The Birth Process and Maternal Care Overview

The Birth Process in Childbearing and Reproductive Health (NuR360 Health)

Overview

• Key Focus Areas: Understanding the signs of labor, stages of labor, differentiating between true and false labor, physiologic responses to labor, admission priorities, and processes.

Labor Fundamentals

What to Learn

• Identify Signs of Labor: Essential for preparing for delivery.

• Stages of Labor: Understanding the labor process broken down into stages.

• True vs. False Labor: Ability to differentiate for effective care.

• Physiological Responses: Recognizing how labor affects the body.

• Admission Processes: Understanding priorities during labor admissions.

Preliminary Signs of Labor

• Lightening:

  • Baby "drops", meaning the fetal head descends into the pelvis.

  • Leads to an easier breathing experience for the mother.

  • Increases frequency of urination.

• Other Symptoms:

  • Increase in Braxton-Hicks contractions leading to backache.

  • Possible weight loss or no weight gain.

  • Decrease in appetite with potential diarrhea or loose stools.

  • Increased energy (nesting) and sudden urge to prepare for the baby.

  • Presence of bloody show (bloody mucous when wiping) and loss of mucus plug.

Differentiating True Labor from False Labor

• True Labor:

  • Contractions:

  • Stronger, regular in frequency, and longer-lasting.

  • Begin in the lower back and wrap to the front.

  • Intensity may increase with walking and continue regardless of comfort measures.

  • Cervical changes:

  • Progressive effacement (thinning) and dilation over time.

  • Moves anteriorly during labor, accompanied by a bloody show.

  • Presenting part becomes engaged in the true pelvis.

• False Labor:

  • Contractions:

  • Irregular and less painful.

  • Tend to stop with measures like oral hydration or bladder emptying.

  • Felt primarily in the lower abdomen or lower back without significant cervical changes.

  • Cervix remains in a posterior position with no significant bloody show.

Stages of Labor

Stage 1: Cervical Effacement and Dilation

• Onset: Onset of regular contractions causing cervical change.

• End: Complete dilation to 10 cm.

• Nursing Actions:

  • Perform Leopold's Maneuvers as indicated.

  • Monitor progress of labor including fetal station and presentation.

  • Prepare for delivery, assessing for rupture of membranes and bladder fullness.

  • Assess maternal temperature every 4 hours (2 hours if membranes are ruptured).

• Phases:

  • Latent (Early): 0-3 cm dilation.

  • Active: 4-7 cm dilation (6-7 cm is a new definition).

  • Transition: 8-10 cm dilation.

Stage 2: Birth

• Onset: Onset of maternal pushing efforts.

• End: Birth of the baby.

• Nursing Actions:

  • Monitor blood pressure, pulse, and respiration every 5-30 minutes.

  • Assess fetal heart rate every 5-15 minutes in relation to fetal risk status.

  • Recognize bulging of the perineum and uncontrollable urge to bear down as signs that birth is imminent.

Stage 3: Expulsion of the Placenta

• Onset: Following the birth of the baby.

• End: Delivery of the placenta.

• Nursing Actions:

  • Monitor vital signs (B/P, pulse, respiration) every 15 minutes.

  • Identify signs of placental separation such as a firm fundus, gushing of dark blood, lengthening of the placenta, and signs of vaginal fullness.

  • Maintain a 30-minute limit for placental separation, administering Pitocin per protocol if needed.

• Oxytocics (Pitocin):

  • Initiate a bolus of Pitocin per protocol.

  • Pitocin must be ran by a pump.

  • If there is no IV in place, administer 10 units intramuscularly (IM).

Stage 4: Recovery/Entry into Postpartum

• Onset: After the delivery of the placenta.

• End: Stabilization of maternal wellbeing.

• Nursing Actions:

  • Monitor B/P, pulse, and respiration every 15 minutes.

  • Assess fundus and lochia (vaginal discharge) every 15 minutes.

  • Ensure a peaceful environment for bonding and discuss postpartum plans with parents.

  • Remove epidural catheter to restore sensation.

Maternal Physiologic Responses to Labor

Cardiovascular System

• Increased:

  • Cardiac output and workload related to anxiety and pain.

  • Heart rate during contractions due to catecholamine release.

  • Blood pressure during contractions due to catecholamine release.

• Supine Hypotension Syndrome: Occurs in a supine position causing hypotension due to decreased cardiac output and stroke volume.

Renal Function

• Decreased urinary output.

• Presence of proteinuria (>1+ due to tissue breakdown).

• Electrolyte balance affected by:

  • Diaphoresis (perspiration).

  • Decreased hydration.

  • Increased respiratory effort.

• Nursing Action: Assess bladder frequently.

Respiratory System

• Increased respiratory rate.

• Increased demand for oxygen.

• Mild changes in acid-base balance may occur.

Gastrointestinal System

• Common symptoms include decreased appetite, diarrhea/loose stool, and decreased gastric motility which leads to delayed gastric emptying time and potential nausea/vomiting.

Immunologic System

• Possible slight increase in temperature and elevated white blood cell count (WBC) due to inflammatory/stress responses, which may reach around 20,000.

Nursing Assessment During Labor and Birth

• Continuous, bedside assessment during all stages of labor is essential to promote the health and safety of both the mother and newborn.

Admission Assessment Components

• Gather demographic information and provider details.

• Review prenatal records.

• Document last menstrual period and expected delivery date (EDD).

• Assess allergies and medication history.

• Collect data on pregnancy history using GTPAL (Gravida, Term, Preterm, Abortions, Living children).

• Evaluate risk factors both prenatal and intrapartum.

• Explore emotional responses, coping mechanisms, the labor and birth plan, social support, and cultural background.

• Investigate any history of domestic violence.

• Conduct a fetal assessment and perform Leopold's Maneuvers.

• Measure maternal vital signs compared to prenatal labs, including extremities for pulses, edema, reflexes, and clonus.

• Conduct lab data assessments (HGB, GBS status).

• Assess fetal movement and conditions of fetal membranes including if ruptured, appearance, and amount.

• Record presence of any bloody show.

Fetal Heart Rate Assessment

• Monitor for accelerations and decelerations (late, early, variable).

• Assess changes in heart rate ranging from normal values of 110-160 bpm. Tachycardia is defined as >160 bpm, while bradycardia is <110 bpm.

• Assess variability which are changes in the heart rate from one beat to the next. A normal value is 6-25 bpm.

Uterine Contraction Assessment

• Monitor for resting tone, with external monitors providing insufficient intensity measures. Need at least 1 minute of rest between.

• Track frequency and duration, noting that labor patterns typically occur every 2-5 minutes and last 60-90 seconds.

Practical Application Scenario

• Case Study: 28-year-old Stacy at 39 weeks gestation presents with contractions. Key questions to ask her may include:

  • What are your current symptoms and how intense are they?

  • How has your experience been with her gestational diabetes?

  • Which specific orders might be anticipated, and primary nursing interventions?

Vaginal Exams Interpretation

• Interpret vaginal exams succinctly:

  • 3/50%/-3 means 3 cm dilation, 50% effaced, -3 station (fetus not engaged).

  • 5/70%/+1 means 5 cm dilation, 70% effaced, +1 station (fetus engaged).

  • 10/100%/+2 means fully dilated (10 cm), 100% effaced, +2 station (fetus well engaged).

  • 6/80/-1 indicates 6 cm dilation, 80% effaced, -1 station (fetus still not engaged).

  • 5/50%/0 represents 5 cm dilation, 50% effaced, with the maternal pelvis at zero station.

Hallmarks of Obstetric Nursing

• Emphasize the importance of:

  • Communicating confidence in patients: affirmations such as "You can do this" or "You are strong".

  • Being present and available for patients and their families: