What is Labor?
Labor refers to the process of childbirth, during which a pregnant woman
experiences rhythmic uterine contractions that lead to the progressive
opening of the cervix and the eventual delivery of the baby. It is a natural and
dynamic process that signifies the end of pregnancy and the beginning of
motherhood.
Establishing Therapeutic Relationship
To gain the patient and family’s cooperation and trust, it is important that
the nurse should be able to establish a therapeutic relationship with them. The
nurse should introduce himself and make them feel welcome. At this point,
they are all anxious and it is best for the nurse to convey his message gently
and confidently. Expectations of the family about birth should be determined
and it is also the best time to ascertain cultural values.
Admission Assessment
When a patient arrives at the labor floor, pertinent information about the
pregnant woman’s health history is taken during admission. These include
personal data (e.g. blood type, allergies, etc.), previous illness, pregnancy
complications, preferences for labor and delivery, and childbirth preparations.
Standard obstetric, medical, and social history taking is also done.
In addition, the nurse assesses the following: vital signs, physical exam,
contraction pattern (frequency, interval, duration, and intensity), intactness of
membranes through a vaginal exam, and fetal well-being through fetal heart
rate, characteristic of amniotic fluid, and contractions. The nurse performs
Leopold’s maneuver to determine the fetal presenting part, point of maximum
impulse, fetal descent, and engagement.
Admission into the labor room is only done when the patient is in active labor.
Stages of Labor
The progress of cervical effacement, cervical dilatation, and descent of the
fetal presenting part dictate stages of labor. Here are the stages of labor and
significant events that mark their beginning and end:
Duration
Stages of
Labor
Start
End
Nullipara
Multipa
10-12 hr but 6-20
hrs is the normal
limit
6-8 hrs but 2is the normal
First Stage
True labor contractions
Full cervical
dilatation
Latent phase
Onset of regularly perceived uterine
contractions (mild contractions
lasting 20-40 sec)
3 cm cervical
dilatation
6 hrs
4.5 hrs
Active phase
Stronger uterine contractions
lasting 40-60secs
7 cm cervical
dilatation
3 hrs
2 hrs
Transitional
phase
Uterine contractions reaching their
peak, occurring every 2-3 minutes
for 60-90 s
10 cm
cervical
dilatation
3 hrs
1.5-2 hrs
<2 hrs
0.5-1 hrs
3 hrs with epidurals
2 hrs with ep
Second Stage
Third Stage
Full cervical dilatation
Infant birth
Infant birth
Placental
delivery
Maximum of 30 min.
First Stage of Labor
As mentioned above, the first stage of labor is divided into three sub-phases,
namely: latent, active, and transitional phases.
Latent Phase
Latent (Preparatory) Phase starts from the onset of true labor contractions to
3 cm cervical dilatation. Here are nursing responsibilities during this phase:
1. Assess patient’s psychological readiness. Provide continuous maternal
support (compared to usual care).
2. Measure duration of latent phase. For nulliparas, it should not be more
than 6 hours. On the other hand, for multiparas, it should be within 4.5
hours. Determine if patient received anesthesia because it can prolong
latent phase. One of the most common cause of prolonged latent phase
is cephalopelvic disproportion (CPD) and it requires cesarean birth.
3. Allow patient to be continually active. Upright maternal positions are
recommended for women on the first stage of labor. Patients without
pregnancy complications can still walk around and make necessary birth
preparations.
4. Conduct interviews and filling in of forms (e.g. birth certificate) at this
phase while the patient experiences minimal discomfort and has control
over contraction pains.
5. Conduct health teaching on breastfeeding, newborn care, and effective
bearing down because during this time, patient’s anxiety is controlled
and she is able to focus on nurse’s instructions.
6. Educate patient on different relaxation techniques. As early as this
phase, encourage patient to begin alternative therapy of pain relief.
7. Ensure that the total number of internal examinations the woman
receives in the entire course of labor is limited to 5 only.
8. Ensure that birthing companion of choice is present all throughout the
course of labor.
Active Phase
Active Phase starts from 4 cm cervical dilatation to 7 cm cervical dilatation.
During this phase, contraction intensity is stronger, interval shortens, and
duration lengthens. This is where true discomfort is first felt by the patient so
she is dependent and her focus is on herself. Here are nursing responsibilities
in this phase:
1. Inform patient on the progress of her labor to lessen her anxiety and
obtain her trust and cooperation.
2. Start monitoring progress of labor with the use of WHO partograph, 2hour action line.
3. Encourage patient to be continually active to maximize the effect of
uterine contractions. Upright maternal positions are recommended if
tolerated.
4. Assist patient in assuming her position of comfort. For those who
can’t stay upright, left-side lying is recommended to avoid disruption in
fetal oxygenation.
5. Monitor maternal vital signs and fetal heart rate every 2 hours, or
depending on the doctor’s order.
6. Anticipate patient needs (e.g. sponging face with cool cloth, keeping
bed clean and dry, providing ice chips or lip balm) to promote comfort.
7. Determine when patient last voided because a full bladder can hinder
fast labor progress.
8. Institute non-pharmacological pain measures (e.g. breathing exercises,
distraction method, imagery, music therapy, etc.)
Transition Phase
Transition Phase starts from 8 cm cervical dilatation to 10 cm (full) cervical
dilatation and full cervical effacement. During this time, patient may
be exhausted and withdrawn or aggressive and restless. Patient’s urge to push
is noticeable. Here are nursing responsibilities in this phase:
1. Inform patient on progress of her labor.
2. Assist patient with pant-blow breathing.
3. Monitor maternal vital signs and fetal heart rate every 30 minutes -1
hour, or depending on the doctor’s order. Contraction monitoring is
also continued.
4. When perineal bulging is noticeable, prepare for delivery. Check room
temperature (25-280C and free of air drafts). The nurse should also notify
staff and prepare necessary supplies and equipment, including
resuscitation machine. Lastly, perform handwashing and double gloving.
WHO do not recommend the following nursing interventions during
labor because they have low quality of evidence:
1. Routine perineal shaving
2. Routine use of enema
3. Admission cardiotocography (CTG) for low-risk women
4. Vaginal douching
5. Routine amniotomy for patients in spontaneous labor
6. Massage and reflexology
Second Stage of Labor
Second Stage of Labor starts when cervical dilatation reaches 10 cm and
ends when the baby is delivered. At this stage, the patient feels an
uncontrollable urge to push. The patient may also experience
temporary nausea together with increased restlessness and shaking of
extremities. The nurse at this stage must coach quality pushing and support
delivery.
Here are nursing care tips for this stage:
1. Instruct patient on quality pushing. The abdominal muscles must aid the
involuntary uterine contractions to deliver the baby out.
2. Provide a quiet environment for the patient to concentrate on bearing
down.
3. Provide positive feedback as the patient pushes.
4. Repeat the doctor’s instructions. At this phase, the patient barely hears
the conversation around the room because all her energy and thoughts
are being directed toward giving birth.
5. Take note of the time of delivery and proceed to initiate essential
newborn care. Delayed cord clamping is recommended.
6. Assist in restrictive episiotomy for patients who had vaginal births.
WHO do not recommend the following interventions during
delivery because they provide low quality evidence:
1. Perineal massage
2. Use of fundal pressure
Third Stage of Labor
Third Stage of Labor or the placental stage starts from birth of infant to
delivery of placenta. It is divided into two separate phases: placental
separation and placental expulsion. Five minutes after delivery of baby,
the uterus begins to contract again, and placenta starts to separate from the
contracting wall. Blood loss of 300-500 mL occurs as a normal consequence of
placental separation. Placenta sinks to the lower uterine segment or upper
vagina. The placenta is then expelled using gentle traction on the cord.
Here are the signs of placental separation:
1.
2.
3.
4.
5.
Lengthening of umbilical cord
Sudden gush of vaginal blood
Change in the shape of uterus (globular in shape)
Firm uterine contractions
Appearance of placenta in vaginal opening
At this stage, here are the nursing care tips:
1. Coach in relaxation for delivery of placenta.
2. Congratulate on delivery of baby.
3. Encourage skin-to-skin contact to facilitate bonding and early
breastfeeding.
4. Ask patient whether placenta is important to them before it is
destroyed. For those who want to take it home, ensure that they
understand and follow standard infection precautions and hospital
policy.
5. Administer prophylactic oxytocin as ordered.
6. Utilize controlled cord traction technique for placental expulsion.
7. Utilize absorbable synthetic suture materials (over chromic catgut) for
primary repair of episiotomy or perineal lacerations.
For immediate postpartum, the nurse checks the vital signs and monitors for
excessive bleeding. The first four hours after birth is sometimes referred to
as the fourth stage of labor because this is the most critical period for the
mother. The nurse is set to perform nursing interventions that would prevent
the patient from infection and hemorrhage. Also, they are being reminded of
the importance of breastfeeding, ambulation, and newborn care.
Here are WHO recommendations for immediate postpartum:
1. Early (<6 hours) resumption of feeding for patients who have vaginal
birth
2. Prophylactic antibiotics for women who sustained third to fourth degree
of perineal tear during delivery
3. In healthy women who delivered vaginally to term infants, early
postpartum discharge is recommended.
On the other hand, here are interventions not
recommended during immediate postpartum:
1. Routine use of ice packs
2. Oral methylergometrine for patients who delivered vaginally
Assessment
The key to a successful individualized care plan is the precise assessment and
accurate obtaining of data. The woman would be placed under observation
during labor to monitor her progress and ensure a safe delivery for her and
the child.
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Assess for the signs of true labor. The signs of true labor are
contractions that begin irregularly but progresses regularly and
predictably, the pain is felt first at the lower back and circles towards the
abdomen, continues to progress no matter what the woman’s activity
level is, increases in duration, frequency, and intensity and cervical
dilation is already present.
Assess for the appearance of show, which is blood mixed with mucus
and would be present once the operculum or mucus plug is expelled.
Assess for the rupture of membranes. This is the scanty or sudden
gush of clear fluid from the vagina.
Assess for the engagement of the fetal head. Engagement refers to
the settling of the presenting part into the pelvis at the level of the
ischial spines.
Assess for the station. Station is the relationship of the presenting part
to the level of the ischial spines.
Assess for the effacement and dilatation of the cervix. Effacement is
the shortening and thinning of the cervical canal. In cervical dilatation,
the enlargement or widening of the cervical canal is assessed.
Planning
With all the data gathered during assessment and through an accurate
diagnosis, a care plan for the woman in labor would be made to aid her
through her progress.
Care of a woman in the first stage of labor
Labor should be allowed to start naturally, not artificially induced.
 The woman must also be allowed to move freely throughout the labor.
Artificial interventions should also be prohibited.
 Allow the woman to assume a non-supine position for delivery.
 Upon delivery of the newborn, mother and child should be given
unlimited opportunity for breastfeeding and bonding.
Care of a woman in the second stage of labor
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During the second stage of labor, the place of delivery of the woman
must be prepared.
The position of birth wherein the woman is most comfortable must also
be determined at this stage.
 Another important part is the promotion of second stage effective
pushing.
 Perineal cleaning is also an integral part of the second stage.
Care of the woman in the third stage of labor
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Placental delivery should be given focus at this stage. Once the placenta
is delivered, oxytocin should be administered intramuscularly to
promote uterine contractions.
If there is episiotomy performed, perineal repair should be integrated
into the care plan.
Implementation
Some interventions are implemented to give comfort and safety for the
mother during and after the labor period. These are essential in promoting the
strength that the mother would need during delivery.
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Encourage the client to void every 2 hours.
Observe and review the client’s breathing techniques.
Inform the client if c interventions are necessary.
Create a birth plan with the client so she could integrate her preferences
in the care plan.
Provide ice chips, hard candies, or fluids to relieve dry mouth.
Provide a comfortable environment to aid in the effective coping
management of the client.
Allow the client to walk and move around freely during labor.
Do not intervene with the client during a contraction to avoid disturbing
her focus on her technique.
Evaluation
After the labor has passed, delivery would commence immediately. And when
the labor period for the woman has gone smoothly, a great chance for a safe
and healthy delivery is within reach.
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Client should exhibit no signs of bladder distention and have the ability
to void every 2 hours.
Client has a good to tolerable level of pain.
Client can express her preferences during labor.
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Client has the ability to understand the usual process of labor.
Client reports that her environment is comfortable and secure.
Client would be able to verbalize her feelings about her experiences
during her labor period.
Induction and Augmentation of Labor
Cervical Ripening
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Cervical ripening must be complete during early labor.
If there is no cervical ripening, there would be no dilatation and
coordination of uterine contractions.
To determine whether the cervix is ripe, Bishop established criteria for
scoring the cervix.
If the woman’s score is 8 or greater, the cervix is already ready or birth
and would respond to induction.
One of the ways to ripen the cervix is known as “stripping the
membranes”, or separating the membranes from the lower uterine
segment manually using a gloved finger in the cervix.
Complications that may arise from this procedure include bleeding due
to undetected low-lying placenta, inadvertent rupture of membranes,
and infection when the membranes rupture.
Another method that is also considered is the use of hygroscopic
suppositories or suppositories of seaweed that swell upon contact with
cervical secretions.
These suppositories gradually and gently urge dilatation.
They are held in place by gauze sponges saturated with povidone iodine
or an antifungal cream.
The number of sponges and dilators should be documented accordingly
to avoid leaving behind one of them inside the cervix.
A more common method of speeding cervical ripening is the application
of a prostaglandin gel to the interior surface of the cervix by a catheter
or suppository, or to the external surface by applying it to
a diaphragm and then replacing it against the cervix.
Additional doses may be applied every six hours, but two or three doses
are usually enough to achieve ripening.
Instruct the woman to remain in a side lying position to avoid leakage of
the medication.
Continuously monitor the FHR at least every 30 minutes after each
complication.
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Side effects of this method include diarrhea, fever, hypertension,
and vomiting.
Oxytocin administration may also be started, but that would be 6 to 12
hours after the last prostaglandin dose.
Use prostaglandin with caution in women with asthma, renal or
cardiovascular disease, or glaucoma.
Women who underwent cesarean birth in the past are contraindicated
with prostaglandin method.
Induction of Labor by Oxytocin
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Administration of oxytocin can initiate contractions in a uterus in
pregnancy term.
Oxytocin is administered intravenously so that when there is
hyperstimulation, then it could be quickly discontinued.
The effects happen immediately because the half-life of oxytocin is
approximately 3 minutes.
Oxytocin is usually mixed with Ringer’s lactate, 10 units of oxytocin in
1000 mL of Ringer’s lactate.
The infusion could also be administered piggyback to a maintenance IV
solution, so that if the infusion would be discontinued, the main IV line
could still be maintained.
The oxytocin solution must always be attached to the port nearest to
the woman so that little solution remains in the tubing if it is
discontinued.
Use of an infusion pump is recommended to regulate the infusion rate
and make sure that the rate would not change even if the woman
moves.
Do not increase the rate without any further instructions because it can
cause tetanic contractions.
Artificial rupture of membranes may be done when cervical dilatation
reaches 4 cm to further induce labor.
Be aware of peripheral vessel dilatation, a side effect of oxytocin
administration, which can cause hypotension.
Assess the woman’s pulse and blood pressure every 15 minutes to be
certain of a safe induction.
Monitor uterine contractions and FHR accordingly.
Contractions should occur no more often than every 2 minutes, should
not be longer than 70 seconds, and not stronger than 50 mmHg.
Stop the IV infusion if the contractions become more frequent or longer
in duration than the safe limits or if there are signs of fetal distress.
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Excessive stimulation of the uterus by oxytocin may lead to tonic uterine
contractions with fetal death or rupture of the uterus.
In the event that hyperstimulation is not stopped even if the infusion
has been discontinued, a beta-adrenergic receptor drug
or magnesium sulfate may be prescribed to decrease myometrial
activity.
A complication of oxytocin infusion is water intoxication because
oxytocin has an antidiuretic effect that results in decreased urine flow.
Symptoms of water intoxication are headache and vomiting.
Water intoxication in its most severe form can cause seizures, coma, and
even death because of the large shift in interstitial tissue fluid.
Monitor the intake and output appropriately and assess urine specific
gravity to detect fluid retention.
Limit the amount of IV fluid to 150 mL/hr by making sure that the main
line is infusing at a rate not greater than 2.5 mL/min.
Induced labor tends to have shorter first stage than the average
unassisted labor.
Assure the woman that uterine contractions in an induced labor are
basically normal so she can use her breathing techniques effectively.
However, hyperbilirubinemia and jaundice in a newborn are possible
because of induction of labor with oxytocin.
The infant should be observed closely for these conditions during the
first few days of life.
Augmentation by Oxytocin
If labor contractions begin spontaneously but become weak, irregular,
and ineffective, augmentation of labor is required.
 Precautions for oxytocin administration are the same as for primary
induction of labor.
 The uterus may respond effectively to oxytocin used as augmentation.
 The drug should be increased in small increments only and fetal heart
sounds should be monitored during the procedure.
The labor process is the gateway towards a safe delivery. Once the woman has
undergone labor, it is imminent that delivery would follow suit. It is important
for the woman to have a smooth labor process for this is where she would be
gathering her strength to deliver her precious bundle of joy.
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Labor Complications
Getting through labor is one of the most anticipated events during a woman’s
pregnancy. To avoid complications during labor, a thorough assessment
should be conducted by the health care providers early during the woman’s
pregnancy.
Uterine Rupture
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Uterine rupture is a rare but serious complication.
Uterine rupture is a condition wherein the uterus cannot sustain the
strain that it underwent.
Factors that contribute to uterine rupture are abnormal presentation,
prolonged labor, multiple gestation, improper use of oxytocin, and
traumatic effects of forceps use or traction.
Fetal death can be avoided in uterine rupture if immediate cesarean
birth can be performed.
Symptoms that a woman may feel preceding rupture are a sudden,
severe pain during a labor contraction or a tearing sensation.
Rupture can be complete or incomplete.
With complete uterine rupture, the rupture goes through the
endometrium, myometrium, and peritoneum, and then the contractions
would immediately stop.
With incomplete uterine rupture, the rupture only goes through the
endometrium and the myometrium only, with the peritoneum still intact.
Symptoms of complete uterine rupture include hemorrhage, shock,
fading fetal heart sounds, distinct swellings of the retracted uterus and
extrauterine fetus.
For incomplete rupture, there is localized tenderness, persistent aching
pain in the lower uterine segment, and lack of contractions and fetal
heart sounds.
Confirmatory diagnosis of uterine rupture can be revealed through
ultrasound.
Administration of emergency fluid replacement as ordered should be
anticipated as well as IV oxytocin.
Laparotomy would be performed to control the bleeding and repair the
rupture.
Cesarean hysterectomy or tubal ligation can also be performed with
consent from the patient to remove the damaged uterus and remove
the childbearing activity of the woman.
Fetal outcome, the woman’s safety, and the extent of the surgery must
be revealed to the patient and allow time for them to express their
emotions.
 The woman would be advised not to conceive again after a rupture of
the uterus unless the rupture is in the inactive lower segment.
 The viability of the fetus and the woman’s prognosis depends on the
extent of the rupture.
Inversion of the Uterus
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Uterine inversion occurs when the uterus turns inside out due to the
delivery of the fetus or the placenta.
 Factors that contribute to inversion are application of traction to the
umbilical cord to remove the placenta, if pressure is applied to the
uterine fundus when the uterus is not contracting, or if the placenta is
attached to the fundus so during birth the fundus pulls it down.
 Signs of inversion include sudden gush of a large amount of blood from
the vagina, a non-palpable fundus, signs of blood loss such
as hypotension, dizziness, and paleness, and if bleeding continues,
exsanguinations.
 The inversion should never be replaced and the placenta, if still
attached, should never be removed.
 Administration of oxytoxic drugs could only worsen the inversion and
make the uterus tense so that it is difficult to replace.
 To manage uterine inversion, an IV line with a large-gauge needle
should be established to restore fluid volume, oxygen administration
should be started, assessment of vital signs, and cardiopulmonary
resuscitation if the woman undergoes arrest.
 Nitroglycerin or a tocolytic drug would be given intravenously to relax
the uterus, and the physician would replace the fundus manually.
 Oxytocin would be given after manual replacement to help the uterus
contract and remain in its natural place.
 Antibiotics would be prescribed because the endometrium was exposed
to prevent infection.
 Inform the woman that a future pregnancy would need to be delivered
via cesarean section because there is a possibility that the inversion
would re-occur.
Amniotic Fluid Embolism
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Amniotic fluid embolism occurs when the amniotic fluid is forced into an
open maternal uterine blood sinus or after membrane rupture or partial
premature separation of the placenta.
 The most likely cause of the embolism is anaphylactoid or humoral
response.
 Amniotic fluid embolism cannot be prevented because it cannot be
predicted.
 Risk factors include abruption placenta, hydramnios, and oxytocin
administration.
 The woman experiences sharp chest pain, inability to breathe, pallor,
and lack of blood flow.
 Emergency measures include oxygen administration and CPR.
 The woman’s prognosis would depend on the speed of the detection of
the condition, the skill and speed of the emergency interventions, and
the size of the embolism.
 Endotracheal intubation and fibrinogen therapy would be needed
because the risk for DIC is high.
 The prognosis for the fetus is uncertain because reduced placental
perfusion happens from a severe drop in maternal blood pressure.
Prolapse of the Umbilical Cord
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In prolapsed of the umbilical cord, a loop of umbilical cord slips down in
front of the presenting fetal part.
Factors that occur with prolapse are a small fetus, placenta previa, CPD,
premature rupture of membranes, hydramnios, and multiple gestation.
During assessment of the presenting fetal part through vaginal
examination, the cord might be felt.
Diagnosis of prolapsed of the membrane can be made through
ultrasound.
Cesarean section should be performed before rupture of the membrane
or the cord would slide down the vagina.
However, cord prolapsed is mostly discovered after rupture of the
membranes, when the fetal heart rate has a variable deceleration.
Assessment of fetal heart sounds is necessary after rupture of
membranes to rule out cord prolapse.
The goal in therapeutic management is to relieve cord compression to
avoid fetal anoxia that can be achieved through manually lifting the
head of the fetal head off the cord through the vagina or placing the
woman in a Trendelenburg position.
Oxygen administration is also necessary to improve the fetal
oxygenation.
 Uterine activity and pressure of the fetus should also be reduced
through a tocolytic agent.
 Once the cord has prolapsed and is exposed to air, drying of the
umbilical cord and atrophy of the umbilical vessels would begin.
 Cover any exposed portion of the cord with a sterile saline compress to
avoid drying.
 If there is already complete dilatation, the physician can deliver the baby
to prevent fetal anoxia.
 If the cervical dilatation is not yet complete, cesarean birth would be
performed as an emergency procedure because of the reduced blood
flow that can harm the fetus.
 Amnioinfusion, which is the addition of a sterile fluid into the uterus to
supplement the amniotic fluid, can be performed just to prevent
additional cord compression.
 During the infusion, monitor the fetal heart rate and uterine
contractions internally and record maternal temperature hourly to
detect infection.
Multiple Gestation
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When a woman has multiple gestation, additional personnel are needed
for the birth and there is excitement inside the birthing room.
Be aware of the needs of the woman during a multiple birth because
she may be more frightened than excited of the delivery.
Multiple gestations often result in fetal anoxia on the part of the second
fetus, so cesarean birth is more preferable than normal delivery.
Anemia and pregnancy-induced hypertension mostly occur in women
with multiple gestations, so assessment of the blood pressure and
hematocrit is necessary.
If the woman plans to give birth vaginally, she should be advised to
come to the hospital early in labor.
Instruct the woman breathing techniques to minimize the use of
analgesia or anesthesia, thereby decreasing the possibility of respiratory
difficulties that the infants might experience because of lung immaturity.
There may not be firm head engagement for multiple gestations
because the babies are small.
Common conditions that occur with multiple gestations are abnormal
fetal presentation, an overstretched uterus, premature separation of
placenta, and uterine dysfunction due to a long labor.
Twin pregnancies usually have vertex presentations, but in gestations
with three or more fetuses, the presentations are varied.
 Oxytocin is administered after the birth of the last fetus unlike in
singleton pregnancies to avoid compromising the remaining fetuses.
 If the next fetus does not have a vertex presentation, external version
might be attempted to make it vertex or cesarean birth can be
performed.
 To shorten the time span between births, an oxytocin infusion can be
started.
 To relax the uterus, nitroglycerin may be administered.
 The first infant’s placenta separates before the birth of the second fetus
which causes a sudden, profuse bleeding at the vagina, creating a great
risk for the woman.
 If the separation of the first placenta causes loosening of the other
placentas or there is a common placenta, the fetal heart rate of the
other fetuses would signal distress.
 Most multiple gestations today which are not in vertex presentation are
born through cesarean section because they need to be born all at once
so they can survive.
 Parents should be given an opportunity to view and inspect their fetuses
to dispel the fears that they have that their infants are less than perfect.
 Assess the woman thoroughly and immediately after birth because an
overly distended uterus might have difficulty in contracting, placing her
at risk for hemorrhage due to uterine atony.
 Infants also need careful assessment to determine their gestational age
and if any unusual conditions have occurred.
Ineffective Uterine Force
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Ineffective labor occurs when uterine contractions become abnormal or
ineffective, as uterine contractions are the basic force behind moving the fetus
through the birth canal.
Hypotonic Contractions
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The number of uterine contractions in hypotonic contractions is
unusually slow or infrequent.
There are only two or three contractions occurring within a 10-minute
period.
The strength of contractions does not rise above 10 mmHg, and they
occur mostly during the active phase of labor.
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Hypotonic contractions occur after administration of analgesia, bowel or
bladder distention, if the uterus is overstretched due to multiple
gestation, a large fetus, hydramnios, or a uterus that is lax from grand
multiparity.
Hypotonic contractions increase the woman’s risk for postpartal
hemorrhage.
In the first hour after birth following a labor of hypotonic contractions,
palpate the uterus and assess the lochia every 15 minutes to ensure that
there are no postpartal hypotonic contractions and inadequate to halt
bleeding.
Hypertonic Contractions
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Hypertonic contractions are marked by an increase in resting tone to
more than 15 mmHg.
Hypertonic contractions tend to occur more frequently and during the
latent phase of labor.
They are more painful than usual, and they make the woman frustrated
with her breathing techniques because they are ineffective.
The lack of relaxation between contractions may not allow optimal
uterine artery filling that could lead to fetal anoxia.
A uterine and fetal external monitor should be applied for at least 15
minutes to check the resting phase of the contractions and that the fetal
pattern is not showing a late deceleration.
Cesarean birth would be necessary if there is late deceleration, an
abnormally long first stage of labor or lack of progress with pushing.
Explain to the woman and her partner that although the contractions
are very strong, they are ineffective and are not achieving cervical
dilatation.
Uncoordinated Contractions
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More than one pacemaker may be initiating contractions with
uncoordinated contractions, or receptor points in the myometrium may
be acting independently of the pacemaker.
It would be difficult for the woman to rest between contractions
because they occur erratically.
A fetal and uterine external monitor must be attached to the woman to
assess the rate, pattern, resting tone, and fetal response to contractions
for at least 15 minutes.
Oxytocin administration can also be done to stimulate a more effective
and consistent pattern of contractions with a better, lower resting tone.
Dysfunctional Labor
Dysfunctional labor during the first stage involves prolonged latent
phase, protracted active phase, prolonged deceleration phase, and
secondary arrest of dilatation.
 Prolonged latent phase can be managed through helping the uterus to
rest, providing adequate fluid for hydration and pain relief.
 Oxytocin is prescribed during a protracted active phase to augment
labor.
 Cesarean birth would also be necessary in a prolonged deceleration
phase.
 In secondary arrest of dilatation, there is no progress with cervical
dilatation for more than 2 hours, and then cesarean birth would be
necessary.
 Dysfunction during the second stage of labor involves prolonged
descent and arrest of descent.
 If the rate of descent is less than 1 cm/hr in a nullipara or 2.0 in a
multipara, then there is prolonged descent of the fetus.
 Encourage the woman to rest and increase her fluid intake.
 Intravenous oxytocin may also be administered to induce the uterus to
contract effectively.
 A semi-Fowler’s position, squatting, kneeling, or more effective pushing
may speed up the descent.
 When no descent occurs for 1 hour in a multipara and 2 hours in a
nullipara, there is an arrest of descent.
 The most likely cause of arrest of descent in the second stage of labor is
CPD, so cesarean birth is necessary.
 Oxytocin could also assist labor if there is no contraindication to vaginal
birth.
Precipitate Labor
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Precipitate labor occurs when uterine contractions are so strong that a
woman gives birth with only a few and rapidly occurring contractions.
Grand multiparity facilitates this kind of labor, or it can also happen after
induction of labor by oxytocin or amniotomy.
Subdural hemorrhage for the fetus may occur from the rapid release of
pressure on the head.
The woman may also obtain lacerations of the birth canal due to
forceful birth.
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If the rate is greater than 5 cm per hour in a nullipara or 10 cm/hr in a
multipara, precipitate labor is already occurring.
Caution a multipara by her 28th week that her labor might still be brief if
she has had a brief labor in the past to allow the woman to plan her
transportation.
A birthing room must be converted to birth readiness before full
dilatation is obtained.
Comfort and Pain Management
Etiology and Physiology of Pain
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Pain is a basic protective mechanism that alerts a person that something
threatening is happening somewhere in the body.
Involuntary muscles do not normally cause pain when contracting,
which is why uterine contractions are unique.
Blood vessels constrict during contractions, reducing the blood supply
to uterine and cervical cells resulting to anoxia of the muscle fibers.
The anoxia causes the pain just like what happens in a heart attack.
Ischemia to the cells increases as labor progresses, and anoxia also
increases leading to intense pain.
Another explanation for the pain is the stretching of the cervix and
perineum.
The moment that the stretching of the cervix is complete, the woman
would feel the strong urge to push, and the pain disappears as the
woman pushes.
The pressure of the fetal presenting parts to the tissues also contributes
to the discomfort that the woman is feeling.
Cultural differences also determine the way a woman may perceive the
pain.
Pain sensations start in nociceptors which are stimulated by mechanical,
chemical, or thermal stimuli.
As they are stimulated, chemical mediators help transmit the pain
impulse along myelinated and unmyelinated fibers to the spinal cord.
Neurotransmitters assist the pain impulse across the synapse between
the peripheral and the spinal nerve.
The pain impulse ascends the spinal cord to the brain cortex where it
would be interpreted as pain.
The Melzack-Wall gate control theory of pain proposes that pain can be
halted at three points: the peripheral end terminals, the synapse points,
or at the point where the impulse is interpreted as pain.
The major action of pain medications is to block the spinal cord
neurotransmitters to halt the pain impulse from crossing towards the
spinal nerve.
Comfort Measures
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Relaxation
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Relaxation is mostly taught in preparing for childbirth classes.
Relaxing keeps the abdominal wall from becoming tense and allows the
uterus to rise during contractions without pressing against the
abdominal wall.
As the woman focuses on relaxing, it will also serve as a distraction
technique because it distracts her from the pain she is feeling.
Advise the woman to find her position of comfort during labor as it will
greatly help her to relax.
Another way for the woman to relax is to listen to her favorite music or
do aromatherapy while inside her birthing room.
Focusing and Imagery
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Focusing is concentrating intently on an object that will serve as the
distraction.
It also keeps the sensory input from reaching the cortex of the brain,
thus avoiding pain.
A photograph would be used by the woman and she concentrates on it
during contractions.
Avoid disturbing the woman by asking questions while she is focusing
because it would break her concentration.
Prayer
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There are women who find prayers comforting whenever they are in a
stressful situation.
Worship objects such as Bibles, rosaries, and crosses could give comfort
to a woman during labor.
Be careful in changing the sheets because the worship objects might be
thrown away; these are sacred to the woman.
Breathing Techniques
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Most preparing for childbirth classes also teach breathing techniques or
patterns.
Breathing techniques help relax the woman’s abdomen during
contractions.
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It can be considered as a distraction technique because the woman
concentrates on slow-paced breathing instead of minding the pain.
Breathing techniques are best taught to the woman before labor, but if
she is not familiar with it, she can still be coached even while she is in
labor.
Herbal Preparations
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There may be little evidence that shows the effectiveness of herbal
medicines against pain during labor, but it is still widely used by some
women.
Raspberry leaves, life root, and fennel are some of the examples of these
herbs.
Heat or Cold Application
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Women who are experiencing back pain during labor will find heat
application to their lower backs soothing.
After labor, a cool cloth to the forehead could also soothe the woman
from too much exertion.
Ice chips also help relieve the dryness of the woman’s mouth during
labor.
Therapeutic Touch and Massage
Therapeutic touch is the use of touch to comfort and relieve pain.
 According to its philosophy, the body contains energy fields.
 If the energy fields are plentiful, it results to good health.
 If the energy fields are few, it results to ill health.
 Therapeutic touch redirects the energy fields that lead to pain through
the laying of hands.
 The release of endorphins is increased as touch or massage is applied,
leading to decrease in pain.
 Effleurage is a form of therapeutic touch taught at Lamaze classes and is
especially helpful during the first and second stages of labor.
Pharmacologic Measures
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Narcotic Analgesics
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Narcotics have potent analgesic effects but are used cautiously because
they can cause fetal CNS depression.
Women in preterm labor should not have any narcotics as
pharmacologic measure because of the lung immaturity of the fetus.
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Meperidine is an advantageous drug during labor because of its
sedative and antispasmodic effects which relieve pain and helps relax
the cervix.
Meperidine is given 3 hours before birth to allow the peak action of the
drug in the fetus to pass by the time of birth.
Regional Anesthesia
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Regional anesthesia involves the injection of a local anesthetic to block
specific nerve pathways.
Research has proven that some effects of the anesthesia to the fetus
result to fetal heart rate decelerations and symptoms of flaccidity,
bradycardia, and hypotension in the newborn.
Regional anesthesia allows the woman to stay awake and aware of the
happenings during birth.
It also helps prevent postpartum hemorrhage as it does not depress the
uterine tone, so the uterus remains capable of contraction after birth.
Local Anesthesia
Local anesthesia reduces the ability of local nerve fibers to conduct pain.
 Local infiltration uses the injection of a local anesthetic into the
superficial nerves of the perineum.
 The effect lasts for 1 hour, which allows for a pain-free birth and
suturing of episiotomy.
 The pudendal nerve block is the injection of an anesthetic near the right
and left pudendal nerve at the level of the ischial spine.
 This anesthetic provides pain relief after 2 to 10 minutes for 1 hour.
 FHR and the maternal blood pressure should be checked immediately
after injection to detect maternal hypotension.
The types of pain relief during labor and birth vary widely, and it is up to the
woman if she would want to employ these measures during the right time.
Proper education and information from the healthcare providers is a must so
that the couple could make the right decision when it comes to the
procedures and measures that they would want during labor and birth.
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Fetal Position, Presentation, Size, & Passage
A pregnant woman would always want the best for the fetus growing inside of
her. However, when problems arise regarding the welfare of the growing fetus,
she may feel fear and anxiety. This is where healthcare providers enter the
scene, to educate and assist the woman in caring for her fetus and also herself.
Occipitoposterior Position
The usual fetal position is posterior rather than anterior.
 Assuming that the presentation is vertex, the occiput is directed
diagonally and posteriorly, either to the left or to the right.
 During internal rotation in these positions, the fetal head must rotate
through an arc of approximately 135 degrees.
 Rotations from a posterior position can be aided by having the woman
assume a hands-and-knee position, squatting or lying on her side;
however, this is tiring for women in labor.
 Posterior positions usually occur in women with android, anthropoid,
and contracted pelvis.
 Posterior positions happen in dysfunctional labor patterns such as
prolonged active phase, arrested descent, or fetal heart sounds heard
best at the lateral sides of the abdomen.
 A head in the posterior position does not fit the cervix like a head in the
anterior position does.
 This can be confirmed through vaginal examination or through
ultrasound because it might cause umbilical cord prolapse.
 Labor is prolonged because the arc of rotation is greater.
 Pressure and pain would be experienced by the woman in her lower
back owing to sacral nerve compression when the fetal head rotates
against the sacrum.
 To relieve a portion of the pain, applying counterpressure on the sacrum
by a back rub may be done, and heat or cold application can also help.
 To help the fetus rotate, the woman may lie on the side opposite the
fetal back or assume a hands-and-knees position.
 The woman should void every 2 hours to keep her bladder empty and
avoid impeding the descent of the fetus.
 The woman may also need an oral sports drink or IV glucose solution to
replace glucose stores used for energy.
 Maternal exhaustion can cause uterine dysfunction, so a rotation of 135
degrees may not be possible if the contractions are ineffective or if the
fetus is larger than average.
 The fetal head might arrest in the transverse position or there might be
no rotation at all, so cesarean birth would be necessary.
 Provide reassurances to the woman that even though her labor is not
“by the book” it is still within safe and controlled limits.
Oversized Fetus
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Macrosomia or an oversized fetus weighs more than 4000 to 4500g, and
this size may become a problem.
 Macrosomic babies are usually born to women with diabetes or develop
gestational diabetes, and multiparas.
 Uterine dysfunction might result from an oversized fetus because of the
overstretching of the fibers of the myometrium.
 The wide shoulders pose a problem at birth because it can cause fetalpelvic disproportion or uterine rupture from obstruction.
 Cesarean birth is necessary if the fetus is so oversized to be born
vaginally.
 To compare the size of the fetus with the woman’s pelvic capacity,
pelvimetry or ultrasound can be performed.
 If a macrosomic baby is born vaginally, there are high risks for cervical
nerve palsy, diaphragmatic injury, or fractured clavicle due to
shoulder dystocia.
 The woman is at risk for over because of the overdistended uterus and
uterine atony.
Shoulder Dystocia
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Shoulder dystocia occurs during the second stage of labor when the
fetal head is born but the shoulders are too broad to enter and be born
through the pelvic outlet.
 The woman is at risk for vaginal and cervical tears, while the fetus is at
risk for cord compression between the fetal body and the bony pelvis.
 If birth is forced through the vaginal opening, the fetus would sustain a
fractured clavicle or a brachial plexus injury.
 Shoulder dystocia usually occurs in women who have diabetes, in
multiparas, and in post-date pregnancies.
 Shoulder dystocia is discovered often during the birth of the head and
the shoulders lock beneath the symphysis pubis.
 Other conditions that may suggest shoulder dystocia are prolonged
second stage of labor, arrest of descent, or when the head starts to
crown, it retracts instead of protruding with each contraction.
 Instruct the woman to flex her thighs sharply on her abdomen
(McRobert’s maneuver) to widen the pelvic outlet and allow the anterior
shoulder to be born.
 Applying suprapubic pressure can also help the shoulder out from
beneath the symphysis pubis.
Breech Presentation
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Most fetuses are in a breech presentation early in pregnancy; however,
by week 38, it turns into a cephalic presentation.
 The fetal head may be the widest single diameter but the fetus’ buttocks
and legs take up more space.
 The fetus turns into a cephalic position mostly because the fundus is the
largest part of the uterus, so the buttocks and the lower extremities are
in the fundus.
 Types of breech presentation include complete, frank, and footling.
 Breech presentation increases the fetal risk for anoxia, traumatic injury
to the head, fracture of the spine or arm, dysfunctional labor, and early
rupture of membranes.
 Meconium present in the amniotic fluid is a sign of buttock pressure,
and this can lead to meconium aspiration once the infant inhales
amniotic fluid.
 Fetal heart sounds are heard high in the abdomen in breech
presentation.
 Leopold’s maneuver and vaginal examination can determine breech
presentation.
 Be certain to monitor the FHR and uterine contractions continuously to
detect fetal distress early and provide prompt intervention.
 In a breech birth, the birth of the head is the most dangerous part
because a loop of the umbilical cord that has passed down alongside
the head may be compressed.
 Intracranial hemorrhage is another danger of breech birth because of
the pressure changes that have occurred spontaneously.
 An infant born from a frank breech position usually extends his or her
legs continuously during the first 2 or 3 days of life, so be sure to point
out to the parents that this is normal.
Face Presentation
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Face and brow presentations are called asynclitism or a fetal head
presenting at a different angle than expected.
In face presentation, the head diameter the fetus presents to the pelvis
is often too large for birth to proceed.
The back would be difficult to outline because it is concave.
Face presentation can be determined through vaginal examination when
the nose, mouth, or chin is felt as the presenting part or through
ultrasound.
Face presentation usually occurs in women with contracted pelvis, or
placenta previa, in a relaxed uterus of a multipara, with prematurity,
hydramnios, or fetal malformation.
 If the chin is anterior and the pelvic diameters are within normal limits,
the infant can be born vaginally.
 If the chin is posterior, cesarean birth is the birth method of choice.
 Facial edema and ecchymosis are present in a baby born after a face
presentation.
 Assess the patency of the infant’s airway closely.
 Reassure the parents that the edema is transient and will disappear after
a few days.
Brow Presentation
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The rarest among the presentations is the brow presentation.
 This presentation usually occurs in multipara women or in a woman with
relaxed abdominal muscles.
 Obstructed labor occurs because the head becomes jammed in the brim
of the pelvis as the occipitomental diameter presents.
 Cesarean birth would be necessary unless the presentation
spontaneously corrects itself.
 Extreme ecchymosis on the face is also present in infants born after a
brow presentation.
 Reassure the parents that the bruising over the same area as the
anterior fontanelle is normal.
Inlet Contraction
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Inlet contraction is the narrowing of the anteroposterior diameter to less
than 11 cm or the transverse diameter to 12 cm or less.
The usual cause is rickets in early life or an inherited small pelvis.
If the fetal head engages during the 36th to 38th week of pregnancy,
then the pelvic inlet is adequate.
If there is no engagement in primigravidas, then either a fetal
abnormality or a pelvic abnormality should be suspected.
Every primigravida should have pelvic measurements taken and
recorded before week 24 of pregnancy so that a birth decision can be
made.
In CPD, the fetus remains in a floating position which could further
complicate the already difficult situation.
If the membranes rupture, then the risk of cord prolapse increases
greatly.
Outlet Contraction
Outlet contraction is the narrowing of the transverse diameter at the
outlet to less than 11 cm.
 This is the distance between the ischial tuberosities, a measurement that
is easy to make during a prenatal visit, so the narrow diameter can be
anticipated before labor starts.
 This can also be assessed easily during labor.
Trial Labor
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Trial labor refers to the determination of the progress of labor in a
woman who has borderline inlet measurement with a good fetal lie and
position.
 Trial labor may continue as long as the descent of the presenting part
and dilatation of the cervix continue to occur.
 Monitor fetal heart sounds and uterine contractions continuously.
 Instruct the woman to void every 2 hours to aid in fetal descent.
 After the rupture of membranes, assess the FHR closely; if the fetal head
is still high, there is an increased danger of prolapsed cord and anoxia in
the fetus.
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Cesarean birth would be necessary if there is no progress in labor after
6 to 12 hours.
 If trial labor fails and cesarean birth is scheduled, provide an explanation
about why cesarean birth is the best birth method.
 Women undergoing trial labor need to be reassured, as well as her
support person, that cesarean birth is only an alternative, not an inferior,
method of birth because the labor is not progressing.
External Cephalic Version
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External cephalic version is the turning of a fetus from a breech to a
cephalic position before birth.
As early as 34 to 35 weeks external cephalic version can be done but the
usual time is 37 to 38 weeks of pregnancy.
Record FHR and ultrasound continuously during the procedure.
The uterus should relax, so the administration of a tocolytic agent is
done.
The breech and vertex of the fetus are located and grasped
transabdominally by the examiner’s hands on the woman’s abdomen.
External cephalic versions can decrease the number of cesarean births
necessary from breech presentations.
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Contraindications to the procedure include multiple gestations, severe
oligohydramnios, vaginal birth, cord coil, and unexplained thirdtrimester bleeding which could be placenta previa.
The feeling of pressure may be uncomfortable for the woman.
Women who are Rh-negative should receive Rh immunoglobulin after
the procedure in case bleeding occurs.
Nursing Process During Labor and Delivery
Assessment
Assessment for delivery starts at the second stage of labor, which is the full
cervical dilatation until the birth of the baby. This would be a crucial time since
the mother would need to deliver her baby at this stage without any troubles
and with her strength intact so she could push for a normal vaginal delivery.
Assess the responses of the mother towards the intensity and duration
of the contractions.
 Assess the comfortability of the mother with her birthing position.
 Assess her breathing techniques if they are effective or could add to the
difficulty that the mother might be experiencing.
 Assess the ability of the support person to assist the mother during
labor and birth.
 Assess the fetal heart sounds to make sure that there is no occlusion in
the cord that could hinder fetal circulation.
 Assess if the environment is comfortable for both the mother and the
baby.
Diagnosis
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The difficulties that the mother may encounter during delivery are endless.
Not all deliveries have gone smoothly, so every caregiver must be capable of
whipping up a diagnosis and care plan immediately to assist the mother
towards a safe and meaningful delivery.
Pain related to intensity of uterine contractions
Planning
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The place of birth must be prepared prior to delivery.
For multigravidas, preparation of the room could start when the cervix
has dilated to 9 to 10 cm.
For primiparas, preparation of the birth place should start when the
head has crowned to the size of a quarter.
 The newborn care area must also be prepared within the same room
and include supplies for eye care, suction and resuscitation equipment,
radiant heat warmer, sterile towels, and identification of the newborn.
 The mother should choose a position that will be most comfortable for
her during birth.
 Alternative birthing positions today are the dorsal recumbent position,
the lateral Sim’s position, squatting, and semi-sitting.
 A health care provider must be situated at the foot of the birthing table
already so that the infant would not fall off if birth happened
precipitously.
Implementation
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Now that the care plan is already established, time to take some action and
implement those interventions listed on your cheat sheet.
If the client has a birth plan, make sure all health care providers are
aware of her individual preferences.
 Encourage the mother to void before delivery to reduce the discomfort.
 Allow client to take ice chips or hard candies for relief of dry mouth.
 Provide a comfortable environment for both the mother and the baby.
 Allow the client to assume a birthing position of her choice as long as it
is not contraindicated.
 Assist the client in venting out any emotions with regards to her delivery
experience.
Evaluation
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A care plan would not be complete if no evaluation was done to test the
effectiveness of your plan.
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Client will be able to manage her discomfort using nonpharmacologic
methods.
Client will be able to identify other pain relief measures.
Client has no signs of bladder distention and can void every 2 hours.
Client states that she has reduced or no mouth discomfort.
Client states that the environment is comfortable enough.
Client reports that the delivery is a tolerable and highly meaningful part
of her life