Chapter 15: Nursing Care of a Family During Labor and Birth

Nursing Process Overview

Assessment
 Must be done quickly yet thoroughly and gently
 Remember pain is a subjective symptom
 Assess how much discomfort she experienced
 Assess how she feels about labor not only in space scale but also subtle signs of pain
Nursing Diagnosis
 Pain related to labor contractions
 Anxiety related to process of labor and birth
 Health seeking behaviors related to management of discomfort labor
 Situational low self-esteem related to inability to used planned childbirth method
Outcome Identification and Planning
 Realistic and can be met
 Incorporate support person
 Planning is flexible and individualized
Implementation
 Be carried out between contractions
Outcome Evaluation
 Patient states pain during labor was tolerable because of her advance preparation
 Patient verbalizes that her need for nonpharmacological comfort measures was met
 Patient and family members state the labor and birth experience was a positive growth
experience for them, both individually and as a family.

A. Theories of Why Labor Begins

 Labor begins between 37 to 42 weeks of pregnancy
 Factors:
1. Hormonal Factor
 Oxytocin stimulation
 Estrogen ratio change
 Fetal cortisol rising level
 Fetal membrane produce prostaglandin
2. Mechanical Factor
 Uterine muscles stretch
 Fetus press on cervix
 Placenta reach age

B. The Components of Labor

1. Passage (woman’s pelvis)
- Route of the fetus must travel from the uterus trough cervix and vagina to external
perineum

2. Passenger (fetus)
a. Structure of the Fetal Skull
 Cranium (upper, composed of 8 bones)
o 4 superior bones: frontal, 2 parietal and occipital
o Other 4 bones: sphenoid, ethmoid and 2 temporal bones

b. Diameters of the Fetal Skull

 Transverse diameter or small diameter to fit maternal pelvis
 Diameters include:
1) Biparietal or transverse (9.25 cm): smallest diameter
2) Suboccipitobregmatic (9.5 cm): smallest anteroposterior diameter
3) Occipitofrontal (12 cm): from occipital prominence to bridge of nose
4) Occipitomental (13.5 cm): widest anteroposterior diameter
 Anteposterior diameter of pelvis
  11 cm wide
 Narrowest diameter at the pelvic inlet

 Degree of flexion of fetal head

1) Full: flexes sharply, chin rest on chest; smallest anteposterior,
subbocipitobregmatic
2) Moderate: occipitofrontal diameter
3) Poor: head hyperextended; occipitomental (large diameter)

c. Molding
 Overlapping of skull bones along the suture line, cause change shape of
fetal skull to long and narrow
 Caused by force of uterine contractions

d. Fetal Presentation and Position

1. Fetal Attitude
- degree of flexion a fetus assumes
 Good: complete flexion
 Moderate: “military position”
 Partial: “brow”
 Complete extension: poor flexion

2. Fetal Lie
- relationship of long axis of fetal body to long axis of woman’s body
Note: long axis is considered cephalic

3. Fetal Presentation
- body parts that will first contact the cervix or be born first
 Cephalic: most frequent; head; had 4 types ( vertex, brow, face and
mentum); vertex is ideal presenting
 Breech: buttocks or feet; good attitude (knee flex); bad attitude (knee
extended); 3 types ( complete, frank and footling)
 Shoulder: shoulder (acromion process), an iliac crest, hand or elbow

4. Fetal Position
- relationship presenting part of to specific quadrant off side of woman pelvis
 Vetrex: occiput (O)
 Face: chin/mentum (M)
 Breech: sacrum (Sa)
 Shoulder: scapula (A)

Abbreviation of position
1st letter: landmark is pointing mother’s right or left
2nd letter: fetal landmark (O, M, Sa, A)
3rd letter: landmark points anteriorly, posteriorly or transversely

 Engagement- settling presenting part of fetus far enough into the pelvis
(floating and dipping)
 Station- relationship of presenting part of fetus to the level of ischial
spines (0= level of ischial spine; -1 to -4= floating; +1 to +5= dipping)
 Mechanisms (Cardinal Movements) of Labor
1. Descent: downward movement of biparietal diameter of fetal to
pelvic inlet
2. Flexion: head bends forward on chest
3. Internal rotation: brings shoulder to optimal position to enter the inlet
4. Extension: head extends and foremost part of the head, face and chin
5. External rotation: head rotate for final time
 6. Expulsion: shoulders are born, easy

3. Powers of Labor
a. Uterine contractions
- Rhythmicity, progressive increase in length and intensity and accompany with
dilatation of cervix

b. Origins
- Begin at pacemaker

c. Phases
- 3 phases:
1. Increment (contraction intensity increases)
2. Acme (contraction at its strongest)
3. Decrement (Intensity decrease)

d. Contour changes
- From round, ovoid structure to elongated with vertical diameter

e. Cervical changes
1. Effacement: shortening and thinning of cervical canal
2. Dilatation: enlargement or widening of cervical canal from opening a few mm
wide to one large enough (approx. 10 cm) to permit passage of fetus

4. Psyche (woman’s psychological outlook)

- Psychological state or feelings a woman bring into labor

C. The Stages of Labor

1. First Stage
- Begins with initiation of true labor contractions and ends when cervix is fully
dilated
- Take 12 hours to complete
a. Latent phase: begins at the onset of regularly perceived uterine contractions
and end with cervical dilatations begin (20 to 40 s)
b. Active phase: cervical dilation occurs rapidly (lasting 40 to 60 secs and
approx. every 3 to 5 mins)
c. Transition phase: reach peak of intensity ( occur every 2 to 3 minutes with
duration of 60 to 70 secs)

2. Second Stage
- Extending from time of full dilatation until infant is born
- Crowning presents

3. Third Stage/ Placental stage

- Lasting from the time infant is born until after the delivery
a. Placental Separation: active bleeding; Schultz (shiny and glistening); Duncan
(raw, red and irregular); (1 to 30 mins)
b. Placental Expulsion

D. Maternal and Fetal Responses to Labor

1. Maternal Physiologic Effects and Psychological Responses
a. Response to Pain
b. Response to Fatigue
c. Response to Fear

2. Fetal Responses to Labor

 a. Neurologic System
b. Integumentary System
c. Cardiovascular System
d. Musculoskeletal System
e. Respiratory System

E. Maternal and Fetal Assessments During Labor

1. Maternal Danger Signs of Labor
a. High or low blood pressure
b. Abnormal pulse
c. Inadequate or prolonged contractions
d. Abnormal lower abdominal contour
e. Increasing apprehension

2. Fetal Danger Signs of Labor

a. High or low fetal heart sounds
b. Meconium staining
c. Hyperactivity
d. Low oxygen saturation

F. Maternal and Fetal Assessment During Labor

1. Immediate Assessment of Woman in First Stage of Labor
a. Initial interview and physical examination
2. Detailed Assessment During the First Stage of Labor
a. History
 Current pregnancy history
 Past pregnancy history
 Past health history
 Family medical record

b. Physical Examination
 Abdominal and lower leg assessment
 Determining fetal position, presentation and lie
1. Determine the place on woman’s abdomen
2. Leopold Maneuvers: systematic method of observation and
palpation to determine fetal position and presentation
3. Vaginal Examination: to determine extent of cervical
softening, effacement and dilatation and to confirm fetal
presentation, position and degree of descent
4. Sonography: to determine diameters of fetal skull and
determine presentation, position, flexion and degree of
descent

c. Assessing Rupture Membranes

 Sterile vaginal examination: vaginal secretions is acid while amniotic fluid
is alkaline
 Ask to describe color, amount, approximate time of rupture

d. Assessment of Pelvic Adequacy

 Using internal conjugate and ischial tuberosity diameters

e. Vital Signs
 Temperature: report greater than 99 degree Fahrenheit (37.2 degree
Celsius)
 Pulse and Respiration: pulse ( range between 70 to 80 beats/min);
respiration (18 to 20breaths/min)
 Blood pressure: rise 5 to 15 mmHg during contractions
 f. Laboratory Analysis
 Blood
 Urine

g. Assessment of Uterine Contractions

 Length
 Intensity: mild (minimally tense); moderate (uterus firm); strong (uterus
feel like wooden board)
 Frequency

3. The Initial Fetal Assessment

a. Auscultation of Fetal hear Sounds
- Transmitted best through convex portion
 Vertex/breech: heard at fetal back
 Face: more convex thorax
 Breech: uterus or umbilical cord of woman
 Cephalic: lower abdomen
 ROA: right lower quadrant
 LOA: left lower quadrant
 LOP or ROP: woman’s side

4. Electric Monitoring
- Set with automatic alarm that triggers FHR goes below 110 beats per min or
above about 170 beats/min
 Initial electric monitoring: noninvase, easily applied and does not require
cervical dilation

5. Fetal Heart Rate and Uterine Contraction Records

 Record on paper rolls
 Uterine contractions: bottom half paper
 FHR: top half paper

6. Fetal Heart Rate Parameters

a. Baseline Fetal Heart Rate
- Normal rate is 110 to 160 beats per min
b. Variability
- Diff between highest and lowest heart rate
 Absent: no amplitude
 Minimal: 5 beats/min or fewer
 Moderate: 6 to 25 beats/ min
 Marked: greater than 25 beats/min

c. Periodic Changes
- Fluctuation in FHR occur in response to contractions and fetal movement
- Described in term of acceleration or deceleration

d. Sinusoidal Pattern

G. The Care of Woman During the First Stage of Labor

Six major concepts to make labor and birth as natural as possible are:
1. Labor should begin on its own, not be artificially induced.
2. Women should be able to move about freely throughout labor, not be confined to bed.
3. Women should receive continuous support during labor.
4. No interventions such as intravenous fluid should be used routinely.
5. Women should be allowed to assume a nonsupine (e.g., upright, side-lying) position for birth.
6. Mother and baby should be together after the birth, with unlimited opportunity for
breastfeeding
 Nursing Interventions:
Powerlessness related to duration of labor
 Help empower women
 Respect contraction time
 Promote change position
 Help with fetal alignment
 Promote voiding and provide bladder care
Risk ineffective breathing pattern related to breathing exercises
 Offer support
 Respect and promote the support person
 Support woman’s pain management needs

H. The Care of a Woman During the Second Stage of Labor

1. Prepare place of birth
2. Position for birth
3. Water birth
4. Promoting effective second-stage pushing
5. Perineal cleaning and massage
6. The birth
7. Cutting and clamping the cord
8. Introducing the infant

I. The Care of a Woman During the Third and Fourth Stages of Labor
1. Delivery of placenta
2. Perineal inspection
3. Immediate postpartum assessment and nursing care

J. The Woman with Unique Concerns in Labor

1. Woman without support person
2. Woman who will be placing baby for adoption
3. Woman with cultural concerns

K. The Woman Who is Morbidly obese