First stage of labor

Conditions Associated with Fetal Compromise during Labor:Maternal hypertension

(may be associated with vasospasm in spiral arteries, which supply the intervillous spaces of the placenta). Maternal hypertension also creates a situation of lesser blood flow through the placenta to the fetus. Prolonged maternal hypertension is associated with intrauterine growth restriction in the fetus.

Conditions Associated with Fetal Compromise during Labor:Maternal hypotension

(may divert blood flow away from the placenta to ensure adequate perfusion of the maternal brain and heart). Maternal hypotension is associated with fetal bradycardia that manifests as decelerations on the fetal monitor tracing. Inadequate blood flow to the placenta occurs due to the decrease in the maternal blood pressure.

Characteristics of the Active Phase:Friedman curve

A labor curve, often called a Friedman curve, may be used to identify whether a woman's cervical dilatation is progressing at the expected rate. Typical labor curves for a multiparous and a nulliparous woman are illustrated for comparison of patterns.

Conditions Associated with Fetal Compromise during Labor:Maternal fever

38° C [100.4° F] or higher

Which cervical dilatation will the nurse expect to observe when assessing a patient in active labor?

5 cm

How long might the typical latent phase of labor last, and how much cervical dilatation is expected?

7 hours, 4 cm of cervical dilatation

During the transition phase, cervical dilatation is expected to be what?

8 to 10 cm

Characteristics of a Normal Transition Phase:Cervical Dilatation

8-10 cm, final

Maternal positions during labor:The Birthing Ball

Advantages: Absorbs some of the pressure of the presenting part as it presses on the cervix during the contraction. Promotes the normal mechanisms of birth. The laboring woman can rock, bounce, or rotate the hips while on the birthing ball. The birthing ball can be sat on, or it can be used to lean the upper body over, thus enhancing relaxation. Support personnel are able to massage the shoulders, neck, and lower back of the laboring woman. Disadvantages: Loss of balance results in falling off of the birthing ball so injury could happen. Birth balls have exploded during use. Nursing implications: The support person must stand near the patient to prevent any falls off of the birthing ball.

Maternal positions during labor:Standing

Advantages: Adds gravity to force of contractions to promote fetal descent. Contractions are less uncomfortable and more efficient. Variation: standing, leaning forward with support reduces back pain because fetus falls forward, away from the sacral promontory. Disadvantages: Tiring over long periods. Continuous electronic fetal monitoring is not possible without telemetry if woman is walking in the hall. Nursing implications: If the woman has intravenous fluid running, give her a rolling pole. Encourage her to alternate walking with other positions whenever she tires or desires to do so. Remind the woman and her partner when she should return to the labor area for evaluation of the fetal heart rate and her labor status.

Maternal positions during labor:Side-Lying

Advantages: Helps the patient rest. Prevents supine hypotension and promotes placental blood flow. Promotes efficient contractions, although they may be less frequent than with other positions. Can be used with continuous fetal monitoring. Disadvantages: Does not use gravity to aid fetal descent. Nursing implications: Teach the woman and her partner that although the contractions are less frequent, they are more effective. This position offers a break from more tiring positions. Use pillows for support and to prevent pressure: at her back, under her superior arm, and between her knees. Use disposable underpads to protect the pillow between the woman's knees from secretions. Some women like to put their superior leg on the bed rail. If the woman wants this variation, pad the bed rail with a blanket to prevent pressure. If she wants to remain recumbent, she should use this position to promote placental blood flow.

Maternal positions during labor:Kneeling, Leaning Forward with Support

Advantages: Reduces back pain because fetus falls forward, away from sacral promontory. Adds gravity to force of contractions to promote fetal descent. Can be used with continuous fetal monitoring. Caregivers can rub her back or apply sacral pressure. Promotes normal mechanisms of birth. Disadvantages: Knees may become tired or uncomfortable. Tiring if used for long periods. Nursing implications: Raise the head of the bed, and have the woman face the head of the bed while she is on her knees. Another method is for the partner to sit in a chair, with the woman kneeling in front, facing her partner, and leaning forward on him or her for support. Use pillow under the knees and in front of the woman's chest, as needed, for comfort. Encourage her to change positions if she becomes tired.

Maternal positions during labor:Hands and Knees

Advantages: Reduces back pain because the fetus falls forward, away from the sacral promontory. Promotes normal mechanisms of birth. The woman can use pelvic rocking to decrease back pain. Caregivers can rub the woman's back or apply sacral pressure easily. Disadvantages: The woman's hands (especially wrists) and knees can become uncomfortable. Tiring when used for a long time. Some women are embarrassed to use this position. Nursing implications: Encourage the woman to change to less tiring positions occasionally. Ensure privacy when encouraging the reluctant woman to try this position if she has back pain. A second hospital gown with the opening in front covers her back and hips but may be too warm.

Maternal positions during labor:Semi-Sitting

Advantages: Same as for sitting. Aligns long axis of uterus with pelvic inlet, which applies contraction force in the most efficient direction through pelvis. Disadvantages: Same as for sitting. Does not reduce pain as well as the forward-leaning positions. Nursing implications: Same as for sitting. Raise bed to about a 30- to 45-degree angle. Encourage the woman to use sitting (leaning forward) or side-lying position if she has back pain so that the caregiver can rub her back or apply sacral pressure.

Maternal positions during labor:Sitting Upright and Sitting, Leaning Forward

Advantages: uses gravity to aid fetal descent. Can be done when sitting on side of bed, in a chair, or on the toilet. Can be used with continuous fetal monitoring. Avoid supine hypotension. Reduces back pain because fetus falls forward, away from sacral promontory. Partner or nurse can rub back or provide sacral pressure to relieve back pain. Disadvantages: May increase suprapubic discomfort. Contractions are the most efficient when the woman alternates sitting with other positions. Nursing implications: The nurse can place a pillow on a chair with a disposable underpad over the pillow to absorb secretions. Use pillows or a footstool to keep a short woman's legs from dangling. Encourage the woman to alternate positions periodically. For example, she can alternate walking with sitting or sitting with side-lying.

Latent Phase: Assessing Contractions

Assess contractions with each assessment of the fetal heart rate. Assess several contractions to evaluate average characteristics of the pattern. Note the time when each contraction begins and ends.

Characteristics of the Active Phase:average duration

Average duration is affected by the number of pregnancies the woman has had. Nullipara: 8-10 hr (range, 6-18 hr); dilatation averages 1.2 cm/hr Multipara: 6-7 hr (range, 2-10 hr); dilatation averages 1.5 cm/hr

Which characterizes a patient's discomfort during the active phase of labor?

Begins with a low backache with sensations similar to menstrual cramps and intensifies as labor progresses

When performing Leopold's First Maneuver, the nurse palpates the uterine fundus and suspects a breech fetal presentation. Which action should the nurse take if breech presentation is supported after the second and third Leopold's maneuvers?

Complete Leopold's Maneuver and alert the healthcare provider.

Which physiological forces play the mostsignificant role in complete dilatation of the cervix?

Contractions

Which assessment finding is common for the patient in the latent phase of labor?

Contractions are mild to moderate and 10-30 minutes apart

Characteristics of the Active Phase:Discomfort

Discomfort often begins with a low backache and sensations similar to those of menstrual cramps; back discomfort gradually sweeps to lower abdomen in a girdle-like fashion; discomfort intensifies as labor progresses.

Characteristics of the Active Phase:Cervical dilatation & uterine contractions

During active labor, the cervix is dilated 4-10 cm. Contractions increase in frequency, duration, and intensity until every 2-3 min, 40-60 sec, and moderate to strong intensity.

Which action, taken by the patient, will reduce discomfort during Leopold's Maneuvers and make fetal presenting parts easier to feel?

Emptying the bladder

Before beginning the maneuver, the nurse:

Explains the procedure to the woman including what is typically found at each step. Reassure her when the assessment findings are normal. Asks the woman to empty her bladder if she has not done so recently to reduce discomfort during palpation and make fetal parts easier to feel. Have her lie on her back with her knees flexed slightly or head slightly elevated to help her relax her abdominal muscles. Place a small pillow or folded towel under one hip to prevent supine hypotension. Washes hands with warm water to prevent transmission of microorganisms and to make your hands warmer when touching the woman. Wear gloves to avoid contact with the woman's secretions as indicated. Stands beside the woman, facing her head, with your dominant hand nearest her, because the first three maneuvers are most easily performed in this position.

Following assessment of an actively laboring woman, the nurse finds a fetal heart rate (FHR) of 180 beats per minute with contractions occurring less than two minutes apart and lasting more than 90 seconds. Incomplete relaxation of the uterus is also observed by the nurse. Which is indicated by these findings?

Fetal compromise

Conditions Associated with Fetal Compromise during Labor:A fetal heart rate (FHR) outside the normal range 110 to 160 for term fetus

Fetal heart rate above 160 bpm is associated with distress or fever. A fetal heart rate less than 110 bpm is associated with hypoxia and fetal distress. Both situations could cause long-term side effects for the infant.

Conditions Associated with Fetal Compromise during Labor:Excessive frequency or duration of contractions.

Greater than 6 contractions in a 10-minute time frame is considered tachysystole and could lead to fetal distress due to hypoxia.

Second Maneuver

Hold your left hand steady on one side of the uterus while palpating the opposite side of the uterus with your right hand to determine which side the fetal back is on and which side the arms and legs ("small parts") are on. Then hold your right hand steady while palpating the opposite side of the uterus with your left hand. The fetal back is a smooth, convex surface. The fetal arms and legs feel nodular, and the fetus often moves them during palpation.

In the active phase of labor, how does the fetus typically reposition after effacement and dilatation of the cervix are complete?

Internal rotation occurs

Which assessment findings would be present in a patient having hypertonic contractions?

Intervals shorter than 30 seconds Durations longer than 90-120 seconds

Latent Phase

Lasts from the beginning of labor until about 3 to 5 cm of cervical dilatation Varies in length by woman Changes in cervical effacement and subtle fetal position occur Lasts approximately 6 to 8 hours

The woman is usually sociable and excited during this early phase of labor. Contractions are mild to moderate and 5 to 30 minutes apart; each contraction lasts for 30 to 45 seconds.during which phase of labor

Latent phase

To assess the fetus's presentation and position, the nurse performs

Leopold's Maneuvers. Completing the maneuver can also aid in locating fetal heart sounds. Leopold's Maneuvers are less likely to yield useful information if the woman has a thick abdominal fat pad, excessive amniotic fluid, or a very preterm fetus

Estimate the average intensity of contractions by noting how easily the uterus can be indented during the peak of the contraction

Mild contractions: The uterus is easily indented with the fingertips. It feels similar to the tip of the nose. Moderate contractions: The uterus is indented with more difficulty. It feels similar to the chin. Firm contractions: The uterus feels "woody" and cannot be readily indented. It feels similar to the forehead

When the nurse is palpating "firm" contractions, how will the uterus feel?

Not readily indented, similar to the forehead

Characteristics of a Normal Transition Phase:Average Duration

Nullipara: approximately 3.5 hours Multipara: 0-30 minutes

Latent Phase: Assessing for Hypertonic Contractions

Occur less than 2 minutes apart Last longer than 90 to 120 seconds Have intervals shorter than 30 seconds

Third Maneuver

Palpate the suprapubic area to confirm the presentation felt in the first maneuver and to determine if the presenting part is engaged. If a breech was palpated in the fundus, expect a hard, rounded head in this area. Grasp the presenting part gently between the thumb and fingers. If the presenting part is not engaged, grasping with the fingers moves it upward in the uterus. Omit the fourth maneuver if the fetus is in a breech presentation, because this maneuver is done only in cephalic presentations to determine if the fetal head is flexed.

First Maneuver

Palpate the uterine fundus to distinguish between a cephalic and breech presentation. The breech (buttocks) is softer and more irregular in shape than the head. Moving the breech also moves the fetal trunk. The head is harder, with a round, uniform shape. The head can move without the entire fetal trunk moving.

Palpation during latent phase

Place the fingertips of one hand on the area where the contractions are best felt, usually the fundus. Use light pressure, and keep your fingertips relatively still rather than moving them over the uterus. :

Characteristics of a Normal Transition Phase:Nursing Implications

Provide constant support, assist with breathing techniques, provide comfort and pericare, offer medications as needed, and provide fluids.

A patient is experiencing a moderate level of pain and discomfort during active labor contractions and requests to remain lying down. Which position should the nurse encourage the patient to assume?

Side-lying

Which are advantages of having the patient in the side-lying position during active labor?

Side-lying is a restful position. Side-lying promotes blood flow Left side-lying reduces supine hypotension.

Characteristics of the Active Phase:Maternal behaviors

Sociable, excited, and somewhat anxious during early labor; the expectant mother becomes more inwardly focused as labor intensifies and may experience some level of behavioral and emotional outburst (crying, yelling, or thrashing, for example) during transition.

Characteristics of a Normal Transition Phase:Uterine Contractions

Strong intensity with a frequency of every 1½-2 min and duration of 60-90 seconds. Back discomfort gradually sweeps to lower abdomen in a girdle-like fashion and intensifies as the transition phase of labor progresses.

When assessing intensity and frequency of uterine contractions during the transition phase, which is a typical finding?

Strong, every 1½-2 min

Conditions Associated with Fetal Compromise during Labor:Incomplete uterine relaxation

Tetanic contractions prevent adequate blood flow to the uterus, placenta, and fetus and manifest as fetal distress.

Which is the nurse assessing when evaluating the frequency of contractions?

The average time that elapses from the beginning of one contraction to the beginning of the next

Characteristics of a Normal Transition Phase:Maternal Behaviors

The mother becomes more inwardly focused as labor intensifies and may experience a feeling of losing control and irritability.

Which is included when teaching the patient and their birthing partner about expected maternal behaviors during the transition phase of labor?

The mother may become easily irritated. The mother typically becomes more inwardly focused. The mother may experience vomiting feeling of losing control.

Characteristics of a Normal Transition Phase:Other Changes

The mother may experience nausea and vomiting, sweating, shaking, hyperventilation, increased bloody show, and having the need to push.

Latent Phase: Patient Teaching

The nurse describes the latent phase of labor, including expected discomforts, social-emotional responses, and the dilatation and effacement of the cervix. The nurse explains available pain relief measures like changes of position and therapeutic touch, as well as possible ways the expectant mother can distract herself during this portion of labor. The nurse may also help facilitate comfort measures the expectant mother and their support person have outlined in a birth plan, if there is one.

Latent Phase: Comfort Measures

The nurse encourages walking, which aids in the progression of labor. Contractions become stronger, more regular, and more frequent, which can shorten labor overall. Walking may also reduce the woman's perception of pain.

The nurse will do what in actice phase of the first stage of labor

The nurse will provide fluids and comfort measures such as walking, rocking, water, and frequent position changes. Encourage the patient to void. Assist with breathing techniques, and offer praise and pericare. Educate the patient on pain relief measures, including medications.

Active Phase of the First Stage of Labor

There is an increase in maternal focus. During the active phase of the first stage of labor, the cervix is dilated 4-10 cm. Contractions are moderate to strong, 3 to 5 minutes apart, and more regular; each lasts 40 to 70 seconds. The fetus descends into the pelvis and fetal internal rotation occurs.

Fourth Maneuver

To perform this maneuver most easily, turn so that you face the woman's feet. Place your hands on each side of the uterus with your fingers pointed toward the pelvic inlet to determine whether the head is flexed (vertex) or extended (face). Slide your hands downward on each side of the uterus. On one side, your fingers easily slide to the upper edge of the symphysis. On the other side, your fingers meet an obstruction, the cephalic prominence. If the head is flexed, the cephalic prominence (the forehead in this case) is felt on the opposite side from the fetal back. If the head is extended, the cephalic prominence (the occiput in this case) is felt on the same side as the fetal back.

Fetus in extension beginning (internal rotation complete). Fetus in extension complete. Fetus in external rotation. This all is what stage of labor

Transition

What is the best location to palpate contractions during the assessment of the laboring patient?

Uterine fundus

Hypertonic contractions negatively impact the

fetus by reducing placental blood flow as there is prolonged compression of vessels that supply placental intervillous spaces.

Transition Phase of Labor

may be used to describe the intense contractions of fetal descent and final cervical dilatation, about 7 or 8 cm to complete. Bloody show often increases with completion of cervical dilatation. Transition is a short but intense phase, with very strong contractions. The woman may have an urge to push down during contractions as the fetal presenting part reaches her pelvic floor.

Active Phase

research has demonstrated safety in a slower transition between latent and active labor than is usually accepted in women in spontaneous labor (Zhang, Landry, Branch, et al., 2010). The cervix more rapidly dilates, between about 4 and 6 cm. Effacement and dilatation of the cervix are completed at approximately 10 cm. Internal rotation occurs as the fetus descends in the pelvis during active labor. Discomfort usually increases as the pace of labor increases.

Conditions Associated with Fetal Compromise during Labor:Meconium

stained (greenish) thick amniotic fluid. Meconium-stained amniotic fluid places the fetus at risk for aspiration of the meconium at birth. Aspiration of meconium into the lungs leads to respiratory distress and increased risk of infection. Meconium is released into the amniotic fluid when the fetus experiences a stressful event in utero.

Conditions Associated with Fetal Compromise during Labor:Cloudy, yellowish, or foul odor to the amniotic fluid

suggests infection). An infection affects both the fetus and mother and places the both at risk for sepsis. The fetus may become distressed due to the effect of the infection.

It is not uncommon for a patient in labor, who has an epidural in place for pain management, to go into what?

urinary retention as a side effect of the anesthesia. Often times the bladder needs to be drained via straight catheterization or placement of an indwelling urinary catheter. To minimize the effects of vena cava syndrome in mom and fetal heart rate deceleration in baby, place a wedge under the patient's pelvis prior to catheterization.