Nursing Care during Labor and Birth Chapter 10: Nursing Care during Labor and Birth

The Nurse’s Role during Admission When a woman arrives at the labor unit, immediate data collection involves observing for signs that birth is imminent, in which case admission procedures are abbreviated until after delivery, as well as determining fetal status, risk factors, and maternal status.

The Nurse’s Role during Admission (cont.) If the birth is not imminent, the RN will conduct a thorough obstetric, medical–surgical, and social history and a complete physical assessment. Also, determine labor status and the woman's labor and birth preferences. Throughout the labor process, monitor maternal and fetal status and labor progress. Frequent checking of vital signs and FHR are critical nursing functions.

Question Mrs. Jones, a gravida 4 para 3, has just come into the labor and delivery suite. She tells the admission nurse that her water broke 2 hours ago and she feels like pushing. What is the first assessment the nurse should make? a. Maternal vital signs b. Imminence of birth c. Take an obstetric history d. Find a good vein and start an IV

Answer b. Imminence of birth Rationale: Nursing assessment for signs that birth is imminent begins from the moment the woman arrives in the labor and delivery unit. If the woman is introverted and stops to breathe or pant with each contraction, you can infer that she is in an advanced stage of labor. In addition, if the woman makes statements such as, “I feel a lot of pressure,” or “The baby is coming,” or “I want to have a bowel movement,” it is likely the woman is in the second stage of labor, and the baby will be born soon.

The Nurse’s Role: Ongoing Assessment of Uterine Contractions and FHR Uterine contraction patterns are evaluated using external or internal methods. External evaluation always involves palpation when using intermittent auscultation (IA). Palpate to determine intensity of the contraction when the external toco is used during continuous fetal monitoring. Internal evaluation requires the use of an internal pressure catheter. The internal pressure catheter measures intensity as well as frequency and duration.

Continuous internal EFM Continuous internal EFM. The internal fetal scalp electrode is placed on the fetal scalp and connected to the reference electrode which is taped to the maternal thigh and connected to the fetal monitor.

The Nurse’s Role: Ongoing Assessment of Uterine Contractions and FHR (cont.) IA of FHR allows for freedom of maternal movement and focuses the nurse's attention on the woman, rather than on the technology. Disadvantages are that IA requires higher staffing levels, and some health care providers fear that subtle signs of fetal compromise may be missed. Continuous electronic monitoring restricts maternal movement and tends to focus the nurse on the monitor versus the woman. Advantages are that the nurse can take care of more clients and can immediately detect changes in fetal status.

The Nurse’s Role: Ongoing Assessment of Uterine Contractions and FHR (cont.) External fetal monitoring is noninvasive and allows for evaluation of FHR patterns. Some external FHR monitors can be done by telemetry which allows for more mobility by the woman. Internal fetal monitoring requires that the membranes be ruptured and the cervix be at least partially dilated. The woman needs to remain in bed while being internally monitored. Internal FHR monitoring involves a scalp electrode being placed which can increase the risk of infection in the fetus.

The Nurse’s Role: Ongoing Assessment of Uterine Contractions and FHR (cont.) LPN/LVNs must be able to detect nonreassuring FHR patterns in order to notify the RN and/or the health care provider, who then makes a final decision regarding care of the client

The Nurse’s Role: Ongoing Assessment of Uterine Contractions and FHR (cont.) Three major deviations from a normal FHR baseline are tachycardia (FHR higher than 160 bpm), bradycardia (FHR lower than 110 bpm), and absent or minimal variability (fluctuations at or below 5 bpm from baseline).

Appearance and causes of periodic changes. A Appearance and causes of periodic changes. A. Early decelerations mirror uterine contractions and are caused by head compression. B. Variable decelerations are variable in onset and shape and are caused by cord compression. C. Late decelerations are offset from uterine contractions and are caused by uteroplacental insufficiency.

The Nurse’s Role: Ongoing Assessment of Uterine Contractions and FHR (cont.) Early decelerations are gradual decreases in the FHR that mirror the contraction. Head compression is the cause, and the pattern is not cause for concern as long as the fetal heart rate returns to baseline. Variable decelerations are abrupt decreases in the baseline that are variable in shape and timing (many are shaped like Vs or Ws) and are caused by cord compression. The pattern is nonreassuring when the decelerations are deep and repetitive and when absent variability or changing baseline is present. Late decelerations are gradual decreases in the FHR that start after the peak of the contraction. Late decelerations indicate uteroplacental insufficiency and are nonreassuring.

Nursing Interventions: Decelerations No intervention is required for early decelerations, other than continued monitoring. Nursing interventions for variable decelerations are aimed at relieving cord compression and include maternal position change or assisting the health care provider with amnioinfusion. Late decelerations require aggressive management. The woman is positioned on either side, oxygen is started via face mask, and any oxytocic infusion is discontinued. Sometimes, tocolytics are prescribed to decrease the frequency and duration of uterine contractions, which improves blood flow to the placenta.

Additional Methods Determining Fetal Status Fetal stimulation Fetal scalp sampling to determine pH Fetal pulse oximetry

Nursing Interventions during the Latent Phase (Early Labor) (cont.) Marked by maternal feelings of excitement as well as by anticipatory anxiety and fear. Teaching about the labor process can help reduce anxiety. Distraction techniques are helpful in facilitating coping.

Nursing Interventions during Active Labor Contractions become more frequent and stronger during the active phase of labor. Distraction techniques typically do not help during active labor. Support of the woman and her partner include encouragement to continue behaviors that promote coping and assistance in finding alternative approaches when coping is ineffective. Reinforcing breathing techniques and rituals can be helpful.

Nursing Interventions during the Transition Phase of Labor The transition phase is the most intense phase of labor. The woman becomes irritable and less cooperative. Assist the woman to rest between contractions and to avoid pushing until the cervix is fully dilated.

Delivery sequence from crowning through birth of the newborn. A. Early crowning of the fetal head. Notice the bulging of the perineum. B. Late crowning. Notice that the fetal head is appearing face down. This is the normal OA position. C. As the head extends, you can see that the occiput is to the mother’s right side—ROA position. D. The cardinal movement of extension. E. The shoulders are born. Notice how the head has turned to line up with the shoulders—the cardinal movement of external rotation. F. The body easily follows the shoulders. G. The newborn is held for the first time! (Photo by B. Proud.)

Nursing Interventions during the Second Stage of Labor: Expulsion of the Fetus Full dilation of the cervix marks the beginning of the second stage of labor. Because the woman can now participate actively by pushing, she often feels re-energized to deal effectively with the labor. The open-glottis or natural method of pushing is recommended. Encouragement and reinforcement of pushing techniques are helpful nursing interventions.

Nursing Process during the Third Stage of Labor: Delivery of Placenta The placenta is delivered in the third stage of labor. Monitor for signs of placental separation and ensure that the fundus remains contracted after the placenta delivers. A healthy placenta after delivery. A. Notice the shiny surface of the fetal side. B. The maternal side is rough and divided into segments (cotyledons).

Nursing Process during the Fourth Stage of Labor: Recovery In the recovery period, the risk for hemorrhage is high. Close monitoring of the fundus, lochia, and vital signs are priority interventions. Comfort measures for the woman and observation of attachment are also important nursing interventions.