processes of labor and delivery

PROCESSES OF LABOR & DELIVERY

Readings

• Ernstmeyer & Christman Health Promotion OER Textbook

• Sections: 10.3, 10.4, 10.5, 10.6, 10.10

• Access: https://wtcs.pressbooks.pub/healthpromo/

NCLEX Test Plan Objectives

• Management of Care:

  • Initiate, evaluate, and update the client plan of care.

  • Maintain client confidentiality and privacy.

  • Perform procedures necessary to safely admit, transfer, and/or discharge a client.

  • Prioritize the delivery of client care based on acuity.

  • Receive, verify, and implement health care provider orders.

• Safety and Infection Control:

  • Protect client from injury.

  • Educate client on safety issues.

  • Apply principles of infection prevention, including hand hygiene, aseptic technique, isolation, sterile technique, universal/standard enhanced barrier precautions.

• Health Promotion and Maintenance:

  • Provide care and education to an antepartum client or a client in labor.

  • Perform targeted screening assessments.

• Psychosocial Integrity:

  • Incorporate client cultural practices and beliefs when planning and providing care.

  • Assess client support system to aid in the plan of care.

  • Assess psychosocial factors influencing care and plan interventions.

  • Recognize non-verbal cues to physical and/or psychological stressors.

  • Promote a therapeutic environment.

• Basic Care and Comfort:

  • Assess and manage clients with alterations in bowel and bladder elimination.

  • Implement measures to promote circulation, such as active or passive range of motion, positioning, and mobilization.

  • Assess clients for pain and intervene as appropriate.

  • Provide non-pharmacological comfort measures.

  • Evaluate client intake and output; intervene as needed.

  • Assess client sleep/rest pattern; intervene as needed.

• Reduction of Risk Potential:

  • Assess and respond to changes and trends in client vital signs.

  • Monitor results of diagnostic tests; intervene as needed.

  • Insert, maintain, or remove urinary catheters.

  • Evaluate client responses to procedures and treatments.

  • Recognize trends and changes in client condition and intervene as needed.

  • Perform focused assessments.

• Pharmacological and Parenteral Therapies:

  • Evaluate client response to medication.

  • Educate client about medications.

  • Review pertinent data prior to medication administration, including contraindications, lab results, allergies, and potential interactions.

  • Administer medications for pain management.

• Physiological Adaptation:

  • Manage care of clients with alterations in hemodynamics, tissue perfusion, and hemostasis.

  • Recognize signs and symptoms of client complications and intervene.

Early Signs of Labor (Possible Hours or Days Prior to True Labor)

• Lightening:

  • Baby drops into pelvis, preparing for labor.

• Cervical Ripening:

  • Cervix shows signs of labor preparation; it becomes softer, opens, thins, and is more anterior in position.

• Braxton Hicks (Practice Contractions):

  • Early pregnancy contractions that serve as practice for labor.

• Nesting:

  • Energy burst to prepare for the arrival of the baby.

• Rupture of Membranes:

  • Breaking of the “waters”.

True Labor vs. False Labor

True Labor

• Regular contraction pattern:

  • Becomes more frequent and longer in duration; predictable.

• Progressive dilation and effacement:

  • Cervical change is noted.

• Contraction intensity increases with walking.

• Discomfort felt in back and front.

• Consistent bloody “show.”

False Labor

• Irregular/weak contractions:

  • Little or no change in contraction frequency and duration; unpredictable.

• Minimal to no cervical change:

  • No progressive dilation or effacement.

• Contractions do not increase in intensity with walking.

• Discomfort only felt in front; no back pain.

• No bloody “show.”

Contraction Terminology

• Duration:

  • The length of one contraction from start to finish.

• Frequency:

  • The measure of how far apart contractions are, from the beginning of one contraction to the beginning of the next.

• Interval:

  • The rest period from when one contraction ends to the next begins; critical for fetal oxygenation.

• Increment, Peak, and Decrement:

  • Describes the three phases of a contraction: muscle tension builds (increment), peaks, then begins to decline (decrement).

When Should a Patient Come to Hospital?

• With any suspected or known leakage of fluid vaginally.

• With bright red vaginal bleeding similar to period or wound.

• With a decrease in fetal movement within any given 12-hour period.

• If the patient cannot walk or talk through contractions.

• Any other intense pain or gut feeling that something is wrong.

Contraction Timing for Admission

• Multipara:

  • If contractions are 6-8 minutes apart for 1 hour.

• Primipara:

  • If contractions are 5 minutes apart for 1 hour.

Assessments/Nursing Interventions Upon Admission

• Prioritize labor status:

  • Check for imminent birth, including fetal heart tones (FHT) and maternal vitals, as these are most critical.

• Status of membranes, cervix, contraction patterns, pain level.

• Expected Delivery Date (EDD) and prenatal care history, assess for risks.

• Use Leopold’s maneuvers for fetal position confirmation, determining external monitor placements.

• Labs and consents should be organized.

Terminology for Rupture of Membranes

• SROM:

  • Spontaneous rupture of membranes.

• AROM:

  • Artificial rupture of membranes.

• PROM:

  • Premature rupture of membranes; leakage of amniotic fluid before labor signs at any gestational age.

Nursing Priority with Membrane Rupture

• Assessment and management of cord prolapse and fetal well-being should be the first priority post-membrane rupture.

• Immediate fetal heart tone assessment and monitoring for non-reassuring patterns (NRFHT) is critical.

Stages of Labor

Stage 1: Labor Onset to Full Dilation (10 cm)

• Latent Phase:

  • Gradual cervical dilation from 0-6 cm.

  • Contractions occur every 5-10 minutes with a duration of 30-45 seconds; mild intensity.

  • Lasts an average of 16 hours.

• Active Phase:

  • Rapid cervical dilation from 6-10 cm.

  • Contractions occur every 2-5 minutes with a duration of 40-90 seconds.

  • Duration can vary from minutes to hours.

Stage 2: Full Dilation to Delivery

• Begins with complete cervical dilation (10 cm) and 100% effacement.

• Includes maternal pushing efforts; ends with delivery of baby or babies.

• Contractions every 2-3 minutes with a duration of 60-90 seconds.

• Duration:

  • Nulliparous patient: 2-4 hours.

  • Multiparous patient: 1-2 hours.

• Note: Epidurals can lengthen this stage for any woman.

Stage 3: Delivery of Placenta

• Begins after the newborn is delivered and ends with the delivery of the placenta.

• Contractions are irregular and less intense but continue.

• Stage lasts 5-30 minutes; longer than 30 minutes may indicate risks of complications.

• Signs of impending placental delivery:

  • Elongation of the cord, gush of blood upon detachment of the placenta, uterus takes on a globular shape.

Immediate Recovery Care

For the Mother:

• Focused assessments related to postpartum hemorrhage emphasizing vital signs, lochia, and fundal assessments to detect red flags.

• Provide peri-care and maintain cold packs on the perineum.

• Encourage patient to keep the bladder empty and explain the importance.

For the Newborn:

• Upon delivery, dry the infant vigorously and suction nose and mouth with a bulb syringe.

• Assign APGAR scores at 1 and 5 minutes post-delivery and intervene as needed; scores assess the newborn's transition to extrauterine life, including:

  • Muscle tone, heart rate, respiratory effort, color, and reflex response when stimulated.

• Assess respiratory status, temperature, cardiovascular status frequently.

• Support thermoregulation, maintenance of glucose levels, and bonding between mother and newborn.

Evaluation of Labor Progress by Nursing Staff

Cervical Assessment:

• Monitor for effacement, dilation, and station, along with membrane status and fluid characteristics.

• Be aware of multiple contraindications to a digital exam.

• No scheduled examinations are standardized; assess based on clinical clues indicating the necessity of a cervical exam.

Contraction Assessment:

• Differentiate between external monitoring (Toco) versus internal monitoring (IUPC).

External vs. Internal Monitoring

• External Monitoring:

  • Placed over the upper fetal back for heart tones and fundus for contractions.

  • If the fetus is in a breech position, placed around the maternal umbilicus.

• Internal Monitoring (FSE/IUPC):

  • Requires skilled placement; membranes must be ruptured and dilation of 2-3 cm is necessary.

  • More accurate but limits maternal mobility; invasive to place.

The P's of Labor to Consider When Assessing Labor Success

• Powers:

  • Effectiveness of pushing efforts and contractions.

• Passageway:

  • Includes the pelvic shape and soft tissues (cervix, vaginal canal, perineal tissues).

• Passenger:

  • Refers to the baby or babies, including size and position; influences labor success.

• Positioning:

  • Maternal positions during labor, where frequent changes encourage cervical changes, and vertical positions assist fetal descent.

  • Use of aids (e.g., peanut balls, fitness balls) to assist in widening the pelvic opening.

• Psyche:

  • Emotional state of the mother; positive or negative feelings significantly impact outcomes.

  • Pre-existing mental health conditions create additional barriers.

Pharmacologic Pain Management Types

• Systemic Analgesia:

  • Anesthesia that works through the body systemically; includes IV meds such as nalbuphine and butorphanol.

• Regional Anesthesia:

  • Lessens sensation in a specific region; includes epidurals and spinals.

• Local Anesthesia:

  • Numbs a specific area locally, such as through local blocks.

• General Anesthesia:

  • Often used for emergency cesarean sections; can affect the baby due to rapid action.

Pharmacologic Pain Management Concerns/Nursing Considerations

• Systemic Analgesia (Nalbuphine):

  • May slow labor if administered too early; careful assessment of labor progress needed.

  • Can lead to respiratory depression in the baby; typically avoided until advanced dilation.

  • Causes less fetal beat-to-beat variability and reduced baseline heart rate.

• Regional Anesthesia (Epidural/Spinal):

  • Administer a fluid bolus (LR) before placement (500-1000 mL) to prevent hypotension.

  • Epidurals take 20-30 minutes to take effect; they should be placed in advanced labor and only affect maternal sensation, not directly the baby.

• General Anesthesia:

  • Used for Cesarean sections where fast delivery is necessary; medications affect the baby immediately.

  • Safety measures include side rails and monitoring aspiration risk.

Epidural/Spinal/General Comparison Chart

Cultural Considerations

• Explore cultural practices and expectations during early prenatal visits.

• Utilize open-ended questions regarding cultural needs and expectations upon labor and delivery admission.

• Display an attitude of cooperation and acceptance toward cultural differences.

• Recognize that differences in expressions of pain and communication patterns are common.

• Staff should exercise repatterning of care to accommodate cultural needs while prioritizing safety.