CHAPTER 11
Normal Childbirth
1 Determine the potential for alteration in health status during the intrapartum period.
2 Recognize the signs and symptoms of labor.
3 Identify phases of the first stage of labor.
4 Describe the normal physiologic changes occurring in all four stages of labor.
5 Discuss methods of pain relief used during labor.
6 Use nursing interventions that reflect knowledge of standards of care, while using evidence-based nursing practice.
7 Accurately record documentation of nursing care.
8 Identify variables that may alter the course of labor and delivery.
9 Modify the nursing plan of care to changes in patient status.
10 Recognize the variables that influence the normal progress of labor.
11 Practice the concept of family-centered care during the intrapartum period.
INTRODUCTION
A The intrapartum period of pregnancy or labor begins with the first stage’s uterine contractions and the progressive dilation of the cervix.
B From complete dilation of the cervix to the infant’s delivery is the second stage of labor.
C The third stage of labor is completed with the expulsion of the placenta and membranes.
CLINICAL PRACTICE
(1) On the average, lightening occurs 10 days before onset of labor in a primigravida.
(2) Increased pressure of presenting part leads to:
b. Increased mucus-like vaginal discharge
(1) Late sign: occurs after the beginning of cervical changes and increased pressure of presenting part
e. Spontaneous rupture of amniotic sac: leakage of clear or cloudy amniotic fluid
f. Burst of energy due to increased epinephrine release caused by decreased progesterone release
g. Gastrointestinal (GI) symptoms
(1) The uterus and presenting part descend into pelvis.
(2) Occurrence is determined by abdominal and pelvic examination.
(1) Ripening and softening of cervix resulting from hormonal changes
(2) Effacement: thinning of the cervix
d. Spontaneous rupture of the amniotic sac
1. Offer support to patient and family.
a. Listen attentively to concerns.
(1) Allow verbalization of feelings.
(2) Provide information and support.
(3) Reinforce and encourage use of prenatal education.
(4) Provide an awareness of changes as labor begins.
(5) Give clear, concise explanations, and repeat as necessary.
(6) Review, demonstrate, and implement anxiety-reduction techniques.
(7) Provide for the presence of a support person.
(8) Explain all nursing activities.
b. Assist with pain management.
c. Assist with prevention of infection.
(1) Monitor the patient’s temperature every 2 hours for elevation.
(2) Observe for foul-smelling vaginal discharge or amniotic fluid.
(3) Educate the patient about the need for perineal cleanliness.
(4) Administer antibiotics as indicated.
(5) Implement Standard Precautions with emphasis on strict handwashing.
First Stage of Labor: Dilation
(2) Slight pulse changes: may increase to more than 100 beats per minute as a result of exhaustion or dehydration.
(3) Blood pressure (BP) changes very little.
(1) Motility and absorption are decreased.
(2) Gastric emptying time is decreased.
(3) Nausea and vomiting are common.
(4) Dry lips and mouth occur, resulting from mouth breathing and dehydration.
(1) The tendency to concentrate urine results in specific gravity greater than 1.025.
(2) Pressure of full bladder may not be felt due to anesthesia; however, without anesthesia, pressure is increased.
(3) Pressure of presenting part on urethra may require catheterization to empty the urinary bladder.
B Phases of labor: latent phase
b. Prenatal history (prenatal record)
(1) Estimated date of confinement (EDC)
(2) Pregnancies, births, abortions, and living children
(4) Medications taken during pregnancy (frequency; time and date of last dose)
(5) Results of laboratory work done during pregnancy (see Chapters 5 and 8 for discussion and interpretation of pregnancy laboratory tests)
(a) Complete blood count (CBC) to include hemoglobin and hematocrit (H&H)
(d) Venereal Disease Research Laboratory (VDRL)/serologic testing (syphilis screening)
(d) Genetic studies: chorionic villus sampling (CVS), amniocentesis, percutaneous umbilical blood sampling (PUBS)
(e) Lecithin/sphingomyelin (L/S) ratio, phosphatidylglycerol (PG)
(f) Maternal serum alpha-fetoprotein (MS-AFP)
(g) Human immunodeficiency virus (HIV) titer
(h) Hepatitis B surface antigen (HbsAg) titer for hepatitis screening
(j) Nonstress test (NST), oxytocin challenge test (OCT), or contraction stress test (CST)
(1) Vital signs: BP, temperature, pulse, respirations, fetal heart rate (FHR), and fetal activity
(b) Present contraction status
[i] Frequency of contractions; contractions may be irregular and may occur every 5 to 10 minutes.
[ii] Duration: 30 to 45 seconds
(c) Vaginal examination if no abnormal vaginal bleeding
[i] Cervix location (posterior, moving to anterior)
[ii] Dilation: 0 to 3 cm; effacement: 0% to 40%
[iii] Fetal presentation, position, and station
C Phases of labor: active phase
a. Contraction pattern evaluated (by electronic fetal monitoring [EFM] or by palpation) every 30 minutes or more frequently, if indicated
(1) Dilation: 4 to 7 cm; effacement: 40% to 80%; station: -2 to 0
(2) Presenting part and position
(4) Progression of labor: suggested dilation rate
D Phases of labor: transition phase
a. Dilation 8 to 10 cm; effacement 80% to 100%; station -1 to +1
E Pain management during first stage of labor
1. Goal: Change perception through relaxation to decrease tension and medication to increase pain threshold.
2. Pain receptors are stimulated by uterine contractions that result in:
3. Pain perception may be affected by:
a. Barbiturates (phenobarbital [Nembutal], secobarbital [Seconal])
b. Tranquilizers (hydroxyzine [Vistaril] and promethazine [Phenergan])
c. Narcotics (meperidine [Demerol], morphine, butorphanol [Stadol], nalbuphine [Nubain], fentanyl [Sublimaze], sufentanil)
(1) Increase pain threshold: Patient’s ability to tolerate or cope with discomfort increases.
(2) May increase or decrease uterine activity
(4) Have narcotic antagonist available: naloxone (Narcan)
(5) Administer during uterine contraction to minimize fetal effect.
(1) Paracervical block (note: This anesthesia is rarely used anymore and is described here only for historic purposes.)
(a) Local anesthesia is injected transvaginally lateral to cervix at dilation of 4 to 6 cm.
(b) Lower uterine segment, cervix, and upper vagina are affected.
(a) Local anesthesia is injected into epidural or caudal space.
(b) Nerves leaving the spinal cord are blocked.
(c) Entire pelvis and lower extremities are affected so that the patient perceives touch but not pain.
(d) Monitor for urinary retention.
(e) Fetal effect: Uterine blood flow is decreased if maternal hypotension occurs, leading to potential fetal distress.
(a) Transcutaneous electrical nerve stimulation (TENS)
[i] Electrodes are placed on either side of patient’s lower spine.
[ii] Patient provides electrical stimulation during contractions.
[iii] TENS provides alternate sensation to decrease perception of pain from contractions.
[i] Acupressure: increases endorphin release and reduces sensation.
[ii] Cutaneous stimulation: effleurage provides an alternative sensation.
[iii] Massage and counterpressure
(c) Therapeutic touch and healing touch
1. Assist with positioning during labor.
a. Discourage supine position to prevent supine hypotension or vena caval syndrome.
b. Use pillows to assist with positioning.
a. Assess BP between contractions for an accurate reading.
b. Monitor BP, pulse, and respirations every 30 to 60 minutes.
c. Observe for vital signs that may indicate bleeding (e.g., elevated pulse, decreased BP).
d. Monitor temperature every 4 hours (every 2 hours after ROM) for elevation, which may indicate dehydration.
3. Maintain an accurate I&O record.
4. Actively integrate patient and family in laboring process.
a. Orient the patient to her environment.
b. Call the patient by her name.
c. Encourage verbalization of feelings, listening attentively.
d. Respect the patient’s privacy.
e. Provide information about routine procedures to patient and her family.
f. Encourage participation by support persons.
g. Encourage expression of feelings.
h. Reinforce previously learned coping methods.
i. Present new methods of coping with the situation.
j. Encourage rest between contractions in active phase and transition.
5. Implement pain management regimen.
a. Minimize environmental stimuli.
b. Assess level of comfort before and after pain management intervention, throughout all stages of labor.
c. Offer comfort measures, including pharmacologic and nonpharmacologic methods of pain relief (see previous section for discussion of options).
d. Offer and explain analgesia or anesthesia, if indicated and desired.
e. Assist with pain management regimen as needed.
6. Monitor fetal well-being during labor.
a. Monitor FHR for signs of distress caused by decreased uteroplacental perfusion (see Chapter 12 for further discussion of fetal assessment in labor)
a. Encourage voiding every 2 hours; catheterize as indicated.
b. Test urine for specific gravity (normal is 1.010 to 1.025).
c. Administer oral or IV fluids as indicated.
a. Document time of ROM and characteristics of amniotic fluid.
b. Monitor temperature every 2 hours after ROM.
c. Monitor laboratory data as indicated, to include WBC count.
d. Perform vaginal examinations only when necessary.
e. Ensure aseptic technique during procedures.
f. Observe FHR for tachycardia, often an early indication of maternal infection.
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