1 Nursing Responsibility During First Stage of Labor J. Nursing Diagnoses for the Intrapartal Patient I. Anxiety 1.

R/ threat to health status !. R/ role "hanges II. Defi"ient #no$le%ge R/ la"& of exposure to "hil%birth pro"ess III. Fatigue 1. R/ stress !. R/ sleep %epri'ation (. R/ in"rease% )etaboli" %e)an%s of pregnan"y I*. A"ti'ity Intoleran"e 1. R/ i)balan"e bet$een oxygen %e)an% an% supply !. R/ pain *. Fear 1. R/ separation fro) support syste) !. R/ la"& of un%erstan%ing of labor pro"ess (. R/ language barrier *I. A"ute Pain 1. R/ uterine "ontra"tions !. R/ birth pro"ess *II. Ineffe"ti'e +oping 1. R/ ina%e,uate opportunity to prepare for stressor !. R/ ina%e,uate le'el in ability to "ope (. R/ un"ertainty -. R/ ina%e,uate so"ial support *III. Interrupte% Fa)ily Pro"esses 1. R/ gain of a fa)ily )e)ber !. R/ "hange in roles (. R/ e"ono)i" "hanges I.. Po$erlessness R/ loss of pri'a"y .. Self/+are Defi"it0 oileting 1. R/ be%rest status 1epi%ural2 !. R/ i)paire% transfer ability .I. Situational Lo$ Self/3stee) R/ per"ei'e% loss of "ontrol .II. I)paire% 4as 3x"hange R/ 'entilation/perfusion i)balan"e ! hypo'ole)i" sho"& .III. Ineffe"ti'e 5reathing Pattern 1. R/ %e"rease% energy

! !. R/ bo%y position (. R/ pain .I*. Ris& for In6ury R/ altere% )obility .*. I)paire% 7rinary 3li)ination 1. R/ %e"rease% sensory )otor fun"tion 1epi%ural2 !. R/ in"rease% stress to bla%%er .*I. Ris& for I)paire% S&in Integrity 1. R/ in"rease% )oisture !. R/ altere% flui% status (. R/ %e"rease% sensation -. R/ surgi"al in"ision of perineu) .*II. I)paire% issue Integrity R/ tearing of perineu) .*III. Ris& for Infe"tion 1. R/ brea& in pri)ary %efense !. R/ in'asi'e pro"e%ures (. R/ rupture of a)nioti" )e)branes I. Nursing +are in Nor)al Labor0 Stage 1 A. Latent Phase 13arly Phase2 I. 8'er'ie$0 1.7p to ( / - ") "er'i"al %ilation. !. A'erage 9 / !: hours 1pri)ipara2. (. A'erage ; / 1- hours 1)ultipara2 II. <hen to go to hospital 1. +ontra"tions a. Nullipara / regular= ; )inutes apart . 1 hour b. >ultipara / regular= 1: )inutes apart . 1 hour !. Rupture% >e)branes / a gush or tri"&le of flui% fro) the 'agina nee%s e'aluating. (. 5lee%ing / bright re% bloo% not )ixe% $ith )u"ous nee%s i))e%iate e'aluation. -. De"rease% Fetal >o'e)ent / notify pro'i%er or go to hospital III. A%)ission to Labor an% Deli'ery 1. 3stablish a therapeuti" relationship a. >a&e the fa)ily $el"o)e 1.2 a&e the ti)e to sho$ you "are !.2 Arrange for an interpreter= if nee%e%

( b. Deter)ining fa)ily expe"tations about birth 1.2 >ay ha'e a $ritten birth plan !.2 5e sure to in"lu%e partner in assess)ent of expe"tations. ". +on'ey "onfi%en"e / use the ter) ?gi'e birth? instea% of ?%eli'er=? the )other is in "ontrol= reassure the $o)an that intense "ontra"tions are nor)al. %. Assign a pri)ary nurse 1101 if possible= or 10!2. e. 7se tou"h for "o)fort0 1.2 5e a$are of "ultural "on"erns 1if tou"h is appropriate2. !.2 Desire for tou"h )ay "hange as labor progresses 1often %oes not li&e it in transition2. f. Respe"t "ultural 'alues / Nurse shoul% in"orporate "ouple@s "ultural 'alues 1i.e.= pri'a"y2 into the birth experien"e. !. I)pen%ing 5irth a. So)e )ay %eli'er shortly after "o)ing to unit b. Signs/ Sy)pto)s of i)pen%ing birth0 1.2 4runting !.2 5earing %o$n (.2 Saying= ? he baby@s "o)ingAAAA? ". *ital Infor)ation to 8btain0 1.2 >other@s na)e !.2 Support person@s na)e (.2 If she ha% prenatal "are -.2 Physi"ian/ )i%$ife@s na)e ;.2 4ra'i%a B Para status C.2 *aginal or "/se"tion 1pre'ious %eli'eries2 D.2 Status of )e)branes 9.2 3D+/ 3DD/ 3D5 E.2 Any proble)s %uring pregnan"y 1:.2 Allergies 11.2 i)e B type of last P8 inta&e 1!.2 *S B fetal heart rate %. Fistory / if not in a hurry. 8btain fro) inter'ie$ B $o)an@s re"or%s0 1.2 <o)an@s reason for "o)ing to hospital 1"ontra"tionsG )e)branesG2 !.2 Prenatal "are history (.2 3D+/ 3DD/ 3D5 -.2 4ra'i%a= Para status ;.2 >e%i"al= surgi"al= B pregnan"y hx C.2 Allergies

D.2 Foo% inta&e B $hen 9.2 Any re"ent illness= in"lu%ing treat)ent E.2 >e%i"ations= al"ohol= B toba""o use 1:.2 5loo% type= Rh fa"tor= Rhoga) shots e. Physi"al Assess)ent 1.2 5rief hea% to toe !.2 Note espe"ially0 a.2 3%e)a b.2 Fy%ration status ".2 8xygenation status %.2 Reflexes / %eep ten%on 1patellar2. If epi%ural= test upper extre)ity e.2 <eight f.2 3li)ination pattern 1last 'oi% B 5>2 f. Lab ests 1.2 Fe)ato"rit !.2 7rine for protein B glu"ose (.2 5loo% type 1if not on prenatal re"or%2 -.2 *DRL ;.2 5eta strep status g. >aternal Assess)ents 1.2 *ital signs / "o)pare $ith baseline or prenatal re"or%. a.2 e)perature 1::.- or greater H G infe"tion b.2 5P sustaine% at 1-:/E: or greater H hypertension ".2 e)perature ,- unless in"rease% or rupture% )e)branes= then ,1 %.2 Pulse= respiratory rate= an% bloo% pressure , hour !.2 +ontra"tions / if on external fetal )onitor= )ust palpate to %eter)ine strength of "ontra"tions. Fa"tors that interfere $ith a""ura"y of %eter)ining %uration an% inter'al0 a.2 Ab%o)inal fat b.2 >aternal position ".2 Fetal position Assess)ent %one0 a.2 , hour / latent phase b.2 , (: )inutes / a"ti'e B transition ".2 , 1; )inutes / se"on% stage Note0 a.2 Fre,uen"y / 5eginning of one "ontra"tion to start of next b.2 Duration / 5eginning to en% of one "ontra"tion

; ".2 Inter'al / 3n% of one "ontra"tion to start of next %.2 Intensity / >il% 1tip of nose2I >o%erate 1"hin2I Fir) 1forehea%2 Pro"e%ure0 7se tips of fingers on fun%us. #eep han% still. >onitor at least ( "ontra"tions to get an a""urate pi"ture. Report0 Fypertoni" "ontra"tions 1%e"rease% pla"ental bloo% flo$2 a.2 Duration J E: se"on%s b.2 Inter'als K C: se"on%s ".2 Fre,uen"y / "loser than ! )inutes %.2 In"o)plete relaxation bet$een "ontra"tions (.2 *aginal 5lee%ing Assess0 "olor= a)ount= o%or. 5loo%y sho$ B s)all a)ounts of 'aginal blee%ing are nor)al %ue to rupture of s)all "apillaries as )u"us plug is expelle% B "er'ix %ilates. -.2 >e)brane Status a.2 >e)branes rupture on their o$n / SR8> 1spontaneous rupture of )e)branes2 b.2 Rupture %ue to an a)nioto)y / AR8> 1artifi"ial rupture of )e)branes2 ".2 Note0 i. FFR 1fetal heart rate2 . 1 )inute 1"or% )ay prolapse or be"o)e "o)presse%. ii. +olor0 +lear or "rea)y0 nor)al Lello$= "lou%y= or foul/s)elling0 infe"tion 4reen0 )e"oniu) stool fro) transient hypoxia iii. A)ount0 J1::: )l / large ;::/1::: / )o%erate tri"&le / s"ant i'. i)e0 $hen B ho$ rupture o""urre%. <o)en )ay thin& it is urine lea&ing %ue to pressure on bla%%er. +he"& $ith nitraMine paper 1sensiti'e to pF / turns blue $ith a)nioti" flui%2. h. Fetal Assess)ents 1.2 FFR / Nor)al 11:/1C:. <ays to assess0 a.2 Fetos"ope b.2 Doppler

C ".2 3xternal )onitor Assess0 a.2 5efore= %uring B after a "ontra"tion b.2 +ount baseline for (:/C: se"on%s bet$een "ontra"tions ".2 +he"& )aternal pulse to )a&e sure you are truly hearing FFR 4oo% signs0 a.2 A'erage rate 11:/1!: 1lo$er2 an% 1;: to 1C: 1higher2 b.2 A""elerations of 1; bp) for 1; se"on%s $ith )o'e)ent ".2 *ariability 1flu"tuations in the fetal heart rate as it respon%s to labor stress2 5a% signs0 a.2 Feart rate outsi%e of nor)al li)its b.2 De"elerations 1slo$ing of heart rate after the "ontra"tion en%s2 ".2 No in"rease in heart rate $hen baby )o'es !.2 Presentation / Leopol%@s >aneu'ers Fa'e patient e)pty bla%%er. Position on ba"& B raise hea% slightly / expose ab%o)en. Stan% at si%e of patient= fa"ing her hea% 1for the 1st through (r% )aneu'ers2. Stan% at si%e of patient fa"ing fee% 1for -th )aneu'er2. 1st >aneu'er0 7sing both han%s= palpate the fun%us to %eter)ine presenting part. Fea% / roun%= har% / )o'es in%epen%ently. 5utto"&s / soft= irregular= )o'es $ith trun&= a%6a"ent to s)all parts !n% >aneu'er0 Pla"e pal)s on either si%e of the ab%o)en $ith right han% first. 3xert %eep= gentle pressure. hen use left han%. Deter)ine $here the fetal ba"& is. 5a"& is a s)ooth "ontinuous plane. 8pposite si%e is no%ular. (r% >aneu'er0 Pla"e thu)b B fingers of one han% o'er sy)physis pubis. Apply pressure %o$n an% to$ar% )other@s ba"&. Deter)ine presenting part an% %egree of %es"ent0 able to )o'e it up$ar% 1?floating? / ballotable2 or engage% 1unable to )o'e.2. -th >aneu'er0 urn to fa"e feet. If bree"h presentation= o)it. Pla"e han%s on either si%e of uterus an% sli%e fingers %o$n$ar% an% pressing in$ar% until fingers feel an obstru"tion near the sy)physis. If obstru"tion is felt on opposite si%e of ba"& of fetus= then hea% is flexe% 1you are feeling the forehea%2. If obstru"tion is felt on the sa)e si%e as the fetal ba"&= then hea% is exten%e% 1you are feeling the o""iput2. i. Progress of Labor I. Dilatation B effa"e)ent "he"&. Done %uring an% bet$een "ontra"tions / affe"te% by "ontra"tion. *aginal exa) perfor)e% $ith a sterile lubri"ate% glo'e% han%. Fre,uen"y of exa)s %epen%s on $o)an@s parity= status of )e)branes= an% spee% of labor. Shoul% be li)ite% to a'oi% intro%u"tion of pathogens.

D !. Station / Re)e)ber this is )easure% in relation to the )aternal is"hial spines. 6. >aternal 5eha'ior A%aptation 5eha'ior "hanges as labor intensifies. During this phase= $o)an is often ex"ite%= so)e apprehension= )ay be experien"ing a sense of relief an% anti"ipation. &. Support Person@s A%aptation >ay be"o)e fearful= anxious= or tire% as labor progresses. >ay feel responsibility to prote"t $o)an. So)e )ay be"o)e angryI others lea'e the roo). +ulture also plays a part0 so)e %o not en"ourage the presen"e of father at the birth. Support person )ay be frien%= other relati'e= or a ho)osexual partner. l. Nursing >easures 1.2 Notify birth atten%ant 1physi"ian or nurse )i%$ife2. In"lu%e the follo$ing0 a.2 4ra'ity= parity= B abortions b.2 3DD ".2 +ontra"tion pattern %.2 Fetal presentation B position e.2 +er'i"al %ilation= effa"e)ent= B station f.2 FFR g.2 >aternal *S h.2 Any abnor)alities i.2 Response to labor 1pain= anxiety2 !.2 +onsent for)s0 "are %uring labor= anesthesia= 'aginal birth B possible "/ se"tion. So)eti)es "onsent for ne$born "are. (.2 I* starte%. 19 or !:/gauge "ath / lo"& or )ay re"ei'e "ontinuous flui%s 1usually LR2. Dextrose is a'oi%e% as it )ay "ause neonatal hypogly"e)ia. -.2 Perineal prep / few %o"tors still $ant the area sha'e% or "lippe%. Not full preps any)ore. ;.2 3ne)a / Fleets )ay be gi'en if stool is present to help $ith fetal %es"ent 1also %e"reases li&elihoo% of stool passing %uring pushing.2 C.2 +o)fort )easures a.2 Lighting / soft= in%ire"t lighting / a'oi% o'erhea% glare. b.2 e)perature / "ool "loths on forehea% %uring labor= fan if possible. >ay nee% so"&s for feet. ".2 +leanliness / +hange go$n an% un%erpa%s as nee%e%. Let her %esires gui%e youI she )ay not $ish to ha'e go$n "hange% in later stages. %.2 >outh "are /I"e "hips= popsi"les or har% "an%y help relie'e %ry )outh. If NP8= )oisten lips $ith $ash"loth or "hapsti"&. >ay $ish to rinse an% spit out.

9 e.2 5la%%er / Full bla%%er %elays %es"ent B intensifies labor. Fa'e her 'oi% at least , !. f.2 Positioning / +hange positions fre,uently. Fan%s B &nees or leaning for$ar% positions help $ith ?ba"& labor? 1fetus@ o""iput is pressing on )other@s sa"ral pro)ontory2. g.2 <ater / Sho$er or tub )ay help relaxation an% $ater sti)ulates nipples / release of oxyto"in 1fro) posterior pituitary2 / in"rease% "ontra"tions. D.2 ea"hing 3n"ourage )other not to push until fully %ilate%. If she pushes early= it )ay result in e%e)atous "er'ix 1blo"&s progress2 or la"erate% "er'ix. ; ") %ilation is )ore than half/$ay there be"ause the last ; ") $ill go ,ui"&er. 5. A"ti'e Phase I. 8'er'ie$0 +er'i"al %ilation -/D ") 3ffa"e)ent "o)plete% Fetus %es"en%s B internal rotation begins Pa"e of labor pi"&s up II. >aternal Assess)ents 1. *ital signs / P= R= 5P hourly. , hourly if )e)branes rupture%. Re"or% B graph i))e%iately.

!. 7rine / Dip for protein 1sign of %e'eloping PIF2= &etones 1)aternal %epletion or ele"trolyte %epletion2. Flui% loss o""urs through urine= e)esis= respiration= an% perspiration. (. 5la%%er / +he"& for %istentionI )ay re,uire I/8 "ath bet$een "ontra"tions. III. Progress of Labor 1. *aginal exa) 1li)it those if )e)branes ha'e rupture%2. / Status of )e)branes inta"tG lea&ingG bulgingG / Status of "er'ix0 soft/ fir)G %ilationG effa"e)entG / Fetal presentation0 presenting partG fetal positionG / Fetal station / 3ngage)ent !. +ontra"tions / Pattern 1fre,uen"y= %uration= inter'al2 / Intensity I*. Fetal Assess)ents 1. FFR / nor)al range0 11:/1C: !. *ariability0 in 'ariability H fetal %istress

E (. +hanges in rate0 a""elerations= %e"elerations *. 5eha'ioral A%aptation 1. >aternal0 largely refle"ts ho$ a"tual experien"e relates to expe"tations a. 5o%y posture/ )o'e)ent0 Loo& for "ues of gro$ing fatigue= tension= or pain. Loo& for in"rease% )us"ular tension. b. Intera"tions $ith staff B partner0 >ore fo"use% in$ar%I use short instru"tions. ". Per"eptions0 >ay %i)inishI lose )o%estyI fo"use% only on labor= not on $hat is going on aroun%. %. 3nergy B fatigue le'el0 A'oi%s unne"essary a"ti'ityI )ay sleep bet$een "ontra"tions. e. Responses to %isturbing sti)uli0 In"rease% irritability )ay push helping han%s a$ay= or atte)pt to re)o'e )onitor= bloo% pressure "uff. f. 3xpressions of %is"o)fort or pain0 Loo& for in"rease% restlessness= )us"ular tension= in"rease% anxiety= fearfulness. hese in%i"ate in"rease% pain B labor progression. !. Support Person / >ost experien"e0 a. Fear an% "on"ern o'er partner@s an% unborn "hil%@s $ell being. b. 3'en if they are prepare%= they usually feel un"o)fortable an% unsure %ue to all they see B hear. (. Nursing Diagnoses0 a. A"ute Pain r/t uterine "ontra"tions A35 gri)a"ing= expresse% %esire for pain relief b. Defi"ient Flui% *olu)e r/t restri"tion of oral flui%s an% in"rease% flui% loss A35 in"rease% urine "on"entration= expresse% thirst ". I)paire% Physi"al >obility r/t ele"troni" fetal )onitoring A35 inability to )o'e %ue to e,uip)ent %. I)paire% 4as 3x"hange r/t hyper'entilation $ith "ontra"tions A35 "/o light/ hea%e%ness= tingling in han%s B lips e. I)paire% 7rinary 3li)ination r/t pressure of fetal %es"ent A35 %isten%e% bla%%er= inability to sense nee% to 'oi% -. Nursing Inter'entions a. Nutrition B Fy%ration / So)e %o"tors/ )i%$i'es still re,uire NP8 statusI others allo$ foo%. It is i)portant to )aintain I* for hy%ration an% nutrition. >onitor "arefully for

1: flui% o'erloa% $hen oxyto"in or other )e%s are being gi'en. >onitor output an% assess for bla%%er %istention. b. +o)fort >easures0 1.2 >assage / 3ffleurage 1light stro&ing2 lo$er ab%o)en / #nea%ing / shoul%ers= ne"& B ba"& / +ounterpressure / sa"ru) 1for ba"& labor2 !.2 5ath B sho$ers / bath 1$hen )e)branes are inta"t2I sho$er 1regar%less of )e)brane status2. A%'antages0 relaxation B pain reliefI %istra"tionI )aintenan"e of upright position. (.2 +ol% pa"&s B hot "o)presses0 a.2 +ol% pa"&s help0 o'er sa"ral areaI to refresh perspiring $o)an b.2 Fot "o)presses0 o'er sa"ral areaI lo$er ab%o)en -.2 A)bulation B position "hanges / a.2 If hea% of fetus is $ell applie% to "er'ix= ris& of "or% prolapse $ith a)bulation is highly unli&ely. b.2 If rupture of )e)branes o""urs $hile a)bulating= the nurse )ust exa)ine i))e%iately B "he"& FFR. A)bulation allo$s gra'ity to help $ith %es"ent B %ilation. ".2 Positions 1see >"#inney B atta"h)ent20 / Stan%ing / Sitting upright / Sitting= leaning for$ar% $ith support / Se)i/sitting / Si%e/lying / #neeling= leaning for$ar% $ith support / Fan%s B &nees ;.2 Relaxation B 'isualiMation 1)in%s help bo%y $or& $ith labor2 a.2 Relaxation / Support )other an% partner in exer"ises/ relaxing )us"le groups= an% rhyth)i" breathing. If no prenatal training= nurse "an assist )other to relax )us"le groups an% ?breathe out tension.? b.2 *isualiMation / >ental pi"tures of the e'ents of labor 1i.e.= "ontra"tions= opening the "er'ix Nrather than 6ust painfulO or breathing bringing in "leansing oxygen to the baby. >other )ay $ish to 'isualiMe her fa'orite ,uiet= "al)ing pla"e.

11 C.2 Pro)oting Self/+are0 he nurse "an assist the )other in )aintaining a sense of "ontrol by en"ouraging her to perfor) effleurage 1if she thin&s it helps2= to urinate fre,uently= "hange positions fre,uently 1espe"ially upright positions to assist $ith labor progress2 an% rest bet$een "ontra"tions. +. ransition Phase I. 8'er'ie$ / >other shoul% ne'er be left alone %uring this phase. / +er'ix %ilate fro) 9/1: ") / 5loo%y sho$ in"reases / Short= but intense phase 1!:/-; )inutes2 II. +ontrolling the 7rge to Push 7rge to push before "o)plete %ilation )ay be triggere% %ue to a reflex a"tion sti)ulate% by the presenting part %es"en%ing. he stret"h an% pressure re"eptors in the lo$er uterine seg)ent an% 'agina are a"ti'ate% as the fetus %es"en%s. he %angers to fetus B )other of early pushing are0 1. In"rease% fetal hea% "o)pression !. +er'i"al la"eration1s2 (. +er'i"al e%e)a -. >aternal exhaustion 1%ue to ineffe"ti'e pushing2= an% ;. Prolonge% labor Nursing >easures0 1. 3xplain i)portan"e of $aiting for "o)plete %ilation !. 3n"ourage her to ?blo$ out? short breaths of air through purse% lips %uring the urge to push. <or&s better if nurse )a&es eye/"onta"t an% %oes this $ith her. (. +hange to a gra'ity/neutral position 1li&e si%e/lying2 to %e"rease %o$n$ar% pel'i" pressure. -. Refo"us her attention to 'isualiMe the last ri) of the "er'ix being retra"te% o'er the baby@s hea% $ith "ontra"tions. III. Pro)oting +o)fort 1. Proble)0 a. Sha&ing= "hills Nursing )easures0 $ar) blan&ets= hol% extre)ities b. Perspiration= feeling hot Nursing )easures0 fan= "ool "loths= i"e "hips ". Restlessness= irritability

1! Nursing )easures0 en"ourage)ent= relaxation te"hni,uesI a'oi% beha'iors $hi"h irritate patient %. Inability to fo"us= "onfusion Nursing )easures0 fir) but &in% instru"tionI breathe $ith patientI use eye "onta"tI sa"ral "ounterpressureI i"e or heat pa"& e. In"rease% sa"ral pain Nursing )easures0 sa"ral "ounterpressureI i"e or heat pa"& f. Inability to "ope Nursing )easures0 reassuran"eI physi"al presen"eI fo"us on shortness of phase g. 3xhaustion Nursing )easures0 fa"ilitate rest bet$een "ontra"tionsI alert patient to beginning of "ontra"tion h. Fi""oughing= burping= flatulen"eI nausea B 'o)iting Nursing )easures0 assure patient that these are nor)alI "ool "lothI pro'i%e e)esis basinI hea% ele'ate% or on left si%e I*. >anaging Sensory 8'erloa% Due to intensity of this phase= the $o)an )ay sho$ apprehension= restlessness= an% )ay appear "onfuse% an% unable to un%erstan% %ire"tions. She )ay experien"e pani" an% beg to be ?put to sleep? or ?get this baby out.? 1. Nursing >easures0 a. Refo"us on breathing through "ontra"tions b. 3n"ourage support person 1or nurse2 to )a&e eye "onta"t. ". <a&e her up $hen next "ontra"tion is starting %. al& in a ,uiet= fir)= reassuring tone *. >onitoring for Potential +o)pli"ations0 Fetal +o)pro)ise 1. S/S )e"oniu)/staine% flui%0 a. Late %e"elerations 1start late in "ontra"tion= after pea&= an% en% after "ontra"tion2 b. *ariable %e"elerations 1"an o""ur any ti)e %uring "ontra"tion B last ! )inutes or less2 ". Fetal bra%y"ar%ia 1K11: . 1: )inutes or )ore2

1( %. Absent or %e"rease% beat/to/beat 'ariability *I. Fyper'entilation0 1. Prone to hyper'entilation %ue to0 a. Apprehension b. Intense physiologi" %e)an%s ". 7se of shallo$= patterne% breathing to "ope $ith "ontra"tions !. +y"le0 rapi% breathing ex"ess of +8! blo$n off respiratory al&alosis (. Signs/ Sy)pto)s0 a. Nu)bness B tingling to lips= fingers= B toes b. DiMMiness ". Light hea%a"hes %. +onfusion -. reat)ent0 breathing exhale% "arbon %ioxi%e in paper bag or "uppe% han%s.