Chapter 16: Nursing Care of the Family During Labor and Birth - Intrapartum Interventions

Mississippi College: NUR390 - Maternal, Newborn, and Women's Health

how many stages of labor are there?

4

what does a woman experience in the first stage of labor?

the woman has contractions and her cervix dilates

what does a woman experience in the second stage of labor?

the woman pushes, giving birth to the baby

what does a woman experience in the third stage of labor?

the woman expels the placenta 

what does a woman experience in the fourth stage of labor?

the postpartum period

the first stage of labor begins with the onset of what?

regular uterine contractions

the first stage of labor ends with what?

full cervical effacement and dilation

what are the two phases of the first stage of labor?

• latent phase

• active phase

what is the range that the woman is dilated to in the latent phase?

0-6 cm

what is the range that the woman is dilated to on the active phase?

6 cm-10 cm

what are some nursing considerations in the first stage of labor?

• determination of true or false labor (typically taught to patient in third trimester)

• Braxton-Hicks are real contractions (painless)

what are the differences between true labor contractions and false labor contractions?

True labor contractions:

• occur regularly, becoming stronger, lasting longer, and occurring closer together

• are usually felt in the lower back, radiating to the lower portion of the abdomen

• continue despite use of comfort measures

False labor contractions:

• occur irregularly or become regular only temporarily

• often stop with walking or position change

• can be felt in the back or the abdomen above the umbilicus

• can often be stopped through the use of comfort measures

what are some comfort measures that a woman can manage during early labor?

• ambulation

• showers

• mindful meditation

• acupressure

• partner support

• massage

• nutrition

what does the assessment for the first stage of labor include?

• prenatal data

• interview

• admission data

• psychosocial factors

• stress in labor

• ethnic or cultural factors

what does the gathering of prenatal data in an assessment include?

• record of prenatal care from HCP

• VS trends

• weight gain 

• immunizations 

• GBS

• previous experience 

• previous deliveries 

what does the interview include in an assessment?

• Why is the patient here?

• SROM or unsure of labor?

• bloody show

• SROM tests —→ Nitrazine test for pH/ Fern test

what factors would be included in the admission data of the assessment?

• record last liquid/food intake

• birth plan

• pain management

• infant feeding preference

• pediatric HCP choice

what is included in the psychosocial factors?

• general appearance and behaviors 

• history of sexual abuse 

how to treat a patient who has experienced sexual abuse?

• explain all procedures and limit invasive ones

• avoid phrases like “open your legs” or “relax and ot won’t hurt so much”

how to care for a patient who undergoes stress during labor?

• encourage sharing concerns and fears

• consider stress and needs of support person

*ethnic and/or cultural factors play a big part as well

what would be included in a physical examination during the first stage of labor?

• heart

• lungs

• skin 

• edema 

• deep tendon reflexes (clonus)

• weight 

• vital sings 

• leopold maneuvers

• assessment of fetal heart rate (FHR) and pattern 

• assessment of uterine contractions 

• vaginal examination 

what are leopold maneuvers?

abdominal palpation that answers 3 questions:

1) which fetal part is in the uterine fundus?

2) where is the fetal back located?

3) what is the presenting fetal part?

supine hypotension occurs because the _____ and _____ _____ are compressed

aortic; vena cava

what is the vertex position?

RLQ/LLQ

what are uterine contractions?

involuntary force acting to expel fetus/placenta from uterus

what are uterine contractions measured by?

• mother’s subjective description

• palpations/timing by the nurse/HCP

• electronic monitoring

what does the fundus feel like during mild uterine contractions (exhibits wavelike pattern)?

slightly tense fundus that is easy to indent with the fingertips (feels like pressing a finger to the tip of the nose)

what does the fundus feel like during moderate uterine contractions (exhibits wavelike pattern)?

firm fundus that is difficult to indent with the fingertips (feels like pressing a finger to the chin)

what does the fundus feel like during strong uterine contractions (exhibits wavelike pattern)?

rigid board-like fundus that is almost impossible to indent with the fingertips (feels like pressing a finger to the forehead)

what does frequency of a contraction mean?

how often uterine contractions occur; the time that passes from the beginning of one contraction to the beginning of the next contraction

what does the intensity of a contraction mean?

the strength of a contraction at its peak

what does the duration of a contraction mean?

the time that passes between the onset and the end of a contraction

what does the resting tone of a contraction mean?

the tension in the uterine muscle between contractions; relaxation of the uterus

what do we assess for in a vaginal examination?

• reveals if in true labor

• have membranes ruptured (SROM)

• performed when necessary to avoid the introduction of microorganisms 

what would be some laboratory and diagnostic tests we would perform in an assessment of the first stage of labor?

urine specimen, blood tests, other tests, and assessment of amniotic membranes and fluid

why do we analyze urine specimens?

for hydration, nutrition, infection, and preeclampsia

why would we perform blood tests with IV start?

for a CBC, HIV, type and screen 

what other tests would we perform?

• COVID

• GBS

why would we assess the amniotic membranes and fluid?

• SROM vs AROM

• record FHR immediately before and after rupture and the color (clear or meconium-stained), estimated amount, and odor of the fluid

• umbilical cord may prolapse when membranes rupture

what would be some nursing interventions in the first stage of labor?

• general hygiene 

• nutrient and fluid intake 

• elimination 

what would be some general hygiene things?

• showers/warm baths

• water immersion helps with pain

• change linens/blue pads as necessary

what would be some things for nutrient and fluid intake?

• oral intake-encourage for energy source; may taper clear liquids to ice chips during second stage if aspiration or operative risk

• IV intake - typical 125 mL/hr (monitor for hypovolemia)

what would be some things we could do to help with elimination?

• voiding (encouraged every two hours) with assistance but may require bedpan/catheter 

what may impede advancement of catheterization?

fetus

is bowel elimination a normal part of labor while pushing?

yes

how could we promote comfort and contractions?

ambulation and positioning 

what position is preferred because it promotes optimal uteroplacental and renal blood flow and increases fetal oxygen saturation?

side-lying (lateral) position

what would be some supportive care during labor and birth?

nurses, father/partner, doulas, grandparents, and siblings

infant is born in the _____ stage of labor?

second 

second stage of labor begins with full _____ _____ (10 cm), complete _____ (100%), and ends with baby’s _____

cervical dilation; effacement; birth

what are the two phases of the second stage of labor?

latent phase and active pushing phase

what occurs during the latent phase?

• relatively calm 

• mom often rests 

what occurs during the active pushing phase?

• urge to bear down

• pants during contractions and pushes between

when preparing for birth, is their a single ideal maternal position?

no

_____ promotes descent

gravity 

if an non-reassuring FHR pattern develops, how should we position mom?

on her side

how many phases are there of a spontaneous birth of a fetus in a vertex presentation?

3

what are the three phases of the spontaneous birth of a fetus in a vertex presentation?

1) birth of the head 

2) birth of the shoulders 

3) birth of the body and extremities 

what is going to be done to avoid soft-tissue damage?

an episiotomy

what is immediately done in the second stage of labor?

assessments and care of the newborn, skin-to-skin, delayed cord-clamping benefits, stabilization of newborn/mom, and APGARS at 1 and 5 minutes

what are the benefits of skin-to-skin?

• positively affects maternal-infant bonding, breastfeeding, cardiorespiratory stability, and body temperature

newborn blood glucose levels during the first 2 hours of life are higher or lower?

higher 

how many degrees of perineal lacerations are there?

4

what is a first degree perineal laceration?

confined to the skin

what is a second degree perineal laceration?

extends into the perineal body 

what is a third degree perineal laceration?

involves injury to the external anal sphincter muscle

what is a fourth degree perineal laceration?

extends completely through the anal sphincter and the rectal mucosa

vaginal and urethral lacerations can lead to?

• cervical injuries 

• urethral injuries 

• episiotomy 

what is an episiotomy?

an incision made in the perineum to enlarge the vaginal outlet

what does an episiotomy protect against?

soft-tissue damage

has the use for episiotomies inclined or declined?

declined 

delivery over intact _____ is best

perineum

an episiotomy is classified by site and direction, which site and direction is most common?

midline and mediolateral

what is the placental stage?

from birth of baby to expulsion of placenta 

what is the shortest stage of labor?

third stage of labor: placental stage; usually within 15 minutes

what is the goal of the third stage of labor: placental stage?

prompt separation and safe expulsion

what are some separation and expulsion signs?

• firmly contracting fundus

• change in shape of uterus

• sudden gush of dark blood from introitus

• apparent lengthening of umbilical cord

• vaginal fullness

*placenta is examined for intactness

*umbilical cord blood sample is obtained (baby’s blood type and Rh status)

what is the fourth stage of labor?

• initiates the immediate recovery/postpartum period 

• begins after the expulsion of the placenta and lasts until the woman is stable in the immediate postpartum period, usually within the first hour after birth

• lasts from 1 to 4 hours after birth 

• close monitoring of mother and newborn during this stage 

what are some nursing interventions for the fourth stage of labor?

• care of the new mother

• care of the family

• family and newborn relationships

• often a lot of reassurance needed