1.

) Stages of Labor with nursing responsibilities in each stage/ also on the behavior of client in the 3 phases in stage 1 STAGE 1: DILATION MAIN GOALS: COMPLETE DILATION OF CERVIX, DESCENT OF FETUS
The first stage of labor occurs when the cervix opens (dilates) and thins out (effaces) to allow the baby to move into the birth canal. This is the longest of the four stages of labor. It's actually divided into three phases of its own latent phase, active phase and the transition phase.

STAGES OF LABOR AND UTERINE CONTRACTIONS Latent phase: cervix 0-3 cm Contractions every 10-20 min, 15- to 30-sec duration, mild intensity; progressing to every 5-7 min, 30- to 40-sec duration, mild to moderate intensity

WOMANS RESPONSE Happy, excited Talkative and eager to be in labor Exhibits need for independence Attempts to care for own bodily needs Seeks information about her care Some apprehension

NURSING INTERVENTIONS Establish rapport Monitor maternal vital signs and FHR Assess status of amniotic uid; if membranes intact or ruptured Observe voiding time and amount Assess coping ability, anxiety Teach breathing techniques if needed Encourage walking if membranes are intact Encourage woman and support person to participate in care Encourage relaxation if lying down (assist with techniques such as efeurage) or sacral pressure Offer uids/ice chips Woman is kept NPO to prevent aspiration Keep couple informed Continue to assess and document maternal vital signs and FHR every 30 min Provide support and encouragement If on electronic fetal monitor, observe for

Active phase: cervix 4-7 cm Contractions every 2-3 min, 50to 60-sec duration, moderate to strong intensity

Apprehensive Ill-dened doubts and fears Exhibits increased fatigue and may feel restless As contractions become stronger, becomes

anxious Becomes more dependent as she is less able to meet her needs Desire for companionship Becomes uncertain if she can cope with contractions Ritual activities or motions during contractions may indicate strong coping strategies are in place

Transition: cervix 8-10 cm Contractions every 2-3 min, 60to 90-sec duration, strong intensity

Marked restlessness and irritability Amnesia between contractions Generalized discomfort, cramps in legs

normal/abnormal signs; explain monitor to woman and support person Assess status of membranes Encourage to void every 1-2 hr to avoid bladder distention Observe for full bladder (woman loses urge to void with epidural block) Assess progress of labor (cervical dilation) Registered nurse may perform vaginal examination (see Figure 8-3) Provide comfort and safety measures: moisten lips, apply ointment, provide ice chips Apply cool cloth to womans forehead Provide back rubs, sacral pressure, efeurage, attention-focusing activities Assist with oral hygiene Keep bed linens dry and bedrails up Provide assistance with position changes, support with pillows, or walking Protect woman from infection with frequent perineal care Inform couple about labor progress Continue nursing interventions from active phase Encourage woman to rest between contractions

Sometimes hiccupping and belching Nausea and vomiting Perspiration on face Trembling of legs Increased vaginal show May feel tearing open or splitting apart with contractions Desires medication May feel out of control Fear of being alone

Talk woman through the contraction by maintaining breathing pattern Assess monitor strip for normal/abnormal signs (if on monitor); if not on monitor, assess FHR and blood pressure every 15 min Recognize woman may not want to be touched during transition period; recognize this is a difcult time for woman Do not leave woman alone Accept behavior of throwing off covers, etc. Get blanket if woman feels cold; assist to change positions Apply cool cloth to head when woman feels hot Encourage voiding, assess for full bladder Provide support, praise, and encouragement for her efforts Provide privacy

STAGE 2: EXPULSION OF FETUS MAIN GOAL: DESCENT TO BIRTH OF BABY, COMPLETE DILATION 10 CM
The second stage of labor begins when the cervix is completely dilated (open), and ends with the birth of the baby.

STAGES OF LABOR AND UTERINE CONTRACTIONS Contractions every 1.5-2 min, 60- to 90-sec duration, strong intensity

WOMANS RESPONSE Desire to push Satisfaction if told baby is almost here complete exhaustion pushes with contractions may feel helpless, out of control, panicky.

NURSING INTERVENTIONS Encourage open-glottis grunting push technique when bearing down is spontaneous Encourage deep breathing between contractions

Rectal and vaginal bulging and attening of perineum

Assess FHR after each contraction (if not on monitor) Assess monitor strip for normal/abnormal ndings Assess contraction for frequency, duration, and intensity Assess progress of labor; inform woman and partner Encourage continued support Remain with woman at all times Cleanse perineal area (stroke downward) Provide necessary materials and equipment for delivery After birth, give immediate care to newborn Assess woman for potential hemorrhage

STAGE 3: EXPULSION OF PLACENTA MAIN GOALS: EXPULSION OF PLACENTA, PREVENTION OF HEMORRHAGE

After the birth of the baby, the uterus continues to contract to push out the placenta (afterbirth). The placenta usually delivers about 5 to 15 minutes after the baby arrives.

STAGES OF LABOR AND UTERINE CONTRACTIONS Contractions temporarily cease 2-3 contractions to expel placenta Upward rise of uterus in abdomen Visible lengthening of umbilical cord Trickle or gush of blood

WOMANS RESPONSE Eager to get acquainted with baby Sense of relief

NURSING INTERVENTIONS Assess womans vital signs Assess for excessive bleeding Provide nursemidwife/physician with necessary materials (for possible episiotomy repair) Take woman to recovery room (if in traditional

 STAGE 4: IMMEDIATE RECOVERY PERIOD (MINIMUM 1 HR)

facility) Encourage parentnewborn bonding

MAIN GOALS: PREVENT HEMORRHAGE, FACILITATE MATERNAL-NEWBORN BONDING

The baby is born and the placenta has delivered.

STAGES OF LABOR AND UTERINE CONTRACTIONS

WOMANS RESPONSE Exhausted but happy labor is over Eager to feed baby Hungry Thirsty Sleepy

NURSING INTERVENTIONS Nursing assessment is directed toward prevention of hemorrhage Assess every 15 min for 1 hr minimum: fundus location (height) and consistency (if not rm, massage and report); lochia amount, color, odor; vital signs: blood pressure, pulse, temperature; perineum: episiotomy for edema, hematoma; state of hydration; bladder for distention; fatigue and exhaustion (provide atmosphere for rest) Encourage mothernewborn bonding: hold baby, breastfeed Provide privacy for woman, partner, and baby to get acquainted

2.EINC / Unang Yakap The EINC practices during Intrapartum period Continuous maternal support, by a companion of her choice, during labor and delivery Mobility during labor the mother is still mobile, within reason, during this stage Position of choice during labor and delivery Non-drug pain relief, before offering labor anesthesia Spontaneous pushing in a semi-upright position Episiotomy will not be done, unless necessary

Active management of third stage of labor (AMTSL) Monitoring the progress of labor with the use of pantograph

Recommended EINC practices for newborn care are time-bound interventions at the time of birth

1. Immediate and thorough drying Time Band: Within 1st 30 seconds: Immediate Thorough Drying a. b. c. d. Call out the time of birth Dry the newborn thoroughly for at least 30 seconds Wipe the eyes, face, head, front and back, arms and legs Remove the wet cloth Do a quick check of breathing while drying Notes: During the 1st second: Do not ventilate unless the baby is floppy/limp and not breathing Do not suction unless the mouth/nose are blocked with secretions or other material Notes: Do not wipe off vernix Do not bathe the newborn Do not do footprinting No slapping No hanging upside - down No squeezing of chest 2. Early skin-to-skin contact If newborn is breathing or crying: a. Position the newborn prone on the mothers abdomen or chest b. Cover the newborns back with a dry blanket c. Cover the newborns head with a bonnet Notes: Avoid any manipulation, e.g. routine suctioning that may cause trauma or infection Place identification band on ankle (not wrist) Skin to skin contact is doable even for cesarean section newborns

3. Properly timed cord clamping a. b. c. d. Remove the first set of gloves After the umbilical pulsations have stopped, clamp the cord using a sterile plastic clamp or tie at 2 cm from the umbilical base Clamp again at 5 cm from the base Cut the cord close to the plastic clamp Notes: Do not milk the cord towards the baby After the 1st clamp, you may strip the cord of blood before applying the 2nd clamp

Cut the cord close to the plastic clamp so that there is no need for a 2nd trim Do not apply any substance onto the cord 4. Non-separation of the newborn and mother for early initiation of breastfeeding

a. b. c. d. 5.

Leave the newborn in skin-to-skin contact Observe for feeding cues, including tonguing, licking, rooting Point these out to the mother and encourage her to nudge the newborn towards the breast Counsel on positioning Newborns neck is not flexed nor twisted Newborn is facing the breast Newborns body is close to mothers body Newborns whole body is supported Counsel on attachment and suckling Mouth wide open Lower lip turned outwards Babys chin touching breast Suckling is slow, deep with some pauses Notes:

Minimize handling by health workers Do not give sugar water, formula or other prelacteals Do not give bottles or pacifiers Do not throw away colostrum Weighing, bathing, eye care, examinations, injections (hepatitis B, BCG) should be done after the first full breastfeed is completed Weighing, bathing, eye care, examinations, injections should be done after the first full breastfeed is completed Postpone washing until at least 6 hours

Unnecessary interventions eliminated The unnecessary interventions during labor and delivery, which do not improve the health of mother and child, are eliminated. These are enemas and shavings, fluid and food intake restriction, and routine insertion of intravenous fluids. Fundal pressure to facilitate second stage of labor is no longer practiced, because it resulted to maternal and newborn injuries and death. Likewise, the unnecessary interventions in newborn care which include routine suctioning, early bathing, routine separation from the mother, foot printing, application of various substances to the cord, and giving pre-lacteals or artificial infant milk formula or other breast-milk substitutes.

3. Newborn Screening Newborn screening (NBS) is a public health program aimed at the early identification of infants who are affected by certain genetic/metabolic/infectious conditions. Early identification and timely

intervention can lead to significant reduction of morbidity, mortality, and associated disabilities in affected infants. NBS in the Philippines started in June 1996 and was integrated into the public health delivery system with the enactment of the Newborn Screening Act of 2004 (Republic Act 9288). From 1996 to December 2010, the program has saved 45 283 patients. Five conditions are currently screened: Congenital Hypothyroidism, Congenital Adrenal Hyperplasia, Phenylketonuria, Galactosemia, and Glucose-6-Phosphate Dehydrogenase Deficiency. Newborn Screening Legislation NBS was integrated into the public health delivery system with the enactment of Republic Act 9288 or Newborn Screening Act of 2004 as it institutionalized the National NBS System, which shall ensure the following: [a] that every baby born in the Philippines is offered NBS; [b] the establishment and integration of a sustainable NBS System within the public health delivery system; [c] that all health practitioners are aware of the benefits of NBS and of their responsibilities in offering it; and [d] that all parents are aware of NBS and their responsibility in protecting their child from any of the disorders. The highlights of the law and its implementing rules and regulations are: 1. DOH is the lead agency tasked with implementing this law; 2. Any health practitioner who delivers or assists in the delivery of a newborn in the Philippines shall prior to delivery, inform parents or legal guardians of the newborns the availability, nature and benefits of NBS; 3. Health facilities shall integrate NBS in its delivery of health services; 4. Creation of the Newborn Screening Reference Center at the National Institutes of Health and establishment and accreditation of NSCs equipped with a NBS laboratory and recall/follow up program; 5. Provision of NBS services as a requirement for licensing and accreditation, the DOH and the Philippine Health Insurance Corporation (PHIC) 6. Inclusion of cost of NBS in insurance benefits

4. Post partum care A postpartum period (or postnatal period) is the period beginning immediately after the birth of a child and extending for about six weeks. Less frequently used is the term puerperium. Physical Further information: Sex after pregnancy The mother is assessed for tears, and is sutured if necessary. Also, she may suffer from constipation or hemorrhoids, both of which would be managed. The bladder is also assessed for infection, retention, and any problems in the muscles. The major focus of postpartum care is ensuring that the mother is healthy and capable of taking care of her newborn, equipped with all the information she needs about breastfeeding, reproductive health and contraception, and the imminent life adjustment. Some medical conditions may occur in the postpartum period, such as Sheehan's syndrome and peripartum cardiomyopathy.

In some cases, this adjustment is not made easily, and women may suffer from postpartum depression, posttraumatic stress disorderor even puerperal psychosis. Postpartum urinary incontinence is experienced by 23.4%[1] to 38.4%[2], likely higher during pregnancy [3]. During the postpartum period, a woman may urinate out up to nine pounds of water. The extra fluid that her body has taken on is no longer needed, so the mother may note that her fluid output is disproportionate to her fluid input. Psychological Early detection and adequate treatment is required. Approximately 25% - 85% of postpartum women will experience the "blues" for a few days. Between 7% and 17% may experience clinical depression, with a higher risk among those women with a history of clinical depression. Rarely, in 1 in 1,000 cases, women experience a psychotic episode, again with a higher risk among those women with pre-existing mental illness. Despite the wide spread myth of hormonal involvement, repeated studies have not linked hormonal changes with postpartum psychological symptoms. Rather, these are symptoms of a pre-existing mental illness, exacerbated by fatigue, changes in schedule and other common parenting stressors.[2] Postpartum psychosis (also known as puerperal psychosis), is a more severe form of mental illness than postpartum depression, with an incidence of approximately 0.2%.

Taking home a new baby is one of the happiest times in a woman's life. But it also presents both physical and emotional challenges.

Get as much rest as possible. The mother may find that all she can do is eat, sleep, and care for her baby. And that is perfectly okay. She will have spotting or bleeding, like a menstrual period, off and on for up to six weeks. She might also have swelling in your legs and feet, feel constipated, have menstrual-like cramping. Even if shes not breastfeeding, she can have milk leaking from her nipples, and her breasts might feel full, tender, or uncomfortable. She should follow her doctor's instructions on how much activity, like climbing stairs or walking, you can do for the next few weeks. Doctors usually recommend that she abstain from sexual intercourse for four to six weeks after birth.

Relief of after pains (nursing intervention)

Positioning (prone position) Analgesia administered an hour before breastfeeding Encourage early ambulation - monitor for dizziness and weakness

Diagnosis

Risk for infection Risk for injury pain knowledge deficit