Ch.

16: Labor and Birth Process

Five Factors Affecting Labor (Powers, Passageway, Passenger, Psychological, Position)
1) Powers
 Primary powers: Contractions
o Effacement
o Dilation
o Decent
 Secondary powers
o Bearing-down efforts - voluntary action of pushing , how well does mom push
o Maternal pushing efforts
o Effective pushing should occur with the contraction
o Teach mom the proper way to push, pushing when she’s at the peak of her contraction
o Pushing at the wrong time is energy wasted
 Effacement: thinning of the cervix from 2-3cm long to paper thin
o Cervix thinning from 4cm to paper thin
o 0% cervix closed
o 50% - slightly thinning
o 100% paper thin, fully effaced
o Expressed in percentages
o Mucus plug – cervix is effacing, protect baby from infection, once lost baby is at risk for infection, mom may mistake it
as urine

 Dilation of Cervix o The lower the station – baby’s coming out (+)
o Expressed in centimeters
o Goal: 10 centimeters

 Descent
o Sagittal sutures can tell you what direction the
baby is facing

 Station
o Measurement of decent
o Baby coming down
o 0 = ischial spine – baby is engaged
o The higher the station the numbers go (-)
  Android
 Anthropoid
 Platypelloid

Passageways: dependent on the ability of the soft tissue to stretch

 Gynecoid – provides most ideal passageway.
2) Passageway: the mother
 The relationship between the fetal presenting part and the pelvis is assessed by fetal station.
 A zero station means the presenting part is at the level of the ischial spines.

Fig. 15-7. Female pelvis. A, Pelvic brim above. B, Pelvic outlet from below.

3) Passenger: the baby

 Size of fetal head:
 2 important fontanels, know when they close
o Anterior - closes at 18 months, shape: diamond
o Posterior - closes at 6-8 weeks, shape: triangular
o Gives skull its flexibility and ability to mold
Fig. 15-1. Fetal head at term. A. Bones. B. Sutures and fontanels. Fig. 15-2. Presentation Positions Vertex. Examples of fetal
vertex (occiput) presentations in relation to front, back, or side of
maternal pelvis.

4) Psychological:
 Postpartum depression
 Stress, anxiety, fear, and pain
 Can cause complication with contractions – stop them or prolong them
 Baby gets stress
 Be that support person, actively coach her if she doesn’t have anyone to, guide her especially if she chooses not to have an
epidural
 Figure out ways to alleviate pain if she chooses to not have epidural – relaxation
5) Position
 Position affects woman’s anatomic and physiologic adaptations to labor
 Position of the mother and the baby
 Frequent changes in position is necessary – relieve fatigue, increases comfort, improved circulation
 Encourage position that is most comfortable to the mom – associated with improved outcomes
 Baby is getting circulation through mom’s movement
 Upright position – gravity
 Staying in one position can delay birth and baby can be stagnant – walk them around the room (some mom’s may not want to
move) moving at least every hour, turn them, have them sit on a yoga ball (rocking of ball can help baby move)
Signs of Labor
 Mechanisms that initiate labor remain unclear and involve many factors.
 Signs of impending labor include:
o Contractions become regular
o Presence of bloody show
o Descent of the fetus into the birth canal (lightening), may occur about two weeks before labor for a primigravida
o Nesting impulse
o GI distress (heartburn, nausea, diarrhea)
o Weight loss of 1 to 3 pounds just before onset of labor
 Labor is confirmed by cervical change (dilation and effacement).
 Contraction become more regular
 Presence of blood show
 Baby moves down to the canal
 Nesting impulse, mom cleans around to get the babies things ready
 May lose some weight
 Check her if her cervix is changing
 Contractions need to be strong enough to produce cervical change
Stages of Labor
1st Stage:
 Latent Phase (0-3 cm)
 light contractions
 Active Phase: regular painful contractions, moderate when palpate
2nd Stage
 Pushing may be delayed until the woman feels the urge to push.
 Second stage may last 20 minutes to 2 hours.
 (8-10 cm)
 Tell significant other that if they feel they are doing something wrong – therapeutic communication “ This is normal, you are
doing great, if she doesn’t want to be touched that’s okay.”
 Cardinal Movements: KNOW THE ORDER! As fetus descends through the birth canal, the fetal head rotates for optimal
delivery.
o Engagement: Fetal head reaches level of the ischial spines.
 Baby’s head lowers below the symphysis.
 Usually occurs before labor begins.
o Descent: Fetus moves past the ischial spines.
 Occurs throughout labor. Typically station is -1/-2 at labor onset and +1 at the beginning of 2nd stage.
o Flexion: Fetal chin touches chest in response to pressure from maternal tissue.
 Chin touching chest
 Flexion feeling only the posterior fontanelle, not anterior
o Internal Rotation: to Occiput Anterior, the posterior fontanelle moves up under the symphysis
o Extension: Fetal chin comes off the chest and the neck arches as the head is born.
 Head crowning right before delivery of the head
o External rotation: Fetal head rotates as the shoulders move into position for delivery.
 Delivery of one shoulder at a time
 Most often anterior shoulder delivers before the posterior shoulder
o Expulsion (Deliver): Body of the fetus is born. ANTERIOR AND THEN POSTERIOR SHOULDER

A. Engagement
B. Descent
C. Flexion
D. Internal rotation to occipito-anterior
position
E. Extension
F. External rotation beginning (restitution)
G. External rotation

3rd Stage
 COMPLETED WITHING 5-30 MINUTES, PLACENTA IS DELIVERED
 FUNDUS CONTRACTS DOWN AFTER PLACENTA IS REMOVED AND GETS SMALLER AND SMALLER
o CONTINUE TO MASSAGE UNTIL NICE AND FIRM – LESS BLEEDING
o IF SOFT – MORE BLEEDING
o FAILURE FOR UTERUS TO CONTRACT – UTERINE WITHOUT TONE
 The third stage is complete within 5 to 30 minutes.
 The uterus contracts to deliver the placenta.
 After delivery of the placenta, the uterus continues to contract to “pinch” or close the open blood vessels in the decidua to prevent
maternal hemorrhage.
 Failure to contract is called uterine atony and is a primary cause of postpartum hemorrhage.

4th Stage
 RECOVERING MOM AND ASSESSING HER UTERUS, POSTION, BLEEDING, AND VS
 During the fourth stage of labor, the nurse should assess uterine position, vaginal bleeding (lochia), and vital signs.
 The nurse should administer pain medications as needed. – IBUPROPHEN OR TYLEON, SEVERE – PERCOSET
 The nurse should assist the patient with skin-to-skin contact and initiating breastfeeding. – PERFECT TIME TO BOND AND
INITIATING BREAST FEEDING
 BABY FRIENDLY = THEY HAVE TO BREAST FEED

Physiological Adaptations to Labor

 Fetal Adaptations
o Fetal HR: Provides information about fetal health in relation to fetal oxygenation.
o Fetal Circulation: affected by many factors
o Fetal Respirations: 7-42 mL of amniotic fluid is squeezed out of the lungs
 LUNGS ARE WET BECAUSE THEY DIDN’T GET THAT SQUEEZE IN THE END
 DON’T BE ALARMED IF YOU HEAR A WET LUNGS, BABIES ABOUT TO SPIT IT OUT
THEMSEVLES
 Maternal Adaptations
o Cardiovascular Changes
o Respiratory Changes
o Renal Changes
o Integumentary Changes
o Musculoskeletal Changes
o Neurological Changes
o GI Changes
o Endocrine Changes
 Ch. 16: Fetal Heart Assessment During Labor
Electronic Fetal Monitoring (EFM)
 produce a record (electronic or paper) for visual interpretation and fetal status
 Who are we assessing? – MOM AND BABY
 Why do we assess? ANTICIPATE WHAT THE BABY NEEDS ONCE DELIVERED, IF BABY IS STRESSED AT TIME OF
DELIVERY – CALL
 What is happening? – BABY GETTING SQUEEZED DURING CONTRACTION (1-3 MINUTES) – SOME BABIES CAN
AND CANNOT TOLERATE THE SQUEEZE, FETAL OXYGEN CAN DECREASE, MEASURE RESPONSE OF FHR WHEN
MOM IS HAVING A CONTRACTION
 How?

 Electronic fetal monitoring: produce a record (electronic or paper) for visual interpretation and fetal status
 CENTRAL MONITORING – AT THE NURSES STATION, SHOWS WHICH MOM IS IN LABOR AND WHAT THE BABY
IS DOING IN THE FETAL MONITOR, NURSES, DRS, CHARGE NURSE READILY AVAILABLE BECAUSE THEY ARE
CONSTANTLY MONITORING
 Intermittent EFM
o Ex: 20 minutes every hour
o RESERVE INTERMITTENT EFM FOR HEALTHY MOTHERS, NO DIABETES OR HTN – HEALTHY MOMS
 Continuous EFM
o External EFM
 Palpation of the fundus to assess strength of contraction
 Tocotransducers = “toco”: Ultrasound/doppler - Measures frequency and duration
 Supplies: Belts, gel, paper, TOCO, transducers, and monitor
 Noninvasive
 TOCO – MEASURE CONTRACTION
 TRANSDUCER – DETECTS FHR
o Internal Monitor
 Fetal Scalp Electrode (FSE): internal fetal heart monitor
 MEASURE FHR
 BABY IS +1 OR +2 – FEED FSE
 KNICKING THE SURFACE OF THE BABY’S HEAD TO GET A FHR
 USE INTERNAL MONITOR – HAVE TO BREAK MOM’S BAG – BREAKING THE BAG OD
WATER
 AROM: ARTIFICAL RUPTURE OF MEMBRANES
 Intrauterine Pressure Catheter (IUPC): Internal contraction monitor that measures exact intrauterine pressure
 MEASURE THE CONTRACTION ACCURATELY
 STERILE TECHNIQUE
 Invasive – infection risk
Assessing Contractions
CONTRACTION: BEGINNING OF ONE TO THE SAME ACTIVE CONTRACTION
FREQUENCY: BEGINNING TO THE BEGINNING OF THE NEXT

HOW TO ASSESS AND DESCRIBE CONTRACTION STRENGTH

 Mild = tip of nose
 Moderate = chin
 Strong = forehead

FHR COMPONENTS
NICHD (National Institute of Child Health and Human
Development) terminology
 Baseline Fetal Heart Rate (FHR)
 o AVERAGE FHR FROM A 10 MINUTE SEGMENT
o MEASURE BETWEEN CONTRACTIONS
o NO ACCELS OR DECELS
o NORMAL IS BETWEEN 110-160 BPM ASSESSED OVER 10 MINUTE PERIOD
 Baseline Variability
o IN RELATION TO FLUNCTUATIONS IN FHR
o INDICATIVE FOR BABY’S OXYGENATION AND MOVING
o Irregular in frequency and amplitude
o (A) Absent: undetectable 0-2 bpm
 BABY IS SLEEPING - MEDICATION THAT’S GIVEN TO MOM OR BABY IS TIRED
 WHATEVER YOU GIVE OR DO TO THE MOM MAKE SURE TO CHECK THE BABY IF THEY ARE
TOLERATING WHAT IS GIVEN
 TRY TO WAKE THE BABY UP
o (B) Minimal: 2 - 5 bpm
 NO ACCELLS
 MILD FLUNCTUATIONS
o (C) Sinusoidal
 Associated with fetal anemia (ominous)
 Associated with narcotic pain relievers (benign)
 ANEMIA OR SOME MEDICATIONS
o (D) Moderate: 6 – 25 bpm
 INCREASES IN FLUNCTUATIONS
 BABY IS GETTING OXYGENATION, ALIVE, AND KICKING
 ACCELERATIONS PRESENT (THIS IS WHAT YOU WANT)
o Marked: >25 bpm
o Normal: 110-160 bpm
o Tachycardia: >160 bpm
o Bradycardia: <110 bpm
 Accelerations (present or absent) – A GOOD THING
o TELLS US THAT THE BABY IS PROPERLY OXYGENATED AND HAS GOOD CIRCULATION
o ABRUPT INCREASE FROM BASELINE FHR
o FULL TERM (15 BPM/15 SECS) ACCEL –
o PRETERM (10BPM/10SECS)
o ACME (THE HIGHEST POINT) > 15 BPM ABOVE BASELINE
 Decelerations (present or absent)
o Early: Gradual decrease and return to BL, mirrors U/C – MIRRORS CONTRACTIONS
 Cause: Response to fetal head compression – often occurs with descent; Considered a benign pattern
 Treatment: No specific treatment – vaginal exam to check for descent.
o Variable: Abrupt (<30) decrease (≥ 15 bpm decrease, lasting ≥ 15 secs and <2 mins from onset to return to BL) May or may
not occur with contractions
 Cause: Cord compression; neck pressure of fetal body on cord, knot in cord
 Treatment: same as LATE
 RETURN TO BASELINE IN LESS THAN 2 MINS
 CAUSED BY COMPRESSION OF CORD OR KNOTS
o Late: Gradual decrease (≥ 30 secs) and gradual return to BL; delayed timing nadir occurs after peak of U/C; persisting after
contraction has finished
 OCCUR AFTER A CONTRACTION
 BABY NOT GETTING THE OXYGEN THAT IT NEEDS
 POOR PRECENTAL PROFUSION
 DISCONTINUE ANY MEDICATION – PITOCIN
 NOTIFY DOCTOR
 NADIR = LOWEST POINT
o Prolonged: decrease in FHR below BL ≥ 15 bpm, lasting ≥ 2 mins, but <10 mins
 Changes or trends over time
o Changes in FHR from baseline categorized by:
 Periodic: with UC
 Episodic: without UC
 Include both Accelerations and Decelerations
Fetal Heart Rate (FHR) Evaluations
Reassuring (Category 1) – WHAT YOU WANT
 Normal Baseline 110 -160 bpm
 Moderate variability
 No periodic changes (no deceleration)
 Accelerations with fetal movement
 When all 4 components are PRESENT = NO FETAL ACIDEMIA
 ABSENCE of Reassuring:
o Accelerations alone are highly reassuring that no fetal acidemia is present
o Moderate variability alone indicates that 98% of the time there is no fetal acidemia
o If no accelerations, and absent or minimal variability and either variable or late decelerations, then 25% of time there is
FETAL ACIDEMIA – CALL THE PEDEATRICIAN, NEONTOLOGIST, RESPIRATORY THERAPIST
Non-Reassuring
 Baseline <110 bpm or >160 bpm
 Decrease in baseline
 Irregular rhythms
 Decreased FHR during or within 30 seconds after contraction
 INTERVENTIONS – RESPONSE TO NON-REASSURING FHR:
o Position change to side lying
o Explain to patient and family – BABY DOESN’T LIKE THIS POSITION, CAN WE REPOSITION YOU?
o IV BOLUS – ALLOW FASTER DELIVERY BY INCREASING CONCENTRATION IN THE BLOOD OVER TIME
TO AN EFFECTIVE LEVEL
o Reduce or Stop Pitocin
o Tetanic Contractions – STOP Pitocin or prostaglandins and administer Terbutaline – SLOW THINGS DOWN
o O2 7- 10 L/min BY NON REBREATHER
o Report findings to provider
o Cervical exam
o Apply internal monitors if indicated – BREAK THE BAG OF WATER FIRST BEFORE INSERTING INTERNAL
MONITORS
o Fetal scalp electrode (FSE) if external not picking up well
o IUPC with hyperstimulation
o Improve BP if not dropped especially after epidural (IV fluids, side lying, medication)
DOCUMENTATION:
 QHOUR
NICDH Categories of FHR Patterns
Normal - ALL required:
 Category 1(WHAT YOU WANT): Strongly associated with normal acid base status
 Moderate variability
 Baseline 110-160
 No late or variable deceleration
 Early deceleration: present or absent
 Acceleration: present or absent
Indeterminate:
 Category 2 (WHERE MOST STRIPS FALL): Not predictive of abnormal fetal acid base status but inadequate evidence to
classify as normal or abnormal
 FHR tracings that do not meet the criteria for Normal or Abnormal
Abnormal – Absent baseline variability and any of the following:
 Category 3 (BAD): Predictive of abnormal fetal acid base status
 Recurrent late deceleration
 Recurrent variable deceleration
 Bradycardia or sinusoidal pattern
Methods of Testing Fetal Well-Being o With oligohydramnios (low amniotic fluid) and
 FHT acceleration response to stimulation (movement, variable decelerations
vibroacoustic stimulation)  Tocolytic therapy – i.e. terbutaline
 Fetal oxygen saturation monitoring  Umbilical cord acid-base determination
o Fetal scalp blood sampling  Fetal Scalp Stimulation
 Amnioinfusion o ELECIT ACCELERATIONS - DON GLOVES
AND TICKLE BABY’S HEAD
 Fetal Vibro Acoustic Stimulation
 o ELECIT ACCELS o Active Labor: Q15-30 minutes
Frequency of Assessment o 2nd stage: Q5-15 mins
 On admission, obtain 20 minutes FM tracing  Low Risk:
 Of Category 1 tracing, no risk factors present, and provider o 1st stage: Q30mins
order for IA o 2nd stage: Q15mins
 Document FHR and uterine activity:  High Risk
o Latent Phase: as ordered o 1st stage: Q15mins
o 2nd stage: Q5mins
Fetal Hypoxia
Hypoxia
 Indicated by non-reassuring FHR patterns
 Can be a short episode, or recurrent or prolonged
 Prolonged likely to lead to acidemia
Meconium
 Fetal stool released in response to hypoxic episode
 MAY MEC IN RESPONSE TO STRESS
 YOU DO NO WANT THE BABY TO ASPIRATE MECONIUM – CAUSE RESPIRATORY ISSUES
 If severe or prolonged, hypoxia can lead to acidemia and fetal damage – need to fix, resolve, or deliver
Documentation
 Category I or Reassuring or description of components
 Don’t use “Non reassuring”
 Describe, what is abnormal – minimal variability, late decelerations, absence of accelerations for last hour. Change in baseline for
the last 10 minutes.
 Be specific.

Accelerations: These are OK and reassuring. Happy Healthy Variable Deceleration:

Baby! Complication: Cord compression
Intervention: Reposition the patient
Early Deceleration:
Complication: Head compression Late Decelerations:
 Mirror image of UCs caused by fetal head moving down in Complication: Placental insufficiency
birth canal and head compression causing vaginal Intervention:
stimulation. Benign.  Turn to left side
Intervention:  O2 10 L/min
 Continue to monitor  IV BOLUS
 Continue vaginal exams PRN to assess descent into the pelvis  Turn off Pitocin
 If no descent, notify MD  Call MD
Variable Deceleration

Late Deceleration
Early Deceleration
 Ch. 16 Epidurals – Management of Discomfort
Combined Spinal-Epidural Analgesia:
 Regional anesthesia into epidural space
 Combination of anesthetic and analgesic
 Includes small amount of opioid with or without local
anesthetic
 L3, L4, or L5
 Subarachnoid space, epidural catheter placed
 Numbs from umbilicus to symphysis (lower abdominal and
back area)
 Epidural usage rate: 90%
o 75%-95% satisfied
 Superior motor ability epidural or spinal
anesthesia/analgesia alone
 Lasts 1-3 hours
 May still feel pressure
 Loss of leg movement
 May benefit anxiety, but may impede labor progress

Testing Epidural Level

 Alcohol swab
 Try lab tube with crushed ice
 Compare to arm

Epidural Benefits
 Excellent Pain Relief
 May decrease anxiety
 Rest for tired women
 May give a sense of control
Dermatomes
Improving Outcomes with Epidural
 Giving the epidural later > 5 cm
 Light vs. regular epidurals
 Labor Down or Passive Descent

Communication w/ Anesthesiologist
 G/P, gestational age, labor status, fetal status, complications
 Maternal Vital signs
 Most recent fluid and food intake – SO THEY DON’T GO INTO SHOCK, MAY ASPIRATE ON THEIR OWN FOOD AND
FLUID
 Relevant lab studies: Hct, WBCs, platelets – NEED TO KNOW NORMAL IN CASE OF HEMMORHAGE
 Pt Risks: esp. PIH, thrombocytopenia, MS, Harrington Rods, morbid obesity, skin infections on back

Pre-anesthesia Nursing
 Baseline maternal assessment
 FHR tracing – 15 – 20 MINUTES
 Gather equipment
 Have Patient void prior to procedure – SHES NOT GOING TO BE ABLE TO GET UP

Nurse Duties Before Anesthesia

 Start IV and give bolus of fluids
 BP baseline
 take BP q 2-5 minutes as ordered
 Oximeter
 Adjust EFM bands
Maternal Hypotension after Epidural
Assessing for Hypotension
 Watch for maternal symptoms and fetal response
 Maternal nausea
 Fetal Heart tone irregularities
 FHR alterations
o Continuous EFM
o Adjust EFM when anesthesia dosed
o FHR Q5 min for first 15 mins
o Monitor changes first hour after any Bolus administration
o Monitor closely when maternal BP drops
o Treatment: Treat hypotension, try another position, O2 on
 Assess for signs of Intravascular Injection of Local Anesthetic
o Rare, happens after test or full dose
Signs and Symptoms:
 Hypotension (<100 mmHg or 20% decrease)
 Drop in FHR below 120 bpm (fetal bradycardia)
 Reduction in FHR variability
Interventions:
 Notify PCP, anesthesiologist
 Position side lying (Lateral) – curved around baby, head flexed, middle back arched outward
o Relieves pressure on the aorta and inferior vena cava
 Sitting: feet supported on stool, head flexed forward, elbows resting on knees or table
 Administer O2 10-12L
 Administer Vasopressor IV per order
 Administer ephedrine if ordered
 Administer IV fluid Bolus
 Elevate legs
 Continue monitoring BP and FHR Q5mins until stable
 Coaching and helping woman cope
 Intrathecal injection – procedure takes time

Labor Pain Management : Pharmacological

Opioids  Onset: 7-10 min IM/ 1-3 min IV
Fentanyl  Notes: Short acting 30-60 min IV/ 1-2 hrs IM
 Notes: Short acting (1-2 hours)  Crosses placenta
 May cause maternal or neonatal respiratory depression  Monitor for Maternal and neonatal resp depression, CNS
depression, FHR changes
 N/V and pruritis common for mom

Meperedine (Demerol) Mixed opioid agonist/antagonists:

 Dose: 50-100mg IM/ 25-50mg IV
 Onset: 40min IM/ 5 min IV
 Notes: Single Dose lasts 3-4 hours, resp depression common
in neonates if birth within 4 hrs after dosing
 Monitor: Maternal resp and CNS depression
Sublimaze (Fentanyl)
 Dose: 100ug IM/ 25-5- ug IV
 Should not be used in women who are dependent on opioids
because may cause withdrawal.
 Less risk of respiratory depression than opioids.
 Nubain—single dose lasts 3 to 6 hours
 Stadol—single dose lasts 3 to 4 hours

Labor Pain Management : Non-Pharmacological

 Gate Control Theory of Pain – LIMITED NUMBER OF SENSATION, NON PAINFUL INPUT, BRAIN CAN ONLY
HANDLE CERTAIN AMOUNT OF STIMULATION
 Relaxation and Breathing Tech
 Effleurage and Counter pressure
 Touch and Massage
 Application of Heat and Cold
 Water Therapy (Hydrotherapy)
 Aromatherapy
 Music

Adjunct Medications for Nausea

Promethazine (Phenergan) Hydroxyzine (Vistaril)
 Dose: 25-75 mg IV or IM  Dose: 25-50 mg IM
 Onset: 10-20 min  Onset: 30 min
 Notes: Antiemetic used with opioids  Notes: Antiemetic used with Opioids
 Single dose lasts 3-4 hours  Single dose lasts 3 hrs
 Monitor Maternal Hypotension  IM only, no IV dosing

Patient Assessment/Education
 Pain Level
o Pain scale
o Assess Q10-15 mins after 1st Bolus until comfortable, then Qhour
o Respond to “window” of pain – LOCATION OF PAIN; IMPORTANT TO TURN YOUR MOM EVERY HOUR TO
CIRCULATE THE MEDICATION TO ALLOW THE EPIDURAL TO MOVE TO OTHER AREAS
o SOME MOMS MAY REFUSE EPIDURALS
o WARS AGAINST EPIDURALS – SEEN AS WEAK IF YOU TAKE IT, PRIDE TO FIGHT THROUGH IT
 Knowledge – EDUCATE ABOUT THE EPIDURAL
 Desires and concerns – “ I WANT TO BE ABLE TO WALK AROUND AFTER BIRTH”
 Education about analgesia and anesthesia – WHAT DO THESE MEDS DO TO YOU AND THE BABY

Sedation Assessment/Sedation Scale

0 – None Alert;
1 - Mild Occasionally drowsy, easy to arouse;
2 - Moderate Frequently drowsy, easy to arouse
3 – Severe Somnolent, difficult to arouse; and
S – Sleeping Normal sleep, easy to arouse.

Assessment of Motor Blockade

Bromage Score:
Bromage 0 (none) = full flexion of knees and feet
Bromage 1 (partial) = just able to move knees and feet
Bromage 2 (almost complete) = able to move feet only
Bromage 3 (complete) = unable to move feet or knees
 TEST IF THE MOM CAN MOVE OUT THE ROOM SAFELY FROM EDPIDURAL
 ARE THEY ABLE TO MOVE THEIR FEET AND FLEX THEIR KNEES
Modified Bromage Scale
Has advantage of testing strength
0 = No paralysis, raises extended leg, full flexion of knee and ankle (full motor strength)
1 = Inability to raise extended leg, able to move knee
2 = Inability to flex knee, able to flex foot
3 = Inability to move leg or foot

Ambulation after Anesthesia Turned Off

 Assist patient to change positions in bed
 If ambulation desired, must assess prior to standing and always in all attempts to ambulate. – ASSESS THAT SHE CAN STAND
 Assess BP and motor blockade prior to sitting, and prior to standing - TO SEE IF SHE’S DOESN’T HAVE HYPOTENSION

Pruritus
 Related to the narcotic analgesic
 Starts 10-30 min, diminishes over an hour.
 Light and tolerable, reassure patient
 If severe (20%), notify anesthesiologist, administer medications per orders. (Diphenhydramine, IM naloxone)

Nausea and Vomiting

 Can be related to hypotension – in that case treat hypotension
 Can be response to the medications, esp. narcotics,
 For pp: naloxone
 Could be response to labor itself
 Position patient.
 Provide emesis basin, sips of water, cool wet wash cloth to face/forehead.

Urinary Retention
 Occurs in over 2/3 of women.
 Encourage voiding q 1-2 hours
 Assess for urinary retention. – BLADDER SCAN
 Urinary catheterization – OVER 350 ML

PCEA Patient Education PATIENT CONTROLLED EPIDURAL ANESTHESIC

 Patient presses button when she needs additional anesthesia. – MOM THE ONLY ONE ALLOWED TO PUSH THE BUTTON
 No one else is to inject for her
 Reinforce safe use of PCEA
 Reassure some symptoms such as pressure are not painful and desirable to feel
 Notify staff if any unexpected sensations following the dose.
 Notify anesthesiologist of dense motor blockade.

Fluid Overload
 Results from TOO MUCH fluid bolus prior to epidural and increased fluid to control hypotension
 Urinary retention – associated with pitocin use
 Monitor I&O, pulse oximeter

Post Dural Headache

 Occurs secondary to leakage of spinal fluid
 Rate usually 1-3%.
 Most often seen 24-38 hrs, after delivery
Assessment
 A headache worse when sitting up/standing, resolved lying down.
 Pain frontal, occipital regions.
 Pain radiating down neck, or stiff neck.
 Nausea/vomiting.
 Visual: photophobia, diplopia, difficulty in accommodation.
 Hearing loss, hyperacusis, tinnitus.
Interventions
 Horizontal rest for comfort
 Increase oral fluids, caffeine may help.
 Avoid positions which cause headache.
 Administer medications, monitor effects.
 Notify Anesthesiologist for patient evaluation – set up for blood patch
o BLOOD PATCH: COMPATABLE BLOOD TO MOM, DR PATCH UP HOLE OF WHERE EPIDURAL
INSERSION WAS SO THAT SPINAL FLUID DOES NOT LEAK OUT, RESULT USUALLY WITH REST, BUT IF
SF LEAK THEN BLOOD PATCH IS INSERTED

Post Epidural Paresthesia

 Temporary, but long term leg weakness due to epidural
 Patient complain of persistent numbness in upper leg,
 Evaluate for weakness
 Notify anesthesia & or neurology
 Usually needs PT to regain strength

Neonatal Side Effects

 Communicate labor medication use to neonatal care providers.
 Monitor neonate for neurobehavioral changes or decreased respiratory rate.
 Administer narcotic antagonist as ordered if indicated- very unusual if epidural only narcotic.
Post-Partum Care
 Turn off the pump after delivery if not contraindicated.
 Advise woman not to get up
 Remove the catheter in the same position as when it was administered – I.e. side lying or sitting up. Inspect the tip for
completion. - DON’T PULL IF THERE IS RESISTANCE, SHOULD COME OUT SMOOTHLY
 Slow easy withdrawal if resistant stop and notify anesthesiologist

AWHONN’s Position
 Non-anesthetist RN should NOT:
o Insert an epidural catheter, initial injection, initiate continuous infusion, or re-bolus the epidural.
o Increase/decrease the rate of a continuous infusion
o Initiate, Reinitiate an infusion once it has been stopped
o Manipulate PCEA doses or dosage intervals
o Be responsible for obtaining informed consent for analgesia/anesthesia procedures; however, the nurse may witness the
patient signature for informed consent
 ADVOCATE WHAT THE PATIENT CAN OR CANNOT UNDERSTAND
 RN MAY:
o Replace empty infusion syringes with new pre-prepared solutions containing the same medication and concentration,
according to standing orders provided by anesthesia care provider
 Ch. 16 Nursing Care During Labor and Birth
Delivery Venues
 Home, Hospital, Birth Center
Nursing Assessment
 How is the mother emotionally and physically?
 How is the baby?
 How is the process of labor?
 How are the assessments of parameters of areas of concern
 Blood sugar, blood pressure, proteinuria, I &O, headache, reflexes, etc.
First Stage of Labor
Admission Data o Fetus
 Prenatal data  Admission to labor unit
 Gravida/Para, Due Date, Gestational Age o Active labor – 4 cm, frequent ctx, mostly effaced
 Problems this & previous pregnancies (primip)
 Psychosocial factors (hx depression, anxiety, support o ROM,
person?, concerns o High risk – PIH, breech, previous cesarean
 Stress in labor Laboratory and diagnostic tests
 Cultural factors  Analysis of urine specimen
Assessment  Blood tests (CBC, hct, blood type & rH, platelets)
 Physical examination  Assessment of amniotic membranes and fluid
 General systems assessment  Signs of potential problems
 Vital signs Plan of Care and Implementation
 Leopold’s maneuvers  Standards of care
 Assessment of fetal heart rate (FHR) and pattern  Physical nursing care during labor
 Rupture of membranes – o General hygiene
o Did she break the bag of water? o Nutrient and fluid intake
o When did it happen? – risk for infection if water no o Elimination
longer there to protect the baby o Ambulation and positioning
o assess the color of the fluid in case there is o Coping and Support
abnormalities of meconium  Keep off Her Back! Do not want to squish inferior vena cava
o How much of the fluid was released? – baby not getting the required O2
o Mucus plug
o When was the last time you went to the bathroom?
When did you think it broke?
o Smell, amount, color, is it still leaking
o Assess for amniotic fluid – pH paper or speculum
exam
 Vaginal/Cervical Examination
o Effacement (0-100% or 0-4 cm long)
 Feeling how dilated the cervix is with
fingers
o Dilation (0-10 cm)
o Softness of the cervix  Supportive care during labor
o Position (Anterior, Posterior) o Nurse
o Identify presenting part & position o Father or partner
o Station o Doulas
 Determination of true or false labor o Grandparents
o Contractions o Siblings during labor and birth
o Cervix  Emergency interventions
Station
  How low is presenting part in the pelvis
 Measured from Ischial spine
 Goes from -5 to +5
 i.e. positive numbers are lower

Fetal Position
 The letters to describe fetal  Face Presentation: the Mentum is the fetal landmark
presentation
 1st letter is blank, or Left or Right
 2nd letter is Occiput, Mentum (chin) or Sacrum
 3rd letter is Anterior, Posterior or Transverse
 OA, LOT, RMA, RST

 Breech Presentation the Sacrum is the fetal landmark

 The relationship of the Occiput, Sacrum, Chin or Scapula of

the fetus to the mother’s pelvis

Where is the Triangular Fontanelle?

 The triangular fontanelle is the place of the occiput.
 If the triangle is posterior – so is the occiput
 If the triangle is posterior, and slightly to left then it is LOP

If the triangle is right under the symphysis then it is OA

Leopold’s Maneuvers

 Ability to palpate mom’s abdomen and which direction

the baby is in
 Head can move independently from the trunk.
 The trunk does not move.

Location of FHR: where you can put the FHR monitors.

Fetal Heart Tones
Passenger- Fetus
 Monitoring fetal status
 Let the mother know your findings. Reassure her or tell her what you are going to do to decrease stress on baby.

Contractions
 Strength (behavior, pt report & palpation)
 Frequency- beginning of contraction to beginning of the next
 Duration

Second
Stage of
Labor
 Begins with full cervical dilation (10 cm)
 Ends with baby’s birth
Preparing for Birth
 Maternal position
 Bearing-down efforts
 FHR and pattern
 Help her to figure out effective pushing – praise her efforts
 Support of father or partner
 Supplies, instruments, and equipment for delivery
 Voluntary Pushing
Prenatal Trauma Related to Childbirth
 Lacerations
o Perineal lacerations
o Vaginal and urethral lacerations
o Cervical injuries
 Episiotomy: repair of tear
 Emergency childbirth

Third Stage of Labor

Placental separation and expulsion
 Firmly contracting fundus
 Change in shape of uterus
 Sudden gush blood from introitus
 Lengthening of umbilical cord
 Vaginal fullness
 Is the placenta intact? Everything is all there. If not intact, part of the
placenta will be missing.

Maternal physical status

 Signs of potential problems
 Care of placenta after delivery
After delivery of the placenta
 MD or CNM will examine the perineum and do what repairs are necessary

Fig. 18-23. Perineal lacerations. A, Bilateral sulcus tears, periurethral tear, and separation of anal sphincter. B, Exposure and
approximation of levator ani structures. C, Approximation of torn
bulbocavernosus muscle.
Document type and degree of tear or episiotomy
 Labial
 Periurethral
 Perineal
 1st degree: small
 2nd degree: average
 3rd degree: into anal sphincter
 4th degree: through anal sphincter into rectum
Fourth Stage of Labor (PP Recovery)
 Assessment
o VS, Fundus, Flow
 Documentation – delivery notes
 Post-anesthesia recovery
 Interactions with newborn
 Family-newborn relationships
o Enhance breastfeeding & bonding
Key Points
 Onset of labor may be difficult to determine
 Home is most often ideal during latent phase of first stage of labor
 Nurse assumes much of responsibility
 FHR and pattern reveal fetal response to stress of labor process
 Woman’s or couple’s perception of birth experience likely to be positive
 Cultural beliefs and practices
 Siblings need preparation and support for the event
 Most parents/families enjoy being able to handle, hold, and explore the baby
 Nurses observe progress in development of parent-child relationships
 Woman benefits from reviewing her childbirth experience with nurse
Labor and Birth Complications
 Placenta Abruption Ch 21 p. 454
 Placenta Previa Ch 21 p. 457
 Shoulder Dystocia Ch 22 p. 473
 Prolapse Cord Ch 22 p. 483
 Uterine Rupture Ch22 p. 483
 AFE (Amniotic Fluid Embolism) Ch 22 p. 485
 Retained Placenta Ch 22 p. 487
 Morbidly adherent Placenta Ch 22 p. 488