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Labor and birth (normal)
Overview
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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
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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).
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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
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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
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Approximately 67% of U.S. women have a normal vaginal birth.
Complications
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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
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Regular uterine contractions
Passage of bloody show
Passage of amniotic fluid
Physical Findings
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Gravid uterus
Possible bloody show
Possible ruptured amniotic membranes
Uterine contractions
Fetal heartbeat
Diagnostic Test Results
Diagnostic Procedures
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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.
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Internal (direct) fetal monitoring uses a spiral electrode to evaluate fetal status during
labor.
Treatment
General
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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
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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
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Ambulation as tolerated
Positioning for comfort; avoid the supine position to prevent maternal hypotension and
impedance of uteroplacental blood flow
Medications
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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
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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
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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
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Acute pain
Anxiety
Ineffective coping
Readiness for enhanced childbearing process
Risk for ineffective childbearing process
Expected Outcomes
The patient will:
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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
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demonstrate continued breathing techniques
express the need to change position
demonstrate evidence of parent-infant bonding after birth.
Nursing Interventions
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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
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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
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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
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Uterine contraction palpation
Vacuum extraction, assisting
Vaginal examination during labor
Venipuncture
Weight measurement, neonate
Patient Teaching
General
Be sure to cover:
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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
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Refer the patient to a lactation consultant, if needed.
Resources
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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)