Contractions

• Occur regularly, becoming stronger, lasting longer, and occurring closer together

• Become more intense with walking

• Are usually felt in lower back, radiating to lower portion of abdomen

• Continue despite use of comfort measures

Cervix (by vaginal examination)

• Shows progressive change (softening, effacement, and dilation signaled by appearance of bloody show)

• Moves to an increasingly anterior position

Fetus

• Presenting part usually becomes engaged in pelvis, which results in increased ease of breathing; at the same time, presenting part presses downward and compresses bladder, resulting in urinary frequency

■ Contractions occur regularly, become stronger, last longer, and occur closer together.

■ Cervical dilation and effacement are progressive.

■ The fetus usually becomes engaged in the pelvis and begins to descend.

Contractions

• Occur irregularly or become regular only temporarily

• Often stop with walking or position change

• Can be felt in back or abdomen above navel

• Can often be stopped through use of comfort measures

Cervix (by vaginal examination)

• Maybe soft but with no significant change in effacement or dilation or evidence of bloody show

• Is often in posterior position

Fetus

• Presenting part is usually not engaged in pelvis

■ False labor does not produce dilation, effacement, or descent.

■ Contractions are irregular, without progression.

■ Activity, such as walking, often relieves false labor.

• Perform every 30 to 60 minutes: maternal blood pressure, pulse, respirations.

• Perform every 30 to 60 minutes, depending on risk status: fetal heart rate (FHR) and pattern, uterine activity, vaginal show.

• Assess temperature every 4 hours until membranes rupture and then every 2 hours.

• Perform vaginal examination as needed to identify progress.

• Observe every 30 minutes: changes in maternal appearance, mood, affect, energy level, and condition of partner/coach.

• Perform every 30 minutes: maternal blood pressure, pulse, and respirations.

• Perform every 15 to 30 minutes, depending on risk status: FHR and pattern, uterine activity, vaginal show.

• Assess temperature every 4 hours until membranes rupture and then every 2 hours.

• Perform vaginal examination as needed to identify progress.

• Observe every 15 minutes: changes in maternal appearance, mood, affect, energy level, and condition of partner/coach.

• Perform every 15 to 30 minutes: maternal blood pressure, pulse, and respirations.

• Perform every 15 to 30 minutes, depending on risk status: FHR and pattern.

• Assess every 10 to 15 minutes: uterine activity, vaginal show.

• Assess temperature every 4 hours until membranes rupture and then every 2 hours.

• Perform vaginal examination as needed to identify progress.

• Observe every 5 minutes: changes in maternal appearance, mood, affect, energy level, and condition of partner/coach.

These maneuvers help identify the (1) number of fetuses; (2) presenting part, fetal lie, and fetal attitude; (3) degree of descent into the pelvis of the presenting part; and (4) expected location of the point of maximal intensity (PMI) of the FHR on the woman’s abdomen.

• Wash hands.

• Ask woman to empty bladder.

• Position woman supine with one pillow under her head and her knees slightly flexed.

• Place small rolled towel under woman’s right or left hip to displace uterus off major blood vessels.

• If right-handed, stand on woman’s right, facing her (if left-handed, stand on woman’s left):

1. Identify fetal part that occupies the fundus. The head feels round, firm, freely movable, and palpable by ballottement; the breech feels less regular and softer. This maneuver identifies fetal lie (longitudinal or transverse) and presentation (cephalic or breech).

2. Using palmar surface of one hand, locate and palpate the smooth convex contour of the fetal back and the irregularities that identify the small parts (feet, hands, elbows). This maneuver helps identify fetal presentation.

3. With right hand determine which fetal part is presenting over the inlet to the true pelvis. Gently grasp the lower pole of the uterus between the thumb and fingers, pressing in slightly. If the head is presenting and not engaged, determine the attitude of the head (flexed or extended).

4. Turn to face the woman’s feet. Using both hands, outline the fetal head with the palmar surface of the fingertips. When the presenting part has descended deeply, only a small portion of it may be outlined.

Palpation of the cephalic prominence helps identify the attitude of the head. If the cephalic prominence is found on the same side as the small parts, this means that the head must be flexed and the vertex is presenting. If the cephalic prominence is on the same side as the back, this indicates that the presenting head is extended and the face is presenting.

• Document fetal presentation, position, and lie and whether presenting part is flexed or extended, engaged, or free floating. Use agency protocol for documentation.

Assessment

Signs That Suggest the Onset of the Second Stage

• Urge to push or feeling need to have a bowel movement

• Sudden appearance of sweat on upper lip

• An episode of vomiting

• Increased bloody show

• Shaking of extremities

• Increased restlessness; verbalization (e.g., “I can’t go on.”)

• Involuntary bearing-down efforts

Physical Assessment

• Perform every 5 to 30 minutes: maternal blood pressure, pulse, and respirations.

• Assess every 5 to 15 minutes, depending on risk status: fetal heart rate and pattern

• Assess every 10 to 15 minutes: vaginal show; signs of fetal descent; and changes in maternal appearance, mood, affect, energy level, and condition of partner/coach.

• Assess every contraction and bearing-down effort.

Interventions

Latent Phase

• Help to rest in a position of comfort; encourage relaxation to conserve energy.

• Promote progress of fetal descent and onset of urge to bear down by encouraging position changes, pelvic rock, ambulation, showering.

Active Pushing (Descent) Phase

• Help to change position and encourage spontaneous bearing-down efforts.

• Help to relax and conserve energy between contractions.

• Provide comfort and pain-relief measures as needed.

• Cleanse perineum promptly if fecal material is expelled.

• Coach to pant during contractions and to gently push between contractions when head is emerging.

• Provide emotional support, encouragement, and positive reinforcement of efforts.

• Keep woman informed regarding progress.

• Create a calm and quiet environment.

• Offer mirror to watch birth.

• Use sterile glove and antiseptic solution or soluble gel for lubrication.

• Position woman to prevent supine hypotension. Drape to ensure privacy.

• Cleanse perineum and vulva if needed.

• After obtaining the woman’s permission to touch her, gently insert index and middle fingers into woman’s vagina.

• Determine:

• Cervical dilation, effacement, and position (e.g., posterior, mid, anterior).

• Presenting part, position, and station; molding of head with development of caput succedaneum (may affect accuracy of determination of station).

• Status of membranes (intact, bulging, or ruptured).

• Characteristics of amniotic fluid (e.g., color, clarity, and odor) if membranes are ruptured.

• Explain findings of examination to woman.

• Document findings and report to primary health care provider

• Intrauterine pressure of ≥80╯mm╯Hg or resting tone of ≥20╯mm╯Hg (both determined by internal monitoring with intrauterine pressure catheter [IUPC])

• Contractions lasting ≥90 seconds

• More than five contractions in a 10-minute period (occur more frequently than every 2 minutes)

• Relaxation between contractions lasting <30 seconds

• Fetal bradycardia or tachycardia; absent or minimal variability not associated with fetal sleep cycle or temporary effects of central nervous system depressant drugs given to the woman; late, variable, or prolonged fetal heart rate decelerations

• Irregular fetal heart rate; suspected fetal arrhythmias

• Appearance of meconium-stained or bloody fluid from the vagina

• Arrest in progress of cervical dilation or effacement, descent of the fetus, or both

• Maternal temperature of ≥38° C

• Foul-smelling vaginal discharge

• Persistent bright or dark red vaginal bleeding

Artificial rupture of membranes (AROM), also known as an amniotomy, may be performed by a midwife or obstetrician to induce or accelerate labor. The membranes may be ruptured using a specialized tool, such as an amnihook or amnicot, or they may be ruptured by the proceduralist's finger.

Time of rupture should be recorded.

Once ruptured, the risk of infection from the vagina can ascend into the amniotic sac, causing chorioamnionitis and placentitis to develop.

Common practice, often beginning at 10-cm dilation and before the urge to bear down is perceived. The woman is coached to hold her breath, closing her glottis, and to push while the nurse or partner counts to 10. This method of bearing down may trigger the Valsalva maneuver, which occurs when the woman closes her glottis (closed-glottis pushing), which increases intrathoracic and cardiovascular pressure. This reduces cardiac output and decreases perfusion of the uterus and the placenta. Adverse effects associated with prolonged breath-holding and forceful pushing efforts include fetal hypoxia and subsequent acidosis, increased risk for pelvic floor damage (structural and neurogenic), and perineal trauma.

(1) birth of the head

(2) birth of the shoulders

(3) birth of the body and extremities

(1) applying pressure against the rectum, drawing it downward to aid in flexing the head as the back of the neck catches under the symphysis pubis.

(2) applying upward pressure from the coccygeal region (modified Ritgen maneuver) to extend the head during the actual birth, thereby protecting the musculature of the perineum

(3) assisting the mother with voluntary control of the bearing-down efforts by coaching her to pant while letting uterine forces expel the fetus.

A Higher incident of third-degree tears and episiotomies that hand-poised approach.

It involves applying an upward pressure from the coccygeal region to extend the head during actual delivery, thereby protecting the musculature of the perineum.

[image]

• First degree: Laceration that extends through the skin and structures superficial to muscles

• Second degree: Laceration that extends through muscles of the perineal body

• Third degree: Laceration that continues through the anal

sphincter muscle

• Fourth degree: Laceration that also involves the anterior rectal wall

Third- and fourth-degree lacerations must be repaired carefully so the woman retains fecal continence.

Assessment

Signs That Suggest the Onset of the Third Stage

• A firmly contracting fundus

• A change in the uterus from a discoid to a globular ovoid shape as the placenta moves into the lower uterine segment

• A sudden gush of dark blood from the introitus

• Apparent lengthening of the umbilical cord as the placenta descends to the introitus

• The finding of vaginal fullness (the placenta) on vaginal or rectal examination or of fetal membranes at the introitus

Physical Assessment

• Perform every 15 minutes: maternal blood pressure, pulse, and respirations.

• Assess for signs of placental separation and amount of bleeding.

• Assist with determination of Apgar score at 1 and 5 minutes after birth.

• Assess maternal and paternal response to completion of childbirth process and their reaction to the newborn.

Interventions

• Assist to bear down to facilitate expulsion of the separated placenta.

• Administer an oxytocic medication as ordered to ensure adequate contraction of the uterus, thereby preventing hemorrhage.

• Provide nonpharmacologic and pharmacologic comfort and pain-relief

measures.

• Perform hygienic cleansing measures.

• Keep informed of progress of placental separation and expulsion and perineal repair if appropriate.

• Explain purpose of medications administered.

• Introduce parents to their baby and facilitate the attachment process by delaying eye prophylaxis; wrap mother and baby together for skin-toskin contact.

• Provide private time for parents to bond with new baby; help them create memories.

• Encourage breastfeeding if desired.

Components of active management include administering an oxytocic medication (e.g., oxytocin [Pitocin]) when the anterior shoulder is birthed or immediately following the birth of the fetus, clamping and cutting the umbilical cord within 3 minutes after birth, and gently controlling cord traction following uterine contraction and separation of the placenta.

This method is attributed to a decrease in the rate

of postpartum hemorrhage caused by uterine atony 

Blood Pressure

• Measure blood pressure every 15 minutes for the first hour.

Pulse

• Assess rate and regularity. Measure every 15 minutes for the first hour.

Temperature

• Determine temperature at the beginning of the recovery period and after the first hour of recovery.

Fundus

• Position woman with knees flexed and head flat.

• Just below umbilicus cup hand and press firmly into abdomen. At the same time stabilize uterus at symphysis with opposite hand (see Fig. 19-4).

• If fundus is firm (and bladder is empty), with uterus in midline, measure its position relative to woman’s umbilicus. Lay fingers flat on abdomen under umbilicus; measure how many fingerbreadths (fb) or centimeters (cm) fit between umbilicus and top of fundus. Fundal height is documented according to agency guidelines. For example, if fundus is 1 fb or 1╯cm above umbilicus, fundal height may be recorded as either +1, u+1, or 1/u. If fundus is 1 fb or 1 cm below umbilicus, fundal height may be recorded as either −1, u−1, or u/1.

• If fundus is not firm, massage it gently to contract and expel any clots before measuring distance from umbilicus.

• Place hands appropriately; massage gently only until firm.

• Expel clots while keeping hands placed as in Fig. 19-1. With upper hand firmly apply pressure downward toward vagina; observe perineum for amount and size of expelled clots.

Bladder

• Assess distention by noting location and firmness of uterine fundus and observing and palpating bladder. A distended bladder is seen as a suprapubic rounded bulge that is dull to percussion and fluctuates like a waterfilled balloon. When bladder is distended, uterus is usually boggy in consistency, well above umbilicus, and to woman’s right side.

• Help woman void spontaneously. Measure amount of urine voided.

• Catheterize as necessary.

• Reassess after voiding or catheterization to make sure that bladder is not palpable and fundus is firm and in midline.

Lochia

• Observe lochia on perineal pads and linen under the mother’s buttocks.

Determine amount and color; note size and number of clots; note odor.

• Observe perineum for source of bleeding (e.g., episiotomy, lacerations).

Perineum

• Ask or help woman turn on her side and flex upper leg on hip.

• Lift upper buttock.

• Observe perineum in good lighting.

• Assess episiotomy or laceration repair for redness (erythema), edema, ecchymosis (bruising), drainage, and approximation (REEDA).

• Assess for presence of hemorrhoids.

With woman sitting with her upper body elevated to at least a 30-degree angle, place wedge or small pillow under hip to prevent vena cava compression and reduce likelihood of supine hypotension.

• The greater the angle of elevation, the more gravity or pressure is exerted that promotes fetal descent, the progress of contractions, and the widening of pelvic dimensions.

• Position is convenient for rendering care measures and external fetal monitoring. 

Have woman alternate between left and right side-lying position and provide abdominal and back support as needed for comfort.

• Removes pressure from the vena cava and back, enhances uteroplacental perfusion, and relieves backache

• Facilitates internal rotation of fetus in a posterior position to an anterior position (woman should lie on same side as fetal spine)

• Makes it easier to perform back massage or counterpressure

• Associated with less frequent but more intense contractions

• May be more difficult to obtain good external fetal monitor tracings

• May be used as a birthing position

• Takes pressure off perineum, allowing it to stretch gradually

• Reduces risk for perineal trauma

The gravity effect enhances the contraction cycle and fetal descent. The weight of the fetus places increasing pressure on the cervix; the cervix is pulled upward, facilitating effacement and dilation; impulses from the cervix to the pituitary gland increase, causing more oxytocin to be secreted; and contractions are intensified, thereby applying more forceful downward pressure on the fetus, but they are less painful.

• Fetus is aligned with pelvis, and pelvic diameters are widened slightly.

• Effective upright positions include:

• Ambulation (see Fig. 16-9)

• Standing and leaning forward with support provided by coach, end of bed, back of chair, or birth ball; relieves backache and facilitates application of counterpressure or back massage

• Sitting up in bed, chair, or birthing chair or on toilet or bedside commode 

• Squatting 

Assume an “all fours” position or lean over an object (e.g., birth ball) while on knees in bed or on a covered floor; can also place knees on seat section of bed while leaning up over back of raised head of bed; allows for pelvic rocking.

• Relieves backache characteristic of “back labor”

• Facilitates internal rotation of the fetus by increasing mobility of the coccyx, increasing the pelvic diameters, and using gravity to turn the fetal back and rotate the head (NOTE: A side-lying position, double hip squeeze, or knee squeeze can also facilitate internal rotation.)

• Helping her maintain control and participate to the extent she wishes in the birth of her infant.

• Providing continuity of care that is nonjudgmental and respectful of her cultural and religious values and beliefs.

• Meeting her expected outcomes for her labor.

• Listening to her concerns and encouraging her to express her feelings.

• Acting as her advocate, supporting her decisions and respecting her choices as appropriate and relating her wishes as needed to other health care providers.

• Helping her conserve her energy and cope effectively with her pain and discomfort by using a variety of comfort measures that are acceptable to her.

• Helping control her discomfort.

• Acknowledging her efforts during labor, including her strength and courage and those of her partner, and providing positive reinforcement.

• Protecting her privacy, modesty, and dignity.

9. A multiparous woman has been in labor for 8 hours. Her membranes have just ruptured. The nurse’s initial response would be to:

a. Prepare the woman for imminent birth.

b. Notify the woman’s primary health care provider.

c. Document the characteristics of the fluid.

d.    Assess the fetal heart rate and pattern

ANS: D

The umbilical cord may prolapse when the membranes rupture. The fetal heart rate and pattern should be monitored closely for several minutes immediately after ROM to ascertain fetal well-being, and the findings should be documented. Rupture of membranes (ROM) may increase the intensity and frequency of the uterine contractions, but it does not indicate that birth is imminent. The nurse may notify the primary care provider after ROM occurs and fetal well-being and the response to ROM have been assessed. The nurse’s priority is to assess fetal well-being. The nurse should document the characteristics of the amniotic fluid, but the initial response is to assess fetal well-being and the response to ROM.