Caring for the Laboring Woman
Frances C. Kelly
Susan C. Swart
Suzanne McMurtry BAIRD
Objectives
As you complete this module, you will learn:
Purpose and goals of intrapartum nursing care
Maternal and fetal assessments performed throughout first- and second-stage labor
Cultural influences on a woman’s labor and birth experience
Incorporate cultural needs of the laboring woman
Expected patterns of labor for both nulliparous and multiparous women
How to differentiate expected from protracted or arrested labor progress through use of a partogram
Characteristics, causes, and interventions for abnormal labor progress
Characteristics, causes, and interventions for abnormal fetal descent
Physiologic care for woman in labor’s second stage that optimizes progress and minimizes risk of maternal and fetal morbidity
Key Terms
When you have completed this module, you should be able to recall the meaning of the following terms. You should also be able to use the terms when consulting with other health professionals. The terms are defined in this module or in the glossary at the end of this book.
active-directed
active phase
arrest of descent
arrest of dilation
bloody show
caput succedaneum
cephalopelvic disproportion
chorioamnionitis
engagement
fetal station
first stage of labor
floating
labor down
latent phase
lithotomy
molding
multiparas
nulliparas
partogram
physiologic care
primigravida
second stage
third stage
Part 1 Intrapartum Nursing Care
What Is the Role of the Nurse during Labor and Birth?
Nurses are uniquely prepared to promote a safe and satisfying labor and birth experience, while partnering with perinatal healthcare providers to prevent the first cesarean birth or other complications.1,2 The labor and delivery nurse is the nearly constant presence, who is likely to identify even subtle changes in the woman’s or fetus’ condition that require more intensive monitoring or intervention. By providing competent, caring, compassionate, and supportive care, the labor and delivery nurse can positively impact the outcomes of both the first and second stages of labor, which is essential to achieving safe passage for the mother and her newborn, and facilitating a positive birth experience.
The attributes of contemporary laboring women are different from those whom delivered five decades ago. Today, obstetric patients tend to be older, have a higher body mass index (BMI), and may experience one or more chronic illnesses.3 Some of these women, who would otherwise not have survived to an age at which childbearing was feasible, are now getting pregnant. Many have chronic diseases such as diabetes mellitus or cystic fibrosis, or have surgically corrected heart defects with the associated long-term sequelae.4
The concepts that underpin this module are:
labor and birth are natural processes;
women do quite well if unnecessary interventions are avoided;
NOTE: Labor practices such as non-medically indicated inductions of labor, admission to the hospital in false labor, and prematurely diagnosing arrest of cervical dilation or fetal descent may all contribute to an unplanned and potentially unnecessary cesarean birth.6
What Are the Goals of Intrapartum Nursing Care?
The goals of intrapartum nursing care include, and are not limited to, the following1:
Promoting patient safety during labor and birth by performing thorough assessments and reassessments of maternal–fetal well-being, and speaking up to address any perceived safety concerns.7
Understanding a laboring woman’s expectations, and incorporating safe requests, and including her partner, significant other, or family.
Advocating on her behalf.
Educating laboring women and their partners or significant others about what to expect during labor and birth.
Promoting physiologic labor and birth by implementing individualized interventions designed to promote effective coping and manage pain.
Recognize and report complications, concerns, or changes in maternal or fetal condition.
Organize the interprofessional team to achieve goals through effective coordination, communication, and collaboration.
Promoting teamwork.
What Are the Maternal and Fetal Assessments Completed during Labor and Birth?
Most pregnancies and the resultant labors and deliveries are low risk.3 In order to achieve the goals of a safe and satisfying labor and birth experience, comprehensive assessments and
reassessments must be performed that include the physical, psychological, and sociocultural needs of the laboring woman. Module 3 provides a detailed review of the admission assessment of a laboring woman.
reassessments must be performed that include the physical, psychological, and sociocultural needs of the laboring woman. Module 3 provides a detailed review of the admission assessment of a laboring woman.
TABLE 5.1 MATERNAL VITAL SIGN PARAMETERS | ||||||||||||||||||
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Maternal Vital Signs
Maternal vital signs are integral components of both admission and ongoing assessments during labor and birth. The results are compared to a woman’s baseline or historical vital signs which are routinely documented in the prenatal record (if available). Obtain maternal vital signs regularly during labor and birth. It is important to interpret results within the context of the woman’s history, her current status, and activities occurring during the labor and birth. Table 5.1 outlines individual components of maternal vital signs, expected findings, potential explanation of abnormal findings, and suggested nursing actions.
General Nursing Actions When Obtaining Vital Signs during Labor
Avoid obtaining vital signs during uterine contractions.
Be alert to any abnormal findings and consider possible causes. Is this an acute or chronic change? Is the change related to a procedure or medication administration?
Do not assume an increase in BP, HR, or RR is due only to unrelieved pain, fear, or anxiety.
Take action, such as assessing for obvious cause(s); discontinue any medication or therapy that may be related to the deviation; re-position the woman; or administer oxygen or intravenous fluids (according to provider and facility reviewed and approved orders and/or protocols).
Repeat assessments if findings remain abnormal and alert the provider.
Provide information, support, and feedback to the woman to decrease fear and anxiety, and increase feelings of control regarding assessments and actions.
Document abnormal findings and assessments.
Cervical Examination
While a cervical examination provides important information, it is an invasive procedure for many if not all women. Performing a cervical examination requires a skillful, yet sensitive
approach. The manner in which the caregiver approaches and conducts the examination must be respectful and patient-centered. The technical aspects of performing a cervical examination are outlined in Module 3.
approach. The manner in which the caregiver approaches and conducts the examination must be respectful and patient-centered. The technical aspects of performing a cervical examination are outlined in Module 3.
When performing a cervical examination, the caregiver should review the maternal history for the following information:
Gestational age, gravidity, and parity
Presence or suspicion of placenta previa in current pregnancy
Report or suspicion of ruptured membranes
Report of vaginal bleeding or spotting
Results of previous cervical examination, if applicable
History of the present labor
when contractions began
contraction frequency and duration
when contractions became regular
Fetal history (e.g., antenatal testing results, congenital or genetic abnormality)
There are several considerations in performing a sensitive cervical examination, including:
Ask the woman’s permission to perform the examination.
Ensure privacy and draping prior to exam and consider the optimal position for you and the woman (experience in performing examinations while women are in alternative positions such as squatting or side-lying may optimize her tolerance of the examination).
Establish an organized approach to performing a cervical examination.
If possible, perform the examination between contractions.
Use lubricant sparingly. Too much lubrication makes the area around the perineum wet and cold (if assessing for evidence of ruptured membranes by using pH paper or obtaining cultures, do so before using lubricants which may interfere with results).
The woman may have varying responses to cervical examination. Potential reactions to an exam may include the following:
Inability to relax during the examination
Tightening of vaginal muscles
Body language that suggests fear and/or anxiety such as covering the eyes
Crying
During the exam, visually inspect the perineum for evidence of:
Amniotic fluid
Bloody show
Active bleeding
Skin lesions
Perform cervical exam and note:
Dilation from 0 cm (closed) to 10 cm (complete)
Effacement from 0% (thick) to 100% (complete)
Position (anterior, midline, posterior)
Consistency (firm, soft)
Assess fetal membrane status:
Intact
Ruptured (color, odor, amount)
Assess presenting part:
Degree of flexion
Fetal station or degree of descent (−3 to +3 or −5 to +5 scale), where 0 is equal to the ischial spines
Presence of molding of fetal cranial bones
Presence of caput succedaneum (edema of fetal scalp)
NOTE: There is no evidence to support or reject that routine cervical examinations in labor improve outcomes for women and/or newborns.8 However, prudent judgment should be used when choosing to perform a cervical examination taking into consideration the woman’s comfort, the indication for the procedure, and status of membranes. Indications to perform a cervical exam may include changes in fetal status (rupture of fetal membranes with fetal heart rate [FHR] decelerations), increase in bloody show (indicating possible cervical change), or evidence that the woman is making progress (e.g., spontaneous bearing-down efforts or urge to push).
Fetal Heart Rate Assessment
The goals of monitoring the FHR during labor include establishing evidence of fetal well-being, and being able to detect signs of potential fetal compromise so that appropriate interventions may be initiated in a timely manner. Completing Module 7 will assist the labor and delivery nurse to differentiate normal from abnormal FHR tracings, as well as those tracings that require additional evaluation and/or intrauterine fetal resuscitation.9,10
During labor, assessment of the FHR may be accomplished by one of the following methods:
Intermittent auscultation with a stethoscope or a Doppler ultrasound device
Continuous electronic fetal monitoring
Although the early proponents of continuous electronic FHR monitoring asserted that using this monitoring method during labor would reduce the rate of cesarean births and may improve various birth outcomes, these assertions have not been supported in numerous published studies.11 A recent Cochrane review, which included four studies representing more than 13,000 women, reported that while not statistically significant, the group of women assigned to receive continuous FHR tracing assessment an admission in labor was more likely to be delivered by cesarean, as opposed to those women who received intermittent FHR auscultation.12 There is little evidence that continuous electronic FHR monitoring among low-risk laboring women is beneficial, and may potentially increase harm.
Both observation and technical skills are used to identify changes in maternal–fetal status; and fetal presentation, position, and descent. These skills, together with experience in FHR monitoring techniques, provide the caregiver with the ability to monitor maternal and fetal well-being. The laboring woman’s risk status and birth plan should guide the care team in choosing the method of FHR monitoring. Regardless of the method chosen to assess for fetal well-being during labor, labor and delivery nurses must demonstrate current clinical knowledge and the ability to accurately interpret the findings. Because effective performance of intermittent auscultation of the FHR requires more hands-on time of the labor nurse, it requires one-to-one nursing care for the laboring woman.13,14 Circumstances such as nurse staffing, as well as provider or patient preference, influence the method selected.
Uterine Activity
Assessing and reassessing uterine activity is an important aspect providing nursing care in the laboring woman. As labor progresses from early to active, uterine contraction frequency, strength, and duration increases due to release of prostaglandins and endogenous oxytocin.15
What Is the Recommended Frequency of FHR and Uterine Activity Assessments during Labor and Birth?
If, on admission the mother is in early labor, not receiving oxytocin, and has a Category I FHR pattern, fetal and uterine evaluation may be carried out less frequently than every 30 minutes, but should be done at least hourly. When active labor begins, evaluation intervals of 15 to 30 minutes are appropriate, depending on risk status. Many providers prefer a baseline strip with electronic FHR monitoring; however, there is no research to suggest a difference in outcome when this strategy is used. Table 5.2 summarizes frequency of assessment recommendations.
NOTE: If the woman or fetus has assessment parameters outside defined norms, assessments should increase until stabilization.
NOTE: When using electronic uterine and fetal monitoring, always palpate uterine contractions and auscultate maternal and fetal heart rates in the first few minutes of using the equipment and periodically throughout labor. This validates that the equipment is working properly.
TABLE 5.2 FREQUENCY OF UTERINE ACTIVITY ASSESSMENT16 | |||||||||||||||
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Part 2 Patterns of Labor
Early research conducted by Friedman to determine expected labor progress among “normal” nulliparous and multiparous women during the first stage of labor, found that cervical dilation progressed on average 1.2 and 1.5 cm per hour, respectively.17 These rates of progress have served as benchmarks against which labor progress is evaluated, and care decisions made for countless numbers of laboring women since that time, even though these research findings were based on 100 “normal labors” that included women with multiple gestations and fetal malpresentations. In order to effectively promote physiologic labor and birth, an understanding of labor patterns of contemporary nulliparous and multiparous women is necessary.
What Are the General Characteristics and Patterns of the First Stage of Labor among Contemporary Laboring Women?
The knowledge gleaned from the work of the Consortium on Safe Labor (CSL) study has informed perinatal healthcare providers about the characteristics of labor among contemporary women.18 The purpose of the study was to identify labor curves according to parity. Based on these data, new definitions and criteria for labor management have been described.
Stage I labor is separated into two phases.
The early phase (preparatory phase) extends from the onset of regular contractions that cause cervical change to the beginning of the active phase, when dilation occurs more rapidly. It usually extends over hours and appears as a nearly flat line on the labor curve.
The active phase (dilational phase) of labor begins when the laboring woman reaches 6 cm of dilation, and ends when the cervix is 10 cm or completely dilated. Effective labor begins with the active phase.
Data included in the National Collaborative Perinatal Project (CPP) indicates that contemporary laboring women tend to19:
be older;
have a higher BMI;
reach a maximum slope of cervical dilation not beginning until the laboring woman reaches 6 cms (as opposed to 4 cm as previously believed);
have a slower than traditionally believed rate of dilation during the active phase of labor;
have a longer first stage of labor even after accounting for maternal and pregnancy characteristics, by a median 2.6 and 2.0 hours in nulliparas and multiparas, respectively.
In another study of spontaneously laboring women with a single, vertex fetus and who experienced a vaginal birth with a normal newborn outcome, several key labor characteristics were described18:
It may take more than 6 hours to progress from 4 to 5 cm of dilation.
It may take more than 3 hours to progress from 5 to 6 cm of dilation.
Before 6 cm, both nulliparous and multiparous laboring women progress at approximately the same rate (Fig. 5.1).
After 6 cm, labor progress accelerates at a faster pace among multiparous laboring women (Fig. 5.1).
Figure 5.2 depicts the 95th percentile for the cumulative duration of labor when admitted at various dilations. This partogram may serve as a useful guide to help identify when a nulliparous woman might be experiencing protracted labor.
The 95th percentiles for the second stage of labor for nulliparous laboring women with and without a neuraxial anesthetic were 3.6 and 2.8 hours, respectively.
How Should the Nurse Assess for Labor Progress?
Recall that contemporary laboring women tend to be older, have higher BMIs, and may have one or more comorbid conditions.18 Along with these changes in their physical characteristics, contemporary laboring women tend to have their labors induced more often, undergo more obstetric-related interventions, and request neuraxial analgesia and anesthesia for pain management. As previously described in this module, the combination of the changes in physical characteristics coupled with more frequent obstetric interventions has altered the contemporary labor curve for both nulliparous and multiparous women (Fig. 5.1). Applying this knowledge to assess labor progress among contemporary laboring women is an essential competency of a labor nurse.
Plotting cervical dilation and fetal station on a graph in nulliparous and multiparous women has provided a norm for assessing and evaluating the adequacy of labor progress for many years. A partogram (sometimes referred to as a partograph) is a graphic illustration of labor progress, and was used originally in developing countries to identify women experiencing a deviation from expected progress. The partograph recommended by the World Health Organization
(WHO) is composed of alert and action lines (Fig. 5.3).20 By plotting dilation, the alert line helped to identify progress that occurred slower than 1 cm an hour once a patient reached 4 cm. The action line, sequenced 4 hours to the right of an alert line, triggered notification of care providers, and facilitated a transfer from outlying birthing centers and hospitals to higher levels of care where a physician was available to perform a cesarean birth. Although available evidence varies, plotting labor progress on a partogram may reduce the risk of prolonged or obstructed labor and prevent a cesarean birth.18,21
(WHO) is composed of alert and action lines (Fig. 5.3).20 By plotting dilation, the alert line helped to identify progress that occurred slower than 1 cm an hour once a patient reached 4 cm. The action line, sequenced 4 hours to the right of an alert line, triggered notification of care providers, and facilitated a transfer from outlying birthing centers and hospitals to higher levels of care where a physician was available to perform a cesarean birth. Although available evidence varies, plotting labor progress on a partogram may reduce the risk of prolonged or obstructed labor and prevent a cesarean birth.18,21
 FIGURE 5.1 Labor curves by parity in singleton, term pregnancies with spontaneous onset of labor, vaginal delivery, and normal neonatal outcomes. (From Zhang, J., Landy, H. J., Branch, D. W., et al., for the Consortium on Safe Labor. (2010). Contemporary patterns of spontaneous labor with normal neonatal outcomes. Obstetrics & Gynecology, 116(6), 1281–1287.) |
 FIGURE 5.2 Contemporary estimates of labor duration by dilation at admission. (From Zhang, J., Landy, H. J., Branch, D. W., et al., for the Consortium on Safe Labor. (2010). Contemporary patterns of spontaneous labor with normal neonatal outcomes. Obstetrics & Gynecology, 116(6), 1281–1287.) |
 FIGURE 5.3 Modified WHO partogram. (From www.who.int/reproductivehealth/publications/maternal_perinatal_health/3_9241546662/en/) |
How Is the Descent of the Fetus Described and Assessed?
The degree of descent of the fetus through the maternal pelvis is determined by evaluating the fetal station. Fetal station may be assessed by palpating the gravid abdomen (Leopold’s) or by performing a cervical examination, and described as the relationship of the presenting part of the fetus to an imaginary line drawn between the ischial spines of the maternal pelvis.
Fetal station is described utilizing either a −3 to +3, or a −5 to +5 scale. Each number represents the distance in centimeters of the fetal presenting part either above or below the maternal ischial spines (Figs. 5.4 and 5.7). The long axis of the birth canal is divided into thirds. The ischial spines are approximately halfway between the pelvic inlet and the pelvic outlet.
NOTE: It is important that the same scale be understood and used consistently by all nursing and medical providers within the labor and delivery unit. For purposes of this module, the authors will use the −3 to +3 station scale.
The following describes levels of fetal descent:
If the presenting part is above the spines and at the level of the pelvic inlet, it is said to be at −3 station if using the −3 to +3 station range.
Floating or Ballotable—when the presenting part is entirely out of the pelvis and can be moved by the examiner abdominally just above the symphysis pubis bone or on cervical exam the fetal presenting part floats out of the pelvis (Fig. 5.5).
If the fetal presenting part has descended one third the distance past the inlet, it is at −1 station.
When the presenting fetal part (e.g., the head) is at the level of the ischial spines, the fetal station is 0 (the largest diameter of the fetal head enters into the smallest diameter of the maternal pelvis). This is fetal engagement (Fig. 5.6).
FIGURE 5.4 Fetal station. (From Kilpatrick, S. & Garrison, E. [2012]. Normal labor. In Gabbe, S. G. Niebyl, J. R. Simpson, J. L. [Eds.], Obstetrics: Normal and problem pregnancies [5th ed., pp. 2267–286]. Philadelphia, PA: Elsevier Saunders.)
FIGURE 5.5 Floating. Fetal head is entirely out of the pelvis.
FIGURE 5.6 Engaged presenting fetal head. A. Front view. B. Side view.
A similar division is assigned to the distances between the ischial spines and the pelvic outlet. If the level of the presenting part is one third or two thirds the distance between the spines and the outlet, it is said to be +1 or +2 station, respectively.
When the presenting fetal part descends to the bony outlet, it is resting on the muscles of the vaginal opening and is at +3 station (Fig. 5.7).
FIGURE 5.7 A. Descent of the presenting fetal part to station −3. Front view using a scale of −3 to +3. B. Descent pathway, side view.
Sometimes the fetal scalp becomes edematous with the pressure of labor. This can be felt as a soft, swollen layer over the hard bony surface of the skull and is called caput succedaneum. Also, it is possible for molding of the fetal skull to occur, which can distort the examiner’s evaluation of the fetal head descent.
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