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November/December 2003 JOGNN 765

CLINICAL ISSUES

Labor and Birth Today: Things Have Changed

Although labor and birth are natural processes,interventions (both necessary and unnecessary) oftenare part of intrapartum nursing practice. The mostcommon aspects of nursing care are covered in thisClinical Issues series, including labor induction,analgesia and anesthesia, management of secondstage, and emergencies that can occur during laborand birth. Finally, we included a research report ofhow expert nurses who care for women during laborview their role.

These topics reflect the reality of being a labornurse today. More women are choosing epiduralanalgesia/anesthesia for management of the pain oflabor. An increasing number of women in the Unit-ed States are having elective induction of labor(Martin, Hamilton, Ventura, Menacker, & Park,2002). Recent evidence suggests that elective laborinduction significantly increases the risk of cesareanbirth, especially for nulliparous women. Currentlymore than one in four births in the United States isby cesarean (Hamilton, Martin, & Sutton, 2003).With the dramatic decrease in the number of womenwho choose a trial of labor after a cesarean birth,elective labor induction promises to contribute tothe rapidly increasing rate of cesarean birth (Martinet al., 2002).

These two interventions have drastically changedintrapartum nursing practice over the past twodecades. Instead of predominantly caring for womenpresenting in spontaneous active labor at any time ofthe day or night, intrapartum nurses find themselvesmanaging oxytocin infusions on the day shift andpreparing for births in the early evening after physi-cian office hours are over. Instead of providing laborsupport, intrapartum nurses are monitoring womenwho have epidural analgesia/anesthesia using auto-matic blood pressure devices, continuous pulseoximetry, and electrocardiogram, none of which arenecessary. These interventions have been added tothe labor process for convenience and to meet thechallenges of gathering numerous clinical data aboutmore than one woman in labor. An intrapartumnurse today is likely to be caring for at least two

women in active labor. Increased technology andlabor epidurals may have contributed to the percep-tion that this nurse-to-patient ratio is acceptable.

More is now known about how the mother andfetus tolerate the second stage of labor. These newfindings can promote a more physiological approachto nursing care during the second stage and lead tobetter outcomes for mothers and babies. After read-ing the article about nursing care during the secondstage, it is hoped that labor nurses will give seriousconsideration to rethinking their usual care routines.Giving up counting during pushing, not coachingwomen to push when obstetrical conditions areunfavorable, and avoiding the supine lithotomyposition during pushing, would be significant stepsin changing second-stage intrapartum nursing prac-tice for the better. In addition to the articles in thisClinical Issues series, the AWHONN practice mono-graph Second Stage Labor Management: Promotionof Evidence-Based Practice and a CollaborativeApproach to Patient Care (Mayberry et al., 2000) isinvaluable as supportive evidence for positive second-stage practice changes.

Although most women and fetuses in labor arehealthy, emergencies can and do occur during theintrapartum period. An overview of common obstet-ric emergencies has been included. An adequateknowledge of what to do during an emergency is arequisite for labor nurses. Careful maternal-fetalassessment and proactive nursing care can oftenmake the difference in whether the mother and babysurvive a catastrophic event during labor and birth.

One of the most significant changes in intra-partum nursing practice over the past few decadeshas been increased autonomy of nurses practicing inthe nurse–managed labor model in community hos-pitals. In response to demands for time efficiency byinstitutions and third-party payers, as well asprovider quality-of-life preferences, most communi-ty attending physicians keep in contact with thelabor nurse via telephone while they are seeingpatients in the office or they are at home after officehours. The labor nurse makes key decisions aboutthe course of labor based on standing orders and a

general understanding of physician preferences, and thesedecisions have a significant impact on labor management.The labor nurses we interviewed were comfortable withthis level of autonomy and enjoyed their role in the laborprocess. Perhaps other labor nurses feel the same. It isgratifying to know that labor nurses love what they doand believe their care makes a positive difference in out-comes for mothers and babies.

Use the information provided in this Clinical Issuesseries to review your current practice and update it asneeded. Work with physician colleagues to incorporatethe latest evidence into intrapartum practice. Mothersand babies are counting on us to provide the best carepossible during labor and birth.

Kathleen Rice SimpsonGuest Editor

REFERENCES

Hamilton, B. E., Martin, J. A., & Sutton, P. D. (2003). Births:Preliminary data for 2002. National Vital StatisticsReport, 51(11), 1-20.

Martin, J. A., Hamilton, B. E., Ventura, S. J., Menacker, F., &Park, M. A. (2002). Births: Final data for 2001. NationalVital Statistics Report, 51(2), 1-103.

Mayberry, L. J., Wood, S. H., Strange, L. B., Lee, L., Heisler,D. R., & Nielson-Smith, K. (2000). Second stage labormanagement: Promotion of evidence-based practice and acollaborative approach to patient care. Washington, DC:Association of Women’s Health, Obstetric and NeonatalNurses.

766 JOGNN Volume 32, Number 6