Which is the initial nursing action when a multipara requests something for pain

Rupture of the chorioamniotic membranes or bloody show is diagnostic for onset of labor.

Bloody show [a small amount of blood with mucous discharge from the cervix] may precede onset of labor by as much as 72 hours. Bloody show can be differentiated from abnormal 3rd-trimester vaginal bleeding Vaginal Bleeding During Late Pregnancy Bleeding during late pregnancy [≥ 20 weeks gestation, but before birth] occurs in 3 to 4% of pregnancies. Some disorders can cause substantial blood loss, occasionally enough to cause hemorrhagic... read more because the amount is small, bloody show is typically mixed with mucus, and the pain due to abruptio placentae Placental Abruption [Abruptio Placentae] Placental abruption [abruptio placentae] is premature separation of the placenta from the uterus, usually after 20 weeks gestation. It can be an obstetric emergency. Manifestations may include... read more [premature separation] is absent. In most pregnant women, previous routine ultrasonography has been done and ruled out placenta previa Placenta Previa Placenta previa is implantation of the placenta over or near the internal os of the cervix. It typically manifests as painless vaginal bleeding after 20 weeks gestation; the source of bleeding... read more . However, if ultrasonography has not ruled out placenta previa and vaginal bleeding occurs, placenta previa is assumed to be present until it is ruled out. In such cases, digital vaginal examination is contraindicated, and ultrasonography is done as soon as possible to determine the location of the placenta and rule out abruptio placentae.

Labor begins with irregular uterine contractions of varying intensity; they apparently soften [ripen] the cervix, which begins to efface and dilate. As labor progresses, contractions increase in duration, intensity, and frequency.

There are 3 stages of labor.

The 1st stage—from onset of labor to full dilation of the cervix [about 10 cm]—has 2 phases, latent and active.

During the latent phase, irregular contractions become progressively coordinated, discomfort is minimal, and the cervix effaces and dilates to 4 cm. The latent phase is difficult to time precisely, and duration varies, averaging 8 hours in nulliparas and 5 hours in multiparas; duration is considered abnormal if it lasts > 20 hours in nulliparas or > 12 hours in multiparas.

If the membranes have not spontaneously ruptured, some clinicians use amniotomy [artificial rupture of membranes] routinely during the active phase. As a result, labor may progress more rapidly, and meconium-stained amniotic fluid may be detected earlier. Amniotomy during this stage may be necessary for specific indications, such as facilitating internal fetal monitoring to confirm fetal well-being. Amniotomy should be avoided in women with HIV infection or hepatitis B or C, so that the fetus is not exposed to these organisms.

The 2nd stage is the time from full cervical dilation to delivery of the fetus. On average, it lasts 2 hours in nulliparas [median 50 minutes] and 1 hour in multiparas [median 20 minutes]. It may last another hour or more if conduction [epidural] analgesia or intense opioid sedation is used. For spontaneous delivery, women must supplement uterine contractions by expulsively bearing down. In the 2nd stage, women should be attended constantly, and fetal heart sounds should be checked continuously or after every contraction. Contractions may be monitored by palpation or electronically.

The 3rd stage of labor begins after delivery of the infant and ends with delivery of the placenta. This stage usually lasts only a few minutes but may last up to 30 minutes.

• 1. Lawrence A, Lewis L, Hofmeyr GJ, Styles C: Maternal positions and mobility during first stage labour. Cochrane Database Syst Rev [8]:CD003934, 2013. doi: 10.1002/14651858.CD003934.pub3

• 2. Aasheim V, et al: Perineal techniques during the second stage of labour for reducing perineal trauma. Cochrane Database Syst Rev 6:CD006672, 2017. doi: 10.1002/14651858.CD006672.pub3

• 3. Gupta JK, Sood A, Hofmeyr GJ, et al: Position in the second stage of labour for women without epidural anaesthesia. Cochrane Database Syst Rev 5:CD002006, 2017. doi: 10.1002/14651858.CD002006.pub4

• 4. Lemos A, Amorim MM, Dornelas de Andrade A, et al: Pushing/bearing down methods for the second stage of labour. Cochrane Database Syst Rev. 3:CD009124, 2017. doi: 10.1002/14651858.CD009124.pub3

Further confirmation is not needed if during examination, fluid is seen leaking from the cervix. Confirmation of more subtle cases may require testing. For example, the pH of vaginal fluid may be tested with Nitrazine paper, which turns deep blue at a pH > 6.5 [pH of amniotic fluid: 7.0 to 7.6]; false-positive results can occur if vaginal fluid contains blood or semen or if certain infections are present. A sample of the secretions from the posterior vaginal fornix or cervix may be obtained, placed on a slide, air dried, and viewed microscopically for ferning. Ferning [crystallization of sodium chloride in a palm leaf pattern in amniotic fluid] usually confirms rupture of membranes.

If rupture is still unconfirmed, ultrasonography showing oligohydramnios [deficient amniotic fluid] provides further evidence suggesting rupture. Rarely, amniocentesis with instillation of dye is done to confirm rupture; dye detected in the vagina or on a tampon confirms rupture.

When a woman’s membranes rupture, she should contact her physician immediately. About 80 to 90% of women with PROM at term [ ≥ 37 weeks] and about 50% of women with preterm PROM [< 37 weeks] go into labor spontaneously within 24 hours; > 90% of women with PROM go into labor within 2 weeks. The earlier the membranes rupture before 37 weeks, the longer the delay between rupture and labor onset. If membranes rupture at term but labor does not start within several hours, labor is typically induced to lower risk of maternal and fetal infection.

Most women prefer hospital delivery, and most health care practitioners recommend it because unexpected maternal and fetal complications may occur during labor and delivery or postpartum, even in women without risk factors. About 30% of hospital deliveries involve an obstetric complication Introduction to Abnormalities and Complications of Labor and Delivery Abnormalities and complications of labor and delivery should be diagnosed and managed as early as possible. Most of the following complications are evident before onset of labor: Multifetal... read more [eg, laceration, postpartum hemorrhage Postpartum Hemorrhage Postpartum hemorrhage is blood loss of > 1000 mL or blood loss accompanied by symptoms or signs of hypovolemia within 24 hours of birth. Diagnosis is clinical. Treatment depends on etiology... read more ]. Other complications include abruptio placentae Placental Abruption [Abruptio Placentae] Placental abruption [abruptio placentae] is premature separation of the placenta from the uterus, usually after 20 weeks gestation. It can be an obstetric emergency. Manifestations may include... read more , abnormal fetal heart rate pattern, shoulder dystocia Fetal Dystocia Fetal dystocia is abnormal fetal size or position resulting in difficult delivery. Diagnosis is by examination, ultrasonography, or response to augmentation of labor. Treatment is with physical... read more , need for emergency cesarean delivery Cesarean Delivery Cesarean delivery is surgical delivery by incision into the uterus. Up to 30% of deliveries in the US are cesarean. The rate of cesarean delivery fluctuates. It has recently increased, partly... read more , and neonatal depression or abnormality.

Nonetheless, many women want a more homelike environment for delivery; in response, some hospitals provide birthing facilities with fewer formalities and rigid regulations but with emergency equipment and personnel available. Birthing centers may be freestanding or located in hospitals; care at either site is similar or identical. In some hospitals, certified nurse-midwives provide much of the care for low-risk pregnancies. Midwives work with a physician, who is continuously available for consultation and operative deliveries [eg, by forceps, vacuum extractor, or cesarean]. All birthing options should be discussed.

For many women, presence of the their partner or another support person during labor is helpful and should be encouraged. Moral support, encouragement, and expressions of affection decrease anxiety and make labor less frightening and unpleasant. Childbirth education classes can prepare parents for a normal or complicated labor and delivery. Sharing the stresses of labor and the sight and sound of their own child tends to create strong bonds between the parents and between parents and child.

The parents should be fully informed of any complications.

Typically, pregnant women are advised to go to the hospital if they believe their membranes have ruptured or if they are experiencing contractions lasting at least 30 seconds and occurring regularly at intervals of about 6 minutes or less. Within an hour after presentation at a hospital, whether a woman is in labor can usually be determined based on the following:

• Occurrence of regular and sustained painful uterine contractions

• Bloody show

• Membrane rupture

• Complete cervical effacement

If these criteria are not met, false labor may be tentatively diagnosed, and the pregnant woman is typically observed for a time and, if labor does not begin within several hours, is sent home.

When pregnant women are admitted, their blood pressure, heart and respiratory rates, temperature, and weight are recorded, and presence or absence of edema is noted. A urine specimen is collected for protein and glucose analysis, and blood is drawn for a complete blood count [CBC], blood typing, and antibody screening. If routine laboratory tests were not done during prenatal visits, they should be done; these tests include screening for HIV, hepatitis B, syphilis, and group B streptococcal infection.

A physical examination is done. While examining the abdomen, the clinician estimates size, position, and presentation of the fetus, using the Leopold maneuver [see figure Leopold maneuver Leopold maneuver

A helpful mnemonic device for evaluation is the 3 Ps:

• Powers [contraction strength, frequency, and duration]

• Passage [pelvic measurements]

• Passenger [eg, fetal size, position, heart rate pattern]

Leopold maneuver

[A] The uterine fundus is palpated to determine which fetal part occupies the fundus. [B] Each side of the maternal abdomen is palpated to determine which side is fetal spine and which is the extremities. [C] The area above the symphysis pubis is palpated to locate the fetal presenting part and thus determine how far the fetus has descended and whether the fetus is engaged. [D] One hand applies pressure on the fundus while the index finger and thumb of the other hand palpate the presenting part to confirm presentation and engagement.

If labor is active and the pregnancy is at term, a clinician examines the vagina with 2 fingers of a gloved hand to evaluate progress of labor. If bleeding [particularly if heavy] is present, the examination is delayed until placental location is confirmed by ultrasonography. If bleeding results from placenta previa, vaginal examination can initiate severe hemorrhage.

If labor is not active but membranes are ruptured, a speculum examination is done initially to document cervical dilation and effacement and to estimate station [location of the presenting part]; however, digital examinations are delayed until the active phase of labor or problems [eg, decreased fetal heart sounds] occur. If the membranes have ruptured, any fetal meconium [producing greenish-brown discoloration] should be noted because it may be a sign of fetal stress. If labor is preterm [