Labor, Birth, Comfort & Cesarean Birth; Chapters 14, 15, & 23

What are the multiple systems that converge when labor begins?

• Labor is a coordinated maternal–fetal process, not one single trigger.

• Uterine activation

  • Coordinated contractions create pressure that promotes cervical effacement and dilation.

• Cervical ripening

  • Collagen remodeling and increased water content soften and thin the cervix.

• Hormonal signaling

  • Oxytocin (also released in breastfeeding), prostaglandins, and maternal–fetal endocrine signals support labor readiness.

• Fetal contribution

  • Presentation, position, attitude, size, and descent influence how effectively the fetus moves through the pelvis.

• Teaching pearl: contractions matter because they produce cervical change— not simply because they are painful.

What are the 5 Ps framework for labor progress?

• When labor stalls, ask which factor is contributing → before you decide to do section want to see if you can change things to have vaginal

• Passenger: Fetal size, lie, presentation, attitude, position

  • Macrosomia: large baby; Large gestational age- LGA > 4,000 g, Small gestational age- SGA < 2,500 g

• Passageway: Pelvis + soft tissues of the birth canal

• Powers: Primary uterine contractions + secondary pushing → how strong are contractions & if pushing is not effective

• Position: Maternal movement and posture can facilitate descent

• Psyche: Fear, stress, support, and sense of control affect coping

• NCLEX move: identify the “P” you can modify before escalating to an invasive intervention

What are the terms for fetal position (how to decode)?

• L or R; Which side of the maternal pelvis?

  • L = left

  • R = right

• O; What fetal landmark?

  • O = occiput (vertex / cephalic presentation)

  • M= Mentum

  • S= Sacral

• A, P or T; Which direction in the maternal pelvis?

  • A = anterior; Anterior/pubic symphysis

  • P = posterior; Posterior/Sacrum

  • T = transverse; Side of pubic symphasis

• LOA

• Left Occiput Anterior

• ROP

• Right Occiput Posterior

• LOT

• Left Occiput Transverse

• OA / OP

• Direct anterior / posterior

• Think: SIDE → LANDMARK → DIRECTION

• Clinical pearl: OA positions usually align well for descent; persistent posterior/transverse positions can make labor progress more difficult.

• ROA; Right Occiput Anterior

ROT; Right Occiput Transverse

ROP; Right Occiput Posterior

LOA; Left Occiput Anterior

LOT; Left Occiput Transverse

LOP; Left Occiput Posterior

RMA- Right Mentum Anterior

RMP- Right Mentum Posterior

LMA- Left Mentum Anterior

LSA- Left Sacral Anterior

LSP- Left Sacral Posterior

What are the stages of labor; what changes and the sequence?

• Cervical change, descent, and placental separation mark the transitions.

• Support needs often increase as labor intensifies.

1st stage: Onset of true labor → 10 cm; Latent + active + transion

• True labor means there is dilation and efacement of the → active is defined as starting at 6cm

• Latent stage: 0-4 cm, contractions q 15-30 mins ~ 30-45 sec; can be long for first time Mom (mild)

  • Talkative, excited, able to follow conversation

  • Nursing response: Encourage rest, hydration, mobility, normalizing

• Active: 4-7 cm, contractions are q 3-5min; ~60 sec each (moderate-strong)

  • More focused inward, needs coaching, fewer words

  • Nursing response: One-step directions, position changes, pain plan, make sure bladder is empy so labor can progress, maybe intiate hyrotherapy at this point

• Transition / late active: 7-10 cm, q 2-3 min, 60-90 sec each (strong)

  • May say “I can’t,” tremble, feel pressure or nausea, may have urge to push (pressure on rectum)

  • Nursing response: Stay present, calm voice, assess progress, prepare for birth, teach to pant to avoid premature pushing

• Do not assume distress = request for medication. Ask what the patient wants and what feels manageable

• 2nd stage: 10 cm → birth; Pushing + descent

  • watch for turtle signs

  • encorage & moniter baby & mom

• 3rd stage: Birth → placenta; Placental separation

• 4th stage: Early recovery; Stabilization

• Clinical focus shifts across labor

  • 1st: assess progress + coping + fetal response

  • 2nd: support pushing, descent, fetal tolerance

  • 3rd: observe separation and blood loss

  • 4th: fundus, bleeding, pain, recovery, bonding → fundus should be firm, midline & moving down

• Blood loss: Vaginal delivery: average 260-350 mL, > 500 is considered hemorrhage

  • C-section: average 650-800ml, >1000 ml is considered hemorrhage

• Avoid rigid clocks. Use progress + clinical condition + current guidelines to guide action.

What is the definition of frequency, duration, intensity, resting tone in regards to contractions?

• Frequency: Beginning of one contraction to beginning of the next

• Duration: Beginning to end of the same contraction → how long did contraction last

• Intensity: Palpated as mild/moderate/strong or measured internally

• Resting tone: Uterus should relax between contractions → resting is need for both Mom and baby so baby can be properly perfused

• Watch the trend: stronger, longer, and closer contractions usually accompany labor progression.

What is included in admission assessment of labor to establish maternal and fetal baseline?

• Maternal

  • Vital signs

  • Pain + coping

  • Contraction pattern

  • Membrane status / fluid

    • Meconium means baby's stool is in amniotic sac which usally means baby is in distress → baby can swolly feces & that will cause issues so would either see if delivery is possible or a amnioinfulsion to thin the meconium

    • Fluid should be clear and it should not have a oder otherwise that can indicate infection

  • Bleeding

  • Hydration / bladder

  • Support person + birth preferences

• Fetal

  • Baseline heart rate

  • Variability

  • Accelerations / decelerations

  • Movement

  • Presentation / position

  • Response to contractions

• Labor progress

  • Cervical dilation: widning of the cervix to accommodate for babies head

  • Effacement: thinning and shortning of cervix

  • Station: desent of head in relation to pelvid

  • Presentation: the positioning of baby

  • Membrane status: intact or ruptures sac

  • Trend over time:

• Red flags: heavy bleeding • severe pain between contractions • abnormal FHR • fever • hypertensive symptoms • cord prolapse concerns

How is fetal heart rate assessed?

• Baseline + variability + accelerations + decelerations.

• Baseline: What is the average rate over a 10-minute window? (want it at ~110-160)

• Variability: How much beat-to-beat fluctuation is present?

• Accelerations: Are there reassuring increases in rate?

• Decelerations: When do they occur relative to contractions?- Dont want late decel or variable decels

• Interpret the tracing in context: contraction pattern + gestational age + medications + maternal condition.

VEAL CHOP

• Variable deceleration; Cord compression

• Early deceleration; Head compression

• Accelerations; Ok

• Late deceleration; Placental insufficiency

What are the types of decelerations?

• Timing relative to the contraction helps guide the first response.

• Early

  • Mirrors the contraction.

  • Common interpretation: fetal head compression.

  • Usually benign when otherwise reassuring.

• Variable

  • Abrupt drop; timing varies.

  • Common interpretation: umbilical cord compression.

  • Reposition and assess severity / recurrence. → to all fours or knee to chest to move baby away from cord

• Late

  • Begins after contraction starts; nadir after peak.

  • Something from Mom affecting baby; like low bp, dehydration, too many contractions etc.

  • Concern: uteroplacental insufficiency.

  • Requires prompt intrauterine resuscitative measures and escalation.

    • Give O2 to Mom, fluids, deal with underlying cause

• First nurse move with a concerning pattern: reposition, assess maternal status, reduce reversible stressors, notify/escalate per protocol.

What are the different types of pain in each stage of labor?

• The source of pain shifts from visceral to somatic as birth approaches.

• First stage: visceral pain

  • Cervical dilation and uterine ischemia create diffuse pain, often felt in the lower abdomen, back, or thighs.

• Second stage: somatic pain

  • Stretching and pressure on pelvic floor, vagina, and perineum create more localized, intense pain.

• Pain ≠ suffering. Coping depends on expectations, support, fear, fatigue, culture, previous experiences, and sense of control

What are some nonpharmacologic comfort measures?

• Many strategies increase control and can be combined with medications.

• Movement: Walking, upright positions, pelvic rocking

• Breathing: Focused breathing, rhythm, vocalization

• Touch: Massage, counterpressure, sacral pressure

• Water: Shower or tub when clinically appropriate

  • some reserch says that birthing baby in water can be less shocking for baby

• Environment: Dim light, music, fewer interruptions

• Support: Continuous presence, partner/doula coaching

• Nursing skill: offer options without overwhelming the patient. One strategy at a time, then reassess.

What are some pharmacologic comfort measures?

• Consider timing, goals, contraindications, and maternal/fetal effects.

• Systemic opioids: IV/IM medication can reduce pain perception.

  • Watch: sedation, respiratory depression, neonatal effects depending on timing.

• Nitrous oxide: Self-administered inhaled analgesia/anxiolysis in some birth settings.

  • Watch: dizziness, nausea, safe administration.

• Neuraxial analgesia: Epidural or combined spinal-epidural provides strong pain relief while patient remains awake.

  • Watch: hypotension, motor block, urinary retention.

  • Hypotension is biggest risk of epidural would give fluids or epi if needed

• Informed choice matters: discuss benefits, limits, expected sensations, and what monitoring will change.

What is nursing care through process of epidural?

• Anticipate hemodynamic changes and protect maternal–fetal perfusion.

• Before

  • Baseline vitals + FHR

  • IV access / fluids per protocol → if platlet low may not give epidural

  • Review labs / contraindications

  • Empty bladder if possible

• After

  • Frequent BP + FHR

  • Assess sensory/motor block

  • Fall precautions

  • Position to avoid aortocaval compression

  • Can get spinal headache bc of leakage of fluid

• If hypotension occurs

  • Reposition laterally

  • increase IV fluids per protocol

  • notify anesthesia/provider

  • vasopressor per order/protocol

  • assess fetal response

• Key connection: maternal blood pressure directly affects uteroplacental perfusion.