Nursing Care of the Family During Labor + Birth

1. Passageway

The passageway refers to the birth canal, which encompasses both the bony pelvis (pelvic inlet, midpelvis, and pelvic outlet) and the soft tissues of the cervix, vagina, and pelvic floor. The adequacy of the passageway is crucial for the fetus to descend and exit.

2. Passenger

The passenger primarily refers to the fetus and the placenta. Key aspects of the passenger that influence labor and birth include:

• Size: The overall size of the fetus.
• Presentation: The part of the fetus lying closest to the maternal cervix.
• Attitude: The relationship of the fetal body parts to one another (e.g., flexion, extension).
• Position: The relationship of the presenting part to the mother's pelvis.
• Lie: The relationship of the long axis of the fetus to the long axis of the mother (longitudinal, transverse, oblique).

3. Powers

The powers are the forces that expel the fetus and placenta from the uterus. These include:

• Uterine Contractions: Involuntary contractions of the uterine muscles, which are responsible for effacement (thinning) and dilation (opening) of the cervix.
• Maternal Pushing Efforts: Voluntary efforts by the mother during the second stage of labor to push the fetus through the birth canal.

4. Position

Position, in this context, refers to the maternal position during labor and birth. Optimal maternal positioning can influence the progress of labor by:

• Utilizing gravity to aid fetal descent.
• Improving maternal comfort and reducing fatigue.
• Enhancing uterine blood flow and overall maternal-fetal well-being.
• Facilitating cervical dilation and fetal rotation.

5. Psyche

The psyche relates to the mother's psychological state and emotional readiness for labor and birth. This includes:

• Emotional Readiness: Her feelings, fears, and anxieties about labor.
• Previous Experiences: Prior birth experiences.
• Support System: The presence and quality of emotional support from partners, family, or healthcare providers.
• Coping Mechanisms: Her ability to cope with pain and stress during labor.
  A positive mental and emotional state can significantly impact the physiological process of labor.

Cephalic Presentation

The most common and ideal fetal presentation where the fetal head is positioned to enter the birth canal first. The fetal head is usually well-flexed, offering the smallest diameter to the pelvis.

Vertex Presentation

A specific type of cephalic presentation where the fetal head is fully flexed, with the chin tucked to the chest, and the occiput (posterior part of the skull) is the presenting part. This is the most favorable presentation for vaginal delivery.

Breech Presentation

A fetal presentation where the buttocks, feet, or both are positioned to enter the mother's pelvis first. This presentation is associated with higher risks and often leads to a Cesarean section.

Frank Breech Presentation

A type of breech presentation where the fetal buttocks present first, with both hips flexed and both knees extended (the legs are straight up towards the head).

Shoulder Presentation (Transverse Lie)

A fetal presentation where the fetus lies horizontally across the mother's abdomen, with the shoulder as the presenting part. This is incompatible with vaginal birth and almost always requires a Cesarean section.

Engagement

When the widest part of the fetal head (biparietal diameter) enters the pelvic inlet.

Descent

The continuous downward movement of the fetus through the pelvis.

Flexion

The fetal head flexes, bringing the chin closer to the chest, presenting the smallest diameter of the head to the pelvis.

Internal Rotation

The fetal head rotates to align its longest diameter with the longest diameter of the mother's pelvis, usually from a transverse to an anteroposterior position.

Extension

The fetal head extends as it passes under the symphysis pubis, allowing the crown, brow, and face to emerge.

External Rotation (Restitution)

After the head is born, it rotates back to align with the shoulders, which are rotating internally to fit through the pelvis.

Fetal Dystocia

Fetal dystocia refers to difficult labor due to issues with the fetus, such as excessive fetal size (macrosomia), abnormal presentation (e.g., breech, transverse lie), or fetal anomalies, which can impede its passage through the birth canal.

Failure of Fetal Rotation or Incomplete Rotation

This occurs when the fetal head does not rotate adequately from a transverse to an anteroposterior position during internal rotation, or when it rotates to an unfavorable position (e.g., persistent occiput posterior, or OP). This can delay labor progression and necessitate interventions.

Nursing Care:

• Maternal Repositioning: Encourage frequent changes in maternal position (e.g., hands and knees, side-lying, lunges, birthing ball rocking) to utilize gravity and pelvic space to facilitate fetal rotation.
• Ambulation: If appropriate and safe, encourage the mother to walk to promote descent and rotation.
• Hydration and Comfort: Ensure adequate hydration and provide comfort measures to manage pain and fatigue during prolonged labor.
• Monitoring: Continuously monitor fetal heart rate and contraction patterns to assess fetal well-being and labor progress.
• Emotional Support: Provide ongoing emotional support and reassurance to the mother and her partner, as prolonged or difficult labor can be emotionally taxing.
• Prepare for Interventions: Anticipate and prepare for potential medical interventions such as manual rotation by a physician, vacuum extraction, forceps delivery, or Cesarean section if rotation does not occur and labor stalls or fetal distress develops.
• Education: Explain the situation to the mother and her partner, discussing the reasons for interventions and what to expect.

Face Presentation

A type of cephalic malpresentation where the fetal head is hyperextended, causing the face to be the presenting part. The chin (mentum) is often the landmark. Vaginal delivery is possible if the chin is anterior (mentum anterior), but if posterior (mentum posterior), it often requires a Cesarean section.

Nursing Care:

• Continuous Fetal Monitoring: Monitor for signs of distress due to pressure on the face/neck.
• Assess for Molding and Bruising: Evaluate for fetal head molding, facial bruising, or edema.
• Monitor Labor Progression: Closely observe labor as these presentations can lead to prolongation.
• Prepare for Interventions: Anticipate potential Cesarean section, especially with mentum posterior.
• Emotional Support: Provide ongoing emotional support due to potentially challenging or prolonged labor.
• Avoid Harmful Interventions: Refrain from unnecessary internal monitoring or procedures that could injure the fetal face/eyes.

Brow Presentation

A type of cephalic malpresentation where the fetal head is partially extended, with the brow (forehead) presenting to the maternal pelvis. This presents the largest fetal head diameter, making vaginal delivery very difficult or impossible. It often converts to a face or vertex presentation during labor, or requires a Cesarean section.

Nursing Care:

• Continuous Fetal Monitoring: Monitor for signs of distress.
• Assess for Molding: Evaluate for fetal head molding.
• Monitor Labor Progression: Closely observe labor; anticipate prolonged or arrested labor.
• Prepare for Interventions: Prepare for a high likelihood of a Cesarean section.
• Emotional Support: Provide emotional support and explain the situation to the family.
• Avoid Manipulation: Avoid cervical exams that attempt to manually change the presentation to prevent worsening extension.
• Comfort Measures: Ensure hydration and provide comfort measures for prolonged labor.

Breech Presentation

A fetal presentation where the buttocks, feet, or both are positioned to enter the mother's pelvis first. This presentation is associated with higher risks for both mother and fetus, including cord prolapse, head entrapment, and birth trauma. It often leads to a Cesarean section, though some types may be considered for vaginal delivery under strict criteria. Frank breech (hips flexed, knees extended) and complete breech (hips and knees flexed) are common types.

Nursing Care:

• Confirm Diagnosis: Verify presentation using Leopold's maneuvers and ultrasound.
• Continuous Fetal Monitoring: Monitor fetal heart rate closely due to increased risk of umbilical cord compression or prolapse.
• Monitor Labor Progression: Assess for prolonged or arrested labor.
• Prepare for ECV: If indicated and not contraindicated, prepare for potential external cephalic version (ECV).
• Prepare for Cesarean Section: This is the most common delivery method; prepare the mother for surgery.
• Skilled Personnel for Vaginal Birth: If vaginal breech birth is attempted, ensure immediate availability of experienced personnel.
• Education and Support: Provide thorough education and emotional support regarding risks and delivery options.
• Monitor for Meconium: Assess for meconium-stained amniotic fluid.

Shoulder Presentation (Transverse Lie)

A fetal presentation where the fetus lies horizontally across the mother's abdomen, with the shoulder as the presenting part. The long axis of the fetus is perpendicular to the long axis of the mother. This is incompatible with vaginal birth and almost always requires a Cesarean section, with attempts at vaginal delivery posing high risks such as uterine rupture or cord prolapse.

Nursing Care:

• Confirm Diagnosis: Verify presentation using Leopold's maneuvers and ultrasound.
• Prepare for Cesarean Section: Prepare for immediate Cesarean section as vaginal delivery is impossible.
• Continuous Fetal Monitoring: Monitor fetal heart rate closely for any signs of distress.
• NPO Status: Ensure NPO status in anticipation of surgery.
• Education and Support: Provide clear explanations and emotional support regarding the necessity of a Cesarean section.
• Assess for Complications: Assess for associated complications such as placenta previa or preterm labor.

External Cephalic Version (ECV)

A procedure to manually turn a fetus from an abnormal presentation (e.g., breech) to a cephalic (head-down) presentation by external abdominal pressure, typically after 36-37 weeks to facilitate vaginal birth.

Nursing Care:

• Patient Education: Explain procedure, risks, and benefits.
• NPO Status: NPO for potential emergency C-section.
• Monitoring: Continuous fetal heart rate (FHR) and maternal vital signs (BP) monitoring before, during, and after.
• Ultrasound: Use for guidance and monitoring fetal position/well-being.
• Medications: Administer tocolytics (e.g., terbutaline) to relax the uterus; administer Rho(D) immune globulin (RhoGAM) for Rh- mothers post-procedure.
• Post-Procedure: Monitor for complications (contractions, pain, FHR changes) for 30-60 minutes.
• Discharge Teaching: Educate on signs of labor or complications to watch for.

Hypertonic Uterine Dysfunction

Hypertonic uterine dysfunction is characterized by frequent contractions with decreased intensity and increased uterine tone, leading to little cervical changes. This condition can cause prolonged labor, significant pain, and maternal fatigue. Treatment typically involves sedation, adequate hydration, and measures to promote relaxation.

Hypotonic Uterine Dysfunction

Hypotonic uterine dysfunction is characterized by infrequent contractions with decreased intensity, commonly occurring in the active phase of labor. Treatment involves augmentation of labor, often through the administration of oxytocics.

Precipitous Labor

Precipitous labor is characterized by rapid labor and birth, usually occurring within 3 hours from the onset of regular uterine contractions to the delivery of the baby.

Risks:

• Maternal Risks:
  • Uterine rupture
  • Lacerations of the cervix, vagina, or perineum
  • Postpartum hemorrhage
  • Amniotic fluid embolism
• Fetal Risks:
  • Fetal hypoxia (due to intense, frequent contractions and reduced uterine blood flow)
  • Intracranial hemorrhage (due to rapid compression and decompression of the fetal head)
  • Birth trauma (e.g., fractures, nerve damage)
  • Meconium aspiration

Nursing Care:

• Continuous Monitoring: Frequently monitor fetal heart rate (FHR) and maternal contraction patterns to assess fetal well-being and labor progression.
• Stay with Client: Do not leave the client unattended; anticipate rapid progression and delivery.
• Prepare for Delivery: Quickly gather necessary supplies for birth and notify the healthcare provider of rapid labor progression.
• Maternal Positioning: Encourage the mother to lie in a side-lying position to help slow labor, reduce the intensity of contractions, and promote uterine blood flow.
• Controlled Delivery: If delivery occurs before the provider arrives, apply gentle counter-pressure to the fetal head to control the expulsion and prevent maternal perineal trauma.
• Emotional Support: Provide continuous emotional support and reassurance to the mother, as the rapid pace of labor can be frightening and overwhelming.
• Post-Delivery Assessment: After birth, vigilantly assess the mother for signs of postpartum hemorrhage, uterine atony, and lacerations. Monitor the neonate for signs of trauma, hypoxia, or meconium aspiration.

According to the Bishop Score, what cervical position earns 0 points?

Posterior

According to the Bishop Score, what cervical position earns 1 point?

Intermediate

According to the Bishop Score, what cervical position earns 2 points?

Anterior

According to the Bishop Score, what cervical consistency earns 0 points?

Firm

According to the Bishop Score, what cervical consistency earns 1 point?

Intermediate

According to the Bishop Score, what cervical consistency earns 2 points?

Soft

According to the Bishop Score, what range of effacement earns 0 points?

0-30\%

According to the Bishop Score, what range of effacement earns 1 point?

31-50\%

According to the Bishop Score, what range of effacement earns 2 points?

51-80\%

According to the Bishop Score, what range of effacement earns 3 points?

>80\%

According to the Bishop Score, what cervical dilation earns 0 points?

0 cm

According to the Bishop Score, what cervical dilation earns 1 point?

1-2 cm

According to the Bishop Score, what cervical dilation earns 2 points?

3-4 cm

According to the Bishop Score, what cervical dilation earns 3 points?

>5 cm

According to the Bishop Score, what fetal station earns 0 points?

-3

According to the Bishop Score, what fetal station earns 1 point?

-2

According to the Bishop Score, what fetal station earns 2 points?

-1, 0

According to the Bishop Score, what fetal station earns 3 points?

+1, +2

Define induction

Initiating labor artificially

Define augmentation

Strengthening labor that began spontaneously but is ineffective