Learning Objectives
1. Identify several choices or options for locations for birth. Discuss the advantages and disadvantages for each option. Identify the nursing considerations for each choice.
2. Define the differences between true labor and false labor. State the nursing considerations related to each type of labor.
3. Explain the significance of lightening, Braxton-Hicks contractions, effacement, dilation, “show,” SROM and AROM, engagement, nulliparous, and parous.
4. Differentiate among the following terms related to contractions: increment, acme, decrement, rest interval, frequency, duration, intensity, and length of relaxation time.
5. Define and discuss the nursing considerations for each of the following terms: lie, presentation, station, and position.
6. Discuss the events that indicate the onset of the first stage of labor. Differentiate among the three phases of the first stage of labor. Identify the nursing considerations for the latent phase, the active phase, and the transitional phase.
7. Identify the events of the second stage of labor and the significance of bearing down and crowning. Identify the nursing considerations related to this stage.
8. Identify the events of the third stage of labor and explain the significance of the expelled placenta. Identify the nursing considerations related to this stage.
9. Identify the events of the fourth stage of labor and explain the significance of involution. Identify the nursing considerations related to this stage.
10. Compare the advantages and disadvantages of comfort measures related to contractions. State the nursing considerations related to epidural and general anesthesia.
11. Discuss the nursing considerations related to external fetal monitoring.
12. Differentiate among the following terms: acceleration, deceleration, early deceleration, late deceleration, and decreased variability.
13. Identify the nursing responsibilities to the newborn and the mother immediately after birth.
14. Define and differentiate among the following terms: lochia rubra, lochia serosa, and lochia alba. State the nursing considerations for each.
15. In the nursing skills laboratory, demonstrate the techniques of postpartum care, including fundal massage, episiotomy and perineal observation, peripad changes, Homans’ sign, and bladder assessment.
16. In the nursing skills laboratory, present a client teaching session on the advantages of breastfeeding. Include the following concepts: colostrum, lactation, the “let-down reflex,” engorgement, and expression of milk.
17. Discuss the chances of becoming pregnant when a woman is breastfeeding. Differentiate between the return of menstruation and ovulation.
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IMPORTANT TERMINOLOGY |
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after-pains |
colostrum |
fetal monitor |
lactation |
presentation |
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amniohook |
crowning |
frequency |
lie |
show |
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amniotomy |
dilation |
fundus |
lightening |
stages of labor |
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birth center |
duration |
intensity |
lochia |
station |
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birth plan |
effacement |
interval |
lochia alba |
tocodynamometer |
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birthing room |
engagement |
intrapartum |
lochia rubra |
uterine |
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Braxton-Hicks |
engorgement |
involution |
lochia serosa |
contractions |
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contractions |
epidural |
labor |
nuchal cord |
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cervical os |
episiotomy |
labor contractions |
postpartum |
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Acronyms
AROM
CNM
CRNA
FHR
LDRP
NP
PA
4 P’s
SROM
SVE
LABOR AND BIRTH AS NORMAL PROCESSES
In this topic, you will learn about the process of normal labor and delivery, as well as how to provide nursing care around the time of birth and during the postpartum (after delivery) period.
A woman’s body is designed for conceiving, carrying, and bearing children. The process of labor is normal, but it is a process that most women experience only a few times in their lives. It is an intense process that requires enormous amounts of physical and emotional energy.
In this topic, you will learn how to promote the normal progression of labor and how to recognize signs of possible complications. You will also learn to deal with the emotional needs of the laboring woman and her family. Although most families have looked forward to delivery for many months, the individuals involved will have unique concerns. As a nurse, you will be expected to provide encouragement, support, and education to assist family members during this intense event. Through the nursing process, you can provide comprehensive care to the growing family.
Careful observations of both the mother and newborn are necessary after delivery. You will perform tasks that prevent the development of complications and promote rapid healing of tissue. You will also function as a teacher to provide knowledge the family needs for maternal and newborn care. For many women, the most important role of the nurse during the postpartum period is the role of educator. Whether this baby is the client’s first child or her fifth, each baby brings changes and challenges to the new parents.
Special Considerations: CULTURE & ETHNICITY
Family Involvement in the Birth Process
Most traditional Cuban fathers are not involved in the birth process at all. The level of the father’s participation depends on the wife’s level of education and assimilation into the American culture. The pregnant woman’s mother may be present during the entire labor and delivery. The laboring woman will usually assume a more passive role than her mother; who will try to direct all activity. In Roma families, the father stays outside the birth room due to modesty about birth events.
The Four Stages of Labor
Labor is a series of events during which a woman’s uterus contracts and expels a fetus and completes the birthing process. There are four stages of labor:
Stage I, Dilation: uterine contractions (also called labor contractions) cause the cervical os (mouth) of the cervix to open (dilate) and move the fetus downward into the birth canal. Stage I has three phases: latent, active, and transitional.
Stage II, Expulsion: uterine contractions continue and increase in intensity until the baby is delivered through the vaginal opening.
Stage III, Placental: uterine contractions expel the placenta after the delivery of the newborn.
Stage IV, Recovery: uterine contractions continue and close off open blood vessels to prevent excessive blood loss.
Although there are many theories, no one is certain what causes labor to begin. Approximately 38 weeks after fertilization (the 40th week after the last menstrual period [LMP]), the fetus is ready to be born. Intrapartum is the time period during which labor and delivery take place; it is followed by the postpartum period, which lasts until the end of the sixth week after the birth.
Choices in Labor and Birth
Because each birth is an important life event, many women and their families have a clear sense of what they would like to occur during the process. There are choices in many areas of intrapartum care. The following are some of the options that should be considered.
Birth Attendant
One of the choices an expectant family makes is its healthcare provider.Many women choose physicians, who may be specialists in either family practice or obstetrics. Other women choose to receive pregnancy and birth care from a certified nurse midwife (CNM). Women who have received prenatal care from a nurse practitioner (NP) or physician assistant (PA) will have a different care provider for the birth; the role of these professionals does not include attending at births.
Birth Setting
Another choice families can make when preparing for birth is the setting for the event. Most women choose to deliver in a hospital setting. In the hospital, they may be assigned to a traditional labor and delivery unit, in which the woman labors in one room and then is taken to a delivery room for the birth. Or, they may be placed in a birthing room, in which both the labor and the delivery take place. In some hospitals, these rooms are called LDRP, or labor/delivery/ recovery/postpartum rooms.
A free-standing (not in a hospital) birth center is another option for giving birth. Free-standing birth centers promote the concept of safe, satisfying, and cost-effective childbirth. The National Association of Childbearing Centers has developed standards and criteria for care and safety in childbirth centers.
Finally, women may choose to give birth at home. Home births may be attended by either a CNM or, less frequently, a physician. One reason some women choose this option is that the home is their territory, which is not the case in either a birth center or a hospital.
Only women in good general health whose pregnancies have progressed normally should be candidates for any type of out-of-hospital birth (birth center or home). At the first signs of complications for the woman or fetus, a transfer to a hospital is indicated to ensure the safety of both.
Birth Plan
A birth plan is a written document in which the expectant mother expresses her desires for labor and birth. Some are brief, whereas others are long and very detailed. Some items that may be included are:
• The woman’s choice of a partner for support during labor
• The type of pain-relief measures the woman desires
• The woman’s feelings about having an intravenous (IV), electronic fetal monitoring, or an episiotomy
It is the nurse’s role to inform the woman or couple preparing a birth plan of the policies of the birth setting and birth attendant, and of the need for flexibility if complications develop. The family should discuss the birth plan with their healthcare provider before the onset of labor.
NCLEX Alert The nursing student should be especially alert to Important Terminology For example, see lie, presentation, station, and position below. What do these words mean? Why are these words important to the client? What does the nurse need to consider when these words are used?
The Process of Labor
Lie, Presentation, Station, and Position
To understand the process of labor and birth, it is helpful to understand the relationship of the fetal body to the maternal body. Several terms are used to describe how the fetus is lying within the mother.
Lie. Lie is a term used to compare the position of the fetal spinal cord (the “long part”) to that of the woman. The normal lie of the fetus is longitudinal (up and down), which means that the fetal spine is parallel to the woman’s. In a transverse lie, the fetus is lying crosswise in the uterus and cannot be delivered until the lie is altered.
Presentation. Presentation refers to the body part of the fetus that lies closest to the pelvis and will enter the birth canal first (Fig. 66-1). The usual presenting part is the head; this is a cephalic presentation. Some people call this a vertex presentation; however, vertex is only one type of cephalic presentation. Vertex presentation occurs when the fetal head is flexed well against the fetal chest (Fig. 66-1 A). Other types of cephalic presentations include face presentation and brow presentation (Fig. 66-1B).
When the buttocks, foot, or knee is the presenting (lowest) part, it is called a breech presentation (Fig. 66-1C). Complicated labor often occurs when body parts other than the fetal head present.
Rarely, the shoulder may be the presenting part, if the fetus is lying in a transverse (horizontal) position. If the fetus cannot be turned from this shoulder presentation to a cephalic presentation, the baby must be delivered by cesarean birth.
Station. Station refers to the descent level of the fetal presenting part into the birth canal. Station is measured as the relationship of the fetal presenting part’s lowest bony portion to the level of the ischial spines of the woman’s pelvic bones (Fig. 66-2).
During pregnancy, the fetus is floating in the amniotic fluid above the level of the symphysis pubis. Near term, the fetal presenting part dips into the pelvis, but can still be dislodged upward. Engagement is the term used when the fetal head has moved downward in the birth canal until it can no longer be pushed up and out of the pelvis. In nulli-parous (first time delivery) women, engagement often occurs before the onset of labor. In parous (having a history of more than one birth) women, engagement usually occurs during labor. Box 66-1 contains some terms related to pregnancy and birth that are important for you to know.
BOX 66-1.
Terminology Relating to Pregnancy and Birth
Nulligravida refers to a woman who has never been pregnant.
Nullipara (adjective: nulliparous) refers to a woman who has never delivered a live child; also seen as “para 0."
Primigravida relates to the woman who is pregnant for the first time.
Multigravida is the term for a woman who has had more than one pregnancy.
Primipara (adjective: primiparous) is the term for a woman who has given birth to one child.
Multipara (adjective: multiparous) is a woman who has given birth to more than one viable infant.
The station at which the fetus is said to be fully engaged is called station 0; that is, the widest part of the presenting part of the fetus has lodged in the pelvic inlet, and the lowest part of the fetal skull is at the level of the mother’s ischial spines (see Fig. 66-2). The other stations are measured in centimeters above or below station 0. When the presenting part is higher (above) the level of the ischial spines, the station is expressed with a negative number (e.g., -1 station is 1 cm above the spines; -2 station is 2 cm above the spines). When the presenting part descends further into the pelvis, the station is expressed as a positive number (e.g., +1 station), again using centimeters as the measuring guide. A station of -15 is considered “floating,” whereas a station of + 5 means the fetal head is at the vaginal opening.
Position. Position refers to the relationship between standardized points on the presenting part of the fetus to a designated point on one of four quadrants of the woman’s pelvis. The standardized or assigned points can include the occipital bone (O), the chin or mentum (M), the buttocks or sacrum (S), and the scapula or acromion process (A). The presenting part (occiput, mentum, sacrum, or acromion) is labeled in relationship to a designated point of one of the four quadrants of the maternal pelvis: right anterior, left anterior, right posterior, and left posterior. There are several positions for a fetus in any presentation. Refer to Figure 66-1 for examples. Abnormal fetal presentations are further discussed in Chpater 68.
• If the assigned part is the occipital bone, a vertex presentation is designated. Figure 66-1A shows three positions in three left vertex (occiput) presentations.
• If the assigned part is the mentum, a face presentation is designated. Figure 66-1B shows three positions in three left face (mentum) presentations.
• If the assigned part is the shoulder or acromion process, a shoulder presentation is designated. In shoulder presentation positions, the fetus is on a transverse lie. The shoulder, arm, backside, or abdomen may be the presenting part.
FIGURE 66-1 · Left fetal presentations. (A) Vertex presentations. (B) Face presentations. (C) Breech presentations. Each position can be left or right; and anterior; posterior; or transverse. Each presentation has a possibility of six positions: LOA—left occiput anterior; LOP—left occiput posterior; LOT—left occiput transverse; ROA— right occiput anterior; ROP—right occiput posterior; ROT—right occiput transverse.
FIGURE 66-2 · Stations of the fetal head. This diagram shows the relationship of the fetal head to the pelvic bones, specifically the ischial spines, during the labor and delivery process. Station zero (0) represents the level of the ischial spines.
• If the assigned part is the buttocks or sacrum, a breech presentation is designated. Figure 66-1C shows three breech (sacrum) positions in three left presentations. Variations of breech position include:
• Complete breech: The fetus has both legs drawn up, bent at both the hip and the knee.
• Frank breech: The fetus has the hips bent, but the knees are extended.
• Kneeling breech: Either one or both legs are extended at the hip, flexed at the knee.
• Footling breech: Either one or both legs are extended both at the hip and knee.
In all types of breech presentation positions, the sacrum is the assigned point.
After you learn which body part is presenting, you can then accurately describe the position of any fetus. For example, the occiput may be on the woman’s right or left side and in the anterior, posterior, or transverse area of the pelvic opening. These positions are often designated by the obstetric personnel and recorded and initialed in the charts. A fetus with the occiput in the left side of the anterior portion of the mother’s pelvis could be described as LOA (left occiput anterior) (see Fig. 66-1A).
Key Concept Some positions of the fetus make delivery difficult or dangerous. For example, in a footling breech position, there is a chance the umbilical cord could prolapse because there is so much empty space within the uterus. This could cut off the blood and oxygen supply to the fetus before it is born.
Signs that Labor is Approaching
The common variables of labor, known as the 4 P’s of labor, are: passage, passenger, powers, and psyche. The passage includes the diameter of the body pelvis and its soft tissues.
The passenger includes the fetus, umbilical cord, and placenta. The powers are the uterine contractions. The psyche includes the process of birthing, the attitude and behaviors of the parents, and the evaluation process of the stages of labor.
Lightening. Lightening is the settling of the fetus into the pelvis. Lay people often say, “the baby has dropped.” Lightening usually occurs 2 to 3 weeks before the onset of labor in primigravidas (women having their first child). If the client is a multigravida (has had more than one pregnancy), lightening may not occur until labor begins. Although lightening allows the pregnant woman to breathe more easily, she will notice an increase in pelvic pressure and urinary frequency and may also have leg cramps and increased leg edema.
Braxton-Hicks Contractions. During pregnancy’s late stages, the uterine muscles prepare for labor and delivery by tightening and relaxing at intervals. These contractions, called Braxton-Hicks contractions, are usually painless, short, and irregular. They are also known as false labor. As labor approaches, these contractions may become stronger and somewhat regular. The woman may sometimes mistake these false labor contractions for true labor. She may experience false labor anytime in the last trimester, but more often during the final 2 or 3 weeks of pregnancy. A change in activity may provide the woman some relief.
Show. A mucous plug seals the cervix during pregnancy. Just before labor, the cervix opens slightly and this plug dislodges. At the same time, some capillaries of the cervix rupture, staining the sticky mucus a pinkish color. This process is called the show, or bloody show, and indicates that labor is about to begin.
