NCLEX Review & Nursing School

Breathing Techniques
Breathing technique during labor and delivery will promote relaxation and oxygenation.

FIRST STAGE LABOR BREATHING
Clenching Breath
Each contraction begins and ends with a deep inspiration and expiration.
Slow Paced Breathing
It is used as long as possible during labor, and promotes relaxation
Modified Paced Breathing
Breathing is shallow and fast, and it is used when slow paced breathing is no longer effective.
Pattern Paced Breathing (pant blow)
After a certain number of breaths, the client exhales with a slight emphasis or blow, and then begins the modified paced breathing.
Breathing to Prevent PushingEncourage client to blow repeatedly using short puffs when the urge to push is strong.

SECOND STAGE LABOR BREATHING
Traditional PushingThe client takes on or more cleansing breaths at the beginning of a contraction and then hold it, pushing as hard as she can for as long as possible. Then quickly exhales, takes another breath and pushes again, repeating the process until the contraction is over.
Other Pushing MethodsThe client exhales small amounts of air through an open glottis during pushing.The client pushes in short bursts only when the urge is strong instead of using prolonged expulsive efforts.

FIRST STAGE
The First stage consists of three phases: LATENT, ACTIVE, AND TRANSITION.
This stage begins with the first true contraction and ends with complete
effacement and dilation to 10 cm.

1. Stage 1- beginning to complete cervical dilation (0-10cm)

1. Phase 1 (latent) 1-3cm

1. Contractions mild-mod

2. 10-30s long, 5-30m apart

2. Phase2 (active) 4-7cm

1. Contractions mod-strong

2. 40-60s long, 3-5m apart

3. Phase4 (transition) 8-10cm

1. Contractions strong

2. 45-60s long, 1.5-2m apart

LATENT PHASE (EARLY LABOR):

• DURATION: 10-12 HOURS IN PRIMIPARA AND 8-10 HOURS IN MULTIPARA
• CERVICAL DILATION IS 1 TO 4 CM
• UTERINE CONTRACTIONS OCCUR EVERY 15-30 MINUTES AND ARE 15-30 SECONDS IN DURATION AND MILD INTENSITY
• MOTHER IS TALK ACTIVE
• ENCOURAGE MOTHER AND PARTNER TO PARTICIPATE IN CARE
• CHANGE POSITION AND AMBULATION TO COMFORT MOTHER
• OFFER FLUIDS AN ICE CHIPS
• INFORM THE PROGRESS TO MOTHER AND PARTNER
• ENCOURAGE VOIDING EVERY 1-2 HOURS

ACTIVE PHASE:

• DURATION: 2-4 HOURS IN PRIMIPARA AND 2-4 IN MULTIPARA
• CERVICAL DILATION IS 4-7 CM
• UTERINE CONTRACTIONS OCCUR EVERY 3-5 MINUTES AND ARE 30-60 SECONDS IN DURATION AND OF MODERATE INTENSITY
• MOTHER BECOMES RESTLESS AND ANXIOUS AS CONTRACTIONS BECOME STRONGER
• MOTHER MAY EXPERIENCE FEELING OF HELPLESSNESS
• ENCOURAGE MOTHER IN MAINTENANCE OF EFFECTIVE BREATHING.
• PROVIDE A QUIET ENVIRONMENT
• INFORM THE PROGRESS TO MOTHER AND PARTNER
• BACKRUBS, SACRAL PRESSURE, PILLOW SUPPORT AND POSITION CHANGES TO PROMOTE COMFORT
• OFFER FLUIDS AND ICE CHIPS
• INSTRUCT PARTNER IN EFFLEURAGE
• ENCOURAGE VOIDING EVERY 1-2 HOURS

TRANSITION PHASE:

• DURATION: 2-4 HOURS IN PRIMIPARA AND 1-2 IN MULTIPARA
• CERVICAL DILATION IS 8-10 CM
• UTERINE CONTRACTIONS OCCUR EVERY 2-3 MINUTES AND ARE 45-90 SECONDS IN DURATION AND STRONG INTENSITY
• MOTHER MAY BECOMES TIRED, RESTLESS, IRRITABLE, AND FEELS OUT OF CONTROL
• ENCOURAGE REST BETWEEN CONTRACTION
• INFORM THE PROGRESS TO MOTHER AND PARTNER
• PROVIDE PRIVACY
• OFFER FLUIDS AND ICE CHIPS
• ENCOURAGE VOIDING EVERY 1-2 HOURS

Special Nursing Interventions First Stage:

• MONITOR VITAL SIGNS
• MONITOR FETAL HEART RATE VIA ULTRASOUND DOPPLER, FETOSCOPE OR ELECTRONIC FETAL MONITOR
• ASSESS FETAL HEART RATE BEFORE, DURING AND AFTER A CONTRACTION (NORMAL FHR IS 120-160 BEATS PER MINUTE)
• MONITOR UTERINE CONTRACTIONS BY PALPATING, DETERMINING FREQUENCY, DURATION, AND INTENSITY OF CONTRACTION
• ASSESS STATUS OF CERVICAL DILATION AND EFFACEMENT
• ASSESS FETAL STATION PRESENTATION AND POSITION BY LEOPOLD’S MANEUVER
• ASSESS THE COLOR OF THE AMNIOTIC FLUID IF THE MEMBRANES HAVE RUPTURED BECAUSE MECONIUM-STAINED FLUID CAN INDICATE FETAL DISTRESS.

SECOND STAGE OF LABOR

2. Stage 2- complete dilation to birth of baby

1. Phase1- 0-+2 station

1. Contractions 2-3m apart

2. Phase2- +2-+4 station

1. Contractions 2-2.5m apart

2. Inc dark red bldy show

3. Inc urgency to bear down

 

• SECOND STAGE OF LABOR BEGINS WITH COMPLETE DILATION AND ENDS WITH DELIVERY OF INFANT
• DURATION: 30-90 MINUTES IN PRIMIPARA AND 15-20 MINUTES IN MULTIPARA
• CERVICAL DILATION COMPLETE
• UTERINE CONTRACTIONS OCCUR EVERY 2-3 MINUTES, LASTING 60-75 SECONDS AND THE INTENSITY IS STRONG
• INCREASE IN BLOODY SHOW
• MOTHER FEELS URGE TO BEAR DOWN

Nursing Interventions:

• ASSESS FETAL WELL-BEING CONTINUOUSLY
• MONITOR MATERNAL VITAL SIGNS
• ENCOURAGE PUSHING
• ENCOURAGE DEEP-FULL BREATH (NOT TO HOLD BREATH LONGER THAN 5 SECONDS WHEN PUSHING)
• COMMEND MOTHER’S EFFORT

THIRD STAGE OF LABOR

1. Phase 3- +4-birth

1. Contractions 1-2m apart

2. Fetal head visible

• THIRD STAGE OF LABOR BEGINS WITH DELIVERY OF INFANT AND ENDS WITH DELIVERY OF PLACENTA
• DURATION: UP TO 20 MINUTES (PRIMIPARA OR MULTIPARA)
• CONTRACTIONS OCCUR UNTIL THE PLACENTA IS BORN
• PLACENTAL SEPARATION AND EXPULSION OCCUR
• BIRTH OF PLACENTA OCCURS 5-30 MINUTES AFTER BIRTH THE BABY

Nursing Interventions:

• ASSESS MATERNAL SIGNS AND UTERINE STATUS
• OBSERVE FOR PLACENTAL SEPARATION
• OBSERVE MOTHER FOR SIGNS OF ALTERED LOC OR ALTERED RESPIRATION (INDICATE ANEURYSM OR EMBOLI)
• ALLOW MATERNAL-INFANT INTERACTION AS SOON AS POSSIBLE

FOURTH STAGE OF LABOR

4. Stage 4 – first four hrs after delivery of placenta

Irreg FHR

    N/I

        L side lying position

        Adm O2

        Check cord prolapsed

        Start IV

Umbilical cord prolapsed

    N/I

        Elevate present part off cord

        CALL FOR HELP

        c/t trendelenberg pos/ knee-chest pos

        adm O2

        start IV

after deliver

    fundus

        position

            1cm/finger breadth above umbilicus for first 12hrs

            Descends 1cm each day

• LAST STAGE OF LABOR BEGINS WITH DELIVERY OF PLACENTA AND ENDS WITH POSTPARTUM STABILIZATION
• DURATION: USUALLY 1-2 HOURS AFTER DELIVERY (PRIMIPARA OR MULTIPARA)
• BLOOD PRESSURE RETURNS TO THE PRE-LABOR LEVEL
• PULSE IS SLIGHTLY LOWER THAN DURING LABOR
• FUNDUS REMAINS CONTRACTED, IN THE MIDLINE, 1-2 FINGERBEADTHS BELOW THE UMBILICUS

Nursing Interventions:

• MATERNAL ASSESSMENT EVERY 15 MINUTES FOR 1 HOURS, EVERY 30 MINUTES FOR 1 HOURS, AND HOURLY FOR 2 HOURS
• ADMINISTER OXYTOCIN PRODUCT IF ORDERED
• ASSESS FUNDUS EVERY 15 MINUTES, IF SOFT, MASSAGE WITH SIDE OF HAND
• ASSESS LOCHIA, CHECKING PERIPAD AND UNDER LOWER BACK
• ASSESS BLADDER FOR DISTENTION BECAUSE FULL BLADDER WILL PREVENT CONTRACTIONS AND INCREASE BLEEDING
• ASSESS EPISIOTOMY FOR INTACTNESS AND POSSIBLE BLEEDING

Assessment of the Lochia
The normal color of lochia are:

1. LOCHIA RUBRA (REDDISH) : 1-3 DAYS POSTPARTUM.
2. LOCHIA SEROSA (BROWNISH): 4-10 DAYS POSTPARTUM.
3. LOCHIA ALBA (WHITESH): 10-14 DAYS POSTPARTUM, OR NO LONGER THAN 3-6 WEEKS.

 

Lochia

Color/volume

Day1-3

Rubra (bld w/ fleshy odor; clots)

Day4-5

Serosa (pink/brown w/ fleshy odor)

Day 10+

Alba (yellow-white)

***foul odor = inf!