Labor and Delivery

Components of Labor

1. Power (Uterine Contractions)

a. Frequency: from the beginning of one contraction to the beginning of the next contraction
b. Duration: from the beginning of one contraction to the end of that same contraction
c. Intensity: strength of contraction, measured with fingertips lightly on the fundus (mild, moderate.
and strong); accurate measurement can only be made with an internal monitor
d. Regularity: establish a pattern that increases in frequency and duration
e. Effacement: thinning of cervix, 0-100%
f. Dilatation: opening of cervix, 0-10 cms
2. Passenger (Fetus)
a. Lie: relationship of the cephalocaudal axis of the infant to the cephalocaudal axis of the mother
1. Transverse lie
2. Longitudinal lie
b. Presentation: body part of the passenger that enters. The pelvic passageway first is called the
“presenting part”
1. Cephalic
a. Vertex: occiput (most common)
b. Brow: sinciput
c. Face: mentum
2. Breech
a. Complete: sacrum
b. Frank
c. Footling
3. Shoulder
c. Position: relationship of the landmark on the presenting fetal part to the front sides, and back of the
maternal pelvis
1. Pelvis is divided into six areas anterior, transverse, or posterior; left or right side
2. Fetal landmarks are: occiput (O), mentum (M), sacrum (S), and scapula (Sc)
3. Most common is left occiput anterior (LOA)
d. Attitude or habitus: to the relationship of the fetal parts to one another, usual is "fetal posh ion"
1. Station: the relationship between the presenting part and the ischial spines;
O-station is engagement
e. Cardinal movements of descent
i. Descent
ii. Flexion
iii. Internal rotation
iv. Extension
v. External rotation or restitution
3. Passageway (Maternal Pelvis)
a. False pelvis helps support pregnant uterus
b. True pelvis forms bony canal; inlet, pelvic cavity, outlet
c. Types
i. Gynecoid: normal female (50%), best for delivery
ii. Android: normal male (20%), not favorable
iii. Platypelloid: flat female pelvis (5%), not favorable
iv. Anthropoid: apelike (25%), favorable
d. Cephalo-pelvic disproportion (CPD)
4. Psyche
a. Physical preparation for childbirth
b. Cultural heritage
c. Previous experience
d. Support systems
e. Self-esteem
Fetal Assessment

1. Sonogram
1. Purpose
1. Locate placenta
2. Diagnose multiple pregnancy
3. Identify some congenital anomalies
4. Determine gestational age
2. Nursing Interventions
1. Assure that client has a full bladder
2. Provide client education
2. Fetal Monitoring
1. Purpose
1. Determine fetal heart rate (FHR): normal is 110-160BPM
2. Recognize periodic changes in FHR
3. Determine frequency and duration of contractions

2. Types

1. Auscultation with fetoscope; palpation

2. External electronic monitoring
3. Internal electronic monitoring
1. Provides actual intrauterine pressures
2. Provides beat-to-beat variability of the FHR, which is an
indication of the sympathetic and parasympathetic
nervous system status
3. Periodic changes
1. Early decelerations: head compression
2. Variable decelerations: cord compression
3. Late decelerations: uteroplacental insufficiency
4. Accelerations: usually a sign of fetal well-being

3. Non-Stress Test (NST)

1. Purpose
1. Assess fetal well-being
2. Look for increase in FHR (accelerations) with fetal activity (reactive NST)
2. A non-reactive, non-stress test is NOT reassuring
4. Contraction Stress Test
1. Types
1. Oxytocin challenge test (OCT)
2. Nipple stimulation test
2. Purpose
1. Look for three contractions in 10 minutes
2. No late decelerations determines fetal well-being
3. A negative CST is reassuring
5. Biophysical Profile
1. Purpose
1. Determine fetal well-being after questionable NST
2. Determine amount of amniotic fluid
2. Nursing Interventions
1. Provide client education
2. Provide emotional support
6. Amniocentesis (performed after 16th week)
1. Purpose
 1. Determine fetal anomalies, sex, fetal maturity
2. Determine lecithin-sphingomyelin (L/S) ratio, bilirubin levels, creatine levels
2. Nursing Interventions
1. Provide client education
2. Assess for premature labor, hemorrhaging
3. Provide RhoGAM for Rh negative client because there is a risk for micro blood transfer and
sensitization.
4.
7. Chorionic Villi Sampling
1. Purpose
1. Determine fetal anomalies, genetic defects
2. Early test: 8-10 weeks
2. Nursing Interventions
1. Provide client education
2. Provide RhoGAM for Rh negative client after procedures

Signs of Impending Labor

1. Lightening- head descent to pelvis

2. Braxton-Hicks Contractions
3. Weight Loss (one to three pounds)
4. Cervical Changes
5. Increase in Back Discomfort
6. Bloody Show
7. Rupture of Membranes
1. Client should contact primary care provider
2. Nursing Interventions
1. Monitor FHR
2. Check for prolapsed cord
3. Test vaginal secretions for alkalinity with Nitrazine paper blue
4. Watch for signs of infection/meconium
8. Sudden Burst of Energy

STAGES OF LABOR
STAGES CHARACTERISTICS INTERVENTIONS
 - First Stage: ("stage of - Duration: - Admission; assessment:
dilatation") begins true medical and OB history, vital
labor, ends with complete -primigravida 3.3-19.7 hours; signs, FHRs, signs of labor,
cervical dilatation; weight, vaginal exam (if no
composed of three phases -multigravida 0.1-14.3hours active vaginal bleeding)

- Latent phase - 0-4 cm dilatation; mild to - Diversional activities; time

moderate contractions q 15-20 contractions; assess
min, lasting 10-30 seconds; maternal-fetal status; pelvic
backache, cramping, bloody rock: promote hydration; use
show; mother talkative, breathing patterns; evaluate
cheerful, anxious labor progress

- 5-7 cm dilatation; strong - Assess maternal-fetal status;

- Active phase contractions 3-5 minutes, backrubs; comfort measures;
lasting 30-60 seconds mother may feel
apprehensive; provide
- Transitional phase - 8-10 cm dilatation; strong encouragement; provide
contractions of 2-3 min, lasting analgesia or anesthesia if
50-90 seconds; legs may requested and is appropriate:
cramp; nausea/vomiting, promote hydration and
perspiration on forehead and elimination; keep perineum
upper lip; dark, profuse bloody clean; promote rest between
show; mother may have contractions; evaluate labor
amnesia between progress
contractions, is irritable,
anxious, and self-oriented - Assess maternal-fetal status;
provide much reassurance;
provide comfort measures;
pant/blow with pushing urges;
be supportive and help mother
maintain control with
breathing; evaluate labor
progress

- Second stage: ("stage of - Duration; primigravida .3-1.9 - Assess maternal-fetal status;

delivery") begins with hrs; multigravida .9-.69 hours; coach pushing; promote
complete dilatation of the contractions 2-3 minutes, comfort; record time of
cervix and ends with lasting 50- 90 seconds; client delivery,
delivery has urge to push and is episiotomy/lacerations,
exhausted medications, or anesthetics;
evaluate labor progress

- Third stage: ("placental - Mild contractions; continue - Assess maternal status,

stage") begins with delivery until placenta is expelled, blood loss; note time of
of infant; ends with delivery normally within 30 minutes; placenta delivery; administer
of placenta client may have to push to an oxytocic after placental
help expel placenta separation, if ordered;
promote bonding

- Fourth stage: ("stage of - Cramping uterine discomfort; - Assess vital signs (BR, P
recovery") the first hour rubra vaginal discharge with and R) fundus, lochia, bladder
after delivery or until stable small clots; discomfort if and perineum q 15 mm. for
episiotomy done; client feels 1st hr., q 30 min., second hr.;
happy, relieved, excited temp, xl; encourage hydration
and elimination; promote
comfort; ice to perineum if
painful; promote bonding
Analgesia/Anesthesia for Labor and Delivery
1. Analgesics: butorphanol tartrate (Stadol), nalbuphine hydrochloride (Nubain), meperidine hydrochloride
(Demerol); often mixed with hydroxyzine HCI (Vistaril) or promethazine HCI (Phenergan) to potentiate; do
not give if within 2 hours of delivery— infant may be depressed and require naloxone HCI (Narcan)
2. Local anesthetic: given locally into perineal tissue during second stage just prior to delivery
3. Paracervical: numbs cervix; good for 1st stage of labor; should not be given after dilation of 8 cms (danger
of injecting fetal head); can cause fetal bradycardia
4. Pudendal: numbs vagina and perineum; good for 2nd stage, large episiotomy, or if anterior posterior repair
is to follow delivery
5. Epidural: numbs from the waist down
1. Nursing interventions: take BP q 5 minutes until stable; assess bladder; assist in turning and
pushing; hydrate client; assess fetal heart rate
2. Complications: hypotension and fetal distress; turn client on side, increase IV rate, give oxygen
6. Saddle (spinal): numbs from waist down
1. Complications; headaches, may need blood patch
2. Nursing interventions: use good body mechanics when moving client
7. General: used primarily for emergency cesarean section

Complications During Labor and Delivery

1. Fetal Distress
1. Etiology
1. Uteroplacental insufficiency
1. Acute uteroplacental insufficiency
1. Excessive uterine activity associated with oxytocin (Pitocin)
2. Maternal hypotension: epidural, venacaval compression, supine position,
internal hemorrhage
3. Placental separation: abruptio, previa
2. Chronic uteroplacental insufficiency
1. PIH
2. Diabetes
3. Postmaturity
2. Nursing Interventions
1. Position client on left side
2. Start IV or increase rate
3. Administer oxygen
4. Notify primary care provider
5. Monitor FHR continuously

Potip

Pitocin off

Oxygen 8 10 by mask

Turn on side

Increase IV

Prepare for C section

2. PROM (Premature Rupture of Membrane)

1. Etiology
1. Infection
2. Trauma
2. Nursing Interventions
1. Assess FHR
2. Assess for infection
3. Assess for prolapsed cord
3.
Umbilical Cord Compression
1. Etiology
1. Prolapsed cord
1. Causes: abnormal presentation, inadequate pelvis, presenting part at high station,
multiple gestation, prematurity, PROM, polyhydramnios
2. Complications: fetal asphyxia
3. Nursing Interventions
1. Keep hand in vagina; push presenting part away from cord
2. Continuously assess fetal welfare by pulsation of the cord
3. Place client in Trendelenburg or knee-chest position
4. Prepare for c-section; type and cross match blood; start IV; obtain consent
2. Nuchal cord (cord around neck)

4. Premature Labor
1. Etiology
1. Chronic pyelonephritis
2. Incompetent cervix
3. Multiple pregnancy
4. History of premature births
5. Sepsis
6. Placental disorders
2. Nursing Interventions
1. Place client on bed rest
2. Assess for signs of infection; monitor vital signs; FHR
3. Administer ritodrine HCI (Yutopar), terbutaline, (Brethine) or magnesium sulfate as ordered to
stop premature labor.
4. Provide emotional support
5. Administer betamethasone (Celestone) to promote fetal lung development.
6. Delivery if near term

5. Amniotic Fluid Emboli

1. Definition: amniotic fluid in blood stream
2. Often happens at delivery
3. Emergency situation, often fatal
6.
Dystocia
1. Definition: prolonged, difficult labor
2. Etiology
1. Dysfunction of uterine contractions
2. Abnormal position
3. Cephalopelvic disproportion (CPD)
4. Maternal exhaustion
3. Nursing Interventions
1. Depends upon cause
2. Can vary from rest to c-section
Operative Obstetrics
1. Episiotomy
1. Definition: incision made into the perineum during delivery
2. Purpose:
1. To spare muscles from overstretching/lacerations; to avoid difficulty holding urine in later life
2. Limit pressure on infant's head
3. Nursing Interventions
1. Assess for healing, infection, laceration of the anal sphincter (4th degree tear), hemorrhage
2. Teach Kegel exercises

2. Forceps
1. Definition: obstetric instrument used to aid in delivery
2. Indications
1. Poor progress
2. Fetal distress
3. Persistent occiput posterior position
4. Exhaustion (maternal)
3. Nursing Interventions
1. Assess infant for intracranial hemorrhage, facial bruising, facial palsy
2. Assist with delivery as needed
3. Check FHR before traction is applied
4. Complications
1. Lacerations to cervix or vagina
2. Rupture of the uterus
3. Compression of cord

3. Vacuum Extraction
1. Definition: an OB procedure using a suction cup to aid in delivery
2. Indications
1. Poor progress
2. Fetal distress
3. Occiput posterior/occiput transverse position
4. Exhaustion (maternal)
3. Nursing Interventions
1. Assess FHR every 5 minutes
2. Assess for cerebral trauma
3. Inform parents that caput will disappear in a few hours
4. Cesarean Section (c-section)
1. Definitions: incision into abdominal wall and uterus to deliver fetus
2. Types
1. Low transverse: decrease chance of uterine rupture with future pregnancies; less bleeding
after delivery
2. Classical: good for emergency delivery; provides more room
3. Indications
1. Fetal distress
2. Cephalo-pelvic disproportion (CPD)
3. Placenta previa, abruptio
4. Uterine dysfunction
5. Prolapsed cord
6. Diabetes
7. Toxemia
8. Malpresentation
4. Nursing Interventions
1. Postoperative assessment
2. Postpartum assessment
 5. Vaginal birth after c-section (VBAC): current accepted standard of care

5. Induction of Labor
1. Definition: process of initiating labor
2. Indications
1. Maternal disease: cardiac, PIH
2. Placental malfunctions (example: partial previa)
3. Fetal conditions (for example: anomaly, death)
4. Post maturity
3. Methods used to soften cervix
1. Prostaglandin E2 gel
2. Laminaria (natural cervical dilation, made from seaweed; left in place for 6-12 hours): be
alert for contraindications such as asthma, nonreassuring FHR, pelvic infection, ROM,
vaginal bleeding
4. Methods used to initiate induction
1. Oxytocin (Pitocin)
2. Rupture of membranes (ROM) (amniotomy)
5. Nursing Interventions
1. Assessment of FHR
2. Assess for prolapsed cord, ruptured uterus
3. Stop oxytocin (Pitocin) if contraction lasts longer than 90 seconds or at signs of fetal
distress