Nursing: Stages of Labor and Maternity Care

Overview of Labor Stages and Progress

• Labor is defined as the delivery of the baby from the mother into the world.

• Full term is considered between $37 \times 42$ weeks. Labor occurring before $37$ weeks is classified as premature.

• The entire process typically spans $12-18$ hours, though this varies significantly between individuals.

The Four Stages of Labor

Stage One: Cervical Dilation and Phases

This stage begins with the onset of true labor contractions and ends when the cervix is fully dilated ($10\,cm$). It is typically the longest stage, lasting around $20$ hours for first-time mothers. It is divided into three distinct phases based on dilation and maternal behavior:

• Phase 1: Latent (Early) Phase

  • Cervical Status: $0-3\,cm$ dilated; $0-30\%$ effaced.

  • Clinical Presentation: The mother is often talkative, excited, and relaxed. Pain is generally manageable.

  • Contractions: Characterized as irregular, short, and far apart. Frequency is every $5-30$ minutes, with a duration of approximately $30$ seconds.

  • Physiology: Stretching of the cervix triggers the hypothalamus and posterior pituitary to release oxytocin, which stimulates uterine contractions.

  • Priority Interventions: Monitoring fetal heart rate (FHR) as the main indicator of fetal oxygenation. Assess for late decelerations.$ATI$ notes contractions may occur every $5-10$ minutes in this phase.

• Phase 2: Active Phase

  • Cervical Status: $4-7\,cm$ dilated.

  • Clinical Presentation: The mother becomes restless, anxious, and irritable. This is often when she seeks hospitalization. Breathing techniques and pain management are the primary focus.

  • Contractions: Stronger and longer. Frequency is $3-5$ minutes apart; duration is approximately $1$ minute.

  • Events: The amniotic sac may rupture (water breaking).

  • Pharmacology:

    • Epidural: Local anesthetic injected into the epidural space around spinal nerves to block contraction pain.

    • IV Narcotics: Must be administered slowly during the peak of contractions to reduce the amount crossing the placental barrier, thereby preventing fetal respiratory depression and sedation.

• Phase 3: Transition Phase

  • Cervical Status: $8-10\,cm$ dilated (10 cm is the "Perfect 10" or full dilation).

  • Clinical Presentation: Extreme anxiety, irritability, and "losing control." Verbatim verbalizations include "I can't do this," "I don't want to do this anymore," or "Get this baby out of me!"

  • Physical Symptoms: Nausea, vomiting, and a bloody show (thick bloody mucus).

  • Rectal Pressure: Mom may report a strong urge to have a bowel movement or an urge to push due to the baby descending into the pelvis and applying pressure.

  • Warning: Do not allow the patient to push until the cervix is at $10\,cm$ dilation to avoid cervical swelling and lacerations.

  • Priority Interventions: Provide emotional support and reassurance. Assess the color of amniotic fluid. Meconium-stained fluid (dark/green) indicates fetal distress or hypoxia and is a major aspiration risk.

Stage Two: Delivery of the Fetus

• Definition: From full dilation to the birth of the baby. Also known as the "pushing phase" or "descent phase."

• Requirements: Cervix must be $100\%$ effaced and $10\,cm$ dilated.

• Ferguson Reflex: The spontaneous, activated urge to bear down when the fetus reaches the pelvic floor.

• Nursing Interventions:

  • Positioning: High Fowler’s, lithotomy, or side-lying.

  • Pushing Education: Encourage the mother to push when she feels the urge, avoid holding her breath, and breathe out slowly through an open mouth to ensure oxygen reaches the fetus.

  • Assessments: Specifically monitor FHR before, during, and after contractions; monitor contraction frequency, duration, and uterine tone between contractions.

Stage Three: Delivery of the Placenta

• Definition: From the birth of the baby to the delivery of the placenta.

• Physiology: The uterus continues to contract, causing the placenta to detach from the wall.

• Intervention: Administer oxytocin ($Pitocin$) after delivery to help the uterus contract and prevent hemorrhage.

• Warning: Never pull on the umbilical cord. This can cause placental tearing or uterine inversion (the uterus flipping inside out), leading to severe hemorrhage and infection.

Stage Four: Recovery Period

• Definition: The period from placental delivery until the mother is stabilized ($2-4$ hours postpartum).

• Uterine Involution: The process of the uterus returning to its pre-pregnant size (approximately $1-2\,cm$ every $24$ hours).

• Goal: Prevent postpartum hemorrhage (PPH) and ensure stabilization.

Postpartum Assessment and Care

Fundal Assessment

• Normal Finding: The fundus should be firm, midline, and at the level of the umbilicus shortly after birth.

• Boggy Fundus: A soft, spongy uterus indicating poor contraction. Action: Perform firm fundal massage until the uterus is firm to stop bleeding.

• Displaced Fundus: If the fundus is deviated (usually to the right or left) and above the umbilicus, it typically indicates a full bladder. Action: Assist the client to void or use an in-and-out catheter, as a full bladder prevents the uterus from contracting.

Lochia Assessment (Normal Postpartum Discharge)

• Mnemonic: "Really Sore After" (Rubra, Serosa, Alba).

• Lochia Rubra: Bright red flow, occurs $0-4$ days postpartum. May contain small clots.

• Lochia Serosa: Pink-brown discharge, occurs $4-10$ days postpartum. Little to no clotting.

• Lochia Alba: Yellowish-white or creamy discharge, occurs $10-28$ days ($up to 6 weeks$) postpartum.

• Warning Signs:

  • Saturating a perineal pad in less than $15-60$ minutes (indicates hemorrhage).

  • Large clots (larger than a nickel or a plum).

  • Foul-smelling odor (indicates infection/endometritis).

Perineal and Supportive Care

• Cleaning: Use a squeeze bottle with warm water; wipe from front to back and blot dry.

• Pain/Swelling: Use ice packs for the first $24$ hours; SIDS baths; topical witch hazel for hemorrhoids and swelling.

• Pharmacology: Opioids, NSAIDs, and stool softeners/laxatives (to prevent straining and injury to the site).

True vs. False Labor and Cervical Changes

Cervical Terms

• Dilation: How wide the cervix is opening ($0-10\,cm$). Memory trick: "D for door is opening."

• Effacement: The thinning and shortening of the cervix ($0-100\%$). Memory trick: "E for elastic cervix."

  • Finger Measurements: Thick as a finger = $0\%$, to the middle knuckle = $50\%$, paper thin = $100\%$.

Comparison Table

• True Labor:

  • Contractions are regular/rhythmic and increase in frequency, duration, and intensity.

  • Contractions become stronger with walking.

  • Pain starts in the lower back and radiates to the abdomen.

  • Progressive cervical change (dilation/effacement) occurs.

• False Labor (Braxton Hicks):

  • Contractions are irregular.

  • Contractions decrease or disappear with walking, rest, or position changes.

  • No cervical changes occur.

Fetal Positioning and Back Labor

Occiput Posterior (OP) Position

• Mnemonic: "OP = Oh Poop!"

• Position: The back of the baby's head is against the mother's spine.

• Result: Intense back pain, slow labor progression, and "labor constipation."

• Interventions:

  • Apply sacral counter pressure during contractions.

  • Position mother on hands and knees or leaning over a birthing ball to promote fetal rotation.

  • Note: Left lateral position is good for oxygenation but will not alleviate back pain from OP positioning.

Signs of Pregnancy

• Presumptive (Subjective): Felt by the woman. Includes amenorrhea, nausea, vomiting, breast tenderness, and quickening (fetal movement felt by mom, which can be mistaken for gas).

• Probable (Objective): Observed by a provider.

  • Goodell’s Sign: Softened cervix.

  • Chadwick’s Sign: Bluish color of the vulva, vagina, and cervix.

  • Hegar’s Sign: Softening of the lower uterine segment.

  • Others: Positive pregnancy test (HCG), ballottement ("bouncy ball" movement).

• Positive (Definitive): Attributed only to the fetus.

  • Heard (fetal heart tones via Doppler).

  • Felt (fetal movement felt by examiner/ultrasound).

  • Seen (visualization on ultrasound).

Diagnostic Procedures in Pregnancy

Ultrasound

• Abdominal Ultrasound: Requires a full bladder to reflect sound waves effectively. Used after $10$ weeks.

• Transvaginal Ultrasound: No full bladder required. Used in early pregnancy ($before 10 weeks$) or to examine the cervix.

Genetic Testing

• Chorionic Villus Sampling (CVS): Performed between $10-13$ weeks. Samples placental tissue. Invasive with miscarriage risk. Rh-negative patients require $RhoGAM$.

• Amniocentesis: Performed between $15-18$ weeks. Needle aspiration of amniotic fluid under ultrasound guidance. Confirms genetic abnormalities or lung maturity. Risks include infection, rupture of membranes, and fetal injury. Rh-negative patients require $RhoGAM$.

Well-being Assessments

• Non-Stress Test (NST): Monitors FHR response to fetal movement.

  • Reactive: At least $2$ accelerations of at least $15\,bpm$ above baseline for at least $15$ seconds within a $20$-minute window. This is the desired outcome.

• Biophysical Profile (BPP): Uses NST and ultrasound to score 5 categories: FHR, fetal breathing, body movements, fetal tone, and amniotic fluid volume.

  • Scoring: $8-10$ is normal. Less than $8$ indicates fetal hypoxia.

• Contraction Stress Test (CST): Nipple stimulation or oxytocin infusion induces contractions to see how the baby responds.

  • Negative: No late decelerations (Good).

  • Positive: Late decelerations with at least $50\%$ of contractions (Bad; indicates placental insufficiency).

Fetal Heart Rate (FHR) Monitoring

Patterns and Interpretations

• Baseline: Normal is $110-160\,bpm$.

• Accelerations: Increase of at least $15\,bpm$ for $15$ seconds. Indicates fetal well-being/oxygenation (Okay).

• Early Decelerations: Uniform, mirror-image drops that sync with the peak of contractions. Caused by head compression (Okay).

• Late Decelerations: Drops that occur after the peak of the contraction. Caused by uteroplacental insufficiency. Intervention: LIONS (Left lying, IV fluids, Oxygen/Stop Pitocin, Notify provider, Surgery prep).

• Variable Decelerations: V-shaped, abrupt drops. Caused by umbilical cord compression. Intervention: Reposition (Trendelenburg or knee-chest), Oxygen, stop Oxytocin.

• Sinusoidal Pattern: Repetitive, wave-like fluctuations with no response to contractions. Critical finding indicating fetal anemia or blood loss. Requires an emergency crash C-section.

VEAL CHOP Mnemonic

• Variable = Cord Compression

• Early = Head Compression

• Accelerations = Okay (Oxygenated)

• Late = Placental Insufficiency

The 5 P's of Labor

1. Passageway: The birth canal (bony pelvis and soft tissues).

   • Pelvic Types: Gynecoid (Favorable/"Pumpkin"), Anthropoid (Favorable/"Human"), Android ("Alien"/Poor prognosis), Platypelloid ("Platypus"/Flat/Poor prognosis).

2. Passenger: The fetus and placenta. Considerations include fetal lie (parallel/transverse), attitude (flexion vs. extension), and station.

   • Fetal Station: Measured in relation to the ischial spines ($0$ station = engaged). Negative numbers are above the spines; positive numbers are below ("plus four on the floor").

3. Powers: Contractions. Measured by duration (start to end of one), frequency (start of one to start of next), and intensity.

4. Position: The maternal physical position (walking, squatting, birthing ball).

5. Psych: The mother's psychological state, stress, and anxiety. Support with clear information and comfort measures.

Fetal Positioning Abbreviation (e.g., LOA)

• First Letter: Left (L) or Right (R) of the mother's pelvis.

• Middle Letter: Presenting part (Occiput [O], Mentum [M], Sacrum [S], Scapula [Sc]).

• Third Letter: Location in the pelvis (Anterior [A], Posterior [P], Transverse [T]).

• Optimal Position: LOA (Left Occiput Anterior) is generally considered the best position for birth ("LOA is okay").

Medications for Labor ### Opiates - Use: Opiates are used for pain management during labor. They can help alleviate moderate to severe pain, providing comfort to the mother. - Side Effects: - Drowsiness - Nausea and vomiting - Constipation - Respiratory depression (especially in neonate) - Itching or rash - Adverse Effects: - Potential for addiction - Sedation of the mother may lead to the decreased ability to participate in labor and delivery.

Nalbuphine - Use: Nalbuphine is a mixed narcotic agonist-antagonist used for pain relief in labor. It helps in managing pain while presenting a lower risk for respiratory depression compared to pure agonists. - Side Effects: - Sedation - Dizziness - Nausea - Headache - Adverse Effects: - If administered too late in labor, it may cause respiratory depression in the newborn.

Epidural - Use: An epidural provides continuous pain relief during labor and delivery by injecting anesthetics into the epidural space. This method allows the mother to remain awake and alert during childbirth while significantly controlling pain. - Side Effects: - Drop in blood pressure - Headache if a dural puncture occurs - Difficulty urinating - Adverse Effects: - Epidural hematoma or infection at the injection site - Potential for adverse neurological effects if the epidural is improperly placed.

General Anesthesia - Use: General anesthesia is primarily used during emergencies or for cesarean sections when rapid onset of unconsciousness is required. - Side Effects: - Nausea and vomiting - Changes in blood pressure or heart rate - Throat irritation due to intubation - Adverse Effects: - Respiratory complications - Risk of aspiration - Potential for awareness during surgery in rare cases

Local Anesthesia - Use: Local anesthesia is often employed for perineal repairs after delivery; it numbs specific areas to relieve pain during minor surgical procedures. - Side Effects: - Local irritation at the injection site - Temporary numbness in surrounding areas - Adverse Effects: - Allergic reactions - Systemic absorption leading to cardiovascular or neurologic symptoms if overdosing occurs.

Three Category Interpretation System

Category I: Normal Fetal Heart Rate Monitoring

• FHR tracing includes all of the following:

  • Baseline FHR: 110-160 bpm

  • Moderate variability

  • Early decelerations present or absent

  • Accelerations present or absent

• Interventions:

  • No interventions required, but requires follow-up and continued surveillance.

Category II: Indeterminate Fetal Heart Rate Monitoring

• All tracing not applicable to Category I or III:

  • Abnormal baseline variability (minimal or absent variability)

  • Marked variability without recurrent decelerations

  • Recurrent late decelerations with moderate variability or intermittent late decelerations

  • Prolonged decelerations (15-120 seconds)

  • Variable decelerations with minimal or moderate variability

• Interventions:

  • Increase frequency of FHR monitoring.

  • Assess maternal position.

  • Administer IV fluids if warranted.

  • Consider oxygen supplementation.

  • Communicate findings to the healthcare team.

Category III: Abnormal Fetal Heart Rate Monitoring

• FHR tracing includes any of the following:

  • Absent baseline variability

  • Recurrent late decelerations

  • Recurrent variable decelerations

  • Sinusoidal pattern

• Interventions:

  • Change maternal position.

  • Administer IV fluids resuscitation.

  • Oxygen supplementation as indicated.

  • Stop oxytocin if being administered.

  • Possible emergent delivery may be indicated.

Leopold's Maneuver

• Purpose: Used to determine the position and presentation of the fetus in the uterus.
• Steps:
  • First Maneuver: The examiner locates the fetal fundus (top of the uterus) to determine which part of the fetus is at the top (head or buttocks).
  • Second Maneuver: The examiner palpates the sides of the mother's abdomen to assess the smoothness of the fetal back and the irregularity of the limbs.
  • Third Maneuver: The examiner grasps the lower part of the abdomen to determine if the presenting part is engaged in the pelvis or at the inlet.
  • Fourth Maneuver: The examiner moves their hands in an arc towards the pubic bone to assess the fetal position more precisely.

Doppler Placement for Fetal Heartbeat

• Location: The Doppler transducer should be placed on the mother's abdomen in the area where the fetal heart tones are best detected, typically over the fetal back.
• Tips: Identify the fetal position during Leopold's Maneuvers to locate the optimal spot for placing the Doppler for clear heart rate monitoring. It is often located in the quadrant where the smooth contour of the fetal back can be felt.
• Timing: Fetal heartbeat can often be detected as early as 10-12 weeks of gestation using a Doppler.