Page 57 - 33Elctronic Book (3) Normal Labor

Close observation is important for both the woman and fetus. The nurse should

observe the following:
• Reaction of the woman to labor.
• Vaginal discharge, show, amniotic fluid, and meconium.

• Progress of labor through descent of head and cervical dilatation.
• Uterine action: The frequency, duration and intensity of uterine contractions

.)

should be checked and recorded every 30 minutes. See table (
Interval minutes 30 minutes 20 - 15 minutes 2 - 3
Duration seconds 35 - 25 seconds 45 - 35 sseconds 70 - 60

Intensity Mild Moderate Strong

▪ Maternal condition:

o Temperature is checked and recorded every 4 hours.
o Respiration, pulse, and BP are checked and recorded every hour.
Signs of maternal distress:

• Increased pulse rates over 100 b/min.
• Elevated temperature, more than 37.5°C.

• Decreased blood pressure.
• Sweating and pale face.
• Signs of dehydration.

• Dark vomitus.
• Ketone bodies in urine.

• Irritability and restlessness.
• Anxious expression

.
▪
▪ Fetal condition:

Monitor and record fetal heart rate to recognize fetal distress or abnormalities. It should
be heard every 4 hours until rupture of membranes, then every 30 minutes.
Signs of fetal distress:
▪ Excessive fetal movement.

▪ Excessive molding of fetal head.
▪ Excessive formation of caput succedaneum.

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