1. Chapter 12--Processes & Stages of Labor and Birth

2. Critical Factors In Labor
The Four P’s: passage, passenger, powers & psyche
Passage:
adequate pelvis?
cephalopelvic disproportion (CPD)
Suspect if presenting part does not engage in pelvis (0 station)

3. Passenger The fetus: head is largest diameter
Fetal head: 4 bones with 3 membranous interspaces (sutures) that allow bones to move & overlap to diminish size of skull
Molding: head becomes narrower, longer, sutures can overlap--normal--resolves 1-2 days after birth
Fontanelles: at junctures of skull bones

4. Passenger Fetus and fetal membranes Molding of head Fetal lie
Longitudinal
Transverse
Oblique
Refer to Box 12-2 for fetal skull landmarks
Refer to Figure 12-4 for Fetal Lie

6. Fetal Lie and Presentation
Leopold's maneuvers/US
Longitudinal lie: Vertical
Presenting part:
cephalic (head),
vertex (occiput), chin (mentum)
breech (buttocks or feet) (c-section)
sacrum
Transverse lie: Horizontal (c-section)
Presenting part: shoulder (acromion)

7. Passenger (cont.) Fetal attitude—flexion Fetal presentation Cephalic
Vertex
Military
Brow
Face

8. Fetal Attitude

9. Advantages of Cephalic Presentations
Head usually largest part of infant
Molding
Optimal shape—smooth and round

10. Breech presentation Assessment: FHT heard high on the abdomen,
Leopold’s, vaginal exam & US.
Higher risk of anoxia from prolapsed cord, traumatic injury to the after coming head,
fracture of spine or arm,
dysfunctional labor
Usually delivered by
C-section

11. Disadvantages of Breech Presentation
Risk of cord prolapse
Presenting part less effective in cervical dilation
Risk of cord compression
Risk of prolonged labor

12. Shoulder Presentation
Occurs when fetus in transverse lie
Cannot be delivered vaginally unless rotation occurs
Refer to Figure 12-8 for Shoulder presentation

13. IMPORTANT TERMS Effacement: shortening and thinning of cervix
Expressed as a percentage (0% to 100%)
Dilation: opening and enlargement of cervix
Expressed in centimeters (1 to 10 cm)

14. Station Effacement Descent of fetal head (in cm) Thinning of cervix

15. Descent of
fetal head:
Station
Floating
Engaged
At outlet/crowning

16. Passageway + Passenger Relationship
Engagement
Station
Ischial spines—0 station
Above ischial spines—(–) minus station
Below ischial spines—(+) plus station
+4 cm means that ...
Refer to Figure 12-9 for station

17. Powers Uterine contractions—primary force
Maternal pushing efforts—secondary force
Characteristics of uterine contractions
Increment
Acme
Decrement

18. Powers Maternal Pushing Efforts
“Bearing down” sensation
Urge to push
No urge to push

19. Assessment of Uterine Contractions
Characteristics
Frequency
Duration
Intensity
Palpation
Electronic fetal monitoring
Refer to Figure 12-1 for Intensity

20. Onset of labor Usually begins between 38 & 42 weeks
Mechanism is unknown
Upper uterus contracts downward pushing presenting part on cervix causing effacement and dilatation
Premonitory signs of labor:
Lightening, Braxton-Hicks contractions (false labor),
cervical changes (ripening),
bloody show (mucous plug),
rupture of membranes (ROM),
sudden burst of energy

21. False vs True Labor: Contractions
False Labor
Benign and irregular contractions
Felt first abdominally and remain confined to the abdomen and groin
Often disappear with ambulation and sleep.
Do not increase in duration, frequency or intensity
True Labor:
Begin irregularly but become regular and predictable
Felt first in lower back and sweep around to the abdomen in a wave
Continue no matter what the women’s level of activity
Increase in duration, frequency, and intensity

22. False vs True Labor: Cervix
False Labor
No significant change in dilation or effacement
No significant bloody show
Fetus- presenting part is not engaged in pelvis
True Labor
Progressive change in dilation and effacement
Bloody show
Presenting part engages in pelvis

23. Critical Thinking
A primigravida client has just arrived in the birthing unit. What steps would be most important for the nurse to perform to gain an understanding of the physical status of the client and her fetus?
A. Check for ruptured membranes, and apply a fetal scalp electrode
B. Auscultate the fetal heart rate between and during contractions
C. Palpate contractions and resting uterine tone
D. Perform a vaginal exam for cervical dilation, and perform Leopold's maneuvers
E. Determine gestational age of fetus

24. First Stage of Labor: 0 to 10 cm: dilatation--opening of cervix)
Latent: slowest part of the process--slow dilation, mild contractions
from onset of regular UCs to rapid dilatation (about 3-4 cms)
Active: labor “picks up steam”--period of more rapid dilation
from 4 cm to full dilatation: stronger UCs
Transition: cm--intense, N/V, shaking

25. Landmarks Abbreviations are used Examples
First and last letter—maternal pelvis
Middle letter—fetus presenting part
Examples
ROA (right occiput anterior)
ROP
LSP

26. Psychosocial Influences
Other critical factors
Readiness, educational preparedness, etc.
Cultural views of childbirth
Role transition facilitated by positive childbirth experience
Negative experience interferes with bonding and maternal role attainment

27. Childbirth Settings and Labor Support

28. Admission Procedures Establish positive relationship
Collect admission data
Initial admission assessments
Focused
Psychosocial assessment
Cultural assessment
Laboratory tests
Refer to Table 12-2 for circumstances that warrant going to birthing center

29. Nursing Care Ongoing assessment Facilitate a positive birth experience
Manage discomfort
Advocate for patient’s needs
Provide anticipatory guidance

30. Care of Laboring Patient Early Labor
Couple excited, talkative, pain is manageable
Initial physical assessment & history
Admission--rapport
Fetal & UC monitoring
Vaginal exams, q 2 hours
Vital signs
Temperature q 4 hours-intact or q 2 hours ROM
Educate regarding labor
Encourage comfort, position changes, bladder emptying
Assess pain, pain tolerance, preferred type of labor/delivery
Reassure regarding what is normal, reduce anxiety

31. Care of Laboring Patient Active Labor
Couple quieter, discouraged, pain increasing
Transition (7-10 cm): Yikes! “out of control”, shaking, nausea/vomiting, sweating, pain is intense
Prepare for delivery
Second stage (Pushing):
Educate/instruct regarding pushing
Assess urge to push and fetal descent
Encourage/motivate patient, assess fatigue
Monitor fetal/maternal response to pushing bulge, crowning
Signs of imminent birth: perineal bulging

32. Labor Support Presence Promote comfort Environment Personal hygiene
Elimination
Supportive relaxation techniques

33. Critical Thinking
A client is admitted to the labor unit with contractions 2 to 3 minutes apart and lasting 60 to 90 seconds. The client is apprehensive and vomiting. This nurse understands this information to indicate that the client is most likely in what phase of labor?
A) Active
B) Transition
C) Latent
D) Second

34. Fetal Assessment Position Fetal heart sounds Baseline FHR Presence of
Variability
Accelerations
Decelerations
Refer to Figure for accelerations
Refer to Figure for decelerations

35. Interpretation of FHR Tracings
Consider contraction frequency and intensity, stage of labor, and earlier FHR pattern
Reassuring
Non-reassuring
Refer to Box 12-4 for Reassuring v. Non-reassuring

36. Nursing Care FHR decelerations Early: no action Variable and late
Lateral position changes
Oxygen per face mask
Palpation for hyperstimulation
Discontinue oxytocin
Increase IVF rate

37. Second Stage of Labor Full dilation through birth of infant
Urge to push
Promote effective pushing
Closed-glottis
Open-glottis
Position of comfort

38. Preparation for Birth Bulging of the perineum and rectum
Flattening and thinning of the perineum
Increased bloody show
Labia begin to separate

39. Dilatation & Effacement

40. Imminent Birth Crowning Burning sensation Intense pressure in rectum
Refer to Figure for Crowning
Refer to Figure for Episiotomy

41. Cardinal Movements of Birth
Mechanisms of labor. A, Descent. B, Flexion.
C, Internal rotation. D, Extension. E, External rotation.
Cardinal Movements of Birth

42. Head Rotation during Descent

43. Crowning
Crowning
In the hospital
Alternative settings

44. Nursing Diagnoses for Intrapartal Patient
Pain
Knowledge deficit
Anxiety
Fatigue
Risk for infection
Impaired fetal gas exchange

45. Third Stage Birth of baby to complete delivery of placenta
Smaller, spherical uterus
Elevation of uterus in abdomen
Lengthening and protrusion of cord
Gush of blood from vagina
Refer to Figure for Schultze & Duncan Manner

46. Fourth Stage Delivery of placenta through 1 to 2 hours after birth
Monitor position and firmness of uterus
“Boggy,” soft uterus
Report immediately
Initiate fundal massage
Assess lochia
Vital signs and urine output
Shivering—offer blankets

47. Fourth Stage —Risk Signs
Hypotension
Tachycardia
Excessive bleeding
Noncontracting uterus

48. Promoting Patient Comfort During Labor and Birth
Chapter 13
Promoting Patient Comfort During Labor and Birth

49. Pain During Labor and Birth
Shaped by past experiences
Assessing pain
Physiological, psychological indicators
Patient responses
May be intensified by fear, anxiety, fatigue

50. Physical Causes of Pain
Labor and Birth

51. Pain Neurology Uterine ischemia Visceral pain—dull and aching
Referred pain
Somatic pain—sharp, burning, prickling

52. Pain Perception and Expression
Highly personal and subjective
Affected by gender, culture, ethnicity, and past experiences
Physiological/affective expression
Increased catecholamines
Increased blood pressure and heart rate
Altered respiratory pattern

53. Factors Affecting Maternal Pain Response
Physical
Physiological
Psychological
Anxiety, fear, previous experience
Support systems, childbirth preparation
Environmental

54. Nonpharmacological Pain Relief Measures
Maternal position and movement
Breathing techniques
Music
Relaxation techniques
Other attention-focusing strategies
Guided imagery

55. Massage and Touch Effleurage Counterpressure Therapeutic touch
Healing touch

56. Other Therapies for Comfort
Hydrotherapy, hypnotherapy, aromatherapy
Application of heat and cold
Biofeedback, TENS, intradermal water block
Acupressure/acupuncture

57. Pharmacological Pain Relief Measures
Timing
Nonpharmacological and pharmacological measures promote positive experience
Informed consent

58. Pharmacological Measures
Sedatives and antiemetics
Systemic opiods & analgesics

59. Nerve Block Analgesia, Anesthesia
Regional anesthesia- Epidural
Local perineal infiltration anesthesia
Pudendal nerve block
Spinal anesthesia block
Complications: maternal hypotension, decreased placental perfusion, ineffective breathing pattern

60. Systemic Analgesia Pre-medication Assessment:
Pain level, VS, allergies, drug dependence (withdrawal), vaginal exam/progress in labor, UC pattern, fetal heart rate tracing
Post-medication Assessment:
VS, esp. RR, LOC, dizziness (bedpan), sedation, FHR
Reversal agent: Naloxone (Narcan)
Competes with narcotic for opiate receptors. Used in both mom and baby. (avoid with narcotic dependence)

61. Regional Anesthesia
Definition: Injection of local anesthesia to block specific nerve pathways
Epidural/spinal anesthesia
Systemic toxicity: cardiovascular collapse
Side effects: Hypotension (preload with IV fluids), fetal distress on FHR tracing, spinal HA
Contraindications: coagulation disorders, low platelet count (< 100), allergy, neurologic disease, aspirin or heparin use
Nursing care: Preload IV fluids (LR), monitor BP, HR, anesthesia level, FHR, foley catheter, maternal positioning

62. Maternal Hypotension Prevention Requires constant nursing attendance
Preload IV fluids
Requires constant nursing attendance
Monitor vital signs

63. Epidural Anesthesia

64. Postdural Puncture (Spinal) Headache
Leakage of cerebrospinal fluid
Intensified in upright position
Auditory and visual problems
Autologous epidural blood patch
Discharge instructions

65. Disadvantages of Epidural
Limited mobility
Common side effects
Accidental injection into blood vessel
Sympathetic blockage
Urinary retention, bladder distention

66. General Anesthesia Major risks –used ONLY in emergencies
Pre-operative preparation
Anesthetic gases and medications
Recovery room nursing care
Refer to Box 13-3 for obstetric complications requiring surgical intervention

67. Nursing Care Related to Comfort Measures
Assessment
Ongoing and collaborative
Diagnoses
Anxiety
Ineffective coping
Acute pain

68. Nursing Care Expected outcomes Plan of care Individualized
Modified as needed
Collaborative approach

69. Caring for the Woman Experiencing Complications During Labor and Birth
Chapter 14
Caring for the Woman Experiencing Complications During Labor and Birth
Refer to Box 14-1 for possible nursing diagnoses

70. Dystocia Long, difficult, or abnormal labor May arise from Powers
Passenger
Passageway
Refer to Box 14-2 for Dystocia

71. Dysfunctional Labor Pattern: Hypertonic
Strong, painful, ineffective contractions
Contributing factor—maternal anxiety
Occiput-posterior malposition of fetus
Management
Rest, hydration, sedation
Facilitate rotation of the fetal head
Refer to Figure 14-1 for Hypertonic & Hypotonic

72. Dysfunctional Labor Pattern: Hypotonic
Contractions decrease in frequency and intensity
Maternal and fetal factors that produce excessive uterine stretching
Management
Walking, position changes
Augmentation of labor

73. Precipitate Labor and Birth
Rapid labor & birth
Nursing considerations
Careful examination for dilation and effacement
Reassure woman and support person
Breathing to avoid pushing and prevent tearing
Careful examination of maternal soft tissue and placenta

74. Pelvic Structure Alterations
Pelvic dystocia
Soft tissue dystocia
Trial of labor
To assess safety of vaginal birth

75. Obstetric Interventions Amniotomy
Artificial rupture of membranes
Augment or induce labor
Nursing
Careful monitoring of vital signs, cervical effacement/dilation, station, FHR, contractions
Document regarding amniotic fluid

76. Obstetric Interventions Amnioinfusion
Risks: infection, overdistention of uterus, increased uterine tone
Nursing
Careful monitoring of infusion, intensity and frequency of contractions, and maternal vital signs
Educate
Pharmacological induction of labor
Nonpharmacological stimulants of labor

77. Episiotomy Midline or mediolateral Nursing care:
Assess for approximation, swelling, oozing, infection
Relief for pain: ice pack in first 24 hours, then heat, local analgesic spray, witch hazel pads (Tucks), sitz bath, peri-bottle for voiding, pain medications

78. Induction of Labor Indications for induction Bishop score
Cervical ripening agents
Mechanical methods
Oxytocin
Augmentation of labor
Refer to Table 14-1 for Bishop scoring system

79. Induction—Nursing Considerations
Informed consent
Careful monitoring of labor
Discuss pain relief measures
Position changes
Keep patient and support person informed of progress

80. Instrumentation Assistance of Birth
Forceps
Indications: unable to push, arrested descent, need a quick delivery, breech
Associated with: maternal/fetal birth trauma, rectal sphincter tear, urinary stress incontinence
Vacuum extraction
Advantages: fewer lacerations, less anesthesia needed,
Disadvantages: marked caput, cephalhematomas, scalp laceration/bruising

82. Maternal Complications Hypertensive Disorders
Preeclampsia-eclampsia, HELLP syndrome
Nursing
Careful assessments
Monitor lab values
Administer platelets as appropriate
Ongoing education
Refer to Box 14-3 for fetal-maternal factors that necessitate immediate interventions
Refer to Box 14-4 for Key parameters to be monitored

83. Maternal Complications Diabetes
Fetal lung maturity
Intrapartum management
-Maternal hydration,
-Insulin, and
-Blood glucose levels
Labor: normal progression of labor
Upright or side-lying position
Encourage breastfeeding

84. Preterm Labor and Birth
Careful maternal monitoring
FHR monitoring ***
Identify and report symptoms suggestive of fetal hypoxia
Assess psychological status

85. Labor and Birth Complications Fetal
Fetal malpresentation
Version: external or internal
Shoulder dystocia
Cephalopelvic disproportion
Multiple gestation
Non-reassuring FHR patterns
Refer to Figure 14-6 for Version
Refer to Figure 14-7 for McRoberts maneuver

86. Macrosomia/Shoulder Dystocia
Wt. > 4500 gms (9-10 lbs)
Associated with:
DM, Gestational DM, Multiparity, Postdates, obesity
Risks:
Shoulder dystocia, difficulty delivering the shoulders after head is delivered (obstetrical emergency)
Maternal: vaginal/cervical tears, pp hemorrhage, rupture
Fetal: compressed cord, fractured clavical, asphyxia & neurologic damage, brachial plexus injury (Erb’sPalsy)
S/S: Turtle sign
Nursing interventions: McRoberts maneuvers, suprapubic pressure. PP: assess for uterine atony/hemorrhage; trauma, cerebral or neurologic damage to baby

87. Video: youtube.com/watch?v=jV6g427UMxY&feature=related

88. McRoberts Maneuvers Video

89. Amniotic Fluid Complications
Oligohydramnios
Hydramnios
Meconium
Nuchal cord

90. Other Complications Uterine rupture Uterine inversion
Obstetric emergency
Uterine inversion
Umbilical cord prolapse

91. Collaboration in Perinatal Emergencies
Refer to Box 14-5 for team expectation in obstetric emergency

92. Perinatal Fetal Loss What to say What NOT to say
Nursing considerations
< 20 weeks
> 20 weeks
name & hold the baby
funeral/memorial service
Resolve support group

93. Cesarean Birth Indications Ethical considerations Surgical procedures
Health of mother or fetus is jeopardized
Ethical considerations
Surgical procedures
Surgical and postoperative care
Vaginal birth after cesarean

94. Cesarean Birth Indications for:
Maternal Factors
Active genital herpes
AIDS/HIV +
Cephalopelvic disproportion
Severe preeclampsia, diabetes
Obstructive tumor
Ruptured uterus
Previous c-section
Failed induction/fx to progress in labor
Elective?
Placenta Factors
Placenta previa
Placental abruption
Umbilical cord prolapse
Fetal Factors
Breech, transverse lie
Macrosomia
Extreme low birth wt
Fetal distress
Fetal anomalies
Multiple gestation

95. Cesarean Birth (cont) Maternal Complications Mortality/morbidity
Infection
Anesthesia reactions
DeepVeinThrombophebis
Bleeding
Ureteral/bladder injury
Increase risk for subsequent pregnancy
Placenta Acreta/Previa, Infertility
Mortality/morbidity
4 x higher than vaginal birth in US. Most risk assoc. with emergency c-section
Incision
Skin vs. uterine
Classical vs low transverse

97. Postterm Pregnancy > 42 weeks
Maternal risks: trauma/hemorrhage due to larger baby, ↑operative delivery/c-section
Fetal risks: placental changes that ↓oxygenation to baby and ↑mortality rate, oligohydramnios (↑cord compression during labor), LGA baby (↑birth trauma, shoulder dystocia), meconium aspiration
Management: > 40 wks, NST, BPP or modified BPP (NST & AFI), induction

98. Post-Op Care Assess fundus/bleeding, vital signs, DVT.
Antibiotics, if infection
Pain: Duramorph. Breakthrough pain meds. Benadryl for itching. Zofran for nausea.
Clear liquids and advance as tolerated.
Assess for GI function. Bowel sounds? Passing flatus?
Ambulation. Pre-medicate, teach splinting with pillow.

99. Critical Thinking
A laboring multipara is having intense uterine contractions with incomplete uterine relaxation between contractions. Vaginal examinations reveal rapid cervical dilation and fetal descent What should the nurse do first?
A) Notify the physician of these findings.
B) Place the woman in knee-chest position.
C) Turn off the lights to make it easier for the woman to relax.
D) Assemble supplies to prepare for birth.

100. Case Study: Linda Mandella
Linda Mandella is in labor with her third baby at the birth center.
She wishes to experience a natural, unmedicated birth. Linda is groaning and crying. A cervical examination performed 2 hours ago revealed that she was 6 cm dilated, and 100% effaced.
Linda’s family is present, and this is the first time that they have been able to attend and support her during the labor and birthing process. The family members are shouting and blaming the nurse for causing Linda to suffer. They demand that the nurse give Linda painkillers to ease her suffering and pain Critical Thinking Questions
1. What are the priority nursing diagnoses at this time?
2. What are the expected outcomes associated with these diagnoses?
3. Describe the teaching/learning needs related to the scenario that correspond to the priority nursing diagnoses.
4. List nursing interventions with rationales that correspond to the priority nursing diagnoses.