NURS 2866 - Chapter 16 - Nursing Care of the Family During Labor and Birth

What are the 4 stages of labor?

Stage 1 (onset → 10 cm dilation); Stage 2 (10 cm → birth); Stage 3 (birth → placenta delivery); Stage 4 (placenta → stable 1–2 hrs postpartum)

What defines the beginning and end of Stage 1 labor?

Begins with regular contractions; ends with complete effacement and dilation to 10 cm

What is effacement?

Thinning of the cervix

What is dilation?

Opening of the cervix

How do true labor contractions present?

Regular, strong, increase with walking, cause cervical change

How do false labor contractions present?

Irregular, decrease with walking, less frequent, NO cervical change

What must the nurse review in prenatal records during admission?

Risk factors; obstetrical history (gravida/para, abortions, living children); prenatal lab results; history of sexual abuse

Why is history of sexual abuse important in labor care?

Labor can increase anxiety and requires extra education and emotional support

What key questions should the nurse ask during labor admission?

What brought her in? contractions? water breaking? vaginal bleeding?

What contraction details must be assessed?

Onset, frequency, duration, pain level

What additional symptoms should be assessed?

Vaginal discharge or fluid leakage

What is the purpose of the Nitrazine test?

To detect ruptured membranes using pH paper

What color indicates amniotic fluid on Nitrazine test?

Blue (alkaline)

What color indicates no amniotic fluid?

Yellow (acidic)

What can cause false positive Nitrazine results?

Blood, semen, recent vaginal exam

When should the Nitrazine test be performed?

BEFORE a vaginal exam

What is included in the objective assessment on admission?

Full head-to-toe baseline assessment; vital signs; fetal heart rate; uterine contractions; vaginal exam

When should a vaginal exam be performed during labor?

On admission for baseline and before giving medications

When should vaginal exams be avoided?

If membranes are ruptured

Why avoid vaginal exams after membrane rupture?

Increased risk of infection/sepsis because amniotic sac protection is lost

What labs are required during labor admission?

Hemoglobin & hematocrit; type & screen; Group B strep (if not done prenatally)

What are the priority nursing interventions during Stage 1 labor?

Provide education and emotional support; reduce anxiety

What should the nurse encourage during labor?

Position changes; fluid intake (if allowed); voiding

Why is bladder emptying important during labor?

Full bladder slows labor and can cause postpartum hemorrhage

What supportive techniques should be taught?

Relaxation techniques

What is the nurse’s advocacy role in labor?

Advocate for patient needs and create a calm environment

What defines Stage 2 labor?

Full dilation (10 cm) to birth of the baby

What occurs in the latent phase of Stage 2?

Passive fetal descent with no pushing (laboring down)

What occurs in the active phase of Stage 2?

Pushing begins

What triggers the urge to push?

Ferguson reflex (pressure on pelvic floor → urge to bear down)

How often should vital signs be assessed in Stage 2?

Every 5–30 minutes

How often should fetal heart rate be assessed in Stage 2?

Every 5–15 minutes

How often are vaginal exams performed in Stage 2?

Every 10–15 minutes

What is the nurse-to-patient ratio during Stage 2?

1:1 nurse-to-mother care

How many nurses are present during delivery?

1 nurse for mom and 1 nurse for baby

What are key nursing interventions during Stage 2?

Positioning mother; teaching pushing techniques; preparing equipment

What equipment must be prepared for delivery?

Sterile supplies; emergency equipment; suction; medications; warming table turned ON

What is the first priority for newborn care?

Skin-to-skin contact

Why must the newborn be dried immediately?

To prevent heat loss and cold stress

What helps maintain newborn temperature?

Drying, blanket, and hat

How long should cord clamping be delayed?

1–5 minutes or until no pulse

What is the benefit of delayed cord clamping?

Provides ~30% more blood volume to the newborn APGAR + Initial Newborn Assessment

What are priorities during APGAR and initial assessment?

Ensure patent airway; ensure breathing; prevent cold stress

What interventions prevent cold stress in newborns?

Drying the baby; using a blanket and hat

What should be done if the newborn is stable?

Apply ID bands; continue skin-to-skin

What should be done if the newborn is NOT stable?

Move to warming table

What are the degrees of perineal lacerations?

1st = superficial (usually no sutures); 2nd = perineal muscles; 3rd = anal sphincter; 4th = rectal mucosa

What is an episiotomy?

Incision to enlarge the vaginal opening (less common now)

What defines Stage 3 labor?

Birth of baby to delivery of placenta

How often should vital signs be assessed in Stage 3?

Every 15 minutes

What are signs of placental separation?

Lengthening umbilical cord; gush of blood

What should the nurse encourage after birth for placenta delivery?

Pushing (placenta is about half the size of the baby)

What medication is given to prevent bleeding after delivery?

Pitocin (IV or IM)

What additional interventions are done in Stage 3?

Perineal care; encourage breastfeeding; promote bonding

Why is fundal massage performed?

To ensure the uterus is firm

Why is Pitocin continued after placenta delivery?

To maintain uterine contraction and prevent bleeding

What is the focus of Stage 4 labor?

Stabilization and family bonding

How often are vital signs assessed in Stage 4?

Every 15 minutes for the first 2 hours

How often should the fundus be checked?

Every 15 minutes

What should be done if the fundus is NOT firm?

Massage the fundus and empty the bladder

What additional postpartum assessments are required?

Lochia (bleeding); perineum (lacerations/episiotomy)

Why is a full bladder dangerous in labor?

Slows labor and increases risk of postpartum hemorrhage

Why do ruptured membranes increase risk?

Increased infection/sepsis risk

Why is cold stress dangerous in newborns?

Increases oxygen consumption

What is the benefit of delayed cord clamping?

Increases newborn blood volume