Maternal-Newborn Nursing: Labor and Birth Study Notes

DAVIS ADVANTAGE for Maternal-Newborn Nursing

Critical Components of Nursing Care

FOURTH EDITION

Authors: Durham Chapman • Miller

F.A. DAVIS

Chapter 8: Labor and Birth

Authors: Roberta F. Durham, RN, PhD; Liujing Chen, RN, BSN

Learning Outcomes

• Describe the four stages of labor and the related nursing and medical care.
• Demonstrate understanding of supportive care of the laboring woman.
• Identify the five P’s of labor.
• Describe the mechanism of spontaneous vaginal delivery and related nursing care.

Introduction

• Intrapartum period, also known as labor:
  • Begins with the onset of uterine contractions (UCs) and lasts until expulsion of the placenta.
• Three stages of labor:
  • Dilation and effacement
  • Expulsion of the fetus
  • Expulsion of the placenta

Intrapartum/Childbirth Process

• Factors affecting labor and delivery:
  • Exact cause is not completely understood.
  • May be caused by an inflammatory process.
• Progression of labor and delivery
• The immediate postpartum period
• Nursing care

Labor Triggers

Maternal Factors:

• Pressure on the cervix.
• Estrogen increases.
• Progesterone is withdrawn to allow estrogen to stimulate contractions.
• Oxytocin stimulates uterine contractions.

Fetal Factors:

• The placenta deteriorates as it ages, triggering contractions.
• Prostaglandins.
• Rising fetal cortisol helps uterine contractions.

Signs of Impending Labor

• Lightening: Engagement; fetus descends into pelvic inlet, making breathing easier.
• Braxton-Hicks: Irregular and intermittent contractions that may increase in frequency and discomfort, do not result in cervical change.
• Cervical Changes: Cervix becomes soft and partially effaced.
• Nesting: Burst of energy before labor.
• Weight Loss: 1 to 3 pounds may occur alongside low backache and bloody show.

Factors Affecting Labor

The Five P's of Labor:

1. Powers (Contractions):

   • Contractions are responsible for dilation and effacement.
   • Phases of contractions:
     • Increment: Building up; longest phase.
     • Acme: Peak or strongest phase.
     • Decrement: Letting up phase.
   • Frequency: Time from the beginning of one contraction to the next.
   • Duration: Time from beginning to end of a single contraction.
   • Intensity: Strength of contraction at its acme (graded as mild, moderate, strong).
   • Resting tone: Pressure in the uterus between contractions.

2. Effacement:

   • Progressive thinning of the cervix (0-100%).

3. Dilation:

   • Opening of cervical os to permit fetus through (0-10 cm).

4. Descent:

   • Progression of the fetus through the maternal pelvis.

5. Passage:

   • Pelvis and birth canal:
     • Types of Bony Pelvis:
     • Gynecoid, Android, Anthropoid, Platypelloid.
     • The bony pelvis is divided into False Pelvis and True Pelvis.
     • Soft Tissue: The cervix.
     • Station: Relationship of ischial spines to the presenting part of the fetus.

Implications of Pelvic Type for Labor and Birth

Characteristics of Pelvic Types:

• Gynecoid:

  • Inlet: Rounded with all inlet diameters adequate.
  • Midpelvis: Adequate with parallel side walls.
  • Outlet: Adequate.
  • Implications for Birth: Favorable for vaginal birth.

• Android:

  • Inlet: Heart-shaped with short posterior sagittal diameter.
  • Midpelvis: Reduced diameters.
  • Outlet: Reduced capacity.
  • Implications for Birth: Not favorable for vaginal birth, descent is slow, fetal head may have arrest during labor.

• Anthropoid:

  • Inlet: Oval in shape, long anteroposterior diameter.
  • Midpelvis: Adequate diameters.
  • Outlet: Adequate.
  • Implications for Birth: Favorable for vaginal birth.

• Platypelloid:

  • Inlet: Oval in shape, long transverse diameters.
  • Midpelvis: Reduced diameters.
  • Outlet: Inadequate capacity.
  • Implications for Birth: Not favorable for vaginal birth, fetal head may engage in a transverse position leading to difficult delivery.

Factors Affecting Labor (Continued)

Passenger (Fetus):

• Fetal Head: The largest portion to come through the birth canal.
• Molding: The ability of the fetal head to change shape for successful passage.
• Sutures: Used to identify the positioning of the fetus.

Key Terms in Fetal Positioning:

• Attitude: Relationship of fetal parts to each other, typically with head flexed forward.
• Lie: Relationship of the fetal spine to the maternal spine (longitudinal, transverse).
• Presentation: Body part entering pelvis first (cephalic, breech, shoulder).
• Presenting Part: The specific fetal structure nearest to the cervix.

Factors Affecting Labor (Continued)

Additional Passenger Factors:

• Position:
  • Presenting part in relation to back, front, or sides of maternal pelvis.
  • Examples: LOA (Left Occiput Anterior), ROP (Right Occiput Posterior).

Factors Affecting Labor (Continued)

Psyche: (Response of the Woman)

• Culturally Sensitive Patient-Centered Care:
  • Patient's cultural background influences their labor experience.
  • Inquire about cultural and religious values, beliefs, and practices.
  • Tailor care to respect cultural preferences and enhance equity in care.

Position:

• Frequent position changes during labor enhance maternal comfort and optimize fetal positioning.
• Recommendations for optimal labor positions include sitting, standing, walking, and utilizing birthing balls.

Nursing Care

• Support in Labor:
  • Create an equitable birthing environment.
  • Include the patient in shared decision-making for the care plan.
• Acknowledgment of Cultural Experiences:
  • Respecting diverse backgrounds helps meet individual patient needs.

Caring for Diverse Patient Populations

Transgender Patients:

• Gender-Affirming Care: Tailoring care to experience appropriately.

Birth Plans for Adoptive Parents:

• Considerations During Labor: Include details regarding the labor support role of adoptive parents.

Adolescent Mothers:

• Foster nonjudgmental, supportive communication throughout labor.

Onset of Labor

True Labor vs. False Labor:

NCLEX Question: Triage Assessment

• Clinical Scenario: 24-year-old G1P0 patient in triage for assessment. Contractions recorded every 5 to 9 minutes.
  • Sterile Vaginal Exam (SVE): 3 cm dilation, 60% effaced, -1 station, ROA.
• Ongoing Monitoring: Patient encouraged to ambulate, external monitors are utilized.
• VS: BP 131/72, P 102, RR 26, T 100.1°F.
  • Pain assessment: 10/10 during contractions, 1/10 between.

Stages of Labor

1. First Stage: Onset of labor to complete cervical dilation.
2. Second Stage: Complete dilation to delivery of the baby.
3. Third Stage: Delivery of the baby to delivery of the placenta.
4. Fourth Stage: Immediate postpartum period.
5. Process and Interventions: Focus on promoting normal physiological birth.

Phases of the First Stage of Labor

1. Early/Latent Phase:

   • 0-4 cm dilated, 0-40% effaced.
   • Mild contractions every 5-10 minutes.

2. Active Phase:

   • 6 cm to complete, 40-80% effaced.
   • More intense contractions every 2-5 minutes.

3. Transition Phase:

   • 8-10 cm dilated, 100% effaced.
   • Intense contractions every 1-2 minutes.

Nursing Interventions During the First Stage

Sterile Vaginal Exam (SVE) Includes:

• Cervical dilation, cervical effacement, position of cervix, station, presentation, fetal position.

Leopold’s Maneuvers:

• First Maneuver: Determine the presenting part in the fundus.
• Second Maneuver: Assess location of the fetal back.
• Third Maneuver: Identify the presenting part.
• Fourth Maneuver: Identify location of cephalic prominence.

Question: The First Stage of Labor

• Includes: Latent phase, Active phase, Transition phase, All of the above.
  • Correct Answer: D. All of the above.

Second Stage of Labor

• Begins with complete dilation (10 cm) and ends with the baby’s birth.
• Urge to Push: Feels similar to bowel movement.
• Cardinal Movements of Labor:
  • Engagement, descent, flexion, internal rotation, extension, external rotation, expulsion.

Nursing Actions During the Second Stage

• Encourage focused pushing, rest when possible, supportive measures (e.g., leg support, ice chips, cooling techniques, verbal encouragement, assist support person).

Third Stage of Labor

Delivery of the Placenta

• Duration typically ranges from 1 to 20 minutes post delivery of baby.
• Signs of Placenta Delivery:
  • Upward rising of the uterus into a rounded shape.
  • Lengthening of the umbilical cord.
  • Sudden gush of blood from vagina.

Fourth Stage of Labor

Care and Interventions

• Preventing postpartum hemorrhage:
  • Administer uterotonics: Oxytocin (Pitocin), Methylergonovine (Methergine), Carboprost (Hemabate), Misoprostol (Cytotec).
• Nursing assessment focuses on stabilization post-delivery (4 hours).

Newborn Care

• Initial Care: The golden hour of newborn-family attachment starts during the first 60 minutes after birth.
• Infants should ideally remain on the birthing parent’s chest if physiologically safe.
• Apgar Scores: Assess newborn at 1 and 5 minutes after birth, helpful for evaluating newborn's response to resuscitation.

Newborn Apgar Score:

Managing Pain During Delivery

Cultural Influences:

• Patient’s communication style may vary from stoic to emotive; care should bridge cultural divides.

Nonpharmacological Management Techniques:

• Relaxation and breathing techniques, thermal stimulation, mental stimulation (focal points), support person presence, aromatherapy, massage, birthing balls, hydrotherapy, and music.

Pharmacological Management:

• Objective of Analgesia During Labor: Provide maximum pain relief with minimum risk to mother and baby.
  • Informed choice confirmation, Maternal vital signs status, No contraindications, and appropriate fetal heart rate status.

Analgesics for Labor Pain Relief:

• Common Medications:
  • Morphine Sulfate
  • Butorphanol tartrate (Stadol)
  • Nalbuphine hydrochloride (Nubain) - Note: Should not be used if the mother is opiate-dependent.
  • Sublimaze (Fentanyl)

Nitrous Oxide as Anesthesia Option:

• Limited use in the US (50% nitrous oxide/50% oxygen).
• Provides quick relief, dissipates quickly (acting in about 50 seconds).
• Gives woman control over use; easy to administer; does not affect fetal heart rate or maternal blood pressure.
• Side effects include dizziness and nausea.

Anesthesia During Labor

Regional Anesthesia:

• Epidural: A combination of opioids and low-dose anesthetics into the epidural space for labor pain relief.

Nursing Care with Epidural:

• Vital signs monitoring, FHR assessment, effectiveness evaluation, nausea/vomiting monitoring, bladder distention assessments, protection of lower extremities from injury.

NCLEX Question: Analgesics Used During Labor

• Options Include:
  • Morphine sulfate, Butorphanol, Sublimaze, All of the above.
  • Correct Answer: D. All of the above.

Case Study Assessment Highlight

• Clinical Scenario Summary: 38-week pregnant woman in labor with contractions every 2-3 minutes. Include vital signs, assessments, and interventions during her care throughout labor.

NCLEX Questions on Labor Signs

• True/False statements assessing knowledge about labor indications, understanding signs of labor, and nurse's role in assessment.

Summary

• Key Topics Covered:
  • Stages of labor
  • The five P’s of labor
  • Nursing assessment, interventions, and the importance of providing patient-centered care in diverse populations.