Nursing Care During Labor and Birth

Factors affecting labor: 5 P’s
• Passenger → the baby
• Passageway → woman’s pelvis
• Powers → of the woman, uterus, contractions
• Position of the mother → squatting is most physiological position to give birth in
o Epidural can be problematic as it makes position changes difficult
• Psychological response → the premise of Lamaze; feeling capable and prepared for childbirth
o IF mother is calm, confident and secure → less fear and pain

Definition of labor
regular uterine contractions causing cervical change

Changes in cervix during labor
o Can be contracting and not in labor → cervix may not be changing
o Cervix gets shorter and thinner as muscle fibers contract and pull up
o In nullip, effacement happens first because muscles have not previously been stretched
o A: fixed long cervix

Cervical effacement
thins and shortens
• 0-100%
• Occurs during the first stage of labor
• Occurs first in primips

Cervical dilation
opens widening the outlet
• 0 cm to 10 cms
• Full dilitation marks the end of the first stage of labor
• Occurs first in multips
• Occurs in response to uterine contractions and hormone influence (prostaglandins)

False labor
o Irregular contractions
• Abdomen
o Stops with change in position
o No change in effacement or dilation
o No “descent”

True labor
o Contractions increase in regularity and intensity
o Lower back, radiates
o No difference with position change
o Results in cervical dilatation and effacement and descent

Assessment of labor
o Uterine activity
o Onset of contractions
o Intensity of contractions
o Status of membranes → did the amniotic membrane rupture?
• “Spontaneous Rupture of Membranes” vs “Assisted Rupture of Membranes”

Uterine activity: frequency
o Beginning to beginning
o Varies with stage and phase of labor
o Frequency increases as labor progresses

Uterine activity: duration
o Beginning to end of contractions

uterine activity: intensity
o Mild, moderate, strong to palpation

uterine activity: resting tone
o Between contractions → position of baby

uterine activity: fetal response
o Measured by baby’s heart rate response to contractions

1st stage of labor
o Onset of labor to full dilatation/dilation
• 3-16+ hours

• Three Phases:
o Latent/Early Phase (0-3 cm)
o Active Phase (4-7 cm)
o Transition (8-10 cm)

2nd stage of labor
o full dilitation to birth of infant
• 10 minutes to 3 hours

3rd stage of labor
o birth of infant to expulsion of placenta
• up to 20 minutes

4th stage of labor
o expulsion of placenta to appx 1-4 hours
o Looking for hemorrhage complication

Nursing role during labor
• Fetal assessment → V/S/HR tracing
• Labor progress
• Maternal and fetal tolerance to labor
• Pain management
• I & O
• Vital signs
• Communication with MD/ CNM
• Have mom empty bladder
• Promote position changes
• Provide hygiene
• Provide support & encouragement
• Assist with breathing techniques

Maternal adaptations during labor
• Increased demand for O2
o risk of hyperventilation
o risk of alkalosis
• Increased Cardiac output → blood volume increased by 50%
o increased pulse
o increased BP
o risk of supine hypotension related to position
• blood can get sequestered in lower half of the body
• Epidurals can drop mother’s BP
• Decreased GI motility
o nausea, vomiting → not uncommon

Supine hypotension
• Pressure from weight of uterus/baby on vena cava if supine
• Decreases blood return to heart
• Decreases blood pressure
• May affect fetal heart rate
o Decreased blood flow to uterus = decreased blood flow to placenta = decreased blood flow to baby

Latent phase (part of phase 1)
• Generally, the longest period
• 7 to 8 hours average for primigravidas
• 5 to 6 hours for multigravidas
• Effacement completed in primigravidas
• Contractions established as rhythmic and coordinated
o Q 30mins – Q 10 – Q 5; 20 – 40 secs; mild
• Dilatation progresses to 2-3 cm
• independence anticipation, excitement, happiness,relief, apprehension
• grimace with cx: uncomfortable
• alert, talkative and sociable

Active phase (part of phase 1)
• Rate of cervical dilation begins to increase
• Stage lasts 2-4+ hours
• Cervical progress 3-7 cms
• Moderate to moderate-strong, longer, more frequent contractions
o Q 5-3; 40-60 secs; mod
• Average rate of dilation:
o 1.2 cm per hour in primigravida
o 1.5 cm per hour in multigravida

Characteristics of active labor
• anxiety increases
• Fears loss of control and anger at the loss of control
• May exhibit decreased ability to cope
• Helplessness and increased dependence
• Becomes serious and concentrates on labor

Transition phase (part of phase 1)
• Cervix becomes part of the lower uterine segment
• Uterine contractions start to put pressure on perineal structure
• Q 1 ½ -3 mins; 60-90 secs; strong
• Generally the most difficult time for woman
o 1 hour for primigravida
o 10-15 minutes for multigravida

Characteristics of Transition
• Amnesia in between cx
• Nausea, vomiting, belching
• leg tremors and involuntary shaking
• increased perspiration
• increase in bloody show → bleeding as the cervix stretches
• irritability
• c/o rectal pressure → having to go to the bathroom

Urge to push
• May experience urge without completed dilation: Ferguson’s reflex
• Stay with Mom
• Change breathing to panting or blowing
• May have mild pushing w/ multips

Nursing care: transition
• Assessments
• Support and Encouragement
• Breathing Reinforcement
• Minimal handling
• Encourage rest
• Provide information
• Provide privacy

Second stage of labor
• From full dilation to delivery of baby
• Accomplished by involuntary and voluntary pushing efforts (bearing down) with uterine contractions
• Open Glottis Pushing → some release in sound (allows blood flow to head and less pressure)
• Delayed Pushing → used when pt has epidural
• Descent of the presenting part through the pelvis
o station

Support during 2nd stage
• Assist with pushing techniques
• Provide encouragement
• Reposition frequently
• Assess bladder distention
• Prepare for birth
• Ongoing fetal assessment

• Incision in the perineum to enlarge the outlet
• Done when baby is showing stress in pushing phase
• Not advantageous

Episiotomy: midline
o Most common
o Easily repaired
o Least painful
o Can extend to anal sphincter

Episiotomy: mediolateral
o Operative birth and possible posterior extension
o May have 3rd degree laceration with epis
o More difficult repair
o Greater blood loss
o More painful ?

Perineal lacerations
• First degree
o Through skin and superficial structures
• Second degree
o Extends through muscles of perineal body
• Third degree
o Continues through anal sphincter muscle
• Fourth degree
o Involves anterior rectal wall

Third stage of labor
• Birth to placenta
o Up to 20 minutes
• Assess placenta for intactness
o Shiny Shultze fetal side
o Dark Duncan maternal side

Fourth stage of labor
• Recovery Period
• Appx 4 hours after placenta
• Immediate hemodynamic stability of mother
• Bonding

Nursing care during fourth stage
• Vital Sign Assessment
• Physical Assessment
o Uterus: firm, not boggy
o Bleeding
o Perineum
o Bladder
• Teaching Needs Assessment

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Labor Process Begins with the first uterine contraction, continues with hard work during cervical dilation and birth and ends as a woman and her family begin the attachment process with the infant EMTALA Emergency Medical Treatment and Active Labor Act …

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