NCLEX 26 Maternity: STAGES OF LABOR
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.
-
Stage 1- beginning to complete cervical dilation (0-10cm)
-
Phase 1 (latent) 1-3cm
-
Contractions mild-mod
-
10-30s long, 5-30m apart
-
Phase2 (active) 4-7cm
-
Contractions mod-strong
-
40-60s long, 3-5m apart
-
Phase4 (transition) 8-10cm
-
Contractions strong
-
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
-
Stage 2- complete dilation to birth of baby
-
Phase1- 0-+2 station
-
Contractions 2-3m apart
-
Phase2- +2-+4 station
-
Contractions 2-2.5m apart
-
Inc dark red bldy show
-
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
-
Phase 3- +4-birth
-
Contractions 1-2m apart
-
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
-
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:
- LOCHIA RUBRA (REDDISH) : 1-3 DAYS POSTPARTUM.
- LOCHIA SEROSA (BROWNISH): 4-10 DAYS POSTPARTUM.
- 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!
Permalink #
Google
said
Sooner or later, Google will find all new spam methods.
The website speed test at Secret Search Engine Labs will analyze
how fast a page on your site is loading and give you tips
on how to improve it. There are other ways to improve your ranking in Googlemaps, the purpose of this blog post
is not to tell you EVERYTHING Frederick Web Promotions can do to improve your ranking, the purpose of this particular blog post is to:.
Permalink #
Google
said
It will also increase the ranking of your website on search engines and will drive more traffic to your website.
In addition, the observing surgeons could transmit their comments to
the operating surgeon, who could read them on the Google Glass monitor.
Reputation Defense Online an around the world Cyber Investigation along with Litigation Assistance Agency for Net Defamation,
often receives inquiries from attorneys along with law enforcement
agencies on the way to subpoena Google’s Legal Division.
Permalink #
Google
said
This is because this device assures to either benefit
or cure the autistic people in more ways than one.
In addition, the observing surgeons could transmit their comments
to the operating surgeon, who could read them on the Google
Glass monitor. * Page SEO: Your page is optimized by various means which include, choosing the right keywords, placing
them right, adding anchor text linking, adding call to action in various places on the page.
Permalink #
jean maxob
said
I use this website to study and it gives me all the information about labor. I really enjoy using your information to share with my classmates. Iam study for nclex exam.thanks ,jm
Permalink # NCLEX Topics Labor and Delivery. - NCLEX Test Online Review said
[…] Breathing Techniques https://allnursingnotes.com/maternity-peds/maternity-quick-e/nclex-26-maternity-stages-of-labor/ […]