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General overview: This review of the anatomical and physiological determinants of successful labor provides baseline data against which the nurse compares findings of an ongoing assessment of the woman in labor. Nursing actions are planned and implemented to meet the present and emerging needs of the woman in labor.

  1. BIOLOGICAL FOUNDATIONS OF LABOR
    1. Premonitory signs
      1. Lightening—process in which the fetus "drops" into the pelvic inlet.
        1. Characteristics
          1. Nullipara—usually occurs 2 to 3 weeks before onset of labor.
          2. Multipara—commonly occurs with onset of labor.
        2. Effects
          1. Relieves pressure on diaphragm—breathing is easier.
          2. Increases pelvic pressure.
            1. Urinary frequency returns.
            2. Increased pressure on thighs.
            3. Increased tendency to vulvar, vaginal, perianal, and leg varicosities.
      2. Braxton Hicks contractions—may become more uncomfortable.
    2. Etiology: unknown. Theories include:
      1. Uterine overdistention.
      2. Placental aging—declining estrogen/progesterone levels.
      3. Rising prostaglandin level.
      4. Fetal cortisol secretion.
      5. Maternal/fetal oxytocin secretion.
    3. Overview of labor process—forces of labor (involuntary uterine contractions) overcome cervical resistance; cervix thins (effacement) and opens (0–10 cm dilation) (Table 4-10. First Stage of Labor ). Voluntary contraction of secondary abdominal muscles during the second stage (e.g., pushing, bearing-down) forces fetal descent. Changing pelvic dimensions force fetal head to accommodate to the birth canal by molding (cranial bones overlap to decrease head size).
      Stages of labor:
      1. First—begins with establishment of regular, rhythmic contractions; ends with complete effacement and dilation (10 cm); divided into three phases:
        1. Latent and early active.
        2. Active.
        3. Transitional.
      2. Second—begins with complete dilation and ends with birth of infant.
      3. Third—begins with birth of infant and ends with expulsion of placenta.
      4. Fourth—begins with expulsion of placenta; ends when maternal status is stable (usually 1–2 hours postpartum).
    4. Anatomical/physiological determinants
      1. Maternal
        1. Uterine contractions—involuntary; birth; begin process of involution.
          1. Characteristics: rhythmic; increasing tone (increment), peak (acme), relaxation (decrement).
          2. Effects:
            1. Decreases blood flow to uterus and placenta.
            2. Dilates cervix during first stage of labor.
            3. Raises maternal blood pressure during contractions.
            4. With voluntary bearing-down efforts (abdominal muscles), expels fetus (second stage) and placenta (third stage).
            5. Begins involution.
          3. Assessment:
            1. Frequency—time from beginning of one contraction to beginning of the next.
            2. Duration—time from beginning of contraction to its relaxation.
            3. Strength (intensity)—resistance to indentation.
            4. False/true labor—differentiation (Table 4-11. Assessment: Differentiation of False/True Labor ).
            5. Signs of dystocia (dysfunctional labor) (see The Intrapartum Experience).
        2. Pelvic structures and configuration:
          1. False pelvis—above linea terminalis (line travels across top of symphysis pubis around to sacral promontory); supports gravid uterus during pregnancy.
          2. True pelvis—below linea terminalis; divided into:
            1. Inlet—"brim," demarcated by linea terminalis.
              1. Widest diameter: transverse.
              2. Narrowest diameter: anteriorposterior (true conjugate).
            2. Midplane—pelvic cavity.
            3. Outlet.
              1. Widest diameter: anterior-posterior (requires internal rotation of fetal head for entry).
              2. Narrowest diameter: transverse (intertuberous); facilitates birth in occipitoanterior (OA) position.
          3. Classifications
            1. Gynecoid—normal female pelvis; rounded oval.
            2. Android—normal male pelvis; funnel shaped.
            3. Anthropoid—oval.
            4. Platypelloid—flattened, transverse oval.
      2. Fetal
        1. Fetal head (Figure 4-7. The Fetal Head).
          1. Bones—one occipital, two frontal, two parietals, two temporals.
          2. Suture—line of junction or closure between bones; sagittal (longitudinal), coronal (anterior), and lambdoid (posterior, frontal); permit molding to accommodate head to birth canal.
          3. Fontanels—membranous space between cranial bones during fetal life and infancy.
            1. Anterior "soft spot"—diamond shaped; junction of coronal and sagittal sutures; closes (ossifies) by 18 months.
            2. Posterior—triangular; junction of sagittal and lambdoid sutures; closes by 4 months of age.
        2. Fetal lie—relationship of fetal long axis to maternal long axis (spine).
          1. Transverse—shoulder presents.
          2. Longitudinal—vertex or breech presents.
        3. Presentation—fetal part entering inlet first (Figure 4-8. Categories of Fetal Presentation).
          1. Cephalic—vertex (most common); face, brow.
          2. Breech
            1. Complete—feet and legs flexed on thighs; buttocks and feet presenting.
            2. Frank—legs extended on torso, feet up by shoulders; buttocks presenting.
            3. Footling—single (one foot), double (both feet) presenting.
        4. Attitude—relationship of fetal parts to one another (e.g., head flexed on chest).
        5. Position—relationship of presenting fetal part to quadrants of maternal pelvis; vertex most common, occiput anterior on maternal left side (LOA) (see Figure 4-8. Categories of Fetal Presentation).
      3. Assessment: determine presentation and position.
        1. Leopold's maneuver—abdominal palpation.
          1. First—palms over fundus, breech feels softer, not as round as head would be.
          2. Second—palms on either side of abdomen, locates fetal back and small parts.
          3. Third—fingers just above pubic symphysis, grasp lower abdomen; if unengaged, presenting part is mobile.
          4. Fourth—facing mother's feet, run palms down sides of abdomen to symphysis; check for cephalic prominence (usually on right side), and if head is floating or engaged.
        2. Location of fetal heart tones (FHTs)—heard best through fetal back or chest.
          1. Breech presentation—usually most audible above maternal umbilicus.
          2. Vertex presentation—usually most audible below maternal umbilicus.
          3. Changing location of most audible FHTs—useful indicator of fetal descent.
          4. Factors affecting audibility:
            1. Obesity.
            2. Maternal position.
            3. Polyhydramnios.
            4. Maternal gastrointestinal activity.
            5. Loud uterine bruit—origin: hissing of blood through maternal uterine arteries; synchronous with maternal pulse.
            6. Loud funic souffle—origin: hissing of blood through umbilical arteries; synchronous with fetal heart rate (FHR).
            7. External noise, faulty equipment.
        3. Vaginal examination: palpable sutures, fontanels (triangular-shaped superior, diamond-shaped inferior = vertex presentation, OA position).
      4. Cardinal movements of the mechanisms of normal labor—vertex presentation, positional changes of fetal head accommodate to changing diameters of maternal pelvis (Figure 4-9. Cardinal Movements in the Mechanism of Labor with the Fetus in Vertex Presentation).
        1. Descent—head engages and proceeds down birth canal.
        2. Flexion—head bent to chest; presents smallest diameter of vertex (suboccipital-bregmatic).
        3. Internal rotation—during second stage of labor, transverse diameter of fetal head enters pelvis; occiput rotates 90 degrees to bring back of neck under symphysis (e.g., left occipitotransverse [LOT] to LOA to OA); presents smallest diameter (biparietal) to smallest diameter of outlet (intertuberous).
        4. Extension—back of neck pivots under symphysis, allows head to be born by extension.
        5. Restitution—head returns to normal alignment with shoulders (with LOA, results in head facing right thigh), presents smallest diameter of shoulders to outlet.
        6. Delivery of head—shoulders in anteriorposterior position.
        7. Expulsion—birth of neonate completed.
      5. Assessment: relationship of fetal head to ischial spines (degree of descent).
        1. Engagement—widest diameter of presenting part has passed through pelvic inlet (e.g., biparietal diameter of fetal head).
        2. Station—relationship of presenting part to ischial spines (IS).
          1. Floating—presenting part above inlet, in false pelvis.
          2. Station –5 is at inlet (presenting part well above IS).
          3. Station 0—presenting part at IS (engaged).
          4. Station +4—presenting part at the outlet.
    5. Warning signs during labor
      1. Contraction—hypertonic, poor relaxation, or tetanic (greater than 90 seconds long and ≤2 minutes apart).
      2. Abdominal pain—sharp, rigid abdomen.
      3. Vaginal bleeding—profuse.
      4. FHR—late decelerations, prolonged variable decelerations, bradycardia, tachycardia (Figure 4-10. Fetal Heart Rate (FHR) Decelerations and Nursing Interventions), decreased variability.
      5. Maternal hypertension.
      6. Meconium-stained amniotic fluid (MSAF).
      7. Prolonged ROM.
  2. PARTICIPATORY CHILDBIRTH TECHNIQUES
    1. Psychoprophylaxis—Lamaze method
      1. Premise—conditioned responses to stimuli occupy nerve pathways, reducing perception of pain. Emphasis is on childbirth as a natural event, with a woman who is informed as the active participant. The ability to relax effectively reduces the perception of pain, and the involvement of the coach fosters the family concept.
      2. Childbirth partners are taught:
        1. Anatomy and physiology of labor.
        2. Psychology of man and woman.
        3. What to expect in the birthing setting.
        4. Conditioned responses to labor stimuli.
          1. Concentration on focal point.
          2. Breathing techniques.
          3. Need for active coaching to enable woman to:
            1. Use techniques appropriate to present stage of labor.
            2. Avoid hyperventilation.
        5. Specific stage—appropriate techniques:
          1. First stage of labor—early: slow, deep chest breathing; active: patterned breathing.
          2. Transition (8–10 cm)—rapid, shallow breathing pattern, to prevent pushing prematurely.
            1. Panting.
            2. Pant-blow.
            3. "He-he" pattern.
          3. Second stage of labor
            1. Pushing (or bearing-down)—aids fetal descent through birth canal.
            2. Panting—aids relaxation between contractions; prevents explosive birth of head.
        6. Effects on labor behaviors/coping:
          1. Helps mother cope with and assist contractions.
          2. Prevents premature bearing-down efforts; reduces possibility of cervical lacerations, edema due to pushing on incompletely dilated cervix.
          3. When appropriate, improves efficiency of bearing-down efforts.
    2. Other methods—include parent classes, classes for siblings, multiparas, and those who plan cesarean birth.
  3. NURSING ACTIONS DURING FIRST STAGE OF LABOR
    1. Assessment: careful evaluation of:
      1. Antepartal history
        1. EDD
        2. Genetic and familial problems.
        3. Preexisting and coexisting medical disorders, allergies.
        4. Pregnancy-related health problems (hyperemesis, bleeding, etc.).
        5. Infectious diseases (past and present herpes, etc.).
        6. Past obstetric history, if any.
        7. Pelvic size estimation.
        8. Height.
        9. Weight gain.
        10. Laboratory results:
          1. Blood type and Rh factor.
          2. Serology.
          3. Urinalysis.
          4. Hepatitis.
          5. Rubella.
        11. Prenatal care history.
        12. Use of medications.
      2. Admission findings
        1. Emotional status.
        2. Vital signs.
        3. Present weight.
        4. Fundal height.
        5. Estimated fetal weight.
        6. Edema.
        7. Urinalysis (for protein and glucose).
      3. FHR—normal, 110 to 160 beats/min (see Figure 4-10. Fetal Heart Rate (FHR) Decelerations and Nursing Interventions).
        1. Check and record every 15 to 30 minutes—monitor fetal response to physiological stress of labor.
        2. Bradycardia (mild, 100–110 beats/min, or 30 beats/min lower than baseline reading).
        3. Tachycardia (moderate, 160–179 beats/min, or 30 beats/min above baseline reading lasting 5 or more minutes).
      4. Contractions—every 15 to 30 minutes.
        1. Place fingertips over fundus, use gentle pressure; contraction felt as hardening or tensing.
        2. Time: frequency and duration.
        3. Intensity/strength at acme:
          1. Weak—easily indent fundus with fingers.
          2. Moderate—some tension felt, fundus indents slightly with finger pressure.
          3. Strong—unable to indent fundus.
      5. Maternal response to labor—assess for effective coping, cooperation, and using effective breathing techniques.
      6. Maternal vital signs—between contractions.
        1. Response to pain or use of special breathing techniques alters pulse and respirations.
        2. BP, P, RR—if normotensive: on admission, and then every hour and prn; after regional anesthesia: every 30 minutes (every 5 minutes first 20 minutes).
        3. Temperature—if within normal range: on admission, and then every 4 hours and prn. Every 2 hours after rupture of membranes.
        4. Before and after analgesia/anesthesia.
        5. After rupture of membranes (see Amniotic fluid embolus, The Intrapartum Experience).
      7. Character and amount of bloody show.
      8. Bladder status: encourage voiding every 1 to 2 hours, monitor output.
        1. Determine bladder distention—palpate just above symphysis (full bladder may impede labor progress or result in trauma to bladder).
        2. Admission urinalysis—check for protein and glucose.
      9. Signs of deviations from normal patterns.
      10. Status of membranes:
        1. Intact.
        2. Ruptured (nitrazine paper turns blue on contact with alkaline amniotic fluid). Fluid may be placed on a glass slide to dry; a fernlike crystallization of sodium chloride will appear. Note, record, and report:
          1. Time—danger of infection if ruptured more than 24 hours.
          2. FHR stat and 10 minutes later—to check for prolapsed cord.
          3. Character and color of fluid (see 11.b.and c.).
      11. Amniotic fluid.
        1. Amount—polyhydramnios (>2000 mL)—associated with congenital anomalies/poorly controlled diabetes.
        2. Character—thick consistency or odor associated with infection.
        3. Color—normally clear with white specks.
          1. Yellow—presence of bilirubin; Rh or ABO incompatibility.
          2. Green or meconium stained; if fetus in vertex position, indicates recent fetal hypoxia secondary to respiratory distress in fetus.
          3. Port wine—may indicate abruptio placentae.
      12. Labor progress:
        1. Effacement.
        2. Dilation.
        3. Station.
        4. Bulging membranes.
        5. Molding of fetal head.
      13. Perineum—observe for bulging.
    2. Analysis/nursing diagnosis:
      1. Anxiety, fear related to uncertain outcome, pain.
      2. Ineffective individual coping related to lack of preparation for childbirth or poor support from coach.
      3. Altered nutrition: less than body requirements related to physiological stress of labor.
      4. Altered urinary elimination related to pressure of presenting part.
      5. Altered thought processes related to sleep deprivation, transition, analgesia.
      6. Fluid volume deficit related to anemia, excessive blood loss.
      7. Impaired (fetal) gas exchange related to impaired placental perfusion.
    3. Nursing care plan/implementation:
      1. Goal: comfort measures.
        1. Maintain hydration of oral mucosa. Encourage sucking on cool washcloth, ice chips, lollipops, clear liquids (if ordered).
        2. Reduce dryness of lips. Apply lip balm.
        3. Relieve backache. Apply sacral counterpressure (particularly with occipitoposterior [OP] presentation).
        4. Encourage significant other to participate.
        5. Encourage ambulation when presenting part engaged.
      2. Goal: management of physical needs.
        1. Encourage frequent voiding to prevent full bladder from impeding oncoming head.
        2. infoImageEncourage ambulation throughout labor; lateral Sims' position with head elevated to:
          1. Encourage relaxation.
          2. Allow gravity to assist in anterior rotation of fetal head.
          3. Prevent compression of inferior vena cava and descending aorta (supine hypotensive syndrome).
          4. Promote placental perfusion.
        3. Perineal prep, if ordered to promote cleanliness.
        4. Fleet's enema, if ordered—to stimulate peristalsis, evacuate lower bowel. Note: contraindicated if:
          1. Cervical dilation (4 cm or more) with unengaged head—due to possibility of cord prolapse.
          2. Fetal malpresentation/malposition—due to possible fetal distress.
          3. Preterm labor—may stimulate contractions.
          4. Painless vaginal bleeding—due to possible placenta previa.
      3. Goal: management of psychosocial needs. Emotional support:
        1. Encourage verbalization of feelings, fears, concerns.
        2. Explain all procedures.
        3. Reinforce self-concept ("You're doing well!").
      4. Goal: management of discomfort.
        1. Analgesia or anesthesia—may be required or desired—to facilitate safe, comfortable birth.
        2. Support/enhance/teach childbirth techniques.
          1. Reinforce appropriate breathing techniques for current labor status.
            1. If woman is hyperventilating, to increase PaCO2, minimize fetal acidosis, and relieve symptoms of vertigo and syncope, suggest:
              1. Breathe into paper bag.
              2. Breathe into cupped hands.
            2. Demonstrate appropriate breathing for several contractions—to reestablish rate and rhythm.
      5. Goal: sustain motivation.
        1. Offer support, encouragement, and praise, as appropriate.
        2. Keep informed of status and progress.
        3. Reassure that irritability is normal.
        4. Serve as surrogate coach when necessary (if no partner, before partner arrives, while partner changes clothes, during needed breaks); assist with effleurage, breathing, focusing.
        5. Discourage bearing-down efforts by pantblow until complete (10-cm) dilation to avoid cervical edema/laceration.
        6. Facilitate informed decision making regarding medication for relaxation or pain relief.
        7. Minimize distractions: quiet, relaxed environment; privacy.
    4. Evaluation/outcome criteria:
      1. Woman manages own labor discomfort effectively.
      2. Woman maintains control over own behavior.
      3. Woman successfully completes first stage of labor without incident.
  4. NURSING ACTIONS DURING SECOND STAGE OF LABOR
    1. Assessment:
      1. Maternal (or couple's) response to labor.
      2. FHR—continuous electronic monitoring, or after each contraction with fetoscope, Doppler.
      3. Vital signs.
      4. Time elapsed—average: 2 minutes to 1 hour; prolonged second stage increases risk of: fetal distress, maternal exhaustion, psychological stress, intrauterine infection.
      5. Contraction pattern—average every 1½ to 3 minutes, lasting 60 to 90 seconds.
      6. Vaginal discharge—increases.
      7. Nausea, vomiting, disorientation, tremors, amnesia between contractions, panic.
      8. Response to regional anesthesia, if administered.
        1. Signs of hypotension—reduces placental perfusion, increases risk of fetal hypoxia.
        2. Effect on contractions—note and report any slowing of labor progress.
      9. Efforts to bear down—increases expulsive effects of uterine contractions.
      10. Perineal bulging with contractions—fetal head distends perineum, crowns; head born by extension.
    2. Analysis/nursing diagnosis:
      1. Pain related to strong uterine contractions, pressure of fetal descent, stretching of perineum.
      2. High risk for injury:
        1. Infection related to ruptured membranes, repeated vaginal examinations.
        2. Laceration related to pressure of fetal head exceeding perineal elasticity.
      3. Impaired skin integrity related to laceration, episiotomy.
      4. Fluid volume deficit related to hypotension secondary to regional anesthesia.
      5. Anxiety related to imminent birth of fetus.
      6. Ineffective individual coping related to prolonged sensory stimulation (contractions) and anxiety.
      7. Altered urinary elimination related to anesthesia and contractions, descent of fetal head.
      8. Sleep pattern disturbance.
    3. Nursing care plan/implementation:
      1. Goal: emotional support.
        1. To sustain motivation/control:
          1. Never leave mother and significant other alone during second stage.
          2. Keep informed of progress.
          3. Direct bearing-down efforts (pushing) without holding breath* while pushing. Encourage pushing "out through vagina" and encourage mother to touch crowning head; position mirror so woman can see perineal bulging with effective efforts; minimize distractions.
        2. To allay significant other's anxiety: reassure regarding mother's behavior if she is not anesthetized.
        3. Support family choices.
      2. Goal: safeguard status.
        1. Precautions when putting legs in stirrups:
          1. If varicosities, do not put legs in stirrups.
          2. Avoid pressure to popliteal veins; pad stirrups.
          3. Ensure proper, even alignment by adjusting stirrups.
          4. Move legs simultaneously into or out of stirrups—to avoid nerve, ligament, and muscle strain.
          5. Provide proper support to woman not using stirrups. Do not hold legs (can cause back injury).
        2. infoImageSupport woman in whatever position selected for birth (e.g., side-lying position).
        3. Cleanse perineum, thighs as ordered.
      3. Goal: maintain a comfortable environment.
        1. Free of unnecessary noise, light.
        2. Comfortable temperature (warm).
      4. Medical management:
        1. Episiotomy may be performed to facilitate birth.
        2. Forceps may be applied to exert traction and expedite birth.
        3. Vacuum extraction also used to assist birth.
      5. infoImageBirthing room birth with alternative positions (squat).
    4. Evaluation/outcome criteria:
      1. Cooperative, actively participates in birth; maintains control over own behavior.
      2. Successful, uncomplicated birth of viable infant.
      3. All assessment findings within normal limits (vital signs, emotional status, response to birth).
      4. Presence of significant other.
  5. NURSING ACTIONS DURING THIRD STAGE OF LABOR
    1. Assessment:
      1. Time elapsed—average: 5 minutes; prolonged third stage (greater than 25 minutes) may indicate complications (placenta accreta).
      2. Signs of placental separation:
        1. Increase in bleeding from the vagina.
        2. Cord lengthens.
        3. Uterus rises in abdomen, assumes globular shape.
      3. Assess mother's level of consciousness.
      4. Examine placenta for intactness and number of vessels in umbilical cord (normal: three. Note: two vessels only—associated with increased incidence of congenital anomalies); condition of placenta for calcification, infarcts, etc.
    2. Analysis/nursing diagnosis:
      1. Family coping: potential for growth related to bonding, beginning achievement of developmental tasks.
      2. Fluid volume deficit related to blood loss during third stage.
    3. Nursing care plan/implementation:
      1. pillImageGoal: prevent uterine atony. Administer oxytocin, as ordered.
      2. Goal: facilitate parent-child bonding.
        1. While protecting neonate from cold stress, encourage parents to see, hold, touch neonate.
        2. Comment about neonate's individuality, characteristics, and behaviors.
        3. After neonate is assessed for congenital anomalies (e.g., cleft palate, esophageal atresia), encourage breastfeeding, if desired.
      3. Goal: health teaching.
        1. Describe, discuss common neonatal behavior in transitional period (periods of reactivity, sleep, hyperactivity).
        2. Demonstrate removal of mucus by aspiration with bulb syringe.
        3. Demonstrate ways of facilitating breastfeeding.
    4. Evaluation/outcome criteria:
      1. Woman has a successful, uneventful completion of labor.
        1. Minimal blood loss.
        2. Vital signs within normal limits.
        3. Fundus well contracted at level of umbilicus.
      2. Parents express satisfaction with outcome, demonstrate infant attachment.
  6. NURSING ACTIONS DURING THE FOURTH STAGE OF LABOR—1 TO 2 HOURS POSTPARTUM
    1. Assessment—every 15 minutes four times; then, every 30 minutes two times—or until stable—to monitor response to physiological stress of labor/birth.
      1. Vital signs:
        1. Temperature taken once; if elevated, requires follow-up—may indicate infection, dehydration, excessive blood loss. Note, record, report temperature of 100.4°F (38°C).
        2. Blood pressure—every 15 minutes × 4.
          1. Returns to prelabor level—due to loss of placental circulation and increased circulating blood volume.
          2. Elevation may be in response to use of oxytocic drugs or preeclampsia (first 48 hours).
          3. Lowered blood pressure—may reflect significant blood loss during labor/birth, or occult bleeding.
        3. Pulse—every 15 minutes × 4.
          1. Physiological bradycardia—due to normal vagal response.
          2. Tachycardia—may indicate excessive blood loss during labor/birth, dehydration, exhaustion, maternal fever, or occult bleeding.
      2. Location and tone of fundus—every 15 minutes × 4 to ensure continuing contraction; prevent blood loss due to uterine relaxation.
        1. Fundus—firm; at or slightly lower than the umbilicus; in midline.
        2. May be displaced by distended bladder—due to normal diuresis; common cause of bleeding in immediate postpartum, uterine atony.
      3. Character and amount of vaginal flow.
        1. Moderate lochia rubra.
        2. Excessive loss: if perineal pad saturated in 15 minutes, or blood pools under buttocks.
        3. Bright red bleeding may indicate cervical or vaginal laceration.
      4. Perineum.
        1. Edema.
        2. Bruising—due to trauma.
        3. Distention/hematoma, rectal pain.
      5. Bladder fullness/voiding—to prevent distention.
      6. Rate of IV, if present; response to added medication, if any.
      7. Intake and output—to evaluate hydration.
      8. Recovery from analgesia/anesthesia.
      9. Energy level.
      10. Verbal, nonverbal interaction between woman and significant other.
        1. Dialogue.
        2. Posture.
        3. Facial expressions.
        4. Touching.
      11. Interactions between parent(s) and newborn; signs of bonding (culturally appropriate).
        1. Eye contact with newborn.
        2. Calls by name.
        3. Explores with fingertips, strokes, cuddles.
      12. Signs of postpartum emergencies:
        1. Uterine atony, hemorrhage.
        2. Vaginal hematoma.
    2. Analysis/nursing diagnosis:
      1. Fluid volume deficit related to excessive intrapartum blood loss, dehydration.
      2. Altered urinary elimination related to intrapartum bladder trauma, dehydration, blood loss.
      3. Impaired skin integrity related to episiotomy, lacerations, cesarean birth.
      4. Altered family processes related to role change.
      5. Altered parenting related to interruption in bonding secondary to:
        1. Compromised maternal status.
        2. Compromised neonatal status.
      6. Knowledge deficit related to self-care procedures, infant care.
      7. Fatigue related to sleep disturbances and anxiety.
      8. Anxiety regarding status of self and infant.
      9. Altered nutrition, less than body requirements, related to decreased food and fluid intake during labor.
    3. Nursing care plan/implementation:
      1. Goal: comfort measures.
        1. Position, pad change.
        2. Perineal care—to promote healing; to reduce possibility of infection.
        3. Ice pack to perineum; as ordered—to reduce edema, discomfort, and pain related to hemorrhoids.
      2. Goal: nutrition/hydration. Offer fluids, foods as tolerated.
      3. Goal: urinary elimination.
        1. Encourage voiding—to avoid bladder distention.
        2. Record: time, amount, character.
        3. Anticipatory guidance related to nocturnal diuresis and increased output.
      4. Goal: promote bonding.
        1. Provide privacy, quiet; encourage sustained contact with newborn.
        2. Encourage: touching, holding baby; breastfeeding (also promotes involution).
      5. Goal: health teaching.
        1. Perineal care—front to back, labia closed (after each void/bowel movement).
        2. Hand washing—before and after each pad change; after voiding, defecating; before and after baby care.
        3. Signs to report:
          1. Uterine cramping/↑ pain.
          2. Increased vaginal bleeding, passage of large clots.
          3. Nausea, dizziness.
    4. Evaluation/outcome criteria:
      1. Expresses comfort, satisfaction in fourth stage.
      2. Vital signs stable, fundus contracted, moderate lochia rubra, perineum undistended.
      3. Tolerates food and fluids well.
      4. Voids an adequate amount.
      5. Demonstrates culturally appropriate contact with infant.
      6. Verbalizes abnormal signs to report to physician.
      7. Returns demonstration of appropriate perineal care.
      8. Ambulates without pain, dizziness, numbness of legs.
  7. NURSING MANAGEMENT OF THE NEWBORN IMMEDIATELY AFTER BIRTH
    1. Assessment:
      1. Mucus in nasopharynx, oropharynx.
      2. Apgar score: note and record—at 1 and 5 minutes of age (Table 4-12. Apgar Score ).
        1. Score of 7–10: good condition.
        2. Score of 4–6: fair condition; assess for CNS depression.
        3. Score of 0–3: poor condition; requires immediate intervention. Asphyxia neonatorum—fails to breathe spontaneously within 30–60 seconds after birth; heart rate (HR) <100.
      3. Number of vessels in umbilical stump.
      4. Passage of meconium stool, urine.
      5. General physical appearance/status.
        1. Signs of respiratory distress (nasal flaring, grunting, sternal retraction, cyanosis, tachypnea).
        2. Skin condition (meconium stained, cyanosis, jaundice, lesions).
        3. Cry—presence, pitch, quality.
        4. Signs of birth trauma (lacerations, dislocations, fractures).
        5. Symmetry (absent parts, extra digits, gross malformations, ears, palm creases, sacral dimples).
        6. Molding, caput succedaneum, cephalohematoma.
        7. Assess gestational age.
      6. Identify high-risk infant.
    2. Analysis/nursing diagnosis:
      1. Ineffective airway clearance related to excessive nasopharyngeal mucus.
      2. Ineffective breathing pattern related to CNS depression secondary to intrauterine hypoxia narcosis, prematurity, and lack of pulmonary surfactant.
      3. Impaired gas exchange related to respiratory distress.
      4. Fluid volume deficit related to birth trauma; hemolytic jaundice.
      5. Impaired skin integrity related to cord stump.
      6. High risk for injury (biochemical, metabolic) related to impaired thermoregulation.
      7. Ineffective thermoregulation related to environmental conditions/prematurity.
    3. Nursing care plan/implementation:
      1. Goal: ensure patent airway.
        1. Suction mouth first, then nose; when stimulated, sensitive receptors around entrance to nares initiate gasp, causing aspiration of mucus present in mouth.
        2. Suction with bulb syringe.
          1. If deeper suctioning necessary, use DeLee Mucus Trap attached to suction. Oral use of DeLee is contraindicated due to risk of contact with baby's secretions (new DeLee now available that has no such risk).
          2. Avoid prolonged, vigorous suctioning.
            1. Reduces oxygenation.
            2. May traumatize tissue, cause edema, bleeding, laryngospasm, and cardiac arrhythmia.
        3. infoImageAssist gravity drainage of fluids. Position: head dependent (Trendelenburg) and side-lying position.
      2. Goal: maintain body temperature—to conserve energy, preserve store of brown fat, decrease oxygen needs; prevent acidosis. Prevent chilling:
        1. Minimize exposure; dry quickly.
        2. Keep warm; apply hat.
        3. Take temperature hourly until stable.
      3. Goal: identify infant:
        1. Apply Identiband.
        2. Take infant's footprints and maternal fingerprints.
      4. pillImageGoal: prevent eye infection (gonorrheal and chlamydial ophthalmia neonatorum). Within 1 hour of birth, apply antibiotic ointment in each eye.
      5. Goal: facilitate prompt identification/vigilance for potential neonatal complications.
        1. Record significant data from mother's chart:
          1. History of: pregnancy, diabetes, hypertension, current drug abuse, excessive caffeine, medications, alcohol, malnutrition.
          2. Course of labor, evidence of fetal distress, medications received in labor.
          3. Birth history of anesthesia.
          4. Apgar score; resuscitative efforts.
      6. Goal: facilitate prompt identification/intervention in hemolytic problems of the newborn.
        1. Collect and send cord blood for appropriate tests:
          1. Blood type and Rh factor.
          2. Coombs' test.
        2. pillImageGive vitamin K to facilitate clotting.
    4. Evaluation/outcome criteria: successful transition to extrauterine life.
      1. Status satisfactory; all assessment findings within normal limits.
      2. Responsive in bonding process with parents.
  8. NURSE-ATTENDED EMERGENCY BIRTH (PRECIPITATE BIRTH)—When woman presents without prenatal care (to emergency department), may represent drug abuse.
  9. ALTERATIONS AFFECTING PROTECTIVE FUNCTION
    1. Induction of labor—deliberate initiation of uterine contractions.
      1. Indications for:
        1. History of rapid or silent labors, precipitate birth.
        2. Woman resides some distance from hospital (controversial).
        3. Coexisting medical disorders:
          1. Uncontrolled diabetes.
          2. Progressive preeclampsia.
          3. Severe renal disease.
          4. Cardiac disease.
        4. PROM—spontaneous rupture of membranes before onset of labor and less than 37 weeks from last menstrual period. Hazards:
          1. Maternal—intrauterine infection (chorioamnionitis, endometritis).
          2. Fetal—sepsis; prolapsed cord.
        5. Rh or ABO incompatibility, fetal hemolytic disease.
        6. Congenital anomaly (e.g., anencephaly).
        7. Postterm pregnancy with nonreactive nonstress test (NST), or oligohydramnios.
        8. Intrauterine fetal demise.
      2. Criteria for induction:
        1. Absence of CPD, malpresentation, or malposition.
        2. Engaged vertex of single gestation.
        3. Nearing, or at term.
        4. Fetal lung maturity.
          1. Survival rate—better at 32 weeks or more.
          2. Lecithin/sphingomyelin ratio greater than 2:1.
          3. Mother who is diabetic—PG is present in amniotic fluid.
        5. pillImage "Ripe" cervix—softening, partially effaced, or ready for effacement/dilation (if not already present). Note: Intravaginal or paracervical application of prostaglandin gel, or misoprostol may be used to prepare cervix for labor.
      3. Methods:
        1. Amniotomy—artificial rupture of membranes with fetal head engaged and dilation of cervix.
        2. pillImageIntravenous oxytocin infusion.
      4. Potential complications:
        1. Amniotomy—irrevocably committed to birth. Hazards:
          1. Prolapsed cord.
          2. Infection.
        2. pillImageIV oxytocin infusion:
          1. Overstimulation of uterus.
          2. Decreased placental perfusion/fetal distress, neonatal jaundice.
          3. Precipitate labor and birth.
          4. Cervical/perineal lacerations.
          5. Uterine rupture.
          6. Postpartum hemorrhage.
          7. Water intoxication—if large doses given in D/W over prolonged period (antidiuretic effect increases water reabsorption).
          8. Hypertensive crisis.

        BEFORE INDUCTION

      5. Assessment—before induction:
        1. Estimate of gestation (EDD, fundal height, cervical status).
        2. Bishop's score: evaluation of cervical inducibility.
        3. General health status:
          1. Weight, vital signs, FHR, edema.
          2. Status of membranes.
          3. Vaginal bleeding.
          4. Coexisting disorders.
        4. History of previous labors, if any.
        5. Emotional status.
        6. Knowledge/understanding of anticipated procedures:
          1. Amniotomy (artificial rupture of membranes).
          2. Cervical ripening (prostaglandin gel, Cervidil, Cytotec).
          3. IV oxytocin infusion.
          4. Fetal monitoring
        7. Preparation for childbirth (Lamaze method, etc.); coping strategies. Identify support person.
      6. Analysis/nursing diagnosis:
        1. Knowledge deficit related to process of induction.
        2. Anxiety/fear related to need for induction of labor.
        3. Ineffective individual coping related to psychological stress.
        4. Pain related to uterine contractions.
      7. Nursing care plan/implementation:
        1. Goal: health teaching.
          1. Explain rationale for procedures:
            1. Amniotomy.
              1. Induces labor.
              2. Relieves uterine overdistention.
              3. Increases efficiency of contractions, shortening labor.
            2. Oxytocin infusion.
              1. Induces labor.
              2. Stimulates uterine contractions.
            3. Internal fetal monitor.
              1. Provides continuous assessment of uterine response to oxytocin stimulation.
              2. Provides continuous assessment of fetal response to physiological stress of labor.
          2. Describe procedure—to reduce anxiety and increase cooperation.
          3. Explain advantages/disadvantages—to ensure "informed consent."
        2. Goal: emotional support—encourage verbalization of concerns; reassure, as possible.
      8. Evaluation/outcome criterion: woman verbalizes understanding of process, rationale, procedures, and alternatives.

        9. DURING INDUCTION AND LABOR

      9. Assessment—during induction and labor:
        1. Amniotomy—same as for spontaneous rupture of membranes:
          1. Observe fluid—note color, amount.
          2. Monitor FHR; assess for fetal distress.
          3. Observe for signs of prolapsed cord.
          4. Assess fetal activity.
            1. Excessive activity may indicate distress.
            2. Absence of activity may indicate distress or demise.
        2. IV oxytocin infusion:
          1. Continually assess response to oxytocin stimulation/flow rate; always given by controlled infusion.
            1. Uterine contractions.
            2. Maternal vital signs, FHR.
          2. Identify signs of:
            1. Deviation from normal patterns:
              1. Lack of response to increasing flow rate.
              2. Uterine hyperstimulation (contractions—less than 2 minutes apart).
              3. Lack of adequate uterine relaxation between contractions.
            2. Side effects of oxytocin: diminished output—potential water intoxication.
            3. Hazards to mother or fetus:
              1. Sustained (over 90-second) or tetanic (strong, spasmlike) contractions—potential abruptio placentae, uterine rupture, fetal hypoxia/anoxia/death.
              2. Fetal arrhythmias, decelerations.
              3. Maternal hypertension—potential for hypertensive crisis, cerebral hemorrhage.
      10. Nursing care plan/implementation:
        1. Same as for other women in labor.
        2. If indications of deviations from normal patterns:
          1. pillImageChange maternal position.
          2. Stop oxytocin infusion, maintain IV with Ringer's lactate, etc.
          3. Begin oxygen per mask; up to 8 to 10 L/min.
          4. Notify physician promptly.
          5. Check maternal blood pressure and pulse rate.
      11. Evaluation/outcome criteria:
        1. Demonstrates response to oxytocin stimulation.
          1. Establishes desired contraction pattern, not hyperstimulated.
          2. Progresses through labor—within normal limits:
            1. Normotensive.
            2. Voids in adequate amounts.
            3. No evidence of deviation from normal contraction patterns.
        2. No evidence of fetal distress.
        3. Experiences normal vaginal birth of viable infant.
    2. Operative obstetrics—procedures used to prevent trauma/reduce hazard to mother or infant during the birth process.
      1. Episiotomy—incision of perineum to facilitate infant's birth.
        1. Rationale:
          1. Surgical incision reduces possibility of laceration.
          2. Protects infant's head from pressure exerted by resistant perineum.
          3. Shortens second stage of labor.
        2. Types:
          1. Midline—chance of extension into anal sphincter greater than with mediolateral.
          2. Mediolateral—healing is more painful than midline.
        3. Assessment:
          1. bulbImageREEDA:
            1. Rednes.
            2. Edem.
            3. Ecchymosi.
            4. Discharg.
            5. Approximation (suture line intact, separated)
          2. Healing.
          3. Bruised; hematoma.
          4. Tenderness; pain. Note: Evaluate complaints of pain carefully. If intense, and unrelieved by usual measures, report promptly. May indicate vulvar, paravaginal, or ischiorectal abscess or hematoma.
        4. Analysis/nursing diagnosis:
          1. Pain related to labor process.
          2. Impaired skin integrity related to surgical incision.
          3. Fluid volume deficit related to hematoma.
          4. Sexual dysfunction related to discomfort.
        5. Nursing care plan/implementation:
          1. Goal: prevent/reduce edema, promote comfort and healing.
            1. Place covered ice pack during immediate postpartum.
            2. pillImageAdminister analgesics, topical sprays, ointments, witch hazel pads, hydrocortisone.
            3. Encourage use of sitz bath or rubber ring.
            4. Encourage Kegel exercises.
            5. Do health teaching:
              1. Instruct in tightening gluteal muscles before sitting.
              2. Instruct to avoid sitting on one hip.
          2. Goal: minimize potential for infection.
            1. Teach/provide perineal care during fourth stage of labor.
            2. Health teaching: instruct in self-perineal care after voiding, defecation, and with each pad change.
        6. Evaluation/outcome criteria:
          1. Woman's incision heals by primary intention.
          2. Woman demonstrates appropriate self-perineal care.
          3. Woman evidences no signs of hematoma, infection, or separation of suture line.
          4. Woman experiences minimal discomfort.
      2. Forceps-assisted birth—use of instruments to assist birth of infant.
        1. Indications:
          1. Fetal distress.
          2. Maternal need:
            1. Exhaustion.
            2. Coexisting disease, such as cardiac disorder.
            3. Poor progress in second stage.
            4. Persistent fetal occipitotransverse (OT) or occipitoposterior (OP) position.
        2. Criteria for forceps application:
          1. Engaged fetal head.
          2. Ruptured membranes.
          3. Full dilation.
          4. Absence of CPD.
          5. Some anesthesia has been given; usually, episiotomy has been performed.
          6. Empty bladder.
        3. Types:
          1. Low—outlet forceps.
          2. Mid—applied after head is engaged (rarely used).
          3. Piper forceps—applied to after-coming head in selected breech births (rarely done).
        4. Potential complications:
          1. Maternal:
            1. Lacerations of birth canal, rectum, bladder.
            2. Uterine rupture/hemorrhage.
          2. Neonatal:
            1. Cephalohematoma.
            2. Skull fracture.
            3. Intracranial hemorrhage, brain damage.
            4. Facial paralysis.
            5. Direct tissue trauma (abrasions, ecchymosis).
            6. Umbilical cord compression.
        5. Assessment:
          1. FHR immediately before—and after—forceps application (forceps blade may compress umbilical cord).
          2. Observe mother/newborn for injury or signs of complications.
        6. Analysis/nursing diagnosis:
          1. Self-esteem disturbance related to inability to give birth without surgical assistance.
          2. Anxiety/fear related to infant's appearance (forceps marks) or awareness of potential complications.
        7. Nursing care plan/implementation:
          1. Goal: minimize feelings of failure due to inability to give birth "naturally."
            1. Explain, discuss reasons/indications for forceps-assisted birth.
            2. Emphasize no maternal control over circumstances.
          2. Goal: reduce parental anxiety, maternal guilt over infant bruising/forceps marks. Explain condition is temporary and has no lasting effects on child's appearance.
        8. Evaluation/outcome criteria:
          1. Woman verbalizes understanding of reasons for forceps-assisted birth.
          2. Woman evidences no interruption in bonding with infant.
          3. Woman experiences uncomplicated recovery.
      3. Vacuum extraction (soft plastic cup with vacuum from a handheld suction pump). Used to assist in rotation or delivery of the fetal head.
        1. Risks may include caput succedaneum and cephalohematoma.
        2. Causes neonatal jaundice; intraventricular hemorrhage can result in death.
      4. Cesarean birth—incision through abdominal wall and uterus to give birth.
        1. Indications for elective cesarean birth:
          1. Known CPD.
          2. Previous uterine surgery (e.g., myomectomy), repeated cesarean births (depends on type of incision done).
          3. Active maternal genital herpes type 2 infection; human papillomavirus (HPV).
          4. Breech presentation. Note: To reduce infant morbidity/mortality, elective cesarean birth is common method of choice.
          5. Neoplasms of cervix, uterus, or birth canal.
          6. Maternal diabetes with placental aging; fetal macrosomia (CPD); >4050 gm.
        2. Criterion for elective cesarean birth: L/S ratio greater than 2:1—indicates presence of pulmonary surfactant; less risk of respiratory distress syndrome.
        3. Indications for emergency cesarean birth:
          1. Fetal:
            1. Fetal distress: prolapsed cord, repetitive late decelerations, prolonged bradycardia.
            2. Fetal jeopardy: Rh or ABO incompatibility.
            3. Fetal malposition/malpresentation.
          2. Maternal:
            1. Uterine dysfunction; rupture.
            2. Placental disorders:
              1. Placenta previa.
              2. Abruptio placentae, with Couvelaire uterus.
            3. Severe maternal preeclampsia/eclampsia.
            4. Fetopelvic disproportion.
            5. Sudden maternal death.
            6. Carcinoma.
            7. Failed induction.
        4. Types:
          1. Low segment—method of choice:
            1. Transverse incision through abdominal wall and lower uterine segment.
            2. Transverse incision through abdominal wall, with vertical incision of lower uterine segment.
            3. Advantages—fewer complications:
              1. Less blood loss.
              2. More comfortable convalescence.
              3. Less adhesion formation.
              4. Lower risk of uterine rupture in subsequent pregnancy/labor and birth.
              5. Cosmetically more acceptable.
          2. Classical—vertical incision through abdominal wall and uterus. May be necessary for anterior placenta previa and transverse lie, less than 28 weeks' prematurity.
          3. Porro's—hysterotomy followed by hysterectomy. Necessary in presence of:
            1. Hemorrhage from uterine atony.
            2. Placenta accreta/percreta.
            3. Large uterine myomas.
            4. Ruptured uterus.
            5. Cancer of uterus or ovary.
        5. Assessment:
          1. Maternal physical status.
            1. Vital signs.
            2. Labor status, if any.
            3. Contractions (if any).
            4. Membranes (intact; ruptured).
            5. Bleeding.
          2. Fetal status.
            1. FHR pattern.
            2. Color and amount of amniotic fluid.
            3. Biophysical profile (BPP), if performed.
          3. Maternal emotional status.
          4. Understanding of procedure, indications for, implications.
          5. Other—as for any abdominal surgery (see Chapter 6. Physiological Integrity).
        6. Analysis/nursing diagnosis:
          1. Self-esteem disturbance related to perceived failure to give birth vaginally.
          2. Anxiety/fear related to impending surgery and/or reasons for cesarean birth.
          3. Ineffective individual coping related to anxiety and fear for self, infant.
          4. Fluid volume deficit related to abdominal surgery or reason for cesarean birth.
          5. Pain related to abdominal surgery.
          6. Constipation related to decreased bowel activity.
          7. Altered urinary elimination related to fluid volume deficit.
        7. Nursing care plan/implementation:
          1. Preoperative:
            1. Goal: safeguard fetal status.
              1. Monitor fetal heart rate continually.
              2. Notify neonatology and neonatal intensive care unit (NICU) of scheduled surgical birth, if suspect complications.
            2. Goal: health teaching.
              1. Describe, discuss anticipated anesthesia.
              2. pillImageExplain rationale for preoperative antacids to minimize effects of aspiration: cimetidine, Bicitra, histamine blocker to decrease production of gastric acid; Reglan (metoclopramide), to hasten gastric emptying.
              3. Describe, explain anticipated procedures—abdominal shave, indwelling catheter, intravenous fluids—to woman and support person.
            3. Other—as for any abdominal surgery.
            4. Prepare for cesarean birth.
          2. Postoperative:
            1. Same as for other clients having abdominal surgery (see Chapter 6. Physiological Integrity).
            2. Same as for other women who are postpartum.
        8. Evaluation/outcome criteria:
          1. Verbalizes understanding of reasons for cesarean birth.
          2. Successful birth of viable infant.
          3. Evidences no surgical/birth complications.
          4. Evidences no interference with bonding.
          5. Expresses satisfaction with procedure and result.
        9. Trial of labor after cesarean (TOLAC)
          1. Candidates for TOLAC.
            1. Previous low transverse cesarean birth.
            2. Fetal head well engaged in pelvis (vertex presentation).
            3. Soft, anterior cervix.
            4. Preexisting reason for repeat cesarean birth not apparent.
          2. Assessment:
            1. Monitor FHR carefully during trial of labor.
            2. Monitor contractions carefully for adequate progress of labor.
            3. Observe mother for signs of complications/uterine rupture.
          3. Analysis/nursing diagnosis:
            1. Knowledge deficit related to trial of labor.
            2. Fear related to outcome for fetus.
            3. Ineffective individual coping related to labor progress and outcome.

* The woman must be discouraged from using the Valsalva maneuver (holding one's breath and tightening abdominal muscles) for pushing during the second stage. This activity increases intrathoracic pressure, reduces venous return, and increases venous pressure. Cardiac output and blood pressure increase, and pulse slows temporarily. During the Valsalva maneuver, fetal hypoxia may occur. The process is reversed when the woman takes a breath.