are of the Mother and Infant During Labor and Birth ELO B: Pain Management During Labor and Birth

Birthing Settings

• Hospital: Offers a traditional setting with various options, including LDR (labor, delivery, recovery) rooms and Single Room Maternity Care (LDRP) rooms.
• Hospital Advantages:
  • Preregistration for easy admission.
  • Easy access to sophisticated services and specialists in case of complications.
  • Ability to provide family-centered care for complicated pregnancies.
• Freestanding Birth Centers: Operated by hospitals but offer a home-like environment for low-risk pregnancies.
• Freestanding Birth Centers Advantages:    - Home-like setting for low-risk women.    - Lower costs due to fewer required departments.
• Freestanding Birth Centers Disadvantages:    - Slight delay in emergency care if complications arise.
• Home Births:
  • Advantages:
    • Control over who is present during labor and birth.
    • Reduced risk of acquiring pathogens from other patients.
    • A low-technology birth option.
  • Disadvantages:
    • Limited choice of birth attendants, with many professionals not attending home deliveries.      - Significant delays in reaching emergency care.      - Possibility of no pre-established relationship with a physician if an emergency transfer is needed.
  • Contraindications for Home Birth:      - Previous cesarean section.      - Malpresentation of the fetus.      - Multiple gestation.      - First-time pregnancy (primipara).      - Gestational age greater than 40 weeks.

Labor and Birth: The Four P's

• Powers:    - Uterine Contractions:        - Involuntary, coordinated, and intermittent.        - Occur during the first stage of labor (onset to full cervical dilation).        - Responsible for moving the fetus through the pelvis and opening the cervix.        - Intensity, effectiveness can be influenced by factors like walking, drugs, anxiety, and vaginal examinations.        - Cervical Changes:          - Cause effacement (thinning) and dilatation (opening) of the cervix.          - Contractions push the fetus downward while pulling the cervix upward.          - Effacement measured as a percentage of original cervix length (100% effaced feels like a thin membrane over the fetus).          - Dilatation measured in centimeters (10 cm = full dilation).          - Contraction Phases:            - Increment: Increasing strength.            - Acme or peak: Highest intensity.            - Decrement: Decreasing intensity as the uterus relaxes.        - Contraction Pattern Terminology:          - Frequency: Time between the beginning of one contraction and the next. Expressed in minutes (e.g., 3 ½ to 4 minutes apart). Contractions occurring more frequently than every 2 minutes may reduce fetal oxygen supply.
           - Duration: Length of each contraction from beginning to end. Expressed in seconds (e.g., 40-60 seconds).          - Intensity: Strength of the contraction. Described as mild, moderate, or strong, palpated externally by the nurse.          - Interval: Time between the end of one contraction and the beginning of the next. Important for placental exchange of oxygen, nutrients, and waste.    - Maternal Pushing Efforts:        - Occur during the second stage of labor (full cervical dilation to birth).        - Add voluntary force to propel the fetus through the pelvis.        - Increased intra-abdominal pressure due to contractions and pushing.        - Mothers usually feel an urge to push when the cervix is fully dilated.        - Factors like exhaustion and epidural analgesia can reduce or eliminate the natural urge.        - Premature pushing before full dilation can lead to exhaustion, fetal hypoxia, and soft tissue tearing.

• Passage:    - The mother's bony pelvis and soft tissues through which the fetus passes.    - Bony pelvis is crucial as it doesn't readily yield to labor forces, unlike soft tissues.    - False pelvis: The upper flaring part of the bony pelvis.    - True pelvis: Lower part, essential for childbirth, divided into three subdivisions:        - Inlet (top).        - Midpelvis (middle).        - Outlet (lower opening).    - The true pelvis functions like a curved cylinder with varying dimensions.    - The measurement of the pelvis must be adequate for the fetal head to pass through. Inadequate space leads to cephalopelvic disproportion, often requiring a Cesarean birth.

• Passenger:    - The fetus, including the placenta and membranes.    - The fetus typically enters the pelvis headfirst.    - Fetal Skull:        - Five major bones, not fully fused, allowing movement and overlapping during passage.        - Reshaping due to pressure is called molding.        - Sutures: Membranous spaces between the bones.        - Fontanelles: Large membranous areas where sutures meet. Palpated to determine fetal presentation during labor.          - Anterior fontanel: Larger, diamond-shaped, formed by four sutures.          - Posterior fontanel: Smaller, triangular depression formed by three sutures.    - Fetal Lie: Orientation of the fetus' long axis to the mother's long axis.        - Longitudinal: Fetal spine parallel to the mother's spine (cephalic or breech presentation). Most common.        - Transverse: Fetal spine perpendicular to the mother's spine.        - Oblique: Between longitudinal and transverse.    - Fetal Attitude: Normal attitude is flexion (head flexed to chest, arms and legs flexed over the thorax). This promotes efficient passage. Extension (head extended, arm extended) is abnormal and may prolong labor.    - Fetal Presentation: Part of the fetus that enters the pelvis first.        - Types:          - Vertex (most favorable cephalic presentation): Head fully flexed, smallest diameter enters first. Most common presentation.            - Military: Head not flexed or extended.            - Brow: Head partly extended, longest diameter of fetal head presenting.            - Face: Head fully extended, face presenting.          - Breech (second most common): Buttocks present, more difficult to deliver vaginally.            - Frank breech: Buttocks present, thighs extended. Only breech presentation that may be delivered vaginally.            - Full (complete) breech: Both fetal legs flexed at hips and knees.            - Footling breech: One or both feet presenting.          - Shoulder presentation: Spine in transverse lie, shoulder presenting first. Requires Cesarean delivery.    - Fetal Position: Relationship of the presenting fetal part to the four quadrants of the mother's pelvis (right/left anterior and posterior).        - Determined by abdominal inspection, palpation, vaginal or rectal examination, auscultation of fetal heart tones, or ultrasound.        - Expressed in abbreviations (e.g., LOA - left occiput anterior).

• Psyche:    - Woman's psychological response to labor and birth.    - Influenced by anxiety, culture, expectations, life experiences, and support.    - Excessive anxiety and fear reduce coping abilities.
         - Can inhibit uterine contractility and placental blood flow due to increased maternal catecholamines.    - Relaxed and optimistic women tolerate discomfort better.    - Culture shapes values, expectations, and responses to birth.        - Assessing individual values and expectations is crucial for providing personalized care.    - Birth is a profound physical and emotional experience.

The Labor Process:

• Impending Labor Signs and Symptoms:    - Braxton-Hicks contractions: Irregular contractions that increase in intensity as full term approaches. They do not dilate the cervix.    - Lightening: Fetus settles into the pelvic inlet, taking pressure off the diaphragm.    - Increased vaginal discharge: Clear, nonirritating mucous secretions due to fetal pressure.    - Bloody show: Thick mucous mixed with pink or brown blood, caused by cervical softening and slight dilation.    - Rupture of the membranes:
         - Amniotic sac may rupture before labor.        - Infection risk increases if there is a delay between membrane rupture and birth.        - Umbilical cord can slip down and be compressed between the pelvis and fetal presenting part.        - Prompt medical attention is needed after membrane rupture.    - Nesting: Sudden burst of energy, but women should be advised to conserve it.    - Small weight loss: 1 to 3 pounds due to hormonal changes, causing fluid excretion.

• Mechanisms of Labor:    - Maneuvers required for the fetus to move through the pelvis.    - Descent: Downward progression of the presenting part.        - Stations: Level of the presenting part in the pelvis, measured in centimeters above or below the ischial spines.          - Minus stations: Above the ischial spines.          - Plus stations: Below the ischial spines.    - Engagement: Widest diameter of the fetal head crosses the pelvic inlet. The head is "fixed" in the pelvis.        - Occurs when the presenting part reaches the level of the ischial spines (0 station or below).    - Flexion of the fetal head: Helps it pass through the pelvis most easily.    - Internal rotation: Fetal head rotates to align its largest diameter with the larger diameter of the midpelvis.    - Extension: Occiput passes under the symphysis pubis, providing leverage for the head to exit.    - Restitution: Head realigns with the body and shoulders after delivery.### Labor and Delivery Process

• Labor occurs in stages and involves the contraction of the uterus and the dilation of the cervix

• External rotation occurs as the shoulders and body move through the birth canal.

• Expulsion is the final stage of labor where the body of the infant leaves the pelvis.

Signs and Symptoms of Labor

• Increased clear vaginal discharge is a common sign that labor may be starting
• Ruptured membranes (water breaking) are also a signal, regardless of contractions
• Bright red bleeding should be evaluated promptly

Guidelines for Reporting to a Birthing Facility

• Contractions:
  • First-time mothers should go to the facility when contractions are 5 minutes apart for an hour
  • Mothers in their second labor or more should go sooner, when regular contractions are 10 minutes apart for an hour.
• Ruptured Membranes: The woman should go to the facility when her membranes rupture.
• Bleeding: Bright red bleeding should be evaluated promptly.
• Decreased Fetal Movement: The woman should be evaluated if the fetus is moving less than usual.

Admission Assessments

• The nurse establishes a therapeutic relationship with the patient and family.
• The nurse will obtain a written birthing plan and information about the family members assisting with care.
• The nurse performs three prompt assessments:
  • Fetal Condition:
    • Fetal heart rate (FHR) is assessed with a fetoscope, Doppler transducer, or external fetal monitor (EFM).
    • If membranes are ruptured, the fluid's color, amount, and odor are assessed.
  • Maternal Condition: Temperature, pulse, respirations, and blood pressure are assessed for signs of infection or hypertension.
  • Impending Birth: The nurse should be prepared to call for help and assist in an emergency delivery.

Admission Procedures

• Consent forms are signed for care during labor, delivery, and postpartum.
• Laboratory tests often include a CBC (Complete Blood Count) and a midstream urine specimen for glucose and protein.
• Women with no prenatal care may need additional labs like drug screens, sexually transmitted infection tests, etc.
• An intravenous line is established for fluid and medication administration.
• Perineal preparation for delivery involves cleansing the perineal area.

True vs. False Labor

• Characteristics of true labor:
  • Contractions have a regular pattern and increase in frequency, duration, and intensity.
  • Contractions become stronger with walking.
  • Discomfort begins in the lower back and travels to the lower abdomen.
  • Progressive effacement and dilation of the cervix occur.
• Characteristics of false labor:
  • Contractions are inconsistent in frequency, duration, and intensity.
  • Walking tends to relieve or decrease contractions.
  • Discomfort is felt primarily 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 and allow prompt interventions.
• Intermittent Auscultation:
  • Allows for greater freedom of movement, ideal for early labor and home births.
  • Requires accurate documentation of FHR.
• Continuous Electronic Fetal Monitoring (EFM):
  • Collects more data on the FHR and contractions, can be external or internal.
  • Internal monitoring requires ruptured membranes and cervical dilation of 1-2 cm.
• Stand FHR monitoring: Every 30 minutes during the active phase of labor and every 15 minutes in the second stage.
• Evaluating Fetal Rate Patterns:
  • Baseline Rate: Average FHR over 10 minutes, should be 110-160 BPM.

Fetal Heart Rate Deviations

• Bradycardia: FHR less than 110 beats per minute for 10 minutes or longer.
• Tachycardia: FHR greater than 160 beats per minute for 2-10 minutes or longer.
• Baseline Variability: Fluctuation in baseline FHR.
  • Moderate Variability: 6-25 beats per minute change, considered reassuring.
  • Marked Variability: More than 25 beats per minute change.
  • Absent Variability: Less than 6 beats per minute change, can indicate complications.
• Episodic Changes: Non-contraction-related changes in FHR.
• Periodic Changes: Contraction-related changes in FHR, including:
  • Accelerations: Temporary, abrupt increase in FHR, considered reassuring.
  • Early Decelerations: Gradual, temporary decrease in FHR during contractions.
  • Variable Decelerations: Sudden drops in FHR that may indicate cord compression.
  • Late Decelerations: Decelerations that start after the contraction begins and return to baseline after contraction ends, may indicate placental insufficiency.
  • Prolonged Decelerations: Abrupt FHR decrease lasting longer than 60 seconds

Nursing Response to Fetal Monitoring

• Nursing responses depend on the FHR pattern and category.
• Reassuring Patterns: Accelerations and early decelerations require ongoing observation.
• Non-reassuring Patterns:
  • Variable Decelerations: Position changes are often implemented.
  • Late Decelerations: Interventions to improve fetal oxygenation may include:
    • Position changes
    • Supplemental oxygen
    • IV fluids
    • Medications to reduce uterine activity
    • Amnioinfusion

Amniotic Fluid

• Inspection of Amniotic Fluid: Color, odor, and amount are recorded.
  • Normal Color: Clear with possible flecks of white vernix.
  • Green-Stained Fluid: May indicate meconium passage and potential respiratory issues at birth.
  • Cloudy or Yellow Fluid with Odor: May indicate infection.

Monitoring the Mother

• Vital Signs: Checked every 4 hours, then every 2 hours if elevated or if membranes are ruptured.
• Contractions: Assessed by palpation or continuous electronic fetal monitoring.
• Progress of Labor: Determines cervical dilation, effacement, and fetal descent.
• Intake and Output: Recording of urination, monitor for bladder distention.
  • Ice chips, popsicles, or hard sugarless lollipops are allowed to keep the mouth moist.
  • Food intake is restricted during active labor.
• Response to Labor: Assess the woman's use of breathing and relaxation techniques, and support adaptive responses.

Helping with Coping During Labor

• Maintaining control of the environment
• Encouraging upright positions during labor
• Teaching breathing & relaxation techniques
• Providing emotional support
• Ensuring partner involvement
• Helping the woman to use different positions
• Making adjustments to birth plan as necessary

Childbirth Pain

• Childbirth pain is a normal part of labor.
• It can be beneficial as it motivates a woman to seek help and assume positions that facilitate fetal descent.
• Several factors influence a woman's experience of pain during labor:
  • Pain threshold and tolerance
  • Sources of pain during labor
  • Physical factors
  • Maternal condition
  • Fetal presentation and position
  • Caregiver interventions
  • Psychosocial and cultural factors
  • Pain perception or threshold is the least amount of sensation a person perceives as painful.
  • Pain tolerance is the amount of pain a person is willing to endure.
• Pain during labor is often caused by the dilation and stretching of the cervix, reduced uterine blood supply during contractions, pressure of the fetus on pelvic structures, and stretching of the vagina and perineum.
• The gate control theory proposes that stimulation of nerve fibers can interfere with the transmission of pain impulses to the brain.

Pain Management Techniques

• Nonpharmacological pain control methods help women cope with labor.
• Some examples of nonpharmacological pain control methods include:
  • Relaxation
  • Skin stimulation
  • Thermal stimulation
  • Positioning
  • Diversion and distraction
• Nonpharmacological pain management does not harm the mother or the fetus, does not slow labor, and carries no risk for allergy or adverse drug effect.
• Relaxation techniques involve occupying the mind to reduce muscle tension, such as adjusting the environment, offering a warm shower, or educating the woman on identifying and releasing tension.
• Skin stimulation techniques include effleurage, sacral pressure, and thermal stimulation.
• Positioning changes relieve muscle fatigue and strain, while facilitating the normal mechanisms of labor.
• Diversion and distraction involve mental stimulation, limiting the woman's ability to perceive sensations as painful.
• Endorphin levels increase during pregnancy and reach a peak during labor, which explains why women often need less analgesia than could be expected for a similar painful experience.

Labor Stages

• Labor is divided into four stages:
  • First stage: dilation and effacement
  • Second stage: delivery
  • Third stage: delivery of the placenta
  • Fourth stage: stabilization

First Stage of Labor

• The first stage of labor begins with the onset of regular contractions and ends with full dilation of the cervix (10 cm).
• The first stage is the longest stage of labor, typically averaging 7.3 to 8.6 hours for the nullipara and 4.1 to 5.3 hours for the multipara.
• The first stage is divided into three phases:
  • Latent phase (4-6 hours): cervix dilates to 4 cm.
  • Active phase (2-6 hours): cervix dilates from 4-7 cm, amniotic membranes may rupture, contractions are 2 to 5 minutes apart, and intensity is moderate to firm.
  • Transitional phase (30 min – 2 hours): cervix dilates from 7-10 cm, cervix is fully effaced, contractions occur at 2-3 minutes apart, and intensity is firm.
• Nursing interventions for the first stage include:
  • Establishing a positive relationship with the woman
  • Encouraging alternating ambulation and rest
  • Assessing FHR
  • Monitoring vital signs every 2 hours
  • Providing comfort measures and encouragement
  • Supporting the coach
  • Facilitating position changes
  • Maintaining communication with the HCP

Second Stage of Labor

• The second stage of labor begins with complete dilation at 10 cm and ends with the birth of the baby.
• The average length of this stage is 30 minutes to 2 hours.
• 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.
• Nursing interventions for the second stage include:
  • Assisting the woman to assume a position that helps her push
  • Assisting with open glottis pushing technique and coping strategies
  • Supporting the coach
  • Maintaining communication with the HCP
  • Assessing the perineum and vaginal discharge
  • Reporting bulging and crowning
  • Observing for bladder distention
  • Preparing sterile supplies for delivery
  • Preparing infant resuscitation equipment
  • Providing feedback to the woman and partner

Third Stage of Labor

• The third stage of labor begins with the delivery of the baby and ends with the delivery of the placenta.
• The average time for both primiparas and multiparas is 5-30 minutes.
• Signs of placental separation include:
  • Lengthening of the cord
  • Uterine fundus rises and becomes firm
  • Fresh blood expelled from the vagina
• The placenta can be delivered in two ways:
  • Schultze Mechanism: the placenta is expelled with the shiny fetal side presenting first.
  • Duncan Mechanism: the rough maternal side is presenting.
• Nursing interventions for the third stage include:
  • Observing and documenting blood loss
  • Documenting delivery of the placenta
  • Examining the placenta to determine if all of it was expelled.
  • Monitoring the mother’s vital signs every 15 minutes
  • Assessing vaginal discharge
  • Massaging the uterus until it is firm is midline or below the level of umbilicus
  • Administering oxytocin to the mother as ordered
  • Obtaining cord blood if needed
  • Noting parent-infant interaction
  • Drying the newborn and placing in a radiant warmer
  • Attaching heart and temperature monitor
  • Assessing and providing immediate newborn care
  • Performing Apgar evaluation
  • Applying proper identification to the mother, infant, and partner

Fourth Stage of Labor

• The fourth stage of labor begins with the delivery of the placenta and ends when the mother's body has stabilized.
• The fourth stage generally lasts from 1 to 4 hours following delivery.
• It is crucial to monitor the woman’s vital signs, especially blood pressure, pulse, and respiratory rates,
• Nursing interventions for the fourth stage include:
  • Providing proper identification of the mother, partner, and newborn
  • Obtaining cord blood if needed
  • Assessing the 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.
  • Assessing the mother’s voiding
  • Monitoring the heart rate and temperature of the newborn. Provide warmth to the newborn.
  • Assessing the newborn for anomalies
  • Assessing fundus and massaging to maintain firm contraction. A fundus that is displaced indicates a full bladder is pressing against it
  • Assessing lochia and observing for hemorrhage
  • Changing the mother’s gown and underpads
  • Encouraging breastfeeding
  • Encouraging bonding between the parents and the infant.

Nonpharmacological Pain Management

• Focal Point Technique: Woman focuses on a photo, object, or spot in the room during a contraction to distract from pain.
• Imagery: Woman creates a tranquil mental environment by imagining a relaxing place.
• Music: Woman uses music to focus attention away from pain and block out disturbing sounds.
• Breathing Techniques: Effective when practiced ahead of time, begin and end with a cleansing breath.

Breathing Techniques - First Stage

• Slow-Paced Breathing: Woman breathes slowly, as during sleep, during contractions.
• Modified-Paced Breathing: Woman breathes rapid and shallow, at twice her usual rate, during contractions.
• Patterned-Paced Breathing: Woman breathes rapid breaths punctuated with an intermittent blow.

Breathing Techniques - Second Stage

• Pushing: Woman takes a cleansing breath, followed by a deep breath, pushes down while exhaling (open glottis pushing) to a count of 10.

Nursing Role in Nonpharmacological Techniques

• Nurse assesses a woman's prior knowledge and preparation.
• Nurse guides and educates woman on simple techniques.
• Nurse minimizes environmental stimuli.
• Nurse assesses pain and adequacy of relief measures.

Pharmacological Pain Management

• Includes analgesics, adjunctive drugs, and anesthetics.
• Specific factors in the physiology of pregnancy affect the pregnant woman’s response to analgesia and anesthesia.

Adverse Effects on the Mother

• Higher risk of hypoxia from pressure of the gravid uterus on the diaphragm.
• Sluggish gastrointestinal tract increases risk of vomiting and aspiration.
• Aortocaval compression increases risk of hypotension and development of shock.

Adverse Effects on the Fetus

• Any drugs effects may directly affect the fetus, indirectly affect the fetus due to maternal effects, or be prolonged in the infant after birth.

Analgesics

• Systemic drugs that reduce pain without loss of consciousness.

Narcotic (Opioid) Analgesics

• Used in frequent, small doses to avoid fetal respiratory depression.
• Examples include Meperidine (Demerol), Fentanyl (Sublimaze), Nalbuphine (Nubain).
• Safety protocols must be implemented to include raising side rails, maintaining close observation, and having naloxone readily available.

Narcotic Antagonist

• Naloxone (Narcan) is used to reverse respiratory depression caused specifically by opioids.
• Administered via IV route, endotracheal tube, and umbilical cord vein.

Adjunctive Drugs

• Improve the effectiveness of analgesics or counteract their side effects.
• Benzodiazepines help to relieve anxiety and nausea.

Anesthetics

• Cause a loss of sensation, especially of pain.

Anesthetics - Inhaled

• Nitrous oxide via face mask during the peak of a contraction can decrease the awareness of pain.
• May cause nausea and dizziness.

Anesthetics - Regional

• Epidural Block: Provides pain relief during labor and delivery.
  • Catheter is threaded into place in the epidural space, just outside the dura.
  • Epidurals often combine anesthetic drugs with a small dose of opioid analgesic.
  • May not be used in the event of abnormal blood clotting, local or severe systemic infection, or hypovolemia.
  • Adverse effects may include maternal hypotension, urinary retention, and delayed birth and hemorrhage.
• Subarachnoid (Spinal) Block: Provides pain relief for cesarean deliveries.
  • A thin needle is inserted into the subarachnoid space, located between the arachnoid mater and the pia mater.
  • Similar limitations as the epidural block.
  • Adverse effects may include maternal hypotension, urinary retention, and postspinal headache.
• Local Block: Injection of anesthetic to numb the perineal area in the event of an episiotomy or for postpartum laceration repair.
• Pudendal Block: Anesthetic is injected into the pudendal nerves to numb the vaginal and perineal area.
  • Adverse effects may include vaginal hematoma and abscess.

Anesthetics - General

• Rarely used, but may be necessary under the following circumstances:
  • Emergency cesarean delivery.
  • Cesarean delivery for a woman who refuses or has contraindications to an epidural or subarachnoid block.
• Adverse maternal effects include potential for regurgitation with aspiration, resulting in aspiration pneumonitis.
• Adverse neonatal effects include respiratory depression due to maternal anesthesia crossing the placenta.

Nursing Role in Pharmacological Techniques

• Thorough admission intake including allergies, pain relief preferences, potential pain relief factors, last oral intake, and medications taken.
• Maintain safety (especially if narcotics or blocks are administered).
• Provide education and reinforce explanations of procedures and expected effects in regards to pain management.
• Assist the healthcare provider during anesthetic procedures.
• Manage medication effects and patient response.

Maternal Nursing Care Immediately After Birth

• Fourth Stage of Labor assessment includes:
  • Vital signs, including temperature.
  • Skin color.
  • Location and firmness of the uterine fundus.
  • Presence and location of pain.
  • IV infusion and medications.
  • Fullness of the bladder or urine output from a catheter.
  • Condition of the perineum for vaginal birth.
  • Condition of dressing for cesarean birth or tubal ligation.
  • Level of sensation and the ability to move lower extremities if an epidural or spinal block is used.
  • Observing for hemorrhage.
  • Promoting comfort with warmth and ice packs as needed.

Newborn Nursing Care Immediately After Birth

• Care is divided into three "transitional phases" to adapt 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: Increases metabolic rate to generate heat, leading to increased respiratory rate and oxygen consumption.
  • Hypothermia: Can cause hypoglycemia as the body uses glucose for heat production.
  • Nursing interventions:
    • Drying the infant with a towel to prevent evaporative heat loss.
    • Placing the infant in a radiant warmer with a skin probe for temperature monitoring.
    • Placing a hat on the infant's head, as the head is the largest surface area for heat loss.
    • 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 stabilizes.

• Cardiorespiratory Function:

  • Respiratory support: Gently wiping the face, nose, and mouth to remove mucus and amniotic fluid.
  • Suctioning: Gentle bulb suctioning of secretions from the nose and mouth to clear airways.
  • Cord clamp: Applied when the infant is stabilized in the radiant warmer.
  • Spontaneous breathing: Usually begins shortly after birth, and the infant's skin color should turn pink as they cry.
  • Acrocyanosis: Bluish color of hands and feet is normal due to sluggish peripheral circulation. Oxygen by facemask may be used until the infant is breathing vigorously.
  • Signs of respiratory distress: Persistent cyanosis, grunting respirations, flaring nostrils, retractions, sustained respiratory rate > 60 BPM, sustained heart rate > 160 BPM or < 110 BPM.

• Apgar Scoring: Evaluates the infant's condition and response to resuscitation. Five factors are evaluated at 1 minute and 5 minutes after birth:

  • Heart rate
  • Respiratory effort
  • Muscle tone
  • Reflex irritability
  • Color
  • Scoring:
    • 8-10: No action required.
    • 4-7: Gentle stimulation may be needed.
    • < 3: Infant requires resuscitation.

• Infant Identification:

  • Pre-printed identification bands are placed on the mother, infant, and father/support person.
  • Bands are snugly fit on the infant's wrist and ankle, as infants lose weight after birth.
  • Footprints, fingerprints, and photographs may be taken for identification purposes.

• Urinary Function and Meconium Passage:

  • Newborns may not urinate for up to 24 hours after delivery.
  • Meconium may be passed within 12-24 hours after delivery.
  • Infants cannot be discharged until documentation of functioning GI and GU systems is available.

• Maternal-Infant Bonding:

  • Encourage skin-to-skin contact and breastfeeding in the first hour of life, as the infant is alert.

• Medications:

  • Erythromycin eye ointment: Administered to prevent ophthalmia neonatorum.
  • Vitamin K: Given to assist with blood clotting.

• Observing for Major Anomalies: Assess for normal movement, facial expressions, trauma, and limb symmetry.

Phase II (1-3 Hours After Birth)

• Transition nursery or postpartum unit.

Phase III (2-12 Hours After Birth)

• Postpartum unit, often with rooming-in with the mother.

Birthing Settings

• There are three main birthing settings: hospital, birthing center, and home.
• Hospitals offer traditional settings, LDR rooms, and Single Room Maternity Care (LDRP).
• Advantages of a hospital setting: pre-registration, easy access to specialized services, and family-centered care for complicated pregnancies.
• Advantages of a birthing center: home-like setting, lower costs, and continuity of care from a Certified Nurse Midwife (CNM).
• Disadvantages of a birthing center: potential delay in emergency care.
• Advantages of a home birth: control over who is present, low-technology birth, and no exposure to other patients.
• Disadvantages of a home birth: limited choice of birth attendants, potential delay in emergency care, and lack of pre-established relationship with a physician.
• Contraindications for home birth include previous cesarean section, malpresentation, multiple gestation, primipara, and gestational age greater than 40 weeks.

Components of the Birthing Process (The "Four P's")

• Powers are the forces that propel the fetus through the birth canal.
  • Uterine contractions: involuntary, coordinated, and intermittent.
  • Maternal pushing efforts: voluntary pushing during the second stage of labor.
• Passage refers to the maternal bony pelvis and soft tissues.
  • Bony pelvis: important for the outcome of labor.
  • True pelvis: divided into three subdivisions: inlet, midpelvis, and outlet.
• Passenger is the fetus, placenta, and membranes.
  • Fetal skull: bones allow for molding during labor.
  • Sutures: membranous spaces between skull bones.
  • Fontanelles: large membranous areas where sutures meet.
  • Fetal lie: orientation of the fetal spine to the maternal spine (longitudinal, transverse, oblique).
  • Fetal attitude: posture of the fetus (flexion is normal).
  • Fetal presentation: the fetal part that enters the pelvis first (vertex, breech, shoulder).
    • Vertex presentation: head fully flexed, most favorable.
    • Breech presentation: buttocks enter the pelvis first.
    • Shoulder presentation: requires cesarean delivery.
  • Fetal position: relationship of the presenting part to the four quadrants of the maternal pelvis (expressed in abbreviations: LOA, ROA, etc.).
• Psyche: woman's psychological response to labor and birth.
  • Influenced by anxiety, culture, expectations, and support.
  • Relaxation and optimism improve coping.

Labor Process

• Impending Labor: signs and symptoms that labor is about to start.
  • Braxton-Hicks Contractions: irregular contractions that prepare the cervix.
  • Lightening: fetus descends into the pelvic inlet.
  • Increased Vaginal Discharge: clear mucus secretions.
  • Bloody Show: mixture of mucus and blood.
  • Rupture of Membranes: may occur before labor begins.
  • Nesting: sudden increase in energy.
  • Weight Loss: small weight loss due to fluid changes.
• Mechanisms of Labor: maneuvers required for the fetus to move through the pelvis.
  • Descent: downward progression of the presenting part.
  • Engagement: widest diameter of the fetal head crosses the pelvic inlet.
  • Flexion: fetal head flexes to facilitate passage.
  • Internal Rotation: aligns the largest fetal diameter with the largest pelvic diameter.
  • Extension: head extends as it passes under the symphysis pubis.
  • Restitution: head realigns with the fetal body after delivery.

Admission to the labor unit

• Nurses need to educate patients at the end of the trimester on when to go to a birthing facility.

• Women in their first labor should go to the hospital when contractions are five minutes apart for an hour.

• Women having their second or more babies should go to the facility sooner, when contractions are ten minutes apart for one hour.

• If a woman's membranes have ruptured, she should go to a birthing center.

• Bright red bleeding should be evaluated promptly.

Admission Assessments

• The nurse establishes a therapeutic relationship with the patient and her family.
• The three assessments performed promptly on admission are: fetal condition, maternal condition, and impending birth.

Fetal Condition Assessment

• For a term fetus, the fetal heart rate (FHR) is assessed with a fetoscope, Doppler transducer, or external fetal monitor (EFM).
• When the amniotic membranes are ruptured, the color, amount, and odor of the fluid are assessed, and the FHR is recorded.

Maternal Condition Assessment

• Temperature, pulse, respirations, and blood pressure are assessed for signs of infection or hypertension.

Impending Birth Assessment

• Behaviors that may suggest a mother is about to give birth include:
  • sitting on one buttock
  • grunting sounds
  • bearing down with contractions
  • stating "The baby's coming"
  • bulging of the perineum/visualization of head
• If the birth is imminent, the nurse should not leave the patient but call for help. Gloves should be put on, and a precipitous (precip) pack/emergency delivery kit should be in reach.

Admission Procedures

• Consent forms are signed for care during labor, delivery, and the post-birth period.
• Blood for hematocrit (CBC usually sent) and a midstream urine specimen for glucose and protein are obtained.
• An IV line allows administration of fluids and drugs.
• The perineal area should be cleansed for delivery.
• Fetal position and presentation are determined using Leopold maneuvers and a vaginal exam.

### 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 that make a woman believe she is in labor, but there is 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

• Nursing care consists of the following elements: monitoring the fetus, monitoring the laboring woman, and helping the woman cope with labor.
• Intrapartum care of the fetus includes assessment of FHR patterns and the amniotic fluid.
• The goal of fetal monitoring is to identify fetal hypoxia early to allow prompt interventions that will avoid fetal injury.

Fetal Heart Rate (FHR) Monitoring

• Intermittent auscultation allows the mother greater freedom of movement.
  • It doesn’t allow automatic recording of the FHR.
  • It is done with a fetoscope or a Doppler transducer.
• 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 externally or internally.
    • Internal devices require the membranes to be ruptured and the cervix dilated 1-2 cm.
    • External EFM is done by a Doppler transducer and a tocotransducer.

### Evaluating Fetal Heart Rate Patterns

• Evaluated for baseline rate, baseline variability, episodic changes, and periodic changes.
• Baseline fetal heart rate is the average heart rate that occurs for at least 2 minutes during a 10-minute period.
• Fetal Bradycardia FHR is less than 110 beats per minute for 10 minutes or longer.
  • Causes: 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: 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.
• Accelerations are temporary, abrupt rate increases of at least 15 beats per minute above baseline FHR. This pattern is very “reassuring.”
• 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. They suggest that the umbilical cord is being compressed or because there is inadequate amniotic fluid to cushion the chord.
• 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. They indicate that the placenta is not delivering enough oxygen to the fetus (uteroplacental insufficiency). Late decelerations accompanied by decreased variability and absent accelerations are non-reassuring and require immediate intervention by the health care provider.
• Prolonged Decelerations are abrupt FHR decreases of at least 15 beats per minute below baseline that last longer than 60 seconds. The is caused by a cord compression or prolapse, maternal supine hypotension, or regional anesthesia.

Nursing Response to Monitoring Patterns

• The significance depends on the pattern or category of Fetal Heart Rate Tracing (I, II, or III).
• Accelerations and early decelerations are reassuring patterns and thus necessitate no intervention other than continued observation.
• Variable decelerations may necessitate changing positions. Changing the mother’s position can relieve pressure on the umbilical cord and can improve blood flow through it. The woman is turned to her left side.
• FHR monitoring is to assess the adequacy of oxygenation and uterine activity. Corrective actions can be taken to restore 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.
  • Implement amnioinfusion to restore fluid to the uterus relieving pressure on the cord.
  • Use altered pushing and breathing techniques.

Amniotic Fluid

• The color, odor, and amount of fluid are recorded.
  • Normal color is clear, possibly with flecks of white vernix.
  • Green-stained fluid may indicate the fetus has passed meconium before birth, a situation associated with fetal compromise.
  • Cloudy or yellow amniotic fluid with an offensive odor may indicate an infection and should be reported immediately.
  • Marked slowing of the rate or variable decelerations suggest that the fetal umbilical cord may have descended with the fluid gush and is being compressed.

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 are checked every 4 hours, then every 2 hours if elevated or if ruptured membranes.
  • 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.
• The progress of labor is determined by 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 includes 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 during Labor:

• The nurse helps the woman to cope with labor by comforting, positioning, teaching, and encouraging her.

• Control the environment by playing familiar music brought from home.

• Maintaining an upright position during labor can shorten the first stage of labor.

• Different positions can help facilitate anterior rotation of the fetus.

  • positions such as a lunge or squatting with contractions.### Labor and Birth

• 5 cm dilation is approximately two-thirds of labor completed; the rate of progress increases

• Pushing before full cervical dilation can cause maternal exhaustion and fetal hypoxia.

• Laboring down allows passive fetal descent during the second stage of labor.

• Providing encouragement during labor is empowering.

• Supporting the partner allows them to participate comfortably and avoid taking over the role of the nurse.

Stages of Labor

• First Stage (Dilation and Effacement):

  • Latent Phase (4-6 hours):
    • Cervical dilation 4 cm
    • Amniotic membranes may be intact.
    • Contractions every 20 minutes decreasing to 5 minutes apart, lasting 15-40 seconds.
    • Intensity mild to moderate.
  • Active Phase (2-6 hours):
    • Cervical dilation 4-7 cm.
    • Amniotic membranes may rupture.
    • Contractions 2 to 5 minutes apart and lasting about 40 to 60 seconds.
    • Intensity moderate to firm.
  • Transitional Phase (30 min – 2 hours):
    • Cervical dilation 7-10 cm.
    • Cervix is fully effaced.
    • Amniotic membranes rupture.
    • Contractions 2-3 minutes apart and lasting 60 to 90 seconds.
    • Intensity firm.

• Second Stage: Delivery:

  • Complete cervical dilation (10 cm) and full effacement.
  • Usually lasts 30 minutes to 2 hours.
  • Contractions every 1-3 mins, lasting 60-80 seconds, intensity firm.

• Third Stage: Delivery of the Placenta:

  • Starts with the delivery of the baby and ends with the delivery of the placenta.
  • Lasts 5-30 minutes.
  • Contractions are intermittent and intensity mild to moderate.

• Fourth Stage: Stabilization

  • Uterus remains midline, firmly contracted at or below the umbilicus level.
  • Lochia rubra saturates the perineal pad (no more than one pad per hour).

Pain Management During Labor

• Nonpharmacological Techniques:
  • Relaxation: adjusting the environment, providing a warm shower or tub, educating the woman on identifying signs of tension.
  • Skin stimulation: Effleurage, sacral pressure, thermal stimulation.
  • Positioning: Frequent changes relieve muscle fatigue and strain.
  • Diversion and distraction: Mental stimulation to limit pain perception.

Labor Pain

• Sources of pain:
  • Dilation and stretching of the cervix.
  • Reduced uterine blood supply during contractions (ischemia).
  • Pressure of the fetus on pelvic structures.
  • Stretching of the vagina and perineum.
  • Fatigue.
  • Fetal presentation and position.

Prepared Childbirth Classes

• Focus on teaching methods to cope with labor and provide support during this process.

Nursing Interventions:

• First Stage of Labor:

  • Establish a positive relationship with the mother.
  • Encourage ambulation and rest.
  • Review breathing and relaxation techniques.
  • Assess fetal heart rate.
  • Document vaginal discharge color.
  • Assess for bladder distention.
  • Provide opportunities to void.
  • Provide moistening mouth care.
  • Monitor IV fluid intake.
  • Maintain warmth and provide comfort measures.

• Second Stage of Labor: - Assist with positioning for pushing. - Support the partner and coach. - Monitor fetal heart rate and contractions. - Assess the perineum, vaginal discharge, and observe for bulging and crowning. - Prepare sterile supplies for delivery. - Prepare infant resuscitation equipment.

• Third Stage of Labor: - Observe and document blood loss. - Document delivery of the placenta. - Examine the placenta. - Monitor maternal vital signs every 15 minutes. - Massage the uterus. - Administer oxytocin as ordered. - Perform newborn care, including Apgar evaluation. - Apply proper identification to mother, infant, and partner.

• Fourth Stage of Labor: - Monitor vital signs every 15 minutes for 1 hour, every 30 minutes during the second hour, and hourly thereafter. - Assess voiding. - Monitor newborn’s heart rate and temperature. - Assess the fundus, massage to maintain firm contraction. - Assess lochia and observe for hemorrhage. - Change the mother’s gown and underpads. - Encourage breastfeeding. - Encourage bonding between parents and infant.

Nursing Interventions Requiring Immediate Action:

• Fetal heart rate of 90 BPM between contractions.
• Maternal tachysystole.
• Fetal heart rate baseline variability.

Nursing Interventions Requiring Observation and Assessment:

• Contractions lasting 60 seconds with an interval of 90 seconds.

Key Nursing Interventions:

• Observing, assessing, and documenting maternal and fetal well-being is essential throughout labor and delivery.

• Providing interventions to maintain a safe, comfortable, and supportive environment.

• Being proactive when assessing for possible complications.

• Partnering with the patient and their family.

• Supporting the mother’s psychological and physical needs throughout labor.### Nonpharmacological Pain Management

• Focal point technique: Woman closes her eyes or focuses on an object to distract from pain.

• Imagery: Woman visualizes a relaxing place to calm her mind.

• Music: Helps divert attention from pain and block out disturbing sounds.

• Breathing techniques: Most effective when practiced beforehand.

  • Slow-paced breathing: Slow, deep breaths during contractions.
  • Modified-paced breathing: Rapid, shallow breaths during contractions.
  • Patterned-paced breathing: Rapid breaths with intermittent blows (“hee hoo” breathing).

Pharmacologic Pain Management

• Analgesics: Relieve pain without loss of consciousness.

  • Narcotic analgesics: Used in small doses, avoided before birth to reduce fetal respiratory depression (eg: Meperidine, Fentanyl, Nalbuphine).
  • Narcotic antagonist: Naloxone (Narcan) used to reverse opioid-induced respiratory depression.

• Adjunctive drugs: Improve analgesic effectiveness or counteract side effects (eg: Benzodiazepines).

• Anesthetics: Cause loss of sensation, typically pain.

  • Inhaled (Nitrous oxide): Used during contractions for pain relief, may cause nausea and dizziness.
  • Regional:
    • Epidural block: Provides pain relief during labor and delivery.
    • Subarachnoid (spinal) block: Used for Cesarean delivery, provides a more profound block.
    • Local block: Numbs perineal area for procedures like episiotomy.
    • Pudendal block: Numbs vaginal and perineal areas for vaginal birth or procedures.
  • General: Rarely used, may be necessary in emergencies.

Nursing Role in Pain Management

• Assessment: Collect complete maternal history for allergies, medications, pain relief preferences, and factors affecting pain management options.
• Safety:* Maintain precautions for patients receiving narcotics or regional anesthesia.
• Education: Reinforce explanations of procedures and expected pain management effects.
• Assistance: Assist healthcare providers during procedures, manage medication effects and patient responses.

Maternal Care Immediately After Birth

• Assessment Schedule: Every 15 minutes for the first hour, then every 30 minutes for the next hour, and hourly after that until transfer to postpartum.
  • Vital signs: Including temperature, assess for fever.
  • Skin color: Assess for changes.
  • Uterine fundus: Ensure midline position, firm contraction, and appropriate location.
  • Pain: Assess location and intensity.
  • IV infusion and medications: Monitor ongoing infusions and administered drugs.
  • Bladder: Assess for fullness or urine output from catheter.
  • Perineum: Inspect for condition after vaginal birth.
  • Cesarean dressing: Assess condition.
  • Sensation: Check for return of sensation and movement if epidural or spinal block was used.
  • Hemorrhage: Observe for signs of bleeding, including quantity, color, and clotting.
• Comfort:
  • Provide warm blanket to help reduce chills.
  • Apply ice pack to perineum as needed.

Newborn Care Immediately After Birth

• Transitional phases: Newborn adapts to extrauterine life through three phases.

Immediate Newborn Care (Birth to 1 Hour)

• Maintaining Thermoregulation

  • Drying the infant with a towel to prevent heat loss through evaporation of amniotic fluid
  • Placing the infant in a radiant warmer with a skin probe placed on the right upper abdomen for temperature regulation
  • Placing a hat on the infant's head after drying to minimize heat loss from the largest body surface area
  • Wrapping the infant in warm blankets or promoting skin-to-skin contact with the mother for warmth
  • Delaying the first bath until the infant's temperature stabilizes at 36.5-37°C

• Maintaining Cardiorespiratory Function:

  • Gently wiping the face, nose, and mouth to remove mucus and amniotic fluid
  • Gentle bulb suctioning of secretions from the nose and mouth to clear airways
  • Applying a cord clamp after the infant is stabilized in the radiant warmer
  • Observing for spontaneous breathing, which usually starts within seconds after birth
  • Acrocyanosis (blue hands and feet) is normal and caused by sluggish peripheral circulation
  • Administering oxygen by face mask if the infant is not crying vigorously

• Apgar Scoring:

  • Evaluates the infant's condition and response to resuscitation at 1 and 5 minutes after birth.
  • Five factors are assessed and scored: heart rate, respiratory effort, muscle tone, reflex irritability, and color.
  • Scores of 8-10 require no action other than continued observation and support.
  • Scores of 4-7 require gentle stimulation (e.g., rubbing the back) and consideration of narcotic-induced respiratory depression.
  • Scores less than 3 necessitate resuscitation.

• Identifying & Observing:

  • Preprinted identification numbers are placed on the mother, infant, and father or support person.
  • Ensure the identification bands are fitted snugly on the infant's wrist and ankle.
  • Footprints and fingerprints are often taken for identification purposes.
  • Observe for urinary function and meconium passage; they may not occur for up to 24 hours after delivery.
  • Infants cannot be discharged until documentation confirms the GI and GU systems are functioning.

• Promoting Maternal-Infant Bonding:

  • Facilitate skin-to-skin contact after the infant is stable, promoting warmth and early bonding.
  • The first hour of life is the ideal time for breastfeeding and bonding as the infant is usually alert.

• Administering Medications:

  • Erythromycin eye ointment is placed in each eye to prevent ophthalmia neonatorum caused by Neisseria gonorrhoeae and Chlamydia trachomatis.
  • Vitamin K (AquaMEPHYTON) is administered in the vastus lateralis muscle to assist in blood clotting.

• Observing for Major Anomalies:

  • Assess the infant's movement, facial expressions, and for trauma, especially if forceps were used.
  • Inspect the face, arms, and legs for immediately obvious anomalies.

Transition Nursery/Postpartum Unit (1-3 Hours After Birth)

Postpartum Unit (2-12 Hours After Birth)

Learning Check Question & Answer

• Question:* The term infant may be placed in skin-to-skin contact with the mother immediately after birth primarily for the purpose of:
• Answer:*
• Maintaining the infant's temperature.
• Rationale:*
• Skin-to-skin contact helps maintain the infant's temperature by transferring heat from the mother, preventing heat loss.
• While breastfeeding and early attachment are indeed important, the primary focus in the immediate period after birth is thermoregulation.
• The placenta is usually expelled before the infant is placed in skin-to-skin contact.

Apgar Scoring:

• Heart Rate:

  • 125 bpm at 1 minute
  • 155 bpm at 5 minutes

• Respiratory Effort:

  • Strong cry at 1 minute
  • Reacts spontaneously at 5 minutes

• Muscle Tone:

  • Flexed body at 1 minute
  • Maintains flexion at 5 minutes

• Reflex Irritability:

  • Cries and flexes body when suctioned at 1 minute
  • Cries when suctioned or stimulated at 5 minutes

• Color:

  • Pink body, blue hands and feet at 1 and 5 minutes

• Total Score:*

• 1 minute: 9

• 5 minutes: 9

• Conclusion:* This baby is responsive and doing well, requiring no further intervention but should continue to be observed.

In-Class Activity

• Students will be divided into small groups.
• Each group will create a story and name for a pregnant woman.
• They will determine the woman's support team (partner, friend, doula, family) and planned delivery location.
• They will consider the woman's previous OB history (G'sP's), any complications, and if she has had a previous cesarean delivery.
• Groups will develop a birth plan for the woman.
• Squads will role-play the assigned scenario, with each member taking on a role (nurse, patient, support person, doula, etc.).
• Squads will choose a different stage of labor for each patient and discuss how the birth plan would be utilized and the nursing interventions to be implemented in each scenario.
• Squads will ensure they clearly explain the different stages of labor and their associated nursing interventions while role-playing.
• Open Q&A session for any questions and clarification of details.
• The instructor will assess understanding based on student questions and explanations about the content.
• The review will summarize the main points covered in the lesson, including:
  • Care of the laboring patient and monitoring fetal status during labor
  • Comfort measures and interventions during labor
  • Care of the pregnant patient and infant immediately after birth

This quiz explores essential aspects of childbirth, including the advantages and disadvantages of various birth settings, the components of the labor process, and specific terms related to contractions and fetal presentations. It aims to provide a comprehensive understanding of what families should consider when planning for childbirth.