Management of discomfort. Nursing care during labour and birth
KEY TERMS AND DEFINITIONS
analgesia Absence of pain without loss of consciousness
anesthesia Partial or complete absence of sensation with or without loss of consciousness
ataractics Medications capable of promoting tranquility; tranquilizers
Bradley method Husband-coached childbirth preparation method using labor breathing techniques and environmental modification
counterpressure Pressure applied to the sacral area of the back during uterine contractions
Dick-Read method A prepared childbirth approach based on the premise that fear of pain produces muscular tension, producing pain, and greater fear; includes teaching physiologic processes of labor, exercise to improve muscle tone, and techniques to assist in relaxation and prevent the fear-tension-pain mechanism
effleurage Gentle stroking used in massage
epidural block Type of regional anesthesia produced by injection of a local anesthetic alone or in combination with a narcotic analgesic into the epidural (peridural) space
epidural blood patch A patch formed by a few milliliters of the mother’s blood occluding a tear in the dura mater around the spinal cord that occurs during induction of spinal block; its purpose is to prevent headache associated with leakage of spinal fluid
gate-control theory of pain Pain theory used to explain the neurophysiologic mechanism underlying the perception of pain: the capacity of nerve pathways to transmit pain is reduced or completely blocked by using distraction techniques
Lamaze (psychoprophylaxis) method Childbirth preparation method developed in the 1950s by a French obstetrician, Fernand Lamaze, that gained popularity in the
local infiltration anesthesia Process by which a substance such as a local anesthetic medication is deposited within the tissue to anesthetize a limited region of the body
neonatal narcosis Central nervous system depression in the newborn caused by an opioid (narcotic); may be exhibited by respiratory depression, hypotonia, lethargy, and delay in temperature regulation
opioid (narcotic) agonist analgesics Medications that relieve pain by activating opioid receptors
opioid (narcotic) agonist-antagonist analgesics Medications that combine agonist activity (activates or stimulates a receptor to perform a function) and antagonist activity (blocks a receptor or medication designed to activate a receptor) to relieve pain without causing significant maternal or fetal/newborn respiratory depression
opioid (narcotic) antagonists Medications used to reverse the effects of an opioid (e.g., naloxone reverses the effects of meperidine)
pudendal block Injection of a local anesthetic at the pudendal nerve root to produce numbness of the genital and perianal region
spinal block Regional anesthesia induced by injection of a local anesthetic agent into the subarachnoid space at the level of the third, fourth, or fifth lumbar interspace
systemic analgesia Pain relief induced when an analgesic is administered parenterally (e.g., subcutaneous, intramuscular, or intravenous route) and crosses the blood-brain barrier to provide central analgesic effects
active phase Phase in the first stage of labor when the cervix dilates from 4 to 7 cm
amniotomy Artificial rupture of the fetal membranes (AROM), using a plastic Amnihook or surgical clamp
bloody or pink show Blood-tinged mucoid vaginal discharge that originates in the cervix and indicates passage of the mucous plug (operculum) as the cervix ripens before labor and dilates during labor; it increases as labor progresses crowning Phase in the descent of the fetus when the top of the head can be seen at the vaginal orifice as the widest part of the head (biparietal diameter) distends the vulva just before birth
doula Experienced female assistant hired to give the woman support during labor and birth
episiotomy Surgical incision of the perineum at the end of the second stage of labor to facilitate birth and to avoid laceration of the perineum
fern test The appearance of a fernlike pattern found on microscopic examination of certain fluids such as amniotic fluid
first stage of labor Stage of labor from the onset of regular uterine contractions to full effacement and dilation of the cervix
latent phase Phase in the first stage of labor when the cervix dilates from 0 to 3 cm
Leopold’s maneuvers Four maneuvers for diagnosing the fetal position by external palpation of the mother’s abdomen
lithotomy position Position in which the woman lies on her back with her knees flexed and with abducted thighs drawn up toward her chest; stirrups attached to an examination table can be used to facilitate assumption of this position
nitrazine test Evaluation of body fluids using a test strip to determine the fluid’s pH; urine will exhibit an acidic result and amniotic fluid will exhibit an alkaline result
nuchal cord Encircling of fetal neck by one or more loops of umbilical cord
Ritgen maneuver Technique used to control the birth of the head; upward pressure from the coccygeal region to extend the head during the actual birth
rupture of membranes (ROM) Integrity of the amniotic membranes is broken either spontaneously or artificially (amniotomy)
second stage of labor Stage of labor from full dilation of the cervix to the birth of the baby
spontaneous rupture of membranes (SROM, SRM) Rupture of membranes by natural means, most often during labor
third stage of labor Stage of labor from the birth of the baby to the separation and expulsion of the placenta
transition phase Phase in the first stage of labor when the cervix dilates from 8 to 1 0 cm
uterine contractions Primary powers of labor that act involuntarily to dilate and efface the cervix, expel the fetus, facilitate separation of the placenta, and prevent hemorrhage
Pregnant women commonly worry about the pain they will experience during labor and birth and how they will react to and deal with that pain. A variety of childbirth preparation methods can help the woman or couple cope with the discomfort of labor. The interventions selected depend on the situation and the preference of both the woman and her health care provider. The discomforts experienced during labor are discussed in this chapter, as are the nonpharmacologic and pharmacologic interventions to relieve the discomforts possible during the different stages of labor. This information provides the basis for understanding the nurse’s role in the management of maternal discomfort during labor.
DISCOMFORT DURING LABOR AND BIRTH
NEUROLOGIC ORIGINS
The discomfort experienced during labor has two origins (Lowe, 1996). During the first stage of labor, uterine contractions cause cervical dilation and effacement, and uterine ischemia (decreased blood flow and therefore local oxygen deficit) results from compression of the arteries supplying the myometrium. Pain impulses during the first stage of labor are transmitted via the T i l and T12 spinal nerve segment and accessory lower thoracic and upper lumbar sympathetic nerves. These nerves originate in the uterine body and cervix.
The discomfort from the cervical changes and uterine ischemia is visceral pain. It is located over the lower portion of the abdomen and radiates to the lumbar area of the back and down the thighs. The woman usually experiences discomfort only during contractions and is free of pain between contractions.
During the second stage of labor, the stage of expulsion of the baby, the woman experiences perineal or somatic pain. Perineal discomfort results from stretching of perineal tissues to allow passage of the fetus and from traction on the peritoneum and uterocervical supports during contractions. Discomfort also can be produced by expulsive forces or by pressure exerted by the presenting part on the bladder, bowel, or other sensitive pelvic structures. Pain impulses during the second stage of labor are transmitted via the SI to S4 spinal nerve segments and the parasympathetic system.
Pain experienced during the third stage of labor and the afterpains of the early postpartum period are uterine, similar to the pain experienced early in the first stage of labor. Areas of discomfort during labor are shown in Fig. 1.
Fig. 1 Discomfort during labor. A, Distribution of labor pain during first stage. B, Distribution of labor pain during transition and early phase of second stage. C, Distribution of pain during late second stage and actual birth. (Gray areas indicate mild discomfort; light-colored areas indicate moderate discomfort; dark-colored areas indicate intense discomfort.)
Pain may be local, with cramping and a tearing or bursting sensation caused by distention and laceration of the cervix, vagina, or perineal tissues. This discomfort is commonly perceived as an intense burning sensation as the tissue stretches. Pain also may be referred (referred pain), in which discomfort originating in the abdominal viscera is felt in the back, flanks, or thighs.
FACTORS INFLUENCING PAIN RESPONSE
A woman’s pain during childbirth is unique to each woman and is influenced by a variety of factors. These factors include culture, anxiety and fear, previous birth experience, childbirth preparation, and support.
Culture
The obstetric population reflects the increasingly multicultural nature of
Anxiety and fear
Anxiety and fear are commonly associated with increased pain during labor. Mild anxiety is considered normal for a woman during labor and birth. However, excessive anxiety and fear causes more catecholamine secretion, which increases the stimuli to the brain from the pelvis because of decreased blood flow and increased muscle tension; this in turn magnifies pain (Lowe, 1996). Thus, as fear and anxiety heighten, muscle tension increases, the effectiveness of the uterine contractions decreases, the experience of discomfort increases, and a cycle of increased fear and anxiety begins.
Previous experience
For women who have had a difficult and painful previous birth experience, anxiety and fear from this past experience may lead to increased pain. Conversely, a woman who has experienced a labor and birth where pain coping skills were successful may experience increased anxiety when those previous coping skills are ineffective during a more difficult labor and birth.
Women with a history of substance abuse experience as much pain during labor as other women. Although it is usually unnecessary to withhold pain medications, close monitoring for complications associated with each substance is part of the nursing assessment.
Pain is a personal response in each individual. As pain is experienced, people develop various coping mechanisms to deal with it. Emotional tension from anxiety and fear may increase pain and perception of pain during labor (see discussion of the Dick-Read method later in this chapter). Pain, or the possibility of pain, can induce fear in which anxiety borders on panic. Fatigue and sleep deprivation magnify pain. Parity may affect perception of labor pain because nulliparous women have longer labors and thus greater fatigue, causing a vicious cycle of increased pain and a more likely use of pharmacologic support.
Childbirth preparation
Even pain stimuli that are particularly intense can, at times, be ignored. This is possible because certaierve cell groupings within the spinal cord, brainstem, and cerebral cortex have the ability to modulate the pain impulse through a blocking mechanism. The gate-control theory of pain helps explain the way hypnosis and pain relief techniques taught in childbirth preparation classes work to relieve the pain of labor. According to this theory, pain sensations travel along sensory nerve pathways to the brain, but only a limited number of sensations, or messages, can travel through these nerve pathways at one time. Using distraction techniques such as massage or stroking, music, and imagery reduces or completely blocks the capacity of nerve pathways to transmit pain. These distractions are thought to work by closing down a hypothetic gate in the spinal cord, thus preventing pain signals from reaching the brain. Perception of pain is thereby diminished.
In addition, when the laboring woman engages ieuromuscular and motor activity, activity within the spinal cord itself further modifies the transmission of pain. Cognitive work involving concentration on breathing and relaxation requires selective and directed cortical activity that activates and closes the gating mechanism as well. The gate-control theory therefore underscores the need for a supportive birth setting that allows the laboring woman to relax and use various higher mental activities.
Comfort
Although the predominant medical approach to labor is that it is painful and the pain must be removed, an alternative view is that labor is a natural process and women can experience comfort and transcend the discomfort or pain (Schuiling & Sampselle, 1999). Having needs and desires met engenders a feeling of comfort. Comfort may be viewed as strengthening; this represents a paradigm shift in the interpretation of pain in labor (Schuiling & Sampselle, 1999). The most helpful interventions in enhancing comfort are a caring nursing approach and a supportive presence.
Support
The pain occurring during childbirth and the management of this pain belong to the woman experiencing the pain; the nurse must engage in a cooperative effort to provide whatever external tools the woman requires to manage her pain experience (Lowe, 1996). These tools include both nonpharmacologic and pharmacologic interventions. The presence of a person (e.g., doula, family member, friend) who provides physical, emotional, and psychologic support to the woman in labor is a beneficial form of care that significantly decreases intervention and complication rates associated with labor (Enkin et al., 2001; Righard, 2001).
Endorphins
Endorphins are endogenous opioids secreted by the pituitary gland that act on the central and peripheral nervous systems to reduce pain. Beta-endorphin is the most potent of the endorphins. The physiologic role of endorphins is not completely understood. It is thought that endorphin levels increase during pregnancy and birth in humans and may increase the ability of women in labor to tolerate acute pain and may reduce their irritability and anxiety. Levels of beta-endorphins are higher when a woman experiences a spontaneous, natural childbirth (Righard, 2001).
NONPHARMACOLOGIC MANAGEMENT OF DISCOMFORT
The alleviation of pain is important. Commonly, it is not the amount of pain the woman experiences, but whether she meets her goals for herself in coping with the pain that influences her perception of the birth experience as “good” or “bad.” The observant nurse looks for clues to the woman’s desired level of control in the management of pain and its relief.
The woman who chooses to deal with childbirth pain using nonpharmacologic or a combination of nonpharmacologic and pharmacologic methods needs care and support from nurses and other care providers who are skilled in pain management. Nonpharmacologic methods for relief of discomfort are taught in many different types of prenatal preparation classes. Regardless of whether a woman or couple has attended these classes or read various books and magazines on the subject in advance, the nurse can teach the woman techniques to relieve discomfort while labor is in progress.
CHILDBIRTH PREPARATION METHODS
Most health care providers recommend or offer childbirth preparation classes to expectant parents. The major methods taught in the
How childbirth education influences a woman’s response to pain is not completely understood. Some data indicate that women who attend childbirth classes report less pain throughout labor and birth than do women who are unprepared, but other investigations have not supported this finding (Lowe, 1996). However, combined results of a number of studies suggest that not only is confidence greater after childbirth preparation but that this confidence is related to decreased pain perception and decreased analgesia during labor (Lowe, 1996).
Dick-Read method
To replace fear of the unknown with understanding and confidence, the Dick-Read method (Dick-Read, 1987) provides information on labor and birth, as well as nutrition, hygiene, and exercise. Classes include practice in three techniques: physical exercise to prepare the body for labor, conscious relaxation, and breathing patterns.
Conscious relaxation involves progressive relaxation of muscle groups in the entire body. With practice, many women can relax on command, both during and between contractions. Some woman actually sleep between contractions.
Breathing patterns include deep abdominal respirations for most of labor, shallow breathing toward the end of the first stage, and, until recently, breath holding for the second stage of labor.
Teachers of the Dick-Read method also contend that the weight of the abdominal musculature of the contracting uterus increases pain. The woman is taught to force her abdominal muscles to rise as the uterus rises forward during a contraction, thus lifting the abdominal muscles off the contracting uterus.
Lamaze method
The Lamaze (psychoprophylaxis) method grew out of Pavlov’s work on classical conditioning. According to Lamaze, pain is a conditioned response. Therefore women can also be conditioned not to experience pain in labor. The Lamaze method does this by conditioning women to respond to mock uterine contractions with controlled muscular relaxation and breathing patterns instead of crying out and losing control (Lamaze, 1972). Coping strategies also include concentrating on a focal point, such as a favorite picture or pattern, to keep nerve pathways occupied so that they cannot respond to painful stimuli.
Fig. 2 Expectant parents learning relaxation techniques. (Courtesy Marjorie Pyle, RNC, Lifecircle,
The woman is taught to relax uninvolved muscle groups while she contracts a specific muscle group (Fig. 2). She applies this during labor by relaxing uninvolved muscles while her uterus contracts. The perception of maintaining control has also been found to be closely associated with satisfaction with the birth experience.
Lamaze teachers believe that chest breathing lifts the diaphragm off the contracting uterus, thus giving it more room to expand. The chest-breathing patterns are varied according to the intensity of the contractions and the progress of labor. Teachers also seek to eliminate fear by increasing the woman’s understanding of her body functions and the neurophysiology of pain. Support in labor is provided by the woman’s partner or other support person or by a specially trained labor attendant termed a monitrice.
Bradley method
The Bradley method, also called husband-coached childbirth, was devised based on observations of animal behavior during birth. It emphasizes working in harmony with the body, using breath control and abdominal breathing, and promoting general body relaxation (Bradley, 1981).
The husband or partner takes an active role in assisting the woman to relax and use correct breathing techniques. This method also stresses environmental factors such as darkness, solitude, and quiet to make childbirth a more natural experience.
Comparison of childbirth methods
Most proponents of prepared childbirth agree that the major causes of pain in labor are fear and tension. All childbirth methods attempt to reduce fear, tension, and pain by increasing the woman’s knowledge of the labor and birth process, enhancing her self-confidence and sense of control, preparing a support person, and training the woman in physical conditioning and relaxation breathing. Women or couples should not expect a pain-free childbirth but rather a childbirth in which pain is controlled using a variety of methods including prepared childbirth techniques.
There are a few fine differences in approach. For example, in the Bradley method, women are discouraged from using medication and encouraged to focus inwardly and to take direction from their own body. In the Lamaze method, external focusing and distraction are stressed. In reality, few instructors adhere strictly to one particular method, but instead incorporate a variety of strategies aimed at increasing the woman’s ability to cope with labor and minimize her need for medication.
RELAXING AND BREATHING TECHNIQUES
Focusing and feedback relaxation
Attention focusing and distraction techniques are forms of care likely to be beneficial in relieving labor pain (Enkin et al., 2001). Some women bring a favorite object, such as a photograph, to the labor room and focus their attention on this object during contractions. Others choose to fix their attention on some object in the labor room. In either event, as the contraction begins, they focus on the object to reduce their perception of pain. With imagery, the nurse encourages the woman to focus on a pleasant scene, a place where she feels relaxed, or an activity she enjoys. She can imagine a walk through a restful garden or breathing in light, energy, and healing color and breathing out worries and tension (Hoffart & Pross-Keene, 1998). These techniques, coupled with feedback relaxation, help the woman work with her contractions rather than against them. The support person monitors this process, telling the woman when to begin the breathing techniques (Fig. 3).
Fig. 3 Laboring woman using focusing and breathing techniques during a uterine contraction with coaching from her partner. (Courtesy Marjorie Pyle, RNC, Lifecircle,
In a common feedback mechanism, the woman and her coach say the word “relax” at the onset of each contraction and throughout it as needed. The nurse can assist the woman by providing a quiet environment and offering cues as needed.
Music
Music, taped or live, cues rhythmic breathing and enhances relaxation during labor, thereby reducing stress, anxiety, and pain. Women should be encouraged to bring their musical preferences and tape or compact disc players to the hospital or birthing center. Use of a headset or earphones may increase the effectiveness of the music because other sounds will be shut out. A study of Lamazetrained women suggested that women who listened to ocean waves and Baroque and New Age music demonstrated an improvement in relaxation responses when compared with women who used only progressive relax ation techniques (Wiand, 1997). Nurses can be advocates for implementation of this complementary therapy by developing protocols for the use of music, assessing a woman’s desire to use music during labor, and mobilizing the musical talents of the woman, her family, and even health care providers (Olsen, 1998).
Breathing techniques
Different approaches to childbirth preparation stress the use of varying breathing techniques to provide distraction, thereby helping the woman maintain control through contractions. In the first stage of labor, such breathing techniques can promote relaxation of the abdominal muscles and thereby increase the size of the abdominal cavity. This lessens the discomfort generated by friction between the uterus and abdominal wall during contractions. Because the muscles of the genital area also become more relaxed, they do not interfere with descent. In the second stage, breathing is used to increase abdominal pressure and thereby assist in expelling the fetus. It can also be used to relax the pudendal muscles to prevent precipitate expulsion of the fetal head.
For couples who have prepared for labor by practicing such relaxing and breathing techniques, occasional reminders may be all that is necessary to help them along. For those who have had no preparation, instruction in simple breathing and relaxation can be given early in labor and often is surprisingly successful. Motivation is high, and readiness to learn is enhanced by the reality of labor.
There are various breathing techniques for controlling pain during contractions. The nurse needs to ascertain what, if any, techniques the laboring couple knows before giving them instruction. Simple patterns are more easily learned. Paced breathing is the technique most associated with prepared childbirth. The Lamaze method uses slowpaced, modified, and patterned breathing techniques with the understanding that each labor is different and that coupies need to adapt breathing techniques to their individual birth experience.
All patterns begin with the routine cleansing breath and end with a deep breath exhaled to “blow the contraction away.” In general, slow abdominal breathing, approximately half the woman’s normal breathing rate, is initiated when the woman cao longer walk or talk through contractions (Box-1). As contractions increase in frequency and intensity, the woman ofteeeds to change to a more complex, chest breathing pattern, which is more shallow and approximately twice her normal rate of breathing. This pattern would require more concentration and therefore block more painful stimuli than a simple breathing pattern.
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Breathing Techniques CLEANSING BREATH Relaxed breath in through nose and out mouth. Used at the beginning and end of each contraction. SLOW-PACED BREATHING (APPROXIMATELY 6 TO 8 BREATHS PER MINUTE) Not less than half normal breathing rate (no. breaths/min divided by 2) IN-2-3-4/OUT-2-3-4/IN-2-3-4/OUT-2-3-4 … MODIFIED-PACED BREATHING (APPROXIMATELY 32 TO 40 BREATHS PER MINUTE) Not more than twice normal breathing rate (no. breaths/min times 2) IN-OUT/IN-OUT/IN-OUT/IN-OUT … For more flexibility and variety, the woman may combine the slow and modified breathing by using the slow breathing for beginnings and ends of contractions and modified breathing for more intense peaks. This technique conserves energy, lessens fatigue, and reduces risk for hyperventilation. PATTERNED-PACED BREATHING (SAME RATE AS MODIFIED) Enhances concentration a. 3:1 Patterned breathing IN-OUT/IN-OUT/IN-OUT/IN-BLOW (repeat through contraction) b. 4:1 Patterned breathing IN-OUT/IN-OUT/IN-OUT/IN-OUT/IN-BLOW (repeat through contraction) You may do any pattern desired, although ratios of 5:1 or higher tend to be very tiring. Some people like to do patterned breathing to a tune (“Yankee Doodle,” “Old McDonald”), to a repeated phrase (“I think I can, I think I can”), or in a pyramid pattern such as 1:1, 2:1, 3:1, 4:1, 5:1-5:1, 4:1, 3:1, 2:1, 1:1. c. Coach call: May be used when the womaeeds more distraction and concentration (e.g., during transition). The woman’s coach signals the breathing ratio with his or her fingers or by verbal cues, changing the ratio after each “IN-BLOW.” Example: IN-OUT/IN-OUT/IN-BLOW IN-OUT/IN-OUT/IN-OUT/IN-OUT/IN-BLOW IN-OUT/IN-BLOW From Shapiro, H. et al. (1997). The Lamaze ready reference guide for labor and birth (2nd ed.). |
The most difficult time to maintain control during contractions comes when the cervix dilates to 8 to 10 cm. This phase is the transition phase of the first stage of labor. Even for the woman who has prepared for labor, concentration on breathing techniques is difficult to maintain. The type of technique used during this phase may be the 4:1 pattern: breath, breath, breath, breath, blow (as though blowing out a candle). This ratio may be increased to 6:1 or 8:1. An undesirable side effect of this type of breathing may be hyperventilation. The woman and her support person must be aware of and watch for symptoms of the resultant respiratory alkalosis: light-headedness, dizziness, tingling of the fingers, or circumoral numbness. Respiratory alkalosis may be eliminated by having the woman breathe into a paper bag held tightly around the mouth and nose. This enables her to rebreathe carbon dioxide and replace the bicarbonate ion. She can also breathe into her cupped hands if no bag is available. Maintaining a breathing rate that is no more than twice the normal rate will lessen chances of hyperventilation. The partner can help the mother maintain her breathing rate using visual, tactile, or auditory means.
As the fetal head reaches the pelvic floor, the woman may experience the urge to push and may automatically begin to exert downward pressure by contracting her abdominal muscles. Nurses guide couples in the application of breathing and relaxation methods during labor, adapting methods to their particular needs, and using pushing techniques for birth that avoid a Valsalva response (Sampselle, 1999). Such techniques often involve moaning or other noise as women push without holding their breath.
The woman can control the urge to push by taking panting breaths or by slowly exhaling through pursed lips. This is good practice for the type of breathing to be used as the fetal head is slowly born.
Effleurage and counterpressure
Effleurage (light massage) and counterpressure are two methods that have brought relief to many women during the first stage of labor. The gate-control theory may supply the reason for the effectiveness of these measures. Effleurage is a light stroking, usually of the abdomen, in rhythm with breathing during contractions. It is used to distract the woman from contraction pain. Often the presence of monitor belts makes it difficult to perform effleurage on the abdomen; thus a thigh or the chest may be used. As labor progresses, hyperesthesia may make effleurage uncomfortable and thus less effective.
Counterpressure is steady pressure applied by a support person to the sacral area with the fist or heel of the hand, which may help the woman cope with the sensations of internal pressure and pain in the lower back. It is especially helpful when back pain is caused by pressure of the occiput against spinal nerves when the fetal head is in a posterior position. Counterpressure lifts the occiput off these nerves, thereby providing some pain relief. Although not scientifically evaluated, pressure may also be applied bilaterally to the hips or knees to reduce low back pain (Simkin & Ancheta, 2000). The support person will need to be relieved occasionally because application of counterpressure is hard work.
Water therapy
Bathing, showering, and jet hydrotherapy (whirlpool baths) using warm water are other nonpharmacologic measures that can be used to promote comfort and relaxation during labor (Fig. 4). Many new birthing units have baths with air jets. With or without air jets, however, the buoyancy of the warm water supports and soothes tense muscles.
Fig. 4 Water therapy during labor. A, Use of shower during labor. B, Woman experiencing back labor relaxes as partner sprays warm water on her back. C, Laboring woman relaxes in Jacuzzi. Note that fetal monitoring can continue during time in the Jacuzzi. (A and B courtesy Marjorie Pyle, RNC, Lifecircle,
Water therapy has several immediate benefits. General body relaxation and relief from discomfort reduce the woman’s anxiety, which in turn decreases adrenaline production. This triggers an increase in the levels of oxytocin (to stimulate uterine contractions) and endorphins (to reduce pain perception). In addition, the bubbles and gentle lapping of the water stimulate the nipples, which increases oxytocin production; this has not been observed to cause uterine hyperstimulation. The cervix has often been observed to dilate 2 to 3 cm in 30 minutes of whirlpool therapy. In addition, it promotes diuresis and a decrease in blood pressure (Simkin, 1995). Whirlpool baths during labor have also been found to have positive effects on analgesia requirements, instrumentation rates, condition of the perineum, and personal satisfaction with labor (Rush et al., 1996).
If the woman is experiencing “back labor” secondary to an occiput posterior or transverse position, she is encouraged to assume the hands-and-knees or the side-lying position in the tub. Because this position decreases pain and increases relaxation and production of oxytocin, the fetus can rotate spontaneously to the occiput anterior position.
In some settings, jet hydrotherapy may need to be approved by the woman’s physician or nurse-midwife. The woman’s vital signs must be withiormal limits, and she should be in the active phase of the first stage of labor. If she is in the latent phase, her contractions slow down (Odent, 1997). Fetal well-being must also be documented.
Fetal heart rate (FHR) monitoring is done by Doppler device, fetoscope, or wireless external monitor device (see Fig. 4, Q. Internal fetal monitoring is contraindicated during use of jet hydrotherapy. The woman’s membranes may be intact or ruptured. If ruptured, the fluid must be clear or only lightly stained with meconium (Simkin, 1995).
There is no limit to the time women can stay in the bath, and often women are encouraged to stay in it as long as desired. However, most women use jet hydrotherapy for 30-60 minutes (Schorn, McAllister&Blanco, 1993). After approximately 2 hours the effectiveness of hydrotherapy seems to diminish as uterine contractions become more intense (Eriksson et al, 1997; Odent, 1997).
During the bath, if the woman’s temperature and the FHR increase, the water is cooled or she is asked to step out of the bath to cool down. The bath water is kept between 36.7° and 37.8° C (Simkin, 1995). The mother’s temperature may remain slightly elevated for a short time after the bath. Fluids and ice chips and a cool face cloth are offered during the bath.
The tub must be kept meticulously clean. The cleansing solutions used vary with the institution; however, household bleach (Clorox) is commonly used.
Transcutaneous Blectrical nerve stimulation
Fig. 5 Placement of TENS electrodes on back for relief of labor pain.
Transcutaneous electrical nerve stimulation (TENS) involves placing of two pairs of electrodes on either side of the woman’s thoracic and sacral spine (Fig. 5). These electrodes provide continuous mild electrical currents from a battery-operated device. During a contraction the woman increases the stimulation by turning control knobs on the device. Women describe the resulting sensation as a tingling or buzzing and the pain relief as good or very good. The use of TENS poses no risk to the mother or fetus, and it is credited with reducing or eliminating the need for analgesia and with increasing the woman’s perception of control over the experience. It may be effective because of the placebo effect; that is, confidence in the effectiveness of TENS may stimulate the release of endogenous opiates in the woman’s body and thus alleviate the discomfort (Scott et al., 1999). At present, TENS is considered a form of care with insufficient quality data to recommend its use (Enkin et al., 2001).
The nurse assists the mother in using TENS by explaining the device and its use, by carefully placing and securing the electrodes, and by closely evaluating its effectiveness.
Other nonpharrnacologic methods
There are various other nonpharmacologic methods for control of the discomfort of labor (
). Many of these are taught in childbirth preparation classes. Most need practice for best results, although the nurse may use some of them successfully without the woman having prior knowledge.
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Nonpharmacologic Strategies to Encourage Relaxation and Relieve Pain CUTANEOUS STIMULATION STRATEGIES Counterpressure* Effleurage (light massage)* Touch and massage* Walking* Rocking* Changing positions* Application of heat or cold* Transcutaneous electrical nerve stimulation Acupressure Showers, baths SENSORY STIMULATION STRATEGIES Aromatherapy Breathing techniques* Music* Imagery* Use of focal points* COGNITIVE STRATEGIES Childbirth education* Hypnosis *Forms of care likely to be beneficial. From Enkin, M. et al. (2001). Effective care in pregnancy and childbirth: A synopsis. Birth, 28[\), 41-51. |
Acupressure. Acupressure techniques can be used in pregnancy, labor, and postpartum to relieve pain and other discomforts. Pressure, heat, or cold is applied to acupuncture points called tsubos. These points have an increased density of neuroreceptors and increased electrical conductivity. The effectiveness of acupressure has been attributed to the gate-control theory and an increase in endorphin levels (Tiran & Mack, 2000). Acupressure is best applied over the skin without using lubricants. Pressure is usually applied with the pads of the thumbs and fingers (Fig. 6). Synchronized breathing by the caregiver and the woman is suggested for greater effectiveness. Acupressure points include shoulders, low back, hips, ankles, nails on the small toes, soles of the feet, and sacral points
Fig. 6 Ho-Ku acupressure point (back of hand where thumb and index finger come together) used to enhance uterine contractions without increasing pain. (From Dickason, E., Silverman, B., & Kaplan, J. [1998]. Maternal-infant nursing care [3rd ed.].
Application of heat and cold. Warmed blankets, warm compresses, a warm bath or shower, or use of a moist heating pad can enhance relaxation and reduce pain during labor. Heat acts to relieve muscle ischemia and increase blood flow to the area of discomfort. Heat application is effective for back pain caused by a posterior presentation or general backache from fatigue (Simkin, 1995).
Cold application such as cool cloths or ice packs may be effective in increasing comfort when the woman feels warm and may be applied to areas of pain. Cooling relieves pain by lowering the muscle temperature and relieving muscle spasms (Simkin, 1995).
Heat and cold may be used alternately for a greater effect. Neither heat nor cold should be applied over ischemic or anesthetized areas because tissues can be damaged.
Touch. Touch and massage are forms of care likely to be beneficial in relieving labor pain (Enkin et al., 2001). Therapeutic touch (TT) uses the concept of energy fields within the body called prana. Prana are thought to be deficient in some people who are in pain. Therapeutic touch uses laying on of hands by a specially trained person to redirect energy fields associated with pain (Mackey, 1995). Little is known about the use or effectiveness of therapeutic touch for relieving labor pain.
Healing touch (HT) is another energy-based touch healing modality. Whereas TT emphasizes a single sequence of energy modulation, HT combines a variety of techniques from a series of disciplines. This gives the practitioner an array of “tools” to use with patients. Practitioners are taught energetic diagnosis and treatment forms and the means for documenting the patient’s response and progress. These techniques are said to align and balance the human energy field, thereby enhancing the body’s ability to heal itself. HT has been used in labor management, but at present, no studies have been published about its effectiveness (HoverKramer et al, 1996) (Fig. 7).
Fig. 7 Healing touch used for labor care. (Courtesy Wendy Wetzel,
Hypnosis. Hypnosis, although not commonly used for pain management in the
Biofeedback. Biofeedback is another relaxation technique that can be used for labor. Biofeedback is based on the theory that if a person can recognize physical signals, certain internal physiologic events can be changed (i.e., whatever signs the woman has that are associated with her pain). A woman must be educated to become aware of her body and its responses and how to relax for biofeedback to be effective (Alexander & Steeful, 1995). Informational biofeedback helps couples develop awareness of their bodies and learn strategies to change their responses to stress. If the woman responds to pain during a contraction with tightening muscles, frowning, moaning, and breath holding, her partner uses verbal and touch feedback to help her relax (Alexander & Steeful, 1995). Formal biofeedback, which uses machines to detect skin temperature, blood flow, or muscle tension, can also prepare women to intensify their relaxation response.
Aromatherapy. Aromatherapy uses oils distilled from plants, flowers, herbs, and trees to promote health and wellbeing and to treat illnesses. The use of herbal teas and vapors is reported to have good effects in pregnancy and labor for some women (Tiran & Mack, 2000). Lavender, clary sage, and bergamot promote relaxation and can be used by adding a few drops to a warm bath, to warm water used for soaking compresses that can be applied to the body, to an aromatherapy lamp to vaporize a room, or to oil for a back massage (
NURSE ALERT Caution: Never apply the oils used for aromatherapy full strength directly to the skin.
PHARMACOLOGIC MANAGEMENT OF DISCOMFORT
Pharmacologic measures for pain management should be implemented before pain becomes so severe that catecholamines increase and labor is prolonged. Pharmacologic and nonpharmacologic measures, when used together, increase the level of pain relief and create a more positive labor experience for the woman and her family. Often, less pharmacologic intervention is required because nonpharmacologic measures enhance or potentiate the analgesic effect (Faucher & Brucker, 2000).
SEDATIVES
Sedatives such as barbiturates relieve anxiety and induce sleep only in prodromal or early latent labor and in the absence of pain. If the woman is experiencing pain, sedatives given without an analgesic may increase apprehension and cause the mother to become hyperactive and disoriented. Undesirable side effects include respiratory and vasomotor depression of both the mother and newborn. These effects are increased if a barbiturate is administered with another central nervous system (CNS) depressant such as an opioid analgesic. Because of these disadvantages, barbiturates are seldom used (Faucher & Brucker, 2000; Scott et al., 1999).
ANALGESIA AND ANESTHESIA
Nursing management of obstetric analgesia and anesthesia combines the nurse’s expertise in maternity care with a knowledge and understanding of anatomy and physiology and of medications and their desired and undesired side effects and methods of administration.
Anesthesia encompasses analgesia, amnesia, relaxation, and reflex activity. Anesthesia abolishes pain perception by interrupting the nerve impulses going to the brain. The loss of sensation may be partial or complete, sometimes with the loss of consciousness.
The term analgesia is best reserved to describe the alleviation of the sensation of pain or the raising of the threshold for pain perception but without loss of consciousness. The type of analgesic or anesthetic chosen is determined in part by the stage of labor the woman is in and by the method of birth planned (
).
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Pharmacologic Control of Discomfort by Stage of Labor and Method of Birth FIRST STAGE Systemic analgesia Narcotic analgesic compounds Mixed narcotic agonist-antagonist compounds, analgesic potentiators Nerve block analgesia/anesthesia Lumbar epidural analgesia SECOND STAGE Nerve block analgesia/anesthesia Local infiltration anesthesia Pudendal block Subarachnoid (spinal) anesthesia Epidural block Epidural and spinal narcotics Inhalation analgesia/anesthesia Nitrous oxide/oxygen General anesthesia VAGINAL BIT Local infiltration Pudendal block Lumbar epidural block Analgesia Anesthesia Subarachnoid block Analgesia Anesthesia CESAREAN BIRTH Subarachnoid block Spinal block Saddle block (low spinal) Lumbar epidural block Anesthesia Inhalation General anesthesia |
Systemic analgesia
Systemic analgesia remains the major method of analgesia for the woman in labor when personnel trained in regional analgesia are not available (Scott et a l , 1999). Systemic analgesics cross the blood-brain barrier to provide central analgesic effects. They also cross the placental barrier. Effects on the fetus depend on the maternal dosage, the pharmacokinetics of the specific medication, and the route and timing of administration. Intravenous (TV) administration is often preferred over intramuscular (IM) administration because the onset of the medication’s effect is faster and more reliable; as a result a higher level of pain relief usually occurs. Classes of analgesics used to relieve the pain of childbirth include opioid (narcotic) agonists and opioid (narcotic) agonist-antagonists. Tranquilizers, such as ataractics, can be used to potentiate the analgesic effect of the opioid analgesics.
Opioid (narcotic) agonist analgesics. Opioid (narcotic) agonist analgesics such as meperidine (Demerol) and fentanyl (Sublimaze) are especially effective for the relief of severe, persistent, or recurrent pain. They have no amnesic effect (see Medication Guides).
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Medication Guide |
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Meperidine is the most commonly used opioid agonist analgesic for women in labor (Faucher & Brucker, 2000; Scott et al., 1999). It overcomes inhibitory factors in labor and may even relax the cervix. After IV injection, the onset of its effect is rapid (30 to 60 seconds); the maximum effect is reached in 5 to 7 minutes and lasts for approximately 2 to 4 hours. The peak effect after an IM injection of meperidine is reached in 30 to 50 minutes. Ideally, birth should occur less than 1 hour or more than 4 hours after an IM injection so that neonatal CNS depression resulting from meperidine is minimized. Because tachycardia is a possible side effect, meperidine is used cautiously in women with cardiac disease (Faucher & Brucker, 2000; Lehne, 2001) (see Medication Guide).
Fentanyl is a potent, short-acting opioid agonist analgesic (see Medication Guide). Onset of the medication effect after IV injection occurs within 2 minutes and lasts approximately 30 to 60 minutes. Onset of the medication effect occurs within 7 to 8 minutes after IM injection, reaches its peak effect in 20 to 30 minutes, and lasts for 1 to 2 hours. Additive CNS and respiratory depression occurs if fentanyl is given with alcohol, antihistamines, antidepressants, or other sedative-hypnotics. Fentanyl is commonly used alone or in combination with a local anesthetic agent for induction of an epidural block (Faucher & Brucker, 2000).
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Medication Guide Fentanyl (Sublimaze) and Sufentanil (Sufenta) |
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ACTION |
Opioid analgesics, rapid action with short duration (1-2 hr) |
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INDICATION |
For epidural or intrathecal analgesia, usually in combination with a local anesthetic |
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DOSAGE AND ROUTE |
Fentanyl —IM 50 to 100 /j,g; IV 25 to 50 /xg Epidural—fentanyl, 1 to 2 g with 0.125% bupivacaine at rate of 8 to 10 ml/hr; sufentanil, 1 g with 0.125% bupivacaine at rate of 10 ml/hr |
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ADVERSE EFFECTS |
Dizziness, drowsiness, allergic reactions, rash, pruritus, respiratory depression, nausea and vomiting, urinary retention |
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NURSING CONSIDERATIONS |
Assess for respiratory depression; naloxone should be available as antidote |
Opioid (narcotic) agonist-antagonist analgesics. An agonist is an agent that activates or stimulates a receptor to act; an antagonist is an agent that blocks a receptor or a medication designed to activate a receptor. Opioid (narcotic) agonist-antagonist analgesics such as butorphanol (Stadol) and nalbuphine (Nubain), in the doses used during labor, provide analgesia without causing significant respiratory depression in the mother or neonate. Both IM and IV routes are used. Butorphanol and nalbuphine may be given during the first stage of labor. Neither of these analgesics is suitable for women with an opioid dependency, as a result of the antagonist activity (see Medication Guide).
Analgesic potentiators (ataractics). Phenothiazines, so-called tranquilizers, have the property of augmenting most of the desirable but few of the undesirable effects of analgesics or general anesthetics. These ataractics do not relieve pain but decrease anxiety and apprehension, as well as potentiate the opioid effects. This potentiation effect causes the two drugs to work together more effectively, so the opioid dose can be reduced. Analgesic potentiators include medications such as promethazine (Phenergan), propiomazine (Largon), hydroxyzine (Vistaril), and promazine (Sparine).
In addition to potentiating the effects of the analgesic, the ataractic (tranquilizer) also acts as an antinauseant and antiemetic. The combination of agents can be administered safely until the end of the first stage of labor. Because hydroxyzine is given only by IM injection in a large muscle, the onset of effect is slower and less predictable. Fetal or neonatal problems rarely develop when the mothers are given recommended doses.
Opioid (narcotic) antagonists. Opioids such as meperidine and fentanyl can cause excessive CNS depression in the mother, newborn, or both. Opioid (narcotic) antagonists, such as naloxone (Narcan), can promptly reverse the depressant effects. The mother must be told, however, that the pain she had been experiencing will return with the administration of the antagonist. In addition, the antagonist also counters the effect of the stress-induced levels of endorphins. An opioid antagonist is especially valuable if labor is more rapid than expected and birth is anticipated when the opioid is at its peak effect (i.e., the 1- to 4-hour window after administration). The antagonist may be given through the woman’s IV line, or it can be administered intramuscularly (see Medication Guide).
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Medication Guide Naloxone (Narcan) |
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ACTION |
Opioid antagonist |
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INDICATION |
Reverses opioid-induced respiratory depression in woman or newborn |
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DOSAGE AND ROUTE |
Adult, 0.4 to 2 mg IV/IM/SC, repeat at 2- to 3-min intervals until desired effect occurs; newborn, 0.1 mg/kg IV (umbilical vein); repeat as for adult, may also be given IM orSC |
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ADVERSE EFFECTS |
Maternal hypotension/hypertension, tachycardia, nausea and vomiting, drowsiness, nervousness |
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NURSING CONSIDERATIONS
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Woman should delay breastfeeding until medication is out of system; do not give if woman is opioid dependent—may cause abrupt withdrawal; if given to woman for reversal of respiratory depression due to opioid analgesic, pain will return |
NURSE ALERT An opioid antagonist must be administered cautiously to an opioid-dependent woman because it can precipitate abstinence syndrome (withdrawal symptoms) (see Signs of Potential Complications box).
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SIGN OF POTENTIAL COMPLICATIONS Maternal Opioid Abstinence Syndrome (OpioId/IMarcotic Withdrawal) Yawning, rhinorrhea (runny nose), sweating, lacrimation (tearing), mydriasis (dilation of pupils) Anorexia Irritability, restlessness, generalized anxiety Tremor Chills and hot flashes Piloerection (“gooseflesh”) Violent sneezing Weakness, fatigue, and drowsiness Nausea and vomiting Diarrhea, abdominal cramps Bone and muscle pain, muscle spasm, kicking movements |
An opioid antagonist can be given to the newborn to treat neonatal narcosis, which is a state of CNS depression in the newborn produced by an opioid. Affected infants may exhibit respiratory depression, hypotonia, lethargy, and a delay in temperature regulation. Alterations ieurologic and behavioral responses may be evident in the newborn for 72 hours after birth. Meperidine may be present in the neonate’s urine for up to 3 weeks. Some depression of attention and social responsiveness can be evident for up to 6 weeks after birth.
Nerve block analgesia and anesthesia
A variety of compounds are used in obstetrics to produce regional analgesia (some pain relief and motor block) and anesthesia (pain relief and motor block). Most of these drugs are related chemically to cocaine and end with the suffix –caine. This helps identify a local anesthetic.
The principal pharmacologic effect of local anesthetics is the temporary interruption of the conduction of nerve impulses, notably pain. Examples of common agents given in 0.25% to 1% solutions are lidocaine (Xylocaine), bupivacaine (Marcaine), chloroprocaine (Nesacaine), tetracaine (Pontocaine), and mepivacaine (Carbocaine).
Rarely, people are sensitive (allergic) to one or more local anesthetics. Such a reaction may include respiratory depression, hypotension, and other serious adverse effects. Atropine, antihistamines, oxygen, and supportive measures should reverse these effects. Sensitivity may be identified by administering minute amounts of the drug to be used to test for an allergic reaction.
Local infiltration anesthesia. Local infiltration anesthesia of perineal tissues is commonly used when an episiotomy is to be done and when time or the fetal head position does not permit a pudendal block to be administered (Scott et al., 1999). Rapid anesthesia is produced by injecting 1% lidocaine or 2% chloroprocaine into the skin and then subcutaneously into the region to be anesthetized. Epinephrine often is added to the solution to intensify the anesthesia in a limited region and to prevent excessive bleeding and systemic effects by constricting local blood vessels (Lehne, 2001). Repeated injection will prolong the anesthesia as long as needed.
Pudendal block. Pudendal block is useful for the second stage of labor, for episiotomy, and for birth. Although it does not relieve the pain from uterine contractions, it does relieve pain in the lower vagina, vulva, and perineum (Fig. 8, A). A pudendal nerve block must be administered 10 to 20 minutes before perineal anesthesia is needed.
Fig. 8 Pain pathways and sites of pharmacologic nerve blocks. A, Pudendal block: suitable during second and third stages of labor and for repair of episiotomy or lacerations. B, Epidural block: suitable for all stages of labor and for repair of episiotomy and lacerations.
The pudendal nerve traverses the sacrosciatic notch just medial to the tip of the ischial spine on each side. Injection of an anesthetic solution at or near these points anes thetizes the pudendal nerves peripherally (Fig. 9). The transvaginal approach is generally used because it is less painful for the woman, has a higher success rate, and tends to cause fewer fetal complications (Chestnut, 1999). Pudendal block does not change maternal hemodynamic or respiratory functions, vital signs, or the FHR. However, the bearing-down reflex is lessened or lost completely.
Fig. 9 Pudendal block. Use of needle guide (
If all branches of the pudendal nerve are anesthetized, analgesia is sufficient for a spontaneous vaginal birth, for outlet (low) forceps-assisted birth, or for vacuum-assisted birth. A pudendal block does not provide analgesia for uterine exploration or manual removal of the placenta (Scott et al., 1999).
Spinal anesthesia. In spinal block, local anesthetic is injected through the third, fourth, or fifth lumbar interspace into the subarachnoid space (Fig. 10), where the medication mixes with cerebrospinal fluid (CSF). This technique is commonly used for cesarean births. A low spinal block may be used for vaginal birth, but it is not suitable for labor. The spinal block given for cesarean birth provides anesthesia from the nipple (T6) to the feet. If used for vaginal birth, the anesthesia level is from the hips (T10) to the feet (Fig. 10, C).
Fig. 10 A, Membranes and spaces of spinal cord and levels of sacral, lumbar, and thoracic nerves. B, Cross section of vertebra and spinal cord. C, Level of anesthesia necessary for cesarean birth and for vaginal births.
For spinal block, the woman is positioned to widen the intervertebral space for ease of inserting the spinal needle and to allow the heavy anesthetic solution to flow downward (Fig. 12-11, A and B). The nurse supports the woman because she must remain still during the placement of the spinal needle. The insertion is made between contractions.
After the anesthetic has been injected, the woman may be positioned in an upright position to get the level of anesthesia for a vaginal birth or positioned supine if the level desired is for cesarean birth. The anesthetic effect usually begins 1 to 2 minutes after the anesthetic is injected and lasts 1 to 3 hours, depending on the type of agent used (Chestnut, 1999).
Fig 11 Position for spinal and epidural blocks. A, Lateral position. B, Upright position. C, Catheter for epidural taped to woman’s back with port segment with post segment located near shoulder (B and C courtesy Michael S. Clement, MD,
Marked hypotension, decreased cardiac output and placental perfusion, and respiratory inadequacy may occur during any spinal anesthesia. Therefore the woman receives hydration with IV fluids before injection of an anesthetic to decrease the potential for hypotension caused by sympathetic blockade. After injection, maternal blood pressure, pulse, respirations, and FHR must be checked and recorded every 5 to 10 minutes. If signs of serious maternal hypotension or fetal distress develop, emergency care must be given (see Emergency box).
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EMERGENCY Maternal Hypotension with Decreased Placental Perfusion SIGNS/SYMPTOMS Maternal hypotension (20% drop from preblock level or less than 100 mm Hg systolic) Fetal bradycardia Decreased beat-to-beat FHR variability INTERVENTIONS Turn woman to lateral position or place pillow or wedqe under hip (see Fig. 14-4) to deflect uterus Maintain IV infusion at rate specified, or increase prn per hospital protocol. Administer oxygen by face mask at 10-12 L/min or per protocol. Elevate the woman’s legs. Notify the Physician/midwife/anesthesiologist/nurse anesthetist. Administer IV vasopressor (e.g., ephedrine) per protocol Remain with woman; continue to monitor maternal blood pressure and FHR every 5 minutes until her condition is stable or per primary health care provider’s order. |
Because the mother is not able to sense her contractions, she must be instructed when to bear down during a vaginal birth. If the birth occurs in a delivery room (rather than a labor-delivery-recovery room), the mother will need assistance in the transfer to a recovery bed after delivery of the placenta.
Advantages of spinal anesthesia include ease of administration and absence of fetal hypoxia with maintenance of normotension. Maternal consciousness is maintained, excellent muscular relaxation is achieved, and blood loss is not excessive.
Disadvantages of spinal anesthesia include drug reactions (e.g., allergy), hypotension, and respiratory paralysis; cardiopulmonary resuscitation may be needed. When a spinal anesthetic is given, the need for operative delivery (i.e., episiotomy, low forceps extraction) tends to increase because the voluntary expulsive efforts are eliminated. After birth the incidence of bladder and uterine atony, as well as postspinal headache, is higher.
Leakage of CSF from the site of puncture of the meninges (membranous coverings of the spinal cord) is thought to be the major causative factor in postlumbar puncture (postspinal) headache. Presumably, postural changes cause the diminished volume of CSF to exert traction on pain-sensitive CNS structures. The resulting headache and auditory and visual problems may persist for days or weeks.
The likelihood of headache after lumbar puncture can be reduced, however, if the anesthesiologist uses a smallgauge spinal needle and avoids making multiple punctures or the meninges. Positioning the woman flat in bed (with only a small, flat pillow for her head) for at least 8 hours after spinal anesthesia has also been recommended to prevent headache, but there is no definitive evidence showing this measure is effective. Positioning the woman on her abdomen is thought to decrease the loss of CSF through the puncture site. Hydration has been claimed to be of value in preventing and treating headache, but there is no compelling evidence to support its use (Cunningham et al 2001) Initial treatment for post-lumbar puncture headache usually includes analgesics, bed rest, caffeine and increased fluid intake (e.g., 150 ml/hr intravenously) (American College of Obstetricians and Gynecologists 1996).
An autologous epidural blood patch is often beneficial; such treatment may be considered if the headache does not resolve spontaneously (Scott et al., 1999). To form a patch, a few milliliters of the woman’s blood without anticoagulant is injected epidurally at the site of the dura puncture (Fig. 12), which then forms a clot that covers the hole and prevents further fluid loss.
Fig. 12 Blood patch therapy for spinal headache.
Epidural block. Relief from the pain of uterine contractions and birth (vaginal and abdominal) can be accomplished by injecting a suitable local anesthetic alone or combined with an opioid agonist (e.g., fentanyl) into the epidural (peridural) space (see Figs. 8, B, and 10, A).
Complete lumbar epidural block for relieving the discomfort of labor and vaginal birth requires a block from T10 to S5. For cesarean birth, a block from at least T6 to SI is essential. The diffusion of epidural anesthesia depends on the location of the catheter tip, the dose and volume of the anesthetic agent used, and the woman’s position (e.g., horizontal or head-up position) (Cunningham et al., 2001).
For induction of lumbar epidural anesthesia, the woman is positioned as for a spinal injection (i.e., sitting) or in a modified Sims position (see Fig. 11). For the modified lateral Sims position, the woman is placed on her side with her shoulders parallel, legs slightly flexed, and back arched.
After the epidural has been started, the woman is preferably positioned on her side so that the uterus does not compress the ascending vena cava and descending aorta, which can impair venous return and decrease placental perfusion. Her position should be alternated from side to side every 30 to 60 minutes. Oxygen should be available to treat hypotension should it occur despite maintenance of hydration with IV fluid and displacement of the uterus to the side. Ephedrine (a vasopressor used to increase maternal blood pressure) and increased IV fluid infusion may be needed (see Emergency box). The FHR and progress in labor must be monitored carefully because the woman in labor may not be aware of changes in the strength of the uterine contractions or the descent of the presenting part.
A single injection or continuous infusion (via pump) through an indwelling plastic catheter results in excellent epidural analgesia-anesthesia. The advantages of an epidural block are numerous: the mother experiences excellent pain relief and remains alert and cooperative, good relaxation is achieved, airway reflexes remain intact, only partial motor paralysis develops, gastric emptying is not delayed, and blood loss is not excessive (see Research box). Fetal distress is rare but may occur in the event of rapid absorption or marked maternal hypotension. The dose, volume, and type of anesthetic can be modified to allow the mother to push, to produce perineal anesthesia, and to permit forceps or even cesarean birth if required (Cunningham et al, 2001).
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RESEARCH Fathers’ Experiences with Epidurals Researchers have documented the psychosocial response to pain in the laboring woman. Although keenly aware and socially responsive in early labor, women become increasingly introspective as labor progresses.They are no longer as responsive to partner or environment, detaching so as to focus inward. This can cause their partners discouragement and frustration. Epidural analgesia is increasingly becoming common pain management for labor, and women often respond to the pain relief by becoming more responsive to their partners and interacting in a positive manner during the labor experience. To examine expectant fathers’ responses to their experiences of labor before and after their partners received epidural anesthesia, a nurse researcher asked 17 men to describe their recent birth experiences. The fathers identified two stages, “losing her,” or detachment/lack of responsiveness before the epidural placement, and “she’s back,” or the relief from pain and return to interaction after the epidural placement. The fathers felt that they were poorly prepared for the severity of their partners’ pain.The fathers were frustrated and fearful when their attempts to relieve it were ineffective, even rebuffed. They used the word helpless repeatedly. When their partners received epidurals, the fathers expressed profound relief at the woman’s pain relief and her ability to interact with them again. IMPLICATIONS FOR PRACTICE Childbirth classes must present a realistic picture of labor. Couples need information about the normal introversion women experience as labor progresses and their partners’ possible feelings of anxiety, frustration, and helplessness. Partners need to know how to adapt to the laboring women’s changing responses. Labor nurses can reinforce what couples learned in childbirth classes and educate those couples who had no prenatal education. Nurses can also be proactive in pain management, and, if an epidural is the choice of the woman, they can reinforce information about epidural analgesia so that the woman and her partner know what to expect. Source: Chapman, L (2000). Expectant fathers and labor epidurals. MCNAm J Matern Child Nurs, 25(3), 133-138. |
The disadvantages of an epidural block for the woman include the need for an IV line, occasional dizziness, weakness of the legs, difficulty emptying the bladder, and shivering (Buggy & Bardiner, 1995; Youngstrom et al., 1996). Because a considerable amount of the drug must be used, adverse reactions or the rapid absorption of the anesthetic agent may result in maternal hypotension, convulsions, or paresthesia.
Data from retrospective studies and clinical trials indicate that epidural analgesia provides a higher level of pain relief than nonepidural pain relief measures. A relationship between epidural analgesia and longer first- and second-stage labor and increased incidence of fetal malposition, use of oxytocin, and forceps- or vacuum-assisted birth has been documented. Women who receive an epidural have a higher rate of fever, especially when labor lasts longer that 12 hours; the temperature elevation most likely is related to thermoregulatory changes, although infection cannot be ruled out. Current research findings have been unable to demonstrate a significant increase in cesarean birth associated with epidural analgesia (Howell, 2001; Lieberman, 1999; Thorpe & Breedlove, 1996). Occasionally, accidental high-spinal anesthesia (and later, postspinal headache) may follow inadvertent perforation of the dural membrane during the administration of lumbar epidural anesthesia.
For some women the epidural block is not effective, and a second form of analgesia is required to establish effective pain relief. When women progress rapidly in labor, pain relief may not be obtained before birth occurs.
Epidural and intrathecal opioids (narcotics). There is a high concentration of opioid receptors along the pain pathway in the spinal cord, in the brainstem, and in the thalamus. Because these receptors are highly sensitive to opioids, a small quantity of an opioid agonist produces marked analgesia that lasts for several hours. Medication (injected through a catheter placed in the epidural or subarachnoid space) reacts with these opioid receptors, and pain transmission is blocked without compromising motor ability. This so-called walking epidural restores the woman’s confidence in her ability to master labor no longer dominated by pain (Youngstrom et al., 1996).
The use of epidural or intrathecal opioids during labor has several advantages. These agents do not cause maternal hypotension or affect vital signs. The woman feels contractions but not pain. Her ability to bear down during the second stage of labor is preserved because the pushing reflex is not lost and her motor power remains intact.
Fentanyl, sufentanil, or preservative-free morphine may be used. Fentanyl and sufentanil produce short-acting analgesia (i.e., 1.5 to 3.5 hours), and morphine may provide pain relief for 4 to 7 hours. Morphine may be combined with fentanyl or sufentanil. The short-acting opioids are often used with multiparous women, and morphine may be used with nulliparous women or women with a history of long labors (Manning, 1996). For most women, intrathecal opioids do not provide adequate analgesia for second-stage labor pain, episiotomy, or birth (Cunningham et al., 2001). Pudendal blocks or local anesthetics may be necessary.
A more common indication for the administration of epidural or intrathecal opioids is the relief of postoperative pain. For example, women who give birth by cesarean receive fentanyl or morphine through the catheter. The catheter may then be removed, and the women are usually free of pain for 24 hours. Occasionally, the catheter is left in place in case another dose is needed.
Women who receive epidurally administered morphine after the cesarean birth are up soon after surgery with surprising ease and are able to care for their babies. The early ambulation and freedom from pain also facilitate bladder emptying. To those women who have had a previous cesarean birth and have experienced the usual postoperative pain, the effects of this approach seem miraculous. However, the mother may not understand why she may experience pain after the opioid effect wears off.
Side effects of opioids administered by the epidural and intrathecal route include nausea, vomiting, pruritus (itching), urinary retention, and delayed respiratory depression. These side effects are more common when morphine is administered. Antiemetics, antipruritics, and opioid antagonists are used to relieve these symptoms. For example, naloxone (Narcan), nalbuphine hydrochloride (Nubain), promethazine (Phenergan), or metoclopramide (Reglan) may be administered. Hospital protocols should provide specific instructions for the treatment of these side effects. Use of epidural opioids is not without risks. Respiratory depression is a serious concern; for this reason the woman’s respiratory rate should be assessed and documented every hour for 24 hours, or per the timing designated by hospital protocol. Naloxone should be readily available for use if the respiratory rate decreases below 10 breaths per minute or if the oxygen saturation rate drops below 89%. Administration of oxygen by face mask may also be initiated, and the anesthesiologist/anesthetist should be notified.
Contraindications to subarachnoid and epidural blocks. Some contraindications to epidural analgesia apply equally to caudal and subarachnoid blocks (Scott et al., 1999):
• Antepartum hemorrhage. Acute hypovolemia leads to increased sympathetic tone to maintain the blood pressure. Any anesthetic technique that blocks the sympathetic fibers can produce significant hypotension that can endanger the mother and baby.
• Anticoagulant therapy or bleeding disorder. If a woman is receiving anticoagulant therapy or has a bleeding disorder, injury to a blood vessel may cause the formation of a hematoma that may compress the cauda equina or the spinal cord and lead to serious CNS sequelae.
• Infection at the injection site. Infection can be spread through the peridural or subarachnoid spaces if the needle traverses an infected area.
• Allergy to the anesthetic drug.
Drug effects oeonate. Debate persists concerning the effects of epidural anesthesia on the newborn’s neurobehavioral responses. Findings from studies that examine associations between neurobehavioral outcome and epidural anesthesia are far from consistent. For example, studies comparing the neonatal neurobehavioral scores for infants born to mothers who did and mothers who did not receive epidural analgesia have shown either little or no difference in the scores (Hamza, 1994; Scherer & Holzgreve, 1995) or have shown that infants of mothers who received epidural anesthesia did not score as well oeurobehavioral tests (Sepkoski et al., 1992).
General anesthesia
General anesthesia rarely is used for uncomplicated vaginal birth and is infrequently used for cesarean birth. It may be necessary if there is a contraindication to nerve block analgesia or anesthesia or if indications necessitate rapid birth (vaginal or cesarean).
If general anesthesia is being considered, the nurse gives the womaothing by mouth and sees that an IV infusion is established. If time allows, the nurse premedicates the woman with a nonparticulate oral antacid such as sodium citrate (30 ml) to neutralize the acidic contents of the stomach. If there is sufficient time, some anesthesiologists/anesthetists and physicians also order the administration of a histamine blocker such as cimetidine to decrease the production of gastric acid and metoclopramide to increase gastric emptying (Scott et al., 1999). Before the anesthesia is given, a wedge should be placed under the woman’s right hip to displace the uterus to the left. Uterine displacement prevents aortocaval compression, which interferes with placental perfusion. Sometimes the nurse is asked to assist with applying cricoid pressure before intubation (Fig. 13)
Fig. 13 Technique for applying pressure on cricoid cartilage to occlude esophagus to prevent pulmonary aspiration of gastric contents during induction of general anesthesia.
Priorities for recovery room care are to maintain an open airway, maintain cardiopulmonary functions, and prevent postpartum hemorrhage. Routine postpartum care is organized to facilitate parent-infant attachment as soon as possible and to answer the mother’s questions. Whenever appropriate, the nurse assesses the mother’s readiness to see the baby, as well as her response to the anesthesia and to the event that necessitated general anesthesia (e.g., cesarean birth when vaginal birth was anticipated).
Inhalation analgesia and anesthesia
Nitrous oxide is the only inhalation agent used for obstetrics in the
Nitrous oxide is commonly used for cesarean births when inhalation anesthesia is needed. It is usually combined with oxygen in a 50:50 mixture. Thiopental, a shortacting barbiturate, combined with succinylcholine, a muscle relaxant, is given intravenously before tracheal intubation.
Other inhalation agents include halothane, enflurane or isoflurane, and methoxyflurane. These agents relax the uterus quickly and facilitate intrauterine manipulation, version, and extraction. However, these agents cross the placenta readily and can produce narcosis in the fetus. They are rarely used today in the
CARE MANAGEMENT
Assessment and Nursing Diagnoses
The assessment of the woman, her fetus, and her labor is a joint effort of the nurse and the physician or nursemidwife, who consult with the woman regarding their findings and recommendations. The needs of each woman are different, and many factors must be considered before deciding whether nonpharmacologic, a combination of nonpharmacologic and pharmacologic, or pharmacologic methods of pain management are used. A self-assessment tool, such as an analog scale, allows the woman to indicate on a line how severe she perceives her pain experience to be. Self-assessment is recommended to ensure that pain management is based on the subjective nature of the woman’s pain rather than on just the nurse’s judgment (Olden et al., 1995).
History
The woman’s prenatal record is read and relevant information identified. This includes the woman’s parity, estimated date of birth, and complications and medications during pregnancy. If the woman has a history of allergies, this is noted and a warning displayed in a prominent place. A history of smoking and neurologic and spinal disorders is also noted.
Interview
Interview data consist of the time of the woman’s last meal and the type of food consumed; the nature of any existing respiratory condition (cold, allergy); and unusual reactions to medications (e.g., allergy), cleansing agents, or tape. The woman is asked whether she attended childbirth preparation classes, and the extent of her preparation and preferences for management of discomfort are noted. Her knowledge of the options for the management of discomfort is also assessed. Information on the woman’s perception of discomfort and about her expressed need for medication are added to the database. Relevant events that have occurred since the woman’s last contact with the physician or nursemidwife are also reviewed (e.g., infections, diarrhea, change in fetal behavior). If verbal and physical signs indicate the existence of substance abuse, the nurse should ask the woman to identify the type of drug used, the last time the drug was taken, and the method of administration.
Physical examination
The character and status of the labor and fetal response are assessed during a physical examination. The nurse evaluates the woman’s hydration status by assessing intake and output measurements, the moistness of the mucous membranes, and skin turgor. Bladder distention is noted. Any evidence of skin infectioear sites of possible needle insertion is recorded and reported. Signs of apprehension such as fist clenching and restlessness are also noted.
If the woman is in labor, the status of maternal vital signs and FHR, uterine contractions, cervical effacement, and dilation; the station; and the anticipated time until birth are all considered. The length of labor and degree of fatigue are other important considerations. If pharmacologic methods are to be used, the type of analgesia or anesthesia chosen varies depending on the phase and stage of labor (see
).
Laboratory tests
The results of laboratory tests are reviewed to determine whether the woman is suffering from anemia (hemoglobin and hematocrit), coagulopathy or bleeding disorder (prothrombin time and platelet count), or infection (white blood cell count and differential).
The following nursing diagnoses are relevant in the management of discomfort during labor and birth:
• Risk for ineffective tissue perfusion related to
-effects of analgesia or anesthesia
-maternal position
• Hypothermia related to
-effects of analgesia or anesthesia
• Anxiety related to lack of knowledge concerning
-procedure for nerve block analgesia
-expected sensation during nerve block analgesia
-mother’s role during nerve block analgesia
-options for effective pain relief during labor
• Risk for injury to fetus related to
-maternal hypotension
-maternal position (aortocaval compression)
Expected Outcomes of Care
The expected outcomes for nursing care in the management of discomfort of labor and birth include the following:
• The woman will experience adequate pain relief without adding to maternal risk (e.g., through the use of appropriate nonpharmacologic methods and appropriate medication, including the appropriate dose, timing, and route of administration).
• The fetus will maintain well-being, and the neonate will adjust to extrauterine life.
• The woman, her partner, and her family will verbalize understanding of their needs in relation to the use of nonpharmacologic methods, analgesia, or anesthesia.
Plan of Care and Interventions
A plan of care is developed for each woman and should address her particular clinical and nursing problems. The nurse collaborates with the primary health care provider relevant to the woman and her family.
Nonpharmacologic interventions
The nurse supports and assists the woman as she uses nonpharmacologic interventions for pain relief and relaxation. During labor, the nurse should ask the woman how she feels in order to evaluate the effectiveness of the specific pain management techniques used. Appropriate interventions can then be planned or continued for effective care, such as trying other nonpharmacologic methods or combining nonpharmacologic methods with medications (see Plan of Care).
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PLAN OF CARE Nonpharmacologic Management of Discomfort NURSING DIAGNOSIS Acute pain related to physiologic response to labor Expected Outcome Woman will express decrease in intensity of discomfort and experience satisfaction with her labor and birth performance. Nursing Interventions/Rationales Assess whether woman and significant other have attended childbirth classes, her knowledge of labor process, and her current level of anxiety to plan supportive strategies. Encourage support person to remain with woman in labor to provide support and increase probability of response to comfort measures. Teach or review nonpharmacologic techniques available to decrease anxiety and pain during labor (e.g., focusing and feedback, breathing techniques, effleurage, and sacral pressure) to enhance chances of success in using techniques. Explore other techniques that the woman or significant other may have learned in childbirth classes (e.g., hypnosis, yoga, acupressure, biofeedback, therapeutic touch, aromatherapy, imaging, music) to provide largest repertoire of coping strategies. Explore use of jet hydrotherapy if ordered by physician or nurse-midwife and if woman meets use criteria (i.e., vital signs withiormal limits [WNL], cervix 4 to 5 cm dilated, active phase of first stage labor) to aid relaxation and stimulate production of natural oxytocin. Explore use of transcutaneous nerve stimulation per physician or nurse-midwife order to provide an increased perception of control over pain and an increase in release of endogenous opiates. Assist woman to change positions and to use pillows to reduce stiffness, aid circulation, and promote comfort. Assess bladder for distention and encourage voiding often to avoid bladder distention, subsequent discomfort, and inhibition of labor. Encourage rest between contractions to minimize fatigue. Keep woman and significant other informed about progress to allay anxiety. Guide couple through the labor stages and phases, helping them use and modify comfort techniques that are appropriate to each phase, to ensure greatest effectiveness of techniques employed. Support couple if pharmacologic measures are required to increase pain relief, explaining effectiveness and safety to reduce anxiety and maintain self-esteem and sense of control over labor process. |
The woman’s perception of her behavior during labor is of utmost importance. If she planned a nonmedicated birth but theeeds and accepts medication, her self-esteem may falter. Verbal and nonverbal acceptance of her behavior is given as necessary by the nurse and reinforced by discussion and reassurance after birth when possible. Explanations about fetal response to maternal discomfort, the effects of maternal fatigue on the progress of labor, and the medication itself are supportive measures. The woman may also be experiencing anxiety and stress related to the anticipated or actual pain. Stress can cause increased maternal catecholamine production. Raised levels of catecholamines have been linked to dysfunctional labor and fetal and neonatal distress and illness. Nurses must be able to implement strategies aimed at reducing this stress.
Informed consent
The physician or nurse-midwife and anesthesia care provider are responsible for informing women of the alternative methods of pharmacologic pain relief available in the hospital setting. A description of the various anesthetic techniques and what they entail is essential to informed consent, even if the woman has received information about analgesia and anesthesia earlier in her pregnancy. The discussion of pain management options should take place just before or early in labor so the woman has time to consider alternatives. Nurses play a part in the informed consent by clarifying and describing procedures or by acting as a patient’s advocate and asking the physician or nurse-midwife for further explanations. The procedure and its advantages and disadvantages must be thoroughly explained.
LEGAL TIP Informed Consent for Anesthesia
The woman receives (in an understandable manner) the following:
• Explanation of alternative methods of anesthesia and analgesia available
• Description of anesthetic and procedure for administration
• Description of the benefits, discomfort, risks, and consequences of the selected anesthetic for the mother and the fetus
• Explanation of how complications can be treated
• Information that the anesthetic is not always effective Indication that the woman may withdraw consent at any time
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• Be written in the woman’s primary language
• Have the woman’s signature
• Have the date of consent
• Carry the signature of anesthesia caregiver, certifying that the woman has received and appears to understand the explanation
Timing of administration
It is often the nurse who notifies the physician or nursemidwife that the woman is ieed of pharmacologic measures to relieve her discomfort. Orders often are written for the administration of pain medication as needed based on the nurse’s clinical judgment. Generally, pharmacologic measures for pain relief are avoided until labor has advanced to the active phase of the first stage of labor and the cervix has dilated to approximately 4 to 5 cm. See
for the pharmacologic measures used to manage the discomfort of labor, summarized by the stage of labor and method of birth.
Preparation for procedures
The nurse reviews the methods of pain relief available to the woman (or validates her choices) and clarifies information as necessary. The procedure and what will be asked of the woman (e.g., to maintain flexed position during insertion of epidural needle) must be explained. The woman can also benefit from knowing the way that the medication is to be given, the degree of discomfort to expect from administration of the medication, the sensations she can expect, the time required for administration, the interval before the medication takes effect, and the expected effect of the medication in terms of pain relief. The nurse explains the need for emptying the bladder before analgesic or anesthetic is given and explains the reason for keeping the bladder empty. When an indwelling epidural catheter is to be threaded, the woman should be told that she may experience a momentary twinge down her leg, hip, or back and that this feeling is not a sign of injury.
A long needle is used for pudendal blocks (see Fig. 9). The sight of this needle may be frightening, and the woman should be reassured that only the tip of the needle will be inserted.
Administration of medications
Accurate monitoring of the progress of labor forms the basis for the nurse’s judgment that a womaeeds pharmacologic control of discomfort. Knowledge of the medications that are used during childbirth is essential. The most effective route of administration is selected for each woman; then the medication is prepared and administered correctly.
Intravenous route. The preferred route of administration of medications such as meperidine or fentanyl is through IV tubing, administered into the port nearest the woman while the infusion of IV solution is stopped. The medication is given slowly in small doses at the beginning of a contraction and over three to five consecutive contractions. Because uterine blood vessels are constricted during contractions, the medication stays within the maternal vascular system for several seconds before the uterine blood vessels reopen. The IV infusion is then restarted slowly to prevent a bolus of medication from forming. Using this method of injection, the amount of drug crossing the placenta to the fetus is minimized. With decreased placental transfer, the mother’s degree of pain relief is maximized.
The IV route is associated with the following advantages:
• The onset of pain relief is more predictable.
• Pain relief is obtained with small doses of the drug.
• The duration of effect is more predictable.
Intramuscular route. IM injections of analgesics, although still used, are not the preferred route of administration for women in labor. Identified disadvantages of the IM route include the following:
• The onset of pain relief is delayed.
• Higher dosages of medication are required.
• Medication from the muscle tissue is released at an unpredictable rate and is available for transfer across the placenta to the fetus.
IM injections are given in the upper portion of the arm (deltoid site) if regional anesthesia is planned later in labor. This is the preferred site because the autonomic blockade from the regional (e.g., epidural) anesthesia increases blood flow to the gluteal region and accelerates absorption of the drug. The maternal plasma level of the drug necessary to bring pain relief usually is reached 45 minutes after IM injection, followed by a decline in plasma levels. The maternal drug levels (after IM injections) are unequal because of uneven distribution (maternal uptake) and metabolism. The advantage of using the IM route is quick administration.
Nerve blocks. An IV line is established before the induction of nerve blocks such as epidural, spinal, and general anesthesia. Anesthesia protocols usually include the administration of a bolus of IV fluid before giving the anesthesia to expand the blood volume to prevent maternal hypotension.
Lactated Ringer’s or Plasma-Lyte A and normal saline solutions are the preferred infusion solutions. Infusion solutions without dextrose are preferred, especially when the solution must be infused rapidly (e.g., to treat severe dehydration or to maintain blood pressure) because solutions containing dextrose rapidly raise the maternal blood glucose levels. The fetus responds to high blood glucose levels by increasing insulin production; fetal or neonatal hypoglycemia may result. In addition, dextrose changes osmotic pressure, so fluid is excreted from the kidneys more rapidly.
The womaeeds assistance in assuming and maintaining the correct position for epidural and spinal anesthesia (see Fig. 11).
Signs of potential problems
Any medication can cause an allergic reaction that may be minor or as severe as anaphylaxis. Minor reactions can consist of a rash, rhinitis, fever, asthma, or pruritus. Management of the less acute allergic response is not an emergency. As part of the assessment for such allergic reactions, the nurse should monitor the woman’s vital signs, respiratory status, cardiovascular status, platelet count, and white blood cell count. The woman is observed for side effects of medications, especially drowsiness (Lehne, 2001).
Severe reactions may occur suddenly and lead to shock. The most dramatic form of anaphylaxis is sudden severe bronchospasm, vasospasm, severe hypotension, and death. Signs of anaphylaxis are largely caused by contraction of smooth muscles and may begin with irritability, extreme weakness, nausea, and vomiting. This may lead to dyspnea, cyanosis, convulsions, and cardiac arrest. The acute allergic reaction (anaphylaxis) must be diagnosed and treated immediately. Treatment usually consists of 1:1000 epinephrine injected subcutaneously or intramuscularly, followed by parenteral administration of antihistamines. Supportive care is given to alleviate symptoms; the type of care is determined by the rapidly assessed cardiovascular and respiratory response of the woman to primary interventions. Cardiopulmonary resuscitation may be necessary. The nurse must also be alert to fetal well-being; any nonreassuring changes in FHR and FHR pattern should be noted and reported to the physician or nurse-midwife.
Safety and general care
After administration of a nerve block, the woman is protected from injury by raising the side rails and by placing a call bell within easy reach for times when the nurse is not in attendance. Oxygen and suction should be readily available at the bedside. The nurse must make sure there is no prolonged pressure on an anesthetized part (e.g., no lying on one side with weight on one leg; no tight linen on feet). If stirrups are used for birth, the nurse should pad them, adjust both stirrups at the same level and angle, place both of the woman’s legs into them simultaneously while avoiding putting pressure against the popliteal angle, and apply restraints without restricting circulation.
The nurse monitors and records the woman’s response to nonpharmacologic pain relief methods and to medication. This includes the level of pain relief, the level of apprehension, the return of sensations and perception of pain, and allergic or untoward reactions (e.g., hypotension, respiratory depression, hypothermia). The nurse continues to monitor maternal vital signs, blood pressure, strength and frequency of uterine contractions, changes in the cervix and station of the presenting part, presence and quality of the bearing-down reflex, bladder filling, and state of hydration. Determining the fetal response after administration of analgesia or anesthesia is vital. The woman is asked if she (or the family) has any questions. The nurse also assesses the woman’s and her family’s understanding of the need for ensuring her safety (e.g., keeping side rails up, calling for assistance as needed).
The time that elapses between the administration of a narcotic and the baby’s birth is noted. Medication given to the newborn to reverse narcotic effects is recorded. Postpartum, the woman who has had spinal, epidural, or general anesthesia is assessed for return of sensory and motor sensation in addition to the usual postpartum assessments.
Evaluation
Evaluation of the effectiveness of care of the womaeeding management of discomfort during labor and birth is based on the previously stated outcomes (see Plan of Care).
Nursing Care During Labor and Birth
For 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 and her family begin the attachment process with the infant. Nursing care management focuses on assessment and support of the woman and her family throughout childbirth with the goal of ensuring the best possible outcome for all involved.
FIRST STAGE OF LABOR
CARE MANAGEMENT
The first stage of labor begins with the onset of regular uterine contractions and ends with complete cervical effacement and dilation. Labor care begins when the woman reports one or more of the following:
• Onset of progressive, regular uterine contractions that increase in frequency, strength, and duration
• Blood-tinged vaginal discharge (bloody or pink show) indicating that the mucous plug (operculum) has passed
• Fluid discharge from the vagina representing the spontaneous rupture of membranes (SROM, SRM)
The first stage of labor consists of three phases: the latent phase (0 to 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.
Nurses should involve the laboring woman as a partner in formulating an individualized plan of care that preserves the woman’s sense of control, facilitates her participation in her own childbirth experience, and enhances her selfesteem and level of satisfaction (Proctor, 1998). Women often have lingering impressions of their childbirth experience. Caregivers who are supportive, respectful, encouraging, kind, patient, professional, and comforting help these women to remember their childbirth experience in positive terms (Fowles, 1998; Tumblin & Simkin, 2001).
ASSESSMENT AND NURSING DIAGNOSES
Assessment begins at the first contact with the woman, whether by telephone or in person. Many women call the hospital or birthing center first to receive validation that it is all right for them to come in for evaluation or admission. The manner in which the nurse communicates with the woman during this first contact can set the tone for a positive birth experience. A caring attitude by the nurse encourages the woman to verbalize her questions and concerns. If possible, the nurse should have the woman’s prenatal record in hand when speaking to her or admitting her for evaluation of labor. Copies of records are often filed on the perinatal unit at some time during a woman’s third trimester. Certain factors are assessed initially to determine whether the woman is in true labor and should come to the hospital for further assessment or admission (Varney, 1997) (see Teaching Guidelines box). When a woman calls and there is a question about whether she is in labor (or in labor advanced enough to be admitted), the nurse should suggest that she either call her physician or nurse-midwife or come to the hospital. This may occur when the woman is in false labor or early in the latent phase of the first stage of labor. She may feel discouraged on learning that the contractions that feel so strong and regular are not causing cervical dilation or are still not strong or frequent enough for admission.
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TEACHING GUIDELINES How to Distinguish True Labor from False Labor TRUE LABOR Contractions Occur regularly, becoming stronger, lasting longer, and occurring closer together. Become more intense with walking. Usually felt in lower back, radiating to lower portion of abdomen. Continue despite use of comfort measures. Cervix (by vaginal examination) Shows progressive change (softening, effacement, and dilation signaled by the appearance of bloody show). Moves to an increasingly anterior position. Fetus Presenting part usually becomes engaged in the pelvis. This results in increased ease of breathing; at the same time, the presenting part presses downward and compresses the bladder, resulting in urinary frequency. FALSE LABOR Contractions Occur irregularly or become regular only temporarily. Often stop with walking or position change. Can be felt in the back or abdomen above the navel. Often can be stopped through the use of comfort measures. Cervix (by vaginal examination) May be soft but there is no significant change in effacement or dilation or evidence of bloody show. Is often in a posterior position. Fetus Presenting part is usually not engaged in the pelvis. |
If the woman lives near the hospital, she may be asked to stay home or return home to allow labor to progress (i.e., until the contractions are more frequent and intense). The ideal setting for the low risk woman in early labor is the familiar environment of her home. The nurse can use a telephone interview to assess the woman’s status and to give instructions regarding the optimum timing for admission and to reinforce teaching of the signs that require immediate notification of the physician or nurse-midwife (Box 1). Measures the woman and her family can use to enhance the progress of labor, reduce anxiety, and maintain comfort should be described. The woman is encouraged to ambulate and asked to adjust her oral intake according to the preferences of her primary health care provider.
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Telephone Interview with Woman in Latent Phase of Labor The perinatal nurse performs the following steps of the nursing process: ASSESSMENT • Gathers data regarding the woman’s status, including signs and symptoms indicative of true or false labor. • Discusses instructions given by the woman’s primary health care provider regarding when to come for admission. PLANNING AND IMPLEMENTATION • Decides whether the woman will come for labor assessment and admission or be encouraged to stay at home until contractions increase in duration, frequency, and intensity. • Assures the woman that she is welcome to call the perinatal unit at any time to discuss her labor status. • Answers questions the woman and her family may have regarding labor or provides instruction as needed (e.g., which entrance of the hospital to enter). • Suggests a variety of positions she can assume to maximally enhance uteroplacental and renal blood flow (i.e., side-lying position) and enhance the progress of labor (i.e., upright positions and ambulation). • Suggests diversional activities, such as walking, reading, watching television, talking to friends. • Suggests measures to maintain comfort, such as a warm bath or shower, back or foot massage. • Discusses the oral intake of foods and fluids appropriate for early labor (light foods or fluids or clear liquids depending on the preference of her primary health care provider). • Instructs the woman to come in immediately if membranes rupture, bleeding occurs, or fetal movements change. EVALUATION • Evaluates whether instructions and information have been understood by the woman by asking her to verbalize her understanding. |
A warm shower can be relaxing for the woman in early labor. However, warm baths should be avoided until the cervix is approximately 5 cm dilated, because water immersion in early labor could prolong the labor process and increase the use of oxytocin to stimulate uterine contractions and epidural analgesia for pain reduction (Eriksson, Mattsson, & Ladfors, 1997; Odent, 1997). Soothing back, foot, and hand massage 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, reading, watching television, doing needlework, or talking with friends can reduce the perception of early discomfort, help the time pass, and reduce anxiety (Austin & Calderon, 1999; Varney, 1997).
The woman who lives at a considerable distance from the hospital may be admitted in early labor. The same measures used by the woman at home should be offered to the hospitalized woman in early labor.
Admission to labor unit
Fig. 1 Woman being admitted. (Courtesy Marjorie Pyle, RNC, Lifecircle,
When the woman arrives at the perinatal unit, assessment is the top priority (Fig. 1). The nurse first performs a screening assessment, using the techniques of interview and physical assessment, and reviews laboratory findings to determine the health status of the woman and her fetus and the progress of her labor. The physician or nurse-midwife is notified, and if the woman is admitted, a detailed systems assessment is done.
Because first impressions are important, the woman and her family are welcomed by name and introduced to the staff members who will be involved in their care. If the woman wishes, her partner is included in the assessment and admission process.
As part of the admission process, the nurse orients the woman and her family to the layout and operation of the unit and the features of their room (e.g., call light, telephone system, personal storage areas, lighting). The nurse may assist in obtaining the required consents for the care the woman and her newborn are to receive (e.g., anesthesia consent). The nurse can minimize the woman’s anxiety by explaining terms commonly used during labor. The woman’s interest and response guide the depth and breadth of these explanations.
Admission data
Fig. 2 Obstetric admitting record. (Permission to use and/or reproduce this copyrighted material has been granted by the owner, Hollister Incorporated,
Admission forms such as the one in Fig. 2 can provide guidelines for the acquisition of important assessment information when a woman in labor is being evaluated or admitted. Additional sources of data include (1) the prenatal record, (2) the initial interview, (3) physical examination to determine baseline physiologic parameters, (4) laboratory and diagnostic test results, (5) expressed psychosocial and cultural factors, and (6) the clinical evaluation of labor status.
Prenatal data. The nurse reviews the prenatal record to identify the woman’s individual needs and risks. Incomplete information regarding a woman’s prenatal health status could adversely affect the quality and safety of the care provided to her and her fetus/newborn during labor and birth and in the postpartum period. Use of standardized worksheets and flow sheets developed by health care providers and computer access to antepartal health records are strategies that can facilitate the gathering of information relevant to the safe and effective management of care during labor (Hill, Lowery, & Chez, 1998).
If the woman has not had any prenatal care, certain baseline information must be obtained. If the woman is experiencing discomfort, the nurse asks questions between contractions when the woman can concentrate more fully on her responses.
It is important to know the woman’s age so that the plan of care can be tailored to the needs of her age-group. For example, a 14-year-old and a 40-year-old have different but specific needs, and their ages place them at risk for different problems. Height and weight relationships are important to determine because a weight gain greater than that recommended may place the woman at a higher risk for cephalopelvic disproportion and cesarean birth. Other factors to consider are general health, current medical conditions or allergies she may have, her respiratory status, and surgical procedures she has undergone.
Her past and present pregnancy history are carefully noted. These include gravidity and parity and problems such as history of vaginal bleeding, pregnancy-induced hypertension (PIH), anemia, gestational diabetes, infections (e.g., bacterial or sexually transmitted), and immunodeficiency.
If this is not the woman’s first labor and birth experience, it is important to note the characteristics of her previous experiences. This information includes the duration of previous labors, the type of anesthesia used, and the kind of birth (e.g., spontaneous vaginal, forceps-assisted, vacuum-assisted, or cesarean birth) and the condition of the baby. The woman’s perception of her previous labor and birth experiences may influence her attitude toward her current experience. The memory of labor and birth events can affect a woman’s postpartum emotional adjustment, self-esteem, and ability to parent effectively (Simkin, 1996).
It is important to confirm that the expected date of birth (EDB) is as accurate as possible. Other data in the prenatal record include patterns of maternal weight gain; physiologic measurements, such as maternal vital signs (blood pressure, temperature, pulse, respiration); fundal height; baseline fetal heart rate (FHR); and laboratory and diagnostic test results. Laboratory tests include the woman’s blood type and Rh factor, a complete or partial blood cell count (CBC or hemoglobin and hematocrit), the 50 g blood glucose test, determination of the rubella titer, serologic tests (Venereal Disease Research Laboratories [VDRL] or rapid plasma reagin [RPR]) for syphilis, hepatitis B surface antigen (HBsAg), culture for group B streptococci, and urinalysis. Additional tests may include a tuberculosis screen with purified protein derivative (PPD), screening for the human immunodeficiency virus (HIV), and screening for the sickle cell trait or other genetic disorders (e.g., maternal serum alpha-fetoprotein). Diagnostic tests can include amniocentesis, nonstress test, contraction stress test, biophysical profile, and ultrasound examination.
Interview. The woman’s primary complaint or reason for coming to the hospital is determined first in the interview. Her primary complaint may be that her bag of waters (amniotic membranes) ruptured, with or without contractions. The woman may have come in for an obstetric check, which is a period of observation reserved for women who are unsure about the onset of their labor. This 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. The woman is asked to recall the events of the previous days and to describe the following:
• Time and onset of regular contractions
• Frequency and duration of contractions
• 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 (rupture of membranes [ROM])
If there has been a discharge that may be amniotic fluid, she is asked the date and time the fluid was first noted and the fluid’s characteristics (e.g., amount, color, unusual odor). In many instances a sterile speculum examination and a Nitrazine test or fern test can confirm that the membranes are ruptured (see Procedure box).
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 in color and feels sticky because of its mucoid nature. It is scant to begin with and increases with effacement and dilation of the cervix. A woman may report a scant brownish discharge that may be attributed to cervical trauma resulting from vaginal examination or coitus within the last 48 hours.
In case general anesthesia is required in an emergency, it is important to assess the woman’s respiratory status. The nurse determines this by asking the woman if she has a cold or related symptoms, stuffy nose, sore throat, or cough. The status of allergies is rechecked, including allergies to medications routinely used in obstetrics, such as meperidine (Demerol) and lidocaine (Xylocaine). Some allergic responses cause swelling of the mucous membranes 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 last solid food and liquid intake.
Any informatioot found in the prenatal record is obtained during the admission assessment. Pertinent data include the birth plan, the choice of infant feeding method, the type of pain management, and the name of the pediatrician.
The nurse uses the information in the birth plan to individualize the care given the woman during labor. The nurse prepares the woman for the possibility that changes may be needed in her plan as labor progresses and assures her that information will be provided so that she can make informed decisions. If no written plan has been prepared, the nurse helps the woman formulate a birth plan when she arrives at the hospital. The nurse describes options available and finds out the woman’s wishes and preferences.
The nurse should discuss with the woman and her family their plans for preserving childbirth memories using photography and videotaping. Health care agencies and insurance companies have voiced concern that this type of recording of childbirth events could be used in court should the couple sue the health care agency or health care providers. The nurse can promote the appropriate use of cameras during labor and birth, including who and what will be recorded, the method that will be used, and the person who will perform this task. Protection of privacy and safety and infection control are major concerns. Policies should be in place that address such issues as use of flash photography in the presence of combustible gases and where the person who is recording the labor and birth should stand. The record should reflect that the childbirth was recorded (Cesario, 1998).
Psychosocial factors. The woman’s general appearance and behavior (and that of her family) provide valuable clues to the type of supportive care she will need (Table 1).
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WOMAN’S RESPONSES |
NURSE/SUPPORT PERSON’S ACTIONS* |
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DILATION OF CERVIX 0-3 CM (LATENT) (contractions 10-30 sec long, 5-30 min apart, mild to moderate) |
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Mood: alert, happy, excited, mild anxiety Settles into labor room; selects focal point Rests or sleeps, if possible Uses breathing techniques Uses effleurage, focusing, and relaxation techniques |
Provides encouragement, feedback for relaxation, companionship Assists woman to cope with contractions Encourages use of focusing techniques Helps to concentrate on breathing techniques Uses comfort measures Assists woman into comfortable position Informs woman of progress; explains procedures and routines Gives praise Offer fluids, ice chips as ordered |
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DILATION OF CERVIX 4-7 CM (ACTIVE) (contractions 30-45 sec long, 3-5 min apart, moderate to strong) |
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Mood: seriously labor oriented, concentration and energy needed for contractions, alert, more demanding Continues relaxation, focusing techniques Uses breathing techniques |
Acts as buffer; limits assessment techniques to between contractions Assists with contractions Encourages woman as needed to help her maintain breathing techniques Uses comfort measures Assists with frequent position changes, emphasizing side-lying and upright positions Encourages voluntary relaxation of muscles of back, buttocks, thighs, and perineum; effleurage Applies counterpressure to sacrococcygeal area Encourages and praises Keeps woman aware of progress Offers analgesics as ordered Checks bladder; encourages her to void Gives oral care; offers fluids, ice chips as ordered |
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DILATION OF CERVIX 8-10 CM (TRANSITION) (contractions 45-90 sec long, 2-3 min apart, strong) |
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Mood: irritable, intense concentration, symptoms of transition (e.g., nausea, vomiting) Continues relaxation, needs greater concentration to do this Uses breathing techniques Uses 4:1 breathing pattern if using psychoprophylactic techniques Uses panting to overcome response to urge to push |
Stays with woman; provides constant support Assists with contractions Reminds, reassures, and encourages woman to reestablish breathing pattern and concentration as needed Alerts woman to begin breathing pattern before contraction becomes too intense if she is sedated or drowsy Prompts panting respirations if woman begins to push prematurely Uses comfort measures Accepts woman’s inability to comply with instructions Accepts irritable response to helping, such as counterpressure Supports woman who has nausea and vomiting; gives oral care as needed; gives reassurance regarding signs of end of first stage Uses relaxation techniques (effleurage and voluntary relaxation) Keeps woman aware of progress |
However, the nurse should keep in mind that general appearance and behavior may vary depending on the stage and phase of labor. Psychosocial factors to assess include the following:
Verbal interactions. Does the woman ask questions? Can she ask for what she needs? Does she talk to her support person)?
Does she talk freely with the nurse or respond only to questions?
Body language. Is she relaxed or tense? What is her anxiety level? How does she react to being touched by the nurse or support person? Does she change positions or lie rigidly still? Does she avoid eye contact? Does she look tired? How much rest has she had during the past day?
Perceptual ability. Does she understand what the nurse says? 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 demonstrate her understanding?
Discomfort level. To what degree does the woman describe what she is experiencing? How does she react to a contraction? Are any nonverbal pain messages seen? Does she complain to the nurse or her partner? Can she ask for comfort measures?
Women with a history of sexual abuse. Memories of sexual abuse can be triggered during labor by intrusive procedures such as vaginal examinations; loss of control; being confined to bed and “restrained” by monitors, intravenous (IV) lines, and epidurals; being watched by students; and experiencing intense sensations in the uterus and genital area, especially at the time when she must push the baby out. Women who are abuse survivors may fight the labor process by reacting in panic or anger toward care providers, may take control of everyone and everything related to their childbirth, may surrender by being submissive and dependent, or may retreat by mentally dissociating themselves from the sensations of labor and birth (Rhodes & Hutchinson, 1994).
The nurse can help these women to associate the sensations they are experiencing with the process of childbirth and not their past abuse. The woman’s sense of control should be maintained by explaining all procedures and why they are needed, validating her needs and paying close attention to her requests, proceeding at the woman’s pace by waiting for her to give permission to touch her, accepting her often extreme reactions to labor, and protecting her privacy by limiting the amount of exposure of her body and the number of persons involved in her care. It is recommended that all laboring women be cared for 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 and to effectively parent her new baby (Heritage, 1998; Waymire, 1997).
Stress in labor. The way in which women and their families 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.
Usually women in labor have a variety of concerns that they will voice if asked but rarely volunteer. To correct misinformation, it is important for the nurse to ask the woman what she expects or to suggest that the woman ask her primary health care provider about an issue. The following are common concerns that women in labor have: Will my baby be all right? Will I be able to stand labor? Will my labor be long? How will I act? Will I need medication? Will it work for me? Will my partner or someone be there to support me? Do I have to have an IV? The nurse’s responsibility to the woman in labor with regard to these concerns is to answer her questions or find out the answers, to provide support for her and her family, to take care of her in partnership with those persons the woman wants as her support team, and to serve as their advocate. Women feel empowered when they are given information they can understand and that shows support for their efforts. This feeling of empowerment gives women the sense that they have the freedom to participate fully in their labor and birth and fosters a positive perception of the experience. In contrast, a woman’s level of anxiety and fear may rise when she does not understand what is being said. The woman who is unfamiliar with expressions such as “bloody show,” “the membranes ruptured,” “scalp electrode,” and “baby’s lying on the cord” could panic. Many such expressions sound violent and could conjure up thoughts of injury or pain.
The nurse communicates to the woman that she is not expected to act in any particular way and that the process will end in the birth of her baby, which is the only expectation she should have. Womeeed to be able to behave in a manner that is natural for them and be able to “let go” (Waldenstrom et al, 1996).
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 ascertain what role the support person intends to fulfill and whether he or she is prepared for that role by making observations and asking 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? The nurse should be sensitive to the needs of support persons and provide teaching and support as appropriate. Often the support this person is able to give the laboring woman is in direct proportion to the support he or she receives from the nurses and other health care providers (Nichols, 1993).
Cultural factors. It is important to note the woman’s ethnic or cultural and religious background to anticipate nursing interventions that may need to be added or eliminated from the individualized plan of care (Fig. 3). The woman should be encouraged 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 physician or nurse-midwife 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 is given only certaiourishments 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 that the rationale for required care measures be carefully explained (Mattson, 2000) (see Cultural Considerations box).
Fig. 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,
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CULTURAL CONSIDERATIONS Birth Practices in Different Cultures Modified from Geissler, E. (1999). Pocket guide to cultural assessment (2nd ed.). St Louis: Mosby. |
Cultural beliefs and values can influence a woman’s reliance on her physician or nurse-midwife during labor, as well as her desire to participate in making decisions about the care she receives (Callister, Vehvilainen-Julkunen, & Lauri, 1996). When assessing a woman’s cultural and religious preferences, Callister (1995) suggests that the nurse ask questions regarding the following:
• Value and meaning placed on the childbirth experience
• View of childbirth as a wellness or illness experience and as a private or social event
• Practices regarding diet, medications, activity, and emotional and physical support
• Appropriate maternal and paternal behaviors
• Birth companions—who they should be and what they should do
• Views regarding the newborn and the newborn’s care immediately after birth
Within cultures women may have the “right” way to behave in labor instilled in them and learn to react to the pain experienced in that way. These behaviors can range from total silence to moaning or screaming, but they are not in and of themselves a reflection of 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 (Table 2). Some women feel it is shameful to scream or cry out in pain 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 on the basis of her ability to adhere to 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 may be scolded, whereas in other cultures support persons will become more helpful (Choudhry, 1997; Weber, 1996).
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TABLE 2 Sociocultural Basis of Pain Experience |
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WOMAN IN LABOR |
NURSE |
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PERCEPTION OF MEANING Origin: Cultural concept of and personal experience with pain; for example: Pain in childbirth is inevitable, something to be borne. Pain in childbirth can be avoided completely. Pain in childbirth is punishment for sin. Pain in childbirth can be controlled. |
Origin: Cultural concept of and personal experience with pain; in addition, nurse becomes accustomed to wrking with certain “expected” pain trajectories. For example, in obstetrics, pain is expected to increase as labor progresses, be intermittent, and have end point; relief can be derived from medications once labor is well established and fetus or newborn can cope with amount and elimination of medications; relief can also come from woman’s knowledge, attitude, and support from family or friends. |
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COPING MECHANISMS Woman may exhibit the following behaviors: Be traditionally vocal or nonvocal; crying out or groaning, or both, may be part of her ritual response to pain. Use counter stimulation to minimize pain (e.g., rubbing, applying heat, or applying counterpressure). Use relaxation, distraction, or autosuggestion as paincountering techniques. Resist any use of “needles” as modes of administering pain relief agents. |
Nurse may respond by: Using self effectively (e.g., using tone of voice, closeness in space, and touch as media for conveying message of interest and caring). Using avoidance, belittling, or other distracting actions as protective device for self. Using pharmacologic resources at hand judiciously. Using comfort measures. Assuming accountability for control and management of pain. |
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EXPECTATIONS OF OTHERS Nurse may be seen as someone who will accept woman’s statement of pain and act as her advocate. Medical personnel may be expected to relieve woman of all pain sensations. Nurse may be expected to be interested, gentle, kind, and accepting of behavior exhibited. |
Only certain verbal or nonverbal responses to pain may be accepted as appropriate responses. Couple that is prepared for childbirth may be expected to refuse medication and to wish to “do everything on their own.” Woman’s definition of pain may not be accepted; that is, woman may wish to experience and participate in controlling pain or may not be able to accept any pain as reasonable. |
In Western societies the father is being increasingly viewed as the ideal birth companion (Chalmers & Meyer, 1994). For European-American couples, attending childbirth classes together has become a traditional, expected activity— a rite of passage (Finn, 1994). Laotian (Hmong) husbands actively participate in the labor process, often by supporting their wife’s position, catching the baby as it emerges, cutting the cord, and burying the placenta. A Mormon woman expects her husband to be present during her labor and to lay his hands on her head, in a blessing that imparts strength, comfort, and well-being for safe passage through childbirth (Callister, 1992, 1995). In some 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 misconstrued by the nursing staff to represent a lack of concern, caring, or interest.
The non-English-speaking woman in labor. A woman’s level of anxiety in labor rises when she does not understand what is happening to her or what is being said (McKay & Smith, 1993). Some misunderstanding may occur with English-speaking women and cause some stress, but the effect of misunderstanding oon-English-speaking women is much more dramatic. These women often feel a complete loss of control over their situation if there is no health care provider 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. Sometimes a support person is able to serve as a translator. However, this must be done with caution because the translator may not be able to convey exactly what the nurse or others are saying or what the woman is saying and may raise the woman’s stress level even more.
Ideally, a bilingual nurse will care for the woman. Alternatively, an employee or volunteer translator may be contacted for assistance. Preferably, the translator is from the woman’s culture. If no one in the hospital is able to translate, a translation service can be called so that a translation can take place over the telephone. For some women, a female translator may be more acceptable. If no translator is available, the labor and birth unit staff can prepare a set of cards with graphic depictions that illustrate common situations. These cards then can be used to communicate with non-English-speaking women. Even when the nurse has limited ability to communicate orally with the woman, in most instances the nurse’s efforts to communicate are meaningful and appreciated by the woman. Speaking slowly and avoiding complex words and medical terms can help a woman to understand (Mattson, 2000).
Physical examination
The initial physical examination includes a general systems assessment; performance of Leopold’s maneuvers to determine fetal presentation and position and the point of maximum intensity (PMI) for auscultating the FHR; assessment of fetal status; assessment of uterine contractions; and vaginal examination to assess the status of cervical effacement and dilation, fetal descent, and amniotic membranes and fluid. The most vital aspect of the assessment is the determination of fetal status. The findings serve as a baseline for assessing the woman’s progress from that point.
It is important to obtain as many related pieces of information as possible before planning and implementing care. Women often focus on the nature of their contractions as the clearest indicator of how far advanced their labor is. However, the findings from the vaginal examination are more valid indicators of the phase of labor, especially for nulliparous women.
The information yielded by a complete and accurate assessment during the initial examination serves as the basis for determining whether the woman should be admitted and what her ongoing care should be. Expected maternal progress and minimum assessment guidelines during the first stage of labor are presented in Table 3 and the Care Path.
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TABLE 3 Expected Maternal Progress in First Stage of Labour |
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The assessment procedures described in the following paragraphs can be used as a basis for teaching women and their families. The equipment needed, the nursing actions involved, and the rationale for each procedure can be shared with the woman. The nurse should thoroughly wash her hands before performing any of these procedures. Handwashing is also important after the examinations are completed. Standard Precautions should be used for all assessment and care measures (
). The assessment findings are explained to the woman whenever possible. Throughout labor, accurate documentation following agency policy and professional standards of care is done as soon as possible after a procedure has been performed.
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Standard Precautions During Childbirth Birth is a time wheurses and other health care providers are exposed to a great deal of maternal and newborn blood and body fluids. Observation of Standard Precautions is necessary to prevent the transmission of infection. Perinatal infections most often are transmitted through contact with body fluids. The Standard Precautions applicable to childbirth include: • Wash hands before and after putting on gloves and performing procedures. • Wear gloves (clean or sterile, as appropriate) when performing procedures that require contact with the woman’s genitalia and body fluids, including bloody show (e.g., during vaginal examination, amniotomy, hygienic care of the perineum, insertion of an internal scalp electrode and intrauterine pressure monitor, and catheterization). • Wear cap, a mask that has a shield or protective eyewear, shoe covers, and cover gown during the birth. Gowns worn by the primary health care provider who is attending the birth should have a waterproof front and sleeves and should be sterile. • Drape the woman with sterile towels and sheets as appropriate. Explain to the woman what can and cannot be touched. • Help the woman’s partner put on appropriate coverings for the birth, such as cap, mask, gown, and shoe covers. Show the partner where to stand and what can and cannot be touched. • Wear gloves and gown when handling the newborn immediately after birth. • Use an appropriate method to suction the newborn’s airway, such as a bulb syringe, mechanical wall suction, or DeLee oral suction device that prevents the newborn’s mucus from getting into the user’s mouth. |
General systems assessment. A brief systems assessment is performed. This includes an assessment of the heart, lungs, and skin; an examination to determine the presence and extent of edema of the legs, face, hands, or sacrum; and testing of deep tendon reflexes and clonus.
Vital signs. Temperature, pulse, respirations, and blood pressure are assessed on admission, and initial values are used for comparison with subsequent values. If the blood pressure is elevated, it should be reassessed 30 minutes later, between contractions, using a correct-size blood pressure cuff to obtain a reading after the woman has relaxed. To prevent supine hypotension and fetal distress, the woman should be encouraged to lie on her side and not supine (Fig. 4). Her temperature is monitored so that signs of infection or a fluid deficit (e.g., dehydration associated with inadequate intake of fluids) can be identified.
Fig. 4 Supine hypotension. Note relationship of pregnant uterus to ascending vena cava in standing position (A) and in supine position (B). C, Compression of aorta and inferior vena cava with woman in supine position. D, Compression of these vessels is relieved by placement of a wedge pillow under the woman’s right side.
Leopold’s maneuvers (abdominal palpation). Leopold’s maneuvers are performed with the woman briefly lying on her back (Fig. 5; see Procedure box). These maneuvers help identify (1) number of fetuses; (2) presenting part, fetal lie, and fetal attitude; (3) degree of the presenting part’s descent into the pelvis; and (4) expected location of the PMI of the fetal heart tones (FHTs) on the woman’s abdomen.
Fig. 5 Leopold’s maneuvers.
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Procedur Leopold’s Maneuver and Determination of the points of Maximum Intensity of the Fetal heart Tone (FHT) LEOPOLD’S MANEUVERS Wash hands. Ask woman to empty bladder. Position woman supine with one pillow under her head and with her knees slightly flexed. Place small rolled towel under woman’s right or left hip to displace uterus off major blood vessels (prevents supine hypotensive syndrome; see Fig. 4). If right-handed, stand on woman’s right, facing her: 1. Identify fetal part that occupies the fundus. The head feels round, firm, freely movable, and palpable by ballottement; the breech feels less regular and softer. This maneuver identifies fetal lie (longitudinal or transverse) and presentation (cephalic or breech) (Fig. 5, A). 2. Using palmar surface of one hand, locate and palpate the smooth convex contour of the fetal back and the irregularities that identify the small parts (feet, hands, elbows). This maneuver helps identify fetal presentation (Fig. 5, B). 3. With right hand, determine which fetal part is presenting over the inlet to the true pelvis. Gently grasp the lower pole of the uterus between the thumb and fingers, pressing in slightly (Fig. 5, C). If the head is presenting and not engaged, determine the attitude of the head (flexed or extended). 4. Turn to face the woman’s feet. Using both hands, outline the fetal head (Fig. 5, D) with the palmar surface of the fingertips. When the presenting part has descended deeply, only a small portion of it may be outlined. Palpation of the cephalic prominence helps identify the attitude of the head. If the cephalic prominence is found on the same side as the small parts, this means that the head must be flexed and the vertex is presenting (Fig. 5, D). If the cephalic prominence is on the same side as the back, this indicates that the presenting head is extended and the face is presenting (Fig. 5, D) ocument fetal presentation, position, and lie and whether presenting part is flexed or extended, engaged, or free floating. Use hospital’s protocol for documentation (e.g., “Vtx, LOA, floating”).
DETERMINATION OF PMI OF FHT Wash hands. Perform Leopold’s maneuvers. Auscultate FHT based on fetal presentation identified with Leopold’s maneuvers. The PMI is the location where the FHT is heard the loudest, usually over the fetal back (see Fig. 6). Chart PMI of FHT using a two-line figure to indicate the four quadrants of the maternal abdomen, as follows: right upper quadrant (RUQ), left upper quadrant (LUQ), left lower quadrant (LLQ), and right lower quadrant (RLQ):
The umbilicus is the reference point for the quadrants (point where the lines cross). The PMI for the fetus in vertex presentation, in general flexion with the back on the mother’s right side, commonly is found in the mother’s right lower quadrant and is recorded with an “X” or with the FHT, as follows:
or
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Fig. 6 Areas of maximum intensity of fetal heart rate for differing positions. RSA, Right sacrum anterior; ROP, right occipitoposterior; RMA, right mentum anterior; ROA, right occipitoanterior; LSA, left sacrum anterior; LOP, left occipitoposterior; LMA, left mentum anterior; LOA, left occipitoanterior. A, Presentation is breech if fetal heart rate is heard above umbilicus. B, Presentation is vertex if fetal heart rate is heard below umbilicus
Assessment of fetal heart rate and pattern. It is important or the nurse to understand the relationship between the location of the PMI of the FHT and fetal presentation, lie, and position. A high risk for childbirth complications may be revealed by variations in these findings. The PMI of the FHT is the location on the maternal abdomen where the FHT is heard the loudest. It is usually directly over the fetal back. The PMI is also an aid in determining the fetal presentation and position. In a vertex presentation, the FHT is heard below the mother’s umbilicus in either the right or left lower quadrant of the abdomen; in a breech presentation, the FHT is heard above the mother’s umbilicus (Fig. 6). As the fetus descends and rotates internally, the FHT is heard lower and closer to the midline of the maternal abdomen. The assessment recommended for determining fetal status in the low risk woman during the first stage of labor is summarized in the Care Path. The FHR and pattern are assessed (1) immediately after ROM, because this is the most common time for the umbilical cord to prolapse; (2) after any change in the contraction pattern or maternal status; and (3) before and after medicating the woman or performing a procedure.
Assessment of uterine contractions. A general characteristic of effective labor is regular uterine activity, but uterine activity is not directly related to labor progress. Uterine contractions are the primary powers that act involuntarily to expel the fetus and the placenta from the uterus. Several methods are used to evaluate uterine contractions. These include the woman’s subjective description, palpation and timing of the contraction by a health care provider, and electronic monitoring.
Each contraction exhibits a wavelike pattern. It begins with a slow increment (the “building up” of a contraction from its onset), gradually reaches an acme (the peak with intrauterine pressure of 50 to 75 mm Hg), and then diminishes rapidly (decrement, the “letting down” of the contraction). An interval of rest follows (intrauterine pressure 5 to 15 mm Hg) that ends when the next contraction begins. The outward appearance of the woman’s abdomen during and between contractions and the pattern of a typical uterine contraction are shown in Fig. 7.
Fig. 7 Assessment of uterine contractions. A, Abdominal contour before and during uterine contraction. B# Wavelike pattern of contractile activity.
The following characteristics are used to describe uterine contractions:
• Frequency of uterine contractions: How often uterine contractions occur; the time that elapses from the beginning of one contraction to the beginning of the next or from the peak of one contraction to the peak of the next (if using electronic monitoring)
• Intensity of uterine contractions: The strength of a contraction at its peak
• Duration of uterine contractions: The time that elapses between the onset and the end of a contraction
• Resting tone of uterine contractions: The tension in the uterine muscle between contractions
Uterine contractions are assessed by palpation or by an external or internal electronic monitor. Frequency and duration can be measured by all three methods of uterine activity monitoring. The accuracy of determining intensity varies by the method used. Palpation is more subjective and is a less precise way of determining the intensity of uterine contractions (Arrabal & Naegy, 1996). The following terms are used to describe what is felt on palpation:
• Mild: Slightly tense fundus that is easy to indent with fingertips (feels like touching finger to tip of nose)
• Moderate: Firm fundus that is difficult to indent with fingertips (feels like touching finger to chin)
• Strong: Rigid, boardlike fundus that is almost impossible to indent with fingertips (feels like touching finger to forehead)
Women in labor tend to describe the pain of contractions in terms of the sensations they are experiencing in the lower abdomen or back, which may be unrelated to the firmness of the uterine fundus. Thus their assessment of the strength of their contractions can be less valid than that of an experienced health care provider, although the amount of discomfort reported is valid.
External electronic monitoring provides information about the relative strength of the uterine contractions. Internal electronic monitoring using an intrauterine pressure catheter is the most reliable way of assessing the intensity of uterine contractions.
On admission, a 20- to 30-minute baseline monitoring of uterine contractions and the FHR usually is done (Scott et al, 1999). The minimum assessment times and the findings expected during each phase of the first stage of labor are summarized in Table 3 and the Care Path.
The nurse’s responsibility in the monitoring of uterine contractions is to ascertain whether they are powerful and frequent enough to accomplish the work of expelling the fetus and the placenta.
NURSE ALERT If the characteristics of contractions are found to be abnormal, either exceeding or falling below what is considered acceptable in terms of the standard characteristics, the nurse should report this to the primary health care provider.
Vaginal examination. The vaginal examination reveals whether the woman is in true labor and enables the examiner to determine whether the membranes have ruptured (Fig. 8). Because this examination is often stressful and uncomfortable for the woman, it should be performed only when indicated by the status of the woman and her fetus. For example, a vaginal examination should be performed on admission, when significant change has occurred in uterine activity, on maternal perception of perineal pressure or the urge to bear down, when membranes rupture, or when variable decelerations of the FHR are noted. A full explanation of the examination and support of the woman are important factors in reducing the stress and discomfort associated with the examination (Bergstrom et al., 1992). Chapter 4 describes a typical vaginal examination. Variations in the examination of the woman in labor include the following:
1. Use a sterile glove and antiseptic solution or soluble gel; use water for lubrication during the initial examination if rupture of membranes is suspected and a Nitrazine test is required.
2. Position the woman to prevent supine hypotension (see Fig. 4). Cleanse perineum and vulva if needed.
3. Ask the woman for permission to touch her before proceeding (Waymire, 1997) and explain that she will feel the insertion of the nurse’s index and middle fingers into the vagina. Perform the examination gently, with concern for the woman’s comfort. Acknowledge the woman’s expressions of pain or discomfort and anxiety.
4. Assess the status of the cervix, presenting part, amniotic membranes, and bloody show (see Fig. 8).
5. Discuss the findings of the examination with the woman or couple.
6. Document the findings and report them to the physician or nurse-midwife.
Fig. 8 Vaginal examination. A, Undilated, uneffaced cervix; membranes intact. B, Palpation of sagittal suture line. Cervix effaced and partially dilated.
Cervical dilation, effacement, and station. Uterine activity must be considered in the context of its effect on cervical effacement and dilation and on the degree of descent of the presenting part. The effect on the fetus also must be considered. The progress of labor can be effectively verified by the use of graphic charts (partograms) on which cervical dilation and station (descent) are plotted. This type of graphic charting assists in early identification of deviations from expected labor patterns. Fig. 9 provides examples of partograms illustrating the expected pattern of cervical dilation and fetal descent for both nulliparous and multiparous women. Hospitals and birthing centers may develop their own graphs for recording assessments.Such graphs may include not only data on dilation
and descent but also on maternal vital signs, FHR,
and uterine activity.
NURSE ALERT) It is important for the nurse to recognize that active labor can actually last longer than the expected labor patterns. This finding should not be a cause for concern unless the maternal-fetal unit exhibits signs of distress (e.g., nonreassuring FHR pattern, maternal fever).
Fig. 9 Partogram for assessment of patterns of cervical dilation and descent. Individual woman’s labor patterns (colored) are superimposed on prepared labor graph (black) for comparison. A, Labor of a nulliparous woman. B, Labor of a multiparous woman. The rate of cervical dilation is plotted with the circled plot points. A line drawn through these symbols depicts the slope of the curve. Station is plotted with Xs. A line drawn through the Xs reveals the pattern of descent.
Laboratory and diagnostic tests
Analysis of urine specimen. A clean-catch urine specimen may be obtained to gather data about the pregnant woman’s health. It is a convenient and simple procedure that can provide information about her hydration status (e.g., specific gravity, color, amount), nutritional status (e.g., ketones), infection (e.g., leukocytes), or the status of possible complications such as PIH, shown by finding protein in the urine. The results can be obtained quickly and help the nurse determine appropriate interventions to implement.
Blood tests. The blood tests performed vary with the hospital protocol and the woman’s health status. An example of a minimum assessment is a hematocrit determination, in which the specimen is centrifuged in the perinatal unit. Blood can be obtained by a finger stick or from the hub of a catheter used to start an IV line. More comprehensive blood assessments such as white blood cell count, red blood cell count, hemoglobin level, hematocrit, and platelet values are included in the CBC. A CBC may be ordered for women with a history of infection, anemia, PIH, or other disorders.
If the woman’s blood type has not been verified, blood is drawn to determine the type and Rh factor. If blood typing has already been done, the primary health care provider may choose not to repeat the test. If obvious signs of immunocompromise or substance abuse are present, other diagnostic blood tests may be ordered.
Assessment of amniotic membranes and fluid. Labor is initiated at term by spontaneous rupture of membranes (SROM, SRM) in approximately 25% of pregnant women. A lag period, rarely exceeding 24 hours, may precede the onset of labor. Membranes (the bag of waters) can also rupture spontaneously any time during labor, most likely during the transition phase of the first stage. Amniotomy, or artificial rupture of membranes (AROM, ARM), may be done to augment or induce labor or to facilitate placement of internal monitors when fetal status indicates the need for some form of direct assessment (e.g., insertion of a fetal scalp electrode or an intrauterine pressure catheter). The tests used to assess amniotic fluid are discussed in the Procedure box, and characteristics of the fluid are described in Table 4
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Assessment of Amniotic Fluid Characteristics |
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CHARACTERISTIC OF FLUID |
NORMAL FINDING |
DEVIATION FROM NORMAL FINDING |
CAUSE OF DEVIATION FROM |
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Color |
Pale, straw colored; may contain white flecks of vernix caseosa |
Greenish brown color
Yellow-stained fluid Port wine-colored |
Hypoxic episode in fetus; meconium in fluid May be normal finding in breech presentation Fetal hypoxia a36 hrs before ROM; fetal hemolytic disease; intrauterine infection Bleeding associated with abruption placentae |
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Viscosity and odor |
Watery; no strong odor |
Thick, cloudy, foul-smelling |
Intrauterine infection Large amount of meconium can make fluid thick |
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Amount |
500 to 1200 ml |
>2000 ml
<300 ml |
Hydramnios; associated with congenital anomalies of the fetus when fetus cannot drink fluid Oligohydramnios; associated with incomplete or absent kidney; obstruction of urethra; infant cannot secrete or excrete urine |
NURSE ALERT The umbilical cord may prolapse when the membranes rupture. It is the nurse’s responsibility to monitor the FHR and pattern for several minutes immediately after rupture of membranes to ascertain fetal well-being and then to document the findings.
Infection. When membranes rupture, microorganisms from the vagina can then ascend into the amniotic sac, causing chorioamnionitis and placentitis to develop. For this reason, maternal temperature and vaginal discharge are assessed frequently (every 1 to 2 hours) so that an infection developing after ROM can be identified early. Even when membranes are intact, however, microorganisms may ascend and cause premature
The nurse is responsible for reporting findings promptly to the physician and nurse-midwife and documenting findings according to agency policy. If abnormal findings are noted, continuous electronic monitoring is usually used and maintained for the duration of labor. The presence of meconium-stained amniotic fluid alerts the nurse to the necessity of observing fetal status more closely. After birth, the newborn may be at high risk for alteration in respiratory status if meconium is aspirated into the lungs with the first breath.
Assessment findings serve as a baseline for evaluating the woman’s subsequent progress during labor. Although some problems of labor are anticipated, others may appear unexpectedly during the clinical course of labor (see Signs of Potential Complications box).
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SIGNS of POTENTIAL COMPLICATIONS LABOR • Intrauterine pressure of more than 75 mm Hg (determined by intrauterine pressure catheter monitoring) or resting tone of more than 15 mm Hg • Contractions consistently lasting 90 seconds or more • Contractions consistently occurring 2 minutes or less apart • Fetal bradycardia, tachycardia, or persistently decreased variability • Irregular FHR; suspected fetal dysrhythmias • Appearance of meconium-stained or bloody fluid from the vagina • Arrest in progress of cervical dilation or effacement or descent of the fetus • Maternal temperature of 38° C or more • Foul-smelling vaginal discharge • Persistent bright or dark red vaginal bleeding |
Nursing diagnoses appropriate for the woman in first stage labor include the following:
Anxiety related to
-negative experience with previous childbirth
-cultural differences
• Impaired urinary elimination related to
-reduced intake of oral fluids
-diminished sensation of bladder fullness associated with epidural anesthesia/analgesia
• Impaired fetal gas exchange related to
-maternal hypotension
-compression of the umbilical cord
• Situational low self-esteem (maternal) related to
-inability to meet self-expectations regarding performance during childbirth
-loss of control during labor
Nursing diagnoses that represent potential areas for concern during the second stage of labor include the following:
• Risk for injury to mother and fetus related to
-persistent use of Valsalva maneuver
• Situational low self-esteem related to
–deficient knowledge of normal, beneficial effects of vocalization during bearing-down efforts
-inability to carry out plan for birth without medication
• Ineffective coping related to
-coaching that contradicts woman’s physiologic urge to push
• Anxiety related to
–inability to control defecation with bearing-down efforts
-deficient knowledge regarding perineal sensations associated with the urge to bear down
Examples of nursing diagnoses relevant to the third stage of labor include the following:
• Risk for deficient fluid volume related to
-blood loss occurring after placental separation and expulsion
-inadequate contraction of the uterus
• Anxiety related to
-lack of knowledge regarding separation and expulsion of the placenta
-occurrence of perineal trauma and the need for repair
• Fatigue related to
–energy expenditure associated with childbirth and the bearing-down efforts of the second stage
Expected Outcomes of Care
Planning with the woman is essential to ensure the implementation of expected outcomes and maintain her sense of control over her own childbirth experience. Expected outcomes for the woman in labor are that the woman will accomplish the following:
• Continue normal progression of labor while the FHR and pattern remain within the expected range and without signs of distress.
• Maintain adequate hydration status through oral or IV intake.
• Actively participate in the labor process.
• Verbalize discomfort and indicate the need for measures that help reduce discomfort and promote relaxation.
• Accept comfort and support measures from significant others and health care providers as needed.
• Sustaio injury to herself or the fetus during labor and birth.
• Initiate, along with the partner and family, the processes of bonding and attachment with the newborn.
• Express satisfaction with her performance during labor and birth.
Plan of Care and Interventions
Standards of care
Standards of care guide the nurse in preparing for and implementing procedures with the expectant mother. Protocols for care based on standards include the following:
• Check the primary health care provider’s orders.
• Assess the orders for appropriateness and correctness (e.g., analgesic to be administered to relieve discomfort).
• Check labels on IV solutions, medications, and other materials used for nursing care.
• Check the expiration date on any packs of supplies used for procedures.
• Ensure that information on the woman’s identification band is accurate (e.g., band is the appropriate color for allergies).
• Employ an empathic approach when giving care:
-Use words the woman can understand when explaining procedures.
-Respect the woman’s individual needs and behaviors.
-Establish rapport with the woman and her support persons/family.
-Be kind, caring, and competent when performing necessary procedures.
-Be aware that pain and discomfort are as the woman describes them.
-Repeat instructions as necessary and ensure that they are understood by the woman.
-Carry out appropriate comfort measures, such as mouth care and back care, and ensure that the support person is coping.
-Recognize that a woman’s current childbirth experience and the actions of nurses and other health care providers can have a positive or negative effect on the woman’s future childbirth experiences.
• Use Standard Precautions, including precautions for invasive procedures.
• Document care according to hospital guidelines, and promptly communicate information to the physician or nurse-midwife.
Physical nursing care during labor
The physical nursing care of the woman in labor is an essential component of her care. The current emphasis on evidence-based practice has led to the following labeling of care measures used during labor and birth:
• Demonstrably beneficial (useful) or likely to be beneficial
• A trade-off between beneficial and having a potentially adverse effect or of unknown effectiveness with insufficient evidence to support use
• Unlikely to be beneficial or likely to be harmful or ineffective
Managing care using this approach will enhance the safety, effectiveness, and acceptability of the physical care measures chosen to support the woman during labor and birth (Enkin et al., 2001; Technical Working Group, World Health Organization, 1997). The various physical needs, the requisite nursing actions, and the rationale for care are presented in the Care Path, Table 5, and the Plan of Care.
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Table 5 Physical Nursing Care During Labor |
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PLAN OF CARE Labor and Birth
NURSING DIAGNOSIS Anxiety related to labor and the birthing process
Expected Outcome Woman exhibits decreased signs of anxiety.
Nursing Interventions/Rationales
Orient woman and significant others to labor and birth unit and explain admission protocol to allay initial feelings of anxiety.
Assess woman’s knowledge, experience, and expectations of labor; note any signs or expressions of anxiety, nervousness, or fear to establish a baseline for intervention.
Discuss the expected progression of labor and describe what to expect during the process to allay anxiety associated with the unknown.
Actively involve woman in care decisions during labor, interpret sights and sounds of environment (monitor sights and sounds, unit activities), and share information on progression of labor (vital signs, FHR, dilation, effacement) to increase her sense of control and allay fears.
NURSING DIAGNOSIS Acute pain related to increasing frequency and intensity of contractions
Expected Outcome Woman exhibits signs of ability to cope with discomfort.
Nursing Interventions/Rationales
Assess woman’s level of pain and strategies that she has used to cope with pain to establish a baseline for intervention.
Encourage significant other to remain as support person during labor process to assist with support and comfort measures, because measures are often more effective when delivered by a familiar person.
Instruct woman and support person in use of specific techniques such as conscious relaxation, focused breathing, effleurage, massage, and application of sacral pressure to increase relaxation, decrease intensity of contractions, and promote use of controlled thought and direction of energy.
Provide comfort measures such as frequent mouth care to prevent dry mouth, application of damp cloth to forehead, and changing of damp gown or bed covers to relieve discomfort associated with diaphoresis; positioning to reduce stiffness.
Encourage conscious relaxation between contractions to prevent fatigue, which contributes to increased pain perceptions.
Explain what analgesics and anesthesia are available for use during labor and birth to provide knowledge to help woman make decisions about pain control.
NURSING DIAGNOSIS Risk for impaired urinary elimination related to sensory impairment secondary to labor
Expected Outcome Bladder does not show signs of distention.
Nursing Interventions/Rationales
Palpate the bladder superior to the symphysis on a frequent basis to detect a full bladder that occurs from increased fluid intake and inability to feel urge to void.
Encourage frequent voiding (at least every 2 hours) and catheterize if necessary to avoid bladder distention because it impedes progress of fetus down birth canal and may result in trauma to the bladder.
Assist to bathroom or commode to void if appropriate and provide privacy to facilitate bladder emptying with an upright position (natural) and relaxation.
NURSING DIAGNOSIS Risk for ineffective individual coping related to birthing process
Expected Outcome Woman actively participates in the birth process with no evidence of injury to her or her fetus.
Nursing Interventions/Rationales
Constantly monitor events of second-stage labor and birth, including physiologic responses of woman and fetus, emotional responses of woman and partner, to ensure maternal, partner, and fetal well-being.
Provide ongoing feedback to woman and partner to allay anxiety and enhance participation.
Continue to provide comfort measures such as positioning; mouth care; clean, dry bedding; cool cloth on forehead; and minimizing distractions to decrease discomfort and aid in focus on the birth process.
Encourage woman to experiment with various positions to assist downward movement of fetus.
Ensure that woman takes deep cleansing breaths before and after each contraction to enhance gas exchange and oxygen transport to the fetus.
Encourage woman to push spontaneously when urge to bear down is perceived during a contraction to aid descent and rotation of fetus.
Encourage woman to exhale, holding breath for short periods while bearing down to avoid holding breath and triggering a Valsalva maneuver and increasing intrathoracic and cardiovascular pressure and decreasing perfusion of placenta! oxygen, placing the fetus at risk.
Have woman take deep breaths and relax between contractions to reduce fatigue and increase effectiveness of pushing efforts.
Have mother pant as fetal head crowns to control birth of head.
Explain to woman and labor partner what is expected in the third stage of labor to enlist cooperation.
Have woman maintain her position to facilitate delivery of the placenta.
Ask mother if she wishes to dispose of the placenta in any specific manner to comply with certain cultural customs.
NURSING DIAGNOSIS Fatigue reiated to energy expenditure required during labor and birth
Expected Outcome Woman’s energy levels are restored.
Nursing Interventions/Rationales
Educate woman and partner about need for rest and help them plan strategies (e.g., restricting visitors, increasing role of support systems performing functions associated with daily routines) that allow specific times for rest and sleep to ensure that woman can restore depleted energy levels in preparation for caring for a new infant.
Monitor woman’s fatigue level and the amount of rest received to ensure restoration of energy
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NURSING DIAGNOSIS Risk for deficient fluid volume related to decreased fluid intake and increased fluid loss during labor and birth
Expected Outcome Fluid balance is maintained, and there are no signs of dehydration.
Nursing Interventions/Rationales
Monitor fluid loss (i.e., blood, urine, perspiration) and vital signs; inspect skin turgor and mucous membranes for dryness to evaluate hydration status.
Administer oral/parenteral fluid per physician/nurse-midwife orders to maintain hydration.
Monitor the fundus for firmness after placental separation to ensure adequate contraction and prevent further blood loss.
Administer medications per physician/nurse-midwife orders to aid contractions of the uterus.
General hygiene. Women in labor should be offered the use of showers or Jacuzzis, if they are available, to enhance the feeling of well-being and to minimize the discomfort of contractions. Women should also be encouraged to wash their hands after voiding and to perform selfhygiene measures. Linen should be changed if it becomes wet or stained with blood, and linen savers (Chux) should be used and changed as needed.
Oral intake. Traditionally, the laboring woman has been offered only clear liquids or ice chips or given nothing by mouth during the active phase of labor. This is to minimize the risk of anesthesia complications and their sequelae should general anesthesia be required in an emergency. These sequelae include the aspiration of gastric contents and resultant compromise in oxygen perfusion, which may endanger the lives of the mother and fetus. This practice is being challenged today because regional anesthesia is used more often than general anesthesia, even for emergency cesarean births. Women are awake during regional anesthesia and are able to participate in their own care and protect their airway.
Withholding of food and drink from women in labor has been identified as a form of care unlikely to be beneficial. Offering oral fluids is demonstrably useful and should be encouraged (Enkin et al., 2001).
Although gastric emptying is slowed as a result of labor, stress, and the use of narcotics or sedatives, fasting does not cause gastric contents to be eliminated and may even cause them to become more acidic. In addition, fasting is identified by many laboring women as a stressor with which they must cope and a source of frustration during labor related to a loss of control with regard to meeting their owourishment needs (Fowles, 1998).
An adequate intake of fluids and calories is required to meet the energy demands and fluid losses associated with childbirth. The progress of labor slows and ketosis develops if these demands are not met and fat is metabolized. Reduced energy for bearing-down efforts can increase the need for a forceps-assisted or vacuum-assisted vaginal birth. This is most likely to occur in women who begin to labor early in the morning after a night without caloric intake. When women are permitted to consume fluids and food freely, they typically regulate their own oral intake, eating light foods (e.g., eggs, yogurt, ice cream, dry toast and jelly or fruit) and drinking fluids during early labor, then tapering off to the intake of clear fluids and sips of water or ice chips as labor intensifies and the second stage approaches. Common practice is to allow clear liquids (e.g., water, tea, apple juice, clear sodas, gelatin, broth) during early labor, tapering off to ice chips and sips of water as labor progresses and becomes more active. Food and fluid consumed orally during labor can meet a laboring woman’s hydration and energy demands more effectively and safely than fluid administered intravenously. In addition, the woman’s sense of control and level of comfort are enhanced (Ludka & Roberts, 1993; Scheepers et al., 2001; Varney, 1997). The CNM Data Group (1999) found that a woman’s culture may influence what she will eat and drink during labor. In addition, women who used nonpharmacologic pain relief measures and labored ionhospital settings were more likely to eat and drink during labor.
Nurses should follow the orders of the woman’s physician or nurse-midwife when offering the woman food or fluids during labor. As advocates, however, nurses can facilitate change by informing others of the current research findings that support the safety and effectiveness of the oral intake of food and fluid during labor and by initiating such research themselves.
Intravenous intake. Fluids are administered intravenously to the laboring woman to maintain hydration, especially when a labor is long and the woman is unable to ingest a sufficient amount of fluid orally or if she is receiving epidural or intrathecal anesthesia. However, routine use of IV fluids during labor is a form of care that is > unlikely to be beneficial and may be harmful (Enkin et al., 2001; Technical Working Group, World Health Organization, 1997). In most cases, an electrolyte solution without glucose is adequate and does not introduce excess glucose into the bloodstream. The latter is important because an excessive maternal glucose level results in fetal hyperglycemia and fetal hyperinsulinism. After birth, the neonate’s high levels of insulin will then deplete his or her glucose stores and hypoglycemia will result (Ludka & Roberts, 1993). If maternal ketosis occurs, the primary health care provider may order an IV solution containing a small amount of dextrose to provide the glucose needed to assist in fatty acid metabolism.
NURSE ALERT Nurses should carefully monitor the intake and output of laboring women receiving IV fluids because these women also face an increased danger of hypervolemia as a result of the fluid retention that occurs during pregnancy.
Voiding. Voiding every 2 hours should be encouraged, especially if the bladder is distended. A distended bladder may impede descent of the presenting part, inhibit uterine contractions, and lead to decreased bladder tone or atony after birth. Women who receive epidural analgesia or anesthesia are especially at risk for the retention of urine, and the need to void should be assessed more frequently in them.
The woman should be assisted to the bathroom to void unless the primary health care provider has ordered bed rest, the woman is receiving epidural analgesia or anesthesia, or, in the nurse’s judgment, ambulation would compromise the status of the laboring woman or her fetus. If external monitoring is being used and the cords will reach, monitoring can continue while the woman uses the bathroom; otherwise, the cords are unplugged from the monitor while the woman is in the bathroom and monitoring is interrupted for that time.
Catheterization. If the woman is unable to void and her bladder is obviously distended, she may need to be catheterized. Most hospitals have protocols that rely on the nurse’s judgment concerning the need for catheterization. Before performing the catheterization, the nurse should clean the vulva and perineum because vaginal show and amniotic fluid may be present. Insert the catheter in between contractions if there appears to be an obstacle that prevents advancement of the catheter (this is most likely the presenting part). If the catheter cannot be advanced, the nurse should stop the procedure and notify the primary health care provider of the difficulty.
Bowel elimination. Most women do not have bowel movements during labor because of decreased intestinal motility. Stool that has formed in the large intestine often is moved downward toward the anorectal area by the pressure exerted by the fetal presenting part as it descends. This stool is often expelled during second-stage pushing and birth. However, the passage of stool with bearing-down efforts increases the risk of infection and may embarrass the woman, thereby reducing the effectiveness of these efforts. To prevent these problems, the nurse should immediately cleanse the perineal area to remove any stool, while at the same time reassuring the woman that the passage of stool at this time is a normal and expected event, because the same muscles used to expel the baby also expel stool. Routine use of an enema to empty the rectum is considered to be harmful or ineffective and should be eliminated (Enkin et al., 2001; Technical Working Group, World Health Organization, 1997).
When the presenting part is deep in the pelvis, even in the absence of stool in the anorectal area, the woman may feel rectal pressure and think she needs to defecate. If the woman expresses the need to defecate, the nurse should perform a vaginal examination to assess cervical dilation and station. When a multiparous woman experiences the urge to defecate, this often means birth will follow quickly.
Ambulation and positioning. Freedom of maternal movement and choice of position throughout labor are forms of care likely to be beneficial for the laboring woman and should be encouraged (Enkin et al., 2001; Technical Working Group, World Health Organization, 1997).
The potential advantages of ambulation include enhanced uterine activity, distraction from labor’s discomforts, enhanced maternal control, and an opportunity for close interaction with the woman’s partner and care provider as they help her to walk. Ambulation is associated with a reduced rate of operative delivery (i.e., cesarean birth, use of forceps, and vacuum extraction) and less frequent use of narcotic analgesia (Albers et al., 1997).
Walking, sitting, or standing during labor is more comfortable than lying down and facilitates the progress of labor (Melzack, Belanger, & Lacroix, 1991). Ambulation should be encouraged if membranes are intact, if the fetal presenting part is engaged after rupture of membranes, and if the woman has not received medication for pain (Fig. 10).
Fig. 10 Woman preparing to walk with partner. (Courtesy Marjorie Pyle, RNC, Lifecircle,
Fig. 11 Maternal positions for labor. A, Squatting. B, Lateral position. Support person is applying sacral pressure while partner provides encouragement. (Courtesy Marjorie Pyle, RNC, Lifecircle,
When the woman lies in bed, she will usually change her position spontaneously as labor progresses (Albers et al., 1997). If she does not change position every 30 to 60 minutes, she should be assisted to do so. The side-lying (lateral) position is preferred because it promotes optimal uteroplacental and renal blood flow and increases fetal oxygen saturation (Fig. 11, B). If the woman wants to lie supine, the nurse may place a pillow under one hip as a wedge to prevent the uterus from compressing the aorta and vena cava (see Fig. 4). Sitting is not contraindicated unless it adversely affects fetal status, which can be determined by checking the FHR. If the fetus is in the occiput posterior position, it may be helpful to encourage the woman to squat during contractions, because this position increases pelvic diameter, allowing the head to rotate to a more anterior position (Fig. 11, A). A hands-and-knees position during contractions is also recommended to facilitate the rotation of the fetal occiput from a posterior to an anterior position as gravity pulls the fetal back forward (Fig. 12, B). Fetal presentations and the mechanisms of labor may be helped or hindered by maternal posture (Andrews & Chrzanowski, 1990; Biancuzzo, 1993; Carbonne et al., 1996; Simkin, 1995). A variety of positions that are recommended for the laboring woman are described in
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Fig. 12 A, Woman standing and leaning forward with support. B, Woman in hands-andknees position. (Courtesy Marjorie Pyle, RNC, Lifecircle,
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BOX 3 Some Maternal Positions* During Labor and Birth SEMIRECUMBENT POSITION With woman sitting with her upper body elevated to at least a 30-degree angle, place wedge or small pillow under hip to prevent vena caval compression and reduce likelihood of supine hypotension (see Fig. 14-4). • The greater the angle of elevation, the more gravity or pressure is exerted that promotes fetal descent, the progress of contractions, and the widening of pelvic dimensions. • Convenient for rendering care measures and for external fetal monitoring. LATERAL POSITION (SEE FIG. 11. B) Have woman alternate between left and right side-lying position, and provide abdominal and back support as needed for comfort. • Removes pressure from the vena cava and back; enhances uteroplacental perfusion and relieves backache. • Makes it easier to perform back massage or counterpressure. • Associated with less frequent, but more intense, contractions. • Obtaining good external fetal monitor tracings may be more difficult. • May be used as a birthing position. • Takes pressure off perineum. UPRIGHT POSITION The gravity effect enhances the contraction cycle and fetal descent: the weight of the fetus places increasing pressure on the cervix; the cervix is pulled upward, facilitating effacement and dilation; impulses from the cervix to the pituitary gland increase, causing more oxytocin to be secreted; and contractions are intensified, thereby applying more forceful downward pressure on the fetus, but they are less painful. • Fetus is aligned with pelvis, and pelvic diameters are widened slightly. • Effective upright positions include the following: – Ambulation (see Fig. 10). – Standing and leaning forward with support provided by coach, end of bed, back of chair, or birth ball; relieves backache and facilitates application of counterpressure or back massage (see Figs. 14-12, A, and 14-13). – Sitting up in bed, chair, birthing chair, on toilet or bedside commode – Squatting (see Figs. 11, A, and 15, C). HANDS-AND-KNEES POSITION—IDEAL POSITION FOR POSTERIOR POSITIONS OF THE PRESENTING PART (SEE FIG. 12, B) Assume an “all-fours” position in bed or on a covered floor; allows for pelvic rocking. • Relieves backache characteristic of “back labor.” • Facilitates internal rotation of the fetus by increasing mobility of the coccyx, increasing the pelvic diameters, and using gravity to turn the fetal back and rotate the head. |
Fig. 13 Laboring woman using birth ball. (Courtesy Polly Perez, Cutting Edge Press,
A birth ball (gymnastic ball, also used in physical therapy) can be used to support a woman’s body as she assumes a variety of labor and birth positions (Fig. 13). The woman can sit on the ball while leaning over the bed, or she can lean over the ball to support her upper body and reduce stress on her arms and hands when she assumes a hands-and-knees position. The birth ball can encourage pelvic mobility and pelvic and perineal relaxation when the woman sits on the firm yet pliable ball and rocks in rhythmic movements. Warm compresses applied to the perineum and lower back can maximize this relaxation and comfort effect. The birth ball should be large enough so that when the woman sits her knees are bent at a 90-degree angle and her feet are flat on the floor and approximately 2 feet apart (Perez, 1998).
Supportive care during labor and birth. Effective physical and emotional support provided to women during labor can result in shorter labors, reduced rates of complications and surgical or obstetric interventions (e.g., cesarean births, labor augmentations and inductions, episiotomies, forceps- and vacuum-assisted births), and enhanced self-esteem and satisfaction (Gagnon & Waghorn, 1999; Kennell et al, 1991; Pascoe, 1993).
Labor rooms should be airy, clean, and homelike. To enhance relaxation, bright overhead lights should be turned off wheot needed. The temperature is controlled to ensure the laboring woman’s comfort. The room should be large enough to accommodate a comfortable chair for the woman’s partner, the monitoring equipment, and hospital personnel. Couples may be encouraged to bring extra pillows to make the hospital surroundings more homelike and to facilitate position changes. Women often state that this type of an environment helps them view their childbirth experience as normal and not related to illness (Proctor, 1998).
Labor support by the nurse. The nurse can alleviate a woman’s anxiety by explaining unfamiliar terms, providing information and explanations without her having to ask, and preparing her for sensations she will experience and procedures that will follow. By encouraging the woman or couple to ask questions, by providing honest and understandable answers, and by meeting learning needs, the nurse can play an important role in helping the woman achieve a satisfying birth experience (Evans & Jeffery, 1995; Proctor, 1998; Tomlinson & Bryan, 1996).
Supportive nursing care for a woman in labor includes (1) helping the woman maintain control and participate to the extent she wishes in the birth of her infant; (2) meeting the woman’s expected outcomes for her labor; (3) acting as the woman’s advocate, supporting her decisions and respecting her choices as appropriate and relating her wishes as needed to other health care providers; (4) helping the woman conserve her energy; (5) helping control the woman’s discomfort; (6) acknowledging and providing reinforcement for the woman’s efforts, as well as those of her partner, during labor; and (7) protecting the woman’s privacy and modesty (see Research Box).
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RESEARCH BOX Labor Support by Nurses The intrapartum nursing role is complex and challenging. Labor support is distinct from the technical, assessment, and administrative duties that the nurse must constantly prioritize. Labor support includes physical comfort, emotional support, information, and advocacy. There is evidence that good labor support leads to improved outcomes in increased vaginal births, decreased length of labor, and decreased analgesia/anesthesia use.To obtain nurses’ perspectives on what activities characterize as labor support, 500 members of the Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) were surveyed using a three-round IMPLICATIONS FOR PRACTICE Assessments and technical interventions, as well as indirect care activities, take up most of the labor nurse’s time, moving the nurse more and more away from the bedside. The woman is left without the needed support or else depends on family, friends, or hired helpers (doulas). Research studies such as this one can remind employers about the importance of supportive care in promoting positive outcomes for the mother and infant and may provide evidence that nurses should be supported to redirect their energies back to caring. Source: Miltner, R. (2000). Identifying labor support actions of intrapartum nurses. J Obstet Gynecol Neonatal Nurs, 23(5), 491-499. |
Couples who have attended childbirth education programs that teach the psychoprophylactic approach will know something about the labor process, coaching techniques, and comfort measures. A review and redemonstration of methods learned in class and practiced in the familiar environment of their home without the pain and discomfort of labor and without the anxiety of being in an unfamiliar environment may be needed. It is important that the nurse caution the womaot to begin patterned breathing techniques during the latent phase of labor because this practice has been associated with an increase in the level of fatigue the woman experiences as labor progresses (Pugh et al., 1998).
Even when expectant parents have not attended childbirth classes, the nurse can teach them various techniques during the early phase of labor. Breathing and relaxation techniques should be simple and performed with the woman until the support person feels ready to take on a more active coaching role. Comfort measures can be demonstrated by the nurse while encouraging the support person to assist and the laboring woman to express her needs and feelings. “Expert watching” or active role modeling can help the partner to learn effective comfort measures (Hodnett, 1996; Tomlinson & Bryan, 1996).
Fig. 14 Partner providing comfort measures. (Courtesy Marjorie Pyle, RNC, Lifecircle,
Comfort measures vary with the situation (Fig. 14). The nurse can draw on the couple’s repertoire of comfort measures learned during the pregnancy. Such measures include maintaining a comfortable, supportive atmosphere in the labor and birth area; using touch therapeutically (e.g., heat or cold applied to the lower back in the event of back labor, a cool cloth applied to the forehead); providing nonpharmacologic measures to relieve discomfort (e.g., massage, hydrotherapy, position changes, music, relaxation techniques); administering analgesics wheecessary; and most of all, just being there (see Tables 1 and 5 and the Care Path). See Chapter 12 for a full discussion of both pharmacologic and nonpharmacologic comfort and relaxation measures.
Most women in labor respond positively to touch. They appreciate gentle handling by staff members. Back rubs and counterpressure may be offered, especially if the woman is experiencing back labor. Hand and foot massage also can be soothing and relaxing (Simkin, 1995). The woman’s perception of the soothing qualities of touch changes as labor progresses. Many women become more sensitive to touch (hyperesthesia) as labor progresses. This is a typical response during the transition phase (see Tables 1 and 3). They may tell their coach to leave them alone or not to touch them. The partner who is unprepared for this normal response may feel rejected and may react by withdrawing active support. The nurse can reassure them that this response is a positive indication that the first stage is ending and the second stage is approaching. Women experiencing increased sensitivity to touch may have a positive response when touched on surfaces of the body where hair does not grow, such as the forehead, the palms of the hands, and the soles of the feet.
Labor support by the father or partner. Although a woman or a man other than the father may be the woman’s partner during labor, the father of the baby is most often the support during labor. He often is able to provide the comfort measures and touch that the laboring womaeeds. When the woman becomes focused on her pain, the partner can sometimes persuade her to try nonpharmacologic variations of comfort measures. In addition, he usually is able to interpret the woman’s needs and desires to staff members.
Throughout the past 20 years, childbirth preparation education has been widely available. The father’s ideal role was thought to be that of labor coach, and he was expected to actively help the woman cope with labor. However, this expectation may be unrealistic, because some men have concerns about their labor-coaching abilities. Men can assume one of at least three different roles during labor and birth—coach, teammate, or witness (Chapman, 1992). As a coach, the father actively assists the woman during and after contractions. Men who are coaches express a strong need to be in control of themselves and of the labor experience. Women also express a great desire for the father to be physically involved in labor. The father who acts as the teammate assists the woman during labor and birth by responding to requests for physical or emotional support, or both. Teammates usually adopt the follower or helper role and look to the woman or nurse to tell them what to do. Women express a strong desire to have the father present and willing to help in any way. The father who acts as a witness acts as a companion, giving emotional and moral support. He watches the woman labor and give birth, but he often sleeps, watches television, or leaves the room for long periods. Witnesses believe that there is little they can do to physically help the woman and look to the nurses and health care providers to be in charge of the experience. Women do not expect more of this type of father than to just be present.
The feelings of a first-time father change as labor progresses. Often calm at the onset of labor, feelings of fear and helplessness begin to dominate as labor becomes more active and the father realizes that labor is more work than he anticipated. The first-time father may feel excluded as birth preparations begin during the transition phase. Once the second stage begins and birth nears, the father’s focus changes from the woman to the baby who is about to be born (Chandler & Field, 1997).
The father will be exposed to many sights and smells he may never before have experienced. It is therefore important to tell him what to expect and to make him comfortable about leaving the room to regain his composure should something occur that surprises him. Before he leaves the room, provision should be made for someone else to support the woman during his absence. Staff members should tell the father that his presence is helpful and encourage him to be involved in the care of the woman to the extent he is comfortable.
Participation in the birth is ego building. The father can be of assistance; his presence is important. Support of the father/partner reflects the nurse’s orientation and commitment to each person, the family, and the community. Ways in which the nurse can support the father/partner are detailed in
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Guidelines for Supporting the Father • Orient to the labor room and the unit; explain location of the cafeteria, toilet, waiting room, and nursery; visiting hours; names and functions of personnel present. • Inform him of sights and smells he can expect to encounter; encourage him to leave the room if necessary. • Respect his or the couple’s decision about the degree of his involvement. Offer them freedom to make decisions. • Tell him when his presence has been helpful and continue to reinforce this throughout labor. • Offer to teach him comfort measures. • Inform him frequently of the progress of the labor and the woman’s needs. Keep him informed about procedures to be performed. • Prepare him for changes in the woman’s behavior and physical appearance. • Remind him to eat; offer him snacks and fluids if possible. • Relieve him of the job of support person as necessary. Offer him blankets if he is to sleep in a chair by the bedside. • Acknowledge the stress experienced by each partner during labor and birth and identify normal responses. • Attempt to modify or eliminate unsettling stimuli, such as extra noise and extra light.
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A well-informed father can make an important contribution to the health and well-being of the mother and child, their family interrelationship, and his self-esteem.
Labor support by the grandparents. When grandparents act as labor coaches, it is especially important to support them and treat them with respect. They may have a way to deal with pain relief based on their experience. They should be encouraged to help as long as their actions do not compromise the status of the mother or the fetus. One example of an acceptable practice would be giving the woman herbal teas during labor. The nurse acts as a role model for parents by acknowledging the value of the grandparent’s contributions to parental support and by recognizing the difficulty parents have in witnessing their child’s discomfort or crisis, regardless of the age of the child. If they have never witnessed a birth, the nurse may need to provide explanations about what is happening. Nursing actions that provide support for the grandparents can have a therapeutic effect on all members of the family.
Siblings during labor and birth. The preparation of siblings for acceptance of the new child helps promote attachment. The age and developmental level of children influence their responses; therefore preparation to be present during labor is adjusted to meet each child’s needs. The child younger than 2 years of age shows little interest in pregnancy and labor; for the older child such preparation may reduce fears and misconceptions. Most parents have a “feel” for their children’s maturational level and their physical and emotional ability to observe and cope with the events of the labor and birth process. Preparation can include a description of the anticipated sights, events (e.g., ROM, monitors, IV infusions), smells, and sounds; a labor and birth demonstration; a tour of the birthing unit; and an opportunity to be around a real newborn (Jonquil, 1993). Children must learn that their mother will be working hard during labor and birth. She will not be able to talk to them during contractions. She may groan, scream, grunt, and pant at times, as well as say things she would not say otherwise (e.g., “I can’t take this anymore,” “Take this baby out of me,” or “This pain is killing me”). They can be told that labor is uncomfortable but that their mother’s body is made for the job. Storybooks about the birth process can be read to or by children to prepare them for the event. Films for preparing older preschool and schoolage children to participate in the labor and birth experience are available. Most facilities require that a specific person be designated to watch over the children who are participating in their mother’s childbirth experience, to provide them with support, explanations, diversions, and comfort as needed (Simkin, 1993). Health care providers involved in attending women during birth must be comfortable with the presence of a child and the unpredictability of the child’s questions, comments, and behaviors.
Doulas. Continuity of care has been cited by women as a critical component of a satisfying childbirth experience. These women expressed concern regarding a change in their caregiver when a new shift began (Proctor, 1998). This need can be met by a specially trained, experienced female labor attendant called a doula. The doula provides a continuous, one-on-one caring presence through the labor and birth of the woman she is attending. The primary role of the doula is to focus on the laboring woman and provide physical and emotional support by using soft, reassuring words; touching, stroking, and hugging; administering comfort measures to reduce pain and enhance relaxation; and walking with the woman, helping her to change positions, and coaching her bearing-down efforts.
The doula also supports the woman’s partner, who often feels unqualified to be the sole labor support. The doula can encourage and praise the partner’s efforts, create a partnership as caregivers, and provide respite care. Doulas also facilitate communication between the laboring woman and her partner, as well as between the couple and the health care team (Perez & Herrick, 1998; Simkin & Way, 1998; Tumblin & Simkin, 2001; Zhang et al., 1996).
Continuous care provided by doulas reduces the cesarean birthrate; duration of labor; use of oxytocin, analgesics, and forceps; and requests for epidural anesthesia (Klaus, Kennell, & Klaus, 1993). Laboring women also reported a higher level of satisfaction with their childbirth experience and greater success with breastfeeding. Longterm benefits of doula care are reflected in more positive maternal feelings regarding their parenting ability and closer interaction with their infants up to 1 year after birth (Landry et al., 1998; Trowell, 1993).
The role of the nurse and the doula are complementary. They should work together as a team with the doula providing supportive nonmedical care measures and the nurse focusing on monitoring the status of the maternal-fetal unit; implementing clinical care protocols, including pharmacologic interventions; and documenting assessment findings, actions, and responses.
Emergency interventions. Emergency conditions that require immediate nursing intervention can arise with startling speed. Interventions for a nonreassuring FHR, inadequate uterine relaxation, vaginal bleeding, infection, and prolapse of the cord are identified in the Emergency box.
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EMERGENCY Interventions for Emergencies |
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SIGNS |
INTERVENTIONS |
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Nonreassuring FHR pattern • Fetal bradycardia (FHR <110 beats/min for >10 min)t • Fetal tachycardia (FHR of >160 beats/min for >10 min in term pregnancy)5 • Irregular FHR, abnormal sinus rhythm shown by internal monitor • Persistent decrease in baseline FHR variability without any identified cause • Late, severe variable, and prolonged deceleration patterns • Absence of FHR |
Notify primary health care provider* Change woman to side-lying position Discontinue oxytocin (Pitocin) infusion, if being infused Increase IV fluid rate, if fluid being infused per protocol order Administer oxygen at 8 to 10 L/min by tight face mask Check maternal temperature for elevation. Start an IV line if one is not in place Administer amnioinfusion if ordered Stimulate fetal scalp or use acoustic stimulation |
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Inadequate uterine relaxation • Intrauterine pressure of >75 mm Hg (shown by intrauterine pressure catheter monitoring) • Contractions consistently lasting >90 sec • Contraction interval of <2 min |
Notify primary health care providert Discontinue oxytocin infusion, if being infused Change woman to side-lying position Increase IV fluid rate, if fluid is being infused Administer oxygen at 8 to 10 L/min by tight face mask Start an IV line if one is not in place Palpate and evaluate contractions Give tocolytics (terbutaline), as ordered |
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Vaginal bleeding • Vaginal bleeding (bright red, dark red, or in an amount in excess of that expected during normal cervical dilation) • Continuous vaginal bleeding with FHR changes • Pain; may or may not be present |
Notify primary health care providert Anticipate emergency (stat) cesarean birth DO NOT PERFORM A VAGINAL EXAMINATION |
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Infection • Foul-smelling amniotic fluid • Maternal temperature of >38° C in presence of adequate hydration (straw-colored urine) • Fetal tachycardia of >160 beats/min for >10 min |
Notify primary health care providert Institute cooling measures for laboring woman Start an IV line if one is not in place Assist with or perform collection of catheterized urine specimen and amniotic fluid sample and send to the laboratory for urinalysis and cultures |
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Prolapse of cord (see Fig. 24-16) • Fetal bradycardia with variable deceleration during uterine contraction • Woman reports feeling the cord after membranes rupture • Cord lies alongside or below the presenting part of the fetus; it can be seen or felt in or protruding from the vagina. • Major predisposing factors are: — Rupture of membranes with a gush — Loose fit of presenting part in lower uterine segment — Presenting part not yet engaged |
Call for assistance Have someone notify the primary health care provider immediately Glove the examining hand quickly and insert two fingers into the vagina to the cervix; with one finger on either side of the cord or both fingers to one side, exert upward pressure against the presenting part to relieve compression of the cord Place a rolled towel under the woman’s hip Place woman in extreme Trendelenburg or modified Sims position or knee-chest position Wrap the cord loosely in a sterile towel saturated with warm sterile normal saline if the cord is protruding from the vagina Administer oxygen at 8 to 10 L/min by face mask until birth is accomplished Start IV fluids or increase existing drip rate Continue to monitor FHR by internal fetal scalp electrode, if possible Do not attempt to replace cord into cervix Prepare for immediate birth (vaginal or cesarean) |
Preparation for giving birth. The first stage of labor ends with the complete dilation of the cervix. The nurse begins to prepare for birth when a multiparous woman is 6 to 8 cm dilated, because progression during the last few centimeters of dilation can occur rapidly. Preparations for a nulliparous woman begin during the transition phase. Factors that influence the rate of progress are fetal position and the size of the fetus.
Birth setting. If a traditional delivery room is used, a multiparous woman is usually transferred near the end of the first stage of labor. Transfer of the nulliparous woman takes place when the presenting part begins to distend the perineum between contractions during the second stage of labor (Fig. 15, A). Transfer to the delivery room is unnecessary in labor-delivery rooms (LDRs), labor-deliveryrecovery-postpartum (LDRP) rooms, and birthing centers.
Fig.15 A, Pushing, side-lying position. Perineal bulging can be seen. B, Pushing, semi-sitting position. Midwife assists partner to feel top of fetal head. (A, Courtesy Michael S. Clement, MD, Mesa, AZ; B, Courtesy Roni Wernik, Palo Alto, CA.)
Women in labor may use a whirlpool bath or Jacuzzi for the relaxing effects. Most authorities recommend that birth occur out of the water even though newborns do not begin to breathe until removed from the water. If birth occurs while in the water, the newborn should be removed immediately (Odent, 1997) (Fig. 16).
Fig. 16 Waterbirth. (Courtesy Global Maternal/Child Health Association, Inc.,
Evaluation
Evaluation of the nursing care provided for a woman and her family during the first stage of labor is based on the expected outcomes of care.
SECOND STAGE OF LABOR
The second stage of labor is the stage in which the infant is born. This stage begins with full cervical dilation (10 cm) and complete effacement (100%) and ends with the baby’s birth. The force exerted by uterine contractions, gravity, and maternal bearing-down efforts facilitates achievement of the expected outcome of a spontaneous, uncomplicated vaginal birth.
The second stage comprises three phases: latent, descent, and transition. These phases are characterized by maternal verbal and nonverbal behaviors, uterine activity, the urge to bear down, and fetal descent. The latent phase is a period of rest and relative calm (i.e., “laboring down”). The woman is quiet and often relaxes with her eyes closed between contractions. The urge to bear down is not well established and is experienced primarily during the acme of a contraction. Allowing a woman to rest during this phase, and waiting until the urge to push intensifies (delayed pushing), has been found to reduce maternal fatigue, conserve energy for bearing-down efforts, and provide optimal maternal and fetal outcomes (Minato, 2000). The descent phase is characterized by strong urges to bear down as the
If a woman is confined to bed in a recumbent position, the rhythmic urge to bear down is suppressed, because gravity is not being used to press the presenting part against the pelvic floor. Being moved to another room and placed on a delivery table in the lithotomy position, as had been the custom in
The only certain objective sign that the second stage of labor has begun is the inability to feel the cervix during vaginal examination, indicating that the cervix is fully dilated and effaced. Other signs that suggest the onset of the second stage include the following:
• Sudden appearance of perspiration on upper lip
• An episode of vomiting
• Increased bloody show
• Shaking of extremities
• Increased restlessness; verbalization that “I can’t go on”
• Involuntary bearing-down efforts
These signs commonly appear at the time the cervix reaches full dilation (Scott et al., 1999). However, women with an epidural block may not exhibit such signs. Other indicators for each phase of the second stage are given in Tables 6 and 7.
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Tables 6 Expected Maternal Progress in Second Stage of Labour |
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TABLE 7 Woman’s Responses and Support Person’s Actions During Second Stage of Labor |
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WOMAN’S RESPONSESt |
NURSE/SUPPORT PERSON’S ACTIONS* |
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LATENT PHASE Experiences a short period of peace and rest |
Encourages woman to “listen” to her body Continues support measures Suggests an upright position to encourage progression of descent if descent phase does not begin after 20 min |
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DESCENT PHASE Senses increased urgency to bear down as reflex is activated Notes increase in intensity of uterine contractionsalters respiratory pattern: short 4- to 5-sec breath holds, 5 to 7 times per contraction Makes grunting sounds or expiratory vocalizations |
Encourages respiratory pattern of short breath holds and open-glottis pushing Stresses normality and benefits of grunting sounds and expiratory vocalizations Encourages bearing-down efforts with urge to push Encourages/suggests maternal movement and position changes (upright, if descent is not occurring) Encourages woman to “listen” to her body regarding movement and position change if descent is occurring Discourages long breath holds (no longer than 5 to 7 sec) If birth is to occur in a delivery room, transfers woman to delivery room early to avoid rushing or, if permitted, offers her option of walking to delivery room Places woman in lateral recumbent position to slow descent if descent is too fast |
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TRANSITIONAL PHASE Behaves in manner similar to behavior during transition in first stage (8-10 cm) Experiences a sense of severe pain and powerlessness Shows decreased ability to listen Concentrates on birth of baby until head is born Experiences contractions as overwhelming in intensity Reports feeling ring of fire as head crowns Maintains respiratory pattern of three to five 7-sec breath holds per contraction, followed by forced expiration Eases head out with short expirations Responds with excitement and relief after head is born |
Encourages slow, gentle pushing Explains that “blowing away the contraction” facilitates a slower birth of the head Provides mirror to help woman see or touch the emerging fetal head (best to extend over two to three contractions) to help her understand the perineal sensations Coaches woman to relax mouth, throat, and neck to promote relaxation of pelvic floor Applies warm compress to perineum to promote relaxation |
Women can begin to experience an irresistible urge to bear down before full dilation. For some women, this occurs as early as 5 cm dilation. This is most often related to the station of the presenting part below the level of the ischial spines of the maternal pelvis. Some health care providers believe that pushing the presenting part through a partly dilated cervix will result in cervical edema and damage. Research is needed to determine the consequences of pushing against a partially dilated cervix. When a woman pushes in relation to the degree of cervical dilation should be based on research evidence rather than tradition or routine practice (Bergstrom et al., 1997; Cosner & dejong, 1993; Varney, 1997).
Assessment is continuous during the second stage of labor. Professional standards of care and agency policy determine the specific type and timing of assessments, as well as the way in which findings are documented (see Care Path). Signs and symptoms of impending birth (see Table 6) may appear unexpectedly, requiring immediate action by the nurse (
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CARE PATH Low Risk Woman in Second and Third Stages of Labor |
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CARE MANAGEMENT |
SECOND STAGE OF LABOR |
THIRD STAGE OF LABOR |
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I. ASSESSMENT MEASUFSES* • Blood pressure, pulse, respirations • Uterine activity • Bearing-down effort • Fetal heart rate (FHR)
• Vaginal show
• Signs of fetal descent: urge to bear down, perineal bulging, crowning • Behavior, appearance, mood, energy level of woman; condition of partner |
Frequency Every 5-30 min
Assess every contraction Assess each effort Every 5-15 min
Every 15 min
Every 10-15 min
Every 10-15 min |
Frequency Every 15 min
Assess for placental separation Perform Apgar at 1 and 5 min Assess bleeding until placental expulsion
Assess response to completion of childbirth process, reaction to newborn |
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II. PHYSICAL CARE MEASURES |
Latent phase: Assist to rest in position of comfort Encourage relaxation to conserve energy Promote urge to push; if delayed: ambulation, shower, pelvic rock, position changes Descent phase: Assist to bear down effectively Help to use recommended positions that facilitate descent Encourage correct breathing during bearing-down efforts Help to relax between contractions Provide comfort measures as needed Cleanse perineum immediately if fecal material is expelled Transition phase: Assist to pant during contraction to avoid rapid birth of head Coach to gently bear down between contractions |
Assist to bear down to facilitate delivery of separated placenta Administer oxytocic as ordered Provide pain relief as needed Provide hygiene and comfort measures as needed |
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III. EMOTIONAL SUPPORT |
Keep informed of progress of fetal descent Provide feedback for bearing-down efforts Explain purpose if medications given Role model comfort measures Provide continuous nursing presence Create a quiet, calm environment Reassure, encourage, praise Take charge as needed, until woman regains confidence in ability to birth her baby Offer mirror to watch birth |
Keep informed about progress of placental separation Explain purpose if medications given Describe status of perineal tissue and inform if repair is needed Introduce parents to their baby Assess and care for newborn within view of parents; delay eye prophylaxis to facilitate eye contact Provide private time for family to bond with their new baby and help them to create memories Encourage breastfeeding if desired |
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Guidуlines for Assistance at the Emergency Birth of a Fetus in the Vertex Presentation 1. The woman usually assumes the position most comfortable for her. A lateral position is often recommended. 2. Reassure the woman that birth is usually uncomplicated and easy in these situations. Use eye-to-eye contact and a calm, relaxed manner. If there is someone else available, such as the partner, that person could help support the woman in the position, assist with coaching, and compliment her on her efforts. 3. Wash your hands and put gloves on, if possible. 4. Place under woman’s buttocks whatever clean material is available. 5. Avoid touching the vaginal area to decrease the possibility of infection. 6. As the head begins to crown, you should do the following: a. Tear the amniotic membrane (caul) if it is still intact. b. Instruct the woman to pant or pant-blow, thus minimizing the urge to push. c. Place the flat side of your hand on the exposed fetal head and apply gentle pressure toward the vagina to prevent the head from “popping out.” The mother may participate by placing her hand under yours on the emerging head, NOTE: Rapid delivery of the fetal head must be prevented because a rapid change of pressure within the molded fetal skull follows, which may result in dural or subdural tears, and may cause vaginal or perineal lacerations. 7. After the birth of the head, check for an umbilical cord. If the cord is around the baby’s neck, try to slip it over the baby’s head or pull it gently to get some slack so that you can slip it over the shoulders. 8. Support the fetal head as restitution (external rotation) occurs. After restitution, with one hand on each side of the baby’s head, exert gentle pressure downward so that the anterior shoulder emerges under the symphysis pubis and acts as a fulcrum; then, as gentle pressure is exerted in the opposite direction, the posterior shoulder, which has passed over the sacrum and coccyx, emerges. 9. Be alert! Hold the baby securely because the rest of the body may emerge quickly. The baby will be slippery! 10. Cradle the baby’s head and back in one hand and the buttocks in the other. Keep the head down to drain away the mucus. Use a bulb syringe, if one is available, to remove mucus from the baby’s mouth. 11. Dry the baby quickly to prevent rapid heat loss. Keep the baby at the same level as the mother’s uterus until the end of the cord stops pulsating, NOTE: It is important to keep the baby at the same level as the mother’s uterus to prevent the baby’s blood from flowing to or from the placenta and the resultant hypovolemia or hypervolemia. Also, do not “milk” the cord. 12. Place the baby on the mother’s abdomen, cover the baby (remember to keep the head warm, too) with the mother’s clothing, and have her cuddle the baby. Compliment her (them) on a job well done, and on the baby, if appropriate. 13. Wait for the placenta to separate; do not tug on the cord, NOTE: Injudicious traction may tear the cord, separate the placenta, or invert the uterus. Signs of placental separation include a slight gush of dark blood from the introitus, lengthening of the cord, and change in the uterine contour from a discoid to globular shape. 14. Instruct the mother to push to deliver the separated placenta. Gently ease out the placental membranes using an up-and-down motion until the membranes are removed. If birth occurs outside a hospital setting, to minimize complications, do not cut the cord without proper clamps and a sterile cutting tool. Inspect the placenta for intactness. Place the baby on the placenta and wrap the two together for additional warmth. 15. Check the firmness of the uterus. Gently massage the fundus and demonstrate to the mother how she can massage her own fundus properly. 16. If supplies are available, clean the mother’s perineal area and apply a peripad. 17. In addition to gentle massage of the fundus, the following measures can be taken to prevent or minimize hemorrhage: a. Put the baby to the mother’s breast as soon as possible. Sucking or nuzzling and licking the nipple stimulates the release of oxytocin from the posterior pituitary, NOTE: If the baby does not or cannot nurse, manually stimulate the mother’s nipples. b. Do not allow the mother’s bladder to become distended. Assess the bladder for fullness and encourage her to void if fullness is found. c. Expel any clots from the mother’s uterus. 18. Comfort or reassure the mother and her family or friends. Keep the mother and the baby warm. Give her fluids if available and tolerated. 19. If this is a multifetal birth, identify the infants in order of birth (using letters A, B, etc.). 20. Make notations regarding the following aspects of the birth: a. Fetal presentation and position b. Presence of cord around neck (nuchal cord) or other parts and number of times cord encircled part c. Color, character, and amount of amniotic fluid, if rupture of membranes occurs immediately before birth d. Time of birth e. Estimated time of determination of Apgar score (e.g., 1 and 5 minutes after birth), resuscitation efforts implemented, and ultimate condition of baby f. Sex of baby g. Time of placental expulsion, as well as the appearance and completeness of the placenta h. Maternal condition: affect, amount of bleeding, and status of uterine tonicity i. Any unusual occurrences during the birth (e.g., maternal or paternal response, verbalizations, or gestures in response to birth of baby) |
DURATION OF SECOND STAGE
The duration of the second stage of labor is influenced by several factors, such as the effectiveness of the primary and secondary powers of labor; the type and amount of analgesia or anesthesia used; the physical and emotional condition, position, activity level, and parity of the laboring woman; and the nature and source of support the woman receives. For many multiparous women, birth occurs within minutes of complete dilation, perhaps only one push later. Nulliparous women often push for 1 to 2 hours before giving birth. If the woman has been given epidurai anesthesia/analgesia, pushing can last more than 2 hours. Epidurai analgesia/anesthesia blocks or reduces the urge to bear down and limits the woman’s ability to attain an upright position to push. By adjusting dosages to the lowest effective level, allowing the epidurai to wear off, or using mixtures containing a narcotic and a local anesthetic, the woman is able to more fully perceive the urge to bear down, to move more freely, and to attain an upright position with assistance. This enhances the ability to bear down effectively and achieve an uncomplicated vaginal birth (Cosner & dejong, 1993; Mayberry et al., 2000; Shermer & Raines, 1997).
Commonly, a second stage of more than 2 hours is considered prolonged in women without regional analgesia. However, the
If the status of the maternal-fetal unit is reassuring and progress is continuing, interventions to end the second stage of labor are unwarranted. The duration of active pushing has been found to be more relevant to the newborn’s condition at birth than the duration of the second stage of labor itself (d’Entremont, 1996; Minato, 2000; Peterson & Besuner, 1997; Roberts & Woolley, 1996).
CARE MANAGEMENT
The nurse continues to monitor the FHR and the events of the second stage and to provide comfort measures for the mother, such as positioning; providing mouth care; maintaining clean, dry bedding; and removing extraneous noise, conversation, or other distractions (e.g., laughing and talking by attending personnel in or outside the labor area). The woman is encouraged to indicate other support measures she would like (see Table 14-7 and the Care Path).
During the second stage the womaeeds continuous support and coaching. Because the coaching process can be physically and emotionally tiring for support persons, the nurse offers nourishment and fluids and encourages them to take short breaks. If birth occurs in an LDR or LDRP room, the partner may be allowed to wear street clothes or be required to wear a clean scrub outfit, cap, and mask (for the birth). The support person who attends the birth in a delivery room is instructed to put on a cover gown or scrub clothes, mask, hat, and shoe covers, as required. The nurse also specifies support measures that can be used for the laboring woman, and points out areas of the room in which the partner can move freely.
Maternal position
There is no single position for childbirth. Labor is a dynamic, interactive process involving the woman’s uterus, pelvis, and voluntary muscles. In addition, angles between the baby and the woman’s pelvis constantly change as the infant turns and flexes down the birth canal. The woman may want to assume various positions for childbirth, and she should be encouraged and assisted in attaining and maintaining her position(s) of choice. Hanson (1998a) found that sitting and side-lying are the two most common positions assumed by women for their bearing-down efforts and birth.
Birth attendants play a major role in influencing a woman’s choice of positions for birth, with midwives tending to advocate the nonlithotomy positions for the second stage of labor (Hanson, 1998b). Upright positions facilitate fetal descent and birth by straightening the longitudinal axis of the birth canal, employing gravity, and enlarging the pelvic dimensions; this reduces the duration of the second stage, the need for forceps- or vacuum-assisted birth, and episiotomy. More intense, efficient uterine contractions occur as a result of increased uteroplacental circulation. Maternal exhaustion is minimized because an upright position enhances the woman’s ability to bear down effectively (Gupta & Nikodem, 2000; Shermer & Raines, 1997).
Squatting is highly effective in facilitating the descent and birth of the fetus. It is considered to be the best position for the second stage of labor (Andrews & Chrzanowski, 1990; Golay, Vedam, & Sorger, 1993; Mayberry et al., 2000; Roberts & Woolley, 1996). Women should assume a modified, supported squat until the fetal head is engaged, at which time a deep squat can be used. A firm surface is required for this position, and the woman will need side support. In a birthing bed a squat bar is available that she can use to help support herself. A birth ball can help a woman maintain the squatting position. The fetus will be aligned with the birth canal, and pelvic and perineal relaxation will be facilitated as she sits on the ball or holds it in front of her for support as she squats (Perez, 1998).
When a woman uses the standing position for bearing down, her weight is borne on both femoral heads, allowing the pressure in the acetabulum to cause the transverse diameter of the pelvic outlet to increase by up to 1 cm (see Fig. 12, A). This can be helpful if descent of the head is delayed because the occiput has not rotated from the lateral (transverse diameter of pelvis) to the anterior position (Biancuzzo, 1993). Birthing chairs/stools or rocking chairs may be used to provide women with a good physiologic position to enhance bearing-down efforts during childbirth. The upright position allows the woman to see the birth as it occurs and to maintain eye contact with the attendant. Most birthing chairs are designed so that if an emergency occurs, the chair can be adjusted to the horizontal or the Trendelenburg position.
Oversized beanbag chairs and large floor pillows may be used for both labor and birth. They can mold around and support the mother in whatever position she selects. Women may want to sit on the toilet or commode to push because they are concerned about stool incontinence during this stage. These women must be closely monitored, however, and removed from the toilet before birth becomes imminent. Because sitting on chairs, stools, toilets, or commodes can increase perineal edema and blood loss, it is important to assist the woman to change her position every 10 to 15 minutes (Shermer & Raines, 1997) (see Fig. 15, Q.
The side-lying position is an effective position for the second stage, with the upper part of the woman’s leg held by the nurse or coach or placed on a pillow (Gupta & Nikodem, 2000) (see Fig. 15, A). Some women prefer a semi-sitting position. To maintain good uteroplacental circulation and to enhance the woman’s bearing-down efforts in this position, the woman’s back and shoulders should be elevated to at least a 30-degree angle and a wedge should be placed under one hip (see Fig. 15, B).
The hands-and-knees position is an effective position for birth because it enhances placental perfusion, helps rotate the fetus from a posterior to an anterior position, and may facilitate the birth of the shoulders, especially if the fetus is large. Perineal trauma may also be reduced (Biancuzzo, 1991; Gannon, 1992).
The nurse should frequently assess the effect of maternal positions on fetal status. If the woman is reluctant or afraid to try different positions, the nurse can actively encourage and assist the woman to do so. Information regarding the variety of effective childbirth positions should be an essential component of prepared childbirth classes.
The birthing bed is commonly used today and can be set for different positions according to the woman’s needs (Fig. 17). The woman can squat, kneel, sit, recline, or lie on her side, choosing the position most comfortable for her without having to climb into bed for the birth. At the same time, there is excellent exposure for examinations, electrode placement, and birth. Squat bars, over-the-bed tables, birth balls, and pillows can be used for support. The bed can be positioned for the administration of anesthesia and is ideal to help women receiving an epidural to assume different positions to facilitate birth. The bed can be used to transport the woman to the operating room if a cesarean birth is necessary.
Fig. 17 Birth bed. (Courtesy Hill-Rom,
Bearing-down efforts
As the fetal head reaches the pelvic floor, most women experience the urge to bear down. Reflexively the woman will begin to exert downward pressure by contracting her abdominal muscles while relaxing her pelvic floor. This bearing down is an involuntary response to the
A strong expiratory grunt or groan (vocalization) often accompanies pushing when the woman exhales as she pushes. This natural vocalization by women during openglottis bearing-down efforts is likely to be discouraged by nurses in part to “conserve the woman’s energy” but also as a result of concern that it will seem to other nurses and patients that the woman has lost control of herself or the nurse has lost control of the patient (McKay & Roberts, 1990; Peterson & Besuner, 1997).
When coaching women to push, the nurse should encourage them to push as they feel like pushing (i.e., instinctive, spontaneous pushing) rather than to give a prolonged push on command (Thomson, 1993). The nurse monitors the woman’s breathing so that the woman does not hold her breath for more than 5 to 7 seconds at a time and reminds her to take deep cleansing breaths before and after each contraction (Hodnett, 1996; Roberts & Woolley, 1996).
Bearing down while exhaling (open-glottis pushing) and taking breaths between bearing-down efforts help maintain adequate oxygen levels for the mother and fetus and results in approximately five pushes during a contraction, with each push lasting about 5 seconds (d’Entremont, 1996; Mayberry, 2000). Women who use spontaneous pushing are less likely to have second- or third-degree perineal lacerations or episiotomies (Sampselle & Hines, 1999).
Prolonged breath holding, or sustained, directed bearing down, which is still a common practice, may trigger the Valsalva maneuver, which occurs when the woman closes the glottis (closed-glottis pushing), thereby increasing intrathoracic and cardiovascular pressure. This approach to bearing down is harmful or ineffective and should be discouraged (Enkin et al., 2001; Metzger & Therrien, 1990; Technical Working Group, World Health Organization, 1997).
A woman may reach the second stage of labor and then experience a lack of readiness to complete the process and give birth to her child. McKay and Barrows (1991) identified several factors that may inhibit the woman’s voluntary bearing-down efforts:
• Doubts about her readiness to be a mother
• Reluctance to care for another baby
• Desire to wait for support person or primary health care provider to arrive
• Fear or anxiety regarding the unfamiliar or painful sensations of the second stage of labor and pushing
• Embarrassment regarding behaviors during pushing, including sounds made and the passage of stool
• Giving up and not wanting to proceed any further toward vaginal birth
• Fear that the baby will be in danger once it emerges from the protective intrauterine environment
By recognizing that a woman may experience a need to hold back the birth of her baby, the nurse can then address the woman’s concerns and effectively coach the woman during this stage of labor.
To ensure the slow birth of the fetal head, the nurse should encourage the woman to control the urge to bear down by coaching her to take panting breaths or to exhale slowly through pursed lips as the baby’s head crowns. At this point the womaeeds simple, clear directions from one person.
Amnesia between contractions often is pronounced in the second stage, and the woman may have to be roused to cooperate in the bearing-down process. Parents who have attended childbirth education classes may have devised a set of verbal cues for the laboring woman to follow. It is helpful for them to have these cues printed on a card that can be attached to the head of the bed so that the nurse can better substitute as coach if the partner has to leave.
Fetal hуart rate and pattern
As noted previously, the FHR must be checked. If the rate begins to slow or if there is a loss of variability, prompt treatment must be initiated. The woman can be turned on her side to reduce the pressure of the uterus against the ascending vena cava and descending aorta (see Fig. 4), and oxygen can be administered by mask at 8 to 10 L/min. This is often all that is necessary to restore the normal rate. If the FHR does not return to a normal rate immediately, the physician or nurse-midwife should be notified quickly because medical intervention may be indicated to hasten the birth.
LEGAL TIP Documentation
Documentation of all observations (e.g., maternal vital signs, FHFt and pattern, progress of labor) and nursing interventions, including patient response, should be done concurrently with care. The course of labor and the maternal-fetal response may change without warning. It is important that all documentation be accurate, complete, and timely and according to agency policy and professional standards of care.
Supplies, instruments, and equipment
To prepare for birth in any setting, the birthing table or case cart is usually set up during the transition phase for nulliparous women and during the active phase for multiparous women.
Fig. 18 Instrument table. (Courtesy Marjorie Pyle, RNC, Lifecircle,
The birthing table is prepared, and instruments are arranged on the instrument table (Fig. 18). Standard procedures are followed for gloving, identifying and opening sterile packages, adding sterile supplies to the instrument table, and unwrapping sterile instruments and handing them to the physician or nurse-midwife. The crib and equipment are readied for the support and stabilization of the infant. A radiant warmer for the newborn is turned on when crowning begins to occur in the nulliparous woman and when the multiparous woman is 8 to 9 cm dilated (Fig. 19).
Fig. 19 Birthing room. (Courtesy Dee Lowdermilk,
The items used for birth may vary among different facilities; therefore each facility’s procedure manual should be consulted to determine the protocols specific to that facility. The nurse estimates the time until the birth will occur and notifies the physician or nurse-rmdwife if he or she is not in the room. Even the most experienced nurse can miscalculate the time left before birth occurs; thus every nurse who attends a woman in labor must be prepared to assist with an emergency birth if the primary health care provider is not present (see
).
Birth in a delivery room or birthing room
The woman will need assistance if she must move from the labor bed to the delivery table (Fig. 20). The woman can help if this is done between contractions, but because of her awkwardness, she cannot be rushed. In a birthing room, no such transfer is necessary (see Fig. 19).
Fig. 20 Delivery room. (Courtesy Michael S. Clement, MD,
The various positions assumed for birth in a delivery room are the Sims position (in which the attendant will need to support the upper part of the woman’s leg), the dorsal position, and the lithotomy position.
The lithotomy position has been the position most commonly used for birth in Western cultures, although this practice is slowly changing (see Fig. 12, B). The lithotomy position makes it more convenient for the physician or nurse-midwife to deal with any complications that arise. To place the woman in this position, her buttocks are brought to the edge of the upper portion of the table and her legs are placed in stirrups. Care must be taken to pad the stirrups, to raise and place both legs simultaneously, and to adjust the shanks of the stirrups so that the calves of the legs are supported. There should be no pressure on the popliteal space. If the stirrups are not the same height, ligaments in the woman’s back can be strained as she bears down, leading to considerable discomfort in the postpartum period. The lower portion of the table may be dropped down and rolled back under the table.
It should be noted that the routine use of a supine or lithotomy position for labor and birth has been identified as a clearly harmful or ineffective practice and should be discouraged (Enkin et al., 2001; Technical Working Group, World Health Organization, 1997).
The maternal position for birth in a birthing room varies from a lithotomy position with the woman’s legs in stirrups, to one in which her feet rest on footrests while she holds onto a squat bar, to a side-lying position with the woman’s upper leg supported by the coach, nurse, or squat bar. The foot of the bed can be removed so that the physician or nurse-midwife attending the birth can gain better perineal access for performing an episiotomy, delivering a large baby, or getting access to the emerging head to facilitate suctioning. Otherwise the foot of the bed is left in place and lowered slightly to form a ledge that allows access for birth and that also serves as a place to lay the newborn.
Once the woman is positioned for birth in either the delivery room or birthing room, the vulva and perineum are cleansed. Hospital protocols and the preferences of physician or nurse-midwife for cleansing may vary and can involve washing the area thoroughly with warm, soapy water or a soapy povidone-iodine (Betadine) solution and then rinsing the area. Next the area may be sprayed with a disinfectant to prevent bacterial growth.
The circulating nurse (usually the same nurse as the labor nurse) continues to coach and encourage the woman. The nurse auscultates the FHR or checks the fetal monitor every 5 to 15 minutes, depending on whether the woman is at low or high risk for problems or per protocol. She keeps the physician or nurse-midwife informed of the rate and pattern of the fetal heart (Tucker, 2000). The equipment for measuring blood pressure should be available for instant use should signs of shock develop. Blood pressure readings taken when the woman pushes will be distorted (increased) by the increase in thoracic and abdominal pressures. An oxytocic medication such as Pitocin may be prepared so that it is ready to be administered after expulsion of the placenta. Standard Precautions should always be followed as care is administered during the process of labor and birth (see
).
The physician or nurse-midwife puts on a cap, a mask that has a shield or protective eyewear, and shoe covers. Hands are then scrubbed, a sterile gown (with waterproof front and sleeves) is donned, and gloves are put on. Nurses attending the birth may also need to wear caps, protective eyewear, masks, gowns, and gloves. The woman may then be draped with sterile towels and sheets. The partner can help the woman remember not to touch the sterile drapes. Nursing contact with the parents is maintained by touching, verbal comforting, explaining the reasons for care, and sharing in the parents’ joy at the birth of their child.
Mechanism of birth: vertex presentation
The three phases of the spontaneous birth of a fetus in a vertex presentation are (1) birth of the head, (2) birth of the shoulders, and (3) birth of the body and extremities (
).
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BOX 6 Normal Vaginal Childbirth
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With voluntary bearing-down efforts, the head appears at the introitus (Fig. 21). Crowning occurs when the widest part of the head (biparietal diameter) distends the vulva just before birth. Immediately before birth, the perineal musculature becomes greatly distended. The physician or nurse-midwife controls the birth of the head by (1) applying pressure against the rectum, drawing it downward to aid in flexing the head as the back of the neck catches under the symphysis pubis; (2) then applying upward pressure from the coccygeal region (modified Ritgen maneuver) (Fig. 22) to extend the head during the actual birth, thereby protecting the musculature of the perineum; and (3) assisting the mother with voluntary control of the bearing-down efforts by coaching her to pant while letting uterine forces expel the fetus.
Fig. 21 Beginning birth with vertex presenting. A, Anteroposterior slit. B, Oval opening. C, Circular shape. D, Crowning.
Fig. 22 Birth of head using modified Ritgen maneuver. Note control to prevent too rapid birth of head.
The umbilical cord often encircles the neck (nuchal cord) but rarely so tightly as to cause hypoxia. After the head is born, gentle palpation is used to feel for the cord. If present, the cord should be slipped gently over the head. If the loop is tight or if there is a second loop, the cord is clamped twice, cut between the clamps, and unwound from around the neck before the birth is allowed to continue.
Mucus, blood, or meconium in the nasal or oral passages may prevent the newborn from breathing. To eliminate this problem, moist gauze sponges are used to wipe the nose and mouth. A bulb syringe is first inserted into the mouth and oropharynx to aspirate contents, and then the nares are cleared in the same fashion while the head is supported.
Prevention of meconium aspiration
If meconium has been present in the amniotic fluid during labor, a DeLee suction apparatus is placed on the sterile field and preparations are made for wall suction. Fluids are withdrawn from the infant’s mouth and nose before the first breath is taken to prevent meconium aspiration. Use of the DeLee device with oral suction to withdraw fluid from the infant should be avoided unless the suction device is designed so that it can keep mucus from entering the health care provider’s mouth.
The time of birth is the precise time when the entire body is out of the mother. This time must be noted on the record.
If the condition of the newborn is not compromised, it may be placed on the mother’s abdomen immediately after birth and covered with a warm, dry blanket. The cord may be clamped at this time, and the physician or nursemidwife may ask if the woman’s partner would like to cut the cord. If so, the partner is given a sterile pair of scissors and instructed to cut the cord 1 inch (2.5 cm) above the clamp.
Use of fundal pressure
Fundal pressure is the application of gentle, steady pressure against the fundus of the uterus to facilitate the vaginal birth. Historically it has been used when the administration of analgesia and anesthesia decreased the woman’s ability to push during the birth, in cases of shoulder dystocia, and when second-stage fetal bradycardia or other nonreassuring FHR patterns were present. Use of fundal pressure by nurses is not advised because there is no standard technique available for this maneuver, and no current legal, professional, or regulatory standards for its use exist. In cases of shoulder dystocia, fundal pressure is not recommended; the all-fours position (the Gaskin maneuver), suprapubic pressure, and maternal position changes are among the recommended interventions (Bruner et al., 1998; Cosner, 1996; Naef & Morrison, 1994; Piper & McDonald, 1994) (see Chapter 24).
Immediate Assessments and Care of the Newborn
The care given immediately after the birth focuses on assessing and stabilizing the newborn. The nurse’s primary responsibility at this time is the infant, because the physician or nurse-midwife is involved with the expulsion of the placenta and the care of the mother. The nurse must watch the infant for any signs of distress and initiate appropriate interventions should these appear.
A brief assessment of the infant can be performed while the mother is holding him or her. This includes checking the infant’s airway and Apgar score. Maintaining a patent airway, supporting respiratory effort, and preventing cold stress by drying the newborn and covering the newborn with a warmed blanket or placing him or her under a radiant warmer are the major priorities in terms of the newborn’s immediate care. Further examination, identification procedures, and care can be postponed until later in the third stage of labor or early in the fourth stage.
PERINEAL TRAUMA RELATED TO CHILDBIRTH
Lacerations
Most acute injuries and lacerations of the perineum, vagina, uterus, and their support tissues occur during childbirth. Some injuries to the supporting tissues, whether they were acute or nonacute and whether they were repaired or not, may lead to gynecologic problems later in life (e.g., pelvic relaxation, uterine prolapse, cystocele, and rectocele).
The tendency to sustain lacerations varies with each woman; that is, the soft tissue in some women may be less distensible. Damage usually is more pronounced in nulliparous women because the tissues are firmer and more resistant than those in multiparous women. Heredity may also be a factor. For example, the tissue of light-skinned women, especially those with reddish hair, is not as readily distensible as that of darker-skinned women and healing may be less efficient.
Immediately after birth the cervix, vagina, and perineum are inspected for damage. During the early postpartum period the nurse and the physician or nurse-midwife continue to carefully inspect the perineum and evaluate lochia and symptoms to identify any previously missed damage.
Perineal lacerations. Perineal lacerations usually occur as the fetal head is being born. The extent of the laceration is defined in terms of its depth:
1. First degree: Laceration that extends through the skin and structures superficial to muscles
2. Second degree: Laceration that extends through muscles of the perineal body
3. Third degree: Laceration that continues through the anal sphincter muscle
4. Fourth degree: Laceration that also involves the anterior rectal wall
Perineal injury is often accompanied by small lacerations on the medial surfaces of the labia minora below the pubic rami and to the sides of the urethra and clitoris. Lacerations in this highly vascular area often result in profuse bleeding. Special attention must be paid to the repair and subsequent care of third- and fourth-degree lacerations so that the woman retains fecal continence. Measures are then taken to promote soft stools for a few days to increase the woman’s comfort and to foster healing. Antimicrobial therapy may be used in some cases.
Vaginal and urethral lacerations. Vaginal lacerations often occur in conjunction with perineal lacerations. Vaginal lacerations tend to extend up the lateral walls (sulci) and, if deep enough, involve the levator ani. Additional injury may occur high in the vaginal vault near the level of the ischial spines. Vaginal vault lacerations may be circular and may result from forceps rotation, especially in the presence of cephalopelvic disproportion, rapid fetal descent, or precipitous birth. Lacerations can also occur around the urethra (periurethral) and in the area of the clitoris.
Cervical injuries
Cervical injuries occur when the cervix retracts over the advancing fetal head. These cervical lacerations occur at the lateral angles of the external os; most are shallow, and bleeding is minimal. Larger lacerations may extend to the vaginal vault or beyond the vault into the lower uterine segment; serious bleeding may occur. Extensive lacerations may follow hasty attempts to enlarge the cervical opening artificially or to deliver the fetus before full cervical dilation is achieved. Injuries to the cervix can have adverse effects on future pregnancies and childbirths.
Episiotomy
An episiotomy is an incision made in the perineum to enlarge the vaginal outlet. It is performed more commonly in the
Risk factors associated with perineal trauma (episiotomy, lacerations) include nulliparity, occiput posterior position of the fetus, large (macrosomic) infants, use of instruments to facilitate birth, prolonged second stage of labor, and fetal distress. Socioeconomic factors associated with a higher rate of episiotomies include the Caucasian and Asian races and private insurance and care (Albers et al, 1996; Hueston, 1996; Lydon-Rochelle, Albers, & Teaf, 1995).
Alternative measures for perineal management, such as warm compresses, manual support, and massage (i.e., prenatal and intrapartum) have been shown to reduce, to varying degrees, the incidence of episiotomies, but further research is recommended (Albers et al, 1996; Davidson, Jacoby, & Brown, 2000; Lydon-Rochelle, Albers, & Teaf, 1995; Renfrew et al, 1998). Nurses acting as advocates can encourage women to use alternative birthing positions that reduce pressure on the perineum and to use spontaneous bearing-down efforts. In addition, nurses can educate other health care providers about measures to preserve perineal integrity and to be more flexible in defining the maximum limit for the duration of the second stage of labor as long as the maternal-fetal unit is stable (Maier & Maloni, 1997). The perineum can be prepared for birth in the prenatal period through the use of Kegel exercises and massage. Use of Kegel exercises in the postpartum period improves and restores the tone and strength of the perineal muscles. Health practices, including good nutrition and appropriate hygienic measures, help maintain the integrity and suppleness of the perineal tissue.
The type of episiotomy is designated by the site and direction of the incision (Fig. 14-23). Midline (median) episiotomy is most commonly used in the
Fig. 23 Types of episiotomies.
Mediolateral episiotomy is used in operative births when the need for posterior extension is likely. Although a fourth-degree laceration may be prevented, a thirddegree laceration may occur. Also, the blood loss is greater and the repair more difficult and painful than with midline episiotomies. Episiotomies and the third- and fourthdegree lacerations that can occur actually cut and extend into muscles, thereby prolonging recovery (Paciornik, 1990; Woolley, 1995).
EMERGENCY CHILDBIRTH
Even under the best of circumstances there probably will come a time when the perinatal nurse will be required to assist with the birth of an infant without medical assistance. Because it is neither possible nor desirable to prevent an impending birth, the perinatal nurse must be able to function independently and be skilled in the safe birth of a vertex fetus (see
).
A lateral Sims position may be the position of choice for birth when (1) the birth is progressing rapidly and there is insufficient time for slow distention of the perineum; (2) the fetal head seems too large to pass through the introitus without laceration, and episiotomy is not possible; or (3) the apparent size of the fetus is consistent with possible shoulder dystocia. In the lateral Sims position, less stress is placed on the perineum and better visualization of the perineum is possible as the upper leg is supported by the woman’s partner or the nurse (see Fig. 15, A). In the event of shoulder dystocia, the lateral Sims position increases the space needed for birth.
THIRD STAGE OF LABOR
The third stage of labor lasts from the birth of the baby until the separation and expulsion of the placenta. The goal in the management of the third stage of labor is the prompt separation and expulsion of the placenta, achieved in the easiest, safest manner.
The placenta is attached to the decidual layer of the basal plate’s thin endometrium by numerous fibrous anchor villi—much in the same way as a postage stamp is attached to a sheet of postage stamps. After the birth of the fetus, strong uterine contractions occur that cause the placental site to shrink markedly. This causes the anchor villi to break and the placenta to separate from its attachments. Normally the first few strong contractions that occur 5 to 7 minutes after the baby’s birth cause the placenta to be sheared away from the basal plate. A placenta cannot detach itself from a flaccid (relaxed) uterus because the placental site is not reduced in size.
PLACENTAL SEPARATION AND EXPULSION
Fig, 24 Third stage of labor. A, Placenta begins to separate in central portion accompanied by retroplacental bleeding. Uterus changes from discoid to globular shape. B, Placenta completes separation and enters lower uterine segment. Uterus is globular in shape. C, Placenta enters vagina, cord is seen to lengthen, and there may be increased bleeding. D, Expulsion (delivery) of placenta and completion of third stage.
Placental separation is indicated by the following signs (Fig. 24):
• A firmly contracting fundus
• A change in the uterus from a discoid to a globular ovoid shape as the placenta moves into the lower uterine segment
• A sudden gush of dark blood from the introitus
• Apparent lengthening of the umbilical cord as the placenta descends to the introitus
• The finding of vaginal fullness (the placenta) on vaginal or rectal examination or of fetal membranes at the introitus
Depending on the preferences of the physician or nurse-midwife, an expectant or active approach may be used to manage the third stage of labor. Expectant management allows the placenta to separate spontaneously; it may involve the use of gravity or nipple stimulation to facilitate separation and expulsion. Active management facilitates placental separation and expulsion with administration of oxytocics after birth of the fetus, early clamping and cutting of the umbilical cord, and application of controlled traction on the cord. Research findings support the superiority of active management in terms of lower blood loss and reduced risk for postpartum hemorrhage and other complications of the third stage of labor (Prendiville, Elbourne, & McDonald, 2001).
To assist in the delivery of the placenta, the woman is instructed to push when signs of separation have occurred. If possible, the placenta should be expelled by maternal effort during a uterine contraction. Alternate compression and elevation of the fundus, plus minimum, controlled traction on the umbilical cord, may be used to facilitate delivery of the placenta and amniotic membranes. Oxytocics may be administered after the placenta is removed because they stimulate the uterus to contract, thereby helping to prevent hemorrhage.
Whether the placenta first appears by its shiny fetal surface (Schultze mechanism) or turns to show its dark roughened maternal surface (
CARE MANAGEMENT
Placental examination and disposal
After the placenta and the amniotic membranes emerge, the physician or nurse-midwife examines them for intactness to ensure that no portion remains in the uterine cavity (i.e., no fragments of the placenta or membranes are retained) (Fig. 25).
Fig. 25 Examination of the placenta. (Courtesy Michael S. Clement, MD,
LEGAL TIP Placental Examination
Examination of the placenta and its cord after birth may provide clues as to the basis for infant health problems, including mental retardation and cerebral palsy. In some instances, poor obstetric outcomes are related to preexisting problems within the placenta and cord and not to childbirth care and events. Nurses can advocate for the development of protocols regarding labor and birth events that would warrant a thorough, pathologic examination of the placenta and cord. A finding that the placenta is abnormal or diseased may play an important role in the defense of health care providers in cases of malpractice (Urbanski, 1997).
Some women and their families may have culturally based beliefs regarding the care of the placenta and the manner of its disposal after birth, viewing the care and disposal of the placenta as a way of protecting the newborn from bad luck and illness. Requests by the woman to take the placenta home and dispose of it according to her customs may be at odds with health care agency policies, especially those related to infection control and the disposal of biologic wastes. Many cultures follow specific rules regarding the disposal of the placenta in terms of method (e.g., burning, drying, burying, eating); site for disposal (in or near the home); and timing of disposal (immediately after birth, time of day, or by astrological signs). Disposal rituals may vary according to the gender of the child and the length of time before another child is desired. If eaten, the placenta can be a means of restoring a woman’s wellbeing after birth or of ensuring quality breast milk. Health care providers can provide culturally sensitive health care by encouraging women and their families to express their wishes regarding the care and disposal of the placenta and by establishing a policy to fulfill these requests (Choudhry, 1997; Howard & Berbiglia, 1997; Schneiderman, 1998).
Maternal physical status
Physiologic changes after birth are profound. The cardiac output increases rapidly as maternal circulation to the placenta ceases and the pooled blood from the lower extremities is mobilized. The pulse rate slows in response to the change in cardiac output and tends to remain slightly slower than the prepregnancy rate for approximately 1 week.
Soon after the birth the woman’s blood pressure usually returns to prepregnancy levels. Several factors contribute to an elevated blood pressure at this time: the excitement of the second stage, certain medications, and the time of day (blood pressure is highest during the late afternoon). Analgesics and anesthetics may also cause hypotension to develop in the hour after birth.
The major risk for women during the third stage of labor is postpartum hemorrhage. When the physician or nursemidwife completes the delivery of the placenta, the nurse observes the mother for signs of excessive blood loss, including alteration in vital signs, pallor, light-headedness, restlessness, decreased urinary output, and alteration in level of consciousness and orientation.
Because of the rapid cardiovascular changes taking place (e.g., the increased intracranial pressure during pushing, the rapid increase in cardiac output and the separation of the placenta), the risk of rupture of a preexisting cerebral aneurysm and the risk of formation of pulmonary etnboli are greater than usual during this period. Another dangerous, unpredictable problem that may occur is the formation of an amniotic fluid embolism (see Chapter 24).
Women with a history of cardiac disorders are at increased risk for cardiac decompensation and pulmonary edema as a result of the circulatory changes associated with the birth of the fetus and expulsion of the placenta.
When the third stage is complete and any lacerations are repaired or an episiotomy is sutured, the vulvar area is gently cleansed with warm sterile water or normal saline, and a sterile perineal pad or ice pack is applied to the perineum. The birthing table or bed is repositioned and the woman’s legs are lowered simultaneously from the stirrups if she gave birth in a lithotomy position. Drapes are removed and dry linen is placed under the woman’s buttocks; she is provided with a clean gown and a warmed blanket. She is assisted into her bed if she is to be transferred from the birthing area to the recovery area; assistance is also necessary to move the woman from the birthing table onto a bed if the woman has had anesthesia and does not have full use of her lower extremities. The side rails are raised during the transfer. She may be given the baby to hold during the transfer or the father or partner may carry the baby or transport it in a crib, either to the nursery or to the recovery area. Maternal and neonatal assessments for the fourth stage of labor are instituted.
summarizes normal vaginal childbirth.
INTERACTIONS WITH THE NEWBORN FOLLOWING BIRTH
Most parents enjoy being able to handle, hold, explore, and examine the baby immediately after birth. Both parents can assist with the thorough drying of the infant. The infant may be wrapped in a receiving blanket and placed on the woman’s abdomen. If skin-to-skin contact is desired, the unwrapped infant may be placed on the woman’s abdomen and then covered with a warm blanket.
Holding the newborext to her skin helps the mother maintain the baby’s body heat and provides skin-to-skin contact; care must be taken to keep the head warm. Stockinette caps are sometimes used to cover the newborn’s head. It is the nurse’s responsibility to make sure the infant stays warm and is in no danger of slipping from the parent’s grasp.
Many women wish to begin breastfeeding their newborns at this time to take advantage of the infant’s alert state (first period of reactivity) and to stimulate the production of oxytocin, which promotes contraction of the uterus. Others prefer to wait until the newborn, parents, and older siblings are together in the recovery area. In some cultures, breastfeeding is not considered acceptable until the milk comes in.
The woman usually feels some discomfort while the physician or nurse-midwife carries out the postbirth vaginal examination. The nurse can encourage the woman to use breathing and relaxation or distraction techniques to assist her in dealing with the discomfort. During this time, the nurse assesses the newborn’s physical condition and performs agency identification procedures; the baby can be weighed, given eye prophylaxis and a vitamin K injection, wrapped in warm blankets, and then given to the partner or back to the mother to hold when she is ready (see Chapter 19).
The woman’s reaction to the sight of her newborn may range from excited outbursts of laughing, talking, and even crying to apparent apathy. A polite smile and nod may be her only acknowledgment of the comments of nurses and the physician or nurse-midwife. Occasionally, the reaction is one of anger or indifference; the woman turns away from the baby, concentrates on her own pain, and sometimes makes hostile comments. These varied reactions can arise from pleasure, exhaustion, or deep disappointment. When evaluating parent-newborn interactions after birth, the nurse should also consider the cultural characteristics of the woman and her family and the expected behaviors of that culture. In some cultures the birth of a male child is preferred and women may grieve when a female child is born (Choudhry, 1997).
Whatever the reaction and its cause may be, the womaeeds continuing acceptance and support from all staff. Notation regarding the parents’ reaction to the newborn can be made in the recovery record. Nurses can assess this reaction by asking themselves such questions as, How do the parents look? What do they say? What do they do? Further assessment of the parent-newborn relationship can be conducted as care is given during the period of recovery. This is especially important if warning signs (e.g., passive or hostile reactions to the newborn, disappointment with sex or appearance of the newborn, absence of eye contact, or limited interaction of parents with each other) were noted immediately after birth. The nurse may find it helpful to discuss any warning signs that may have beeoted with the woman’s physician or nurse-midwife.
Siblings, who may have appeared only remotely interested in the final phases of the second stage, tend to experience renewed interest and excitement when the newborn appears. They can be encouraged to hold the baby (Fig. 26).
Fig. 26 Big brother becomes acquainted with new baby sister. (Courtesy Marjorie Pyle, RNC, Lifecircle,
Parents usually respond to praise of their newborn. Many need to be reassured that the dusky appearance of their baby’s extremities immediately after birth is normal until circulation is well established. If appropriate, the nurse should explain the reason for the molding of the newborn’s head. Information about hospital routine can be communicated. It is important, however, for nurses to recognize that the cultural background of the parents may influence their expectations regarding the care and handling of their newborn immediately after birth. For example, some traditional Southeast Asians believe that the head should not be touched because it is the most sacred part of a person’s body. They also believe that praise of the baby is dangerous because jealous spirits may then cause the baby harm or take it away (Geissler, 1999). Hospital staff members, by their interest and concern, can provide the environment for making this a satisfying experience for parents, family, and significant others.
Determining a woman’s satisfaction with and impressions of her childbirth experience is a critical component in the provision of high-quality maternal-newborn health care that meets the individual needs of women and families (Fowles, 1998; Young, 1998). In addition, reviewing the childbirth experience with someone who will listen, support, and explain has been found to reduce the degree of postpartum depression experienced by many women during the first week or so following birth (Wessely, 1998).
