Normal Labor and Delivery
Nursing Care
STAGES
Stage I:
LATENT
PHASE
0-3 cm
SUPPORTIVE
DATA
MOTHER’S
RESPONSE
Contractions:
mild.
Duration:
30-45 sec.
Frequency:
5-20 min.
Scant
discharge, pink
show.
Surge of energy
and
excitement.
Talkative;
outgoing.
Anxiety low.
Learning.
NURSING
INTERVENTIONS
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Orient to the hospital
Monitor VS and FHT’s
Assess goals
Assess history and
physical
Labor Assessment (lie,
presentation,
position, station,
condition of BOW)
Admission Procedures
– IV, NPO, Enema,
EFM
Assess support and if
had childbirth classes
Non-pharmacological
measures
Relaxation techniques
Breathing techniques –
shallow breathing
Diversional techniques
Assess voiding
ACTIVE
PHASE
4-7 cm
Contractions:
moderate.
Duration:
45-60 sec.
Frequency:
2-5 min.
More serious.
Dependent.
Restless or
edgy.
Focuses on self.
 Anticipate needs:
1. sponge face
2. keep bed clean, dry
3. mouth care
4. assess voiding
 Use non-pharm.
measures.
 Stay at bedside praise!
 Point out progress.
 Modified-paced
breathing.
 Offer analgesia or
anesthesia.
TRANSITION
PHASE 8-10
cm
Contractions:
strong.
Irregular with
multiple peaks.
Duration:
60-90 secs.
Frequency:
2 min.
Desires
companionship.
Withdrawn.
Drowsy.
Amnesia
between
contractions.
Nausea,
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Provide support- may
need to breathe with
the patient – get in
her face, maintain
eye contact.
Back rub
Assist with pant-blow
breathing
trembling.
Irritable,
aggressive.
Urge to push.
Leg shakes.
Nausea and
vomiting.
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Watch for
hypervention – have
breathe in mask and
slow down the
breathing
Do NOT allow to push
by having patient
blow-blow-blow with
urge.
Do not be offended
by irritability
STAGE II
Contractions:
strong
Duration:
50-90 sec.
Frequency:
1-2 min.
Sudden
Appearance of
sweat on
upper lip.
An episode of
vomiting,
Bulging,
perineum.
Increased
bloody show.
Pressure on
rectum.
Mechanisms of
labor.
Relief with
pushing.
Exhausted.
 Direct pushing efforts
and teach how to
push correctly,
“Quality pushing”.
 Keep perineum clean
and dry.
 Environment quiet.
 Help to delivery
position.
 Repeat Doctor’s
instructions.
STAGE III
Placenta
delivers. S&S
of placental
separation:
1. Globular
rise in
abdomen.
2. Sudden
gush of blood.
3. Lengthening
of umbilical
cord.
Relief,
euphoria.
Cries with joy.
Talkative.
Focused on
infant and
husband.
 Congratulate.
 Coach in relaxation for
delivery of placenta.
 Initiate contact with
infant.
Admission to the Hospital:
1. Initial Assessment
a.
Vital signs and FHT’s (make sure baby is doing O.K.)
b.
Is she in labor?
c.
How far progressed?
d.
Have membranes ruptured?
e.
Psychological response *verbal interaction-talkative, speaks freely,
support person with her. *Body posture and set - relaxed or tense.
*Cultural background influences the response.
2. History and Physical
a.
Data related to this pregnancy
b.
Labor examination (presentation, position, lie, station, etc.)
3. Procedures
a.
Vital signs and FHTs, history and physical
b.
Enema - Never give enema if: bleeding, premature labor, or too
advanced in labor. Give an enema to: stimulate labor, remove material
from bowel, impede descent, prevent contamination
c.
Perineal prep - “mini-prep”
d.
IV - provides Alifeline@ if complications occur
e.
NPO - ice chips, candy on a stick usually no food because gastric
emptying slows during labor
f.
EFM - apply electronic fetal monitor and run a strip
Stage Two of Labor
Signs and Symptoms
1.
2.
3.
Increase in body show
Pressure on rectum B involuntary bearing down
Bulging of perineum
Stage two is the pushing stage and the key is Quality Pushing. Teach mom
how to push! Optimum position for pushing is in a vertical position. Pelvic inlet
points forward and outlet points downward.
Stage 2 – Mechanisms of Labor
The baby moves through the birth canal in the following manner:
1. Descent
2. Flexion
3. Internal Rotation
4. Extension
5. External Rotation
6. Expulsion
Episiotomy vs. Laceration
Episiotomy-
Laceration-
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Stage 3 of Labor
Signs and Symptoms of Placental Separation:
1. A globular rise in the abdomen
the placenta changes from a discoid to a globular shape
2. Sudden gush of blood
3.Lengthening of the cord
Stage 3 – Nursing Care
 Congratulate on delivery of baby
 Coach in relaxation for delivery of the placenta
 Initiate contact with the infant
 May allow to breast feed if desires
__________________________________________________________
Test Yourself!
 The cardinal movement that facilitates the emergence of the fetal head
____________.
a. Flexion
b. Extention
c. External rotation
 Cardinal movement that allows the smallest diameter of the head to pass
through the pelvis is__________________.
a. Flexion
b. Internal rotation
c. Extension
 Cardinal movement that occurs as the fetal shoulders engage and descend
through the pelvis is termed ______.
A. Internal rotation
B. External rotation
Pain Management During Labor
I.
Causes of Pain
Stage One:
 Stretching of the cervix during dilatation and effacement
 Uterine anoxia due to compressed muscle cells during
(decreased blood flow and therefore local oxygen deficit)
 Stretching of the uterine ligaments
**This type of pain is visceral. Usually the woman feels
contraction
the pain only during a contraction.
Stage Two:
 Uterine anoxia
 Distention of the vagina and perineum
 Compression of the nerve ganglia in the cervix and lower uterine
segment
 Pressure on the urethra, bladder, rectum during fetal descent
 Traction on and stretching of the perineum
**This pain is perceived as an intense burning sensation that is felt as the
tissue stretches. Pain may also be referred, in which the discomfort is felt in the
back, flanks, and thighs.
Notes:
II. Factors Affecting the Mothers Response to Pain
 Knowledge and confidence gained through childbirth classes
 Cultural influences on expression of pain
 Maternal fatigue and anxiety
 Previous experiences with pain
III. Methods of Pain Relief
A. Nonpharmacologic
1. Childbirth methods
a. Breathing techniques
b. Relaxation techniques; progressive relaxation
c. Touch
d. Focusing attention on one object
2. Effleurage B gentle, rhythmic stroking of abdomen or thigh during
contraction
3. Sensory stimulation
a. Listening to music; subdued lighting
b. Applying heat and cold
c. Warm showers: water hydrotherapy
d. Lower back massage
e. Counterpressure
f. Position changes
g. Imagery
B. Pharmacologic Methods
1. Analgesia
Demerol, Stadol
2. Barbiturates
Seconal
3. Tranquilizers
Vistaril
4. Regional Anesthesia
b. Epidural
c. Spinal
d. Pudendal
5. Local Anesthesia
6. General Anesthesia B used mainly with cesarean births
Notes:
IV. Goals of Pain Management
Provide maximal relief of pain with maximal safety for mother and fetus
V.
Nursing Care
Collaborate with mother to determine the most effective method of pain
relief during each stage and phase of labor.
Anesthesia Given During Labor and Delivery
General Anesthesia
Gas inhaled; given during delivery; the entire body is affected; no
consciousness. Disadvantages B nausea, slow to fully awaken, sluggishness
or respiratory depression in infant.
Regional Anesthesia
Injection of anesthetic agent so that they come into no direct contact with
nervous tissue. Small fibers that conduct sensation of pain, temperature,
pressure, and touch can be blocked without affecting the large fibers to
maintain muscle tone, position, and motor function.
Paracervical Block
Injection of small quantities of caine drug through vagina into outer rim of cervix
Used in active labor (4-7 cm)
*For labor not delivery. Helps dilatation and effacement
Complete relief of lower uterine pain, cervix, upper vagina. Does not affect
lower vagi and perineum
Can‘t be given after 8 cm. Drug easily and rapidly absorbed into maternal blood
and thus into baby causing fetal bradycardia. Can push in delivery.
Epidural Block
Caine drug injected through a catheter placed in epidural space around spinal
cord. In lumbar 3-5
Used for L&D. Given at 5-6 cm. In primi; at 4-5 cm. multi. Used for C-birth
Naval to toes. Loss of bearing down and bladder sensation.
May take up to 30 minutes to take effect. Hard to get in proper position while in
labor. May slow or stop labor. May need to augment with pitocin. Increased
use of forceps. Maternal drop in blood pressure, chills, shakes, nausea,
vomiting. With hypotension in mom will see fetal decelerations and bradycardia.
Requires skilled person to do this procedure.
Caudal Block
Caine drug injected through catheter placed in lower epidural/caudal space
Used for L&D. Must lie in lateral Sims position for administration. Area affected
is cervix, low vagina, perinea area. Nursing implications are much the same as
an epidural.
Spinal/Saddle Block
Caine drug injected through dura to sub-arachnoid into the spinal fluid in the
spinal canal.
Used for delivery. Given late in second stage, when fetal head is on the
perineum. Used for C-birth.
Naval to toes or below; breasts to toes.
May cause hypotension. Need for woman to lie flat for 6-12 hours after the
block, and possible headache afterwards. Nurse needs to assess maternal vital
signs and FHR. Consent must be signed prior to procedure. Must help in
positioning woman. Forceps delivery because no urge to push.
Pudendal Block
With use of trumpet needle guide insert through vagina both sides to pudendal
nerves. (Runs lateral to tip of ischial spines.)
Used for delivery and third stage, and repair of episiotomy. No help with
contractions.
Lower 2/3 of vagina and perineum
May be given by physician or anesthetist. Simple and safest and most useful.
Does not depress neonate.
Local Anesthesia
Injection of anesthetic agent into the subcutaneous tissue of perineum in a
fan-like pattern. Used for repair of episiotomy. May cause swelling of
perineum.
Analgesics Given During Labor and Delivery
Sedatives
Seconal
Nembutal
Reduce amount of analgesia and promote relaxation and decreases
apprehension. Given in latent phase
No effect on pain. May slow labor. May depress baby.
Tranquilizers
Phenergan
Vistaril
Reduces anxiety, N&V, potentiate analgesics
Slow labor, drop in maternal B/P
Narcotic Analgesics
Stadol
*Given in active stage. If effective will provide some pain relief. The woman
should be able to maintain relaxation techniques, and see no change in
contractions.
Complications: Slow labor, drop in maternal B/P. If given late in labor will
depress baby and have to give Narcan.