Nursing Care of the Family during Labor and Birth



Nursing Care of the Family during Labor and Birth


Kitty Cashion



Learning Objectives



• Review the factors included in the initial assessment of the woman in labor.


• Describe the ongoing assessment of maternal progress during the first, second, third, and fourth stages of labor.


• Recognize the physical and psychosocial findings indicative of maternal progress during labor.


• Identify signs of developing complications during labor and birth.


• Identify nursing interventions for each stage of labor and birth.


• Examine the influence of cultural and religious beliefs and practices on the process of labor and birth.


• Describe the role and responsibilities of the nurse during an emergency childbirth.


• Discuss how the nurse can increase the use of evidence-based practices in caring for women during labor and birth.



Key Terms and Definitions

























Web Resources


Additional related content can be found on the companion website at image


http://evolve.elsevier.com/Lowdermilk/Maternity/



F or most women, labor begins with the first uterine contraction, continues with hours of hard work during cervical dilation and birth, and ends as the woman begins to recover physically from birth and she and her significant others begin the attachment process with the newborn. Nursing care management focuses on assessment and support of the woman and her significant others throughout labor and birth, with the goal of ensuring the best possible outcome for all involved.


A woman often has lingering impressions of her childbirth experience. Caregivers who are respectful, supportive, and calm help the woman to remember her childbirth experience in positive terms. Involving the laboring woman as a partner in the formulation of an individualized plan of care helps preserve the woman’s sense of control, facilitates her participation in her own childbirth experience, and enhances her self-esteem and level of satisfaction. A satisfactory view of childbirth may also enhance a woman’s adaptation to her role as a mother.



image Case Study: First Stage of Labor



First Stage of Labor image


Care Management image


The first stage of labor begins with the onset of regular uterine contractions and ends with full cervical effacement and dilation. It consists of the following three phases: the latent phase (through 3 cm of dilation), the active phase (4 to 7 cm of dilation), and the transition phase (8 to 10 cm of dilation). Most nulliparous women seek admission to the hospital in the latent phase because they have not experienced labor before and are unsure of the “right” time to come in. Multiparous women usually do not come to the hospital until they are in the active phase of the first stage of labor.



Assessment


Assessment begins at the first contact with the woman, whether by telephone or in person. Many women still call the hospital or birthing center first for validation that coming in for evaluation or admission is acceptable. Many hospitals, however, now discourage this practice because of concerns related to legal liability. Nurses are often instructed to tell patients who call with questions “You need to call your primary care provider,” or “If you think you need to be checked, come to the hospital.” If advice is given over the telephone, it must be carefully documented in the patient’s record or in a telephone triage logbook on the unit (Gilbert, 2007).


Some pregnant women call the primary health care provider or come to the hospital while in false labor or early in the latent phase of the first stage of labor. Some feel discouraged after learning that the contractions that feel so strong and regular are not true contractions because they are not causing cervical dilation or are still not strong or frequent enough for admission. During the third trimester of pregnancy, women should be instructed regarding the stages of labor and the signs indicating its onset. They should be informed of the possibility that they will not be admitted if they are 3 cm or less dilated (see Teaching Guidelines box).



Teaching Guidelines


How to Distinguish True Labor from False Labor




If the woman lives near the hospital and has adequate support and transportation, she may be asked to stay home or return home to allow labor to progress (i.e., until the uterine contractions are more frequent and intense). The ideal setting for the low risk woman at this time is the familiar environment of her home. The woman who lives at a considerable distance from the hospital or has a history of rapid labors in the past, however, may be admitted in latent labor. A warm shower is often relaxing for the woman in early labor. Soothing back, foot, or hand massages or a warm drink of preferred liquids such as tea or milk can help the woman to rest and even to sleep, especially if false or early labor is occurring at night. Diversional activities such as walking outdoors or in the house, reading, watching television, doing needlework, or talking with friends can reduce the perception of early discomfort, help the time pass, and reduce anxiety.


When the woman arrives at the perinatal unit, assessment is the top priority (Fig. 12-1). 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 performed.


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Fig. 12-1 Woman being assessed for admission to the labor and birth unit. (Courtesy Dee Lowdermilk, Chapel Hill, NC.)


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 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, 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 that compliance with the EMTALA regulations is achieved while providing safe and efficient care (Angelini & Mahlmeister, 2005; Tucker, Miller, & Miller, 2009).


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 the woman 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 admissions 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 parents 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, and how to adjust lighting in the room and the different bed positions.


The nurse assures the woman that she is in competent, caring hands and that she and her partner can ask questions related to her care and her status and those 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. 12-2). More and more hospitals now use an electronic medical record in which almost all charting is done on computer. Sources of data include the prenatal record, the initial interview, physical examination to determine baseline physiologic parameters, laboratory and diagnostic test results, expressed psychosocial and cultural factors, and the clinical evaluation of labor status.


image
image
Fig. 12-2 Admission screens in an electronic patient 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. Paper or electronic copies of prenatal records are generally filed in the perinatal unit at some time during the woman’s pregnancy (usually in the third trimester) so that they are readily available on admission. If the woman has had no prenatal care or her prenatal record is unavailable, then the nurse must obtain certain baseline information. If the woman is having discomfort, then the nurse should ask questions between contractions when the woman can concentrate more fully on her answers. At times the partner or support person may need to be a secondary source of essential information.


Knowing the woman’s age is important in order to individualize the plan of 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 weight gain greater than that recommended may place the woman at a higher risk for cephalopelvic disproportion and cesarean birth, especially if she is petite and has gained 16 kg or more. Other factors to consider are the woman’s general health status, current medical conditions or allergies, respiratory status, and previous surgical procedures.


Thoroughly review her prenatal record. Take note of her obstetric and pregnancy history, which includes gravidity, parity, and problems such as history of vaginal bleeding, gestational hypertension, anemia, gestational diabetes, infections (e.g., bacterial, viral, or sexually transmitted), and immunodeficiency status. Confirm the expected date of birth (EDB). 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 7-1 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 19 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 nurse determines the woman’s chief complaint or reason for coming to the hospital in the interview. Her primary reason, for example, 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, a period of observation reserved for women who are unsure about the onset of their labor. This check allows time on the unit for the diagnosis of labor without official admission and minimizes or avoids cost to the patient when used by the hospital and approved by the woman’s health insurance plan.


Even the experienced mother may have difficulty determining the onset of labor. Ask the woman to recall the events of the previous days and to 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, 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 [S] [ROM]). If a discharge has occurred that may be amniotic fluid, ask her the date and time she first noticed the fluid and its characteristics (e.g., amount, color, unusual odor). In many instances, a sterile speculum examination and a Nitrazine (pH) test or fern test can confirm that the membranes are ruptured (see Procedure box).



Procedure


Tests for Rupture of Membranes



Nitrazine Test for pH








Test for Ferning or Fern Pattern





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 feels thick and sticky because of its mucoid nature.


Very little bloody show occurs 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 within the last 48 hours.


In case general anesthesia is needed in an emergency, assessing the woman’s respiratory status is important. The nurse determines this status by asking the woman if she has a “cold” or related symptoms (e.g., “stuffy nose,” sore throat, or cough). Recheck the status of allergies, including allergies to latex 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). Some allergic responses cause swelling of the mucous membranes of the respiratory tract, which could interfere with breathing and the administration of inhalation anesthesia. Also, inquire about allergies to tape.


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 12-1), 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 12-1   Birth Plan


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



• 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, and items from home such as pillows


• Labor activities such as preferred positions for labor and for birth, ambulation, birth balls, showers and whirlpool baths, and 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, delaying eye care, and breastfeeding


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


The childbirth.org website (www.childbirth.org) provides couples with an interactive birth plan along with examples of birth plans.


The nurse reviews the birth plan. If no written plan has been prepared, then the nurse helps the woman formulate a birth plan 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 plan of care as much as possible. The nurse 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 that she can make informed decisions. The woman must also realize, however, that the longer her list of “wishes” is, the greater 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 by using photography and videotaping and provide information about the agency’s policies regarding these practices and under what circumstances they are allowed. Protection of privacy and safety and infection control are major concerns for the expecting parents and the agency. 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 12-1 and Box 12-2).



BOX 12-2   Psychosocial Assessment of the Laboring Woman







TABLE 12-1


Expected Maternal Progress in First Stage of Labor


































































  PHASES MARKED BY CERVICAL DILATION*
CRITERION LATENT (0-3 cm) ACTIVE (4-7 cm) TRANSITION (8-10 cm)
Duration† Approx 6-8 hr Approx 3-6 hr Approx 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
Multiparous: –2 cm to 0 Varies: +1 to +2 cm Varies: +2 to+3 cm
Show color Brownish discharge, mucous 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 control of pain, 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; 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


image


*In the nullipara, effacement is often complete before dilation begins; in the multipara, effacement 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 feel as if she is being confined to bed and “restrained.” Being watched 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 to 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. 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 to 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 to 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. Some women may use these expectations 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 shaky or terminated relationship. In many instances, women have heard horror stories or have seen friends or relatives going through labors that appear anything but easy. Multiparous women will often base their expectations of the present labor on their previous childbirth experiences.


Discuss the feelings 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 is 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 inhibit the process of labor as a result of the inhibiting effects of catecholamines associated with the stress response on uterine contractions (Zwelling, Johnson, & Allen, 2006).


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 by helping make sure these are met. The nurse can determine what role the support person intends to fulfill and whether he or she is prepared for that role by making observations and asking her 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 he or she 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 these persons 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, noting the woman’s ethnic or cultural and religious background is increasingly important so as to anticipate nursing interventions to add or eliminate from the individualized plan of care (Fig. 12-3). Nurses should be committed to providing culturally sensitive care and to developing an appreciation and respect for cultural diversity (Callister, 2005). 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, then 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, having a male caregiver examine a pregnant woman would be unacceptable. In some cultures, taking the placenta home is traditional; in other cultures the woman has only certain nourishments during labor. Some women believe that cutting the body, as with an episiotomy, allows the spirit to leave the body and that rupturing the membranes prolongs, not shortens, labor. The nurse should explain the rationale for required care measures carefully (see Cultural Considerations box).


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Fig. 12-3 Birthing room specific to a Native American population. Note the arrow pointing east, the rug on the wall, and the cord hanging from the ceiling. (Courtesy Patricia Hess, San Francisco, CA; Chinle Comprehensive Health Care Center, Chinle, AZ.)


Cultural Considerations


Birth Practices in Different Cultures




Somalia: Because Somalis in general do not like to show any sign of weakness, women are extremely stoic during childbirth.


Japan: Natural childbirth methods practiced; may labor silently; may eat during labor; father may be present.


China: Stoic response to pain; fathers not usually present; side-lying position preferred for labor and birth because this position is thought to reduce infant trauma.


India: Natural childbirth methods preferred; father is not usually present; female relatives are usually present.


Iran: Fathers not present; female support and female caregivers preferred.


Mexico: May be stoic about discomfort until second stage, then may request pain relief; fathers and female relatives may be present.


Laos: May use squatting position for birth; fathers may or may not be present; female attendants preferred.


Source: D’Avanzo, C. E. (2008). Mosby’s pocket guide to cultural health assessment (4th ed.). St. Louis: Mosby.


Within cultures, women may have an idea of the “right” way to behave in labor and may react to the pain experienced in that way. These behaviors can range from total silence to moaning or screaming, but they do not necessarily indicate the degree of pain. A woman who moans with contractions may not be in as much physical pain as a woman who is silent but winces during contractions. Some women believe that screaming or crying out in pain is shameful if a man is present. If the woman’s support person is her mother, she may perceive the need to “behave” more strongly than if her support person is the father of the baby. She will perceive herself as failing or succeeding based on her ability to follow these “standards” of behavior. Conversely, a woman’s behavior in response to pain may influence the support received from significant others. In some cultures, women who lose control and cry out in pain are scolded, whereas in other cultures, support persons will become more helpful.


A companion is an important source of support, encouragement, and comfort for women during childbirth. The woman’s cultural and religious background influences her choice of birth companion. Trends in the society in which she lives also influence her choice. For example, in Western societies the father is viewed as the ideal birth companion. For European-American couples, attending childbirth classes together has become a traditional, expected activity. Laotian (Hmong) husbands also traditionally participate actively in the labor process. In some other cultures the father may be available, but his presence in the labor room with the mother may not be considered appropriate, or he may be present but resist active involvement in her care. Such behavior could be perceived by the nursing staff to indicate a lack of concern, caring, or interest. Women from many cultures prefer female caregivers and want to have at least one female companion present during labor and birth. If couples from these cultures immigrate to the United States or Canada, their roles may change. The nurse will need to talk to the woman and her support persons to determine the roles they will assume.



The non–English-speaking woman in labor.

A woman’s level of anxiety in labor increases when she does not understand what is happening to her or what is being said. Non–English-speaking women often feel a complete loss of control over their situation if no health care provider is present who speaks their language. They can panic and withdraw or become physically abusive when someone tries to do something they perceive might harm them or their babies. A support person is sometimes able to serve as an interpreter. However, caution is warranted because the interpreter may not be able to convey exactly what the nurse or others are saying or what the woman is saying, which can increase the woman’s stress level even more.


Ideally, a bilingual nurse will care for the woman. Alternatively, contact a hospital employee or volunteer interpreter for assistance (see Box 1-7). Ideally, the interpreter is from the woman’s culture. For some women a female interpreter is more acceptable than a male interpreter. If no one in the hospital is able to interpret, call a service so that interpretation can take place over the telephone. Even when the nurse has limited ability to communicate verbally with the woman, in most instances the woman appreciates the nurse’s efforts to do so. Speaking slowly and avoiding complex words and medical terms can help a woman and her partner to understand.

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Related posts:

  1. Labor and Birth at Risk
  2. Transition to Parenthood
  3. Postpartum Complications
  4. Assessment and Care of the Newborn and Family

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Oct 8, 2016 | Posted by in NURSING | Comments Off on Nursing Care of the Family during Labor and Birth

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