Nursing Care of the Laboring Patient
Stage 1: Active Phase
■Power: Contractions palpate moderate to strong, every 2–5 minutes lasting 40–60 seconds
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■Psyche: Patient may have greater difficulty coping with the pain of contractions
■Measuring progress in labor: Cervical dilation (4–7 cm)
■Passageway
■ Encourage frequent position changes
■ Check bladder status and encourage patient to void every 2 hours
■Nursing considerations
■ Monitor vital signs every 30 minutes
■ Fetal heart tones every 15–30 minutes
■Pain management
■ Continue with effective techniques used in latent phase
■ Systemic medications to decrease pain perception
• Document and report maternal and fetal response to systemic medications
• Neonatal side effects related to both dose and timing of administered medication
Systemic Pain Medications in Labor
Medication Drug Nursing
Class Action Considerations
Opioid
Side effect: nausea and vomiting
Long-acting active metabolite, may cause respiratory depression (in the neonate) Caution with women who are opiate dependent, may cause withdrawal
IV push dosing should be at the beginning of a contraction to limit transfer to fetus No analgesic effect
May have prolonged depressant effect on neonate
■ Epidurals in labor
• Oxygen, suction equipment, emergency medications should be at bedside
• Document vital signs and monitor fetal heart rate prior to procedure
• Encourage patient to void
• Administer IV bolus prior to epidural insertion (500 cc to 1000 cc of saline or lactated Ringer’s solution) to prevent maternal hypotension
• Position and support patient during insertion of epidural catheter
• Note maternal vital signs before and after test dose, then every 5 minutes with administration; thereafter, monitor vital signs and FHR per hospital protocol
• Evaluate bladder status every hour and encourage to void; catheterize if unable to void or bladder overdi-stended
• Assess for level of anesthesia
• Monitor for comfort with contractions
• Monitor progress of labor
• Assist with position changes
• Report adverse effects Hypotension Pruritis (itching) Pyrexia (fever) Respiratory depression Stage 1: Transition
■Power: Contractions palpate strong, every 1.5–3 minutes lasting 45–90 seconds
■Psyche: Patient may feel a loss of control; provide encourage-ment to patient
■Measuring progress in labor Cervical dilation (8–10 cm) Fetal descent (0/1 station)
■Physical changes common with transition
■ Urge to push if presenting part is low
■ Nausea/vomiting
■ Trembling limbs
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■ Beads of sweat on upper lip
■ Increased bloody show
■Passageway: Activity more restricted, however, encourage positions that promote fetal rotation and descent
■ Squatting
■ Hands and knees position
■ Side-lying
■Nursing considerations
■ Encourage patient to void
■ Monitor vital signs and fetal heart tones every 5–15 minutes
■Pain management
■ Continue with effective techniques used in active phase
■ If systemic medications are given, consider amount of time estimated until birth and potential for newborn effects (respiratory depression)
■ Have naloxone hydrochloride (Narcan) available to reverse effects if needed
■ Document maternal and fetal response to medications
Second Stage of Labor: Expulsion
■10 cm dilated until the birth of the baby
■Power: Contractions palpate strong, every 2–3 minutes lasting 60–90 seconds
■Psyche: Patient may be eager or afraid to push
■Measuring progress in labor
■ Descent of fetus: from 1 station to crowning
■ Cardinal movements of labor (changes in fetal position that facilitate birth)
• Engagement/Descent/Flexion
• Internal rotation
• Extension
• External rotation
• Expulsion
■Passageway
■ Promote effective pushing
• Wait for urge to bear down called the “Ferguson reflex”
• Discourage prolonged breath-holding
• Encourage open glottis pushing
■ Position for pushing
• Squatting
• Side-lying
• Modified Lithotomy Encourage patient to void Patient may pass stool with pushing
■Nursing considerations
■ Monitor vital signs every 15–30 minutes
■ Fetal heart tones every 5–15 minutes
■Pain management per primary health-care provider
■ Pudendal block: Local anesthetic that blocks pudendal nerve to numb lower vagina and perineum for vaginal birth; useful with forcep delivery
■ Local anesthesia to perineum: Numbs perineum for episiotomy/laceration repair
■Prepare for the birth of the baby
■ Cleanse the perineum
■ Check working order of suction equipment, oxygen, radiant warmer
■ Neonatal resuscitation equipment should be readily avail-able for every delivery
■ Prepare delivery instruments
■Note precise time of birth
■Provide immediate care of the newborn
■ Assess airwayand suction as needed
• Remove excess fluid from infant’s nose and mouth (infants are obligate nose breathers)
• If meconium is noted in nose or mouth, endotracheal intubation and suctioning must be performed imme-diately
■ Assess breathingeffort (rate of at least 30 per minute)
• If respiratory effort is not observed, gently stimulate infant by tapping sole of foot or stroking the back
• Positive pressure ventilate if tactile stimulation does not result in respiratory effort
■ Assess circulation: heart rate 100 BPM
■ Temperature regulation
• Dry infant
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• Place infant under prewarmed radiant warmer with temperature probe applied
• Remove wet towels and lay infant on warm blankets
• Keep temperature of labor room warm
• Once infant is stabilized, encourage skin-to-skin contact with mother
■ Assign Apgar Score at 1 and 5 minutes
• Score of 10 possible; Score of at least 8 desirable
Apgar Score
■ Assess for abnormalities that may need immediate attention (example: neural tube defects, open lesions, or birth injuries)
■ Examine umbilical cord and count number of vessels: 2 arteries and 1 vein; place plastic clamp on cord
■ Identification
• Fingerprint mother and footprint newborn
• Apply identification bands to both mother and newborn before leaving birthing room
■ Medications
• Administer eye prophylaxis; ophthalmic antibiotic ointment (based on hospital protocol) to prevent chlamydial or gonococcal eye infection
• Administer vitamin K, IM to boost production of clotting factor (needed due to sterile gut at birth)
Absent Absent Limp No response Blue or pale
Less than 100 Slow, irregular Some flexion of
extremities Grimace Body pink;
extremities blue
Greater than 100 Good; crying Active motion Cough, sneeze or
vigorous cry Completely pink
■ Weigh and measure infant (head, chest, and abdominal circumference as well as length)
■ Assess skin for lacerations, bruising, or edema
■ Note passage of stool/urine
Third Stage: Delivery of Placenta
■Power: Strong uterine contractions cause the placenta to detach from the uterine wall
■Psyche: Patient may be exhausted; encourage bonding with baby
■Signs of placental separation
■ Sudden gush or trickle of blood from vagina
■ Lengthening of visible umbilical cord at introitus
■ Contraction of the uterus
■Nursing considerations
■ Instruct patient to push when appropriate
■ Note time of placenta delivery
■ After placenta expelled:
• Monitor amount of bleeding
• Monitor vital signs
• Assess fundus – Height – Location – Tone
■ Administer oxytocic medication as ordered
• Stimulates uterus to contract
• Prevents hemorrhage
■ Cleanse and apply ice pack to the perineum
■ Provide clean linen under patient
■ Provide warm blanket: patients often tremble/shiver immediately after the birth
■ Assess level of consciousness/comfort
■ Place newborn in arm of mother, encouraging skin-to-skin contact
■ Assist with positioning for breastfeeding and bonding