1. Nursing Care of Mother and Infant During Labor and Birth
Chapter 6
Nursing Care of Mother and Infant During Labor and Birth
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2. Cultural Influences on Birth Practices (p. 116)
Role of woman in labor and delivery
Cultural preferences require flexibility
Role of father/partner in labor and delivery
May be driven by cultural practices
Refer to Table 6-1 (pp ).
Discuss the responsibilities of the nurse when interacting with families of different cultures.
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3. Settings for Childbirth (p. 116)
Hospitals
Advantages-preregistration, easy access to sophisticated resources, family centered care for complicated pregnancy
Disadvantages
Freestanding birth centers
Advantages-home like settings, lower costs
Disadvantages-immediate emergency access
Home
Advantages-control over persons around; no risk of cross contamination; low tech birth
Disadvantages-limited choice of birth attendants; immediate emergency access
Review the advantages and disadvantages of each setting.
Does your community have a freestanding birth center?
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4. Components of the Birth Process (p. 116, 119-126)
The Four “Ps”
Powers
Passage
Passenger
Psyche
The powers that influence labor cause the cervix to dilate and move the fetus downward. Sources of power include uterine contractions and pushing efforts by the laboring woman.
The passage refers to the patient’s pelvis.
The passenger is the fetus.
What impact can the patient’s psyche have on the labor’s progress and/or outcomes?
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5. Factors that Influence the Progress of Labor (p. 116, 119-126)
Preparation
Position
Professional
Place
Procedures
People-Table 6-1-***Birth Practices of Selected Cultural Groups***
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6. Uterine Contractions (pp. 119-120)
Effect of contractions on the cervix
Efface
Dilate
Phase of contractions
Increment
Peak
Decrement
A uterine contraction results from involuntary smooth muscle contractions.
The contractions assist in the effacement (thinning) of the cervix.
During labor, one of the nurse’s roles is to monitor uterine contractions.
Define frequency and duration.
What are the differences among mild, moderate, and firm contractions?
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7. Uterine Contractions (pp. 119-120)
Frequency
elapsed time from the beginning of one contraction to the beginning of the next contraction
Duration
Elapsed time from the beginning to the end of same contraction
Persistent contraction lasting longer than 90 sec reduce fetal oxygen supply
It is important to have mother relax during contractions
Intensity
Mild
Moderate
Firm
Maternal pushing
A uterine contraction results from involuntary smooth muscle contractions.
The contractions assist in the effacement (thinning) of the cervix.
During labor, one of the nurse’s roles is to monitor uterine contractions.
Define frequency and duration.
What are the differences among mild, moderate, and firm contractions?
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8. Safety Alert! (p. 122)
Report to the RN any contractions that occur more frequently than every 2 minutes, last longer than 90 seconds, or have intervals shorter than 60 seconds
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9. Cervical Effacement and Dilation (p. 120)
Cervical effacement and dilation can be likened to sucking on a Lifesaver. As the candy becomes thinner, the center opening becomes wider.
Describe the differences between cervical effacement and dilation for the primigravida and multigravida woman.
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10. Contraction Cycle (p. 121)
Nurses must understand the components of the contraction cycle.
Review the increments and peak of the contraction pattern.
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11. Nursing Tip (p. 122)
Provide emotional support to the laboring woman so she is less anxious and fearful.
Excessive anxiety or fear can cause greater pain, inhibit the progress of labor, and reduce blood flow to the placenta and fetus.
What interventions can the nurse implement to reduce anxiety and fear during labor?
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12. The Passage (p. 122) Bony pelvis Soft tissues True False
Directly involved in childbirth
Inlet
Midpelvis
Outlet
False
Flares
Upper portion of pelvis
Soft tissues
If previous delivery, will yield more readily to contractions and pushing efforts
May not yield as readily in primiparas or older women
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13. The Passenger—Fetal Skull (pp. 122-123)
The bones in the fetal head are separated by connective tissue.
What is the importance of this tissue in relation to the birthing process?
Compare and contrast the fontanelles
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14. The Passengers—Fetal Lie (pp. 122-123)
Fetal lie refers to the position of the fetus in relation to the maternal spine.
Review the various fetal lie positions.
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15. The Passengers—Presentation (pp. 123-124)
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16. The Passengers—Presentation (pp. 123-124)
Fetus
Fetal Head-fontanelles (anterior/posterior)
Lie-how the fetus is aligned with mother’s spine
Attitude-normally one of flexion with the head flexed and arms and legs flexed
Presentation-the fetal part that enters the pelvis 1st
-Vertex-head is fully flexed-most favorable
-Military head is neither flexed or extended
-Brow head is partly extended
-Face-head is fully flexed and face is presents
-Breech-Frank, Full or complete, Footling
Position- how a reference point on fetal presenting part within mother’s pelvis
Occiput-how fetus is in cephalic vertex presentation
Sacrum-how fetus is in a breech presentation
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17. Psyche (pp. 124-125) Mental state can influence the course of labor.
The woman’s cultural and individual values influence how she will cope with childbirth.
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18. Classifications of Fetal Presentations and Positions (p. 125)
Review the terminology used in each of the fetal presentations.
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19. Signs of Impending Labor (p. 126)
Braxton Hicks contractions
Increased vaginal discharge
Bloody show
Rupture of the membranes
Energy spurt
Weight loss
Compare and contrast the clinical manifestations of Braxton Hicks contractions and true labor.
Bloody show is a normal occurrence prior to the onset of labor. Describe the manifestations associated with bloody show.
Rupture of membranes warrants evaluation of the pregnant woman at the health care facility.
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20. Mechanisms of Labor (p. 126)
Descent
Station-0 station at ischial spines above them minus stages below designated as plus stages; measured in cm
Engagement
Flexion
Internal rotation
Extension
External rotation
Expulsion
Mechanisms of labor refer to those physiological changes in positioning which take place during a normal vaginal delivery.
Describe each of these positions.
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21. Birth Station (pp. 126, 128)
Station refers to the position of the fetal head relative to the ischial spines.
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22. Mechanisms of Labor (p. 126)
Also referred to as “cardinal movements.”
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23. When to Go to the Hospital or Birth Center (p. 128)
Contractions
Ruptured membranes
Bleeding other than bloody show
Decreased fetal movement
Any other concern
What is the timeline for patient education concerning how and when to seek care?
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24. Admission Data Collection (p. 128-129)
Three major assessments performed promptly on admission
Fetal condition-FHR w/fetoscope
Maternal condition-V/S
Impending birth-observing mother; making grunting noises, bearing down with contractions, stating “The baby is coming.”, Bulging of perineum or fetal presenting part at vaginal opening
Discuss Skill 6-1, Assisting with an Emergency Birth (p. 129).
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25. Admission Procedures (p. 130)
Permits/consents
Laboratory tests
Intravenous infusion
Perineal prep
Determining fetal position and presentation
Discuss the actions required for each task listed.
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26. Comparison of False and True Labor (p. 131)
False labor
Contractions irregular
Painless tightening of abdominal muscles
Walking relieves contractions
Bloody show usually not present
No change in effacement/dilation of cervix
True labor
Contractions gradually develop a regular pattern
Contractions become stronger and more effective with walking
Discomfort in lower back/abdomen
Bloody show often present
Progressive effacement and dilation of cervix
Refer to Table 6-2 (p. 131).
What is the greatest difference between the types of labor? False labor does not result in cervical changes, while true labor causes changes in cervical dilation and effacement.
At what point during the pregnancy should education be provided regarding false and true labor? Successful education should begin early in the pregnancy. This approach allows time for reinforcement throughout the pregnancy at each visit to the health care provider.
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27. Nursing Care Before Birth (p. 131)
After admission to the labor unit, nursing care consists of
Monitoring the fetus
Monitoring the laboring woman
Helping the woman cope with labor
Fetal monitoring can be intermittent or continuous.
Review factors which can determine the type of monitoring employed
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28. Monitoring the Fetus (p. 131)
Fetal heart rate
Intermittent auscultation
Continuous electronic fetal monitoring
Review Skill 6-2 on p. 132, Box 6-2 on p. 133, and Skill 6-3 on p. 134.
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29. FHR Outside of Normal Limits (p. 132)
Any FHR outside the normal limits and any slowing of the FHR that persists after the contraction ends is promptly reported to the health care provider.
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30. Evaluating Fetal Heart Rate Patterns (pp. 133-136)
Baseline FHR
BPM
Fetal bradycardia
<110 BPM
Fetal tachycardia
>160 BPM
Baseline variability
Moderate variability
Marked variability
Absent variability
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31. Evaluating Fetal Heart Rate Patterns (pp. 137)
Accelerations-temporary, abrupt rate increases at least 15 bpm above baseline and lasts 15 sec but less than 2 min-suggest well oxygenated fetus
Early decelerations-FHR decreases no more than 40 bpm and return after contraction-U shape; compression of fetal head
Variable decelerations-FHR decreases 15 bpm last 15 sec to 2 min-V or W shape-suggest umbilical cord compressed-due to be around fetal neck or inadequate amniotic fluid; reposition and monitor if they continue give oxygen
Late decelerations-begin after contraction and do not return after contraction; suggest placenta not delivering enough oxygen (uteroplacental insufficiency)-nonreassuring-could indicate fetal hypoxia or fetal heart depresssion; reposition to prevent supine hypotension, administer O L/min, increase IV fluids; stop oxytocin; administer tocolytic drugs
Prolonged decelerations-caused by cord compression or prolapse; maternal supine hypotension; or due to regional anesthesia
Recurrent decelerations-occur more than 50% of uterine contractions
Intermittent decelerations-occur in less than 50% of uterine contractions
Sinusoidal pattern-may happen due to medication provided such as Demoral, or Stadol
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32. Nonreassuring patterns
Reassuring and Nonreassuring FHR and Uterine Activity Patterns (p. 135)
Reassuring patterns
Nonreassuring patterns
Stable fetal heart rate (FHR)
Moderate variability
Accelerations
Uterine contraction frequency greater than every 2 minutes; duration less than 90 seconds; relaxation interval of at least 60 seconds
Tachycardia
Bradycardia
Decreased or absent variability; little fluctuation in rate
Late decelerations
Variable decelerations
See Box 6-3 on p. 135 for more details.
A part of the nursing assessment is the evaluation of fetal heart patterns.
Nonreassuring patterns need reported to the health care provider.
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33. Late Decelerations (p. 135)
Review Box 6-3, p. 135.
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34. Inspection of Amniotic Fluid (p. 137)
Amniotic Membranes-rupture spontaneously or artificially by Dr. by going an amniotomy-Priority-FHR will need to be assessed for at least 1 full minute and record and report. When membranes are ruptured will need to evaluate:
Color
Normal is clear fluid, may have flecks of white vernix
Green-stained may indicate fetus passed meconium (first stool but before birth)
Can lead to fetal compromise
Odor
Should not smell
If it does, it may indicate infection
Amount
Scant—trickle
Moderate— ~500 mL
Large— ≥ 1,000 mL
What nursing interventions would be needed for normal-appearing amniotic fluid, meconium-stained, and large quantities?
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35. Monitoring the Woman (p. 137)
Vital signs
Contractions
Progress of labor
Intake and output
Response to labor
Discuss the frequency of each of the items to be monitored.
Closed glottis pushing decreases fetal oxygenation and should be avoided.
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36. Six Lamaze Institute Basic Practices for Maternity Care (p. 140)
Labor should begin on its own.
Woman should have freedom of movement.
Woman should have a birth support person or doula.
No routine interventions should be performed.
Woman should be in non-supine positions.
Woman should not be separated from infant.
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37. Helping the Woman Cope with Labor (p. 140)
Labor support
Teaching
Positioning and breathing techniques
Help to remind mother not to push before cervix fully dilated
When cervix is fully dilated then take a deep breath & exhale at beginning of a contraction then take another deep breath and push while exhaling
Providing encouragement
Supporting/teaching the partner
Teach how labor pains affect the woman’s behavior/attitude
How to adapt responses to the woman’s behavior
What to expect in his/her own emotional responses
Effects of epidural analgesia
Review the components of labor support with the class.
What are the recommended positions of comfort for the laboring women?
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38. Stages and Phases of Labor (p. 143)
First stage—dilation and effacement (can last 4 to 6 hours)
Latent Phase-Cervix 1-4 cm; cooperative, alert
Active Phase-Cervix 4-7 cm; apprehensive, anxious
Transition Phase-Cervix 7-10 cm; irritable, rejects support
Second stage—expulsion of fetus (30 minutes to 2 hours)
Third stage—expulsion of placenta (5 to 30 minutes)
Fourth stage—recovery
The labor of the primigravida will last longer than that of a multigravida.
What behaviors are associated with each of the stages of labor?
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39. Vaginal Birth After Cesarean (p. 143)
Main concern
Uterine scar will rupture
Can disrupt placental blood flow
Lead to hemorrhage
Woman may need more support than other laboring women
Nurse provides empathy and support
Discuss some of the psychological barriers that may arise for a woman with VBAC.
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40. Nursing Responsibilities During Birth (pp. 144-146)
Preparing the delivery instruments and infant equipment
Perineal scrub
Administering medications
Providing initial care to the infant
Assessing Apgar score
Assessing infant for obvious abnormalities
Examining the placenta
Identifying mother and infant
Promoting parent-infant bonding
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41. Immediate Postpartum Period: Third and Fourth Stages of Labor (p. 146)
Third stage—expulsion of placenta
Schulze or Duncan’s
Fourth stage—nursing care includes
Identifying and preventing hemorrhage
Evaluating and intervening for pain
Observing bladder function and urine output
Evaluating recovery from anesthesia
Providing initial care to the newborn infant
Promoting bonding and attachment between the infant and family
After the birth of the baby, the nurse continues to assess the mother.
Review both normal and abnormal findings.
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42. Nursing Care Immediately After Birth (p. 147)
Care of the mother
Observing for hemorrhage
Vital signs
Skin color
Location and firmness of uterine fundus
Lochia
Pain
Promoting comfort
Keep warm and dry
Ice to perineum to help reduce swelling and bruising
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43. Nursing Care Immediately After Birth (cont.) (p. 147)
Care of the newborn
Phase 1
From birth to 1 hour (usually in delivery room)
Phase 2
From 1 to 3 hours (usually in transition nursery or postpartum unit)
Phase 3
From 2 to 12 hours (usually in postpartum unit if rooming-in with the mother)
If the newborn does not experience any difficulty with adaptation to extrauterine life, the infant will often remain with the mother in the delivery room.
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44. Phase 1: Care of the Newborn (p. 150)
Initial care includes
Maintaining thermoregulation
Maintaining cardiorespiratory function
Observing for urination and/or passage of meconium
Identifying the mother, father, and newborn
Performing a brief assessment for major anomalies
Encouraging bonding/breastfeeding
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45. Care of the Newborn (p. 147)
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46. Apgar Scoring (pp )
Scoring is done in the following 5 areas with scoring from 0-2 in each area
Heart rate
Respiratory effort
Muscle tone
Reflex response to suction or gentle stimulation on the soles of the feet
Skin color
The Apgar is performed twice. At what times is the scoring performed?
A point-based system is used. Each of the parameters is given a score between 0 and 2 points.
What are the implications of the score obtained?
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47. Administering Medications to the Newborn (p. 152)
Eye care
Vitamin K (AquaMEPHYTON)
Review Skill 6-6 on p. 153 and Skill 6-7 on p. 154.
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48. Observe for Major Anomalies (p. 153)
Head trauma from delivery
Symmetry and equality of extremities
Are they of equal length?
Do they move with same vigor on both sides?
Assess digits of hands and feet
Any evidence of webbing or abnormal number of digits
What else should be assessed in regard to major anomalies?
Which anomalies require immediate notification to the RN or health care provider?
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49. Umbilical Cord Blood Banking (p. 153)
This type of blood is capable of regenerating stem cells that are able to replace diseased cells.
Informed consent is essential.
Collect blood after cord has been clamped.
Blood must be transported within 48 hours of collection to blood banking facility.
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50. Emerging Technologies and Practice (p. 154)
STAN technology: type of waveform analysis that detects intrapartal changes in fetal ST waveforms, indicative of developing fetal metabolic acidosis.
PERICALM-EFM: computerized interpretation of real-time FHR patterns that provides automatic analysis of fetal heart pattern to compliment clinical judgment as well as permanent documentation in EMR.
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