CRITICAL PATHWAY for Intrapartal Stages - cont'd
Category	First Stage	Second and Third Stage	Fourth Stage Birth to 1 Hour Past Birth
Assessments	Uterine contractions q15-30min: contractions q2min, 60-75 sec, strong FHR q30min (for low-risk women) and q15min (for high-risk women) if reassuring; if nonreassuring, see above
Teaching/ psychosocial	Establish rapport Orient to environment, expected assessments, and procedures Answer questions and provide informa- Orient to EFM if used Teach relaxation, visualization, and breathing pattern if needed Explain comfort measures available Assume advocacy role for woman/ family during labor and birth	Orient to expected assessments and procedures Answer questions and provide information Explain comfort measures available Continue advocacy role	Explain immediate assessments and care after this first hour Teach self-massage of fundus and expected findings Instruct to call for assistance if mother desires to get OOB Begin newborn teaching; bulb syringe, positioning; maintaining warmth Assist parents in exploring their new- Assist with first breastfeeding experience Expected Outcomes: Client and partner verbalize/demonstrate understanding of teaching
Nursing care management and report	Straight cath prn if bladder distended If regional block administered monitor BP, FHR, sensation per protocol Provide continuing status reports to CNM/physician Perineal clip per woman’s request Small enema per woman’s request Perform sterile vaginal examination as indicated	Straight cath prn if bladder distended Continue monitoring VS, FHR and sensation if regional block has been given	Straight cath if bladder distended Monitor return of motor ability and sensation if regional block has been Weigh perineal pads if lochia flow > 1 saturated pad in 15 min, presence of boggy uterus and clots; low BP increased P Expected Outcomes: Maternal/fetal well-being maintained and supported Mother and newborn experience safe labor and birth Family participates in process as desired.
Activity	Encourage ambulation unless contraindicated Maintain bed rest immediately after administration of IV pain medication, or following regional block Woman rests comfortably between contractions	Position comfortably for birth Woman rests comfortably between pushing efforts and while awaiting birth of placenta	Position of comfort Expected Outcomes: Activity maintained as desired unless contraindicated Comfort enhanced by positioning/ movement
Comfort	Institute comfort measures: ambulation, frequent position change, effleurage, focal point, patterned paced breathing, visualization, therapeutic touch, back rub, moist cloths to face, holding hand, words of encouragement, changing underpad, shower, whirlpool, staying with the woman/family, warmed blanket at back, sacral pressure Offer pain medication or administer if requested Assist with administration of regional block	Institute comfort measures Second stage: cool cloth to forehead, encouragement, coaching, help support legs while pushing, position of comfort for pushing and birth Third stage: cool cloth to forehead, assist parents to see newborn, position mother to hold newborn, provide encouragement	Institute comfort measures: Perineal discomfort: gently cleanse and apply ice pack; position to decrease pressure on perineum Uterine discomfort: palpate tundus gently Hemorrhoids: ice pack General fatigue: position of comfort, encourage rest Administer pain medication Expected Outcomes: Optimal comfort level maintained Active reduction of pain/discomfort achieved