1. Nursing Care of Mother and Infant During Labor and Birth
Chapter 6
Nursing Care of Mother and Infant During Labor and Birth
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2. Settings for Childbirth (p. 116)
Hospitals
Advantages – access to emergency care, physician relationship
Disadvantages – high cost
Freestanding birth centers
Advantages – lower cost
Disadvantages – delay in emergency care
Home
Advantages - control
Disadvantages – extended delay to emergency care
Review the advantages and disadvantages of each setting.
Does your community have a freestanding birth center?
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3. Components of the Birth Process (p. 116, 119-126)
The Four “Ps”
Powers - mother pushing, uterine contractions
Passage – mother’s bony pelvis and soft tissues
Passenger – fetus, placenta, amniotic membrane and amniotic fluid
Psyche – the entire emotional, mental state of the mother
The powers that influence labor cause the cervix to dilate and move the fetus downward. Sources of power include uterine contractions and pushing efforts by the laboring woman.
The passage refers to the patient’s pelvis.
The passenger is the fetus.
What impact can the patient’s psyche have on the labor’s progress and/or outcomes?
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4. Factors that Influence the Progress of Labor (p. 116, 119-126)
Preparation – attending prenatal classes
Position – fetal presenting part within the mother’s pelvis
Professional – nurses, coaches
Place –setting of labor and delivery
Procedures – internal exams
People – supportive family members
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5. Uterine Contractions (pp. 119-120)
Effect of contractions on the cervix
Efface - thin
Dilate - open
Phase of contractions
Increment – increasing strength
Peak – greatest strength
Decrement – decreasing strength
A uterine contraction results from involuntary smooth muscle contractions.
The contractions assist in the effacement (thinning) of the cervix.
During labor, one of the nurse’s roles is to monitor uterine contractions.
Define frequency and duration.
What are the differences among mild, moderate, and firm contractions?
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6. Uterine Contractions (pp. 119-120)
Frequency – elapsed time between one contraction and the next
Duration - average number of seconds the contractions last – elapsed time from beginning of a contraction to the end of the same contraction
Intensity – mild- fundus easily indented, moderate – fundus can be indented, firm – fundus cannot be readily indented with fingertips
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7. Safety Alert! (p. 122)
Report to the RN any contractions that occur more frequently than every 2 minutes, last longer than 90 seconds, or have intervals shorter than 60 seconds
Persistent contractions durations longer than 90 seconds may reduce fetal oxygen supply
Contractions occurring more often than every 2 minutes may reduce fetal oxygen supply
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8. Cervical Effacement - thinning and Dilation - opening(p. 120)
Cervical effacement and dilation can be likened to sucking on a Lifesaver. As the candy becomes thinner, the center opening becomes wider.
Describe the differences between cervical effacement and dilation for the primigravida and multigravida woman.
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9. Contraction Cycle (p. 121) - Powers
Nurses must understand the components of the contraction cycle.
Review the increments and peak of the contraction pattern.
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10. Nursing Tip (p. 122)
Provide emotional support to the laboring woman so she is less anxious and fearful.
Excessive anxiety or fear can cause greater pain, inhibit the progress of labor, and reduce blood flow to the placenta and fetus.
What interventions can the nurse implement to reduce anxiety and fear during labor?
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11. The Passage (p. 122) Bony pelvis - True
Directly involved in childbirth
False
Flares
Upper portion of pelvis
Soft tissues – cervix, ligaments and fascia
If previous delivery, will yield more readily to contractions and pushing efforts
May not yield as readily in primiparas or older women
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12. Passengers – page 122
Passengers are the fetus, the placenta, amniotic membrane and fluid
Fetal head – composed of bones separated by tissue called sutures and fontanelles where the sutures meet
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13. The Passenger—Fetal Skull (pp
The Passenger—Fetal Skull (pp ) – two important fontanelles in obstetrics – the anterior and posterior fontanelles
The bones in the fetal head are separated by connective tissue.
What is the importance of this tissue in relation to the birthing process?
Compare and contrast the fontanelles
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14. The Passengers—Fetal Lie (pp
The Passengers—Fetal Lie (pp ) – how the fetus is oriented to the mother’s spine
Fetal lie refers to the position of the fetus in relation to the maternal spine.
Review the various fetal lie positions.
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15. The Passengers—Presentation (pp
The Passengers—Presentation (pp ) – the fetal part that enters the pelvis first
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16. Psyche (pp. 124-125) Mental state can influence the course of labor.
The woman’s cultural and individual values influence how she will cope with childbirth.
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17. Classifications of Fetal Presentations and Positions (p. 125)
Review the terminology used in each of the fetal presentations.
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18. Signs of Impending Labor (p. 126)
Braxton Hicks contractions – irregular “false” labor
Increased vaginal discharge
Bloody show – thick mucus with blood
Rupture of the membranes
Energy spurt
Weight loss
Compare and contrast the clinical manifestations of Braxton Hicks contractions and true labor.
Bloody show is a normal occurrence prior to the onset of labor. Describe the manifestations associated with bloody show.
Rupture of membranes warrants evaluation of the pregnant woman at the health care facility.
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19. Mechanisms of Labor (p. 126)
Descent – presenting part usually the fetus head
Station – level of presenting part to the pelvis
Engagement - when presenting part (head) reaches “0” station
Flexion – flex of fetus head to chest
Internal rotation – head turns swing anteriorly
External rotation – head realigns with shoulders
Expulsion – anterior shoulder, then posterior shoulder are born – then rest of body
Mechanisms of labor refer to those physiological changes in positioning which take place during a normal vaginal delivery.
Describe each of these positions.
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20. Mechanisms of Labor (p. 126)
Also referred to as “cardinal movements.”
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22. Birth Station (pp. 126, 128)
Station refers to the position of the fetal head relative to the ischial spines.
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23. When to Go to the Hospital or Birth Center (p. 128)
Contractions – pattern of increasing frequency – 1st child…every 5 minutes for one hour. 2nd child…every 10 minutes for one hour
Ruptured membranes
Bleeding other than bloody show
Decreased fetal movement
Any other concern
What is the timeline for patient education concerning how and when to seek care?
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24. Admission Data Collection (p. 128)
Three major assessments performed promptly on admission
Fetal condition – fetal heart rate
Maternal condition – vital signs – assess for signs of infection or hypertension
Impending birth – sitting on one buttock, making grunting sounds, bearing down with contractions, stating “the baby’s coming”, bulging of the perineum or fetal presenting part becomes visible
Discuss Skill 6-1, Assisting with an Emergency Birth (p. 129).
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25. Admission Procedures (p. 130)
Permits/consents
Laboratory tests – hematocrit and urine
Intravenous infusion – IV line started
Perineal prep - cleansing
Determining fetal position and presentation- Leopold’s maneuvers helps to determine location of the fetal back
Discuss the actions required for each task listed.
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26. Comparison of False and True Labor
False labor
Contractions irregular
Walking relieves contractions
Bloody show usually not present
No change in effacement/dilation of cervix
True labor
Contractions gradually develop a regular pattern
Contractions become stronger and more effective with walking
Discomfort in lower back/abdomen
Bloody show often present
Progressive effacement and dilation of cervix
Refer to Table 6-2 (p. 131).
What is the greatest difference between the types of labor? False labor does not result in cervical changes, while true labor causes changes in cervical dilation and effacement.
At what point during the pregnancy should education be provided regarding false and true labor? Successful education should begin early in the pregnancy. This approach allows time for reinforcement throughout the pregnancy at each visit to the health care provider.
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27. Question 1 Which is a characteristic of true labor?
Contractions are regular, and the intensity remains the same.
Contractions are irregular, and the intensity remains the same.
Contractions are regular and are intensified by walking.
Contractions are regular and are not intensified by walking.
Answer: 3
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28. Nursing Care Before Birth (p. 131)
After admission to the labor unit, nursing care consists of
Monitoring the fetus – assessing fetal heart patterns to detect fetal hypoxia. Most hospitals use continuous EFM.
Monitoring the laboring woman
Helping the woman cope with labor
Fetal monitoring can be intermittent or continuous.
Review factors which can determine the type of monitoring employed
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29. Monitoring the Fetus (p. 131)
Fetal heart rate monitor by fetoscope or Doppler transducer
Intermittent auscultation gives the mother greater freedom of movement
Continuous electronic fetal monitoring used by hospitals- provides record for the chart
The baseline fetal heart rate is the average FHR that occurs for 2 minutes during a 10-minute period and averaged over 30 minutes.
Review Skill 6-2 on p. 132, Box 6-2 on p. 133, and Skill 6-3 on p. 134.
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30. FHR Outside of Normal Limits (p. 132)
Any FHR outside the normal limits and any slowing of the FHR that persists after the contraction ends is promptly reported to the health care provider.
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31. Evaluating Fetal Heart Rate Patterns (pp. 133-136)
Baseline FHR BPM
Fetal bradycardia <110 BPM
Fetal tachycardia >160 BPM
Baseline variability – fluctuations showing intact nervous system and cardiac status of fetus
Moderate variability change of 6 to 25 bpm from baseline
Marked variability- more than 25 beats of fluctuation over the baseline – may be cord prolapse or maternal hypotension
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32. Absent variability – is less than 6 beats/min change from baseline for a 10 minute period – caused by uteroplacental insufficiency or maternal hypotension, cord compression or fetal hypoxia
Have patient lie on side, increase fluids, administer oxygen at 8 to 10L/min by mask, notify health care provider
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33. Accelerations are temporary, abrupt rate increases of at least 15 beats/min above baseline that last 15 seconds but less than 2 minutes from onset to return to baseline
This pattern suggests that fetus is well oxygenated and is known as a “reassuring” pattern.
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34. Nonreassuring patterns
Reassuring and Nonreassuring FHR and Uterine Activity Patterns (p. 135)
Reassuring patterns
Nonreassuring patterns
Stable fetal heart rate (FHR)
Moderate variability
Accelerations
Uterine contraction frequency greater than every 2 minutes; duration less than 90 seconds; relaxation interval of at least 60 seconds
Tachycardia
Bradycardia
Decreased or absent variability; little fluctuation in rate
Late decelerations
Variable decelerations
See Box 6-3 on p. 135 for more details.
A part of the nursing assessment is the evaluation of fetal heart patterns.
Nonreassuring patterns need reported to the health care provider.
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35. Inspection of Amniotic Fluid (p. 137)
Color
Normal is clear fluid, may have flecks of white vernix
Green-stained may indicate fetus passed meconium (first stool but before birth)
Can lead to fetal compromise
Odor
Should not smell
If it does, it may indicate infection
Amount
Scant—trickle
Moderate— ~500 mL
Large— ≥ 1,000 mL
What nursing interventions would be needed for normal-appearing amniotic fluid, meconium-stained, and large quantities?

36. Nitrazine paper into fluid from vagina
Nitrazine paper test p 138
Nitrazine paper into fluid from vagina
Blue-green – alkaline and is likely amniotic fluid
Yellow to yellow –green – acidic and is most likely urine
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37. Monitoring the Woman (p. 137)
Vital signs – checked every 4 hours – temp of or higher should be reported
Contractions – monitor by EFM or palpation
Progress of labor
Intake and output
Response to labor
Discuss the frequency of each of the items to be monitored.
Closed glottis pushing decreases fetal oxygenation and should be avoided.
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38. Six Lamaze Institute Basic Practices for Maternity Care (p. 140)
Labor should begin on its own.
Woman should have freedom of movement.
Woman should have a birth support person or doula.
No routine interventions should be performed.
Woman should be in non-supine positions.
Woman should not be separated from infant.
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39. Helping the Woman Cope with Labor (p. 140)
Labor support
Teaching
Providing encouragement
Supporting/teaching the partner
Teach how labor pains affect the woman’s behavior/attitude
How to adapt responses to the woman’s behavior
What to expect in his/her own emotional responses
Effects of epidural analgesia
Review the components of labor support with the class.
What are the recommended positions of comfort for the laboring women?
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40. Stages and Phases of Labor (p. 143)
First stage—dilation and effacement (can last 4 to 6 hours)
Second stage—expulsion of fetus (30 minutes to 2 hours)
Third stage—expulsion of placenta (5 to 30 minutes)
Fourth stage—recovery
The labor of the primigravida will last longer than that of a multigravida.
What behaviors are associated with each of the stages of labor?
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41. Question 2 During which stage of labor does “crowning” occur? First
Second
Third
Fourth
Answer: 2
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42. Vaginal Birth After Cesarean (p. 143)
Main concern
Uterine scar will rupture
Can disrupt placental blood flow
Lead to hemorrhage
Woman may need more support than other laboring women
Nurse provides empathy and support
Discuss some of the psychological barriers that may arise for a woman with VBAC.
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43. Nursing Responsibilities During Birth (pp. 144-146)
Preparing the delivery instruments and infant equipment
Perineal scrub
Administering medications
Providing initial care to the infant
Assessing Apgar score
Assessing infant for obvious abnormalities
Examining the placenta
Identifying mother and infant
Promoting parent-infant bonding
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44. Immediate Postpartum Period: Third and Fourth Stages of Labor (p. 146)
Third stage—expulsion of placenta
Schulze or Duncan’s
Fourth stage—nursing care includes
Identifying and preventing hemorrhage
Evaluating and intervening for pain
Observing bladder function and urine output
Evaluating recovery from anesthesia
Providing initial care to the newborn infant
Promoting bonding and attachment between the infant and family
After the birth of the baby, the nurse continues to assess the mother.
Review both normal and abnormal findings.
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45. Nursing Care Immediately After Birth (p. 147)
Care of the mother
Observing for hemorrhage
Vital signs
Skin color
Location and firmness of uterine fundus
Lochia
Pain
Promoting comfort
Keep warm and dry
Ice to perineum to help reduce swelling and bruising
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46. Nursing Care Immediately After Birth (cont.) (p. 147)
Care of the newborn
Phase 1
From birth to 1 hour (usually in delivery room)
Phase 2
From 1 to 3 hours (usually in transition nursery or postpartum unit)
Phase 3
From 2 to 12 hours (usually in postpartum unit if rooming-in with the mother)
If the newborn does not experience any difficulty with adaptation to extrauterine life, the infant will often remain with the mother in the delivery room.
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47. Phase 1: Care of the Newborn (p. 147)
Initial care includes
Maintaining thermoregulation
Maintaining cardiorespiratory function
Observing for urination and/or passage of meconium
Identifying the mother, father, and newborn
Performing a brief assessment for major anomalies
Encouraging bonding/breastfeeding
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48. Apgar Scoring (pp. 151-152) Heart rate Respiratory effort Muscle tone
Reflex response to suction or gentle stimulation on the soles of the feet
Skin color
The Apgar is performed twice. At what times is the scoring performed?
A point-based system is used. Each of the parameters is given a score between 0 and 2 points.
What are the implications of the score obtained?
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50. Administering Medications to the Newborn (p. 152)
Eye care
Vitamin K (AquaMEPHYTON)
Review Skill 6-6 on p. 153 and Skill 6-7 on p. 154.
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51. Question 4 What medication is most often used for neonatal eye care?
Silver nitrate 1%
Triple dye
Silver nitrate 2%
Erythromycin ophthalmic ointment
Answer: 4
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52. Observe for Major Anomalies (p. 153)
Head trauma from delivery
Symmetry and equality of extremities
Are they of equal length?
Do they move with same vigor on both sides?
Assess digits of hands and feet
Any evidence of webbing or abnormal number of digits
What else should be assessed in regard to major anomalies?
Which anomalies require immediate notification to the RN or health care provider?
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53. Umbilical Cord Blood Banking (p. 153)
This type of blood is capable of regenerating stem cells that are able to replace diseased cells.
Informed consent is essential.
Collect blood after cord has been clamped.
Blood must be transported within 48 hours of collection to blood banking facility.
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54. Emerging Technologies and Practice (p. 154)
C: type of waveform analysis that detects intrapartal changes in fetal ST waveforms, indicative of developing fetal metabolic acidosis.
PERICALM-EFM: computerized interpretation of real-time FHR patterns that provides automatic analysis of fetal heart pattern to compliment clinical judgment as well as permanent documentation in EMR.
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