Labor and Delivery

Terminology
“Lie”—The relationship of the long axis of the fetus to the long axis of the uterus.
Longitudinal or transverse
“Presentation”—That part of the baby lowest in the pelvis
Vertex or cephalic 96—97% of the time
Breech 3-3.5 % of the time
Terminology continued
“Attitude” refers to the degree of flexion of the fetus.
Complete flexion is the best attitude
“Position” refers to the relationship of the presenting part of the fetus to the pelvic
quadrants of mother.
The occiput is the point of reference for the cephalic presentation.

Terminology
“Station” refers to the location of the presenting part of the fetus as it makes it descent
into the true pelvis.
Point of reference is the ischial spines.
Floating is above the spines.
Engaged is the level of the spines.
“Lightening” is another term for engagement.

Terminology
“Effacement” refers to the thinning out of the cervical canal.
It is expressed in percentages.
Primigravidas usually efface more quickly than they dilate.
Multiparas typically will experience effacement and dilatation at the same time.
Terminology
“Dilatation” refers to the stretching of the cervix to accommodate delivery.
Complete dilatation is 10 Centimeters
Uterine contractions provide the force
“Show” refers to the blood tinged mucosy vaginal discharge.
The mucous plug is dislodged
Becomes more bloody as labor progresses.

MECHANISMS OF LABOR
Descent or lightening
Flexion
Internal Rotation
Extension
External Rotation
Expulsion or birth
Fetal Aspects of Labor
The fetal skull is not ossified.
There are fontanels and interspaces to allow for molding of the fetal head.
The anterior fontanel is diamond shaped at the junction of the two frontal bones and the
two parietal bones.
The Fetal Skull
The posterior fontanel is smaller and is triangular in shape at the junction of the
occipital bone and the parietal bones.
The interspaces or suture lines are:
Sagital—between the parietal bones

Coronal—between the frontal and parietal bones.

Lambdoid—between the occipital bone and the parietal bones.

Impending Labor
(Preliminary signs)
Lightening—the settling down into the true pelvis
Burst of energy and increase in activity level.
Braxton-Hicks contractions may be confused as false labor.
Ripening of the cervix.
Rupture of the membranes.
Show—vaginal discharge.
True Labor
The onset of regular contractions that show a pattern.
They will come at regular intervals and as labor progresses will be closer together.
They will increase in intensity.
They will increase in length or duration.
True Labor
Contractions are involuntary. But mother can work with them to decrease her
discomfort and increase the effectiveness.
There are three phases:
Increment—building up

Acme—height of intensity

Decresendo—begins to relax

Relaxation interval is also important.

Evaluating Contraction Pattern

Timing of the contractions is important and can be felt at the fundus.
Interval or frequency is from the beginning of one to the beginning of the next.
Duration is how long the contraction lasts.
Intensity is the strength of the contraction.
Relaxation interval is the period in between contractions.
Stages of Labor
Stage One is the “Dilating” stage.
Latent phase
Active phase
Transitional phase
Stage Two is the “Birthing” stage.
Stage Three is the “Placental” stage.
Stage Four is the “Recovery” stage.
Nursing Care in Labor/delivery
On Admission need to be calm and reassuring.
Mother may be stressed and tired.

Collecting data:
Need to know EDC, previous OB history, pre-natal care.

Onset of labor—contractions, bloody show, condition of membranes.

Vital signs—mother and baby.

Lab Work on Admission

Urinalysis—voided or catheterized in Delivery.
Protein

Glucose

Bacteria

Blood work:
CBC

H & H

VDRL or RPR

Type

GBS

Nursing Care During Labor

During Latent phase:
Vital signs and interview on admission
Encourage activity and ambulation (if ROM intact).
Provide information regarding what to expect.
Diet may be only clear liquids or NPO.
Nursing Care During Labor
During Active phase:
Mother will be concentrating more on her labor.
Assess her ability to cope and effectiveness of her support system.
Never leave mother in active labor alone.
Offer opportunity to void every two hours.
Usually will be NPO with IV fluids to provide for hydration and medications as needed.

Nursing Care During Labor

Transitional phase:
This is the last bit of stretching that must be done before birth.
Most difficult part of the labor process.
Prepare for delivery
At complete dilatation for primigravida
At 7-8 cm for multipara
Nursing Care During Labor
Continue to offer opportunity to void as needed.
Vital signs for mother and baby more often.
Signs you might observe are:
Nausea/vomiting

Involuntary shaking/tremors of the legs

Mood change

Desire to push

Nursing Care During Labor

With rupture of membranes:
May be SROM or AROM
Assess fetal condition by noting FHT’s
Note amount and color of fluid:
Meconium staining

With PROM these additional problems may occur.

Infection

Prolapsed cord

Preparation for Delivery

Provide for cleanliness throughout labor.
Perineal cleansing
Prepare sterile table and equipment.
Provide emotional supportive care to patient and family.
Notify physician .
Evaluating the Fetal Condition
The fetal heart tones are the best indicator of fetal condition.
Can be assessed with fetoscope, doppler, or monitor.
Best to listen during or immediately following a contraction to determine fetal distress.
The Fetal Heart Tones
The location they are best heard can be an indicator of fetal position.

Above the umbilicus may be a breech position.

Below the umbilicus probably indicates a vertex presentation.

The Fetal Heart Tones

The location can also indicate fetal descent.
May be heard in the side at the level of umbilicus at first.
As progress is made in descent will be closer to midline and lower.
Just prior to birth may be in midline just over the pubic bone.
The Fetal Heart Tones
Generally will need to establish a baseline for each baby.
Average range for normal FHT’s is 120 to 160 beats per minute.
Should have beat-to-beat variability of 6 – 10 per minute.
Reduced variability may be due to sedatives/analgesics given to mom, or fetal sleep or
inactivity.
The Fetal Heart Tones
Persistent fetal tachycardia may be due to:
Maternal fever
Preterm labor
Fetal hypoxia
Persistent fetal bradycardia may be due to:
Maternal hypotension

Decelerations of Fetal Heart Tones

May indicate fetal distress.
Should be evaluated in relation to the contractions.
Early decels are early in the contraction as it is beginning.
Late decels occur late toward the end of the contraction.
Variable decels do not show any typical pattern in relation to the contractions.
Decelerations of the FHT’s
Early decelerations probably are due to head compression with the contractions.
These usually have a rapid recovery to baseline.
Do not require any nursing intervention.
Decerlerations
Late decelerations are probably due to utero-placental insufficiency.
These usually are delayed recovery to baseline.
Nursing interventions required:
Turn to the left-side lying position
Oxygen given at 8-10 liters
Turn off or reduce the rate of pitocin
Decelerations
Variable decels are likely due to cord compression.
These usually also are delayed to recover to baseline.
This may be due to position of baby in utero, or prolapsed cord.
Position patient to relief pressure and notify physician.

Nursing Care During Stage Two

Continue to assess vital signs of mother and baby more often as labor progresses.
Watch for signs of impending birth:
Bulging perineum

Crowning

Dilated anus

Uncontrollable urge to push

Perineal cleansing prep.

Notify physician
Danger Signals to Note
Abnormal vaginal bleeding
Cessation of contractions after labor established
Elevated B/P, sever headaches, blurred vision
Elevated temperature, pulse, respirations
Rigid uterus after contraction
Exhaustion
Danger Signals
Irregular fetal heart rate:
Persistent tachycardia
Persistent bradycardia
Decelerations
Meconium-stained amniotic fluid
Hyperactivity of the fetus
Prolapsed of the cord
Assisted Deliveries
Forceps may assist mother in delivery to shorten the 2nd stage of labor.
Mother may be exhausted and unable to push.
Baby may be showing of fetal distress.
Low outlet forceps may be used.
Vacuum extraction is another method.
Care of the Infant
Airway clearance and establishment of independent respirations are the first priority.
Warmth is of immediate concern as well.
Cord is clamped and cut.
Bonding –give baby to parents as soon as possible.
Assessment of Neonate
Apgar Assessment Results
Rating of 7 – 10 is a vigorous newborn.
Rating of 4 – 6 is a moderately depressed newborn who may require some intervention.
Rating of less than 3 is s severely depressed baby who will require intervention.

Prophylactic Care
Eye treatment
To prevent ‘opthalmic neonatorum’
Conjunctivitis from gonorrhea or clamydia
Ilotycin, Tetracycline, Silver Nitrate
Aquamephyton
To prevent bleeding problems in newborn.
Vitamin K is given as one time dose of 0.5-1 mg.
Other Needs of the Newborn
Identification is very important.
Triple band bracelets are commonly used.
Baby’s footprints and mother’s thumb prints are used, as well as a photo.
Security is also an important concern.
The OB area is a locked, secured
unit.
Nursing Care During Stage Three
Placenta is delivered following birth of the baby.
Pitocin hastens delivery of the placenta and is usually given at this point.
Signs of placental separation are:
Globular shape and firm uterus
Lengthening of the cord
Gush of blood or increase in bloody flow.
Stage Three
Mechanism of placental delivery are:
Schultze Mechanism--80% of the time the shiny fetal surface is seen first.

Duncan Mechanism—20% of the time the dull maternal surface escapes first.

The placenta will be carefully inspected after delivery

For abnormalities

For completness

Nursing Care During Stage Four

Early Post-partum recovery—the first 1-2 hours after delivery.
Careful observation and assessment is of utmost importance and may be done every 15
minutes during the first hour.
Check B/P, Pulse

Fundal tone and location

Lochial flow

Perineal assessment

Stage Four continued

Hemorrhage is the number 1 priority of concern at this time.
Pitocin may be use to control P-P bleeding.
Warmth is also a need during this period.
May be hungry and thirsty.
Allow for privacy with family for bonding.

Special Situations
Precipitate delivery
Cerebral trauma for baby

Risks for lacerations for Mom

Breech presentations
Cerebral trauma for baby

Longer, more difficult labor for Mom

Twin (Multiple) Births

Premature births

Maternal risks PIH, P-P bleeding

nd
Delivery of 2 twin often more problems