Understanding Labor and Delivery

• Childbirth is a normal physiologic process involving the welfare of two, and nursing care should be sensitive to cultural needs.
• It is a family affair and the experience will be long remembered

Nursing Care Priorities

• Monitor the mother's progress of labor and any complications and ensure safe and satisfactory pain management.
• Monitor the fetus' tolerance of labor and watch for signs of distress

Labor

• Labor refers to the physiologic process during which the fetus, umbilical cord, placenta, and amniotic membranes are expelled via uterine contractions and cervical effacement and dilation.
• The exact trigger for labor is unknown.
• Labor usually occurs when the fetus is mature enough, typically 38-40 weeks after the last normal menstrual period (LNMP).

Signs of Impending Labor

• Bloody show is the loss of the mucus plug and may occur a few days before labor.
• A burst of energy, or "nesting," can occur 24-48 hours before labor.
• Spontaneous rupture of membranes (SROM) necessitates going to the hospital, even without other signs of labor.
• Lightening is another sign.
• Contractions can either be Braxton-Hicks ("false labor") or true labor (regular and progressively more intense).

Cervical Changes

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

True vs False Labor

• True labor produces progressive effacement and dilatation of the cervix.
• False (prodromal) labor does not produce progressive effacement and dilatation of the cervix.
• Assessing dilatation is the best way to differentiate between true and false labor.

Critical Factors of the Birth Process ("The Four + Ps")

• Passage: Includes the pelvis and soft tissues.
• Passenger: Refers to the fetus
• Powers: Includes uterine contractions.
• Psyche: Refers to the psychological state of the mother.

Passage in Detail #1

• Pelvis: The flexibility of the pelvis affects birth outcomes, with cartilage softening due to relaxin.

Passage in Detail #2

• Soft tissues: Includes the cervix, muscles, ligaments, and perineum, which yield to the pressure of the presenting part of the fetus.

Passenger: Fetus #1

• Fetal head: Sutures allow molding while fontanelles are intersections between bones
• Lie: Describes how the fetal spine lines up with the maternal spine; 99% are longitudinal (parallel).

Passenger: Fetus #2 - Fetal Presentation

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

Fetal Presentation Variations

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

Passenger: Fetus #3

• Fetal position relates the landmark on the presenting fetal part to the front, side, or back of the maternal pelvis (3 letters); LOA is most common.
• Attitude is the degree of flexion, with flexed occupying less space.

Passenger: Fetus #4

• Fetal station is the relationship of the landmark on the presenting fetal part to the ischial spines providing information regarding fetal descent.
• At the level of ischial spines: station = 0.
• Above the spines: station is (-) cm, and below: station is (+) cm.

Powers: Uterine Contractions

• In the first stage of labor are the primary force
• Contractions cause effacement (thin, %) and dilatation (open, cm) of the cervix.
• Contractions are involuntary and influenced by many factors.

Describing Uterine Contractions

• Onset: This is the beginning of the contraction
• Duration: The time from the beginning to the end of a contraction
• Frequency: The time from the beginning of one contraction to the beginning of the next contraction
• Intensity: The strength of the contraction at its peak

Maternal Pushing

• Occurs once the cervix is fully dilated
• Most women will have the urge to push
• Voluntary pushing added to involuntary uterine contractions causes the baby to descend through the pelvis, and continue through the stations

Maternal Position

• Upright positions influence & reduce length of labor, including: standing, sitting, kneeling, & walking.
• Avoid supine position, but if this is needed place a wedge under lower back to displace uterus off inferior vena cava
• Comfort is key, so encourage woman to find position of comfort

Psyche/ Mindset

• State of mind can influence course of labor.
• The patient is influenced by confidence in self & trust in providers, cultural & individual values, coping mechanisms & support system and preparation for childbirth, which may decrease pain & increase satisfaction.
• The nurse provides reassurance, praise, information, and support.

Basic Principles for Maternity Care

• Labor is best when begins on its own.
• Encourage freedom of movement.
• A birth support person or doula can be helpful
• Avoid routine interventions
• Encourage a non-supine position
• Keep infant together with mother
• Encourage in-person nursing

4 Stages of Labor (Overview)

• First stage: Beginning of true labor to 10 cm, including the latent, active, and transition phases.
• Second stage: 10 cm to birth of the infant (pushing).
• Third stage: From the birth of the infant to the delivery of the placenta.
• Fourth stage: 1 to 4 hours after birth (recovery).

Latent Phase: 1 - 3 cm Dilation

• Characteristics: Mild infrequent contractions, woman relatively comfortable & excited, the stage can last 10 – 20 hours
• Nursing Care: Establish relationship, Orient to unit, review plans & requests, and monitor the mother & fetus intermittently. The nurse can encourage ambulation

Active Phase: 4-6 cm Dilation

• Characteristics: Contractions more frequent & intense (q2-3 minutes that are >60 seconds long). Woman more inwardly focused, but still cooperative and may need analgesia or anesthesia (epidural).
• Nursing Care includes monitoring, comfort measures & hygiene, keeping the bladder empty. It also includes supporting/assisting with breathing/relaxation

Transition Phase: 7-10 cm Dilation

• Characteristics: Intense, frequent contractions (q2-3 minutes for 60-90 seconds). The woman may become irritable & uncooperative.
• Nursing Care: Continue maternal & fetal assessments, continue comfort measures, reassure woman and do not leave her alone

Birth Settings

• Hospital (~99% of births): Advantage = ready access to all services & personnel; Disadvantage = expensive & intimidating.
• Birthing Center: Advantage = More homelike, less expensive; Disadvantage = delay if complication occurs
• Home: Advantage = Control, low tech, fewer pathogens; Disadvantage = Few attendants willing, delay in emergency

Need for Admission

• Teach the pregnant woman to seek admission for regular uterine contractions (Nullipara/primipara; contraction every 5 min for one hour)
• For Multipara w/ hx rapid labor; contraction every 7-10 min for one hour
• Rupture of membranes or vaginal bleeding other than "bloody show"
• The urge to push during contractions or any other concerns are also reasons for admission

Admission Data Collection

• Maternal vital signs & condition, and cervix.
• Review Fetal condition: including the FHR and Amniotic fluid
• Signs of impending birth, and paperwork consisting of Consents, Labs, IV access. etc.
• Also, review the prenatal record including: Blood type & Rh, EDD, and birth plan

Observation without Admission

• Monitor false or early labor patients for 20 min to verify fetal well being and ambulate.
• If no cervical change (and membranes intact), return home to await true labor. Reassure and reinforce instructions to patient

After Admission to Labor Unit

• Priority nursing actions: Monitoring the fetus, and the laboring woman
• Help the woman cope with labor.

Evaluating Progress of Labor

• Contractions and a Vaginal exam, to see the Cervix - effacement & dilatation & Fetal station - descent are ways to evaluate progresss
• There is no set interval and exams should be minimized, in order to reduce infection and be sensitive to patient discomfort

Maternal Response to Labor

• Assess response to labor by eval of the patients breathing & relaxation techniques tension or difficulty coping Support adaptive responses by maintaining open communication and hygiene and comfort measures.
• Teach, keep informed of progress and encourage and assist the partner

Amniotic Fluid

• Record color, odor, and amount.
• Clear, straw-colored fluid with flecks of white vernix is normal.
• Green fluid indicates meconium and potential fetal distress.
• Cloudy fluid with odor indicates infection
• The nitrazine test is performed to verify alkalinity (pH above 7.0)

Ongoing Maternal Physical Assessment

• Vital signs: Initially may be elevated due to excitement; repeat.
• Temperature: Every 4 hours, every 2 hours after membranes rupture; report Temp ≥100.4°F.
• Pulse, respiration, and blood pressure: Every 1 hour.
• Measure Input & Output (I&O).
• Encourage voiding every 1-2 hours because a full bladder will interfere with descent

Assisting the Laboring Woman

• Promote comfort: control the Environment (light, room temp, covers)
• Encourage Hygiene: frequently change underpads
• Encourage Position: Ambulate during early labor, get Upright, hands & knees, and side lying, but Avoid supine position

Fetal Heart Rate

• Monitor fetus for early signs of hypoxia so you can quickly respond There are two ways to monitor the fetal heart rate, intermitten auscultation, and continuously with an electronic fetal monitor Continuous- can be external or internal

Electronic Fetal Monitoring

• The nurses are responsible for continuous monitoring of data, and rapidly identifying non-reassuring patterns
• Act with prompt intervention and Document interventions & additional information within the medical record

Fetal Heart Rate

• Normal baseline rate: 110-160 bpm.
• Tachycardia: >160 bpm, possibly due to maternal fever.
• Bradycardia: 110bpm, possibly due to hypoxia
• Gives a recording of FHR and a wavy reassuring appearance

Accelerations

• These involve a rate increase by 15 beats for at least 15 seconds and are good/reassuring, requiring no response

Early Decelerations

• Rate decreases with contraction, recovering at the end and indicates head compression.

Late Decelerations

• The rate slows and doesn't return to baseline until after the contraction is over, indicated placenta not delivering enough O₂ to the fetus/ Uteroplacental insufficiency (UPI).
• When this happens use Side-lying, O₂, IV, stop oxytocin, notify MD

Variable Decelerations

• Involve a rate dropping abruptly in irregular V, W, or U shaped pattern
• Meaning: Cord compression.
• Action: Reposition the patient, employ amnioinfusion

Understanding Pain in Childbirth

• Pain is an unpleasant and distressing personal symptom.
• Childbirth pain is part of the normal birth process and is self-limiting; can motivate woman to seek help from others and facilitate birth

Psychosocial Pain Factors

• Culture: Whether the pain comes from an expressive vs. stoic culture-based
• Anxiety: Increases tension & decreases tolerance
• Experience
• Preparation: Many types, but more helpful if more realistic
• Support of significant other(s)

Pain in Childbirth

• Causes - contractions, dilation, stretching, ischemia, and pressure.
• Women's experiences of pain vary.
• Supportive care enhances pain coping.
• Prenatal education includes pain control options for labor: Non-pharmacological and Pharmacological.
• The patient has the right about how she is treated regarding pain management interventions

Non-pharmacologic Pain Relief

• Advantages: No harm to mother or fetus, does not slow labor, no allergy, no side effects.
• Limitations: May not provide adequate pain relief, poor pain relief increases fear & anxiety, and most require preparation prior to labor.

Analgesia & Anesthesia

• Narcotic analgesia during labor crosses the placenta and may cause neonatal respiratory depression.
• Naloxone (Narcan) is a narcotic antagonist for opioid overdoses
• Regional Anesthetic, such as an epidural can be used for Labor or cesarean. Hypotension is the most common adverse reaction
• General anesthesia is rarely used.

Nurse's Role in Pain Management

• Nursing roles include:
• Non-pharmacologic: Support and assess effectiveness
• Pharmacologic: Assess appropriateness, administer or assist, and monitor for adverse reactions (maternal and neonatal).

Second Stage Characteristics

• The cervix will reach 10 cm to facilitate for delivery of the baby Pushing
• Indications of imminent birth: Urge to bear down (feels like BM), Bulging of perineum, and crowning
• Contraction remains still intense but will be less so during transition
• Mother usually regains control and pushing feels good and useful

Nursing Care: Second Stage Checklist

• Coach pushing efforts to promote safety
• Evaluate progress & monitor fetus to note changes and prevent fetal distress
• Communicate with provider to note changes to the treatment plan
• Assist with positioning to accommodate patient comfortability
• Prep perineum (usually cleansing only) to ensure safety
• Support woman & partner in emotional needs

Nursing Care During Birth

• Prepare the room & equipment: Sterile instruments
• Ensure a Radiant warmer & baby supplies are ready
• Stabilize & assess newborn, Identify mother & infant.
• Promote parent-infant bonding and Encourage the mother to do early breastfeeding.

Episiotomy

• A surgical incision to enlarge vaginal opening, but Should not be routinely used
• Vs. laceration = uncontrolled tear
• Risks include extension, infection
• After procedure preform following Nursing care protocols:
• Cold packs first 12 hours and Warmth after 12 - 24 hours
• And apply heat packs or sitz bath
• Absorbable sutures used

Infection Control: Birth

• Use Standard precautions.
• With any Body fluids present such as Blood, Amniotic fluid or Vaginal secretions
• Use Clean (or sterile) gloves and Water-repellent cover gown
• Cover yourself with a Mask & eye shield

Third Stage: Expulsion of Placenta

• During/ After Slight cramp with delivery of the placenta
• Uterus must contract firmly to control bleeding
• After delivering baby administer oxytocin as ordered, after delivery of baby or placenta
• Monitor blood pressure and/or blood loss
• Initial newborn care which includes; bonding and assisting mother with breastfeeding

Fourth Stage: Recovery

• Uterus should be firm, between pubis & umbilicus with Lochia (bleeding) < 1 pad/hour
• Possible Cramping, perineal burning or pain, and May experience shaking chills
• Nursing is tasked with: Q15 min assessing: VS, fundus, lochia, and/or perineum and to Provide hygiene and Promote warmth & nutrition
• Also maintain and Encourage the bladder be empty

Nursing Care of Mother Immediately After Birth

• Assess frequently (q 15 min x 1 hr) for hemorrhage for Bleeding < 1 pad / hour and if uterus is,Firm
• Check Vital signs, blood Pressure, Pulse, Respiration for shock; and Temp
• Always Promote bladder emptying and promote comfort to the patient by using the aid of a Warm blanket and/or a Perineal ice pack

Initial Care of Newborn (1st hour)

• Maintain warmth by keeping bay clean of wet linens
• Keep in mind, Baby is less efficient at generating heat. And hypothermia can lead to other problems Hypoglycemia and respiratory distress
• Establish cardio-respiratory function: Cord clamped, Suction mouth & nose, Rub back or flick soles of feet to stimulate cry
• Administer APGAR score at 1 & 5 minutes

Initial Care of Newborn (1st hour) Cont:

• Encourage bonding & early breastfeeding
• Observe and document urinary & bowel elimination
• Identify the infant and perform Eye care and assist with Vitamin K injections
• Always remember The newborn will be returning to the doctor next week for a checkup

Abnormal Labor: Dystocia

• Dysfunctional labor, an abnormality of the Powers, Passenger, Passage, or Psyche.
• Earlier identification increases chance of a successful outcome

PROM: Premature Rupture of Membranes

• Spontaneous ROM at term, but before labor.
• Management: Strict bedrest
  • Daily NST & BPP, WBC
  • Monitor for infection; i.e. temperature >100.4F/38°C
  • Prevention of Chorioamniotis
  • Induce labor >36 weeks or patient shows signs of infection

Prolonged Pregnancy – Post-term

• Is any Pregnancy >42 weeks
• Is Minimal risk but high stress
• Fetal risks: Placental insufficiency, meconium aspiration, ↑ risk of stillbirth, macrosomia Medical management: Verify true gestation, close monitoring: after 42 weeks induce labor Nursing implications: Monitor fetus/neonate

Powers: Decreased Uterine Muscle Tone (Hypotonic)

• Contractions diminish after 4 cm, too weak for active phase. This is caused by overdistension.
• You can treat with: - Amniotomy/AROM - Augment labor with oxytocin (Pitocin)
• Best Nursing implications: Reassure patient and Encourage ambulation and an upright position

Prolonged Labor (Dystocia)

• Long or difficult labor
• Risks include: Infection, Maternal exhaustion and anxiety or fear
• There is also a possible Postpartum hemorrhage
• Best Nursing implications: Help woman conserve strength and Observe for infection and Support Coping

Preterm Labor

• Labor before week 37
• Leading cause of neonatal mortality in US from Many possible risk factors leading to it
• Medical treatment: Women at risk taught to and recognize signs and home should be used for monitoring Attempt is made to stop preterm labor; with tocolysis medication- MgSO4 Attempt to increase fetal lung maturity with betamethasone Activity restriction and partial bedrest may be enforced

Preterm Labor cont;

• Treatment: Progesterone, Antibiotics, and Hydration
• The best option is the use of Tocolytics, these are drugs that suppress uterine activity short term,
• Are Effective with pregnancies only weeks 24 - 34
• Best Nursing implementations:
• Manage treatment and monitor and educate the patients with Teaching & support

Abnormal Fetal Presentation

• Face and breech presentations where fetus does not pass easily through pelvis
• Or Breech or transverse position
• Management: <37 weeks - watch patient

• 37 weeks - attempt external version;

• attempt to turn fetus. If labour is persistent - begin cesarean The Nursing team should Assist with both version and CS

Abnormal Position - OP

• Persistent Occiput Posterior: Prolonged “back” labor Maternal implications
• Fetal risks include: Excessive molding and caput may occur Greatest Nursing implications: best when Nursing assists in positioning for best labor progress

Macrosomia

• A Fetus is >4,000 gms (8.8 lbs) is at increased Maternal risk such as laceration and postpartum bleeding. It increases the chance of Fetal injury or shoulder dystocia or Brachial Plexus injury or Clavicle Issues
• Closely monitor labor: or Prepare for potential cesarean

Multifetal Pregnancy

• Is associated w/ Increased risks/ complications: Such as Prematurity or Uterine Overdistension
• Also GH or Abnormal presentation/position Leading to further complications of Maternal Hemorrhage Best Nursing care: Monitor each fetus and Be ready to Anticipate CS and Team prepared for each baby

Prolapsed Cord

• Is a critical Emergency:
• Where Cord slips down between fetus & pelvis is potentially compressed and cuts off circulation
• At risk with and following ROM particularly where the fetus is not engaged Prompt Treatment plan:
• Push up on fetal head, to take pressure off spinal cord Ensure there is a plan to Deliver, even and most likely by going to a C-Section situation with patient permission
• Remain, Calm and Quick action; Debrief afterward

Precipitous Labor & Birth

• Is any labor Completed in < or equal to 3 hours, that may sometimes be unattendend!
• Best Nuring implications:
• Patient needs Close monitoring and oxygen administration should be provided by the team with and Don't leave the patients side Carefully observe mother: observe Mother and Baby for injuries throughout the delivery process, and after the birthing processes

Uterine Rupture

• Tearing of the uterine muscle
• Many Risk factors: - weakened CS scar or from many other births through c section, with Intense labor plus abdominal trauma, particularly after Amniotic bands may be applied
• Significant Signs & symptoms: - Shock caused by and/or w Pain Stop contractions plus a large Hemorrhage with the lack or absence of a baby in the womb - Fetal Heartbeat also may be at a stop
• Is often a Surgical Emergency!!!!

Amniotic Fluid Embolism

• It is also an Emergency and Rare
• It occurs when Amniotic Fluid Embolism enters and effects the circulation of a pregnant women Mortality rate associated being at or near 80% Effective Treatment Methods:
• Start Respiratory support, Oxygen and attempt CPR to manage the women's cardio- vascular system
• Begin to Treat patient for being in shock as a result
• Replace coagulation factors used, with care
• Take patient to to intensive care setting where - Input and Output levels should be recorded and pulse Ox can be tracked

Perinatal Loss

• Involves Fetal loss or death is usually a result from something the patient is unaware of approximately 60% Best Care:
• Patients should be cared for in a hospital setting, to best support any grief coming, as well as being aware of symptoms such as Denial plus guilt and anger with depression or not accepting
• The use of memory and pictures: Should be used and offered but Never forced to ensure they are treated with kindness in a dignified setting

Delivery Related Procedures

• Amniotomy
• Amnioinfusion
• Version
• Induction
• Episiotomy
• Assisted Delivery

This resource covers key aspects of labor and delivery, including signs, stages, fetal adaptation, and assessments. It helps in understanding cervical changes, nursing interventions, and characteristics of true vs. false labor. Also covers fetal presentation and amniotic fluid characteristics.