Labor and Childbirth Stages

• Labor and childbirth is the process where a pregnant woman expels the fetus and placenta.
• Nursing care during labor and childbirth ensures a safe, positive experience for both the mother and baby.

Stages of Labor

• The first stage starts with regular uterine contractions and ends with full cervical dilation at 10 cm.
  • The latent phase involves cervical effacement and early dilation from 0-3 cm, with mild, infrequent contractions.
  • The active phase includes cervical dilation from 4-7 cm, with contractions becoming more frequent, longer, and intense.
  • The transition phase occurs with cervical dilation from 8-10 cm and is the shortest, most intense phase.
• The second stage begins with complete cervical dilation and concludes with the baby's birth, also involving the urge to push.
• The third stage begins immediately after the baby's birth, ending with the expulsion of the placenta.
• The fourth stage lasts for the first 1-4 hours after placental expulsion, during which the mother's body begins physiological readjustment.

Nursing Assessment During Labor

• Regular assessment of maternal vital signs includes blood pressure, pulse, respirations, and temperature.
• Fetal heart rate (FHR) monitoring assesses the FHR for baseline, variability, accelerations, and decelerations.
  • Normal FHR baseline ranges from 110-160 bpm.
• Uterine contractions should be evaluated for frequency, duration, intensity, and resting tone through palpation or electronic monitoring.
• Vaginal examinations help determine the progress of labor via cervical dilation and effacement.
• Leopold's maneuvers or vaginal examination aid in determining the fetal position and presentation.
• Maternal pain level should be assessed using a pain scale, along with observation for nonverbal cues of discomfort.
• Assessment of amniotic membranes includes noting the time of rupture, color, odor, and amount of amniotic fluid.
• The maternal emotional status and coping mechanisms should also be evaluated.

Pain Management During Labor

• Non-pharmacological methods include breathing and relaxation techniques.
  • Breathing techniques include slow-paced, modified-paced, and patterned-paced breathing.
  • Relaxation techniques include progressive relaxation, guided imagery, and massage.
  • Hydrotherapy involves showering, bathing, or using a birthing tub.
  • Effleurage is light massage of the abdomen.
  • Counterpressure involves applying pressure to the lower back.
  • Application of heat or cold can provide relief.
  • Ambulation and position changes can aid in comfort.
• Pharmacological methods can assist in pain management.
  • Opioid analgesics are administered intravenously or intramuscularly.
  • Epidural analgesia involves injecting a local anesthetic into the epidural space.
  • Spinal analgesia consists of injecting a local anesthetic into the subarachnoid space.
  • Pudendal block includes injecting a local anesthetic into the pudendal nerve to relieve perineal pain during the second stage of labor.
  • Nitrous oxide is an inhaled gas to reduce pain and anxiety.

Fetal Heart Rate Monitoring

• Assess fetal well-being during labor via FHR monitoring.
• Baseline FHR is the average FHR during a 10-minute period, excluding accelerations, decelerations, and marked variability.
• Variability refers to fluctuations in the FHR baseline.
  • Absent variability is when the amplitude range is undetectable.
  • Minimal variability is when the amplitude range is ≤ 5 bpm.
  • Moderate variability is when the amplitude range is 6-25 bpm.
  • Marked variability is when the amplitude range is > 25 bpm and can indicate fetal stress.
• Accelerations are abrupt increases in FHR above the baseline; the peak is ≥ 15 bpm above the baseline and lasts ≥ 15 seconds from onset to return.
• Decelerations are transitory decreases in the FHR baseline.
  • Early decelerations are visually apparent, gradual decreases and return to baseline FHR associated with uterine contractions, caused by fetal head compression.
  • Late decelerations are visually apparent, gradual decrease and return to baseline FHR associated with uterine contractions, which begin after the contraction has started, and the nadir after the peak, caused by uteroplacental insufficiency.
  • Variable decelerations are abrupt decreases in FHR below the baseline, ≥ 15 bpm below the baseline and lasts ≥ 15 seconds but < 2 minutes from onset to return, caused by umbilical cord compression.
  • Prolonged decelerations are decreases in FHR of ≥ 15 bpm below the baseline and lasts ≥ 2 minutes but < 10 minutes.

Interventions for Non-Reassuring Fetal Heart Rate Patterns

• Change maternal position to left lateral.
• Administer oxygen via face mask at 8-10 L/min.
• Increase intravenous fluids.
• Discontinue oxytocin if it is being administered.
• Notify the healthcare provider.
• Prepare for possible delivery if the FHR pattern does not improve.

Nursing Interventions During Labor

• Provide emotional support and encouragement.
• Monitor maternal vital signs and FHR.
• Assess uterine contractions and cervical changes.
• Assist with pain management techniques.
• Encourage voiding every 2 hours.
• Promote rest between contractions.
• Provide clear explanations and updates on the progress of labor.
• Prepare the delivery room.
• Assist with delivery.
• Provide immediate newborn care.

Episiotomy and Lacerations

• Episiotomy is an incision of the perineum to enlarge the vaginal opening.
• Lacerations are tears in the perineum that occur during childbirth.
  • First-degree lacerations involve the perineal skin and vaginal mucous membrane.
  • Second-degree lacerations extend into the muscles of the perineum.
  • Third-degree lacerations extend into the anal sphincter muscle.
  • Fourth-degree lacerations extend completely through the anal sphincter and into the rectal mucosa.
• Nursing care includes assessing the perineum for edema, bruising, and hematoma formation.
• Apply ice packs to the perineum for the first 24 hours.
• Administer analgesics for pain relief.
• Encourage sitz baths.
• Teach perineal hygiene.

Third Stage of Labor: Placental Delivery

• Signs of placental separation include the uterus becoming globular and firm, a sudden gush of blood, and lengthening of the umbilical cord.
• Nursing actions include administering oxytocin or other uterotonic medications as prescribed to contract the uterus.
• Assist with placental expulsion.
• Inspect the placenta for completeness.
• Massage the uterus to prevent postpartum hemorrhage.

Fourth Stage of Labor: Postpartum Recovery

• Regular nursing assessments include maternal vital signs every 15 minutes for the first hour.
• Assess the uterine fundus for firmness and position.
• Assess lochia (vaginal discharge) for amount, color, and odor.
• Assess the perineum for edema, bruising, and hematoma formation.
• Assess the bladder for distention.
• Monitor the patient's pain level.
• Nursing interventions include encouraging breastfeeding.
• Provide comfort measures.
• Promote bonding between mother and baby.
• Monitor for signs of postpartum complications.

Potential Labor Complications

• Fetal distress involves non-reassuring fetal heart rate patterns.
• Shoulder dystocia is difficulty delivering the fetal shoulders after the head has been delivered.
• Umbilical cord prolapse occurs when the umbilical cord precedes the fetus.
• Amniotic fluid embolism is when amniotic fluid enters the maternal circulation.
• Postpartum hemorrhage is excessive bleeding after childbirth.
• Uterine rupture refers to tearing of the uterus.
• Infection is also a potential complication.