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Practical Nursing Series:
Maternal Newborn Nursing
Maternal Newborn Nursing adheres to the revised objectives
approved by the Oklahoma Board of Nursing.
This full-color text provides a basic overview of maternal and
newborn care skills that the practical nursing student needs
in order to be successfully employed in today’s healthcare
setting. Maternal Newborn Nursing is designed to teach the
nursing student the basics of maternal and newborn care
skills and the ability to apply their knowledge to prepare for
the NCLEX-PN.
Modules include:
 Antepartum Care
 Intrapartum Care
 Postpartum Care
 Newborn Care
Practical Nursing:
Maternal Newborn Nursing
2011
Teacher Edition: HO1035
Student Workbook: HO3035
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Copyright 2011 Oklahoma Department of Career and Technology Education
IM
Practical Nursing
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Maternal Newborn
Nursing
Teacher Edition
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CIMC
HO1035
MODULE 2
i N T r A PA r T U M C A r E
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Intrapartum is the phase of pregnancy when
delivery of the fetus takes place.
The LPN will often be responsible for caring for
patients during labor and delivery. This module is
designed to outline the events that occur during
normal labor and delivery, as well as some of the
complications that can arise. The nurse’s role in
providing support for the patient and the family
during labor and delivery is presented.
Observing the birth of a new life is fascinating.
Labor and delivery is a unique specialty as there is
the responsibility for the laboring patient as well as
the fetus. Responsibilities also may include family
and other loved ones in attendance. Many times
entire families will show up for the emotional event.
The nurse is responsible for providing a professional
and safe environment, and at times, must care for
the family.
Most hospitals require a Registered Nurse (RN) to
work in labor and delivery (L&D) because this is
an area of high litigation and requires a great deal
of knowledge and critical thinking. Some hospitals
allow practical nurses to work in the area, within
their scope of practice. These skills may include
limited assessment skills, monitoring patient and
fetus and providing support and comfort during the
birthing experience.
i
Review the
Learning
Objectives with
the students. Look ahead to
the Learning Activities in
this module and plan to
introduce them.
LEarnIng ObjECtIvEs
1. Differentiate between true labor and false labor.
2. Classify the stages and phases of labor.
3. Describe fetal physiologic responses to labor.
4. Identify nursing actions necessary when admitting a woman to the labor
unit.
5. Identify the role of the practical nurse in the interpretation of:
• Fetopelvicrelationship
• Fetalassessment
• Contractions
• Leopold’smaneuvers
• Vaginalexamination
6. Identify types of pain management used during labor.
7. Describe the physiological and psychological care for a patient during
laboranddelivery.
8. Identify potential maternal and fetal complications during labor and
delivery.
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10.
Differentiate between induction and augmentation techniques of labor:
• Amniotomy
• Medications
Describemethodsofdeliveryusedduringsecondstageofdelivery:
• Episiotomy
• Forceps
• Vacuumextractor
11. DiscussresponsibilityoftheLPN/LVNwhilecaringforthemotherand
newbornduringlaboranddelivery.
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C I M C • M AT E R N A L N E W B O R N N U R S I N G
MODULE Overview
Intrapartum care is the care of women and their babies during childbirth. The student will learn the intrapartum
period extends from the beginning of contractions that cause cervical dilation to four hours after delivery of the
newborn and placenta. The student will learn intrapartum refers to the medical and nursing care given to a pregnant
woman and her family during labor and delivery.
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C I M C • M AT E R N A L N E W B O R N N U R S I N G
L E a r n I n g
O b j ec t i v e
O b j E C t I v E
Identify nursing actions necessary
when admitting a woman to the
labor unit.
The fetus is considered term at 37 weeks and can
continue in the womb up to 42 weeks. At 40 weeks
the fetus should be fully developed, the lungs
should be fully mature and ready for life outside
the womb. In the time leading up to delivery, the
patient and family prepare for birth. Many times,
they have dreamed, planned, read books and/or
attended birthing classes. The patient arrives in
labor and delivery (L&D) with expectations of the
perfect birth and baby. The nurse should respect
the patient’s expectations while following hospital
policy and procedures and maintaining the safety of
the patient and the fetus.
What causes labor to begin is not fully understood.
However, the fluctuation of prostaglandin and
estrogen levels and the stretching and thinning of
the uterus are theories. Some patients get excited
when they lose the mucous plug. The mucous plug
is a thick yellowish piece of mucous that is located
in the cervix opening. Its purpose is to prevent
ADDITIONAL
CRITICAL THINKING
QUESTIONS
bacteria from entering the uterus. As the cervix
softens and dilates, the plug may fall out up to two
weeks before labor begins or during delivery.
aDMIssIOn tO LabOr
anD DELIvEry
• A patient at 38 weeks
gestation tells the nurse
that it feels like her baby
is sitting on her bladder
causing her to urinate
frequently. However,
the patient states it has
made it easier for her
to breathe. The nurse
recognizes that this is
a sign of lightening.
Discuss lightening.
Nursing actions upon admission to labor and delivery
include:
•
•
Make patient as comfortable as possible
•
Complete needed admission and treatment
forms
•
•
Take vital signs
•
Apply fetal monitor to the patient’s abdomen
(usually with elastic belts)
Reviews the patient’s health history and
prenatal records
Assist with obtaining lab specimens and
evaluation results
There are several focused questions that are part of an
intrapartum admission. This usually can be done by
the RN, but some data gathering may be delegated
to the LPN. This information can be helpful when
assessing the progression of labor.
Typical Admission Questions
Question
Rationale
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When is your due date?
This is important to know because the infant
may need a critical care nursery if it is preterm.
If the patient is past expected due date, the
infant may need to be delivered.
When was the last time you felt the baby move?
Fetal activity represents a fetus that is
oxygenated and alive.
What is the GTPAL?
The number of pregnancies is important and
may help predict the pace of labor or let the
nurse know of possible complications.
Gravida (G) = total number of pregnancies
Term (T) = number of pregnancies carried to 37 weeks
Preterm (P) = number of pregnancies delivered before
37 weeks
Abortions (A) = number of elective or spontaneous
abortions
Living (L) = number of living children at this time
M O D U L E 2 • I N T R A pA RT U M C A R E • s t U D E n t E D I t I O n
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Answer: True contractions do not go away with hydration or walking.
Instead, they are regular in frequency, duration and intensity, and become
stronger with walking. Braxton-Hicks contractions decrease with hydration
and walking.
patient experiences a large gush of fluid from her vagina while walking in the
• A
hallway of the birthing unit. What is the first nursing action after establishing the fluid
is amniotic fluid?
Answer: Fetal heart rate must be monitored for distress. There is a high risk
of umbilical cord prolapse with the rupture of membranes, and therefore,
FHR is the first thing the nurse should assess once rupture of membranes has
been established.
M O D U L E 2 • I ntra p artum C are • T E A C H E R E D I T I O N
Answer: The
patient has
experienced
lightening,
whereby the
fetus drops down
as it prepares
to engage.
This puts more
pressure on the
bladder but can
alleviate difficulty
breathing and
indigestion
problems.
• A
patient reports that
her contractions started
about two hours ago,
did not go away when
she had two glasses of
water and rested, and
became stronger since
she started walking. She
thinks the contractions
occur every 10 minutes
and last about half a
minute. She hasn’t had
any fluid leak from
her vagina. However,
she did think she saw
some blood when she
wiped after voiding. The
patient is experiencing
true contraction.
The pregnant patient
asks the difference
between Braxton-Hicks
contraction and true
contraction.
3
Question
learning
link
www
Rationale
What was the method of delivery of your previous
delivery?
Usually delivery is done the same as previous
deliveries.
How long was the labor and were there any
complications with your last pregnancy?
The time frame of last labor may offer some
indication of the length of this labor.
Have you ever had a cesarean section and why was it
performed?
If a patient had an emergency cesarean
section, the patient may need another
cesarean section.
Labor and Delivery
Flashcards
Has your water broken?
Spontaneous rupture of membranes (SROM).
If yes, what color was it?
http://quizlet.
com/1771872/351-laborand-delivery-flash-cards/
When did it break?
Green color might be caused by meconium.
Meconium fluid occurs when the baby is
stressed during pregnancy and could be a
problem if the infant inhales it into the lungs.
Special precautions are taken at birth with
meconium.
If the membranes are ruptured more than 24
hours, infection may occur.
Are you having contractions?
This is important to know because the duration
and frequency of contractions are related to
the amount of blood the fetus receives.
When did it start to become regular?
What does it feel like?
Timing contractions assists in determining
stages of labor.
Is there vaginal bleeding? If so, how much and when
did it start?
Vaginal bleeding of any amount must be
investigated.
Blood-tinged mucous is normal and vaginal
bleeding is not.
Have you ever been diagnosed with a sexually
transmitted disease?
This is important to know because the infant
passes through the vaginal canal and sexually
transmitted disease (STD’s) can be dangerous
for the fetus.
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Vaginal birth is contraindicated with active
vaginal herpes.
Are you allergic to latex or Betadine?
Many of these products used during delivery
may cause allergic response.
Who would you like with you during labor and
delivery?
This is important due to patient’s need of
support during the labor and delivery process.
Do you have any special requests for your labor and
delivery experience?
The patient has the opportunity to request
mirrors, special needs during labor, and pain
management.
The birth plan and cultural requests can also be
made at this time.
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4
C I M C • M AT E R N A L N E W B O R N N U R S I N G
C I M C • M AT E R N A L N E W B O R N N U R S I N G
L E a r n I n g
O b j ec t i v e
O b j E C t I v E
Differentiate between true labor
and false labor.
t rU E O r Fa L s E L a b O r
When the assessment is completed, it must be
determined if the patient is in true or false
labor. This is determined by the RN in
cooperation with the physician. Once the
cervix starts to dilate, the patient is considered to
be in true labor. The difference between true and
false labor is that cervical dilation occurs with true
labor. Some patients may experience BraxtonHicks contractions (BHC). BHC’s can occur
during late pregnancy and feel like a tightening,
mostly in the abdomen. They are usually irregular
contractions and for most patients, the contractions
remain the same and do not progress to regular
intense contractions that cause cervical dilation.
The contractions in true labor will increase in
intensity and cause dilation of the cervix.
Characteristics of True and False Labor
Characteristic
True Labor
False Labor
Contraction length
Last longer as labor progresses
Vary in length
Contraction frequency
More frequent as labor
progresses
Rarely follow a pattern
Contraction strength
Get stronger as labor progresses
Vary in intensity
Contraction location
Start in the lower back and
travel to the lower abdomen
Felt mostly in the fundus
Effect of contractions on the
cervix
Effaces or dilates as labor
progresses
May cause some softening of
the cervix
Effect of contractions on the
fetus
Pushes the fetus downward into
the pelvis
Does not affect fetal position
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The process of labor and delivery involves what is
referred to as the five P’s:
• Passageway (pelvis, cervix, and vagina)
• Passenger (fetus and placenta)
• Powers (contractions)
• Positions utilized by the mother
• Psychological factors related to pregnancy
One part of the passageway is the pelvic opening.
For a vaginal birth to occur, the fetal head must be
able to pass through the mother’s pelvic opening.
The primary care provider will palpate and measure
the distance between bony prominences in order to
determine the shape and size of a woman’s pelvis.
The cartilage of the symphysis pubis softens in
response to hormones and allows the pelvic bones to
open somewhat during birth.
Ultrasound is also used to help determine the size
of the fetus and the likelihood of the head fitting
through the pelvic opening. Women who have a
heart-shaped pelvis or an oval pelvis are more likely
to require a forceps-assisted delivery. Women with
a heart-shaped pelvis may even need a cesarean
delivery, depending on fetal size and pelvic size.
M O D U L E 2 • I N T R A pA RT U M C A R E • s t U D E n t E D I t I O n
M O D U L E 2 • I ntra p artum C are • T E A C H E R E D I T I O N
5
5
Many times cesarean sections are required due to the
difficulty the baby has trying to mold the head to
pass through the shape of the pelvis. The size and
presenting part of the fetus, the passenger, also
plays a big part in a safe vaginal delivery. The most
common and ideal shaped pelvis for vaginal birth is
the gynecoid pelvis.
Cervical dilation and effacement are part of the
passageway. Pre-pregnancy the cervix is long and
thick and has a tiny opening called the cervical
os which is plugged with mucous to prevent
microorganisms from entering the uterus. For
vaginal birth to occur, the cervix must open wide
enough to allow a seven or more pound, 22-inch
long (average) infant to pass through it. The
fibrous musculature of the cervix softens and thins
(effacement) and the os opens (dilation). The term
presentation refers to the part of the fetus that
enters the pelvis first. The presenting part of the
fetus is usually the head, referred to as cephalic
presentation. The head is against the inner os of the
cervix. As Braxton-Hicks contractions and labor
contractions occur, the head presses against the os
and surrounding musculature. This pressure causes
the cervix to thin and open, which allows the
“passenger” to be born.
The descent of the fetus into the pelvis is
described as station. The station of the presenting
part is measured in centimeters. For example:
-2,-1, zero, +1, +2. Zero station is level with
the ischial spines. Minus numbers are above
the ischial spines and plus numbers are below.
The major power during labor is the contractions
of the uterus. Another power is the mother pushing
during the birth. Uterine contractions start at the
top, or fundus, of the uterus and spread over the
uterus in about 15 seconds. Then the uterus relaxes,
allowing blood flow to increase again to the fetus and
allowing the mother to rest. During a contraction,
the nurse can place a hand on the patient’s fundus
and feel the firmness of the uterus.
Effective contractions last up to 90 seconds and have
a minimum of 60 seconds of relaxation between
each contraction. If contractions last longer than
this, they can compromise blood flow to the fetus.
The frequency of contractions is measured from the
beginning of one contraction to the beginning of
the next contraction. When contractions are said to
be three minutes apart, it means that three minutes
elapse from the beginning of one contraction to the
beginning of the next contraction. The duration of
a contraction is the length of time one contraction
lasts. When uterine contractions occur, the fetal
circulation is slowed during the contraction. The
umbilical cord contains 2 arteries and one vein. There
should be at least a minute between contractions to
allow adequate fetal blood flow and oxygenation of
the fetus.
The position of the mother is important when
contractions are occurring. When the woman lies
on her back, her contractions will have less intensity,
although they may be more frequent than when she
uses other positions. When the mother lies on her
side, her contractions are more intense, but less
frequent, so labor progresses more quickly. It is best
for the mother to lie on her side, since it will prevent
supine hypotension syndrome (see Antepartum
Care module) and it provides the best oxygenation
for the fetus.
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Dilation occurs with the opening of the
cervical os. This opening is measured in centimeters and referred to as; fingertip- which is
barely open, 1 cm, 2 cm…then progresses to
complete, which is 10 cm. At 10 cm, the cervix
is no longer felt.
–3
–2
–1
0
+1
+2
+3
s tations
6
C I M C • M AT E R N A L N E W B O R N N U R S I N G
CLASSROOM ACTIVITY
• Obtain an OB static manikin. Demonstrate fetal attitude, lie, presentation and position.
6
C I M C • M AT E R N A L N E W B O R N N U R S I N G
L E a r n I n g
O b j E C t I v E s
O b j ec t i v e
Classify the stages and phases of
labor.
O b j ec t i v e
Differentiate between induction
and augmentation techniques of
labor:
•
•
O b j ec t i v e
Amniotomy
Medications
Describe methods of delivery used
during second stage of delivery:
•
•
•
Episiotomy
Forceps
Vacuum extractor
s tag E s a n D p h a s E s
OF LabOr
First Stage
The first stage of labor begins with the onset of
cervix dilation 0-2 cm and ends when the cervix is
completely dilated. The first stage occurs in three
phases.
1. Latent phase — also called the early phase.
During the latent phase, the uterine contractions
become regular and are mild in strength. Uterine
contractions are described by frequency, duration
and strength or intensity. Uterine contractions
average from 50-60 seconds in duration and 3-5
minutes apart in frequency. The cervix dilates from
0 cm to 4 cm. Many women arrive at the hospital
with some effacement and dilation. Dilation and
effacement occur during the latent phase. The fetus’
head becomes engaged, moving against the cervix
into the pelvis.
3. Transition phase — The transition phase
begins after cervical dilation of 8 cm and continues
until 10 cm, known as completely dilated. This
is the last and toughest phase for the patient.
The urge to push is great and the cervix may not
be fully dilated. The patient is instructed not to
push. Uterine contractions are strong in intensity,
occurring every 2-3 minutes and lasting up to
60- 80 seconds. The patient needs help with
breathing techniques to maintain focus and
control. Some patients may become frustrated and
angry and have feelings of being out of control;
they may beg to ‘get it out’. Encourage the patient
and assure her that this phase will pass and she will
be able to push soon.
learning
w
ww
links
Stages of Labor – Video
http://www.medicalvideos.
us/videos-369-Signs-andSymptoms-of-Labour
Second Stage
Transition Stage – Video
The second stage of labor begins when the cervix is
fully dilated, 10 cm, and ends with the birth of the
baby.
http://www.medicalvideos.
us/videos-372-Transition
The patient is instructed to push and the significant
other is supportive and encouraged to participate.
For the patient, the urge to push is great and a
relief to some. Patients may request a mirror to
watch for progression; others do not want to look.
Uterine contractions are at the strongest level as
the fetus descends to the perineal floor. As the
fetus begins to crown, the perineum stretches and
becomes thin. The vaginal opening begins to open
at the peak of contractions and may disappear
between contractions. As the fetus progresses under
the pubic arch, the opening will increase and the
anus may protrude. The PCP should be present
and the patient is prepped for delivery. When the
head crowns, extends beyond the labia and does
not go away between contractions, the PCP decides
if an episiotomy is necessary. The head extends
out of the vagina, next the shoulders, and then the
body follows with another push. The infant cries
and the umbilical cord is cut. Watch the significant
others at the time of birth and encourage a seat if
they become nauseated or light-headed.
2nd Stage of Labor –
Video
http://www.medicalvideos.
us/videos-365-SecondStage-of-Labour
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2. Active phase — The active phase begins after
cervical dilation of 4 cm and continues until 8 cm.
The contractions should be regular at this time and
the patient’s anxiety increases due to increased pain.
The patient may begin to ask for pain medication or
an epidural. The fetus may begin to descend and the
patient needs encouragement to breathe and relax.
M O D U L E 2 • I N T R A pA RT U M C A R E • s t U D E n t E D I t I O n
7
CLASSROOM ACTIVITY
• Divide the students into four groups. Assign each group a stage of labor – First, second, third, and fourth stage.
Have the students develop a poster highlighting the signs and symptoms of their assigned stage of labor.
M O D U L E 2 • I ntra p artum C are • T E A C H E R E D I T I O N
7
Fetal Passage Through Birth Canal
Mechanism
Description
Stage
Engagement
Occurs when the fetus’ head or
other presenting part enters the
true pelvis.
Before stage 1 in primigravidas
and during stage 1 in
multigravidas
Descent
After engagement, the fetus’
head moves through the
passageway as contractions
occur. This is measured in
centimeters above and below
the ischial spine and is referred
to as station.
Stage 1
Flexion
The fetus’ neck flexes, causing
the chin to rest on the sternum
so that the narrowest part of the
head enters the passageway.
Stage 1
Internal rotation
The fetus’ head rotates so that
occiput is next to the mother’s
symphysis pubis.
Stage 2
Extension
The fetus’ head moves under the
symphysis pubis and the neck
extends as the head leaves the
passageway.
Stage 2
Third Stage
Fourth Stage
The third stage of labor begins after the delivery of
the baby and ends with the delivery of the placenta.
The fourth stage of labor begins after the delivery of
the placenta and ends after four hours.
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A sample of cord blood is taken from the cord,
labeled and sent to the lab by the nurse. During this
time the PCP is looking for tears or clots. The shiny
side of the placenta is called the Schultze mechanism.
This is the side of the membrane that held the fetus.
The side that attaches the placenta to the uterine
wall is referred to as the Duncan mechanism. This
appears as a dark roughened surface.
The PCP makes sure the placenta is delivered
without leaving retained placental fragments. The
placenta should deliver within 30 minutes after
delivery and there is usually a small gush of blood
as the placenta delivers. The nurse may inject the IV
bag with oxytocin to aid in the contraction of the
uterus and decrease bleeding.
8
8
There are many changes the patient has gone through.
The physical energy required during delivery and
the loss of placenta and blood volume may cause the
patient to shiver at this time. Comfort and bonding
with the infant are encouraged. The patient is tired
and may request drink and food. This is a normal
process and the nurse may hear the patient tell the
birthing story repeatedly to family or friends. While
this is a great time for bonding and family, the
nurse is still responsible for evaluating the patient’s
uterus, blood flow, and vital signs and monitoring
the infant.
It is important to remember that this is the ideal
sequence and progression of the labor stages.
The experience is individual to each patient and
there are many factors that can affect every labor
experience. Primipara patients often deliver within
C I M C • M AT E R N A L N E W B O R N N U R S I N G
C I M C • M AT E R N A L N E W B O R N N U R S I N G
24 hours and subsequent labors are shorter.
A Multipara patient’s labor is on average 12-14
hours and each delivery is expected to be shorter.
InDUCtIOn anD
a U g M E n tat I O n O F L a b O r
An induction may be ordered to begin labor because
labor sometimes does not begin on its own. An
induction of labor is ordered for the following
reasons:
•
•
•
Past due dates
Fetus is large (macrosomia)
PCP believes the infant should be delivered
because the infant is term
One way to induce labor is by artificial rupture of
membranes (AROM). An amniotomy can also be
done for the augmentation of labor. Augmentation
is needed when the uterine contractions have
decreased and/or labor has stalled or not
progressed. A physician uses a sterile hook-like
instrument to open the sac allowing the amniotic
fluid to escape.
Amniotic fluid smells salty or fleshy and should not
smell foul. Foul odor or green meconium stained
fluid is not expected and can mean difficulty for
the fetus. A rule of thumb is that the fetus should
be delivered within 24 hours after rupture of
membranes to prevent infection.
membranes, the nurse should note the color,
amount and unexpected odors. Monitor FHR and
contractions closely during and after.
Oxytocin (Pitocin) is used to induce labor by
generating uterine contractions. The medication is
increased slowly until the uterine contractions are
of adequate frequency and duration that results in
cervical dilation. Oxytocin can be started during
labor to strengthen contractions, which is another
form of augmentation. The patient must be
monitored closely with the use of oxytocin.
Monitor FHR and contractions continuously to
prevent hyperstimulation. Hyperstimulation of
the uterus is contractions that are too frequent or
do not rest and will cause fetal distress.
Uterine contractions cause cervical dilation, but
the cervix should be thin and favorable. When the
cervix is not favorable, thick and hard, the cervix is
prepared by ripening. Cervical ripening is done with
prostaglandin agents. Prostaglandin agents such as
dinoprostone (Prepidil, Cervidil) or misoprostol
(Cytotec) are inserted into the cervical opening
to promote cervical softening and dilation. The
patients are usually brought in the night before
induction and receive the cervical ripening agent.
Oxytocin is started the next morning according to
protocol. Occasionally uterine hyperstimulation
occurs and the medication is removed or washed
out. Sometimes the patient actually begins labor
shortly after induction.
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The fluid is assessed for color and amount. Yellowish
or brownish color may indicate problems for the
fetus. As soon as membranes rupture, the nurse
should assess the fetal heart rate (FHR) immediately.
Labor generally starts within six to eight hours.
Once the membranes are ruptured, the patient will
be kept in bed with bathroom privileges.
Nursing interventions include:
Have the patient empty their bladder before
insertion.
Instruct the patient to remain recumbent for
30 minutes after insertion.
Monitor the contractions and the FHR
during and after insertion.
Nursing Interventions
Prepare the patient by informing them of what to
expect, placing them in a reclined position with the
feet pulled up, and pads placed under the buttocks
to collect the fluid. When the PCP ruptures the
M O D U L E 2 • I N T R A pA RT U M C A R E • s t U D E n t E D I t I O n
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9
There may be instances when an induction,
augmentation or cervical ripening is contraindicated.
They may be for the following reasons:
•
•
•
Placenta previa
Breech or transverse lie presentation
Previous cesarean section with a classic
incision. (A classic incision is used in
emergency situations and the uterus is cut
vertically which causes the uterus to be more
susceptible to rupture.)
MEthODs OF DELIvEry
Occasionally, during the second stage of labor, the
PCP has to help the fetus pass through the vaginal
canal. An episiotomy may be done to allow the fetal
head or shoulders to exit easily or may be done to
prevent tearing of the perineum. An episiotomy
is easier to repair than irregular tears. Most often
the episiotomy is made midline into the perineum
to prevent tearing into the rectal sphincter. The
decision for an episiotomy should be discussed with
the PCP before labor begins.
Fetal bradycardia can be noted due to compression
of the fetal head during use. Occasionally, these
techniques do not work and a cesarean section
is ordered for a safe delivery. After delivery the
newborn’s face should be examined for any signs of
bruising or caput and must be documented.
Nursing Interventions
•
Obtain the needed equipment and maintain a
sterile field.
•
•
Record time of application.
•
Monitor FHR’s related to what is happening
during delivery.
Monitor uterine contractions and inform
the patient and PCP when to push because
the use of forceps and/or a vacuum are used
during a contraction for the best results.
Forceps or a vacuum extractor may be requested by
the PCP for delivery.
Forceps are medical instruments made of surgical
steel and are used to rotate, grip or pull the fetus
in a position for delivery. Station of the head must
be within acceptable range or forceps and vacuum
extractors are not appropriate. Forceps are applied to
the sides of the fetal head and cheeks. The vacuum
extractor is plastic and is applied to the top of the
fetal head. Suction is increased during a contraction
and released between contractions. The PCP pulls
down on the handle attached to the suction cup to
deliver the head. Forceps or a vacuum extractor may
be required in the following situations:
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10
•
•
Helping the fetus under the pubic arch
•
The patient has become exhausted and can no
longer push effectively
•
Anesthesia has affected the patient’s ability to
push
Delivering the fetus quickly due to fetal or
maternal distress
C I M C • M AT E R N A L N E W B O R N N U R S I N G
C I M C • M AT E R N A L N E W B O R N N U R S I N G
LEarnIng aCtIvIty
1
naME
Introduction
In this activity, you will learn about ways nurses can be supportive during the labor and delivery
process. You will also learn about appropriate assessments to make of the patient and ways you can
support her partner. Ways to help the mother with breathing techniques during labor will also be
examined.
activity
Work in groups of five on this activity, or as directed by the facilitator.
Choose one of the following topics to research and present to the group. You will become the
group “expert” on this topic.
•
•
•
•
•
Assessment of patient when admitted to labor and delivery
Nursing care of patient during labor (Stage 1 and 2)
Nursing care of patient and baby just after delivery (Stage 3 and 4)
Involvement of the father or partner during labor and delivery
Emotional support for the patient and partner
Use three resources for research and list them.
Prepare handouts or visual aids to help others in the group remember the key information in the
presentation.
a p p l i c at i o n
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Present your findings to the class. It will be graded using the following rubric.
A Level 3 presentation will:
• Include complete thorough information about the nursing assessment and care of this aspect
of labor
• Include visual aids and handouts to help learners remember the information presented
• Include a list of three or more references used in your research
• Be well-organized and completed in the time allowed
M O D U L E 2 • I N T R A pA RT U M C A R E • s t U D E n t E D I t I O n
M O D U L E 2 • I ntra p artum C are • T E A C H E R E D I T I O N
11
11
A Level 2 presentation will:
• Include adequate information about the nursing assessment and care of a patient with the
disorder
• Include visual aids or handouts to help learners remember the information presented
• Include a list of at least two references used in research
• Be fairly organized and completed within one minute of the time allowed
A Level 1 presentation will:
• Include minimal information about nursing assessment and care of this aspect of labor
• Lack visual aids or handouts
• Include one reference used in research
• Lack organization and be completed in more than one minute over time
NO POINTS will be awarded the presentation/learner that:
• Lacks accurate information about the assessment and nursing care of this aspect of labor
• Lacks references used in research
• Does not participate in the Learning Activity
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12
C I M C • M AT E R N A L N E W B O R N N U R S I N G
C I M C • M AT E R N A L N E W B O R N N U R S I N G
L E a r n I n g
O b j E C t I v E s
O b j ec t i v e
Describe fetal physiologic
responses to labor.
O b j ec t i v e
Identify the role of the practical
nurse in the interpretation of:
•
•
•
•
•
O b j ec t i v e
Fetopelvic relationship
Fetal assessment
Contractions
Leopold’s maneuvers
Vaginal examination
Identify potential maternal and
fetal complications during labor
and delivery.
rEspOnsEs anD
C O M p L I C at I O n s
Fetal Physiologic Responses
The fetus begins development at conception and
hopefully makes it to term before delivery, when the
fetus can function outside the womb. What occurs
during labor and delivery is monitored closely. The
following explains fetal heart rate (FHR), also called
fetal heart tones (FHT).
The position of the laboring patient can affect the
readings.
The internal monitor includes a spiral electrode and
an intrauterine catheter. The cervix must be dilated
2-3 cm, and the membranes must be ruptured to
insert these components. Fetal monitor provides
a visual tracing for fetal heart tones and uterine
contractions. The use of the fetal scalp electrode
(FSE) is to better maintain a tracing and requires
training to apply. The fetal heart rate (FHR) is
graphed at the top, and the uterine activity is
graphed at the bottom of the paper. The spiral
electrode is attached to the presenting part of the
fetus (usually the scalp), and it monitors fetal heart
rate. The intrauterine catheter is inserted through
the opening cervix into the uterus. It is compressed
during contractions and can, as a result, monitor the
frequency, duration, and intensity of contractions.
It can also measure the resting muscle tone of the
uterus. The information is also recorded on a strip
chart in the same manner as an external monitor.
The nurse assesses the tracing to evaluate the
fetal heart rate and uterine contractions. When
assessment of the fetal heart rate occurs, assessment
of the fetal well being occurs as well. FHT’s provide
clues that the baby is getting the oxygen it needs or
is in distress.
Fetal Heart Rate
CLASSROOM
ACTIVITIES
• Make an appointment to
have the students rotate
through a simulation
lab for OB simulation
scenarios to focus on the
demonstration of normal
and abnormal rhythms
of FHR during the stages
of labor.
• M
ake an appointment to
have the students rotate
through a simulation
lab for OB simulation
scenarios to focus on
scenarios of normal
and abnormal labor
progression.
• M
ake an appointment to
have the students rotate
through a simulation
lab for OB simulation
scenarios to focus on
fetal lie using Leopold’s
maneuver and vaginal
assessment.
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•
Monitoring the Fetus
Electronic monitors are often used during labor to
assess the fetal heart rate in response to contractions
and to assess the contractions. Two different types of
monitors are used: internal and external.
An external fetal monitor includes two transducers
that are placed on the mother’s abdominal wall.
One transducer uses ultrasound to detect and record
the fetal heart rate. The other transducer, called a
tocotransducer, monitors the frequency and duration
of uterine contractions and fetal movement. The
information from both of these is recorded on a
strip chart. The external monitor is non-invasive, so
it does not require that the membranes be ruptured
or that the cervix be dilated. However, it cannot
measure the intensity of the uterine contractions.
Normal baseline (not during contractions) FHR
is 120 to 160 beats per minute. When monitoring
the FHR, the nurse is assessing the heart rate
and variability. Rate and variability represent the
oxygenation of the fetus’s central nervous system
(CNS). The following are terms to become familiar
with when evaluating FHT’s.
Normal or baseline fetal heart rate —
120-160 beats per minute (BPM)
•
Fetal tachycardia — FHR is greater than
160 for more that 10 minutes; common
causes include:
º Elevated maternal temperature and/or
ADDITIONAL
CRITICAL THINKING
QUESTIONS
dehydration
• A patient is in active
labor. Her cervix is
dilated to 5 cm and her
membranes are intact.
M O D U L E 2 • I N T R A pA RT U M C A R E • s t U D E n t E D I t I O n
13
The FHR and uterine
contractions are being
monitored by external fetal monitor. The nurse notes a FHR of 115 to 120 beats/min with occasional increases up
to 158/min that last 25 sec, and beat-to-beat variability of 20 beats/min.
A. There is no slowing of FHR from baseline noted. What signs is the patient exhibiting?
Answer: There is a normal FHR baseline of 115 to 120 beats/min. Therefore, there is no evidence of fetal
bradycardia or tachycardia. There is moderate variability with FHR accelerations increasing 158 beats/min, lasting for
25 sec. There are no FHR decelerations because the FHR does not slow down. These are all reassuring FHR patterns.
B.The nurse auscultates the FHR and determines a rate of 150 to 155 beats/min. What nursing intervention is
appropriate?
Answer: Normal fetal heart rate is between 110 to 160 beats/min. Therefore, this finding does not need to
be reported to the primary care provider.
M O D U L E 2 • I ntra p artum C are • T E A C H E R E D I T I O N
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º Side effect of some medications
CLASS DISCUSSION
Decelerations — are patterns that can occur
within the baseline of the FHR. They may
occur with or without contractions and this is
important to note. The following are the most
common types of deceleration patterns that
may occur.
•
Early Decelerations — Early decelerations
are the result of the fetus’ head being
compressed. The pattern occurs with the
contraction and reflects the contraction. The
FHT’s decrease by several beats and returns to
baseline with the end of the contraction. Early
decelerations are not a problem. Nursing
interventions include:
º Intrauterine infection
• As a class, discuss fetal
oxygenation.
•
•
Answer: A fetus is
most oxygenated
during the
relaxation period
of contractions.
During
contractions, the
arteries to the
uteroplacental
intervillous spaces
are compressed
resulting in a
decrease in fetal
circulation and
oxygenation.
The constriction
is most acute
during the
contraction peak
of the uterine
contraction
intensity, but is
also present on
the incline and
decline of the
contractions.
Fetal bradycardia — FHR less than 120
BPM for 10 minutes; common causes are
suspected decreased fetal oxygenation due to
the following:
º Uterine contractions too close or lasting
too long
º Maternal drop in blood pressure
•
•
Accelerations — are momentary increases in
the FHR baseline. They increase by at least 10
beats above baseline, last for 15 seconds and
return to baseline. Accelerations are “good”
signs of fetal oxygenation.
Variability — fluctuations of the FHR
tracing. This is the increase and decrease
of beats related to the sympathetic and
parasympathetic nervous system. This is one
of the best indicators of fetal oxygenation.
When moderate variability is noted, that is
a good sign of fetal wellbeing. The rating of
variability is as follows:
º Absent — The fetal heart tracing is flat.
THIS MUST BE REPORTED TO THE
PCP IMMEDIATELY.
º Minimal — Fetal heart tracing appears
to fluctuate only 5 BPM. For example:
FHR is between 130-135 BPM. Minimal
variability may be related to pain
medication or infant sleep cycle and
should be monitored if persistent.
º Notify the RN or PCP of these changes.
º Turn the patient to change head
compression.
º Late decelerations are the result of
uteroplacental insufficiency. The pattern
occurs with start of a contraction. The
baseline drops several beats and does
not return to baseline until AFTER the
contraction has ended. This means the
fetus does NOT have the reserve of oxygen
it needs to cope with labor. The fetus is not
getting the oxygen it needs to take care of
the CNS. THIS MUST BE REPORTED
TO THE PCP IMMEDIATELY.
º Turn the patient to the side to improve
maternal and fetal circulation.
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º Moderate — Fetal heart tracing appears
to fluctuate 6-25 BPM. This is considered
normal and desirable. The CNS of the
baby is well oxygenated and fetal reserve is
appropriate.
ADDITIONAL
CRITICAL THINKING
QUESTIONS
14
Answer: Internal
monitoring
of the FHR is
more accurate
than external
monitoring.
External
monitoring can be
used throughout
the birth process.
The membrane
must have
ruptured and the
cervix dilated to
at least 2 to 3 cm
before an internal
º Stop oxytocin drip and notify the RN and
PCP.
º Monitor hydration status and if maternal
hypotension is noted, check standing
orders.
º Marked — Fetal heart tracing appears
to fluctuate greater than 25 BPM. This
may occur with rapid descent of the fetus
and should not occur for greater than ten
minutes without reporting to the RN or
PCP.
• Compare internal to
external fetal heart
monitoring.
º Apply oxygen per face mask at 8-10 liters.
14
C I M C • M AT E R N A L N E W B O R N N U R S I N G
monitor can be placed. Internal monitoring, not external monitoring,
increases fetal and maternal risk for infection.
• A
nurse places an external fetal monitor on a patient who is in labor. Which of the
following instructions is most appropriate for the nurse to give to the patient?
Answer: It is optimal for the patient to lie on her side to increase
uteroplacental perfusion and fetal oxygenation. Supine positioning is
contraindicated to avoid vena cava syndrome. The patient should be
encouraged to reposition herself frequently to promote fetal oxygenation and
assist in the progress of labor. Ultrasound transducer and toco transducer will
need to be readjusted by the nurse with patient repositioning to maintain a
good signal on the monitor.
C I M C • M AT E R N A L N E W B O R N N U R S I N G
•
Variable Decelerations — Variable
decelerations are the result of cord
compression and may occur with or without a
contraction. They drop sharply below baseline
and return just as quickly. They appear as a
V or W within the baseline. Nursing
interventions include:
º Change maternal position to see if cord
compression improves.
º Conduct vaginal exam to check for
prolapsed cord.
presentation part and require practice to become
competent with the skill. This skill is often done
by the RN and may not be the responsibility of
the LPN. When the fetus enters the pelvis, the
preferable entry is with the head.
learning
w
ww
links
Vertex presentation means that the presenting part
is the head. The head can enter in various directions.
Face-up is called occipital posterior and face down
is called occipital anterior. The preferable direction
that presents the least complicated vaginal birth is
occipital anterior. There are other types of vertex
deliveries, such as face or brow, but will not be
discussed in detail.
Fundus Examination –
Video
http://www.medicalvideos.
us/play.php?vid=364
The following presenting parts often require a
cesarean section for the safety of the fetus:
•
Breech means the presenting part is the
buttocks.
•
Nursing 411 – Leopold’s
Maneuver video
Footling breech means the feet or foot is the
presenting part.
•
A transverse lie is when the fetus is laying
sideways and does not engage into the pelvis.
http://nursing411.
org/Videos/Leopolds_
Maneuvers/Leopolds_
Maneuvers.html
Potential Complications
Most deliveries are vaginal and require no special
interventions for delivery. When problems arise
the nurse must act quickly and be prepared for any
emergency. Most labor and delivery units require
registered nurses for staffing. However, as a LPN
you will need to know what is normal and what
complications can occur.
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The nurse is also responsible for assessing fetal
position and presentation. These may be done
by Leopold’s maneuvers, vaginal exam and/or
ultrasound (US). Some facilities train the nurse to
perform a limited US for presentation of the fetus
before the patient can be induced. The Leopold’s
maneuvers require palpation of the abdomen to
determine fetal position, number of fetus, and
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Complications During Labor
Complications
Signs and Symptoms
Needed Action
Post-Term
Placenta reaches 40 weeks and
begins to slowly calcify and does
not work as efficiently
Non-stress tests to assess fetal
wellness
Ultrasound
The amniotic fluid will decrease
and fetus is less protected
Induction of labor is advised
before 42 weeks
Fetal reserve is diminished and
the fetus does not cope well
with labor
Macrosomia, large fetus
Places the patient at a greater
risk of birthing complications
Cesarean section
Fetal risk for hypoglycemic
reactions
Multiple gestation
Prepare for complications and
fatigue of the mother
FHT’s must be monitored
carefully
Uterus is distended and may
have difficulty contracting
Present differently, one vertex
and the next breech
One may be delivered vaginally
and the next by emergency CS
Hypertonic contractions
Too often or do not relax,
resulting in fetal distress
Discontinue oxytocin
Inhalation of amyl nitrate
to relax the uterus or SQ
terbutaline (usually done by
an RN)
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Hypotonic contraction
Do not promote cervical dilation
Delayed delivery with the
possible complication of
infection or fetal distress
Possible interventions include:
Artificial rupture of membranes
(AROM), augmentation with
oxytocin
Increased risk that after delivery
the uterus becomes boggy and
places the patient at risk for post
partum hemorrhage
16
16
C I M C • M AT E R N A L N E W B O R N N U R S I N G
C I M C • M AT E R N A L N E W B O R N N U R S I N G
Complications During Labor
Complications
Signs and Symptoms
Needed Action
Uterine rupture
Occur with a prolonged,
obstructed labor
Assess patients in labor for
sharp abdominal pain during
contractions, abdominal
tenderness, signs of shock, loss
of FHR, and vaginal bleeding
Ruptures while the fetus is still
inside, resulting in hemorrhage
of patient and fetus
VERY SERIOUS EMERGENCY
THAT REQUIRES QUICK
RECOGNITION AND TREATMENT
Immediate surgery will be
required to deliver the infant
and repair the uterus, if possible
A hysterectomy may be
necessary
Abruptio placenta
Placenta detaches too early
from the uterine wall, before
or during labor, and blood and
oxygen are cut off to the fetus
Visible bleeding can occur if the
detachment is low
Monitor FHT’s and UC’s. Very
serious emergency that requires
quick recognition and treatment
Prepare for emergency CS if
abruption is large and FHT’s are
non-reassuring
Great deal of pain
Bleeding can be hidden by the
pressure of the fetal head
Placenta previa – complete or
partial
Complete placenta previa occurs
when the placenta implants
over the cervical inner os
Monitor FHT’s and contractions
Prepare for emergency CS for
hemorrhage, abruption, or
abnormal FHTs
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Complication because, as the
pregnancy advances, the cervix
thins and opens
Separation of the placenta at
the cervix and painless vaginal
bleeding
Placental abruption
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Hypertension in pregnancy
The mother and fetus are negatively affected when
the patient has high blood pressure. If hypertension
occurs with pregnancy and disappears with
delivery, the diagnosis is usually pregnancy induced
hypertension (PIH). Hypertension can result in a
smaller fetus and placenta, with an increased risk
for other complications such as abruption and
preterm delivery. Blood pressure problems can exist
before pregnancy and are referred to as chronic
hypertension.
Pre-eclampsia — is hypertension with the addition of protein in the urine called proteinuria.
Pre-eclampsia is a complication that can lead to
maternal seizures and becomes eclampsia. During
the seizure the infant is exposed to danger due to the
lack of oxygen. Persons with severe pre-eclampsia
may develop HELLP syndrome:
ADDITIONAL
CRITICAL THINKING
QUESTIONS
• Compare the use
of the following
medication: calcium
gluconate, oxytocin,
magnesium sulfate and
prostaglandin.
Answer:
Magnesium
sulfate is an
anticonvulsant
that would be
prescribed for a
patient exhibiting
signs and
symptoms of sever
preeclampsia with
the symptoms of
elevated blood
pressure and
3+ proteinuria.
Oxytocin is
used to augment
labor. Calcium
gluconate is
the antidote
for magnesium
sulfate and used
in the event
of magnesium
sulfate toxicity.
Prostaglandin is
administered into
the amniotic sac
or by a vaginal
suppository
to augment or
induce labor.
this complication may not be identified for certain
until labor has begun but does not progress. A
cesarean delivery will be done if the fetal head cannot
pass through the mother’s pelvis.
Occiput posterior presentation
When the baby’s head is positioned so that the
face will be up at delivery, it is said to be occiput
posterior (OP). Because of this position, the labor
may not progress well. The mother experiences
increased pain, especially back pain. The nurse can
help relieve some of the discomfort by assisting the
patient with pelvic rocking and by applying counter
pressure to the patient’s lower back. This helps lift
the infant’s head off of the mother’s spinal cord.
The nurse also needs to give the patient emotional
support. A cesarean delivery may be required.
•
H = Hemolysis
Precipitous delivery
•
EL = Elevated liver enzymes
•
LP = Low platelet count.
Sometimes a birth occurs so quickly that the usual
preparations cannot be made. The PCP may not
even be present. This is more likely to occur in a
multipara than a primipara. The nurse may be
the only person available to assist in a precipitous
delivery. If this occurs, the nurse should:
Laboratory tests are performed to diagnose severe
pre-eclampsia.
Intrauterine fetal death (IUFD)
This can occur anytime after 20 weeks gestation. If
it occurs before 20 weeks gestation, then it is called
a miscarriage. There are many reasons that an IUFD
can occur, such as a cord accident or a placental
abruption. Many times a reason is not found.
•
•
•
Never leave the patient alone.
Call for help using the call light or intercom.
If at all possible, wash, put on gloves, and
place a sterile drape under the patient.
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The psychological support of the patient is important.
Reassure the family that you are there for them and
will answer any questions. Many hospitals have
programs to help families deal with an IUFD.
Cephalopelvic disproportion
Cephalopelvic disproportion occurs when the
fetus’s head is too large to pass through the mother’s
pelvic inlet and outlet. Pelvic measurements
help the physician determine the likelihood that
cephalopelvic disproportion may occur. However,
18
Remain calm and reassuring to the mother.
Never forcibly hold the infant’s head back to
delay the birth — it can cause fetal distress.
Prolapsed cord
The umbilical cord can prolapse (protrude into the
vagina) before or beside the presenting part of the
fetus. This can be caused if the membranes rupture
before the presenting part is engaged in the pelvis
or if the presenting part is a shoulder or foot. A
premature birth, because the fetus is small, allows
more room for the cord to prolapse. A prolapsed
cord may also be seen with placenta previa.
C I M C • M AT E R N A L N E W B O R N N U R S I N G
ontrast missed abortion, ectopic pregnancy, severe preeclampsia and hydatidiform
• C
mole.
Answer: Signs and symptoms of an ectopic pregnancy include unilateral
lower quadrant abdominal pain with or without bleeding. A missed abortion
occurs when products of conception are retained and there is a brownish
discharge. Severe preeclampsia does not have vaginal bleeding unless initiated
by worsening complications and presents with an epigastric, right upper
quadrant pain. Hydatidiform mole causes dark brown bleeding in the second
trimester and is not generally accompanied by abdominal pain.
C I M C • M AT E R N A L N E W B O R N N U R S I N G
If the nurse can see the cord or palpate it in the
vagina or cervix, a prolapsed cord is occurring. If the
cord is compressed against the mother’s pelvis and
the fetus, oxygenation to the fetus will be decreased
or obstructed. The FHR may be irregular with
periodic bradycardia.
The nurse should place the mother in Trendelenburg
position and administer oxygen by mask. The PCP
should be notified immediately.
Uterine dystocia
Problems with the uterus that can contribute to a
difficult labor include abnormally-shaped uterus,
scar tissue in the uterus, fibroid tumors of the uterus,
and over-distention of the uterus due to multiple
pregnancy.
Contractions of the uterus can either be hypertonic
or hypotonic, causing uterine dystocia. Hypertonic
contractions occur when the contractions are
uncoordinated and involve only portions of the
uterus. They are very strong contractions but
ineffective for causing effacement and dilation of
the cervix.
D E L I v E ry C O M p L I C at I O n s
Sometimes an infant cannot be delivered without
assistance or cannot be delivered vaginally. Forceps
are spoon-shaped tong-like instruments used to help
deliver the fetal head. Several different types exist.
They are often used to deliver the aftercoming head
in a breech presentation.
Cesarean delivery is done by making an abdominal
incision and an incision through the uterine wall
through which the infant is born. It is performed in
approximately 20 percent of deliveries. Reasons for
cesarean deliveries include:
•
•
•
•
•
•
Cephalopelvic disproportion
Breech presentation
Fetal distress
Placenta previa
Abruption
Vaginal infections such as herpes genitalis
Hypotonic contractions are not as intense as needed
to bring about effacement and dilation. This may be
because the fetal head cannot fit through the pelvis
or because the uterine tone is flaccid. Oxytocin
may be ordered to increase the intensity of the
contractions.
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L E a r n I n g
ADDITIONAL
CRITICAL THINKING
QUESTIONS
• A patient is sleeping well
and wakes up two hours
later. Her contractions are
every three to five min.
and stronger. Her cervix
is 3cm dilated, 80%
effaced, and -1 station.
The patient states that she
wants pain medication at
this time.
O bje c ti v e
Identify types of pain management
used during labor.
O bje c ti v e
Describe the physiological and
psychological care for a patient
during labor and delivery.
physIOLOgICaL anD
psyChOLOgICaL nUrsIng
CarE
Pain Management
The nurse supports the patient throughout the labor
process. Very few births occur without pain. Pain
management interventions may include relaxation
exercises, massage, a warm shower, walking, and/or
sitting on a labor ball. These work well for some, but
not for all. Encouragement and letting the patient
know they are not alone and that “she can do this”
is one of the most important interventions for a
delivery without medications.
A. What are some
interventions the nurse
can suggest at this
time?
O b j E C t I v E s
Answer: Patterned
breathing techniques; frequent
emptying of the
bladder; Stadol 2
mg IV prescribed;
application of heat
or cold; distraction
or a focal point.
Nonpharmacologic
comfort measures
can be safely used
at this time while
the patient is in
the latent phase of
labor. The patient
may have the
opioid analgesic.
Many times patients will arrive with a birth plan
that states she does not wish to use medications.
Occasionally the patient will change her mind during
labor and ask for the pain relief medications. It is
important to remain supportive and nonjudgmental.
Every patient experiences pain differently and must
not feel that they have failed because they used
pain medications. Encourage and explain that it is
not a weakness and is okay to use medications if
she needs them. It is important to remember that
when a patient has a birthing plan that requests no
medications, the patient should be the person who
brings up pain medications. Often the patient will
ask you what you think. It is important to explain
the use of medications in a non-partial manner and
tell the patient it is up to her. Remaining neutral
helps the patient feel in control and supported.
and depress the respirations of the infant at birth.
Patient teaching regarding the complications of these
medications may be needed. It’s important for the
healthcare team to use caution in the administration
and timing of medications in relationship to the
events of labor.
Narcotic analgesics, such as meperidine (Demerol)
and butorphanol tartrate (Stadol), are ordered IM
or IV. Antianxiety agents, such as hydroxyzine
HCL (Vistaril) or diazepam (Valium), may be
ordered to reduce anxiety and as an adjunct to the
narcotic medications. Regional anesthetics include
paracervical, epidural, spinal, and pudendal blocks.
A paracervical block is an anesthetic administered on
either side of the cervix as it dilates, causing lack of
feeling in the cervix and uterus. It can slow labor.
An epidural block is an anesthetic administered into
the epidural space at the end of the spinal canal. A
catheter may be inserted and left in place during
labor, so that the anesthesia can be administered
periodically. An epidural block causes anesthesia of
the pelvic region. It can cause maternal hypotension
and may slow labor if started too early. It will also
prevent the mother from being able to push in the
second stage of labor if it is still present, and may
cause fetal heart decelerations.
Nursing Interventions
Confirm there is a consent signed, assist the PCP in
preparing the patient for an epidural, administer an
IV fluid bolus, and monitor the mother and fetus
before and after the epidural. Epidural checks are
required every 30 minutes after insertion. The level
of the epidural is tested by the nurse to insure the
level does not go too high and does not decrease or
stop respirations.
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B.The patient is
5cm dilated and
displays restlessness, moaning, and
is beginning to
hyperventilate.
She says the
breathing and
other techniques
aren’t working, and
asks the nurse to
give her something
for pain. The nurse
obtains a prescrip
tion for Stadol
2mg IV. What are
the nursing
implications for
this medication?
20
Because labor can be long and intense, many
women need analgesia and/or anesthetic during this
time. The physician must determine what type of
medications should be given and when, in order
to prevent the fetus from being adversely affected.
These medications can cross the placental barrier
20
A spinal block is given into the epidural space
around the spinal cord. It causes anesthesia from the
point it is administered downward. It may be given
to anesthetize from the waist down for a cesarean
section. It can cause hypotension and post-spinal
headache.
C I M C • M AT E R N A L N E W B O R N N U R S I N G
Answer: The nurse monitors the patient for signs of allergic or adverse reactions; the nurse has naloxone available to administer for respiratory depression of the neonate; the nurse has an emesis basin available in the event of
nausea and vomiting.
C.The patient is 8cm dilated, 100% effaced, the fetus is at -1 station, and the
membranes have ruptured. She states the pain is worse than ever and wants
more of the IV pain medication, Stadol, which she received 3 hours earlier.
What is the best nursing action?
Answer: Notify the primary care provider and obtain a prescription for epidural anesthesia if the patient is requesting pharmacologic pain relief. It is too
close to delivery for IV opioid administration. It is possible that the patient
might deliver while the opioid is at its peak level causing respiratory depression in the neonate. It does not make a difference how frequently the Stadol
is prescribed to be given if it is too near delivery time to administer an opioid.
C I M C • M AT E R N A L N E W B O R N N U R S I N G
A pudendal block is injected into the pudendal
nerves and causes anesthesia of the perineum. It has
no side effects unless there is an allergic reaction to
the anesthesia used.
Different people and different cultures react
differently to pain, and the pain of labor and delivery
is no exception. Laboring mothers or their partners
may feel that the women are not receiving enough
medication to manage their pain. It is important to
reassure the patient and her partner and to explain
that possible effects on the baby influence the
physician’s decisions about the type, amount, and
timing of analgesia/anesthesia administration.
Physiological and Psychological Care
for a Patient
Patients may be fearful of the pain and process
of labor, and are often fearful about the health
and well-being of their baby. It is very important
for the nursing staff to be reassuring and calming
during all the stages of labor. Some cultures value
the characteristic of stoicism during labor. Other
cultures expect the mother to be very vocal during
labor. Many cultures do not believe that the father
should be with the woman during labor and delivery.
Older women assume that role. It is very important
for nurses to support the patient and her partner in
taking roles that are comfortable for them. It is not
up to the nursing staff to insist that the father or
partner be present during the first and second stages
of labor.
L E a r n I n g
Objecti v e
O b j E C t I v E
learning
w
ww
links
Discuss responsibility of the LPN/
LVN while caring for the mother
and newborn during labor and
delivery.
MOthEr anD nEwbOrn CarE
During a vaginal delivery, immediately after the
infant is delivered, the nose and mouth are suctioned
with a bulb syringe to clear the airway. The infant
usually begins breathing and crying once delivery is
complete. If stimulation is needed, the physician rubs
the soles of the infant’s feet. The umbilical cord is
clamped with a special clamp about two inches from
the infant’s abdomen and again several inches above.
The cord is cut between the two clamps. The cord is
inspected for the presence of two veins and an artery.
Any abnormalities are noted and documented. Apgar
scores are determined. The Apgar is an assessment
of the infant’s heart rate, respirations, muscle tone,
color, and response to stimulation. The assessment is
done one minute after birth and again five minutes
after birth. A score of 8 to 10 is desirable, with 10
being the highest possible score. Generally the Apgar
score increases by approximately 1 to 2 points at the
five-minute assessment.
Newborn Delivery
– Medication and
Treatment
http://emedicine.medscape.
com/article/83021treatment
Childbirth Video Gallery
http://www.
givingbirthnaturally.com/
childbirth-video.html
Childbirth Video Clips
http://childbirthvideo.biz/
The infant is shown to the parents, unless an
emergency situation requires intervention. The
mother may hold the infant, or it may be placed
in a warmer. It is important to keep the baby warm
and dry to prevent heat loss. The infant is assessed
frequently and, if any problems occur, the parents
should be reassured and supported. Matching
identification bracelets are placed on the mother
and the baby.
Medical Videos – Full
Obstetric Examination &
Normal Delivery
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Obstetric-Examination
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The third stage of labor is the delivery of the
placenta. It lasts from 5 to 20 minutes. The placenta
naturally detaches from the uterine wall as the uterus
shortens. A sudden gush of blood from the vagina
indicates that the placenta is about to be delivered.
The patient feels a few contractions and pushes one
or two times to deliver the placenta. The appearance
of the placenta is noted and documented.
M O D U L E 2 • I N T R A pA RT U M C A R E • s t U D E n t E D I t I O n
CLASSROOM
ACTIVITY
21
ADDITIONAL CRITICAL THINKING QUESTION
• A patient is in the fourth stage of labor, has just delivered a newborn, and is stable.
The nurse knows that during the maternal recovery period vital signs should be
assessed at regular intervals. What are the appropriate vital sign intervals?
• Make an appointment to
have the students rotate
through a simulation
lab for OB simulation
scenarios to focus on
the simulation of fourth
stage of labor for the
mother and neonate
recovery scenarios.
Answer: The fourth stage of labor is referred to as the maternal recovery
period which lasts from one to four hours. If all factors are stable, postpartum
assessments of vital signs as well as uterine firmness, location, and position
should be done every 15 minutes for the first hour, every 30 minutes for the
second hour, hourly for at least two hours, and then every four to eight hours
for the remainder of the patient’s hospitalization.
M O D U L E 2 • I ntra p artum C are • T E A C H E R E D I T I O N
21
The fourth stage of labor is stabilization of the
mother. After delivery of the infant and placenta,
the uterus contracts to smaller and smaller size.
As it contracts, the muscle fiber network causes
compression on the blood vessels that were attached
to the placenta, controlling bleeding. The nurse
assesses the mother’s vital signs, the size and location
of the uterus, firmness of the uterus, the amount
and type of vaginal drainage, and the appearance
of the episiotomy and other tissues. If the uterus is
soft, the nurse will massage the fundus to control
bleeding. The nurse also assesses the amount of
vaginal bleeding by counting the number of pads
saturated per hour.
learning
w
ww
links
Medical Videos – Videos
of different types of births
http://www.medicalvideos.
us/videos-1294-NaturalVaginal-Child-BirthDelivery-Video
Nursing Interventions
For the first hour after delivery, the nurse monitors
the following every 15 minutes:
http://www.medicalvideos.
us/videos-2459-VaginalChildBirth-after-CesareanSection-C-Section
http://www.medicalvideos.
us/videos-2289-Caesareansection-for-a-breech
•
•
Newborn — color and respiratory effort.
•
Uterine position — expected to be midline
and at the umbilicus.
Maternal vital signs — monitor for
unexpected values.
•
•
Uterine tone — expected to be firm and is
massaged to promote firm tone.
Lochia flow — expected to be small to scant.
º Massage first and if bleeding continues,
notify the RN and/or PCP.
º Monitor for clots or heavy flow.
Note: Heavy flow and clots can mean
retained placenta and can lead to dilation
and curettage (D&C). In extreme
hemorrhages the patient is at risk for a
hysterectomy (removal of the uterus).
•
Episiotomy — if present, edges are
approximated.
•
Bladder — empty or distended. Remember
that there is a lot going on hemodynamically
during this time and fluid shifts cause
diuresis. If the bladder becomes over
distended, the uterus can become boggy and
increase lochia flow.
If all of the above are within normal limits, after
one hour the assessment occurs every 30 minutes
for an hour.
IMPORTANT FACT:
After delivery, breast feeding patients
are encouraged to breast feed as soon
as possible to help the infant to latch on.
Latch on is when the infant has the nipple
and areola properly positioned in the
mouth. When the infant is properly latched
on, the mother’s breasts are less sore.
http://www.medicalvideos.
us/videos-2433-VacuumExtraction
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http://www.medicalvideos.
800-654-4502
us/videos-2172-MidlineEpisiotomy
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http://www.medicalvideos.
us/videos-237-EpisiotomyRepair
http://www.medicalvideos.
us/videos-2499-Amniotomy
http://www.medicalvideos.
us/videos-328-Forceps-inChildbirth
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C I M C • M AT E R N A L N E W B O R N N U R S I N G
C I M C • M AT E R N A L N E W B O R N N U R S I N G
LEarnIng aCtIvIty
2
naME
Introduction
Providing psychological support is important during labor and delivery.
activity
Consider each of the following situations. Decide how the nursing staff can best provide
emotional support to each of these women.
s i t u at i o n a
Mary Mandelay is a 22-year-old primipara. She seems very frightened when the nurses come into
the room. Her partner, Juan, a 23-year-old male, seems very uncomfortable. He paces the room
and changes the television stations constantly. Mary is very quiet initially but, as labor progresses,
she begins to cry and scream with each contraction, while still in the early phase of the first stage
of labor. Her partner often walks out into the hall and asks the nurses to give her something to
calm her down. No other family members are present.
LEARNING
ACTIVITY ANSWERS
Situation A
The nursing staff can
provide emotional support
to Mary by telling her
what to expect as labor
progresses. Nursing staff can
also help coach her through
breathing techniques and
use distraction during
the early stages of labor.
Nursing staff can ask if
Mary wants any other
support people to be called
to be with her during labor.
Praise her for all that she
accomplishes.
What can the nursing staff do to provide emotional support to Mary?
What can the nursing staff do to provide emotional support to Juan?
s i t u at i o n b
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Tamara Henderson is a 34-year-old multipara. She is a gravid 3/para 2. She states that she is
worried about whether the baby will be all right. She had taken some prescription medications
early in her pregnancy before she was aware that she was pregnant, and she is concerned that the
baby will have some kind of defect. She has had an amniocentesis and other tests that did not
indicate any problems. Her husband is with her. He tells her, “Now, Tamara, everything is going
to be fine. Quit worrying so much.” She does not seem reassured by his words. As the labor
progresses, she begins to cry. She tells the nurse she does not need further pain medicine, but that
she is afraid of what the baby will be like.
What can the nursing staff do to provide emotional support to Tamara?
Does her husband need emotional support at this time? If so, what should the nursing staff do?
M O D U L E 2 • I N T R A pA RT U M C A R E • s t U D E n t E D I t I O n
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Situation B
The nursing staff can provide emotional support to Tamara by allowing her to discuss her
fears and reassuring her that no problems were detected in the tests. They should do this
without belittling Tamara’s feelings and fears. The nursing staff can also encourage her to
focus on the healthy delivery of her baby.
Tamara’s husband may need emotional support as well. He may not realize that he is not
reassuring her with what he says. The nursing staff can help involve him in the labor as
coach and supporter, helping both of them focus on the healthy delivery of the baby.
M O D U L E 2 • I ntra p artum C are • T E A C H E R E D I T I O N
The nursing staff can
provide emotional support
to Juan by explaining what
he can do to help Mary.
They can teach him how to
coach Mary with breathing
techniques and how to help
distract her during early
labor. They can also ask if
he wants any other support
people to be nearby during
labor. They can kindly
explain when and why
medication can and cannot
be given during labor.
23
situation C
Situation C
Cynthia Salenski is a 30-year-old primipara. She has been in labor for six hours and has entered the
mid or active phase of labor. Her husband and her mother are at her bedside. She and her husband
took Lamaze classes and he is her coach. As she progresses in the active phase of labor, she becomes
increasingly irritable. She yells at her husband as he tries to coach her through the contractions using
breathing techniques. He leaves the room in frustration. Her mother attempts to soothe her, but
Cynthia tells her mother to get out and leave her alone. Her husband tells the nurse that Cynthia is
usually in control, always cool and calm. As he says this, the nurse and he can hear Cynthia cursing
him during a contraction.
The nurse can offer
emotional support to
Cynthia by helping manage
her pain and by helping
her understand what is
happening as her labor
intensifies. The nurse can
gently soothe and coach
Cynthia into using the
breathing techniques she
has learned. The nurse
can allow Cynthia to
verbalize her distress and
understand that the labor is
more intense than she had
anticipated.
How can the nurse offer emotional support to Cynthia?
How can the nurse offer emotional support to her husband and her mother?
a pplic ation
Use these scenarios and responses to compare with other situations that you have heard regarding
the birthing experience. Be prepared to handle similar situations in the clinical environment.
The nurse can give
emotional support to
Cynthia’s mother and
husband by explaining that
the labor has intensified
beyond what Cynthia was
prepared to endure. The
nurse can explain what is
being done to help relieve
some of Cynthia’s pain.
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The nurse can suggest ways
for the husband and mother
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to be helpful without
necessarily talking to her
during contractions. They
can rub her back, keep a
cool cloth on her forehead,
and just quietly be with her.
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C I M C • M AT E R N A L N E W B O R N N U R S I N G
C I M C • M AT E R N A L N E W B O R N N U R S I N G
KEy sUMMary
ɶ The birth process requires careful monitoring of the patient and fetus.
ɶ Physiological and psychological care is balanced between safety and the patient’s
expectations.
ɶ True labor requires cervical change.
ɶ Braxton-Hicks contractions occur with false labor.
ɶ Induction of labor is ordered when the fetus is better off outside the womb due to factors
such as fetal size and expected delivery date.
ɶ Augmentation is increasing uterine contraction intensity and frequency to cause cervical
change.
ɶ Induction and augmentation can be achieved through artifical rupture of membrane and/or
oxytocin drip.
ɶ The first stage of labor begins with mild contractions and is divided into three phases: latent,
active and transition. This stage begins with the onset of cervix dilation 0-2 cm and ends
when the cervix is completely dilated.
ɶ The second stage of labor starts with complete dilation of the cervix, 10 cm, and ends with
the delivery of the baby.
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ɶ The third stage of labor begins with the delivery of the baby and ends with the delivery of
the placenta.
ɶ The fourth stage begins after the delivery of the placenta and ends after four hours.
ɶ Evaluation of fetal oxygenation is assessed through accurate assessment of FHT’s.
ɶ Patients have the right to choose the pain management right for them and to change their
mind if needed.
ɶ Pain can be managed with breathing and relaxation techniques and/or various analgesics
and analgesia.
M O D U L E 2 • I N T R A pA RT U M C A R E • s t U D E n t E D I t I O n
M O D U L E 2 • I ntra p artum C are • T E A C H E R E D I T I O N
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ɶ The RN can do vaginal exams to check cervical dilation and station of the fetus. However, this
exam is not within the scope of practice for the LPN.
ɶ Contractions start out mild and progress to moderate then strong in intensity. Uterine
contractions are measured by duration, frequency and intensity. Duration is how long
a contraction lasts. Effective contractions are from 50-90 seconds and a rest period, or
relaxation, of 1-3 minutes is required to supply oxygenated blood to the fetus.
ɶ The frequency of contractions is measured from the beginning of one contraction to the
beginning of the next contraction.
ɶ Even with the best planning, emergencies and complications can occur in L&D and the nurse
must be prepared.
ɶ Post-delivery assessments must be completed every 15 minutes for the first hour.
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C I M C • M AT E R N A L N E W B O R N N U R S I N G
C I M C • M AT E R N A L N E W B O R N N U R S I N G
gLOssary
Amniotomy: Artificial rupture of membranes used to induce or augment labor.
Augmentation: Done when the uterine contractions have decreased and/or labor has
stalled or not progressed. Medications such as oxytocin or an amniotomy may be used to
augment labor.
Braxton-Hicks contractions: Often called false labor and are usually mild and mistaken
for true labor.
Caput: The head of an organ.
Dilation: The opening of the cervix for birth. Measured in centimeters.
Effacement: The thinning of the cervix. Measured in percentages.
Episiotomy: Surgical cutting of the perineum to enlarge the vaginal opening.
False labor: Contractions that are usually irregular and do not cause dilation of the
cervix.
Fundus: The top of the uterus that is measured, palpated and massaged during
pregnancy.
GTPAL: Gravida (G) = total number of pregnancies, Term (T) = number of pregnancies
carried to 37 weeks, Preterm (P) = number of pregnancies delivered before 37 weeks,
Abortions (A) = number of elective or spontaneous abortions, Living (L) = number of living
children at this time.
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Hyperstimulation: The uterus is having contractions that are too often or do not rest
and will cause fetal distress.
Intrapartum: The phase of pregnancy when delivery takes place.
Lochia: The bloody postpartum vaginal discharge.
Macrosomia: The fetus is estimated large, about 9 pounds.
Meconium: First stool of the newborn. Meconium stained fluid is stool passed in utero
and may cause complications if thick and inhaled at birth by the newborn.
Mucous plug: A thick yellowish piece of mucous that is located in the cervical os and
prevents the ascent of bacteria into the uterus.
M O D U L E 2 • I N T R A pA RT U M C A R E • s t U D E n t E D I t I O n
M O D U L E 2 • I ntra p artum C are • T E A C H E R E D I T I O N
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Multipara: More than one birth and not the first birth.
Gynecoid pelvis: Most common shape of pelvis and ideal for vaginal birth.
Pre-eclampsia: A disease of pregnancy with symptoms of hypertension, proteinuria,
edema, hyperreflexia and visual disturbances.
Primipara: The first birth.
Spontaneous rupture of membranes (SROM): Spontaneous rupture of the amniotic
membrane, often referred to as “water breaking.”
True labor: Uterine contractions that start out mild and irregular, then increase in
intensity, regularity, duration and frequency, resulting in dilation of the cervix.
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C I M C • M AT E R N A L N E W B O R N N U R S I N G
C I M C • M AT E R N A L N E W B O R N N U R S I N G
rEsOUrCE bIbLIOgraphy
Christiansen, B. L. & Kockrow, E. O. (2006) Foundations & Adult Health Nursing. St.Louis, MO:
Mosby.
Leifer, G. (2007). Introduction to Maternity & Pediatric Nursing. St.Louis, MO: Mosby.
Leifer, G. (2006). Maternity Nursing, An Introductory Text. St. Louis, MO: Mosby.
London, M.L. Ladewig, P.W. Ball, J. W. and Bindler, R.C. (2007) Maternal & Child Nursing.
New Jersey: Prentice Hall.
Nursing Focus: Labor and Delivery Focus. Stillwater, OK: Oklahoma Department of Career and
Technology Education, Curriculum and Instructional Materials Center, 2001.
Nursing Focus: Postpartum Focus. Stillwater, OK: Oklahoma Department of Career and Technology
Education, Curriculum and Instructional Materials Center, 2001.
Nursing Focus: Infant Focus. Stillwater, OK: Oklahoma Department of Career and Technology
Education, Curriculum and Instructional Materials Center, 2001.
Ramont, R. P. & Niedringhaus, D.M. (2008) Fundamental Nursing Care. 2nd Ed. New Jersey:
Prentice Hall.
Timby, B.K. (2009) Fundamental Nursing Skills and Concepts. 9th Ed. Wolters Kluwer/Lippincott
Williams &Wilkins.
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M O D U L E 2 • I ntra p artum C are • T E A C H E R E D I T I O N
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nOtEs
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C I M C • M AT E R N A L N E W B O R N N U R S I N G
C I M C • M AT E R N A L N E W B O R N N U R S I N G
A D D I T I O N A L L ea r n i ng A ct i v i ty
N ame
I nt r oduc tio n
This activity allows you to familiarize yourself with medications commonly used in L&D.
A ct i v it y
Look up the following medications in a drug book. What are the nursing implications related to
L&D for administering the med?
•• Butorphanol tartrate - (Stadol)
•• Nalbuphine hydrochloride - (Nubain)
•• Meperidine - (Demerol)
•• Morphine
•• Oxytocin
•• Terbutaline
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List what each medication is used
for and when it is contraindicated to use the medication.
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A pplicatio n
M O D U L E 2 • I ntra p artum C are • T E A C H E R E D I T I O N
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A D D I T I O N A L L ea r n i ng A ct i v i ty A ns w e r s
N ame
Drug
Indications
Contraindications
Butorphanol
tartrate (Stadol)
Narcotic used for pain relief in the early
stages of labor
Can cause respiratory depression in the
infant
Can be given IV or nasal spray
Nalbuphine
hydrochloride
(Nubain)
Opiate agonist-antagonist comparable to
morphine
Meperidine
(Demerol)
Alters how pain is recognized, starts
working in less than five minutes and can
be administered into muscle, vein or by
PCA pump
Oxytocin
Can cause central nervous system
depression in infant and mother
Advantages are it begins working within
5 minutes and has minimal nausea and
fetal effects
If given within 2 to 4 hours before
delivery
Can cause breathing difficulties for infant
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Do not use if patient:
Natural hormone that causes uterus
to contract for induction of labor,
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• Had prior delivery by C-section
strengthening labor contractions and
controlling bleeding after childbirth
• Is not in controlled clinical setting
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where uterine contractions can be
monitored
• Is having premature labor
• Has placenta previa or breech birth
Terbutaline
Derived from the hormone epinephrine
and used to treat preterm labor
Reduces the number and length of
contractions
32
Women with heart disease,
hyperthyroidism, and poorly controlled
diabetes should not take terbutaline
C I M C • M AT E R N A L N E W B O R N N U R S I N G