5. Obstetrics Nursing Chapter Quiz

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Questions and Answers

What sign or symptom normally occurs shortly before labor begins?

Moderate amount of vaginal bleeding

Sudden weight loss of 5-8 pounds

An urge to push or bear down

Increased clear vaginal discharge (correct)

The most appropriate nursing response when a woman states her water broke but she's not having contractions is:

Labor should begin within a few hours at most

There is no concern unless the fluid is bloody

Urine leakage may be confused with ruptured membranes

She should come to the birth center for evaluation (correct)

During normal labor, contractions characteristically become:

More frequent and of shorter duration

Less frequent and of shorter duration

More frequent and of longer duration (correct)

Less frequent and of longer duration

What does engagement refer to in the context of labor?

Engagement occurs when the widest diameter of the fetal head crosses the inlet of the mother's pelvis. Signup and view all the answers

What is the normal baseline fetal heart rate range during labor?

110-160 beats per minute. Signup and view all the answers

What immediate nursing action is required if late decelerations are noted in a fetal heart rate pattern?

Immediate intervention is required to improve placental oxygenation to the fetus. Signup and view all the answers

The ______ is an assessment tool for the fetal heart rate during labor.

Electronic Fetal Monitor (EFM) Signup and view all the answers

What is the primary advantage of the traditional hospital setting?

It is safe: All emergency equipment and personnel are readily available. Signup and view all the answers

What are Powers in the context of labor?

Involuntary uterine contractions that cause the cervix to open and propel the fetus downward through the birth canal. Signup and view all the answers

How are dilation and effacement estimated?

Effacement is described as a percentage of the original length of the cervix from 0-100%, and dilation is measured from 1 cm to 10 cm. Signup and view all the answers

Which of the following is true about Braxton-Hicks contractions?

They prepare the cervix and adjust fetal position. Signup and view all the answers

What is a disadvantage of freestanding birth centers?

There may be a slight delay in emergency care. Signup and view all the answers

A low-risk woman may prefer a _____ setting for childbirth.

homelike Signup and view all the answers

What is a contraindication to a home birth?

Previous cesarean section Signup and view all the answers

What does fetal presentation refer to?

Fetal presentation refers to the fetal part that enters the pelvis first and lies over the inlet. Signup and view all the answers

Which fetal presentation is most favorable for vaginal delivery?

Vertex presentation Signup and view all the answers

The first stage of labor involves maternal pushing efforts.

False Signup and view all the answers

What factors can influence the intensity and effectiveness of uterine contractions?

All of the above Signup and view all the answers

Match the following fetal presentations with their descriptions:

Vertex = The fetal head is fully flexed. Breech = The buttocks present. Shoulder = The shoulder enters the pelvis first. Face = The head is fully extended and the face presents. Signup and view all the answers

Which observations require immediate nursing intervention during labor? (Select all that apply)

FHR of 90 BPM between contractions Signup and view all the answers

What should the nurse do when a laboring woman begins making grunting noises and bearing down during a strong contraction?

Look at her perineum for increased bloody show or perineal bulging. Signup and view all the answers

What is the appropriate priority nursing action for a woman in active labor with FHR reaching 90 BPM during a contraction?

Continue to monitor closely. Signup and view all the answers

What is the first stage of labor defined by?

Dilation and effacement of the cervix Signup and view all the answers

What are the three phases that occur within the first stage of labor?

Latent Phase, Active Phase, Transitional Phase. Signup and view all the answers

The ________ phase begins with complete dilation at 10 cm and full effacement of the cervix.

Second Stage Signup and view all the answers

The average length of the first stage of labor is typically between 7.3 to 8.6 hours for multiparas.

False Signup and view all the answers

Match the symptoms with their corresponding stages of labor.

Latent Phase = Contractions every 20 minutes to 5 minutes apart Active Phase = Contractions every 2 to 5 minutes lasting about 40 to 60 seconds Transitional Phase = Cervix dilation from 7-10 cm Second Stage = Delivery begins with complete dilation at 10 cm Signup and view all the answers

What signs indicate placental separation?

Lengthening of cord, uterine fundus rises and becomes firm, fresh blood expelled from vagina. Signup and view all the answers

Lochia rubra should saturate more than one pad per hour.

False Signup and view all the answers

Which aspect of childbirth preparation classes is important for women?

All of the above Signup and view all the answers

What distinguishes childbirth pain from other types of pain?

It is part of the normal birth process, self-limiting, and often declines rapidly after birth. Signup and view all the answers

A pregnant woman asks if she should take prepared childbirth classes. The best response from the nurse is to tell her that classes will:

Provide methods to help her cope with labor Signup and view all the answers

Which of the following is most appropriately used for pain relief during labor when the cervix is dilated less than 4 cm?

Meperidine (Demerol) via IM route Signup and view all the answers

Which technique is likely to be most effective for back labor?

Applying firm pressure in the sacral area Signup and view all the answers

Select the most important nursing assessments immediately after a woman receives an epidural block.

Bladder distention Signup and view all the answers

According to the gate control theory, which technique should be most helpful in interrupting transmission of labor pain to the brain?

Application of heat Signup and view all the answers

Immediately after birth, nursing care for the woman who had subarachnoid block anesthesia for a repeat cesarean birth should include:

Assessing for return of sensation Signup and view all the answers

A woman is using prepared childbirth breathing techniques and complains of tingling in her fingers and dizziness. The nurse should:

Tell her to exhale slowly into her cupped hands Signup and view all the answers

What are the advantages of nonpharmacological pain management techniques during labor?

Nonpharmacological pain management does not harm the mother or fetus, does not slow labor if pain control is adequate, and carries no risk for allergy or adverse drug effects. Signup and view all the answers

The priority nursing observation during the fourth stage of labor is for:

Vaginal bleeding Signup and view all the answers

What is the purpose of relaxation techniques during labor?

Relaxation techniques require concentration, occupying the mind while reducing muscle tension. Signup and view all the answers

The primary means of identifying hemorrhage after vaginal birth is to:

Observe the uterine fundus and lochia Signup and view all the answers

The term infant may be placed in skin-to-skin contact with the mother immediately after birth primarily for the purpose of:

Maintaining the infant’s temperature Signup and view all the answers

What does effleurage involve?

Effleurage involves stroking the abdomen or legs in a circular movement during contractions. Signup and view all the answers

What is the baby's APGAR score at 1 minute?

9 Signup and view all the answers

What are the disadvantages of pharmacological pain management during labor?

Medication effects may directly or indirectly affect the fetus, and medications may slow the progress of labor if used too early. Signup and view all the answers

What is the role of a nurse in nonpharmacological pain management techniques?

The nurse should assess prior knowledge and preparation, guide and educate the woman on simple techniques, minimize environmental stimuli, and assess pain and relief measures. Signup and view all the answers

What is the baby's APGAR score at 5 minutes?

9 Signup and view all the answers

Study Notes

Hospital Birthing Settings

Traditional Setting: Labor takes place in a functional labor room. The mother is moved to an operating room-like delivery area when birth is imminent. The mother stays in the recovery area for observation before transferring to the postpartum unit.
LDR Room: Labor, delivery, and recovery occur in the same room. These rooms are designed for a comfortable and home-like experience.
Single Room Maternity Care (LDRP): Similar to LDR but includes postpartum stay. The infant remains in the same room as the mother until discharge.

Advantages of Hospital-Based Birth Settings

Preregistration: Provides access to important information upon admission.
Easy Access to Sophisticated Services: Specialized personnel and equipment are readily available in case of complications.
Family-Centered Care: Capable of providing care for women with complicated pregnancies.

Freestanding Birth Centers

Operated by Hospitals: Located near hospitals for easy transfer if complications arise.
CNM-Assisted Births: Certified nurse midwives provide primary care to both the mother and infant before and after delivery.

Advantages of Freestanding Birth Centers

Home-like Setting: Suitable for low-risk pregnancies.
Lower Costs: Freestanding centers minimize the need for expensive departments.

Disadvantages of Freestanding Birth Centers

Potential Delay in Emergency Care: Slight delay in receiving emergency care if life-threatening complications occur.

Home Births

Decision Factors: Families weigh the potential benefits and drawbacks of a home birth.

Advantages of Home Births

Control Over Presence: Families can dictate who can attend the birth.
Reduced Pathogen Exposure: No risk of contracting pathogens from other patients.
Low-Technology Birth: Appeals to families seeking a less medicalized birth experience.

Disadvantages of Home Births

Limited Birth Attendant Choices: Many doctors and midwives are hesitant to attend home births.
Delay in Emergency Care: Significant delay in reaching emergency care if complications occur.
Lack of Established Relationship with Physician: No pre-established relationship with a physician if a hospital transfer becomes necessary.

Contraindications to Home Birth

Previous cesarean section
Malpresentation of the fetus
Multiple gestation
First-time mothers (primipara)
Gestational age greater than 40 weeks

Components of the Birth Process (The Four Ps)

Powers: Uterine contractions and the mother’s pushing efforts propel the fetus through the pelvis.
- Uterine Contractions:
  - Normal contractions are coordinated, involuntary and intermittent.
  - Contractions influence cervical effacement and dilation.
  - Each contraction has three phases: Increment (increasing strength), Acme (peak intensity), and Decrement (decreasing intensity).
  - Contraction characteristics:
    - Frequency: The elapsed time between the beginning of one contraction and the next.
    - Duration: The length of each contraction.
    - Intensity: The strength of the contraction.
    - Interval: The period of time between the end of one contraction and the beginning of the next.
- Maternal Pushing Efforts: Voluntary pushing adds to the force that expels the baby during the second stage of labor.
Passage: The mother’s bony pelvis and soft tissues that the fetus must pass through.
- Bony Pelvis: Significantly impacts the outcome of labor.
- False Pelvis: Upper, flaring part of the bony pelvis.
- True Pelvis: Lower, most important part for childbirth, divided into:
  - Inlet: Top of the true pelvis
  - Midpelvis: Middle
  - Outlet: Lower pelvic opening
Passenger: The fetus.
- Fetal Skull: Bones are not fused, allowing for molding (reshaping) during birth.
  - Sutures: Membranous spaces between the bones.
  - Fontanelles: Large, membranous areas where sutures meet.
- Fetal Lie: Orientation of the long axis of the fetus relative to the mother’s spine.
  - Longitudinal: Fetus's spine parallel to mother's spine, most common.
  - Transverse: Fetus's spine perpendicular to mother's spine.
  - Oblique: Fetus’s axis between longitudinal and transverse.
- Fetal Attitude: The posture of the fetus.
  - Flexion: Normal attitude where the head is flexed towards the chest.
  - Extension: Abnormal attitude where the head is extended.
- Fetal Presentation: The fetal part that enters the pelvis first.
  - Vertex Presentation: Fetal head is fully flexed, most common.
  - Breech Presentation: Buttocks enter the pelvis first.
  - Shoulder Presentation: Shoulder enters the pelvis first, requires cesarean delivery.
- Fetal Position: The relationship of the presenting part to the four quadrants of the mother’s pelvis.
  - Quadrants: Right and left anterior, and right and left posterior.
  - Abbreviations: Used to describe fetal presentation and position.
  - Three Letters:
    - First: Indicates the position of the fetal reference point (right, left, or omitted).
    - Second: Indicates the fixed fetal reference point (occiput for vertex, mentum for face, sacrum for breech).
    - Third: Indicates the anterior or posterior quadrant.
Psyche: The woman’s psychosocial response to labor and birth.
- Anxiety and Fear: Can decrease coping ability and inhibit uterine contractions.
- Culture: Influences expectations and responses to childbirth.
- Birth as an Emotional Experience: A profound, transformative event for the woman and family.

Impending Labor

Signs and Symptoms: May occur hours or weeks before the actual onset of labor.
- Braxton-Hicks Contractions: Irregular contractions that begin early in pregnancy and intensify as full term approaches.
- Lightening: Fetus settles into the pelvic inlet, relieving pressure on the diaphragm.
- Increased Vaginal Discharge: Elevated levels of mucus secretions.
- Bloody Show: Mixture of mucus and blood, occurs as the cervix softens and dilates.
- Rupture of Membranes: Amniotic sac breaks before labor begins.
- Nesting: Sudden surge of energy.
- Small Weight Loss: Due to changes in hormone levels.

Mechanisms of Labor

Descent: The presenting part moves downward through the pelvis.
- Stations: Measured in centimeters above or below the ischial spines.
Engagement: Widest part of the presenting part crosses the pelvic inlet.
Flexion: Fetal head flexes to pass more easily through the pelvis.
Internal Rotation: Fetal head aligns with the larger diameter of the midpelvis.
Extension: Occiput moves under the symphysis pubis, allowing the head to leave the pelvis.
Restitution: Head realigns with the body after delivery.
External Rotation: Shoulders and the body rotate through the birth canal.
Expulsion: Body of the infant leaves the pelvis.

Admission to a Birthing Facility

Women in labor for the first time should go to the hospital when contractions are five minutes apart for one hour.
Women having second labor or more babies should go to the facility sooner, when regular contractions are ten minutes apart for one hour.
The woman should go to the birth facility when her membranes have ruptured.
The woman should be evaluated once her membranes rupture regardless of whether contractions are occurring
Bright red bleeding should be evaluated promptly, Normal bloody show, is thick, pink or dark red and thick mucous.
If the fetus is moving less than usual, the woman should be evaluated.
Decreased fetal activity can also be a sign of fetal compromise or fetal demise.
If a woman has any other concerns, she should contact her HCP or go to the birth facility.

Admission Assessments

The nurse establishes a therapeutic relationship with the woman and her family members.
The nurse develops this relationship throughout labor by determining the woman’s expectations about birth and helping to achieve them.
The nurse will convey confidence in the woman’s ability to cope with labor and give birth to her child.
The woman should have a written birth plan that has been discussed with their HCP and the facility personnel
The family members that are to be present and part of her care should be stated in the birth plan

Three Admission Assessments:

Fetal condition
Maternal condition
Impending birth

Fetal Condition:

For the assessment of a term fetus.
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 is assessed, and the FHR is recorded.

Maternal Condition:

The temperature, pulse, respirations and blood pressure are assessed for signs of infection or hypertension

Impending Birth:

Behaviors that suggest impending 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.

Additional Assessments:

Reason for coming to the hospital.
Prenatal care.
OB history.
Medical/Surgical history.
Allergies.
Food intake.
Any recent illness.
Medications, drug/ETOH use.
Home environment.

Woman’s Plan of Care:

Support person
Planned pain management methods

Status of Labor:

Cervical dilation and effacement.
Fetal presentation, position, and station.
Contractions are assessed for frequency, duration and intensity.

Physical examination:

Evaluates overall health.

Admission Procedures:

Consent forms: The woman signs consent for care during labor, delivery and post birth period, such as an emergency cesarean section.
Laboratory Tests: Blood for hematocrit (CBC usually sent) and midstream urine specimen for glucose and protein are obtained.
Intravenous infusion: an IV line allows administration of fluids and drugs.
Perineal preparation for delivery: includes cleansing the perineal area.
Determining the fetal position and presentation: Fetal presentation and position using a combo of Leopold maneuvers and vaginal exam.

True Labor vs. False Labor

True Labor: is characterized by progress and consistency
False Labor: the woman may have contractions and other symptoms making her believe she is in labor but there is no cervical effacement or dilation.

Characteristics of True Labor

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; often feels like menstrual cramps at first. Some may persist as only back pain.
Progressive: effacement and dilation of the cervix occur. This is the most important characteristic of true labor.

Characteristics of False Labor

Contractions: are inconsistent in frequency, duration, and intensity while being observed for a short time (1-2 hours).
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, so accurate and complete documentation is required.
Is done with a fetoscope or a Doppler transducer.

Continuous Electronic Fetal Monitoring (EFM)

Allows the nurse to collect more data about the fetus, because fetal heart rate and contractions are continuously recorded.
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 dilated 1-2 cm.
The internal device is disposable to possess little risk of infection.
External EFM is done by a Doppler transducer, which uses sound waves to detect motion of the fetal heart and calculate the rate.
Contractions are sensed externally with a tocotransducer, which has a pressure sensitive button.
The toco is placed on the mother’s upper uterus

Evaluating fetal rate patterns:

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:

The average heart rate that occurs for at least 2 minutes during a 10 minutes 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:
- Fetal hypoxia
- Maternal hypoglycemia
- Maternal hypotension
- Profound cord compression

Fetal Tachycardia:

FHR is greater than 160 beats per minute that lasts 2-10 minutes or longer.
Causes:
- Maternal fever
- Maternal dehydration

Baseline Variability:

Describes the fluctuation or constant baseline in a 10 minutes window.
Variability is seen as a sawtooth appearance with larger, undulating, wavelike movements.
Baseline variability is 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 and can indicate core prolapse or maternal hypotension.
- Absent variability is less than 6 beats per minute change from baseline and can indicate maternal hypotension, cord compression or fetal hypoxia.

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 that quickly return to baseline

Accelerations:

Temporary, abrupt rate increase of at least 15 beats per min above baseline FHR.
Occurs with fetal movement.
This pattern is very “reassuring” pattern.

Early decelerations:

Temporary, gradual rate decreases during contractions no more than 40 beats per minute below baseline.
FHR always returns to the baseline by the end of the contraction.

Variable decelerations:

Abrupt decreases of 15 beats per min below baseline, lasting 15 -20 seconds.
These decreases begin and end abruptly.
They do not always exhibit a consistent pattern in relation to contractions.
They suggest that the umbilical cord is being compressed or because there is inadequate amniotic fluid to cushion the cord.

Late decelerations:

Similar to early decelerations except they begin after the beginning of the contraction returns to baseline after the end of the contraction.
Indicate that the placenta is not delivering enough oxygen to the fetus (uteroplacental insufficiency).
This is known as a “non-reassuring” pattern.
Late decelerations that are accompanied by decreased variability and absent accelerations are non-reassuring and require immediate intervention by the health care provider.

Prolonged decelerations:

Abrupt FHR decreases of at least 15 beats per min 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 of nursing response 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.
FHR monitoring is to assess the adequacy of oxygenation and uterine activity.
There may be many causes of fetal hypoxia.
FHR monitoring is not diagnostic but instead is used to identify complications that may cause interruption in fetal oxygen supply that leads to non-reassuring patterns.
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. Stop the oxytocin or administer tocolytic that decrease uterine activity
- 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, such as changing from Valsalva to open glottis pushing, fewer pushing efforts during contractions, pushing with every other contraction, pushing only with the urge to push.
If these measure don’t improve fetal heart tracings, then measure focus on expediting delivery of the fetus.

Inspection of amniotic fluid

Whether spontaneous or artificially with amniotomy
The color, odor and amount of fluid are recorded.

Characteristics of Amniotic Fluid:

Normal color is clear, possibility with flecks of white vernix.
Amount of amniotic fluid is usually estimated as scant (only a trickle), moderate (about 500 mL), or large (1000 mL or more).
Green-stained fluid may indicate the fetus as passed meconium before 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.
Nitrazine test or fern test may be performed if it is unclear whether the mother’s membranes have ruptured.

Monitoring the woman

Intrapartum care of the woman includes assessing her VS, contractions, progress of labor, intake and output, and responses to labor.

Monitoring Vital Signs:

Checked every 4 hours, then every 2 hours if it is elevated or if ruptured membranes have occurred.
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. Both can reduce blood flow to the placenta.

Monitoring Contractions:

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

Monitoring Progress of Labor:

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

Monitoring Intake and Output:

Recording time and approximate amount of each urination.
She may not sense a full bladder, so checking for a bulge above the symphysis pubis is important.
Ice chips, popsicles or hard sugarless lollipops can be used to keep mouth moist. Do not allow food during active labor.

Monitoring 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 during labor:

Comforting, positioning, teaching, and encouraging her.
Another aspect of intrapartum care is care of the woman’s partner.

Labor Support:

Control the environment by playing familiar music brought from home which creates a calming effect.
Maintaining an upright position during labor can shorten the first stage of labor, like sitting in a rocking chair or using a birthing ball.
Different positions can help facilitate anterior rotation of the fetus or increase pelvic space, like the lunge, or squatting with contractions.

Teaching:

Teach the woman different positions or breathing techniques if measures taught in childbirth classes are inadequate.
Women may be discouraged when their cervix is at 5 cm.
The nurse must often help the woman to avoid pushing before her cervix is completely dilated.

Laboring down:

An intervention during the second stage of labor that allows passive fetal descent.
This allows uterine contractions and gravity to bring the baby closer to crowning before the overwhelming urge to push takes over.

pushing techniques:

Once Stage 2 of labor begins, the nurse teaches or supports effective pushing techniques.
Prolonged breath holding while pushing can impair fetal blood circulation.
The woman should push for 4-6 seconds at a time.

Encouragement

Encouragement is essential for both the laboring woman and her partner.
The nurse should encourage the woman to summon inner strength and give her courage to continue.
The partner should also be encouraged, as labor coaching is a demanding job.

Supporting the Partner

The nurse should allow the partner to take the role that they are comfortable with.
The nurse should not take the partner's place, but remain available as needed.

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, averaging 7.3 to 8.6 hours for nulliparas and 4.1 to 5.3 hours for multiparas.
The first stage of labor has three phases: Latent, Active, and Transitional.

Latent Phase

The Latent Phase begins with the onset of regular contractions until 4 cm of cervical dilation.
During the Latent Phase:
- Amniotic membranes may still be intact.
- There may be bloody show.
- Contractions are every 20 minutes, decreasing to 5 minutes apart.
- Contraction duration increases to 15-40 seconds.
- Contraction intensity is mild to moderate.
The woman in the Latent Phase is usually cooperative, alert, talkative, welcomes diversions, urinates frequently, and is thirsty.

Latent Phase Nursing Interventions

Establish a positive relationship with the woman.
Encourage alternating ambulation and rest.
Review breathing and relaxation techniques with the woman and her coach.
Assess fetal heart rate.
Document the color of vaginal discharge.
Assess for a distended bladder and encourage voiding.
Provide lollipops if desired.
Assess vital signs every 2 hours.
Allow the woman to shower.
Teach the woman what to expect as labor progresses.

Active Phase

The Active Phase begins when the cervix dilates from 4-7 cm.
During the Active Phase:
- Amniotic membranes may rupture.
- Effacement of the cervix occurs.
- Contractions are 2 to 5 minutes apart and last about 40 to 60 seconds.
- Contraction intensity is moderate to firm.
The woman in the Active Phase is apprehensive, anxious, introverted, less social, focused on breathing, perspires, has facial flushing, requests pain relief, fears losing control, and may need epidural analgesia.

Active Phase Nursing Interventions

Help the coach implement coping strategies such as breathing and relaxation.
Continue maternal and fetal assessments.
Reassure the woman.
Praise the woman's 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 and encourage voiding.
Report the color, odor, and amount of vaginal discharge.
Report if meconium is seen.
Maintain warmth and provide general comfort measures.

Transitional Phase

The Transitional Phase begins when cervical dilation reaches 7-10 cm.
During the Transitional Phase:
- The cervix is fully effaced.
- Amniotic membranes rupture.
- Contractions occur at 2-3 minutes apart and last 60 to 90 seconds.
- Contraction intensity is firm.
The woman in the Transitional Phase is irritable, rejects support from her partner, is introverted, wants to give up, is restless, experiences tremors in her legs, fears losing control, and requests medication.

Transitional Phase Nursing Interventions

Provide firm coaching of breathing and relaxation techniques, focusing on the woman's needs.
Support the partner.
Praise and reassure the woman.
Assess fetal heart rate monitoring strips.
Assess the color of vaginal discharge.
Keep the woman informed of her progress with each contraction.
Accept negative comments from the woman.
Maintain a positive approach.

Second Stage of Labor

The second stage begins with complete dilation at 10 cm and full (100%) effacement of the cervix, and ends with the birth of the baby.
The average length of the second stage is 30 minutes to 2 hours.
Contractions are every 1-3 minutes, lasting 60-80 seconds.
The intensity of contractions is firm.
An episiotomy may be performed by the healthcare provider.
Primiparas are usually ready for delivery when 3-4 cm of the fetal head is visible at the vaginal opening (crowning).
Multiparas are usually ready when the cervix is fully dilated, before crowning.
The woman in the second stage experiences a bulging perineum, may pass stool, has an uncontrollable urge to push, states "The baby is coming," feels exhausted after each contraction, is unable to follow directions easily, and feels excitement concerning imminent birth.

Second Stage Nursing Interventions

Assist the woman to assume a position that helps her push.
Assist with open glottis pushing technique and coping strategies.
Support the woman's partner.
Maintain communication with the healthcare provider.
Assess the 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 her 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.
Contractions are intermittent, with mild to moderate intensity.
The uterus contracts to the size of a grapefruit.
An 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.

Placental Delivery Mechanisms

Schultze Mechanism: The placenta is expelled with the shiny fetal side presenting first.
Duncan Mechanism: The rough maternal side is presenting (less common).
The woman in the third stage is elated, feels relief, experiences tremors, has increased physical energy, is curious about the infant, desires to nurse the infant, and experiences minimal pain as the placenta is expelled.

Third Stage Nursing Interventions

Observe and document blood loss.
Document delivery of the placenta.
Examine the placenta to determine if all of it was expelled (a retained placenta can cause hemorrhage).
Monitor the mother's vital signs every 15 minutes.
Assess vaginal discharge.
Massage the uterus until it is firm and in the midline, or below the level of the umbilicus.
Administer oxytocin to the mother as ordered.
Obtain cord blood if needed.
Note parent-infant interaction.
Dry the newborn and place in a radiant warmer.
Attach a heart and temperature monitor to the newborn.
Assess and provide immediate newborn care.
Perform an Apgar evaluation.
Apply proper identification to the mother, infant, and partner.

Fourth Stage of Labor

The fourth stage begins with the delivery of the placenta and ends with the mother's stabilization.
The uterus remains midline, firmly contracted at or below the umbilicus level.
Cramping may occur.
Lochia rubra saturates the perineal pad (no more than one pad per hour), and the woman should not pass large clots.
A continuous trickle of bright red blood suggests a bleeding laceration.
Blood pressure, pulse, and respiratory rates are checked to identify shock.
The woman may have shaking chills, which may be a thermoregulation response.
An oral temperature of 100.4°F or higher should be reported as it suggests infection.
The bladder should be assessed for distention (a full bladder can displace the uterus and prevent it from contracting).
The woman uses this time to get acquainted with her baby, partner, and infant.
The mother breastfeeds the infant.

Fourth Stage Nursing Interventions

Provide proper identification of the mother, partner, and newborn.
Obtain cord blood if needed.
Assess 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.
Assess the mother's voiding.
Monitor the newborn’s heart rate and temperature.
Assess the newborn for anomalies.
Assess the fundus and 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.

Childbirth Pain

Pain is an unpleasant and distressing symptom that is personal and subjective.
Childbirth pain differs from other types of pain in several ways:
- It is part of a normal birth process.
- The woman has several months to prepare for pain management.
- It is self-limiting and rapidly declines after birth.

Factors Influencing Childbirth Pain

Several factors contribute to pain during labor:
- Pain threshold and tolerance.
- Sources of pain during labor (dilation and stretching of the cervix, reduced uterine blood supply, pressure of the fetus, stretching of the vagina and perineum).
- Physical factors (central nervous system, endorphin levels).
- Maternal condition (cervical readiness, pelvic size, labor intensity, fatigue).
- Fetal presentation and position.
- Caregiver interventions.
- Psychosocial and cultural factors.

Nonpharmacological Pain Management

Nonpharmacological pain control methods help the woman cope with natural labor, labor that is not yet established or too far advanced, and for the discomfort that remains despite medication.
Advantages of nonpharmacological pain management:
- Does not harm the mother or fetus.
- Does not slow labor if pain control is adequate.
- Carries no risk for allergy or adverse drug effect.

Nonpharmacological Techniques

Relaxation: Techniques require concentration and reduce muscle tension.
Skin Stimulation: Includes effleurage, sacral pressure, and thermal stimulation.
Positioning: Frequent changes relieve muscle fatigue and strain.
Diversion and Distraction: Involves mental stimulation to limit the woman's ability to perceive sensations as painful (focal point technique, imagery, music, television).
Breathing: Techniques should be practiced ahead of time. Different patterns are effective depending on the stage of labor (slow-paced, modified-paced).
Hyperventilation is possible with paced breathing techniques and should be monitored (see Box 7.2).

Prepared Childbirth Education

Prepared childbirth classes provide valuable information and techniques to help women cope with labor.
They cover topics such as:
- Changes of pregnancy
- Fetal development
- Prenatal care
- Hazardous substances to avoid
- Good nutrition and exercise benefits
- Relieving common pregnancy discomforts
- Working during pregnancy and parenthood
- Coping with labor and delivery
- Pain management
- Care of the infant
- Early growth and development

Focused Childbirth Education

Focused childbirth classes cover specific topics such as:
- Gestational Diabetes Mellitus
- Exercise
- Sibling
- Grandparent
- Breastfeeding
- Infant care
- Cesarean and vaginal birth after cesarean (VBAC)
- Adolescent childbirth
- Refresher classes.

Nonpharmacological Pain Management

Patterned-paced breathing is a technique involving rapid breaths punctuated with blows, like "pant-blow" or “hee hoo” breathing. It can be done in constant or stair-step patterns.
Pant-blow pattern is helpful for managing the urge to push before full cervical dilation, preventing glottis closure and breath-holding.
Sacral pressure is a technique that applies firm pressure in the sacral area and is considered most effective for back labor.
Application of heat is the technique most helpful in interrupting pain transmission to the brain based on the gate control theory.
Tingling in fingers and dizziness while using prepared childbirth breathing techniques might indicate hyperventilation. The nurse should advise the woman to exhale slowly into cupped hands.

### Pharmacological Pain Management

Analgesics are systemic drugs that reduce pain without causing unconsciousness.
- Narcotic (opioid) analgesics are used in small doses and avoided if birth is expected within an hour to prevent fetal respiratory depression.
  - Common drugs include meperidine (Demerol), fentanyl (Sublimaze), and nalbuphine (Nubain).
  - Safety protocols include raising side rails, close observation, and having naloxone readily available.
- Narcotic antagonist naloxone (Narcan) reverses respiratory depression caused by opioids, administered IV, endotracheally, or via umbilical cord vein.
Adjunctive drugs enhance analgesic effectiveness or counteract side effects.
- Benzodiazepines help with anxiety and nausea but can affect fetal heart rate variability and newborn thermoregulation.
Anesthetics cause a loss of sensation, including pain.
- Can be regional or generalized, administered by physicians, nurse-midwives, or specialized anesthesia clinicians.
- Inhaled (Nitrous oxide) via face mask during contractions reduces pain perception without negative effects on mother or fetus.
  - May cause nausea and dizziness.
- Regional blocks provide pain relief during labor and delivery.
  - Epidural block involves inserting a catheter into the epidural space, administering anesthetic drugs and a small dose of opioid analgesic.
    - Maternal hypotension can be countered with IV fluids.
    - Urinary retention requires frequent bladder palpation and catheterization if needed.
    - Prolonged second stage can occur due to less intense urge to push and relaxation of pelvic muscles.
  - Subarachnoid (spinal) block involves injecting anesthetic into the subarachnoid space.
    - Provides deeper block than epidural and used mainly for cesarean deliveries.
    - Maternal hypotension, urinary retention, and postspinal headache are potential adverse effects.
  - Local block numbs the perineal area for episiotomy or laceration repair.
  - Pudendal block numbs the vaginal and perineal areas for vaginal birth, episiotomy, and forceps-assisted delivery.
    - Vaginal hematoma and abscess are rare adverse effects.
- General anesthesia is rarely used, mainly for emergency cesarean delivery or women with epidural/subarachnoid block contraindications.
  - Adverse maternal effects include aspiration pneumonitis due to regurgitation.
  - Adverse neonatal effects include respiratory depression due to anesthetic crossing the placenta.
Nursing role in pharmacological pain management:
- Thorough admission intake includes assessing allergies, pain relief preferences, factors affecting pain management, last oral intake, and medications taken.
- Maintaining safety involves keeping side rails up, explaining fall precautions, and providing education about procedures and expected effects.
- Assisting healthcare providers during anesthetic procedures involves wearing PPE and maintaining a sterile field.
- Managing medication effects and patient response involves continuous vital sign monitoring, respiratory assessment, and naloxone availability for narcotics.
- For epidural or subarachnoid blocks, monitor maternal hypotension, urinary retention, and signs of imminent birth.
- For general anesthesia, administer medications to reduce gastric acidity, monitor vital signs, and assist with ambulation once sensation and motor control return.

Fourth Stage of Labor

The goal of the fourth stage of labor is to monitor mother and infant closely for the first 2 hours following birth to identify and intervene in any complications.
Vital sign assessment every 15 minutes for 1 hour, then every 30 minutes for the next hour, and hourly thereafter includes temperature, skin color, location and firmness of the uterine fundus, pain assessment, IV infusion and medications, bladder fullness or urinary output, perineum condition (for vaginal birth), dressing condition (for cesarean birth or tubal ligation), sensation and movement of lower extremities (if epidural/spinal block used), and observation for signs of hemorrhage.
Encourage comfort measures during the fourth stage of labor.
- Provide a warm blanket.
- Place an ice pack on the perineum to reduce bruising and edema.

Newborn Care Immediately After Birth

Newborn care is divided into three transitional phases to adapt to extrauterine life.
Phase 1 (Birth to 1 hour):
- Maintaining thermoregulation:
  - Drying the infant, placing in radiant warmer with skin probe, covering head with hat, wrapping in warm blankets, skin-to-skin contact with mother, and delaying bath help maintain thermal stability.
- Maintaining cardiorespiratory function:
  - Wiping face, nose, and mouth to remove secretions, gentle bulb suctioning, and placing the infant on mother’s abdomen help clear airways and support respiratory function.

Immediate Newborn Care

Maintaining thermoregulation is crucial to minimize heat loss and oxygen consumption needs.
- Cold stress increases metabolic rate, leading to increased respiratory rate and oxygen consumption. If oxygen demand cannot be met, hypoxia can result.
- Hypothermia can cause hypoglycemia, as the body uses glucose to generate heat. Hypoglycemia increases the risk of neurological problems.
Skin to skin contact between mother and newborn or breast feeding can also prevent heat loss.
Birth weight, length, and head circumference measurements should be recorded.
Apgar score should be assessed at 1 and 5 minutes, and documented.
Physical assessment should focus on identifying potential problems.
- Appearance
  - Turgor (skin elasticity)
  - Color
  - Clubbing (nail bed abnormalities)
  - Edema
  - Acrosyanosis (bluish coloration of hands and feet)
  - Milia (small white bumps on face)
  - Lanugo (fine hair)
  - Vernix caseosa (cheesy substance that covers the skin)
  - Mongolian spots
  - Erythema toxicum
- Respiratory System
  - Respiratory rate
  - Respiratory effort
  - Signs of distress
  - Auscultation of breath sounds
- Cardiovascular System
  - Heart rate
  - Auscultation of heart sounds
  - Pulse strength
- Gastrointestinal System
  - Abdominal distention
  - Bowel sounds
  - Passage of meconium
- Urinary System
  - Passage of urine
  - Voiding pattern
- Musculoskeletal System
  - Muscle tone
  - Range of motion
  - Limb symmetry
  - Deformities
- Neuromuscular System
  - Reflexes
  - Level of consciousness
  - Activity level
- Sensory System
  - Pupillary response
  - Response to stimuli
  - Hearing
  - Taste
  - Smell
Vitamin K injection and eye prophylaxis are routinely administered.
Proper identification bracelets should be placed on infant and mother.
Initial feeding is encouraged once respirations are stable.
Initial care:
- Diapering
- Washing and drying infant
- Positioning infant
Phase 2 (1 to 6 hours):
- Stability of vital signs
- Feeding and elimination patterns
- Monitoring for signs of infection
- Assessing for jaundice
- Observation for behaviors
- Facilitating parent-infant bonding
Phase 3 (6 hours to discharge):
- Continued assessment and care
- Education and support for parents
- Preparation for home care
- Follow-up appointments
Ongoing care until discharge includes:
- Assessing for common complications
  - Respiratory distress syndrome
  - Hypoglycemia
  - Jaundice
  - Infections
- Providing supportive care for infant and family
- Providing education and resources
- Discharge planning

Postpartum Infant Care

Suctioning may be initiated before cutting the cord.
A cord clamp is applied when the infant is stable in the radiant warmer.
Spontaneous breathing begins within seconds of birth.
Acrocyanosis, a bluish color of the hands and feet, is normal and caused by sluggish peripheral circulation.
Signs of respiratory distress include:
- Persistent cyanosis beyond hands and feet
- Grunting respirations
- Flaring of the nostrils
- Retractions under the sternum or between the ribs
- Sustained respiratory rate higher than 60 BPM
- Sustained heart rate greater than 160 BPM or less than 110 BPM
The Apgar score assesses an infant's condition at 1 and 5 minutes after birth.
- A score of 8-10 indicates no action is required.
- A score of 4-7 suggests gentle stimulation.
- A score of <3 indicates the need for resuscitation.
Preprinted identification bands are placed on the mother, infant, and father or support person for identification.
Footprints and fingerprints may be taken for identification.
Newborns may not urinate for up to 24 hours.
Meconium may be passed within 12-24 hours.
Infants cannot be discharged until it's documented that the GI and GU systems are functioning.
Skin-to-skin contact promotes bonding and maintains the infant's temperature.
Erythromycin eye ointment is administered to prevent ophthalmia neonatorum.
Vitamin K is given to assist with blood clotting.

Stages of Postpartum Care

Phase I: Immediately after birth; Care focuses on stabilizing the infant and promoting bonding
Phase II: From 1-3 hours after birth; Care is provided in the transition nursery or postpartum unit
Phase III: From 2-12 hours after birth; Care is provided in the postpartum unit if rooming in with the mother.

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Test your knowledge on essential obstetrics nursing concepts, including labor signs, fetal heart rate monitoring, and birth setting preferences. This quiz covers various aspects of labor and delivery, offering questions that will engage your understanding of the nursing role during childbirth. Perfect for nursing students and professionals alike!