NURSING CARE DURING THE STAGES OF LABOR

NOTES IN MATERNAL AND CHILD NURSING
Reference: NURSE’S NOTES: MATERNAL and CHILD NURSING
Maritess Manalang-Quinto, RN, MAN(c)

Nursing Care of the Mother
1. Care of the Woman During the First Stage
Stage Profile: Marked by duration and stress of labor
Nursing interventions:
- Reduce anxiety and offer assistance
- Do not interrupt breathing during contractions
- Promote change of positions
- Encourage voiding and promote bladder care
- Encourage client to suck on hard candy, ice chips
- Apply cream on dry lips of client
- Administer IV solution in case of DHN
- When hyperventilating, keep paper bag nearby and teach on how to use it

2. Care of the Woman During the Second Stage
Stage Profile: Marked by intense contractions
Nursing Interventions:
- Provide client support
- Assess and record v/s, FHR, uterine contractions
- Prepare place of birth in advance
- Convert the labor room to birth room
- Make the client select positioning for birth
- Promote second stage pushing
- Clean perineum with warm antiseptic before birth

As soon as head is about 8cm across:
Perform the Ritgen’s maneuver
Encourage the woman to continue pushing until the occiput of fetal head is firmly a the pubic arch
Once head is delivered
Note time of birth, announce sex of infant
Cut and clamp the cord
Introduce infant to initiate parent child relationship

3. Care of the Woman in the Third and Fourth Stages of Labor
Stage Profile: Placental separation and delivery
Nursing interventions:
- Administer oxytocin (IM or IV
- Inspect delivered placenta
- Monitor vital signs (q 15 minutes)
- Palpate fundus
- Observe character and amount of lochia

Non Pharmacologic Pain relief
Relaxation
Focusing on imagery
Support from a doula or coach
Breathing techniques
Bathing/ hydrotherapy : C/I in ruptured membranes
Therapeutic touch and massage
Hypnosis: deep form of relaxation
Biofeedback: based on belief that people can control and
regulate internal events like HR and pain response
Acupressure and acupuncture
Heat or cold application
Pharmacologic pain relief
Local infiltration
Pudendal nerve block
Spinal anesthesia
Epidural anesthesia