Labor and Delivery Notes

INTRODUCTION TO LABOR AND DELIVERY

• Instructor: Professor Carrie Jackson, BSN, MSN, RNC-OB & EFM, CNE

OVERVIEW OF LABOR AND DELIVERY (L&D)

• Key Topics:

  • What does L&D mean to YOU?

  • Fetal Assessment During Labor

  • Leopold maneuvers

  • Intermittent auscultation and uterine contraction palpation

  • Continuous Electronic Fetal Monitoring (EFM)

  • Pain Management

TERMINOLOGY IN LABOR AND DELIVERY

• Major Terms:

  • Antepartum: Period before labor begins.

  • Intrapartum: Period during labor.

  • Postpartum: Period after childbirth.

  • Labor & Delivery (L&D) RN Responsibilities:

  • Care for Maternal-Fetal Unit (Mother & Fetus)

  • Care for Neonate after delivery

  • Support Family

  • Collect assessment data on maternal and fetal well-being during labor, including psychosocial and cultural factors affecting labor progress.

LEOPOLD MANEUVERS

• Definition: Abdominal palpation techniques used to assess fetal position.

• Three Key Questions:

  1. Which fetal part is in the uterine fundus?

  2. Where is the fetal back located?

  3. What is the presenting fetal part?

• Using Leopold Maneuvers:

  • Estimate fetal size.

  • Important for determining placement of the Ultrasound Fetal Heart Monitor or Doppler.

DOPPLER FOR FETAL HEART RATE AUSCULTATION

• Procedure:

  • Perform Leopold maneuvers.

  • Position listening device over maximal intensity area.

  • Palpate maternal radial pulse simultaneously.

  • Count Fetal Heart Rate (FHR) for 30-60 seconds.

  • Determine baseline FHR between uterine contractions (UC).

  • Monitor FHR during UC and for 30 seconds after to identify changes.

TRUE VS FALSE LABOR

• True Labor:

  • Characterized by regular contractions increasing in frequency, duration, and intensity.

  • Brings about progressive cervical dilation and effacement.

• Braxton Hicks Contractions:

  • Often felt as tightening in the uterus; associated with false labor.

  • Helps ripen and soften the cervix.

• Signs of Labor:

  • Lightening: Fetal presenting part descends into the true pelvis.

  • Nesting: Increased energy before labor.

  • Bloody Show: Pink-tinged secretions from cervical dilation.

THE P'S OF LABOR

• Passageway:

  • Route through which the fetus travels for vaginal birth.

  • Pelvic Shapes:

  • Gynecoid: True female pelvis; 50% of women; round.

  • Anthropoid: Common in men; 23% of women; heart-shaped.

  • Android: 24% of women; oval-shaped.

  • Platypelloid: 3% of women; flat-shaped.

• Passenger:

  • Factors including fetal head size, attitude, lie, presentation, position, station, and engagement affect the labor process.

• Powers:

  • Uterine contractions (primary stimulus) lead to cervical dilation and effacement.

  • Second-stage power: Intra-abdominal pressures from maternal pushing.

• Position:

  • Importance of maternal position changes during labor.

• Psychological Response:

  • Childbearing influences a woman's self-confidence, self-esteem, relationships, and views on life.

STAGES OF LABOR

• First Stage: Dilation from 0 to 10 cm.

  • Latent Phase: 0-6 cm.

  • Active Phase: 6-10 cm.

• Second Stage: From 10 cm to birth.

  • Latent Phase: Laboring down, delayed pushing.

  • Active Pushing.

• Third Stage: Delivery of baby and placenta (shortest stage).

• Fourth Stage: Postpartum stabilization (1-2 hours after birth).

AMNIOTOMY: ARTIFICIAL RUPTURE OF MEMBRANES (AROM)

• Indications:

  • Cord Prolapse

  • Infection

  • Placental Abruption

• Risks:

  • Baseline fetal evaluation is mandatory.

  • Assess FHR due to the risk of cord prolapse.

• Performed by: MD or Certified Nurse Midwife (CNM) only.

SPONTANEOUS RUPTURE OF MEMBRANES (SROM)

• Definition: Occurs in 25% of pregnancies.

• PROM (Prelabor Rupture of Membranes): Loss of amniotic fluid before labor starts occurs in 8-10% of term pregnancies.

• Risks After SROM:

  • Infection risk increases as barrier is lost.

  • Risk of cord prolapse can arise if engagement has not occurred.

EFFECTS OF CONTRACTIONS ON PLACENTAL PERFUSION

• Each contraction reduces blood flow to the fetus, which decreases oxygen transfer.

INDUCTION AND AUGMENTATION OF LABOR

• Risks of Induction and Augmentation:

  • Tachysystole (increased uterine activity)

  • Uterine rupture

• Contraindications:

  • Placental previa

  • Abnormal fetal presentation (e.g., breech)

  • Active genital herpes

  • Previous classical cesarean section.

• Technique: Includes assessing indications, using Bishop’s Score for cervical readiness, and cervical ripening methods (Cervidil, Cytotec).

• Oxytocin Administration: IV administration requires Continuous Electronic Fetal Monitoring (EFM).

NURSING CONSIDERATIONS WITH PITOCIN

• Continuous FHR tracing and monitoring.

• Interventions include discontinuing oxytocin for non-reassuring FHR.

• Positioning (left/right side), increasing IVF, monitoring maternal responses, and postpartum risk awareness (e.g., hemorrhage).

FETAL ASSESSMENT DURING LABOR

• Monitor for conditions affecting fetal well-being, including maternal HTN, anemia, hemorrhage, and supine hypotension.

• Importance of uterine contractions and their effect on fetal perfusion, leading to acid-base balance and potential outcomes like hypoxia.

FETAL HEART RATE PATTERNS

• Normal Baseline: 110 to 160 bpm.

• Variability: Interplay between fetal sympathetic and parasympathetic systems.

• Critical Monitoring Aspects:

  • Frequency (Q 2-5 min)

  • Duration (average 60-90 sec)

  • Adequate resting tone between contractions (30 seconds minimum).

FETAL HEART RATE (FHR) KEY CONCEPTS

• Bradycardia: FHR < 110 bpm for at least 10 minutes.

• Tachycardia: FHR > 160 bpm for at least 10 minutes.

• Variability Categories:

  • Minimal: >2 and <5 bpm.

  • Moderate: 6 to 25 bpm (reassuring).

  • Marked: >25 bpm.

DECELERATIONS IN FHR

• Types of Decelerations:

  • Early: Related to head compression.

  • Late: Associated with uteroplacental insufficiency (UPI).

  • Variable: Caused by umbilical cord compression.

  • Prolonged: FHR decline lasting 2-10 minutes.

FHR CATEGORIES

• Category I (Normal/reassuring):

  • FHR baseline 110-160 bpm

  • Moderate variability

  • Absence of late/variable decelerations.

• Category II (Indeterminate):

  • Bradycardia without absent variability

  • Minimal baseline variability.

  • Decelerations may or may not occur.

• Category III (Non-reassuring):

  • Associated with fetal hypoxemia.

  • Bradley or sinusoidal patterns present.

NURSING INTERVENTIONS FOR NON-REASSURING FHR PATTERNS

• Change maternal positions, increase IV fluids, consider discontinuing Pitocin, notify MD using SBAR framework, and oxygen therapy as ordered.

PAIN MANAGEMENT DURING LABOR

• Physiological Factors: Pain caused by tissue ischemia and cervical dilation leading to increased lactic acid.

• Psychological Factors: Preparation through childbirth classes, hypnobirthing, or traditional pain management methods (e.g., Lamaze).

STAGES OF PAIN DURING LABOR

• First Stage: Uterine cramping, cervical stretching, and pressure from contractions.

• Second Stage: Pushing phase involves high levels of pressure and visceral pain.

• Third Stage: Delivery of the placenta with possible manual extraction and reparative processes.

NON-PHARMACOLOGICAL PAIN MANAGEMENT

• Techniques promoting relaxation include auditory and tactile stimuli, a calm environment, massage, positional changes, water immersion, and gravity aids (e.g., birthing ball).

PHARMACOLOGICAL PAIN MANAGEMENT

• Discuss options, risks, and direct/indirect effects on the fetus and maternal health.

• Systemic Drugs include opioids, antiemetics, and tranquilizers.

• Regional Pain Management: Epidurals and Patient Controlled Epidural Anesthesia (PCEA). Provide hydration, monitor bladder status, and assess maternal and fetal response.

REFERENCES

• Lowdermilk, D. L., Cashion, Alden, K. R., Olshansky, & Perr, S. E. (2024). Maternity and Women's Health Care (13th ed.). Elsevier - Evolve. https://bookshelf.vitalsource.com/books/9780323811798