Page 211 - ترم ثاني كتاب تمريض صحة الام الكتروني

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• Membranes rupture.
• Perineum starts to bulge and the anal orifice starts to dilate.

• Woman starts involuntary bearing down and feels the desire to defecate.
• She may be eager to sleep.

• She is apprehensive, irritable, unwilling to be touched, and may cry if
disturbed.
• She is frustrated, and unable to manage labor alone.

Nursing Diagnosis
• Pain related to descent of the fetus and stretching of vagina

and perineum.
• Fatigue related to inability to rest and pushing efforts.
• Anxiety related to unknown outcome of labor process.

• High risk of infection

Planning and Implementation
▪ Transfer to delivery room:

o Primigravida is transferred to the delivery room when the cervix is fully
dilated and the presenting part is seen.

o Multipara is transferred when the cervix is 7-8 cm (3-4 fingers).
▪ Posture of woman in labor:
The woman lies on the delivery table in one of the following positions:
▪ Dorsal or lithotomy position:

Woman lies on her back and puts her legs up into the stirrups or leg hold. he
T

advantages of this position are:
rd
✓ Change of position is not needed to check FHS and to conduct the 3 stage
of labor.
✓ Draping woman and preserving aseptic techniques are easy.
▪ Left lateral position:

Woman lies on left side, her thighs are partly flexed and another person holds

:
her knees apart. The advantages of this posi tion are
✓ Decrease liability for perineal laceration.
.
✓ Easy removal of feces

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