Management of

Discomfort
Chapter 19

Nonpharmacologic Strategies

Cutaneous Stimulation Strategies

Counterpressure *
Effleurage (light massage) *
Therapeutic touch & massage *
Walking *
Rocking *
Changing positions *
Application of heat or cold *
Transcutaneous electrical nerve stimulation
Acupressure
Water therapy (hydrotherapy)
Intradermal water block

Nonpharmacologic Strategies
Sensory

Stimulation Strategies

Aromatherapy
Breathing techniques *
Music *
Imagery *
Use of focal points *

Nonpharmacologic Strategies
Cognitive

Strategies

Childbirth education *
Hypnosis
Biofeedback

First Stage of Labor

Systemic

analgesia

Opioid agonist analgesics

Opioid agonist-antagonist analgesics, codrugs
Epidural

(block) analgesia
Combined spinal epidural (CSE)
analgesia
Paracervical block (rarely used)
Nitrous oxide

Second Stage of Labor

Nerve

block analgesia / anesthesia

Local infiltration anesthesia

Pudendal block
Spinal (block) anesthesia
Epidural (block) analgesia
Combined spinal-epidural (CSE) analgesia
Nitrous

oxide

Vaginal Birth
Local

infiltration anesthesia
Pudental block
Epidural (block) analgesia / anesthesia
Spinal (block) anesthesia
Combined spinal epidural (CSE)
analgesia / anesthesia
Nitrous oxide

Cesarean Birth
Spinal

(block) anesthesia
Epidural (block) anesthesia
General anesthesia

Nsg. Assessments (Fetal)

Prior

to med administration:

FHR within normal range (no late decels or

nonreassuring patterns).
Average long term variability.
Present short term variability (with spiral
electrode).
Normal fetal movements.
Accels with fetal movement.
Term fetus. (EDC)

Nsg. Assessments (Maternal)

Prior

to med administration:

Term pregnancy (EDC).

Evaluation of cervical dilation.
Evaluation of contraction pattern.
Evaluation of maternal comfort.
Med allergies.
Empty bladder.

Nsg. Assessments (Additional)

Prior

to med administration:

A well established contraction pattern.

Fetal presenting part is engaged.
Cervix dilated.
Delivery should be anticipated but not
imminent.

Concerns: Regional Anesthesia

Maternal

hypotension, and subsequent

fetal distress. *
Adverse maternal reactions. (can range
from palpitations to complete
cardiovascular collapse).
Uteroplacental insufficiency.
Frequent monitoring of maternal vital
signs & FHR are needed!

Fetal Assessment
During Labor
Chapter 20

Assessment for Genetic

Disorders

Chapter 22

Maternal age
Ethnic background
Family history
Reproductive history
Maternal disease
Environmental hazards

Strategies in Health Education

and Counseling

Chapter 22

Frame teaching to match the clients

perception
Fully inform clients of the purpose and
expected effects
Be specific
Use a combination of strategies
Involve others
Refer
Monitor progress through follow-up
contacts

BIOPHYSICAL PROFILE
(BPP)
A noninvasive

assessment of the fetus

and its environment by U/S, noting
normal and abnormal biophysical
responses to stimuli.
A normal BPP indicates that the CNS is
functional and the fetus is not
hypoxemic.
A scoring system, of 5 variables, with a
total score up to 10.

Biophysical Profile Variables

Chapter 22

Fetal breathing movements

Gross body movement
Fetal tone
Amniotic fluid volume index
Non-stress test

BPP: VARIABLES & SCORES

FETAL BREATHING MOVEMENTS:
>1 episode in 30 min, each > 30
seconds. (normal score = 2)
Episodes absent or no episode > 30
sec in 30 min. (abnormal = 0)
GROSS BODY MOVEMENTS:
>3 discrete body or limb movements in
30 min. (normal = 2)
< 3 episodes of body or limb movement
in 30 min. (abnormal =0)

FETAL TONE:
> episodes of active extgension
with return to flexion of fetal limb(s)
or trunk, opening & closing hand
being considered normal tone.
(normal =2)
Slow extension with return to
flexion, movement of limb in full
extension, or fetal movement
absent. (abnormal = 0)

REACTIVE FETAL HEART RATE:

> 2 episodes of acceleration (>15
bpm) in 20 min, each lasting > 15
sec. & associated with fetal
movement. (normal = 2)
< 2 episodes of acdceleration or
acceleration of < 15 bpm in 20 min.
(abnormal = 0)

QUALITATIVE AMNIOTIC FLUID

VOLUME:
> 1 pockets of fluid measuring >1
cm in 2 perpendicular planes.
(normal =2)
Pockets absent or poscet < 1 cm in
2 perpendicular planes. (abnormal
= 0)

Interpretation of BPP Scores:

Normal

= 8-10 (if Amniotic fluid index is

adequate)
Equivocal = 6
Abnormal = <4

Documentation of a
Contraction Stress Test
Negative: No late decelerations with 3
adequate uterine contractions in a 10minute window, normal baseline FHR
and accelerations with fetal movement.
Positive: Late decelerations occur with
more than half the uterine contractions.
Chapter 22

Documentation of a
Contraction Stress Test (cont.)
Suspicious: Late decelerations occur
with less than half the uterine
contractions.
Unsatisfactory: Inadequate fetal heart
rate recording or less than 3 uterine
contractions in 10 minutes.
Chapter 22

Indications for the NST

Chapter 22

Suspected post-maturity
Maternal diabetes
Maternal hypertension: chronic and
pregnancy-related disorders
Suspected or documented IUGR
History of previous stillbirth
Isoimmunization

Indications for the NST (cont.)

Chapter 22

Older gravida
Decreasing fetal movement
Sever maternal anemia
Multiple gestation
High-risk antepartal conditions: PROM,
PTL, bleeding
Chronic renal diseases

Electronic Fetal Monitoring

External:

ultrasound transducer

Internal:

spiral electrode

Ultrasound Transducer
High-frequency

sound waves reflect

mechanical action (fetal heart tone &
valves) of the fetal heart.
Noninvasive. (Does NOT require
rupture of membranes or cervical
dilation)
Used in both antepartum and
intrapartum period.
Short-term variability and beat-to-beat
changes in the FHR cannot be
assessed accurately by this method.

Spiral Electrode
Applied

to the fetal presenting part to

assess the FHR.
Converts the fetal ECG as obtained
from the presenting part to the FHR via
a cardiotachometer.
Used ONLY when membranes are
ruptured & cervix is sufficiently dilated.
Short-term variability CAN be assessed
using this method.

FHR Variability
Increased

Variability: marked variability

from a previous average variability.
Causes: early mild hypoxia; fetal
stimulation (uterine palpation, contractions,
fetal activity; maternal activity; illicit drugs).
Significance: unknown.
Nsg.Intervention: observe for any
nonreassuring patterns; if using external
fetal monitoring consider an internal mode
for a more accurate tracing.

FHR Variability
Decreased

Variability: marked
decrease in variability from a previous
average variability.
Causes: hypoxia / acidosis; CNS
depressants; analgesics / narcotics;
barbiturates; tranquilizers, anaractics;
parasympatholytics; general anesthetics;
prematurity (<24 wks); fetal sleep cycles;
congenital abnormalities; fetal cardiac
dysrhythmias.

FHR Variability
Decreased

Variability (continued):

Significance: benign when associated with

fetal sleep cycles; if drugs, variability
usually increases as drugs are excreted;
when associated with uncorrectable late
decelerations indicates presence of fetal
acidosis and can result in low APGARs.
Nsg.Interventions: none, if fetal sleep
cycle, or CNS depressants; consider fetal
scalp stimulation or apply a spiral
electrode; monitor fetal oxygen saturation;
prepare for birth if indicated.

Other DEFINITIONS
Tachycardia:

a baseline FHR >160

bpm for a duration of 10 minutes or
longer.
Bradycardia: a baseline FHR <110 bpm
for a duration of 10 minutes or longer.

FHR Changes
Accelerations
Decelerations

Early
Late
Variable
Prolonged

Baseline FHR
Definition:

the average rate during a 10

minute period that excludes periodic or
episodic changes, periods of marked
variability, and segments of the baseline
that differ by more than 25 bpm.
Range: 110-160 bpm.

Accelerations
Definition:

A visually apparent abrupt

increase in FHR above the baseline
rate.
An increase of 15 bpm and lasting 15
seconds or more, with the return to
baseline less than 2 minutes from the
beginning of the acceleration.
Can be periodic or episodic.

Early Decelerations
Definition:

a transitory gradual
decrease and return to baseline FHR in
response to fetal head compression.
Generally starts before the peak of the
uterine contractions.
Returns to the baseline at the same
time as the contraction returns to its
baseline.
Considered benign. No interventions.

Late Decelerations

Definition: a transitory gradual decrease in

and return to baseline of FHR associated with
contractions.
Begins after the contraction has started, and
the lowest part of the decel occurs after the
peak of the contraction.
Usually does NOT return to baseline until
after the contraction is over.
Indicates uteroplacental insufficiency.
Interventions required!
Considered ominous sign when theyre
uncorrectable, especially when associated
with decreased variability and tachycardia.

Late Decelerations
Interventions:

Change maternal position (lateral)

Correct maternal hypotension (elevate legs)
Increase rate of maintenance IV
D/C oxytocin if infusing
Administer O2 at 8-10 L/min (face mask)
Fetal scalp or acoustic stimulation
Assist with fetal O2 saturation if ordered
Assist with birth if pattern cannot be
corrected.

Variable Decelerations

Definition: an abrupt decrease in FHR that is

variable in duration, intensity,and timing
related to onset of contractions; caused by
umbilical cord compression.
Onset to the beginning of the nadir is <30
seconds; decrease in > 15 bpm, lating >15
seconds; variable times in contracting phase;
often preceded by transitory acceleration.
Return to baseline is rapid and <2 min from
onset; sometimes with transitory acceleration
immediately before and after decel.
Described as: mild, moderate, or severe.

Variable Decelerations
Interventions:

Change maternal position (side to side).

If

severe:

D/C oxytocin if infusing

Administer O2 at 8-10 L/min (face mask)
Assist with vag or speculum exam
If cord is prolapsed, examiner will elevate
fetal presenting part with cord between
gloved fingers until c/s is accomplished
Assist with amnioinfusion if ordered
Assist with fetal O2 saturation monitoring if
ordered
Assist with fetal O2 saturation if ordered

Prolonged Decelerations

Definition: a visually apparent decrease in

FHR below the baseline 15 bpm or more and
lasting more than 2 minutes but less than 10
minutes.
Benign causes: pelvic exam, application of
spiral electrode, rapid fetal descent &
sustained maternal valsalva maneuver.
Other causes (severe): progressive severe
variable decels, sudden umbilical cord
prolapse, hypotension, paracervical
anesthesia, tetanic contraction & maternal
hypoxia (may occur with seizure).

Nursing Care
During Labor
Chapter 21

QUESTIONS TO ASK
LABORING CLIENT:
UTERINE CONTRACTIONS
Time of onset: What was the time of
the 1st ctx, & at what time did the
ctx.become regular?
Frequency: How often do the ctx.
occur?
Duration: How long do the ctx.last?

 Intensity:

What is the level of pain?

Describe the nature & location of the
pain?
Effect of Ambulation: do the
ctx.become more or less frequent and
intense with ambulation?
ADDITIONAL HISTORY:
Bloody show: What was the frequency
& amt.of discharge?
Vaginal bleeding: What was the
amount, color, and consistency?

 Membranes:

Is there leaking or have

you experienced spontaneous rupture of
membranes? What was the amont,
color, consistency, & time of
occurrence?
Fetal Activity: Has the fetus moved or
kicked since labor began?
Nutrition, hydration, and sleep: When
was the last time you ate, drank, or
slept?
Social support available: Is someone
with you?

 General

emotional well-being: Are you

relaxed? Are you using breathing
techniques? (can also be observed).
Transportation: Is transportation to the
birth site available?

MONITORING DURING
LABOR:
Purpose

= to determine that maternalfetal status is within normal limits during

labor and that maternal status is within
normal limits in the immediate
postpartum period; to intervene when
deviations from normal are noted.

Assess the following parameters during

the 1st and 2nd stages of labor at regular
intervals:
Vital signs: BP on admission & at least
hourly during the active phase of labor
(more frequently if elevated or epidural).
T-P-R on admission & q4hr (more
frequently if ROM or elevation).
Fetal well-being: auscultate & record
FHR on admission or place on EFM for
20-30 min. Use continuous or
intermittent monitoring depending on
maternal-fetal risk.

 Uterine

activity: Assess & record

frequency, duration, and intensity of
uterine ctx q30-60 minutes by direct
palpation or through interpretation of
electronic fetal monitoring strips.
Labor progress: perform a vag.exam to
assess cervical effacement & dilatation,
fetal position & station, & status of
membranes. (use Friedmans curve).
I & O: ensure adequate hydration.
Initiate IV fluid as needed or before
administration of epidural. Encourage
to empty bladder frequently.

HOW LABOR PROGRESS IS

MEASURED:
Contraction

pattern.
Cervical consistency & effacement.
Cervical changes.
Cervical dilatation.
Station.

WAYS TO FACILITATE
LABOR PROGRESS:
Work

with ctx.rather than against them.

Encourage relaxation between ctx.
Assist in paced breathing techniques,
focus, visual imagery, ambulation,
change position regularly, good
communication with nurse & support
person.

PSYCHOSOCIAL
ASSESSMENT IN LABOR:

Support system.
Level of understanding of labor process &
procedures.
Effectiveness of coping strategies to deal with
labor process & pain of level.

The psychosocial assessment provides the basis for

education of the patient, anticipatory guidance,
and provision of supportive care including both
pharmacologic & nonpharmacologic measures

LABORATORY DATA:
URINE:

test for protein, ketones,

glucose, WBCs, nitrates (should all be
negative).
HEMATOCRIT & HEMOGLOBIN: HCT
<32%, and HGB <11g/L may indicate
iron deficiency anemia or hemorrhage.
WBC COUNT: values of 4500 11,000
are normal; up to 25,000 can be normal
for labor, birth, and early pp (d/t stress).

 SEROLOGIC

TESTS FOR SYPHILIS

(VDRL): samples may be obtained on
admission, depending on institutional
policy. Results should be negative.
HEPATITIS B SURFACE ANTIGEN:
repeat test if antepartum results are >
30 days old.
Rh FACTOR & ABO TYPING:
necessary during the antepartum
period, and pp when indicated.

PROMOTING A NORMAL
CHILDBIRTH:
Maintain

an awareness and
appreciation of the individuality of each
womans labor.
Be aware of cultural differences related
to labor and birth.
Update your knowledge on intrapartum
research topics (stay current).

 Become

reenergized by meeting and

sharing with other professionals who
work with the same challenges &
issues. Join specialty organizations.
Know your professional standards of
practice. These form your basis for safe
practice.
Advocate for womens needs on the
basis of your knowledge of safe
practice.
Be aware of your biases regarding labor
and birth.

POSSIBLE NURSING DX:

FIRST-STAGE LABOR:
Knowledge deficit: lack of information
related to expected physical changes,
symptoms of labor, and options
available to the childbearing woman.
Pain related to the process of labor or
birth.
Anxiety related to childbirth, pelvic
examinations, or obstetric interventions.
Fear related to parenting.

 Fluid

volume excess related to intake

during labor.
Altered nutrition: less than body
requirements related to decreased
intake during labor.
SECOND-STAGE LABOR:
Fear related to birth process, pain, and
unknown outcome.
Fatigue related to physical exertion
during labor and lack of sleep.
Pain related to fetal descent, crowning,
and perineal stretching.

THIRD- AND FOURTH-STAGE LABOR:

Risk for infection related to uterine
placental site, episiotomy incision, and
fatigue.
Urinary retention related to loss of
sensation to void and rapid bladder
filling.
Ineffective breastfeeding related to
maternal knowledge deficit, anxiety, or
fatigue.

Friedmans Curve
Emanuel

Friedman began work in

1950s, and over 20 years defined the
phases and length of the stages of labor
for nulliparous and multiparous women.
His work showed that cervical dilatation
& fetal descent follow a predictable
pattern & appear as an S curve when
plotted on a graph.
Analysis of labor progress is plotted on
a graph (a partograph).

 Can

be used to plot cervical dilatation

and fetal descent on the graph, and if
labor begins to slow in comparison to
the average rate of progress defined by
Friedman, and this data can provide a
basis for decision making about the
progress of a womans labor.
Friedmans work is the most universally
accepted scientific treatment of labor &
is nationally used in normal labor, and
to diagnose dystocia (abnormal labor)
when deviations are apparent.

LEOPOLDS MANEUVERS:
Purpose:

to provide information about

fetal presentation, position, presenting
part, lie, attitude, and descent.
Can aid in location of fetal heart tones,
assessment of fetal size, and
determination of single vs multiple
gestation.
Used in late 2nd trimester or 3rd
trimester, when fetal parts can be felt
through abdominal wall.