Nursing Care during Labor

and Pain Management

RNSG 2504/1517
Fall 2015
Birth Settings
• Hospital
• Most traditional
• Offer in-hospital birthing rooms
• Birthing Centers
• Home environment
• Short stay
• Have quick access to hospital if needed
• Home Birth
• In comfortable surroundings
• Low risk mom and baby
• Couple should understand the risk
Birth center
Birthing at a birth center
Cultural considerations
• Modesty
• Pain
• Position
• Female care provider
• Support person
Care Management
• Most women come to the hospital when:
• Onset of regular contractions
• SROM
• Bloody show
First impressions
• How the nurse communicates with the
patient can influence how she will feel
about her birth experience
• She must feel safe
Data Collection
• Review prenatal record, EDD, previous
health conditions, hepB status, Rh
• I.D. bracelet, Allergies
• V/S
• When did labor start
• Record FHR
• SROM? nitrazine, ferning
• IV fluids?
• Last food intake
• Consents
• Orient to unit
• Cervical exam if no bleeding and term
Ongoing Assessments
Warning signs to report
• Fever .100.4

• Contractions lasting >90 sec

• Contractions < 2 minutes apart
• Fetal bradycardia or tachycardia
• Loss of baseline variability

• Meconium stained fluid

• Foul smelling fluid
• Excessive bleeding and hypotension
 Practice question
Which statement is the best rationale for assessing maternal
vital signs between contractions?

A) During a contraction, assessing fetal heart rates is the

priority.
B) Maternal circulating blood volume increases temporarily
during contractions.
C) Maternal blood flow to the heart is reduced during
contractions.
D) Vital signs taken during contractions are not accurate.
 Monitoring Uterine
Contractions
• By monitor
• Contraction pattern will be recorded on graph paper

• Palpation
• At least three consecutive contractions
• Fingertips on fundus
• Duration, frequency and intensity
Contractions
Fetal Monitoring
 Practice question
To assess the duration of labor contractions, the nurse
determines the time:

A) From the beginning of one contraction to the beginning

of the next.
B) From the beginning to the end of each contraction.
C) Of the strongest intensity of each contraction.
D) Of uterine relaxation between two contractions.
 Maternal-placental
insufficiency

FHR Late Decelerations

Poor or reduced variability
Early Deceleration

Head compression--normal
Late Deceleration
 Practice question
When the deceleration pattern of the fetal heart rate "mirrors"
the uterine contraction, which nursing action is indicated?

A) Administer oxygen by nasal cannula.

B) Reposition the woman.
C) Apply a fetal scalp electrode.
D) Record this reassuring pattern.
Nurse’s role
• Assessment
• Support family
• Promote comfort
• Ensure safety
• Education
• Report progress
• Report abnormal findings
• Prevent infection
• Documentation
• BIRTH PLANS
Nurses role: Documentation
• Fetal Heart Tracing
• Considered a legal part of woman’s
labor record!
• Vaginal exams
• Amniotomy or spontaneous rupture
• Maternal v/s & FHR
• Maternal position in bed
• Application of internal devices
• Medications
• Oxygen
• Maternal behaviors, coughing, vomiting
• Fetal scalp stimulation
• Pushing
• Anesthesia, epidural
Nursing care Stage one, Latent phase
• Mom:
• Happy, controlled, talkative,
independent, Takes care of own
needs.

• Nurse: Establish rapport

• Monitor V/S, fetus
• Assess membranes
• Voiding
• Assess coping
• Encourage walking if membranes
are intact
• Encourage support person
• Keep NPO, ice chips
• Keep couple informed
Nursing Care Stage One Active Phase
• Mom:
• Apprehensive, doubts and fears, fatigued,
restless
• Becomes more dependent
• Desires companionship
• Doubts self
• Look for ritual motions, indicates strong coping

• Nurse:
• Continue to assess and document
• Provide support and encouragement
• Encourage to void q 1-2 hours
• Assess progress of labor
• Provide comfort measures
• Assist with position changes
• Birthing ball, whirlpool tub
• Cold pack, massage/pressure for back labor
• Frequent perineal care
Nursing Care Stage One Transition
• Mom:
• Marked irritability
• Amnesia between contractions
• General discomfort
• Hiccupping, belching
• Nausea and vomiting
• Perspiration, small bead on upper lip
• May feel out of control
• Fears being alone

• Nurse:
• Encourage rest between contractions
• Assess monitor strip and V/S
• Very difficult for women
• Do not leave her alone
• Accept behaviors, encourage and
support
• Provide medications if desired
• Provide privacy
Nursing Care Stage 2, Expulsion of Fetus
• Mom
• Pressure! Exhausted
• Feels helpless
• Rectal vaginal bulging, flattening of
perineum

• Nursing
• Encourage open glottis pushing
• Positions best for pushing vs for staff
• Deep breathing between contractions
• Assess monitor strip, V/S
• Inform of progress
• SUPPORT!
• Remain at bedside at all times
Nursing Care Stage 3, Expulsion of Placenta
• Mom:
• Eager to see and hold baby
• Visible lengthening of cord
• Trickle or gush of blood
• 2-3 contractions
• Nurse:
• Assess vital signs
• Assess for excessive bleeding
• Repair?
• Assess fundal height and firmness
Nurses Role Stage Four: Immediate Recovery
• Mom:
• Exhausted but happy
• Eager to feed baby
• Hungry, thirsty, sleepy
• Nurse:
• Prevent Hemorrhage
• Assess every 15 minutes for 1 hour,
BUBBLE-HE
• Encourage bonding, breast feeding
• Provide for privacy
Pain in Labor
• Educate
• Assess
• Provide support
• Offer medication
 • Dilatation and stretching
of the cervix
• Uterine contractions
• Ischemic muscles
Sources of Pain in
• Pressure and pulling of
Labor pelvic structures
• Ligament, fallopian tubes,
peritoneum
• Distention and stretching
of the vagina and
perineum
• Splitting and tearing
sensation
 Nonpharmacologic pain control
measures
• Education
• General comfort measures
• Cognitive stimulation
• Cutaneous stimulation-effleurage
• Breathing techniques
• Relaxation
• Hypnosis
Pharmacologic pain control
Benefits vs. risk to fetus
• Maximum relief, minimal risk
• Minimal side effects
• Given with the woman's knowledge
• Adequate fetal monitoring and emergency
equipment
• The drug must allow the women’s uterus
to contract
• Must not be given < 1hour before delivery
• Drugs cross the placenta
• Only reduce pain perception
Pharmacologic pain control
• Analgesia
• Meperidine = Demerol
• Fentanyl = Sublimaze
• Butorphanol = Stadol
• Nalbuphine = Nubain

• Naloxone = Narcan, reverses narcotics

• Morphine stays in system 7 hours, not

usually used for this reason
 Pharmacologic pain control
Sedatives
• Do not relieve pain
• Do cross the placenta
• May inhibit the mother’s ability to cope in
labor
• Not generally used

• Diazepam (Valium)
• Midazolam (Versed)
Pharmacologic pain control
Antiemetics, antianxiety
• Promethazine = Phenergen
• Hydroxyzine = Vistaril

• Can control nausea

• Reduce dose of narcotic needed
Anesthesia
Regional
• Contraindications: hypovolemia, blood
clotting problems, allergy or infections

Side effects:
• Hypotension
• Distended bladder - foley
• Headache
Pudendal
Local
Epidural / Spinal
Spinal
Informed consent
Assist with insertion,
Monitor pain relief
IV fluids
Monitor vital signs q 2 min X 20, q 15 until stable
Anesthesia
General
• Unconscious
• Aspiration
• Crosses placenta
 Fourth Stage of Labor
Recovery
• From the delivery of the placenta to the first 1
to 4 hours after delivery, or until v/s are stable

• Thirsty, hungry

• Chilled, shaking

• Promote bonding

• Monitor v/s, fundus, bleeding

 Maternal Response to Labor
• WBC’S increase 25 – 30,000, mostly in response to stress
• Glucose levels drop
• Gastric motility and absorption are reduced
• Gastric emptying is prolonged
• Polyuria, increased cardiac output increases renal plasma
flow
• Bladder is compressed, hematuria may be present
• Oxygen demand and consumption increase
Maternal Response to Labor
• Pain, anxiety, and apprehension
• Significant increase in cardiac output
• Each strong contraction greatly decreases
or stops the blood flow to the placenta,
redistributing of about 300 to 500 mls of
blood
• Increased blood pressure, slowing of pulse
The End—Questions?