Nursing Care of Mother and Infant During Labor and Birth PDF

Nursing Care of Mother and Infant During Labor and Birth OBJECTIVES 1. Define each key term listed. 2. Discuss specific cultural beliefs the nurse may encounter when providing care to a woman in labor. 3. Compare the advantages and disadvantages for each type of childbearing setting: hospital, frees...

Nursing Care of Mother and Infant During Labor and Birth OBJECTIVES 1. Define each key term listed. 2. Discuss specific cultural beliefs the nurse may encounter when providing care to a woman in labor. 3. Compare the advantages and disadvantages for each type of childbearing setting: hospital, freestanding birth center, and home. 4. Describe the four components (“four Ps”) of the birth process: powers, passage, passengers, and psyche. 5. Describe how the four Ps of labor interrelate to result in the birth of an infant. 6. Explain the normal processes of childbirth: premonitory signs, mechanisms of birth, and stages and phases of labor. 7. Explain how false labor differs from true labor. 8. Determine appropriate nursing care for the intrapartum patient, including the woman in false labor and the woman having a vaginal birth after cesarean (VBAC). 9. Explain common nursing responsibilities during the labor and birth. 10. Describe the care of the newborn immediately after birth. KEY TERMS absent variability (p. 141) accelerations (p. 141) acrocyanosis (k-rō-sī--NŌ-sĭs, p. 157) adjustment (p. 148) amnioinfusion (m-nē-ō-ĭn-FYŪ-zhŭn, p. 143) amniotomy (m-nēŎT-ŏ-mē, p. 144) baseline fetal heart rate (p. 140) baseline variability (p. 140) bloody show (p. 132) cold stress (p. 157) coping (p. 148) crowning (p. 150) decelerations (p. 141) dilate (p. 126) 261 doula (DŪ-l, p. 149) efface (ĕ-FĀS, p. 126) episodic changes (p. 141) fetal bradycardia (p. 140) fetal tachycardia (p. 140) fontanelle (FŎN-t-nĕl, p. 128) laboring down (p. 149) late decelerations (p. 142) Leopold’s maneuver (p. 136) lie (p. 129) marked variability (p. 141) microbiome (p. 161) microbiota (p. 161) moderate variability (p. 141) molding (p. 129) neutral thermal environment (p. 157) nitrazine test (p. 144) nuchal cord (NŪ-kl kŏrd, p. 142) ophthalmia neonatorum (ŏf-THL-mē- nē-ō-n-TŎR-m, p. 159) periodic changes (p. 141) prolonged decelerations (p. 142) station (p. 132) sutures (p. 128) tachysystole (p. 143) trial of labor after cesarean (TOLAC) (p. 150) uteroplacental insufficiency (yū-tr-ō-pl-SĔN-tl ĭn-sŭ-FĬSH-n-sē, p. 142) vaginal birth after cesarean (VBAC) (p. 150) http://evolve.elsevier.com/Leifer Childbirth is a normal physiological process that involves the health of the mother and a fetus who will become part of our next generation. The nursing care is unique because every nursing intervention involves the welfare of two patients and the use of skills from medical-surgical and pediatric nursing, psychosocial and communication skills, and specific skills involved in obstetric care. In addition, labor and delivery are often a family affair, with fathers, grandparents, and others closely involved. Each family participant often remembers the details of this experience for a long time. 262 Nursing Tip The bedside nurse in the labor and delivery unit bridges the gap between sophisticated technology and the individual patient’s needs, providing a positive outcome both physically and psychologically. The privacy and rights of the mother must be protected, the policies and procedures of the institution must be considered, and the nurse must be familiar with the scope of practice set out by the state board of nursing. Recent changes in the management of labor and delivery include practices related to induction and augmentation of labor, fetal monitoring techniques, maternal positions, types of analgesia offered, and assistive devices such as vacuum extraction. This chapter provides information concerning the birth process and the nursing responsibilities during labor and delivery. 263 Cultural influence on birth practices The needs of the woman giving birth may be influenced by her cultural background, which may be very different from that of the nurse but must be understood and respected. In a multicultural environment, nothing is routine. Patient and cultural preferences require flexibility on the part of the nurse. Women of most cultures prefer the presence of a support person at all times during labor and delivery, and that can include the father or family as well as professional staff. The United States is a multicultural society. Table 6.1 lists common traditional birth practices of selected cultures. The practices of these cultural groups may vary depending on the amount of time the individuals have been in the United States and the degree to which they have assimilated into the culture. Table 6.1 Birth Practices of Selected Cultural Groupsa 264 265 266 NOTE: Use professional translators whenever possible. Family members may not convey taboo topics accurately. a Many behaviors and preferences related to these traditional customs may not be practiced today by the woman in labor. This information is presented so that the nurse can understand various behaviors and preferences of some patients during labor to meet individual needs in the plan of care and teaching. Data adapted from Lipson JG, Dibble SL: Culture and nursing care, ed 2, San Francisco, 2005, University of California, San Francisco, School of Nursing; Murasaki S: Diary of Lady Murasaki, New York, 1996, Penguin Books; Bates B, Neuman A, Turner B: Imagery and symbolism in the birth practices of traditional cultures, Women Health Nurs (Wiley) 12(1):29-36, 2007; Chalmers B: Childbirth across cultures: research and practice, Women Health Nurs (Wiley) 39(4):276-280, 2012; D’Anzo C: Mosby’s pocket guide to cultural health assessment, ed 4, St Louis, 2008, Mosby. 267 Settings for childbirth Depending on facilities available in the area and the risks for complications, a woman can choose among three settings in which to deliver her child. Most women give birth in the hospital, whereas others choose freestanding birth facilities or their own home with a certified nurse-midwife or lay midwife in attendance. Hospitals The woman who chooses a hospital birth may have a “traditional” setting, in which she labors, delivers, and recovers in separate rooms. After the recovery period, she is transferred to the postpartum unit. A more common setting for hospital maternity care is the birthing room, often called a labor, delivery, and recovery (LDR) room. The woman labors, delivers, and recovers all in the same room. She is then transferred to the postpartum unit for continuing care. The appearance of the birthing room is more homelike than institutional. The fully functional birthing bed has wood trim that hides its utilitarian purpose (Fig. 6.1). The beds have receptacles for various fittings, such as a “squat bar,” which facilitates squatting during second-stage labor. The foot of the bed can be detached or rolled away to reveal foot supports or stirrups. FIG. 6.1 Typical labor, delivery, and recovery room. Homelike furnishings can be quickly adapted to provide essential equipment when the woman enters the active phase of labor. (Courtesy Hill-Rom Services, Batesville, IN.) Another hospital birth setting is a single-room maternity care arrangement, often called a labor, delivery, recovery, and postpartum room. It is similar to the LDR room, but the mother and infant remain in the same room until discharge. Advantages of hospital-based birth settings include the following: • Preregistration, which allows important information to be available on admission • Easy access to sophisticated services and specialized personnel if complications develop • Ability to provide family-centered care for the woman who has a complicated pregnancy Freestanding birth centers Some communities have birth centers that are separate from, although usually near, hospitals and are similar to outpatient surgical centers. Many birth centers are operated by full-service hospitals and are close enough for easy transfer if the mother, fetus, or newborn develops complications. Certified nurse-midwives often attend the births. Advantages of freestanding birth centers include the following: • A homelike setting for the low-risk woman 268 • Lower costs because the freestanding center does not require expensive departments such as emergency or critical care Disadvantages include the following: • A slight but significant delay in emergency care if the mother, fetus, or newborn develops life-threatening complications Home Some women give birth at home. Many factors enter into their decision, and most families have carefully weighed the pros and cons of their choice. Advantages of a home birth include the following: • Control over persons who will or will not be present for the labor and birth, including children • No risk of acquiring pathogens from other patients • A low-technology birth, which is important to some families Disadvantages vary with the location and may include the following: • Limited choice of birth attendants, as most physicians and certified nurse-midwives choose not to attend home births; in many communities, only lay midwives are available, whose training, abilities, and licensure status vary widely • Significant delay in reaching emergency care if the mother, fetus, or newborn develops lifethreatening complications • Possibility of no preestablished relationship with a physician in case an emergency arises that necessitates the woman or newborn to be transferred to a hospital Contraindications for home birth include previous cesarean section, malpresentation, multiple gestation, primipara, and gestational age greater than 40 weeks (Greenbaum, 2017). 269 Components of the birth process Four interrelated components, often called the “four Ps,” make up the process of labor and birth: powers, passage, passengers, and psyche. These factors are discussed in detail in the following sections. Other factors that influence the progress of labor include preparation, such as attendance at prenatal classes; position, horizontal or vertical; professional help, such as knowledgeable nurses in attendance who explain and coach; the place or setting, as a lack of privacy and changes in shift personnel can interrupt rapport; procedures, such as internal examinations; and people, such as the presence of supportive family members (VandeVusse, 1999). Powers The powers of labor are forces that cause the cervix to open and that propel the fetus downward through the birth canal. The two powers are uterine contractions and the mother’s pushing efforts. Uterine Contractions Uterine contractions are the primary powers of labor during the first of the four stages of labor (from onset until full dilation of the cervix). Uterine contractions are involuntary smooth muscle contractions; the woman cannot consciously cause them to stop or start. However, their intensity and effectiveness are influenced by a number of factors, such as walking, drugs, maternal anxiety, and vaginal examinations. Effect of contractions on the cervix Contractions cause the cervix to efface (thin) and dilate (open) to allow the fetus to descend in the birth canal (Fig. 6.2). Before labor begins, the cervix is a tubular structure about 2 to 3.8 cm long. Contractions simultaneously push the fetus downward as they pull the cervix upward (an action similar to pushing a ball out the cuff of a sock). This causes the cervix to become thinner and shorter. Effacement is determined by a vaginal examination and is described as a percentage of the original cervical length. When the cervix is 100% effaced, it feels like a thin, slick membrane over the fetus. 270 FIG. 6.2 Cervical effacement and dilation. (A) No effacement, no dilation. (B) Early effacement and dilation. (C) Complete effacement, some dilation. (D) Complete dilation and effacement. (From Lowdermilk DL, Perry SE, Cashion K, et al: Maternity & Women’s Health Care, ed 11, St. Louis, 2016, Elsevier.) Dilation of the cervix is determined during a vaginal examination. Dilation is described in centimeters, with full dilation being 10 cm (Fig. 6.3). Both dilation and effacement are estimated by touch rather than being precisely measured. 271 FIG. 6.3 Cervical dilation in centimeters. Full dilation is 10 cm (1 cm is approximately one finger’s width). Phases of contractions Each contraction has the following three phases (Fig. 6.4): 1. Increment: The period of increasing strength 2. Peak, or acme: The period of greatest strength 3. Decrement: The period of decreasing strength 272 FIG. 6.4 Contraction cycle. Each contraction can be likened to a bell shape, with an increment, peak (acme), and decrement. The frequency of contractions is the average time from the beginning of one to the beginning of the next. The duration is the average time from the beginning to the end of one contraction. The interval is the period of uterine relaxation between contractions. Contractions are also described by their average frequency, duration, intensity, and interval. Frequency Frequency is the elapsed time from the beginning of one contraction until the beginning of the next contraction. Frequency is described in minutes and fractions of minutes, such as “contractions every 4 minutes.” Contractions occurring more often than every 2 minutes may reduce fetal oxygen supply and should be reported. Duration Duration is the elapsed time from the beginning of a contraction until the end of the same contraction. Duration is described as the average number of seconds contractions last, such as “duration of 45 to 50 seconds.” Persistent contraction durations longer than 90 seconds may reduce fetal oxygen supply and should be reported. Intensity Intensity is the approximate strength of the contraction. In most cases, intensity is described in words such as “mild,” “moderate,” or “strong,” which are defined as follows: • Mild contractions: Fundus is easily indented with the fingertips; the fundus of the uterus feels similar to the tip of the nose. • Moderate contractions: Fundus can be indented with the fingertips but with more difficulty; the fundus of the uterus feels similar to the chin. • Firm contractions: Fundus cannot be readily indented with the fingertips; the fundus of the uterus feels similar to the forehead. Interval The interval is the amount of time the uterus relaxes between contractions. Blood flow from the mother into the placenta gradually decreases during contractions and resumes during each interval. The placenta refills with freshly oxygenated blood for the fetus and removes fetal waste products. Persistent contraction intervals shorter than 60 seconds may reduce fetal oxygen supply. Safety Alert! Report to the registered nurse any contractions that occur more frequently than every 2 minutes, last longer than 90 seconds, or have intervals shorter than 60 seconds. 273 Maternal Pushing When the woman’s cervix is fully dilated, she adds voluntary pushing to involuntary uterine contractions. The combined powers of uterine contractions and voluntary maternal pushing in stage 2 of labor propel the fetus downward through the pelvis. Most women feel a strong urge to push or bear down when the cervix is fully dilated and the fetus begins to descend. However, factors such as maternal exhaustion or sometimes epidural analgesia (see Chapter 7) may reduce or eliminate the natural urge to push. Some women feel a premature urge to push before the cervix is fully dilated because the fetus pushes against the rectum. This should be discouraged, as it may contribute to maternal exhaustion and fetal hypoxia and tearing of maternal soft tissues. The practice of “laboring down,” or controlled pushing, is discussed later in Laboring Down. Nursing Tip Provide emotional support to the laboring woman so that she is less anxious and fearful. Excessive anxiety or fear can cause greater pain, inhibit the progress of labor, and reduce blood flow to the placenta and fetus. Passage The passage consists of the mother’s bony pelvis and the soft tissues (cervix, muscles, ligaments, and fascia) of her pelvis and perineum (see Chapter 2 for a review of the structure of the bony pelvis). Bony Pelvis The pelvis is divided into the following two major parts: (1) the false pelvis (upper, flaring part) and (2) the true pelvis (lower part). The true pelvis, which is directly involved in childbirth, is further divided into the inlet at the top, the midpelvis in the middle, and the outlet near the perineum. It is shaped like a curved cylinder or a wide, curved funnel. The measurements of the maternal bony pelvis must be adequate to allow the fetal head to pass through, or cephalopelvic disproportion will occur, and a cesarean birth may be indicated. Soft Tissues In general, women who have had previous vaginal births deliver more quickly than women having their first births because their soft tissues yield more readily to the forces of contractions and pushing efforts. This advantage is not present if the woman’s previous births were cesarean. Soft tissue may not yield as readily in older mothers or after cervical procedures that have caused scarring. Passengers The passengers are the fetus, placenta (afterbirth), amniotic membranes, and amniotic fluid. Because the fetus usually enters the pelvis head first (cephalic presentation), the nurse should understand the basic structure of the fetal head. The Fetus Fetal head The fetal head is composed of several bones separated by strong connective tissue, called sutures (Fig. 6.5). A wider area, called a fontanelle, is formed where the sutures meet. The following two fontanelles are important in obstetrics: 1. The anterior fontanelle, a diamond-shaped area formed by the intersection of four sutures (frontal, sagittal, and two coronal) 274 2. The posterior fontanelle, a tiny triangular depression formed by the intersection of three sutures (one sagittal and two lambdoid) FIG. 6.5 The fetal skull, showing sutures, fontanelles, and important measurements. (A) Superior view. The anterior fontanelle has a diamond shape; the posterior fontanelle is triangular. The biparietal diameter is an important fetal skull measurement. (B) Lateral view. The measurements of the fetal skull are important to determine if cephalopelvic disproportion will be a problem. The mechanisms of labor allow the fetal head to rotate so that the smallest diameter of the head passes through the pelvis as it descends. (From Matteson PS: Women’s health during the childbearing years: a community-based approach, St. Louis, 2001, Mosby.) The sutures and fontanelles of the fetal head allow it to change shape as it passes through the pelvis (molding). They are important landmarks in determining how the fetus is oriented within the mother’s pelvis during birth. The main transverse diameter of the fetal head is the biparietal diameter, which is measured between the points of the two parietal bones on each side of the head. The anteroposterior diameter of the fetal head can vary depending on how much the head is flexed or extended. Lie Lie describes how the fetus is oriented to the mother’s spine (Fig. 6.6). The most common orientation is the longitudinal lie (greater than 99% of births), in which the fetus is parallel to the mother’s spine. The fetus in a transverse lie is at right angles to the mother’s spine. The transverse lie may also be called a shoulder presentation. In an oblique lie, the fetus is between a longitudinal lie and a transverse lie. 275 FIG. 6.6 Lie. In the longitudinal lie, the fetus is parallel to the mother’s spine. In the transverse lie, the fetus is at right angles to the mother’s spine. The shoulder presents at the cervix. Attitude The fetal attitude is normally one of flexion, with the head flexed forward and the arms and the legs flexed. The flexed fetus is compact and ovoid and most efficiently occupies the space in the mother’s uterus and pelvis. Extension of the head, arms, or legs sometimes occurs, and labor may be prolonged. Presentation Presentation refers to the fetal part that enters the pelvis first. The cephalic presentation is the most common. Any of the following four variations of cephalic presentations can occur, depending on the extent to which the fetal head is flexed (Fig. 6.7): 1. Vertex presentation: The fetal head is fully flexed. This is the most favorable cephalic variation because the smallest possible diameter of the head enters the pelvis. It occurs in about 96% of births. 2. Military presentation: The fetal head is neither flexed nor extended. 3. Brow presentation: The fetal head is partly extended. The longest diameter of the fetal head is presenting. This presentation is unstable and tends to convert to either a vertex or a face presentation. 4. Face presentation: The head is fully extended and the face presents. 276 277 FIG. 6.7 Fetal presentations. (A) Cephalic vertex. (B) Cephalic face. (C) Cephalic brow. (D) Shoulder. (E) Frank breech. (F) Full or complete breech. (G) Footling breech (can be single or double). The vertex presentation in which the fetal chin is flexed on the chest is the most common and favorable for a vaginal birth because it allows the smallest diameter of the head to go through the bony pelvis of the mother. Note how the anterior and posterior fontanelles can be used to determine fetal presentation and position in the pelvis. (From Matteson PS: Women’s health during the childbearing years: a community-based approach, St. Louis, 2001, Mosby.) The next most common presentation is the breech, which can have the following three variations (see Fig. 6.7E–G): 1. Frank breech: The fetal legs are flexed at the hips and extend toward the shoulders; this is the most common type of breech presentation. The buttocks present at the cervix. 2. Full or complete breech: A reversal of the cephalic presentation, with flexion of the head and extremities. Both feet and the buttocks present at the cervix. 3. Footling breech: One or both feet are present first at the cervix. Many women with a fetus in the breech presentation have cesarean births because the head, which is the largest single fetal part, is the last to be born and may not pass through the pelvis easily because flexion of the fetal head cannot occur (see Fig. 8.6). After the fetal body is born, the head must be delivered quickly so the fetus can breathe; at this point, part of the umbilical cord is outside the mother’s body and the remaining part is subject to compression by the fetal head against the bony pelvis. When the fetus is in a transverse lie, the fetal shoulder enters the pelvis first. A fetus in this orientation must be delivered by cesarean section because it cannot safely pass through the pelvis. Position 278 Position refers to how a reference point on the fetal presenting part is oriented within the mother’s pelvis. The term occiput is used to describe how the head is oriented if the fetus is in a cephalic vertex presentation. The term sacrum is used to describe how a fetus in a breech presentation is oriented within the pelvis. The shoulder and back are reference points if the fetus is in a shoulder presentation. The maternal pelvis is divided into four imaginary quadrants: right and left anterior and right and left posterior. If the fetal occiput is in the left front quadrant of the mother’s pelvis, it is described as left occiput anterior. If the sacrum of a fetus in a breech presentation is in the mother’s right posterior pelvis, it is described as right sacrum posterior. Abbreviations describe the fetal presentation and position within the pelvis (Box 6.1). Three letters are used for most abbreviations: 1. First letter: Right or left side of the woman’s pelvis. This letter is omitted if the fetal reference point is directly anterior or posterior, such as occiput anterior (OA). 2. Second letter: Fetal reference point (occiput for vertex presentations, mentum [chin] for face presentations, and sacrum for breech presentations). 3. Third letter: Front or back of the mother’s pelvis (anterior or posterior). Transverse (T) denotes a fetal position that is neither anterior nor posterior. Box 6.1 Classifications of Fetal Presentations and Positions Cephalic presentations Vertex Presentations LOA—left occiput anterior ROA—right occiput anterior ROT—right occiput transverse LOT—left occiput transverse OA—occiput anterior OP—occiput posterior Face Presentations LMA—left mentum anterior RMA—right mentum anterior LMP—left mentum posterior RMP—right mentum posterior Breech presentations LSA—left sacrum anterior RSA—right sacrum anterior LSP—left sacrum posterior RSP—right sacrum posterior Abbreviations that designate brow, military, and shoulder presentations are not included here because they occur infrequently. Fig. 6.8 shows various fetal presentations and positions. 279 FIG. 6.8 Fetal position. The right occipitoanterior (ROA) or left occipitoanterior (LOA) is most favorable for normal labor. When the occiput faces the posterior section of the woman’s pelvis, a longer, “back labor” birth process is anticipated. (From Lowdermilk DL, Perry SE, Cashion K, et al: Maternity & Women’s Health Care, ed 11, St. Louis, 2016, Elsevier.) Psyche Childbirth is more than a physical process; it involves the woman’s entire being. Women do not recount the births of their children in the same manner that they do surgical procedures. They describe births in emotional terms, such as those they use to describe marriages, anniversaries, religious events, or even deaths. Families often have great expectations about the birth experience, and the nurse can promote a positive childbearing experience by incorporating as many of the family’s birth expectations as possible; for example, in some cultures the woman’s position during delivery may be upright or squatting rather than recumbent, and the woman’s attitude during the labor and delivery process may be affected if her cultural preferences are not respected. A woman’s perception of the process and her mental state can influence the course of her labor. For example, the woman who is relaxed and optimistic during labor is better able to tolerate discomfort and work with the physiological processes. By contrast, marked anxiety can increase her perception of pain and reduce her tolerance to it. Anxiety and fear also cause the secretion of stress compounds from the adrenal glands. These compounds, called catecholamines, inhibit uterine 280 contractions and divert blood flow from the placenta. A woman’s cultural and individual values influence how she views and copes with childbirth. 281 Normal childbirth The specific event that triggers the onset of labor remains unknown. Many factors play a part in initiating labor, which is an interaction of the mother and fetus. These factors include stretching of the uterine muscles, hormonal changes, placental aging, and increased sensitivity to oxytocin. Labor normally begins when the fetus is mature enough to adjust easily to life outside the uterus yet still small enough to fit through the mother’s pelvis. This point is usually reached between 39 and 40 weeks, or approximately 280 days after the woman’s last menstrual period. Signs of impending labor Signs and symptoms that labor is about to start may occur from a few hours to a few weeks before the actual onset of labor. Braxton Hicks Contractions Braxton Hicks contractions are irregular contractions that begin during early pregnancy and intensify as full term approaches. They often become regular and uncomfortable, leading many women to believe that labor has started (see Nursing Care of the Woman in False Labor later in this chapter for a discussion of true and false labor). Although Braxton Hicks contractions are often called “false” labor, they play a part in preparing the cervix to dilate and in adjusting the fetal position within the uterus. Lightening and Increased Vaginal Discharge “Lightening” occurs when the fetus settles into the pelvic inlet and the fundus no longer presses on the diaphragm. The woman may feel increased pelvic pressure and have increased vaginal secretions. Fetal pressure causes an increase in clear and nonirritating vaginal secretions. Irritation or itching with the increased secretions is not normal and should be reported to the health care provider because these symptoms are characteristic of infection. Cervical Changes The cervix, which is rigid and firm during pregnancy, becomes soft and significantly shortened as labor progresses. The cervix may open 1 to 2 cm. Bloody Show As the time for birth approaches, the cervix undergoes changes in preparation for labor. It softens (“ripens”), effaces, and dilates slightly. When this occurs, the mucous plug that has sealed the uterus during pregnancy is dislodged from the cervix, tearing small capillaries in the process. Bloody show is thick mucus mixed with pink or dark brown blood. It may begin a few days before labor, or a woman may not have bloody show until labor is under way. Bloody show may also occur if the woman has had a recent vaginal examination or intercourse. Rupture of the Membranes The amniotic sac (bag of waters) sometimes ruptures before labor begins. Infection is more likely if many hours elapse between rupture of the membranes and birth because the amniotic sac seals the uterine cavity against organisms from the vagina. In addition, the fetal umbilical cord may slip down and become compressed between the mother’s pelvis and the fetal presenting part. For these two reasons, women should go to the birth facility when their membranes rupture, even if they have no other signs of labor. Energy Spurt Many women have a sudden burst of energy shortly before the onset of labor (“nesting”). The nurse should teach women to conserve their strength, even if they feel unusually energetic. Weight Loss 282 Occasionally a woman may notice that she loses 1 to 3 lb shortly before labor begins because hormonal changes cause her to excrete extra body water. Mechanisms of labor As the fetus descends into the pelvis, it undergoes several positional changes so that it adapts optimally to the changing pelvic shape and size. Many of these mechanisms, also called cardinal movements, occur simultaneously (Fig. 6.9). 283 284 FIG. 6.9 Mechanisms of labor are also called cardinal movements. The positional changes allow the fetus to fit through the pelvis with the least resistance. (A) Descent, engagement, and flexion. (B) Internal rotation. (C) Beginning extension. (D) Birth of the head by complete extension. (E) External rotation, birth of shoulders and body. (F) Separation of placenta begins. (G) Complete separation of placenta from uterine wall. (H) Placenta is expelled and uterus contracts. (From Moore KL, Persaud TVN, Torchia MG: The developing human: clinically oriented embryology, ed 10, Philadelphia, 2016, Saunders.) Descent Descent is required for all other mechanisms of labor to occur and for the infant to be born. Descent occurs as each mechanism of labor comes into play. Station describes the level of the presenting part (usually the head) in the pelvis. Station is estimated in centimeters from the level of the ischial spines in the mother’s pelvis (a 0 [zero] station). Minus stations are above the ischial spines, and plus stations are below the ischial spines (Fig. 6.10). As the fetus descends, the minus numbers decrease (e.g., − 2, − 1) and the plus numbers increase (e.g., + 1, + 2). 285 FIG. 6.10 The station describes the level of the presenting part in relation to the ischial spines of the mother’s pelvis. The “minus” stations are above the ischial spines, and the “plus” stations are below the ischial spines. (From Matteson PS: Women’s health during the childbearing years: a community-based approach, St. Louis, 2001, Mosby.) Engagement Engagement occurs when the presenting part (usually the biparietal diameter of the fetal head) reaches the level of the ischial spines of the mother’s pelvis (presenting part is at 0 station or lower). Engagement often occurs before the onset of labor in a woman who has not previously given birth (a nullipara); if the woman has had previous vaginal births (a multipara), engagement may not occur until well after labor begins. Flexion 286 The fetal head should be flexed to pass most easily through the pelvis. As labor progresses, uterine contractions increase the amount of fetal head flexion until the fetal chin is on the chest. Internal Rotation When the fetus enters the pelvis head first, the head is usually oriented so that the occiput is toward the mother’s right or left side. As the fetus is pushed downward by contractions, the curved, cylindrical shape of the pelvis causes the fetal head to turn until the occiput is directly under the symphysis pubis (occiput anterior [OA]). Extension As the fetal head passes under the mother’s symphysis pubis, it must change from flexion to extension so that it can properly negotiate the curve. To do this, the fetal neck stops under the symphysis, which acts as a pivot. The head swings anteriorly as it extends with each maternal push until it is born. External Rotation When the head is born in extension, the shoulders are crosswise in the pelvis and the head is twisted in relation to the shoulders. The head spontaneously turns to one side as it realigns with the shoulders (restitution). The shoulders then rotate within the pelvis until their transverse diameter is aligned with the mother’s anteroposterior pelvis. The head turns farther to the side as the shoulders rotate within the pelvis. Expulsion The anterior shoulder followed by the posterior shoulder are born, quickly followed by the rest of the body. 287 Admission to the hospital or birth center Intrapartum nursing care begins before admission by educating the woman about the appropriate time to come to the facility. Nursing care includes admission assessments, collection of data, and the initiation of necessary procedures. Many women have false labor and are discharged after a short observation period. When to go to the hospital or birth center During late pregnancy the woman should be instructed about when to go to the hospital or birth center. There is no exact time, but the general guidelines are as follows: • Contractions: The woman should go to the hospital or birth center when the contractions have a pattern of increasing frequency, duration, and intensity. The woman having her first child is usually advised to enter the facility when contractions have been regular (every 5 minutes) for 1 hour. Women having second or later children should go sooner, when regular contractions are 10 minutes apart for a period of 1 hour. • Ruptured membranes: The woman should go to the facility if her membranes rupture or if she thinks they may have ruptured. • Bleeding other than bloody show: Bloody show is a mixture of blood and thick mucus. Active bleeding is free flowing, bright red, and not mixed with thick mucus. • Decreased fetal movement: The woman should be evaluated if the fetus is moving less than usual. Many fetuses become quiet shortly before labor, but decreased fetal activity can also be a sign of fetal compromise or fetal demise. • Any other concern: Because these guidelines cannot cover every situation, the woman should contact her health care provider or go to the birth facility for evaluation if she has any other concerns. Water birth Some pregnant women choose to be followed by a certified nurse-midwife at an independent birthing center in the community that provides a water birth experience. Relaxing in a birth pool can be comforting and helpful in managing contractions. Underwater birth is often promoted as “natural birth,” but it has not been declared a safe evidence-based practice. At the present time, there is insufficient, rigorous evidence for the safety of underwater birth from randomized controlled trials and research studies (Simpson, 2016). An American College of Obstetricians and Gynecologists (ACOG) news release in 2016 declared “immersion in water during labor is okay,” but delivery “should be on land” (ACOG, 2016). Although ACOG has guidelines for water birth, there is an increased risk of complications to the mother including infection and to the newborn including aspiration, altered temperature regulation, and respiratory distress. Therefore delivery in a water bath is not recommended (ACOG, 2016). Admission data collection The nurse should observe the appropriate infection control measures when providing care in any clinical area. Water-repellent gowns, eye shields, and gloves are worn in the delivery area, and the newborn infant is handled with gloves until after the first bath. General guidelines for wearing protective clothing in the intrapartal area are provided in Appendix A. When a woman is admitted, the nurse establishes a therapeutic relationship by welcoming her and her family members. The nurse continues developing the therapeutic relationship during labor by determining the woman’s expectations about birth and helping to achieve them. Some women have a written birth plan that they have discussed with their health care provider and the facility personnel. The woman’s partner and other family members she wants to be part of her care are included. From the first encounter, the nurse conveys confidence in the woman’s ability to cope with labor and give birth to her child. The three major assessments performed promptly on admission are (1) fetal condition, (2) 288 maternal condition, and (3) impending (nearness to) birth. Fetal Condition The fetal heart rate (FHR) is assessed with a fetoscope (stethoscope for listening to fetal heart sounds), a handheld Doppler transducer, or an external fetal monitor. When the amniotic membranes are ruptured, the color, amount, and odor of the fluid are assessed, and the FHR is recorded. Maternal Condition The temperature, pulse, respirations, and blood pressure are assessed for signs of infection or hypertension. Impending Birth The nurse continually observes the woman for behaviors that suggest she is about to give birth including the following: • Sitting on one buttock • Making grunting sounds • Bearing down with contractions • Stating “The baby’s coming” • Bulging of the perineum or the fetal presenting part becoming visible at the vaginal opening If it appears that birth is imminent, the nurse does not leave the woman but summons help or uses the call bell. Gloves should be applied in case the infant is born quickly. Emergency delivery kits (called “precip trays” for “precipitous birth”) that contain essential equipment are in all delivery areas. The student should locate this tray early in the clinical experience because one cannot predict when it will be needed. The nurse’s priority is to prevent injury to the mother and infant. The nurse should don gloves and a cover gown and assist with the delivery until help arrives (Skill 6.1). Skill 6.1 Assisting With an Emergency Birth Purpose To prioritize care and to prevent injury to the mother and child Steps 1. Obtain an emergency delivery tray (“precip tray”). 2. Do not leave the woman if she exhibits any signs of imminent birth, such as grunting, 289 bearing down, perineal bulging, or a statement that the baby is coming. Summon the experienced nurse with the call bell and try to remain calm. 3. Put on gloves and a cover gown. Use of either clean or sterile gloves is acceptable because no invasive procedures will be done. Gloves and a cover gown are used primarily to protect the nurse from exposure to body fluids while supporting the infant during the delivery. 4. Support the infant’s head and body as it emerges. Wipe secretions from the infant’s face. 5. Feel around the infant’s neck for the presence of the umbilical cord (nuchal cord). If the cord is around the infant’s neck, it may be long enough to slip over the infant’s head, or it may be clamped with two clamps and cut. 6. Control delivery of the head to prevent laceration of the perineum, but do not hold the head back. 7. Use a bulb syringe to remove secretions from the mouth and nose; then clamp and cut the cord. 8. Dry the infant quickly, clear the airway, and wrap in blankets or place in skin-to-skin contact with the mother to maintain the infant’s temperature. 9. Observe the infant’s color and respirations. The cry should be vigorous and the color pink (bluish hands and feet are normal). Rub the back and stimulate as needed. 10. Observe for placental detachment and bleeding. After the placenta detaches, observe for a firm fundus. If the fundus is not firm, massage it. The infant can suckle at the mother’s breast to promote the release of oxytocin, which stimulates uterine contraction. 11. Document events as they occurred and include the sex of the infant, the time of birth, and expulsion of the placenta. Nursing Tip It is unlikely that a nursing student will be called on to deliver an infant during an unexpected birth, but the process should be reviewed in case this does occur. Additional Data Collection If the maternal and fetal conditions are normal, and if birth is not imminent, other data can be gathered in a more leisurely way. Most birth facilities have a preprinted form to guide admission assessments. Women who have had prenatal care should have a prenatal record on file for retrieval of that information. Examples of the assessment data needed include the following: • Basic information should be obtained: the woman’s reason for coming to the facility, the name of her health care provider, medical and obstetrical history, allergies, food intake, any recent illness, medication use (including illicit substances), and home environment. • Woman’s plans for birth should be determined. • Status of labor should be evaluated. The registered nurse, certified nurse-midwife, or physician does a vaginal examination to determine cervical effacement and dilation as well as fetal presentation, position, and station. Contractions are assessed for frequency, duration, and intensity by palpation and/or with an electronic fetal monitor. • A woman’s general condition should be evaluated by performing a brief physical examination. Any edema, especially of the fingers and face, and any abdominal scars should be further explored. Fundal height is measured (or estimated by an experienced nurse) to determine if it is appropriate for her gestation. Reflexes are checked to identify hyperactivity that may occur with gestational hypertension. Admission procedures Several procedures may be performed when a woman is admitted to a birth facility. Some common procedures are described in the following sections. 290 Permission and consent forms The mother signs permission and consent forms for her care and the care of her infant during labor, delivery, and the postbirth period. Permission for an emergency cesarean delivery may be included. The health care provider and the nurse must witness all signatures and confirm that proper information was given to the patient. Laboratory tests A blood sample for the measurement of hematocrit and a midstream urine specimen for determination of glucose and protein levels are common tests performed on admission. The hematocrit test is often omitted if a woman has had regular prenatal care and a recent evaluation. The woman who did not have prenatal care will have additional tests that may include a complete blood count, urinalysis, a drug screen, tests for sexually transmitted infections, and others as indicated. Intravenous infusion An intravenous (IV) line is started to allow for the administration of fluids and drugs. The woman may have a constant fluid infusion, or venous access may be maintained with a saline lock to permit greater patient mobility in early labor. Perineal preparation Perineal preparation for delivery includes cleansing the perineal area. Removing pubic hair is rarely done because routine episiotomy is no longer practiced, and evidence has shown that it does not prevent infection as was once believed. Determining fetal position and presentation The nurse may assist the health care provider in determining the fetal position and presentation by abdominal palpations called Leopold’s maneuver (Fig. 6.11). Sometimes performance of this technique at the time of admission shows a previously unidentified multifetal pregnancy. Leopold’s maneuver is also helpful in locating the fetal back, which is the best location for hearing the FHR, and thus determining optimal placement of the fetal monitor sensor. 291 292 FIG. 6.11 Leopold’s maneuver. (A) Presentation. Hands are placed on either side of the maternal abdomen to palpate the uterine fundus to determine if a round, hard object is felt at the fundus (the fetal head, indicating a breech presentation) or a soft, irregular contour (the fetal buttocks, indicating a vertex presentation). (B) Position. Hands are placed on either side of the maternal abdomen. Support one side of the abdomen while palpating the other side. Palpating a hard, smooth contour indicates location of the fetal back, whereas feeling soft, irregular objects indicates the small parts or extremities. (C) Confirm presentation. The suprapubic area is palpated to determine that the vertex or head is presenting. Feeling a hard, round area that does not move may indicate the head is engaged. (D) Attitude. Attitude of the fetal head is determined by palpating the maternal abdomen with fingers pointing toward the maternal feet. The hand is moved downward toward the symphysis pubis. Feeling a hard, round object on the same side as the fetal back indicates the fetus is in extension. Feeling the hard, round object opposite the fetal back indicates the head is in flexion. 293 Nursing care of the woman in false labor True labor is characterized by changes in the cervix (effacement and dilation), which is the key distinction between true and false labor. Table 6.2 lists other characteristics of true and false labor. Table 6.2 Comparison of False Labor and True Labor False labor (prodromal labor or prelabor) Contractions are irregular or do not increase in frequency, duration, and intensity. Walking tends to relieve or decrease contractions. Discomfort is felt in the abdomen and groin. Bloody show is usually not present. There is no change in effacement or dilation of the cervix. True labor Contractions gradually develop a regular pattern and become more frequent, longer, and more intense. Contractions become stronger and more effective with walking. Discomfort is felt in the lower back and the lower abdomen; often feels like menstrual cramps at first. Bloody show is often present, especially in women having their first child. Progressive effacement and dilation of the cervix occur. A better term for false labor might be prodromal labor because these contractions help prepare the woman’s body and the fetus for true labor. Many women are observed for a short time (1 to 2 hours) if their initial assessment suggests that they are not in true labor and their membranes are intact. The mother and fetus are assessed during observation as if labor were occurring. Most facilities run an external electronic fetal monitor strip for at least 20 minutes to document fetal wellbeing. The woman can usually walk about when not being monitored. If she is in true labor, walking often helps to intensify the contractions and bring about cervical effacement and dilation. After the observation period, the health care provider, who performs another vaginal examination, reevaluates the woman’s labor status. If there is no change in the cervical effacement or dilation, the woman is usually sent home to await true labor. Sometimes the woman in very early labor is sent home if it is her first child and she lives nearby because the latent phase of most first labors is quite long. Each woman in false labor (or early latent-phase labor) is evaluated individually. Factors to be considered include the number and the duration of previous labors, distance from the facility, and availability of transportation. Safety Alert! Encourage the woman in false labor to return to the facility when she thinks she should. It is better to have another “trial run” than to wait at home until she is in advanced labor. If the woman’s membranes are ruptured, she is usually admitted even if labor has not begun because of the risk for infection or a prolapsed umbilical cord (see Chapter 8). The woman in false labor is often frustrated and needs generous reassurance that her symptoms will eventually change to true labor. No one stays pregnant forever, although it sometimes feels that way to a woman who has had several false alarms and is tired of being pregnant. Guidelines for coming to the facility should be reinforced before she leaves. 294 Nursing care before birth After admission to the labor unit, nursing care consists of the following elements: • Monitoring the fetus • Monitoring the laboring woman • Helping the woman cope with labor Monitoring the fetus Intrapartum care of the fetus includes assessment of FHR patterns and the amniotic fluid. In addition, several observations of the mother’s status, such as vital signs and contraction pattern, are closely related to fetal well-being because they influence fetal oxygen supply. Fetal Heart Rate The goal of fetal monitoring is to enable early detection of fetal hypoxia, which can have many causes, and to allow prompt interventions that will avoid fetal injury. The FHR can be assessed by intermittent auscultation, by using a fetoscope or Doppler transducer, or by continuous electronic fetal monitoring (EFM). (See Skill 6.2 for the procedure for assessing FHR.) EFM is more widely used in the United States, but intermittent auscultation is a valid method of intrapartum fetal assessment when performed according to established intervals and with a 1:1 nurse–patient ratio. Skill 6.2 Determining Fetal Heart Rate Purpose To assess and document the fetal heart rate (FHR) Steps 1. Determine best location for assessing FHR. 2. Identify where the clearest fetal heart sounds will most likely be found, over the fetal back and usually in the mother’s lower abdomen (see Fig. 6.12). 295 (Courtesy Pat Spier, RN-C.) 3. Assess fetal heart rate using one of the following methods: Fetoscope a. Place the head attachment (if there is one) over your head and the earpieces in your ears. b. Place the bell in the approximate area of the fetal back and press firmly while listening for the muffled fetal heart sounds. When they are heard, count the rate in 6-second increments for at least 1 minute. c. Multiply the low and high numbers by 10 to compute the average range of the rate (for example, 130 to 140 beats/min). d. Assess rate before and after at least one full contraction cycle. e. Check the mother’s pulse rate at the same time if uncertain whether the fetal heart sounds are being heard; the rates and rhythms will be different. Doppler Transducer a. Place water-soluble gel on the head of the hand-held transducer. b. Position the earpieces in your ears, or connect the transducer to a speaker. c. Turn the switch on and place the transducer head over the approximate area of the fetal back. d. Count as instructed with fetoscope. If earpieces are used, let the parents hear the fetal heartbeat. External Fetal Monitor a. Read the manufacturer’s instructions for specific procedures. b. Connect cable to correct socket on monitor unit. c. Put water-soluble gel on the transducer, and apply as instructed for Doppler transducer. d. A belt, a wide band of stockinette, or an adhesive ring is used to secure the transducers for external fetal monitoring. e. The rate is calculated by the monitor and displayed on an electronic panel. f. The displayed number will change as the machine recalculates the rate. 296 4. Report the following: a. Promptly report rates below 110 beats/min or above 160 beats/min for a full-term fetus. b. Report slowing of the rate that lingers after the end of a contraction. c. Report a lack of variability in FHR (see Figs. 6.13, 6.14, and 6.15). 5. Chart the rate. The guidelines for a normal FHR at term are as follows: • Lower limit of 110 beats/min • Upper limit of 160 beats/min Intermittent auscultation Intermittent auscultation allows the mother greater freedom of movement, which is helpful during early labor and is the method used during home births and in most birth centers. However, in contrast to continuous monitoring, intermittent auscultation does not automatically record the results, so the nurse must provide careful documentation. Intermittent auscultation of the FHR should be performed as noted in Skill 6.2 and Box 6.2. Fig. 6.12 shows the approximate locations of the fetal heart sounds according to various presentations and positions of the fetus. Any FHR outside the normal limits and any slowing of the FHR that persists after the contraction ends is promptly reported to the health care provider. Box 6.2 When to Auscultate and Document the Fetal Heart Rate Use these guidelines for charting the fetal heart rate when the woman has intermittent auscultation or continuous electronic fetal monitoring. Low-risk women (no risk factor identified) Every hour in the latent phase Every 30 minutes in the active phase Every 15 minutes in the second stage High-risk women (a risk factor is identified) Every 30 minutes in the latent phase Every 15 minutes in the active phase Every 5 minutes in the second stage, before and after contractions Routine auscultations When the membranes rupture (spontaneously or artificially) Before and after ambulation Before and after medication or anesthesia administration or a change in medication At the time of peak action of analgesic drugs After a vaginal examination After the expulsion of an enema After catheterization If uterine contractions are abnormal or excessive Modified from ACOG: ACOG guidelines for fetal monitoring: practice bulletin #116, Obstet Gynecol 114:136-138, 2010; Miller A: Intrapartal fetal evaluation. In Gabbe, et al: Obstetrics: normal and 297 problem pregnancies, ed 7, St. Louis, 2017, Elsevier. FIG. 6.12 (A–E) Determining placement of fetoscope or sensor to assess fetal heart rate. Approximate the location of the strongest fetal heart sound when the fetus is in various positions and presentations. The fetal heart sounds are heard best in the lower abdomen in a cephalic (vertex) presentation and higher on the abdomen when the fetus is in a breech presentation (E). (A) Left occipitoanterior (LOA); (B) right occipitoanterior (ROA); (C) left occipitoposterior (LOP); (D) right occipitoposterior (ROP); (E) left sacrum anterior (LSA). (From Matteson PS: Women’s health during the childbearing years: a community-based approach, St. Louis, 2001, Mosby.) Continuous electronic fetal monitoring Continuous EFM allows the nurse to collect more data about the fetus than intermittent auscultation. FHR and uterine contraction patterns are continuously recorded. Most hospitals use continuous EFM because the permanent recording becomes part of the mother’s chart. Some monitors make use of telemetry (similar to a cordless telephone) and permit the woman to walk while a transmitter sends the data back to the monitor to be recorded at the nurses’ station. In the absence of that capability, intermittent monitoring is a variation that promotes walking during labor. An initial recording of at least 30 minutes is obtained, and then the fetus is remonitored at regular intervals in the first stage of labor (see Skill 6.2). In the absence of any risk factors, the FHR should be monitored every 30 minutes in the active, first stage of labor and every 15 minutes in the second stage, preferably before and after a contraction (ACOG, 2016). Safety Alert! Standard FHR monitoring is every 30 minutes in the active phase of the first stage of labor and every 15 minutes in the second stage. If any risk factor is present, FHR monitoring is every 15 minutes in the active first stage and every 5 minutes in the second stage. EFM can be performed with external or internal devices. Internal devices require that the membranes be ruptured and the cervix dilated 1 to 2 cm for device insertion. Internal devices are disposable to reduce transmission of infection. A small spiral electrode applied to the fetal presenting part allows internal FHR monitoring. Two types of devices are used for internal contraction monitoring. One uses a fluid-filled catheter connected to a pressure-sensitive device on the monitor. The other uses a solid catheter with an electronic pressure sensor in its tip. External FHR monitoring is done with a Doppler transducer, which uses sound waves to detect motion of the fetal heart and calculate the rate, just as the handheld model does. Contractions are sensed externally with a tocotransducer (“toco”), which has a pressure-sensitive button. The tocotransducer is positioned over the mother’s upper uterus (fundus), about where the nurse would palpate contractions by hand (Skill 6.3). 298 Skill 6.3 External Electronic Fetal Monitoring Purpose To monitor the fetal heart rate continuously Steps 1. Turn on the fetal monitoring device per hospital protocol. 2. Apply and secure the sensors on the mother’s abdomen. a. Place one sensor over the fundus of the uterus to record uterine contractions. b. Place one sensor over the location of the strongest fetal heart sound to record the FHR. This woman has twins and requires two fetal heart sensors. (Courtesy Pat Spier, RN-C.) 299 Evaluating fetal heart rate patterns The FHR is recorded on the upper grid of the paper strip and is expressed as beats per minute (beats/min or bpm); the uterine contraction pattern is recorded on the lower grid. Both grids must be evaluated together for accurate interpretation of FHR patterns. The FHR is evaluated for baseline rate, baseline variability, episodic changes, and periodic changes. Episodic changes are transient changes in the FHR that are not associated with uterine contractions. Periodic changes are transient and brief changes in the FHR that are associated with uterine contractions such as accelerations and decelerations. • Baseline fetal heart rate is the average FHR that occurs for at least 2 minutes during a 10minute period and is averaged over 30 minutes. It is assessed while there are no uterine contractions. The baseline FHR should be 110 to 160 beats/min for at least a 2-minute period. • Fetal bradycardia occurs when the FHR is less than 110 beats/min for 10 minutes or longer. Causes of fetal bradycardia can include fetal hypoxia, maternal hypoglycemia, maternal hypotension, or prolonged umbilical cord compression. When bradycardia is accompanied by a loss of baseline variability or by late decelerations, immediate intervention is required for a favorable outcome. • Fetal tachycardia is a baseline FHR greater than 160 beats/min that lasts 2 to 10 minutes or longer (ACOG, 2010). It can be caused by maternal fever or maternal dehydration. When fetal tachycardia occurs along with loss of baseline variability or with late decelerations, immediate intervention is required. • Baseline variability describes fluctuation or constant changes in the baseline FHR above and below the baseline in a 10-minute window (Fig. 6.13). Variability causes a recording of the FHR to have a sawtooth appearance with larger, undulating, wavelike movements. Baseline variability is a reflection of an intact central nervous system and cardiac status of the fetus. Recording of the fetal heart rate (FHR) in the u