ATI Engage: Progression of Uncomplicated Labor

Learning Objectives for Maternal and Newborn Health

• Explain the various factors that affect the progression of an uncomplicated labor.
• Explore the pathophysiology and physiological adaptations resulting from an uncomplicated labor.
• Explore the care provided to the maternal newborn client during the first stage of an uncomplicated labor.
• Explore fetal assessment strategies during an uncomplicated labor.
• Apply the nursing process using clinical judgment functions while providing care to the maternal newborn client and fetus during an uncomplicated labor.

Progression of Uncomplicated Labor: Fetal Factors

• Presentation (The Presenting Part):     * Cephalic: The head is the presenting part; suture lines are palpable on examination.     * Breech: The buttocks or feet are the presenting part.     * Shoulder: The shoulder is the presenting part.     * Compound: A presenting extremity accompanies the primary presenting part (e.g., a hand next to the head).
• Position: Refers to the location of the presenting part within the maternal pelvis.     * Denominator: The clinical landmark used to describe position (e.g., occiput, sacrum, or mentum).     * Direction: The orientation towards the left or right side of the maternal pelvis.     * Anatomical Location: Orientation relative to the pelvis, described as anterior, posterior, or transverse.
• Lie: The relationship of the fetal spine to the maternal spine.     * Longitudinal: The fetal spine is parallel to the maternal spine.     * Horizontally (Transverse): The fetal spine is perpendicular to the maternal spine.     * Oblique: The fetal spine is at an angle to the maternal spine.
• Attitude: The relationship of the fetal head to the fetal spine.     * Vertex: The optimal attitude where the head is down and the chin is tucked to the chest.     * Face: An attitude where the fetal neck is extended, and the face presents first.

Progression of Uncomplicated Labor: Maternal Factors

• Maternal Structure: The physical anatomy and shape of the pelvis.
• Powers of Labor:     * Uterine Contractions: Involuntary contractions of the uterine muscle.     * Maternal Pushing Effort: Voluntary efforts by the mother during the second stage.
• Positioning of the Client: The physical position the mother assumes during labor.
• Psychosocial Factors:     * Fatigue: Maternal energy levels.     * Support: The presence and quality of labor support (doulas, partners, staff).

Adaptations and Mechanisms of Labor

• Signs of Impending Labor:     * Lightening: The fetus "drops" or descends into the true pelvis.     * Vaginal Discharge: Changes in mucus or the "bloody show."     * Nesting: A sudden burst of energy to prepare for the baby.     * Cervical Change: The cervix begins to soften, efface, and dilate.     * Rupture of Membranes (ROM): Spontaneous or artificial breaking of the amniotic sac.
• Prenatal Care Considerations:     * Delayed or a lack of prenatal care can significantly increase the risk of maternal and fetal morbidity and mortality.

Maternal Physiological Adaptations to Labor

• Cardiovascular and Hematologic Systems:     * Increased overall blood volume.     * Increased cardiac output and stroke volume.     * Increased heart rate (which typically resolves or returns toward baseline between contractions).     * Increased lymphocyte count.
• Pulmonary/Respiratory Systems:     * Increased oxygen consumption by the body.     * Increased production of lactic acid.
• Gastrointestinal (GI) System:     * Delayed gastric emptying.     * Symptoms including nausea and vomiting.
• Renal System:     * Potential for incontinence.     * Presence of proteinuria.
• Endocrine System:     * Increased estrogen to progesterone ratio.     * Increased prostaglandin production.     * Release of Oxytocin.
• Reproductive System:     * Significant uterine and cervical changes.     * Physical changes to the pelvic floor muscles.

Fetal Adaptations to Labor

• Position Changes: The fetus moves and rotates through the birth canal.
• Compression: Physical pressure on the fetal body during passage.
• Respiratory Changes: A decrease in fetal breathing movements.
• Oxygenation: Potential for transient hypoxia.
• Meconium: Potential passage of stool (meconium) into the amniotic fluid.
• Molding: The overlapping of cranial bones to allow the head to pass through the pelvis.

The First Stage of Labor

• Definition: Begins at the onset of regular labor contractions and ends when the cervix is fully dilated ($10\,\text{cm}$) and fully effaced.
• Phases of the First Stage:     * Latent Phase: Characterized by irregular contractions. Cervical dilation starts at $0\,\text{cm}$ to $4\,\text{cm}$ at onset, and may increase to $6\,\text{cm}$ during the transition toward the active phase.     * Active Phase: Characterized by the descent of the presenting part of the fetus and progression to full dilation ($10\,\text{cm}$).

Initial Care and Assessment in Labor

• Client Preferences: Documenting and respecting the laboring person's birth plan.
• Vital Signs: Regular monitoring of maternal physiological status.
• True Labor Assessment: Differentiating between Braxton Hicks and true labor contractions that cause cervical change.
• Monitoring: Assessing uterine contractions and overall fetal wellbeing.
• History and Physical: Gathering medical history and performing a full physical assessment.

Monitoring Uterine Contractions

• Assessment Methods:     * Manual palpation.     * Tocodynamometer (TOCO): External monitor for contraction frequency and duration.     * Intrauterine Pressure Catheter (IUPC): Internal monitor used to measure the exact intensity of contractions.
• Monitoring Schedule: Can be continuous or intermittent based on risk profile.
• Contraction Characteristics:     * Frequency: The time from the beginning of one contraction to the beginning of the next.     * Intensity: The strength of the contraction (mild, moderate, or strong).     * Duration: The time from the beginning of a contraction to the end of that same contraction.     * Resting Tone: The pressure of the uterus between contractions.

Vaginal Examination and Membrane Assessment

• Dilation: Measure of how open the cervix is ($0-10\,\text{cm}$).
• Cervical Effacement: Measure of how thin or shortened the cervix is (expressed in percentage).
• Station: The position of the fetal presenting part relative to the maternal ischial spines.
• Amniotic Membrane Assessment:     * Evaluate for color (e.g., clear, meconium-stained).     * Assess for odor, consistency, and amount.     * Fetal Heart Rate (FHR): Must be assessed immediately following the rupture of membranes.     * Tests for Rupture:         * Nitrazine Paper: Tests pH (amniotic fluid is alkaline).         * Fern Test: Observation of dried fluid under a microscope (shows fern-like patterns).         * Immunoassay Testing: Biomarker tests for amniotic fluid proteins.

Laboratory and Diagnostic Tests

• Group B Streptococcus (GBS): Screened at $36$ to $37\,\text{weeks}$ gestation. If positive, the client is treated with prophylactic antibiotics during labor.
• Blood Type and Rh Factor: Identification of maternal blood group and Rh status.
• HIV: Viral screening.
• Hepatitis B Surface Antigen (HBsAg): Screening for active or carrier status.
• Complete Blood Count (CBC): Assessing for anemia, infection (WBC), and clotting factors (platelets).
• Rubella: Testing for immunity status.
• STI Screening: Screening for sexually transmitted infections.

Treatment, Therapies, and Nursing Care

• Individualization: Care is tailored based on the specific status of the mother and the fetus.
• Core Responsibilities: Support, education, and providing physical comfort.
• Clinical Coordination: Managing the care team and environment.
• Pain Management: Non-pharmacological and pharmacological interventions.
• Patient Advocacy: Ensuring the client's rights and wishes are upheld.
• Physical Needs:     * Nutrition and hydration.     * Elimination (bladder and bowel care).     * Ambulation and frequent position changes.     * Hygiene and supportive care.
• Cultural Competence: Respecting and integrating cultural beliefs and practices.

Fetal Assessment Strategies

• Leopold Maneuvers:     * Used to identify the position, presentation, and lie of the fetus.     * Consists of four specific steps.     * Usually performed before placing fetal monitors to ensure optimal sensor placement.
• Fetal Monitoring Types:     * Intermittent Auscultation: Using a handheld doppler or fetoscope every $15$ to $30\,\text{minutes}$ during the first stage; reserved for low-risk patients.     * Electronic Fetal Monitoring (EFM): Used for patients who are not categorized as low-risk.     * External Monitoring: External Doppler ultrasound transducer.     * Internal Monitoring: Internal fetal scalp electrode (FSE) for direct fetal ECG assessment.

Fetal Heart Rate (FHR) Patterns and Variability

• Baseline Fetal Heart Rate: The expected normal range is $110$ to $160\,\text{beats per min}$.
• Variability (Fluctuations in Baseline):     * Absent: No detectable fluctuations.     * Minimal: Fluctuations are less than $5\,\text{beats per min}$.     * Moderate: Fluctuations are $6$ to $25\,\text{beats per min}$.     * Marked: Fluctuations are more than $25\,\text{beats per min}$.
• Accelerations: Transient increases in FHR above the baseline.
• Decelerations: Decreases in FHR below the baseline (Variable, Early, Late, or Prolonged).

Analysis of Decelerations

• Variable Decelerations:     * Description: An abrupt decrease in FHR; often shaped like the letters V, U, or W.     * Cause: Umbilical cord compression.
• Early Decelerations:     * Description: A gradual decrease that mirrors the uterine contraction (starts and ends with the contraction).     * Cause: Compression of the fetal head during a contraction.     * Intervention: Typically benign; does not warrant clinical intervention.
• Late Decelerations:     * Description: The FHR decreases after the peak of the contraction and recovers after the contraction has ended.     * Cause: Uteroplacental insufficiency.     * Associations: Linked with certain maternal clinical conditions or placental abruption.
• Prolonged Decelerations:     * Definition: A decrease in the FHR of at least $15\,\text{beats per min}$ lasting between $2\,\text{min}$ and $10\,\text{min}$.     * Context: Considered a non-reassuring pattern.     * Associations: Linked with maternal hypotension, rapid cervical dilation, anesthesia, or artificial rupture of membranes.     * Outcome: If there is no recovery to the baseline, an emergent birth is necessary.
• Sinusoidal Pattern:     * Description: A smooth, undulating wave-like pattern.     * Context: A medical emergency requiring immediate intrauterine resuscitation.

Fetal Heart Rate Abnormalities and Categories

• Bradycardia: A fetal heart rate less than $110\,\text{beats per min}$ lasting for at least $10\,\text{minutes}$ or more. Requires immediate intervention. Associated with hypoxia, cord compression, cord prolapse, placental abruption, or uterine rupture.
• Tachycardia: A fetal heart rate greater than $160\,\text{beats per min}$ for more than $10\,\text{minutes}$. The goal is to correct the underlying cause, such as maternal temperature (fever) or dehydration.
• Fetal Monitoring Categories:     * Category I: Normal FHR patterns.     * Category II: Indeterminate patterns requiring monitoring and possible intervention.     * Category III: Abnormal/Non-reassuring patterns requiring immediate action.

Care Management and Intrauterine Resuscitation

• Intrauterine Resuscitation Steps:     * Repositioning the maternal client (usually to the side).     * Administration of IV fluids.     * Providing oxygen support.     * Discontinuing uterotonic medications (e.g., stopping Pitocin).     * Facilitating an emergent birth if interventions fail.
• Additional Interventions:     * Monitoring uterine activity.     * Fetal scalp stimulation to assess for a response (acceleration).     * Amnioinfusion: Infusing fluid into the amniotic cavity (often to relieve cord compression).

Questions & Discussion

• Fetal Presentation: Which fetal presentation, position, lie, and attitude are optimal for uncomplicated labor and delivery? Explain why this is the best option.
• Physiological Changes: Discuss the various physiological changes that occur in the maternal client during labor. How can the nurse support the client during these changes?
• Interventions: List the important assessments, treatments, and interventions the nurse will perform during the first stage of labor. What are some priorities to consider in the first stage of labor?

The Nursing Process (Clinical Judgment Functions)

• Recognize Cues: Assessment of the maternal-fetal unit.
• Analyze Cues: Identifying the significance of assessment data.
• Prioritize Hypothesis: Determining the most urgent needs.
• Generate Solutions: Planning nursing care and interventions.
• Take Action: Implementation of the care plan.
• Evaluate Outcomes: Assessing the effectiveness of the nursing actions.