Stages and Phases of Labor

2. Cesarean Birth
   1. Definitions
      1. Surgical incision into the uterus and abdominal wall to deliver the fetus
      2. Low transverse incision
      3. Classical incision
      4. Primary cesarean birth
      5. Repeat cesarean birth
      6. Vaginal birth after cesarean
   2. Data collection
      1. Note maternal risk factors
      2. Observe for dystocia, maternal factors precluding safe vaginal delivery for mother and/or fetus, and rescue of fetus for non-reassuring heart rate or heart rate incompatible with labor
      3. Review of physical preparation of the woman for surgical delivery
      4. Emotional/psychological preparation of the woman for surgical delivery
      5. Review of prepatory measures for surgical intervention
      6. Prompt notification of health care provider in emergency situations involving maternal or fetal emergencies
         
      3. Management
         1. safely and efficiently perform surgical intervention
         2. provide physical and psychological/emotional support in preparation for procedure
         3. physically prepare client for intraoperativeprocedure
         4. educate regarding need for preparation, events of intraoperative period and postoperative procedures for well-being
         5. prepare for newborn management
      4. Nursing interventions
         1. if repeat cesarean, review client understanding of preparation, operative procedure and postoperative care
         2. if maternal conditions deteriorate or fetal status becomes incompatible with labor, immediate emergency procedures are instituted
         3. immediate notification of medical personnel, anasthesia, pediatric providers
         4. institute procedures to maintain organ perfusion with particular emphasis on uterine perfusion
         5. obtain surgical and anthesia consent
         6. bolus the client with intravenous fluids prior to anesthesia
         7. skin preparation and floey catheter, as ordered
         8. preoperative medication in preparation for anesthesia
         9. nursing presence at bedside to alleviate anxiety, fear and to explain emergency interventions
         10. accompany client to surgical suite and maintain continuity of care
         11. assist with anesthesia conduction/induction
         12. prepare neonatal stabilization and resuscitation equipment
         13. monitor postoperatively until stable
      5. Evaluation
         1. maternal morbidity and mortality are minimized or avoided
         2. neonatal morbidity and mortality are minimized or avoided
         3. client verbalizes understanding of surgical intervention
         4. parental-newborn bonding is supported
   
   
3. Complications During Pregnancy
   1. Pregnancy-induced hypertension (PIH) with preeclampsia and eclampsia
      
   2. Diabetes in Pregnancy
      1. Definitions
         1. predisposing factors
         2. classifications
         3. gestational diabetes
         4. goal: euglycemia
            
      2. Data collection
         1. glucose challenge test (GCT) at 24-28 weeks, if GCT >140 mg/dL proceed to 3 hour oral glucose tolerance test (GTT)
         2. if GTT positive, dietary controls initiated
         3. if dietary controls fail to keep FBS <105mg/dL, insulin therapy is initiated
         4. observe for glycosuria, ketonuria, polydypsia, polyphagia, polyuria
         5. monitor for excessive weight gain or excessive weight loss
         6. fetal growth is estimated serially with sonograms
         7. antepartumvisits biweekly until 34 weeks, then weekly
         8. biophysical profile (BPP) at 34 weeks, then weekly
         9. daily fetal movement counts
         10. client's understanding of findings of hyperinsulinismand ketoacidosis
      3. Management
         1. maintain euglycemiathroughout pregnancy
         2. mother proceeds to term (>37 weeks) with reassuring fetal condition
         3. delivery of infant without morbidity or mortality
      4. Nursing interventions
         1. monitor blood sugar and report abnormalities
         2. reinforce education of client regarding:
            1. increased risk for genitourinary infections, dystocia, hydramnios, cesarean birth
            2. diet, glucose screening and insulin administration
            3. treatment for hyperglycemia, hyperinsulinemia and recognize signs of ketoacidosis
         3. most clients with GDM will return to normal glucose levels after childbirth
         4. clients with GDM are at greater risk for GDM in future pregnancies
      5. Evaluation
         1. client verbalizes understanding of treatment regime
         2. client verbalizes understanding of potential complications
         3. client is hospitalized if complications arise
         4. maternal/fetal morbidity and mortality are minimized
            
   3. Anemia in pregnancy
      1. Definitions
         1. physiologic anemia of pregnancy: normal adaptation during pregnancy
         2. iron deficiency anemia: results from poor iron intake
         3. first trimester - Hgb <11g/dL or Hct < 35%
         4. second trimester - Hgb <10.5g/dL or Hct < 35%
         5. third trimester - Hgb < 10g/dL or Hct <33%
            
      2. Data collection
         1. laboratory values
         2. pallor, listlessness, fatigue
         3. slow capillary refill
         4. poor weight gain
         5. infection, bleeding
         6. fetus: small for gestational age (SGA), intrauterine growth retardation (IUGR)
      3. Management
         1. improve dietary status
         2. monitor for hemorrhagic signs
         3. monitor fetal growth
      4. Nursing interventions
         1. reinforce teaching regarding:
            1. nutritional instructions: iron rich diet, > vitamin C and folic acid
            2. oral iron supplement
            3. parenteral iron (Imferon) if necessary
            4. need to take oral supplements with orange juice for absorption and between meals
            5. include roughage and eight glasses water to prevent constipation
            6. diet, fluids, medication, presence of black stools
         2. discuss the need to space activities
      5. Evaluation
         1. maternal laboratory values will improve
         2. maternal energy levels will improve
         3. fetal growth will be maintained within normal levels
         4. client will verbalize foods in iron rich diet, oral iron regime and findings to report to health care provider
            
   4. Cardiovascular disorders in pregnancy
      1. Definitions
         1. classifications I, II, III and IV cardiac disease are all exacerbated by pregnancy related to the normal physiological increases in blood volume and heart work
         2. evaluation of cardiac status is determined at the end of the first trimester and at approximately 28 to 32 weeks
         3. cardiac decompensation in pregnancy
      2. Data collection
         1. establish cardiac defect classification
         2. establish maternal activity expectations related to classification
         3. monitor and educate client as to findings of cardiac decompensation
         4. weekly or twice monthly visits related to classification
         5. monitor fetal well-being with sonogram, biophysical profile (BPP), nonstress test (NST)
         6. counsel regarding activity and rest periods, nutrition, and medications
         7. educate regarding delivery plans and postpartum plans
         8. dyspnea, palpitations, syncope and edema occur commonly in pregnancy and can mask findings of developing or worsening cardiac conditions
            
      3. Management
         1. maternal health will suffer minimal adverse effects
         2. client will accept activity restrictions to maintain maternal/fetal well-being
         3. client and newborn will be successfully delivered
         4. maternal cardiac condition will stabilize postpartum
      4. Nursing interventions (depend on classification)
         1. class I: obtain additional rest, seek early treatment for infection, plan normal vaginal delivery unless valve lesions preclude pushing, then regional anasthesia and extraction
         2. class II: avoid strenuous exercise, administer prophylactic antibiotics in labor and medication for normal heart work, plan vaginal delivery with oxygen, regional anesthesia and fetal extraction
         3. class III: reduce physical activity, eliminate stress, administer prophylactic antibiotics in labor and medication for normal heart work, plan induction of labor with cardiac monitoring, oxygen, regional anasthesia and fetal extraction
         4. class IV: recommend early therapeutic abortion, as 50% mortality rate with birth. Vaginal delivery in intesive care setting with invasive cardiac monitoring, regional anesthesia, and birth extraction. Cardiac specialist in attendance.
      5. Evaluation
         1. maternal cardiac status undergoes minimal deterioration and morbidity
         2. maternal mortality is reduced
         3. fetal well-being is maintained with minimal morbidity and no mortality
         4. client understands consequences and potential outcome of pregnancy