Chapter 018

Chapter 18
Nursing Care During Labor and Birth
Mosby items and derived items 2010, 2006, 2002 by Mosby, Inc., an affiliate of Elsevier Inc.
Nursing Care During Labor and Birth
Labor begins with first uterine contraction, continues with hard work during cervical dilation and birth, and ends as woman and family begin attachment process with infant
First Stage of Labor
Begins with onset of regular uterine contractions Ends with full cervical effacement and dilation
First Stage of Laborcontd
Three phases

Latent phase: up to 3 cm of dilation Active phase: 4 to 7 cm of dilation Transition phase: 8 to 10 cm of dilation
Nursing care management
Nulliparous women seek admission during latent phase Multiparous women do not usually come to hospital or birth center until active phase Caregivers can strongly influence lingering impressions of childbirth experience
EMTALA
Emergency Medical Treatment and Active Labor Act

Federal regulation enacted to ensure that woman receives emergency treatment or labor care Nurses must be familiar with their responsibilities Agencies must have policies and procedures in place to ensure compliance
Assessment and nursing diagnosis
Determination of true or false labor Contractions Cervix Fetus Admission to labor unit
Admission data Prenatal data Interview Psychosocial factors Stress in labor Cultural factors
Physical examination General systems assessment Vital signs Leopolds maneuvers Assessment of fetal heart rate (FHR) and
pattern
Fig. 18-5. Leopold's maneuvers.
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Physical examination Assessment of uterine contractions
Frequency Intensity Duration Resting tone Cervical effacement, dilation, fetal descent
Vaginal examination
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Laboratory and diagnostic tests Analysis of urine specimen Blood tests Assessment of amniotic membranes and fluid Signs of potential problems
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Plan of care and implementation

Standards of care Physical nursing care during labor General hygiene Nutrient and fluid intake Elimination Ambulation and positioning
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Plan of care and implementation
Supportive care during labor Nurse Father or partner Doulas Grandparents Siblings during labor and birth Emergency interventions
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Second Stage of Labor
Infant is born

Begins with full cervical dilation (10 cm) Complete effacement Ends with babys birth
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Second Stage of Laborcontd
Three phases
Latent: relatively calm with passive descent of baby through birth canal Descent: active pushing and urges to bear down Transition: presenting part is on perineum, and bearing-down efforts are most effective for promoting birth
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Preparing for birth

Maternal position Bearing-down efforts FHR and pattern Support of father or partner Supplies, instruments, and equipment
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Fig. 18-6. Areas of maximal intensity of fetal heart rate for differing positions. RSA,Right sacrum anterior; ROP, right occipitoposterior; RMA, right mentum anterior; ROA, right occipitoanterior; LSA, left sacrum anterior; LOP, left occipitoposterior; LMA, left mentum anterior; and LOA, left occipitoanterior. A, Presentation is breech if fetal heart tones (FHTs) are heard above umbilicus. B, Presentation is vertex if FHTs are heard below umbilicus.
Mosby items and derived items 2010, 2006, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. 18
Fig. 18-7. Location of the fetal heart rate. A, With fetus in right occipitoanterior (ROA) position. B, Changes in location of point of maximal intensity of fetal heart tones as fetus undergoes internal rotation from ROA to OA for birth. C, With fetus in left sacrum posterior position.
Fig. 18-8. Assessment of uterine contractions. A, Abdominal contour before and during uterine contractions. B, Wavelike pattern of contractile activity.
Fig. 18-9. Vaginal examination. A, Undilated, uneffaced cervix; membranes intact. B, Palpation of sagittal suture line. Cervix effaced and partially dilated.
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Fig. 18-4. Supine hypotension. Note relationship of gravid uterus to ascending vena cava in standing posture (A) and supine posture (B). C, Compression of aorta and inferior vena cava with woman in supine position. D, Relieved by use of a wedge pillow placed under woman's right side.

Preparing for birth Birth in delivery room or birthing room Birth in LDR or LDRP room Water birth
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Mechanism of birth: vertex presentation

Birth of head Birth of shoulders Birth of body and extremities
Management of infant born with meconiumstained fluid
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Immediate assessment and care of newborn Fundal pressure

No longer advised for nurses since no standard technique is available for this maneuver Contraindicated in shoulder dystocia
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Fig. 18-21. Beginning birth with vertex presenting. A, Anteroposterior slit. B, Oval opening. C, Circular shape. D, Crowning.
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Fig. 18-22. Birth of head with modified Ritgen maneuver. Note control to prevent too rapid birth of head.
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Perineal trauma related to childbirth
Lacerations Perineal lacerations Vaginal and urethral lacerations Cervical injuries Episiotomy
Emergency childbirth
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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 bulbocavernous muscle.
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Fig. 18-24. Types of episiotomies.
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Third Stage of Labor
Placental separation and expulsion

Firmly contracting fundus Change in shape of uterus Sudden gush of dark blood from introitus Apparent lengthening of umbilical cord Vaginal fullness
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Fig. 18-25. Third stage of labor. A, Placenta begins the separation process in central portion with retroplacental bleeding. Uterus changes from discoid to globular shape. B, Placenta completes separation and enters lower uterine segment. Uterus is globular in shape. C, Placenta enters vagina, cord is seen to lengthen, and there may be increased bleeding. D, Expulsion (birth) of placenta and completion of third stage.
Unn. Fig. 18-1. Normal Vaginal Childbirth: First Stage: Anteroposterial slit; vertex visible during contraction.
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Unn. Fig. 18-2. Normal Vaginal Childbirth: First Stage: Oval Opening; vertex presenting.
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Unn. Fig. 18-3. Normal Vaginal Childbirth: Second Stage: Crowning.
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Unn. Fig. 18-4. Normal Vaginal Childbirth: Second Stage: Nurse-midwife using Ritgen maneuver as head is born by extension.
Unn. Fig. 18-5. Normal Vaginal Childbirth: Second Stage: After nurse-midwife checks for nuchal cord, she supports head during external rotation and restitution.
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Unn. Fig. 18-6. Normal Vaginal Childbirth: Second Stage: Use of bulb syringe to suction mucus.
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Unn. Fig. 18-7. Normal Vaginal Childbirth: Second Stage: Birth of posterior shoulder.
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Unn. Fig. 18-8. Normal Vaginal Childbirth: Second Stage: Birth of newborn by slow expulsion.
Unn. Fig. 18-9. Normal Vaginal Childbirth: Second Stage: Second stage complete.
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Unn. Fig. 18-10. Normal Vaginal Childbirth: Third Stage: Newborn placed on mothers abdomen while cord is clamped and cut.
Unn. Fig. 18-11. Normal Vaginal Childbirth: Third Stage: Note increased bleeding as placenta separates.
Unn. Fig. 18-12. Normal Vaginal Childbirth: Third Stage: Expulsion of placenta.
Unn. Fig. 18-13. Normal Vaginal Childbirth: Third Stage: Expulsion is complete.
Unn. Fig. 18-14. Normal Vaginal Childbirth: The Newborn: Newborn awaiting assessment.
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Unn. Fig. 18-15. Normal Vaginal Childbirth: The Newborn: Newborn assessment under radiant warmer.
Unn. Fig. 18-16. Normal Vaginal Childbirth: The Newborn: Parents admiring their newborn.
Third Stage of Laborcontd
Maternal physical status
Signs of potential problems Excessive blood loss Alteration in vital signs and consciousness Care of placenta after delivery
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Fourth Stage of Labor

Assessment Postanesthesia recovery Interactions with newborn Family-newborn relationships
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Key Points
Onset of labor may be difficult to determine for both nulliparous and multiparous women Home is most often ideal place for woman during latent phase of first stage of labor
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Key Pointscontd
Nurse assumes much of responsibility for:

Assessing progress of labor Keeping primary health care provider informed about progress in labor Deviations from expected findings
FHR and pattern reveal fetal response to stress of labor process
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Key Pointscontd
Womans or couples perception of birth experience likely to be positive when events and performances are consistent with expectations
Especially in terms of maintaining control and adequacy of pain relief
Womans level of anxiety may increase when she does not understand medical terminology used or because of a language barrier
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Key Pointscontd
Coaching, emotional support, and comfort measures assist woman to use energy constructively in relaxing and working with contractions Doulas provide continuous supportive presence during labor that can have positive effect on childbirth
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Key Pointscontd
Cultural beliefs and practices of a woman and her significant others can have a profound influence on their approach to labor and birth
Siblings present for labor and birth need preparation and support for the event Most parents/families enjoy being able to handle, hold, and explore the baby
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Key Pointscontd
Nurses observe progress in development of parent-child relationships and are alert for warning signs during immediate postpartum period Woman benefits from reviewing her childbirth experience with nurse who managed her care during labor and birth
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Chapter 018

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Chapter 18

Nursing Care During Labor and Birth

Nursing Care During Labor and Birth

First Stage of Labor

First Stage of Laborcontd

Latent phase: up to 3 cm of dilation Active phase: 4 to 7 cm of dilation Transition phase: 8 to 10 cm of dilation

First Stage of Laborcontd

Nursing care management

Emergency Medical Treatment and Active Labor Act

First Stage of Laborcontd

Assessment and nursing diagnosis

First Stage of Laborcontd

Assessment and nursing diagnosis

First Stage of Laborcontd

Assessment and nursing diagnosis

Fig. 18-5. Leopold's maneuvers.

First Stage of Laborcontd

Assessment and nursing diagnosis

Physical examination Assessment of uterine contractions

First Stage of Laborcontd

Assessment and nursing diagnosis

First Stage of Laborcontd

Plan of care and implementation

First Stage of Laborcontd

Plan of care and implementation

Second Stage of Labor

Second Stage of Laborcontd

Second Stage of Laborcontd

Preparing for birth

Second Stage of Laborcontd

Second Stage of Laborcontd

Mechanism of birth: vertex presentation

Birth of head Birth of shoulders Birth of body and extremities

Management of infant born with meconiumstained fluid

Second Stage of Laborcontd

Immediate assessment and care of newborn Fundal pressure

Second Stage of Laborcontd

Perineal trauma related to childbirth

Fig. 18-24. Types of episiotomies.

Third Stage of Labor

Placental separation and expulsion

Unn. Fig. 18-3. Normal Vaginal Childbirth: Second Stage: Crowning.

Third Stage of Laborcontd

Maternal physical status

Fourth Stage of Labor

Assessment Postanesthesia recovery Interactions with newborn Family-newborn relationships

Nurse assumes much of responsibility for:

FHR and pattern reveal fetal response to stress of labor process

Especially in terms of maintaining control and adequacy of pain relief

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