Labor and Birth Process

Initiation of Labor
 Changes w/in occurs gradually over period of days to weeks
o Myometrium
o Decidua
o cervix
Factors Influencing the Onset of Labor
 Uterine stretch  fetus and amniotic fluid volume
 Progesterone withdrawal  producing less
 Becoming estrogen dominance
 Increased oxytocin sensitivity  # of receptors increase at end of
pregnancy
 Increased release of prostaglandins  contractions, cervical softening,
myometrial sensitization  dilation

Premonitory Signs of Labor – preparation for labor

*every woman may not experience all of these signs
 Cervical changes
 cervical softening
 needed for effacement and dilation
 possible cervical dilation
 occurs 1 mo – 1 hr before labor begins
 Lightening
 presenting part descend into true pelvis
 uterus lowers and moves into a more anterior position
 shape of uterus changes
 increased pelvic pressure, leg cramping, dependent edema,
lower back discomfort
 increase vaginal discharge and freq urintation
 occurs 2 wks or more before labor begins
 multiparas may start until labor
 Increased energy level (nesting)
 24-48 hrs before labor
 Increase in epinephrine release  decrease in progesterone
 Bloody show (expulsion of mucous plug  cervical softening and
increase pressure of presenting part)
 Thinning of cervix
 Loosing of mucous plug is not a sign of start of labor
 Pink tinged = ruptured cervical capillaries release small blood
that mixes with mucus
 Braxton Hicks contractions
 Mild, irregular, no pattern
 
Does not change the cervix

Can be decreased by walking, voiding, eating, increase fluid
intake, changing positions
 Last about 30 secs to 2 min
 Spontaneous rupture of membranes
 PROM  prelabor rupture of membranes if loss prior to onset of
labor
 Normally labor will start w/in 24 hrs
 ask the right questions if this occurred outside of the hospital
 could be gush or steady leakage
 danger for infection, prolapse cord

True vs. False Labor

 True  contractions at regular interval that increase in frequency,
duration and intensity  causing progressive cervical dilation and
effacement
 False  Braxton hicks  do not contribute towards labor
 Differences Between True and False Labor
Parameters True Labor False Labor

Contraction Regular, becoming closer together, usually Irregular, not occurring close together
timing 4–6 minutes apart, lasting 30–60 seconds

Contraction Become stronger with time, vaginal pressure Frequently weak, not getting stronger
strength is usually felt with time or alternating (a strong one
followed by weaker ones)

Contraction Starts in the back and radiates around toward Usually felt in the front of the abdomen
discomfort the front of the abdomen

Any change in Contractions continue no matter what Contractions may stop or slow down with
activity positional change is made. walking or making a position change.

Stay or go? Stay home until contractions are 5 minutes Drink fluids and walk around to see if
apart, last 45–60 seconds, and are strong there is any change in the intensity of
enough so that a conversation during one the contractions; if the contractions
is not possible—then go to the hospital or diminish in intensity after either or
birthing center. both, stay home.

Critical Factors Affecting Labor and Birth

“Five Ps”
 Passageway (birth canal: pelvis and soft tissues)
 Passenger (fetus and placenta)
 Powers (contractions)
  Position (maternal)
 Psychological response

Five Additional Factors Affecting the Labor Process

 Philosophy (low tech, high touch)
 Partners (support caregivers)
 Patience (natural timing)
 Patient preparation (childbirth knowledge base)
 Pain control (comfort measures)

Passageway: pelvis and soft tissue

Bony Pelvis
 Linea terminalis: division of false and true pelvis
 True pelvis (below linea terminalis – what divides the false pelvis from
true pelvis)
 Fetus travels through
 Made up of 3 plances
 Inlet  allows entrance to true pelvis
 Mid-pelvis  snug curved space that fetus travels to reach
outside  chest compressed  lung fluid/mucus expelled
 Outlet (pelvic measurements)
 Diagonal conjugate – distance between sacral
prominence and inferior margin of pubis
 Transverse – distance at medial and lowest aspect
o Hand span or clenched fist measurement
 True
 False pelvis (above linea terminalis)
 Upper flared parts of two iliac bones and concavities
 Wings of base of sacrum

 Pelvic shape
 Gynecoid: favorable for vaginal delivery
 Inlet is round and outlet is roomy
 Android: male shaped, not favorable (inlet heart shaped, can
make for difficult descent and failure of rotation)
  Leads to csection birth
 Anthropoid: usually adequate (oval, more likely to have a
posterior/OP delivery)
 Inlet is oval and sacrum is long  deep pelvis
 Platypelloid: not favorable (flat, usually baby is transverse)
 Cavity is shallow but widens at outlet
 Usually require csection

Passageway: Soft Tissues

 Cervix: thins through effacement (thins) to allow presenting part to
descend into vagina
 Pelvic floor muscles help fetus rotate anteriorly as it passes through
canal
 Vagina soft tissue expands to accommodate fetus

Important Terms
 Effacement: shortening and thinning of cervix
 Expressed as a percentage (0% to 100%)
 Dilation: opening and enlargement of cervix
 Expressed in centimeters (0 to 10 cm)
Passenger – fetus w/ placenta
 Fetal skull – size and presence of molding
 Fetal attitude – degree of body flexion
 Fetal lie – relationship of body parts
 Fetal presentation – first body part
 Fetal position – relationship to maternal pelvis
 Fetal station
 Fetal engagement

Passenger: Fetal Skull

 Largest and least compressible structure
 To proportion of rest of body
 Sutures (spaces between cranial bones):
 allow for overlapping and changes in shape (molding – elongated
shape from overlapping of cranial bones)
 help identify position of fetal head
 Fontanelles (intersections of sutures):
 help in identifying position of fetal head and in molding
 Diameters: occipitofrontal, occipitomental, suboccipitobregmatic, and
biparietal
Passenger: Fetal Attitude
 Posturing – flexion or extensions of joints
o All joints flexed – fetal back is rounded, chin to chest, thighs
flexed on abdomen, legs are flexed at knees
o Smallest part of skull presents to pelvis first
 Abnormal – no flexion or extensions  increases diameter of
presenting part  increases difficulty of birth

Passenger: Fetal Lie

 Relationship of the long axis (spine) to the spine of the mother
o longitudinal lie – spine of fetus is parallel to mother spine
 head or breech
o Transverse lie – spine of fetus I perpendicular to mother spine
 Lies across abdomen -horizontal
o Oblique – spine of fetus at an angle
 No palpable part is presenting
 Usually transitory
Passenger: Fetal Presentation – body part that enters pelvic
Inlet first (presenting part)
 Cephalic (vertex) – head first
 Military B- head straight, skull presenting part
 Brow C- neck extended, forehead presenting
 Face (see Figure 13.7) D – face is presenting

Breech Presentation - pelvis first

a. Frank b. Complete c. Single Footing d. Double footing

 More likely with preterm births or fetal abnormalities [hydrocephaly] &
abnormalities of the maternal uterus or pelvis
 Can be necessary to have a cesarean birth
 Disadvantages
  Risk of cord prolapse
 Presenting part less effective in cervical dilation
 Risk of cord compression
 Risk of prolonged labor
Shoulder (Acromion process is landmark) – scapula first
 Occurs when fetus in transverse lie
o Maternal abdomen appears large side to side
o Lower than expected fundal height
 Shoulder dystocia – head extends and emerges and then retracts
“turtle sign”
 Associated w/ placenta previa, prematurity, high parity, premature
rupture, multiple gestations, fetal anomalies
 Fetus cannot be delivered vaginally unless rotation occurs

Passenger: Fetal Position – relationship of a point on the presenting part to

designated point of maternal pelvis
Landmarks
 Occipital bone (O): vertex presentation
 Chin (mentum [M]): face presentation
 Buttocks (sacrum [S]): breech presentation
 Scapula (acromion process [A]): shoulder presentation
 Three-letter abbreviation for identification
 4 quadrants – right anterior, left anterior, right posterior, left posterior
Passenger: Fetal Station – relationship of presenting part to level of
maternal pelvic ischial spines (narrowest part)
 0 – at level of ischial spine
o (-) if above
o (+) if below

Passenger: Fetal Engagement

 Presenting part reaching 0 station
  Floating: no engagement; presenting part freely movable about pelvic
inlet

Cardinal Movements of Labor

 Positional changes as it travels through passageway
 Engagement – greatest transverse diameter of the head in vertex
passes through inlet (usually 0 station)
 Descent downward movement until w/in inlet
o Occurs w/ contractions
o Forced by pressure of amniotic fluid, pressure of the fundus,
contractions, extension and straightening of fetal body
o Occurs throughout labor ending at birth
Flexion – vertex meets resistance from cervix, walls of pelvis, pelvic
floor
-as a result chin is brough into thorax
Internal Rotation – as head descends lower portion of head meets
resistance from side of pelvic floor  head rotates 45 degrees
Extension – w/ further descent and full flexion of head, nucha becomes
under symphysis  resistance from pelvic floor  extends head to pass
under pubic arch
- Occurs after internal rotation is complete
- Head emerges
External Rotation – after head is born  untwists causing moving 45
degrees back to original left or right position
- Allows shoulders to rotate internally to fit maternal pelvis
Expulsion of the rest of body – assisted by health care providers
Powers
 Uterine contractions (primary stimulus)
 2nd powers - Intra-abdominal pressure from mother pushing and
bearing down
 Contractions: involuntary, thin and dilate cervix
 Cause complete dilation and effacement of cervix during 1st
stage
  Three parameters
 Frequency
 How often they occur
 From beginning of one contraction to beginning of next
contraction
 Duration
 How long they lasts
 From beginning of one contraction to end of the same
 Intensity
 Strength
 Measured by palpation or internal intrauterine pressure
catheter
 mmHg
Assessment of Uterine Contractions

Characteristics
-external monitoring only assess frequency and duration
 -palpation is the only way to know the intensity when using external
monitoring
-internal monitoring can only assess intensity
 Frequency
 Measured from the beginning of one contraction to the beginning
of the next contraction
 Duration
 Measured from the start of one contraction to the end of the
same contraction
 Intensity
 Frequently measured by palpation and described as mild,
moderate or strong
 Palpation
 Mild -A lot of mush and a little firmness
 Moderate - Push on the chin a little mush and a little firmer
 Strong - No mush and hard
 Electronic fetal monitoring
 Internal or external

Electronic Monitoring – "toco"

 External monitor—tocodynamometer
 Noninvasive – measures uterine activity/movement
 Pressure-sensitive device that is applied against the uterine
fundus
 when the uterus contracts, movement is measured and recorded
on graph paper
 Internal monitor—internal pressure catheter
 Invasive – also measures uterine activity mm/hg
 Membranes must be ruptured – IUPC (internal uterine pressure
catheter) is inserted through the cervix and into the uterus to
measure internal pressure generated during the contraction
Psychological Response – anxiety/fear causes catecholamines to be
secreted inhibits uterine blood flow and placental perfusion
 Factors influencing a positive birth experience
 Clear information on procedures
 Support, not being alone
 Sense of mastery, self-confidence
 Trust in staff caring for her
 Positive reaction to the pregnancy
 Personal control over breathing
 Preparation for the childbirth experience
Physiologic Responses to Labor: Maternal
 Increased heart rate (10-20 bpm), cardiac output, blood pressure ([35
mmHg] during contractions)
  Increased white blood cell count (30,000)
 Increased respiratory rate and oxygen consumption – from increase in
metabolism
 Decreased gastric motility and food absorption  increases risk of
nausea/vomiting during transition stage
 Decreased gastric emptying and gastric pH
 Hunger normally decreases when in labor
 Increasing risk of vomiting w/ aspiration
 Slight temperature elevation – from muscle activity
 Muscle aches/cramps – from stress
 Increased BMR
 Decreased blood glucose levels
 Using more energy

Physiologic Responses to Labor: Fetal

 Periodic FHR accelerations and slight decelerations
 Related to fetal movement, fundal pressure, uterine contractions
 Decrease in circulation and perfusion
 Secondary to uterine contractions
 Increase in arterial carbon dioxide pressure (PCO2)
 Decrease in fetal breathing movements
 Decrease in fetal oxygen pressure; decrease in partial pressure of
oxygen

Stages of Labor First stage

  Involves thinning and opening of the cervix
 True labor to complete cervical dilatation (10 cm)
 Longest of all stages – starts w/ 1st true contraction and ends
with full dilation
 Should not be pushing  edema
 Two phases
 Latent phase (0-6 cms)
 Begins w/ start of regular contractions and ends
when rapid cervical dilation begins
 Dilates slowly to 6cm
 Effacement 0-40%
 Contractions 5-10 mins, last 30-45 secs
 Contractions are tolerated  mild manageable
o Like menstrual cramps
 Not necessarily in rhythm
 talkative
 Longest phase
 May remain at home
 Starts w/ apprehension/excitement
 Active phase (6-10cms)
 Dilations occur more rapidly (1.2-1.5 cm/hr) until
complete and effacement is complete
 Contractions last around full min
 More consistent
o 2-5 mins and increase in duration 45-60 secs
 Painful and intense
o May request pain meds
 Fetus descends farther in pelvis
 Limited interactions w/in room
 Start to use relaxation and paced breathing
 Do not push before cervix is 10 cm dilated

2nd Stage – expulsive stage

- involves moving fetus through birth canal
-10 cm dilated  birth
-pushing begins
-begins when cervix is completely dilated and
Ends w/ birth
-last mins to hrs
-contractions occur every 2-3 mins, lasting 60-90 secs
-strong by palpation
-Cardinal movements occur
-contractions are freq and strong  gives urge to push
-Spontaneous pushing vs directed pushing
 - Spontaneous – natural way of managing  mother pushes when
feels
the need rather than when directed (reduces fetal oxygenation)
-Open – glottis Method – involuntary pushing w/ expiratory grunting
and vocalization
-Laboring down (passive descent)– used w/ epidural  fetus descends
w/out coached pushing
-urge to push felt when direct contact of fetus to pelvic floor
-mother feels more in control and less irritable/agitated
-can last up to 3 hrs (1st time) or 2 hrs (ones after)
-Crowned – top of head no longer regresses between contractions

Preparation for Birth

 Bulging of perineum and rectum
 Flattening and thinning of the perineum
 Increased bloody show
 Labia begin to separate

Stages of Labor Third stage – placental expulsion

 Third stage: birth of infant to delivery of placenta
 Placental separation and expulsion: uterus will continue to
contract, placenta will be delivered. Must be examined to make
sure all sections are present
 Usually takes 5-10 minutes, may take up to 30minutes, if
beyond =retained placenta
 Uterotonic will be administered, start assessments: Bubble-He,
VS, Infant assessments etc.

Fourth Stage 1-4 hrs after delivery

-starts from expulsion of placenta and ends w/ maternal stabilization
-most critical stage
-transition
-close monitoring of both mother and newborn
-attachment process begins
-assess fundus, bleeding, bladder, vital signs every 15 mins for 1 st hour
-lacerations/episiotomy
-provide hygiene/ice pack
-promote comfort
-assist when able to ambulate

Signs of Placental Separation

-w/in 5-30 mins
 The uterus rises upward
 The umbilical cord lengthens
  From the weight of the clamp
 A sudden trickle of blood is released from the vaginal opening
 Gush of blood
 The uterus changes its shape to globular

Factors Influencing Pain During Labor and Birth

 Physiologic
 Spiritual
 Psychosocial
 Cultural
 Environmental

Nursing Management During Labor and Birth

Key Terms Related to Fetal Heart Rate

 Accelerations – transitory abrupt increases in FHR above baseline for
at least 30 secs (from onset to peak)
 Artifact – irregular variations or absence of FHR on monitor (from
mechanical limitations or electrical interference)
 Baseline fetal heart rate – refers to average FHR during 10 min
segment
o Excludes periodic tachycardia/bradycardia
 Baseline variability – irregular fluctuation in baseline FHR
o Measured as amplitude of peak to trough in b/min
 Deceleration – transient fall in FHR caused by stimulation of
Parasympathetic nervous system
o Shape and association to contraction
 Electronic fetal monitoring
 Periodic baseline changes – temporary, recurrent changes in response
to stimulus (contraction)
o Accelerations or decelerations
Overview of Nursing Management of Laboring Women
 Assessment
 Comfort measures
 Emotional support
 Information and instruction
 Advocacy
 Support for the partner
Maternal Assessment During Labor and Birth
 Maternal status (vital signs, pain, prenatal record review)
o Vaginal examination (cervical dilation, effacement, membrane
status, fetal descent, and presentation)
  Dilation – 1-10 cm opening and enlargement
 Effacement – 0%-100% shortening/thinning of cervix
 Presenting part – vertex, breech, transverse
 Station – relationship between presenting and ischial
spines
 (-) above (+) is below
o Rupture of membranes
 can occur at any point in labor, or before labor begins
 can occur spontaneously or artificially
 Assess for: Amount, color, blood, consistency, presence of
meconium, particulate?
 Cloudy, foul smelling = infection
 Green = meconium
 Note time
 Fetal heart rate must be assessed immediately after
ROM to evaluate for fetal response to ROM
o Uterine contractions (see Figure 14.2)
o Leopold maneuvers
 Involves 4 maneuvers to determine the presentation,
position and fetal lie
 Uses flat palm of hand w/ fingers together palpate uterus
1. What fetal part (head/buttocks) located in fundus?
2. Which side is fetal back located? (heart tones heard
best through the back of fetus)
3. What is the presenting part?
4. Is the fetal head flexed and engaged in pelvis?
Ferning
Assessment of Uterine Contractions
 Characteristics
o Systole – contractions
o Diastole - relaxation
 Frequency
o Measured from the beginning of one contraction to the beginning
of the next contraction
 Duration
o Measured from the start of one contraction to the end of the
same contraction
 Intensity
o Frequently measured by palpation and described as mild,
moderate or strong
 Increment – buildng up
 Peak – acme
 Decrement – letting down
  Resting
 5-10 mmHg
 > 30 mmHg initiates dilation
 Reaches 50-80 during active labor
 BY - Palpation or internal fetal monitoring

Fetal Assessment During Labor and Birth

 Amniotic fluid analysis (still watching for SROM vs. AROM, color,
consistency etc)
 Fetal Heart Rate (FHR)
o Initial 10- to 20-minute continuous FHR assessment on entry
into labor/birth area
o Completion of a prenatal and labor risk assessment on all clients
o Intermittent auscultation every 30 minutes during active labor
for low-risk women and every 15 minutes for high-risk women
 Able to move around
 Used to detect baseline, rhythm and changes
 Cannot detect variability and decelerations
o During second stage of labor intermittent auscultation every 15
minutes for low-risk women and every 5 minutes for high-risk
women
 Fetal heart rate monitoring
o Doppler or fetoscope
o Electronic fetal monitor
o Handheld versus electronic; intermittent versus continuous;
external versus internal
 Fetal heart rate patterns
o Baseline, baseline variability, periodic changes (see Table 14.1)
 Other assessment methods
o Fetal scalp sampling, pulse oximetry, stimulation
Continuous Electronic Fetal Monitoring
 Uses a machine to produce a continuous tracing of the FHR
 Produce a graphic record of the FHR pattern
 Primary objective
o To provide information about fetal oxygenation and prevent fetal
injury from impaired oxygenation
o To detect fetal heart rate changes early before they are
prolonged and profound
 Can be used while membranes are intact – non invase
o Gives FHR, contraction frequency and duration
Criteria for Using Continuous Internal Monitoring of the FHR
 Ruptured membranes
  Cervical dilation of at least 2 cm
 Present fetal part low enough to allow placement of the scalp electrode
 Skilled practitioner available to insert spiral electrode
 Internal monitoring is invasive and is used in high risk situations or
when external monitoring is not giving a clear picture (artifact)

Interpretation of FHR patterns

 Goal: assess adequacy of fetal oxygenation during labor
 Understanding of FHR physiology and influences on FHR is essential
 Normal FHR is 110 to 160 beats per minute
o Tachycardia >160 for 10+ minutes
 Early fetal hypoxia, maternal fever, dehydration, drugs,
infection, fetal anemia, prematurity
o Bradycardia <110 for 10+minutes
 late fetal hypoxia, medications, maternal hypotension
(epidural), maternal or fetal hypothermia/dehydration,
prolonged cord compression
Baseline GHR
 average rate during 10 min segment
 excludes periodic or episodic rate changes
 assessed w/ no contractions and fetus is not experiencing episodic
FHR changes
 110-160 bpm lasts 10 mins or longer
Four Categories of Baseline Variability – irregular fluctuation in baseline,
peak to trough in bpm
 Absent: fluctuation range undetectable
o Uteroplacental insufficiency, cord compression, preterm fetus,
maternal hypotension, hyperstimulation, abruptio placenta, fetal
dysrhythmia
 Interventions: improve blood flow and perfusion
 Lateral positioning, ^ IV, O2, internal fetal
monitoring, report to dr, prep for surgery
 Minimal: fluctuation range observed at <5 bpm
 Moderate: (normal) fluctuation range from 6 to 25 bpm
o Well O2
o Sign of fetal well being
 Marked: fluctuation range >25 bpm
o Cord prolapsed/compression, maternal hypotension,
hyperstimulation, abruption placenta
 Interventions – lateral positioning, ^ IV rate, supp O2,
stop oxy infusion, internal monitoting, report to dr,
prepare for surgery
 Periodic baseline changes:
 o Accelerations – abrupt increases above baseline that last < 30
secs from onset to peak
 > 15 bpm above base duration 15 secs – 2 mins
 Considered reassuring and require no interventions
o Decelerations – transient fall caused by stimulations
 Early – nadir (lowest point) occurs at peak of contraction
 Decreases no more than 3-40 bpm below baseline
 Onset, nadir, recovery occur at same time of onset,
peak, recovery of contraction
 Normally occurs during active stage of delivery,
pushing, crowning, vacuum extraction
 Result of head compression  reflex vagal response
 slowing of HR during contractions
 No distress and require no interventions
 Late – decrease in HR occurs after peak of contraction
 Can be recurrent w/ each contraction over a period
 Caused by decrease uteroplacental perfusion,
maternal hypotension, gestational hypertension,
placenta aging, hyperstimulation from O2 infusion,
smoking, anemia, cardiac disease
 Variable – abrupt decreases in HR below baseline have
unpredictable shape
 No consistent relationship to contractions
 ‘V’ or ‘W’ shape
 With cord compression
 A slow return to baseline warrants further monitoring
and evaluation
FHR variability
 Fluctuations in the baseline FHR
 Indicates the “push-pull” effect between the fetal sympathetic
(increases the FHR) and parasympathetic nervous system (decreases
the FHR)
 Most important predictor of adequate fetal oxygenation and fetal well
being during labor
 Fetal Heart Rate Decelerations

Accelerations (in normal range) are considered reassuring

Elevation of FHR = 15 bpm above baseline for 15 secs but < 2mins

Just remember “VEAL CHOP”

 Variables decelerations -------- Cord Compression
 Early decelerations ----------- Head Compression
 Accelerations --------- OK
 Late decelerations ------ Placental Issues
Nursing Care
  FHR decelerations
o Early: no action (cat I)
o Variable (indeterminate, abnormal) and Late (cat III)
 Position changes
 Oxygen via face mask
 Assess for underlying contributing causes
 Discontinue oxytocin
 Correct maternal hypotension (increase IV fluids)
 Notify provider, obtain further orders
Fetal Distress = lack of variability, late decelerations, fetal tachycardia 
notify dr

Interpreting FHR Patterns

Interventions for Category III Patterns

Comfort and Pain Management
 Pain as universal experience; intensity highly variable
 Mandate for pain assessment in all clients admitted to health care
facility
 Numerous nonpharmacologic and pharmacologic choices available
o Continuous labor support
 Emotional support, comfort measures, advocacy,
Info/advice, support to partner
o Hydrotherapy
 External use of water (showering/soaking)
 Warmth and buoyancy help release muscle tension
 Promotes vasodilation and reduction in catecholamines
 Contractions less painful
o Ambulation and position changes
 Supine s/be avoided  decrease labor progression,
compression of vena cava, decrease blood return to heart
 Common Positions for Use during Labor and Birth

Standing • Takes advantage of gravity

during and between
contractions
• Makes contractions feel less
painful and be more
productive
• Helps fetus line up with
angle of maternal pelvis
• Helps increase urge to push
 in second stage of labor

Walking • Has the same advantages

as standing
• Causes changes in the
pelvic joints, helping the
fetus move through the
birth canal

Standing and leaning forward on partner, bed, or birthing ball • Has the same advantages
as standing
• Is a good position for a
backrub
• May feel more restful than
standing
• Can be used with electronic
fetal monitor

Slow dancing (standing with woman’s arms around partner’s neck, head • Has the same advantages
resting on his chest or shoulder, with his hands rubbing woman’s lower as walking
back; sway to music and breathe in rhythm if it helps) • Back pressure helps relieve
back pain
• Rhythm and music help
woman relax and provide
comfort

The lunge (standing facing a straight chair with one foot on the seat with • Widens one side of the
knee and foot to the side; bending raised knee and hip, and lunging pelvis (the side toward
sideways repeatedly during a contraction, holding each lunge for 5 lunge)
seconds; partner holds chair and helps with balance) • Encourages rotation of the
baby
• Can also be done in a
kneeling position

Sitting upright • Helps promote rest

• Has more gravity advantage
than lying down
• Can be used with electronic
fetal monitor

Semi-sitting (setting the head of the bed at a 45-degree angle with pillows • Has the same advantages
used for support) as sitting upright
• Is an easy position if on a
bed
Sitting on toilet or commode • Has the same advantages
as sitting upright
• May help relax the
perineum for effective
bearing down

Rocking in a chair • Has the same advantages

as sitting upright
• May help speed labor
(rocking movement)

Sitting, leaning forward with support • Has the same advantages

as sitting upright
• Is a good position for a
backrub

On all fours, on hands and knees • Helps relieve backache

• Assists rotation of baby in
posterior position
• Allows for pelvic rocking
and body movement
• Relieves pressure on
hemorrhoids
• Allows for vaginal
examinations
• Is sometimes preferred as a
pushing position by women
with back labor

Kneeling, leaning forward with support on a chair seat, the raised head of the • Has the same advantages
bed, or on a birthing ball as all-fours position
• Puts less strain on wrists
and hands

Side-lying • Is a good position for resting

and convenient for many
kinds of medical
interventions
• Helps lower elevated blood
pressure
• May promote progress of
labor when alternated with
walking
• Is useful in slowing a rapid
 second stage
• Avoids vena cava syndrome
• May offer increased control
of pushing efforts
• Takes pressure off
hemorrhoids
• Facilitates relaxation
between contractions

Squatting • May relieve backache

• Takes advantage of gravity
• Requires less bearing-down
effort
• Widens pelvic outlet by
approximately 28%
• Pressure is evenly
distributed to the perineum,
reducing the need for
episiotomy
• May help fetus turn and
move down in a difficult
birth
• Helps if the woman feels no
urge to push
• Allows freedom to shift
weight for comfort
• Offers an advantage when
pushing, since upper trunk
presses on the top of the
uterus

Supported squat (leaning back against partner, who supports woman under • Requires great strength in
the arms and takes the entire woman’s weight; standing up between partner
contractions) • Lengthens trunk, allowing
more room for fetus to
maneuver into position
• Lets gravity help

Dangle (partner sitting high on bed or counter with feet supported on chairs • Has the same advantages
or footrests and thighs spread; woman leaning back between partner’s of a supported squat
legs, placing flexed arms over partner’s thighs; partner gripping sides with • Requires less physical
his thighs; woman lowering herself and allowing partner to support her full strength from the partner
weight; standing up between contractions)
 o Acupuncture and acupressure
o Attention focusing and imagery
o Therapeutic touch
 Massage – increases production of endorphins
 effleurage (light stroking, superficial touch of abdomen in
rhythm w/ breathing during contractions)
o Breathing techniques (e.g., patterned-paced breathing)
 Focused more on breathing than on pain
 Pharmacologic Measures
o Systemic analgesia – involves use of one or more
 Route: typically administered parenterally through existing
IV line – circulatory system
 Relief occurs w/in mins and last for several hrs
 Can cause resp depression – need to monitor
 Opioids given close to birth can cause resp
depression in newborn
 Drugs
 Common Agents Used for Systemic Analgesia
Type Drug Comments
Opioids Morphine 2–5 mg IV May be given IV or epidurally
Rapidly crosses the placenta, causes a
decrease in FHR variability
Can cause maternal and neonatal CNS
depression
Decreases uterine contractions
  Meperidine (Demerol) May be given IV, intrathecally, or epidurally
25–75 mg IV with maximal fetal uptake 2–3 hr after
administration
Can cause CNS depression
Decreases fetal variability
  Butorphanol (Stadol) 1–2 Is given IV
mg IV
  Q 2–4 hr Is rapidly transferred across the placenta
Causes neonatal respiratory depression
  Nalbuphine (Nubain) 10– Is given IV
20 mg IV Causes less maternal nausea and vomiting
Causes decreased FHR variability, fetal
bradycardia, and respiratory depression
  Fentanyl (Sublimaze) Is given IV or epidurally
50–100 mcg IV Can cause maternal hypotension, maternal
and fetal respiratory depression
Rapidly crosses placenta
Antiemetics Hydroxyzine (Vistaril) Does not relieve pain but reduces anxiety and
50–100 mg IM potentiates opioid analgesic effects; cannot
be given IV
Is used to decrease nausea and vomiting
  Promethazine Is used for antiemetic effect when combined
(Phenergan) 25–50 with opioids
mg IV or IM Causes sedation and reduces apprehension
May contribute to maternal hypotension and
neonatal depression
  Prochlorperazine Frequently given with morphine sulfate for
(Compazine) 5–10 mg sleep during prolonged latent phase;
IV or IM counteracts the nausea that opioids can
produce
Benzodiazepine Diazepam (Valium) 2–5 Is given to enhance pain relief of opioid and
s mg IV cause sedation
May be used to stop eclamptic seizures
Decreases nausea and vomiting
Can cause newborn depression; therefore,
lowest possible dose should be used
  Midazolam (Versed) 1–5 Is not used for analgesic but amnesia effect
mg IV Is used as adjunct for anesthesia
Is excreted in breast milk

o Regional or local anesthesia

 Epidural block: continuous infusion or intermittent
injection; usually started when dilation >5 cm
 Increases duration of 2nd stage of labor
 Contraindicated w/ previous spinal
surgery/abnormalities, coagulation defects, cardiac
disease, obesity, infections, hypovolemia
 Complications: n/v, hypotension, fever, pruritus,
intravascular injection, allergic reaction, resp
depression
 Combined spinal–epidural block (“walking epidural”)
 Opioid w/out local anesthetic is injected
 Quick onset 3-5 mins last for 3 hrs
 Motor function remain active
 Doesn’t affect 2nd stage – still able to bear down
 Patient-controlled epidural
 Program pump, control dosage
 Local infiltration (usually for episiotomy or laceration
repair)
 Lidocaine in superficial perineal nerve – numbs area
  Done right before episiotomy or suturing laceration
 No side effects for mom or baby
 Pudendal block (usually for second stage, episiotomy, or
operative vaginal birth)
 Long lasting analgesia
 Nerve block injection near ischial spine
 Pain relief in lower vagina, vulva, perineum
 Given 15 mins before
 No side effects for mom or baby
 Intrathecal (spinal) analgesia/anesthesia (during labor and
cesarean birth)
 Caine agent w/ or w/out opiods
 Side effects – hypotension and headache
 Lasts a few hours
 Can add morphine or fentanyl
Location of Episiotomy

Epidural Catheter Insertion

Complications of Regional Anesthesia

 Maternal Hypotension
 o Most common side effect
o Prevention
 Preload IV fluids continuously until delivery
 Use dextrose free solution to decrease risk of fetal
hyperglycemia w/ rebound hypoglycemia
o Monitor VS – requires constant nursing attendance
 n/v
 fever
 pruritus
 intravascular injection
 respiratory depression
 urinary retention
 Fetal distress (bradycardia) due to maternal hypotension

General Anesthesia
 Emergency cesarean birth or woman with contraindication to use of
regional anesthesia
 IV injection, inhalation, or both
 Commonly, first thiopental IV to produce unconsciousness
 Next, muscle relaxant
 Then intubation, followed by administration of nitrous oxide and
oxygen; volatile halogenated agent also possible to produce amnesia
Complications include: fetal depression, uterine relaxation, maternal
vomiting and aspiration

First Stage of Labor: Phone Assessment – True or False labor?

 Estimated date of birth
 Fetal movement; frequency in past few days
 Other premonitory signs of labor experienced
 Parity, gravida, and previous childbirth experiences
 Time frame in previous labors
 Characteristics of contractions – freq, duration, intensity
 Bloody show and membrane status (whether ruptured or intact)
 Presence of supportive adult in household or if she is alone

Nursing Care During First Stage of Labor

 General measures
o Obtain admission history
o Check results of routine laboratory tests and any special tests
o Ask about childbirth plan
o Complete a physical assessment
 Initial contact either by phone or in person
First Stage of Labor: Admission Assessment
  Maternal health history
 Physical assessment (body systems, vital signs [temp, P, R, BP], heart
and lung sounds, height and weight)
o Fundal height measurement
o Uterine activity, including contraction frequency, duration, and
intensity
o Status of membranes (intact or ruptured)
o Cervical dilatation and degree of effacement
o Fetal heart rate, position, station
o Pain level
o Ambulate safely
o Leopold maneuvers – fetal lie
 Fetal assessment
 Lab studies
o Routine: urinalysis, CBC
o Syphilis screening, HbsAg screening [Hep B], GBS [Group B
strep], HIV (with woman’s consent), and possible drug screening
if not included in prenatal history
o Rh factor if unknown
 Assessment of psychological status
o Every hr during latent phase VS [BP, P, R]
o Every 30 mins during active phase
o Temp every 4 hrs 1st stage and every 2 hrs once membranes
rupture
 Woman’s knowledge, experience, and expectations
 Vital signs
 Vaginal examinations
 Uterine contractions
 Pain level
 Coping ability
 FHR
 Amniotic fluid
 Summary of Assessments during the First Stage of Labor
Assessmentsa Latent Phase (0–6 cm) Active Phase (6–10 cm)

Vital signs (BP, pulse, Every 30–60 min Every 15–30 minutes
respirations)

Temperature Every 4 hours; more frequently if Every 4 hours; more frequently

membranes are ruptured if membranes are ruptured

Contractions (frequency, Every 30–60 minutes by palpation or Every 15–30 minutes by

 duration, intensity) continuously if EFM palpation or continuously if
EFM

Fetal heart rate Every hour by Doppler or continuously by Every 15–30 minutes by
EFM Doppler or continuously by
EFM

Vaginal examination Initially on admission to determine phase As needed to monitor labor

and as needed based on maternal cues progression
to document labor progression

Behavior/psychosocial With every client encounter: talkative, With every client encounter:
excited, anxious self-absorbed in labor;
intense and quiet now

Nursing Management: Second Stage

 Assessment
o Typical signs of second stage
o Contraction frequency, duration, intensity
o Maternal vital signs every 5 -15 mins
o Fetal response to labor via FHR
o Amniotic fluid with rupture of membranes
o Coping status of woman and partner
o Sudden appearance of sweat on upper lip
o Increase in blood tinged show
o Low grunting sounds
o Complaints of rectal/perineal pressure
o Beginning of involuntary bearing down
o Progress of labor
 Bulging, labial separation, advancing retreating of head,
crowning
 Interventions
o Supporting woman and partner in active decision making
o Supporting involuntary bearing-down efforts; encouraging no
pushing until strong desire or until descent and rotation of fetal
head well advanced
o Providing instructions, assistance, pain relief
o Using maternal positions to enhance descent and reduce pain
o Preparing for assisting with delivery
 Interventions with birth
o Cleansing of perineal area and vulva
o Prepare for birth
  Summary of Assessments during the Second, Third, and Fourth
Stages of Labor
Assessmentsa Second Stage of Third Stage of Labor Fourth Stage of Labor
Labor (Birth of (Placenta Expulsion) (Recovery)
Neonate)

Vital signs (BP, pulse, Every 5–15 minutes Every 15 minutes Every 15 minutes
respirations)

Fetal heart rate Every 5–15 minutes by Apgar scoring at 1 and Newborn—complete head-
Doppler or 5 minutes to-toe assessment; vital
continuously by EFM signs every 15 minutes
until stable

Contractions/uterus Palpate every one Observe for placental Palpating for firmness and
separation position every 15 minutes
for first hour

Bearing down/pushing Assist with every effort None None

Vaginal discharge Observe for signs of Assess bleeding after Assess every 15 minutes
descent—bulging of expulsion with fundus firmness
perineum, crowning

Behavior/psychosocial Observe every 15 Observe every 15 Observe every 15 minutes:

minutes: cooperative, minutes: often usually excited, talkative,
focus is on work of feelings of relief awake; needs to hold
pushing newborn out after hearing newborn, be close, and
newborn crying; inspect body
calmer
Suggested positions for 2nd stage
 Lithotomy – feet up in stirrups
 Semi-sitting w/ pillows under knees, arms, back
 Later/side lying – curved back and upper leg supported by partner
 Sitting on birthing stool – opens pelvis, pull of gravity
 Squatting – sense of control
 peanut ball – widen pelvic diameter
 Kneeling w/ hand on bed and knees comfortably apart
Nursing Management: Third Stage
 Assisting w/ birth
 suctioning of newborn
 umbilical cord clamping
o 2 plastic clamps are placed on the umbilical cord and the cord is
cut between the clamps
o Nurse: inspect cut cord for presence of 2 arteries and 1 vein
 o Collect cord blood sample for laboratory analysis
 Cord blood banking
 Place baby on mom’s abdomen/chest if stable
 Provide immediate care of newborn
o Drying
o APGAR score
o identification
 Assessment
o Placental separation; placenta and fetal membranes
examination; perineal trauma; episiotomy; lacerations
Assessment during the third stage of labor includes:
 Monitoring placental separation by looking for the following signs:
 Firmly contracting uterus
 Change in uterine shape from discoid to globular ovoid
 Sudden gush of dark blood from vaginal opening
 Lengthening of umbilical cord protruding from vagina
 Examining placenta and fetal membranes for intactness the second time (the
health care provider assesses the placenta for intactness the first time)
 Assessing for any perineal trauma, such as the following, before allowing the birth
attendant to leave:
 Firm fundus with bright red blood trickling: laceration
 Boggy fundus with red blood flowing: uterine atony
 Boggy fundus with dark blood and clots: retained placenta
 Inspecting the perineum for condition of episiotomy if performed
 Assessing for perineal lacerations and ensuring repair by birth attendant
Interventions
o Instructing to push when separation apparent; giving oxytocin if
ordered; assisting woman to comfortable position; providing
warmth; applying ice to perineum if episiotomy; explaining
assessments to come; monitoring mother’s physical status;
recording birthing statistics; documenting birth in birth book
Nursing Management: Fourth Stage
 Assessment: vital signs [1st hr after every 15 mins, next hr every 30
min] (P slower 60-70 than during labor, R 16-24), fundus (every 15
mins 1st hr), perineal area, comfort level, lochia [every 15 mins for 1st
hr, 30 min for next hr], bladder status [s/be large amount of urine
(diuresis)need to empty each time, palpate if needed]
 Interventions
o Support and information
o Fundal checks; perineal care and hygiene
o Bladder status and voiding
o Comfort measures
o Parent–newborn attachment
o Teaching