LABOR AND BIRTH PROCESS AND move. same.

NURSING MANAGEMENT (chapter 13

and 14)  
False Labor Factors That Affect Labor
 Irregular contractions The Five P’s:
 No regular pattern  Passageway (birth canal)
 Discomfort in lower abdomen and  Passenger (fetus and placenta)
groin  Powers (contractions)
 Show is not present  Position of the mother
 Does not cause cervical change  Psychologic response
 Activity does not increases Labor Definition
contractions  Coordinated sequence of
 Sedation will stop or decrease involuntary uterine contractions
contractions  Contractions 3 minutes apart or less
  lasting 60 seconds or longer
True Labor  Resulting in effacement and
 Regular contractions dilatation of the cervix and delivery of
 Contractions Progresses to a pattern the fetus and placenta.
 Discomfort begins in back and  
radiates to the abdomen Possible Causes of Labor Maternal
 Activity increases contraction  Uterine muscle stretching
frequency  Pressure on the cervix
 Sedation does not diminish  Oxytocin
contraction pattern  Placental aging
 Causes cervical changes  Estrogen/Progesterone ratio change
 Show usually present  Fetal cortisol concentration
   Prostaglandins
 
FACTOR TRUE LABOR FALSE LABOR
THEORIES:
Contractions Produce Do not  OXYTOCIN STIMULATION: term
progressive produce uterus sensitive to oxytocin leading to
dilation and progressive pressure exerted on cervix by fetus.
effacement of and  PROGESTERONE WITHDRAWAL:
the cervix. effacement. decreases progesterone by fetus &
Occur Irregular and and increases prostaglandins in
regularly and do not chorioamnion resulting to increase
increase in increase in uterine contractions.
frequency, frequency,  ESTROGENSTIMULATIONL:
duration, and duration, and decreases progesterone allows
intensity. intensity. estrogen to increase contractile
response of uterus.
Show Is present Not present,  FETAL CORTISOL: changes
may have biochemistry of fetal membrane and
brownish decreases progesterone & increases
discharge prostaglandin in placenta.
that may be  DISTENTION: uterine muscles
from vaginal stretch causing increase of
exam if prostaglandin.
within the  AMNIOTIC MEMBRANES (sac) makes
last 48 hrs. arachidonic acid to prostaglandin -^
uterine contractility.
Cervix Becomes Usually
 
effaced and uneffaced
Signs Preceding Labor
dilates and closed.
 Lightening
progressively.
 Increase vaginal discharge
Fetal No significant May intensify  Cervix softening
movement change, even for a short  Rupture of membranes
though fetus period or may  Energy burst
continues to remain the  Braxton-Hicks contractions
  Weight loss  
 Bloody show Passageway
 Presenting Part  Pelvic structure and shape
 Cephalic  Soft tissues
 Shoulder  Cervix
 Breech  Pelvic floor
o Frank- hips are flexed and  Vagina
legs extended Passenger
o Full or complete- hips and  Size of the fetal head
knees are flexed and the feet are  Presenting part
not below the level of the feral  Fetal lie
buttocks.  Fetal attitude
o Footling or incomplete- one  Fetal position
or both feet are presenting as  
the lowest part of the fetus.  Fetal Skull
 Fetal Lie  Largest and least compressible
 Fetal lie is the relationship of the structure
spine of the fetus to the spine of the  Sutures: allow for overlapping and
mother changes in shape (molding); help
 Longitudinal identify position of fetal head
 Transverse  Fontanels: intersections of sutures;
 Fetal Attitude help in identifying position of fetal
 Fetal attitude is flexion or extension head and in molding
of the joints and the relationship of  
fetal parts to one another
 Fetal Position
 relationship of the presenting part
of the fetus to a designated point of
the maternal pelvic structure

 RIGHT OCCIPUT POSTERIOR (ROP)

o Baby's back favors mothers
right and the back of baby's head
is towards mothers posterior. In
ROP, baby is head down and the
back is to the right side. This
position can be deceptively
reassuring. ROP is the most
common of the four posterior
positions.
Powers
 Contractions primary force
 Frequency
 Duration
 Intensity
 Pushing secondary force
Four Stages of Labor
 First Stage starts with Onset of labor
to complete dilation
o Latent phase Dilatation 0 to 3
cm
 Effacement 0 to 40%
o Active phase Dilatation 4 to 7
cm
 Effacement 40 to 80%
 o Transition Dilatation 8–10 cm
 Effacement 100%
 Second stage complete dilation to
birth
 Third stage birth to placental
separation and expulsion
 Fourth stage four hours following
delivery of the place
Initial Maternal Assessment
 Presenting complaint
 EDC
 Gravida/Para
o GRAVIDA- number of
pregnancies
o PARA- number of births after
20 weeks
 Contraction Pattern
 Membrane status
 Presence of fetal movement
 Complications
 Five digit system
o G- total number of
pregnancies
o T- full term pregnancies (37-
40 weeks)
o P- preterm deliveries (20-36)
o A- abortions and
miscarriages (before 20 weeks)
o L-- living children
Maternal Position
 Affects woman’s anatomic and
physiologic adaptations to labor
 Frequent changes in position
o Relieve fatigue
o Increase comfort
o Improve circulation
o Facilitates decent and
rotation
 
Psychological Response
 Factors Influencing a Positive Birth
Experience
o Clear information on
procedures
o Support, not being alone
o Sense of mastery, self-
confidence
o Trust in staff caring for her
o Positive reaction to the
pregnancy
o Personal control over
breathing
o Preparation for the childbirth
experience
Factors That Affect Labor
 5 Additional P’s
o Philosophy
o Partner
o Patience
o Pain management
Cardinal movements of Labor
 Engagement
 Descent
 Flexion
 Internal rotation
 Extension
 External rotation (restitution)
 Expulsion (birth)
 
Nurses Role
 During labor and delivery fetal
assessment includes determining fetal
well-being and interpreting signs and
symptoms of possible compromise
 Nurse needs to be knowledgeable of
the different FHR categories and the
appropriate interventions that may be
required
Monitoring Techniques
 Electronic fetal monitoring
 External monitoring
o FHR—ultrasound transducer
o UCs—Toco transducer
 Internal monitoring (invasive)
o Spiral electrode (FSE)
o Intrauterine pressure
catheter (IUPC)
FHR Categories
 Category I normal
 Category II indeterminate
 Category III predictive of abnormal
fetus acid base status
 
Determining FHR Patterns
 Fetal assessment
o Baseline FHR
o Variability
o Accelerations
o Periodic changes
(decelerations)
o Early (head compression)
 o Late (placental insufficiency)
o Variable (cord compression)
Baseline Fetal Heart Rate
 Baseline Rate is the average FHR
that occurs during a 10-minute
segment excluding periodic or
episodic rate changes
 Normal 110-160
 Bradycardia <110
 Tachycardia >160
Fetal Heart Rate Variability
 Irregular Fluctuations in FHR
baseline measured as amplitude of
the peak to trough in bpm
 Absent fluctuation undetectable
 Minimal <5 bpm
 Moderate (normal) 6-25 bpm
 Marked >25bpm
 
Fetal Assessment
 FHR provides information about the
fetal oxygen status.
 Locations for auscultating
 Doppler Nursing Procedure 12.1 pg.
355
 Continuous FHR via ultrasound
transducer
 Fetal movement
 
Contraction Assessment
 Frequency
 Duration
 Strength/Intensity
 Resting tone
 
Pelvic Exam
 Effacement
 Dilation
 Presenting part
 Station
 Status of membranes
 
General Systems Assessment
 Vital signs
 General physical assessment
 Leopold’s maneuvers Procedure
14.1 pg. 424
 Review prenatal record for lab
results and history
Physiologic Adaptation to Labor
 Maternal Adaptation
 Cardiovascular changes
 Respiratory changes
 Musculoskeletal changes
 Gastrointestinal changes
Fetal adaptation to labor
 Fetal heart rate changes due to
contractions
 Fetal circulation & respiratory
changes preparing for birth
 Fetal heart rate baseline and
variability
 Fetal heart rate response to
contractions
o Prolonged Deceleration
 Abrupt decrease in FHR of at
least 15 bpm lasting longer
than 2 minutes, but less
than 10 minutes.
 FHR usually drops to less
than 90 bpm
Fetal Heart Rate
V Variable
E Early
A Acceleration
L Late
C Cord
H Head Compression
O Oxygenated fetus
P Placental problems
 
Fetal Assessment Methods
 Umbilical Cord Blood Analysis
 Fetal Scalp Stimulation
Pain Management
 Nonpharmacologic
o Simple, safe, and inexpensive
o Provide sense of control over
childbirth
o Natural child birth requires
practice for best results
o Try variety of methods and
seek alternatives, including
pharmacologic methods if
needed
o Imagery and visualization
o Position Changes Table 14.2
pg.437
o Music
o Touch and massage
o Breathing techniques
o Effleurage and counter
pressure
o Water therapy
(hydrotherapy)
 Pharmacologic
o Systemic Analgesia
 Use of one or more
drugs administered orally,
IM, or IV. These meds are
distributed via the
circulatory system.
  Pain relief can occur
within a few min. and last
up to several hrs.
 Side effect can be
respiratory depression in
the mother as well as the
newborn after birth
 Opioids
 Ataractics/Antiemetic
s bpm, lasting between 15
 Benzodiazepines
 
Fetal Heart Rate Patterns
Changes in fetal heart rate
 Periodic occur with Contractions
 Episodic (non-periodic) not
associated with contractions
 Accelerations
 Decelerations
Accelerations
 Positive sign of fetal wellbeing
 Abrupt increase in FHR above the
base line lasting <30 sec from onset to
peak
 Term 15 bpm above baseline &
duration >15 sec. but <2min
 Prior to 32 weeks 10 by 10
 Prolonged 2 min. to <10min
Decelerations
 Early decelerations
 Late decelerations
 Variable decelerations
 Prolonged decelerations
o Early Decelerations
 Gradual decrease in
FHR, The nadir of the early
deceleration occurs with
the peak of a contraction.
 A late deceleration is
defined as a waveform
with a gradual decrease
and return to baseline with
time from onset of the
deceleration to the lowest
point of the deceleration
(nadir) >30 seconds
 Head
compression/vagal
response
 No treatment
required/benign pattern
o Late Decelerations
 Gradual decrease in
FHR of the deceleration
occurring after the peak of
the contraction. The FHR
does not return to baseline
until the contraction has
ended
 Caused by
uteroplacental insufficiency
 Fetus is in distress
o Variable Decelerations
 Abrupt decrease in
FHR below the baseline.
The decrease is at least 15
sec and under 2 minutes.
They can vary with
contractions.
 Shaped like a “V” or a
“W”
 Associated with cord
compression
 Gown, gloves, and protective
equipment for personnel
 Cleansing of the perineum
 Deliver the newborn
 
Second Stage of Labor
 Assessment of contractions and FHR
 Fetal descent
 Psychological considerations
 Maternal positioning
 Coaching maternal breathing and
pushing efforts
 Perineal
o Lacerations (Depth)
 * 1st degree
 * 2nd degree
 * 3rd degree
 * 4th degree
 Episiotomy
o Midline
o mediolateral
 
Third Stage of Labor
Delivery of the placenta
 Assess for perineal trauma
 Repair of episiotomy/Perineal
lacerations
 Newborn care
 Emotional support /Foster bonding
 
Placental separation and expulsion
 Firmly contracting fundus
 Change in uterus
 Sudden gush of dark blood from
introitus
 Apparent lengthening of umbilical
cord
 Vaginal fullness
 
Newborn care
 Time of birth noted
  Drying, stimulation, suctioning of Preparation for Delivery
the newborn  Prepare instrument table
 Respiratory effort, heart rate, color,  Adequate lighting
tone noted  Oxygen and suction equipment
 One- and five-minute Apgar scores  Radiant warmer, blankets,
 Cord blood obtained  identification for newborn
 Identification  Pitocin
   Positioning of mother for birth
Regional Analgesia/Anesthesia  
 Pudendal never block  
 Epidural (Vaginal Del or C/S)  Fourth Stage of Labor
 Spinal (C/S)  
 General (C/S) Maternal Assessment
   Uterus
 Lochia
 Perineum
 Bladder
Epidural Analgesia  Vital signs
 Combination of local anesthetic  Pain
(lidocaine) & an opioid (morphine or  Newborn-family attachment
fentanyl)  Breastfeeding initiated
 Injected into the epidural space
 Medication can be balanced to  
provide pain relive and the ability to  
ambulate
 
General Anesthesia
 Reserved for emergency cesarean
births when there is not enough time
to do a spinal or epidural for
anesthesia
 Combination of IV injection and
inhalation agents
 
Epidurals/Spinals/General Anesthesia
 Anesthesia interview
 Consent form
 Labs (platelets less than 100,000 can
place an epidural/spinal)
 
Nursing Responsibilities During 1st Stage of
Labor
 Vital signs
 Hydration and nutrition
 Elimination
 Assessment of contractions and FHR
 Labor Support
 Comfort measures/Pain
management
 Education
 
Heart Rate Absent < 100 bpm > 100 bpm
Respiratory Apneic Slow, irregular, shallow Regular 30-60
effort breaths/min 
Strong, good cry
Muscle Tone Limp, Flaccid Some flexion, limited Tight flexion, good
resistance to extension resistance to extension
 with quick response to
flexed position
Reflex No Response   Sneeze, cough, or
irritability Grimace or frown when vigorous cry
irritated
Skin color Cyanotic or Appropriate body color; blue Completely pink
Pale extremities