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:

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.

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).

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).

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.