Nursing Care During Labor

• Childbirth is a normal physiologic process focusing on the welfare of two: mother and child, with the experience remembered as a family affair.
• Nurses should be sensitive to the cultural needs of patients during childbirth.

Nursing Care Priorities

• Focuses on monitoring the mother's labor progression and any complications.
• Also focuses on monitoring the fetus's tolerance of the labor process as well as paying attention to safety and satisfaction with the pain management methods being used.

Labor Defined

• Labor is the physiologic process leading to expulsion of the fetus, umbilical cord, placenta, and amniotic membranes.
• It is characterized by uterine contractions and cervical effacement and dilation
• The exact trigger that initiates labor is not definitively known.
• Labor typically occurs when the fetus is mature, roughly 38 to 40 weeks after the last normal menstrual period (LNMP).

Fetal Descent

• As the fetus descends into the pelvis, it changes position to adapt to the size and shape of the pelvis.
• This involves specific movements: Descent, Engagement (head reaches ischial spines), Flexion, Internal rotation, Extension, External rotation, and Expulsion.

Signs of Impending Labor

• Bloody show: Loss of mucus plug, which may occur a few days before labor.
• Burst of energy: It occurs 24-48 hours before onset of labor which is referred to as "nesting".
• Spontaneous rupture of membranes (SROM): In this case, the patient should go to the hospital,. This even applies if there are no other signs of labor
• Lightening occurs
• The start of contractions can either be Braxton-Hicks ("false labor"), or True labor, which are regular and progressively more intense.

Cervical Changes

• A cervix is thick and closed during pregnancy.
• During labor, the cervix undergoes effacement (thinning), expressed as a percentage, where 100% is fully effaced.
• Dilation (opening) occurs during labor, measured in cm, where 10 cm is fully dilated.

True vs. False/Prodromal Labor

• True labor produces progressive effacement and dilatation of the cervix.
• False labor does not produce progressive effacement and dilatation of the cervix.
• Assessing dilatation differentiates true from false labor.
• Reassure laboring women, so she is not made to feel foolish if it turns out that the labor is false.

Critical Factors of the Birth Process

• The "Four + Ps" include: Passage, Passenger, Powers, and Psyche.
• Additional "Ps" include: Position, Pain management, Patience, Preparation, Professional help, Place, Procedures, People.

Passage

• Includes the Pelvis and Soft tissues.
• It is important for the outcome of labor, and is less flexible. Cartilage softens due to relaxin.
• Soft tissues includes the Cervix, Muscles, ligaments, & perineum. They yield under the pressure of the presenting fetal part.

Passenger: Fetus

• Fetal head: Sutures allow molding, and Fontanelles are intersections between bones.
• Lie: Fetal spine lines up to maternal spine.
• 99% are longitudinal and parallel.

Relationship of Presenting Part & Passage

• Fetal presentation refers to the part of the fetus that enters the pelvis first.
• Types of Fetal presentation include: Cephalic = head first (96%), Breech = buttocks first (3%), and Shoulder.

Fetal Presentation Variations

• Cephalic: Vertex with complete flexion, most common & smallest diameter, Face with full extension, Brow or military with poor flexion, partial extension.
• Breech: Full or complete with hips & knees flexed, Frank with hips flexed, knees extended, and Footling with hip(s) & knee(s) extended.

Passenger: Fetus

• Fetal position: refers to the Relationship of landmark on presenting fetal part to front, side, or back of maternal pelvis (3 letters).
• LOA (Left Occiput Anterior) is the most common.
• Attitude: refers to the Degree of flexion: Flexed occupies less space.

Passenger: Fetus

• Fetal station: the Relationship of landmark on presenting fetal part ischial spines
• It provides information regarding fetal descent.
• At level of ischial spines is at 0 station.
• Above the spines is a negative number in cm and below is a positive number in cm.

Powers: Uterine Contractions

• This is the Primary force of labor during the 1st stage.
• Effects of contractions on the cervix includes Effacement (thin) measured in % and Dilatation (open) measured in cm.
• Contractions are involuntary, and cannot be consciously started or stopped; influenced by many factors.

Describing Uterine Contractions

• Onset: Beginning of contraction.
• Duration: Time from beginning of a contraction to end of that contraction.
• Frequency: Time from beginning of one contraction to beginning of next contraction.
• Intensity: Strength of contraction at acme/peak.

Maternal Pushing

• Most women feel the urge to push once the cervix is fully dilated.
• Voluntary pushing is added to involuntary uterine contractions.
• Combined powers propel the baby down through the pelvis.
• Station measures how the baby travels through the pelvis.

Maternal Position

• Influences progress of labor positively.
• An upright position can reduce the length of labor.
• Examples: Standing, sitting, kneeling, and walking.
• To ensure comfort, avoid supine position. If needed, place a wedge under the lower back to displace the uterus off the inferior vena cava.

Psyche

• State of mind can influence the course of labor.
• Influenced by: Confidence in self & trust in providers, Cultural & individual values, Coping mechanisms, support system, Preparation for childbirth - that may lead to Decreased pain & increased satisfaction
• Nurse provides reassurance, praise, information, and support.

Basic Principles for Maternity Care

• Labor should begin on its own when possible.
• Ensure freedom of movement
• Involve a birth support individual or doula.
• Avoid "routine" intervention whenever possible.
• Avoid supine position
• Do not separate the infant
• Implement In-person nursing

4 Stages of Labor (Overview)

• First stage: Beginning of true labor to 10 cm.
• Latent, active, and transition phases occur in the first stage.
• Second stage: 10 cm to birth of infant, including pushing.
• Third stage: Birth of infant to delivery of placenta.
• Fourth stage: 1 to 4 hours after birth, the recovery period.

Latent Phase: 1-3 cm

• Contractions mild & infrequent (q5 by end).
• Woman relatively comfortable and excited although somewhat anxious.
• Can last 10-20 hours
• Nursing care: Establish relationship, Orient to unit, review plans & requests, Monitor mother & fetus intermittently, Encourage ambulation

Active Phase: 4 - 6 cm

• Characteristics: Contractions more frequent & intense (q2-3, >60 sec).
• The woman becomes more inwardly focused, although still cooperative.
• May need analgesia or anesthesia (epidural)
• Nursing care: Monitor, Comfort measures & hygiene, Keep bladder emptying, Support/assist in breathing/relaxation

Transition Phase - 7-10 cm

• Characteristics: Intense, frequent contractions (q2-3, 60-90 sec)
• The laboring women may become irritable and uncooperative.
• Nursing care: Continue maternal & fetal assessments, continue comfort measures, reassure, and don't leave her alone.

Birth Settings

• Hospital (~99%)
• Ready access to services & personnel.
• Is more expensive, and intimidating.
• Birthing Center + More homelike, less expensive, but there is a delay if complication occurs.
• Home is more controlled, low-tech, and has fewer pathogens, but there are fewer attendants and is delayed in an emergency.

Need for Admission

• Teach pregnant woman the following:
• Regular uterine contractions: Nullipara/primipara; q5 min x1 hr or Multipara w/ hx rapid; q7-10 min x1 hr
• Rupture of membranes
• Vaginal bleeding that's not "bloody show"
• Urge to push during contractions
• Any other concerns

Admission Data Collection

• Collecting maternal V/S & condition, the cervix conditions.
• Collect fetal condition, like FHR, and Amniotic fluid.
• Looking for signs of impending birth.
• Part of the admission procedure is to get paperwork completed ahead of time, Consents signed, Labs and IV in place.
• Review prenatal record; Blood type & Rh, EDD, birth plan...

Observation without Admission

• Used for "False" or early labor
• Monitor for 20 min to verify fetal well being .
• Ambulate if possible
• If there is no cervical change and the membranes are still intact, advise them to return home to await true labor.
• Reassure laboring women & reinforce instructions, as this can be a frustrating & embarrassing time for them.

After Admission to Labor Unit

• Priority nursing actions include:
  • Monitor the fetus
  • Monitor the laboring woman
  • Help the woman cope with labor

Evaluating Progress of Labor

• Includes observing Contractions and performing a Vaginal exam in order to assess the condition of the Cervix (effacement & dilatation), Fetal station (descent)
• There is no set interval for exams - Watch for signs of progress.
• Minimize exams to reduce the risk of infection and to make the woman comfortable.

Maternal Response to Labor

• Assess response to labor which includes her Breathing & relaxation techniques and whether or not there is tension or problems coping.
• Support adoptive responses as well which include: Maintain open communication, Hygiene and comfort measures, Teaching, keeping her informed of progress, Encouraging her, as well as Care for her partner(s)

Amniotic Fluid

• Record color, odor, and amount.
• Color/odor: Clear, straw colored, with flecks of white vernix which are normal.
• Green in coloration indicates meconium, or fetal distress, while Cloudy with odor indicates an infection
• Use a Nitrazine test to verify alk. pH
• The Amount is subjective

Ongoing Maternal Physical Assessment

• Vital signs: 1st may be elevated due to excitement. Repeat the observation.
• Take Temp q4h, or q2h after membranes rupture (report Temp ≥100.4)
• P, R, BP q1hr
• I&O: Encourage voiding q 1-2 hrs. A full bladder will interfere with descent.

Assisting the Laboring Woman

• Promote comfort with the Environment, and try to control light, room temp, and covers so the are not too hot or cold..
• Provide general Hygiene: Change underpads frequently.
• Adjust the Position: Ambulate during early labor, use Upright, hands & knees, and squatting as possible.
• Lying on the Side also is positive measure
• Avoid supine position.

Assisting the Laboring Woman

• Teaching: Reinforce childbirth preparation class and Teach breathing techniques & positioning
• Coach pushing when fully dilated.
• Provide encouragement: Keep them informed of progress, offer a Caring presence
• Support the partner

Fetal Heart Rate

• Monitor fetus for early signs of hypoxia with rapid response.
• Monitor with either intermittent auscultation or continuous electronic fetal monitoring.
• Electronic fetal monitoring can be either External (with an ultrasound transducer) or Internal (with a fetal scalp (spiral) electrode)

Electronic Fetal Monitoring

• Nursing responsibilities:
  • Continuous monitoring of data
  • Rapid identification of non-reassuring patterns
  • Prompt intervention
  • Document interventions & additional information EFM is part of medical record

Fetal Heart Rate

• Normal baseline rate is 110 - 160 bpm.
• Tachycardia is >160 bpm which can be caused by maternal fever.
• Bradycardia is <110 bpm which can be caused by fetal hypoxia.
• Variability: Normal fluctuations in rate which gives a reassurance recording of FHR a wavy appearance.

Accelerations

• Description: Rate increase is 15 beats for at least 15 seconds
• This indicates Good / reassuring status, and requires no Response

Early Decelerations

• Description: Rate decreases with contraction and recovers at end of contraction
• This is caused due to Head compression and requires no response as the Baby may be getting closer

Late Decelerations

• Description: Rate slows and doesn't return to baseline until after contraction is over.
• Meaning: Placenta is not delivering enough O2 to fetus, or there is Uteroplacental insufficiency (UPI)
• Response: Side-lying position, O2, IV, stop oxytocin, notify MD

Variable Decelerations

• The rate drops abruptly in irregular V, W, or U shaped pattern, and may become prolonged - is an Emergency!
• This indicates Cord compression
• Response: Reposition, amnioinfusion

Pain in Childbirth

• Pain: is considered an Unpleasant and distressing symptom and is Personal and subjective for each patient.
• Childbirth pain: Part of normal birth process that can take Months to prepare for, can be self limiting, and Can motivate woman to seek help from others and facilitate birth.

Psychosocial Pain Factors

• Culture, which is learned, so patients may be expressive vs. stoic
• Anxiety: increases tension & decreases tolerance
• Experience of previous deliveries
• Preparation: Many types; helpful if realistic
• Support of significant other(s) is critical

Pain In Childbirth

• Causes: contractions, dilation, stretching, ischemia, pressure.
• Women's experiences of pain vary
• Supportive care enhances pain coping
• Prenatal education includes pain control options for labor
• Non-pharmacological or Pharmacological methods
• Patient has choice regarding pain management interventions

Non-pharmacologic Pain Relief

• Advantages:
  • No harm to mother or fetus
  • There is no slowing of labor
  • No allergy
  • No side effects
• Limitations:
  • May not provide adequate pain relief, no matter how well prepared & practiced
  • Poor pain relief increases fear & anxiety
  • Most require preparation prior to labor

Analgesia & Anesthesia

• Narcotic analgesia use during labor crosses the placenta .

• It can cause neonatal respiratory depression:

• The antagonist to Naloxone (Narcan) can be used.

• Regional anesthetic- epidural is used during labor or for cesarean

• Hypotension is the most common adverse reaction to an epidural.

Second Stage Characteristics

• The Cervix is 10 cm, leading to the birth of the baby, along with the need for laboring women to start pushing, is an indication that the second stage is here.
• there is an Urge to bear down (feels like BM) for most women.
• The Bulging of perineum and crowning can be observed.
• Contractions still intense: but less than during transition
• Mother usually regains control and Pushing typically feels good/useful

Nursing Care: Second Stage

• Coach pushing efforts
• Evaluate progress & monitor fetus
• Communicate with provider
• Assist with positioning
• Prep perineum (usually cleansing only)
• Support woman & partner

Nursing Care During Birth

• Prepare the room & equipment: Set up sterile instruments and ensure a radiant warmer and baby supplies ready

• Stabilize & assess newborn after birth: First, Identify mother & infant, Promote parent-infant bonding, and Encourage early breastfeeding

Episiotomy

• This refers to a Surgical incision to enlarge the vaginal opening, that is Not routinely used
• This is done to avoid a Vs. laceration which can turn into an uncontrolled tear
• Risks: Extension, and Infection
• Nursing Care: Apply Cold packs first 12 hours and Warmth after 12 - 24 hours and with the addition of heat packs or sitz bath.
• Absorbable sutures are used

Infection Control: Birth

• Follow Standard precautions, as well as the implementation of
• Body fluids present: can mean the presence of Blood, Amniotic fluid, and Vaginal secretions.
• Clean (or sterile) gloves must be worn, as well as Water repellent cover gown and Mask & eye shield

Third Stage: Expulsion of Placenta

• Patient may experience slight cramp with delivery of the placenta
• Uterus must contract firmly to control bleeding
• Nursing care includes Administering of oxytocin as ordered, after delivery of baby or placenta, Monitor blood pressure, and blood loss,
• Also provide Initial newborn care with Bonding and Initiate breastfeeding

Fourth Stage: Recovery

• Characteristics: Uterus firm, between pubis & umbilicus: with Lochia (bleeding) < 1 pad/hour
• Patient experiences Cramping, perineal burning or pain and May have shaking chills
• Focus Nursing care by assessing VS, fundus, lochia, perineum Q15 minutes.
• Provide hygiene, warmth, nutrition, and Maintain empty bladder and focus on Encourage bonding & breastfeeding

Nursing Care of Mother Immediately After Birth

• Assess frequently, for example, q 15 min x 1 hr, to observe for hemorrhage: look for Bleeding < 1 pad / hour with no clots, as well as Firm fundus and stable vital signs (VS - BP, P, R)
• signs of shock; Temp
• Promote bladder emptying for the patient to avoid future compilations
• Promote comfort: Warm blanket

Initial Care of Newborn (1st hour)

• Maintain warmth by drying baby and removing wet linens.
• Baby isn't efficient at generating heat, causing Hypothermia that can lead to Hypoglycemia as well as respiratory distress.
• Establish cardio-respiratory function: Make sure Cord is clamped, Suction mouth & nose, Rub back or flick soles of feet to stimulate cry
• APGAR score is assessed at 1 & 5 minutes

APGAR Score

• A method to quickly summarize the health of newborn children against infant mortality.
• Scored by assessing the infant with values of 0, 1, and 2 in each of the following criteria; Sign, Heart rate, Respiratory effort, Muscle tone, Reflex irritability, and Color.

Initial Care of Newborn (1st hour)

• Encourage bonding & early breastfeeding.
• Observe and document urinary & bowel elimination.
• Identify the infant
• Facilitate Eye care and Vitamin K where appropriate

Abnormal Labor

• Dysfunctional labor or dystocia
• Abnormality of: Powers, Passenger, Passage, and Psyche
• Earlier identification increases the chance of a successful outcome

PROM

• Premature rupture of membranes: Spontaneous ROM at term, yet before labor.
• If the patient is <37 weeks without infection, they may be hospitalized on strict bed rest, with daily NST & BPP, WBC (PPROM).
• If the patient is >36 weeks or with infection regardless of gestational age, induce labor becomes a necessity
• Nursing implications: Monitor for infection: T >100.4°F, 38°C and Prevention of Chorioamniotis

Prolonged Pregnancy (Post-term)

• Pregnancy >42 weeks poses Minimal maternal physical risk, yet can cause great a deal of stress for the family.
• It imposes serious Fetal risks, such as Placental insufficiency, meconium aspiration, and ↑ risk of stillbirth or macrosomia.
• Medical management: Includes a need to verify true gestation and close monitoring, and after 42 weeks; induce the patient

Powers: Decreased Uterine Muscle Tone (Hypotonic)

• Description: Contractions diminish after 4 cm, and become too weak for the active phase, and are More likely to occur with overdistension
• Medical treatment: includes Amniotomy/AROM and to Augment labor with oxytocin (Pitocin)
• Nursing implications: focus on Reassurance and Encourage ambulation and upright position.

Prolonged Labor (Dystocia)

• Refers to long or difficult labor that imposes great Risks, such as Infection, Maternal exhaustion, Postpartum hemorrhage, and anxiety and fear

Nursing implications: Help the patient conserve strength, observe for potential infection, and offer ongoing Supportive coping

Preterm Labor

• If the patient is in Labor before week 37, there is a high chance of neonatal mortality in US
• The underlying Cause is is still unknown in most cases.
• Medical treatment: Women at risk are taught to recognize signs of labor, with home monitoring programs which include an Attempt to stop preterm labor by way of tocolysis using drugs like MgSO4, to help Speed fetal lung maturity with betamethasone, and recommend Activity restriction using a partial bedrest regimen

Preterm Labor

• Common Pharmacological treatments used are Progesterone, Antibiotics, Hydration, and Tocolytics, the latter of which are Drugs suppress uterine activity for a Short term; only weeks 24-34
• Nursing implications include Manage treatment and follow a monitor regimen, as well a perform patient Teaching and offering ongoing Support

Abnormal Fetal Presentation

• Abnormal Presentation (face, breech) means Fetus cannot pass easily through pelvis
• In the case of a Breech or transverse lie: if less than 37 weeks watch, if over 37 weeks attempt external version; attempt to turn fetus, but if it is persistent & labor begins the patient will need a cesarean section

Abnormal Position (OP)

Persistent Occiput Posterior carries Maternal implications, causing Prolonged “back” labor as well carries Fetal implications that causes Excessive molding and caput. Nursing implications include assisting in positioning for best labor progress.

Macrosomia

• Fetus will weight >4,000 gms (8.8 lbs) which poses Maternal risks, such as lacertaion and postpartum hemorrhage
• Fetal risks include shoulder dystocia, brachial plexus injury or fractured clavicle

Multifetal Pregnancy

• Increased complications are more probable when Prematurity, uterine overdistention, GH, abnormal presentation/position are involved, possibly leading to maternal hemorrhage
• Nursing care must carefully Monitor each fetus, Anticipate the need for patient to get booked for a CS, as well as the medical team needing to be prepared for each baby.

Prolapsed Cord

• A Emergency situation occurs if Cord slips down between fetus & pelvis and is compressed, cutting off circulation
• This imposes and Risk factor when ROM occurs when fetus isn't engaged
• The main focus of Treatment is to Push up on fetal head to relieve pressure, as well as to Deliver immediately and ensure the patient is booked for a crash cesarean
• In this case, remain Calm and provide quick action and debrief afterward

Precipitous Labor & Birth

• It is Completed with 3 hours.
• Usually there is an often unattended component, and this requires the nurse to provide close monitoring, administering of O2, and that they are careful to not to leave alon, to observe mother and baby for injuries post delivery

Uterine Rupture

• This involves the Tearing of uterine muscle that places the patient at high Risk factors, as well as a weakened CS scar, history of many other births, the state of being in intense labor, and a history of the patient incurring abdominal trauma
• Signs & symptoms for a Uterine Rupture include: patient going into shock and feeling intense pain, for the contractions to stop, hemorrhaging
• This situation is a surgical emergency!!!!

Amniotic Fluid Embolism

• When Amniotic fluid enters maternal circulation the patient can develop: -Rare complications
  • Mortality near 80%
• Treatment involves: -Respiratory support - deliver O2, and implement CPR
  • Treat shock
  • Replace coagulation factors
  • Observe closely for signs of shock.

Perinatal Loss

• Fetal demise, most often with no known cause in 60% of cases requires a Grief processing that will allow mothers and their families to eventually reach Denial, then deal with the Grief phases - a step toward acceptance
• Nursing care: -Provide Care in other hospital until with resources and support.
  • Respect and facilitate the creation of Mementos and pictures

Obstetric Procedures

• These include: Amniotomy, Amnioinfusion, Version (Ch. 10), Induction or augmentation, Episiotomy (Ch. 10), Assisted vaginal birth ( Forceps or vacuum extraction), and Cesarean

Amniotomy (AROM)

• To perform an Artificial ROM is to Stimulate contractions, which comes at a range of potentialComplications, like Prolapse of umbilical cord, and Infection
• Nursing care involves closely Monitoring FHT, Assessing color, odor of fluid, monitoring temp, and Providing comfort & hygiene

Amnioinfusion

• Infusion NS into uterus helps Relieve cord compression and offers a way to Dilute meconium
• However, Amnioinfusion comes with high risk Complications, like, Prolapse of umbilical cord, and Infection
• Nursing care: Make sure you carefully Monitor uterine contractions using and IUPC, and Promote comfort & hygiene

Labor Induction

• Labor Induction describes that the Initiation of labor (UCs) before it begins naturally stems from a range of Indications, such as: GH, PROM, uterine infection, DM, non-reassuring NST, and fetal death
• However, this must be indicated, because of Contraindications, such as, previa, prolapse
• Techniques used to promote and start labor includes Cervical ripening: prostaglandin, luminaria, AROM, to promote labor

Labor Induction

• Risks include over stimulation, fetal distress, and rupture caused by wrong dates Nursing implications: -Ensure close monitoring of contractions, pay attention to abnormal FHT, and to carefully administer the ordered oxytocin
• Augmentation enhances labor once it has begun and will entail similar procedures to start.

Additional Procedures

Vacuums suction to help deliver the fetal head and the use Forceps ,is often used to Instrument help rotate fetal head

• However, the Use of Forceps can only be done on Limited occasions, mainly when the patient is deep in in the late 2nd stage, and this Does not mean it is a one-for-one way of replacing a CS as this Risk of trama to mother and/or fetus often exists

Cesarean Birth

• Birth through incisions done with common Indications stemming from: placenta previa or abruptio, cord prolapse, abnormal labor, active herpes, breech or transverse lie, fetal distress, and CPD, the list of Contraindications remains small Risks still exists even during a cesarean for both the maternal side where surgery or anesthesia can compromise some patients, and there will need to be a proper preparation stage to NPO, get labs checked, insert a foley, check vital and fetal heart signs

These questions cover nursing care priorities, the definition of labor, reasons to visit the hospital, and fetal adaptation during descent. It also test the differences between true and Braxton-Hicks contractions, effacement, and initial nursing actions when a patient reports water breaking.