Nursing Care of Mother and Infant During Labor and Birth

Chapter 6Chapter 6

Nursing Care of Mother and Infant Nursing Care of Mother and Infant During Labor and Birth During Labor and Birth

• It is important to remember that every nursing intervention involves the welfare of two patients and the use of skills from:– Medical-surgical and pediatric nursing– Psychosocial and communication skills– OB care

Cultural Influences on Birth Cultural Influences on Birth PracticesPractices

• Role of woman in labor and delivery– Cultural preferences require flexibility

• Role of father/partner in labor and delivery– May be driven by cultural practices

Settings for childbirthSettings for childbirth

• Hospitals- LDR, LDRP

Birth Centers- CNM often attending- Advantages: homelike setting, lower costs- Disadvantages: delay in emergencies

• Home- Advantages: control, no risk of acquiring infection from others, low technology- Disadvantages: most MDs, CNMs won’t attend, delay in emergency, no doctor – patient relationship

Components of the Birth ProcessComponents of the Birth Process

• The Four “Ps”– Powers Contractions– Passage Pelvis– Passenger Fetus– Psyche:

Uterine ContractionsUterine Contractions

• Effect of contractions on the cervix– Efface (thin)– Dilate (open)

• Phase of contractions– Increment (increasing)– Peak (greatest)– Decrement

(decreasing)

• Frequency– Beginning of one to the next

• Duration – Beginning to end of same– > 90 sec. reduce fetal O2

• Intensity (strength)– Mild– Moderate– Firm

• Maternal pushing– When cervix is fully dilated

- analgesia

Four P’sFour P’s

• #1 P = PowersI. Contractions: primary powers of 1st stage of

laborI. Involuntary smooth muscle contractions

a. cause cervix to efface (thin) & dilate (open)b. frequency – time from beginning of one contraction to beginning of next*contractions closer than Q2min may reduce fetal O2 and should be reportedc. duration – time from beginning of contraction to end*persistent duration longer than 90 seconds may reduce fetal O2


• Powers (cont.)d. Intensity – strength of contraction (mild,

moderate, firm)e. Interval – amount of time the uterus relaxes

- Blood flow from mom to placenta decreases during contractions & resumes during interval*persistent contraction intervals shorter than 60 seconds may reduce fetal O2

f. Duration of contractions increase while interval between contractions decreases

Contraction cycleContraction cycle

Increment: period of increasing strength

Peak or acme: period of greatest strength

Decrement: period of decreasing strength

Cervical Effacement and DilationCervical Effacement and Dilation

Cervical dilationCervical dilation


• Pushing-When cervix is fully dilated and fetus starts to descend-Exhaustion or epidural may reduce or eliminate urge to push-Premature pushing should be discouraged

(increases exhaustion and fetal hypoxia)

Nursing Tip Nursing Tip

• Provide emotional support to the laboring woman so she is less anxious and fearful

• Excessive anxiety or fear can cause greater pain, inhibit the progress of labor, and reduce blood flow to the placenta and fetus


• #2 P = Passage-consists of mother’s bony pelvis and soft tissues*measurements must be adequate to allow fetal head to pass through


• # 3 P = Passenger: the fetus, placenta, membranes & amniotic fluida. Head – composed of several bones separated by connective tissue called sutures, plus 2 fontanels

*both allow fetal head to change shape as it passes through the pelvisb. Lie – describes how the fetus is oriented to mother’s spine

*99% are longitudinal (parallel to mom’s spine)


• Passenger (cont.)c. attitude – normally flexion (most compact) “fetal position”d. presentation – fetal part that enters pelvis 1st

cephalic is most common 1. vertex presentation with head fully flexed is most favorable (smallest possible diameter enters pelvis – 96% of births) 2. breech – a) frank: legs flexed @ hips, extending toward shoulders – most common breech b) full: reverse of cephalic c) footling

e. position – how fetus is oriented in pelvisocciput: describes how head is oriented if fetus is in vertex presentation

The Passenger—PresentationThe Passenger—Presentation

Fetal positionFetal position


• #4 P = Psyche • mental state can influence the course of labor

* Anxiety + fear = stress compounds (inhibit contractions, divert blood flow from placenta)* Reduces pain tolerance* Cultural and individual values influence point of view and coping with childbirth

Signs of Impending LaborSigns of Impending Labor

1) Braxton-Hicks contractions (false labor)- prepares cervix to dilate, adjusts fetal positioning

- Irregular contractions2) Increased vaginal discharge – from fetal

pressure. Should not cause irritation or itching

3) Bloody show – thick mucus + pink or dk. brown blood. May be a few days before labor or after labor starts

- Recent vaginal exams

Signs of Impending LaborSigns of Impending Labor

4) Rupture of membranes – infection can occur d/t break in amniotic sac seal, umbilical cord can become compressed. Woman should go to birth facility

5) Energy spurt – “nesting”N.I.: teach women to conserve their strength

6) Weight Loss – r/t loss of extra body water caused by hormonal changes. One to three pounds.

Mechanisms of Labor (Figure 6-9)Mechanisms of Labor (Figure 6-9)

• Also called Cardinal Movements – fetal position changes to adapt to pelvis*Know these in order!

1) Descent: required for all other mechanisms of labor and for birth

– Station describes level of presenting part in pelvis• minus stations above ischial spines, plus stations

below ischial spines • Pg. 129

Birth StationBirth Station

Ohhhh my!!!!Ohhhh my!!!!

Mechanisms of LaborMechanisms of Labor

2) Engagement: presenting part of fetal head is zero station or lower

Often happens before labor in nullipara

3) Flexion: contractions increase head flexion until the chin is on the chest

4) Internal Rotation: pelvic shape causes head to turn until occiput is directly under symphysis pubis-occiput anterior

• Fetus is pushed downward by contractions


5) Extension: fetal head must extend once it passes under the symphysis pubis– Must change from flexion to extension so it can

properly negotiate the turn6) External Rotation: head realigns with

shoulders and shoulders rotate to transversally align with AP pelvis

7) Expulsion: anterior, then posterior shoulder are born, quickly followed by the rest of the body

* See text pg. 128


When to Go to the Hospital When to Go to the Hospital or Birth Centeror Birth Center

• When contractions have a pattern of increased frequency, duration & intensitynullipara – Q5 min for 1 hourmultipara – Q10 min for 1 hour

• Ruptured membranes• Bleeding other than bloody show• Decreased fetal movement• Any other concern

False Vs. True LaborFalse Vs. True Labor

• False labor – Contractions irregular– Walking relieves

contractions– Bloody show usually not

present– No change in

effacement/dilation of cervix

• True labor– Contractions gradually

develop a regular pattern– Contractions become

stronger and more effective with walking

– Discomfort in lower back/abdomen

– Bloody show often present

– Progressive effacement and dilation of cervix

Nursing care of woman in False Nursing care of woman in False LaborLabor

• Often will observe for a few hours to see if there will be progression

• Often will run a fetal monitor strip to document fetal well-being

• Encourage woman to walk about, which may intensify contractions and bring about cervical effacement & dilation

• If no change, woman is usually sent home to await true labor

• Reassure pt. that symptoms will eventually change to true labor. Encourage pt. to return when she thinks she should.

Monitoring the FetusMonitoring the Fetus

• Normal FHR: 110-120 to 150-160 bpm• EFM: FHR & uterine contraction patterns are

continuously recorded-external or internal (membranes ruptured, dilated 1-2 cm)

Some Terms to Know:baseline rate: rate between contractionsvariability: describes fluctuations, or constant changes in baseline – is a reassuring sign!

• Changes in variab. “saw-tooth” pattern on monitor strip

More on Fetal MonitoringMore on Fetal Monitoring

• More terms to know:Accelerations: rate increases of at least 15 bpm over baseline that last approx 15 secs – reassuring sign (fetus well oxygenated)Early Decelerations: rate decreases during contractions that return to baseline by end – good (results from compression of fetal head)Variable Decelerations: begin & end abruptly, no pattern. Suggest umbilical cord compression or inadequate amniotic fluid.Late Decelerations: rate decrease that doesn’t return to baseline by end – nonreassuring

• Placenta is not delivering enough oxygen to the fetus (uteroplacental insufficiency)

Reassuring and Nonreassuring FHRReassuring and Nonreassuring FHRand Uterine Activity Patternsand Uterine Activity Patterns

• Reassuring patterns– Stable fetal heart rate (FHR) – Moderate variability– Accelerations– Uterine contraction 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

Nursing response to monitor Nursing response to monitor patternspatterns

• Accelerations & early decelerations are OK, require no response by nurse

• Variable decelerations – reposition the woman first! To relieve pressure on cord & improve blood flow through it.

• Late decelerations – repositioning, O2, increase IV fluid, stop oxytocin, give drugs to decrease contractions

Late DecelerationsLate Decelerations

AA

BB

CC

Amniotic FluidAmniotic Fluid

• Amniotomy – artificial rupture of membranes• Green-stained fluid may indicate fetus has

passed stool• Fetal compromise – respiratory problems at birth

• Cloudy or yellow fluid with bad odor may indicate infection

• Assess FHR for at least 1 minute after membranes rupture

• Nitrazine test: pH paper• Alkaline amniotic fluid turns it dark blue-green or dark

blue

Helping the Woman Cope with Helping the Woman Cope with LaborLabor

Labor support/CoachTeaching• Avoid pushing before cervix is fully dilated – teach

breathing techniques• Support effective pushing along with breathing Providing encouragement (OB team)Supporting/teaching the partner Pg.143

• Teach how labor pains affect the woman’s behavior/attitude• How to adapt responses to the woman’s behavior• What to expect in his/her own emotional responses • Encourage to take breaks and eat meals

Stages and Phases of LaborStages and Phases of Labor

• 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

Four Stages of LaborFour Stages of Labor

• First stage: dilation – Onset of labor to full 10-cm dilation– Subdivided into phases: latent, active, transitionLatent Phase: (4-6 hrs.)

1 to 4 cm dilation of cervix, mild to moderate contractions from Q20 min down to Q5 min.N.I.: review breathing & relaxation, assess FHR

Active Phase: (2-6 hrs.)4 to 7 cm dilation of cervix, moderate to firm contractions 2 to 5 minutes apart.N.I.: Help coach apply breathing & relaxation strategies.


Transition: (30 min – 2 hours)dilation 7 to 10 cm, fully effaced; contractions Q 2 – 3 mins, firm. Pt. irritable, rejects support person.N.I.: Support coach, help with breathing & relaxation, focusing, provide praise & reassurance.

Second stage: expulsion (30 min-2 hrs.)Full cervical dilation to birth of infant


• Third stage: placental stage (5 to 30 mins)– Expulsion of placentaN.I.: examine placenta for completeness

• Fourth stage: immediate postbirth recovery period- p. 148– 1 to 4 hours postbirth – Uterus midline & firmly contracted at or below

umbilicusN.I.: Assess for full bladder, VS Q 15 mins, assess

fundus & massage if needed, assess lochia- no more than 1 pad per hour, no large clots.

Ice pack may be placed on the perineum to reduce bruising & edema.

Vaginal Birth After CesareanVaginal Birth After Cesarean

• Main concern• Uterine scar will rupture• Can disrupt placental blood flow• Lead to hemorrhage• Woman may need more support than other

laboring women – anxious of ability to deliver• Nurse provides empathy and support

Nursing Responsibilities During Nursing Responsibilities During BirthBirth

• Preparing the delivery instruments and infant equipment

• Perineal scrub• Administering

medications• Providing initial

care to the infant

• Assessing Apgar score• Assessing infant for

obvious abnormalities• Examining the

placenta• Identifying mother and

infant• Promoting parent-

infant bonding

Nursing Care Immediately After Nursing Care Immediately After BirthBirth

• Care of the mother– Observing for hemorrhage

• Vital signs• Skin color• Location and firmness of uterine fundus• Lochia• Pain

– Promoting comfort• Keep warm and dry• Ice to perineum to help reduce swelling and bruising

Nursing Care Immediately After Nursing Care Immediately After Birth Birth (cont.)(cont.)

• Care of the infant– 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 NewbornPhase 1: Care of the Newborn

• 1st Phase- birth to 1 hour*Maintain thermoregulation by drying infant, warmer, hat, wrapping when out of warmer*Maintain cardiorespiratory function by wiping & suctioning nose & mouth, cord clampings/s resp. distress:persistent cyanosis, grunting, nostril flaring, retractions, resp. rate ^ 60/min, HR ^ 160 or below 110.*Apgar score: evaluates five factors at 1 min & 5 min*not a predictor of intelligence or abilities*8 to 10- continue to observe, 4 to 7- gentle stimulation.*Less than 3- active resuscitation

Newborn Care-Phase 1 cont.Newborn Care-Phase 1 cont.

• Meds – Erythromycin eye ointmentagainst gonorrhea, chlamydia - Vitamin K to assist in clotting

Assess for anomaliesInspect head & face for symmetry, trauma; look for obvious anomalies (cleft lip, spina bifida); fingers & toes, urination and/or meconium.

Umbilical Cord Blood BankingUmbilical Cord Blood Banking

• This type of blood is capable of regenerating stem cells that are able to replace diseased cells

• Informed consent is essential• Collect blood after cord has been clamped• Blood must be transported within 48 hours of

collection to blood banking facility

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Nursing Care of Mother and Infant During Labor and Birth