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Chapter 6
Nursing Care of Mother and
Infant During Labor and Birth
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Settings for Childbirth (p. 116)
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Hospitals
 Advantages – access to
emergency care, physician
relationship
 Disadvantages – high cost
Freestanding birth centers
 Advantages – lower cost
 Disadvantages – delay in
emergency care
Home
 Advantages - control
 Disadvantages – extended
delay to emergency care
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Components of the Birth
Process (p. 116, 119-126)
The Four “Ps”
 Powers - mother pushing, uterine
contractions
 Passage – mother’s bony pelvis and soft
tissues
 Passenger – fetus, placenta, amniotic
membrane and amniotic fluid
 Psyche – the entire emotional, mental state of
the mother
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Factors that Influence the Progress
of Labor (p. 116, 119-126)
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Preparation – attending prenatal classes
Position – fetal presenting part within the
mother’s pelvis
Professional – nurses, coaches
Place –setting of labor and delivery
Procedures – internal exams
People – supportive family members
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Uterine Contractions (pp. 119-120)
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Effect of contractions on the cervix
 Efface - thin
 Dilate - open
Phase of contractions
 Increment – increasing strength
 Peak – greatest strength
 Decrement – decreasing strength
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Uterine Contractions (pp. 119-120)
• Frequency – elapsed time between one contraction and
the next
• Duration - average number of seconds the contractions
last – elapsed time from beginning of a contraction to
the end of the same contraction
• Intensity – mild- fundus easily indented, moderate –
fundus can be indented, firm – fundus cannot be readily
indented with fingertips
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Safety Alert! (p. 122)
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Report to the RN any contractions that occur
more frequently than every 2 minutes, last
longer than 90 seconds, or have intervals
shorter than 60 seconds
Persistent contractions durations longer than
90 seconds may reduce fetal oxygen supply
Contractions occurring more often than every
2 minutes may reduce fetal oxygen supply
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Cervical Effacement - thinning and
Dilation - opening(p. 120)
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Contraction Cycle (p. 121) - Powers
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Nursing Tip (p. 122)
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Provide emotional
support to the laboring
woman so she is less
anxious and fearful.
Excessive anxiety or
fear can cause greater
pain, inhibit the progress
of labor, and reduce
blood flow to the
placenta and fetus.
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The Passage (p. 122)
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Bony pelvis True
 Directly involved
in childbirth
False
 Flares
 Upper portion of
pelvis

Soft tissues – cervix,
ligaments and fascia
 If previous delivery,
will yield more
readily to
contractions and
pushing efforts
 May not yield as
readily in primiparas
or older women
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Passengers – page 122
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Passengers are the fetus, the
placenta, amniotic membrane
and fluid
Fetal head – composed of
bones separated by tissue
called sutures and fontanelles
where the sutures meet
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The Passenger—Fetal
Skull (pp. 122-123) – two important fontanelles
in obstetrics – the anterior and posterior
fontanelles
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The Passengers—Fetal
Lie (pp. 122-123) – how the fetus is
oriented to the mother’s spine
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The Passengers—Presentation (pp. 123-124) –
the fetal part that enters the pelvis first
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Psyche (pp. 124-125)
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Mental state can
influence the course of
labor.
The woman’s cultural
and individual values
influence how she will
cope with childbirth.
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Classifications of Fetal Presentations and
Positions (p. 125)
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Signs of Impending
Labor (p. 126)
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Braxton Hicks contractions – irregular “false”
labor
Increased vaginal discharge
Bloody show – thick mucus with blood
Rupture of the membranes
Energy spurt
Weight loss
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Mechanisms of Labor (p. 126)
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Descent – presenting part usually the fetus head
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Station – level of presenting part to the pelvis
Engagement - when presenting part (head)
reaches “0” station
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Flexion – flex of fetus head to chest
Internal rotation – head turns swing anteriorly
External rotation – head realigns with shoulders
Expulsion – anterior shoulder, then posterior
shoulder are born – then rest of body
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Mechanisms of Labor (p. 126)
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Birth Station (pp. 126, 128)
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When to Go to the Hospital or Birth
Center (p. 128)
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Contractions – pattern of increasing
frequency – 1st child…every 5 minutes for
one hour. 2nd child…every 10 minutes for
one hour
Ruptured membranes
Bleeding other than bloody show
Decreased fetal movement
Any other concern
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Admission Data
Collection (p. 128)
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Three major assessments performed
promptly on admission
 Fetal condition – fetal heart rate
 Maternal condition – vital signs – assess
for signs of infection or hypertension
 Impending birth – sitting on one buttock,
making grunting sounds, bearing down
with contractions, stating “the baby’s
coming”, bulging of the perineum or fetal
presenting part becomes visible
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Admission Procedures (p. 130)
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Permits/consents
Laboratory tests – hematocrit and urine
Intravenous infusion – IV line started
Perineal prep - cleansing
Determining fetal position and presentationLeopold’s maneuvers helps to determine
location of the fetal back
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Comparison of False and True Labor
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False labor
 Contractions irregular
 Walking relieves contractions
 Bloody show usually not present
 No change in effacement/dilation of cervix
True labor
 Contractions gradually develop a regular pattern
 Contractions become stronger and more effective
with walking
 Discomfort in lower back/abdomen
 Bloody show often present
 Progressive effacement and dilation of cervix
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Question 1
Which is a characteristic of true labor?
1) Contractions are regular, and the intensity remains
the same.
2) Contractions are irregular, and the intensity
remains the same.
3) Contractions are regular and are intensified by
walking.
4) Contractions are regular and are not intensified by
walking.
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Nursing Care Before
Birth (p. 131)
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After admission to the labor unit, nursing care
consists of
 Monitoring the fetus – assessing fetal heart
patterns to detect fetal hypoxia. Most
hospitals use continuous EFM.
 Monitoring the laboring woman
 Helping the woman cope with labor
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Monitoring the Fetus (p. 131)
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Fetal heart rate monitor by fetoscope or
Doppler transducer
Intermittent auscultation gives the mother
greater freedom of movement
Continuous electronic fetal monitoring used
by hospitals- provides record for the chart
The baseline fetal heart rate is the average
FHR that occurs for 2 minutes during a 10minute period and averaged over 30 minutes.
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FHR Outside of Normal
Limits (p. 132)
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Any FHR outside the normal limits and any
slowing of the FHR that persists after the
contraction ends is promptly reported to the
health care provider.
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Evaluating Fetal Heart Rate Patterns
(pp. 133-136)
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Baseline FHR 110-160 BPM
Fetal bradycardia <110 BPM
Fetal tachycardia >160 BPM
Baseline variability – fluctuations showing intact
nervous system and cardiac status of fetus
Moderate variability change of 6 to 25 bpm from
baseline
Marked variability- more than 25 beats of fluctuation
over the baseline – may be cord prolapse or maternal
hypotension
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Absent variability – is less than 6 beats/min change
from baseline for a 10 minute period – caused by
uteroplacental insufficiency or maternal
hypotension, cord compression or fetal hypoxia
Have patient lie on side, increase fluids, administer
oxygen at 8 to 10L/min by mask, notify health care
provider
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Accelerations are temporary,
abrupt rate increases of at
least 15 beats/min above
baseline that last 15 seconds
but less than 2 minutes from
onset to return to baseline
This pattern suggests that
fetus is well oxygenated and
is known as a “reassuring”
pattern.
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Reassuring and Nonreassuring FHR and
Uterine Activity Patterns (p. 135)
Reassuring patterns
 Stable fetal heart rate
(FHR)
 Moderate variability
 Accelerations
 Uterine contraction
frequency greater than
every 2 minutes;
duration less than 90
seconds; relaxation
interval of at least 60
seconds
Nonreassuring patterns
 Tachycardia
 Bradycardia
 Decreased or absent
variability; little
fluctuation in rate
 Late decelerations
 Variable decelerations
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Inspection of Amniotic Fluid (p. 137)
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Color
 Normal is clear fluid, may have flecks of white
vernix
 Green-stained may indicate fetus passed
meconium (first stool but before birth)
• Can lead to fetal compromise
Odor
 Should not smell
• If it does, it may indicate infection
Amount
 Scant—trickle
 Moderate— ~500 mL
 Large— ≥ 1,000 mL
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Nitrazine paper test p 138
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Nitrazine paper into fluid from
vagina
 Blue-green – alkaline and is likely
amniotic fluid
 Yellow to yellow –green – acidic
and is most likely urine
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Monitoring the Woman (p. 137)
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Vital signs – checked every 4 hours – temp of
100.4 or higher should be reported
Contractions – monitor by EFM or palpation
Progress of labor
Intake and output
Response to labor
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Six Lamaze Institute Basic Practices for
Maternity Care (p. 140)
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Labor should begin on its own.
Woman should have freedom of movement.
Woman should have a birth support person or
doula.
No routine interventions should be performed.
Woman should be in non-supine positions.
Woman should not be separated from infant.
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Helping the Woman Cope
with Labor (p. 140)
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Labor support
Teaching
Providing encouragement
Supporting/teaching the partner
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Teach how labor pains affect the woman’s
behavior/attitude
How to adapt responses to the woman’s behavior
What to expect in his/her own emotional
responses
Effects of epidural analgesia
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Stages and Phases of
Labor (p. 143)
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First stage—dilation and effacement (can last
4 to 6 hours)
Second stage—expulsion of fetus (30
minutes to 2 hours)
Third stage—expulsion of placenta (5 to 30
minutes)
Fourth stage—recovery
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Question 2
During which stage of labor does “crowning”
occur?
1)
2)
3)
4)
First
Second
Third
Fourth
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Vaginal Birth After
Cesarean (p. 143)
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Main concern
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Uterine scar will rupture
Can disrupt placental blood flow
Lead to hemorrhage
Woman may need more support than other
laboring women
Nurse provides empathy and support
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Nursing Responsibilities
During Birth (pp. 144-146)
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Preparing the delivery instruments and infant
equipment
Perineal scrub
Administering medications
Providing initial care to the infant
Assessing Apgar score
Assessing infant for obvious abnormalities
Examining the placenta
Identifying mother and infant
Promoting parent-infant bonding
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Immediate Postpartum Period: Third
and Fourth Stages of Labor (p. 146)
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Third stage—expulsion of placenta
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Schulze or Duncan’s
Fourth stage—nursing care includes
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Identifying and preventing hemorrhage
Evaluating and intervening for pain
Observing bladder function and urine output
Evaluating recovery from anesthesia
Providing initial care to the newborn infant
Promoting bonding and attachment between the
infant and family
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Nursing Care Immediately
After Birth (p. 147)
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Care of the mother
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Observing for hemorrhage
• Vital signs
• Skin color
• Location and firmness of uterine fundus
• Lochia
• Pain
Promoting comfort
• Keep warm and dry
• Ice to perineum to help reduce swelling and
bruising
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Nursing Care Immediately
After Birth (cont.) (p. 147)
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Care of the newborn
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Phase 1
•
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Phase 2
•
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From birth to 1 hour (usually in delivery room)
From 1 to 3 hours (usually in transition nursery or
postpartum unit)
Phase 3
•
From 2 to 12 hours (usually in postpartum unit if roomingin with the mother)
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Phase 1: Care of the
Newborn (p. 147)
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Initial care includes
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Maintaining thermoregulation
Maintaining cardiorespiratory function
Observing for urination and/or passage of
meconium
Identifying the mother, father, and newborn
Performing a brief assessment for major
anomalies
Encouraging bonding/breastfeeding
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Apgar Scoring (pp. 151-152)
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Heart rate
Respiratory effort
Muscle tone
Reflex response to suction or gentle
stimulation on the soles of the feet
Skin color
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Administering Medications to
the Newborn (p. 152)
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Eye care
Vitamin K (AquaMEPHYTON)
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Question 4
What medication is most often used for
neonatal eye care?
1)
2)
3)
4)
Silver nitrate 1%
Triple dye
Silver nitrate 2%
Erythromycin ophthalmic ointment
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Observe for Major
Anomalies (p. 153)
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Head trauma from delivery
Symmetry and equality of extremities
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Are they of equal length?
Do they move with same vigor on both sides?
Assess digits of hands and feet
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Any evidence of webbing or abnormal number of
digits
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Umbilical Cord Blood
Banking (p. 153)
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This type of blood is capable of regenerating
stem cells that are able to replace diseased
cells.
Informed consent is essential.
Collect blood after cord has been clamped.
Blood must be transported within 48 hours of
collection to blood banking facility.
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Emerging Technologies and Practice
(p. 154)
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C: type of waveform analysis that detects
intrapartal changes in fetal ST waveforms,
indicative of developing fetal metabolic
acidosis.
PERICALM-EFM: computerized interpretation
of real-time FHR patterns that provides
automatic analysis of fetal heart pattern to
compliment clinical judgment as well as
permanent documentation in EMR.
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