Nursing Care of a Family During Labor and Birth PDF

Nursing Care of a Family During Labor and Birth NCM 107 CHAPTER 15 Theories of Why Labor Begins Some of the theories: The uterine muscle stretches from the increasing size of the fetus, which results in release of prostaglandins. The fetus presses on the cervix, which stimulates the release of o...

Nursing Care of a Family During Labor and Birth NCM 107 CHAPTER 15 Theories of Why Labor Begins Some of the theories: The uterine muscle stretches from the increasing size of the fetus, which results in release of prostaglandins. The fetus presses on the cervix, which stimulates the release of oxytocin from the posterior pituitary. Oxytocin stimulation works together with prostaglandins to initiate contractions. Changes in the ratio of estrogen to progesterone occur, increasing estrogen in relation to progesterone, which is interpreted as progesterone withdrawal. The placenta reaches a set age, which triggers contractions. Theories of Why Labor Begins Rising fetal cortisol levels reduce progesterone formation and increase prostaglandin Formation The fetal membrane begins to produce prostaglandins, which stimulate contractions The role of prostaglandins answers the often-asked question: Does coitus help induce labor? Semen does contain prostaglandins, which can be helpful in softening, also known as “ripening,” of the cervix; if a cervix is ready to ripen, semen prostaglandins could possibly stimulate the beginning of contractions. Rhythmic contractions brought on by female orgasm can conceivably help as well, although, again, not until a uterus is prepared and ready for labor.  The Components of Labor A successful labor depends on four integrated concepts, often referred to as the four Ps: 1. The passage (pelvis) is of adequate size and contour. 2. The passenger (the fetus) is of appropriate size and in an advantageous position and presentation. 3. The powers of labor (uterine factors) are adequate. 4. The psyche, or psychological state, which may either encourage or inhibit labor. This can be based on the pregnant person’s past life experiences as well as present psychological state. 1. THE PASSAGE The passage refers to the route a fetus must travel from the uterus through the cervix and vagina to the external perineum Views of the pelvic inlet and outlet. A. The pelvic inlet. B. The pelvic outlet. 1. THE PASSAGE In most instances, if a disproportion between fetus and pelvis occurs, the pelvis is the structure at fault. If the fetus is the cause of the disproportion, it is often not because the fetal head is too large but because it is presenting to the birth canal at less than its narrowest diameter. Keep this in mind when discussing with parents why an infant may not be able to be born vaginally 2. THE PASSENGER The passenger is the fetus. The body part of the fetus that has the widest diameter is the head, so this is the part least likely to be able to pass through the pelvic ring. Whether a fetal skull can pass depends on both its structure (bones, fontanelles, and suture lines) and its alignment with the pelvis. Structure of the Fetal Skull The cranium - the uppermost portion of the skull, is composed of eight bones. The four superior bones (the bones important in childbirth) : frontal (actually two fused bones) two parietal occipital The other four bones of the skull (sphenoid, ethmoid, and two temporal bones) lie at the base of the cranium and so are of little significance in childbirth because they are never presenting part Diameters of the Fetal Skull The shape of a fetal skull causes it to be wider in its anteroposterior diameter than in its transverse diameter. To fit through the inlet of the birth canal best, a fetus must present the smaller diameter (the transverse diameter) of the head to the smaller diameter of the maternal pelvis (the diagonal conjugate); otherwise, progress can be halted and vaginal birth may not be possible. Diameters of the Fetal Skull The smallest diameter of the fetal skull is the biparietal diameter or the transverse diameter, which measures about 9.25 cm. The smallest anteroposterior diameter is the suboccipitobregmatic measurement (approximately 9.5 cm) and is measured from the inferior aspect of the occiput to the center of the anterior fontanelle. The occipitofrontal diameter, measured from the occipital prominence to the bridge of the nose, is approximately 12 cm. The occipitomental diameter, which is the widest anteroposterior diameter (approximately 13.5 cm), is measured from the posterior fontanelle to the chin. Diameters of the Pelvis The anteroposterior diameter of the pelvis, a space approximately 11 cm wide, is the narrowest diameter at the pelvic inlet, and so the best presentation for birth is when the fetus presents a biparietal diameter (the narrowest fetal head diameter) to this Diameters of the Fetal Skull If a fetus presents one of the anteroposterior diameters of the skull to the anteroposterior diameter of the inlet, engagement, or the settling of the fetal head into the pelvis, may not occur. If the fetus does not rotate, leaving the anteroposterior diameter of the skull presenting to the transverse diameter of the outlet, an arrest of progress may occur. Diameters of the Fetal Skull The anteroposterior diameter that presents to the birth canal is determined not only by rotation but also by the degree of flexion of the fetal head. In full flexion, the fetal head flexes so sharply that the chin rests on the chest, and the smallest anteroposterior diameter, the suboccipitobregmatic, presents to the birth canal. If the head is held in moderate flexion, the occipitofrontal diameter presents. In poor flexion (the head is hyperextended), the largest diameter (the occipitomental) will present. A. Complete flexion allows the smallest anteroposterior diameter of the head to enter the pelvis. B. Moderate flexion causes a larger diameter to enter. C. Poor flexion forces the largest diameter against the pelvic brim so the head is too large to enter the pelvis. Molding Molding is overlapping of skull bones along the suture lines, which causes a change in the shape of the fetal skull to one long and narrow, a shape that facilitates passage through the rigid pelvis. Molding Molding is caused by the force of uterine contractions as the vertex of the head is pressed against the not-yet-dilated cervix. The overlapping that occurs in the sagittal suture line and, generally, the coronal suture line can be easily palpated on the newborn skull. Parents can be reassured that molding only lasts a day or two and will not be a permanent condition Fetal Presentation and Position Other factors that play a part in whether a fetus is properly aligned in the pelvis and is in the best position to be born are fetal attitude fetal lie fetal presentation fetal position Fetal Attitude Attitude describes the degree of flexion a fetus assumes during labor or the relation of the fetal parts to each other A. The fetus in full flexion presents the smallest anteroposterior diameter (suboccipitobregmatic) of the skull to the inlet in this good attitude (vertex presentation). B. The fetus is not as well flexed (military attitude) and presents the occipitofrontal diameter to the inlet (sinciput presentation). C. The fetus in partial extension (brow presentation). D. D. The fetus in complete extension presents a wide (occipitomental) diameter (face presentation). Fetal Attitude A fetus in optimal attitude is in complete flexion: The spinal column is bowed forward, the head is flexed forward so much that the chin touches the sternum, the arms are flexed and folded on the chest, the thighs are flexed onto the abdomen, and the calves are pressed against the posterior aspect of the thighs. This usual “fetal position” is advantageous for birth because it helps a fetus present the smallest anteroposterior diameter of the skull to the pelvis and also because it puts the whole body into an ovoid shape, occupying the smallest space possible. Fetal Attitude A fetus is in moderate flexion if the chin is not touching the chest but is in an alert or “military position”. This position causes the next widest anteroposterior diameter, the occipitofrontal diameter, to present to the birth canal. A fair number of fetus assume a military position early in labor. This does not usually interfere with labor, however, because later mechanisms of labor (descent and flexion) force the fetal head to fully flex. Fetal Attitude A fetus in partial extension presents the “brow” of the head to the birth canal Fetal Attitude If a fetus is in complete extension, the back is arched and the neck is extended, presenting the occipitomental diameter of the head to the birth canal (a face presentation). This unusual position usually presents too wide a skull diameter to the birth canal for vaginal birth. Such a position may occur in an otherwise healthy fetus or may be an indication there is less than the usual amount of amniotic fluid present (oligohydramnios), which is not allowing the fetus adequate movement space. It also may reflect a neurologic abnormality in the fetus, causing spasticity. Fetal Lie Lie is the relationship between the long (cephalocaudal) axis of the fetal body and the long (cephalocaudal) axis of a female’s body—in other words, whether the fetus is lying in a horizontal (transverse) or a vertical (longitudinal) position.  Fetal Lie Longitudinal lies are further classified as: Cephalic/ Vertex - the fetal head will be the first part to contact the cervix Breech - a foot or the buttocks as the first portion to contact the cervix Fetal Presentation Fetal presentation denotes the body part that will first contact the cervix or be born first and is determined by the combination of fetal lie and the degree of fetal flexion (attitude). Cephalic Presentation A cephalic presentation is the most frequent type of presentation, occurring as often as 96% of the time. With this type of presentation, the fetal head is the body part that first contacts the cervix. The vertex is the ideal presenting part because the skull bones are capable of effectively molding to accommodate the cervix. Cephalic Presentation During labor, the area of the fetal skull that contacts the cervix often becomes edematous from the continued pressure against it. This edema is called a caput succedaneum. In the newborn, the point of presentation can be determined by the location of the caput. Breech Presentation A breech presentation means either the buttocks or the feet are the first body parts that will contact the cervix. A good attitude brings the fetal knees up against the fetal abdomen. A poor attitude means the knees and legs are extended.  TYPES OF BREECH PRESENTATIONS TYPE LIE ATTITUDE DESCRIPTION Complete Longitudinal Good (full The fetus has the thighs tightly flexed on the flexion) abdomen; both the buttocks and the tightly flexed feet present to the cervix.  TYPES OF BREECH PRESENTATIONS TYPE LIE ATTITUDE DESCRIPTION Frank Longitudinal Moderate Attitude is moderate because the hips are flexed, but the knees are extended to rest on the chest. The buttocks alone present to the cervix.  TYPES OF BREECH PRESENTATIONS TYPE LIE ATTITUDE DESCRIPTION Footling Longitudinal Poor Neither the thighs nor lower legs are flexed. If one foot presents, it is a single-footling breech; if both present, it is a double-footling breech. Shoulder Presentation In a transverse lie, a fetus lies horizontally in the pelvis so the longest fetal axis is perpendicular to that of the pregnant person. The presenting part is usually one of the shoulders (acromion process), an iliac crest, a hand, or an elbow. The usual contour of the pregnant person’s abdomen at term may appear fuller side to side rather than top to bottom. A transverse or shoulder presentation Shoulder Presentation This presentation may be caused by pelvic contractions, in which the horizontal space is greater than the vertical space or by the presence of a placenta previa (the placenta is located low in the uterus, obscuring some of the vertical space). It also can be caused by relaxed abdominal walls from grand multiparity, which allows the unsupported uterus to fall forward  Fetal Position Fetal position is the relationship of the presenting part to a specific quadrant and side of the pregnant person’s pelvis. For convenience, the maternal pelvis is divided into four quadrants according to the birthing person’s right and left: A. right anterior B. left anterior C. right posterior D. left posterior Four parts of a fetus are typically chosen as landmarks to describe the relationship of the presenting part to one of the pelvic quadrants. Fetal Position In a vertex presentation, the occiput (O) is the chosen point. In a face presentation, it is the chin (mentum [M]). In a breech presentation, it is the sacrum (Sa). In a shoulder presentation, it is the scapula or the acromion process (A). Fetal Position Position is indicated by an abbreviation of three letters. The middle letter denotes the fetal landmark (O for occiput, M for mentum, Sa for sacrum, and A for acromion process). The first letter defines whether the landmark is pointing to the birthing parent’s right (R) or left (L). The last letter defines whether the landmark points anteriorly (A), posteriorly (P), or transversely (T). Fetal Position If the occiput of a fetus points to the left anterior quadrant in a vertex position, for example, this is a left occipitoanterior (LOA) position. If the occiput points to the right posterior quadrant, the position is right occipitoposterior (ROP). LOA is the most common fetal position Right occipitoanterior (ROA) is the second most frequent.  Examples of Possible Fetal Positions Vertex Presentation Breech Presentation Shoulder Presentation (Occiput) (Sacrum) (Acromion Process) LOA, left occipitoanterior LSaA, left sacroanterior LAA, left scapuloanterior LOP, left occipitoposterior LSaP, left sacroposterior LAP, left scapuloposterior LOT, left occipitotransverse LSaT, left sacrotransverse RAA, right scapuloanterior ROA, right occipitoanterior RSaA, right sacroanterior RAP, right scapuloposterior ROP, right occipitoposterior RSaP, right sacroposterior ROT, right occipitotransverse RSaT, right sacrotransverse The fetal position. All are vertex presentations. A, anterior; L, left; O, occiput; P, posterior; R, right; T, transverse. Fetal vertex (occiput) presentations in relation to the front, back, or side of the maternal pelvis Fetal Position Position is important because it can influence both the process and efficiency of labor. Typically, a fetus is born fastest from an ROA or LOA position. Labor can be considerably extended if the position is posterior (ROP or LOP) and may be more painful because the rotation of the fetal head puts pressure on sacral nerves. Encouraging a patient to rest in a Sims position on the same side as the fetal spine or use a hands-and-knees position may encourage rotation from an occipitoposterior to an occipitoanterior position prior to and during labor Engagement Engagement refers to the settling of the presenting part of a fetus far enough into the pelvis that it rests at the level of the ischial spines, the midpoint of the pelvis. Descent to this point means the widest part of the fetus (the presenting skull diameter in a cephalic presentation, or the intertrochanteric diameter in a breech presentation) has passed through the pelvis or the pelvic inlet has been proven adequate for birth. In a primipara, nonengagement of the head at the beginning of labor suggests that a possible complication such as an abnormal presentation or position, abnormality of the fetal head, or cephalopelvic disproportion exists. In multiparas, engagement may or may not be present at the beginning of labor. The degree of engagement is established by a vaginal and cervical examination. Engagement A presenting part that is not engaged is said to be “floating.” One that is descending but has not yet reached the ischial spines may be referred to as “dipping Station Station refers to the relationship of the presenting part of the fetus to the level of the ischial spines The station (anteroposterior view). The station, or degree of engagement, of the fetal head is designated by centimeters above or below the ischial spines. At −4 station, the head is “floating.” At 0 station, the head is “engaged.” At +4 station, the head is “at outlet.” Station When the presenting fetal part is at the level of the ischial spines, it is at a 0 station (synonymous with engagement). If the presenting part is above the spines, the distance is measured and described as minus stations, which range from −1 to −4 cm. If the presenting part is below the ischial spines, the distance is stated as plus stations (+1 to +4 cm). At a +3 or +4 station, the presenting part is at the perineum and can be seen if the vulva is separated (i.e., it is crowning) (Cardinal Movements) of Labor Cardinal movements of labor: Engagement Descent Flexion Internal rotation Extension external rotation Expulsion  Descent Descent is the downward movement of the biparietal diameter of the fetal head within the pelvic inlet. Full descent occurs when the fetal head protrudes beyond the dilated cervix and touches the posterior vaginal floor. Descent occurs because of pressure on the fetus by the uterine fundus. Flexion As descent is completed and the fetal head touches the pelvic floor, the head bends forward onto the chest, causing the smallest anteroposterior diameter (the suboccipitobregmatic diameter) to present to the birth canal. Flexion is also aided by abdominal muscle contraction during pushing. Internal Rotation During descent, the biparietal diameter of the fetal skull was aligned to fit through the anteroposterior diameter of the pregnant person’s pelvis. As the head flexes at the end of descent, the occiput rotates so the head is brought into the best relationship to the outlet of the pelvis, or the anteroposterior diameter is now in the anteroposterior plane of the pelvis. This movement brings the shoulders, coming next, into the optimal position to enter the inlet, or puts the widest diameter of the shoulders (a transverse one) in line with the wide transverse diameter of the inlet INTERNAL ROTATION COMPLETION OF INTERNAL ROTATION & BEGINNING OF EXTENSION Extension As the occiput of the fetal head is born, the back of the neck stops beneath the pubic arch and acts as a pivot for the rest of the head. The head extends, and the foremost parts of the head, the face and chin, are born  EXTERNAL ROTATION External Rotation In external rotation, almost immediately after the head of the infant is born, the head rotates a final time (from the anteroposterior position it assumed to enter the outlet) back to the diagonal or transverse position of the early part of EXTERNAL ROTATION – labor. NOTE SHOULDERS- RESTITUTION This brings the after coming shoulders into an anteroposterior position, which is best for entering the outlet. The anterior shoulder is born first, assisted perhaps by downward flexion of the infant’s head. Expulsion Once the shoulders are born, the rest of the baby is born easily and smoothly because of its smaller size. This movement, called expulsion, is the end of the pelvic division of labor. 3. THE POWERS OF LABOR This is the force supplied by the fundus of the uterus and implemented by uterine contractions, which causes cervical dilatation and then expulsion of the fetus from the uterus. After full dilatation of the cervix, the primary power is supplemented by use of a secondary power source, the abdominal muscles. It is important for patients to understand that they should not bear down with their abdominal muscles to push until the cervix is fully dilated. Doing so impedes the primary force and could cause fetal and cervical damage. Uterine Contractions During pregnancy, the uterus begins to contract and relax periodically as if it is rehearsing for labor (Braxton Hicks contractions, or false labor). These contractions are usually mild but can be strong enough to be mistaken for true labor. The mark of Braxton Hicks contractions is that they are usually irregular and are painful, but they do not cause cervical dilatation. In contrast, effective uterine contractions have rhythmicity, a progressive increase in length and intensity, and accompany dilatation of the cervix. DIFFERENTIATING BETWEEN TRUE AND FALSE LABOR CONTRACTIONS False Contractions True Contractions Begin and remain irregular Begin irregularly but become regular and predictable Felt first abdominally and remain Felt first in lower back and sweep confined to the abdomen and groin around to the abdomen in a wave Often disappear with ambulation or Continue no matter what the patient’s sleep level of activity Do not increase in duration, frequency, Increase in duration, frequency, and or intensity intensity Do not achieve cervical dilatation Achieve cervical dilatation Phases A contraction consists of three phases: Increment - when the intensity of the contraction increases Acme/peak - when the contraction is at its strongest Decrement - when the intensity decreases Between contractions, the uterus relaxes. As labor progresses, the relaxation intervals decrease from 10 minutes early in labor to only 2 to 3 minutes. Then duration of contractions also changes, increasing from 20 to 30 seconds at the beginning to a range of 60 to 70 seconds by the end of the first stage  Contour Changes As labor contractions progress and become regular and strong, the uterus gradually differentiates itself into two distinct functioning areas: Upper portion - which thickens lower segment - which becomes thin-walled, supple, and passive so the fetus can be pushed out of the uterus easily. The contour of the overall uterus also changes from a round, ovoid structure to an elongated one with a vertical diameter markedly greater than the horizontal diameter. Cervical Changes Even more marked than the changes in the body of the uterus are two changes that occur in the cervix: Effacement Dilatation  Effacement Effacement is shortening and thinning of the cervical canal. All during pregnancy, the canal is approximately 2.5 to 5 cm long. During labor, the longitudinal traction from the contracting uterus shortens the cervix so much that the cervix virtually disappears. Dilatation Dilatation refers to the enlargement or widening of the cervical canal from an opening a few millimeters wide to one large enough (approximately 10 cm) to permit passage of a fetus Dilatation Dilatation occurs first because uterine contractions gradually increase the diameter of the cervical canal lumen by pulling the cervix up over the presenting part of the fetus. Secondly, the fluid-filled membranes push ahead of the fetus and serve as an opening wedge. As dilatation begins, there is an increase in the amount of vaginal secretions (show) because minute capillaries in the cervix rupture and the last of the mucus plug that has sealed the cervix since early pregnancy is released. 4. THE PSYCHE The fourth “P,” or psychological outlook, refers to the psychological state or feelings a pregnant person brings into labor. For many, this is a feeling of apprehension or fright. For almost everyone, it includes a sense of excitement or awe. Those who manage best in labor typically have a strong sense of self-esteem and a meaningful support person with them. Pregnant people without adequate support can have a labor experience so frightening and stressful that they develop symptoms of post-traumatic stress disorder The Stages of Labor Labor is traditionally divided into three stages: The first stage of dilatation - which begins with the initiation of true labor contractions and ends when the cervix is fully dilated The second stage - extending from the time of full dilatation until the infant is born The third or placental stage - from the time the infant is born until after the delivery of the placenta The first 1 to 4 hours after birth of the placenta is sometimes termed the “fourth stage” to emphasize the importance of close maternal observation needed at this time Stages of Labor THE FIRST STAGE The first stage, which takes about 12 hours to complete It is divided into three segments: Latent phase Active phase transition phase The Latent Phase The latent or early phase begins at the onset of regularly perceived uterine contractions and ends when rapid cervical dilatation begins. Cervical dilation is 1 to 4 cm. Uterine contractions occur every 15 to 30 minutes, are 15 to 30 seconds in duration, and are of mild intensity. The Latent Phase In a patient who is psychologically prepared for labor and who does not tense at each tightening sensation in their abdomen, latent phase contractions cause only minimal discomfort and can be managed by controlled breathing. During this phase, encourage patients to continue to walk about and make preparations for birth, such as doing last-minute packing for their stay at the hospital or birthing center, preparing older children for their departure and the upcoming birth, or giving instructions to the person who will take care of them while they are away. If desired, they could begin alternative methods of pain relief such as aromatherapy, distraction, or acupressure.  The Active Phase Cervical dilation is 4 to 7 cm. Uterine contractions occur every 3 to 5 minutes, are 30 to 60 seconds in duration, and are of moderate intensity. Show (increased vaginal secretions) and, perhaps, spontaneous rupture of the membranes may occur during this time. Encourage patients to be active participants in labor by keeping active and assuming whatever position is most comfortable for them during this time, except flat on their back. The Transition Phase During the transition phase, contractions reach their peak of intensity, occurring every 2 to 3 minutes with a duration of 60 to 70 seconds, and a maximum cervical dilatation of 8 to 10 cm occurs. If it has not previously occurred, show will occur as the last of the mucus plug from the cervix is released. If the membranes have not previously ruptured, they will usually rupture at full dilatation (10 cm). By the end of this phase, both full dilatation (10 cm) and complete cervical effacement (obliteration of the cervix) have occurred. The Transition Phase During this phase, a patient may experience intense discomfort that is so strong it might be accompanied by nausea and vomiting. They may also experience a feeling of loss of control, anxiety, panic, and/or irritability. Because of the intensity and duration of the contractions, it may seem as though labor has taken charge of them. A few minutes before, they may have enjoyed having their forehead wiped with a cool cloth or their back rubbed. Now, they may knock a partner’s hand away. Their focus turns entirely inward to the task of birthing the baby. As a patient reaches the end of this stage at 10 cm of dilatation, unless they have been administered epidural anesthesia, a new sensation, the irresistible urge to push, usually begins  THE SECOND STAGE The second stage of labor is the time span from full dilatation and cervical effacement to birth of the infant. Uterine contractions occur every 2 to 3 minutes, lasting 60 to 75 seconds, and are of strong intensity. A patient typically feels contractions change from the characteristic crescendo–decrescendo pattern to an uncontrollable urge to push or bear down with each contraction as if to move their bowels. They may experience only momentary nausea or vomiting because pressure is no longer exerted on their stomach as the fetus descends into the pelvis. The patient pushes with such force that they perspire and the blood vessels in their neck become distended THE SECOND STAGE The fetus begins descent and, as the fetal head touches the internal perineum to begin internal rotation, the perineum begins to bulge and appear tense. The anus may become everted, and stool may be expelled. As the fetal head pushes against the vaginal introitus, this opens and the fetal scalp appears at the opening to the vagina and enlarges from the size of a dime, to a quarter, then a half-dollar. This is termed crowning. THE SECOND STAGE It takes a few contractions of this new type for a patient to realize everything is alright, just different, and to appreciate it feels better and less frightening to push with contractions. As they concentrate on pushing, they may become unaware of the conversation in the room. Pain may disappear as all of their energy and thoughts are directed toward giving birth. As the fetal head is pushed out of the birth canal, it extends and then rotates to bring the shoulders into the best line with the pelvis. The body of the baby is then born THE THIRD STAGE The third stage of labor, the placental stage, begins with the birth of the infant and ends with the delivery of the placenta. Two separate phases are involved: Placental separation Placental expulsion Placental Separation Active bleeding on the maternal surface of the placenta begins with separation, which helps to separate the placenta still further by pushing it away from its attachment site. As separation is completed, the placenta sinks to the lower uterine segment or the upper vagina. The placenta has loosened and is ready to deliver when: There is lengthening of the umbilical cord. A sudden gush of vaginal blood occurs. The placenta is visible at the vaginal opening. The uterus contracts and feels firm again.  Placental Separation If the placenta separates first at its center and lastly at its edges, it tends to fold on itself like an umbrella and presents at the vaginal opening with the fetal surface evident. Appearing shiny and glistening from the fetal membranes, this is called a Schultze presentation. If, however, the placenta separates first at its edges, it slides along the uterine surface and presents at the vagina with the maternal surface evident. It looks raw, red, and irregular, with the ridges or cotyledons that separate blood collection spaces evident; this is called a Duncan presentation. Although there is no difference in the outcome, record which way the placenta presented. A simple trick of remembering the presentations is remembering that if the placenta appears shiny, it is a Schultze presentation. If it looks “dirty” (the irregular maternal surface shows), it is a Duncan presentation. The fetal (A) and maternal (B) surfaces of the placenta. Placental Separation This stage can take anywhere from 1 to 30 minutes and still be considered normal. Because bleeding occurs as the placenta separates, before the uterus contracts sufficiently to seal maternal capillaries, there is a blood loss of about 300 to 500 mL, not a great amount in relation to the extra blood volume that was formed during pregnancy. Placental Expulsion Once separation has occurred, the placenta delivers either by the natural bearing-down effort of the birthing parent or by gentle pressure on the contracted uterine fundus by the primary healthcare provider (a Credé maneuver). Pressure should never be applied to a uterus in a noncontracted state because doing so could cause the uterus to evert (turn inside out), accompanied by massive hemorrhage. If the placenta does not deliver spontaneously, it can be removed manually. Placental Expulsion It needs to be inspected after delivery to be certain it is intact and part of it was not retained (which could prevent the uterus from fully contracting and lead to postpartal hemorrhage). In recognition of cultural preferences, be certain to ask if a patient wants to take home the placenta because this can be a strong cultural tradition you don’t want to break Some patients choose to have a cord blood sample withdrawn from the cord to be banked for stem cell transplantation in the future. Maternal and Fetal Responses to Labor Labor is a local process that involves the abdomen and reproductive organs, but because it is such an intense process, it has systemic physiologic effects on both a birthing parent and the fetus. Its intensity is so great that almost all body systems are affected by it THE MATERNAL PHYSIOLOGIC EFFECTS AND PSYCHOLOGICAL RESPONSES Pregnancy has effects on many systems of the birthing parent. During labor, there are yet further effects which may require the nurse to deliver specific care to their patient. Knowing and recognizing what is normal and what is not normal can help to ensure safe provision of care.  PHYSIOLOGIC EFFECTS OF LABOR System Response Recommended Nursing Action Cardiovascular Cardiac output increases 40%–50% from Monitor closely for system prelabor levels. hemorrhage. Blood loss at birth is 300–500 mL on Monitor for signs of average. pathology with hypertensive Blood pressure may rise with pain response episodes. and, due to work of the system during Ensure that patients are well contractions, by an average systolic rise of 15 hydrated prior to epidural mm Hg per contraction. Epidural anesthesia administration. This usually may cause hypotension. involves an IV fluid bolus  PHYSIOLOGIC EFFECTS OF LABOR System Response Recommended Nursing Action Hematopoietic During labor, WBCs increase to a level of Continue to monitor for any system 25,000–30,000 cells/mm3 compared to 5,000– signs of infection. 10,000 cells/mm3. Respiratory Increased respiratory rate to respond to Monitor for any signs of System increased cardiovascular parameters hyperventilation. If Total oxygen needs increase 100% during the hyperventilation occurs, second stage of labor. rebreathing into a paper bag can be helpful. If needed, use appropriately patterned breathing to regulate respiratory rate.  PHYSIOLOGIC EFFECTS OF LABOR System Response Recommended Nursing Action Temperature Body temperature may increase up Monitor for any signs of infection. regulation to 1°F. Offer cool washcloths for the patient’s Diaphoresis occurs with forehead for comfort if needed. accompanying evaporation to cool and limit excessive warming. Fluid balance Insensible water loss increases Encourage patients to sip fluid during labor during labor due to diaphoresis and the same as they would if they were the increase in rate and depth of exercising to keep hydrated. respirations. If a patient is nauseated by labor, encourage sips of fluid, ice chips, or hard candy to supply some extra fluid.  PHYSIOLOGIC EFFECTS OF LABOR System Response Recommended Nursing Action Urinary system Pressure of the fetal head as it Ask the birthing parent to void descends in the birth canal against the approximately every 2 hours during anterior bladder reduces bladder tone labor to avoid overfilling because or the ability of the bladder to sense overfilling can decrease postpartal filling. bladder tone. Musculoskeletal During pregnancy, relaxin is secreted Monitor for appropriate mobility and system from the ovaries, causing the cartilage be mindful of fall risks. between joints to be more flexible. This allows the joints of the pelvis to be able to open as much as 2 cm in labor to allow for fetal passage.  PHYSIOLOGIC EFFECTS OF LABOR System Response Recommended Nursing Action GI system Blood shunts to life-sustaining Although many hospital protocols organs causing the GI system to dictate that patients who present in become fairly inactive during labor should not partake of oral labor. nutrition, there is little evidence to Digestive and emptying time of the support this restrictive practice. stomach becomes lengthened. Some patients experience a loose bowel movement as contractions grow strong.  PHYSIOLOGIC EFFECTS OF LABOR System Response Recommended Nursing Action Neurologic and Increased pain Where pain registers is important in sensory Increased respiratory rate appreciating why epidural anesthesia is response effective. For early labor, the anesthetic block needs to suppress the lower thoracic synapses; for birth, it needs to block sacral nerves. Discuss nonpharmacologic pain techniques if the patient does not desire medication.  PHYSIOLOGIC EFFECTS OF LABOR System Response Recommended Nursing Action Psychological Labor can lead to emotional Continue to encourage the process of responses distress because it is not only painful labor. and fatiguing but it also represents Prior to birth, a birthing parent can the beginning of a major life change investigate the services of a doula. for a birthing parent and partner. A doula is an individual with specialized training who provides physical, emotional, and psychological support to laboring parents. A doula does not perform clinical tasks. However, the simple gift of presence has been shown to reduce the need for analgesia and anesthesia requests, shorten labor times, and increase satisfaction with the birth experience. FETAL RESPONSES TO LABOR The pressure and circulatory changes that occur with contractions not only affect the birthing parent but also can cause detectable physiologic changes in the fetus as well. The Neurologic System Uterine contractions exert pressure on the fetal head, so the same response that is involved with any instance of increased intracranial pressure occurs. The fetal heart rate (FHR) decreases by as much as five beats per minute during a contraction, as soon as contraction strength reaches 40 mm Hg; although not measurable, fetal blood pressure also rises. The decrease in FHR appears on a fetal heart monitor as a normal or early deceleration pattern The Cardiovascular System A sufficiently mature fetus is unaffected by the continual variations of heart rate that occur with labor contractions. During a contraction, as the arteries of the uterus become sharply constricted, and the filling of cotyledons almost completely halts, the amount of nutrients, including oxygen, exchanged during this time is greatly reduced, causing a slight but inconsequential fetal hypoxia. The increase in blood pressure caused by increased intracranial pressure raises blood pressure and keeps circulation from falling below normal for the duration of a contraction The Integumentary System The pressure involved in the birth process is often reflected in minimal petechiae or ecchymotic areas on a fetus (particularly the presenting part). There may also be edema of the presenting part (caput succedaneum) from this pressure. The Musculoskeletal System The force of uterine contractions tends to push a fetus into a position of full flexion or with the head bent forward, which is the most advantageous position for birth. The Respiratory System The process of labor appears to aid in the maturation of surfactant production by alveoli in the fetal lung. Both the pressure applied to the chest from contractions and passage through the birth canal help to clear the respiratory tract of lung fluid. For this reason, an infant born vaginally is usually able to establish respirations more easily than a fetus born by cesarean birth Measuring Progress in Labor A patient’s progress in labor is recorded on a labor record (a Partogram) devised by the World Health Organization, or a like form on which vital signs, FHR, cervical dilatation, descent of the fetal head, urine tests, and any drugs administered can be recorded. Remember, when using such forms, how much and what type of analgesia a patient receives in labor should not influence the length of labor but may affect how long the second stage (pushing) lasts. Measuring Progress in Labor After each cervical examination, cervical dilatation and fetal descent (which may be referred to as “station”) are plotted on the graph. The pattern of cervical dilatation usually plots as a rising S-shaped curve. You may need to remind patients that assessments of cervical dilatation are subjective, so one examiner may report a different finding from another. Labor may take over 6 hours to progress from 4 to 5 cm and over 3 hours to progress from 5 to 6 cm of dilatation. Nulliparas and multiparas progress at a pace that is similar before 6 cm. However, after 6 cm, labor accelerates much faster in multiparas than in nulliparas. MATERNA L DANGER SIGNS OF LABOR High or Low Blood Pressure Normally, a birthing parent’s blood pressure rises slightly in the second (pelvic) stage of labor because of their pushing effort. A systolic pressure greater than 140 mm Hg and a diastolic pressure greater than 90 mm Hg, or an increase in the systolic pressure of more than 30 mm Hg or in the diastolic pressure of more than 15 mm Hg (the basic criteria for gestational hypertension), should be reported. Just as important to report is a falling blood pressure because it may be the first sign of intrauterine hemorrhage, although a falling blood pressure from hemorrhage is often associated with other clinical signs of hypovolemic shock, such as apprehension, increased pulse rate, and pallor Abnormal Pulse Most patients during pregnancy have a pulse rate of 70 to 80 beats per minute. This rate normally increases slightly during the second stage of labor because of the exertion involved. A maternal pulse rate greater than 100 beats per minute during labor is unusual and should be reported because it may be another indication of hemorrhage Inadequate or Prolonged Contractions Uterine contractions normally become more frequent, intense, and longer as labor progresses. If they become less frequent, less intense, or shorter in duration, this may indicate uterine exhaustion (inertia). This problem may be correctable but needs augmentation or other interventions. Observe also if there is a period of relaxation between contractions so the intervillous spaces of the uterus can fill and maintain an adequate supply of oxygen and nutrients for the fetus. As a rule, uterine contractions lasting longer than 70 seconds are becoming long enough to compromise fetal well-being because this interferes with adequate uterine artery filling. Abnormal Lower Abdominal Contour If a patient has a full bladder during labor, a round bulge appears on the lower anterior abdomen. This is a danger signal for two reasons: The bladder may be injured by the pressure of the fetal head pressing against it The pressure of the full bladder may not allow the fetal head to descend. To avoid a full bladder, ask patients to try to void about every 2 hours during labor. Increasing Apprehension Warnings of psychological danger during labor are as important to consider in assessing maternal well-being as are physical signs. Approaching the second stage of labor, a patient who is becoming increasingly apprehensive despite clear explanations of unfolding events may not be “hearing” because they have a concern that has not been met. Using an approach such as, “You seem more and more concerned. Could you tell me what is worrying you?” may be helpful. Increasing apprehension also needs to be investigated for physical reasons because it can be a sign of oxygen deprivation or internal hemorrhage.  FETAL DANGER SIGNS OF LABOR ❑High or Low Fetal Heart Rate As a rule, an FHR of more than 160 beats per minute (fetal tachycardia) or less than 110 beats per minute (fetal bradycardia) is a sign of possible fetal distress. An equally important sign is a late or variable deceleration pattern revealed on a fetal monitor Frequent monitoring by a fetoscope, Doppler, or a monitor is necessary to detect these changes as they first occur. Meconium Staining Meconium staining, a green color in the amniotic fluid, reveals the fetus has had a loss of rectal sphincter control, allowing meconium to pass into the amniotic fluid. It may indicate a fetus has or is experiencing hypoxia, which stimulates the vagal reflex and leads to increased bowel motility. Although meconium staining may be usual in a breech presentation because pressure on the buttocks causes meconium loss, it should always be reported immediately even with breech presentations so its cause can be investigated Hyperactivity Ordinarily, a fetus remains quiet and barely moves during labor. Fetal hyperactivity may be a subtle sign that hypoxia is occurring because frantic motion is a common reaction to the need for oxygen. Low Oxygen Saturation Oxygen saturation in a fetus is normally 40% to 70%. A fetus can be assessed for this by a catheter inserted next to the cheek (under 40% oxygenation needs further assessment). If fetal blood is obtained by scalp puncture, the finding of acidosis (blood pH lower than 7.2) suggests fetal well-being is becoming compromised and that further investigation is also necessary. Maternal and Fetal Assessments During Labor THE IMMEDIATE ASSESSMENT OF A PATIENT IN FIRST STAGE OF LABOR A number of immediate assessment measures are necessary to safeguard maternal and fetal health when a patient first arrives at a birthing facility. After the patient and any support person are oriented to the area, focus on obtaining this vital assessment data. The Initial Interview and Physical Examination Information about the pregnancy can be gained from the prenatal record electronically on admission or if a paper copy has been forwarded to the birth setting beforehand. Additional important data that needs to be obtained includes a description of labor thus far, general physical condition, and preparedness and plans for labor and birth. This amount of information is scant but helps to establish whether the patient is in active labor and needs immediate preparation for birth or whether they have arrived at the birthing setting at an early stage of labor and therefore will benefit most from paced interventions The Initial Interview and Physical Examination Ask about the following: Expected date of birth/delivery (EDB or EDD) When contractions began Amount and character of any show Whether rupture of membranes has occurred Any known drug allergies The Initial Interview and Physical Examination Ask about the following: Any recreational or prescription drugs used (patients addicted to opioids need special precautions before analgesia is administered for pain management; their newborn may need special care to prevent neonatal abstinence syndrome from opioid withdrawal) Past pregnancy and present pregnancy history if the prenatal record is not available. It is important to note the route of delivery with any prior births as well as any complications which may have occurred. The birth plan or what individualized measures they think will create a memorable experience such as whether they want analgesia or who they would like to cut the umbilical cord The Initial Interview and Physical Examination Assess the following: Vital signs: temperature, pulse, respirations, and blood pressure (assess between contractions for comfort and accuracy) Nature of contractions (frequency, duration, and intensity) Rating of pain on a 10-point scale What the patient has done to be prepared for labor such as learning breathing exercises Urine specimen for protein and glucose Position and presentation of the fetus The Initial Interview and Physical Examination It is important to document fetal presentation and position at the beginning of labor because these help predict if the presentation of a body part other than the vertex could be putting a fetus at risk or leading to the possibility that labor will be longer than usual because fetal descent will be less effective, causing ineffective dilatation of the cervix. A different presentation could also lead to early rupture of membranes, increasing the possibility of infection, fetal anoxia from cord prolapse, and meconium staining, all of which can lead to cesarean birth or respiratory distress at birth THE DETAILED ASSESSMENT DURING THE FIRST STAGE OF LABOR If the patient is in active labor, the history taken on arrival may be the only history obtained until after the baby is born. If birth is not imminent, both a more extensive history and a physical examination can be obtained. The History Performing a detailed interview of a person in labor can be difficult because of the constant interruptions labor contractions cause. If a patient concentrates so intently on a breathing exercise that they completely forget a question asked just before a contraction, repeat the question as the contraction subsides, as if it had not been asked before, or as if it is no trouble to ask it again. Current Pregnancy History Important information needed for a complete history includes documentation of gravida and parity status, a description of this pregnancy (e.g., intended or not, place and pattern of prenatal care, adequacy of nutrition, whether any complications such as spotting, falls, hypertension of pregnancy, infection, alcohol or drug ingestion occurred during pregnancy), plans for labor (e.g., Do they want to have the baby naturally? Will they use breathing exercises? Will a support person remain with the patient continuously?), and plans for childcare (e.g., Will they breastfeed? Have they chosen a primary healthcare provider for the baby? If the baby is male, do they want him circumcised?). Past Pregnancy History Document prior pregnancies, abortions, or miscarriages, including number, dates, types of birth, any complications, and outcomes, including health, sex, and birth weights of previous children. Past Health History Document any previous surgeries (abdominal surgical adhesions might interfere with fetal passage), heart disease or diabetes (special precautions will be required during labor and birth), anemia (blood loss at birth may be more important than usual), tuberculosis (requiring testing after birth to be certain healed lung lesions weren’t reactivated by birth), kidney disease or hypertension (blood pressure must be monitored even more carefully than usual), or sexually transmitted infection such as herpes (the infant may be exposed to the disease by vaginal contact if the disease is active). Determine also whether a patient is at risk for prescription or nonprescription drug abuse or HIV exposure Family Medical History Ask if any family member has a condition that could be inherited such as a cognitive challenge, heart disease, blood dyscrasia, diabetes, kidney disease, allergies, seizures, hearing loss, or malignant hyperthermia (a dominantly inherited disorder that causes a dangerous increase in temperature in response to certain anesthetics). The Physical Examination After history taking, a patient needs a physical examination, including a pelvic examination, to confirm general health, the presentation and position of the fetus, and the stage of cervical dilatation. In order to have an HIV test, a patient must sign additional informed consent over and above the usual health facility consent. The Physical Examination The physical assessment during labor begins, as does all physical assessments, with overall appearance: Does the patient appear tired? Pale? Ill? Frightened? Are there signs of edema or dehydration? Do they have open lesions anywhere? Be prepared to adapt further examination techniques with regard to stage of labor, frequency of contractions, and labor progression The Physical Examination Be certain to palpate for enlargement of neck lymph nodes to detect the possibility of a respiratory infection. Inspect the mucous membrane of the mouth and the conjunctiva of the eyes for color to see if paleness suggests anemia. Examine teeth for caries or abscesses because an oral infection might account for a postpartal fever. Examine the outer and inner surfaces of the lips carefully to detect herpes lesions (pinpoint vesicles on an erythematous base). Report to the patient’s primary care provider if herpetic lesions are present anywhere because, although oral lesions are invariably a type 1 herpes virus (common cold sores), type 2 (genital) herpes virus needs to be identified because this can be lethal to newborns; a patient’s obstetric healthcare provider may suggest that the patient with oral herpes lesions take isolation precautions such as not kissing the newborn until the lesions crust. The Physical Examination Auscultate the lungs to be certain they are clear of rales. Listen for normal heart sounds and rhythms as well. Many pregnant people at term have a grade 2 to 3 systolic ejection murmur because of the extra volume of blood that must cross their heart valves. Document if this is noticeable. Next, inspect and palpate the breasts. Are they free of cysts and lumps? Mark the chart of a patient who has a palpable mass in their breasts for reexamination after labor and birth. This is probably an enlarged milk gland but needs further evaluation to be certain it is not something more serious such as a breast malignancy Abdominal and Lower Leg Assessment Assessing a patient’s abdomen is important to estimate fetal size by fundal height (which should be at the level of the xiphoid process at term). Palpate and percuss the bladder area (over the symphysis pubis) to detect a full bladder. Assess for abdominal scars to reveal previous abdominal or pelvic surgery that could have left adhesions. Finally, inspect lower extremities for skin turgor to assess hydration and also for edema and varicose veins. Patients with large varicosities are more prone to thrombophlebitis after birth than others. Severe edema suggests hypertension of pregnancy. Determining Fetal Position, Presentation, and Lie Four methods can be used to determine if the fetus is in an optimal position for birth: Determining the place on the patient’s abdomen where fetal heart tones are heard strongest Abdominal inspection and palpation, called Leopold maneuvers Vaginal examination Sonography Leopold Maneuvers Leopold maneuvers are a systematic method of observation and palpation to determine fetal presentation and position and are done as part of a physical examination. Vaginal Examination Vaginal examinations are best done between contractions. Although more of the fetal skull can be palpated during a contraction because the cervix retracts more at that time, an examination during a contraction is more uncomfortable and rarely is justified by the additional amount of information gained. A palpation of membranes during a contraction, when they are under pressure, also can cause them to rupture. Vaginal Examination Vaginal examinations should not be done in the presence of fresh bleeding because fresh bleeding may indicate that a placenta previa (implantation of the placenta so low in the uterus that it is encroaching on the cervical os) is present. Performing a vaginal examination in this instance might tear the placenta and cause hemorrhage, resulting in danger to both the pregnant person and fetus. Make certain a primary care provider knows about the fresh bleeding before attempting a vaginal examination. Sonography Although not routine, sonography may be used to determine the diameters of the fetal skull and to determine presentation, position, flexion, and degree of descent of a fetus at the beginning of labor. This is usually done by a portable unit, but if it’s necessary for a patient to be transported to another department to have this done, be certain someone accompanies them, so, if labor should become more active, they can be returned quickly to the labor or birth service for needed care. Assessing Rupture of Membranes One out of every four labors begins with spontaneous rupture of the fetal membranes. When this occurs, a birthing parent feels a sudden gush or a slow trickle of amniotic fluid from their vagina. Assessing Rupture of Membranes A sterile vaginal examination using a sterile speculum usually reveals whether amniotic fluid is present in the vagina. After vaginal secretions are obtained with a sterile, cotton-tipped applicator, test them with a strip of Nitrazine paper. Vaginal secretions are usually acid; amniotic fluid, in contrast, is alkaline. If amniotic fluid has passed through the vagina recently, the pH of the vaginal fluid will probably be alkaline (greater than 6.5) when tested by Nitrazine paper (appears blue-green or gray to deep blue). Assessing Rupture of Membranes If the patient’s membranes ruptured at home, ask them to describe the color of the amniotic fluid, the amount, the odor, and the approximate time of rupture. Amniotic fluid should be clear as water. Yellow-stained fluid suggests a blood incompatibility between the birthing parent and fetus (the amniotic fluid is bilirubin stained from the breakdown of red blood cells). Green fluid suggests meconium staining. Assessment of Pelvic Adequacy Evaluating pelvic adequacy using internal conjugate and ischial tuberosity diameters is generally done during pregnancy either manually or by sonogram; so, by weeks 32 to 36 of pregnancy, a primary care provider can be alerted that cephalopelvic disproportion could occur. Because the diameters obtained during pregnancy have not changed, they are not retaken if already obtained. Vital Signs Temperature Temperature is usually obtained every 4 hours during labor. Report a temperature greater than 99°F (37.2°C) because it may indicate the development of infection. Unless there are accompanying symptoms, however, temperature elevation in a patient who has taken little fluid by mouth usually reflects dehydration (urge them to drink at least sips of water to maintain hydration). After rupture of the membranes, temperature should be taken every 2 hours because the possibility of infection markedly increases after that time. Pulse and Respiration A persistent pulse rate of more than 100 beats per minute could be tachycardia from dehydration or hemorrhage and so needs investigation. Respiratory rate during labor is usually 18 to 20 breaths per minute. Do not count respirations during contractions because patients tend to breathe rapidly from pain. Observe for hyperventilation (rapid, deep respirations) because prolonged hyperventilation can cause a “blowing off” of carbon dioxide and accompanying symptoms of dizziness and tingling of hands and feet. Rebreathing into a paper bag and reassurance the feeling is normal help to reverse this process. Blood Pressure Blood pressure is usually measured and recorded every 4 hours as well. As with pulse and respirations, measure blood pressure between contractions, both for a patient’s comfort and for accuracy, because maternal blood pressure tends to rise 5 to 15 mm Hg during a contraction. An increase in blood pressure at other times is potentially dangerous because it may indicate the development of hypertension of pregnancy. A decrease in blood pressure or a decrease in the pulse pressure (the difference between the systolic and diastolic pressures) may indicate hemorrhage. If a patient received an analgesic agent (such as meperidine), which tends to cause hypotension, check the blood pressure approximately 15 minutes after administration to be certain extreme hypotension did not occur. Laboratory Analysis Blood Blood is drawn for hemoglobin and hematocrit, a serologic test for syphilis (Venereal Disease Research Laboratory [VDRL] test), hepatitis B antibodies, and blood typing to determine whether a blood incompatibility is likely to exist in the newborn and what type of blood will need to be supplied if the patient should have an acute blood loss. If a patient gives permission for HIV testing, blood for this will be drawn as well. Urine Obtain a clean-catch urine specimen and test it at the point of care for protein and glucose, then send it to the laboratory for a complete urinalysis. If a patient reports any symptoms that suggest a urinary tract infection such as burning on urination, blood in urine, extreme frequency, or flank pain, obtain a clean-catch specimen for culture. A person in labor is able to void most easily if allowed to use a bathroom. However, if a patient has ruptured membranes, check whether ambulating to a bathroom is safe by confirming the fetal head is well engaged so gravity does not cause a prolapsed cord. Use a bedpan or receptacle placed on a commode to collect any material passed from the vagina so this can be assessed as well The Assessment of Uterine Contractions Depending on the hospital or birthing center policy, most patients are monitored by an external contraction monitor for about 20 minutes in early labor. The monitor is then removed, and contractions are assessed intermittently by Doppler because extensive electronic monitoring has not shown to lower fetal mortality with low-risk patients, can limit mobility, and can lead to an increase in cesarean birth.  Length of Contractions To determine the length of a contraction with a monitor in place, simply observe the rhythm strip and, using the time line, count the number of seconds the contraction lasted. To determine the beginning of a contraction without a monitor, rest a hand on a patient’s abdomen at the fundus of the uterus very gently until you sense the gradual tensing and upward rising of the fundus that accompanies a contraction. Time the duration of the contraction from the moment the uterus first tenses until it has relaxed again. Intensity of Contractions The intensity of a contraction refers to its strength. On a monitor, this is the height of the waveform. If you are assessing manually, rate a contraction according to: Mild - if the uterus does not feel more than minimally tense Moderate - if the uterus feels firm Strong - if the uterus feels as hard as a wooden board or you are unable to indent the uterus with your fingertips at the peak of the contraction After estimating either the intensity or duration of a contraction, recheck the fundus at the conclusion of the contraction to be certain it does relax and becomes soft to the touch again. Frequency of Contractions Lastly, time the frequency of contractions or how often they are occurring. Frequency is timed from the beginning of one contraction to the beginning of the next. Use as light a touch as possible on a patient’s abdomen while evaluating contractions or estimating their strength manually. THE INITIAL FETAL ASSESSMENT Although fairly passive in labor, a fetus is subjected to extreme pressure by uterine contractions and passage through the birth canal, so it is important to ascertain that the FHR remains within normal limits despite these pressures. Auscultation of Fetal Heart Sounds Fetal heart sounds are transmitted best through the convex portion of a fetus because that is the part that lies in closest contact with the uterine wall. In a vertex or breech presentation, fetal heart sounds are usually best heard through the fetal back. In a face presentation, the back becomes concave so the sounds are best heard through the more convex thorax. In breech presentations, fetal heart sounds are heard most clearly high in the uterus, at a patient’s umbilicus or above. Auscultation of Fetal Heart Sounds In cephalic presentations, they are heard loudest low in a patient’s abdomen. In an ROA position, sounds are heard best in the right lower quadrant. In an LOA position, sounds are heard best in the left lower quadrant. In posterior positions (LOP or ROP), heart sounds may be loudest at a patient’s side. Locating fetal heart sounds by fetal position: (A) Left occipitoanterior (LOA), (B) right occipitoanterior (ROA), (C) left occipitoposterior (LOP), (D) right Auscultation of Fetal Heart Sounds Hearing fetal heart sounds in these positions not only confirms that the fetus is responding well to labor but also provides confirmatory information about fetal position. Conversely,recognizing fetal position aids in locating fetal heart sounds. As a rule, determine the FHR every 30 minutes beginning latent labor, every 15 minutes during active first-stage labor, and every 5 minutes during the second stage of labor. This can be done by inspecting an FHR monitoring strip or by periodic auscultation by a fetoscope (a modified stethoscope attached to a headpiece), a Pinard stethoscope (a hollow tube that directs sound into the ear), or a Doppler unit (which uses ultrasound waves that bounce off the fetal heart to produce echoes or clicking noises, which reflect the fetal heartbeat as labor progresses. A. Auscultation of the fetal heartbeat using a fetoscope B. A Doppler ultrasound device can be used to monitor fetal heart rate intermittently in low-risk labor. C. A nurse-midwife using a Pinard stethoscope. ELECTRONIC MONITORING Monitors are set with automatic alarms that trigger if an FHR goes below 110 beats per minute or above about 170 beats per minute, and so they may ring many times if a patient is active in labor. This causes their use to result in unnecessary cesarean births as well as frightened parents (which could adversely affect early parent–infant bonding) Monitoring does offer advantages from a healthcare provider’s standpoint because observin the FHR on a monitor is quicker than listening with a Doppler and yields information on not only the rate but also on how the FHR responds to a forceful contraction. Use of monitors for a shortterm initial assessment followed by intermittent manual monitoring is a compromise solution. Be certain to inform parents that the FHR can vary greatly during labor so they’re not surprised when they see this and also that a monitor is only an aid and should not be the focus of their attention. Otherwise, a couple can become so focused on a monitor screen or paper strict that they lose the ability to concentrate on previously learned relaxation and breathingntechniques. When giving care, be sure not to focus solely on the equipment, continue to communicate to the couple, not the machine, and offer support to the birthing parent and anysupport person as needed Initial Electronic Monitoring Electronic monitoring is noninvasive, easily applied, and does not require cervical dilatation or fetal descent before it can be used, so it can be introduced at any time during labor. The presence and duration of uterine contractions is gained by means of a pressure transducer or tocodynamometer (toko is Greek for “contraction”) strapped to the patient’s abdomen or held in place by stockinette Two devices (a transducer for the uterus and an ultrasound sensor for the fetus) are strapped to the patient’s abdomen. External electronic monitoring in place. Two devices (a transducer for the uterus and an ultrasound sensor for the fetus) are strapped to the patient’s abdomen Initial Electronic Monitoring A disadvantage is the patient may feel discomfort from the straps holding the monitors in place, and the snugness of the sensor head may limit the ability to breathe deeply. If a patient changes position (which is recommended to do often during labor), the sensor often needs to be repositioned. Remind a patient that the fetal heart signal may stop when they change position so they do not think the silence indicates the baby’s heart has stopped beating. Urge patients not to lie on their backs for monitoring but to rest on their side, sit in a chair, or bend forward over the foot of the bed or a birthing ball or rail so the likelihood of supine hypotension syndrome is not increased. FETAL HEART RATE AND UTERINE CONTRACTION RECORDS Labor monitors trace both the FHR and the duration and interval of uterine contractions onto an oscilloscope screen and produce a permanent record on paper rolls. Uterine contraction information is recorded on the bottom half of the paper, whereas FHR is recorded on the top half. Time can be calculated by counting the number of bold vertical lines on the paper (the space between two bold lines represents 60 seconds). The Baseline Fetal Heart Rate A baseline FHR is determined by analyzing the pace of fetal heartbeats recorded in a minimum of 2 minutes obtained between contractions. A normal rate is 110 to 160 beats per minute. Variability FHR variability, or the difference between the highest and lowest heart rates shown on a strip, is one of the most reliable indicators of fetal well-being. Variability is reflected on an FHR tracing as a slight irregularity or “jitter” to the wave. The degree of baseline variability increases (five to 15 beats per minute) when a fetus moves; it slows if a fetus sleeps. If no variability is present, it indicates the natural pacemaker activity of the fetal heart (effects of the sympathetic and parasympathetic nervous systems) may be affected. This may occur as a response to narcotics or barbiturates administered during labor, but the possibility of fetal hypoxia and acidosis must also be considered and investigated.  Variability Variability should be recorded as: Absent: No amplitude range is detectable. Minimal: Amplitude range is detectable but is 5 beats per minute or fewer. Moderate (normal): Amplitude range is 6 to 25 beats per minute. Marked: Amplitude range is greater than 25 beats per minute. Periodic Changes Periodic changes or fluctuations in FHR occur in response to contractions and fetal movement and are described in terms of accelerations or decelerations. Periodic changes are short-term changes in rate other than baseline; they last from a few seconds to 1 or 2 minutes. Accelerations Nonperiodic accelerations are temporary normal increases in FHR caused by fetal movement, a change in maternal position, or administration of an analgesic. An acceleration is a visually apparent abrupt increase (onset to peak in less than 30 seconds) in the FHR. At 32 weeks of gestation and beyond, an acceleration has a peak of 15 beats per minute or more above baseline with a duration of 15 seconds or more but less than 2 minutes from onset to return. Before 32 weeks of gestation, an acceleration has a peak of 10 beats per minute or more above baseline, with a duration of 10 seconds or more but less than 2 minutes from onset to return. Prolonged acceleration lasts 2 minutes or more but less than 10 minutes in duration. If an acceleration lasts 10 minutes or longer, it is a baseline change or a new baseline is established Decelerations Decelerations are visually apparent, usually symmetrical, periodic decreases in FHR resulting from pressure on the fetal head during contractions as parasympathetic stimulation in response to vagal nerve compression brings about a slowing of FHR. Early deceleration follows the pattern of the contraction, beginning when the contraction begins and ending when the contraction ends. However, the waveform of the FHR change is the inverse of the contraction waveform, or the lowest point of the deceleration occurs with the peak of the contraction (a mirror image of the contraction). The rate rarely falls below 100 beats per minute, and it returns quickly to between 110 and 160 beats per minute at the end of the contraction. Early fetal heart rate deceleration (the time between 2 and 4 seconds) follows the pattern of the contraction starting when the contraction begins and ending when the contraction subsides. This is a normal pattern for a healthy fetus. Early decelerations Early decelerations normally occur late in labor, when the head has descended fairly low; they are viewed as innocent. If they occur early in labor, before the head has fully descended, the head compression causing the waveform change could be the result of cephalopelvic disproportion and is a cause to investigate. Early decelerations caused by head compression Late Decelerations Late decelerations are those in which the onset, nadir, and recovery of the deceleration occur after the beginning, peak, and ending of the contraction, respectively. This is an ominous pattern in labor because it suggests uteroplacental insufficiency or decreased blood flow through the intervillous spaces of the uterus during uterine contractions. This pattern may occur with marked hypertonia or increased uterine tone. Immediately change the patient’s position from supine if they are lying down to lateral to relieve pressure on the vena cava and supply more blood to the uterus and fetus. Intravenous (IV) fluid or oxygen may be prescribed. Prepare for a prompt cesarean birth of the infant if the late decelerations persist or if FHR variability becomes abnormal (absent or decreased) Prolonged Decelerations Prolonged decelerations are decelerations that are a decrease from the FHR baseline of 15 beats per minute or more and last longer than 2 to 3 minutes but less than 10 minutes. They generally reflect an isolated occurrence, but they may signify a significant event, such as cord compression or maternal hypotension. For this reason, they must be reported and documented. If a deceleration lasts longer than 10 minutes, it is considered a baseline change. Late deceleration (the time between 20 and 22 seconds) occurs after the peak of a contraction and continues beyond the end of the contraction. This is an ominous pattern in labor because it suggests the fetus is growing short of oxygen. The prolonged deceleration (between 26 and 31 seconds) is also ominous. Variable Decelerations The pattern of variable decelerations refers to decelerations that occur at unpredictable times in relation to contractions. They may indicate compression of the cord, which can be an ominous development in terms of fetal well-being. Cord compression may be occurring because of a prolapsed cord, but it most often occurs because the fetus is simply lying on the cord. Variable Decelerations It tends to occur more frequently after rupture of the membranes than when membranes are intact, or with oligohydramnios (the presence of less than a normal amount of amniotic fluid), such as occurs in postterm pregnancy or with intrauterine growth restriction. As a first step, if the patient is not already lying on their side, change their position from supine to lateral. If a prolapsed cord is diagnosed as the cause of the variable decelerations, oxygen will be prescribed as well as changing the patient’s position to a knee-to-chest one to help relieve pressure on the cord. A fetal heart rate (FHR) showing variable and prolonged decelerations. Note the abrupt drop in FHR in both types of decelerations. The variable decelerations return to baseline more quickly than the prolonged deceleration at 26 to 31 minutes, however. The Sinusoidal Pattern In a fetus that is severely anemic or hypoxic, central nervous system control of heart pacing maybe so impaired that the FHR pattern resembles a smooth, frequently undulating wave with a cycle frequency of 3 to 5 per minute and persisting 20 minutes or more. Although the cause of this pattern is poorly understood, it is recognized to be as ominous as a late deceleration or variable deceleration pattern and so needs to be reported. For unknown reasons, on occasion, especially after administration of a narcotic to the birthing parent, a pseudosinusoidal or false sinusoidal pattern may appear. These are usually transient, resolve spontaneously without intervention, and are associated with a good fetal outcome. The pattern may show some variability and perhaps an FHR acceleration. Identifying these is equally important so they can be differentiated from a true sinusoidal pattern. FHR baseline, variability, and patterns are categorized from 1 to 3 to help establish if a deviation is serious. Knowing these helps you to understand why interventions are initiated at certain points ( The Care of a Patient During the First Stage of Labor Labor and birth are natural processes, so the average patient should be able to complete labor and birth without assistance from medical interventions. Nurses can be instrumental in keeping labor as free of unnecessary interventions as possible so it remains not only safe but also a joyful and memorable experience. The Care of a Patient During the First Stage of Labor Six major concepts that make labor and birth as natural as possible include the following: Labor should begin on its own, not be artificially induced. Patients should be able to move about freely throughout labor, not be confined to bed. Patients should receive continuous support from a caring support person during labor. No interventions such as IV fluid should be used routinely. Patients should be allowed to assume a nonsupine position such as upright and side lying for birth. Birthing parent and baby should be housed together after the birth, with unlimited opportunity for breastfeeding  The Care of a Patient During the First Stage of Labor Interventions: a. Encourage mother and partner to participate in care. b. Encourage maintenance of effective breathing patterns. c. Provide a quiet environment d. Keep mother and partner informed of progress e. Promote comfort with back rubs, sacral pressure, pillow support, and position changes. f. Offer fluids and ice chips. g. Encourage voiding every 1 to 2 hours The Care of a Patient During the Second Stage of Labor The second stage of labor is the time from full cervical dilatation to birth of the newborn. Even those who have taken childbirth education classes and who believe they are well prepared for any length or type of contractions are surprised at the intensity of the pushing sensation they feel in this stage of labor. Because the feeling to push becomes so strong, some react by crying and screaming. Others react by tensing their abdominal muscles and trying to resist pushing, thus making the sensation even more painful and frightening. If the patient has not received an epidural for pain management, they may push with contractions and rest in between. Some breathe out as they push (open glottis), while others are told to hold their breath while pushing (Valsalva maneuver). Recent research has determined there is no difference in length of second stage or neonatal outcomes whether the patient uses open glottis techniques. The best practice is to encourage birthing parents to assume any position that is comfortable for them and breathe any way that is natural for them A general timetable for second-stage care is shown in Table 15.7. Be certain to assess fetal heart sounds at the beginning of the second stage to be certain the start of the baby’s passage into the birth canal is not occluding the cord and interfering with fetal circulation. Assisting a patient into whatever position they feel will be most effective for pushing (e.g., squatting, sittingupright, leaning forward against a partner) is important to help align the fetal presenting part with the cervix, increase the pelvic diameters, and use the fetal weight to help descent so that a prolonged second stage does not occur. A danger of a prolonged second stage is chorioamnionitis (membrane infection), an increased rate of cesarean birth, and future urinary incontinence The Care of a Patient During the Second Stage of Labor a. Perform assessments every 5 minutes. b. Monitor maternal vital signs. c. Monitor FHR via ultrasound Doppler, fetoscope, or electronic fetal monitor. d. Assess FHR before, during, and after a contraction, noting that the normal FHR is 110 to 160 beats per minute. e. Monitor uterine contractions by palpation or tocodynamometer, determining frequency, duration, and intensity. f. Provide mother with encouragement and praise and provide for rest between contractions. The Care of a Patient During the Second Stage of Labor g. Keep mother and partner informed of progress. h. Maintain privacy. i. Provide ice chips and ointment for dry lips. j. Assist mother into a position that promotes comfort and facilitates pushing efforts, such as lithotomy, semisitting, kneeling, side-lying, or squatting. k. Monitor for signs of approaching birth, such as perineal bulging or visualization of the fetal head. l. Prepare for birth (expulsion of the fetus). PREPARING THE PLACE OF BIRTH Birthing parents can choose a variety of positions for birth. In the past, a lithotomy position was preferred because it offers a clear view of the perineum, but it is no longer a position of choice. Lying flat on the back may slow, not help, fetal descent, and lying longer than 1 hour in a lithotomy position can lead to intense pelvic congestion and possibly thrombophlebitis. More effective birth positions include the lateral or Sims position, a dorsal recumbent position (on the back with knees flexed), semi-sitting, or squatting. Using these positions plus warm compresses to the perineum place less tension on the perineum and result in fewer perineal tear The Water Birth Birthing parents may not only use a warm water tub for labor comfort and relaxation but also to give birth under water. The increased buoyancy they feel from the water helps them change positions easily; a sitting posture helps with fetal descent The Water Birth The baby is born underwater and then immediately brought to the surface for a first breath. A potential difficulty is contamination of the bath water with feces, which could lead to uterine infection or aspiration of the contaminated bath water by a newborn, which could lead to pneumonia. Newborns, however, have a dive reflex, which alerts them not to breathe while under water, so this is not usually a problem. Maternal chilling when a birthing parent leaves the water is another factor to consider and prevent. Yet another concern is that a short umbilical cord could tear as the baby is brought to the surface. To help prevent this, limit the amount of water in the tub to about 12 in.  PROMOTING EFFECTIVE SECOND-STAGE PUSHING For the most effective pushing during the second stage of labor, a patient should wait to feel the urge to push even though a pelvic exam has revealed they are fully dilated. Pushing is usually best done from a semi-Fowler position with legs raised against the abdomen, squatting, or on all fours rather than lying flat to allow gravity to aid the effort. Make sure the patient pushes with contractions and rests between them. Positions for pushing during second-stage labor: (A) squatting with support person, (B) on all fours, and (C) on all fours with chest support If there is a reason such as a nuchal cord (cord located around the baby’s neck), which must be removed before the infant is fully born, it may be necessary to prevent a patient from pushing immediately after delivery of the fetal head. To help them do this, ask them to pant with contractions. Because it is difficult to push effectively when using the diaphragm for panting, this limits pushing. Remember, however, that pushing is involuntary. Regardless of how much a birthing parent wants to cooperate, stopping this overwhelming urge to push is almost beyond their power. Demonstrating panting may be most effective. Be sure they are inhaling adequately with panting. Otherwise, they might hyperventilate and become lightheaded. Have them take deep cleansing breaths between contractions to prevent this PERINEAL CLEANING AND MASSAGE Massaging the perineum as the fetal head enlarges the vaginal opening helps to keep it supple and prevent tearing. To remove vaginal or rectal secretions and prepare the cleanest environment for the birth of the baby, the care provider may clean the perineum with a warmed antiseptic such as Iodophor (a cold solution causes cramping) and then rinse the area with sterile water. If assisting with this, always clean from the vagina outward (so microorganisms are moved away from the vagina, not toward it), using a clean compress for each stroke. Be certain to include a wide area (vulva, upper inner thighs, pubis, and anus).  The pattern for cleaning the perineum before birth. Cleaning from the birth canal outward moves bacteria away from, not into, the vagina. THE BIRTH As soon as the head of a fetus is prominent (approximately 8 cm across) at the vaginal opening, one technique to help the fetus achieve extension and allow the smallest head diameter to present is for the care provider to place a sterile towel over the rectum and press forward on the fetal chin while the other hand presses downward on the occiput (a Ritgen maneuver). The birthing parent is asked to continue pushing until the occiput of the fetal head is firmly at the pubic arch. The head is then gently born between contractions if possible. This helps to prevent the head from being expelled too rapidly, creating a major pressure change in the skull, which might then rupture cerebral blood vessels. It also reduces the possibility of a perineal tear. A patient who has not had anesthesia experiences the birth of the head as a flash of pain or a burning sensation, as if someone had momentarily poured hot water on the perineum Immediately after the birth of the baby’s head, the primary care provider passes their fingers around the newborn’s neck to determine whether a loop of umbilical cord is encircling the neck. It is not uncommon for a single loop of cord to be positioned this way (termed a nuchal cord). If such a loop is felt, it is gently loosened and drawn down over the fetal head. If it is too tightly coiled to allow this, it is clamped and cut before the shoulders are born. Otherwise, it could tear and interfere with the fetal oxygen supply. After expulsion of the fetal head, external rotation occurs (a birthing parent can feel this happening by gently touching the head if they want to). Gentle pressure is then exerted downward on the side of the infant’s head by the primary care provider so the anterior shoulder is born. Slight upward pressure on the side of the head allows the anterior shoulder to nestle against the symphysis pubis and the posterior shoulder to be born. The remainder of the body then slides free without any further difficulty.  THE BIRTH A child is considered born when the whole body is born. This is the time that should be noted and recorded as the time of birth, which is a nursing responsibility (most primary care providers regard it as their responsibility or pleasure to announce the sex of the infant). The newborn is immediately laid on the birthing parent’s naked abdomen and covered with a warmed blanket and cap to conserve heat and encourage bonding. With this, the second stage of labor is complete CUTTING AND CLAMPING THE CORD Cutting the cord is part of the stimulus that initiates a first breath or marks the newborn’s most important transition into the outside world, the establishment of independent respirations. The timing of cord clamping, however, varies depending on the parent’s preference and the maturity of the infant CUTTING AND CLAMPING THE CORD Before cutting, the cord is clamped with two hemostats placed 8 to 10 in. from the infant’s umbilicus. It is often customary for the birthing parent’s partner or support person to have the privilege of cutting the cord between the hemostats. A cord blood sample is often obtained to provide a ready source of infant blood if blood typing or other emergency measures, such as establishing whether fetal acidosis was present, needs to be done. Blood may also be taken for cord blood banking so the family has stem cells available if needed in the future CUTTING AND CLAMPING THE CORD The vessels in the cord are then counted to be certain three are present and an umbilical clamp is applied to replace the forceps. Some umbilical clamps in hospitals have an alarm attached that will ring if the infant is taken further than set hospital boundaries, a precaution against newborn abduction.  INTRODUCING THE INFANT After the cord is cut, it is time for the new parents to spend quality time with their newborn. The infant can remain on the birthing parent’s abdomen for skin-to-skin contact. If a partner or support person wants to hold the infant, dry the infant well with a warmed towel, wrap in a sterile blanket, and cover the head with a wrapped towel or cap. Be certain to handle newborns gently but firmly as they are slippery from amniotic fluid and vernix INTRODUCING THE INFANT Most newborns receive prophylactic eye ointment against the possibility of a chlamydia infection. Don’t administer this until after the parents have had this chance to see their infant for the first time (and the infant has had a chance to see them) This initial contact is also the optimal time to begin breastfeeding because an infant seems to be hungry at birth, and sucking at the breasts stimulates the release of endogenous oxytocin, encouraging uterine contraction and involution, or the return of the uterus to its prepregnant state The Care of a Patient During the Third and Fourth Stages of Labor The third stage of labor is the time from the birth of the baby until the placenta is delivered. For most, this is a time of great excitement because the infant has been born, but this can also be a time of feeling anticlimactic because the infant has finally arrived after being anticipated for so long a time.  THE DELIVERY OF THE PLACENTA The placenta will deliver spontaneously following most births. Although this is true in most cases, up to 30 minutes is considered normal. After delivery, the placenta is inspected to be certain it is intact without gross abnormalities and that no cotyledons remain in the uterus. Normally, a placenta is one-sixth the weight of the infant. If it is unusually large or small, you may be asked to weigh it. THE DELIVERY OF THE PLACENTA After the placenta inspection, if the birthing parent’s uterus has not contracted firmly on its own, the primary care provider will massage the fundus to urge it to contract. Oxytocin (Pitocin 10 units) may be prescribed to be administered intramuscularly (IM) or per 1,000 mL IV fluid to also help contraction. If excessive bleeding with poor uterine contraction remains, an injection of carboprost tromethamine (Hemabate) or methylergonovine maleate (Methergine) is yet another solution to increase uterine contraction and to guard against hemorrhage. It is important to know prior to the second stage whether a birthing parent has a contraindication to either of these drugs such as asthma or hypertension. THE DELIVERY OF THE PLACENTA The administration of these drugs is a nursing responsibility in most healthcare facilities. Because Pitocin causes hypertension by vasoconstriction, be certain to obtain a baseline blood pressure measurement before administration. Question the use of such a drug if the patient had an elevated blood pressure during pregnancy that is still present. The fourth stage of labor includes the first few hours after birth. It signals the beginning of dramatic changes because it marks the beginning of both a new life and a new family.  THE PERINEAL INSPECTION To be certain the perineum did not tear from the pressure of the fetal head, the perineum is carefully inspected after birth. Perineal tears are rated grade 1 to grade 4, grade 1 being minimal and grade 4 extending to and including the rectum Most are small enough that no suturing is needed. If a tear is large enough to require suturing, a patient usually has enough natural perineal anesthesia from pressure of the fetal head or enough effect from epidural anesthesia that they will not feel pain from the suturing. If they do have pain, a local anesthetic, usually lidocaine, can be given to make the process painfree. THE IMMEDIATE POSTPARTUM ASSESSMENT AND NURSING CARE This is the beginning of the postpartal period or the fourth stage of labor. Because the uterus may be so exhausted from labor that it cannot maintain contraction, there is a high risk of hemorrhage during this time (it is the most dangerous time of birth for the birthing person). Obtain vital signs (pulse, respirations, and blood pressure) every 15 minutes for the first hour and then according to agency policy or the patient’s condition. Pulse and respirations may be fairly rapid immediately after birth (80 to 90 beats per minute and 20 to 24 breaths per minute), and blood pressure may be slightly elevated due to exertion and excitement of the moment or recent oxytocin administration. Wash the perineum with the agency-designated solution and apply a perineal pad. Palpate the fundus for size, consistency, and position and observe the amount and characteristics of lochia each time you record vital signs THE IMMEDIATE POSTPARTUM ASSESSMENT AND NURSING CARE Return the birthing bed to its original position. Offer a clean gown and a warmed blanket because a birthing parent often experiences chills and a shaking sensation 10 to 15 minutes after birth. This may be due to the low temperature of a birthing room but may also be a result of the sudden release of pressure on pelvic nerves or of excess epinephrine production during labor. In any event, it is a normal phenomenon but can be frightening to the patient if they associate the chills with fever or infection and worry they will be ill at a time when they most want to be well to care for a new child. You can reassure them this is a transitory sensation, is very common, and passes quickly.