ob 19

Fourth Stage of Labor

The first 1 to 2 hours after birth, sometimes called the fourth stage of labor, is a crucial time for mother and newborn. Both are not only recovering from the physical process of birth but also becoming acquainted with each other and additional family members. During this time maternal organs undergo their initial readjustment to the nonpregnant state, and the functions of body systems begin to stabilize.

Second Stage of Labor Care Management Preparing for Birth Birth in a Delivery Room or Birthing Room Mechanism of Birth: Vertex Presentation

The three phases of the spontaneous birth of a fetus in a vertex presentation are (1) birth of the head, (2) birth of the shoulders, and (3) birth of the body and extremities With voluntary bearing-down efforts, the head appears at the introitus Crowning occurs when the widest part of the head (the biparietal diameter) distends the vulva just before birth. Immediately before birth, the perineal musculature becomes greatly distended. If an episiotomy (incision into the perineum to enlarge the vaginal outlet) is necessary, it is done at this time to minimize soft-tissue damage. A local anesthetic may be administered if necessary before performing an episiotomy. Box 19-12 shows the process of normal vaginal childbirth using a series of photographs. The physician or nurse-midwife may use a hands-on approach to control the birth of the head, believing that guarding the perineum results in a gradual birth that will prevent fetal intracranial injury, protect maternal tissues, and reduce postpartum perineal pain. This approach involves (1) applying pressure against the rectum, drawing it downward to aid in flexing the head as the back of the neck catches under the symphysis pubis; (2) applying upward pressure from the coccygeal region (modified Ritgen maneuver) to extend the head during the actual birth, thereby protecting the musculature of the perineum; and (3) assisting the mother with voluntary control of the bearing-down efforts by coaching her to pant while letting uterine forces expel the fetus. Some health care providers use a hands-poised (hands-off) approach when attending a birth. In this approach, hands are prepared to place light pressure on the fetal head to prevent rapid expulsion. The provider does not place hands on the perineum or use them to assist with birth of the shoulders and body. The hands-on and hands-poised approaches have similar results in terms of perineal and vaginal tears, but the hands-on technique is associated with a higher incidence of third-degree tears and episiotomies. In one study the hands-poised approach resulted in fewer third-degree tears However, the hands-on approach may result in less perineal pain. The umbilical cord often encircles the neck (nuchal cord) but rarely so tightly as to cause hypoxia. After the head is born, gentle palpation is used to feel for the cord. If present, the health care provider slips the cord gently over the head if possible. If the loop is tight or if there is a second loop, he or she will probably clamp the cord twice, cut between the clamps, and unwind the cord from around the neck before the birth is allowed to continue. Mucus, blood, or meconium in the nasal or oral passages may prevent the newborn from breathing. To eliminate this problem, moist gauze sponges are used to wipe the nose and mouth. A bulb syringe may be inserted first into the mouth and oropharynx and then into both nares to aspirate contents.

Care Management Nursing Interventions Supportive Care During Labor and Birth Labor Support by the Nurse

Supportive nursing care for a woman in labor includes: Helping her maintain control and participate to the extent she wishes in the birth of her infant Providing continuity of care that is nonjudgmental and respectful of her cultural and religious values and beliefs Meeting her expected outcomes for her labor Listening to her concerns and encouraging her to express her feelings Acting as her advocate, supporting her decisions and respecting her choices as appropriate, and relating her wishes as needed to other health care providers Helping her conserve her energy and cope effectively with her pain and discomfort by using a variety of comfort measures that are acceptable to her Helping control her discomfort Acknowledging her efforts during labor including her strength and courage, as well as those of her partner, and providing positive reinforcement Protecting her privacy, modesty, and dignity Women who have attended childbirth education programs that teach the psychoprophylactic (Lamaze) approach will know something about the labor process, coaching techniques, and comfort measures. The nurse plays a supportive role and keeps the woman and her partner informed of the labor progress. If necessary, review the methods learned in class and practiced at home because it may be difficult for the woman to effectively use these methods and techniques now that she is in labor and in an unfamiliar setting. Even when a laboring woman has not attended childbirth classes, the nurse can teach her simple breathing and relaxation techniques during the early phase of labor. In this case the nurse provides more of the coaching and supportive care until the support person feels ready to take on a more active coaching role The nurse can demonstrate comfort measures while encouraging the support person to assist and the laboring woman to express her needs and feelings. Observing the comforting approaches of the nurse can help the partner learn effective comfort measures. Comfort measures vary with the situation The nurse can draw on the woman's list of comfort measures and relaxation techniques learned during the pregnancy and through life experiences. Such measures include maintaining a comfortable, calm, supportive atmosphere in the labor and birth area; using touch therapeutically (e.g., heat or cold applied to the lower back in the event of back labor, a cool cloth applied to the forehead, massage); providing nonpharmacologic measures to relieve discomfort (e.g., hydrotherapy); and most important, just being there Most women in labor respond positively to touch, but you should obtain permission before using any touching measures. Women appreciate gentle assistance by staff members. Back rubs and counterpressure may be offered, especially if the woman is experiencing back labor. Teach the support person to exert counterpressure against the woman's sacrum over the occiput of the head of a fetus in a posterior position Double hip or knee squeezes can also be helpful in reducing back pain. The back pain is caused by the occiput pressing on spinal nerves, and counterpressure lifts the occiput off these nerves, providing some relief from pain. The partner will need to be relieved after a while, however, because exerting counterpressure is hard work. Hand and foot massage also can be soothing and relaxing. The woman's perception of the soothing qualities of touch may change as labor progresses. Many women become more sensitive to touch (hyperesthesia) as labor progresses. This is a typical response during the transition phase They may tell their coach to leave them alone or not to touch them. The partner who is unprepared for this normal response may feel rejected and may react by withdrawing active support. The nurse can reassure him or her that this response is a positive indication that the first stage is ending and the second stage is approaching. Women with increased sensitivity to touch may tolerate it better on surfaces of the body where hair does not grow, such as the forehead, the palms of the hands, and the soles of the feet.

Care Management Assessment Stress in Labor

The way in which women and their support persons or family members approach labor is related to how they have been socialized to the childbearing process as well as how they deal with other stressors in their lives. Their reactions reflect their life experiences regarding childbirth—physical, social, cultural, and religious. Society communicates its expectations regarding acceptable and unacceptable maternal behaviors during labor and birth. These expectations may be used by some women as the basis for evaluating their own actions during childbirth. An idealized perception of labor and birth may be a source of guilt and cause a sense of failure if the woman finds the process less than joyous, especially when the pregnancy is unplanned or is the product of a dysfunctional or terminated relationship. Often women have heard horror stories or have seen friends or relatives going through labors that appear anything but easy. Multiparous women often base their expectations of the present labor on their previous childbirth experiences. Discuss the feelings a woman has about her pregnancy and fears regarding childbirth. This discussion is especially important if the woman is a primigravida who has not attended childbirth classes but has obtained information on childbirth from reality birth television shows or is a multiparous woman who has had a previous negative childbirth experience. Women in labor usually have a variety of concerns that they will voice if asked but may not volunteer. Major fears and concerns relate to the process and effects of childbirth, maternal and fetal well-being, and the attitude and actions of the health care staff. Every effort should be made to provide support and to encourage those with her to be supportive. Women who have continuous labor support are more likely to have a spontaneous vaginal birth and are less likely to have intrapartum analgesia or anesthesia, a cesarean or an operative vaginal birth, and a baby with a low 5-minute Apgar score; or to report dissatisfaction with their childbirth experiences The father, coach, or significant other also experiences stress during labor. The nurse can assist and support these individuals by identifying their needs and expectations, helping to make sure these are met, and interpreting events that are occurring. The nurse can determine what role the support person intends to fulfill and whether he or she is prepared for that role by making observations and asking herself or himself such questions as, "Has the couple attended childbirth classes?" "What role does this person expect to play?" "Does he or she do all the talking?" "Is he or she nervous, anxious, aggressive, or hostile?" "Does he or she look hungry, tired, worried, or confused?" "Does he or she watch television, sleep, or stay out of the room instead of paying attention to the woman?" "Where does he or she sit?" "Does he or she touch the woman; what is the character of the touch?" Be sensitive to the needs of support persons and provide teaching and support as appropriate. In many instances the support these people provide to the laboring woman may be in direct proportion to the support they receive from the nurses and other health care providers.

Care Management Nursing Interventions Ambulation and Positioning

Upright positions and mobility during labor may be more pleasant for laboring women. These practices have also been associated with improved uterine contraction intensity and shorter labors, less need for pain medications, reduced rate of operative birth (e.g., cesarean birth, forceps- and vacuum-assisted birth), increased maternal autonomy and control, distraction from the discomforts of labor, and an opportunity for close interaction with the woman's partner and care provider as they help her assume upright positions and remain mobile No harmful effects have been observed from maternal activity and position changes. However, confinement to bed is the norm for laboring women in U.S. hospitals. The increased use of epidurals during childbirth accompanied by multiple medical interventions (e.g., electronic fetal monitors, IV infusions) and reduced motor control contribute to this practice, thereby interfering with a woman's freedom of movement and often slowing labor progress. It is important to encourage ambulation if membranes are intact, after ROM if the fetal presenting part is engaged, and if the woman has not received medication for pain The woman also may find it comfortable to stand and lean forward on her partner, doula, or nurse for support at times during labor In some circumstances, ambulation may be contraindicated because of maternal or fetal status. When the woman lies in bed, she usually changes her position spontaneously as labor progresses. If she does not change position every 30 to 60 minutes, assist her to do so. The side-lying (lateral) position is preferred because it promotes optimal uteroplacental and renal blood flow and increases fetal oxygen saturation If the woman wants to lie supine, the nurse should place a pillow under one hip as a wedge to prevent the uterus from compressing the aorta and vena cava Sitting is not contraindicated unless it adversely affects fetal status, which you can determine by checking the FHR and pattern. If the fetus is in the occiput posterior position, it may be helpful to encourage the woman to squat during contractions because this position increases the pelvic diameter, allowing the head to rotate to a more anterior position A hands-and-knees position during contractions or a lateral position on the same side as the fetal spine also are recommended to facilitate the rotation of the fetal occiput from a posterior to an anterior position, as gravity pulls the fetal back forward. These positions also provide access to the back for application of counterpressure by the partner, doula, or nurse Women with epidural anesthesia may not be able to squat or assume a hands-and-knees position depending on the degree of motor involvement resulting from the epidural. Much research continues to focus on acquiring a better understanding of the physiologic and psychologic effects of maternal position in labor. The woman can use a birth ball (gymnastic ball, physical therapy ball) to support her body as she assumes a variety of labor and birth positions She can sit on the ball while leaning over the bed or lean over the ball to support her upper body and reduce stress on her arms and hands when she assumes a hands-and-knees position. The birth ball can encourage pelvic mobility and pelvic and perineal relaxation when the woman sits on the firm yet pliable ball and rocks in rhythmic movements. Warm compresses applied to the perineum and lower back can maximize this relaxation and comfort effect. The birth ball should be large enough that, when the woman sits, her knees are bent at a 90-degree angle and her feet are flat on the floor and approximately 2 feet apart.

Care Management Assessment Physical Examination Assessment of Uterine Contractions

A general characteristic of effective labor is regular uterine activity (i.e., contractions becoming more frequent with increased duration), but uterine activity is not directly related to labor progress. Uterine contractions are the primary powers that act involuntarily to expel the fetus and the placenta from the uterus. Several methods are used to evaluate uterine contractions, including the woman's subjective description, palpation and timing of contractions by a health care provider, and electronic monitoring. Each contraction exhibits a wavelike pattern. It begins with a slow increment (the "building up" of a contraction from its onset), gradually reaches a peak, and then diminishes rapidly (decrement, the "letting down" of the contraction). An interval of rest ends when the next contraction begins. A uterine contraction is described in terms of the following characteristics: Frequency: How often uterine contractions occur; the time that passes from the beginning of one contraction to the beginning of the next contraction Intensity: The strength of a contraction at its peak Duration: The time that passes between the onset and the end of a contraction Resting tone: The tension in the uterine muscle between contractions; relaxation of the uterus Uterine contractions are assessed by palpation or by using external or internal electronic monitors Frequency and duration can be measured by all three methods of uterine activity monitoring. The accuracy of determining intensity and resting tone varies by the method used. The woman's description and examiner's palpation are more subjective and less precise ways of determining the intensity of uterine contractions and resting tone than are the external or internal electronic monitors. The following terms describe what is felt on palpation: Mild: Slightly tense fundus that is easy to indent with fingertips (feels like pressing finger to tip of nose) Moderate: Firm fundus that is difficult to indent with fingertips (feels like pressing finger to chin) Strong: Rigid boardlike fundus that is almost impossible to indent with fingertips (feels like pressing finger to forehead) Women in labor tend to describe the pain of contractions in terms of the sensations they are experiencing in the lower abdomen or back, which are sometimes unrelated to the firmness of the uterine fundus. Therefore, their assessment of the strength of their contractions can be less accurate than that of the health care provider, although the amount of discomfort reported is valid. External electronic monitoring provides some information about the strength of uterine contractions when the appearance of contractions on admission is compared with those that occur later in labor. Internal electronic monitoring with an intrauterine pressure catheter, however, is the most accurate way of assessing the intensity of uterine contractions and uterine resting tone On admission to a hospital, uterine contractions and FHR and pattern are usually monitored electronically for at least a 20- to 30-minute period as a baseline. You must consider uterine activity in the context of its effect on cervical effacement and dilation and on the degree of descent of the presenting part You must also consider the effect on the fetus. You can verify the progress of labor effectively through the use of graphic charts (partograms) on which you plot cervical dilation and station (descent). This type of graphic charting assists in early identification of deviations from expected labor patterns. Hospitals and birthing centers may develop their own assessment graphs that may include data not only on dilation and descent but also maternal vital signs, FHR, and uterine activity.

Assessment During the Fourth Stage of Labor

Blood Pressure • Measure blood pressure every 15 minutes for the first 2 hours. Pulse • Assess rate and regularity. Measure every 15 minutes for the first 2 hours. Temperature • Determine temperature at the beginning of the recovery period. Temperature should then be assessed every 4 hours for the first 8 hours after birth and then at least every 8 hours. Fundus • Position woman with knees flexed and head flat. • Just below umbilicus, cup hand and press firmly into abdomen. At the same time, stabilize the uterus at the symphysis with the opposite hand (see Fig. 20-1). • If fundus is firm (and bladder is empty), with uterus in midline, measure its position relative to woman's umbilicus. Lay fingers flat on abdomen under umbilicus; measure how many fingerbreadths (fb) or centimeters (cm) fit between umbilicus and top of fundus. Fundal height is documented according to agency guidelines. For example, if the fundus is 1 fb or 1 cm above the umbilicus, fundal height may be recorded as either +1, u+1, or 1/u. If the fundus is 1 fb or 1 cm below the umbilicus, fundal height may be recorded as either −1, u−1, or u/1. • If fundus is not firm, massage it gently to contract and expel any clots before measuring distance from umbilicus. • Place hands appropriately; massage gently only until firm. • Expel clots while keeping hands placed as in Figure 20-1. With upper hand, firmly apply pressure downward toward vagina; observe perineum for amount and size of expelled clots. Bladder • Assess distention by noting location and firmness of uterine fundus and by observing and palpating bladder. A distended bladder is seen as a suprapubic rounded bulge that is dull to percussion and fluctuates like a water-filled balloon. When the bladder is distended, the uterus is usually boggy in consistency, well above the umbilicus, and to the woman's right side. • Assist woman to void spontaneously. Measure amount of urine voided. • Catheterize as necessary. • Reassess after voiding or catheterization to make sure the bladder is not palpable and the fundus is firm and in the midline. Lochia • Observe lochia on perineal pads and on linen under the mother's buttocks. Determine amount and color; note size and number of clots; note odor. • Observe perineum for source of bleeding (e.g., episiotomy, lacerations). Perineum • Ask or assist woman to turn onto her side and flex upper leg on hip. • Lift upper buttock. • Observe perineum in good lighting. • Assess episiotomy or laceration repair for redness (erythema), edema, ecchymosis (bruising), drainage, and approximation (REEDA). • Assess for presence of hemorrhoids.

Fourth Stage of Labor Care Management Assessment

If the recovery nurse has not previously cared for the new mother, he or she begins with an oral report from the nurse who attended the woman during labor and birth and a review of the prenatal, labor, and birth records. Of primary importance are conditions that could predispose the mother to hemorrhage, such as precipitous labor, a large baby, grand multiparity (i.e., having given birth to five or more viable infants), or induced labor. For healthy women, hemorrhage is the most dangerous potential complication during the fourth stage of labor. During the fourth stage of labor the mother is assessed frequently The American Academy of Pediatrics (AAP) and the ACOG recommend that blood pressure and pulse be assessed at least every 15 minutes for the first 2 hours after birth. Temperature should be assessed every 4 hours for the first 8 hours after birth and then at least every 8 hours

Women with a History of Sexual Abuse

Labor can trigger memories of sexual abuse, especially during intrusive procedures such as vaginal examinations. Monitors, intravenous (IV) lines, and epidurals can make the woman feel a loss of control or feel as if she is being confined to bed and "restrained." Being observed by students and having intense sensations in the uterus and genital area, especially at the time when she must push the baby out, can also trigger negative memories. The nurse can help the abuse survivor associate the sensations she is experiencing with the process of childbirth and not with her past abuse. Help maintain her sense of control by explaining all procedures and why they are needed, validating her needs, and paying close attention to her requests. Wait for the woman to give permission before touching her, and accept her often extreme reactions to labor Avoid words and phrases that can cause the woman to recall the words of her abuser (e.g., "open your legs," "relax and it won't hurt so much"). Limit the number of procedures that invade her body (e.g., vaginal examinations, urinary catheter, internal monitor, forceps or vacuum extractor) as much as possible. Encourage her to choose a person (e.g., doula, friend, family member) to be with her during labor to provide continuous support and comfort and to act as her advocate. Nurses are advised to care for all laboring women in this manner because it is not unusual for a woman to choose not to reveal a history of sexual abuse. Careful attention to these care measures can help a woman perceive her childbirth experience in positive terms.

Fourth Stage of Labor Care Management Nursing Interventions Care of the Family

Most parents enjoy being able to hold, explore, and examine the baby immediately after birth. Both parents can assist with thoroughly drying the infant. Usually the infant is wrapped in a receiving blanket and given to the mother or father/partner to hold. Skin-to-skin contact is encouraged. The nurse places the unwrapped infant on the woman's chest or abdomen and then covers the baby and mother with a warm blanket. Holding the newborn next to her skin helps the mother maintain the baby's body heat and provides skin-to-skin contact. Stockinette caps are often used to keep the newborn's head warm and prevent heat loss. Many women wish to begin breastfeeding their newborns at this time to take advantage of the infant's alert state (first period of reactivity) and to stimulate the production of oxytocin that promotes contraction of the uterus and prevents hemorrhage. In Baby Friendly hospitals, breastfeeding is initiated within the first hour after birth, and any unnecessary separation of mother and baby is strongly discouraged. However, some women prefer to wait to breastfeed until they have had time to rest. Be aware that in some cultures breastfeeding is not acceptable to some women until the milk comes in. In the Hispanic culture, for example, the colostrum is thought to be bad or old milk Therefore, women may wait several days after giving birth before initiating breastfeeding.

Care Management Nursing Interventions Elimination Bowel Elimination

Most women do not have bowel movements during labor because of decreased intestinal motility. Stool that has formed in the large intestine often moves downward toward the anorectal area as a result of pressure exerted by the fetal presenting part as it descends. This stool is often expelled during second-stage pushing and birth. However, the passage of stool with bearing-down efforts increases the risk of infection and may embarrass the woman, thereby reducing the effectiveness of her pushing efforts. To prevent these problems, the nurse should immediately cleanse the perineal area to remove any stool, while reassuring the woman that the passage of stool at this time is a normal and expected event, because the same muscles used to expel the baby also expel stool. Routine use of enemas on hospital admission for women at term has shown only modest benefits. There is a trend toward lower infection rates and the newborns have fewer lower respiratory tract infections and less need for antibiotics. However, because enemas cause discomfort for women and increase the costs of giving birth, the small benefits do not outweigh the disadvantages of this practice In addition, a Cochrane review of this topic found that the evidence does not support the routine use of enemas during labor When the presenting part is deep in the pelvis, even in the absence of stool in the anorectal area, the woman may feel rectal pressure and think she needs to defecate. If the woman expresses the urge to defecate, the nurse should perform a vaginal examination to assess cervical dilation and station. When a multiparous woman experiences the urge to defecate, this often means birth will follow quickly.

Second Stage of Labor Care Management Preparing for Birth Perineal Trauma Related to Childbirth Perineal Lacerations

Perineal lacerations usually occur as the fetal head is being born. The extent of the laceration is defined in terms of its depth First degree: Laceration that extends through the skin and vaginal mucous membrane but not the underlying fascia and muscle Second degree: Laceration that extends through the fascia and muscles of the perineal body, but not the anal sphincter Third degree: Laceration that involves the external anal sphincter Fourth degree: Laceration that extends completely through the rectal mucosa, disrupting both the external and internal anal sphincters Perineal injury often is accompanied by small lacerations on the medial surfaces of the labia minora below the pubic rami and to the sides of the urethra (periurethral) and clitoris. Lacerations in this highly vascular area often result in profuse bleeding. Third- and fourth-degree lacerations must be carefully repaired so that the woman retains fecal continence. Simple perineal injuries usually heal without permanent disability, regardless of whether they were repaired. However, repairing a new perineal injury to prevent future complications is easier than correcting long-term damage.

First Stage of Labor

The first stage of labor begins with the onset of regular uterine contractions and ends with full cervical effacement and dilation. The first stage of labor consists of three phases: the latent (early) phase (through 3 cm of dilation), the active phase (4 to 7 cm of dilation), and the transition phase (8 to 10 cm of dilation).

Third Stage of Labor Care Management

The goal in the management of the third stage of labor is the prompt separation and expulsion of the placenta, achieved in the easiest, safest manner. The third stage is generally by far the shortest stage of labor. The placenta is usually expelled within 10 to 15 minutes after the birth of the baby. If the third stage has not been completed within 30 minutes, the placenta is considered to be retained and interventions to hasten its separation and expulsion are usually instituted Under normal circumstances the placenta is attached to the decidual layer of the basal plate's thin endometrium by numerous fibrous anchor villi—much in the same way a postage stamp is attached to a sheet of postage stamps. After the birth of the fetus, strong uterine contractions and the sudden decrease in uterine size cause the placental site to shrink. This causes the anchor villi to break and the placenta to separate from its attachments. Normally the first few strong contractions that occur after the baby's birth cause the placenta to shear away from the basal plate. A placenta cannot detach itself from a flaccid (relaxed) uterus because the placental site is not reduced in size.

Care Management Assessment Physical Examination Assessment of Fetal Heart Rate and Pattern

The point of maximal intensity (PMI) of the FHR is the location on the maternal abdomen at which the FHR is heard the loudest. It is usually directly over the fetal back. In a vertex presentation you can usually hear the FHR below the mother's umbilicus in either the right or the left lower quadrant of the abdomen. In a breech presentation you usually hear the FHR above the mother's umbilicus. In addition, you must assess the FHR after ROM because this is the most common time for the umbilical cord to prolapse, after any change in the contraction pattern or maternal status, and before and after the woman receives medication or a procedure is performed.

Second Stage of Labor

The second stage of labor is the stage in which the infant is born. This stage begins with full cervical dilation (10 cm) and complete effacement (100%) and ends with the baby's birth. The median duration of second-stage labor is 50 to 60 minutes in nulliparous women and 20 to 30 minutes in multiparous women The use of epidural anesthesia often increases the length of the second stage of labor because the epidural blocks or reduces the woman's urge to bear down and limits her ability to attain an upright position to push.

Fourth Stage of Labor Care Management Nursing Interventions Care of the Family Family-Newborn Relationships

The woman's reaction to the sight of her newborn may range from excited outbursts of laughing, talking, and even crying, to apparent apathy. A polite smile and nod may be her only acknowledgment of the comments of nurses and the nurse-midwife or physician. Occasionally the reaction is one of anger or indifference; the woman turns away from the baby, concentrates on her own pain, and sometimes makes hostile comments. These varied reactions can arise from pleasure, exhaustion, or deep disappointment. When evaluating parent-newborn interactions after birth, the nurse should consider the cultural characteristics of the woman and her family and the expected behaviors of that culture. In some cultures the birth of a male child is preferred, and women may grieve when a female child is born Whatever the reaction and its cause, the woman needs continuing acceptance and support from all staff. Make a notation regarding the parents' reaction to the newborn in the recovery record. Assess this reaction by asking yourself such questions as, "How do the parents look?" "What do they say?" "What do they do?" Conduct further assessment of the parent-newborn relationship as you give care during the period of recovery. This assessment is especially important if you notice warning signs (e.g., passive or hostile reactions to the newborn, disappointment with gender or appearance of the newborn, absence of eye contact, or limited interaction of parents with each other) immediately after birth. Nurses should discuss any warning signs with the woman's nurse-midwife or physician. Siblings, who may have appeared only remotely interested in the final phases of the second stage, tend to experience renewed interest and excitement when the newborn appears. They can be encouraged to hold the baby Parents usually respond to praise of their newborn. Many need to be reassured that the dusky appearance of their baby's hands and feet immediately after birth is normal until circulation is well established. If appropriate, explain the reason for the molding of the newborn's head. Communicate information about hospital routine. Recognize, however, that the cultural background of the parents may influence their expectations regarding the care and handling of their newborn immediately after birth. For example, Korean mothers may believe that the head should not be touched because it is the most sacred part of a person's body. Hispanic mothers may believe that the "evil eye" or too much praise of the baby will cause illness, restlessness, or excessive crying Hospital staff members, by their interest and concern, can provide the environment for making this a satisfying experience for parents, family, and significant others.

Second Stage of Labor Care Management Preparing for Birth Equipment

To prepare for birth in any setting, the birthing table is usually set up during the transition phase of first stage labor for nulliparous women and during the active phase for multiparous women. Prepare the birthing bed or table, and arrange instruments on the instrument table or delivery cart Follow standard procedures for gloving, identifying and opening sterile packages, adding sterile supplies to the instrument table, unwrapping sterile instruments, and handing them to the nurse-midwife or physician. Ready the crib or radiant warmer and equipment for the support and stabilization of the infant The items used for birth may vary among different facilities; therefore, consult each facility's procedure manual to determine the protocols specific to that facility. The nurse estimates the time until the birth will occur and notifies the nurse-midwife or physician if he or she is not in the woman's room. Even the most experienced nurse can miscalculate the time left before birth occurs; therefore, every nurse who attends a woman in labor must be prepared to assist with an emergency birth if the physician or nurse-midwife is not present

Second Stage of Labor the active pushing (descent) phase

during the active pushing (descent) phase the woman has strong urges to bear down as the Ferguson reflex is activated when the presenting part presses on the stretch receptors of the pelvic floor. At this point the fetal station is usually +1 and the position is anterior. This stimulation causes the release of oxytocin from the posterior pituitary gland, which provokes stronger expulsive uterine contractions. The woman becomes more focused on bearing-down efforts, which become rhythmic. She changes positions frequently to find a more comfortable pushing position. The woman often announces the onset of contractions and becomes more vocal as she bears down. The urge to bear down intensifies as descent progresses and the presenting part reaches the perineum. The woman may be more verbal about the pain she is experiencing; she may scream or swear and may act out of control. The nurse encourages the woman to "listen" to her body as she progresses through the phases of the second stage of labor. When a woman listens to her body to tell her when to bear down, she is using an internal locus of control and often feels more satisfied with her efforts to give birth to her baby. This enhances her sense of self-esteem and accomplishment and her efforts become more effective. Always encourage the woman's trust in her own body and her ability to give birth to her baby. Validate the woman's experience of pressure, stretching, and straining as normal and a signal that the descent of the fetus is progressing and that her body is capable of withstanding birth. Honestly explain what is happening and describe the progress being made.

Care Management Nursing Interventions Supportive Care During Labor and Birth Labor Support by the Father or Partner

the father of the baby is usually the support person during labor. He is often able to provide the comfort measures and touch that the laboring woman needs. When the woman becomes focused on her pain, sometimes the partner can persuade her to try nonpharmacologic variations of comfort measures. In addition, he usually is able to interpret the woman's needs and desires for staff members. The feelings of a first-time father change as labor progresses. Although he is often calm at the onset of labor, feelings of fear and helplessness begin to dominate as labor becomes more active and the father realizes that it is more stressful than he anticipated. The interactions of health care providers with the fathers and the fathers' perception of the health care providers' competence were also related to the fathers' birth experiences Staff members should tell the father that his presence is helpful and encourage him to be involved in the care of the woman to the extent to which he and his partner are comfortable. He should be reassured that he is not assuming the responsibility for observation and management of his partner's labor, but that his responsibility is to support her as the labor progresses. The nurse can suggest alternative comfort measures when those he is using are no longer helpful or are rejected by his partner. The first-time father may feel excluded as birth preparations begin during the transition phase. Once the second stage begins and birth nears, the father's focus changes from the woman to the baby who is about to be born. The father will be exposed to many sights and smells he may never have experienced. the nurse needs to tell him what to expect and make him comfortable about leaving the room to regain his composure should something occur that surprises him, but make sure that someone else is available to support the woman during his absence. Nursing actions that support the father convey several important concepts: - first, he is a person of value; - second, he can be a partner in the woman's care; and - third, childbearing is a team effort. A well-informed father can make an important contribution to the health and well-being of the mother and child, their family interrelationship, and his self-esteem.

SIGNS OF POTENTIAL COMPLICATIONS Labor

• Intrauterine pressure of ≥80 mm Hg or resting tone of ≥20 mm Hg (both determined by internal monitoring with intrauterine pressure catheter [IUPC]) • Contractions lasting ≥90 seconds • More than five contractions in a 10-minute period (contractions occur more frequently than every 2 minutes) • Relaxation between contractions lasting <30 seconds • Fetal bradycardia or tachycardia; absent or minimal variability not associated with fetal sleep cycle or temporary effects of central nervous system (CNS) depressant drugs given to the woman; late, variable, or prolonged fetal heart rate (FHR) decelerations • Irregular FHR; suspected fetal arrhythmias • Appearance of meconium-stained or bloody fluid from the vagina • Arrest in progress of cervical dilation or effacement, descent of the fetus, or both • Maternal temperature of ≥38° C (100.4° F) • Foul-smelling vaginal discharge • Persistent bright or dark red vaginal bleeding

BOX 19-9 Guidelines for Supporting the Father∗

• Orient him to the labor room and the unit; explain location of the cafeteria, toilet, waiting room, and nursery; give information about visiting hours; introduce personnel by name and describe their functions. • Inform him of sights and smells he can expect; encourage him to leave the room if necessary. • Respect his or the couple's decision about the degree of his involvement. Offer them freedom to make decisions. • Tell him when his presence has been helpful, and continue to reinforce this throughout labor. • Offer to teach him comfort measures; demonstrate or role-play these measures. • Inform him frequently of the progress of the labor and the woman's needs. Keep him informed about procedures to be performed. • Prepare him for changes in the woman's behavior and physical appearance. • Remind him to eat; offer him snacks and fluids if possible. • Relieve him of the job of support person as necessary. Offer him blankets if he is to sleep in a chair by the bedside. • Acknowledge the stress experienced by each partner during labor and birth, and identify normal responses. • Attempt to modify or eliminate unsettling stimuli, such as extra noise and extra light; create a relaxing and calm environment.

Second Stage of Labor Care Management Preparing for Birth Perineal Trauma Related to Childbirth Episiotomy

An episiotomy is an incision in the perineum used to enlarge the vaginal outlet Its use has steadily declined in recent years due to a lack of sound, rigorous research to support its benefits. Episiotomies are performed in approximately 10% of births in the United States This practice is even less common in Europe and Canada, probably because of the more routine use in those countries of the side-lying position for birth. This position places less tension on the perineum, making possible a gradual stretching of the perineum with fewer indications for episiotomy. Whenever possible, giving birth over an intact perineum provides the best outcomes (e.g., less blood loss, less risk of infection, and less postpartum pain). Different types of episiotomies may be performed, classified by the site and direction of the incision; the type that provides the best outcome is unknown Midline (median) episiotomy is most commonly used in the United States. It is effective, easily repaired, and generally the least painful. However, midline episiotomies also are associated with a higher incidence of third- and fourth-degree lacerations Sphincter tone is usually restored after primary healing and a good repair. Mediolateral episiotomy is used in operative births when the need for posterior extension is likely. Although a fourth-degree laceration may be prevented, a third-degree laceration may occur. The blood loss is also greater and the repair more difficult and painful than with midline episiotomies (Cunningham et al.). It is also more painful in the postpartum period, and the pain lasts longer. An increasingly common practice in many settings now is to support the perineum manually during birth rather than performing an episiotomy with the goal of minimizing trauma. If tears occur, they are often smaller than an episiotomy, are repaired easily or do not need to be repaired at all, and heal quickly with less pain. Episiotomies are associated with more posterior perineal trauma, suturing and healing complications, and later pain with intercourse. Therefore, episiotomy should be avoided whenever possible

active phase

4-7cm of dilation

First Stage of Labor Care Management Assessment

Assessment begins at the first contact with the woman, whether by telephone or in person. Nurses are often instructed to tell women who call with questions to call their nurse-midwife or physician or to come to the hospital if they feel the need to be checked. The nature of the telephone conversation, including any advice or instructions given, should be documented in the woman's record During the third trimester of pregnancy, women should be instructed about the stages of labor and the signs indicating its onset. They should be informed that they will usually not be admitted if the cervix is dilated 3 cm or less If the woman lives near the hospital or birth center and has adequate support and transportation, she may be encouraged to stay at home or return home to allow labor to progress (e.g., until the uterine contractions are more frequent and intense). The ideal setting at this time for the woman at low risk for obstetric complications is usually the familiar environment of her home, where she can move around freely and eat and drink at will. The woman who lives at a considerable distance from the hospital or birth center, who lacks adequate support and transportation, or who has a history of rapid labors in the past, however, may be admitted in latent labor. The same measures used by the woman at home should be offered to the woman admitted in early labor. A warm shower is often relaxing during early labor. However, warm baths before labor is well established could inhibit uterine contractions and prolong the labor process Soothing back, foot, and hand massage or a warm drink of preferred liquids such as tea or milk can help the woman rest and even sleep, especially if false or early labor is occurring at night. Diversional activities such as walking outdoors or in the house, reading, watching television, "playing" on a computer or smart phone, or talking with friends can reduce the perception of early discomfort, help the time pass, and decrease anxiety. When the woman arrives at the birth center or hospital perinatal unit, assessment is the top priority The nurse first performs a screening assessment by using the techniques of interview and physical assessment and reviews the laboratory and diagnostic test findings to determine the health status of the woman and her fetus and the progress of her labor. The nurse also notifies the nurse midwife or physician. If the woman is admitted, a detailed systems assessment is done. When the woman is admitted to a hospital, she is usually moved from an observation area to the labor room; the labor, delivery, and recovery (LDR) room; or the labor, delivery, recovery, and postpartum (LDRP) room. In the hospital setting the woman undresses and puts on her own gown or a hospital gown. The nurse places an identification band on the woman's wrist. Her personal belongings are put away safely or given to family members, according to agency policy. Women who participate in expectant parents classes often bring a birth bag or Lamaze bag with them. The nurse then shows the woman and her partner the layout and operation of the unit and room, how to use the call light and telephone system, and how to adjust lighting in the room and the different bed positions. Sources of data include the prenatal record, the initial interview, physical examination to determine baseline physiologic parameters (e.g., vital signs), laboratory and diagnostic test results, select psychosocial and cultural factors, and the clinical evaluation of labor status.

Key Points

• The onset of labor may be difficult to determine for both nulliparous and multiparous women. • The familiar environment of her home is most often the ideal place for a woman during the latent phase of the first stage of labor. • The nurse assumes much of the responsibility for assessing the progress of labor and for keeping the nurse-midwife or physician informed about that progress and deviations from expected findings. • The fetal heart rate and pattern reveal the fetal response to the stress of the labor process. • Assessing the laboring woman's urinary output and bladder is critical to ensure her progress and to prevent bladder injury. • Regardless of the actual labor and birth experience, the woman's or couple's perception of the birth experience is most likely to be positive when events and performances are consistent with expectations, especially in terms of maintaining control and adequacy of pain relief. • The woman's level of anxiety may increase when she does not understand what is being said to her about her labor because of the medical terminology used or because of a language barrier. • Coaching, emotional support, and comfort measures assist the woman to use her energy constructively in relaxing and working with the contractions. • The progress of labor is enhanced when a woman changes her position frequently during the first stage of labor. • Doulas provide a continuous, supportive presence during labor that can have a positive effect on the process of childbirth and its outcome. • The cultural beliefs and practices of a woman and her significant others, including her partner, can have a profound influence on their approach to labor and birth. • Siblings present for labor and birth need preparation and support for the event. • Women with a history of sexual abuse often experience profound stress and anxiety during childbirth. • Inability to palpate the cervix during vaginal examination indicates that complete effacement and full dilation have occurred and is the only certain, objective sign that the second stage has begun. • Women may have an urge to bear down at various times during labor; for some it may be before the cervix is fully dilated and for others it may not occur until the active phase of the second stage of labor. • When encouraged to respond to the rhythmic nature of the second stage of labor, the woman normally changes body positions, bears down spontaneously, and vocalizes (open-glottis pushing) when she perceives the urge to push (Ferguson reflex). • Women should bear down several times during a contraction using the open-glottis pushing method. They should avoid sustained closed-glottis pushing because this will inhibit oxygen transport to the fetus. • Nurses can use the role of advocate to prevent routine use of episiotomy and reduce the incidence of lacerations by empowering women to take an active role in their birth and by educating health care providers about approaches to managing childbirth that reduce the incidence of perineal trauma. • Objective signs indicate that the placenta has separated and is ready to be expelled; excessive traction (pulling) on the umbilical cord before the placenta has separated can result in maternal injury. • During the fourth stage of labor, the woman's fundal tone, lochial flow, and vital signs should be assessed frequently to ensure that she is physically recovering well after giving birth. • Most parents and families enjoy being able to hold, explore, and examine the baby immediately after the birth.

transition phase

8-10 cm of dilation

Care Management Assessment Laboratory and Diagnostic Tests Analysis of Urine Specimen

A clean-catch urine specimen may be obtained to gather further data about the pregnant woman's health. Analysis of the specimen is a convenient and simple procedure that can provide information about her hydration status (e.g., specific gravity, color, amount), nutritional status (e.g., ketones), infection status (e.g., leukocytes), or the status of possible complications such as preeclampsia, shown by finding protein in the urine. In many hospitals this test must be done in the laboratory rather than at the bedside, even if a urine dipstick is used.

Second Stage of Labor Care Management Preparing for Birth Fetal Heart Rate and Pattern

As noted, you must check the fetal heart rate regularly If the baseline rate begins to slow, if absent or minimal variability occurs, or if deceleration patterns (e.g., late, variable, or prolonged decelerations) develop, initiate interventions promptly. Turn the woman onto her side to reduce the pressure of the uterus against the ascending vena cava and descending aorta Oxygen can be administered by nonrebreather mask at 10 L/min These interventions are often all that is necessary to restore a normal pattern. If the FHR and pattern do not become normal immediately, notify the nurse-midwife or physician because the woman may need medical intervention to give birth.

Second Stage of Labor Care Management Preparing for Birth Bearing-Down Efforts

As the fetal head reaches the pelvic floor, most women experience the urge to bear down. Reflexively the woman will begin to exert downward pressure by contracting her abdominal muscles while relaxing her pelvic floor. This bearing down is an involuntary response to the Ferguson reflex. A strong expiratory grunt or groan (vocalization) often accompanies pushing when the woman exhales as she pushes. This natural vocalization by women during open-glottis bearing-down efforts should not be discouraged. When coaching women to push, encourage them to push as they feel like pushing (instinctive, spontaneous pushing) rather than to give a prolonged push on command (directed, closed-glottis pushing). Prolonged breath-holding, or sustained, directed bearing down is still a common practice, often beginning at 10-cm dilation and before the urge to bear down is perceived. The woman is coached to hold her breath, closing her glottis, and to push while the nurse or partner counts to 10. This method of bearing down is strongly discouraged because it may trigger the Valsalva maneuver, which occurs when the woman closes her glottis (closed-glottis pushing), which increases intrathoracic and cardiovascular pressure. This reduces cardiac output and decreases perfusion of the uterus and the placenta. Adverse effects associated with prolonged breath-holding and forceful pushing efforts include fetal hypoxia and subsequent acidosis, increased risk for pelvic floor damage (structural and neurogenic), and perineal trauma. The benefits of spontaneous pushing efforts rather than sustained Valsalva pushes include less fatigue and enhanced comfort. In addition, these more effective bearing-down efforts result in less time spent actively pushing. Based on this evidence, it is essential that labor and birth nurses advocate for the practice of delayed and spontaneous bearing-down efforts with the woman in an upright or lateral position. A woman can become confused and anxious when she is being told to do something in conflict with what her body is telling her. Using phrases such as "You are doing so well; do it again," "You are moving the baby down," and "Follow what your body is telling you," rather than "Push, push, push," encourages a woman to feel confident in her body and what she is feeling. Monitor the woman's breathing so that she does not hold her breath for more than 6 to 8 seconds at a time followed by a slight exhale (a combination of open-glottis and voluntary closed-glottis pushing). Remind her to ventilate her lungs fully by taking deep cleansing breaths before and after each contraction. Bearing down while exhaling (open-glottis pushing) and taking breaths between bearing-down efforts help to maintain adequate oxygen levels for the mother and fetus, thus enhancing fetal well-being. The active pushing phase of the second stage of labor is considered to be the most physiologically stressful part of labor. Therefore, every effort should be made to ensure that women use nondirected spontaneous pushing to conserve energy and maximize the effect of each bearing-down effort. A woman's bearing-down efforts naturally will become more forceful and frequent as the second stage progresses to birth. A woman may reach the second stage of labor and then experience a lack of readiness to complete the process and give birth to her baby. She may have doubts about her readiness to be a mother or may desire to wait for her support person or nurse-midwife or physician to arrive. Fear, anxiety, or embarrassment regarding unfamiliar or painful sensations and behaviors during pushing (e.g., sounds made, passage of stool) may be other inhibiting factors. Fear that the baby will be in danger once it emerges from the protective intrauterine environment also may be present. By recognizing that a woman may experience a need to hold back the birth of her baby, you can address the woman's concerns and effectively coach her during this stage of labor. To ensure the slow birth of the fetal head, encourage the woman to control the urge to bear down by coaching her to take panting breaths or exhale slowly through pursed lips as the baby's head crowns. At this point the woman needs simple, clear directions from one person. Amnesia between contractions often occurs in the second stage of labor; therefore, you may have to rouse the woman to get her to cooperate in the bearing-down process. Parents who have attended childbirth education classes may have devised a set of verbal cues for the laboring woman to follow.

Care Management Nursing Interventions Supportive Care During Labor and Birth Labor Support by doulas

Continuity of care has been cited by women as a critical component of a satisfying childbirth experience. A specially trained, experienced female labor attendant called a doula can meet this need. The doula is a professional or lay labor-support person who is present during labor in addition to the labor and birth nurse The primary role of the doula is to focus on the laboring woman and to provide physical and emotional support by using soft, reassuring words of praise and encouragement; touching; stroking; and hugging. The doula also administers comfort measures to reduce pain and enhance relaxation and coping, walks with the woman, helps her to change positions, and coaches her bearing-down efforts. Doulas provide information about labor progress and explain procedures and events. They advocate for the woman's right to participate actively in managing her labor. The doula also supports the woman's partner, who often feels unqualified to be the sole labor support and may find it difficult to watch the woman when she is experiencing pain. The doula can encourage and praise the partner's efforts, create a partnership as caregivers, and provide respite care. Doulas also facilitate communication between the laboring woman and her partner, as well as between the couple and the health care team Doula support during labor is associated with decreased use of analgesia, decreased incidence of operative birth, increased incidence of spontaneous vaginal birth, and increased maternal satisfaction with the childbirth experience The roles of the nurse and the doula are complementary. They should work together as a team, recognizing and respecting the role each plays in supporting and caring for the woman and her partner during the childbirth process. Both the nurse and the doula provide supportive care measures. The nurse also focuses on monitoring the status of the maternal-fetal unit, implementing clinical care protocols (including pharmacologic interventions), and documenting assessment findings, actions, and responses

Third Stage of Labor Care Management Placental Separation and Expulsion

Depending on preference, the nurse-midwife or physician may use either a passive or an active approach to manage the third stage of labor. Passive management involves patiently watching for signs that the placenta has separated from the uterine wall spontaneously and monitoring for spontaneous expulsion. This approach is commonly practiced in the United States Active management of third-stage labor is practiced in many countries around the world. Components of active management include administering an oxytocic medication (e.g., oxytocin [Pitocin]) when the anterior shoulder is birthed or immediately following the birth of the fetus, clamping and cutting the umbilical cord within 3 minutes after birth, and gently controlling cord traction following uterine contraction and separation of the placenta. Evidence-based literature and the World Health Organization now recommend active management of the third stage of labor because its use decreases the rate of postpartum hemorrhage caused by uterine atony To assist in the delivery of the placenta, the woman is instructed to push when signs of separation have occurred If possible, the woman should expel the placenta during a uterine contraction. Alternate compression and elevation of the fundus along with minimal, controlled traction on the umbilical cord may also be used to facilitate delivery of the placenta and amniotic membranes. Oxytocics are usually administered after the placenta is removed when active management of third stage labor is not implemented because they stimulate the uterus to contract, thereby helping to prevent hemorrhage Whether the placenta first appears by its shiny fetal surface (Schultze mechanism) or turns to show its dark roughened maternal surface first (Duncan mechanism) is of no clinical importance. After the placenta and the amniotic membranes emerge, the nurse-midwife or physician examines them for intactness to ensure that no portion remains in the uterine cavity (i.e., no fragments of the placenta or membranes are retained) At this time the nurse will obtain a sample of blood from the umbilical cord to be used for determining the baby's blood type and Rh status. Some parents will also have made arrangements to have blood from the cord collected for storage and possible future use. When the third stage of labor has been completed the nurse-midwife or physician examines the woman for any perineal, vaginal, or cervical lacerations requiring repair. The nurse may need to assist by providing adequate lighting or exposure of the woman's perineum and vagina so that a thorough examination can be performed. If an episiotomy was performed, it will be sutured. Immediate repair promotes healing, limits residual damage, and decreases the possibility of infection. The woman usually feels some discomfort while the nurse-midwife or physician carries out the postbirth vaginal examination. Help the woman to use breathing and relaxation or distraction techniques to assist her in dealing with the discomfort. During this time the "baby nurse" performs a quick assessment of the newborn's physical condition and places matching identification bands on baby and mother. Weighing the baby, eye prophylaxis, and a vitamin K injection can be delayed until after the initial bonding time with the parents. After any necessary repairs have been completed, cleanse the vulvar area gently with warm water or normal saline, and apply a perineal pad or an ice pack to the perineum. Reposition the birthing bed or table, and lower the woman's legs simultaneously from the stirrups if she gave birth in a lithotomy position. Remove any drapes, and place dry linen under the woman's buttocks. Provide her with a clean gown and a blanket, which is warmed, if needed. Some women and their families may have culturally based beliefs regarding the care of the placenta and the manner of its disposal after birth, viewing the care and disposal of the placenta as a way of protecting the newborn from bad luck and illness. In Spanish the placenta is referred to as el compañero or "the companion" of the child A request by the woman to take the placenta home and dispose of it according to her customs sometimes conflicts with health care agency policies, especially those related to infection control and the disposal of biologic wastes. Many cultures follow specific rules regarding the disposal of the placenta in terms of method (burning, drying, burying, eating), site for disposal (in or near the home), and timing of disposal (immediately after birth, time of day, astrologic signs). Disposal rituals may vary according to the gender of the child and the length of time before another child is desired. Some cultures believe that eating the placenta is a means of restoring a woman's well-being after birth or ensuring high-quality breast milk. Health care providers can provide culturally sensitive health care by encouraging women and their families to express their wishes regarding the care and disposal of the placenta and by establishing a policy to fulfill these requests

Care Management Nursing Interventions Elimination Voiding

Encourage voiding every 2 hours. A distended bladder may impede descent of the presenting part, slow or stop uterine contractions, and lead to decreased bladder tone or uterine atony after birth. Women who receive epidural analgesia or anesthesia are especially at risk for the retention of urine.

Care Management Assessment Physical Examination Leopold Maneuvers (Abdominal Palpation)

Leopold maneuvers are performed with the woman briefly lying on her back These maneuvers help to answer three important questions: (1) What fetal part is in the uterine fundus? (2) Where is the fetal back located? (3) What is the presenting fetal part?

Care Management Nursing Interventions Nutrient and Fluid Intake Intravenous Intake

Fluids commonly are administered intravenously to the laboring woman to maintain hydration, especially if labor is long and the woman is unable to ingest a sufficient amount of fluid orally or if she is receiving epidural or intrathecal anesthesia. In most cases an electrolyte solution without glucose (e.g., Ringer's lactate or normal saline) is adequate and does not introduce excess glucose into the bloodstream. Infusions containing glucose can also reduce sodium levels in the woman and the fetus, leading to transient neonatal tachypnea. If maternal ketosis occurs, the nurse-midwife or physician can order an IV solution containing a small amount of dextrose to provide the glucose needed to assist in fatty acid metabolism.

Care Management Nursing Interventions Elimination Catheterization

If the woman is unable to void and her bladder is distended, she may need to be catheterized. Many hospitals have protocols or standing orders that rely on the nurse's judgment concerning the need for catheterization. Before performing the catheterization, clean the vulva and perineum because vaginal show and amniotic fluid may be present. If an obstacle that prevents advancement of the catheter is present, this obstacle is most likely the presenting part. If you cannot advance the catheter, stop the procedure and notify the nurse-midwife or physician of the difficulty.

Care Management Nursing Interventions General Hygiene

Offer women in labor the use of showers or warm-water baths, if they are available, to enhance the feeling of well-being and to minimize the discomfort of contractions. Water immersion during active labor is associated with a decrease in the use of analgesia and reports of less maternal pain Also encourage women to wash their hands or use cleansing foam after voiding and performing self-hygiene measures. Change the linen if it becomes wet or stained with blood and use linen savers (Chux), changing them as needed.

Second Stage of Labor Care Management Preparing for Birth Maternal Position

No single position for childbirth exists. Labor is a dynamic, interactive process involving the woman's uterus, pelvis, and voluntary muscles. In addition, angles between the baby and the woman's pelvis constantly change as the infant turns and flexes down the birth canal. The woman may want to assume various positions for childbirth. She should be encouraged to change positions frequently and assisted in attaining and maintaining her position(s) of choice Supine, semirecumbent, or lithotomy positions are still widely used in Western societies despite evidence that an upright position shortens labor Birth attendants play a major role in influencing a woman's choice of positions for birth, with nurse-midwives tending to advocate nonlithotomy positions (e.g., upright, lateral) for the second stage of labor. An upright position (walking, sitting, kneeling, or squatting) offers a number of advantages. Gravity can promote the descent of the fetus. Uterine contractions are generally stronger and more efficient in effacing and dilating the cervix, resulting in shorter labor An upright position also is beneficial to the mother's cardiac output, thereby increasing perfusion of the uterus. The use of upright and lateral positions is also associated with less pain and perineal damage, fewer episiotomies and abnormal FHR patterns, and fewer operative vaginal births The benefits of upright positions may be related to: Straightening of the longitudinal axis of the birth canal and improving the alignment of the fetus for passage through the pelvis Application of gravity to direct the fetal head toward the pelvic inlet, thereby facilitating descent Enlargement of pelvic dimensions and restriction of the encroachment of the sacrum and coccyx into the pelvic outlet Increased uteroplacental circulation, resulting in more intense, efficient uterine contractions Enhancement of the woman's ability to bear down effectively, thereby minimizing maternal exhaustion Squatting is highly effective in facilitating the descent and birth of the fetus. It is one of the best and most natural positions for second stage labor and has been associated with the same benefits as other upright and lateral positions Women should assume a modified, supported squat until the fetal head is engaged, at which time a deep squat can be used. A firm surface is required for this position, and the woman will need side support In a birthing bed, a squat bar is available that she can use to help support herself. A birth ball can also help a woman maintain the squatting position. The fetus will be aligned with the birth canal, and pelvic and perineal relaxation is facilitated as she sits on the ball or holds it in front of her for support as she squats. When a woman uses the supported standing position for bearing down, her weight is borne on both femoral heads, allowing the pressure in the acetabulum to cause the transverse diameter of the pelvic outlet to increase by up to 1 cm. This can be helpful if descent of the head is delayed because the occiput has not rotated from the lateral (transverse diameter of pelvis) to the anterior position. Birthing chairs or rocking chairs may be used to provide women with a good physiologic position to enhance bearing-down efforts during childbirth, although some women may feel restricted by a chair. The upright position also provides a potential psychologic advantage in that it allows the mother to see the birth as it occurs and to maintain eye contact with the attendant. Oversized beanbag chairs and large floor pillows can be used for both labor and birth. They can mold around and support the mother in whatever position she selects. These chairs are of particular value for mothers who wish to be actively involved in the birth process. Birthing stools can be used to support the woman in an upright position similar to squatting. Some women may feel more comfortable sitting on the toilet or commode during pushing because they are concerned about stool incontinence during this stage. Encourage them to empty their bladder to avoid the effects of a distended bladder. You must closely monitor these women, however, and ask them to move from the toilet before birth becomes imminent. Because sitting on chairs, stools, toilets, or commodes can increase perineal edema and blood loss, assist the woman to change her position frequently (e.g., every 10 to 15 minutes). The side-lying, or lateral, position, with the upper part of the woman's leg held by the nurse or coach or placed on a pillow, is an effective position for the second stage of labor Some women prefer a semisitting (semirecumbent) position instead If the semirecumbent position is used, do not force the woman's legs against her abdomen as she bears down. This position will increase perineal stretching and the risk for perineal trauma as well as spinal and lower extremity neurologic injuries The hands-and-knees position is yet another effective position for birth The birthing bed can be set for different positions according to the woman's needs The woman can squat, kneel, sit, recline, or lie on her side, choosing the position most comfortable for her without having to climb into bed for the birth. At the same time, the birthing bed provides excellent access and visualization for the attendant to perform examinations, place electrodes, and assist the woman giving birth. You can position the bed for the administration of anesthesia and it is ideal to help women receiving an epidural to assume different positions to facilitate birth. You can also use the bed to transport the woman to the operating room if a cesarean birth is necessary. The woman can use squat bars, over-the-bed tables, birth balls, and pillows for support.

Care Management Assessment Physical Examination General Systems Assessment

On admission, the nurse should perform a brief systems assessment. This includes an assessment of the heart, lungs, and skin and an examination to determine the presence and extent of edema of the face, hands, sacrum, and legs. It also includes testing of deep tendon reflexes and for clonus, if indicated. Also note the woman's weight. Increasing numbers of women are overweight or obese. Excessive size can make nursing care during labor and birth more difficult and places the woman at risk for complications such as operative birth, infection, and blood clots.

Care Management Assessment Psychosocial Factors

The woman's general appearance and behavior (and that of her partner) provide valuable clues to the type of supportive care she will need. However, keep in mind that general appearance and behavior may vary, depending on the stage and phase of labor Women with a History of Sexual Abuse

Common Maternal Positions∗ During Labor and Birth

Semirecumbent Position With the woman sitting with her upper body elevated to at least a 30-degree angle, place a wedge or small pillow under her hip to prevent vena cava compression and reduce the likelihood of supine hypotension • The greater the angle of elevation, the more gravity or pressure is exerted that promotes fetal descent, the progress of contractions, and the widening of pelvic dimensions. • This position is convenient for providing care measures and for external fetal monitoring. Lateral Position Have the woman alternate between a left and right side-lying position, and provide abdominal and back support as needed for comfort. • Removes pressure from the vena cava and back, enhances uteroplacental perfusion, and relieves backache • Facilitates internal rotation of fetus in a posterior position to an anterior position (woman should lie on same side as fetal spine) • Makes it easier to perform back massage or counterpressure • Associated with less frequent, but more intense, contractions • May be more difficult to obtain good external fetal monitor tracings • May be used as a birthing position • Takes pressure off perineum, allowing it to stretch gradually • Reduces risk for perineal trauma Upright Position The gravity effect enhances the contraction cycle and fetal descent: the weight of the fetus places increasing pressure on the cervix; the cervix is pulled upward, facilitating effacement and dilation; impulses from the cervix to the pituitary gland increase, causing more oxytocin to be secreted; and contractions are intensified, thereby applying more forceful downward pressure on the fetus, but they are less painful. • Fetus is aligned with pelvis, and pelvic diameters are widened slightly • Effective upright positions include: • Ambulation • Standing and leaning forward with support provided by coach, end of bed, back of chair, or birth ball; relieves backache and facilitates application of counterpressure or back massage • Sitting up in bed, in chair, in birthing chair, on toilet, or on bedside commode • Squatting Hands-and-Knees Position—Position for Posterior Positions of the Presenting Part Assume an "all fours" position or lean over an object (e.g., birth ball) while on the knees in bed or on a covered floor; this allows for pelvic rocking. • Relieves backache characteristic of "back labor" • Facilitates internal rotation of the fetus by increasing mobility of the coccyx, increasing the pelvic diameters, and using gravity to turn the fetal back and rotate the head (NOTE: A side-lying position, double hip squeeze, or knee squeeze also can facilitate internal rotation.)

Care Management Nursing Interventions Supportive Care During Labor and Birth

Support during labor and birth involves emotional support, physical care and comfort measures, and advice and information. The value of the continuous supportive presence of a person (e.g., doula, childbirth educator, family member, friend, nurse, partner) during labor has long been known. Women who have continuous support beginning in early labor are less likely to use pain medication or epidurals, more likely to have a spontaneous vaginal birth, and less likely to report dissatisfaction with their birth experience. No harmful effects from continuous labor support have been identified. To the contrary, there is good evidence that labor support improves important health outcomes Labor rooms should be airy, clean, and homelike. The laboring woman should feel safe in this environment and free to be herself and to use the comfort and relaxation measures she prefers. To enhance relaxation, turn off bright overhead lights when not needed, and keep noise and intrusions to a minimum. Control the temperature to ensure the laboring woman's comfort. The room should be large enough to accommodate a comfortable chair for the woman's support person, the monitoring equipment, and hospital personnel. Encourage women to bring their own pillows to make the hospital surroundings more homelike and to facilitate position changes. Environmental modifications should reflect the preferences of the woman, including the number of visitors and availability of a telephone, television, and music.

Second Stage of Labor Care Management Preparing for Birth Perineal Trauma Related to Childbirth Vaginal and Urethral Lacerations

Vaginal lacerations often occur in conjunction with perineal lacerations. Vaginal lacerations tend to extend up the lateral walls (sulci) and, if deep enough, involve the levator ani muscle. Additional injury may occur high in the vaginal vault near the level of the ischial spines. Vaginal vault lacerations are often circular and may result from use of forceps to rotate the fetal head, rapid fetal descent, or precipitous birth.

the three stages of labor

latent active transition

Most nulliparous women planning a hospital or birth center birth seek admission in the

latent (early) phase because they have not experienced labor before and are unsure of the "right" time to come in.

The second stage of labor is composed of two phases

the latent phase and the active pushing phase. Maternal verbal and nonverbal behaviors, uterine activity, the urge to bear down, and fetal descent characterize these phases

Multiparous women usually do not come to the birth center or hospital until

they are in the active phase of the first stage of labor.

latent (early) phase

through 3 cm of dilation

Standard Precautions During Childbirth

• Wash hands before and after putting on gloves and performing procedures; cleansing alcohol rubs can be used if hands are not visibly soiled. • Wear gloves (clean or sterile, as appropriate) when performing procedures that require contact with the woman's genitalia and body fluids, including bloody show (e.g., during vaginal examination, amniotomy, hygienic care of the perineum, insertion of an internal scalp electrode and intrauterine pressure monitor, and urinary catheterization). • Wear a mask that has a shield or protective eyewear, and cover gown when assisting with the birth. Cap and shoe covers are worn for cesarean birth but are optional for vaginal birth in a birthing room. Gowns worn by the nurse-midwife or physician who is attending the birth should have a waterproof front and sleeves and should be sterile. Mask also should be worn during spinal puncture or insertion of an epidural catheter. • Drape the woman with sterile towels and sheets as appropriate. Explain to the woman what can and cannot be touched. • Help the woman's partner put on appropriate coverings for the type of birth, such as cap, mask, gown, and shoe covers. Show the partner where to stand and what can and cannot be touched. • Wear gloves and gown when handling the newborn immediately after birth. • Use an appropriate method to suction the newborn's airway, such as a bulb syringe or mechanical wall suction

Care Management Assessment Cultural Factors Culture and Father Participation

A companion is an important source of support, encouragement, and comfort for women during childbirth. The woman's cultural and religious background influences her choice of birth companion as do trends in the society in which she lives.

Care Management Assessment Cultural Factors The Non-English-Speaking Woman in Labor

A woman's level of anxiety in labor increases when she does not understand what is happening to her or what is being said. Non-English-speaking women often feel a complete loss of control over their situation if no health care provider is present who speaks their language. They can panic and withdraw or become physically abusive when someone tries to do something they perceive might harm them or their babies. A support person is sometimes able to serve as an interpreter. However, caution is warranted because the interpreter may not be able to convey exactly what the nurse or others are saying or what the woman is saying, which can increase the woman's stress level even more. Ideally, a bilingual or bicultural nurse will care for the woman. Alternatively a hospital employee or volunteer interpreter may be contacted for assistance Ideally, the interpreter is from the woman's culture. For some women, a female is more acceptable than a male interpreter. If no one in the hospital is able to interpret, call a service so that interpretation can take place over the telephone. Even when the nurse has limited ability to communicate verbally with the woman, in most instances the woman appreciates his or her efforts to do so. Speaking slowly, avoiding complex words and medical terms, and using gestures can help a woman and her partner understand. Often the woman understands English much better than she speaks it.

Care Management Nursing Interventions emergency interventions

Although rare, emergency conditions that require immediate nursing intervention can arise with startling speed.

Care Management Nursing Interventions

The nursing process provides the framework for the nursing care management of women in labor. The physical nursing care given to a woman in labor is an essential component of her care. The current emphasis on evidence-based practice supports the management of care by using this approach to enhance the safety, effectiveness, and acceptability of the physical care measures chosen to support the woman during labor and birth

Care Management Assessment Physical Examination Vaginal Examination

The vaginal examination reveals whether the woman is in true labor and enables the examiner to determine whether the membranes have ruptured Because this examination is often stressful and uncomfortable for the woman and may introduce microorganisms into the vagina if the membranes are ruptured, perform it only when indicated by the status of the woman and her fetus. For example, perform a vaginal examination on admission, prior to administering medications (e.g., analgesics, increasing oxytocin infusion), when significant change has occurred in uterine activity, on maternal request or perception of perineal pressure or the urge to bear down, when membranes rupture, or when you note variable decelerations of the FHR. A full explanation of the examination and support of the woman are important in reducing the stress and discomfort associated with the examination

Fourth Stage of Labor Care Management Assessment Postanesthesia Recovery

The woman who has given birth by cesarean or has received regional anesthesia for a vaginal birth requires special attention during the recovery period. Obstetric recovery areas are held to the same standard of care that would be expected of any other postanesthesia recovery (PAR) unit A PAR score is determined for each woman on arrival and is updated as part of every 15-minute assessment. Components of the PAR score include activity, respirations, blood pressure, level of consciousness, and color. If the woman received general anesthesia, she should be awake and alert and oriented to time, place, and person. Her respiratory rate should be within normal limits, and her oxygen saturation level at least 95%, as measured by a pulse oximeter. If the woman received epidural or spinal anesthesia, she should be able to raise her legs, extended at the knees, off the bed, or flex her knees, place her feet flat on the bed, and raise her buttocks well off the bed. The numb or tingling, prickly sensation should be entirely gone from her legs. The length of time required to recover from regional anesthesia varies greatly. Often it takes several hours for these anesthetic effects to disappear completely.

Care Management Assessment Laboratory and Diagnostic Tests Infection

When membranes rupture, microorganisms from the vagina can then ascend into the amniotic sac, causing chorioamnionitis and placentitis to develop. For this reason, limit the number of vaginal examinations and assess maternal temperature and vaginal discharge frequently (at least every 2 hours) so that you can quickly identify an infection developing after ROM. Even when membranes are intact, however, microorganisms may ascend and cause infection. Assessment findings serve as a baseline for evaluating the woman's subsequent progress during labor. Although some problems can be anticipated, others may appear unexpectedly during the clinical course of labor

false labor

Contractions • Occur irregularly or become regular only temporarily • Often stop with walking or position change • Can be felt in the back or the abdomen above the umbilicus • Can often be stopped through the use of comfort measures Cervix (by Vaginal Examination) • May be soft but with no significant change in effacement or dilation or evidence of bloody show • Is often in a posterior position Fetus • Presenting part is usually not engaged in the pelvis

Care Management Assessment Cultural Factors

Nurses should be committed to providing culturally sensitive care and to developing an appreciation and respect for cultural diversity Encourage the woman to request specific caregiving behaviors and practices that are important to her. Within cultures, women may have an idea of the "right" way to behave in labor and may react to the pain experienced in that way. These behaviors can range from total silence to moaning or screaming, but they do not necessarily indicate the degree of pain being experienced.

Care Management Assessment Interview

The woman's primary reason for coming to the hospital is determined in the interview. This allows time for the diagnosis of labor without official hospital admission and minimizes or avoids cost to the woman when used by the hospital and approved by her health insurance plan. She is asked to recall the events of the previous days and to describe the following: Time and onset of contractions and progress in terms of frequency, duration, and intensity Location and character of discomfort from contractions (e.g., back pain, abdominal or suprapubic discomfort) Persistence of contractions despite changes in maternal position and activity (e.g., walking or lying down) Presence and character of vaginal discharge or "show" The status of amniotic membranes, such as a gush or seepage of fluid (spontaneous rupture of membranes [SROM]). If there has been a discharge that may be amniotic fluid, she is asked the date and time the fluid was first noted and the fluid's characteristics (e.g., amount, color, unusual odor). In many instances, a sterile speculum examination and Nitrazine (pH) and fern tests can confirm that the membranes are ruptured Bloody show is distinguished from bleeding by the fact that it is pink and feels sticky because of its mucoid nature. There is very little bloody show in the beginning, but the amount increases with effacement and dilation of the cervix. A woman may report a small amount of brownish to bloody discharge that may be attributed to cervical trauma resulting from vaginal examination or coitus (intercourse) within the past 48 hours. Assessing the woman's respiratory status is important in case general anesthesia is needed in an emergency. Because vomiting and subsequent aspiration into the respiratory tract can complicate an otherwise normal labor, the nurse records the time and type of the woman's most recent solid and liquid intake. The nurse obtains any information not found in the prenatal record during the admission assessment. Pertinent data include the birth plan, the choice of infant feeding method, the type of pain management (including nonpharmacologic comfort measures) preferred, and the name of the pediatric health care provider. She or he obtains a client profile that identifies the woman's preparation for childbirth, the support person or family members desired during childbirth and their availability, and ethnic or cultural expectations and needs. The nurse also determines the woman's use of alcohol, drugs, and tobacco during pregnancy. The nurse reviews the birth plan. If no written plan has been prepared, the nurse helps the woman formulate a birth plan by describing options available and determining the woman's wishes and preferences. As caregiver and advocate, the nurse integrates the woman's desires into the nursing care plan while explaining what may or may not be possible given the hospital's policies. She or he also prepares the woman for the possibility that her plan may change as labor progresses and assures her that the staff will provide information so that she can make informed decisions. The woman must also understand that the longer her "wish list", the less is the likelihood that all of her expectations will be met. The nurse should discuss with the woman and her partner their plans for preserving childbirth memories through the use of photography and videotaping.

Care Management Nursing Interventions Nutrient and Fluid Intake Oral Intake

An adequate intake of fluids and calories is required to meet the energy demands and fluid losses associated with childbirth. The progress of labor slows, with a more rapid development of hypoglycemia and ketosis if these demands are not met and fat is metabolized. Reduced energy for bearing-down efforts (pushing) increases the risk for a forceps- or vacuum-assisted birth. This is most likely to occur in women who begin to labor early in the morning after a night without caloric intake. When women are permitted to consume fluid and food freely, they typically regulate their own oral intake, eating light foods (e.g., eggs, yogurt, ice cream, dry toast and jelly, fruit) and drinking fluids during early labor and tapering off to the intake of clear fluids and sips of water or ice chips as labor intensifies and the second stage approaches Common hospital practice is to allow clear liquids (e.g., water, tea, fruit juices without pulp, clear sodas, coffee, sports drinks, fruit ice, Popsicles, gelatin, broth) during early labor, tapering off to ice chips and sips of water as labor progresses and becomes more active. Herbal teas can provide not only hydration but also other beneficial effects. Chamomile tea can enhance relaxation, lemon balm or peppermint tea can reduce nausea, and teas of ginger or ginseng root are energizing A woman's culture may influence what she will eat and drink during labor. In addition, women who use nonpharmacologic pain relief measures and labor at home or in birthing centers are more likely to eat and drink during labor. The amount of solid and liquid carbohydrates to offer a woman in labor is still unclear. Although it is known that energy needs increase as labor becomes prolonged, there is limited evidence regarding the effect of oral carbohydrate intake in enhancing the progress of labor and reducing the risk for dystocia A Cochrane database review of this topic concluded that there is no justification for restricting food or fluid intake during labor in women at low risk for complications . Nurses should follow the orders of the woman's primary health care provider when offering the woman food or fluid during labor. However, as advocates, nurses can facilitate change by informing others of the current research findings that support the safety and effectiveness of the oral intake of food and fluid during labor and initiating such research themselves.

Care Management Assessment Physical Examination Vital Signs

Assess vital signs (temperature, pulse, respirations, and blood pressure using a correct size cuff) on admission. The initial values are used as the baseline for comparison for all future measurements. If the blood pressure is elevated, reassess it 30 minutes later, between contractions, to obtain a reading after the woman has relaxed. Encourage the woman to lie on her side to prevent supine hypotension and the resulting fetal hypoxemia Monitor her temperature so you can identify signs of infection or a fluid deficit (e.g., dehydration associated with inadequate intake of fluids).

BOX 19-10 Nursing Care in Second-Stage Labor

Assessment Signs That Suggest the Onset of the Second Stage Urge to push or feeling need to have a bowel movement Sudden appearance of sweat on upper lip An episode of vomiting Increased bloody show Shaking of extremities Increased restlessness; verbalization (e.g., "I can't go on.") Involuntary bearing-down efforts Physical Assessment Assess every 5 to 30 minutes: maternal blood pressure, pulse, and respirations. Assess every 5 to 15 minutes, depending on risk status: fetal heart rate and pattern. Assess every 10 to 15 minutes: vaginal show, signs of fetal descent, and changes in maternal appearance, mood, affect, energy level, and condition of partner/coach. Assess every contraction and bearing-down effort. Interventions Latent ("Laboring Down") Phase Help to rest in a position of comfort; encourage relaxation to conserve energy. Promote progress of fetal descent and onset of urge to bear down by encouraging position changes, pelvic rock, ambulation, showering. Active Pushing (Descent) Phase Help to change position and encourage spontaneous bearing-down efforts. Help to relax and conserve energy between contractions. Provide comfort and pain-relief measures as needed. Cleanse perineum promptly if fecal material is expelled. Coach to pant during contractions and to gently push between contractions when head is emerging. Provide emotional support, encouragement, and positive reinforcement of efforts. Keep woman informed regarding progress. Create a calm and quiet environment. Offer mirror to watch birth.

Second Stage of Labor Care Management Preparing for Birth Perineal Trauma Related to Childbirth Cervical Injuries

Cervical injuries occur when the cervix retracts over the advancing fetal head. These cervical lacerations occur at the lateral angles of the external os. Most lacerations are shallow and bleeding is minimal. Larger lacerations may extend to the vaginal vault or beyond it into the lower uterine segment; serious bleeding may occur. Extensive lacerations may follow hasty attempts to enlarge the cervical opening artificially or to deliver the fetus before full cervical dilation is achieved. Injuries to the cervix can have adverse effects on future pregnancies and childbirths.

True Labor

Contractions • Occur regularly, becoming stronger, lasting longer, and occurring closer together • Become more intense with walking • Are usually felt in the lower back, radiating to the lower portion of the abdomen • Continue despite use of comfort measures Cervix (by Vaginal Examination) • Shows progressive change (softening, effacement, and dilation signaled by the appearance of bloody show) • Moves to an increasingly anterior position Fetus • Presenting part usually becomes engaged in the pelvis, which results in increased ease of breathing; at the same time, the presenting part presses downward and compresses the bladder, resulting in urinary frequency

Fourth Stage of Labor Care Management

In most hospitals the mother remains in the labor and birth area during this recovery time. In an institution where LDR rooms are used, the woman stays in the same room where she gave birth. In traditional settings women are taken from the delivery room to a separate recovery area for observation. Arrangements for care of the newborn vary during the fourth stage of labor. In many settings the baby remains with the mother, and the labor or birth nurse cares for both of them. In other institutions the baby is taken to the nursery for several hours of observation after an initial bonding period with the parents, siblings, and perhaps other family members

BOX 19-2 The Birth Plan

The birth plan should include the woman's or couple's preferences related to: • Presence of birth companions such as the partner, older children, parents, friends, and doula, and the role each will play • Presence of other persons such as students, male attendants, and interpreters • Clothing to be worn • Environmental modifications such as lighting, music, privacy, focal point, items from home such as pillows • Labor activities such as preferred positions for labor and for birth, ambulation, birth balls, showers and whirlpool baths, oral food and fluid intake • List of comfort and relaxation measures • Labor and birth medical interventions such as pharmacologic pain relief measures, intravenous therapy, electronic monitoring, induction or augmentation measures, and episiotomy • Care and handling of the newborn immediately after birth such as immediate skin-to-skin contact, cutting of the cord, eye care, breastfeeding • Cultural and religious requirements related to the care of the mother, newborn, and placenta

Third Stage of Labor

The third stage of labor lasts from the birth of the baby until the placenta is expelled.

Second Stage of Labor Care Management Preparing for Birth Birth in a Delivery Room or Birthing Room

The woman will need assistance if she must move from the labor bed to the delivery table The various positions assumed for birth in a delivery room are the Sims or lateral position in which the attendant supports the upper part of the woman's leg, the dorsal position (supine position with one hip elevated), and the lithotomy position. The lithotomy position makes dealing with some complications that arise more convenient for the nurse-midwife or physician To place the woman in this position, bring her buttocks to the edge of the bed or table and place her legs in stirrups. Take care to pad the stirrups, to raise and place both legs simultaneously, and to adjust the shanks of the stirrups so that the calves of the legs are supported. No pressure should be placed on the popliteal space. Stirrups that are not the same height will strain ligaments in the woman's back as she bears down, leading to considerable discomfort in the postpartum period. The lower portion of the table may be dropped down and rolled back under the table. The maternal position for birth in a birthing room varies from a lithotomy position with the woman's feet in stirrups or resting on footrests or with her legs held and supported by the nurse or support person, to one in which her feet rest on footrests while she holds on to a squat bar, to a side-lying position with the woman's upper leg supported by the coach, nurse, or squat bar. Once the woman is positioned, the foot of the bed is removed so that the nurse-midwife or physician attending the birth can gain better perineal access for performing an episiotomy, delivering a large baby, using forceps or vacuum extractor, or getting access to the emerging head to facilitate suctioning. Alternately, the foot of the bed can be left in place and lowered slightly to form a ledge that allows access for birth and serves as a place to lay the newborn Once the woman is positioned for birth either in a delivery room or birthing room, the vulva and perineum are cleansed. Hospital or birthing center protocols and the preferences of nurse-midwives or physicians for cleansing may vary. The nurse continues to coach and encourage the woman and monitor the fetal status. Keep the nurse-midwife or physician informed of the FHR and pattern. Prepare or obtain an oxytocic medication such as oxytocin (Pitocin) so that it is ready to be administered immediately after expulsion of the placenta. Always follow Standard Precautions as care is administered during the process of labor and birth In the hospital delivery room, the nurse-midwife or physician may put on a cap, a mask that has a shield or protective eyewear, and shoe covers. After washing hands, the provider puts on a sterile gown (with waterproof front and sleeves) and sterile gloves. Nurses attending the birth also may need to wear caps, protective eyewear, masks, gowns, and gloves. The woman may then be draped with sterile drapes. In the birthing room, Standard Precautions are observed, but the amount and types of protective coverings worn by those in attendance may vary. Maintain contact with the parents by touching, verbal comforting, describing progress, explaining the reasons for care, and sharing in the parents' joy at the birth of their baby.

BOX 19-13 Nursing Care in Third-Stage Labor

Assessment Signs That Suggest the Onset of the Third Stage A firmly contracting fundus A change in the uterus from a discoid to a globular ovoid shape as the placenta moves into the lower uterine segment A sudden gush of dark blood from the introitus Apparent lengthening of the umbilical cord as the placenta descends to the introitus The finding of vaginal fullness (the placenta) on vaginal or rectal examination or of fetal membranes at the introitus Physical Assessment Assess every 15 minutes: maternal blood pressure, pulse, and respirations. Assess for signs of placental separation and amount of bleeding. Assist with determination of Apgar score at 1 and 5 minutes after birth (see Table 24-1). Assess maternal and paternal response to completion of childbirth process and their reaction to the newborn. Interventions Assist to bear down to facilitate expulsion of the separated placenta. Administer an oxytocic medication as ordered to ensure adequate contraction of the uterus, thereby preventing hemorrhage. Provide nonpharmacologic and pharmacologic comfort and pain relief measures. Perform hygienic cleansing measures. Keep mother/partner informed of progress of placental separation and expulsion and perineal repair if appropriate. Explain purpose of medications administered. Introduce parents to their baby and facilitate the attachment process by delaying eye prophylaxis; wrap mother and baby together for skin-to-skin contact. Provide private time for parents to bond with new baby; help them create memories. Encourage breastfeeding if desired.

Care Management Nursing Interventions Supportive Care During Labor and Birth Labor Support by grandparents

When grandparents act as labor coaches, it is especially important to support and treat them with respect. They may have ways to deal with pain based on their experience. Grandparents should be encouraged to help as long as their actions do not compromise the status of the mother or the fetus. The nurse treats grandparents with dignity and respect by acknowledging the value of their contributions to parental support and recognizing the difficulty parents have in witnessing the woman's discomfort or crisis. If they have never witnessed a birth, the nurse may need to provide explanations of what is happening. Many of the activities used to support fathers also are appropriate for grandparents

Second Stage of Labor Care Management Preparing for Birth Support of the Father or Partner

During the second stage the woman needs continuous support and coaching Because the coaching process is often physically and emotionally tiring for support persons, the nurse offers them nourishment and fluids and encourages them to take short breaks as needed If birth occurs in an LDR or LDRP room, the support person usually wears street clothes. Instruct the support person who attends the birth in a delivery or operating room to put on a cover gown or scrub clothes, mask, hat, and shoe covers, if required by agency policy. The nurse also specifies support measures that can be used for the laboring woman and points out areas of the room in which the partner can move freely. Encourage partners to be present at the birth of their infants if doing so is in keeping with their cultural and personal expectations and beliefs. The presence of partners maintains the psychologic closeness of the family unit, and the partner can continue to provide the supportive care given during labor. The woman and her partner need to have an equal opportunity to initiate the attachment process with the baby.

Second Stage of Labor Care Management Preparing for Birth Birth in a Delivery Room or Birthing Room Fundal Pressure

Fundal pressure is the application of gentle, steady pressure against the fundus of the uterus to facilitate the vaginal birth. Use of fundal pressure by nurses is not advised because there is no standard technique available for this maneuver. Historically it has been used when the administration of analgesia and anesthesia decreased the woman's ability to push during the birth, in cases of shoulder dystocia, and when second-stage fetal bradycardia or other abnormal FHR patterns were present. However, no legal, professional, or regulatory standards exist for its use and no evidence related to its effectiveness in facilitating a safe vaginal birth is available

Fourth Stage of Labor Care Management Nursing Interventions Care of the New Mother

If food and fluids were restricted, especially if excessive fluid loss occurred during labor and birth (blood, perspiration, or emesis), the woman will be very hungry and thirsty soon after birth. In the absence of complications, a woman who has given birth vaginally may have fluids and a regular diet as soon as she desires In the immediate postpartum period, women who give birth by cesarean are usually restricted to clear liquids and ice chips. As soon as they have had a chance to bond with the baby and eat, most new mothers are ready for a nap or at least a quiet period of rest. Following this rest period, the woman may want to shower and change clothes. Most new mothers are capable of self-management or are assisted in these activities by family members or support persons.

Care Management Assessment Laboratory and Diagnostic Tests Other Tests

If the woman's group B streptococcus status is not known, a rapid test may be done on admission. The rapid test results are usually available within an hour or so and will determine if the woman must be given antibiotics during labor.

Care Management Assessment Laboratory and Diagnostic Tests Assessment of Amniotic Membranes and Fluid

Labor is initiated at term by SROM in approximately 25% of pregnant women. A lag period, rarely exceeding 24 hours, may precede the onset of labor. Membranes (the BOW) also can rupture spontaneously any time during labor, but most commonly in the transition phase of the first stage of labor. If the membranes do not rupture spontaneously, the BOW may be ruptured artificially at some time during labor. However, this practice is discouraged if there is no medical reason because it can increase the laboring woman's sensation of pressure and pain and is not necessary for a normal birth to occur. Artificial rupture of membranes (AROM), called an amniotomy, is performed by the physician or nurse-midwife using a plastic AmniHook or a surgical clamp. Whether the membranes rupture spontaneously or artificially, the time of rupture should be recorded. Other necessary documentation includes information regarding the FHR before and after rupture, the color (clear or meconium stained), estimated amount, and odor of the fluid.

Second Stage of Labor Care Management Preparing for Birth Perineal Trauma Related to Childbirth

Most acute injuries and lacerations of the perineum, vagina, uterus, and their support tissues occur during childbirth. Alternative measures for perineal management, such as application of warm compresses and gentle perineal massage and stretching have been suggested to lessen the degree of perineal lacerations and trauma. Perineal massage during the last month of pregnancy has clear benefits of reducing perineal trauma during birth and pain afterward for women who had not given birth vaginally before. A Cochrane review found that warm compresses during the second stage of labor may be beneficial in reducing the incidence of third- and fourth-degree lacerations Some degree of trauma to the soft tissues of the birth canal and adjacent structures occurs during every birth. The tendency to sustain lacerations varies with each woman; that is, the soft tissue in some women may be less distensible. Damage usually is more pronounced in nulliparous women because the tissues are firmer and more resistant than are those in multiparous women. Heredity is also a factor. For example, the tissue of light-skinned women, especially those with reddish hair, is not as readily distensible as that of darker-skinned women, and healing may be less efficient. Other risk factors associated with perineal trauma include maternal nutritional status, birth position, pelvic anatomy (e.g., narrow subpubic arch with a constricted outlet), fetal malpresentation and position (e.g., breech, occiput posterior position), large (macrosomic) infants, use of forceps or vacuum to facilitate birth, prolonged second-stage labor, and rapid labor in which there is insufficient time for the perineum to stretch. Some injuries to the supporting tissues, whether they are acute or nonacute and whether they were repaired or not, may lead to genitourinary and sexual problems later in life (e.g., pelvic relaxation, uterine prolapse, cystocele, rectocele, dyspareunia, urinary and bowel dysfunction) Performing Kegel exercises in the prenatal and postpartum periods improves and restores the tone and strength of the perineal muscles Health practices, including good nutrition and appropriate hygienic measures, help maintain the integrity and suppleness of the perineal tissues, enhance healing, and prevent infection.

Care Management Nursing Interventions Siblings During Labor and Birth

Preparing siblings for acceptance of the new child helps promote the attachment process and may help older children accept this change. The older child or children who know they are important to the family become active participants. Rehearsal for the event before labor is essential. The age and developmental level of children influence their responses; therefore, preparation for the children to be present during labor is adjusted to meet each child's needs The child younger than 2 years shows little interest in pregnancy and labor. However, for the older child, such preparation may reduce fears and misconceptions. Parents need to be prepared for labor and birth themselves and feel comfortable about the process and the presence of their children. Most parents have a "feel" for their children's maturational level and their physical and emotional ability to observe and cope with the events of the labor and birth process. Preparation can include a description of the anticipated sights, events (e.g., ROM, monitors, IV infusions), smells, and sounds; a labor and birth demonstration; a tour of the birthing unit; and an opportunity to be around a real newborn. Storybooks about the birth process can be read to or by children to prepare them for the event. Films are available for preparing preschool and school-age children to participate in the labor and birth experience. Children must learn that their mother will be working hard during labor and birth. She will not be able to talk to them during contractions. She may groan, scream, grunt, and pant at times as well as say things she would not say otherwise (e.g., "I can't take this anymore," "Take this baby out of me," or "This pain is killing me"). You can tell them that labor is uncomfortable, but that their mother's body is made for the job. Most agencies require that a specific person be designated to watch over the children who are participating in their mother's childbirth experience, to provide them with support, explanations, diversions, and comfort as needed. Health care providers involved in attending women during birth must be comfortable with the presence of children and the unpredictability of their questions, comments, and behaviors.

Care Management Assessment Laboratory and Diagnostic Tests Blood Tests

The blood tests performed vary with the hospital protocol and the woman's health status. Currently, all blood tests must be performed in the hospital laboratory rather than on the perinatal unit. Often blood samples are obtained from the hub of the catheter when an IV is started or a heplock or saline lock is inserted. A hematocrit will likely be ordered. More comprehensive blood assessments such as white blood cell count, red blood cell count, hemoglobin level, hematocrit, and platelet values are included in a complete blood count (CBC). A CBC may be ordered for women with a history of infection, anemia, gestational hypertension, or other disorders. Many hospitals require that a CBC be done before epidural anesthesia is initiated. Any woman whose human immunodeficiency virus (HIV) status is undocumented at the time of labor should be screened with a rapid HIV test unless she declines (opts-out) testing Most hospitals require that a "type and screen," to determine the woman's blood type and Rh status, be performed on admission. Even if these tests have already been performed during pregnancy, the hospital's laboratory or blood bank must verify the results in-house. If the woman had no prenatal care or if her prenatal records are not available, a prenatal screen will likely be drawn on admission. The prenatal screen includes laboratory tests that would normally have been drawn at the initial prenatal visit

Second Stage of Labor The latent ("laboring down") phase

The latent ("laboring down") phase is a period of rest and relative calm. During this phase the fetus continues to descend passively through the birth canal and rotate to an anterior position as a result of ongoing uterine contractions The urge to bear down is not strong, and some women do not experience it at all or only during the acme (peak) of a contraction. Careful monitoring with assurance of normal fetal status should be used during delayed pushing. If descent is slow and the woman becomes anxious, she should be encouraged to change positions frequently or to stand by the bedside to use the advantage of gravity and movement to facilitate descent and progress to the active pushing phase signaled by a perception of the need to bear down

Care Management Assessment Physical Examination

The initial physical examination includes a general systems assessment and an assessment of fetal status. During the examination uterine contractions are assessed and a vaginal examination is performed. The findings of the admission physical examination serve as a baseline for assessing the woman's progress from that point. The information obtained from a complete and accurate assessment during the initial examination serves as the basis for determining whether the woman should be admitted and what her ongoing care should be. Birth is a time when nurses and other health care providers may be exposed to a great deal of maternal and newborn blood and body fluids. Therefore, Standard Precautions should guide all assessment and care measures Hand hygiene (e.g., washing hands with soap or application of an alcohol-based antiseptic rub) before and after assessing the woman and providing care is critical in preventing infection transmission. The nurse should explain assessment findings to the woman and her partner whenever possible. Throughout labor, accurate documentation, following agency policy, is done as soon as possible after a procedure has been performed If in-room computer stations are used, make sure to turn the computer so that your back is not to the woman while you are documenting.

Care Management Assessment Prenatal Data

The nurse should carefully review the woman's prenatal records, taking note of her obstetric and pregnancy history including gravidity; parity; and problems such as history of vaginal bleeding, gestational hypertension, anemia, pregestational or gestational diabetes, infections (e.g., bacterial, viral, sexually transmitted), and immunodeficiency status. In addition, the expected date of birth (EDB) should be confirmed. Other important data found in the prenatal record include patterns of maternal weight gain, physiologic measurements such as maternal vital signs (blood pressure, temperature, pulse, respirations), fundal height, baseline fetal heart rate (FHR), and laboratory and diagnostic test results. Common diagnostic and fetal assessment tests performed prenatally include amniocentesis, nonstress test (NST), biophysical profile (BPP), and ultrasound examination. If the woman has had no prenatal care or her prenatal records are unavailable, the nurse must obtain certain baseline information. If the woman is having discomfort, the nurse should ask questions between contractions when the woman can concentrate more fully on her answers. Accurate height and weight measurements are important. A pregnancy weight gain greater than recommended may place the woman at a higher risk for cephalopelvic disproportion and cesarean birth. Other factors to consider are the woman's general health status, current medical conditions or allergies, respiratory status, and previous surgical procedures. If this labor and birth experience is not the woman's first, the nurse needs to note the characteristics of her previous experiences. This information includes the duration of previous labors, the types of pain relief measures, including anesthesia used, the type of birth (e.g., spontaneous vaginal, forceps-assisted, vacuum-assisted, or cesarean birth), and the condition of the newborn.

Second Stage of Labor Care Management

The only certain objective sign that the second stage of labor has begun is the inability to feel the cervix during vaginal examination, indicating that the cervix is fully dilated and effaced. Other signs that suggest the onset of the second stage include the urge to push or feeling the need to have a bowel movement. Women with an epidural block may not exhibit such signs. Women who are laboring without regional anesthesia can experience an irresistible urge to bear down before full dilation. This is most often related to the station of the presenting part below the level of the ischial spines of the maternal pelvis. This occurrence creates a conflict between the woman, whose body is telling her to push, and her health care providers, who may believe that pushing the fetal presenting part against an incompletely dilated cervix will result in cervical edema and lacerations, as well as slow the labor progress. Evaluate the premature urge to bear down as a sign of labor progress, possibly indicating the onset of the second stage of labor. Base the timing of when a woman pushes in relation to whether her cervix is fully dilated on research evidence rather than on tradition or routine practice. Pushing with the urge to bear down at the acme of a contraction may be safe and effective for a woman if her cervix is soft, retracting, and 8 cm or more dilated and if the fetus is at +1 station and rotating to an anterior position Assessment continues during the second stage of labor. Professional standards and agency policy determine the specific type and timing of assessments, as well as the way in which findings are documented Signs and symptoms of impending birth may appear unexpectedly, requiring immediate action by the nurse The nurse continues to monitor maternal-fetal status and events of the second stage and provide comfort measures for the mother. This includes helping her change position; providing mouth care; maintaining clean, dry bedding; and keeping extraneous noise, conversation, and other distractions (e.g., laughing, talking of attending personnel in or outside the labor area) to a minimum. The woman is encouraged to indicate other support measures she would like In the hospital, birth may occur in an LDR, LDRP, or delivery room. If the mother is to be transferred to the delivery room for birth, perform the transfer early enough to avoid rushing her. The birth area also is readied

Second Stage of Labor Care Management Preparing for Birth Immediate Assessments and Care of the Newborn

The time of birth is the precise time when the entire body is out of the mother and must be recorded. In the case of multiple births, each birth is noted in the same way. If the newborn's condition is not compromised, he or she should be dried and placed on the mother's abdomen immediately after birth and covered with a warm, dry blanket. The cord may be clamped at this time, and the nurse-midwife or physician may ask if the woman's partner would like to cut the cord. If so, the partner is given a sterile pair of scissors and instructed to cut the cord 1 inch (2.5 cm) above the clamp. The care given immediately after the birth focuses on assessing and stabilizing the newborn. AWHONN (2010) recommends that at least two nurses be present for each birth. One nurse is responsible for care of the newborn while the other nurse assists the nurse-midwife or physician with delivery of the placenta and care of the mother. The "baby nurse" must watch the infant for any signs of distress and initiate appropriate interventions. AWHONN also recommends that, in cases of multiple births, each baby has his own nurse (AWHONN). Perform a brief assessment of the newborn immediately while the mother is holding the infant. This assessment includes assigning Apgar scores at 1 and 5 minutes after birth Maintaining a patent airway, supporting respiratory effort, and preventing cold stress by drying and, preferably, covering the newborn with a warmed blanket while on his mother's abdomen skin-to-skin or, less optimally, placing him or her under a radiant warmer are the major priorities in terms of the newborn's immediate care. You can postpone further examination, identification procedures, and care until later in the third stage of labor or early in the fourth stage.