A warm shower is often relaxing during early labor. However, warm baths before labor is well established could inhibit uterine contractions and prolong the labor process (Waterbirth International, 2012). Soothing back, foot, and hand massage or a warm drink of preferred liquids such as tea or milk can help the woman rest and even sleep, especially if false or early labor is occurring at night. Diversional activities such as walking outdoors or in the house, reading, watching television, “playing” on the computer, or talking with friends can reduce the perception of early discomfort, help time pass, and reduce anxiety.

When the woman arrives at the perinatal unit, assessment is the top priority (Fig. 16-1). The nurse first performs a screening assessment by using the techniques of interview and physical assessment and reviews the laboratory and diagnostic test findings to determine the health status of the woman and her fetus and the progress of her labor. The nurse also notifies the primary health care provider; and, if the woman is admitted, a detailed systems assessment is done.

FIG 16-1 Woman being admitted. (Courtesy Julie Perry Nelson, Loveland, CO.)

Legal Tip

Obstetric Triage and EMTALA

The Emergency Medical Treatment and Active Labor Act (EMTALA) is a federal regulation enacted to ensure that a woman gets emergency treatment or active labor care whenever such treatment is sought. According to the EMTALA, true labor is considered to be an emergency medical condition. Nurses working in labor and birth units must be familiar with their responsibilities according to the EMTALA regulations, which include providing services to pregnant women when they experience an urgent pregnancy problem (e.g., labor, decreased fetal movement, rupture of membranes [ROM], recent trauma) and fully documenting all relevant information (e.g., assessment findings, interventions implemented, patient responses to care measures provided). A pregnant woman presenting in an obstetric triage is considered to be in “true” labor until a qualified health care provider certifies that she is not. Agencies need to have specific policies and procedures in place so compliance with EMTALA regulations is achieved while safe and efficient care is provided (Miller, Miller, and Tucker, 2013).

When the woman is admitted, she is usually moved from an observation area to the labor room; the labor, delivery, and recovery (LDR) room; or the labor, delivery, recovery, and postpartum (LDRP) room. If she wishes, include her partner in the assessment and admission process. The nurse can direct significant others not participating in this process to the appropriate waiting area. The woman undresses and puts on her own gown or a hospital gown. The nurse places an identification band on the woman’s wrist. Her personal belongings are put away safely or given to family members according to agency policy. Women who participate in expectant parent classes often bring a birth bag or Lamaze bag with them. The nurse then shows the woman and her partner the layout and operation of the unit and room, how to use the call light and telephone system, how to adjust lighting in the room, and the different bed positions.

The nurse reassures the woman that she is in competent, caring hands and that she and people to whom she gives permission can ask questions related to her care and status and that of her fetus at any time during labor. The nurse can minimize the woman’s anxiety by explaining terms commonly used during labor. The woman’s interest, response, and prior experience guide the depth and breadth of these explanations.

Most hospitals have specific forms, whether paper or electronic, that are used to obtain important assessment information when a woman in labor is being evaluated or admitted (Fig. 16-2, A and B). More and more hospitals now use an electronic medical record; almost all charting is done on computer. Sources of data include the prenatal record, initial interview, physical examination to determine baseline physiologic parameters (e.g., vital signs), laboratory and diagnostic test results, expressed psychosocial and cultural factors, and clinical evaluation of labor status.

FIG 16-2 Admission screens in an electronic medical record. A, General admission screen. B, Current admission screen. (Courtesy Kitty Cashion, Memphis, TN.)

Prenatal Data

The nurse reviews the prenatal record to identify the woman’s individual needs and risks. Copies of prenatal records are generally filed in the perinatal unit at some time during the woman’s pregnancy (usually in the third trimester) or accessed by computer so they are readily available on admission. If the woman has had no prenatal care or her prenatal records are unavailable, the nurse must obtain certain baseline information. If she is having discomfort, the nurse should ask questions between contractions when she can concentrate more fully on her answers. At times the partner or support person(s) may need to be secondary sources of essential information. According to the Health Insurance Portability and Accountability Act (HIPAA), the woman must give permission for other persons to be involved in the exchange of information regarding her care. This permission should be obtained during pregnancy, and a signed form included in her health records.

Knowing the woman’s age is important so the nurse can individualize care to the needs of her age-group. For example, a 14-year-old girl and a 40-year-old woman have different but specific needs, and their ages place them at risk for different problems. Accurate height and weight measurements are important. A pregnancy weight gain greater than recommended may place the woman at a higher risk for cephalopelvic disproportion and cesarean birth. This is especially true for women who are petite and have gained 16 kg or more. A prepregnancy body mass index (BMI) greater than 30 is also a cause for concern. Other factors to consider are the woman’s general health status, current medical conditions or allergies, respiratory status, and previous surgical procedures.

The nurse should review the woman’s prenatal records carefully, taking note of her obstetric and pregnancy history, including gravidity; parity; and problems such as history of vaginal bleeding, gestational hypertension, anemia, pregestational or gestational diabetes, infections (e.g., bacterial, viral, sexually transmitted), and immunodeficiency status. In addition, the expected date of birth (EDB) should be confirmed. Other important data found in the prenatal record include patterns of maternal weight gain; physiologic measurements such as maternal vital signs (blood pressure, temperature, pulse, respirations); fundal height; baseline fetal heart rate (FHR); and laboratory and diagnostic test results. See Table 8-1 for a list of common prenatal laboratory tests. Common diagnostic and fetal assessment tests performed prenatally include amniocentesis, nonstress test (NST), biophysical profile (BPP), and ultrasound examination. See Chapter 10 for more information.

If this labor and birth experience is not the woman’s first, the nurse needs to note the characteristics of her previous experiences. This information includes the duration of previous labors, the type of anesthesia used, the kind of birth (e.g., spontaneous vaginal, forceps-assisted, vacuum-assisted, or cesarean birth), and the condition of the newborn. Explore the woman’s perception of her previous labor and birth experiences because this perception may influence her attitude toward her current experience.

Interview

The woman’s primary reason for coming to the hospital is determined in the interview. For example, it may be that her bag of waters (BOW, amniotic membranes) ruptured with or without contractions. The woman may have come in for an obstetric check to determine if she is truly in labor. She may be admitted to the Labor and Birth Unit for a period of observation lasting up to 23 hours. If it is determined after several hours of observation that she is not in true labor, she is discharged. Admission for 23 hours of observation is much less expensive than an inpatient admission; thus it minimizes or avoids cost to the woman and her health insurance plan.

Even the experienced woman may have difficulty determining the onset of labor. She is asked to recall the events of the previous days and describe the following:

• Time and onset of contractions and progress in terms of frequency, duration, and intensity

• Location and character of discomfort from contractions (e.g., back pain, abdominal or suprapubic discomfort)

• Persistence of contractions despite changes in maternal position and activity (e.g., walking or lying down)

• Presence and character of vaginal discharge or “show”

• The status of amniotic membranes such as a gush or seepage of fluid (spontaneous rupture of membranes [SROM]). If there has been a discharge that may be amniotic fluid, she is asked the date and time the fluid was first noted and its characteristics (e.g., amount, color, unusual odor). In many instances a sterile speculum examination and a Nitrazine (pH) and fern test can confirm that the membranes are ruptured (Box 16-1).

Box 16-1 Procedure

Tests for Rupture of Membranes

Nitrazine Test for pH

• Explain procedure to woman or couple.

Procedure

• Wash hands.

• Use cotton-tipped applicator impregnated with Nitrazine dye for determining pH (differentiates amniotic fluid, which is slightly alkaline, from urine and purulent material [pus], which are acidic).

• Dip cotton-tipped applicator deep into vagina to pick up fluid. (Procedure may be performed during speculum examination.)

Read Results

• Membranes probably intact: Identifies vaginal and most body fluids that are acidic:

Yellow	pH 5.0
Olive-yellow	pH 5.5
Olive-green	pH 6.0

• Membranes probably ruptured: Identifies amniotic fluid that is alkaline:

Blue-green	pH 6.5
Blue-gray	pH 7.0
Deep blue	pH 7.5

• Realize that false test results are possible because of presence of bloody show, insufficient amniotic fluid, or semen.

• Provide pericare as needed.

• Remove gloves and wash hands.

Document Results

• Results are positive or negative.

Test for Ferning or Fern Pattern

• Explain procedure to woman or couple.

Procedure

• Wash hands, apply sterile gloves, obtain specimen of fluid (usually during sterile speculum examination).

• Spread drop of fluid from vagina on clean glass slide with sterile cotton-tipped applicator.

• Allow fluid to dry.

• Examine slide under microscope; observe for appearance of ferning (a frondlike crystalline pattern) (do not confuse with cervical mucus test, when high levels of estrogen cause ferning).

• Observe for absence of ferning (alerts staff to possibility that amount of specimen was inadequate or that specimen was urine, vaginal discharge, or blood).

• Provide pericare as needed.

• Remove gloves and wash hands.

Document Results

• Results are positive or negative.

These descriptions help the nurse assess the degree of progress in the process of labor. Bloody show is distinguished from bleeding by the fact that it is pink and feels sticky because of its mucoid nature. There is very little bloody show in the beginning, but the amount increases with effacement and dilation of the cervix. A woman may report a small amount of brownish-to-bloody discharge that may be attributed to cervical trauma resulting from vaginal examination or coitus (intercourse) within the last 48 hours.

Assessing the woman’s respiratory status is important in case general anesthesia is needed in an emergency. The nurse determines this status by asking the woman if she has a cold or related symptoms (e.g., “stuffy nose,” sore throat, cough). The status of allergies, including allergies to latex and tape, and medications routinely used in obstetrics such as opioids (e.g., hydromorphone [Dilaudid], butorphanol [Stadol], fentanyl [Sublimaze], nalbuphine [Nubain]), anesthetic agents (e.g., bupivacaine, lidocaine, ropivacaine), and antiseptics (Betadine) is reviewed. Some allergic responses cause swelling of the mucous membranes of the respiratory tract, which could interfere with breathing and the administration of inhalation anesthesia. Because vomiting and subsequent aspiration into the respiratory tract can complicate an otherwise normal labor, the nurse records the time and type of the woman’s most recent solid and liquid intake.

The nurse obtains any information not found in the prenatal record during the admission assessment. Pertinent data include the birth plan (Box 16-2), the choice of infant feeding method, the type of pain management preferred, and the name of the pediatric health care provider. Obtain a patient profile that identifies the woman’s preparation for childbirth, the support person or family members desired during childbirth and their availability, and ethnic or cultural expectations and needs. Determine the woman’s use of alcohol, drugs, and tobacco before or during pregnancy.

Box 16-2 The Birth Plan

The birth plan should include the woman’s or couple’s preferences related to:

• Presence of birth companions such as the partner, older children, parents, friends, and doula and the role each will play.

• Presence of other persons such as students, male attendants, and interpreters.

• Clothing to be worn.

• Environmental modifications such as lighting, music, privacy, focal point, items from home such as pillows.

• Labor activities such as preferred positions for labor and for birth, ambulation, birth balls, showers and whirlpool baths, oral food and fluid intake.

• List of comfort and relaxation measures.

• Labor and birth medical interventions such as pharmacologic pain-relief measures, intravenous therapy, electronic monitoring, induction or augmentation measures, and episiotomy.

• Care and handling of the newborn immediately after birth such as cutting of the cord, eye care, and breastfeeding.

• Cultural and religious requirements related to the care of the mother, newborn, and placenta.

The childbirth website www.childbirth.org provides couples with an interactive birth plan along with examples of birth plans and descriptions of options that can be included.

The nurse reviews the birth plan. If no written plan has been prepared, he or she helps the woman formulate one by describing options available and determining the woman’s wishes and preferences. As caregiver and advocate the nurse integrates the woman’s desires into the nursing care plan as much as possible. She or he also prepares the woman for the possibility of change in her plan as labor progresses and assures her that the staff will provide information so she can make informed decisions. However, the woman must also realize that the longer her wish list, the greater is the likelihood that her expectations will not be met.

The nurse should discuss with the woman and her partner their plans for preserving childbirth memories through the use of photography and videotaping. Information should be provided about agency policies regarding these practices and under which circumstances they are allowed. Protection of privacy and safety and infection control are major concerns for the expecting parents and the agency. To avoid future embarrassment and distress, the nurse should clarify with the woman exactly which parts of her childbirth she wishes to have photographed and the degree of detail. Remind patients and families that pictures should not be posted on social media sites without the knowledge and consent of every person who appears in the picture. The woman’s record should reflect that the childbirth was recorded. Some hospitals and health care providers do not allow videotaping of the birth because of concerns related to legal liability.

Psychosocial Factors

The woman’s general appearance and behavior (and that of her partner) provide valuable clues to the type of supportive care she will need. However, keep in mind that general appearance and behavior may vary, depending on the stage and phase of labor (Table 16-1 and Box 16-3).

Box 16-3 Psychosocial Assessment of the Laboring Woman

Verbal Interactions

• Does the woman ask questions?

• Can she ask for what she needs?

• Does she talk to her support person(s)?

• Does she talk freely with the nurse or respond only to questions?

Body Language

• Does she change positions or lie rigidly still?

• What is her anxiety level?

• How does she react to being touched by the nurse or support person?

• Does she avoid eye contact?

• Does she look tired? If she appears tired, ask her how much rest she has had in the past 24 hours.

Perceptual Ability

• Is there a language barrier?

• Are repeated explanations necessary because her anxiety level interferes with her ability to comprehend?

• Can she repeat what she has been told or otherwise demonstrate her understanding?

Discomfort Level

• To what degree does the woman describe what she is experiencing, including her pain experience?

• How does she react to a contraction?

• How does she react to assessment and care measures?

• Are any nonverbal pain messages noted?

• Can she ask for comfort measures?

TABLE 16-1

EXPECTED MATERNAL PROGRESS DURING FIRST STAGE OF LABOR

CRITERION	PHASES MARKED BY CERVICAL DILATION*
CRITERION	0-3 cm (LATENT)	4-7 cm (ACTIVE)	8-10 cm (TRANSITION)
Duration†	About 6-8 hr	About 3-6 hr	About 20-40 min
Contractions
Strength	Mild to moderate	Moderate to strong	Strong to very strong
Rhythm	Irregular	More regular	Regular
Frequency	5-30 min apart	3-5 min apart	2-3 min apart
Duration	30-45 sec	40-70 sec	45-90 sec
Descent
Station of presenting part	Nulliparous: 0	Varies: +1 to +2 cm	Varies: +2 to +3 cm
Station of presenting part	Multiparous: −2 cm to 0	Varies: +1 to +2 cm	Varies: +2 to +3 cm
Show
Color	Brownish discharge, mucus plug, or pale pink mucus	Pink-to-bloody mucus	Bloody mucus
Amount	Scant	Scant to moderate	Copious
Behavior and appearance‡	Excited; thoughts center on self, labor, and baby; may be talkative or silent, calm or tense; some apprehension; pain controlled fairly well; alert, follows directions readily; open to instructions	Becomes more serious, doubtful of pain control, more apprehensive; desires companionship and encouragement; attention more inwardly directed; fatigue evidenced; malar (cheeks) flush; has some difficulty following directions	Pain described as severe; backache common; frustration, fear of loss of control, and irritability may be voiced; expresses doubt about ability to continue; vague in communications; amnesia between contractions; writhing with contractions; nausea and vomiting, especially if hyperventilating; hyperesthesia; circumoral pallor, perspiration of forehead and upper lip; shaking tremor of thighs; feeling of need to defecate, pressure on anus

^*In the nullipara effacement is often complete before dilation begins; in the multipara it occurs simultaneously with dilation.

^†Duration of each phase is influenced by such factors as parity; maternal emotions; position; level of activity; and fetal size, presentation, and position. For example, the labor of a nullipara tends to last longer, on average, than the labor of a multipara. Women who ambulate and assume upright positions or change positions frequently during labor tend to experience a shorter first stage. Descent is often prolonged in breech presentations and occiput posterior positions.

^‡Women who have epidural analgesia for pain relief may not demonstrate some of these behaviors.

Women with a History of Sexual Abuse.

Labor can trigger memories of sexual abuse, especially during intrusive procedures such as vaginal examinations. Monitors, intravenous (IV) lines, and epidurals can make the woman feel a loss of control or as if she is being confined to bed and “restrained.” Being observed by students and having intense sensations in the uterus and genital area, especially at the time when she must push the baby out, can also trigger memories.

The nurse can help the abuse survivor associate the sensations she is experiencing with the process of childbirth and not with her past abuse. Help maintain her sense of control by explaining all procedures and why they are needed, validating her needs, and paying close attention to her requests. Wait for the woman to give permission before touching her, and accept her often extreme reactions to labor (Simpson, 2008). Avoid words and phrases that can cause the woman to recall the words of her abuser (e.g., “open your legs,” “relax and it won’t hurt so much”). Limit the number of procedures that invade her body (e.g., vaginal examinations, urinary catheter, internal monitor, forceps or vacuum extractor) as much as possible. Encourage her to choose a person (e.g., doula, friend, family member) to be with her during labor to provide continuous support and comfort and act as her advocate. Nurses are advised to care for all laboring women in this manner because it is not unusual for a woman to choose not to reveal a history of sexual abuse. These care measures can help a woman perceive her childbirth experience in positive terms.

Stress in Labor

The way in which women and their support person or family members approach labor is related to the manner in which they have been socialized to the childbearing process. Their reactions reflect their life experiences regarding childbirth—physical, social, cultural, and religious. Society communicates its expectations regarding acceptable and unacceptable maternal behaviors during labor and birth. These expectations may be used by some women as the basis for evaluating their own actions during childbirth. An idealized perception of labor and birth may be a source of guilt and cause a sense of failure if the woman finds the process less than joyous, especially when the pregnancy is unplanned or is the product of a dysfunctional or terminated relationship. Often women have heard horror stories or have seen friends or relatives going through labors that appear anything but easy. Multiparous women often base their expectations of the present labor on their previous childbirth experiences.

Discuss the feelings that a woman has about her pregnancy and fears regarding childbirth. This discussion is especially important if the woman is a primigravida who has not attended childbirth classes or a multiparous woman who has had a previous negative childbirth experience. Women in labor usually have a variety of concerns that they will voice if asked but rarely volunteer. Major fears and concerns relate to the process and effects of childbirth, maternal and fetal well-being, and the attitude and actions of the health care staff. Unresolved fears increase a woman’s stress and can slow the process of labor as a result of the inhibiting effects of catecholamines associated with the stress response on uterine contractions.

The father, coach, or significant other also experiences stress during labor. The nurse can assist and support these individuals by identifying their needs and expectations and helping to make sure that these are met. She or he can determine what role the support person intends to fulfill and whether that person is prepared for the role by making observations and asking herself or himself such questions as, “Has the couple attended childbirth classes?” “What role does this person expect to play?” “Does he or she do all the talking?” “Is she or he nervous, anxious, aggressive, or hostile?” “Does he or she look hungry, tired, worried, or confused?” “Does he or she watch television, sleep, or stay out of the room instead of paying attention to the woman?” “Where does he or she sit?” “Does he or she touch the woman; what is the character of the touch?” Be sensitive to the needs of support persons and provide teaching and support as appropriate. In many instances the support that these people provide to the laboring woman is in direct proportion to the support they receive from the nurses and other health care providers.

Cultural Factors

As the population in the United States and Canada becomes more diverse, it is increasingly important to note the woman’s ethnic or cultural and religious values, beliefs, and practices to anticipate nursing interventions to add or eliminate from an individualized, mutually acceptable plan of care that provides a feeling of safety and control (Fig. 16-3). Nurses should be committed to providing culturally sensitive care and developing an appreciation and respect for cultural diversity (Callister, 2008). Encourage the woman to request specific caregiving behaviors and practices that are important to her. If a special request contradicts usual practices in that setting, the woman or the nurse can ask the woman’s primary health care provider to write an order to accommodate the special request. For example, in many cultures it is unacceptable to have a male caregiver examine a pregnant woman. In some cultures it is traditional to take the placenta home; in others the woman has only certain nourishments during labor. Some women believe that cutting her body, as with an episiotomy, allows her spirit to leave her body and that rupturing the membranes prolongs, not shortens, labor. It is important to explain the rationale for required care measures carefully (see Cultural Competence box).