Normal Labor and Delivery

Delivery Venue Options

Hospitals:

- most common

- access to key personnel, equipment, pain control, emergency services

Home Births:

- may have negative hospital experience

- may feel more comfortable, empowered, in control

Birthing Centers:

- freestanding centers not in hospital

- mostly midwives

- low-risk pregnancies

- transfer agreements with hospitals

Five Ps of Labor

Power:

- uterine contractions and pushing efforts

Passageway:

- anatomy of patient's pelvis and tissues

Passenger:

- fetus

Psyche:

- patient's state of mind

Position:

- patient's position

Power

Primary powers:

- involuntary uterine contractions

- occurs in upper 2/3 of uterus

- applies pressure to fetus to dilate and efface the cervix

- frequency, duration, intensity

- oxytocin can be administered

Secondary powers:

- voluntary action of pushing after cervix is dilated

- should occur with the contractions

- may require coaching

Passageway

- gynecoid pelvis shape is ideal

- ability of soft tissue to stretch

- fetal station is the relationship between the fetal presenting part and the pelvis

- zero station means the presenting part is level with the ischial spines

Passenger

Fetal presentation:

- part of the fetus entering the pelvis first

- majority of babies are cephalic (head first)

- breech is feet or buttocks first

Fetal attitude:

- position of fetal parts in relation to each other

- flexion vs. extension (vertex is ideal)

Other:

- fetal lie

- fetal position

- molding

Psyche

Slows labor:

- anxiety

- stress

- fear

- pain tolerance

Augments labor:

- relaxation

Position

- contractions more effective when patient is upright

- gravity assists successful L&D

- angle of pelvis is best when hips are flexed like squatting

- encourage positions of comfort

- lithotomy position for ease of the provider

Signs of Labor

Impending:

- regular contractions

- bloody show

- lightening

- nesting or energy burst

- GI distress

- weight loss

Confirmed:

- cervical change with contractions

Assessing ROM

- labor generally starts within 24hr of ROM

- prolonged ROM is risk for infection

- assess FHR after ROM in hospital

- amniotic fluid is watery, clear/yellow, without foul odor

- confirm ROM with fern test and nitrazine paper

Stages and Phases of Labor

First stage:

- dilation and effacement of cervix

- Latent or early phase (0-5cm)

- Active phase (6-10cm)

- Transition phase (8-10cm)

Second stage:

- starts with cervix completely dilated

- ends with birth of baby

Third stage:

- starts with birth of baby

- ends with delivery of placenta

Fourth stage:

- starts with delivery of placenta

- ends after 4 hours or when patient becomes clinically stable

First Stage

Latent phase:

- longest lasting phase of labor

- period of excitement

- contractions feel like menstrual cramps and are mild to palpation

Active phase:

- patient may become focused, anxious, restless

- contractions become more regular and painful

- contractions are moderately strong to palpation

Transition phase:

- contractions strong and close together

- patient may feel out of control, irritable, dependent

- shortest lasting phase of labor

Second Stage

- pushing may be delayed

- may last minutes to 3+ hours

- fetus descends and rotates; cardinal movements

Cardinal Movements in Second Stage

Engagement:

- fetal head reaches level of ischial spines

Descent:

- fetus moves past the ischial spines

Flexion:

- fetal chin touches chest in response to pressure from maternal tissue

Internal rotation:

- fetal head rotates

Extension:

- fetal chin comes off the chest and the neck arches as the head is born

External rotation (restitution):

- fetal head is born and rotates again as the shoulders move into position for birth

Expulsion:

- body of the fetus is born

Third Stage

- complete within 5-30min

- uterus contracts to deliver the placenta

- after delivery, continues to contract to prevent hemorrhage

- failure to contract is uterine atony and primary cause of postpartum hemorrhage

Fourth Stage

- assess uterine position, vaginal bleeding, vital signs

- administer pain meds as needed

- assist with skin-to-skin and feeding

Nursing Care During Labor

- start IV

- draw blood + collect urine

- monitor vital signs

- provide and interpret fetal monitoring

- encourage voiding q2hr

- assess progress

- provide support

-provide education

- administer pain meds

Fetal Monitoring

- assessment of FHR for patterns that indicate fetal compromise

- normal or reassuring pattern associated with positive outcomes

- abnormal or nonreassuring pattern associated with hypoxemia and hypoxia

- intermittent monitoring q15-30min in first stage and q5-15min in second stage

- continuous monitoring is standard in U.S.

- with continuous strip is reviewed q30 for first stage and q15 second stage for low-risk, more frequently for high-risk

Fetal Monitoring Characteristics

- baseline HR of 110-160

- variability is the irregular fluctuations in the baseline FHR

- moderate variability has an amplitude of 6-25bpm

- accelerations are an increase in baseline of at least 15 beats in 15 seconds

- decelerations are decreases in FHR from baseline

VEAL CHOP MINE

FHR Pattern (VEAL):

- variable deceleration

- early deceleration

- acceleration

- late deceleration

Cause (CHOP):

- cord compression

- head compression

- okay!

- placental insufficiency

Management (MINE):

- maternal repositioning

- identify labor progress

- no interventions

- excute interventions

Accelerations

- healthy fetal/placental exchange

- caused by fetal movement

- can be induced with fetal scalp stimulation or vibroacoustic stimulation

Fetal Bradycardia

Definition:

- FHR <110 for 10+ min

Causes:

- uteroplacental insufficiency

- cord prolapse

- maternal hypotension

- prolonged cord compression

- fetal heart block

- medications

Interventions:

- IV fluids

- side-lying

- d/c pitocin

- tocolytics

Fetal Tachycardia

Definition:

- FHR >160 for 10+ min

Causes:

- maternal fever/infection

- fetal anemia

- fetal cardia dysrhythmias

- maternal cocaine/methamphetamine use

- maternal dehydration

Interventions:

- manage fever

- IV fluid bolus

Minimal Variability

Causes:

- medications

- fetal hypoxemia

- fetal sleep cycle

- congenital abnormalities

Interventions:

- fetal scalp stim

- side-lying position

- fetal scalp electrode to assess

Early Decelerations

Causes:

- fetal head compression

- sign of labor progression

Interventions:

- check cervix

Late Decelerations

Causes:

- uteroplacental insufficiency

- inadequate fetal oxygenation

- maternal hypotension

- placenta previa/abruption

- uterine tachysystole

Interventions:

- side-lying positon

- hands and knees

- IV fluids

- d/c pitocin

- O2 via nonrebreather

- prepare for delivery

Variable Decelerations

Definition:

- at least 15 beats below baseline for at least 15 sec

- with or without a contraction

Causes:

- cord compression or abnormalities

Interventions:

- reposition patient

- amnioinfusion

- d/c pitocin

Contraction Monitoring

Frequency:

- every 2-3 min

Duration:

- 60-90 sec

Intensity:

- mild, moderate, strong

Labor Pain Factors

- fear

- history of sexual abuse/trauma

- previous birth trauma

- support system

- fatigue

Labor Pain Manifestations

- abdomen, lower back, thighs

- continuous in low back with occiput-posterior position

- continuous abdominal pain may indicate placental abruption

Pharmacological Labor Pain Management

Opioids:

- fentanyl, short-acting, may cause respiratory depression

Mixed opioid agonist/antagonist:

- may cause withdrawal with opioid dependence

- less risk of respiratory depression

- nalbuphine (Nubain)

- butorphanol (Stadol)

Nitrous oxide:

- self-administered gas

- may cause nausea, vomiting, lightheadedness

Non-pharmacological Labor Pain Management

- focused breathing

- hypnotherapy

- position changes

- cutaneous stimulation

- aromatherapy

- music

- counter pressure

- focal points

- soft lighting, minimize noise/stimuation

- rocking, walking, birthing ball, shower, tub

Epidural Analgesia

- administered via catheter into epidural space

- shouldn't eliminate feeling of pressure

- may cause hypotension, respiratory depression, inhibition of bowel/bladder, itching

- fluid bolus administered prior

- ephedrine for hypotension

- side-lying after epidural

- vital signs q2min during, q5min immediately following, then q15min

- assess FHR q15min (continuous)

- foley or intermittent straight cath