Maternal–Newborn Nursing: Labor, Pain, & Postpartum Comprehensive Notes

The 4 Ps of the Birth Process

• Four interactive factors that determine the course and outcome of every labor.

Power – Forces of Labor

• Involuntary uterine contractions
  • Primary force of labor.
  • Responsible for cervical effacement (thinning) and dilation (widening).
• Voluntary maternal pushing efforts
  • Triggered by pressure of presenting part against vaginal wall/rectum.
  • Secondary force – supplements uterine power to expel fetus.
• Clinical significance
  • Ineffective power → prolonged labor (labor dystocia).
  • Excessive power (tachysystole) → fetal hypoxia, abruption, postpartum hemorrhage.

Passage – Maternal Pelvis & Soft Tissues

• Structures
  • Bony pelvis (true pelvis most critical).
  • Soft tissues: cervix, vaginal walls, pelvic floor, introitus.
• Divisions of the pelvis
  • False pelvis (upper) – supports uterus; little obstetric importance.
  • True pelvis (lower) – pathway for birth.
  • Pelvic inlet, pelvic cavity, pelvic outlet.
• Symphysis pubis
  • Softened by hormone relaxin.
  • Slightly widens during childbirth, increasing diameter.
• Four classic pelvic shapes
  1. Gynecoid – wide, round; ideal for vaginal birth.
  2. Android – heart-shaped; narrow fore-pelvis → difficult descent.
  3. Anthropoid – oval, long anteroposterior diameter; favorable for OP positions.
  4. Platypelloid – wide transverse diameter but shallow AP; head may engage transversely.
• Complication
  • Cephalopelvic Disproportion (CPD): fetal head too large or maternal pelvis too small → obstructed labor, ↑ cesarean rate.

Passenger – Fetus, Placenta, Membranes

• Fetal head anatomy
  • Frontal, parietal (2), occipital bones.
  • Sutures & fontanelles allow moulding to pelvic contours.
  • Occipitofrontal diameter measured to judge size.
• Fetal lie
  • Longitudinal (parallel to maternal spine) – normal.
  • Transverse (perpendicular) – abnormal; vaginal birth impossible.
• Fetal attitude (posture)
  • Flexion – chin on chest, extremities flexed, spine C-shaped; smallest diameters enter pelvis.
  • Extension – varying degrees; face or brow presentation → larger diameters.
• Fetal presentation – part entering pelvic inlet first
  • Cephalic (head) – \approx 96\% of births.
  • Vertex (complete flexion) – optimal.
  • Military (neutral), Brow (partial extension), Face (full extension).
  • Breech (buttocks/feet)
  1. Frank – hips flexed, knees extended (legs to shoulders).
  2. Footling – one or both feet present first.
  3. Complete – hips & knees flexed, buttocks first.
  • Shoulder (transverse lie) – requires cesarean unless converted.
• Fetal position – relationship of reference point to maternal pelvis
  • Three-letter code
  • First: R/L of maternal pelvis.
  • Second: Reference point (O-occiput, M-mentum, S-sacrum, A-acromion).
  • Third: A-anterior, P-posterior, T-transverse.
  • Example: LOA (Left Occiput Anterior) – most favorable for descent & flexion.

Psyche – Maternal Psychological State

• Influencing factors: anxiety, cultural beliefs, expectations, support system, prior birth, overall mental health.
• Positive emotions → enhanced oxytocin → more efficient contractions.
• High stress/anxiety → catecholamine surge → vasoconstriction, ↓ uterine perfusion, dysfunctional labor.

Intrapartum Uterine Activity & Dysfunctional Labor

Anatomy & Physiology of the Uterus

• Three layers: Perimetrium (outer), Myometrium (muscular), Endometrium (inner).
• Sections: Fundus (upper), Body (middle), Cervix (lower cylinder).
• Oxytocin
  • Receptors increase in 3rd trimester, maximally in fundus.
  • Triggers coordinated contractions from fundus → cervix.

Normal Contraction Pattern

• Frequency: \le 5 contractions per 10\;\text{min} (averaged over 30\;\text{min}).
• Duration: seconds from start to end of a single contraction.
• Intensity: mild/moderate/strong (palpation) or \text{mmHg} (IUPC).
• Resting tone: soft palpation or \approx 10\,\text{mmHg} via IUPC; maintains placental flow.

Assessment Parameters

• Frequency – onset to onset (min).
• Duration – onset to end (sec).
• Intensity – palpation (nose/chin/forehead) or IUPC (objective pressure).
• Resting tone – uterine firmness between contractions.

Monitoring Tools

• Tocodynamometer (external) – senses pressure; gives frequency + relative intensity.
• Intrauterine Pressure Catheter (IUPC)
  • Requires ruptured membranes and \ge 2\,\text{cm} dilation.
  • Accurately measures peak pressure & resting tone.

Dysfunctional Labor Patterns

1. Tachysystole
   • >5 contractions in 10 min (avg over 30 min).
   • Causes: excess oxytocin, prostaglandins, stimulant drugs.
   • Risks: fetal hypoxia, uterine rupture, placental abruption, PPH.
2. Precipitous Labor
   • Entire birth completed <3 h from onset.
   • Maternal: lacerations, hemorrhage, abruption.
   • Fetal: hypoxia, intracranial hemorrhage, trauma.
3. Labor Dystocia (Failure to Progress)
   • Weak/irregular contractions → poor cervical change or descent.
   • Leads to maternal exhaustion, infection, ↑ cesarean, neonatal sepsis.

Labor Pain & Pain Management

Nature of Labor Pain

• Normal, time-limited, intermittent; ends with birth.
• Motivates maternal behaviors that facilitate delivery.

Types & Etiology of Pain

• Visceral (early 1st stage)
  • Uterine ischemia, cervical dilation, lower uterine stretch, pressure on adjacent organs.
• Somatic (late 1st & 2nd stage)
  • Stretching of vagina/perineum, fetal pressure on pelvic floor & lumbosacral plexus.

Physiologic Effects of Uncontrolled Pain

• ↑ Cortisol & catecholamines → vasoconstriction → ↓ uterine blood flow → fetal hypoxia.
• ↑ Maternal O₂ & glucose consumption → worsens hypoxia; contributes to postpartum fatigue, bonding difficulty.

Non-Pharmacologic Pain Management

• Cognitive
  • Continuous labor support (partner, doula).
  • Music, guided imagery, focused breathing & relaxation.
• Cutaneous/sensory
  • Massage (effleurage, sacral, back).
  • Birthing ball, hydrotherapy (warm shower/tub), heat/cold packs.

Pharmacologic Options

• Systemic analgesia
  • IV opioids: Fentanyl, Remifentanil, Butorphanol, Nalbuphine.
  • Cross placenta → possible neonatal respiratory depression; avoid within 1!$–4 h of expected birth.
• Neuraxial / Regional
  • Epidural, spinal, combined spinal-epidural; local anesthetic (Bupivacaine/Ropivacaine) ± opioid.
  • Advantages: excellent pain relief while awake; adjustable.
  • Watch for maternal hypotension → fetal bradycardia.
• Pudendal block
  • Local anesthetic via vaginal mucosa; numbs lower vagina & perineum (2nd stage, forceps, repair).
• Nitrous oxide
  • Self-administered mask; rapid onset/offset; maintains consciousness.
• General anesthesia
  • Induction of unconsciousness; reserved for emergent cesarean or contraindications to regional.

Nursing Role in Pain Management

• Assess pain, coping behaviors, preferences.
• Provide anticipatory guidance & informed choice (effectiveness, risks, fetal impact).
• Coordinate with anesthesia, maintain IV access, preload fluids for epidural.
• Continuous monitoring: maternal BP, RR (hold opioid if <12\,/\text{min}), O₂ sat, FHR.
• Intervene for hypotension: stop oxytocin, bolus fluids, 8!$–10\,\text{L} O₂ via non-rebreather, notify provider, prepare ephedrine.

Analgesics in Obstetrics (Pregnancy → Postpartum)

Non-Opioid Analgesics

• Acetaminophen: safe first-line for headaches, mild pain.
• NSAIDs (e.g., ibuprofen)
  • Generally avoided in pregnancy (renal impairment, oligohydramnios, premature ductus arteriosus closure).
  • Useful postpartum for uterine cramping if not contraindicated.

Opioids

• Full agonists (Fentanyl, Remifentanil) & partial agonists (Butorphanol, Nalbuphine).
• Actions: ↓ pain perception, ↑ threshold.
• Side effects: maternal respiratory depression, sedation, N/V, pruritus, hypotension; fetal bradycardia, hypotonia.
• Contraindications: significant respiratory disease, concomitant CNS depressants, chronic use → NAS.

Regional Anesthetics

• Local anesthetics block \text{Na}^+ channels → stop nerve propagation.
• Types: Pudendal, Epidural, Spinal, Combined.
• Adverse events: maternal hypotension ↓ placental perfusion, motor block, infection, post-dural puncture headache, LAST (local anesthetic systemic toxicity) → seizures, cardiac arrest.

Nursing Considerations (Before–During–After)

• Assess pain score, contraction pattern, FHR.
• Review labs (Hgb/Hct, platelets, coagulation) before neuraxial block.
• Preload 500–1000\,\text{mL} crystalloid to mitigate hypotension.
• Positioning: seated or lateral with flexed spine for epidural/spinal.
• Continuous surveillance: BP q 2–5\,\text{min} initially, then per policy; watch for high block (dyspnea, numb fingers, ↓ LOC).
• Post-dose: monitor bladder (indwelling cath), motor return, pain relief quality, epidural site dressing/infusion pump.

Uterine Activity – Quick Reference Table

• Frequency – start-to-start (min).
• Duration – start-to-end (sec).
• Intensity – palpation or IUPC (\text{mmHg}); mild (nose), moderate (chin), strong (forehead).
• Resting tone – soft abdomen; \approx 10\,\text{mmHg} on IUPC.
• Tachysystole – >5/10 min.
• Precipitous labor – birth <3 h.
• Labor dystocia – ineffective pattern, slow progress.

Postpartum Care – Fourth Stage of Labor (First 6 Weeks)

Newborn Immediate Priorities

• Cardiopulmonary Adaptation
  • Apgar at 1 & 5 min (repeat q 5 min until \ge7).
  • HR, Respiration, Tone, Reflex, Color scored 0/1/2.
  • Intervene for bradycardia (<100), apnea, poor tone.
• Thermoregulation
  • Risk: wet skin → evaporative heat loss → cold stress (↑ O₂, hypoglycemia).
  • Measures: Dry, warm blankets, skin-to-skin, radiant warmer, hat, ongoing temp checks.
• Identification/Security
  • Matching ID bands (infant + parent(s)) placed before leaving delivery area.

Postpartum Patient Assessment

• Lochia
  • Rubra → Serosa → Alba; excessive bleeding or large clots indicate hemorrhage.
• Uterine Fundus
  • Should be firm, midline, at or below umbilicus; boggy → massage.
  • Full bladder displaces fundus laterally & up → encourage voiding/cath.
• Vital signs
  • Tachycardia + hypotension = concern for blood loss.
• Pain & Comfort
  • Pharmacologic: NSAIDs, opioids, ice packs, sitz baths.
• Falls & Safety
  • Orthostatic hypotension, lingering anesthesia; assist with first ambulation.

Family-Centered Care & Bonding

• Golden hour: encourage skin-to-skin, eye contact, breastfeeding initiation.
• Positive attachment behaviors: holding, speaking softly, stroking infant.
• Assess for impaired bonding (withdrawal, negative comments); intervene with support/education.
• Consider cultural practices & resources.

Integrated Connections & Clinical Pearls

• Effective Power + Adequate Passage + Favorable Passenger + Positive Psyche = Efficient labor.
• Tachysystole often iatrogenic → titrate or stop oxytocin; intrauterine resuscitation reduces fetal acidemia.
• LOA vertex + gynecoid pelvis + flexed attitude = textbook delivery scenario.
• Pain management tailored to stage: visceral pain predominates early (epidural ideal); somatic perineal pain peaks in 2nd stage (pudendal block).
• Immediate postpartum hemorrhage prevention starts in delivery room: fundal massage, assess lochia, maintain uterine tone (consider prophylactic oxytocin).