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Labor and birth (normal) Overview Series of events by which uterine contractions and abdominal pressure expel the fetus and placenta from the uterus Traditionally divided into four stages o Stage one: From onset of labor until the cervix is fully dilated Further divided into latent, active, and descent or transition phases Stage one phases recognized by specific contraction patterns, maternal physical sensations, and maternal behavior o Stage two: From full cervical dilation until birth o Stage three: From birth until birth of the placenta o Stage four: From birth of the placenta until 1 hour postpartum Pathophysiology Regular contractions cause progressive dilation and effacement of the cervix. Cervical effacement is the shortening and thinning of the cervical canal until the canal disappears. In a primigravida (a woman pregnant for the first time), effacement occurs before dilation; in a multigravida (a woman who has been pregnant more than once), dilation may occur before complete effacement. Cervical dilation is the enlargement or widening of the cervical canal, from an opening that's a few centimeters wide to an opening that's large enough to accommodate the passage of the fetus (about 10 cm). Cervical dilation occurs as the uterine contractions gradually increase the diameter of the cervical canal lumen by pulling the cervix up and over the fetal presenting part. Cervical dilation also occurs as the fluid-filled membranes push against the cervix or, if the membranes are ruptured, the presenting part pushes against the cervix. (See Effacement and dilation of the cervix.) Effacement and dilation of the cervix The illustrations below show effacement and dilation of the cervix. At the beginning of labor, effacement hasn't yet occurred (A). Effacement begins, but dilation isn't yet apparent (B). Effacement is almost complete (C). Complete effacement has occurred, and dilation proceeds rapidly (D). Passage of the fetus through the birth canal involves fetal position changes and movements (cardinal movements of labor) so that the smallest diameter of the fetal head (in cephalic presentation) is always heading toward the smallest diameter of the maternal pelvis. (See Mechanisms of normal labor.) Mechanisms of normal labor The illustrations below show the mechanisms of normal labor and the cardinal positions of the fetus from a left occiput anterior position. To view the image in PDF format, click on this link. Source: Pillitteri, A. (2010). Maternal and child health nursing (6th ed.). Philadelphia, PA: Lippincott Williams & Wilkins. Causes Theories about labor: o Uterine muscle stretching results in a release of prostaglandins o Pressure on the cervix stimulates the release of oxytocin from the posterior pituitary o Oxytocin stimulation works together with prostaglandin to initiate contractions Incidence Approximately 67% of U.S. women have a normal vaginal birth. Complications Prolonged labor (failure to progress) Abnormal presentation (breech, transverse lie, occiput anterior) Prolapsed umbilical cord Preterm labor Preterm rupture of amniotic membranes Umbilical cord compression Shoulder dystocia Perineal laceration Assessment History Regular uterine contractions Passage of bloody show Passage of amniotic fluid Physical Findings Gravid uterus Possible bloody show Possible ruptured amniotic membranes Uterine contractions Fetal heartbeat Diagnostic Test Results Diagnostic Procedures Amniotic fluid assessment determines the presence of amniotic fluid in vaginal secretions. Cervical (vaginal) examination assesses cervical effacement, dilation, and fetal presentation, position, and station. External fetal monitoring monitors the fetal heart rate (FHR) by auscultating either with a fetoscope or a Doppler ultrasound stethoscope placed on the maternal abdomen; monitoring can also assess maternal uterine contractions. Internal (direct) fetal monitoring uses a spiral electrode to evaluate fetal status during labor. Treatment General Amniotomy to induce or augment labor when the patient's membranes fail to rupture spontaneously Anxiety management Epidural anesthesia for pain relief Fetal assessment Maternal uterine contraction assessment Maternal vital signs measurement Oxygen administration Oxytocin administration during labor and delivery Oxytocin administration, postpartum Oxygen administration Pain management I.V. fluid administration Diet Clear liquids, such as flavored gelatin, fruit juice without pulp, clear tea, carbonated beverages, water, black coffee, and broth in low-risk women (those not at risk for aspiration, such as morbidly obese or diabetic women and those with airway difficulty) No solid foods during labor Activity Ambulation as tolerated Positioning for comfort; avoid the supine position to prevent maternal hypotension and impedance of uteroplacental blood flow Medications Bupivacaine (Marcaine) for pain relief; used with epidural anesthesia Butorphanol tartrate for pain relief Cefazolin sodium (Ancef) (for penicillin-allergic women who don't have a history of anaphylaxis, angioedema, respiratory distress, or urticaria following administration of a penicillin or a cephalosporin) for group A beta-hemolytic streptococci and other strains of streptococci prophylaxis. Lidocaine hydrochloride (Xylocaine) for use with local (pudendal) anesthesia for episiotomy Methylergonovine maleate (Methergine) to prevent and control postpartum hemorrhage Nalbuphine hydrochloride (Nubain) for pain relief Oxytocin (Pitocin) to prevent and control postpartum hemorrhage Oxygen Lactated Ringer solution for hydration and to treat indeterminate or abnormal FHR patterns Ropivacaine (Naropin) for pain relief; used with epidural anesthesia Penicillin for GBS prophylaxis Surgery Episiotomy (perineotomy), a common surgical procedure in which an incision is made into the perineum, the area between the vagina and anus (See Recognizing an episiotomy.) o hastens the second stage of labor o substitutes a straight, neat surgical incision for the ragged lacerations that can result from tearing o used when fetal distress necessitates vacuum delivery o creates a larger diameter for manipulation during birth in anticipation of a potential shoulder dystocia Recognizing types of episiotomy The illustration below shows a midline and a mediolateral episiotomy. Source: Pillitteri, A. (2010). Maternal and child health nursing (6th ed.). Philadelphia, PA: Lippincott Williams & Wilkins. Nursing Considerations Nursing Diagnoses Acute pain Anxiety Ineffective coping Readiness for enhanced childbearing process Risk for ineffective childbearing process Expected Outcomes The patient will: express a reduction in pain to a tolerable level as the result of breathing techniques, pain medication administration, or both express confidence and understanding about the labor process state feeling less anxious and fearful express confidence in her ability to maintain active participation during labor demonstrate continued breathing techniques express the need to change position demonstrate evidence of parent-infant bonding after birth. Nursing Interventions Assess maternal vital signs at least every 4 hours. Assess the character and amount of amniotic fluid (clear, bloody, meconium-stained, or odorous). Assess the character and amount of blood show or vaginal bleeding. Assess maternal and fetal responses to labor. Assess the level of maternal discomfort and coping, and the effectiveness of pain management as well as pain-relief measures. Determine, evaluate, and record intermittent auscultation, or review and document the electronic fetal monitor (EFM) tracing of FHR every 30 minutes during the active phase of the first stage of labor and at least every 15 minutes during the active, pushing phase of the second stage of labor. Determine, evaluate, and record palpations of uterine activity, or review and document the EFM tracing of uterine activity every 30 minutes during the active phase of the first stage of labor and at least every 15 minutes during the active, pushing phase of the second stage of labor. When complications occur or risk factors are present, the American Academy of Pediatrics (AAP) and the American Congress of Obstetricians and Gynecologists (ACOG) suggest determining, evaluating, and recording intermittent auscultation or reviewing and documenting the EFM tracing of FHR at least every 15 minutes during the active phase of the first stage of labor and at least every 5 minutes during the active, pushing phase of the second stage of labor, preferably before, during, and after a uterine contraction. Immediately after birth, assess maternal blood pressure and pulse at least every 15 minutes for 2 hours, or more frequently and for a longer period if complications occur; assess maternal temperature at least every 4 hours for 8 hours after birth, and then at least every 8 hours. If the patient received epidural anesthesia, assess maternal blood pressure after the initiation or re-bolus of regional block medication, including patient-controlled epidural anesthesia (PCEA), every 5 minutes for the first 15 minutes; then repeat every 30 minutes for 1 hour after the procedure. Assess FHR and uterine activity after the initiation or re-bolus of regional block anesthesia, including PCEA, every 5 minutes for the first 15 minutes. Assess the neonate's Apgar scores at 1 minute and 5 minutes after birth. If the neonate has an Apgar score of less than 7, assess the Apgar score every 5 minutes up to 20 minutes. Assess and record the neonate's temperature, heart rate, respiratory rate, type of respiration, skin color, adequacy of peripheral circulation, muscle tone, level of consciousness, and activity at least every 30 minutes until the neonate's condition has remained stable for at least 2 hours. Monitoring Maternal vital signs Maternal intake and output Uterine activity and contractions Cervical dilation and effacement Maternal pain Maternal pain relief FHR Neonate vital signs Associated Nursing Procedures Amniotic fluid assessment using AmniSure Amniotic fluid assessment using Nitrazine paper Amniotic fluid assessment using the fern test Amniotomy, assisting Apgar scoring Birthing ball use Bladder catheterization during labor Breathing techniques during labor Epidural anesthesia, care during labor Fetal heart rate monitoring, auscultation Fetal monitoring, external Fetal monitoring, internal Fetal scalp blood sampling Gestational age determination Incubator preparation IV catheter insertion IV pump use IV secondary line drug infusion IV solution change Labor, care during Neonate identification and footprinting Oxygen administration Oxygen administration, nasal prongs, neonate Oxytocin administration during labor and delivery Oxytocin administration, postpartum Pain assessment Pain management Parent-neonate bonding Radiant warmer or incubator use Respiratory rate assessment, neonate Skin-to-skin contact, initiating, neonatal Uterine contraction palpation Vacuum extraction, assisting Vaginal examination during labor Venipuncture Weight measurement, neonate Patient Teaching General Be sure to cover: all procedures, including the rationale for procedures and possible outcomes nutrition, especially during breast-feeding need to notify the practitioner of possible complications (such as fever over 100° F [37.8° C]) how to care for the perineum and breasts pattern of menstruation after birth resumption of sexual activity when to return for postpartum appointments. Discharge Planning Refer the patient to a lactation consultant, if needed. Resources American Congress of Obstetricians and Gynecologists: www.acog.org Association of Women's Health, Obstetric and Neonatal Nurses: www.awhonn.org Selected References 1. American College of Obstetricians and Gynecologists. (2010, reaffirmed 2013). ACOG practice bulletin no. 116: Management of intrapartum fetal heart rate tracings. Obstetrics & Gynecology, 116(5), 1232–1240. (Level V) 2. American College of Obstetricians and Gynecologists. (2009, reaffirmed 2013). ACOG practice bulletin no. 106: Intrapartum fetal heart rate monitoring: Nomenclature, interpretation, and general management principles. Obstetrics & Gynecology, 114(1), 192–202. (Level V) 3. Cunningham, F. G., et al. (2014). William's obstetrics (24th ed.). Philadelphia, PA: McGraw-Hill. 4. Funai, E. F., & Norwitz, E. R. Management of normal labor and delivery. (2015). In: UpToDate, Lockwood, C. J., & Barss, V. A. (Eds.). Retrieved from: www.uptodate.com 5. Funai, E. F., & Norwitz, E. R. Mechanism of normal labor and delivery. (2014). In: UpToDate, Lockwood, C. J. (Ed.). Retrieved from: www.uptodate.com 6. Herdman, T. H., & Kamitsuru, S. (Eds.). (2014). NANDA International Nursing Diagnoses: Definitions & Classification 2015–2017. Oxford: Wiley Blackwell. 7. Hogan, M. (2012) Pearson reviews and rationales: Maternal-newborn nursing with reviews and rationales (3rd ed.). Boston, MA: Pearson Education. 8. Lawrence, A., et al. Maternal positions and mobility during first stage labour. Cochrane Database of Systematic Reviews, 2013(10), CD003934. (Level I) 9. Nishi, D., et al. (2014). Hypnosis for induction of labour. Cochrane Database of Systematic Reviews, 2014(8), CD010852. (Level I) 10. Pillitteri, A. (2014). Maternal & child health nursing: Care of the childbearing & childrearing family (7th ed.). Philadelphia, PA: Wolters Kluwer. 11. Simpson, K. R., & Creehan, P. A. (2014). AWHONN's perinatal nursing (4th ed.). Philadelphia, PA: Wolters Kluwer. 12. Sng, B. L., et al. (2014). Early versus late initiation of epidural analgesia for labour. Cochrane Database of Systematic Reviews, 2014(10), CD007238. (Level I)