NURSING SKILLS PROJECT WORK


INTRODUCTION

It takes nine months to grow a baby, and only a matter of hours (though they may seem like very long hours) to bring one into the world. Yet it is those hours that seem to occupy the minds of expectant women (and their partners) most. More questions and concerns revolve around the process of labour and delivery than around any other aspect of pregnancy; when will labour start? More important when will it end? Will I be able to tolerate the pain? Will I need an episiotomy? What if I don’t make any progress?

Answers to questions and reassurances for concerns will be found in this compilation.

PRELABOUR, FALSE LABOUR, REAL LABOUR

It always seems simple on T.V. Somewhere around 3A.M, the pregnant woman sits up in bed, puts a knowing hand on her belly and reaches over to rouse her sleeping husband with a calm, almost serene, ´´It´s time , honey.´´

How, one wonders, does this woman know it´s time? How does she recognise labour with such cool, clinical confidence when she´s never been in labour before.

One, on the other side of the screen (with no script in hand), is more likely to be with complete uncertainty. Are these really labour pains, or just more Braxton Hicks? Should I wake up my spouse and start heading for the hospital? If I do and it isn´t time, will I turn out to be a pregnant woman who cried ´´labour´´ once too often, and will anybody take me seriously when it´s for real? Will I leave for the hospital too late, may be giving birth in the back of the taxi? The questions multiply faster than the contractions.

The fact is that most women worry and end up misjudging the onset of their labour. The vast majority, thanks to instinct, luck or those with no doubt about the killer contractions, show up at the hospital neither too early nor too late, but just about the right time. Still there is no reason for one to leave her deliberations up to chance.  Becoming familiar in advance with pre-labour, false labour and real labour will help tp allay the concerns and clear up the confusion when those contractions begin.

No one knows exactly what triggers labour (and women are concerned with ´´when´´ than ´´why´´) but it is believed that a combination of fetal, placental and maternal factors are involved. This very intricate process begins with the fetus, whose brain sets off a relay of chemical messages (which probably translates into something like, ´´Mom, let me out of here! ´´) that kick off a chain reaction of hormones in the mother. These hormonal changes in turn pave the way for the work of prostaglandins and oxytocin, substances that trigger contractions when all labour systems are ´´go.´´

PRELABOUR SYMPTOMS

The physical changes of pre-labour can precede real labour by a full month or more- or by only an hour or so. Pre-labour is characterized by the beginning of cervical effacement and dilatation, which a practitioner can confirm on examination, as well as by a wide variety of related signs that a patient may notice herself.

1  LIGHTENING AND ENGAGEMENT. Usually somewhere between two and four weeks before the onset of labour in the first-time mothers, the fetus begins to descend into the pelvis. This milestone is rarely reached in second or later births until labour is about to commence.

2  SENSATION OF INCEASING PRESSURE IN THE PELVIS AND RECTUM. Crampiness (similar to menstrual cramps) and groin pain are particularly common in second and later pregnancies. Persistent low backache may also be present.

3  LOSS OF WEIGHT OR CESSATION OD WEIGHT GAIN. Weight gain might slow down in the ninth month; as labour approaches, some women even lose a bit of weight, up to two or three pounds.

4  A CHANGE IN ENERGY LEVELS. Some women at nine months find out that they are increasingly fatigued. Others experience energy spurts. An uncontrollable urge to scrub floors and clean out the closets has been related to the ´´nesting instinct, ´´ in which the female of the species prepares the nest for the impending arrival.

5  A CHANGE IN VAGINAL DISCHARGE. One may find that her discharge increases and thickens.

6  PINK OR BLOODY SHOW. As the cervix effaces and dilates, capillaries frequently rupture, tinting the mucus pink or streaking it with blood. This ´´show´´ usually means labour will start within twenty-four hours- but could be as much as several days.

7  LOSS OF THE MUCOUS PLUG. As the cervix begins to thin and open, the ´´cork´´ of mucous that seals the opening of the uterus becomes dislodged. This gelatinous chunk of mucus can be passed through the vagina a week or two before the first real contractions or just as labour begins.

8  INTENSIFICATION OF BRAXTON HICKS CONTRACTIONS. These practice contractions may become more frequent and stronger, even painful.

9  DIARRHOEA. Some women experience loose bowel movements just prior to the onset of  labour.

 
FALSE LABOUR SYMPTOMS

Real labour has not begun if:

1.  Contractions are not at all regular and don´t increase in frequency or severity.

2.  Contractions subside if one walks around or changes positions

3.  Show, if any, is brownish. (This kind of discharge is often the result of an internal exam or intercourse within the past forty-eight hours.)

4.  Fetal movements intensify briefly with contractions. (The practitioner has to be alerted immediately if activity becomes frantic.)


REAL LABOUR SYMPTOMS

When contractions of the pre-labour are replaced by stronger, more painful, and more frequent ones, the question arises: ´´Is this the real thing or the false labour?´´ It is probably real if:

1  The contractions intensify, rather than ease up, with activity and aren´t relieved by a change in position.

2  Contractions become progressively more frequent and painful and generally (but not always) more regular. However, not every contraction will necessarily be more painful or longer (they usually last about thirty to seventy seconds) than the previous one, but the intensity does build up as real labour progresses. Nor does frequency always increase in regular, perfectly even intervals- but it does increase.

3  Contractions may feel like gastrointestinal upset and be accompanied by diarrhoea. Early labour contractions can also feel like heavy menstrual cramps. Pain may be just in the lower abdomen or it may also radiate to the legs (particularly the upper thighs). Location, however, is not as reliable an indication, because false labour contractions may also be felt in these places.

4  Show is present and pinkish or bloody-streaked

5  Membranes rupture, though in 15 percent of labours, the waters break. In a gush or a trickle- before labour begins and in many others, membranes do not rupture spontaneously and are ruptured artificially by the practitioner.  


CONCERNS & RECOMMENDATIONS

DARKENED AMNIOTIC FLUID (MECONIUM STAINING). The amniotic fluid of a pregnant woman may be probably stained with meconium, a greenish brown substance that comes from the baby´s digestive tract. Ordinarily meconium is passed after birth as the baby´s first stool. Sometimes – particularly when the fetus has been under stress in the womb and very often when it has passed it´s due date- the meconium is passed prior to birth into the amniotic fluid.

The practitioner should be notified immediately as it could also indicate an increased risk of infection around the time of delivery and should the patient should be watched more carefully.

 
INADEQUATE AMNIOTIC FLUID. Usually the mother´s nature keeps the uterus well stocked with a self-replenishing supply of amniotic fluid.

However, when levels run low during labour, the natural source should be supplemented with a saline (salt) solution pumped directly into the amniotic sac through a catheter into the uterus. This procedure is called amnioinfusion, may also be used when there is moderate or very thick meconium staining the amniotic fluid. This procedure can also significantly reduce the possibility of surgical delivery.
 

RUPTURE OF MEMBRANES. Normally most women whose membranes rupture expect to feel that first contraction within twelve hours; most others within twenty-four hours. So it´s likely that labour is on the way- and soon.

However, in some it takes a little longer to get going. In such situations as the risk of infection to baby and/ or mother through the ruptured amniotic sac increases, it is recommended by most physicians to induce labour within twenty- four hours of a rupture if a woman is at o near her due date.

The first thing one should do after experiencing a flow of fluid from her vagina( besides grab a towel and pads) is to call the attention of her doctor o nurse-midwife. In the meantime, the vaginal area should be kept clean to avoid infection. No sexual intercourse and always wipe from front to back after usin the toilet.

 
LABOUR INDUCTION. There are variety of medical situations in which it is probably wise-or even necessary- to deliver a baby before nature appears ready, willing and able to do so. In some cases caesarean section is the best way to accomplish this. In other cases, when there´s no immediate risk to baby (due to distress, for instance), both baby and mother are deemed able to tolerate labour and the practitioner may have a reason to believe that a vaginal delivery is possible, induction is usually the first choice. For example:

1 When fetus isn´t thriving- because of inadequate nourishment, postmaturity (being in the uterus ten days to two weeks beyond the estimated due date), low levels of amniotic fluid, or any reason- and is mature enough to do well outside the uterus.

2 When tests suggest that the placenta is no longer functioning optimally and the uterus is no longer a healthy home for the fetus.

3 When the membranes rupture ina term pregnancy and labour doesn´t begin within twenty-four hours thereafter (though some practitioners will induce much sooner)

4 When the amniotic fluid is infected.

5 When a pregnancy has gone two or more weeks past a due date that is considered accurate.

6 When the mother has diabetes and the placenta is deteriorating prematurely, or when it´s feared will be very large- and thus difficult to deliver-if carried to full term.

7 When the mother has preeclampsia (toxaemia) that cannot be controlled with bed rest and medication and delivery is necessary for her sake and/or her baby´s.

8 When the mother has a chronic or acute illness, such as high blood pressure or kidney disease, that threatens her well-being or that of her baby if the pregnancy continues.

9 When the fetus is afflicted with severe Rh disease that necessitates early delivery.

The first and most important step in ensuring a successful induction is ripening the cervix- making it soft and ready for labour. Ripening the cervix is usually accomplished by administering a hormonal substance such as prostaglandin E-2 in the form of vaginal gel (or a vaginal suppository in tablet form).

The next step some practitioners take is to artificially rupture the membrane (the ´´ bag of waters, ´´ also known as the amniotic sac) that surround the fetus.

Sometimes a woman goes into labour on her own, but for one reason or another, her contraction are either not effectively dilating the cervix or are too sluggish for labour to progress as it should. Often the physician will administer oxytocin to stimulate stronger and more effective contractions that will get the labour back on track.


LABOUR POSITIONS. The best labour position is the one that´s best for the patient. With the exception of lying flat on your back- which cannot only slow down labour but also compress major blood vessels, possibly interfering with blood flow to the fetus- almost any position or combination of positions can end up working well. Particular efficient are upright positions that employ the forces of gravity, speeding dilation and baby´s descent; studies show that they can actually shorten labour. These include standing, sitting (in bed, in the escorts arms), squatting or half kneeling, half squatting (on the floor or on the bed).

 

CONCLUSION

It is understood that labour coincides with delivery, hence i deem it important to elaborate on the stages and phases of childbirth.

Childbirth is divided (more loosely by nature, more formally by obstetrical science) into three stages. The first stage is labour, divided into three phases. Early (or latent), active and transitional, ending with full dilation (opening) of the cervix; the second stage is delivery, culminating in the birth of the baby and the third stage is the delivery of the placenta, or afterbirth.

The whole process averages about fourteen hours for first-time mothers, about eight hours for women who have already had children-but the range is enormous, from a few hours to a few days.

Unless labour is cut short by the need for a caesarean, all women who carry to term go through all three phases of the first stage. Some, however, may not recognize that they are in labour until the second, or even the third phase, because their initial contractions are mild or painless. The third phase is complete once the cervix has dilated to a full 10 centimetres.

If labour doesn´t seem to be progressing along the typical course, some doctors will augment mother nature´s efforts by administering oxytocin and if that fails, will pre-empt her entirely with a caesarean. Others may allow more time before taking such action, as long as both mother and baby are doing well.

An episiotomy, which is a minor surgical procedure (during which an incision is made in the perineum to enlarge the vaginal opening just before the emergence of the baby´s head) may be indicated when a baby is large and needs a roomier exit route. When forceps or vacuum delivery need to be performed, or for the relief of shoulder dystocia (in which a shoulder gets stuck in the birth canal during delivery).

There are two basic types of episiotomy: the median and the mediolatera . the median incision, is made directly back toward the rectum. In spite of its advantages (it´s provides more exit space per inch of incision, heals well and is easier to repair, causes less blood loss and results in less postpartum discomfort or infection), it is less frequently practiced because it has a greater risk of tearing completely through the rectum. To avoid this tearing, most gynaecologists prefer the mediolateral incision, which slants away from the rectum, especially in first births.

To reduce the possibility of an episiotomy and to ease delivery without one, it´s a good idea for the pregnant woman to do kegel exercises and perineal massage for six to eight weeks before her due date.

After a successful delivery, the first test done on the baby is the Apgar score. This is to enable medical personnel to quickly evaluate the condition of a newborn. At one minute after birth, a nurse or doctor checks the infants: Appearance (colour), Pulse (heartbeat), Grimace (reflex), Activity (muscle tone) and Respiration. Hence the acronym ´´APGAR.´´ Babies who score above 6 are fine. Those who score between 4 and 6 often need resuscitation, which generally includes suctioning their airways and administering oxygen. Those who score under 4 require more dramatic lifesaving techniques.

The APGAR test is administered once again at five minutes after birth. If thescore is 7 or better at this point, the outlook for the infant is very good. It it´s lower, it means the baby need some careful watching, but still is very likely to turn out fine.

Other test like taking the babies weight should also be performed on the newborn.