Medical and health personnel network organized on the nurse qualification examination preparation: labor nursing.
I. Observation and care of women in the first stage of labor
(a) Clinical manifestations
1. Regular contractions: at the beginning of labor, the duration of contractions is shorter (about 30 seconds), with longer intervals (5 to 6 minutes). As labor progresses, the duration of contractions is prolonged (50-60 seconds) and their intensity increases, and the intervals are gradually shortened (2-3 minutes). When the uterine opening is nearly complete, the duration of contractions can be as long as 1 minute or more, with intervals of only 1 minute or slightly longer.
2, cervical dilatation: the first stage of labor is subdivided into latent and active periods. The latent period is defined as the period from the onset of labor to the uterine dilatation of the mouth of the uterus 3cm, which takes about 8 hours, more than 16 hours is called the latent period prolongation. The active period is from the cervix dilated 3cm to the mouth of the uterus opened 10cm. about 4 hours, more than 8 hours is called the active period prolonged.
3, the degree of descent of the fetal head: is an important observation to determine whether the vaginal delivery.
4, rupture of membranes: when the pressure in the amniotic cavity increases to a certain degree, the membranes will rupture naturally, called rupture of membranes. Rupture of membranes occurs when the uterine opening is nearly full.
(B) Nursing measures
1, to be admitted to the hospital after labor, when special circumstances occur, such as premature rupture of membranes, vaginal bleeding, etc., should be admitted to the hospital urgently. The environment should be quiet, with appropriate temperature and humidity. Strengthen communication and eliminate the tension of the expectant mother. Detect vital signs and fetal monitoring. If contractions are not strong and membranes have not been broken, walking around the room may help speed up the progress of labor. Immediately after rupture of membranes, lie in bed, listen to the fetal heartbeat, and record the time of rupture of membranes, amniotic fluid volume and character. Encourage the expectant mother to eat small amounts of food, high calorie, easy to digest food, to ensure energy and stamina. Prevent urinary retention.
2, labor care Listen to the fetal heartbeat: available fetal heart stethoscope or fetal monitor, every 0.5 ~ 1 hour, the normal fetal heart rate of 120 ~ 160 times / min. Observe uterine contractions. Perform anal examination during contractions. If there is abnormal vaginal bleeding or placenta praevia is suspected, anal examination should be prohibited to avoid inducing bleeding. If the uterine opening is full to 10cm in primiparous women and 3-4cm in experienced women with good contractions, they should be escorted to the delivery room to prepare for delivery.
The observation and care of women in the second stage of labor
(a) Clinical manifestations
The contractions lasted for a long time, with short intervals. After the opening of the uterus, the woman to be born has a sense of defecation, contractions involuntarily downward breath holding force, physical exertion is very large, often manifested in profuse sweating, limbs at random, lumbosacral pain, calf muscle spasm. As labor progresses, the perineum gradually swells and thins, and the anus relaxes. The head of the fetus is exposed to the vaginal opening during contractions and retracts back into the vagina when contractions are intermittent, which is called fetal head pulling out. If the head of the fetus is no longer retracted between contractions, it is called the head of the fetus on the crown.
(2) auxiliary examination: fetal heart rate monitoring with a fetal monitor can be found in time to deal with abnormalities.
(C) Nursing measures
1, delivery room preparation: with the mother and baby's rescue equipment and medicines.
2. Instruct the expectant mother in the correct use of abdominal pressure: the general condition of the expectant mother should be closely observed, blood pressure should be measured, and the fetal heart should be listened to diligently, once every 5 to 10 minutes. Instructing the mother to hold her breath and exert herself during contractions to increase abdominal pressure and deliver the fetus is the primary nursing goal of the second stage of labor. The expectant mother usually takes a semi-sitting position, in the contraction interval, the expectant mother should try to relax, quiet rest.
3, fetal monitoring: the conditions can use fetal heart monitor.
4, disinfection of the vulva: first wash away the blood and mucus of the vulva with warm water, and then carry out two times of vulvar cleansing and one disinfection.
5, delivery preparation: open the delivery bag, ready sterile saline, newborn suction device.
6, fetal head delivery: perineum is too tight or the fetal head is too large, it is estimated that the delivery of perineal tear is unavoidable, episiotomy should be performed.
7, umbilical cord treatment: after wiping around the umbilical root with sterile gauze, sterilize the umbilical cord with 2.5% iodine and 75% ethanol, and then ligate the umbilical cord. Use 20% potassium permanganate or 3% iodine to evenly rub the broken end of the umbilical cord.
3. Observation and care of women in the third stage of labor
(a) Clinical manifestations
1. Placental detachment: The volume of the uterine cavity suddenly and markedly decreases after the delivery of the fetus, and the placenta and the uterine wall are dislocated and detached and discharged. Placental abruption signs: the uterine body hardens into a spherical shape, the uterine floor rises up to the umbilicus; the vagina suddenly bleeds a lot of blood; the vaginal opening of the exposed section of the umbilical cord prolongs by itself; with the ulnar side of the palm of the hand in the maternal pubic symphysis above the lower part of the uterus, the uterine body rises up and the umbilical cord is no longer retracted exposed.
2, after the delivery of the fetus, the bottom of the uterus descends to the flat umbilicus, contractions are suspended, and then reappear after a few minutes.
(2) Nursing measures:
1, to assist the delivery of the placenta: when it is determined that the placenta is completely detached, the left hand should be used to hold the bottom of the uterus to gently press the uterus during the contraction, and the mother to exert a little downward force, at the same time, the right hand gently pulling the umbilical cord, to assist in the delivery of the placenta. After the placenta is delivered, massage the uterus to reduce bleeding.
2, check the placenta, fetal membranes: if found to have residual, should be aseptically hand into the uterine cavity to remove the residual tissue.
3. Check the soft birth canal: if there is any laceration, it should be sutured immediately.
4, to prevent postpartum hemorrhage: after the delivery of the fetus, follow the doctor's instructions for the use of oxytocin.
5, immediate care of the newborn: after the delivery of the newborn, the Apgar score is used to determine whether the newborn is asphyxiated and the degree of asphyxia. The Apgar score is based on five signs: heart rate, respiration, muscle tone, laryngeal reflexes and skin color in the first minute after birth, with 0 to 2 points for each, and 10 points out of 10. 8 to 10 points are for normal newborns, 4 to 7 points are for mild asphyxia, and 0 to 3 points are for severe asphyxia. Neonatal warming: Newborns should be wiped on a baby radiation warming table after birth. Early Breast Opening: Within 1 hour of birth, if the newborn is not abnormal, place the newborn naked on the mother's chest for skin-to-skin contact for 30 minutes. By sucking on the mother's breast, the newborn can promote early breast milk secretion and prevent postpartum hemorrhage. Eye care: After birth, eye drops are applied to both eyes to prevent infection of the newborn's eyes as he or she passes through the birth canal. Newborns are measured for weight and length, a wrist strip with the mother's name and hospitalization number is tied around the right wrist, and the baby's right sole and mother's thumbprint are printed on the baby's chart.
6. Immediate postpartum care: continue to be observed in the delivery room for 2 hours after delivery. Uterine contractions, uterine fundus height, bladder fullness, vaginal bleeding, perineum, vagina with or without hematoma should be observed. Measure blood pressure and pulse every 15 to 30 minutes, and ask the mother if she has dizziness and fatigue.
Examples
1. Uterine contractions begin at the horns of the uterus on both sides, rapidly converge toward the midline of the uterine fundus, then spread to the lower uterine segments, and spread evenly and harmoniously throughout the uterus. This characteristic is called the ( )
A. Polarity
B. Rhythmicity
C. Symmetry
D. Retraction
E. Intermittency
Answer C
A. In the process of delivery of the fetus, the pressure in the cavity can be increased to a maximum of 7.33 kPa during contraction. The pressure in the cavity peaks during contractions and then gradually decreases to a baseline level, after which a second contraction begins after an interval. This regular, rhythmic contraction until the end of labor is the regularity of uterine contractions. During labor, the uterine contractions start from the two official horns, conduct first to the midline of the uterus, and then gradually conduct downward, which is the symmetry of uterine contractions. The contraction of the uterine fundus is stronger and longer than the contraction of the lower segment, the muscles of the uterine fundus contract and retract and gradually thicken, and the lower segment stretches and expands and thins to form the birth canal. This is the polarity of uterine contraction. Only uterine contractions with these three characteristics can be effective contractions.
2. In the second stage of labor, the contraction that assists in the completion of internal rotation and extension of the fetal antrum in the pelvic cavity is ( )
A. Uterine contractility
B. Abdominal contractility
C. Diaphragmatic contractility
D. Anorectal contractility
E. Pelvic floor contraction
Answer D
The contraction of the anus and the anus are the most important factors in the development of the uterus. p>
The contraction of the anorectal muscles has three roles: to assist in the internal rotation of the exposed part of the fetus in the pelvic cavity; to assist in the supination and delivery of the fetus when the occipital part of the fetal head is exposed under the pubic arch; and to assist in the delivery of the placenta by the contraction of the anorectal muscles.
3. Mothers sent to the delivery room to prepare for the delivery of the correct indications ( )
A. primiparous women, transient women with regular contractions
B. primiparous women with the uterus open to 3-4 cm, transient women with the uterus open 10 cm and good contractions
C. primiparous women with the uterus open to 3-4 cm, transient women with the uterus open 3-4 cm and contractions
D. primiparous women with the uterus open to 3-4 cm, transient women with the uterus open 3-4 cm and good contractions
D. primiparous women with the uterus open to 4 cm. p>
D. The uterus is open to 10 cm in primiparous women and 10 cm in transient women with good contractions
E. The uterus is open to 10 cm in primiparous women and 3-4 cm in transient women with good contractions
Answer E
The indications of preparedness to deliver a newborn are an opening of the uterus of primiparous women of up to 10 cm, and an opening of the uterus of transient women of 3-4 cm with good contractions.