Nursing Care of the Family During Labor and Birth

Chapter 16

Nursing Care of the Family During Labor and Birth

Kitty Cashion

Learning Objectives

On completion of this chapter, the reader will be able to:

• Review the factors included in the initial assessment of the woman in labor.

• Describe the ongoing assessment of maternal progress during the first, second, third, and fourth stages of
labor.

• Recognize the physical and psychosocial findings indicative of maternal progress during labor.

• Describe fetal assessment during labor.

• Identify signs of developing complications during labor and birth.

• Incorporate evidence-based nursing interventions into a comprehensive plan of care relevant to each stage of
labor.

• Recognize the importance of support (family, partner, doula, nurse) in fostering maternal confidence and
facilitating the progress of labor and birth.

• Analyze the influence of cultural and religious beliefs and practices on the process of labor and birth.

• Evaluate research findings on the importance of support from family, partner, doula, and nurse in facilitating
maternal progress during labor and birth.

• Describe the role and responsibilities of the nurse during emergency childbirth.

• Evaluate the impact of perineal trauma on the woman’s reproductive and sexual health.

The labor process is an exciting and anxious time for the woman and her significant others (support persons,
family). In a relatively short period they experience one of the most profound changes in their lives. Although
most women in the United States labor and give birth in a hospital under the care of a physician, others choose
different settings and care providers. Available childbirth options vary greatly from place to place (see
Community Focus box).

 Community Focus

Availability of Alternative Childbirth Options in the Community

Consult the yellow pages of the telephone directory and the Internet to explore options for childbearing families
in your community. Is there a birthing center in your community? Are certified nurse-midwives available? Are
other types of licensed midwives available? Is there an option for a home birth? For a water birth? During your
clinical rotation in maternity nursing, interview a staff nurse in labor and delivery (L&D) and ascertain his or
her views of midwives and home births. Interview a childbirth educator and ascertain his or her views of
midwives and home births. Contrast the views of the L&D nurse and the childbirth educator. Is there a
difference in their views? Prepare a patient handout listing the options for childbearing families in your
community. Discuss the findings from your interview with your clinical group.

For most women labor begins with the first uterine contraction, continues with hours of hard work during
cervical dilation and birth, and ends as the woman and her family begin the attachment process with the
newborn. Nursing care management focuses on assessment and support of the woman and her significant others
throughout labor and birth, with the goal of ensuring the best possible outcome for all involved.

First Stage of Labor

The first stage of labor begins with the onset of regular uterine contractions and ends with complete cervical
effacement and dilation. The first stage of labor consists of three phases: the latent phase (through 3 cm of
dilation), the active phase (4 to 7 cm of dilation), and the transition phase (8 to 10 cm of dilation).

Care Management
Most nulliparous women seek admission to the hospital in the latent phase because they have not experienced
labor before and are unsure of the “right” time to come in. Multiparous women usually do not come to the
hospital until they are in the active phase. Even though no two labors are identical, women who have given birth
before often are less anxious about the process unless their previous experience has been negative.

Assessment

Assessment begins at the first contact with the woman, whether by telephone or in person. Many women call
the hospital or birthing center first for validation that it is all right for them to come in for evaluation or
admission or that they can remain at home. However, many hospitals discourage the nurse from giving advice
regarding what to do because of legal liability. Nurses are often instructed to tell women who call with
questions to call their primary health care provider or to come to the hospital if they feel the need to be checked.
The nature of the telephone conversation, including any advice or instructions given, should be documented in
the patient’s record (Gilbert, 2011).

A pregnant woman may first call her primary care provider or come to the hospital while in false labor or early
in the latent phase of the first stage of labor. She may feel discouraged, angry, or confused on learning that the
contractions that feel so strong and regular to her do not indicate true labor because they are not causing
cervical dilation or that they are still not strong or frequent enough for admission. During the third trimester of
pregnancy women should be instructed regarding the stages of labor and the signs indicating its onset. They
should be informed of the possibility that they will not be admitted if they are 3 cm or less dilated (see Patient
Teaching box).

Patient Teaching

How to Distinguish True Labor from False Labor

True Labor
Contractions

• Occur regularly, becoming stronger, lasting longer, and occurring closer together

• Become more intense with walking

• Are usually felt in lower back, radiating to lower portion of abdomen

• Continue despite use of comfort measures

Cervix (by vaginal examination)

• Shows progressive change (softening, effacement, and dilation signaled by appearance of bloody show)

• Moves to an increasingly anterior position

Fetus

• Presenting part usually becomes engaged in pelvis, which results in increased ease of breathing; at the same
time, presenting part presses downward and compresses bladder, resulting in urinary frequency

False Labor

Contractions

• Occur irregularly or become regular only temporarily

• Often stop with walking or position change

• Can be felt in back or abdomen above navel

• Can often be stopped through use of comfort measures

Cervix (by vaginal examination)

• May be soft but with no significant change in effacement or dilation or evidence of bloody show

• Is often in posterior position

Fetus

• Presenting part is usually not engaged in pelvis

If the woman lives near the hospital and has adequate support and transportation, she may be encouraged to stay
home or return home to allow labor to progress (i.e., until the uterine contractions are more frequent and
intense). The ideal setting for the low risk woman at this time usually is the familiar environment of her home.
However, the woman who lives at a considerable distance from the hospital, who lacks adequate support and
transportation, or who has a history of rapid labors in the past may be admitted in latent labor. The same
measures used by the woman at home should be offered to the hospitalized woman in early labor.
A warm shower is often relaxing during early labor. However, warm baths before labor is well established
could inhibit uterine contractions and prolong the labor process (Waterbirth International, 2012). Soothing back,
foot, and hand massage or a warm drink of preferred liquids such as tea or milk can help the woman rest and
even sleep, especially if false or early labor is occurring at night. Diversional activities such as walking
outdoors or in the house, reading, watching television, “playing” on the computer, or talking with friends can
reduce the perception of early discomfort, help time pass, and reduce anxiety.

When the woman arrives at the perinatal unit, assessment is the top priority (Fig. 16-1). The nurse first performs
a screening assessment by using the techniques of interview and physical assessment and reviews the laboratory
and diagnostic test findings to determine the health status of the woman and her fetus and the progress of her
labor. The nurse also notifies the primary health care provider; and, if the woman is admitted, a detailed systems
assessment is done.

FIG 16-1 Woman being admitted.

(Courtesy Julie Perry Nelson, Loveland, CO.)

Legal Tip

Obstetric Triage and EMTALA

The Emergency Medical Treatment and Active Labor Act (EMTALA) is a federal regulation enacted to ensure
that a woman gets emergency treatment or active labor care whenever such treatment is sought. According to
the EMTALA, true labor is considered to be an emergency medical condition. Nurses working in labor and
birth units must be familiar with their responsibilities according to the EMTALA regulations, which include
providing services to pregnant women when they experience an urgent pregnancy problem (e.g., labor,
decreased fetal movement, rupture of membranes [ROM], recent trauma) and fully documenting all relevant
information (e.g., assessment findings, interventions implemented, patient responses to care measures
provided). A pregnant woman presenting in an obstetric triage is considered to be in “true” labor until a
qualified health care provider certifies that she is not. Agencies need to have specific policies and procedures in
place so compliance with EMTALA regulations is achieved while safe and efficient care is provided (Miller,
Miller, and Tucker, 2013).

When the woman is admitted, she is usually moved from an observation area to the labor room; the labor,
delivery, and recovery (LDR) room; or the labor, delivery, recovery, and postpartum (LDRP) room. If she
wishes, include her partner in the assessment and admission process. The nurse can direct significant others not
participating in this process to the appropriate waiting area. The woman undresses and puts on her own gown or
a hospital gown. The nurse places an identification band on the woman’s wrist. Her personal belongings are put
away safely or given to family members according to agency policy. Women who participate in expectant
parent classes often bring a birth bag or Lamaze bag with them. The nurse then shows the woman and her
partner the layout and operation of the unit and room, how to use the call light and telephone system, how to
adjust lighting in the room, and the different bed positions.

The nurse reassures the woman that she is in competent, caring hands and that she and people to whom she
gives permission can ask questions related to her care and status and that of her fetus at any time during labor.
The nurse can minimize the woman’s anxiety by explaining terms commonly used during labor. The woman’s
interest, response, and prior experience guide the depth and breadth of these explanations.

Most hospitals have specific forms, whether paper or electronic, that are used to obtain important assessment
information when a woman in labor is being evaluated or admitted (Fig. 16-2, A and B). More and more
hospitals now use an electronic medical record; almost all charting is done on computer. Sources of data include
the prenatal record, initial interview, physical examination to determine baseline physiologic parameters (e.g.,
vital signs), laboratory and diagnostic test results, expressed psychosocial and cultural factors, and clinical
evaluation of labor status.
 FIG 16-2 Admission screens in an
electronic medical record. A, General admission screen. B, Current admission screen. (Courtesy Kitty Cashion,
Memphis, TN.)

Prenatal Data

The nurse reviews the prenatal record to identify the woman’s individual needs and risks. Copies of prenatal
records are generally filed in the perinatal unit at some time during the woman’s pregnancy (usually in the third
trimester) or accessed by computer so they are readily available on admission. If the woman has had no prenatal
care or her prenatal records are unavailable, the nurse must obtain certain baseline information. If she is having
discomfort, the nurse should ask questions between contractions when she can concentrate more fully on her
answers. At times the partner or support person(s) may need to be secondary sources of essential information.
According to the Health Insurance Portability and Accountability Act (HIPAA), the woman must give
permission for other persons to be involved in the exchange of information regarding her care. This permission
should be obtained during pregnancy, and a signed form included in her health records.

Knowing the woman’s age is important so the nurse can individualize care to the needs of her age-group. For
example, a 14-year-old girl and a 40-year-old woman have different but specific needs, and their ages place
them at risk for different problems. Accurate height and weight measurements are important. A pregnancy
weight gain greater than recommended may place the woman at a higher risk for cephalopelvic disproportion
and cesarean birth. This is especially true for women who are petite and have gained 16 kg or more. A
prepregnancy body mass index (BMI) greater than 30 is also a cause for concern. Other factors to consider are
the woman’s general health status, current medical conditions or allergies, respiratory status, and previous
surgical procedures.

The nurse should review the woman’s prenatal records carefully, taking note of her obstetric and pregnancy
history, including gravidity; parity; and problems such as history of vaginal bleeding, gestational hypertension,
anemia, pregestational or gestational diabetes, infections (e.g., bacterial, viral, sexually transmitted), and
immunodeficiency status. In addition, the expected date of birth (EDB) should be confirmed. Other important
data found in the prenatal record include patterns of maternal weight gain; physiologic measurements such as
maternal vital signs (blood pressure, temperature, pulse, respirations); fundal height; baseline fetal heart rate
(FHR); and laboratory and diagnostic test results. See Table 8-1 for a list of common prenatal laboratory tests.
Common diagnostic and fetal assessment tests performed prenatally include amniocentesis, nonstress test
(NST), biophysical profile (BPP), and ultrasound examination. See Chapter 10 for more information.

If this labor and birth experience is not the woman’s first, the nurse needs to note the characteristics of her
previous experiences. This information includes the duration of previous labors, the type of anesthesia used, the
kind of birth (e.g., spontaneous vaginal, forceps-assisted, vacuum-assisted, or cesarean birth), and the condition
of the newborn. Explore the woman’s perception of her previous labor and birth experiences because this
perception may influence her attitude toward her current experience.

Interview

The woman’s primary reason for coming to the hospital is determined in the interview. For example, it may be
that her bag of waters (BOW, amniotic membranes) ruptured with or without contractions. The woman may
have come in for an obstetric check to determine if she is truly in labor. She may be admitted to the Labor and
Birth Unit for a period of observation lasting up to 23 hours. If it is determined after several hours of
observation that she is not in true labor, she is discharged. Admission for 23 hours of observation is much less
expensive than an inpatient admission; thus it minimizes or avoids cost to the woman and her health insurance
plan.

Even the experienced woman may have difficulty determining the onset of labor. She is asked to recall the
events of the previous days and describe the following:

• Time and onset of contractions and progress in terms of frequency, duration, and intensity

• Location and character of discomfort from contractions (e.g., back pain, abdominal or suprapubic discomfort)

• Persistence of contractions despite changes in maternal position and activity (e.g., walking or lying down)

• Presence and character of vaginal discharge or “show”

• The status of amniotic membranes such as a gush or seepage of fluid (spontaneous rupture of membranes
[SROM]). If there has been a discharge that may be amniotic fluid, she is asked the date and time the fluid was
first noted and its characteristics (e.g., amount, color, unusual odor). In many instances a sterile speculum
examination and a Nitrazine (pH) and fern test can confirm that the membranes are ruptured (Box 16-1).

Box 16-1   Procedure

Tests for Rupture of Membranes

Nitrazine Test for pH

• Explain procedure to woman or couple.

Procedure

• Wash hands.

• Use cotton-tipped applicator impregnated with Nitrazine dye for determining pH (differentiates amniotic fluid,
which is slightly alkaline, from urine and purulent material [pus], which are acidic).

• Dip cotton-tipped applicator deep into vagina to pick up fluid. (Procedure may be performed during speculum
examination.)

Read Results

• Membranes probably intact: Identifies vaginal and most body fluids that are acidic:

Yellow pH 5.0
Olive-yellow pH 5.5
Olive-green pH 6.0

• Membranes probably ruptured: Identifies amniotic fluid that is alkaline:

Blue-green pH 6.5
Blue-gray pH 7.0
Deep blue pH 7.5

• Realize that false test results are possible because of presence of bloody show, insufficient amniotic fluid, or
semen.

• Provide pericare as needed.

• Remove gloves and wash hands.

Document Results

• Results are positive or negative.

Test for Ferning or Fern Pattern

• Explain procedure to woman or couple.

Procedure
• Wash hands, apply sterile gloves, obtain specimen of fluid (usually during sterile speculum examination).

• Spread drop of fluid from vagina on clean glass slide with sterile cotton-tipped applicator.

• Allow fluid to dry.

• Examine slide under microscope; observe for appearance of ferning (a frondlike crystalline pattern) (do not
confuse with cervical mucus test, when high levels of estrogen cause ferning).

• Observe for absence of ferning (alerts staff to possibility that amount of specimen was inadequate or that
specimen was urine, vaginal discharge, or blood).

• Provide pericare as needed.

• Remove gloves and wash hands.

Document Results

• Results are positive or negative.

These descriptions help the nurse assess the degree of progress in the process of labor. Bloody show is
distinguished from bleeding by the fact that it is pink and feels sticky because of its mucoid nature. There is
very little bloody show in the beginning, but the amount increases with effacement and dilation of the cervix. A
woman may report a small amount of brownish-to-bloody discharge that may be attributed to cervical trauma
resulting from vaginal examination or coitus (intercourse) within the last 48 hours.

Assessing the woman’s respiratory status is important in case general anesthesia is needed in an emergency.
The nurse determines this status by asking the woman if she has a cold or related symptoms (e.g., “stuffy nose,”
sore throat, cough). The status of allergies, including allergies to latex and tape, and medications routinely used
in obstetrics such as opioids (e.g., hydromorphone [Dilaudid], butorphanol [Stadol], fentanyl [Sublimaze],
nalbuphine [Nubain]), anesthetic agents (e.g., bupivacaine, lidocaine, ropivacaine), and antiseptics (Betadine) is
reviewed. Some allergic responses cause swelling of the mucous membranes of the respiratory tract, which
could interfere with breathing and the administration of inhalation anesthesia. Because vomiting and subsequent
aspiration into the respiratory tract can complicate an otherwise normal labor, the nurse records the time and
type of the woman’s most recent solid and liquid intake.

The nurse obtains any information not found in the prenatal record during the admission assessment. Pertinent
data include the birth plan (Box 16-2), the choice of infant feeding method, the type of pain management
preferred, and the name of the pediatric health care provider. Obtain a patient profile that identifies the woman’s
preparation for childbirth, the support person or family members desired during childbirth and their availability,
and ethnic or cultural expectations and needs. Determine the woman’s use of alcohol, drugs, and tobacco before
or during pregnancy.

Box 16-2   The Birth Plan

The birth plan should include the woman’s or couple’s preferences related to:

• Presence of birth companions such as the partner, older children, parents, friends, and doula and the role each
will play.

• Presence of other persons such as students, male attendants, and interpreters.

• Clothing to be worn.

• Environmental modifications such as lighting, music, privacy, focal point, items from home such as pillows.

• Labor activities such as preferred positions for labor and for birth, ambulation, birth balls, showers and
whirlpool baths, oral food and fluid intake.

• List of comfort and relaxation measures.

• Labor and birth medical interventions such as pharmacologic pain-relief measures, intravenous therapy,
electronic monitoring, induction or augmentation measures, and episiotomy.

• Care and handling of the newborn immediately after birth such as cutting of the cord, eye care, and
breastfeeding.

• Cultural and religious requirements related to the care of the mother, newborn, and placenta.

The childbirth website www.childbirth.org provides couples with an interactive birth plan along with examples
of birth plans and descriptions of options that can be included.

The nurse reviews the birth plan. If no written plan has been prepared, he or she helps the woman formulate one
by describing options available and determining the woman’s wishes and preferences. As caregiver and
advocate the nurse integrates the woman’s desires into the nursing care plan as much as possible. She or he also
prepares the woman for the possibility of change in her plan as labor progresses and assures her that the staff
will provide information so she can make informed decisions. However, the woman must also realize that the
longer her wish list, the greater is the likelihood that her expectations will not be met.

The nurse should discuss with the woman and her partner their plans for preserving childbirth memories
through the use of photography and videotaping. Information should be provided about agency policies
regarding these practices and under which circumstances they are allowed. Protection of privacy and safety and
infection control are major concerns for the expecting parents and the agency. To avoid future embarrassment
and distress, the nurse should clarify with the woman exactly which parts of her childbirth she wishes to have
photographed and the degree of detail. Remind patients and families that pictures should not be posted on social
media sites without the knowledge and consent of every person who appears in the picture. The woman’s record
should reflect that the childbirth was recorded. Some hospitals and health care providers do not allow
videotaping of the birth because of concerns related to legal liability.

Psychosocial Factors

The woman’s general appearance and behavior (and that of her partner) provide valuable clues to the type of
supportive care she will need. However, keep in mind that general appearance and behavior may vary,
depending on the stage and phase of labor (Table 16-1 and Box 16-3).

Box 16-3   Psychosocial Assessment of the Laboring Woman

Verbal Interactions

• Does the woman ask questions?

• Can she ask for what she needs?

• Does she talk to her support person(s)?

• Does she talk freely with the nurse or respond only to questions?

Body Language

• Does she change positions or lie rigidly still?

• What is her anxiety level?

• How does she react to being touched by the nurse or support person?

• Does she avoid eye contact?

• Does she look tired? If she appears tired, ask her how much rest she has had in the past 24 hours.

Perceptual Ability

• Is there a language barrier?

• Are repeated explanations necessary because her anxiety level interferes with her ability to comprehend?

• Can she repeat what she has been told or otherwise demonstrate her understanding?

Discomfort Level

• To what degree does the woman describe what she is experiencing, including her pain experience?

• How does she react to a contraction?

• How does she react to assessment and care measures?

• Are any nonverbal pain messages noted?

• Can she ask for comfort measures?

TABLE 16-1

EXPECTED MATERNAL PROGRESS DURING FIRST STAGE OF LABOR

PHASES MARKED BY CERVICAL DILATION*

CRITERION
0-3 cm (LATENT) 4-7 cm (ACTIVE) 8-10 cm (TRANSITION)
Duration† About 6-8 hr About 3-6 hr About 20-40 min
Contractions      
 Strength Mild to moderate Moderate to strong Strong to very strong
 Rhythm Irregular More regular Regular
 Frequency 5-30 min apart 3-5 min apart 2-3 min apart
 Duration 30-45 sec 40-70 sec 45-90 sec
Descent      
 Station of Nulliparous: 0 Varies: +1 to +2 cm Varies: +2 to +3 cm
 PHASES MARKED BY CERVICAL DILATION*
CRITERION
0-3 cm (LATENT) 4-7 cm (ACTIVE) 8-10 cm (TRANSITION)
presenting
Multiparous: −2 cm to 0 Varies: +1 to +2 cm Varies: +2 to +3 cm
part
Show      
Brownish discharge,
 Color mucus plug, or pale pink Pink-to-bloody mucus Bloody mucus
mucus
 Amount Scant Scant to moderate Copious
Pain described as severe; backache
common; frustration, fear of loss of
Excited; thoughts center Becomes more serious, control, and irritability may be voiced;
on self, labor, and baby; doubtful of pain control, more expresses doubt about ability to
may be talkative or silent, apprehensive; desires continue; vague in communications;
calm or tense; some companionship and amnesia between contractions;
Behavior and
apprehension; pain encouragement; attention writhing with contractions; nausea and
appearance‡
controlled fairly well; more inwardly directed; vomiting, especially if
alert, follows directions fatigue evidenced; malar hyperventilating; hyperesthesia;
readily; open to (cheeks) flush; has some circumoral pallor, perspiration of
instructions difficulty following directions forehead and upper lip; shaking tremor
of thighs; feeling of need to defecate,
pressure on anus
*
In the nullipara effacement is often complete before dilation begins; in the multipara it occurs simultaneously
with dilation.
†
Duration of each phase is influenced by such factors as parity; maternal emotions; position; level of activity;
and fetal size, presentation, and position. For example, the labor of a nullipara tends to last longer, on average,
than the labor of a multipara. Women who ambulate and assume upright positions or change positions
frequently during labor tend to experience a shorter first stage. Descent is often prolonged in breech
presentations and occiput posterior positions.
‡
Women who have epidural analgesia for pain relief may not demonstrate some of these behaviors.

Women with a History of Sexual Abuse.

Labor can trigger memories of sexual abuse, especially during intrusive procedures such as vaginal
examinations. Monitors, intravenous (IV) lines, and epidurals can make the woman feel a loss of control or as if
she is being confined to bed and “restrained.” Being observed by students and having intense sensations in the
uterus and genital area, especially at the time when she must push the baby out, can also trigger memories.

The nurse can help the abuse survivor associate the sensations she is experiencing with the process of childbirth
and not with her past abuse. Help maintain her sense of control by explaining all procedures and why they are
needed, validating her needs, and paying close attention to her requests. Wait for the woman to give permission
before touching her, and accept her often extreme reactions to labor (Simpson, 2008). Avoid words and phrases
that can cause the woman to recall the words of her abuser (e.g., “open your legs,” “relax and it won’t hurt so
much”). Limit the number of procedures that invade her body (e.g., vaginal examinations, urinary catheter,
internal monitor, forceps or vacuum extractor) as much as possible. Encourage her to choose a person (e.g.,
doula, friend, family member) to be with her during labor to provide continuous support and comfort and act as
her advocate. Nurses are advised to care for all laboring women in this manner because it is not unusual for a
woman to choose not to reveal a history of sexual abuse. These care measures can help a woman perceive her
childbirth experience in positive terms.

Stress in Labor

The way in which women and their support person or family members approach labor is related to the manner
in which they have been socialized to the childbearing process. Their reactions reflect their life experiences
regarding childbirth—physical, social, cultural, and religious. Society communicates its expectations regarding
acceptable and unacceptable maternal behaviors during labor and birth. These expectations may be used by
some women as the basis for evaluating their own actions during childbirth. An idealized perception of labor
and birth may be a source of guilt and cause a sense of failure if the woman finds the process less than joyous,
especially when the pregnancy is unplanned or is the product of a dysfunctional or terminated relationship.
Often women have heard horror stories or have seen friends or relatives going through labors that appear
anything but easy. Multiparous women often base their expectations of the present labor on their previous
childbirth experiences.

Discuss the feelings that a woman has about her pregnancy and fears regarding childbirth. This discussion is
especially important if the woman is a primigravida who has not attended childbirth classes or a multiparous
woman who has had a previous negative childbirth experience. Women in labor usually have a variety of
concerns that they will voice if asked but rarely volunteer. Major fears and concerns relate to the process and
effects of childbirth, maternal and fetal well-being, and the attitude and actions of the health care staff.
Unresolved fears increase a woman’s stress and can slow the process of labor as a result of the inhibiting effects
of catecholamines associated with the stress response on uterine contractions.

The father, coach, or significant other also experiences stress during labor. The nurse can assist and support
these individuals by identifying their needs and expectations and helping to make sure that these are met. She or
he can determine what role the support person intends to fulfill and whether that person is prepared for the role
by making observations and asking herself or himself such questions as, “Has the couple attended childbirth
classes?” “What role does this person expect to play?” “Does he or she do all the talking?” “Is she or he
nervous, anxious, aggressive, or hostile?” “Does he or she look hungry, tired, worried, or confused?” “Does he
or she watch television, sleep, or stay out of the room instead of paying attention to the woman?” “Where does
he or she sit?” “Does he or she touch the woman; what is the character of the touch?” Be sensitive to the needs
of support persons and provide teaching and support as appropriate. In many instances the support that these
people provide to the laboring woman is in direct proportion to the support they receive from the nurses and
other health care providers.

Cultural Factors

As the population in the United States and Canada becomes more diverse, it is increasingly important to note
the woman’s ethnic or cultural and religious values, beliefs, and practices to anticipate nursing interventions to
add or eliminate from an individualized, mutually acceptable plan of care that provides a feeling of safety and
control (Fig. 16-3). Nurses should be committed to providing culturally sensitive care and developing an
appreciation and respect for cultural diversity (Callister, 2008). Encourage the woman to request specific
caregiving behaviors and practices that are important to her. If a special request contradicts usual practices in
that setting, the woman or the nurse can ask the woman’s primary health care provider to write an order to
accommodate the special request. For example, in many cultures it is unacceptable to have a male caregiver
examine a pregnant woman. In some cultures it is traditional to take the placenta home; in others the woman has
only certain nourishments during labor. Some women believe that cutting her body, as with an episiotomy,
allows her spirit to leave her body and that rupturing the membranes prolongs, not shortens, labor. It is
important to explain the rationale for required care measures carefully (see Cultural Competence box).
 FIG 16-3 Birthing room specific to Native-
American population. Note arrow pointing east, rug on wall, and rope or sash belt hanging from ceiling.
(Courtesy Patricia Hess, San Francisco, CA; Chinle Comprehensive Health Care Center, Chinle, AZ.)

 Cultural Competence

Birth Practices in Different Cultures

• Somalia: Because Somalis in general do not like to show any sign of weakness, women are extremely stoic
during childbirth

• Japan: Natural childbirth methods practiced; may labor silently; may eat during labor; father may be present

• China: Stoic response to pain; father not usually present; side-lying position preferred for labor and birth
because this position is thought to reduce infant trauma
• India: Natural childbirth methods preferred; father not usually present; female relatives usually present

• Iran: Father not present; female support and female caregivers preferred

• Mexico: May be stoic about discomfort until second stage, and then may request pain relief; father and female
relatives may be present

• Laos: May use squatting position for birth; father may or may not be present; female attendants preferred

Within cultures women may have an idea of the “right” way to behave in labor and may react to the pain
experienced in that way. These behaviors can range from total silence to moaning or screaming, but they do not
necessarily indicate the degree of pain. A woman who moans with contractions may not be in as much physical
pain as a woman who is silent but winces during contractions. Some women believe that screaming or crying
out in pain is shameful if a man is present. If the woman’s support person is her mother, she may perceive the
need to “behave” more strongly than if her support person is the father of the baby. She perceives herself as
failing or succeeding based on her ability to follow these “standards” of behavior. Conversely a woman’s
behavior in response to pain may influence the support received from significant others. In some cultures
women who lose control and cry out in pain may be scolded, whereas in others support persons become more
helpful (D’Avanzo, 2008).

Culture and Father Participation.

A companion is an important source of support, encouragement, and comfort for women during childbirth. The
woman’s cultural and religious background influences her choice of birth companion as do trends in the society
in which she lives. For example, in Western societies the father is viewed as the ideal birth companion. For
European-American couples, attending childbirth classes together has become a traditional, expected activity.
Laotian (Hmong) husbands also traditionally participate actively in the labor process. In some other cultures the
father may be available; but his presence in the labor room with the mother may not be considered appropriate,
or he may be present but resist active involvement in her care. Such behavior could be perceived by the nursing
staff to indicate a lack of concern, caring, or interest. Women from many cultures prefer female caregivers and
want to have at least one female companion present during labor and birth. They also are usually very
concerned about modesty. If couples from these cultures immigrate to the United States or Canada, their roles
may change. The nurse needs to talk to the woman and her support people to determine the roles they will
assume.

The Non–English Speaking Woman in Labor.

A woman’s level of anxiety in labor increases when she does not understand what is happening to her or what is
being said. Non–English speaking women often feel a complete loss of control over their situation if no health
care provider is present who speaks their language. They can panic and withdraw or become physically abusive
when someone tries to do something they perceive might harm them or their babies. A support person is
sometimes able to serve as an interpreter. However, caution is warranted because the interpreter may not be able
to convey exactly what the nurse or others are saying or what the woman is saying, which can increase the
woman’s stress level even more.

Ideally a bilingual nurse cares for the woman. Alternatively a hospital employee or volunteer interpreter may be
contacted for assistance. Ideally the interpreter is from the woman’s culture. For some women a female is more
acceptable than a male interpreter. If no one in the hospital is able to interpret, call a service so interpretation
can take place over the telephone. Even when the nurse has limited ability to communicate verbally with the
woman, in most instances the woman appreciates his or her efforts to do so. Speaking slowly and avoiding
complex words and medical terms can help a woman and her partner understand. Often the woman understands
English much better than she speaks it.
Physical Examination

The initial physical examination includes a general systems assessment and an assessment of fetal status.
During the examination uterine contractions are assessed, and a vaginal examination is performed. The findings
of the admission physical examination serve as a baseline for assessing the woman’s progress from that point.
The information obtained from a complete and accurate assessment during the initial examination serves as the
basis for determining whether the woman should be admitted and what her ongoing care should be. Expected
maternal progress and minimal assessment guidelines during the first stage of labor are presented in Table 16-1
and Box 16-4.

Box 16-4   Nursing Assessments in First-Stage Labor

Latent Phase

• Perform every 30 to 60 minutes: maternal blood pressure, pulse, respirations.

• Perform every 30 to 60 minutes, depending on risk status: fetal heart rate (FHR) and pattern, uterine activity,
vaginal show.

• Assess temperature every 4 hours until membranes rupture and then every 2 hours.

• Perform vaginal examination as needed to identify progress.

• Observe every 30 minutes: changes in maternal appearance, mood, affect, energy level, and condition of
partner/coach.