Normal Labor, Delivery, and Postpartum Care (Maternal and Newborn Nursing) Part 2

True Versus False Labor

A pregnant woman may find that distinguishing between true and false labor contractions is difficult. False labor contractions are generally felt low in the abdomen. They occur in an irregular pattern, and their intensity does not grow substantially with time. Although false labor may be annoying, the contractions come and go, and a change of position or activity can relieve the discomfort. In false labor, no change is found in the cervix on internal examination, and there is no bloody show. However, the pelvic examination itself may dislodge the mucous plug and cause some spotting that resembles show.

In true labor, the involuntary uterine contractions are rhythmic, grow stronger over time, and begin the true work of labor. These contractions occur at fairly regular intervals, starting at about 20 to 30 minutes apart and increasing until they are about 2 to 3 minutes apart. True labor contractions usually last about 30 seconds initially and increase in duration as labor progresses. The interval (frequency), or time from the start of one contraction until the start of the next one, in true labor gradually decreases (gets shorter), whereas the intensity (strength) and duration (length) of each contraction increase. The bloody show usually appears during this time. Usually, the true labor contraction feels like lowerback pain that moves gradually around to the abdomen. These contractions help create effacement (thinning) and dilation (opening) of the softened cervix. The most important difference between true and false labor is whether or not the cervix changes. During labor, the cervix will become 100% effaced, meaning almost paper-thin, and 10 cm dilated, which will permit the fetus to pass through it (Table 66-1). In Practice: Educating the Client 66-1 provides information about when the client should notify her practitioner.


TABLE 66-1. False vs. True Labor

FALSE LABOR

TRUE LABOR

Contractions

Timing

Duration

Frequency

Intensity

Effect of position or activity change Location where felt

Irregularly spaced Variable Variable Variable

Contractions lessen Primarily in low abdomen

Regular, rhythmic

Increases over time

Becomes closer over time

Becomes stronger over time

Becomes stronger with ambulation or activity

Starts in back, radiate to abdomen

Cervical Change

None

Progressive effacement and dilation

Presence of “Show”

None

Usually present

NCLEX Alert Important concepts to consider for examinations relate to differentiation between true and false labor nursing considerations/interventions, and client teaching.

Uterine Contractions

Contractions of the uterine muscles bring about the birth of the fetus. The uterine muscle is a smooth muscle, and the contractions are involuntary; therefore, the woman cannot hurry, slow, lengthen, or shorten them.

During each contraction, the muscle fibers of the uterus tighten. When the contraction ends and the uterus is at rest, the muscles remain slightly shorter than when it started. This is called retraction of the muscles. As this process continues over the hours of labor, the shorter muscles pull against the point of least resistance, or the cervix, and cause effacement, and later dilation. The pressure from the taut bag of waters or the presenting part of the fetus helps maintain the dilation of the cervix. Each labor contraction has three phases:

1.    Increment: This phase, during which the contraction builds from the resting phase to full strength, is longer than the other two combined.

2.    Acme: This is the time during which the contraction is at full intensity. This phase becomes longer as labor progresses.

IN PRACTICE: EDUCATING THE CLIENT 66-1

NOTIFYING THE PRACTITIONER

A woman should notify her practitioner when she is having regular, rhythmic contractions that are getting closer together, lasting longer and becoming stronger She should also notify her practitioner immediately if the membranes (“bag of waters") break or leak—whether or not she is having any uterine contractions. The practitioner will need to know if the woman is having contractions before, during, or after the membranes rupture.

3. Decrement: During this phase, the uterine contraction eases, until the resting state is achieved.

The time between contractions is called the relaxation time or rest interval and is equally as important as the contractions themselves. If the relaxation time is short or absent, the fetus may suffer from lack of oxygen, and the woman may become extremely tired.

Nursing Alert Report immediately if contractions come more often than every 2 minutes or if each contraction lasts 90 seconds or longer. Rationale: There is not enough relaxation time for the fetus to be well oxygenated. This event is rare during normal labor but must be carefully watched for when oxytocin is used for labor augmentation or induction.

Some people refer to contractions as “labor pains.” When giving nursing care, the term contraction is preferred to avoid reinforcing the idea of pain. You may inform the client that she may feel some discomfort and prepare her for the experience. However, if she insists that she is in pain, do not ignore or correct her! Instead, work with her on ways to relieve the pain. Such methods may include relaxation techniques, breathing techniques, vocalizations, and the use of pain medication.

Special Considerations: CULTURE & ETHNICITY

Expressions of Pain During Labor and Birth

Among most Native Americans, stoicism is encouraged and practiced in childbirth. In African American culture, the expression of pain can be quite open and public.

Rupture of the Membranes. The fetus lies in a two-layered sac filled with amniotic fluid commonly called the “bag of waters.” By the pregnancy’s 40th week, the amniotic fluid volume has reached approximately 1,000 mL (about 1 quart). Before the birth of the fetus, the membranes break, and the fluid is released. If left to nature, this usually happens just before delivery and provides additional protection for the fetal head during labor, by serving as a dilating wedge against the opening cervix.

When the membranes break, either a sudden gush or a gentle trickle of fluid results. The breaking of the bag of waters without medical intervention is termed spontaneous rupture of membranes (SROM) and occurs in approximately 25% of all births. Even after the rupture of the membranes, more amniotic fluid is produced (the stories of “dry birth” are best categorized as myths).

In the remaining 75% of births, the birth attendant may perform artificial rupture of the membranes (AROM), a procedure called amniotomy. This procedure is performed using a special hook (amniohook) under sterile conditions. This procedure may stimulate true labor to begin or may speed the active labor process.

Nursing Alert Report any yellow, green, or cloudy amniotic fluid. Rationale: Normal amniotic fluid is dear and colorless, and has a slightly salty odor. Yellow or green fluid may indicate the fetus has passed meconium (stool) while still in utero. White or cloudy fluid may indicate the presence of pus in response to an infection.

A simple test, known as the Nitrazine test, will determine if the amniotic sac has ruptured. A strip of Nitrazine paper is placed against the client’s vaginal wall and is compared with a color standard. The normal pH of the vagina is 5.0 (acidic); the pH of the amniotic fluid is 7.0 to 7.5 (neutral to slightly alkaline). If the paper turns blue, it is probably stained with amniotic fluid, indicating the amniotic sac has ruptured. If the test or urine strip remains yellow, it is probably in contact with vaginal secretions only. Blood or urine may also turn the paper blue, so it is important to avoid touching these body fluids with the paper.

When providing nursing care to a woman whose membranes have ruptured, record the time, method of rupture (SROM or ArOm), color of fluid, and fetal heart rate.

When the membranes are ruptured, microorganisms from the vagina can travel through the cervix and enter the uterus, which poses a risk of infection to both the mother and infant. For this reason, the nurse should obtain a baseline maternal temperature at the time the bag of waters ruptures and continue to assess the woman’s temperature every 2 hours until delivery. If the woman’s temperature begins to increase, the practitioner will usually initiate measures to prevent infection of the fetus. These measures may include giving intravenous antibiotics to the mother and planning the immediate delivery of the infant.

TABLE 66-2. Average Time Frames of Labor

NULLIPARA

MULTIPARA

STAGE

AVERAGE

UPPER

NORMAL

AVERAGE

UPPER

NORMAL

Stage I, Latent Phase

9 h

20 h

5 h

14 h

Stage I, Active Phase

6 h

12 h

2.5 h

6 h

Stage I,

Transitional

Phase

1 h

2 h

15 min

1 h

Stage II

1 h

2 h

15 min

1 h

The practitioner will also assess the fetal heart rate for the possibility of a prolapsed cord (cord presenting before the fetal head) if the presenting part is not engaged at the time of membrane rupture. If there is any question about whether the presenting part is engaged, a woman who was ambulatory should be placed on bed rest. Providers differ in their practices regarding ambulation for a woman with ruptured membranes when the fetus is of normal size, in cephalic presentation, and engaged. In this instance, there is little risk of cord prolapse, and ambulation may be permitted or encouraged. The healthcare facility policies and the woman’s practitioner provide individual guidelines regarding activity.

Stages of Labor

The entire labor process lasts on average between 8 and 18 hours for the primigravida and between 1 and 14 hours for the multigravida. There are four stages of labor: Stage I (dilation), Stage II (expulsion), Stage III (placental), and Stage IV (recovery).

Stage I (Dilation). Stage I begins with the onset of true labor contractions and ends with complete cervical effacement and dilation. This stage is divided into three phases: latent, active, and transitional (see Tables 66-2 and 66-3). Stage I can begin with the spontaneous rupture of the membranes (“breaking of the bag of waters”). Uterine muscles contract with increasing strength and frequency to supply the pressure needed for cervical stretching and dilating.

TABLE 66-3. Phases of Stage I

PHASE

FREQUENCY OF CONTRACTIONS

DURATION OF CONTRACTIONS

CHARACTER AND INTENSITY OF CONTRACTIONS

CERVICAL

DILATION

MOTHER’S BEHAVIOR

Latent

5-20 min

30-50 sec

Irregular, mild

0-4 cm

Follows directions, excited, talkative

Active

2-4 min

45-60 sec

Regular, moderate to strong

4-8 cm

Serious, apprehensive

Transitional

2-3 min

60-90 sec

Regular, very strong

8-10 cm

Difficulty following directions Frustrated, irritable

Two distinct cervical changes occur during Stage I: effacement and dilation. Effacement refers to the thinning of the cervix. The cervix, normally long and thick (approximately 1-2 cm in length), shortens or thins as a result of contractions. This thinning is measured in percentages. The higher the percentage, the thinner or shorter the cervix. Complete effacement is known as “100% effaced,” which describes a cervix that has become almost paper-thin. In dilation, the cervical os (opening), normally held closed in a tight circle, begins to open. Dilation is measured in centimeters from 1 to 10. Complete dilation (10 cm or about 3.9 inches) is necessary to allow the uterus to expel the fetus. Cervical dilation is the result of uterine contractions.

Medical personnel are able to estimate the amount of dilation and effacement by feeling the cervix during a rectal or sterile vaginal examination. In a primigravida, effacement usually occurs first, then dilation. In a multigravida, effacement and dilation occur simultaneously.

Key Concept Effacement of the cervix is expressed in percentages. Full effacement is 100%. Dilation is expressed in centimeters, according to the diameter of the cervical opening. Complete dilation is 10 cm.

Stage II (Expulsion). Stage II begins with complete cervical effacement and dilation and ends with the expulsion of the fetus. It lasts about 1 to 2 hours for a primigravida and usually about 25 minutes for a multigravida, but can take as long as 1 hour (about 10-15 contractions).

During this stage, the woman’s abdominal muscles and diaphragm join the uterine muscles to push the newborn out of the woman’s body. The woman may say she feels “pushing pains” or a “bearing down” feeling. The rectum dilates, the perineum bulges, and the top of the fetal head appears. This is known as crowning. An expulsive grunt from the woman as she exhales is a classic sign of Stage II.

The birth of the newborn in a normal presentation involves the birth of the head, with the face downward. The head then immediately rotates to one side. The shoulders are born, one at a time, and the rest of the newborn follows quickly. The birth of the body ends the second stage of labor. The cord is clamped in two places and cut between the clamps (Fig. 66-3).

Stage III (Placental). Stage III extends from the time the newborn is delivered until the placenta and membranes are expelled. The placenta is attached to the uterine wall; after the newborn is delivered, the uterine muscles contract. With this contraction, the uterus becomes much smaller in size, and the placenta is sheared away from the wall and then expelled. Stage III can last as long as 30 minutes for a primigravida, but usually takes only 5 to 15 minutes for either the primigravida or multigravida.

The placenta is delivered after the uterus contracts. With the contraction, the uterus rises into the abdomen and becomes round, or globular. As the placenta moves into the vagina, the umbilical cord lengthens, and there may be a sudden trickle or gush of blood. The birth attendant (or the nurse) keeps a hand firmly over the empty uterus until it feels firm and hard, indicating that the muscles and the blood vessels are contracted, and minimal danger of hemorrhage exists. If the placenta is expelled with the shiny (membranous) side out, it is called a Schultze presentation (it helps to remember this as “shiny Schultze”); this is the fetal side of the placenta. Schultze presentation occurs in approximately 80% of births. If the placenta is expelled with the dull side out, it is called a Duncan presentation (“dirty Duncan”). This is the maternal side, which is rough and irregular. Excessive bleeding is more likely with this type of placental presentation.

The birth attendant examines the expelled placenta and membranes to determine if the placenta is intact. Retained placental fragments are a major cause of hemorrhage following delivery. The birth attendant also examines the cervix, vagina, and perineum and then sutures the episiotomy, if performed, or any lacerations. Blood loss during a normal delivery is usually estimated to be 300 to 350 mL.

Stage IV (Recovery). Stage IV includes the first 1 to 4 hours following the expulsion of the placenta. During this time, the woman’s body begins the process of involution, as her reproductive organs begin to return to their normal prepregnant size. Total involution takes about 6 weeks. During Stage IV, the nurse must closely observe for signs of hemorrhage, urinary retention, hypotension, and undesirable side effects from anesthesia.

The other critical event of this stage is bonding (attachment) between the parents and infant. The more time the mother, baby, and other family members spend together during this time, the better the chance of good parental-infant attachment. Bonding is important to the development of a solid relationship between the parents and infant (Fig. 66-4).

NCLEX Alert Common questions on nursing examinations relate to the nursing care and interventions necessary for each stage of labor

NURSING CARE DURING LABOR

Nursing Care During Stage I

Maternal Comfort and Care

Stage I nursing care focuses on frequent monitoring of the woman’s vital signs, contractions, and cervical change, as well as the fetus’ well-being to ensure the safety of both. These findings help the birth attendant to determine the fetus’ condition and the woman’s progress. Of equal importance is the role of the nurse in the physical and emotional support of the woman.

Admission. Admission procedures for women in labor vary among healthcare facilities. However, the important elements of an admission history are standard in all institutions. The admitting nurse asks about the estimated date of delivery (EDD) and confirms this by comparing the information obtained with the prenatal record, which may already be on file at the hospital or may be brought by the woman. If the newborn is preterm, special precautions are taken, and special equipment is readied.

The normal birth process.

FIGURE 66-3 · The normal birth process.

The nurse also obtains the following information:

•    When labor began

•    How close the contractions are

•    How long each contraction lasts

•    Whether the client has noticed any bleeding

•    Whether the bag of waters has ruptured

The anesthesiologist or certified registered nurse anesthetist (CRNA) will also want to know when the client last ate.

Nursing Alert Report any bright-red bleeding at once. Rationale: A client who is bleeding should never be examined vaginally until ultrasound rules out placenta previa.

Other routine procedures include checking temperature, pulse, respirations, and blood pressure; urine dipstick testing for sugar and albumin; and blood tests for hemoglobin, hematocrit, and confirmation of the mother’s blood type.

Bonding during Stage IV

FIGURE 66-4 · Bonding during Stage IV

The fetal heart tones should first be checked at the time of admission. The birth attendant may examine the woman’s heart, lungs, and abdomen and will also listen to the fetal heartbeat. In most facilities, an external fetal monitor is applied to the woman’s abdomen to obtain a baseline fetal heart-rate tracing. A sterile vaginal examination often determines how far labor has progressed.

Nursing Alert Be sure to ask the woman upon admission about allergies to povidone-iodine (Betadine), lidocaine (Xylocaine), any other drugs, and latex. Rationale: Allergic reactions can range from uncomfortable to fatal.

Remember to keep the woman and her partner informed of progress and to observe closely at all times for any signs of fetal distress. Box 66-2 lists danger signs in labor. You must report any of these signs to the team leader immediately.

BOX 66-2.

Danger Signs in Labor

♦    Sharp, unremitting pain

♦    Prolonged contractions or failure of the uterus to relax (rigid uterus after a contraction)

♦    Change in character of the fetal heartbeat; abnormal deceleration pattern on fetal monitor

♦    Maternal bleeding

♦    Extreme maternal exhaustion

♦    Cessation of labor after it has begun

♦    Hypotension or increased pulse rate of the mother

♦    Prolapse of the umbilical cord

♦    Irregular fetal heartbeat

♦    Passage of meconium-stained amniotic fluid when fetus is in vertex position

♦    Exaggerated movement of the fetus

♦    A pH value below 7.2 of fetal blood drawn from scalp veins (indicating fetal acidosis)

Observation and Data Gathering. Uterine contractions are one means of checking progress. A sterile vaginal examination (SVE), usually performed by the midwife, obstetrician, or registered nurse, also assesses the labor’s progress. In addition to the degree of cervical dilation and effacement, the examiner is able to determine the presenting part, station, size of the pelvic outlet, and status of the membranes.

Nursing students may assist by ensuring that the client is draped properly and that the examiner has the needed supplies (sterile gloves, lubricant, and, if necessary, an amnio-hook). Students should not be asked to perform SVEs. If, as a graduate, you are asked to perform an SVE, you must receive in-service instruction in the procedure from the healthcare facility first.

Emotional and Physical Support. Nursing support during Stage I is directed toward making the woman as comfortable as possible and encouraging her to do the things (e.g., breathing) that promote the normal progression of labor. Labor is exactly what it implies, hard work. In the past, women were encouraged to be passive during labor, to lie down and rest. More current thinking is that the woman should be an active participant in the labor process. By laboring in different positions, walking, or even showering during labor, the healthy woman is more likely to have a normal progression of her labor.

Special Considerations :CULTURE & ETHNICITY

Activity During Labor

Traditional Puerto Rican women prefer being in bed for labor, whereas Haitian women may walk, pace, sit, squat, and rub their belly. Samoan women may be either active or passive, as they prefer Many West Indian women continue with housework during the early stages of labor.

Carefully observe the client’s physical state during labor and delivery. Measure and record her vital signs at least every 4 hours and the fetal heart tones at regular intervals. Follow healthcare facility routines carefully.

Stay with the client and do everything possible to help her work with the contractions and relax and rest between them. Encourage the father or support person to be as involved as the couple wishes. Remind the woman to breathe slowly and deeply and to use any techniques learned in childbirth preparation classes to relax her muscles and allow the contractions to do the work. Sponge the woman’s face and hands occasionally, rub her back, offer her a sip of water or ice chips from time to time, change her gown or bedding if they become damp or soiled, and see that the air in the room is fresh.

Special Considerations :CULTURE & ETHNICITY

Environmental Considerations

Filipino women may want noise and stimulation minimized for fear that too much commotion will increase labor pains.

Ensure that the client’s bladder is empty. A full bladder prevents the fetal head from descending into the woman’s pelvis and thereby slows labor’s progress. A full bladder during labor may also result in trauma, urinary incontinence during delivery, or urinary retention in the immediate postpartum period, in which case catheterization may become necessary.

Early labor is best spent out of the bed. The healthy woman may choose to walk, sit in a rocking chair, shower, and engage in diversionary activities such as card games or conversation. As the labor becomes more intense, she will concentrate more and more on the contractions and may have little tolerance for suggestions that she earlier would have welcomed.

For those times when the woman is in bed, she might prefer to have the head of the bed elevated. If she does lie flat, however, she should lie on her left side, rather than on her back, to prevent hypotension, which results from compression of the aorta and vena cava by the weight of the uterus falling backward against the spine (see Fig. 65-11).

Some hospitals allow the woman to be ambulatory only as long as the bag of waters is intact; other hospitals allow a woman whose membranes have ruptured to be up and about if the fetal presenting part is well applied to the cervix. Be sure to know and follow the policies of your institution and the woman’s birth attendant.

Water and clear fluids are usually allowed during the very early stages of labor. Some believe that solid foods may cause the woman to vomit, particularly if she is to have a general anesthetic; others would prefer that the gastric acid be diluted by oral intake, even if a general anesthetic becomes necessary. It has become common practice in many hospitals to give IV solutions to maintain caloric and fluid intake and to lessen exhaustion and dehydration. However, be aware that a full liter bag of 5% dextrose contains only about 125 calories and, if given at a slow infusion rate, will not be sufficient to prevent maternal exhaustion.

Special Considerations :CULTURE & ETHNICITY

Food and Drink During Labor

Offer Korean women lukewarm water only; no ice should be given, in order to maintain the balance between hot and cold. This balance is also seen as precarious during labor in Vietnamese women. Most South Asian women encourage light meals during labor.

Relief of Discomfort. If the client desires, after labor is well established, she may be given medication to make her more comfortable and relaxed. The type of drug may vary with the locale, the provider, and the woman’s condition. Analgesics reduce the discomforts of labor, sedatives promote rest, and tranquilizers relax the client. Sometimes a combination of two drugs is administered. Anti-emetics may also be given for women who experience nausea or vomiting during labor.

Nursing Alert After consulting with her provider, a woman often makes a decision about when to use medication during labor Rationale: Medications may slow labor if given too early or may cause the newborn to be lethargic if given too late.

Many clients receive some form of anesthesia during labor and delivery. One of the most common methods of anesthesia is epidural anesthesia, also called the lumbar epidural block. A small catheter is inserted into the epidural space within the spinal column. The catheter is taped into place, and a test dose of the anesthetic drug is given. If no undesired side effects arise, the drug can be carefully administered through the catheter during labor and delivery—either intermittently or continuously—using a pump. Most women receive pain relief within 20 minutes. An anesthesiologist should monitor the administration of this type of anesthesia because serious side effects (e.g., maternal hypotension) can occur.

The woman receiving epidural anesthesia during labor should be positioned on her side, with her head slightly raised. If she lies on her back, a small firm pillow should be placed under her right hip so that the uterus tilts to the left. This measure will help prevent the compression of the woman’s aorta and vena cava. Monitor the woman’s blood pressure frequently (at least every 15 minutes). The fetal heart rate should be monitored either continuously with an electronic monitor, or frequently with a fetoscope. Disadvantages of delivery using epidural anesthesia include the blocking of the urge to push in Stage II and an increased chance of forceps delivery.

Other anesthetics can be injected into the spinal canal (saddle block), the caudal space (caudal block), or the pudendal nerve (pudendal block). Sometimes the local anesthetic is injected around the cervix (cervical block). Although the client is awake during delivery, she loses sensation in the anesthetized site. The following anesthetic agents are frequently used:

•    Tetracaine hydrochloride (Pontocaine)

•    Dibucaine hydrochloride (Nupercainal)

•    Lidocaine hydrochloride (Dilocaine, Xylocaine)

General anesthesia is rarely used because the client receiving this type of anesthesia is asleep when the newborn arrives. Babies born this way may not breathe spontaneously and may be difficult to awaken. General anesthesia is used in emergencies only (e.g., emergency cesarean delivery) because of the possibility of newborn central nervous system depression. In most cesarean deliveries, general anesthesia is not given until after the baby is delivered, with either spinal or epidural anesthesia used before that.

Each type of anesthesia has distinct advantages and disadvantages. The client’s needs and wishes and the availability of medications dictate the form used. Many women view labor as a natural function and desire to deliver with little or no medication.

Nursing Alert For the woman receiving anesthesia, report the following findings immediately:

•    Inability to move the legs

•    Numbness in the legs

•    Ringing in the ears

•    Dizziness

•    Metallic taste

•    Hypotension or seizures

Rationale: These serious side effects of anesthesia can be fatal to the woman and/or the fetus.

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