Nursing Care of Mother and Infant During Labor and Birth

Chapter 6: Nursing Care of Mother and Infant During Labor and Birth

The Process of Labor

• Labor is the physiological process whereby the fetus, placenta, and amniotic membranes are expelled from the uterus.

• Note: The labor process follows a fairly predictable sequence of events.

Factors Contributing to Onset of Labor

• Hormones play a significant role in initiating labor. like estrogen , protgesteron, and oxytocin (produced more once uterus stretches) = irritability which makes the utureous to contract all contribute to the regulation of uterine contractions and the softening of the cervix, helping to facilitate the birthing process.

• Stretching of the uterus signals the onset of labor → stimulates production or secreations of prostaglandins, which further promote cervical dilation and enhance uterine contractions.

• Interplays among the following components:

  • Placenta → produces hormones that assist in maintaining pregnancy and preparing the body for labor, such as human chorionic gonadotropin (hCG) and relaxin, which aids in the softening of the cervix and pelvic ligaments.

  • Fetal pituitary gland → secretes hormones such as adrenocorticotropic hormone (ACTH) that influence the mother's adrenal glands, leading to increases in cortisol, which aids in the maturation of fetal organs and prepares the baby for birth.

  • Hypothalamus → regulates the release of hormones essential for labor, including oxytocin, which stimulates uterine contractions and helps facilitate the birth process.

  • Adrenal glands → produce epinephrine and norepinephrine, which increase heart rate and blood pressure, ensuring adequate blood flow to both the mother and fetus during labor.

Factors that Influence the Progress of Labor

• Preparation for labor and delivery is crucial.

• Position of the laboring woman can affect labor dynamics. IS the baby in the right position

• Professional presence and support can influence labor outcomes.

• Place of delivery impacts the labor experience.

• Procedures performed during labor can affect its progress.

• People involved provide psychological and emotional support.

Components of the Birth Process

• The birth process is defined by four essential components, known as the four “Ps”:

  • Pelvis: Size and shape of the pelvis.

  • Passenger: Size and position of the fetus.

  • Powers: Effectiveness and strength of uterine contractions.

  • Psyche: The psychological state of the mother, including her preparation and previous birth experiences.

  • occiput anterior (OA): The ideal fetal position for birth, where the back of the baby's head is facing the mother's abdomen, which can facilitate a smoother delivery.

  • Breech presentation: A non-ideal fetal position where the baby's buttocks or feet are positioned to come out first, often requiring special management and interventions during delivery.

The Passage

• Bony Pelvis: Fundamental to the birth process.

• Soft Tissues:

  • In women who have delivered previously, these tissues yield more effectively to contractions and pushing efforts.

  • In primiparas (first-time mothers) or older women, the soft tissues may resist yielding to contractions.

The Passenger

• The passengers involved in the labor process include:

  • Fetus: The unborn child.

  • Placenta: The organ that provides nutrients to and removes waste from the fetus.

  • Membranes: The amniotic sac and membranes surrounding the fetus.

  • Amniotic fluid: The fluid in which the fetus floats, providing cushioning and growth support.

The Fetal Skull

• Key Anatomical Features:

  • Coronal Suture

  • Sagittal Suture

  • Frontal Bone

  • Parietal Bone

  • Occipital Bone

• Important Measurements:

  • Biparietal diameter = $9.5 ext{ cm}$

  • Supraoccipitomental diameter = $13.5 ext{ cm}$

  • Submentobregmatic diameter = $9.5 ext{ cm}$

  • Occipitofrontal diameter = $11 ext{ cm}$

  • Suboccipitobregmatic diameter = $9.5 ext{ cm}$

Fetopelvic Relationship

• Fetal Attitude: Refers to the relationship of fetal parts to each other (flexion, extension).

• Fetal Lie: Orientation of the fetus in relation to the mother's spine (longitudinal, transverse).

• Fetal Presentation: The part of the fetus that presents at the cervix (cephalic, breech).

• Fetal Position:

  • Indicated as:

    • R (right), L (left),

    • O (occiput), S (sacrum), M (mentum [face])

    • A (anterior), P (posterior).

The Power: Uterine Contractions

• Mechanics of Contractions:

  • Begin at the top of the uterus (fundus) and spread throughout the uterus within approximately 15 seconds.

  • Retraction (Brachystasis): Uterine muscles maintain their shortened state after contraction, leading to a decrease in the size of the uterine cavity and thickening of the muscle tissue at the upper portion.

  • This mechanism encourages downward movement of the fetus.

Uterine (Labor) Contractions

• Each contraction must be followed by a period of relaxation. INTERVAL between contractions allows the uterus to regain its tone and provides adequate blood flow to the placenta, ensuring that the fetus receives necessary oxygen and nutrients. IT SHOULD NOT BE LESS THAN 30 SECONDS

• Contractions can lead to decreased blood flow through: SHOULD NOT LAST MORE THAN 90 SECONDS → CAN CUT OFF BLOOD SUPPLY TO THE BABY

  • Uterine arteries

  • Intervillous spaces.

• This decline can result in a decrease in the fetal heart rate (FHR).

Contractions and Maternal Position

• Supine position:

  • More frequent contractions but with reduced strength.

• Side-lying position:

  • Less frequent contractions but higher intensity.

  • Benefits include improved progress of labor and enhanced oxygenation of the fetus.

Contractions and the Cervix

• Contractions efface (thin) and dilate (open) the cervix.

• Before the onset of labor, the cervix is typically a 2-cm tubular structure.

• Contractions push the fetus downward while simultaneously pulling the cervix upward, resulting in the cervix becoming thinner and shorter.

• Effacement is assessed through vaginal examination, described as a percentage of the original cervical length.

• If it is 1 cm it is 50% efface if it is 2 cm it is 0% effaced, indicating that no thinning has occurred if paperlike thin 100% effaced

Cervical Effacement and Dilation

• Cervical components include:

  • Internal os (opening of the cervical canal into the uterus) and external os (opening of the cervical canal into the vagina), both of which play a crucial role in labor progression and birth.

Station

• Station refers to how far the fetal presenting part has descended into the mother’s pelvis. The station is measured in relation to the ischial spines, which are bony protrusions in the pelvis; a station of 0 indicates that the fetal head is engaged at the level of the ischial spines, while positive numbers indicate descent into the birth canal.

• EX: internal exam shows 3 cm dilated 30% effaced -3 indicates that the fetal head is situated above the ischial spines, suggesting that further descent is needed for effective labor progression.

Characteristics of Uterine Contractions

• Frequency: The time from the beginning of one contraction to the beginning of the next.

• Duration: The time from the beginning to the end of the same contraction (should not exceed 90 seconds).

• Intensity: Strength of contractions: mild (nose), moderate (jaw bone), or strong(forehead)

• Interval: Amount of time the uterus relaxes between contractions (should not be less than 30 seconds).

Assessment Cycle of Contractions

• Increment: Increase in intensity leading to the peak (acme).

• Decrement: Gradual decrease in intensity, leading to relaxation.

• Duration: Measured in seconds.

• Frequency: Measured in minutes and fractions of a minute.

The Psyche: Psychological Aspect

• Anxiety or fear can diminish a woman’s coping abilities during labor.

• Maternal catecholamines (stress hormones) can inhibit uterine contractions and reduce placental blood flow.

• Relaxation significantly enhances the natural labor process and energy conservation is emphasized until the expulsion phase.

Signs of Impending Labor

• Braxton Hicks (painless) contractions may become more frequent.

• Noticeable lightening or fetal descent. the baby drop

• Increased vaginal discharge. not a sign of true labor and does not indicate that labor is imminent.

• Presence of a bloody show.

• Rupture of the membranes (water breaking).

• An energy spurt (nesting instinct) often occurs.

• Potential weight loss due to fluid loss.

Mechanisms of Labor (EDFIE3)

1. Engagement: Fetal presenting part reaches station 0 or lower.

2. Descent: Movement of the fetus down the birth canal.

3. Flexion: Chin to chest position facilitates passage.

4. Internal Rotation: Fetal occiput rotates to an anterior or posterior position.

5. Extension: Fetal head extends as it emerges from under the pubic symphysis.

6. External Rotation: Fetal shoulders rotate to the anterior-posterior position.

7. Expulsion: Birth of the fetus.

When to Go to the Hospital or Birth Center

• Notable contractions. every 3-5 minutes and if it continues even when resting     

• Ruptured membranes can also indicate that it is time to seek medical assistance, especially if the fluid is green or brown, suggesting meconium presence. Cord prolapse is another critical indicator that requires immediate medical attention, as it can compromise the baby's oxygen supply during labor.

• Bleeding unrelated to the bloody show is a concerning sign that should prompt immediate evaluation, as it may indicate complications such as placental abruption or placenta previa.

• Notable decreased fetal movement.

• Any other areas of concern or distress.

Admission Data Collection

• Three major assessments conducted promptly upon admission:

  • Fetal condition.

  • Maternal condition.

  • Impending birth assessment.

Admission Procedures

• Completion of necessary permits and consents.

• Laboratory tests as required.

• Initiation of intravenous infusion if necessary.

• Perineal preparation as indicated.

• Determining fetal position and presentation appropriately.

Comparison of False and True Labor

• False Labor Characteristics:

  • Irregular contractions.

  • Relief upon walking.

  • Usually no bloody show.

  • No significant changes in effacement or dilation.

• True Labor Characteristics: CONTRACTIONS AND DILATION

  • Regular pattern of contractions that become progressively stronger with ambulation.

  • Discomfort manifests in the lower back or abdomen.

  • Presence of a bloody show.

  • Progressive cervical effacement and dilation.

Nursing Care Before Birth

• Immediate nursing care upon admission involves:

  • Monitoring the fetus continuously.

  • Monitoring the laboring woman continually.

  • Assisting the woman with coping strategies for labor.

Monitoring the Fetus

• Fetal Heart Rate (FHR)

  • Monitor every 30 minutes during the active, first phase of labor.

  • Monitor every 15 minutes in the second stage and preferably before each contraction.

  • Risk factors present:

  • Monitor every 15 minutes in active first stage.

  • Monitor every 5 minutes during the second stage.

• Types of Monitoring:

  • Intermittent auscultation

  • Continuous electronic fetal monitoring

Determining Fetal Position by Abdominal Palpation

• Leopold’s Maneuvers:

  • Used to determine fetal position.

  • Can reveal if a multifetal pregnancy exists, especially in women without prenatal care.

  • Helps locate the best position for auscultating FHR.

  • Fetal hr is best heard in the RLQ the head is in vaginal canale and the back in the left lateral position, allowing for optimal sound transmission.

  • LUQ or Above the umbillicus is breeched

  • if below the umbillicus is syphalic or head

Intermittent Fetal Heart Monitoring During Labor

• Monitoring Method:

  • Low-risk technology via intermittent auscultation with a hand-held Doppler or fetoscope.

  • Assess at 15-minute intervals during the first stage of labor.

  • Assess at 5-minute intervals during the second stage of labor.

Reassessment of FHR

• Indicators for reassessment include:

  • Rupture of membranes (ROM)

  • Vaginal examination

  • Ambulation (before and after)

  • Change in the infusion rate of oxytocin

  • Administration of drugs (before and after)

  • Urinary catheterization

  • Expulsion of enema

  • Recognition of abnormal uterine activity

  • Decrease in fetal activity

External Fetal Monitoring

• Components:

  • Ultrasound transducer and tocometer are applied to the woman’s abdomen.

  • Secured with elastic strips, belts, or stockinette.

  • Sound waves are utilized for monitoring.

• Uterine Contractions:

  • Can be monitored for frequency and duration.

  • Cannot monitor for uterine intensity.

Signs of Fetal Distress

• Observations to Report:

  • A loss of baseline variability.

  • Variable or late decelerations that persist after maternal position changes.

  • Persistent fetal tachycardia.

Internal Fetal Monitoring

• Advantages:

  • Higher accuracy as the main advantage.

• Requirements:

  • Requires ruptured amniotic membranes.

  • The cervix must be dilated to at least 2 cm.

  • Attach a spiral electrode to the fetal presenting part.

  • Introduce a pressure transducer into the uterine cavity.

Normal Fetal Heart Rate Pattern

• Typically, a heart rate between 110 to 160 beats/min.

• Beat-to-beat variability is between 6 and 25 beats/min. change from the baseline

• No decelerations but may see accelerations.

Accelerations

• Definition: Brief, temporary increases in FHR at least 15 beats/min above baseline.

• Causes:

  • Usually occur with fetal movements.

  • May occur with vaginal examinations, uterine contractions, or fundal pressure.

  • Vibroacoustic stimulation can help elicit fetal movements.

Decelerations

• Definition: Transitory decreases in FHR from baseline.

• Types of Decelerations:

  • Early

  • Late → take care of immediately

  • Variable

Reassuring and Nonreassuring Fetal Activity Patterns

• Reassuring Patterns:

  • Stable FHR

  • Moderate variability

  • Accelerations present

  • Uterine contractions described by:

  • Frequency greater than every 2 minutes.

  • Duration less than 90 seconds.

  • Relaxation interval of at least 60 seconds.

• Nonreassuring Patterns:

  • Tachycardia

  • Bradycardia

  • Decreased or absent variability; little fluctuation in rate.

  • Late decelerations

  • Variable decelerations

Emergency Interventions for Nonreassuring Heart Rate

• Immediate actions:

  • Administer oxygen to the woman: 8 to 10 L/min by face mask.

  • Turn the woman to a side-lying position.

  • Stop oxytocin infusion.

  • Keep IV line open and increase fluid.

  • Notify the healthcare provider.

Variable Decelerations

• Characteristics:

  • Transient drops in FHR before, during, or after uterine contraction.

  • Related to brief compression of the umbilical cord.

  • Abrupt decelerations are often associated with accelerations before or after.

  • Requires a position change of the woman to alleviate effects.

Nurse’s Role in Electronic Fetal Monitoring (EFM)

• Continually assess whether the FHR pattern is:

  • Reassuring, indicating adequate fetal oxygenation.

  • Non-reassuring, indicating fetal distress, which necessitates appropriate interventions.

Monitor Strips Documentation

• Document on the strip (or in the computer) each time an action occurs, such as vaginal examinations or voiding.

• Important for assessment of tracing strips and providing permanent documentation of care provided.

• Record the time EFM was discontinued and restarted.

VEAL CHOP MINE Nursing Mnemonic

• FHR Pattern (VEAL) | Cause (CHOP) | Management (MINE)

  • Variable deceleration | Cord compression | Maternal repositioning

  • Early deceleration | Head compression | Identify labor progress

  • Acceleration | Okay! | No interventions

  • Late deceleration | Placental insufficiency | Execute interventions

• Helpful tool for fetal heart rate monitoring concepts.

Inspection of Amniotic Fluid

• Color:

  • Normal is clear fluid; may have flecks of white vernix.

  • Green-stained indicates meconium passage, which may lead to fetal compromise.

• Odor:

  • Should not have a smell.

  • An odor may indicate an infection.

• Amount:

  • Scant: trickle.

  • Moderate: ~500 mL.

  • Large: ≥1000 mL.

Monitoring the Woman

• Assessment Areas:

  • Vital signs

  • Contraction patterns

  • Progress of labor

  • Intake and output

  • Response to labor

Helping the Woman Cope with Labor

• Support Techniques:

  • Labor support and teaching.

  • Providing encouragement.

  • Supporting and teaching the partner on how to assist.

  • Explain the impact of labor pains on the woman’s behavior and how partners can respond.

  • Discussing expectations regarding emotional responses.

  • Addressing the effects of epidural analgesia.

Stages and Phases of Labor

• Stages:

  • First stage: dilation and effacement (can last 4 to 6 hours).

  • Second stage: expulsion of fetus (30 minutes to 2 hours).

  • Third stage: expulsion of placenta (5 to 30 minutes).

  • Fourth stage: recovery.

Phases of the First Stage of Labor

• Phases:

  • Latent

  • Active

  • Transition

Latent Phase

• Dilation: 0 cm to 5 cm.

• Contractions Characteristics:

  • Contractions stabilize, usually mild.

  • Frequency: 5 to 30 minutes.

  • Duration: 30 to 45 seconds.

• Behavioral Responses:

  • Can walk through most contractions.

  • Talkative or calm and able to focus on teaching.

  • Coping well with the experience.

• Monitoring:

  • BP, PR, and RR every 30 to 60 minutes.

  • Temperature every 2 to 4 hours.

  • FHR every 30 to 60 minutes.

Active Phase

• Dilation: 5 to 10 cm.

• Contractions Characteristics:

  • More regular, moderate to strong.

  • Frequency: 3 to 5 minutes.

  • Duration: 40 to 90 seconds.

• Behavioral Responses:

  • More serious, pain is more severe.

  • Nausea, vomiting, and urge to push may occur.

• Monitoring:

  • BP, PR, RR every 25 to 30 minutes.

  • FHR every 15 to 30 minutes.

Second Stage of Labor

• Characteristics:

  • Begins when the cervix is completely dilated and ends with the birth of the fetus.

  • The woman may feel an urge to bear down.

  • Encourage not to hold breath more than 5 seconds while pushing; prevents Valsalva’s maneuver.

  • Use open-glottis breathing: air is released through the mouth during pushing.

• Monitoring:

  • BP, PR, and RR every 5 to 30 minutes.

  • FHR every 5 to 15 minutes and immediately after birth.

Characteristics of Second Stage of Labor

• Can last from a few minutes to 2 hours.

• Fetal head causes bulging of perineum; crowning occurs when the head is seen at the external vaginal opening.

• Head may appear to recede between contractions.

• Contractions:

  • Forceful, every 2 to 3 minutes lasting 60 to 90 seconds.

  • Increased bloody show usually occurs.

Episiotomy

• May be performed to shorten the second stage of labor and prevent perineal laceration.

• Not routinely performed.

Delivery of Fetus

• Suction nose and mouth once the head is delivered. Dry baby , temp and respiration assessment should be conducted immediately after suctioning to ensure stability.

• Once the body is delivered, clamp umbilical cord in two places and cut it.

• Nasal and oral suction may be repeated.

• Baby is handed off to a pediatric nurse and pediatrician for examination.

• The mother receives care from an obstetrician or nurse-midwife.

Third Stage of Labor

• Referred to as the placental separation stage.

• Duration: Begins with the birth of the fetus and ends with the expulsion of the placenta; can last up to 30 minutes.

• Methods of Delivery: Duncan and Schultze methods for placental delivery.

• Monitoring: BP, PR, and RR every 15 minutes.

Fourth Stage of Labor

• Characteristics:

  • Stage of recovery, begins at delivery of the placenta.

  • Lasts 1 to 4 hours or until mother’s vital signs stabilize.

• Blood Loss: 250 to 500 mL, leading to:

  • Drop in blood pressure.

  • Increase in pulse rate.

• Monitoring:

  • BP, PR, RR every 15 minutes for the first 2 hours after birth.

  • Temperature checked every 4 hours for the first 8 hours and then at least every 8 hours.

Nursing Care in the Fourth Stage of Labor

• Assess uterine fundus and lochia every 15 minutes for the first hour and then as necessary.

• Massage the uterine fundus and/or administer oxytocics to prevent hemorrhage.

• Encourage voiding to prevent bladder distention, which can cause uterine atony.

• Promote opportunities for maternal/newborn bonding.

• Offer assistance with breastfeeding.

Uterus in Fourth Stage of Labor

• Must stay contracted to compress open blood vessels at the placental site.

• Palpable as a firm, rounded mass at or below the level of the umbilicus.

• The first hour after delivery is critical for observing the mother for signs of excessive bleeding and assessing the firmness of the contracting uterus.

Vaginal Birth After Cesarean

• Main Concern:

  • Risk of uterine rupture can disrupt placental blood flow and lead to hemorrhage.

  • Women may require more support than other laboring women.

  • Nurses provide empathy and support.

Nursing Responsibilities During Birth

• Prepare delivery instruments and infant equipment.

• Perform perineal scrub.

• Administer medications as required.

• Provide initial care to the infant.

• Assess Apgar score.

• Evaluate the infant for obvious abnormalities.

• Examine the placenta.

• Identify mother and infant for recordkeeping.

• Promote parent-infant bonding.

Immediate Postpartum Period Nursing Care

• Care Focus:

  • Identify and prevent hemorrhage.

  • Evaluate and intervene for pain management.

  • Monitor bladder function and urine output.

  • Evaluate recovery from anesthesia.

  • Provide initial care to the newborn infant.

  • Promote bonding and attachment between the infant and family.

Nursing Care Immediately After Birth (1 of 2)

• Mother Care:

  • Monitor for hemorrhage: vital signs, skin color, location and firmness of uterine fundus, lochia, and pain.

  • Promote comfort: keep warm and dry, apply ice to perineum to reduce swelling and bruising.

Nursing Care Immediately After Birth (2 of 2)

• Newborn Care:

  • Phase 1: From birth to 1 hour (usually in delivery room).

  • Phase 2: From 1 to 3 hours (usually in transition nursery or postpartum unit).

  • Phase 3: From 2 to 12 hours (usually in postpartum unit if rooming-in with the mother).

Phase 1: Care of the Newborn

• Initial care includes:

  • Maintaining thermoregulation.

  • Maintaining cardiorespiratory function.

  • Monitoring for urination and passage of meconium.

  • Identifying the mother, father, and newborn.

  • Perform a brief assessment for major anomalies.

  • Encourage bonding and breastfeeding.

Apgar Scoring

• Components:

  • Heart rate

  • Respiratory effort

  • Muscle tone

  • Reflex response to suction or gentle stimulation on the soles of the feet

  • Skin color

The Apgar Score Table

• Total Scores:

  • 0-3: Severely depressed

  • 4-6: Moderately depressed

  • 7-10: Excellent condition

Administering Medications to the Newborn

• Eye Care: Administer erythromycin eye ointment 1 hour after birth.

• Vitamin K: Administer IM through the vastus lateralis (Aqua MEPHYTON/Phytonadione). pick the medial middle third

Observing for Major Anomalies

• Assess for head trauma from delivery.

• Check for symmetry and equality of extremities:

  • Are limbs of equal length and movement capability?

• Inspect digits of hands and feet for any evidence of webbing or abnormal number of digits.

Umbilical Cord Blood Banking

• This type of blood can regenerate stem cells that replace diseased cells.

• Informed consent is essential.

• Collect blood after the cord has been clamped.

• Blood must be transported within 48 hours of collection to a blood banking facility.