NURS 1400 Unit 2
Theories for the Onset of Labor
• Maternal factors
– Estrogen and progesterone
– Prostaglandins
– Oxytocin
• Fetal factors
– Fetal adrenocorticotropic hormone
Fetal Factors Affecting
the Process of Labor
• Head size
– Molding
• Presentation
– Cephalic, breech,
shoulder
Fetal attitude
flexion,
fetal lie
longitudinal
• Lie
– Longitudinal, oblique,
transverse
• Attitude
– Flexion
• Position
Fetal attitude
flexion,
fetal lie
transverse
Factors Affecting Labor Progress
– The birth passageway (birth canal)
– The passenger (fetus)
– The physiologic forces of labor
– The position of the mother
– The woman’s psychosocial considerations
Passenger
•
•
•
•
•
Fetal head
Fetal attitude
Fetal lie
Fetal presentation
Fetal position
Fetal Attitude
• The relation of the fetal body parts to one
another (Figure 22-4)
• Normal attitude is flexion
Figure 22–4 Fetal attitude. A, The attitude (or relationship of body parts) of this fetus is normal. The head is flexed forward with the chin almost
resting on the chest. The arms and legs are flexed. B, In this view, the head is tilted to the right. Although the arms are flexed, the legs are
extended.
Figure 22–4 (continued) Fetal attitude. A, The attitude (or relationship of body parts) of this fetus is normal. The head is flexed forward with
the chin almost resting on the chest. The arms and legs are flexed. B, In this view, the head is tilted to the right. Although the arms are flexed,
the legs are extended.
Fetal Lie
• The relationship spinal column of the fetus
that of the mother
• Longitudinal or transverse
Fetal Presentation
•
•
•
•
Engagement
Station (Figure 22-7)
Ischial spines are zero station
Presenting part moves from – to +
Figure 22–7 Measuring the station of the fetal head while it is descending. In this view the station is 22/23.
Fetal Position
• Right (R) or left (L) side of the maternal pelvis
• Landmark: occiput (O), mentum (M), sacrum
(S), or acromion (scapula[Sc]) process (A)
• Anterior (A), posterior (P), or transverse (T)
Physiology of Labor
• Primary force is uterine muscular contractions
• Secondary force is pushing during the second
stage of labor
Uterine Contractions
• Frequency
• Duration
• Intensity
Figure 22–9 Characteristics of uterine contractions.
Causes of
Cervical Effacement
• Estrogen
- Stimulates uterine muscle contractions
• Collagen fibers in the cervix are broken down
• Increase in the water content of the cervix
Cervical Effacement
•
•
•
•
Physiologic retraction ring
Upper uterine segment thickens and pulls up
Lower segment expands and thins out
Effacement
Figure 22–10 Effacement of the cervix in the primigravida. A, At the beginning of labor, there is no cervical effacement or dilatation. The fetal
head is cushioned by amniotic fluid. B, Beginning cervical effacement. As the cervix begins to efface, more amniotic fluid collects below the fetal
head. C, Cervix is about one-half (50%) effaced and slightly dilated. The increasing amount of amniotic fluid below the fetal head exerts
hydrostatic pressure on the cervix. D, Complete effacement and dilatation.
Figure 22–10 (continued) Effacement of the cervix in the primigravida. A, At the beginning of labor, there is no cervical effacement or
dilatation. The fetal head is cushioned by amniotic fluid. B, Beginning cervical effacement. As the cervix begins to efface, more amniotic fluid
collects below the fetal head. C, Cervix is about one-half (50%) effaced and slightly dilated. The increasing amount of amniotic fluid below the
fetal head exerts hydrostatic pressure on the cervix. D, Complete effacement and dilatation.
Figure 22–10 (continued) Effacement of the cervix in the primigravida. A, At the beginning of labor, there is no cervical effacement or
dilatation. The fetal head is cushioned by amniotic fluid. B, Beginning cervical effacement. As the cervix begins to efface, more amniotic fluid
collects below the fetal head. C, Cervix is about one-half (50%) effaced and slightly dilated. The increasing amount of amniotic fluid below the
fetal head exerts hydrostatic pressure on the cervix. D, Complete effacement and dilatation.
Figure 22–10 (continued) Effacement of the cervix in the primigravida. A, At the beginning of labor, there is no cervical effacement or
dilatation. The fetal head is cushioned by amniotic fluid. B, Beginning cervical effacement. As the cervix begins to efface, more amniotic fluid
collects below the fetal head. C, Cervix is about one-half (50%) effaced and slightly dilated. The increasing amount of amniotic fluid below the
fetal head exerts hydrostatic pressure on the cervix. D, Complete effacement and dilatation.
The Five Ps of Labor
•
•
•
•
•
Passageway
Passenger
Powers
Position
Psychological
response
Station or relationship of the fetal presenting
part to the ischial spines.
Positions of a Vertex Presentation
Leopold’s Maneuvers
• Is the fetal lie longitudinal or transverse?
• What is in the fundus? Am I feeling buttocks or
head?
• Where is the fetal back?
• Where are the small parts or extremities?
• What is in the inlet? Does it confirm what I found
in the fundus?
• Is the presenting part engaged, floating, or dipping
into the inlet?
Figure 23–7 Leopold’s maneuvers for determining fetal head position, presentation, and lie. NOTE: Many nurses do the fourth maneuver first to
identify the part of the fetus in the pelvic inlet.
Figure 23–7 (continued) Leopold’s maneuvers for determining fetal head position, presentation, and lie. NOTE: Many nurses do the fourth
maneuver first to identify the part of the fetus in the pelvic inlet.
Figure 23–7 (continued) Leopold’s maneuvers for determining fetal head position, presentation, and lie. NOTE: Many nurses do the fourth
maneuver first to identify the part of the fetus in the pelvic inlet.
Figure 23–7 (continued) Leopold’s maneuvers for determining fetal head position, presentation, and lie. NOTE: Many nurses do the fourth
maneuver first to identify the part of the fetus in the pelvic inlet.
Powers of Labor
• Primary powers
– Involuntary uterine
contractions
• Effacement
• Dilation
• Secondary powers
– Voluntary pushing in
second stage
Maternal Position
• Ambulation
• Lateral recumbent in
bed
• Fowler’s position in bed
or chair
• Birthing ball
• Avoid supine position
Psychological Response
of the Mother
• Culture
• Expectations and goals
for the labor process
• Feedback from people
participating in the birth
process
Signs and Symptoms
of Impending Labor
•
•
•
•
•
•
Lightening
Cervical change
Braxton Hicks contractions
Bloody show
Energy spurt
Gastrointestinal disturbances
Stages of Labor
• First stage–onset of labor to complete dilation of the
cervix
– Latent phase (ends with cervix 3–4 cm dilated)
– Active phase (3–4 cm to 8 cm dilated)
– Transition (8–10 cm dilated)
• Second stage–complete dilation to birth
• Third stage–birth to placental expulsion
• Fourth stage–four hours following delivery of
the placenta
True Labor
• Progressive dilatation and effacement
• Regular contractions increasing in frequency,
duration, and intensity
• Pain usually starts in the back and radiates to
the abdomen
• Pain is not relieved by ambulation or by resting
True Labor
True Labor
True Labor
True Labor
True Labor
True Labor
False Labor
• Lack of cervical effacement and dilatation
• Irregular contractions do not increase in
frequency, duration, and intensity
• Contractions occur mainly in the lower
abdomen and groin
• Pain may be relieved by ambulation, changes
of position, resting, or a hot bath or shower
First Stage of Labor: Latent Phase
• Beginning cervical dilatation and effacement
• No evident fetal descent
• Uterine contractions increase in frequency,
duration, and intensity
• Contractions are usually mild
First Stage of Labor:
Active Phase
• Cervical dilatation from 4 to 7 cm
• Progressive fetal descent
• Contractions more frequent and intense
First Stage of Labor:
Transition
• Cervical dilatation from 7 to 10 cm
• Progressive fetal descent
• Contractions more frequent and intense
Second Stage of Labor
• Begins with complete dilatation (10 cm)
• Ends with birth of the baby
Figure 22–12 Mechanisms of labor. A, B, Descent. C, Internal rotation. D, Extension. E, External rotation.
Third Stage of Labor
• From birth of infant to delivery of placenta
Fourth Stage of Labor
•
•
•
•
•
•
4 hours after birth
Physiologic readjustment
Thirsty and hungry
Shaking
Bladder is often hypotonic
Uterus remains contracted
Cardinal Movements of Labor
Palpation: Advantages
•
•
•
•
Noninvasive
Readily accessible, requiring no equipment
Increases the “hands on” care of the patient
Allows the mother freedom
Palpation: Disadvantages
• Does not provide actual quantitative measure
of uterine pressure
• No permanent record
• Maternal size and positioning may prevent
direct palpation
External Electronic Uterine
Monitoring: Advantages
• Noninvasive
• Easy to place
• May be used before and following rupture of
membranes
• Can be used intermittently
• Provides a permanent, continuous recording
External Electronic Uterine
Monitoring: Disadvantages
• The nurse must compare subjective findings
with monitor
• The belt may become uncomfortable
• The belt may require frequent readjustment
• The mother may feel inhibited to move
Internal Electronic Uterine
Monitoring: Advantages
• Provides pressure measurements for
contraction intensity and uterine resting tone
• Allows for very accurate timing of UCs
• Provides a permanent record of the uterine
activity
Internal Electronic Uterine
Monitoring: Disadvantages
• Membranes must be ruptured and adequate
cervical dilation must be achieved
• Invasive
• Increases the risk of uterine infection or
perforation
• Contraindicated in cases with active infections
• Use with a low-lying placenta can result in
placenta puncture
Figure 23–3 INTRAN Plus intrauterine pressure catheter. There is a micropressure transducer (electronic sensor) located at the tip of the
catheter and a port for amnioinfusion at the distal end of the catheter. SOURCE: Photographer: Elena Dorfman.
Auscultation: Advantages
•
•
•
•
Uses minimum instrumentation
Is portable
Allows for maximum maternal movement
Convenient and economical
Auscultation: Disadvantages
• Can only provide the baseline fetal heart rate,
rhythms, and obvious increases and decreases
• Does not provide a permanent record
External Electronic Fetal Heart
Monitoring: Advantages
• Produces a continuous graphic recording
• Can show the baseline, baseline variability, and
changes in the FHR
• Noninvasive
• Does not require rupture of membranes
External Electronic Fetal Heart
Monitoring: Disadvantages
• Is susceptible to interference from maternal
and fetal movement
• May produce a weak signal
• Tracing may become sketchy and difficult to
interpret
Internal Electronic Fetal Heart Monitoring:
Advantages
• Clearer tracings
• Provides information about short term
variability
Internal Electronic Fetal Heart Monitoring:
Disadvantages
• Infection
• Injury
• Requires ruptured membranes and sufficient
cervical dilatation
Labor Induction and Augmentation
• Bishop score used to evaluate for induction
• Cervical ripening methods
– Dinoprostone (Prepidil, Cervidil), misoprostel
(Cytotec)
• Oxytocin (pitocin) for induction/augmentation
Labor Induction and Augmentation
(continued)
• Nursing considerations
– Monitor vital signs, I&O
– Monitor for hyperstimulation
– Monitor FHR for decelerations
Forceps-Assisted Birth
Vacuum-Assisted Birth
Systemic Responses
to Labor
•
•
•
•
•
•
Changes in cardiac output
Diaphoresis
Hyperventilation
Changes in ABG levels
Polyuria
Slight proteinuria
Systemic Responses
to Labor (continued)
•
•
•
•
Reduced gastric motility
Increased WBCs
Decreased maternal blood glucose
Pain
Fetal Adaptations
• Fetal heart rate decelerations due to
intracranial pressure
• Quiet and awake state
• Aware of pressure sensations
Nursing Management of
Fetal Intolerance of Labor
• Normal FHR 110–160 bpm
• Interventions for abnormal FHR patterns
– Reposition the client
– Turn off oxytocin if infusing
– Increase mainline IV rate
– O2 at 8–10 L/minute
– Vaginal exam to rule out cord prolapse
– Notify health care provider
– Prepare to administer terbutaline
Analgesia in Labor
• Medications
– Fentanyl (Sublimaze)
– Butorphanol (Stadol)
– Nursing implications
– Given too early may slow labor
– Will decrease variability of the FHR
– Given too late may cause respiratory depression in
the newborn
Nurse’s Role in Pain Relief
• Support decision for pharmaceutical pain relief
• Offer alternative therapies if pharmaceuticals
not desired
• Support changes in decision
• Educate about options
• Reassure that accepting medication for pain is
not failure
Systemic Analgesia
Common indications for medications
Systemic Analgesia
• Goal is to provide maximum pain relief with
minimal risk
• Alteration in maternal state affects fetus
Administration of
Systemic Analgesia
•
•
•
•
•
When woman is uncomfortable
Well-established labor pattern
Contractions occurring regularly
Significant duration of contractions
Moderate to strong intensity
Maternal Assessments
•
•
•
•
The woman is willing to receive medication
Vital signs are stable
Contraindications are not present
Knowledge of other medications being
administered
Fetal Assessments
•
•
•
•
Fetal heart rate between 110 and 160 bpm
Reactive nonstress test
Short-term variability is present
Long-term variability is average
Assessment of
Labor Progress
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•
•
•
Contraction pattern
Cervical dilatation
Fetal presenting part
Station of the fetal presenting part
Nursing Considerations
• Record the drug name, dose, route, site on
EFM strip and chart
• Record the woman’s blood pressure and pulse
(before and after) on the EFM strip and chart
• Safety precautions
– Raising the side rails
– Assessment of the FHR
Sedatives
• Use: early latent phase
• Purpose: relaxation and sleep
• Common medications - Seconal and Ambien
H1-receptor antagonists
• Use - Early latent phase
• Purpose - Sedative, antiemetic
• Common medications - Phenergan, Vistaril,
Bendadryl
Narcotics
• Use: active phase
• Purpose - pain management
• Common medications - Stadol, Nubain,
Demerol
• Narcotic antagonist - Narcan
Regional Anesthesia
• Temporary and reversible loss of sensation
• Prevents initiation and transmission of nerve
impulses
• Types
– Epidural
– Spinal
– Combined epidural-spinal
Position for Epidural Block
Epidural: Advantages
• Produces good analgesia
• Woman is fully awake during labor and birth
• Continuous technique allows different blocking
for each stage of labor
• Dose of anesthetic agent can be adjusted
Epidural: Disadvantages
•
•
•
•
•
•
Maternal hypotension
Postdural puncture seizures
Meningitis
Cardiorespiratory arrest
Vertigo
Onset of analgesia may not occur for up to 30
minutes
Spinal Block: Advantages
•
•
•
•
Immediate onset of anesthesia
Relative ease of administration
Smaller drug volume
Maternal compartmentalization of the drug
Spinal Block: Disadvantages
• High incidence of hypotension
• Greater potential for fetal hypoxia
• Uterine tone is maintained, making
intrauterine manipulation difficult
• Short acting
Combined Spinal-Epidural:
Advantages
• Spinal agent has a faster onset
• Medication can be added to increase the
effectiveness
• Preserves motor functioning
• Most drugs are used in low dose
Combined Spinal-Epidural: Disadvantages
• Higher incidence of nausea and pruritus
Pudendal
• Perineal anesthesia for the second stage of
labor, birth, and episiotomy repair
• Advantages are ease of administration and
absence of maternal hypotension
• Urge to bear down may be decreased
Figure 25–7 A, Pudendal block by the transvaginal approach. B, Area of perineum affected by pudendal block.
Figure 25–7 (continued) A, Pudendal block by the transvaginal approach. B, Area of perineum affected by pudendal block.
Local
• Used for episiotomy repair
• Advantage is that it involves the least amount
of anesthetic agent
• The major disadvantage is that large amounts
of solution must be used
Nursing Management:
Prior to Administration
•
•
•
•
Assess maternal and fetal status
Assess labor progress
Start an IV and administer preload
Help woman into position
Nursing Management:
After Administration
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•
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•
•
Monitor maternal and fetal vital signs
Assess for hypotension
Tale corrective measures for hypotension
Administer antiemetics as needed
Monitor respiratory rate
Assess bladder and catheterize if unable to
void
Complications of
Epidural Anesthesia
• Toxic reactions
– Unintentional placement of the drug
– Excessive amount of the drug
– Accidental intravascular injection
• Spinal headaches
Complications of
Spinal Anesthesia
•
•
•
•
•
•
Hypotension
Drug reaction
Total spinal neurologic sequelae
Spinal headache
Nausea, shivering, and urinary retention
Ineffective anesthesia
Complications of
Pudendal Anesthesia
•
•
•
•
Systemic toxic reaction
Broad ligament hematoma
Perforation of the rectum
Trauma to the sciatic nerve
Methods of General
Anesthesia
• Intravenous injection
– Sodium thiopental (Pentothal)
– Ketamine
• Inhalation of anesthetic agents
– Nitrous Oxide
– Low-dose halogenated agents
Complications of
General Anesthesia
• Fetal depression
– Depth and duration
• Uterine relaxation
• Potential for chemical pneumonitis
– Decrease in gastrointestinal motility
– Acidic gastric secretions
Contraindications
• Preterm infant
– Avoid analgesia during labor
• Preeclampsia
– Regional anesthesia is preferred
– General anesthesia may aggravate hypertension
Contraindications
(continued)
• Diabetes
– Potential for decreased uteroplacental flow due to
hypotension
– Increased risk of cardiovascular depression with
regional
• Cardiac
– Continuous epidural avoids cardiovascular changes
with bearing down
Contraindications
(continued)
• Bleeding
– Regional blocks are contraindication due to
reduction in volume
Regional Analgesia and Anesthesia:
Epidural
• Disadvantages
– Client is confined to bed
– May interfere with pushing efforts
– May cause hypotension
– May not be aware of the need to void
Regional Analgesia and Anesthesia:
Epidural (continued)
• Nursing implications
– IV bolus prior to procedure
– Monitor VS, especially BP and FHR
– Client must remain in bed
– Assess bladder filling
Maternal Status Assessment
•
•
•
•
•
Presenting complaint
EDC
Parity
Contraction pattern
Status of the membranes,
fluid color
• Allergies
• Bloody show
• Complications during
pregnancy
Risk Factor Assessment
• Preexisting medical diseases
– Diabetes, hypertension, heart disease, infections,
renal disease, anemia
• Previous poor pregnancy outcome
– Perinatal mortality, preterm delivery, IUGR,
malformations, hemorrhage
Risk Factor Assessment (continued)
• Risk factors developing during the pregnancy
– PIH, GDM, multiple gestation, placenta previa,
abnormal presentation, IUGR, drug exposure,
smoking, alcohol use
• Inadequate maternal weight gain
Fetal Status
• Methods for monitoring
– External ultrasound transducer
– Fetal scalp electrode
• Fetal heart rate and pattern
• Fetal heart rate response to
contractions
• Presentation
• Lie
• Engagement (station)
Labor Status
• Methods for monitoring
– External tocotransducer
– Intrauterine pressure catheter (IUPC)
• Uterine activity
– When contractions began
– Frequency
– Duration
– Strength
– Resting tone
Fetal Membrane Status
• Normal fluid is colorless and clear
• Tests to assess rupture of the membranes
– Nitrazine test, Fern test
• Risk factors
– Polyhydramnios
– Oligohydramnios
– Meconium
– PROM, PPROM
– Foul-smelling fluid (chorioamnionitis)
Cervical Status and Fetal Descent
• Effacement
– Thinning of the cervical canal
– Expressed in %
• Dilation
– Opening of the cervix
– Closed to 10 cm (complete)
• Presenting part
– Vertex most common
• Station
– Expressed in cm above or below
the ischial spines
General Systems Assessment
• Vital signs
– BP, P, R, T
• Abdomen
– Rash, lesion, scars, Leopold’s maneuvers
• Bladder
• Lower extremities
– Edema
– DTR
– Clonus
Evaluation of Laboratory Tests
• Urine specimen analysis
– Protein, glucose, ketones, infection
• Blood tests
– Rh factor, antibodies, rubella, syphilis, hepatitis B,
HIV, glucose levels, hemoglobin
• Cultures
– GBS, gonorrhea, chlamydia, herpes
Nursing Responsibilities
During Labor
• Maternal assessment
– Vital signs
– Hydration and nutrition
– Elimination
Nursing Responsibilities
During Labor (continued)
• Fetal assessment
– Baseline FHR
– Variability
– Accelerations
– Periodic changes (decelerations)
• Early (head compression)
• Late (placental insufficiency)
• Variable (cord compression)
Interventions for Nonreassuring
Fetal Heart Rate Pattern
• Change maternal
position
• Oxygen
• Increase IV fluids
• Stop pitocin
• Vaginal examination to
rule out cord prolapse
• Notify the primary care
provider
• Anticipate
administration of
terbutaline
• Anticipate starting an
amnioinfusion
• Document all
information
Stages and Phases of Labor
• First stage (0–10 cm dilated)
– Latent phase (0–3 cm)
– Active phase (4–7 cm)
– Transition phase (8–10 cm)
• Second stage (10 cm to birth)
• Third stage (birth to delivery of the placenta)
• Fourth stage (recovery)
Labor Progress: First Stage
• Uterine assessment
– Montevideo units
• Rupture of fetal membranes
– Spontaneous (SROM) or artificial (AROM)
– Assess FHR, color, odor, amount
• Documentation and communication
• Activity
Labor Progress: First Stage (continued)
•
•
•
•
•
Comfort measures
Pain management
Psychologic considerations
Friedman labor curve
Role of the support person
Labor Progress: Second Stage
• Continued assessment of
contractions and fetal status
• Fetal descent assessment
• Psychological considerations
• Maternal positioning
• Coaching maternal breathing
and pushing efforts
Preparation for Delivery
•
•
•
•
Prepare instrument table
Adequate lighting
Oxygen and suction equipment
Radiant warmer, blankets, identification for
newborn
• Pitocin available for administration after
delivery
Preparation for Delivery (continued)
• Positioning of mother for birth
• Gown, gloves, and protective equipment for
personnel
• Cleansing of the perineum
The Process of Birth
Delivery of the head
Crowning
Delivery of the body
Third Stage
• Newborn care
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–
–
–
–
–
Time of birth noted
Drying, stimulation, suctioning of the newborn
Respiratory effort, heart rate, color, tone noted
One- and five-minute Apgar scores assigned
Cord blood obtained
Identification
• Delivery of the placenta
– Oxytocin administered to control bleeding
• Repair of episiotomy/tears
Immediately after birth
Delivery of the placenta
Applying the cord clamp
Controlling maternal bleeding
Fourth Stage
• Newborn-family attachment
– Family together if infant stable
– Breastfeeding initiated
• Maternal status
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–
–
–
–
–
–
Uterus
Lochia
Perineum
Bladder
Vital signs
Pain
Psychosocial status
Nursing Interventions:
Latent Phase
• Anticipatory guidance
• Encourage ambulation
• Offer fluids
Nursing Interventions:
Active Phase
• Palpate contractions every 15-30 minutes
• Vaginal exams to assess cervical dilatation,
effacement, and fetal station and position
• Encourage client to void
• Assess vital signs every hour
Nursing Interventions:
Active Phase (continued)
• Auscultate fetal heart rate every 30 minutes
• Start IV fluid infusion if unable to tolerate
fluids
• Assess color and odor of amniotic fluid and
fetal heart rate when ruptured
Nursing Interventions:
Transition Phase
•
•
•
•
•
•
Palpate contractions every 15 minutes
Sterile vaginal exams to assess labor progress
Assess maternal vital signs every 30 minutes
Assess fetal heart rate every 30 minutes
Assist with breathing
Keep woman from pushing until fully dilated
Nursing Interventions:
Second Stage
• Sterile vaginal exams to assess fetal descent
• Assess maternal vital signs every 5 minutes
• Provide support and information about labor
progress
• Assist with pushing
• Assist the physician or CNM with the birth
Nursing Interventions:
Third Stage
• Provide newborn care
• Assist with delivery of placenta
Nursing Interventions:
Fourth Stage
•
•
•
•
•
Palpate fundus every 15 minutes for one hour
Assess vaginal bleeding
Encourage bonding and breastfeeding
Assess perineum
Perineal care
Figure 24–12 Suggested method of palpating the fundus of the uterus during the fourth stage. The left hand is placed just above
the symphysis pubis, and gentle downward pressure is exerted. The right hand is cupped around the uterine fundus.
Comfort Measures:
First Stage
•
•
•
•
•
•
Frequent position changes
Hydrotherapy
Perineal care
Clear fluids and ice chips
Birthing balls
Provide information and support
Comfort Measures:
First Stage (continued)
•
•
•
•
•
•
Relaxation between contractions
Distraction
Effleurage
Firm pressure on back or sacrum
Visualization
Controlled breathing
Comfort Measures:
Second Stage
•
•
•
•
•
•
Same as first stage
Cool cloths
Encourage rest between contractions
Assist into pushing position
Sips of fluids or ice chips
Reassurance
Figure 24–4 A birthing ball is used to promote maternal comfort during labor. The birthing ball facilitates fetal descent and fetal rotation and
helps increase the diameter of the pelvis.
Comfort Measures:
Fourth Stage
• Heated blanket
• Provide food
• Encourage rest
Care of the Newborn
•
•
•
•
•
•
Maintain respirations
Provide and maintain warmth
Apgar score
Physical assessment
Newborn identification
Facilitate attachment
Figure 24–11 A newborn infant being suctioned with a DeLee mucus trap to remove excess secretions from the mouth and nares.
SOURCE: Photographer, Elena Dorfman.
Third Stage of Labor
• Watch for signs of placental separation
• Palpate fundus
• Encourage breathing and abdominal relaxation
during delivery of placenta
• Possible administration of Pitocin
Facilitating Attachment
•
•
•
•
Minimize newborn interventions
Provide privacy
Keep lights low
Facilitate parental wishes
APGAR System
Initial newborn evaluation
Forceps-Assisted Birth:
Maternal Indications
• Heart disease
• Acute pulmonary edema or pulmonary
compromise
• Certain neurological conditions
• Intrapartal infection
• Prolonged second stage
• Exhaustion
Figure 27–5 Application of forceps in occiput-anterior (OA) position. A, The left blade is inserted along the left side wall of the pelvis over the
parietal bone. B, The right blade is inserted along the right side wall of the pelvis over the parietal bone. C, With correct placement of the blades,
the handles lock easily. During uterine contractions, traction is applied to the forceps in a downward and outward direction to follow the birth
canal.
Figure 27–5 (continued) Application of forceps in occiput-anterior (OA) position. A, The left blade is inserted along the left side wall of the
pelvis over the parietal bone. B, The right blade is inserted along the right side wall of the pelvis over the parietal bone. C, With correct
placement of the blades, the handles lock easily. During uterine contractions, traction is applied to the forceps in a downward and outward
direction to follow the birth canal.
Figure 27–5 (continued) Application of forceps in occiput-anterior (OA) position. A, The left blade is inserted along the left side wall of the
pelvis over the parietal bone. B, The right blade is inserted along the right side wall of the pelvis over the parietal bone. C, With correct
placement of the blades, the handles lock easily. During uterine contractions, traction is applied to the forceps in a downward and outward
direction to follow the birth canal.
Forceps-Assisted Birth:
Fetal Indications
• Premature placental separation
• Prolapsed umbilical cord
• Nonreassuring fetal status
Types of Forceps
• Outlet forceps
• Midforceps
• Breech forceps
Figure 27–4 Forceps are composed of a blade, shank, and handle and may have a cephalic and pelvic curve. (Note labels on Piper and TuckerMcLean forceps.) The blades may be fenestrated (open) or solid. The front and lateral views of these forceps illustrate differences in blades,
open and closed shanks, and cephalic and pelvic curves. Elliot, Simpson, and Tucker-McLean forceps are used as outlet forceps. Kielland and
Barton forceps are used for midforceps rotations. Piper forceps are used to provide traction and flexion of the aftercoming head (the head
comes after the body) of a fetus in breech presentation.
Fetal Risks
• Ecchymosis, edema, or both along the sides of
the face
• Caput succedaneum or cephalhematoma
• Transient facial paralysis
• Low Apgar scores
• Retinal hemorrhage
• Corneal abrasions
Fetal Risks (continued)
•
•
•
•
Ocular trauma
Other trauma (Erb’s palsy, fractured clavicle)
Elevated neonatal bilirubin levels
Prolonged infant hospital stay
Maternal Risks
•
•
•
•
Lacerations of the birth canal
Periurethral lacerations
Extension of a median episiotomy into the anus
More likely to have a third- or fourth-degree
laceration
• Report more perineal pain and sexual problems in
the postpartum period
• Postpartum infections
Maternal Risks (continued)
•
•
•
•
•
Cervical lacerations
Prolonged hospital stay
Urinary and rectal incontinence
Anal sphincter injury
Postpartum metritis
Nursing Management
•
•
•
•
Explains procedure to woman
Monitors contractions
Informs physician/CNM of contraction
Encourages woman to avoid pushing during
contraction
• Assessment of mother and her newborn
• Reassurance
Indications for
Vacuum Extraction
•
•
•
•
Prolonged second stage of labor
Nonreassuring heart rate pattern
Used to relieve the woman of pushing effort
When analgesia or fatigue interfere with ability
to push effectively
• Borderline CPD
Vacuum Extraction
Procedure
• Procedure
– Suction cup placed on fetal occiput
– Pump is used to create suction
– Traction is applied
– Fetal head should descend with each contraction
Figure 27–6 Vacuum extractor traction. A, The cup is placed on the fetal occiput, creating suction. Traction is applied in a downward and
outward direction. B, Traction continues in a downward direction as the fetal head begins to emerge from the vagina. C, Traction is maintained
to lift the fetal head out of the vagina.
Figure 27–6 (continued) Vacuum extractor traction. A, The cup is placed on the fetal occiput, creating suction. Traction is applied in a
downward and outward direction. B, Traction continues in a downward direction as the fetal head begins to emerge from the vagina. C, Traction
is maintained to lift the fetal head out of the vagina.
Figure 27–6 (continued) Vacuum extractor traction. A, The cup is placed on the fetal occiput, creating suction. Traction is applied in a
downward and outward direction. B, Traction continues in a downward direction as the fetal head begins to emerge from the vagina. C, Traction
is maintained to lift the fetal head out of the vagina.
Nursing Management
•
•
•
•
Inform woman about procedure
Pumps the vacuum
Supports the woman
Assesses the mother and neonate for
complications
Neonatal Risks with
Vacuum Extraction
•
•
•
•
•
•
Scalp lacerations and bruising
Shoulder dystocia
Subgaleal hematomas
Cephalhematomas
Intracranial hemorrhages
Subconjunctival hemorrhages
Neonatal Risks with
Vacuum Extraction (continued)
•
•
•
•
Neonatal jaundice
Fractured clavicle
Erb’s palsy
Damage to the sixth and seventh cranial
nerves
• Retinal hemorrhage
• Fetal death
Maternal Risks with
Vacuum Extraction
•
•
•
•
•
•
Perineal trauma
Edema
Third- and fourth-degree lacerations
Postpartum pain
Infection
More sexual difficulties in the postpartum
period
Indications for
Cesarean Birth
•
•
•
•
•
•
Complete placenta previa
CPD
Placental abruption
Active genital herpes
Umbilical cord prolapse
Failure to progress in labor
Indications for
Cesarean Birth (continued)
• Proven nonreassuring fetal status
• Benign and malignant tumors that obstruct the
birth canal
• Breech presentation
• Previous cesarean birth
• Major congenital anomalies
• Cervical cerclage
Indications for
Cesarean Birth (continued)
• Severe Rh isoimmunization
• Maternal preference for cesarean birth