Nursing care of a family during Labor and Birth

Theories of Labor Onset

Labor normally begins when a fetus is sufficiently mature to cope w/ extrauterine life.
Progesterone withdrawal is the trigger that stimulates labor.
In some, labor begins before a fetus is mature ; delayed until fetus and placenta passed beyond the optimal point for birth.
Why progesterone withdrawal begins:

Uterine muscle stretching

Results in release of prostaglandins

Pressure on the cervix

Stimulates the release of Oxytocin form posterior pituitary

Oxytocin stimulation

Works together w/ prostaglandins to initiate contractions

Change in the ratio of estrogen

to progesterone

Increasing estrogen in relation to progesterone w/c is interpreted as progesterone withdrawal

Placental age

Rising fetal cortisol level

Reduces progesterone formation and increase prostaglandin formation

Fetal membrane production of

prostaglandins

Stimulates contraction

Triggers contractions at a set point

Signs of Labor
I. PRELIMINARY SIGNS OF LABOR

Lightening

Descent of the fetal presenting part into the pelvis

Gives a woman relief from the diaphragmatic pressure and shortness of breath

In primiparas:
Occurs 10 to 14 days before labor begins
Occurs early because of tight abdominal muscles
In multiparas :
Occurs on the day of labor or even after labor has begun
As the fetus sinks lower into the pelvis , woman may experience:
Leg pains from the increased pressure on her sciatic nerve
Increased amount of vaginal discharge
Urinary frequency from pressure on her bladder
Increase in level of activity

It is related to an increase in epinephrine initiated by a decrease in progesterone

The additional epinephrine prepares a womans body for the work of labor ahead

Slight loss of weight

As progesterone level falls, body fluid is more easily excreted from body
Increase in urine production can lead to a weight loss

Braxton hicks contraction

False contractions that simulate true labor

Woman usually notices extremely strong Braxton hicks contraction in the last week or days before labor begins.

Ripening of cervix

Throughout pregnancy, cervix feels softer than usual (Goodells sign)

At term, cervix become still softer (butter-soft)

II. SIGNS OF TRUE LABOR

Uterine contractions

The surest sign that labor has begun is productive uterine contractions

Show

As the cervix softens and ripens, the mucus plug or operculum that filled the cervical canal is expelled
Exposed cervical capillaries seep blood as a result of pressure exerted by the fetus
This blood mixed w/ mucus (bloody show)

Rupture of the membranes

Experienced either as a sudden gush or as scanty , slow seeping of clear fluid from vagina
2 risks :
o Intrauterine infection
o Prolapsed umbilical cord w/c could cut off O2 supply to the fetus

Components of Labor
A successful labor depends on 4 integrated concepts:
1. A womans pelvis (passage) is of adequate size and contour.
2. The fetus (passenger) is of appropriate size and in an advantageous position and presentation.
3. The uterine factors (powers of labor) are adequate . This is influenced by womans position during labor.
4. Womans psychological outlook is preserved, so that afterward labor can be viewed as a positive experience.
I. PASSAGE
Route a fetus must travel from the uterus through cervix and vagina to the external perineum.
Because cervix and vagina are contained inside the pelvis, a fetus must also pass through the pelvic ring.
2 pelvic measurements (to determine the adequacy of pelvic size):

Diagonal conjugate

The anteroposterior diameter of the inlet.

Transverse diameter

At the inlet
Anteroposterior diameter is the narrowest diameter
At the outlet
Transverse diameter is the narrowest
If a disproportion bet. fetus and pelvis occurs
The pelvis is the structure at fault.
If fetus is the cause of disproportion
Often because the fetal head is presented to the birth canal at less than its narrowest diameter, not
because the fetus is actually too large.

II. PASSENGER
STRUCTURE OF FETAL SKULL
Cranium Uppermost of skull consist of 8 bones:

4 superior bones:

Presenting parts in childbirth

Other 4 bones:

Frontal (2 fused bones)

Parietal
Occipital

Lie at the base of cranium

Sphenoid
Ethmoid
Temporal bones (2)

Suture Lines
- Bones of the skull meet at suture lines
- Important in birth because, as membranous interspaces, they allow the cranial bones to move and overlap, molding or diminishing size of skull so that it can pass
through birth canal more readily.

Sagittal suture

Joins 2 parietal bones.

Coronal suture

Line of juncture of frontal bones and 2 parietal bones.

Lambdoid suture

Line of juncture of occipital bone and 2 parietal bones.

Fontanelles
Membrane-covered spaces found at the junction of main suture lines.

Anterior
fontanelle

Sometimes referred to as bregma

Lies at the junction of coronal and sagittal sutures.
Diamond shape because it consists of 4 bones (2 fused frontal bones, 2 parietal bones)
Anteroposterior diameter : 3 to 4 cm
Transverse diameter : 2 to 3 cm
Closes when infant is 12 to 18 months of age.

Posterior fontanelle

Lies at the junction of lambdoidal and sagittal sutures.

Triangular shaped because it involves 3 bones (2 parietal bones, occipital bone)
Smaller than anterior fontanelle measuring app. 2 cm across its widest part.
Closes when an infant is about 2 mos.

FOntanelle spaces
- Compress during birth to aid in molding of fetal head.

Vertex

Space bet. 2 fontanelles

Sinciput

Area over frontal bone

Occiput

Area over occipital bone

DIAMETERS OF FETAL SKULL

To best fit through the birth canal, a fetus must present the smallest diameter (transverse diameter) to the smaller diameter of maternal pelvis.
Diameter of Anteroposterior fetal skull

Suboccipitobregmatic diameter

From inferior aspect of occiput to the center of anterior fontanelle.

9.25 cm

Occipitofrontal diameter

From occipital prominence to the bridge of nose

12 cm

Occipitomental diameter

From posterior fontanelle to the chin.

13.5 cm

At the pelvic inlet

Anteroposterior diameter of pelvis is 11 cm wide so a fetus must present:

Biparietal diameter
Narrowest fetal head diameter
9.25 cm

At the pelvic outlet

Fetus must rotate to present the narrowest fetal head diameter to maternal transverse diameter (11 cm)
If a fetus presents the anteroposterior diameter of skull ( a measurement wider than biparietal diameter) to the
anteroposterior diameter of inlet, engagement may not occur
If fetus does not rotate so the anteroposterior diameter of skull is presented to the transverse diameter of outlet ,
arrest of progress may occur.

MOLDING
Change in the shape of fetal skull produced by the force of uterine contractions pressing the vertex of head against the not-yet dilated cervix.
Pressure causes the not yet completely ossified bones of fetus to overlap and mold the head into a narrower and longer shape, a shape that facilitates
passage through pelvis.
Overlapping of sagittal suture line and gen. the coronal suture line can be easily palpated in the newborn skull.
Not a permanent condition.
FETAL PRESENTATION and POSITION
Attitude
Degree of flexion ; Relation of fetal parts to each other.

Complete flexion

Spinal column is bowed forward

Head is flexed forward so much that the chin touches the sternum
Arms are flexed and folded on chest
Thighs are flexed onto abdomen
Helps present the smallest anteroposterior diameter of skull to the pelvis; puts the body into an ovoid shape occupying
The smallest space possible

Moderate flexion

Chin is not touching the chest

It is in military position
Causes the next-widest anteroposterior diameter (occipital frontal diameter) to present to birth canal

Brow

Partial extension

Face presentation

Complete extension
Back is arched , neck is extended
Presenting the occipitomental diameter to birth canal.
May occur if there is less than the normal amount of amniotic fluid present w/c does not allow fetus adequate movement.

Engagement
Settling of the presenting part of a fetus far enough into the pelvis to be at the level of ischial spines (midpoint of pelvis)
Descent at this point means that the widest part of the fetus (biparietal diameter in cephalic presentation; intertrochanteric diameter in breech position) has
passed through pelvis inlet or the pelvic inlet has been proved adequate for birth.

In primipara

In multiparas

Nonengagement of head at the beginning of labor indicates possible complications

Engagement may or may not be present at the beginning of labor.

Floating

Presenting part that is not engaged

Dipping

One that is descending but has not yet reached the ischial spines.

Station
Relationship of the presenting part of fetus to the level of ischial spines.

0 station

Presenting part is at the level of ischial spines

Minus stations (-1 to -4)

Above the spines

Plus stations (+1 to +4)

Below the ischial spines

Fetal Lie
Relationship bet. long axis (Cephalocaudal ) of fetal body and long axis (Cephalocaudal) of woman body.
Whether a fetus is lying in horizontal (transverse) or in vertical (longitudinal) position.
TYPES OF FETAL PRESENTATION
Denotes body part that will first contact the cervix or be born first.
Determined by combination of fetal lie and Attitude.

Cephalic presentation

Fetal head is the body part that will first contact the cervix.
4 types: vertex, brow, face, mentum
Vertex is the ideal presenting part because the skull bones are capable of effectively molding to
accommodate cervix. This may aid in cervical dilatation and prevents prolapsed cord (a portion of cord passing bet.
presenting part and cervix and entering vagina before fetus )
Caput succedaneum
During labor , the area of fetal skull that contacts the cervix often becomes edematous from continued
pressure against it

Breech presentation

Either the buttocks or feet are the first body parts that will contact the cervix.
3 types: complete, frank, footling
Affected by Fetal attitude :
o A good attitude - brings the fetal knees up against fetal abdomen
o A Poor attitude - fetal knees are extended

Shoulder presentation

Transverse Lie in w/c fetus lies horizontally

Presenting part is usually one of the shoulder, an iliac crest, a hand or elbow.
Causes:
o Relaxed abdominal walls from grand multiparity w/c allow unsupported uterus to fall forward.
o Pelvic contraction in w/c horizontal space is greater than vertical space.
o Placenta previa in w/c the placenta is located low in uterus obscuring some of vertical space resulting in
a limited ability of fetus to turn.
In transverse lie, contour of abdomen at term is distorted or is fuller side to side rather than top to bottom.
Fetus in such condition must be born by cesarean birth

TYPES OF FETAL POSITION

Relationship of the presenting part to a specific quadrant of a womans pelvis.
4 quadrant of Maternal pelvis:
1. Right and Left Anterior
2. Right and Left posterior

4 parts of a fetus have been chosen as landmarks to describe relationship of presenting part to one of pelvic quadrant:

Vertex presentation

Occiput is the chosen point

Face presentation

Chin

Breech presentation

Sacrum

Shoulder presentation

Scapula or Acromnion process

Position is indicated by an abbreviation of 3 letters:

First letter

R Right
L Left

Middle
letter

O Occiput
M Mentum or chin
Sa Sacrum
A Acromnion process

Last letter

A Anteriorly
P Posteriorly
T Transversely

LOA Left occipitoanterior ; common fetal position

ROP Right occipitoposterior ; 2nd most frequent

Fetus is born fastest from an ROA or LOA position; extended if the position is ROP or LOP.
Posterior positions may be more painful for a woman because the rotation of fetal head puts pressure on sacral nerves causing sharp back pain.
Encouraging woman to rest in Sims position may encourage rotation from an occipitoposterior to an occipitoanterior position
MECHANISMS (CARDINAL MOVEMENTS) OF LABOR
Cardinal Movements
Position changes to keep smallest diameter of the fetal head always presenting to the smallest diameter of pelvis.

Descent

Downward movement of the biparietal diameter of the fetal head to within the pelvic inlet.
Occurs because of the pressure on fetus by uterine fundus.
Pressure of fetal head on sacral nerves at pelvic floor causes the mother to experience a pushing sensation.
Full descent occurs when the fetal head extrudes beyond the dilated cervix and touches the posterior vaginal floor.

Flexion

Head bends forward onto the chest, making the smallest anteroposterior diameter present to the birth canal.

Internal Rotation

Head flexes as it touches the pelvic floor and the occiput rotates to bring the head into the best relationship to the oulet of
pelvis. (Anteroposterior diameter is now in the anteroposterior plane of pelvis)
This movement brings the shoulders, coming next into optimal position to enter inlet, putting the widest diameter of
shoulders (a transverse one) in line w/ the wide transverse diameter of inlet.

Extension

As the occiput is born, the back of the necks stops beneath the pubic arch and acts as a pivot for the rest of head.
Head extends and the foremost parts of head, face, chin are born

External rotation

Almost immediately after the head is born, the head rotates back to the diagonal or transverse position of the early part of
labor.
This brings the aftercoming shoulders into an anteroposterior position w/c is best for entering the outlet.

Expulsion

Once the shoulders are born, the rest of the baby is born easily and smoothly because of its smaller size.
End of pelvic division of labor.

IMPORTANCE OF DETERMINING FETAL PRESENTATION AND POSITION

Help predict if the presentation of a body part other than vertex could be putting fetus at risk; If so labor is longer
because of the :
o Ineffective descent of the fetus
o Ineffective dilatation of cervix
o Irregular or weak uterine contraction

Longer labor may lead to :

o Early rupture of membrane
o Increasing possibility of infection
o Fetal anoxia
o Meconium staining

Cervical lacerations may occur if a fetus is born vaginally after a complicated labor.

4 methods used to determine fetal position, presentation and lie:

Combined abdominal inspection and palpation (Leopolds maneuvers)

Vaginal examination
Auscultation of fetal heart tones
Ultrasound

III. POWERS OF LABOR

Force supplied by the fundus of uterus implemented by uterine contractions.
A natural process that causes cervical dilatation and then expulsion of fetus from uterus.
After full dilatation of cervix, the primary power is supplemented by use of abdominal muscles.
Women should not bear down w/ their abdominal muscles until the cervix is fully dilated; doing so impedes the primary force and could cause fetal and cervical
damage.
UTERINE CONTRACTIONS
Origins

Labor contractions begin at a pacemaker point located in the uterine myometrium near one of the
uterotubal junctions.
Each contraction begins at that point and then sweeps down over the uterus as a wave.
In some women, contractions appear to originate in the lower uterine segment rather than in fundus;
These are ineffective contractions and may actually cause tightening rather than dilatation.
Some women seem to have additional pacemaker sites in other portions of uterus; If so this causes
uncoordinated contractions w/c may slow labor and fetal distress as they may not allow for adequate
placental filling.

Phases

Increment

Intensity of contraction increases

Acme

Contraction is at its strongest

Decrement

Intensity decreases

Between contractions

Uterus relaxes

As labor progresses

Relaxation intervals decrease from 10 min. early in labor to 2 to 3 min.

Duration increasing from 20 to 30 sec. to a range of 60 to 90 sec.

Contour changes
- As labor contractions progress and become regular and strong, uterus gradually differentiates itself into 2 distinct functioning areas:

Upper portion

Thicker and active , preparing it to be able to exert the strength necessary to expel the
fetus when the expulsion phase of labor is reached.

Lower portion

Thin walled, supple, and passive so that the fetus can be easily pushed out of the uterus.

Physiologic retraction ring

The boundary bet. the 2 portion of uterus becomes marked by a ridge on the
inner uterine surface

Pathologic retraction ring

Bandls ring ; the normal physiologic retraction ring may become prominent and
observable as an abdominal indentation.
Danger sign signifies impending rupture of lower segment if obstruction to
labor is not relieved.

Contour of uterus changes from round to an elongated one whose vertical diameter is markedly greater than its horizontal diameter:
This serves to straighten the body of fetus, placing it in better alignment w/ cervix and pelvis.
Elongation of uterus exerts pressure against the diaphragm. (Uterus is taking control of a womans body)

CERVICAL CHANGES

Effacement

Shortening and thinning of cervical canal.

Normally, it is 1-2 cm. ; With effacement, it disappears.
Occurs because of longitudinal traction from the contracting uterine fundus.

In primiparas:

It is accomplished before dilatation begins.

Dilatation will progress rapidly after the completion of effacement.

In multiparas:

Dilatation may proceed before effacement is complete.

Effacement must occur at the end of dilatation otherwise, cervical tearing could result.

Dilatation

Enlargement or widening of cervical canal (app.10 cm) to permit passage of fetus.

As begins, there is an increase in the amount of vaginal secretions or show because the last of the
operculum is dislodged and minute capillaries in the cervix rupture.
Occur for 2 reasons:
o Uterine contractions gradually increase the diameter of cervical canal lumen by pulling the cervix up
over the presenting part of fetus.
o Fluid-filled membranes press against the cervix.

IV. PSYCHE
Psychological state or feelings that a woman brings into labor
- Women who manage best in labor typically are those who have strong sense of self-esteem and a meaningful support person w/ them

Stages of Labor
I. 1ST STAGE
- Initiation of true labor contractions and ends when the cervix is fully dilated

Latent Phase/
Preparatory phase

Active Phase

Transition Phase

Begins at the onset of regularly perceived uterine contractions and ends when rapid cervical dilatation
begins
Contractions : 20 to 40 sec.
Cervical effacement occurs ; Cervix dilates from 0 to 3 cm
Lasts app. 6 hrs in nullipara , 4.5 hrs in multipara
A woman who enters labor w/ a nonripe cervix will have a longer than usual latent phase
Analgesia given too early may prolong this phase
Measuring the length of the latent phase is important because a reason for a prolonged latent phase is
CPD that could require a CS birth
A woman can (and should) continue to walk about and make preparations for birth
In a birth setting, allow woman to continue to be active , encourage her to continue or begin alternative
methods of pain relief

Cervical dilatation : 4 to 7 cm
Contractions : 40 to 60 sec every 3 to 5 min.
Lasts app. 3 hrs in a nullipara and 2 hrs in a multipara
Show and Rupture of membranes may occur
Can be a difficult time for a woman because contractions grow strong , last longer and begin to cause
true discomfort

Contractions : Reach their peak of intensity , 60 to 90 sec every 2 to 3 min.

Maximum cervical dilatation
If membrane have not previously ruptured , they will rupture as a rule at full dilatation (10 cm)
By the end , both full dilatation (10 cm) and complete cervical effacement have occurred
A woman may experience intense discomfort , that it is accompanied by N/V
She may also experience a feeling of loss of control, anxiety, panic or irritability
Her focus is entirely inward on the task of birthing her baby

II. 2ND STAGE

- Extending from time of full dilatation and cervical effacement until the infant is born
- A woman feels uncontrollable urge to push w/ each contraction as if to move her bowels
- She may experience momentary N/V because pressure is no longer exerted on her stomach as the fetus descends into the pelvis
- She pushes w/ such force that she perspires and blood vessels in her neck may become distended
- As the fetal head touches/pushes against the perineum :
> Perineum begins to bulge and appears tense
> Anus may become everted
> Stool may be expelled
> Vaginal introitus opens and fetal scalp appears at the opening to the vagina
- The need to push becomes so intense that she cannot stop herself
- As she pushes using her abdominal muscles to aid the involuntary uterine contractions , fetus is pushed out of the birth canal
III. 3RD STAGE
- Placental stage
- Begins w/ the birth of the infant and ends w/ the delivery of the placenta
- After birth of an infant, a uterus can be palpated as a firm, round mass just inferior to the level of the umbilicus
- After a few min. of rest, uterine contractions begin again and the uterus assumes a discoid shape . It retains this new shape until the placenta has separated app.
5 min. after the birth of an infant
Placental separation
- Active bleeding on the maternal surface of placenta begins w/ separation , this bleeding helps to separate the placenta still farther by pushing it away from its
attachment site
- As separation is completed, the placenta sinks to the lower uterine segment or the upper vagina

Signs that may indicate placenta has loosened and is ready to deliver :
Lengthening of the umbilical cord
Sudden gush of vaginal blood
Change in the shape of the uterus
Firm contraction of the uterus
Appearance of the placenta at the vaginal opening

Schultze presentation

If placenta separates first at its center and last at its edges

Presents at the vaginal opening w/ fetal surface evident
Appearing shiny and glistening from the fetal membranes

Duncan presentation

If placenta separates first at its edges

Presents at the vagina w/ maternal surface evident
Looks raw, red and irregular

Placental expulsion
- Placenta is delivered either by :
> Natural bearing down effort of the mother
> Gentle pressure on the contracted uterine fundus by a physician /nurse (Credes maneuver)
- If does not deliver spontaneously, can be removed manually
- Pressure must never be applied to a uterus in a noncontracted state because doing so may cause the uterus to evert and hemoorhage
IV. 4TH STAGE
- First 1 to 4 hours after birth of the placenta
Maternal and Fetal Responses to Labor
I. PHYSIOLOGIC EFFECTS OF LABOR ON A WOMAN

CARDIOVASCULAR
SYSTEM

Cardiac output
Each contraction greatly decreases blood flow to the uterus because the contracting uterine wall puts pressure on the
uterine arteries w/c then increases the amount of blood that remains in a womans gen. circulation = Increase in peripheral
resistance / Increase in systolic and diastolic BP
The work of pushing during labor = Increase cardiac output by as much 40 % to 50 % above prelabor level
Normal blood loss (vaginal birth) : 300-500 mL ; Women usually tolerate this loss well because the blood volume increases
during pregnancy by 1 to 2 L
Immediately after birth, w/ the weight and pressure removed from the pelvis, blood from the peripheral circulation floods
into the pelvic vasculature = Momentarily dropping BP in the vena cava but the body quickly compensates by sending a heavy
bolus of blood to the heart by about 80 % above prelabor levels
Decreases gradually within the first hr of birth by about 50 % ; An ave. womans heart adjusts well to these sudden changes
Blood Pressure
With the increased cardiac output caused by contraction = BP increase / Systolic : 15 mmHg w/ each contraction
When a woman lies in a supine position and pushes during 2 nd stage of labor = Pressure of uterus on the vena cava causes BP
to drop leading to hypotension
AN upright or side-lying position during labor not only makes pushing more effective but also can help avoid hypotension

WBC increase : 25,000-30,000 cells/mm3 (normal 5,000 to 10,000 cells/mm3 ) Result of stress and heavy exertion
Clotting factors increase w/c provides protection from hemorrhage but also increases mothers risk for a venous
thrombosis during pregnancy and after birth

Total oxygen consumption increases by about 100 % during the 2nd stage of labor w/c can result in hyperventilation
Using app. breathing patterns during labor can help avoid severe hyperventilation

TEMPERATURE

Slight elevation due to Increased muscular activity

Diaphoresis occurs

FLUID BALANCE

Insensible water loss increase during labor due to:

Increase in rate and depth of respiration (causes moisture to be lost w/ each breath)
Diaphoresis
Increased fluid losses and Decreased oral intake may make IVF replacement necessary

HEMATOPOIETIC
SYSTEM

RESPIRATORY SYSTEM

URINARY SYSTEM

MUSCOLOSKELETAL
SYSTEM

Reduced sensation of bladder due to :

o Intense contractions
o Effects of regional anesthesia
o Pressure of the fetal head as it descends in the birth canal against the anterior bladder

Specific gravity may rise to a high normal level of 1.020 to 1.030

Not unusual protein trace (1+) because of breakdown of protein caused by increased muscle activity
Normal hypervolemia of pregnancy is reversed during the first 5 days postpartum ; Large quantities of urine are excreted

Week before labor : Addtl softening causes the symphysis pubis and sacral/coccyx joints to become even more relaxed and
movable
Woman may report the said increased pubic flexibility as increased back pain and nagging pain at the pubis as she walks or
turns in labor

GI SYSTEM

NEUROLOGIC AND
SENSORY RESPONSES

Becomes inactive during labor probably because of:

o The shunting of blood to more life-sustaining organs
o Pressure on the stomach and intestines from the contracting uterus
Gastric motility is reduced w/c can result in N/V
Most women are not hungry but are thirsty and have dry mouth
Solid food is withheld to prevent vomiting and aspiration of undigested food in the event that gen. anesthesia is required

Responses related to pain = Increased pulse and RR

Early in labor : Contraction of uterus and dilatation of cervix cause the discomfort
Pain is registered at uterine and cervical nerve plexuses (at the level of 11 th and 12th thoracic nerves)
Moment of birth : Pain is centered on the perineum
Perineal pain is registered at S2 to S4 nerves

Care of a woman during the first stage of Labor

1st STAGE of Labor
- Begins w/ beginning of uterine contractions ; Ends when cervix has reached full dilatation
Major concepts to make labor and birth as natural as possible :

Labor should begin on its own, not be artificially induced

Women should be able to move about freely throughout labor, not be confined to bed
Women should receive continuous support during labor
No interventions should be used routinely
Women should be allowed to assume a nonsupine position for birth
Mother and baby should be together after birth w/ unlimited opportunity for
breastfeeding

- Woman has to be reassured when they arrive at a birthing center that everything is going well
- For a woman who has been unable to manage pain by breathing exercise , pain relief may be her priority need
NURSING DIAGNOSIS
1. Powerlessness r/t duration of labor

Care includes :
o Helping woman feel confident in her ability to control pain and progress labor
o Maintaining physiologic stability

If a woman is not concentrating on controlled breathing exercises , contractions become biting in their
intensity
Give couples frequent progress reports during labor so they do not become discouraged or fearful
Women may be enduring so much pain and are under so much stress they do not hear or process
instructions well , reminding them that they have not processed information well is not therapeutic
because it can lower their self esteem and sense of self control
A woman needs to feel that she has some control over her situation during labor

o
o
o
o

Stating their preferences

Breathing w/ contractions
Changing positions to the one that makes them most comfortable
Expressing feelings in their own way

Respect contraction time

Once her concentration is disrupted , she will feel the extent of the contraction
Instead of interrupting, allow her to finish breathing w/ contraction

Promote change of positions

A woman may be out of bed or in whatever position she prefers

A woman whose membranes have ruptured should lie on her side , umbilical cord may prolapsed
into vagina if she walks
If medication is given , educate woman to remain in bed for app. 15 min. afterward to avoid a
fall if she should become dizzy in medication
While woman is in bed, encourage her to lie on her side , preferably on the left side .. allowing
free blood return from the lower extremities and adequate placental filling and circulation
A squatting position is very effective for birth because it helps align the fetal presenting part
w the cervix and uses the fetal weight to help bring about cervical dilatation

Promote Voiding and Provide

Bladder Care

A full bladder or bowel can impede fetal descent , encourage woman to void q 2 to 4 hrs
Remind woman to void during labor because she may mistakenly interpret the discomfort of a
full bladder as part of the sensations of labor
Assess for full bladder by percussion
o Empty bladder : Dull
o Full bladder : Resonant
If she cannot void , she may need to be catheterized
Catheterizing is uncomfortable for her and may be difficult for you , vulva is edematous from
pressure of fetal presenting part, stretching the urethral canal downward and making the
urethra difficult to locate

When catheterizing , use small catheter for best results and use aseptic technique to avoid
introducing any microbes that might result to UTI

2. Risk for ineffective breathing pattern r/t breathing exercises

Hyperventilation
Occurs when a woman exhales more deeply than she inhales
Extra CO2 is blown off and Respiratory alkalosis results
Can occur when woman is practicing breathing exercises
Most apt to occur during actual labor
Woman feels light-headed and may have tingling or numbness in her toes and
fingertips
If allowed to progress, may lead to coma
To halt, use a paper bag when doing breathing exercises
Be certain when a woman is breathing rapidly that she is not hyperventilating
Be certain that woman ends all breathing sessions w/ a long cleansing breath to
help restore CO2 balance

3. Anxiety r/t stress of labor

Labor is such an intense process that it creates a high level of emotional stress for both
woman and support person
Ability to tolerate stress depends on :
o Persons perception of the event
o Support people available
o Past experience
Ways to reduce stress :
o Helping woman perceive labor clearly
o Provide support

Offer Support

Respect and Promote

support person

Patting a womans arm while telling her that she is progressing in labor
Brushing a wisp of hair off her forehead
Wiping her forehead w/ a cool cloth

Admit a womans support person to the birthing area and allow him or her to remain w/ the
woman throughout the birth
Be sure that all healthcare personnel are aware of who the support person is and make or
her feel welcome

4. Risk for fluid volume deficit r/t prolonged lack of oral intake and diaphoresis from effort of labor

Most women enjoy ice chips, popsicles, or lollipops to provide source of fluid
Women in prolonged labor may need isotonic sports drinks to prevent secondary uterine
inertia ( a cessation of labor contractions) , generalized hydration and exhaustion

Amniotomy
- Artificial rupturing of membranes
- Allows fetal head to contact the cervix more directly
- A womans cervix must be dilated at least 3 cm ; Placed in a dorsal recumbent position
- An amniohook or a hemostat is passed vaginally , membranes are torn and amniotic fluid is allowed to escape
- There is a risk for a Cord prolapsed
- Always measure FHR immediately after the rupture

Care of a woman during second stage of Labor

2ND STAGE OF LABOR
- From full cervical dilatation to birth of newborn

The feeling of push so strong, some women react to this change in contractions by growing increasingly argumentative and
angry or by crying and screaming
Other women react by tensing their abdominal muscles and trying to resist , making the sensation even more painful and
frightening
Holding the breath for a prolonged time impairs blood return from the vena cava (Valsalva maneuver)
Encourage women to assume any position w/c is comfortable for them and breathe any way that is natural for them except
holding their breath
Women need to have an experienced health care person w/ them to reassure them that the change in contractions is normal
and to give knowledgeable support that everything is all right
Assess FHR to be certain that the start of babys passage into the birth canal is not occluding the cord
Prolonged 2nd stage is associated w/ chorioamniotis (uterine infection) and an increased rate of cesarean birth

I. PREPARING PLACE OF BIRTH

Table set

sponges
drapes
scissors
basins
clamps
bulb syringe
vaginal packing
sterile gowns
gloves
towels

For Baby care :

radiant heat warmer

equipment for suction and resuscitation
supplies for eye care
identification of the newborn

II. POSITIONING FOR BIRTH

Women can choose variety of positions for birth

Lithotomy was the major position for birth
Alternative birth positions :
o Lateral/Sims position
o Dorsal recumbent position
o Semi-sitting position
o Squatting
The above positions place less tension on the perineum resulting in fewer perineal tears
If physician prefers lithotomy
o Position the woman into the bed stirrups while physician is scrubbing and donning sterile mask, gown, and gloves
o Raise both womans legs at the same time to prevent strain on her back and lower abdominal muscles
o To prevent Thrombophlebitis , be certain that there is no pressure on her calves
o Pushing becomes less effective in this position , the top portion of the table should be raised to a 30-60 degree angle
o Lying for longer than 1 hr in this position leads to intense pelvic congestion because blood flow to the lower extremities is
impeded
o Pelvic congestion may lead to an increase in Thrombophlebitis in the postpartal period , may also contribute to Excessive
blood loss w/ birth and Placental loosening
o Place the womans legs in this position only at the last moment
o Make sure there is always someone at the foot of a broken birthing bed so that if birth should occur precipitously , infant
will not fall and be injured
Lithotomy provides the best position for :
o Performing an episiotomy or a forceps-assisted birth
o Viewing the perineum to detect lacerations or other problems at birth

III. PROMOTING EFFECTIVE SECOND STAGE PUSHING

For the most effective pushing , woman should wait to feel the urge to push even though she is fully
dilated
She should push w/ contractions and rest bet. them
Pushing is usually best done from a semi-Fowlers , squatting or all-fours position rather than lying flat to
allow gravity to aid the effort
A woman can use short pushes or long , sustained ones w/c ever are more comfortable
Holding breath during contraction could cause a Valsalva maneuver or temporarily impede blood return to
the heart because of increased intrathoracic pressure
Urge her to breathe out during a pushing effort
In multipara, to keep 2nd stage from moving too fast, it may be necessary to prevent the woman from
pushing .. ask her to pant w/ contractions, this limits pushing
Be sure she is inhaling adequately , otherwise she might hyperventilate and become lightheaded while
panting

IV. PERINEAL CLEANING

> TO remove vaginal or rectal secretions

> Prepare the cleanest environment for the birth of baby

Clean the perineum w/ a warmed antiseptic ; A cold solution causes cramping

Always clean the vagina outward using a clean compress for each stroke
Include wide areas : vulva, upper inner thighs , pubis, anus
As the woman pushes , the pressure of the fetal head on the bowel may cause a fecal
material to be expelled from the rectum , this will be removed to prevent contamination
of birth canal

V. EPISIOTOMY

A surgical incision of the perineum

o To prevent tearing of the perineum
o To release pressure on the fetal head
o May shorten the last portion of the 2 nd stage of labor
Midline episiotomy (midline of the perineum)
o Heal more easily
o Cause less blood loss
o Less postpartal discomfort
Mediolateral episiotomy (directed laterally away from the rectum)
Anal sphincter tears can lead to fecal incontinence later in life
The pressure of the fetal presenting part against the perineum is so intense that the
nerve endings in the perineum are momentarily deadened , this lack of sensation allows an
episiotomy to be done w/o anesthesia
For some, a pudendal block may be done to ensure that there is no pain , lidocaine is
injected via a long needle through the vaginal wall near the iscial spine , numbing the lower
vaginal area and the perineum
At the time of episiotomy, there is a slight loss of blood but the pressure of the
presenting part immediately seals the cut edges and minimizes bleeding

VI, BIRTH

Ritgen Maneuver
o Physician place a sterile towel over the rectum and press forward on the fetal chin while the other hand is pressed downward
the occiput
o Helps fetus achieve extension
Pressure should never be applied to the fundus of uterus to effect birth , uterine rupture could occur
Woman is asked to continue pushing until the occiput of the fetal head is firmly at the pubic arch
Head is born bet. contractions
o Helps prevent the head from being expelled too rapidly
o Helps avoid perineal tears
o Helps avoid rapid change in pressure in infants head w/c could rupture cerebral blood vessels

Woman may be asked to pant deliberately so that she does not push during a contraction
She may be asked to push again w/o contraction present to deliver the shoulders
A woman who has not had anesthesia experiences birth of the head as a flash of pain or a burning sensation
Immediately after birth of the babys head , physician suctions the infants mouth w/ a bulb syringe and then passes his or her
fingers along the occiput to the newborns neck to determine whether a loop of umbilical cord is encircling the neck (nuchal cord)
If loop is felt, it is gently loosened and drawn down over the fetal head
If loop is tightly coiled, it is clamped and cut before the shoulders are born
After expulsion of infants head , external rotation occurs
o Gentle pressure is exerted downward on the side of the infants head and anterior shoulder is born
o Slight upward pressure on the side of the head allows anterior shoulder to nestle against symphysis as the posterior shoulder
is born
Remainder of the body slides w/o difficulty
Child is considered born when the whole body is born
Nursing responsibility is to note and record the time of birth

VII. CUTTING AND CLAMPING OF THE CORD

Infant is then laid on the abdominal drape of the mother while the cord is cut
Cord continues to pulsate for a few min. after birth and then pulsation ceases
Delaying cutting cord until pulsation ceases and maintaining the infant at a uterine level allows as much as 100 mL of bloof
to pass from the placenta into fetus
o Helps ensure an adequate RBC in the newborn
o But could cause overinfusion w/ placental blood and possibility of polycythemia and hyperbilirubinemia
Timing of cord clamping varies depending on:
o Physicians preference
o Maturity of infant
Cord is clamped w/ 2 Kelly hemostats placed 8 to 10 inches from the infants umbilicus and then is cut bet. them
Cutting the cord is part of the stimulus that initiates a first breath

VIII. INTRODUCING THE INFANT

Wrap the infant in a sterile blanket

Be sure to hold newborn firmly because they are covered w/ slippery amniotic fluid and vernix
Lay infant on a radiant warmer , dry him or her well w/ a warmed towel
Rewrap the infant snugly and cover the head w/ a wrapped towel or cap
DO not administer prophylactic eye ointment to the infant until after the parents have had the chance to see their
infant
If woman wishes to breastfeed , this is an optimal time to begin
AN infant sucking at the breast stimulates release of endogenous oxytocin , encouraging uterine contraction and
involution

Care of a woman during third and fourth stage of Labor

3rd STAGE OF LABOR
- From birth of the baby until the placenta is delivered
4th STAGE OF LABOR
- First few hrs after birth
I. PLACENTA DELIVERY

If placenta does not deliver spontaneously :

o Physician will ask the mother to bear down gently
o Apply gentle pressure on the contracted uterine fundus
o Gentle traction of the umbilical cord
o Can be removed manually (to limit amt. of postpartum bleeding)
After delivery, placenta is inspected to be certain that it is intact, normal in appearance and weight

II. OXYTOCIN

Once the placenta is delivered, Oxytocin is ordered to be administered IM or IV

Increases uterine contractions and thereby minimizes uterine bleeding
Given as 10 U /L
Carboprost tromethamine (Hemabate) may be administered if woman has excess bleeding w/ poor uterine
contraction
Do not administer until the physician indicates it is appropriate
Causes hypertension by vasoconstriction , obtain baseline BP measurement before administration

III. PERINEAL REPAIR

After delivery of placenta, if an episiotomy was performed , woman needs perineal stitches put into place
Can be a tedious one from mothers perspective
It is important to be sensitive to the mothers needs at this time
A woman who gave birth w/o anesthesia will still have so much natural pressure anesthesia of the
perineum that she will not require an anesthetic
In actuality ,BY the time placenta is delivered (app. 5 min) enough sensation has returned to the perineum
that woman will probably need some type of medication for comfort
Women who received regional anesthetic during labor (e.g. pudendal block) and those who have had
epidural anesthesia will probably not need addtnl medication during repair

IV. IMMEDIATE POSTPARTUM ASSESSMENT AND NURSING CARE

Following placenta delivery, lower both of a womans legs from stirrups , at the same time to prevent back
injury
Obtain V/S q 15 min
o BP (slightly elevated)
o P (80-90bpm)
o RR (20-24 rpm)
Woman experiences chill and shaking sensation 10-15 min. after birth (transitory sensation) , d/t
o Low temp. of birthing room
o Sudden release of pressure on pelvic nerves
o Excess epinephrine production

Palpate womans fundus for size, consistency , and position

Observe the amt and characteristics of lochia
Perform perineal care and apply perineal pad

V. AFTERCARE

Uterus may be so exhausted from labor that it cannot maintain contraction, there is
high risk of hemorrhage during this time
Woman often is so exhausted that she may be unable to assess her own condition or
report any changes

Unique Concerns of a woman in labor

I. A WOMAN W/O SUPPORT PERSON

A woman who has no support person needs a supportive nurse to be w/ her

A woman whose acceptance of her pregnancy was slow to develop may call for
increased assessment of parent-child bonding in immediate postpartal period

II. A WOMAN WHO WILL BE PLACING HER BABY FOR ADOPTION

This decision may have seemed easy to make during pregnancy, but once she holds the baby in her
arms .. the prospect of giving up the child may be more painful than she realized
Be certain you do not offer influencing advice because the woman is the only person who knows
whether keeping this child is right for her

III. VBAC

Women w/ low transverse uterine incision on their previous CS birth are usually candidates
for vaginal birth w/ their next pregnancy
Length of labor for VBAC is usually comparable to that of primiparas because it is the first
vaginal birth
Keep woman well informed and urge her to breathe w/ contractions
Women having VBAC usually have external electronic monitoring because of the risk for
uterine rupture