Chapters 14-16 Comprehensive Study Guide to the Stages of Labor and Intrapartum Complications

The Four Stages of Labor and Intrapartum Process

• Stage One: Onset of Regular Contractions to Full Dilation     * During Stage One, the cervix moves from the onset of regular contractions to full dilation and effacement.     * Latent Phase: This occurs from $0\,\text{to}\,6\,\text{cm}$ of dilation.         * Characteristics: Patients are typically able to talk, move around, and express excitement.         * Contractions: Often irregular, mild to moderate, occurring every $5\,\text{to}\,30\,\text{minutes}$, with a duration of $30\,\text{to}\,45\,\text{seconds}$.         * Nursing Care: Movement (ambulating), position changes, and comfort measures.     * Active Phase: This occurs from $6\,\text{to}\,8\,\text{cm}$ of dilation.         * Characteristics: Patients usually request an epidural during this phase.         * Contractions: More regular, moderate to strong, occurring every $3\,\text{to}\,5\,\text{minutes}$, with a duration of $40\,\text{to}\,70\,\text{seconds}$.         * Nursing Care: Closer monitoring and pain management; membranes are frequently ruptured here to progress labor.     * Transition Phase: This occurs from $8\,\text{to}\,10\,\text{cm}$ of dilation.         * Characteristics: This is a temporary but intense period where patients experience significant pain, lose focus, and require maximum support.         * Contractions: Very strong, occurring every $2\,\text{to}\,3\,\text{minutes}$, with a duration of $45\,\text{to}\,60\,\text{seconds}$.         * Nursing Intervention: Encourage "pant-pant-blow" breathing. It is critical to ensure the patient does not push during this stage to prevent cervical laceration and internal bleeding.

• Stage Two: Full Dilation to Birth of the Neonate     * This stage involves the period from complete dilation ($10\,\text{cm}$) to the expulsion of the baby from the body.     * Processes: Patients may "labor down" or begin active pushing.     * Contractions: Intense and frequent, occurring nearly every $1\,\text{to}\,2\,\text{minutes}$, often described as "back-to-back."     * Monitoring: Vital signs taken every $5\,\text{minutes}$ for the fetal heart strip (or every $15\,\text{minutes}$ if stable).     * Maternal Symptoms: Shaking may occur due to hormonal shifts, especially during rapid delivery.

• Stage Three: Delivery of the Placenta     * This stage begins the moment the baby is born and ends with the delivery of the placenta.     * Duration: Can take up to $30\,\text{minutes}$. The more preterm the mother is, the longer placental delivery usually takes.     * Warning: Never pull the placenta out, as this can cause the uterus to involute.

• Stage Four: Early Postpartum Recovery     * This stage covers the period from the delivery of the placenta through the first $2\,\text{hours}$ postpartum.     * Critical Monitoring: This is the highest-risk period for postpartum hemorrhage and hypovolemic shock.

Admissions Assessment and Cultural Considerations

• Admissions Process     * Includes collecting an admissions history, full assessment, and prenatal records.     * Determining the Birth Plan: Use of epidurals, pain medications, or preference for low/no intervention.     * Membrane Status: Determine if the patient has ruptured or if membranes are intact.     * Vaginal Exams: Avoid vaginal exams if there is any active bleeding.     * Fetal Heart Rate (FHR): Establish a baseline with at least a $20\,\text{to}\,30\,\text{minute}$ strip.     * Cervical Dilation: Checked to establish a baseline and differentiate between true labor and false labor (Braxton Hicks).

• Cultural and Spiritual Assessment     * Use open-ended questions to assess preferences. Cultural respect improves trust, cooperation, and pain management.     * Considerations: Requirement for a quiet labor environment, use of herbs, dietary alterations, preferred birthing positions (e.g., squatting vs. lying on the back), and presence of specific support people.

Intrapartum Nursing Interventions and Monitoring

• Leopold's Maneuver     * Used to determine fetal position and optimal placement of the FHR monitor.     * Breech Presentation: Monitor is placed above the umbilicus.     * Cephalic/Vertex Presentation: Monitor is placed below the umbilicus.

• Ongoing Assessments     * Vaginal Exams: Assess effacement, dilation, fetal station, and the presenting part (confirming it is the head).     * Rupture of Membranes: Can be confirmed via the Nitrazine test.     * Bladder Care: Encourage voiding every $2\,\text{hours}$, as a full bladder can inhibit cervical dilation.     * Temperature Monitoring: Checked frequently to detect infection, particularly after membranes have ruptured.

Perineal Lacerations and Cord Complications

• Perineal Lacerations (Degrees of Severity)     * First Degree: Extends through the skin of the perineum but does not involve muscle.     * Second Degree: Extends through the skin and muscles into the perineum, excluding the anal sphincter.     * Third Degree: Extends through the skin, muscle, perineum, and the external anal sphincter muscle.     * Fourth Degree: Extends through the skin, muscle, anal sphincter, and exterior rectal wall. Typically requires repair in the Operating Room (OR).

• Umbilical Cord Prolapse     * Occult Cord Prolapse: The cord lies along the presenting part but does not descend past it. It is not immediately dangerous but can cause fetal distress.     * Funic Presentation: The cord is positioned between the fetus and the cervix with intact membranes.     * Overt Prolapse: The cord slips past the presenting part into the cervical canal and vagina. This is a severe emergency that compromises fetal circulation, leading to hypoxia and brain damage.     * Interventions: Call for help (do not leave the patient). With a sterile gloved hand, manually elevate the fetal presenting part off the cord. Position the patient in knee-chest or Trendelenburg (if they have an epidural). Administer oxygen and fluids; prepare for emergent OR delivery. Never attempt to push the cord back into the uterus.

Complications in Labor: Meconium and Dystocia

• Meconium-Stained Fluid     * Appearance: Greenish, yellow, brown, or blackish fluid.     * Cause: Fetal hypoxia stimulates vagal activity and GI peristalsis, causing meconium passage in utero.     * Nursing Care: Suction the mouth first, then the nose (to prevent the baby from gasping and inhaling meconium upon first breath). Depressed newborns require ET (endotracheal) suctioning below the vocal cords.

• Labor Dystocia (Dysfunctional Labor)     * Related to the "Five P's": Power, Passenger, Psyche, Position, and Passageway.     * Hypertonic Uterus: More than $5\,\text{contractions}$ in a $10\,\text{minute}$ window. Characterized by uncoordinated contractions and lack of uterine relaxation. Management includes rest, hydration, lateral positioning, and analgesics; avoid oxytocin.     * Hypotonic Uterus: Weak contractions; often requires internal monitoring (IUPC) or oxytocin.

• Shoulder Dystocia     * Occurs when the baby's shoulder is stuck behind the pelvic bone. Risk of brain damage and brachial plexus injury.     * Interventions:         1. McRoberts Maneuver: Pull knees back toward the abdomen and ears to increase pelvic diameter.         2. Suprapubic Pressure: Downward pressure applied above the pubic bone with a fist to rotate the shoulder.         3. Gaskin Maneuver: Placing the patient on hands and knees.         4. Internal Rotations: Rubin or Wood's Corkscrew maneuvers.         5. Last Resorts: Clavicular fracture (intentional breaking of the baby's collarbone) or the Zavonelli Maneuver (pushing the baby back into the uterus for an emergency C-section).

• Precipitous Labor     * Labor lasting less than $3\,\text{hours}$. Risks include maternal tears, neonatal bruising, hemorrhage, and hypoxia.

Uterine Rupture and Amniotic Fluid Embolism (AFE)

• Uterine Rupture     * Complete: Full thickness tear through the uterine wall, peritoneum, and ligaments.     * Incomplete (Dehiscence): Muscle tears but peritoneum remains intact.     * Symptoms: Ripping/tearing sensation, sharp abdominal pain, cessation of contractions, change in uterine shape, loss of fetal station, and hypovolemic shock.     * Risk Factors: Previous C-section (TOLAC), polyhydramnios, macrosomia, oxytocin hyperstimulation, multiparity.

• Amniotic Fluid Embolism (AFE)     * Symptoms: Sudden chest pain, shortness of breath, cyanosis, hypotension, and Disseminated Intravascular Coagulation (DIC).     * Interventions: Call rapid response, stabilize ABCs (Airway, Breathing, Circulation), provide oxygen and fluids, and prepare for emergency C-section or hysterectomy.     * Case Example: A patient with AFE required a hysterectomy, esophagectomy, and removal of one ovary while needing CPR and a potential bedside C-section.

Labor Induction and Procedures

• External Cephalic Version (ECV)     * Rotation of a breech/transverse fetus via external manipulation under ultrasound guidance at $36\,\text{to}\,37\,\text{weeks}$.     * Requirements: Ultrasound, lubricating jelly, and RhoGAM for Rh-negative patients.     * Contraindications: Placenta previa, twins, or prior vertical C-section.

• Bishop Score     * Assesses readiness for induction based on five factors: Dilation, Effacement, Consistency, Position, and Station.

• Cervical Ripening and Induction Methods     * Mechanical: Balloon catheters and hygroscopic dilators (expand via fluid absorption).     * Chemical: Misoprostol (Cytotec) and Dinoprostone (Cervadil).     * Surgical: Membrane stripping (sweeping fingers to release hormones) or Amniotomy (Artificial Rupture of Membranes - AROM).     * Oxytocin (Pitocin): Titrated by $2\,\text{units}$ every $30\,\text{minutes}$ (max $20\,\text{units}$, or $10\,\text{units}$ for TOLAC). If hyperstimulation occurs (more than $5\,\text{contractions}$ in $10\,\text{minutes}$ or contractions lasting $>90\,\text{seconds}$), stop the pump and consider Terbutaline.

• Amnioinfusion     * The infusion of normal saline or LR via IUPC to resolve cord compression and variable decelerations.

Assisted Deliveries and C-Sections

• Operative Vaginal Birth     * Forceps or Vacuum (e.g., Kiwi vacuum).     * Rule: The Kiwi vacuum allows for only "three pop-offs"; after the third, the procedure must stop to prevent damage.     * Episiotomy: A surgical cut to the perineum to make space; currently discouraged unless fetal distress is present.

• Cesarean Section     * Incision Types:         * Low Transverse: Most common and safest; the only type that allows for a future TOLAC.         * Low Vertical/Classical: Higher risk; prohibits future trial of labor.     * TOLAC vs. VBAC:         * TOLAC: Trial of Labor After Cesarean.         * VBAC: Vaginal Birth After Cesarean (successful delivery).