Management of
Discomfort
Chapter 19
Nonpharmacologic Strategies

Cutaneous Stimulation Strategies
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Counterpressure *
Effleurage (light massage) *
Therapeutic touch & massage *
Walking *
Rocking *
Changing positions *
Application of heat or cold *
Transcutaneous electrical nerve stimulation
Acupressure
Water therapy (hydrotherapy)
Intradermal water block
Nonpharmacologic Strategies

Sensory Stimulation Strategies
– Aromatherapy
– Breathing techniques *
– Music *
– Imagery *
– Use of focal points *
Nonpharmacologic Strategies

Cognitive Strategies
– Childbirth education *
– Hypnosis
– Biofeedback
First Stage of Labor

Systemic analgesia
– Opioid agonist analgesics
– Opioid agonist-antagonist analgesics, codrugs
Epidural (block) analgesia
 Combined spinal epidural (CSE)
analgesia
 Paracervical block (rarely used)
 Nitrous oxide

Second Stage of Labor

Nerve block analgesia / anesthesia
– Local infiltration anesthesia
– Pudendal block
– Spinal (block) anesthesia
– Epidural (block) analgesia
– Combined spinal-epidural (CSE) analgesia

Nitrous oxide
Vaginal Birth
Local infiltration anesthesia
 Pudental block
 Epidural (block) analgesia / anesthesia
 Spinal (block) anesthesia
 Combined spinal – epidural (CSE)
analgesia / anesthesia
 Nitrous oxide

Cesarean Birth
Spinal (block) anesthesia
 Epidural (block) anesthesia
 General anesthesia

Nsg. Assessments (Fetal)

Prior to med administration:
– FHR within normal range (no late decels or
nonreassuring patterns).
– Average long term variability.
– Present short term variability (with spiral
electrode).
– Normal fetal movements.
– Accels with fetal movement.
– Term fetus. (EDC)
Nsg. Assessments (Maternal)

Prior to med administration:
– Term pregnancy (EDC).
– Evaluation of cervical dilation.
– Evaluation of contraction pattern.
– Evaluation of maternal comfort.
– Med allergies.
– Empty bladder.
Nsg. Assessments (Additional)

Prior to med administration:
– A well established contraction pattern.
– Fetal presenting part is engaged.
– Cervix dilated.
– Delivery should be anticipated but not
imminent.
Concerns: Regional Anesthesia
Maternal hypotension, and subsequent
fetal distress. *
 Adverse maternal reactions. (can range
from palpitations to complete
cardiovascular collapse).
 Uteroplacental insufficiency.

Frequent monitoring of maternal vital
signs & FHR are needed!
Fetal Assessment
During Labor
Chapter 20
Assessment for Genetic
Disorders
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Chapter 22
Maternal age
Ethnic background
Family history
Reproductive history
Maternal disease
Environmental hazards
Strategies in Health Education
and Counseling
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Chapter 22
Frame teaching to match the client’s
perception
Fully inform clients of the purpose and
expected effects
Be specific
Use a combination of strategies
Involve others
Refer
Monitor progress through follow-up
contacts
BIOPHYSICAL PROFILE
(BPP)
A noninvasive assessment of the fetus
and its environment by U/S, noting
normal and abnormal biophysical
responses to stimuli.
 A normal BPP indicates that the CNS is
functional and the fetus is not
hypoxemic.
 A scoring system, of 5 variables, with a
total score up to 10.

Biophysical Profile Variables
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Chapter 22
Fetal breathing movements
Gross body movement
Fetal tone
Amniotic fluid volume index
Non-stress test
BPP: VARIABLES & SCORES
FETAL BREATHING MOVEMENTS:
 >1 episode in 30 min, each > 30
seconds. (normal score = 2)
 Episodes absent or no episode > 30 sec
in 30 min. (abnormal = 0)
GROSS BODY MOVEMENTS:
 >3 discrete body or limb movements in
30 min. (normal = 2)
 < 3 episodes of body or limb movement
in 30 min. (abnormal =0)
FETAL TONE:
 > episodes of active extgension
with return to flexion of fetal limb(s)
or trunk, opening & closing hand
being considered normal tone.
(normal =2)
 Slow extension with return to
flexion, movement of limb in full
extension, or fetal movement
absent. (abnormal = 0)
REACTIVE FETAL HEART RATE:
 > 2 episodes of acceleration (>15
bpm) in 20 min, each lasting > 15
sec. & associated with fetal
movement. (normal = 2)
 < 2 episodes of acdceleration or
acceleration of < 15 bpm in 20 min.
(abnormal = 0)
QUALITATIVE AMNIOTIC FLUID
VOLUME:
 > 1 pockets of fluid measuring >1
cm in 2 perpendicular planes.
(normal =2)
 Pockets absent or poscet < 1 cm in
2 perpendicular planes. (abnormal
= 0)
Interpretation of BPP Scores:
Normal = 8-10 (if Amniotic fluid index is
adequate)
 Equivocal = 6
 Abnormal = <4

Documentation of a
Contraction Stress Test
Negative: No late decelerations with 3
adequate uterine contractions in a 10minute window, normal baseline FHR
and accelerations with fetal movement.
Positive: Late decelerations occur with
more than half the uterine contractions.
Chapter 22
Documentation of a
Contraction Stress Test (cont.)
Suspicious: Late decelerations occur
with less than half the uterine
contractions.
Unsatisfactory: Inadequate fetal heart
rate recording or less than 3 uterine
contractions in 10 minutes.
Chapter 22
Indications for the NST
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Chapter 22
Suspected post-maturity
Maternal diabetes
Maternal hypertension: chronic and
pregnancy-related disorders
Suspected or documented IUGR
History of previous stillbirth
Isoimmunization
Indications for the NST (cont.)
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Chapter 22
Older gravida
Decreasing fetal movement
Sever maternal anemia
Multiple gestation
High-risk antepartal conditions: PROM,
PTL, bleeding
Chronic renal diseases
Electronic Fetal Monitoring
 External:
ultrasound transducer
 Internal:
–spiral electrode
Ultrasound Transducer
High-frequency sound waves reflect
mechanical action (fetal heart tone &
valves) of the fetal heart.
 Noninvasive. (Does NOT require
rupture of membranes or cervical
dilation)
 Used in both antepartum and
intrapartum period.
 Short-term variability and beat-to-beat
changes in the FHR cannot be
assessed accurately by this method.

Spiral Electrode
Applied to the fetal presenting part to
assess the FHR.
 Converts the fetal ECG as obtained
from the presenting part to the FHR via
a cardiotachometer.
 Used ONLY when membranes are
ruptured & cervix is sufficiently dilated.
 Short-term variability CAN be assessed
using this method.

FHR Variability

Increased Variability: marked variability
from a previous average variability.
– Causes: early mild hypoxia; fetal
stimulation (uterine palpation, contractions,
fetal activity; maternal activity; illicit drugs).
– Significance: unknown.
– Nsg.Intervention: observe for any
nonreassuring patterns; if using external
fetal monitoring consider an internal mode
for a more accurate tracing.
FHR Variability

Decreased Variability: marked
decrease in variability from a previous
average variability.
– Causes: hypoxia / acidosis; CNS
depressants; analgesics / narcotics;
barbiturates; tranquilizers, anaractics;
parasympatholytics; general anesthetics;
prematurity (<24 wks); fetal sleep cycles;
congenital abnormalities; fetal cardiac
dysrhythmias.
FHR Variability

Decreased Variability (continued):
– Significance: benign when associated with
fetal sleep cycles; if drugs, variability
usually increases as drugs are excreted;
when associated with uncorrectable late
decelerations indicates presence of fetal
acidosis and can result in low APGARs.
– Nsg.Interventions: none, if fetal sleep
cycle, or CNS depressants; consider fetal
scalp stimulation or apply a spiral
electrode; monitor fetal oxygen saturation;
prepare for birth if indicated.
Other DEFINITIONS
Tachycardia: a baseline FHR >160
bpm for a duration of 10 minutes or
longer.
 Bradycardia: a baseline FHR <110 bpm
for a duration of 10 minutes or longer.

FHR Changes
Accelerations
 Decelerations

– Early
– Late
– Variable
– Prolonged
Baseline FHR
Definition: the average rate during a 10
minute period that excludes periodic or
episodic changes, periods of marked
variability, and segments of the baseline
that differ by more than 25 bpm.
 Range: 110-160 bpm.

Accelerations
Definition: A visually apparent abrupt
increase in FHR above the baseline
rate.
 An increase of 15 bpm and lasting 15
seconds or more, with the return to
baseline less than 2 minutes from the
beginning of the acceleration.
 Can be periodic or episodic.

Early Decelerations
Definition: a transitory gradual
decrease and return to baseline FHR in
response to fetal head compression.
 Generally starts before the peak of the
uterine contractions.
 Returns to the baseline at the same
time as the contraction returns to its
baseline.
 Considered benign. No interventions.

Late Decelerations
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Definition: a transitory gradual decrease in
and return to baseline of FHR associated with
contractions.
Begins after the contraction has started, and
the lowest part of the decel occurs after the
peak of the contraction.
Usually does NOT return to baseline until
after the contraction is over.
Indicates uteroplacental insufficiency.
Interventions required!
Considered ominous sign when they’re
uncorrectable, especially when associated
with decreased variability and tachycardia.
Late Decelerations

Interventions:
– Change maternal position (lateral)
– Correct maternal hypotension (elevate legs)
– Increase rate of maintenance IV
– D/C oxytocin if infusing
– Administer O2 at 8-10 L/min (face mask)
– Fetal scalp or acoustic stimulation
– Assist with fetal O2 saturation if ordered
– Assist with birth if pattern cannot be
corrected.
Variable Decelerations

Definition: an abrupt decrease in FHR that is
variable in duration, intensity,and timing
related to onset of contractions; caused by
umbilical cord compression.
 Onset to the beginning of the nadir is <30
seconds; decrease in > 15 bpm, lating >15
seconds; variable times in contracting phase;
often preceded by transitory acceleration.
 Return to baseline is rapid and <2 min from
onset; sometimes with transitory acceleration
immediately before and after decel.
 Described as: mild, moderate, or severe.
Variable Decelerations

Interventions:
– Change maternal position (side to side).

If severe:
– D/C oxytocin if infusing
– Administer O2 at 8-10 L/min (face mask)
– Assist with vag or speculum exam
– If cord is prolapsed, examiner will elevate
fetal presenting part with cord between
gloved fingers until c/s is accomplished
– Assist with amnioinfusion if ordered
– Assist with fetal O2 saturation monitoring if
ordered
– Assist with fetal O2 saturation if ordered
Prolonged Decelerations

Definition: a visually apparent decrease in
FHR below the baseline 15 bpm or more and
lasting more than 2 minutes but less than 10
minutes.
 Benign causes: pelvic exam, application of
spiral electrode, rapid fetal descent &
sustained maternal valsalva maneuver.
 Other causes (severe): progressive severe
variable decels, sudden umbilical cord
prolapse, hypotension, paracervical
anesthesia, tetanic contraction & maternal
hypoxia (may occur with seizure).
Nursing Care
During Labor
Chapter 21
QUESTIONS TO ASK
LABORING CLIENT:
UTERINE CONTRACTIONS
 Time of onset: What was the time of
the 1st ctx, & at what time did the
ctx.become regular?
 Frequency: How often do the ctx.
occur?
 Duration: How long do the ctx.last?
Intensity: What is the level of pain?
Describe the nature & location of the
pain?
 Effect of Ambulation: do the
ctx.become more or less frequent and
intense with ambulation?
ADDITIONAL HISTORY:
 Bloody show: What was the frequency
& amt.of discharge?
 Vaginal bleeding: What was the
amount, color, and consistency?

Membranes: Is there leaking or have
you experienced spontaneous rupture
of membranes? What was the amont,
color, consistency, & time of
occurrence?
 Fetal Activity: Has the fetus moved or
kicked since labor began?
 Nutrition, hydration, and sleep: When
was the last time you ate, drank, or
slept?
 Social support available: Is someone
with you?

General emotional well-being: Are you
relaxed? Are you using breathing
techniques? (can also be observed).
 Transportation: Is transportation to the
birth site available?

MONITORING DURING
LABOR:

Purpose = to determine that maternalfetal status is within normal limits during
labor and that maternal status is within
normal limits in the immediate
postpartum period; to intervene when
deviations from normal are noted.
Assess the following parameters during
the 1st and 2nd stages of labor at regular
intervals:
 Vital signs: BP on admission & at least
hourly during the active phase of labor
(more frequently if elevated or epidural).
T-P-R on admission & q4hr (more
frequently if ROM or elevation).
 Fetal well-being: auscultate & record
FHR on admission or place on EFM for
20-30 min. Use continuous or
intermittent monitoring depending on
maternal-fetal risk.
Uterine activity: Assess & record
frequency, duration, and intensity of
uterine ctx q30-60 minutes by direct
palpation or through interpretation of
electronic fetal monitoring strips.
 Labor progress: perform a vag.exam to
assess cervical effacement & dilatation,
fetal position & station, & status of
membranes. (use Friedman’s curve).
 I & O: ensure adequate hydration.
Initiate IV fluid as needed or before
administration of epidural. Encourage
to empty bladder frequently.

HOW LABOR PROGRESS IS
MEASURED:
Contraction pattern.
 Cervical consistency & effacement.
Cervical changes.
 Cervical dilatation.
 Station.

WAYS TO FACILITATE
LABOR PROGRESS:

Work with ctx.rather than against them.
Encourage relaxation between ctx.
Assist in paced breathing techniques,
focus, visual imagery, ambulation,
change position regularly, good
communication with nurse & support
person.
PSYCHOSOCIAL
ASSESSMENT IN LABOR:

Support system.
 Level of understanding of labor process &
procedures.
 Effectiveness of coping strategies to deal with
labor process & pain of level.
The psychosocial assessment provides the
basis for education of the patient, anticipatory
guidance, and provision of supportive care
including both pharmacologic &
nonpharmacologic measures
LABORATORY DATA:
URINE: test for protein, ketones,
glucose, WBCs, nitrates (should all be
negative).
 HEMATOCRIT & HEMOGLOBIN: HCT
<32%, and HGB <11g/L may indicate
iron deficiency anemia or hemorrhage.
 WBC COUNT: values of 4500 – 11,000
are normal; up to 25,000 can be normal
for labor, birth, and early pp (d/t stress).

SEROLOGIC TESTS FOR SYPHILIS
(VDRL): samples may be obtained on
admission, depending on institutional
policy. Results should be negative.
 HEPATITIS B SURFACE ANTIGEN:
repeat test if antepartum results are >
30 days old.
 Rh FACTOR & ABO TYPING:
necessary during the antepartum
period, and pp when indicated.

PROMOTING A NORMAL
CHILDBIRTH:
Maintain an awareness and
appreciation of the individuality of each
woman’s labor.
 Be aware of cultural differences related
to labor and birth.
 Update your knowledge on intrapartum
research topics (stay current).

Become reenergized by meeting and
sharing with other professionals who
work with the same challenges &
issues. Join specialty organizations.
 Know your professional standards of
practice. These form your basis for safe
practice.
 Advocate for women’s needs on the
basis of your knowledge of safe
practice.
 Be aware of your biases regarding labor
and birth.

POSSIBLE NURSING DX:
FIRST-STAGE LABOR:
 Knowledge deficit: lack of information
related to expected physical changes,
symptoms of labor, and options
available to the childbearing woman.
 Pain related to the process of labor or
birth.
 Anxiety related to childbirth, pelvic
examinations, or obstetric interventions.
 Fear related to parenting.
Fluid volume excess related to intake
during labor.
 Altered nutrition: less than body
requirements related to decreased
intake during labor.
SECOND-STAGE LABOR:
 Fear related to birth process, pain, and
unknown outcome.
 Fatigue related to physical exertion
during labor and lack of sleep.
 Pain related to fetal descent, crowning,
and perineal stretching.

THIRD- AND FOURTH-STAGE LABOR:
 Risk for infection related to uterine
placental site, episiotomy incision, and
fatigue.
 Urinary retention related to loss of
sensation to void and rapid bladder
filling.
 Ineffective breastfeeding related to
maternal knowledge deficit, anxiety, or
fatigue.
“Friedman’s Curve”
Emanuel Friedman began work in
1950s, and over 20 years defined the
phases and length of the stages of labor
for nulliparous and multiparous women.
 His work showed that cervical dilatation
& fetal descent follow a predictable
pattern & appear as an S curve when
plotted on a graph.
 Analysis of labor progress is plotted on
a graph (a partograph).

Can be used to plot cervical dilatation
and fetal descent on the graph, and if
labor begins to slow in comparison to
the average rate of progress defined by
Friedman, and this data can provide a
basis for decision making about the
progress of a woman’s labor.
 Friedman’s work is the most universally
accepted scientific treatment of labor &
is nationally used in normal labor, and
to diagnose dystocia (abnormal labor)
when deviations are apparent.

LEOPOLD’S MANEUVERS:
Purpose: to provide information about
fetal presentation, position, presenting
part, lie, attitude, and descent.
 Can aid in location of fetal heart tones,
assessment of fetal size, and
determination of single vs multiple
gestation.
 Used in late 2nd trimester or 3rd
trimester, when fetal parts can be felt
through abdominal wall.
