient will modify her habits of eating
- Patient will adopt appropriate measures to obtain relief
- Patient will experience cessation of vomiting and improvement of general health.
Nursing interventions
- Assess and document the extent of nausea and vomiting to have a database
- Reassure patient that nausea will usually subside by the 4th month of pregnancy in order to reduce her anxiety
- Instruct patient to eat dry, unsalted crackers before rising in the morning to prevent nausea from an empty stomach
- Instruct patient to avoid greasy or spicy food, which irritate the stomach. Fats with meals depress gastric motility and secretion of digestive enzyme and slow intestinal peristalsis causing gastroesophageal reflux
- Advise patient to avoid cooking odors that precipitate nausea
- Advise mothers to eat six small meals instead of three large ones to avoid overloading the stomach
- Advise mothers to eat foods high in carbohydrates as they are easier to digest
- Instruct her to take iron pills and vitamins after meals to avoid irritating the stomach
- Advise to take frequent walks outside as fresh air reduces nausea and helps reinforce a positive outlook
- Instruct to separate food and fluid intake by half an hour. Drinking excessive fluids with food distends stomach, predisposing to nausea.
- Advise client to avoid very cold food and fluids at meal times as they may cause nausea and abdominal cramping
- Instruct her to consult physician before taking over-the-counter medications for nausea and vomiting to avoid harmful effects on fetus.
Evaluations for expected outcomes
- Patient identifies factors and food habits that aggravate nausea and vomiting
- Patient modifies her habits of eating
- Patient adopts measures to obtain relief from nausea
- Patient experiences reduction in nausea and cessation of vomiting
- Patient experiences improvement of general health
Documentation
- Patient's description of nausea, vomiting and aggravating factors
- Patient's general health observed
- Instructions given to patient and her response to teaching
- Change in eating and drinking habits observed and reported by patient
3. Urinary Frequency and Dysuria Related to Physiological Changes of Pregnancy
Definition
Frequency, urgency and pain on urination experienced by some women during pregnancy.
Assessment
- Nature and duration of urinary frequency
- Daily fluid intake
- Symptoms of UTI such as pain on urination, and fever
- Patients understanding of the physiological changes in pregnancy.
Defining characteristics
- Frequency and urgency of urination
- Dysuria if associated infection present
- Sleep disturbance due to urinary frequency
- Occurrence of complaints in the early and late months of pregnancy.
Expected outcomes
- Patient will experience relief from frequency of urination and dysuria
- Patient will increase her fluid intake during day time
- Patient will practice measures to prevent bladder distention and urinary stasis
- Patient will learn to report signs of developing urinary tract infections.
Nursing interventions
- Reassure patient that urinary frequency is normal in the early and late months of pregnancy because enlarging uterus places pressure on the bladder
- Instruct patient to avoid drinking large amounts of fluids within 2 to 3 hours of bedtime to prevent nocturnal urination and sleep loss
- Instruct client to ingest the required amount of fluid early in the day to reduce the need for evening liquids
- Instruct client to void when the urge occurs to prevent bladder distention and urinary stasis which may predispose to urinary tract infection
- Teach patient signs and symptoms of UTI
- Teach patient to report signs and symptoms of UTI promptlyEarly detection of UTI allows early treatment and helps prevent complications such as pyelonephritis.
Evaluations for expected outcome
- Patient develops knowledge of the causes of urinary frequency
- Patient adapts and adjusts to the change in urinary elimination
- Patient modifies her fluid intake pattern
- Patient learns to identify and report signs of UTI if she develops it.
- Patient experiences more rest during night and relaxation during day time.
Documentation
- Patient's description of urinary frequency and dysuria
- Measures of relief explained and response of patient
- Relief measures observed and reported
NURSING DIAGNOSES FOR LABOR AND DELIVERY CLIENTS
1. Acute Pain Related to Physiological Response to Labor
Definition
An unpleasant sensory and emotional experience arising from actual or potential tissue damage; pain may be sudden or slow in onset, vary in intensity from mild to severe and constant or recurring.
Assessment
- Characteristics of pain including location, intensity and source of relief
- Physiological variables including age, and pain tolerance
- Psychological variables including personality, previous experience with pain and anxiety
- Socio-cultural variables such as cognitive style, culture, attitudes and values
- Knowledge and expectations of labor and delivery.
Defining characteristics
- Alteration is muscle tone-listless to rigid
- Autonomic response such as diaphoresis, change in blood pressure and respiratory rate, dilated pupils
- Change in appetite
- Communication of pain
- Behavior such as pacing and seeking out other people
- Expressions of pain such as moaning and crying
- Grimacing and other facial expressions
- Guarding or protective behavior
- Narrowed focus such as altered perception, impaired thought process and withdrawal from people
- Self-focusing
- Sleep disturbance.
Expected outcomes
- Patient will identify characteristics of pain
- Patient will describe factors that intensify pain
- Patient will modify behavior to decrease pain
- Patient will express decrease in intensity of pain
- Patient will express satisfaction of her performance during labor and delivery.
Nursing interventions
- Orient patient to labor and delivery rooms on admission
- Explain admission protocol and labor process
- Show patient her room, bed and facilities such as call bell, toilet, television etc, to allay her fear and anxiety
- Assess patient's knowledge of labor process to plan nursing interventions
- Explain availability of analgesics and/or anesthesia (epidural) to patient and family for reducing anxiety
- Encourage support person or family member to remain with patient if hospital policy permits
- Instruct patient and support person in techniques to decrease the discomfort of labor
- Discuss techniques of conscious relaxation
- Instruct to concentrate on an internal or external focal point
- Instruct in deep chest breathing during contractions
- Instruct in shallow chest breathing and slow panting like breathing between contractions which will avoid hyperventilations
- Instruct patient in effleurage
- In early labor provide patient with diversional activities such as watching television if possible to reduce anxiety
- Apply sacral pressure if needed to decrease back pain
- Assist to change position and provide additional pillow to reduce stiffness and promote comfort
- Assess bladder for distention and encourage to void every two hours to reduce discomfort during contractions and facilitate fetal descend
- Provide frequent mouth care. Provide ice chips or wet gauze for dry lips caused by breathing techniques and nil-by-mouth
- Apply cool, damp wash cloth to forehead to relieve diaphoresis
- Provide clean gown and bed linen as needed. Diaphoresis and vaginal discharge can dampen bed linen and gown
- Encourage patient to rest and relax between contractions to decrease discomfort
- Discuss with patient and support person that pain medications are available if alternate pain control methods provide inadequate relief
- When required, administer prescribed analgesics to cope with labor process.
Evaluations
- Patient identifies characteristics of pain and describes factors that intensify it
- Patient modifies behaviors to decrease pain and discomfort such as using breathing techniques, asking for analgesia and assuming comfortable position
- Patient reports decrease in discomfort
- Patient expresses satisfaction with her performance during childbirth.
Documentation
- Patient's childbirth preparation
- Patient's description of pain and discomfort
- Observation of patient's response to labor
- Nursing interventions carried out to decrease discomfort
2. Deficient Knowledge Related to Information about Birth Process
Definition
Inadequate understanding of or inability to perform skills needed to cope effectively with the process of labor.
Assessment
- Age of patient
- Psychosocial status such as expectations of the birth process and interest in learning
- Current knowledge about pregnancy, birth and recovery
- Ability to learn and attention span
- Support system including presence of support person interested in helping the patient.
Defining characteristics
- Inability to follow through with instructions
- Inappropriate or exaggerated behaviors such as hysteria hostility, agitation and apathy
- Verbalization of problems.
Expected outcomes
- Patient will recognize that increased knowledge and skill will help her cope better with birth process
- Patient will demonstrate understanding of what is taught
- Patient will demonstrate ability to perform skills needed for coping with labor
- Patient will express realistic expectations about birth process
- Patient will express satisfaction with her increased knowledge.
Nursing interventions
- Find a quiet, private place to teach the patient
- Establish a trusting relationship with the patient and develop mutual goals for learning
- Select appropriate teaching methods and materials such as discussions and demonstrations using audiovisual aids
- Teach information and skills needed for understanding and coping during birth to increase the patient's sense of competence.
Evaluations for expected outcomes
- Patient expresses desire to put knowledge into practice during labor
- Patient describes birth process in her own words
- Patient responds to labor without undue anxiety and uses breathing, relaxation and position changes
- Patient voices satisfaction with newly acquired knowledge and skills.
Documentation
- Patient's understanding about birth process
- Patient's expression of need for better understanding
- Learning goals established with the patient
- Information and skills taught to patient
- Teaching methods used
- Patient's response to teaching
- Patient's mastery of knowledge and skills demonstrated
3. Ineffective Coping Related to Labor and Delivery
Definition
Inability to use adaptive behaviors in response to labor and delivery.
Assessment
- Age, health beliefs, feelings about pregnancy, decision-making ability,motivation to learn and obstacles to learning
- Pain threshold, perception of pain and response to analgesia
- Stage and length of labor, complications, ability to concentrate and use techniques, presence and effectiveness of support person
- Mode of delivery
- Previous experience with pregnancy, labor and delivery and knowledge of birth process
- Preexisting pregnancy-induced or medical conditions.
Defining characteristics
- Expressed inability to cope
- Fatigue
- Inability to meet basic needs and role expectations
- Poor concentration and problem solving abilities
- Destructive behavior towards self or others.
Expected outcomes
- Patient will express need to develop better coping behaviors
- Patient will set realistic learning goals
- Patient will use learned coping skills
- Patient will communicate feelings about pregnancy, labor and delivery
- Patient will maintain appropriate sense of control throughout the course of labor and delivery
- Patient will demonstrate ability to cope with unexpected changes.
Nursing Interventions
- Establish a relationship of mutual trust and respect to enhance patient's learning
- Develop learning goals with the patient to foster a sense of control
- Select appropriate teaching strategies to encourage compliance
- Teach skills that the patient can use during labor and delivery and have her give a return demonstration of each skill.
- During the latent phase of labor (dilation 1 to 4 cm).
- Encourage patient to participate in her own care
- Review breathing techniques she can use during labor
- Involve support person in care and comfort measures
- Provide continuous or frequent monitoring to identify any deviation from normal.
- During the active phase of labor (dilation 4 to 8 cm).
- Encourage patient to assume comfortable position to promote relaxation between contractions
- Assist patient with breathing techniques to reduce anxiety and prevent hyperventilation
- Encourage the support person to participate in patient care such as changing soiled linen, providing sacral pressure, back rub and offering ice chips to moisten lips
- Administer analgesia as ordered to reduce pain
- Reassure patient about fetal status.
- During the transitional phase of labor (dilatation 8 to 10 cm).
- During delivery of the placenta.
- Encourage patient to maintain her position to facilitate delivery of placenta
- Show the neonate to the patient and reassure about the neonate's condition to provide emotional support
- Allow the patient to hold the neonate if permitted
- Allow her to breastfeed neonate if she desires to promote bonding
- In a delivery, allow the patient to express her feelings and explain to her the care being provided to enable her cope with the task of motherhood.
Evaluation for expected outcomes
- Patient participate in establishing learning goals
- Patient successfully uses breathing and relaxation techniques during labor and delivery
- Patient maintains appreciable sense of control during labor and delivery
- Nurses and support persons provide effective comfort to patient during labor and delivery
- Patient demonstrates ability to cope with unexpected changes.
Documentation
- Patient's knowledge of labor and delivery
- Patient's expressions of motivation to learn
- Methods used to teach patient
- Information taught and skills demonstrated
- Patient's level of satisfaction with delivery
4. Anxiety Related to Hospitalization and Birth Process
Definition
Feeling of threat or danger to self-related to pregnancy or delivery.
Assessment
- Expressed worries fears and concerns
- Expectations of labor experience
- Reactions to uterine activity, fatal movement, and interactions with nurse and significant others
- Ability to concentrate, learn and remember
- Physiologic status
- Usual coping methods
- Mood and personality
- Progress of labor.
Defining characteristics
- Excessive attention to uterine activity and fetal movements
- Excessive reaction to uterine contractions
- Expressed concern about childbirth
- Expressed fear of unspecified negative outcomes
- Expressed feelings of helplessness
- Fear and apprehension
- Inability to concentrate and remember
- Increased muscle tension in body
- Increased perspiration
- Rapid pulse rate
- Restlessness, shakiness and trembling.
Expected outcomes
- Patient will express feelings of anxiety
- Patient will identify causes of anxiety
- Patient will make use of available emotional support
- Patient will show fewer signs of anxiety
- Patient will identify positive aspects of her efforts to cope during childbirth
- Patient will acquire increased knowledge about childbirth
- Patient will be better prepared to cope with future births.
Nursing interventions
- Assess the patient's knowledge and expectations of labor to identify the precise source of anxiety
- Discuss normal labor progression with patient and explain what to expect during labor to help her understand her own experience
- Involve the patient in making decisions about care to reduce the sense of powerlessness
- Share information about progress of labor and neonate's condition with patient to provide reassurance and to increase her sense of participation
- Interpret to patient sights and sounds in labor room such as fetal heart sounds, fetal monitor strip and activities to reduce anxiety and increase confidence
- Attend to the patient's comfort needs to increase her trust
- Encourage patient to use coping skills such as breathing relaxation and positioning to increase her sense of power and control
- Spend as much time as possible with the patient to provide comfort and assistance, thereby promoting the patient's sense of security
Evaluation for expected outcomes
- Patient expresses feelings of anxiety about pregnancy and childbirth
- Patient identifies causes of anxiety
- Patient communicates with nurse and family members, to gain reassurance and emotional support
- Patient's physiologic and behavioral signs return to normal
- Patient express satisfaction with her behavior while giving birth.
Documentation
- Patient's expression of anxiety
- Patient's statement of reasons for anxiety
- Observations of physical and behavioral signs of anxiety
- Interventions to assist patient with coping
- Patient's response to interventions
NURSING DIAGNOSIS FOR POSTPARTUM CLIENTS
1. Deficient Knowledge Related to Postpartum Care
Definition
Inadequate understanding of postpartum self-care activities or inability to perform skills needed to practice health related behaviors.
Assessment
- Age and learning ability
- Decision-making ability
- Interest in learning
- Knowledge and skill regarding postpartum self-care
- Obstacles to learning
- Support systems and usual coping pattern
- Physical abilities to perform self-care activities.
Defining characteristics
- Inability to follow through with instructions
- Inappropriate or exaggerated behaviors such as hostility, agitation or apathy
- Poor knowledge level
- Verbalization of problem.
Expected outcomes
- Patient will express desire to learn how to care for herself after delivery
- Patient will verbalize or demonstrate understanding of what she has learned about self-care
- Patient will incorporate newly learned skills into daily routine
- Patient will make changes in postpartum routine
- Patient will seek help from health care professional if required.
Nursing interventions
- Establish mutual trust and respect to enhance patient's learning
- Assess patient's level of understanding of postpartum self-care activities to establish a baseline for learning
- Assist patient in making-decisions regarding target dates for mastering postpartum self-care skills
- Select teaching strategies best suited for patient's individual learning style to enhance learning
- Teach skills which the patient can incorporate into her daily life such as perineal care, sitz bath, application and removal of perineal pads and breast care
- Teach patient about the process of involution to help her understand postpartum changes
- Teach patient the importance of adequate nutrition and hydration to ensure proper urinary and bowel elimination
- Discuss the importance of adequate rest to promote emotional and physical stability
- Help the patient to incorporate learned skills into her daily routine during hospitalization
- Encourage patient to continue hygienic practices even after discharge from hospital.
Evaluation for expected outcomes
- Patient expresses motivation to learn
- Patient establishes realistic learning goals
- Patient demonstrates understanding of what she has learned
- Patient incorporates what she has learned into her daily routine such as breast care, perineal care and obtaining adequate rest and sleep
- Patient states intension of making changes in daily routine
- Patient expresses intension to seek help from health professional if required.
Documentation
- Patient's understanding and skill in postpartum self-care
- Patient's expressions which indicate her motivation to learn
- Methods used to teach patient
- Information taught to patient
- Skills demonstrated to patient
- Patient's response to teaching
2. Pain Related to Postpartum Physiological Changes
Definition
An unpleasant sensory and emotional experience that arises from actual or potential tissue damage.
Assessment
- Patient's description of pain
- Patient's age, parity and pain tolerance
- Previous experience with pain in post delivery period
- Presence of physical factors such as breast engorgement, cracked nipples and hemorrhoids.
Defining characteristics
- Alteration in vital signs, diaphoresis, etc
- Communication of pain in verbal and nonverbal forms
- Behavior changes such as pacing and repetitive actions
- Expressions of pain such as crying, groaning and grimacing
- Sleep disturbance.
Expected outcomes
- Patient will identify characteristics of pain and describe the factors that intensify it
- Patient will carry out appropriate interventions for pain relief
- Patient will express relief from pain and comfort.
Nursing interventions
- Assess patient's pain symptoms and plan appropriate nursing interventions
- Discuss the reasons for pain and its expected duration to reduce the patient's anxiety
- Inspect the presence of hemorrhoids and provide instructions for hemorrhoid care if indicated
- Assess for uterine tenderness and presence and frequency for afterbirth pains every 4 hours for first 24 hours and every shift thereafter as indicated. Oxytocin administration, multiparity and breastfeeding are factors that may intensify uterine contractions
- Instruct breastfeeding mother to wear supportive bra to increase comfort
- If breastfeeding mother is engorged instruct her to use warm compress or take warm shower to simulate the flow of milk and help relieve stasis and discomfort
- If nipples become sore, instruct mother to air dry the nipples for 20-30 minutes after feeding to roughen the nipples.
- Apply breast cream as ordered to soften nipples and relieve pain
- Instruct nonbreastfeeding mother to wear tight, supportive bra or breast binder and apply ice packs as needed to prevent or reduce lactation.
Evaluations for expected outcomes
- Patient describes pain and factors that intensify it
- Patient carries out appropriate interventions for pain relief as instructed
- Patient expresses relief of pain and discomfort
- Patient's breasts remain soft and lactation continues to be adequate
- Patient expresses understanding of instructions and follows through.
Documentation
- Patient's description of pain and discomfort
- Observations of pain manifestations
- Comfort measures and medications provided for pain relief
- Effectiveness of interventions carried out
- Instructions provided to patient about pain and pain relief measures
3. Deficient Fluid Volume Related to Postpartum Hemorrhage
Definition
Excessive fluid and electrolyte loss resulting from excessive postpartum bleeding.
Assessment
- History of problems that can cause fluid loss such as hemorrhage, vomiting and diarrhea
- Vaginal signs such as visible bleeding, laceration, etc
- Fluid and electrolyte status including weight, intake and output, urine specific gravity, skin turgor, mucous membranes and serum electrolytes and blood urea nitrogen levels
- Laboratory values such as hemoglobin (Hb) level and hematocrit (HCT) value
- Risk factors such as grand multiparty, overdistended uterus, prolonged labor, previous history of postpartum hemorrhage, traumatic delivery, uterine fibroids, and bleeding disorders.
Defining characteristics
- Decreased pulse volume and pressure
- Decreased urine output and increased concentration
- Dry skin and mucous membranes
- Increased hematocrit
- Increased pulse rate
- Low blood pressure
- Poor skin turgor
- Thirst
- Weakness
- Change in mental status.
Expected outcomes
- Patient's vital signs will remain stable
- Patient's hematology values will be within normal range
- Patient's uterus will remain firm and contracted
- Signs of shock will be identified quickly and treatment initiated immediately by medical personnel
- Patient's blood volume will return to normal
- Patient's urinary output will return to normal.
Nursing interventions
- Following delivery, monitor the color, amount, and consistency of lochia every 15 minutes for one hour, every 4 hours for 24 hours and then every shift until discharge
- Count or weigh sanitary pads if lochia is excessive
- Monitor and record vital signs every 15 minutes for one hour, every hour for 4 hours and every 4 hours for 24 hours to detect signs of hemorrhage and shock
- Immediately after delivery, palpate the fundus every 15 minutes for one hour, every hour for 4 hours, hours for 24 hours and then every shift until discharge to note its location and muscle tone. Lack of uterine muscle tone or strength (atony) is the most common cause of postpartum hemorrhage
- Gently massage a boggy fundus, to make it become firm (over stimulation can cause relaxation)
- Teach patient to assess and gently massage the fundus and notify if bogginess persists
- Explain to patient the process of involution and the need to palpate the fundus to decrease her anxiety and increase cooperation
- Evaluate postpartum hematology studies and report abnormal values to plan required interventions
- Administer fluids, blood or blood products or plasma expanders as ordered to replace lost blood volume
- Monitor patient's intake and output every shift
- Note bladder distension and catheterize as ordered as distended bladder interferes with the involution of uterus
- Assess patient regularly for signs and symptoms of shock such as rapid thready pulse, increased respiratory rate, decreased blood pressure and urine output and cold, clammy, pale, skin.
Evaluations for expected outcomes
- Patient's vital signs remain stable
- Results of hematology studies are within normal range
- Patient's uterus remains firm
- Patient does not develop distended bladder
- Patient's blood loss after delivery is less than 500 ml
- Patient's blood volume is replenished
- Quick identification and prompt treatment are provided if patient develops shock.
Documentation
- Estimation of blood loss
- Location and tone of fundus
- Laboratory results
- Replacement of lost fluid
- Nursing interventions to control active blood loss
- Vital signs, intake and output
4. Pain Related to Episiotomy or Cesarean Incision
Definition
Unpleasant sensory and emotional experiences arising from tissue damage which vary in intensity from mild to severe and be constant or recurring.
Assessment
- Patient's description of pain including quality and intensity
- Patient's age and pain tolerance
- Patient's anxiety level and any symptoms of secondary gain.
Defining characteristics
- Alteration in vital signs, diaphoresis or dilated pupils
- Change in appetite and eating
- Communication of pain in verbal and nonverbal forms
- Expressions of pain such as crying moaning and grimacing
- Guarding or protective activities
- Sleep disturbance.
Expected outcomes
- Patient will describe nature of pain and intensity
- Patient will understand and carry out appropriate interventions for pain relief
- Patient will express comfort and relief from pain.
Nursing interventions
- Examine the episiotomy site for redness, edema, ecchymosis, drainage and approximation to detect trauma to perineal tissues or developing complications
- Discuss reasons for pain and discomfort and measures to be carried out for relief
- Apply ice pack to the episiotomy site for the first 24 hours to increase vasoconstriction and reduce edema and discomfort
- Provide warm sitz bath (temperature 100 ° to 105 ° F/37.8 to 40.6 degree C) from 2nd postpartum day. Instruct patient to take sitz baths three times a day with each lasting for 20 minutes. Sitz bath increases circulation, reduces edema and promotes healing
- Provide infrared light to perineum if ordered to reduce discomfort
- Apply any prescribed sprays, creams or ointments for reduction of swelling and discomfort
- Instruct patient to tighten buttocks before sitting and to sit on flat firm surface. This reduces stress and direct pressure on the perineum
- Administer prescribed pain medications to provide pain relief
- For post cesarean patients, provide an additional pillow and teach to splint the incision site when moving or coughing to provide support for the abdominal muscles.
Evaluations for expected outcomes
- Patient reports characteristics and intensity of pain
- Patient carries out appropriate interventions for pain relief as instructed
- Patient expresses relief of pain and discomfort
- Episiotomy cesarean incision heals normally
- Patient expresses understanding of instructions given and implements care activities.
Documentation
- Patient's description of pain and pain relief experienced
- Nurse's observation of patient's response to interventions for pain relief
- Comfort measures and medications provided for pain relief
NURSING DIAGNOSIS FOR NEONATAL CLIENTS
1. Ineffective Breastfeeding Related to Difficulty with Breastfeeding Process
Definition
State in which mother or neonate experiences dissatisfaction or difficulty with breastfeeding process.
Assessment
- Maternal status such as age, parity, previous bonding history and breastfeeding preparation in prenatal period
- Adequacy of milk supply, nipple shape and perceptions about breastfeeding
- Neonate's growth rate and age-weight relationship.
Defining characteristics
- Inadequate milk supply
- Arching and crying when at breast
- Evidence of inadequate milk intake
- Fussiness and crying within an hour of breastfeeding
- Inability to latch on to nipple correctly
- Lack of sustained sucking at breast
- Insufficient emptying of breasts
- Lack of response to other comfort measures
- Sore nipples for mother after first week of breastfeeding.
Expected outcomes
- Mother will express satisfaction with breastfeeding techniques and practice
- Mother will show decreased anxiety and apprehension
- Neonate will feed well on both breasts and appear satisfied for at least two hours after feeding
- Neonate will grow and thrive.
Nursing interventions
- Educate mother in breast care and breastfeeding techniques
- Be available and encourage mother during initial breastfeeding episodes
- Teach techniques for encouraging the let-down reflex such as warm shower before feeding, breast massage and holding the neonate close to the breasts
- Provide quiet, private, comfortable, environment for mother and baby to promote successful breastfeeding
- Encourage mother to clarify questions regarding successful breastfeeding.
Evaluations for expected outcomes
- Mother expresses satisfaction with breastfeeding practices
- Mother exhibits decreased anxiety and apprehension
- Neonate feeds successfully on both breasts and appears satisfied for at least 2 hours after feeding
- Neonate grows and thrives.
Documentation
- Mother's expressions of satisfaction and comfort with breastfeeding ability
- Observations of bonding and breastfeeding processes
- Teaching and instructions given
- Neonates weight and growth
2. Hypothermia Related to Cold Stress or Sepsis
Definition
State in which neonate's body temperature is below normal range.
Assessment
- Gestational age
- Intrapartal history
- Presence of maternal risk factors such as fever, diabetes mellitus, dystocia and perinatal asphyxia
- Vital signs including core temperature, heart rate, respiration and blood pressure
- Lab values such as blood gas, serum glucose and electrolytes
- Skin color: central and peripheral
- Birth weight.
Defining characteristics
- Body temperature below normal level
- Cool, pale skin
- Cyanotic nailbeds
- Increased heart rate and blood pressure
- Piloerection
- Shivering
- Slow capillary refill.
Expected outcomes
- Neonate will exhibit normal body temperature
- Neonate will have warm, dry skin and normal capillary refill
- Neonate will not develop complications of hypothermia
- Neonate will not shiver
- Neonate will maintain normal temperature
- Mother will verbalize knowledge of how hypothermia develops and will state measures to prevent recurrence of hypothermia.
Nursing interventions
- Monitor body temperature every hour by axillary route. If using a radiant warmer, monitor the device's temperature reading hourly and compare it with the neonates body temperature
- Monitor and record vital signs every 1 to 4 hours. Perform continuous electronic cardiorespiratory monitoring as appropriate
- For mild hypothermia, dress the baby with a shirt, diaper, stockinet or knitted hat and wrap in double blankets
- Change wet diapers promptly
- Perform all procedures under a radiant warmer if possible
- Postpone bathing
- For severe hypothermia, place the neonate in an isolette or overhead radiant warmer bed, and provide supportive measures
- Keep the neonate undressed
- Set the isolette temperature at 36 degree to 36.6 degree C (96.8 degree to 97.8 degree F)
- Attach a skin probe to the right upper quadrant of the neonate's abdomen
- Monitor carefully for evaporative and insensible fluid loss
- Carry out prescribed treatment regimen such as administering IV fluids and small frequent feeding
- Discuss precipitating factors with mother and family members to prevent recurrence
Evaluations for expected outcomes
- Neonate's temperature returns to normal
- Neonate exhibits warm, dry skin and normal capillary refill time
- Neonate does not develop complications of hypothermia
- Neonate does not demonstrate signs of hyperthermia related to radiant heat source
- Neonate is successfully weaned from isolette or radiant warmer
- Parents verbalize understanding of causes of hypothermia and preventive measures
- Mother demonstrates proper temperature measurement technique.
Documentation
- Neonate's physical findings such as cardiovascular status and temperature
- Nursing interventions carried out
- Neonate's response to interventions
- Mother's and family member's willingness and ability to provide adequate care at home
- Expected outcomes evaluated.
3. Risk for Infection Related to Neonate's Immature Immune System
Definition:
Presence of internal or external hazards that threaten neonate's health.
Assessment:
- Gestational age of neonate
- Temperature, heart rate and respirations
- Labor and delivery record including maternal fever, premature rupture of membranes and foul smelling amniotic fluid
- Recent or current maternal infections
- Signs of infection of umbilical cord and skin at base of cord such as redness, odor and discharge
- Signs and symptoms of developing infections such as lethargy, jaundice, skin lesions, thrush, unstable body temperature, hypoglycemia, diarrhea, vomiting, poor feeding patterns, cyanosis and mottling of skin
- Signs of respiratory distress such as grunting, retractions, nasal flaring and cyanosis
- Evidence of chronic intrauterine infections such as growth retardation and hepatosplenomegaly.
Risk factors
- Early rupture of amniotic membranes
- Environmental exposure to pathogens during birth process
- Inadequate primary responses such as broken skin
- Invasive procedures
- Poor feeding pattern
- Tissue destruction
- Trauma
- Medication use.
Expected outcomes
- Neonates vital signs will remain within normal range
- Neonate will be alert and active
- Neonate will remain free from signs and symptoms of infection
- Neonate's umbilical cord will remain free of infection and heal properly
- Mother and family members will practice good handwashing technique before handling neonate.
Nursing interventions
- Review the maternal chart and delivery record to detect risk factors that predispose the neonate to infection
- Follow sterile techniqueRemove, rings, wrist watches and bracelets before handling the neonate
- Scrub hands and arms with antimicrobial preparation before entering nursery and after contact with contaminated material
- Wash hands after handling the neonate and instruct parents in handwashing techniques
- Perform umbilical cord care with each diaper change or as facility policy dictates in order to promote healing
- Assess respirations, heart rate and temperature every 15 minutes for first hour, then every hour for four hours, then every four hours for 24 hours, then every shift or as indicated. [Unstable vital signs, persistent elevations in temperature or hypothermia may indicate neonatal infection]
- Observe neonate for signs and symptoms of infection and notify physician if signs and symptoms of infection appear
- Observe standard precautions: Wear gloves for neonate's first bath and when in contact with blood and body secretions. [These actions prevent cross contamination and transmission of pathogens].
- Encourage mother to begin breastfeeding early. Colostrum and breast milk provide passive immunity and helps reduce infection.
Evaluations for expected outcomes
- Neonate's vital signs remain within normal range
- Neonate remains alert and active
- Neonate is free from signs and symptoms of infection
- Umbilical cord is clean, dry and healing
- Mother and family members demonstrate proper handwashing technique before handling neonate.
Documentation
- Vital signs
- Appearance of umbilical cord
- Feeding pattern and weight gain
- Condition of oral mucosa
- Skin color and rashes
- Elimination pattern
- Activity pattern
- Interventions performed to reduce risk of infection
- Neonates response to nursing interventions
- Evaluation of outcomes observed.
4. Ineffective Breastfeeding Related to Limited Maternal Experience
Definition
State in which mother or neonate experiences dissatisfaction or difficulty with breastfeeding process.
Assessment
- Age and maturity of mother
- Previous bonding history –parity
- Level of prenatal breastfeeding preparation
- Previous breastfeeding experience
- Actual or perceived inadequate milk supply
- Nipple shape such as inverted nipple
- Stressors such as family and career
- Views on breastfeeding
- Support from spouse and family members
Defining characteristics
Mother
- Actual or perceived inadequate supply of milk
- Insufficient emptying of each breast
- Lack of observable signs of oxytocin release
- Sore nipples after first week of breastfeeding.
Baby
- Arching and crying when at breast
- Evidence of inadequate intake of milk
- Fussing and crying within one hour after feeding
- Inability to latch on to nipple correctly
- Lack of response to comfort measures and efforts at pacifying
- Lack of sustained sucking at breast
- Resistance to latch on to breast
- Unsatisfactory breastfeeding process.
Expected outcomes
- Mother will express understanding of breastfeeding techniques and practice
- Mother will display decreased anxiety and apprehension
- Mother and baby will experience successful breastfeeding
- Neonate's initial weight loss will be within accepted norms
- Neonates nutritional needs will be met adequately.
Nursing interventions
- Assess mother's knowledge of breastfeeding
- Educate mother in breast care and breastfeeding techniques
- Provide written materials and audiovisual aids which illustrate proper feeding technique
- Teach techniques for encouraging the let-down reflex such as: warm shower, breast massage, relaxation, holding neonate close to the breasts and infant sucking
- Stay with mother during feeding and encourage to ask questions to increase understanding
- Evaluate nipple position in neonate's mouth and sucking motion
- Ensure that the neonate is awake and alert when feeding, unwrap as needed
- Evaluate neonate for anomalies that may interfere with breastfeeding ability such as cleft lip or palate
- When ready to start feeding, let a drop or two of breast milk fall on baby's lips. The neonate may open his mouth on tasting the milk
- Instruct the mother in breast care techniques such as wearing supportive bra, washing and air drying nipples to prevent cracking, soreness and bleeding which interfere with feeding
- Teach mother on ways to prevent breast engorgement
- Teach mother the factors that enhance milk production as well as those that can alter production and quality of milk
- Provide positive reinforcement for the mother's efforts in order to decrease her anxiety and increase her confidence and self-esteem.
Evaluations for expected outcomes
- Mother properly positions baby during breastfeeding
- Uses appropriate techniques to encourage attachment to nipple
- Mother expresses decreased anxiety and increased enthusiasm for breastfeeding
- Neonate feeds successfully on both breasts and appears satisfied for at least 2 hours after feeding
- Neonate's nutritional needs are met
Documentation
- Mother's level of knowledge related to breastfeeding
- Mother's expression of dissatisfaction with breastfeeding ability
- Mother's breast-care practices
- Maternal conditions that interfere with breastfeeding such as inverted nipples
- Mother's and neonate's behavior during and after breastfeeding such as positioning on breasts and baby's level of satisfaction
- Frequency and duration of breastfeeding
- Teaching and instructions given and mother's response to teaching
- Neonates weight and growth
- Mother's and neonate's response to nursing interventions.
BIBLIOGRAPHY
- Carpenito J. Lynda “Nursing Diagonosis, Application to Clinical Practice”, 4th edn. J.B. Lippincot Company , Philadelphia, 1992.
- Doeges E Marilyan, Moorehouse F. Mary and Barley T Joseph, “Application of Nursing Process and Nursing Diagnosis, 2nd edn, Jaypee Brothers , New Delhi 1995.
- Dutta D.C. Textbook of Obstetrics, 5th edn, New Central Brook Company , Calcutta 2001.
- Fraser M. Diane and Cooper A Margaret, Myles Textbook for Midwives, 14th edn, Churchill Livingstone , Edinburgh 2003.
- Jacob Annamma. A comprehensive Textbook of Midwifery, Jaypee Brothers , New Delhi 2005.
- Sparks R Sheila and Tailor M. Cynthia “Spark's and Tailor's Nursing Diagnosis” Reference Mannal, 6th edn, Lippincott Williams and Wilkins , Philadelphia 2005.
- Varney Helen and Kriebs M. Jan and Gegor Carolyin. Textbook of Nurse Midwifery, 4th edn, All India Publishers and Distributors Regd , New Delhi 2005.
PERFORMING AN ANTENATAL ABDOMINAL EXAMINATION AND PALPATION
Definition
Examination of a pregnant woman to determine the normalcy of fetal growth / in relation to the gestational age, position of the fetus in uterus and its relationship to the maternal pelvis.
Purposes
- To measure the abdominal girth and fundal height
- To determine the abdominal muscle tone
- To determine the fetal lie, presentation, position, variety (anterior or posterior) and engagement
- To determine the possible location of the fetal heart tones
- To observe the signs of pregnancy
- To detect any deviation from normal.
Articles
- Fetoscope / stethoscope / Doppler machine
- Measuring tape / Pelvimeter.
Procedure:
Location of the maximum intensity of the fetal heart tones
Sl. No. | Presentation and positional varieties | Location |
---|---|---|
1. | Cephalic | Midway between umbilicus and level of anterior superior iliac spine |
2. | Breech | Level with or above umbilicus |
3. | Anterior | Close to the abdominal midline |
4. | Transverse | In lateral abdominal area |
5. | Posterior | In flank area |
*Note: | Pelvic palpation may be performed as the 3rd maneuver to feel for the cephalic prominances and to confirm the presentation, before performing Pawlick's grip. Pawlick's grip as the 3rd maneuver is recommended as this sequence has advantages of completing the three maneuvers which require the nurse to be facing the client's head and then turning to her feet for pelvic palpation (4th maneuver) without taking her hands off the mothers abdomen. |
CONDUCTING A NORMAL VAGINAL DELIVERY
Definition:
Conducting or managing a normal vaginal delivery involves the hand maneuvers used to assist the baby's birth, immediate care of the newborn and the delivery of the placenta.
Purposes:
- To have the child birth event take place in a prepared and safe environment.
- To conduct delivery with least trauma to mother and baby.
- To assist mother go through the process without undue stress, injury or complication.
- To promote transition to the extrauterine life of the newborn, smooth and safe.
- To avoid complications.
Articles:
For mother:
A Sterile delivery pack containing
- Articles for cutting and suturing an episiotomy
- A pair of straight, blunt ended scissors
- Episiotomy scissors
- Artery clamps—3
- Tissue forceps—1
- Needle holder—1
- Syringe and needle for infiltration—10 ml
- Scissors for cutting the cord
- Bowl for cleaning solution
- Basin to receive placenta
- Cotton balls
- 4 × 4 gauze pieces
- Towel to cover the hand supporting the perineum
- Sterile gown
- Leggings for the mother
- Apron, gloves and mask for staff.
For newborn:
- Baby blanket or flannel cloth-2, one to receive and dry the baby of excess secretions and another to wrap the baby.
- Neonatal resuscitation equipment checked and ready for use.
- Oxygen source with tubing.
- Suction apparatus and mucous extractor.
- Cord clamp.
- Bulb syringe for nasal and oropharyngeal suctioning of the baby.
Clean tray with:
- Suture material
- Perineal pads for the mother
- Oxytocic drugs
- Sterile gloves
- Methergine
- Lignocaine 2%
- Syringes and needles for injection.
Points to remember:
- Follow strict aseptic technique
- Never ask the mother to bear down before full dilatation
- Always give episiotomy at the peak of a uterine contraction
- Check that the resuscitation set, suction apparatus and other equipments are in good working condition
- Record any alteration in uterine contraction or FHR. Record the time of rupture of membranes and color of amniotic fluid
- Note FHR when the uterine contractions are not present.
Preparation:
- Provide local preparation as per agency policy.
- Administer enema.
Procedure:
Nursing Action | Rationale |
---|---|
1. Transfer mother to the labor room | |
2. Change her clothings into hospital gown | |
3. Monitor uterine contraction and PV findings | Helps in assessing progress of labor |
4. Assess the presentation, lie, position, attitude, station, cervical dilatation, effacement, etc. | Helps in assessing progress of labor |
5. Maintain labor progress chart | Helps in determining abnormalities |
6. Note the color of the liqor if the membranes rupture | Meconium stained liquor indicates fetal distress |
7. Note the fetal heart rate every 10-15 mts, if not on continuous fetal monitoring | Detects fetal distress at an early stage |
8. Avoid giving solid foods | During labor emptying time of the stomach is delayed and may cause regurgitation |
9. Give her fluids in the form of lemon juice or fruit juice (If an operative delivery is anticipated keep mother on NPO) | |
10. Instruct her to follow the breathing technique | Ensures more oxygen supply to the fetus and promotes relaxation |
11. Instruct mother to lie down in left lateral position | Enhances more blood supply to the fetus as well as prevents supine hypotensive syndromes |
12. Give adequate explanation regarding breathing, relaxation and pushing (bearing down) to mother | Obtains her co-operation and participation during the process |
13. Once the onset of second stage has been confirmed place the women in dorsal position with bent at knees bent at lower end of the delivery bed. Ensure that bladder is empty. | Gives view to the perineum and to assess the progress clearly |
14. Open the delivery pack, arrange the articles and pour cleansing solution in the bowl. | For convenience and timely use |
15. Perform a surgical hand scrub and put on sterile gown and gloves | |
16. Drape the mother's perineum and delivery area | Obtains a sterile field for delivery |
17. Clean the perineum in the following manner using one cotton ball separately for each stroke a) Mons pubis in zigzag manner from level of clitoris upward b) Clitoris to fourchette-one downward stroke c) Farther labia minora and then near side d) Labia majora farther side first and then near side e) Thighs in long strokes away from the perineum f) Anus in one circular stroke | Proper cleansing makes the perineum free from microorganism |
18. Delivery of the head As the head becomes visible at the introitus, place the pads of your fingertips on the portion of the vertex at vaginal introitus. | |
19. As more of the head is visible, spread your fingers over the vertex of the baby's head, with fingertips pointing towards the unseen face of the fetus and the elbow pointing upwards, towards the mother | Gives pressure against the fetal head to keep it well flexed |
20. Cover the hand not used on baby's head with a towel and place the thumb in the crease of the groin midway on one side of the perineum. Place the middle finger in the same way on the other side of perineum. | Prevent contamination from the anus. |
21. As the head advances allow it to gradually extend beneath your hand by exerting control but not prohibitive pressure | Control of the head in this manner will prevent explosive crowning and pressure on the perineum |
22. With the hand over the perineum, apply pressure downward and inward towards each other across the perineal body at the same time | This support will prevent rapid birth of head causing intracranial damage to baby and laceration to perineum |
23. Observe the perineum in the space between the thumb and middle finger while offering head control and perineal support | Detects signs of impending tear such as stretch marks beneath the perineal skin |
24. Give an Tepisiotomy if required when there is bulging thinned perineum during the peak of a contraction or just prior to crowning | Avoids injury to the anal spinchter and spontaneous laceration of the perineum |
25. As soon as the head is born, during the resting phase, before the next contraction. Place the fingertips of one hand on the occiput and slide them down to the level of shoulders | |
26. Sweep the fingers in both directions to feel for the umbilical cord | |
27. If the cord is felt and if it is loose, slip it over the baby's head. If the cord is tight apply clamps about 3 cm, apart and cut the cord at the middle of the neck (mother must be instructed to pant while clamping, cutting and unwinding the cord). | Prevents the cord from becoming tightened around the neck |
28. Wipe the baby's face and wipe off fluid from nose and mouth. | Facilitates breathing |
29. Suction the oral and nasal passage with a bulb syringe | Prevents aspiration of the fluid |
30. Delivery of shoulders: - Wait for a contraction and watch for restitution and external rotation of head | Allows time for shoulders to rotate to the anteroposterior diameter of the outlet |
31. When the shoulders reach the anteroposterior diameter of the pelvic outlet, proceed to deliver. One shoulder at a time in the following manner.
| Avoids overstretching of the perineum |
32. Grasp the baby around the chest and lift the baby towards the mother's abdomen | This allows the mother to immediately see her baby and have close physical contact |
33. Note the time of birth | |
34. Place two clamps on the cord about 8-10 cm from the umbilicus and cut it while covering it with a gauze | |
35. Give the baby to the nursery nurse who will place him in the designated area, dry him and carry out the assessment and care. | |
36. Place the placenta receiver against the perineum. | For receiving the placenta and membranes |
37. Place one hand over the fundus to feel the contraction of the uterus. | |
38. Watch for signs of placental separation: Lengthening of cord, gush of bleeding, fundus becoming round and placenta descending into the vagina | Contraction and placental separation may occur in minutes |
39. When placental descend is confirmed ask the patient to beardown as the uterus contracts, as she did during the second stage of labor (controlled cord traction can be used to deliver placenta) | Bearing down simultaneously with a contraction aids expulsion of the placenta |
40. As soon as the placenta passes through the introitus, grasp it in cupped hands. | |
41. Twist the placenta round and round with gentle traction so that the membranes are stripped off intact. If the length of the membranes make the movements difficult, catch the membranes with an artery forceps and give gentle traction till they are stripped off and expelled intact. | |
42. If spontaneous expulsion fails to occur in 20-30 min, perform controlled cord traction or Brandt Andrews. | |
43. Examine the patient's vulva, vagina and perineum for any laceration. | |
44. Massage the uterus to make it contract for expulsion of any retained bloodclots. | |
45. Suture episiotomy layer by layer if one was made. | |
46. Clean the vulva and surrounding area with antiseptic solution and place perineal pad. | |
47. Straighten mother's legs, cross them and make her comfortable. | Reduces bleeding |
48. Clean and replace articles. | |
49. Remove gloves and wash hands. | Prevents spread of microorganisms |
50. Record the details of delivery and condition of the mother and baby in the patient's chart. |
PERFORMING AN EXAMINATION OF PLACENTA
Definition:
A thorough inspection and examination of the placenta and membranes, soon after expulsion, for its completeness and normalcy.
Purposes:
- To ensure that the entire placenta and membranes have been expelled and no part has been retained.
- To make sure that placenta is of normal size, shape, consistency and weight.
- To detect abnormalities such as infarctions, calcification or additional lobes.
- To ascertain the length of the cord, number of blood vessels and site of insertion of the cord.
- To prevent PPH and infection.
- To check weight of placenta and measure cord length.
Equipments:
- Placenta in a bowl
- A washable surface to lay the placenta
- A weighing machine
- Measuring tape
- Kidney tray
- Pair of gloves.
Procedure:
Sl. No. | Nursing Action | Rationale |
---|---|---|
1. | Don gloves | Protects nurse from contamination |
2. | Using gloved hands hold the placenta by the cord allowing the membranes to hang (twisting the cord twice around the fingers will provide a firm grip). | Hanging membranes will provide a better view to check its completeness |
3. | Identify the hole through which the baby was delivered. | If the membranes are not torn into pieces, a single round hole can be identified clearly |
4. | Insert hand through the hole and spread out the fingers to view the membranes and the blood vessels. | The position of cord insertion and the course of blood vessels can be noted in this position. |
5. | Remove the hand from inside the membranes and lay the placenta on a flat surface with the fetal surface up. Identify the site of cord insertion. | Normally the cord is inserted in the center of placenta Lateral or velamentous insertion may be noted. |
6. | Examine the two membranes, amnion and chorion for completeness and presence of abnormal vessels indicating succenturiate lobe. | Amnion is shiny and chorion is shaggy. Amnion can be peeled from the chorion upto the umbilical cord |
7. | Invert the placenta, expose the maternal surface and remove any clots present. | |
8. | Examine the maternal surface by spreading it in the palms of your two hands and placing the cotyledons in close approximation (any broken fragments must be replaced before accurate assessment is made). | Ensures that no part of the placenta or membranes is left inside the uterus |
9. | Assess for presence of abnormalities such as infarctions, calcifications or succenturiate lobes. | |
10. | Inspect the cut end of the umbilical cord for presence of three umbilical vessels. | Two arteries and one vein should normally be seen Absence of an artery may be associataed with renal abnormalities. |
11. | Measure the length of the umbilical cord by holding it extended against a graduated surface/side of the weighing scale (The length of the cord on the baby may be added to get the total length where applicable) | Average length of the cord is 50 cm |
12. | Weigh the placenta by placing it on the weighing scale meant for the purpose. | Normally the placenta weighs about 1/6th of the baby's weight |
13. | Place the placenta in the bin for proper disposal. | |
14. | Clean the area used for examination of the placenta and membranes, the weighing scale and the bowl. | |
15. | Remove gloves and wash hands. | |
16. | Record in the patient's chart, the findings of placental examination and weight of the placenta, length of the cord and any special observations made. | Acts as a communication between staff members |
GIVING A PERINEAL CARE
Definition:
Cleansing the patient's external genitalia and surrounding skin using an antiseptic solution.
Purposes:
- To cleanse the perineal skin.
- To reduce chances of infection of episiotomy wound.
- To stimulate circulation.
- To reduce body odor and improve self-image.
- To promote the feeling of well-being.
Equipments:
- A clean tray containing
- Sterile antiseptic lotion - 2% dettol or savlon.
- Sterile normal saline in a bottle.
- Cheatle forceps.
- Antiseptic or antibiotic medication if ordered.
- Sterile sanitary pad.
- Kidney tray.
- Sterile gloves.
- Mackintosh.
- Sterile pack or tray containing
- Artery forceps - 2
- Dissecting forceps - 1
- Cotton balls.
- Gauze pieces.
- Sterile towel to wipe hands after surgical scrub.
- Additional items
- Infrared light.
- Bedpan (if procedure is done at bedside).
Procedure:
Sl. No. | Nursing Action | Rationale |
---|---|---|
1. | Explain the procedure to patient, the purpose and how she has to co-operate. | Gains confidence and co-operation of the patient |
2. | Assemble articles at the bedside or in the treatment room. | Saves time and effort |
3. | Ask the patient to empty her bowel and bladder and wash the perineal area before coming for perineal care | Ensures cleanliness and reduces number of organisms in the perineal area |
4. | Screen the bed or close the doors as appropriate | |
5. | Assist the patient to assume dorsal recumbent position with knees bend and drape the area using diamond draping method. | Dorsal position facilitates better viewing of the perineum |
6. | Open sterile tray, arrange articles with cheatle forceps and pour antiseptic solution in the sterile gallipot in this tray. | |
7. | Adjust the position of the infrared light so that it shines on the perineum at a distance of 40-50 cm. | |
8. | Scrub hands and dry with the sterile towel. | |
9. | Put on sterile gloves. | |
10. | Take the cotton swabs with artery forceps, dip in savlon and squeeze excess lotion with dissecting forceps into the kidney tray. | Maintains asepsis |
11. | With the swab clean from urethra towards anus. Clean the area from midline outward in the following order until clean and discard the swab after each stroke. Strokes area to be in the following order:
| Cleaning from more cleaner area to least clean area prevents contamination |
12. | Wipe all traces of antiseptic away with sterile normal saline swabs in the same manner as described above using thumb forceps | |
13. | Dry the episiotomy with gauze pieces | |
14. | Provide perineal light / infrared light for 10 mts if indicated | Provides soothing effect from heat |
15. | Put prescribed medication on a gauze piece and apply to the episiotomy | Prevents entry of pathogenic organisms |
16. | Place sanitary pad from front to back. Do not shift position of the pad once it is applied | Avoids chances of contamination |
17. | Discard gloves and used items in the kidney tray, wash forceps and tray and keep ready for sterilization | Reduces chances of contamination |
18. | Replace other articles in designated places | |
19. | Make the patient comfortable and leave the unit clean | |
20. | Record procedure in the patient's chart including details regarding status of lochia and condition of episiotomy wound | Documentation helps for communication between staff members and provides evidence of care given and observations made |
Special Considerations:
- If a sitz bath is indicated, give it before perineal care.
- If patient has urinary catheter, provide catheter care along with perineal care.
PROVIDING IMMEDIATE NEWBORN CARE
Definition:
Care provided to baby soon after birth.
Purposes:
- To clear air passage and facilitate breathing.
- To observe for any external anomalies.
- To provide adequate warmth.
- To help the newborn to adapt to the extrauterine environment.
- To prevent injury and infections.
- To keep baby clean.
Equipments:
- Suction machine.
- Mucous sucker.
- Radiant warmer.
- Cord clamp.
- Sterile cotton balls.
- Sterile cord cutting scissors.
- Measuring tape.
- Rectal thermomenter.
- Baby cloth (Frock).
- Baby sheet.
- Identification tag.
- Alcohol swabs/Alcohol solution and cotton balls.
General Instructions:
- The emergency equipment for neonatal resuscition is to be always kept ready in neonatal area.
- Inj. Naloxane to be kept ready in case mother was sedated prior to delivery.
- Do not stimulate baby (rubbing the back or suctioning nose and avoid bagging) if amiotic fluid is meconium stained.
- If there is any deviation from normal, a neonatologist is to be informed. If mother has diabetes mellitus and is on insulin, and if the baby's weight is less than 2 kg or more than 3.8 kg transfer to nursery.
Procedure:
Sl. No. | Nursing Action | Rationale |
---|---|---|
I. | Immediate care: | |
1. | Place the baby soon after delivery on a tray covered with sterile linen with the head slightly downward (15 degree). | Facilitates drainage by gravity of the mucus accumulated in the tracheobronchial tree |
2. | Place the tray between the legs of the mother at a lower level than the uterus. | |
3. | Clear the air passage off mucus using a mucus extractor or bulb syringe. | Maintains patent airway |
4. | Check Apgar rating at 1 minute and 5 min and record. | Assesses the health status of newborn |
5. | Clamp and ligate the cord. Cord is to be clamped and divided, following birth of the baby. | |
6. | Tie identification tag which has mother's name and hospital number on wrist of both mother and baby. | Avoids confusion between staff and chances of wrong identification |
II | Care of the umbilical cord: | |
7. | Clean with spirit/Alcohol around umbilicus, from center out ward up till 10 cm away from umbilicus or according to institutional policy | Reduces risk of infection If the cord is exposed to the air, without any application of dusting powder, it dries up and falls of much earlier |
III | Care of eyes: | |
8. | Clean the eyes with sterile cotton balls soaked in normal saline | |
9. | Instill soframycin eyedrops (erythromycin eye ointment) to each eye | Acts as a prophylaxis against ophthalmia neonatorum and chalamydia trachomatis |
IV | Clothings: | |
10. | Clothe the baby using a dress that is appropriate for the climate. Extremities should be free for movement. Apply a napkin which should be changed periodically. | Moisture increases chances of microorganisms colonizing in the skin and crevices |
11. | Check patency of rectum by introducing lubricated rectal thermometer | Identifies imperforated anus |
12. | Check the weight and length of the baby, the baby should be weighed naked | Normal measurements
|
13. | Check vital signs | |
14. | Administer vitamin-K 1 mg intra muscularly | Minimises risk of hemorrhage |
15. | Administer prophylactic antibiotic therapy if ordered in conditions like:
| Prevents secondary infection |
16. | Observe the baby frequently atleast for 4-8 hours | Identifies any abnormal signs developing in newborn |
17. | Fill babycard and antenatal folder and document any abnormality | Acts as a communication between staff members |
BATHING A NEWBORN
Purposes:
- To keep the baby's skin clean.
- To refresh the baby.
- To stimulate circulation.
Equipments:
- Big basin
- A soft wash cloth or absorbent pad for sponging and drying
- Mild non perfumed soap in a container
- Cotton balls
- A towel to place under the baby during bath
- Bath blanket or towel to cover the newborn during bath
- Nylon brush/soft brush for cleaning newborn's scalp
- Sterile water to clean the eyes of baby
- Diaper
- Baby cloth (shirt or gown)
- Baby oil or mild lotion
- Tissue paper.
Procedure:
Sl. No. | Nursing Action | Rationale |
---|---|---|
1. | Explain the procedure to mother | Helps in obtaining co-operation |
2. | Ensure that the room is warm and free of draughts. This is particularly important when caring for newborns | Temperature regulating mechanisms are not completely developed in newborn |
3. | Remove the infant's diaper, and wipe away any faeces on the baby's perineum with the tissues | |
4. | Reassure the infant before and during the bath by holding the infant firmly but gently | |
5. | Undress the infant and place him or her in a supine position on a towel and cover | |
6. | Place small articles such as safety pins out of the infant's reach | Prevents injury |
7. | Ascertain the infant's weight and vital signs | |
8. | Clean the baby's eyes with sterile water only, using clean cotton swabs. Use separate ball for each eye and wipe from inner to outer canthus. (In some agencies the infant's eyes and scalp are cleaned before the infant is undressed). | Using separate cotton balls prevent the transmission of microorganisms from one eye to the other. Wiping away from the inner canthus avoids entry of debris into the nasolacrimal duct |
9. | Wash and dry the baby's face using water only. Soap is used to clean the ears. | Soap can be irritating to the eyes, if used on face |
10. | Pick the baby up using the foot ball hold (that is hold the baby against your side supporting the body with your forearm and the head with the palm of your hand). Position the baby's head over the wash basin and lather the scalp with a mild soap. Massage the lather over the scalp using finger tips. | Loosens any dry scales from the scalp and helps to prevent cradle cap. If cradle cap is present it may be treated with baby oil, a dandruff shampoo or ointment prescribed by physician. |
11. | Rinse and dry the scalp well. Place the baby supine again. | |
12. | Apply soap, wash rinse and dry each arm and hand paying particular attention to the axilla. Avoid using soap to the palmar surface and avoid excessive rubbing. Dry thoroughly. | Rubbing can cause irritation and moisture can cause excoriation of the skin. Avoiding soap on palms prevents baby putting soappy fingers in mouth. |
13. | Apply soap, wash rinse and dry the baby's chest and abdomen. Keep the baby covered with the bath blanket or towel between washing and rinsing. | Covering the infant prevents chilling |
14. | Apply soap and rinse the legs and feet. Dry it. Expose only one leg and foot at a time. Give special attention to the area between toes. | Keeping exposure to a minimum maintains the baby's warmth |
15. | Turn the baby on her or his stomach or side, wash, rinse and dry the back. | |
16. | Place the baby on his or her back. Clean and dry the genitals and anterior perineal area from front to back: a. Clean the folds of the groin. b. For females, separate the labia and clean them. Clean the genital area from front to back using moistened cotton balls. Use a clean swab for each stroke. c. If a male infant is uncircumcised, retract the foreskin if possible and clean the glans penis using a moistened cotton ball. If the foreskin is tight do not forcibly retract it. Gentle pressure on a tight foreskin over a period of days or weeks may accomplish eventual retraction. After swabbing, replace the foreskin to prevent oedema of the glans penis. Clean the shaft of the penis and scrotum (In some agencies foreskin is not retracted). d. If a male infant has been recently circumcised, clean the glans penis by gently squeezing a cotton ball moistened with sterile water over the site. Note any signs of bleeding or infection. Petroleum jelly or bacteriocidal ointment is applied to the circumcision site. Avoid applying excessive quantities of ointment. | The rectal area is cleaned last since it is most contaminated. The smegma that collects between the folds of the labia and under the foreskin in males, facilitates bacterial growth and must be removed. Lotions, powders and dirt can accumulate between the labia under the foreskin and need to be removed. Excess ointment may obstruct the urinary meatus. |
17. | Clean the posterior perineum and buttocks, grasp both of the baby's ankles, raise the feet and elevate the buttocks. Wash and rinse the area with the wash cloth. Dry the area and apply ointment. Do not apply powder. | |
18. | Clean the base of the umbilical cord with a cotton ball dipped in 70% ethyl alcohol (Some agencies use other antiseptics such as providone-Iodine). | Alcohol promotes drying and prevents infection. |
19. | Check for dry, cracked or peeling skin and apply a mild baby oil or lotion. | |
20. | Cloth the baby with a clean dress and the diaper below the cord site. | Exposing the cord site to air will promote healing. |
21. | Until the umbilicus and circumcision site are healed, position the baby on his side in the crib with a rolled towel or diaper behind the back for support | This position allows more air to circulate around the cord site |
22. | Swaddle wrap the baby. | Gives the baby a sense of security as well as keeps him warm |
23. | Return the baby to mother and provide needed instructions. | |
24. | Clean and replace / discard used articles as appropriate | |
25. | Record any significant observation such as reddened area or skin rashes, the color and the consistency of the stool and the state of the cord stump. | Helps in planning treatment |