CHAPTER 14 – Nursing Management During Labor & Birth: Comprehensive Bullet-Point Study Notes

Key Terminology Related to Fetal Heart Rate (FHR)

• Accelerations
  • Abrupt rises in FHR (≥ 15 bpm above baseline, lasting 15–30 s)
  • Signify adequate fetal oxygenation & intact autonomic pathway.

• Decelerations
  • Transient declines in FHR; classified as early, variable, late, prolonged.
  • Pattern & timing help differentiate head compression vs. cord compression vs. uteroplacental insufficiency.

• Baseline FHR
  • Mean FHR rounded to nearest 5 bpm over a 10-min window, excluding accelerations/ decelerations & marked variability. Normal = 110–160 bpm.

• Baseline Variability
  • Beat-to-beat fluctuations reflecting sympathetic / parasympathetic interplay.
  • Four categories (see “Variability & Category Table”).

• Artifact
  • Non-physiologic spikes or gaps produced by maternal movement, poor electrode contact, or electrical interference; can mask true FHR.

• Periodic Baseline Changes
  • Recurring accelerations or decelerations linked to uterine contractions.

• Electronic Fetal Monitoring (EFM)
  • Graphic, real-time tracing of FHR & uterine activity; may be external (ultrasound + tocotransducer) or internal (spiral scalp electrode + intrauterine pressure catheter).

Nursing Management of Laboring Patients

• Assessment – Continuous, systematic collection of maternal & fetal data (vitals, pain, FHR, contraction pattern).

• Comfort Measures – Positioning, touch, hydrotherapy, pharmacologic regimens.

• Emotional Support – Decreases catecholamine surge → better uterine perfusion & coping.

• Information & Instruction – Empowerment reduces anxiety; enables shared decision-making.

• Advocacy – Ensuring patient’s birth plan, cultural wishes, and safety are honored.

• Partner Support – Guides family member in providing care & maintaining own well-being.

Maternal Assessment During Labor & Birth

Initial / Ongoing Components

• Maternal Status
  • Vitals (BP, HR, RR, T) every 30–60 min in low-risk latent phase; pain scale 0–10 each encounter.
  • Review prenatal record: labs, GBS status, allergies.

• Vaginal Examination
  • Cervical dilation (cm), effacement (%), consistency, position.
  • Fetal station (-5 \text{ to } +5), presentation, and position.

• Membrane Status
  • Intact vs. ROM; note color, odor, amount; positive nitrazine/fern tests confirm rupture.

• Uterine Contractions
  • Frequency (minutes), duration (seconds), intensity (palpation or IUPC \text{mmHg}), resting tone.

• Leopold Maneuvers
  • Four systematic abdominal palpations; estimates fetal lie, presentation, and attitude; guides placement of external transducers.

Fetal Assessment During Labor & Birth

• Amniotic Fluid Analysis – Meconium-staining may signal hypoxia; bloody fluid → abruption suspicion.

• Fetal Heart Rate Monitoring
  • Intermittent Auscultation (IA): Doppler or Pinard; promotes mobility.
  • Continuous EFM: Provides detailed trend data; indicated for high-risk conditions (HTN, diabetes, oxytocin induction).

• Other Methods
  • Fetal scalp blood sampling (pH, lactate)
  • Fetal pulse oximetry (rare in U.S.)
  • Vibroacoustic or scalp stimulation → evokes accelerations.

Evidence-Based FHR Assessment Frequency

• On admission – Continuous tracing for first 10–20 min to establish baseline.

• Active First Stage
  • Low-risk: IA every 30 min
  • High-risk: IA every 15 min

• Second Stage
  • Low-risk: IA every 15 min
  • High-risk: IA every 5 min (Answer to Quiz #1 = a. Every 5 minutes)

Continuous Internal Fetal Monitoring

• Criteria

  1. ROM (amniotic sac ruptured)

  2. Cervix ≥ 2 cm dilated

  3. Presenting part low enough

  4. Skilled practitioner available.

• Advantages – Accurate beat-to-beat data, true uterine pressure & resting tone.

• Risks – Infection, scalp trauma, contraindicated with maternal HIV/HBV.

Variability & Category Table (Table 14.1)

• Baseline Variability
  • Absent: undetectable
  • Minimal: < 5 bpm • Moderate (normal): 6–25 bpm • Marked: > 25 bpm

• Three-Tier System
  • Category I (Normal) – Predicts normal acid-base; all of: baseline 110–160 bpm, moderate variability, no late/variable decels.
  • Category II (Indeterminate) – Everything not clearly I or III; needs surveillance (e.g., tachycardia > 160 bpm, minimal variability, prolonged decels >2 but <10 min).
  • Category III (Abnormal) – Predicts acidosis: recurrent late/variable decels with absent variability, bradycardia < 110 bpm, or sinusoidal pattern.

Interventions for Category III (Box 14.1)

• Notify provider & document.

• Discontinue uterotonics (e.g., oxytocin).

• Maternal repositioning (left/right lateral, knee-chest).

• \text{O}_2 @ 10 L non-rebreather.

• IV bolus (↑ intravascular volume).

• Correct hypotension (ephedrine, positioning).

• Modify pushing efforts.

• Prepare for prompt operative or cesarean birth if unresolved within 30 min.

Pain & Comfort Management

• Pain as Universal Yet Variable – Cultural, physiologic, psychosocial factors influence perception; mandates individualized assessment each encounter.

Non-Pharmacologic Measures

• Continuous labor support (doula) – ↓ analgesia, ↓ cesarean rates.

• Hydrotherapy – Warm water ↓ catecholamines → relaxation.

• Ambulation & Position Changes – Upright positions shorten first stage, relieve back pain.

• Acupuncture / Acupressure – ↑ endorphin release.

• Attention-focusing, imagery.

• Therapeutic touch, massage, effleurage.

• Patterned-paced breathing to promote relaxation & gate-control.

Pharmacologic Measures

Systemic Analgesia (Drug Guide 14.1)

• Opioids: butorphanol, nalbuphine, fentanyl, remifentanil (rapid onset, short half-life).

• Antiemetics: hydroxyzine, promethazine – potentiate opioid effect & reduce nausea.

• Benzodiazepines: diazepam, midazolam – anxiolysis; risk neonatal CNS depression.

• Administer IV in small, titrated doses at start of contraction to reduce fetal exposure.

Regional / Neuraxial Techniques

• Epidural Block – Continuous or PCA; begin when cervix > 5 cm.

• Combined Spinal-Epidural (CSE) “Walking Epidural.”

• Intrathecal (Spinal) Analgesia – Rapid pain relief, often for cesarean.

• Pudendal Block – Local anesthesia to pudendal nerve; perineal procedures.

• Local Infiltration – Lidocaine for episiotomy repair.

General Anesthesia

• Indications: emergent cesarean, contraindication to neuraxial.

• Sequence: thiopental (unconsciousness) → succinylcholine (muscle relaxant) → intubation → nitrous oxide 50% + \text{O}_2; volatile agent for amnesia.

First Stage of Labor

Phone Triage

• EDB, frequency of fetal movements, parity/gravida, contraction pattern, ROM status, bloody show, past labor length, support person availability.

• Nurse determines stay home vs. come in. (Answer to Quiz #3 = False statement.)

Admission Assessment

• History – Prenatal labs, complications (GDM, pre-eclampsia).

• Physical – Vitals, heart/lung, weight, fundal height.

• Uterine Activity – Frequency, duration, intensity.

• Membranes & Cervix – ROM? dilation/effacement.

• Fetal Assessment – FHR baseline, position (Leopold), station.

• Pain & Psychologic Status – Coping, anxiety, support.

• Lab Work – UA, CBC, GBS, syphilis, HBsAg, HIV (consent), tox screen as indicated.

Continuing Assessment

• Knowledge / expectations.

• Vitals per protocol.

• Vaginal exams PRN to assess progress (minimize infection post ROM).

• Evaluate amniotic fluid qualities (Table 14.3).

• Ongoing FHR & contraction charting.

Second Stage of Labor

Assessment

• Signs: strong expulsive UC, perineal/rectal pressure, involuntary bearing-down, trembling, sweat.

• Contraction pattern, maternal vitals, FHR response every 5–15 min, coping.

• Quiz #4 answer: rectal/perineal pressure = correct sign.

Interventions

• Encourage rest until spontaneous urge to push (delayed pushing improves outcomes).

• Positional strategies (squatting, lateral, upright) enhance pelvic diameter & comfort.

• Provide clear coaching, mirror, emotional reinforcement.

• Pain relief: epidural bolus, cooling cloths, counterpressure.

Birth Assistance

• Cleanse perineum, support perineal tissue, control head extension.

• Immediate newborn care: dry, stimulate, position; assign Apgar at 1 & 5 min.

• Delayed cord clamping 30–60 s improves neonatal iron stores.

Third Stage of Labor

• Assessment – placental separation (gush of blood, lengthening cord, globular fundus), inspect membranes, perineum, lacerations.

• Interventions – Gentle maternal push; administer oxytocin 10 IU IM or per IV infusion to ↓ PPH risk; provide warmth; ice perineum; documentation (birth time, placenta time, EBL).

Fourth Stage (Recovery, 1st hour PP)

• Assessment – Maternal vitals q 15 min, fundus (midline, firm, at umbilicus), lochia (rubra, moderate), perineum (REEDA), bladder (distension).

• Interventions – Fundal massage, assist to void or straight cath, refreshments, analgesia, skin-to-skin, breastfeeding initiation, hygiene, teaching on danger signs.

Ethical & Practical Considerations

• Balancing continuous surveillance with maternal mobility & birth experience.

• Informed consent for all analgesia/anesthesia; respect for cultural practices.

• Documentation integrity: every intervention, FHR pattern, response; critical in litigation.

Quick Reference Numbers & Formulas

• Normal Baseline FHR: 110 \text{–}160\, \text{bpm}

• Variability: Moderate 6 \text{–}25\, \text{bpm}

• Tachycardia: >160 bpm ≥ 10 min

• Bradycardia: <110 bpm ≥ 10 min

• Prolonged Decel: >2 min but <10 min

• Montevideo Units (MVU) via IUPC: \Sigma \text{(peak mmHg − baseline mmHg)} over 10 min; adequate labor ≥ 200 MVU.

Sample Scenario & Application

"A G2P1 at 40+2 weeks with insulin-controlled GDM is on oxytocin. FHR baseline 170 bpm with minimal variability & recurrent late decels."
→ Categorize as Category III (tachycardia + recurrent lates + minimal variability) → Implement Box 14.1 interventions, discontinue oxytocin, maternal repositioning, O₂, bolus, call provider, prep for possible cesarean if unresolved.