LABOR and BIRTH

LABOR 2. Increase in Level of Activity

 It is a series of events by which uterine  “burst of energy”
contractions expel a fetus and placenta  Due to increased epinephrine release
from a woman’s body. initiated by a decrease in progesterone
produced by the placenta
THEORIES OF LABOR ONSET: 3. Slight Weight Loss
A. Uterine muscle stretching, which results in  1 to 3 lbs. may occur 2 to 3 days before
release of prostaglandins the onset of labor
B. Pressure on the cervix, which stimulates he  Due to increase in urine production
release of oxytocin from the posterior (progesterone level falls)
pituitary 4. Braxton-Hicks Contractions
C. Oxytocin stimulation, which works together  “false” labor contractions
with prostaglandin to initiate contractions 5. Cervical softening and effacement
D. Placental age, which triggers contractions at  Goodell’s sign – “ripening” of the cervix
a set point (as soft as the earlobe)
E. Change in the ratio of estrogen to
progesterone (increasing estrogen in relation SIGNS OF TRUE LABOR:
to progesterone, which is interpreted as 1. Uterine Contractions
progesterone withdrawal)  Involuntary, come without warning, and
F. Rising fetal cortisol levels, which reduces intensity can be frightening in early labor
progesterone formation and increases  Nursing Management: Teach woman to
prostaglandin formation do deep breathing exercises
G. Fetal membrane production of 2. Show
prostaglandin, which stimulates contractions  Also termed as “bloody show” – pink
tinge blood mixed with mucus
PRELIMINARY SIGNS OF LABOR: Operculum (mucus plug) is expelled as
1. Lightening the cervix softens
 Descent of the fetus and uterus into the 3. Rupture of the Membranes
pelvic cavity 10-14 days or 2 weeks  Sudden gush or scanty, slow seeping of
before the onset of labor clear fluid from the vagina
 Gives a woman relief from diaphragmatic  Early rupture of membranes can be
pressure and shortness of breath advantageous (causes fetal head to settle
 Woman may experience shooting leg snugly into the pelvis, shortening labor)
pains from the increased pressure on her  2 risks: intrauterine infections and
sciatic nerve, increased amounts of prolapse of the umbilical cord
vaginal discharge, and urinary frequency
from pressure on her bladder.

TRUE LABOR FALSE LABOR

Contractions  Regular intervals  Irregular intervals
 Starts at the back  Chiefly abdomen
 Increase in intensity  Intensity remains the
& duration  Same or variable
 Shortened intervals  Long intervals
Bloody show  Present  Not present
Cervix  Effaced & dilated  No change
Sedation  Does not stop contractions  Decreases contractions
Components of Labor (4 P’s + 1):  palpating during a pelvic examination
helps to establish the position of fetal
1. The PASSAGEWAY head
 Adequacy of the maternal pelvis and birth a) Sinciput
canal in allowing fetal descent b) Occiput
 Refers to the pelvic planes and pelvic  Molding – overlapping of skull bones along
diameters with the suture lines, which causes a
 2 pelvic measurements: change in the shape of the fetal skull to
1) Diagonal conjugate (anteroposterior one long and narrow, a shape that
diameter of the inlet) facilitates passage through the rigid pelvis
2) Transverse diameter of the outlet
 Types of Pelvis: FETAL PRESENTATION AND POSITION:
1. GYNECOID - normal female pelvis; A. FETAL ATTITUDE
inlet is well-rounded forward and  It describes the degree of flexion a
back; most ideal for childbirth fetus assumes during labor or the
2. ANTHROPOID - Transverse diameter relation of the fetal parts to each
is narrow, AP diameter is larger than other
normal a. Vertex (Complete flexion) - good
3. PLATYPELLOID - Inlet is oval, AP attitude
diameter is shallow b. Sinciput (moderate flexion) –
4. ANDROID - Male pelvis; inlet has a military attitude
narrow, shallow posterior portion and c. Brow (partial extension)
pointed anterior portion. d. Face (poor flexion, complete
extension)
2. The PASSENGER B. ENGAGEMENT
 The size and number of fetus and its ability  It refers to the settling of the
to move through the passageway presenting part of a fetus far enough
 Structure of the Fetal Skull into the pelvis that it rests at the
a. 4 Superior bones: level of the ischial spines.
1) Frontal bone (two bones fused as  Descent to this point means the
one bone) widest part of the fetus has passed
2) 2 Parietal bones through the pelvis or the pelvic inlet
3) Occipital bone has been proven adequate for birth
b. Sphenoid  Nonengagement: PRIMIPARA –
c. Ethmoid possible complication
d. 2 temporal bones  It is established by a vaginal and
 Suture lines - important in birth cervical examination:
a. Sagittal suture 1) “Floating” – a presenting part is
b. Coronal suture not engaged
c. Lambdoid suture 2) “Dipping” – one that is
 Fontanels – membrane-covered spaces descending but has not yet
found at the juncture of the main suture reached the ischial spines
lines; fontanel spaces compress to aid in C. STATION
molding  It refers to the relationship of the
a. Anterior fontanel (bregma) – lies at presenting part of the fetus to the
the junction of coronal and sagittal level of the ischial spines
sutures; diamond-shaped  Measurement of stations:
b. Posterior fontanel - lies at the  0 Station – at the level of
junction of lambdoid and sagittal ischial spines (engaged)
sutures; triangular-shaped  -1 to -4 cm Station – above the
 Vertex spines
 the space between the two fontanels  +1 to +4 cm Station – below
 compresses during birth to aid in the ischial spines; +3 or +4
molding of the fetal head station (“crowning”)
 o Longitudinal, moderate
D. FETAL LIE attitude
 It is the relationship between the o the most common variety
long axis of the fetal body and the 3) Footling
long axis of a woman’s body o Neither the thighs nor
1) Horizontal (transverse) - lower legs are flexed
shoulder o If one foot presents, it is a
2) Vertical (longitudinal) – 99% single-footling breech; if
 Cephalic both present, it is a double-
 Breech footling breech
3. SHOULDER PRESENTATION
FETAL PRESENTATION:  The fetus lies horizontally /
o It denotes the body part that will first transversely in the pelvis so the
contact the cervix or be born first longest fetal axis is perpendicular
o It is determined by the combination of to that of the mother
fetal lie and the degree of fetal flexion  Possible causes:
(attitude)  Pelvic contractions
o It has three (3) types:  Placenta previa
1. CEPHALIC PRESENTATION  Relaxed abdominal walls
 The most frequent type (95%)  The presenting part is usually:
 The fetal head is the body part  one of the shoulders
that contacts the cervix (acromion process)
 Four (4) types:  An iliac crest
1) Vertex – longitudinal, full  A hand
flexion (good)  An elbow
2) Brow – longitudinal, military
flexion (moderate) FETAL POSITION:
3) Face – longitudinal (poor o It is the relationship of the presenting
attitude) part to a specific quadrant of the
4) Mentum (chin) – longitudinal mother’s pelvis
(very poor) o Four (4) quadrants of the pelvis:
2. BREECH PRESENTATION 1. Right anterior
 Either the buttocks or the feet are 2. Left anterior
the first body parts that will 3. Right posterior
contact the cervix (3%) 4. Left posterior
 Affected by fetal attitude: o Four (4) parts of the fetus chosen as
 A good attitude brings the fetal landmarks:
knees up against the fetal 1. Occiput (O) - in a vertex position
abdomen 2. Chin/Mentum (M) – in a face
 A poor attitude means the presentation
knees and legs are extended 3. Sacrum (Sa) – in a breech
 Types of Breech Presentation: presentation
1) Complete breech 4. Scapula/Acromion process (A) – in
o Thighs tightly flexed on the a shoulder presentation
abdomen; both the o Fetal position is important because it
buttocks and the tightly can influence both the process and
flexed feet present to the efficiency of labor
cervix o Most desirable positions: ROA and LOA
o longitudinal, good attitude (make delivery faster)
(full flexion)
2) Frank breech 3. The POWERS OF LABOR
o Hips are flexed, but the  It refers to the frequency, duration, and
knees are extended to rest strength (intensity) of uterine contractions
on the chest; buttocks alone to cause complete cervical effacement and
present to the cervix dilation.
 It is the force supplied by the fundus of elongated one with a vertical diameter
the uterus and implemented by uterine markedly greater than the horizontal
contractions, which causes cervical diameter
dilatation and then expulsion of the fetus.  The elongation of uterus causes
pressure against the diaphragm and
 After full dilatation of the cervix, the causes the sensation that a uterus is
primary power is supplemented by the use “taking control” of a woman’s body
of the abdominal muscles (secondary
power) CERVICAL CHANGES
 Two (2) changes:
UTERINE CONTRACTIONS 1. Effacement
 Braxton-Hicks contractions – periodic  Shortening and thinning of
contraction and relaxation of the uterus cervical canal
(false labor); irregular and painful but does  Primipara: effacement is
not cause cervical dilatation accomplished before dilatation
 True uterine contractions have rhythmicity,  Multipara: dilatation may
a progressive increase in length and proceed before effacement is
intensity, and accompany dilatation of the complete
cervix.  Must occur by the end of
 Contractions are assessed according to dilatation before the fetus cab be
frequency, duration, and strength. safely pushed through the
cervical canal; otherwise, cervical
A. Origins of Contractions tearing can result
 Contractions begin in uterine 2. Dilatation
myometrium (“pacemaker”)  Enlargement or widening of the
 Contractions normally start in the cervical canal from few
uterine fundus, not in the lower uterine millimeters wide to
segment approximately 10 cm to permit
 Contractions that originate in the lower passage of a fetus
uterine segment may cause tightening  Occurs first because:
rather the dilatation of the cervix; may • Uterine contractions
cause pain before the contraction is gradually increase the
readily palpated in the fundus diameter of the cervical canal
 Uncoordinated contractions may slow lumen by pulling the cervix
labor and can lead to failure to progress up over the presenting part
and fetal distress of the fetus
B. Phases of Contractions • Fluid-filled membranes push
 Three (3) phases: ahead of the fetus and serve
1) Increment – when the intensity of as a wide opening wedge. If
the contraction increases they are ruptured, the
2) Acme – when the contraction is at its presenting part will serve this
strongest / peak same function
3) Decrement – when the contraction  As dilatation begins, there is an
decreases increase in the amount of vaginal
C. Contour Changes secretions (show), because
 Two (2) distinct functioning areas of minute capillaries in the cervix
uterus as labor contractions progress rupture and the last of the mucus
and become regular and strong: plug that has sealed the cervix
1. Upper portion – active segment; since early pregnancy is released.
thickens to supply force for
contractions 4. The PSYCHE
2. Lower segment – passive segment;  The client’s psychological response /
becomes thin-walled, supple, and outlook
passive to help fetus pushed out of  The woman’s psychological state or
the uterus easily feelings (apprehension or fright;
 Contour of the overall uterus changes excitement or awe), culture and values,
from a round, ovoid structure to an available support systems, preparation for
 childbirth, experiences, and coping
strategies.
 The progress of labor and birth can be
THE STAGES OF LABOR
adversely affected by maternal fear and
tension.
 Norepinephrine and epinephrine may Intrapartum Pain Management:
stimulate both alpha and beta receptors of A. Goals:
the myometrium and interfere with the 1. To provide maximal relief of pain with
rhythmic nature of labor. maximal safety for the mother and the fetus
 Anxiety can also increase pain perception 2. To facilitate labor and delivery as a positive
and lead to an increased need for family experience
analgesia & anesthesia.
 Nursing responsibility: B. Nursing care common to all stages:
 Encourage women to ask questions at 1. Establish trust; answer questions.
prenatal visits and to attend 2. Support parents/coach; use standard
preparation for childbirth classes. precautions.
 Encourage women to share their 3. Monitor: Contractions, dilation,
experience after labor. engagement and position/presentation,
fetal/maternal VS (assess between
5. The PLACENTAL Factors contractions, FHR), dehydration, edema.
 Protrusion of placenta 4. Provide fluids per order; encourage voiding
 Placental abnormalities every 1–2 hours; inform parents/MD of
progress.
5. For ↓BP: Turn to side, then retake.
6. For O2 saturation↓90%: Provide oxygen.
7. Fetal monitoring for ruptured membranes:
Assess for prolapsed cord, meconium-
stained amniotic fluid (indicates fetal
compromise), signs and symptoms of
infection.

1. FIRST STAGE
 from the onset of regular contractions to full dilatation of the cervix; takes 12 hours to complete
 Phases:
Phases Duration Interval Intensity Cervical Behavior
Dilatation
LATENT 10-30 sec. 5-30 min. mild to 0-3 cm cooperative
moderate
ACTIVE 30-40 sec. 3-5 min. moderate to 4-7 cm apprehensive
strong
TRANSITION 45-90 sec. 2-3 min. strong 8-10 cm out of control
 NURSING CARE / MANAGEMENT:
1) Encourage ambulation/upright position if no ruptured membranes.
2) Review breathing and focusing techniques.
3) Offer fluids/foods, if ordered.
4) Assess fetal presentation and position (Leopold’s maneuver).
5) Assist with position changes, hygiene and oral care.
6) Provide counter-pressure to sacrococcygeal area, pillow support and backrubs.
7) Offer/explain pain medications ordered.
8) Talk through contraction.
9) Initiate hydrotherapy if desired.
10) Encourage breathing and focusing techniques.
11) Stay with patient; accept irritability.
12) Use relaxation techniques between contractions.
 13) Teach to pant (avoids premature pushing).
14) Provide supportive care for N&V and pain relief as indicated.
15) Prepare for birth.

2. SECOND STAGE (“Pushing Stage”) 2) Semi-Fowler’s with legs raised

 From full cervical effacement and dilatation against the abdomen
to birth of the infant (McRobert’s Maneuver)
 Takes about one (1) hour to complete 3) Lateral or Sim’s
 Woman feels contractions change from the 4) Dorsal recumbent
characteristic crescendo pattern to an 5) Semi-sitting
uncontrollable urge to push and bear down 6) Sitting (water birth)
with each contraction as id to move her 7) Squatting with support
bowels 8) On all-fours
 She may experience momentary nausea 9) On all-fours with chest support
and vomiting • The woman must push (short
 She perspires and blood vessels in her neck pushes, or long, sustained ones)
become distended with contractions and rest between
 Mechanism of Labor: (ED FIRE ERE) them
o Engagement • Breathing:
o Descent 1) Urge the woman to grunt or
o Flexion breathe out during a pushing
o Internal Rotation effort (to prevent Valsalva
o Extension maneuver)
o External Rotation 2) Teach to “Pant like a puppy” -
o Expulsion Pushing is prevented at some
 Dilatation complete point (in case of nuchal cord);
 Progress determined by descent through be sure she is inhaling
birth canal (fetal station) adequately (to avoid
 Strong contractions every 2–3 minutes, 60– hyperventilation and light-
75 seconds long; headedness)
 ↑bloody show; fetal head visible  Clean and Massage Perineum
(crowning) • Cleaning the perineum removes
 Mother: vaginal or rectal secretions and
1) Relaxes between but pushes with prepares the cleanest environment
contractions for the birth of the baby
2) May complain of severe pain or burning • Massaging the perineum helps to
sensation as perineum distends keep the vagina supple and
 NURSING CARE / MANAGEMENT: prevent tearing
 Prepare the Place of Birth  Assess for crowning
• Equipment: mayo table with  Offer mother mirror to see birth
sponges, drapes, scissors, basins,  Assist for Birth
clamps, vaginal packing, sterile • Use Ritgen’s Maneuver
gowns, gloves, towels • Head is gently born between
• Birthing bed contractions to prevent the head
• Newborn care area: heat warmer, from being expelled too rapidly (to
suction and resuscitation machine, avoid ruptured cerebral blood
baby’s mittens, and supplies for vessels) and to prevent possible
vaccines, eye prophylaxis, perineal tear
anthropometric measurements, • Check for nuchal cord
and identification • Apple gentle pressure downward
 Promote Effective Second-Stage on the side of the fetal head so
Pushing anterior shoulder is born, then the
• Push only at full dilatation and if remainder of the body slides
there is urge to push without difficulty
• Position the woman in: • Note and record time of birth
1) Lithotomy • Initiate mother-infant bonding
right away
 • Assess neonate (APGAR score)  Retained placental fragments lead to
 Cut and Clamp the Cord postpartum hemorrhage
• Maintain timing of cord clamping  Expelled placenta may be:
and cutting (depends on maturity o Brought home by family
of infant) o Used for blood withdrawal for
• Obtain cord blood sample (if stem cell transplantation
necessary) o Used for blood withdrawal for
• Count vessels of cord (AVA) community stem cell banking
• Apply umbilical clamp  NURSING CARE / MANAGEMENT:
 Introduce the Infant  Delivery of the Placenta
• Do newborn care 1) If placenta is not delivered after
1) Maintain skin-to-skin contact about 10 minutes, ask the mother
of mother-infant to bear down gently or apply
2) Dry infant in an orderly gentle pressure on the contracted
manner uterine fundus along with the
3) Administer eye ointment gentle traction on the umbilical
4) Do anthropometric cord
measurements 2) Inspect placenta after delivery if it
5) Inject Vitamin K and Hepa. B is intact.
6) Put identification band 3) Massage the fundus (if uterus has
7) Initiate breastfeeding for at not contracted firmly on its own).
least 30 minutes 4) Administer oxytocin and
carboprost tromethamine (as
3. THIRD STAGE (“Placental Stage”) ordered) to increase uterine
 Begins from birth of the neonate and ends contraction and prevent
with the delivery of the placenta haemorrhage.
 Signs of Placental Separation: 5) Obtain BP before administering
1. sudden gush of vaginal blood Pitocin and other blood-related
2. firming and upward movement/ drugs.
contraction of fundus  Perineal Inspection
3. placenta is visible at the vaginal 1) Inspect for perineal tears (Degree
opening 1-4)
4. lengthening of umbilical cord 2) Do perineal repair (episioraphy)
 Contractions every 3–4 minutes  Immediate Postpartum
 Occurs 5-10 minutes after delivery of the Assessment
baby; must be completed within 30 1) Obtain vital signs every 15 minutes
minutes for the first hour and then according
 ↓bleeding as uterus shrinks to agency’s policy or the woman’s
 May have perineal laceration or condition
prophylactic incision (episiotomy) • P: 80-90 beats/min; R: 20-24
 PLACENTAL EXPULSION cycles/min; BP: may be slightly
 Brandt-Andrews Maneuver – it is a elevated; T: low; often
method of expressing the placenta by experiences chills and shaking
grasping the umbilical cord with one sensation 10-15 minutes after
hand and placing the other hand on the birth
abdomen. 2) Palpate and assess position and
 Placenta is delivered either by the tone of fundus (2 fingerbreadths
natural bearing-down effort of the below umbilicus), bleeding (2
mother or may be removed manually pads/hr., no free-flow/clots with
by applying gentle pressure on the fundal massage), perineum (sutures
contracted uterine fundus by the intact, no bulging, slight bruising,
practitioner (Crede Maneuver). Too no severe pain), and bladder
much pressure applied to an (nondistended)
uncontracted uterus can avert it and 3) Wash perineum with solution and
can cause massive hemorrhage. apply perineal pad
 4) Observe the amount and 6) Assess spontaneous voiding, if
characteristics of lochia each time discomfort is tolerable (3 on 1–10
you check the V/S pain scale)
5) Offer clean gown/clothing and 7) Provide hygiene
warm blanket

Stage Do’s Don’ts

1st STAGE (Latent) o Assess progress of labor o Do not do vaginal

o REFER: if after 8 hrs, examination more
 cervix is dilated 0-3
contractions are stronger & frequently than 4 hours
cm
more frequent but no
cervical dilatation & + / -
ruptured membranes

1st STAGE (Active) o Check emergency signs every o Do not do pushing unless
30 min. delivery is imminent
 cervix is dilated 4-7
o Check VS every 4 hrs. o Do not give medications
cm
o Record time of ROM; AF color to speed up labor

2nd STAGE o Check perineum for thinning o Do not apply fundal

& bulging every 5 min. pressure
 cervix is dilated 10
o Check FHT
cm
o Observe mood & behavior
 bulging thin
perineum & head is
visible

3rd STAGE o Deliver the placenta o Do not squeeze or

o Check for completeness of massage the abdomen to
 between birth of
membranes deliver the placenta
the baby and
the delivery of
the placenta

MATERNAL AND FETAL RESPONSES TO LABOR  PHYSIOLOGIC FETAL RESPONSES TO LABOR

A. Neurologic System
 PHYSIOLOGIC EFFECTS OF A WOMAN TO B. Cardiovascular System
LABOR C. Integumentary System
A. Cardiovascular System D. Musculoskeletal System
B. Hematopoietic System E. Respiratory System
C. Respiratory System
D. Temperature Regulation MATERNAL DANGER SIGNS OF LABOR:
E. Fluid Balance 1. High or low blood pressure
F. Urinary System 2. Abnormal pulse
G. Musculoskeletal System 3. Inadequate or prolonged contractions
H. Gastrointestinal System 4. Pathologic retraction ring
I. Neurologic and Sensory Responses 5. Abnormal lower abdominal contour
6. Increasing apprehension
 PSYCHOLOGICAL RESPONSES OF A WOMAN
TO LABOR FETAL DANGER SIGNS:
A. Response to Pain 1. High or low FHR
B. Response to Fatigue 2. Meconium staining
C. Response to Fear 3. Hyperactivity
D. Cultural Influences 4. Low oxygen saturation
 Measuring Progress in Labor: • Every 15 minutes (ACTIVE first stage
 PARTOGRAM – records: labor)
 Vital signs • Every 5 minutes (second stage of labor)
 FHR • Equipment used:
 Cervical dilatation  Fetoscope
 Descent of the fetal head  Pinard stethoscope
 Urine tests  Doppler
 All drugs administered during labor

MATERNAL AND FETAL ASSESSMENTS 2) Electric Monitoring

DURING LABOR: • Strength and duration of uterine
A. Immediate Assessment of a Woman in First contractions is gained by means of a
Stage of Labor pressure transducer or
1) Initial Interview tocodynamometer
 Baby’s EDB • FHR is monitored with the use of an
 When her contractions began ultrasonic sensor or monitor,
 Amount and character of any show converting fetal heart movements into
 Whether rupture of membranes has audible beeping sounds and records
occurred them on graph paper
 Any known drug allergies
 Past and present pregnancy history FHR Parameters:
 Use of any recreational or prescription a) Baseline FHR
drugs  Minimum of 2 minutes obtained
 Birth plan between contractions
2) Initial Physical Examination  Normal rate: 120-160 beats/min.
 Vital signs b) Variability
 Nature of her contractions  Absent: no amplitude range
 Her rating of pain on a 10-point scale detected
 What she has done to be prepared for  Minimal: 5 beats/min. or fewer
labor  Moderate (normal): 6-25
 Urine specimen for protein and glucose beats/min.
 Position and presentation of her fetus  Marked: more than 25 beats/min.
3) Leopold’s maneuver  Fetal bradycardia and
4) Vaginal examination tachycardia:
5) Sonography o Moderate bradycardia: 100-
6) Assessing ROM 109 beats/min.
7) Assessment of pelvic adequacy o Marked bradycardia: less
8) Vital signs than 100 beats/min
9) Laboratory analysis o Moderate tachycardia: 161-
10) Assessment of uterine contractions 180 beats/min
o Marked tachycardia: more
B. Initial Fetal Assessment than 180 beats/min
1) Auscultation of Fetal Heart Sounds
• VERTEX or BREECH: fetal back 3) Periodic Changes
• FACE: fetus’ thorax • Accelerations
• BREECH: uterus, woman’s umbilicus or  Temporary normal increases in FHR
above caused by fetal movement, a change
• CEPHALIC: woman’s abdomen in maternal position, or
• ROA: RLQ administration of analgesic
• LOA: LLQ • Decelerations
• LOP or ROP: woman’s side  Visually apparent, usually
symmetrical, periodic decreases in
FHR Monitoring: FHR resulting from pressure on the
• Every 30 minutes (beginning of LATENT fetal head during contractions due
labor) to vagal nerve compression
  Early onset: Fetal head compression,
generally benign; Second stage: If B) AUGMENTATION OF LABOR
close together, stop patient from  Acceleration of labor once it has begun, by
pushing until FHR returns to normal; giving oxytocin as ordered
Rule out cephalopelvic disproportion  Indications: Prolonged or dysfunctional
if head is above ischial spines. labor, failure to dilate
 Variable:  Contraindications, complications, and
o Rapid onset and rapid return nursing: same as labor induction
with variable relationship to
contraction C) ARTIFICIAL RUPTURE OF MEMBRANES
o OK if FHR baseline is acceptable; (AROM, AMNIOTOMY)
if it lasts 30 seconds or recovery  Indications: Hasten labor, permit internal
to baseline is slow, report to fetal monitoring
MD.  Complication: Risk for infection the longer
o Can indicate possible cord it takes to give birth
compromise (prolapse, around  Nursing actions:
fetal neck/shoulder, knotted).  Assess FHR
o If due to cord compression:  Maintain horizontal position
Stop or ↓ oxytocin, lateral  Assess for cord prolapse
position, O2, IV fluids, prepare  Provide perineal care
for cesarean if not corrected
 Late onset: Starts at height of D) FORCEPS AND VACUUM ASSISTED BIRTH
contraction and returns to baseline  Maternal Indications: Prolonged 2nd
after contraction ends; reflects stage; fatigue; maternal illness
uteroplacental insufficiency  Fetal Indications: Nonreassuring FHR
 Complications: Vaginal/rectal lacerations,
4) Sinusoidal Pattern fetal injury
• Severely anemic or hypoxic fetus:  Nursing action: Forceps—Monitor FHR to
smooth, frequently undulating wave ensure cord is not compressed
with a cycle frequency of 3-5/minute  Nursing actions: Vacuum – (35 weeks)
and persisting 20 minutes or more  Apply soft cup over posterior fontanelle
 ↑pressure to 440-600 mmHg
 Apply gentle traction during pushing
Medical Interventions Associated With Labor: (Important: Discontinue after 3 pulls,
20 min, 3 cup detachments or observed
A) INDUCTION OF LABOR scalp trauma)
 Ripened cervix: Dinoprostone (ProstinE2,  Avoid trapping maternal tissue in cup
Cervidil), prostaglandin gel (PGE2),  Teach mother that chignon will resolve
laminaria tents; ↑contractions once uterus in 3-7 days
is inducible: amniotomy, oxytocin (Pitocin)  Monitor S&S of complications
 Indications: Postterm, preeclampsia,  Provide support
eclampsia, intrauterine growth restriction,
DM, fetal demise E) CESAREAN BIRTH
 Contraindications: Placenta previa,  Birth via abdominal incision; low transverse
prolapsed cord, transverse fetal lie, active incision most common; vertical incision
genital herpes, vertical cesarean scar ↑risk of uterine rupture in future
 Complications: Uterine tetany pregnancies
(contractions ↓ 2 min. apart or lasting 90  Indications: Stalled labor progress
sec.), nausea, ↓urine output (dystocia), repeat cesarean, breech
 Nursing actions: presentation, fetal compromise, active
 Monitor fetal and maternal responses genital herpes, placenta previa, abruptio
 For uterine tetany: discontinue placenta, cord prolapse, preeclampsia,
oxytocin eclampsia
 Place in left side-lying position  Complications: Wound infection or
 Give O2 as ordered dehiscence, hemorrhage, bladder/bowel
 Prepare for cesarean birth
 injury, thrombophlebitis, fetal injury or  Insertion of analgesic into perineal tissue;
aspiration ↓pain of birth and episiotomy
 Nursing actions:  Advantages: Technically uncomplicated;
 Put emphasis on healthy neonate and does not alter maternal VS or FHR; minimal
mother complications, patient is awake
 Teach about surgery, anesthesia, and  Disadvantages: A large volume of agent is
recovery needed
 Assess for S&S of complications  Nursing actions:
 Assess effectiveness
 Ensure a thermal injury does not occur
LABOR AND BIRTH: Analgesia and Anesthesia, if cold application is used to
Pharmacology and Medication ↓inflammation
Administration
C) SPINAL BLOCK
A) EPIDURAL BLOCK/INFUSION  Injection of anesthetic into spinal fluid
 Injection of anesthetic into epidural space provides anesthesia for cesarean birth &
to ↓pain of labor and birth occasionally for vaginal birth with mid-
 Advantages: Titratable level, patient is forceps delivery or vacuum extraction
awake; nausea & sedation are minimal;  Advantages: Ease of administration,
urge to push may be preserved; no immediate onset, patient is awake, smaller
headache med volume, less shivering, little placental
 Disadvantages: Maternal ↓BP; labor transfer
progress & fetal descent may be slowed;  Disadvantages: Finite duration, possible
less effective pushing in 2nd stage; may severe maternal hypotension & total spinal
cause N&V, pruritus, urinary retention anesthetic response; may ↓ ability to push
 Nursing Actions:  Nursing actions:
 Have patient void before; routinely  Treat hypotension by giving 500–1000
assess for bladder distention mL IV fluids 15–30 min. before block
 Minimize hypotension by giving 500–  Assist to side-lying or sitting position
1000 mL IV fluids 15–30 min. before during insertion; patient must remain
placement; maintain side-lying still. Time insertion between
position; alternate sides contractions
 Assist to side-lying or sitting position  Insert urinary retention catheter before
and support during insertion; patient cesarean birth
must remain still; time insertion  Assess VS before insertion and
between contractions routinely thereafter
 Use an infusion pump; ensure catheter  Move patient with caution because of
placement remains intact temporary leg paralysis
 Assess VS before & routinely (q1–2min  VAGINAL BIRTH:
for 1st 10min & then q5–15min); may o Assist to sitting position for 1–2
cause ↓BP & respiratory depression; min. after block so that solution
follow standing orders if ↓BP occurs: migrates toward sacral area before
terminate infusion, O2 by mask, side lying.
Trendelenburg position, bolus of o Maintain continuous electronic
crystalloid fluid, notify practitioner fetal monitoring. Encourage
 Maintain continuous electronic fetal bearing down during contractions
monitoring  CESAREAN BIRTH:
 Assess pain control; notify practitioner o Assist to supine position, with a left
if breakthrough pain occurs because lateral tilt, so that cephalad spread
dose is ↓than therapeutic or integrity of anesthesia occurs
of line is altered  Interventions after birth:
 Assess level of sensation & ability to o Maintain bed rest for 6–12 hours
move feet/legs; recovery takes several o Two-person assist with first
hr; 2–person assist with 1st ambulation ambulation
o Assess for urinary retention
B) LOCAL INFILTRATION because sensation/control may not
 return for 8–12 hours; catheterize b. Ritodrine
as ordered c. Magnesium sulfate
d. Betamethasone
D) GENERAL ANESTHESIA  Contraindications: before 20
 Induced unconsciousness; requires weeks AOG, hemorrhage,
tracheal intubation with cuffed hypertension, hypertension,
endotracheal tube, ventilation, and infection, and bleeding
oxygenation disorders
 Advantages: Total pain relief, optimum  Side Effects: pulmonary
operating conditions edema
 Disadvantages: Patient is not awake; may
cause ↓ maternal respirations, vomiting, B) Prolapsed Umbilical Cord - prolapse may
aspiration, uterine atony; may induce fetal occur at any time after the membranes
depression rupture if the presenting part is not fitted
 Nursing actions: into the cervix
 Place in a supine position with left- - displacement or descent of the cord
lateral tilt into the vagina ahead of the fetal
 Insert IV line presenting part
 Administer prophylactic antacid, as  Causes:
ordered 1. Premature Labor or PROM
 Preoxygenate 3–5 min. with 100% O2; 2. Breech presentation
maintain cricoid ring pressure to 3. Unengaged presentation
occlude esophagus until practitioner 4. Small fetus
inflates cuff of endotracheal tube  Assessment:
 When extubated: Maintain open 1. Fetal hypoxia
airway; administer O2; monitor VS, 2. Cord prolapsed up to vagina
ECG, pulse oximetry; keep suction and  Nursing Interventions:
resuscitative equipment readily 1. Check FHT
available 2. Elevate the fetal presenting part to
relieve pressure
3. Prepare for immediate CS
COMPLICATIONS of LABOR AND DELIVERY:
C) Premature Rupture of Membranes (PROM) -
A) Preterm/Premature Labor - labor that occurs rupture of fetal membranes with loss of
after the 20th week & before the end of 37th amniotic fluid before the onset of labor
week of pregnancy  Causes:
 Causes: 1. premature labor
1. Cervical incompetence 2. infection of membranes
2. Polyhydramnios 3. prolapsed cord
3. PROM  Assessment:
4. Multiple gestation 1. sudden gush of clear fluid from the
5. Dehydration vagina, with continued minimal
6. Intrauterine infection leakage
(chorioamnionitis) 2. fetal hypoxia
 Assessment: 3. protrusion of membranes
1. persistent uterine contractions (4  Nursing interventions:
every 20 minutes) 1. Check FHT
2. cervical changes: 2. Position the mother on knee-chest
- effacement > 80% or Trendelenberg position
- dilatation > 1 cm 3. Administer medications as ordered
3. engagement of presenting part a. Tocolytics (w/in 2 hours)
 Nursing Interventions: b. Antibiotics
1. Bed rest, side lying position
2. Monitor FHT D) Dystocia – difficult labor
3. Administer medications as  Causes:
prescribed - Tocolytics 1. CPD
a. Terbutaline 2. problems with presentation
 3. problems with passageway 1. prolonged labor
4. dysfunctional uterine contractions 2. multiple gestation
 Assessment: 3. traumatic maneuvers using forceps
1. fetal distress 4. unwise use of oxytocin
2. prolonged labor
3. slower progress of labor than  Assessment:
expected 1. Abdominal pain
2. Strong uterine contractions w/out
 Nursing interventions: cervical dilatation
1. Provide comfort measures 3. Indention across the abdomen over
2. Monitor the mother & the fetus the uterus à Pathologic retraction
continuously ring
3. Administer oxytocin or analgesia as  Nursing Management:
needed 1. Check FHT & maternal vital signs
2. Administer fluid replacement
E) Uterine Rupture - complete or incomplete 3. Prepare for emergency surgery
separation of uterine tissues as a result of
tear in the wall of the uterus from stress of
labor
 Causes:

F) Hypotonic and Hypertonic Contractions -

HYPOTONIC CONTRACTIONS HYPERTONIC CONTRACTIONS

The number of contractions is low The number of contractions is high &

& infrequent occurs frequently
PHASE OF LABOR Active Latent
SYMPTOMS • contractions not increasing  painful contractions
beyond 2 or 3 in a 10-min  intensity of contractions is not
period stronger than hypotonic
• strength of contractions does contractions
not rise above 25 mmHg  increase resting tone to more
• resting tone remains below 10 than 15 mmHg
mmHg
MEDICATIONS Oxytocin Morphine sulfate
MANAGEMENT 1. Palpate the uterus 1. Provide bed rest
2. Assess the lochia every 15 2. Maintain a darkened room
minutes (to ensure that lights and decrease noise &
postpartum contractions are not stimulation
also hypotonic to avoid bleeding)