1.1 NURSING CARE DURING LABOR AND BIRTH

Guidelines for Reporting to a Birthing Facility

• Women should report to the hospital when contractions are regular, increase in frequency, duration, and intensity.
• First-time mothers should go to the hospital when contractions are five minutes apart for one hour.
• Mothers who have given birth before should go to the hospital sooner, when regular contractions are ten minutes apart for one hour.
• Mothers should report to the hospital when their membranes have ruptured.
• Mothers should report to the hospital for bright red vaginal bleeding.
• Mothers should report to the hospital if they experience decreased fetal movement.

Admission Assessments

• The nurse develops a therapeutic relationship with the patient and her family.
• The patient's written birth plan should be reviewed.
• The patient should be assessed for fetal condition, maternal condition, and impending birth.

Fetal Condition Assessment

• Fetal heart rate (FHR) is assessed with a fetoscope, Doppler transducer, or external fetal monitor (EFM).
• After membranes rupture, the color, amount, and odor of the fluid are assessed, and the FHR is recorded.

Maternal Condition Assessment

• The patient's temperature, pulse, respirations, and blood pressure are assessed for signs of infection or hypertension.

Impending Birth Assessment

• Signs of impending birth include sitting on one buttock, grunting sounds, bearing down with contractions, stating "The baby's coming," and bulging of the perineum.
• If the birth is imminent, the nurse should stay with the patient, call for help, and have gloves and an emergency delivery kit ready.

Additional Assessments

• The patient's reason for coming to the hospital, prenatal care, OB history, medical history, allergies, food intake, recent illnesses, medications, and home environment should be assessed.

Admission Procedures

• The patient should sign consent forms for care during labor, delivery, and post-birth period, including emergency Cesarean section.
• Blood for hematocrit (CBC) and a midstream urine specimen for glucose and protein are obtained.
• An intravenous (IV) line is established to administer fluids and drugs.
• The perineal area is cleansed in preparation for delivery.
• Fetal presentation and position are determined using Leopold maneuvers and a vaginal examination.

Distinguishing True Labor from False Labor

• True Labor
  • Contractions are regular, becoming more frequent, longer, and more intense.
  • Contractions become stronger with walking.
  • Discomfort begins in the lower back and gradually travels to the lower abdomen.
  • Progressive effacement and dilation of the cervix occur.
• False Labor
  • Contractions are irregular in frequency, duration, and intensity.
  • Walking tends to relieve or decrease contractions.
  • Discomfort is felt in the abdomen and groin.
  • There is no change in effacement or dilation of the cervix.

Fetal Monitoring

• The goal of fetal monitoring is to identify fetal hypoxia early to allow prompt interventions.

Intermittent Auscultation

• Intermittent auscultation allows for greater freedom of movement.
• The FHR is assessed with a fetoscope or Doppler transducer.
• Accurate and complete documentation of the FHR is required.

Continuous Electronic Fetal Monitoring (EFM)

• EFM allows the nurse to collect more data about the fetus because the FHR and contractions are continuously recorded.
• EFM can be done external or internal.
• External EFM is done with a Doppler transducer and tocotransducer.

Evaluating Fetal Heart Rate Patterns

• The FHR is evaluated for baseline rate, baseline variability, episodic changes, and periodic changes.
• Baseline Fetal Heart Rate
  • The average heart rate that occurs for at least 2 minutes during a 10-minute period.
  • The baseline should be 110-160 beats per minute (BPM) for a 2-minute period.
• Fetal Bradycardia
  • An FHR less than 110 BPM for 10 minutes or longer.
  • Causes include fetal hypoxia, maternal hypoglycemia, maternal hypotension, and profound cord compression.
• Fetal Tachycardia
  • An FHR greater than 160 BPM that lasts 2-10 minutes or longer.
  • Causes include maternal fever and dehydration.
• Baseline Variability
  • The fluctuation or constant baseline in a 10-minute window.
  • A reflection of an intact CNS and cardiac status of the fetus.
  • Moderate Variability: Change of 6-25 beats per minute from the baseline FHR.
  • Marked Variability: Change of more than 25 beats of fluctuation over the FHR.
  • Absent Variability: Less than 6 beats per minute change from baseline.
• Episodic Changes: Changes in the FHR that are not associated with uterine contractions.
• Periodic Changes: Temporary changes in the baseline rate associated with uterine contractions.
• Accelerations: Temporary, abrupt rate increase of at least 15 beats per minute above baseline FHR.
• Early Decelerations: Temporary, gradual rate decreases during contractions no more than 40 beats per minute below baseline.
• Variable Decelerations: Abrupt decreases of 15 beats per minute below baseline, lasting 15-20 seconds.
• Late Decelerations: Similar to early decelerations but begin after the beginning of the contraction and return to baseline after the end of the contraction.
• Prolonged Decelerations: Abrupt FHR decreases of at least 15 beats per minute below baseline that last longer than 60 seconds.

Nursing Response to Fetal Monitoring Patterns

• The significance of nursing response depends on the category of Fetal Heart Rate Tracing (I, II, or III).
• Reassuring Patterns: Accelerations and early decelerations.
• Variable Decelerations: Changing the mother's position may relieve pressure on the umbilical cord.
• FHR monitoring is used to identify complications that may cause interruption in fetal oxygen supply.
• Corrective Actions: Implementing position changes, administering oxygen, administering IV fluids, correcting hypotension, decreasing uterine activity, implementing amnioinfusion, and altering pushing and breathing techniques.
• If corrective actions fail, the focus shifts to expediting the delivery of the fetus.

Inspection of Amniotic Fluid

• The color, odor, and amount of fluid are documented.
• Normal Amniotic Fluid: Clear, possibly with flecks of vernix.
• Green-Stained Fluid: May indicate the fetus has passed meconium before birth.
• Cloudy or Yellow Amniotic Fluid: May indicate an infection.
• Assess FHR for a full minute after the membranes rupture.

Monitoring the Woman

• Intrapartum care of the woman includes assessing vital signs, contractions, progress of labor, intake and output, and responses to labor.

Vital Signs

• Vital signs are checked every 4 hours, then every 2 hours if elevated or if ruptured membranes are present.
• A temperature of 100.4 degrees Fahrenheit or greater should be reported.
• Maternal hypotension is a systolic pressure less than 90 mmHg. Maternal hypertension is a BP greater than 140/90 mmHg.
• Maternal hypotension or hypertension can reduce blood flow to the placenta.

Contractions

• Contractions are assessed by palpation or continuous EFM.
• Normal contractions are fewer than 5 in a 10-minute period for 30 minutes.

Progress of Labor

• The dilation and effacement of the cervix are determined by vaginal examination.
• The descent of the fetus is determined in relation to the ischial spines (station).
• Watch for physical and behavioral changes associated with labor progression.

Intake and Output

• Record the time and approximate amount of each urination.
• Monitor for a full bladder.
• Encourage ice chips, popsicles, or hard sugarless lollipops to keep the mouth moist.
• Do not allow food during active labor.

Response to Labor

• Assess the woman's use of breathing and relaxation techniques and support her adaptive responses.

Labor Support

• Control the environment by playing familiar music.
• Maintain an upright position during labor to shorten the first stage of labor.
• Regular changes in position make the laboring woman more comfortable and promote the normal processes of labor.

Teaching

• If measures learned in childbirth classes are inadequate, try different positions or breathing techniques.
• A woman should try new techniques for 2-3 contractions before abandoning them.

Labor & Pain

• Childbirth pain is a normal part of the process.
• It can motivate the woman to seek help and utilize different positions for optimal fetal descent.
• Several factors influence pain perception and tolerance
  • Pain threshold is the least amount of sensation perceived as painful.
  • Pain tolerance is the amount of pain someone is willing to endure.
  • Pain threshold remains constant, but tolerance changes depending on circumstances.
  • The nurse's role is to modify factors to improve the woman's tolerance for pain.

Sources of Pain During Labor

• Dilation and stretching of the cervix
• Reduced uterine blood supply (ischemia)
• Fetal pressure on pelvic structures
• Stretching of the vagina and perineum

Factors Contributing to Labor Pain

• Physical Factors:
  • Central nervous system
    • The Gate Control Theory proposes that physical stimulation of nerve fibers interferes with pain transmission to the brain.
    • Endorphin levels rise during pregnancy and peak during labor. This explains why women often require less analgesia for comparable levels of pain.
• Maternal Condition:
  • Cervix: Prelabor changes that facilitate dilation and effacement determine cervical readiness. If the cervix hasn't undergone these changes, more contractions are needed.
  • Pelvis: The size and shape of the pelvis significantly influence fetal descent.
  • Labor Intensity: Short, intense labor often has more frequent, intense, and sudden contractions with less recovery time, leading to abrupt tissue stretching and limited pain management options.
  • Fatigue: Fatigue reduces pain tolerance and the ability to use coping skills.
• Fetal Presentation and Position:
  • Abnormal fetal presentation or position can cause uneven pressure on the cervix, resulting in less effective dilation and effacement, prolonging labor.
  • Posterior fetal occiput can cause persistent back pain and a longer labor process.
• Caregiver Interventions:
  • Invasive interventions can potentially add to labor pain:
    • Intravenous lines
    • Continuous fetal monitoring, especially if it restricts mobility.
    • Amniotomy
    • Frequent vaginal examinations.

Nonpharmacological Pain Management Techniques

• Relaxation:
  • Involves concentrating to reduce muscle tension.
  • Techniques include:
    • Adjusting the environment
    • Offering a warm shower or tub
    • Orienting the woman to the environment, procedures, and the normality of labor.
    • Educating the woman and her partner on recognizing tension and releasing it from specific areas.
  • Changing techniques regularly is encouraged, as consistent use of one technique can reduce its effectiveness.
• Skin Stimulation:
  • Effleurage: Stroking the abdomen or legs in a circular motion during contractions.
  • Sacral Pressure: Applying pressure against the lower back.
  • Thermal Stimulation:
    • Hydrotherapy (shower, tub)
    • Applying warmth (blankets, heat packs)
• Positioning:
  • Frequent position changes relieve muscle fatigue and strain, facilitating normal labor processes.
• Diversion and Distraction:
  • Involves mental stimulation to minimize the perception of pain.

Pain Management in Labor: Advantages and Limitations of Nonpharmacological Techniques

• Advantages:
  • Nonpharmacological techniques do not harm the mother or fetus.
  • Do not slow labor if pain control is adequate.
  • Carry no risk of allergy or adverse drug effects.
• Limitations:
  • For optimal results, these techniques should be practiced beforehand in preparation classes.

Nonpharmacological Pain Management Techniques

• Focal Point Technique: Closing eyes or focusing on a photo, object, or spot in the room during contractions to distract from pain.
• Imagery: Creating a tranquil mental environment by imagining a place of relaxation and peace.
• Music: Distraction from pain and blocking out disturbing sounds.
• Television and Electronic Devices: Providing background noise and distraction, often during early labor.
• Breathing Techniques: Most effective when practiced beforehand.
  • Slow-paced breathing: Inhaling and exhaling slowly, like during sleep, at the start of a contraction.
  • Modified-paced breathing: Rapid and shallow breathing during the contraction, returning to normal breathing at the end.
    • Caution: Potential for hyperventilation.
  • Patterned-paced breathing: Rapid breaths punctuated with an intermittent blow (pant-blow or "hee hoo" breathing).
    • Pant-Blow Pattern: Used when the urge to push is felt before the cervix is fully dilated.
• Second Stage Labor: After full dilation, pushing involves:
  • Cleansing breath, followed by a deep breath.
  • Pushing down while exhaling (open glottis pushing) to a count of 10.
  • Releasing the breath, taking another deep breath, and repeating the pushing process during each contraction.

Nursing Role in Nonpharmacological Techniques

• Assess the woman's and her partner’s prior knowledge and preparation.
• Provide guidance and education on simple techniques.
• Reduce environmental stimulation.
• Evaluate pain levels and the effectiveness of pain relief measures.

Pharmacologic Pain Management

• Pain reduction can help women be more active participants in birth, promoting relaxation and working with contractions.
• Pain in labor may cause a stress response, potentially leading to maternal and fetal acidosis.
• Two individuals are affected: The mother and her fetus. Any medication effects may directly or indirectly influence the fetus, possibly persisting after birth.
• Limitations:
  • Medications may slow labor if used too early.
  • Some medical complications and concurrent medications may limit safe pharmacological options.

Analgesics:

• Narcotic Analgesics:
  • Used in small, frequent doses.
  • Avoided if birth is expected within an hour to prevent fetal respiratory depression.
  • Common drugs include:
    • Meperidine (Demerol)
    • Fentanyl (Sublimaze)
    • Nalbuphine (Nubain)
• Narcotic Antagonist: Naloxone (Narcan)
  • Used to reverse respiratory depression, typically in the infant, caused by opioids.
  • Administered intravenously, through an endotracheal tube, or via the umbilical cord vein.
  • Potential for withdrawal in drug-dependent women.

Adjunctive Drugs:

• Benzodiazepines: Help relieve anxiety and nausea.
• Possible effects: Influence fetal heart rate variability and newborn thermoregulation.

Anesthetics:

• Regional Anesthesia:
  • Epidural Block: Provides pain relief during labor and delivery (vaginal or Cesarean).
    • Requires a large-bore needle to thread a catheter into the epidural space.
    • Complications: Maternal hypotension (managed with IV fluids), urinary retention, prolonged second stage of labor.
  • Subarachnoid (Spinal) Block: Single-shot injection providing a more profound block than the epidural, primarily used for C-sections.
    • Complications: Maternal hypotension, urinary retention, postspinal headache (managed with bed rest, analgesics, fluids, and blood patch).
  • Local Block: Anesthetic injection to numb the perineal area for episiotomies or postpartum laceration repair.
  • Pudendal Block: Anesthetic injection into the pudendal nerves located in the pelvis to numb the vaginal and perineal area.
    • Possible Complications: Vaginal hematoma, abscess.
• General Anesthesia: Rarely used, but necessary in emergencies, such as:
  • Emergency C-sections.
  • C-sections for women refusing or having contraindications to regional anesthesia.
  • Maternal Risks: Potential for regurgitation and aspiration pneumonitis.
  • Neonatal Risks: Respiratory depression due to maternal anesthesia crossing the placenta.

Nursing Role in Pharmacologic Techniques:

• Thorough Admission Assessment:
  • Allergies to food, medications (especially dental anesthetics), and latex.
  • Pain relief preferences and factors affecting pain relief.
  • Previous back surgeries, infections, and blood pressure abnormalities.
  • Previous experiences with pain management modalities.
  • Last oral intake and medications taken.
• Maintain Safety:
  • Keep side rails up and implement fall precautions.
• Provide Education: Reinforce pain management procedures and expected effects.
• Assist Healthcare Provider:
  • During anesthetic procedures, wear appropriate PPE and maintain a sterile field.
  • Assist with patient positioning.
• Manage Medication Effects and Patient Response:
  • Narcotics:
    • Respiratory assessments.
    • Continuous fetal monitoring.
    • Naloxone readily available.
    • Observe the neonate for prolonged narcotic effects.
  • Epidural or Subarachnoid Blocks:
    • Monitor for maternal hypotension.
    • Continuous pulse oximetry and electronic fetal monitoring.
    • Monitor for signs of imminent birth (patient may not know due to reduced sensation).
  • General Anesthesia:
    • Administer medications to reduce gastric acidity.
    • Frequent vital sign monitoring.
    • Assess sedation and administer oxygen until fully awake.
    • Monitor urine output.
    • Assist with ambulation once full sensation and motor control return.

Maternal Nursing Care Immediately After Birth (Fourth Stage of Labor):

• Assess the mother every 15 minutes for 1 hour, then every 30 minutes for the next hour, and hourly thereafter until postpartum transfer.
• Assessment Parameters:
  • Vital Signs: Include temperature (report oral temperature of 38°C/100.4°F or higher or if the woman has a higher risk of infection)
  • Skin color
  • Uterine Fundus Location and Firmness: Ensure the uterus is midline, at or below the umbilicus, and firm. Administer oxytocin as needed.
  • Pain Location and Presence
  • IV Infusion and Medications
  • Bladder Fullness or Urine Output: A full bladder can displace the uterus and inhibit contraction.
  • Perineum Condition (for vaginal birth).
  • Dressing Condition (for cesarean birth or tubal ligation).
  • Sensation and Ability to Move Lower Extremities (if an epidural or spinal block was used).
  • Hemorrhage Observation: Look for dark red vaginal bleeding (lochia rubra), no more than one pad saturated in an hour, and no passing of large clots.
    • Constant bright red blood suggests a bleeding laceration. Check vital signs to identify increasing pulse and decreasing blood pressure, indicating potential shock.
• Promote Comfort:
  • Warm blanket (may be used to maintain infant warmth).
  • Ice pack on the perineum (continued for at least 12 hours) to reduce bruising and edema.

Newborn Nursing Care Immediately After Birth:

• Three Adaption Phases:
  • These phases involve the newborn adapting to extrauterine life.

Immediate Newborn Care (Phase 1)

• Thermoregulation: Maintaining a neutral thermal environment is crucial after birth.
  • Cold stress can increase metabolic rate, leading to increased respiratory rate and oxygen consumption.
  • Hypothermia can cause hypoglycemia, impacting the newborn's neurological development.
• Nursing Interventions for Thermoregulation:
  • Drying the infant with a towel promptly to prevent evaporative heat loss.
  • Placing the infant in a radiant warmer with a skin probe for accurate temperature monitoring.
  • Covering the infant's head with a hat to minimize heat loss from the largest body surface area.
  • Wrapping the infant in warm blankets or providing skin-to-skin contact with the mother for warmth.
  • Delaying the first bath until the infant's temperature is stable (36.5-37°C).
• Cardiorespiratory Function:
  • Clearing the airway by gently wiping mucus and amniotic fluid from the face, nose, and mouth.
  • Performing bulb suctioning to clear secretions from the nose and mouth as needed.
  • Applying a cord clamp after stabilization in the radiant warmer.
  • Observing for spontaneous breathing, which typically begins within seconds.
  • Acrocyanosis (bluish hands and feet) is normal due to sluggish peripheral circulation.
  • Administering oxygen via facemask if needed until the infant cries vigorously.
• Respiratory Distress Signs:
  • Persistent cyanosis beyond hands and feet.
  • Grunting respirations.
  • Nasal flaring.
  • Retractions under the sternum or between the ribs.
  • Sustained respiratory rate higher than 60 breaths per minute.
  • Sustained heart rate greater than 160 beats per minute or less than 110 beats per minute.
• Apgar Scoring:
  • Evaluates infant's condition at 1 and 5 minutes after birth.
  • Scores 0-2 for each of five factors: heart rate, respiratory effort, muscle tone, reflex irritability, and color.
  • Score of 8-10 indicates no immediate intervention required.
  • Score of 4-7 warrants gentle stimulation and observation.
  • Score less than 3 necessitates resuscitation.
• Infant Identification:
  • Using preprinted identification bands on the mother, infant, and father/support person.
  • Ensuring the numbers on all bands match.
  • Taking footprints and fingerprints for identification purposes.
• Urinary and Meconium Function:
  • Newborns may not urinate for up to 24 hours after delivery.
  • Meconium passage can occur within 12-24 hours.
  • Discharge is delayed until documentation of functional GI and GU systems.
• Maternal-Infant Bonding:
  • Encouraging skin-to-skin contact between mother and newborn.
  • Initiating breastfeeding during the alert period in the first hour of life.
• Medications:
  • Erythromycin eye ointment for all newborns to prevent ophthalmia neonatorum (caused by Neisseria gonorrhoeae and Chlamydia trachomatis).
  • Vitamin K (AquaMEPHYTON) to assist with blood clotting, given intramuscularly in the vastus lateralis muscle before leaving the delivery room.
• Anomaly Observation:
  • Assessing for normal movement, facial expressions, and symmetry.
  • Checking for trauma, especially if forceps were used during delivery.
  • Inspecting for obvious anomalies like spina bifida or cleft lip.
  • Assessing arm and leg length for equality.

Transition Phase (Phase II)

• Takes place 1-3 hours after birth in the transition nursery or postpartum unit.

Postpartum Care (Phase III)

• Occurs 2-12 hours after birth in the postpartum unit, often with rooming in.
• This phase will be discussed in a later context.

Birthing Settings

• Hospital offers the traditional setting, LDR (labor, delivery, recovery) room, and Single Room Maternity Care (LDRP {labor, delivery, recovery, and post-partum} room).
• Hospital advantages include: pre-registration, easy access to sophisticated services and specialized personnel for emergencies, ability to provide family-centered care for complicated pregnancies.
• Freestanding Birth Centers operated by full-service hospitals, offer a homelike setting with lower costs.
• Freestanding Birth Center disadvantages include potential delays in emergency care due to distance from the hospital.
• Home Births offer control over who is present during labor and birth, a lack of potential pathogen exposure from other patients, and a low-technology birth experience.
• Home Birth disadvantages include limited choice of birth attendants, possible delays in emergency care, and a potential absence of a pre-established relationship with a physician for necessary transfers.
• Contraindications to a home birth include: previous Cesarean section, malpresentation, multiple gestation, primipara, and gestational age greater than 40 weeks.

The Four Components of Labor

• Powers: Consists of uterine contractions and maternal pushing efforts.
  • Uterine Contractions: are coordinated, involuntary, and intermittent muscles pulling the cervix upward while pushing the fetus downward during the first stage of labor.
    • Effacement is described as a percentage of the original cervix length, reaching 100% when thin and slick.
    • Dilatation is described in centimeters, with full dilation being 10 cm.
    • Contraction phases: Increment (increasing strength), Acme (peak intensity), Decrement (decreasing intensity).
    • Frequency is the time between the beginning of one contraction to the beginning of the next.
    • Duration is the length of each contraction from beginning to end.
    • Intensity is the strength of the contraction, described as mild, moderate, or strong.
    • Interval is the time between the end of one contraction to the start of the next.
  • Maternal Pushing is the voluntary effort to help expel the fetus during the second stage of labor (from full cervical dilation to birth).
• Passage: Refers to the mother's bony pelvis and soft tissues (cervix, muscles, ligaments, and fascia) of the pelvis and perineum.
  • False Pelvis: The upper flaring part of the bony pelvis.
  • True Pelvis: The lower part of the bony pelvis, directly involved in childbirth, and divided into inlet, midpelvis, and the outlet.
• Passenger: The fetus, placenta and membranes.
  • Fetal Skull: Consists of five bones that allow for molding, reshaping in response to pressure.
  • Sutures: Membranous spaces between the skull bones.
  • Fontanelles: Large membranous areas where sutures meet (anterior - diamond-shaped, posterior - triangle-shaped).
  • Fetal Lie: Orientation of the fetus's long axis to the mother's long axis.
    • Longitudinal: Fetal spine parallel to mother's spine (cephalic or breech).
    • Transverse: Fetal spine perpendicular to mother's spine.
    • Oblique: Fetal spine between longitudinal and transverse.
  • Fetal Attitude: Normal attitude is flexion (head to chest, arms and legs flexed).
  • Fetal Presentation: Fetal part entering the pelvis first.
    • Vertex: Fetal head fully flexed (most favorable).
    • Breech: Buttocks presenting (three variations).
    • Shoulder: Spine in transverse lie (requires Cesarean section).
  • Fetal Position: Relationship of the presenting fetal part to the four quadrants of the mother's pelvis.
• Psyche: The woman's psychological response to labor and birth influenced by anxiety, culture, expectations, life experiences, and support.
  • Anxiety and Fear: Decreased coping with pain and maternal catecholamine release leading to uterine contractility and placental blood flow inhibition.
  • Cultural Values: Affect expectations for and responses to birth, providing a framework for care.
  • Personal Values: Understand and respect the woman's individual values and expectations.

Laboring Process

• Impending Labor Signs: Braxton-Hicks contractions, lightening, increased vaginal discharge, bloody show, rupture of membranes, increased energy (nesting), and slight weight loss.
• Mechanisms of Labor: Movements the fetus makes to navigate the maternal pelvis.
  • Descent: Downward progression of the presenting part through the true pelvis.
  • Engagement: Widest diameter of fetal head crosses the inlet of the mother's pelvis.
  • Flexion: Fetal head flexes for easier passage through the pelvis.
  • Internal Rotation: Fetal head aligns with the larger diameter of the midpelvis.
  • Extension: Occiput passes under the symphysis pubis.
  • Restitution: Fetal head realigns with the body and shoulders.
  • External Rotation: Fetal head rotates to align with the shoulders.
  • Expulsion: Birth of the fetus. ### Admission to the Labor Unit & Procedures
• Nurses must present clear guidelines for when mothers should go the birth facility.
• Women should go to the birth facility when contractions are regular, increase in frequency, duration, and intensity.
  • Women in first labors should go when contractions are five minutes apart for one hour.
  • Women having second or more labors should go sooner, when regular contractions are ten minutes apart for one hour.
• The woman should go to the facility when her membranes have ruptured (a gush or trickle of fluid from the vagina), regardless of contractions.
• Bright red bleeding should be evaluated promptly.
• If the fetus is moving less than usual, the woman should be evaluated.
• Decreased fetal activity can be a sign of fetal compromise or fetal demise.
• The nurse establishes a therapeutic relationship by welcoming her and her family members.
• The nurse should know the woman's birth plan.
• The three assessments performed promptly on admission are fetal condition, maternal condition and impending birth.
• Fetal heart rate (FHR) is assessed with a fetoscope, Doppler transducer, or external fetal monitor (EFM).
• Assess amniotic fluid color, amount, and odor when membranes rupture.
• Evaluate maternal temperature, pulse, respirations and blood pressure for signs of infection or hypertension.
• Look for behaviors that suggest the woman is about to give birth, such as sitting on one buttock, grunting sounds, bearing down with contractions, stating "The baby's coming," bulging of the perineum or visualization of the head.
• If birth is imminent, don't leave the patient; call for help, put on gloves, and have a precipitous pack/emergency delivery kit available.
• A more complete admission assessment is taken if the focused assessment of mother and fetus are normal and the birth is not imminent.
  • This includes prenatal care, OB history, medical/surgical history, allergies, food intake, any recent illness, medications, drug/ETOH use, and home environment.
  • Inquire about the woman's plan for birth: support person, planned pain management methods.
  • Assess the status of labor: Cervical dilation and effacement, fetal presentation, position, and station.
• Obtain consent forms for labor, delivery, and post birth period, including an emergency cesarean section.
• Obtain blood for hematocrit (CBC usually sent) and a midstream urine specimen for glucose and protein.
  • Additional labs may be drawn for women with no prenatal care, such as a drug screen, tests for sexually transmitted infections, and others as indicated.
• An IV is started to allow administration of fluids and drugs.
• Cleanse the perineal area.
• Determine fetal position and presentation using Leopold maneuvers and a vaginal exam.

Contractions and True vs. False Labor

• True labor is characterized by progress and consistency.
  • Contractions usually have a regular pattern and become more frequent, longer, and more intense.
  • Contractions become stronger and more effective with walking.
  • Discomfort begins in the lower back and gradually travels to the lower abdomen.
  • Progressive effacement and dilation of the cervix occur.
• False labor is characterized by contractions and other symptoms, but no cervical effacement or dilation.
  • Contractions are inconsistent in frequency, duration, and intensity.
  • Walking tends to relieve or decrease contractions.
  • Discomfort is felt in the abdomen and groin.
  • There is no change in effacement or dilation of the cervix.

Fetal Monitoring

• The goal of fetal monitoring is to identify fetal hypoxia early to allow prompt interventions that will avoid fetal injury.
• Intermittent auscultation allows the mother greater freedom of movement.
  • Doesn't allow for automatic recording of the FHR; accurate and complete documentation is required.
• Continuous electronic fetal monitoring (EFM) allows the nurse to collect more data about the fetus.
  • A variation of intermittent monitoring promotes walking during labor.
• EFM can be done external or internal.
  • Internal devices require the membranes to be ruptured and the cervix to be dilated 1-2 cm.
• External EFM is done by a Doppler transducer, which uses sound waves to detect motion of the fetal heart and calculate the rate.
• Stand FHR monitoring is every 30 minutes in the active phase of the first stage of labor and every 15 minutes in the second stage.

Fetal Heart Rate (FHR) Patterns

• FHR is evaluated for baseline rate, baseline variability, episodic changes (transient changes in heart rate not associated with contractions), and periodic changes (brief changes in heart rate that are associated with contractions).
• Baseline fetal heart rate is the average heart rate that occurs for at least 2 minutes during a 10-minute period and is averaged over 30 minutes.
• Baseline should be 110-160 BPM for a 2-minute period.
• Fetal Bradycardia: FHR is less than 110 beats per minute for 10 minutes or longer.
  • Causes include fetal hypoxia, maternal hypoglycemia, maternal hypotension, and profound cord compression.
• Fetal Tachycardia: FHR is greater than 160 beats per minute that lasts 2-10 minutes or longer.
  • Causes include maternal fever and maternal dehydration.
• Baseline variability describes the fluctuation or constant baseline in a 10-minute window.
  • Moderate variability change of 6-25 beats per minute from the baseline FHR.
  • Marked variability change of more than 25 beats of fluctuation over the FHR.
  • Absent variability is less than 6 beats per minute change from baseline.
• Episodic changes are changes in the FHR that are not associated with uterine contractions.
• Periodic changes are temporary changes in the baseline rate associated with uterine contractions that quickly return to baseline.
• Accelerations are temporary, abrupt rate increase of at least 15 beats per min above baseline FHR.
• Early decelerations are temporary, gradual rate decreases during contractions no more than 40 beats per minute below baseline.
• Variable decelerations are abrupt decreases of 15 beats per min below baseline, lasting 15-20 seconds.
• Late decelerations are similar to early decelerations except they begin after the beginning of the contraction and return to baseline after the end of the contraction.
  • Late decelerations indicate that the placenta is not delivering enough oxygen to the fetus (uteroplacental insufficiency).
• Prolonged decelerations are abrupt FHR decreases of at least 15 beats per min below baseline that last longer than 60 seconds.

Nursing Responses to Monitoring Patterns

• Accelerations and early decelerations are reassuring patterns and thus necessitate no intervention other than continued observation.
• Variable decelerations may necessitate changing positions.
  • The woman is turned to her left side; other positions may be tried if the side-lying position doesn't restore the pattern.
• Correcting fetal hypoxia requires restoring oxygenation to the fetus:
  • Implement position changes to relieve pressure on the cord.
  • Administer oxygen via facemask at 10L/min to increase fetal oxygenation.
  • Administer IV fluids such as saline to improve cardiac output.
  • Correct hypotension caused by dehydration or analgesics.
  • Implement measures to reduce uterine activity (stop oxytocin or administer tocolytic).
  • Implement amnioinfusion to restore fluid to the uterus relieving pressure on the cord.
  • Use altered pushing and breathing techniques in the second stage of labor.

Amniotic Fluid

• Normal amniotic fluid is clear, possibly with flecks of white vernix.
• Green-stained fluid may indicate that the fetus has passed meconium before birth, which can cause respiratory problems at birth.
• Cloudy or yellow amniotic fluid with an offensive odor may indicate an infection and should be reported immediately.
• Assess FHR for a full minute after the membranes rupture.

Monitoring the Woman

• Intrapartum care of the woman includes assessing her VS, contractions, progress of labor, intake and output, and responses to labor.
• Vital Signs checked every 4 hours, then every 2 hours if elevated or if ruptured membranes.
  • Temperature of 100.4 or greater should be reported.
  • Maternal hypotension is systolic pressure less than 90 or maternal hypertension is BP greater than 140/90.
• Contractions can be assessed by palpation or by continuous EFM.
• Progress of labor is determining the dilation and effacement of the cervix by vaginal examination.
• Intake and output involves recording time and approximate amount of each urination.
• Response to labor including her use of breathing and relaxation techniques and support adaptive responses.
• Nonverbal behaviors that suggest difficulty coping with labor may include a tense body posture and thrashing in bed.

Helping with Coping

• Maintain a comfortable environment: familiar music, upright positions, and regular position changes.
• The nurse helps the woman to cope with labor by comforting, positioning, teaching, and encouraging her.
• If measures taught in childbirth classes are inadequate, positions or breathing techniques different from those learned should be tried.

Characteristics Distinguishing True Labor from False Labor

• True labor:
  • Contractions become regular and increase in frequency, duration, and intensity.
  • Walking strengthens contractions and helps move the fetus.
  • Discomfort that begins in the back and radiates to the lower abdomen.
  • Progressive effacement and dilation of the cervix occur.
• False labor:
  • Contractions are inconsistent in frequency, duration, and intensity.
  • Walking relieves or decreases contractions.
  • Discomfort felt in the abdomen and groin.
  • There is no change in effacement or dilation of the cervix.
• Each woman in false labor is evaluated individually; factors considered include: number and duration of previous labors, distance from the facility, and availability of transportation.

Normal Labor Contractions

• Normal labor contractions typically become more frequent and of longer duration as labor progresses.### Stages of Labor

• First Stage: Begins with regular contractions and ends with full cervical dilation (10 cm). Average duration for nulliparas: 7.3 - 8.6 hours, for multiparas: 4.1 - 5.3 hours.

• Latent Phase: Cervical dilation from 0 - 4 cm, amniotic membranes intact, bloody show, contractions every 20 minutes decreasing to 5 minutes apart, lasting 15-40 seconds, mild to moderate intensity. Characteristics: cooperative, alert, talkative, welcomes diversions, frequent urination, thirsty.

• Active Phase: Cervical dilation from 4 - 7 cm, amniotic membranes may rupture, contractions 2-5 minutes apart, lasting 40-60 seconds, moderate to firm intensity. Characteristics: apprehensive, anxious, introverted, less social, focused on breathing, perspires, facial flushing, requests pain relief, fears losing control.

• Transitional Phase: Cervical dilation from 7-10 cm, cervix fully effaced, amniotic membranes rupture, contractions 2-3 minutes apart, lasting 60-90 seconds, firm intensity. Characteristics: irritable, rejects support person, introverted, wants to give up, restless, tremor of legs, fears losing control.

• Second Stage: Begins with complete cervical dilation (10 cm) and ends with baby's birth. Average duration: 30 minutes - 2 hours, contractions every 1-3 minutes lasting 60-80 seconds, firm intensity.

• Third Stage: Begins with delivery of the baby and ends with delivery of the placenta. Average duration: 5 - 30 minutes, contractions intermittent, mild to moderate intensity.

• Fourth Stage: Stabilization period following placental delivery, the uterus remains midline, firmly contracted at or below the umbilicus level.

Childbirth Pain

• Characteristics: Part of normal birth process, can be beneficial (motivating to seek help, assuming positions for fetal descent), self-limiting and declines after birth, motivating as it results in baby's birth.
• Sources of Pain: Dilation and stretching of the cervix, reduced uterine blood supply during contractions, pressure of the fetus on pelvic structures, stretching of the vagina and perineum.

Pain Management

• Nonpharmacologic Techniques: Relaxation, skin stimulation, thermal stimulation, positioning, diversion and distraction.
• Gate Control Theory: Physical stimulation of nerve fibers interfere with transmission of pain impulses to the brain, supporting the effectiveness of nonpharmacologic methods.
• Endorphins: Levels increase during pregnancy, peaking during labor, leading to less analgesia needed.
• Factors Influencing Pain Tolerance: Pain threshold, pelvis shape, labor intensity, fatigue.

Nursing Interventions

• First Stage: Establish positive relationship, encourage alternating ambulation and rest, review breathing and relaxation techniques, assess FHR, document vaginal discharge, assess for bladder distention, provide opportunities to void, monitor vital signs every 2 hours, teach what to expect as labor progresses.
• Active Phase: Help coach implement coping strategies (breathing, relaxation), continue maternal and fetal assessments, reassure woman, praise progress, facilitate position changes, maintain communication with HCP, moisten mouth, monitor IV fluid intake, watch for bladder distention, encourage voiding, report vaginal discharge, maintain warmth, provide general comfort measures.
• Transitional Phase: Provide firm coaching of breathing and relaxation techniques, focus on coping methods, support coach, praise and reassure woman, assess FHR and contractions, assess vaginal discharge, keep woman informed of progress, accept negative comments, maintain positive approach.
• Second Stage: Assist woman to assume pushing position, assist with open glottis pushing technique, support coach, maintain communication with HCP, assess perineum and vaginal discharge, report bulging and crowning, observe for bladder distention, prepare sterile supplies for delivery, prepare infant resuscitation equipment, provide feedback to woman and partner.
• Third Stage: Observe and document blood loss, document delivery of placenta, examine the placenta, monitor vital signs, assess vaginal discharge, massage uterus, administer oxytocin as ordered, obtain cord blood if needed, note parent-infant interaction, dry newborn and place in radiant warmer, attach heart and temperature monitor, assess and provide immediate newborn care, perform Apgar evaluation, apply proper identification to mother, infant, and partner.
• Fourth Stage: Provide proper identification of mother, partner, and newborn, obtain cord blood if needed, assess vital signs every 15 minutes for 1 hour, every 30 minutes during the second hour and hourly thereafter until transfer to the postpartum unit, assess bladder, monitor newborn heart rate and temperature, provide warmth to newborn, assess for anomalies, assess fundus and massage, assess lochia and observe for hemorrhage, change mother's gown and underpads, encourage breastfeeding, encourage bonding between parents and infant.

Nonpharmacological Pain Management

• Focal Point Technique: Woman focuses on a specific object or spot to distract from pain
• Imagery: Woman imagines a peaceful and relaxing environment
• Music: Helps block out distracting sounds and focus attention away from pain
• Television and Electronics: Provide background noise and distraction, particularly during early labor stages
• Breathing Techniques: Most effective when practiced beforehand; should not be used until necessary to avoid habituation and fatigue
  • Slow-Paced Breathing: Deep, slow breaths at the start of a contraction; slows breathing rate by half
  • Modified-Paced Breathing: Rapid, shallow breaths during contraction; rate is twice the regular rate; caution for hyperventilation
  • Patterned-Paced Breathing: Rapid breaths punctuated by blows (pant-blow or "hee-hoo"); helps prevent breath holding during pushing

Pharmacological Pain Management

• Analgesics: Systemic drugs that reduce pain without loss of consciousness.
  • Narcotic Analgesics: Used in small doses to avoid fetal respiratory depression, especially during labor.
  • Examples: Meperidine (Demerol), Fentanyl (Sublimaze), Nalbuphine (Nubain)
  • Naloxone (Narcan): Narcotic antagonist used to reverse respiratory depression in infants caused by opioids.
• Adjunctive Drugs: Improve effectiveness of analgesics or counteract side effects.
  • Benzodiazepines: Reduce anxiety and nausea but can affect fetal heart rate and newborn thermoregulation.
• Anesthetics: Cause loss of sensation, particularly pain.
  • Inhaled (Nitrous Oxide): Reduces pain awareness during labor.
  • Regional:
    • Epidural Block: Provides pain relief during labor and delivery.
    • Subarachnoid (Spinal) Block: Used for cesarean deliveries, provides a deeper and faster block.
    • Local Block: Numbing agent used for episiotomy or laceration repair.
    • Pudendal Block: Numbing agent for vaginal birth, episiotomy, and forceps-assisted delivery.
  • General: Rarely used and only if necessary for emergency cesarean delivery or when regional blocks are not viable.

Nursing Role in Pharmacological Techniques

• Thorough admission intake for allergies, medications, pain preferences, and factors affecting pain relief
• Maintaining patient safety by implementing fall precautions and explaining procedures
• Assisting healthcare providers during anesthetic procedures and managing medication effects

Maternal Nursing Care After Birth

• Fourth stage of Labor Assessment Schedule:
  • Vital signs, including temperature, every 15 minutes for the first hour
  • Uterine fundus position, firmness, and pain
  • IV infusion and medications
  • Bladder fullness or urine output
  • Perineum condition for vaginal birth
  • Dressing for cesarean birth or tubal ligation
  • Level of sensation and movement following epidural or spinal block
  • Observe for hemorrhage
  • Promote comfort with warm blankets, ice pack, and perineal care

Newborn Nursing Care After Birth

• Three Transitional Phases: Stages involved in adapting to life outside the womb

Newborn Care Phase 1 (Birth to 1 Hour)

• Thermoregulation: Maintaining a neutral thermal environment is critical to minimize heat loss and oxygen consumption.
  • Cold stress: Increases metabolic rate for heat generation, leading to increased respiratory rate, oxygen consumption, and potential hypoxia.
  • Hypothermia: Can cause hypoglycemia as the body uses glucose for heat generation, potentially leading to neurological problems.
• Nursing interventions: drying the infant, radiant warmer with skin probe, hat, warm blankets, skin-to-skin contact, delayed bathing until temperature stabilizes.
• Cardiorespiratory function:
  • Respiratory support: Gentle wiping of face, nose, and mouth to remove mucus, gentle bulb suctioning of secretions, cord clamping after stabilization, administration of oxygen if needed.
  • Signs of respiratory distress: persistent cyanosis (other than hands and feet), grunting respirations, nostril flaring, retractions (under sternum or between ribs), sustained respiratory rate greater than 60 BPM, sustained heart rate greater than 160 BPM or less than 110 BPM.
• Apgar Scoring: Evaluates infant condition and response to resuscitation at 1 minute and 5 minutes after birth
  • Apgar score: evaluated based on heart rate, respiratory effort, muscle tone, reflex irritability and color.
  • Scores 8-10: No action needed, continued observation and support.
  • Scores 4-7: Gentle stimulation (rubbing back), consider narcotic-induced respiratory depression.
  • Scores < 3: Immediate resuscitation.
• Infant Identification: Using preprinted numbers on mother, infant, and support person, ensuring numbers match on all wristbands. Footprints, fingerprints, and pictures may be taken for identification.
• Urinary and Meconium Passage:
  • May not urinate for up to 24 hours.
  • Meconium passage can occur within 12-24 hours.
  • Discharge is contingent on documented functioning of GI and GU systems.
• Maternal-Infant bonding:
  • Encourage skin-to-skin contact and breastfeeding during the first alert hour after birth.
• Medications:
  • Erythromycin eye ointment: Administered in each eye for 1 hour after birth to prevent ophthalmia neonatorum.
  • Vitamin K (AquaMEPHYTON): Given in the vastus lateralis muscle to assist with blood clotting.
• Anomaly Observation: Observing normal movement, facial expressions, assessing for trauma and major anomalies (e.g., spina bifida, cleft lip, arm/leg length discrepancies).

Newborn Care Phase II (1-3 Hours)

• Transition nursery or postpartum unit.

Newborn Care Phase III (2-12 Hours)

• Postpartum unit, rooming in with the mother
• Care will be discussed at a later time.

Learning Questions

• Skin-to-skin contact: Primarily to maintain infant's temperature.
• Apgar score:

  • Sign | 1 Minute | 5 Minutes

  • ------------- | --------- | ----------

  • Heart Rate | 125 bpm | 155 bpm

  • Respiratory | Strong cry | Reacts spontaneously

  • Muscle tone | Flexed body | Maintains flexion

  • Reflex | Cries, flexes | Cries when stimulated

  • Color | Pink body, blue extremities | Pink body, blue extremities

  • Scores: 1 minute - 9; 5 minutes - 9. This baby is responsive and requires no further intervention, but should continue to be observed.

Birth Settings

• Hospital: Traditional, LDR, and LDRP rooms are options.
  • Traditional: Labor, delivery, and recovery occur in separate rooms.
  • LDR: Labor, delivery, and recovery happen in the same home-like room.
  • LDRP: Labor, delivery, recovery, and postpartum stay are all in the same room.
• Freestanding Birth Centers: Operated by hospitals, offering home-like settings for low-risk pregnancies.
• Home Births: Choices include control over attendants and environment, but complications can lead to significant delays in emergency care.

Components of the Birth Process: The Four Ps

• Powers: Uterine contractions and maternal pushing efforts.
  • Uterine Contractions:
    • Coordinated, involuntary, and intermittent.
    • Influence contraction intensity and effectiveness: walking, drugs, anxiety, and vaginal examinations.
    • Cervical effacement and dilation:
      • Effacement: thinning of the cervix (0-100%).
      • Dilation: opening of the cervix (1-10 cm).
    • Phases of a Contraction:
      • Increment: Increasing strength.
      • Acme: Peak intensity.
      • Decrement: Decreasing intensity.
    • Contraction Description:
      • Frequency: Time between the beginning of contractions.
      • Duration: Length of each contraction.
      • Intensity: Strength of contraction (mild, moderate, strong).
      • Interval: Time between the end of one contraction and the beginning of the next.
• Passage: The mother's bony pelvis and soft tissues.
  • Bony Pelvis: Most important due to its rigidity.
  • False Pelvis: Upper flaring part of the pelvis.
  • True Pelvis: Lower part, vital for childbirth.
    • Inlet: Top of the true pelvis.
    • Midpelvis: Middle section.
    • Outlet: Lower pelvic opening.
• Passenger: The fetus, placenta, and membranes.
  • Fetal Skull: Made of five bones, allowing for molding during birth.
  • Sutures: Membranous spaces between the skull bones.
  • Fontanelles: Larger membranous areas where sutures intersect.
  • Fetal Lie: Orientation of the fetus to the mother's spine.
    • Longitudinal: Most common (99%).
    • Transverse.
    • Oblique.
  • Fetal Attitude: Fetal posture (flexion or extension).
  • Fetal Presentation: The fetal part entering the pelvis first.
    • Vertex: Head fully flexed (most common).
    • Breech: Buttocks first
    • Shoulder: Shoulders enter first.
  • Fetal Position: Relationship of the presenting fetal part to the four quadrants of the mother's pelvis.
    • Described using three letters:
      • First letter: Right, left, or midline.
      • Second letter: Fixed fetal reference point.
      • Third letter: Anterior, posterior, or transverse.
  • Positions: LOA (left occiput anterior), ROA (right occiput anterior), etc.
• Psyche: The expectant mother's psychological response to labor and birth.
  • Influenced by anxiety, culture, expectations, life experiences, and support.
  • Anxiety and fear decrease a woman's ability to cope with pain.
  • Relaxation and optimism promote better tolerance of discomfort.
  • Culture shapes expectations and responses to birth practices.

Labor Process

• Impending Labor: Signs and symptoms that labor is about to start.
  • Braxton-Hicks contractions: Irregular contractions that intensify as full term approaches.
  • Lightening: Fetus settles into the pelvic inlet.
  • Increased vaginal discharge: Clear mucous secretions.
  • Bloody show: Mixture of mucus and blood.
  • Rupture of membranes: Amniotic sac ruptures.
  • Nesting: Sudden increase in energy.
  • Small weight loss (1-3 lbs): Due to fluid excretion.
• Mechanisms of Labor: Manuevers required for the fetus to move through the pelvis.
  • Descent: Downward progression of the presenting part through the pelvis.
    • Stations: Measure the level of the presenting part in centimeters above or below the ischial spines.
  • Engagement: Widest diameter of the fetal head crosses the pelvic inlet.
  • Flexion: Fetal head flexes to pass through the pelvis.
  • Internal Rotation: Aligning the fetal head with the pelvic diameter for passage.
  • Extension: Occiput passes under the symphysis pubis.
  • Restitution: Head realigns with the body.
  • External Rotation: Shoulders rotate to align with the pelvis.
  • Expulsion: Delivery of the fetus.

Guidelines for Reporting to a Birthing Facility

• Mothers need clear guidelines for when to go to the birth facility.
• Women in early labor, first time mothers, should go to the hospital when contractions are five minutes apart for one hour.
• Women having their second labor or more babies should go to the facility sooner, when regular contractions are ten minutes apart for one hour.
• When membranes have ruptured, the mother should go to the birth facility regardless of whether contractions are occurring.
• Bright red bleeding should be evaluated promptly.
• If the fetus is moving less than usual, the mother should be evaluated.

Admission Assessments

• The nurse establishes a therapeutic relationship with the mother and her family.
• The nurse will identify the family members present and their role in the mother's care.
• The three assessments performed promptly on admission are fetal condition, maternal condition, and impending birth.
• Fetal heart rate (FHR) is assessed with a fetoscope, Doppler transducer, or external fetal monitor (EFM).
• When the amniotic membranes are ruptured, assess the color, amount, and odor of the fluid, and record the FHR.
• Maternal temperature, pulse, respirations, and blood pressure are assessed for signs of infection or hypertension.
• Behaviors that suggest impending birth include sitting on one buttock, grunting sounds, bearing down with contractions, stating "the baby's coming," and bulging of the perineum.

Admission Procedures

• Consent forms are obtained for care during labor, delivery, and post-birth period, including an emergency cesarean section.
• Blood for hematocrit and a midstream urine specimen for glucose and protein are obtained.
• An intravenous infusion line allows administration of fluids and drugs.
• Perineal preparation for delivery includes cleansing the perineal area.
• Fetal presentation and position are determined using Leopold maneuvers and a vaginal exam.

True Labor vs. False Labor

• True labor is characterized by progress and consistency.
• True labor contractions have a regular pattern and become more frequent, longer, and more intense.
• True labor contractions become stronger and more effective with walking.
• Discomfort in true labor begins in the lower back and gradually travels to the lower abdomen.
• Progressive effacement and dilation of the cervix occur, which is the most important characteristic of true labor.
• False labor contractions are inconsistent in frequency, duration, and intensity.
• False labor contractions tend to decrease or relieve with walking.
• False labor discomfort is felt in the abdomen and groin.
• There is no change in effacement or dilation of the cervix in false labor.

Monitoring the Fetus

• The goal of fetal monitoring is to identify fetal hypoxia early to allow prompt interventions that will avoid fetal injury.
• Intermittent auscultation allows for greater freedom of movement and is the method used in home birth and birthing centers.
• Continuous electronic fetal monitoring (EFM) allows the nurse to collect more data about the fetus.
• EFM can be done external or internal; internal devices require ruptured membranes and cervical dilation.
• External EFM is done with a Doppler transducer and a tocotransducer.
• The FHR is evaluated for baseline rate, variability, episodic changes, and periodic changes.
• The baseline FHR is the average heart rate that occurs for at least 2 minutes during a 10-minute period.
• Fetal bradycardia is an FHR less than 110 beats per minute for 10 minutes or longer.
• Fetal tachycardia is an FHR greater than 160 beats per minute for 2-10 minutes or longer.
• Variability is seen as a sawtooth appearance with larger, undulating, wavelike movements.
• Episodic changes are changes in the FHR that are not associated with uterine contractions.
• Periodic changes are temporary changes in the baseline rate associated with uterine contractions that quickly return to baseline.
• Accelerations are temporary, abrupt rate increases of at least 15 beats per minute above the baseline FHR.
• Early decelerations are temporary, gradual rate decreases during contractions no more than 40 beats per minute below baseline.
• Variable decelerations are abrupt decreases of 15 beats per minute below baseline, lasting 15-20 seconds.
• Late decelerations are similar to early decelerations except they begin after the contraction begins and return to baseline after the end of the contraction.
• Prolonged decelerations are abrupt FHR decreases of at least 15 beats per minute below baseline that last longer than 60 seconds.

Nursing Response to Fetal Monitoring Patterns

• Accelerations and early decelerations are reassuring patterns and necessitate no intervention other than continued observation.
• Variable decelerations may necessitate changing positions.
• FHR monitoring is not diagnostic but instead is used to identify complications that may cause interruption in fetal oxygen supply.
• Corrective actions for non-reassuring FHR patterns include position changes, oxygen administration, IV fluids, correcting hypotension, reducing uterine activity, amnioinfusion, and altered pushing and breathing techniques.
• If these measures do not improve fetal heart tracings, then measures focus on expediting delivery of the fetus.

Monitoring the Woman

• Intrapartum care of the woman includes assessing her vital signs, contractions, labor progress, intake and output, and responses to labor.
• Vital signs are checked every 4 hours, then every 2 hours if they are elevated or if the membranes rupture.
• Contractions can be assessed by palpation or by continuous EFM.
• Labor progress is determined by assessing cervical dilation, effacement, and fetal descent.
• Intake and output involves recording time and approximate amount of each urination.
• Ice chips, popsicles, or hard sugarless lollipops can be used to keep the mouth moist during active labor.
• Nonverbal behaviors that suggest difficulty coping with labor may include a tense body posture and thrashing in bed.

Helping with Coping During Labor

• The nurse helps the woman cope with labor by comforting, positioning, teaching, and encouraging her.
• Labor support can include controlling the environment, maintaining an upright position during labor, and encouraging regular changes in position.
• Teaching includes instructing the woman on different positions or breathing techniques to help manage labor.
• The nurse will also provide support to the woman's partner during labor.

Stages of Labor & Nursing Interventions

• First stage: Cervical dilation and effacement
  • Begins at onset of regular contractions.
  • Ends when cervix is fully dilated (10 cm).
  • Longest stage of labor.
  • Averaging 7.3 to 8.6 hours for nulliparas, and 4.1 to 5.3 hours for multiparas.
  • Latent Phase (4-6 hours):
    • Cervical dilation up to 4 cm.
    • Amniotic membranes likely intact.
    • May experience bloody show.
    • Contractions every 20 minutes (decreasing to every 5 minutes).
    • Duration increases to 15-40 seconds by the end of the latent phase.
    • Intensity: Mild to moderate.
    • Woman is usually cooperative, alert, talkative, welcomes diversions, frequent urination, thirsty.
    • Nursing Interventions:
      • Establish a positive relationship.
      • Encourage alternating ambulation and rest.
      • Review breathing and relaxation techniques with the coach.
      • Assess fetal heart rate (FHR).
      • Document the color of vaginal discharge.
      • Assess for bladder distention, and provide opportunities to void.
      • Consider providing lollipops.
      • Assess vital signs every 2 hours.
      • Encourage a shower.
      • Teach what to expect as labor progresses.
  • Active Phase (2-6 hours):
    • Cervical dilation from 4-7 cm.
    • Amniotic membranes may rupture.
    • Effacement of cervix occurs.
    • Contractions are 2 to 5 minutes apart and last about 40 to 60 seconds.
    • Intensity: Moderate to firm.
    • Woman is apprehensive, anxious, introverted, less social, focused on breathing, perspires, facial flushing, requests pain relief, fears losing control, may need epidural analgesia.
    • Nursing Interventions:
      • Help coach implement coping strategies (breathing, relaxation).
      • Continue maternal and fetal assessments.
      • Reassure the woman.
      • Praise progress.
      • Facilitate position changes.
      • Maintain communication with the healthcare provider.
      • If the woman is NPO, moisten her mouth.
      • Monitor IV fluid intake.
      • Watch for bladder distention, encourage voiding.
      • Report color, odor, and amount of vaginal discharge; report if meconium is seen.
      • Maintain warmth, and provide general comfort measures.
  • Transitional Phase (30 min – 2 hours):
    • Cervical dilation is 7-10 cm.
    • Cervix is fully effaced.
    • Amniotic membranes rupture.
    • Contractions occur at 2-3 minutes apart and last 60 to 90 seconds.
    • Intensity: Firm.
    • Woman is irritable, rejects support person, introverted, wants to give up, restless, leg tremors, fears losing control and requests medication.
    • Nursing Interventions:
      • Provide firm coaching of breathing and relaxation techniques.
      • Support the coach.
      • Praise and reassure the woman.
      • Assess monitor strips of fetal heart rate and contractions.
      • Assess color of vaginal discharge.
      • Keep the woman informed of progress with each contraction.
      • Accept negative comments.
      • Maintain a positive approach.
• Second stage: Delivery
  • Begins with complete dilation at 10 cm and full (100%) effacement of the cervix.
  • Ends with the birth of the baby.
  • Average length of this stage is 30 minutes to 2 hours.
  • Contractions: Every 1-3 mins, lasting 60-80 seconds.
  • Intensity: Firm.
  • Episiotomy may be performed by the healthcare provider.
  • Primiparas are ready for delivery when 3-4 cm of the fetal head is visible (crowning) at the vaginal opening.
  • Multiparas are usually ready when the cervix is fully dilated, before crowning.
  • Woman experiences:
    • Bulging perineum.
    • May pass stool.
    • Uncontrollable urge to push.
    • States "The baby is coming".
    • Exhaustion after each contraction.
    • Unable to follow directions easily.
    • Excitement concerning imminent birth.
  • Nursing Interventions:
    • Assist woman to assume a position that helps her push.
    • Assist with open glottis pushing technique and coping strategies.
    • Support the coach.
    • Maintain communication with the healthcare provider..
    • Assess perineum and vaginal discharge.
    • Report bulging and crowning.
    • Observe for bladder distention.
    • Prepare sterile supplies for delivery.
    • Prepare infant resuscitation equipment.
    • Provide feedback to the woman and partner.
• Third stage: Delivery of the placenta
  • Delivery of the baby starts this stage, ending with the delivery of the placenta.
  • Average time for both primiparas and multiparas is 5-30 minutes.
  • Contractions are intermittent, intensity is mild to moderate.
  • Uterus contracts to the size of a grapefruit.
  • Episiotomy is sutured by the healthcare provider.
  • Signs of placental separation:
    • Lengthening of the umbilical cord.
    • Uterine fundus rises and becomes firm.
    • Fresh blood expelled from the vagina.
  • Methods of placental delivery:
    • Schultze Mechanism: Placenta is expelled with the shiny fetal side presenting first.
    • Duncan Mechanism: Rough maternal side is presenting. (Less common).
  • Woman experiences:
    • Elated.
    • Feels relief.
    • Tremors.
    • Increased physical energy.
    • Curiosity about the infant.
    • Desire to nurse the infant.
    • Pain is minimal as the placenta is expelled.
  • Nursing Interventions:
    • Observe and document blood loss.
    • Document delivery of the placenta.
    • Examine the placenta to determine if all of it was expelled (retained placenta can cause hemorrhage because it prevents the uterus from contracting).
    • Monitor mother’s vital signs every 15 minutes.
    • Assess vaginal discharge.
    • Massage uterus until it is firm is midline or below the level of umbilicus.
    • Administer oxytocin to mother as ordered.
    • Obtain cord blood if needed.
    • Note parent-infant interaction.
    • Dry newborn and place in radiant warmer.
    • Attach heart and temperature monitor.
    • Assess and provide immediate newborn care.
    • Perform Apgar evaluation.
    • Apply proper identification to the mother, infant, and partner.
• Fourth stage: Stabilization
  • Uterus remains midline, firmly contracted at or below umbilicus level.
  • Some cramping may occur.
  • Lochia rubra saturates the perineal pad (no more than one pad per hour), the woman should not pass large clots.
  • Continuous trickle of bright red blood suggests a bleeding laceration.
  • Blood pressure, pulse, and respiratory rates are checked to identify shock.
  • Woman may have shaking chills. A warm blanket can help to make her more comfortable.
  • An oral temperature of 100.4 F should be reported as it suggests infection.
  • Assess the bladder for distention, which may occur right after birth.
  • Woman often doesn't feel the urge to urinate because of the effects of anesthesia, perineal trauma, and loss of fetal pressure against the bladder.
  • A full bladder can displace the uterus and prevent it from contracting, leading to hemorrhage.
  • If the woman cannot urinate, she will need to be catheterized.
  • Time for mother, partner, and infant to become acquainted.
  • Encourage breastfeeding.
  • ** Nursing Interventions:**
    • Provide proper identification of the mother, partner, and newborn.
    • Obtain cord blood if needed.
    • Assess woman’s vital signs: every 15 minutes for 1 hour, every 30 minutes during the second hour, and hourly thereafter until transfer to the postpartum unit.
    • Assess mother’s voiding.
    • Monitor heart rate and temperature of newborn. Provide warmth to newborn.
    • Assess newborn for anomalies.
    • Assess fundus and massage to maintain firm contraction (A displaced fundus indicates a full bladder is pressing against it).
    • Assess lochia and observe for hemorrhage.
    • Change the mother’s gown and underpads.
    • Encourage breastfeeding.
    • Encourage bonding between parents and infant.

Maternal Monitoring During Labor

• Immediate Nursing Interventions:
  • A fetal heart rate of 90 BPM between contractions.
  • Maternal tachysystole (excessive uterine contractions).

Pain Management During Labor

• Nonpharmacological Pain Management Techniques:
  • Relaxation:
    • Adjusting the environment.
    • Offering a warm shower or tub.
    • Orienting the woman to the environment, procedures, and the normality of labor.
    • Educating the woman and her partner to identify tension and guide her to release it from specific areas.
  • Skin Stimulation:
    • Effleurage: Woman strokes her abdomen or legs in a circular movement during contractions.
    • Sacral Pressure: Applying pressure against the lower back.
    • Thermal Stimulation: Hydrotherapy (shower, tub, whirlpool), warm blankets or heat packs, or cool cloths on the face.
  • Positioning: Frequent changes to relieve muscle fatigue and strain, and facilitate labor mechanisms.
  • Diversion and Distraction: Mental stimulation to limit the perception of pain.

Nonpharmacological Pain Management Techniques

• Focal Point Technique: Involves focusing on an external object or point in the room to distract from pain.
• Imagery: Creating a mental environment of relaxation and peace to divert attention from pain.
• Music: Shifts focus away from pain and blocks disturbing sounds.
• Electronic Devices: Provide background noise and distraction.
• Breathing Techniques: Most effective when practiced beforehand and should not be used until needed. Begin and end with a cleansing breath, a deep inspiration and expiration.
  • Slow-paced breathing: Slow, deep breaths like during sleep, at least half the normal breathing rate.
  • Modified-paced breathing: Rapid and shallow breaths, no more than twice the usual rate.
  • Patterned-paced breathing: Rapid breaths punctuated with intermittent blows, in a constant or stair-step pattern. Pant-blow pattern is used if the woman feels the urge to push before full cervical dilation.
• Pushing Technique: Take a cleansing breath, followed by a deep breath, and push down while exhaling for a count of 10.
• Nursing role in nonpharmacological techniques: Assess prior knowledge, guide and educate, minimize environmental stimuli, assess pain and relief measures.
• Back Labor: Firm pressure in the sacral area is most effective.

Pharmacological Pain Management Techniques

• Analgesics: Systemic drugs that reduce pain without loss of consciousness.
  • Narcotic Analgesics: Used in frequent, small doses; avoid if birth is expected within an hour to prevent fetal respiratory depression.
    - Common Drugs: Meperidine (Demerol), Fentanyl (Sublimaze), Nalbuphine (Nubain).
  • Naloxone (Narcan): Narcotic antagonist used to reverse respiratory depression caused by opioids.
• Adjunctive Drugs: Improve the effectiveness of analgesics or counteract their side effects.
  • Benzodiazepines: Reduce anxiety and nausea but may affect fetal heart rate variability and newborn thermoregulation.
• Anesthetics: Cause a loss of sensation, particularly pain.
  • Inhaled (Nitrous Oxide): Via face mask during peak contractions, reduces pain awareness with no negative effects on woman or fetus.
  • Regional:
    • Epidural Block: Provides pain relief during labor and delivery for vaginal or cesarean birth.
    • Subarachnoid (Spinal) Block: Used primarily for cesarean deliveries, provides a "one-shot" injection of anesthetic.
    • Local Block: Injection of anesthetic to numb the perineal area for episiotomy or postpartum laceration repair.
    • Pudendal Block: Anesthetic injected into pudendal nerves to numb the vaginal and perineal area, used for vaginal birth, episiotomy, and forceps-assisted delivery.
  • General Anesthesia: Rarely used, potentially needed for emergency cesarean deliveries, women refusing regional blocks, or maternal contraindications.
• Nursing Role in Pharmacological Techniques: Thorough admission intake, maintain safety, provide education, assist healthcare providers, manage medication effects and patient response.

Immediate Postpartum Maternal Care

• Fourth Stage of Labor Assessment:
  • Vital Signs: Every 15 minutes for 1 hour, every 30 minutes for the second hour, and hourly thereafter.
  • Uterine Fundus: Ensure midline, at or below the umbilicus, and firm.
  • Pain: Assess location and presence.
  • IV Infusion: Monitor medications and fluids.
  • Bladder: Assess fullness or urine output.
  • Perineum: Assess condition for vaginal births.
  • Dressing: Assess condition for cesarean births or tubal ligations.
  • Sensation and Movement: If epidural or spinal block used.
  • Hemorrhage: Assess bleeding, blood pressure, pulse, and respirations frequently.
  • Comfort: Warm blanket to address chills and ice pack to reduce perineal bruising and edema.

Immediate Postpartum Newborn Care

• Three "transitional phases" of newborn care are crucial for adapting to extrauterine life.

Immediate Care After Birth (Phase 1)

• Thermoregulation:

  • Maintaining a neutral thermal environment is crucial to minimize heat loss and oxygen consumption.
  • Cold stress can lead to increased metabolic rate for heat generation, resulting in faster breathing and higher oxygen demand. If the newborn cannot meet this demand, hypoxia may occur.
  • Hypothermia can cause hypoglycemia as the body uses glucose for heat production. Hypoglycemia is linked to neurological problems in newborns.
  • Nursing interventions:
    • Drying the newborn with a towel to prevent evaporative heat loss.
    • Placing the infant in a radiant warmer with a skin probe for temperature monitoring.
    • Putting a hat on the infant's head to minimize heat loss from the largest body surface area.
    • Wrapping the newborn in warm blankets or facilitating skin-to-skin contact with the mother.
    • Delaying the first bath until the infant's temperature stabilizes.

• Cardiorespiratory function:

  • Gently wiping the face, nose, and mouth to remove mucus and amniotic fluid
  • Bulb suctioning of secretions for airway clearance, performed before clamping the cord.
  • Applying a cord clamp once the infant is stable in the radiant warmer.
  • Spontaneous breathing typically starts within seconds of birth.
  • Acrocyanosis (blue hands and feet) is normal due to slow peripheral circulation.
  • Oxygen via facemask may be provided until vigorous crying is established.
  • Signs of respiratory distress requiring immediate attention:
    • Persistent cyanosis beyond hands and feet
    • Grunting respirations
    • Nasal flaring
    • Retractions (under the sternum or between the ribs)
    • Sustained respiratory rate over 60 BPM
    • Sustained heart rate above 160 BPM or below 110 BPM

• Apgar Scoring:

  • Evaluates infant's condition and response to resuscitation at 1 and 5 minutes after birth.
  • Five factors: heart rate, respiratory effort, muscle tone, reflex irritability, color.
  • Scores:
    • 8-10: No action needed, continued observation.
    • 4-7: Gentle stimulation like rubbing the back, consider narcotic-induced respiratory depression.
    • < 3: Requires resuscitation.
  • Resuscitation equipment, medications, and personnel must be readily available.

• Identification:

  • Preprinted identification numbers are placed on the mother, infant, and father/support person.
  • Bands are securely placed on the infant's wrist and ankle.
  • Nurse verifies matching identification numbers every time the infant is returned to the mother.

• Urinary and Meconium Passage:

  • Urination may not occur for up to 24 hours after delivery.
  • Meconium passage can happen within 12-24 hours after birth.
  • Discharge is delayed until documentation confirms functioning GI and GU systems.

• Maternal-Infant Bonding:

  • Encourage close contact between mother and infant.
  • Once stable, place the infant in the mother's arms or facilitate skin-to-skin contact.
  • The first hour of life is ideal for initiating breastfeeding and bonding.

• Medications:

  • Eye Care: Erythromycin eye ointment is given to all newborns to prevent ophthalmia neonatorum caused by Neisseria gonorrhoeae and Chlamydia trachomatis, administered 1 hour after birth.
  • Vitamin K: AquaMEPHYTON is administered to assist with blood clotting. Newborns lack the intestinal flora needed to produce Vitamin K naturally. A single dose is given in the vastus lateralis muscle before leaving the delivery room.

• Observing for Major Anomalies:

  • Assess for normal movement and facial expressions.
  • Examine the face for trauma, especially if forceps were used.
  • Look for obvious anomalies like spina bifida or cleft lip.
  • Check arm and leg length for equality.

Transition Nursery/Postpartum Unit (Phase II)

• Care from 1-3 hours after birth.
• Usually takes place in a transition nursery or postpartum unit.

Postpartum Unit (Phase III)

• Care from 2-12 hours after birth.
• Usually occurs in the postpartum unit with rooming-in with the mother.

Skin-to-Skin Contact:

• The primary purpose of placing an infant in skin-to-skin contact with the mother immediately after birth is to maintain the infant's temperature.
• Other benefits include breastfeeding, promoting early parent-infant attachment, but temperature regulation is most critical.

Apgar Scoring Example:

• Baby Boy:
  • 1 minute: 9
  • 5 minutes: 9
• This baby is responsive and doing well, requiring no further intervention, but continued observation is necessary.

Role Playing Activity:

• Divide students into small groups.
• Each group:
  • Creates a story and name for a pregnant woman.
  • Determines her support team (partner, friend, doula, family).
  • Decides her delivery location (hospital, birthing center, home).
  • Identifies previous OB history (G’sP’s).
  • Discusses potential complications, such as previous Cesarean delivery.
  • Develops a birth plan.
  • Role-plays different stages of labor, utilizing the birth plan and applying relevant nursing interventions.