1. First Stage of Labor: Considering Familial Expectation

As the expectant family approaches the birth of their child, they undergo an array of emotions from excitement and anticipation to anxiety and fear about the labor and birth process. The nurse can assist them through this stressful process by providing guidance, teaching, and comfort throughout the process. To do this effectively, nurses should first complete an admission assessment. Information is obtained from the prenatal chart and from the mother regarding the onset, frequency, and intensity of contractions and the status of the amniotic membranes, whether ruptured or intact. If ruptured, the time of rupture as well as the amount and color of the fluid are important. The degree of cervical dilation and effacement will also be assessed. Fetal status is also assessed with an electronic fetal monitor (EFM) or a handheld Doppler. The mother should also be asked questions regarding any events that have occurred since her last prenatal visit. These assessments will help determine whether the woman is actually in labor and how soon she will deliver. Her comfort level should be assessed, including the amount of pain she may be experiencing.

The woman will also be asked about psychosocial support, including any cultural or spiritual preferences that should be incorporated into her plan of care. The couple should be asked about any birthing plan they may have and should be assessed for their understanding of the labor and birthing process. Client teaching should be provided accordingly. Obtaining this information will greatly enhance the nurse’s ability to provide individualized care. Finally, proper documentation of the assessment should be completed per institutional protocol.

2. First Stage of Labor: Assessments

Nursing care during the first stage of labor involves meeting the needs of the laboring woman and her family during the three phases of this stage. It also involves specific nursing assessments. Maternal vital signs should be taken and documented according to institutional protocol, but generally they will be assessed every 30–60 minutes for low-risk women during the latent and active phases. During the transition phase, vital signs will be assessed every 30 minutes. For high-risk women, vital signs are taken at least every 30 minutes during the latent and active phases. Depending on the woman’s status, the time may be increased to every 15 minutes during transition. Any significant increases or decreases in blood pressure or pulse or increases in temperature should be reported to the woman’s health care provider.

Uterine activity should be assessed and documented according to institutional protocol as well. Generally, contraction frequency, duration, and intensity are assessed along with the fetal heart rate (FHR) every 30–60 minutes in low-risk women and every 30 minutes in high-risk women during the latent and active phases. During transition, low-risk women will be assessed for uterine activity and FHR every 15–30 minutes; for high-risk women, every 15 minutes. If intermittent auscultation is used, the FHR is auscultated throughout an entire contraction and for 15–20 seconds after the contraction ends. This allows confirmation of a normal baseline rate and detection of any FHR decelerations. Intermittent auscultation of the FHR can be performed every 30–60 minutes for the low-risk woman. This approach can be used with the high-risk woman if the baseline rate is within normal limits (110–160 beats/min in a term fetus) and there are no decelerations detected; otherwise, continuous electronic fetal monitoring (EFM) is used. As with the maternal vital signs, any deviations from the normal requiring intervention should be documented and reported to the health care provider. Examples of findings requiring intervention include abnormal FHR baseline,

FHR decelerations, fetal bradycardia or tachycardia, and uterine tachysystole.

3. First Stage of Labor: Promoting Comfort

The nurse can provide optimum comfort for the laboring woman by finding out what will work best for her. Does the woman want to be totally pain free? Does she want to go through the birth process naturally without pharmacologic interventions? Is her partner interested in ways he or she can promote optimum comfort in the woman? Is the couple not sure what they want to do and are they asking the nurse’s advice? Once their goals are known, the nurse is able to support them in their choices for alleviating labor discomfort and pain. The following outlines interventions that promote comfort during the first stage of labor.

If the woman has chosen a pharmacologic approach to relieving discomfort, the nurse will provide teaching about their chosen method and will obtain an order and administer parenteral medication. If she has chosen a regional analgesic, the nurse notifies the anesthesiologist so the woman can be evaluated. The nurse will then assist in the administration of the anesthetic.

With nonpharmacologic methods to manage pain, such as effleurage, breathing, and relaxation techniques, the nurse can reinforce teaching that the woman and her partner may have received in childbirth education classes. If childbirth education classes were not attended, the nurse can provide simple instructions regarding strategies they can use to meet their pain relief goals.

Offering mouth care periodically can be comforting to a laboring woman as her mouth can become dry due to the breathing techniques she uses to cope with labor pain. She

can also suck on hard candies or ice chips to moisten her mouth. Mouth care should also be offered if she is experiencing nausea and vomiting during labor.

Other ways to promote comfort during this time will include assisting the woman to change positions often, supporting her extremities with pillows. If allowed, rocking in a rocking chair, sitting on a “birthing ball,” or ambulation can also provide comfort. Massage and coaching the woman in breathing and relaxation techniques are things the woman’s partner can do to support her.

As labor progresses, the woman will experience leaking of amniotic fluid and the vaginal discharge known as “bloody show.” Frequently changing the underpads and bed linens, as well as providing Peri-care, will promote comfort.

Keeping the bladder empty during labor will also provide comfort. As the fetus descends, it will put pressure on the bladder, causing pain and discomfort. The mother should be encouraged to void every 2 hours.

The first stage of labor ends with the complete dilation and effacement of the cervix.

4. Second Stage of Labor: Preparing for Birth

The second stage of labor begins when the woman’s cervix is completely dilated and effaced. She can now begin bearing down efforts to push the fetus out. During this time, vital signs and uterine activity will be assessed every 15–30 minutes or as per institutional protocol. The fetal heart rate (FHR) will be assessed every 5–15 minutes during the second stage. During this time the woman will need support and coaching to push effectively. Structured closed glottis pushing is effective but has been shown to be unnecessary and should be discouraged.1 Pushing with an

open glottis, or with every other contraction, will allow the woman to maintain her oxygenation and that of her fetus. The nurse can also promote effective pushing efforts by assisting the laboring woman into positions that are comfortable and that will promote fetal descent. During this time, the woman’s partner and family will require support and reassurance as well. Nurses can encourage partners and significant others, showing them ways they can support the woman through the final leg of this birthing journey.

5. Second Stage of Labor: Promoting Comfort

Strategies that promote comfort during the second stage of labor are very similar to those employed during the first stage. However, the woman may have increased anxiety and feelings of being out of control that will require extra reassurance and support. The nurse and the woman’s partner or significant other can reassure her by praising her efforts and keeping her apprised of her progress, thus reducing her anxiety. She may also experience diaphoresis and feelings of being overheated that can be relieved with a cool, moist cloth applied to her forehead. Offering her ice chips and changing her gown and underpads will also make her more comfortable.

6. Second Stage of Labor: Providing Assistance during the Birth

As birth becomes imminent the nurse is responsible for making sure that the delivery table and other equipment are ready. The nurse will also make sure that personal protective equipment (PPE) is available for him/herself and the health care provider. The

nurse will position the woman for birth in a manner that is comfortable for her and that makes her accessible to the health care provider. These positions include but are not limited to the semi-recumbent or semi-Fowler’s, side-lying, squatting, and hands and knees positions. Once the woman is positioned, the nurse will assist the health care provider in draping the woman’s legs and abdomen, providing a sterile field. The health care provider will cleanse the woman’s perineum as she is encouraged to continue her bearing down efforts. As the fetal head begins to crown, the woman may experience a stretching, burning sensation, and she may require the nurse and/or her partner to assist her in focusing on her breathing techniques to get past the discomfort. Once the fetal head has been delivered, the mouth and nose are suctioned and the health care provider will check for a nuchal cord before assisting the delivery of the shoulders. Once the shoulders have been delivered, the rest of the body will follow. Documentation of the time of birth as well as any other information (use of forceps or vacuum extraction) should be completed according to institutional protocol. Birth marks the end of the second stage of labor.

7. Third Stage of Labor: Care during Delivery of the Placenta

The third stage of labor begins once the birth has occurred. During this stage, nursing responsibilities focus on assisting in the delivery of the placenta, care of the newborn, and monitoring the new mother for signs of complications. Delivery of the placenta usually takes place within 30 minutes of birth and is performed by the health care provider. Signs that the placenta is about to deliver include lengthening of the umbilical cord, a gush of blood from the vagina, a change in the shape of the uterus from a disk to a globe, and maternal reports of increased contraction pain.

The umbilical cord should never be forcibly pulled, as this could cause uterine inversion resulting in hemorrhage, or the cord could break, requiring manual removal of the placenta. Gentle traction can be applied to ease the placenta through the birth canal. Once the placenta has been expelled, the nurse should note the time for documentation in medical record. Oxytocin (Pitocin) is often given after expulsion of the placenta to promote uterine contractility and decrease vaginal bleeding. Ten to twenty units of oxytocin can be added to an IV infusion or 10 units can be given intramuscularly. The placenta will be inspected by the health care provider to make sure that it is intact and that no tissue or membranes have been left in the uterus. The health care provider will then inspect the mother’s perineum, vagina, and cervix for lacerations. If any are noted or if there is an episiotomy, preparations will be made for repair.

During this time, the nurse will also monitor the new mother for signs of complications such as hypotension or excessive vaginal bleeding. The nurse will begin to monitor vital signs every 15 minutes until any perineum repair is complete. Peri care can then be provided with a warm water wash, and peripads are applied. An ice pack can be applied if there was an episiotomy or laceration repair.

8. Third Stage of Labor: Immediate Care of the Newborn

Care of the newborn immediately after birth centers on maintaining a patent airway and cardiorespiratory circulation. Nursing responsibilities at this time are as follows:

Immediately after birth the health care provider will place the newborn on the mother’s chest or abdomen. Sometimes the newborn will be handed off to a nurse, who will place the

newborn under a radiant warmer. In either scenario the newborn will be dried thoroughly to prevent heat loss. This stimulation will also promote the newborn’s respiratory efforts.

The newborn’s mouth and nose will be suctioned with a bulb syringe or mechanical suction to remove secretions. Suctioning the mouth and oropharynx first will prevent the newborn from reflexively aspirating any contents of the nasopharynx.

Once the airway is clear, the nurse can assess the newborn’s heart rate, respirations, muscle tone, grimace, and color. These criteria are used in the Apgar score, which assesses the newborn’s immediate transition from intrauterine to extrauterine life. It is not used to determine the need for resuscitation. The newborn is scored at 1 minute and again at 5 minutes of life. A score of 7–10 reflects little to no difficulty adapting; 4–6, moderate difficulty in adapting; and 0–3, severe difficulty in adapting. If the 5-minute Apgar score is less than 7, the assessment can be performed again at 10 minutes and at 20 minutes. Lastly, it is most important to understand that Apgar scores are not used to determine the need for resuscitation. It would be inappropriate to wait 60 seconds to initiate resuscitation if the newborn is apneic or pulseless.

Once the newborn has been stabilized, an initial set of vital signs is taken. If it has not been done already, the umbilical cord can be clamped approximately an inch from the abdomen.

For identification purposes, the newborn is footprinted and two ID bands are placed on the newborn’s wrist and ankle. The mother’s thumbprint may also be taken, and she is given an ID bracelet with information that matches her newborn’s bracelet. Some institutions may give the significant other an ID bracelet as well. If stable, the

newborn is swaddled and given to the mother so that bonding can begin. The newborn may be put to breast or bottle fed at this time.

9. Third Stage of Labor: Promoting Maternal/Newborn Bonding

Bonding refers to that initial attraction felt by parents for their newborn during the first 30–60 minutes after birth. It is unidirectional from parent to child and is enhanced through parental/infant touch and interaction. The first hours after birth are ideal to begin the bonding process. At this time the newborn is in a quiet alert state, able to interact with his/her parents. Nurses can enhance this process by providing a quiet, private space for the parents and their newborn. Turning down the room lights and delaying the administration of eye prophylaxis can further enhance the experience by making it easier for the newborn to establish eye contact with his/her parents. Bonding behaviors can include gazing into the newborn’s eyes, softly talking to the newborn in a high-pitched voice, and lightly touching and inspecting the newborn. This is also the ideal time for the nurse to assist the mother in initiating breastfeeding.

10. Fourth Stage: Assessments

The fourth stage of labor consists of the first 1 to 4 hours postpartum after expulsion of the placenta. During this time the mother’s condition is stabilizing and requires close monitoring for signs of complication including excessive vaginal bleeding. Nursing assessments during this time are as follows:

While institutional policy and procedure should be followed, generally, maternal vital signs including assessments for pain are performed every 15 minutes x 4, then every 30 minutes x 2, then every 1 hour until the mother is stable and/or she is transferred to the postpartum unit.

Fundal assessments are performed on the same schedule as vital signs. The fundus is palpated in relation to the umbilicus. Immediately after birth the fundus will be midway between the umbilicus and symphysis pubis. It should be firm and midline. Vaginal bleeding should be of moderate amounts. This assessment is documented as “fundus firm at the level of the umbilicus.” Vaginal bleeding is documented as being scant, small, moderate, or heavy and as lochia rubra, serosa, or alba. If the fundus is difficult to locate and feels soft, it is considered “boggy” and should be massaged until it firms up and feels like a grapefruit.

The maternal perineum should be assessed for integrity. If there is an episiotomy or laceration it should be assessed for REEDA (redness, erythema, edema, drainage, and approximation).

The mother’s response to regional anesthesia should be assessed and documented with the vital signs. The nurse will monitor for the return of sensation and motor function in the lower extremities. Mothers should be assisted out of bed the first time to avoid injury and ensure there are no residual effects from the anesthesia.

Bladder distention can displace the uterus, inhibiting its ability to contract, which can result in excessive vaginal bleeding. The mother should be encouraged to void every 2 hours to keep her bladder empty. Sometimes mothers are unable to void due the effects of regional anesthesia or trauma to the bladder or urethra during birth. If this occurs, pouring warm water over the perineum or listening to running water may help her to void. If she is still unable to

void catheterization may be necessary. When the woman does void (or is catheterized), it should be documented for amount and color.

11. Fourth Stage: Promoting Comfort

Providing comfort during the initial postpartum period involves addressing pain and discomfort, nutritional needs, and rest. Nursing interventions to address these needs are as follows:

Although labor is behind her, the new mother will still experience pain and discomfort due to uterine involution, perineal discomfort, and general aches and pains. Oral analgesics such as acetaminophen and ibuprofen can take care of most of the pain she may have. Ice packs to the perineum can help relieve discomfort while reducing swelling.

Giving birth is hard work and can work up quite an appetite. As long as her condition is stable, the new mother can eat or drink whatever she likes. Do not forget her partner, as he/she worked hard as well.

Although the mother may be very tired, the nurse should encourage her to keep the baby skin-to skin as much as possible and assist her in initiating breastfeeding within the first hour. After the fourth stage of labor the post partum nurse may review strategies for getting enough rest with the baby present. The Baby Friendly Hospital Initiative, started almost 20 years ago by the World Health Organization, encourages rooming in, keeping the infant in continuous contact with family members, and the abolition of central nurseries for well babies.

12. Fourth Stage: Initiation of Maternal/Newborn Teaching

Client teaching began on admission to the birth unit and continues during the initial postpartum period. Taking the mother’s readiness to learn into account, the nurse can provide teaching on the following self-care and newborn care topics:

Mothers should be taught the importance of frequent peripad changes and how to use a peri bottle to cleanse the perineum after each void or bowel movement.

During this time, mothers can also be taught the importance of keeping their bladder empty and reporting any excessive vaginal bleeding.

If she plans to breastfeed, the mother can be shown how to put her newborn to breast. If the baby does not latch on during that first session, she can be reassured that this is not unusual. It is enough if the baby just licks and nuzzles the breast, as this is another way her baby gets to know her.

If she has chosen to formula feed, the mother can be shown the correct way to position her newborn for feeding and burping.

After the first 24 hours when she has had a chance to rest and spend additional time with her newborn, the mother will have additional questions about her own care and that of her newborn. Postpartum nurses and other health care providers will take that opportunity to build upon the teaching the mother had previously

13. Preterm Labor: Overview

Preterm labor (PTL) refers to labor onset prior to 37 completed weeks gestation regardless of birth weight. According to the March of Dimes, the incidence of preterm labor has increased more than 20% since 1990, with the current U.S. rate at 12.8%. Prematurity is responsible for 90% of all neonatal deaths. The majority of neonatal mortality occurs in those born before 32 weeks gestation. African American women are twice as likely as White women to experience preterm labor and their infants are less likely to survive. Risk factorsassociated with preterm labor include demographic factors, pre-existing medical conditions, concurrent obstetric conditions, environmental factors, and psychosocial factors.

14. Preterm Labor: Etiology and Manifestations

Preterm labor is associated with various causes; however, sometimes the cause is unknown. There are three main reasons that preterm births occur. These include:

Intentional preterm delivery secondary to a maternal or fetal condition

Preterm premature rupture of membranes (PPROM) Spontaneous onset of preterm labor secondary to infections,

intrauterine bleeding, over-stretching of the uterus, and premature activation of the normal physiological initiators of labor.

Manifestations of preterm labor include:

Abdominal pain, cramping or contractions (> 4 per hour) Diarrhea Lower back pain Pelvic pressure Increase in vaginal discharge

Cervical dilation/effacement

Diagnosis is confirmed by cervical dilation and persistent uterine activity. Health care providers can screen for women who may be at high risk for developing preterm labor by using such tests as fetal fibrinectin (fFN) testing, transvaginal ultrasound for cervical length, and screening for bacterial vaginosis, which is highly associated with preterm labor.

15. Preterm Labor: Management and Prevention

Preterm labor can be managed on an inpatient or outpatient basis utilizing a combination of nonpharmacological and pharmacological measures.

Outpatient management for PTL includes:o Regular prenatal visits to assess cervical dilation and

effacemento Fetal surveillance (biophysical profiles and fetal kick

counts)o Potential home uterine monitoringo Bed rest and sexual activity restrictions

Inpatient management for PTL includes:o Ongoing monitoring of uterine activity and fetal

surveillanceo Administration of tocolytics and corticosteroids

Attempts to arrest PTL are not made in the following situations:

Fetal demise Chorioamnionitis Maternal hemorrhage Placental abruption Severe preeclampsia or eclampsia

Evidence of fetal compromise Fetal maturity

Prevention of preterm labor requires client education regarding risk factors and screening for infections such as bacterial vaginosis (BV), trichomonas vaginalis, group B hemolytic streptococcus (GBS), and urinary tract infections.

16. Preterm Labor Care Plan: Nursing Assessment and Analysis

Nursing care of the pregnant woman experiencing preterm labor includes the assessment of maternal vital signs, uterine activity, fetal status, and the maternal response to tocolytictherapy. Nurses should also assess the woman’s understanding of preterm labor, its impact on pregnancy, and her prescribed treatment regimen.

Applicable nursing diagnoses will include:

Knowledge deficit related to recognition of and treatment for PTL

Fear or anxiety related to potential preterm birth Risk for injury, fetal, related to premature cervical dilation

and effacement Ineffective coping related to imposed activity restrictions

17. Preterm Labor Care Plan: Planning and Nursing Interventions

When planning care for women experiencing preterm labor, client-centered goals are important. Applicable goals would include that the mother will do the following:

Verbalize her understanding of PTL and its implications for pregnancy.

Be free of complications during hospitalization. Utilize available options to alleviate boredom. Verbalize any fears or concerns regarding her condition. Demonstrate adequate coping mechanisms.

Nursing interventions will include:

Providing client education regarding the signs of preterm labor, self-care measures (maintaining hydration, avoiding sexual activity and nipple stimulation, complying with activity restrictions), treatment regimens, and the importance of good prenatal care

Providing emotional support, as women experiencing PTL sometimes have difficulty coping with the imposed activity restrictions such as bed rest and medication side effects. They should have the opportunity to express their concerns/fears regarding their condition

Assisting mothers and their families in identifying available support systems to assist in home maintenance and child care

Assisting the mother in identifying effective coping strategies related to activity restrictions and associated boredom

18. Preterm Labor Care Plan: Evaluation of Nursing Care

To determine whether client goals have been met and the effectiveness of implemented interventions, the nurse evaluates the plan of care. Expected client outcomes will include:

The woman can verbalize her understanding of causes, symptoms, and treatment for PTL.

The woman demonstrates appropriate self-care measures in response to PTL symptoms.

The woman verbalizes a decrease in her anxiety about her condition.

The woman and her family demonstrate adequate coping skills.

The woman gives birth to her newborn safely.

19. Labor Dystocia: Hypertonic Labor

Dysfunctional labor refers to problems with the "powers" of the labor process, resulting in hyper- or hypotonic uterine contractions. Tachysystole, also known as hypertonic contractions, is defined as excessive spontaneous or stimulated uterine activity. It is characterized by contractions occurring every 2 minutes or less. Spontaneous tachysystole refers to hypertonic contractions that the woman is producing without the use of contraction stimulants, such as pitocin during latent labor. The table below outlines manifestations, risk factors, treatment, and nursing considerations for tachysystole.

Risk factors Maternal fear of labor Occiput posterior position of the fetus Fetal status at risk for compromise due to an

increased uterine resting tone that interferes with uteroplacental exchange

Manifestations Increased pain and discomfort Coping difficulties Fatigue Potential for infection Dehydration if the labor is prolonged

Treatment The healthcare provider may opt to "rest" the laboring woman by administering an analgesic such as morphine or vistaril. This will often break the tachysystole pattern as well as provide the woman with a respite in preparation for the rest of the labor process.

If the tachysystole pattern has been stimulated by the administration of an oxytocin infusion, then the infusion is decreased or discontinued until the desired contraction pattern is achieved.

Nursing responsibilities

Provide support and reassurance to the woman and her support person.

Promote client comfort include position changes, effleurage, and breathing and relaxation techniques.

Client education regarding tachysystole and dysfunctional labor will help the woman understand what is happening as well as cope with the process.

20. Labor Dystocia: Arrest of Dilation and Descent

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The term hypotonic labor refers to uterine contractions that are irregular in frequency and have low intensity. This term has now been replaced with the phrase "arrest of dilation or descent." Laboring women who experience arrest of dilation or descent usually make less than 1 cm of cervical change per hour or fail to make any cervical change within 2 hours. When this occurs the healthcare provider will evaluate the woman for cephalopelvic disproportion (CPD) and, with that ruled out, will consider labor augmentation with an amniotomy and/or an oxytocin infusion. If CPD is confirmed and the fetal presenting part is not engaged in the pelvis, labor augmentation is contraindicated. Risk factors for arrest of dilation or descent include fetal macrosomia, multiple gestations, and hydramnios.

Nursing interventions for the laboring woman experiencing arrest of dilation or descent should center on promoting maternal and fetal well-being. They will include:

Monitoring maternal vital signs Monitoring uterine activity and assessing the fetal heart rate

(FHR) Assisting the healthcare provider or nurse-midwife in

performing an amniotomy if indicated Assessing the color, amount, and odor of the amniotic fluid

afterward Administering the oxytocin infusion, if ordered

Monitoring its effects on mother and fetus

Applicable nursing diagnoses for arrest of dilation or descent include:

Anxiety related to labor process Acute pain related to uterine contraction pattern

Desired outcomes will include:

The woman and her family are able to verbalize their understanding of dysfunctional labor and its effects on the progression of her labor.

The woman reports an increase in her comfort level and a decrease in anxiety.

The woman experiences an effective labor pattern that results in the birth of a healthy newborn

21. Labor Dystocia: Pelvic Dystocia

Pelvic dystocia refers to abnormalities of the maternal pelvis resulting from contractures of the pelvic diameters. Examples of potential issues with pelvic dystocia occur in women whose pelvis has an android (or male) shape; it has contractures of the midpelvis and outlet portion; or a platypelloid (flat female) shape that has contractures of the inlet. These conditions can result in fetal CPD (cephalopelvic disproportion) or a prolapsed umbilical cord if rupture of membranes occurs and the fetal presenting part is not engaged in the pelvis.

Management requires that the pelvic measurements be obtained and assessed for the probability of a successful labor. If a trial of labor (TOL) is indicated, the progression of labor is closely monitored. If there is evidence of labor arrest, then the healthcare

provider or nurse midwife will make the decision for a cesarean birth.

Nursing responsibilities when caring for a woman who has pelvic dystocia and who is being allowed to labor are similar to caring for a normal laboring woman.

Close monitoring of maternal vital signs Monitoring uterine activity and assessment of the fetal

response to labor Assessing the woman’s understanding of her healthcare

provider or midwife’s concerns regarding her labor process Client teaching to alleviate any anxiety the woman and/or

her family may have

Applicable nursing diagnoses include:

Knowledge deficit related to the implications of pelvic dystocia on labor

Anxiety related to unknown outcome of labor

Expected client outcomes include:

The client is able to verbalize her understanding of pelvic dystocia, CPD, and their implications for her labor.

The client reports a decrease in anxiety about the outcome of her labor.

22. Labor Dystocia: Fetal Anomalies

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Fetal anomalies associated with labor dystocia include fetal malposition, malpresentation, cephalopelvic disproportion (CPD), and multiple gestations.

The most common fetal malposition is occiput posterior (OP) and is seen most commonly in women with an anthropoid-shaped pelvis. During labor, women characteristically experience intense low back pain due to the fetal occiput applying pressure to the maternal sacrum during contractions. It is common for the fetus in the OP position to rotate to an occiput anterior (OA) position, on its own or with healthcare provider intervention, and deliver without incident. If not, the fetus can deliver in the OP position; however, this is associated with an increased incidence of prolonged labor and operative deliveries. Other associated maternal risk factors include oxytocin augmentation, episiotomy

or severe perineal lacerations, blood loss > 500 mL, and postpartum infection.

Several fetal malpresentations can complicate the labor and delivery process. They include the cephalic brow, military, and face presentations; the complete, frank, and footling breech presentations; and the shoulder presentation. While it is possible for the cephalic and breech malpresentations to deliver vaginally, birth is most likely to be via cesarean section. With a shoulder presentation there is a transverse fetal lie. In this case birth is always accomplished by cesarean section.

Multiple gestations complicate the labor and delivery process in that there is more than one fetus to consider. Whether twins, triplets, or other multiple gestations, a variety of fetal positions and presentations can occur. A vaginal birth is very possible with a twin gestation if the fetal status is not compromised and the fetuses are in a cephalic vertex (occiput) position. Very often multiple gestations are delivered via cesarean section.

Nursing responsibilities for care of a woman whose labor is complicated by fetal malposition, malpresentation, or multiple gestation centers on client education on the implications these anomalies may have on the birthing process. Women will also require preparation for the possibility of a cesarean birth as well as emotional support.

Applicable nursing diagnoses will include risk for injury, fetal or maternal; fear or anxiety related to fetal outcome; knowledge deficit related to implications of labor dystocia secondary to fetal anomalies. Expected client outcomes include:

The mother safely delivers her newborn. The mother reports a decrease in fear or anxiety.

The mother and her family are able to verbalize their understanding of the implications of a malpresentation/position to the labor/delivery process.

23. Labor Dystocia: Precipitate Labor/Birth

Precipitate labor and birth is defined as labor that lasts 3 hours or less from onset to birth. This is different from a precipitate birth, which can occur after a labor of any length, but the birth occurs suddenly and is unattended or nurse-attended. In a precipitate labor and birth, the rapid cervical dilation, effacement, and fetal descent are thought to occur as a result of a decrease in resistance of the maternal soft tissues and strong uterine contractions. Cervical dilation can occur at a rate of 5–10 cm per hour. Multiparous women and those with a history of precipitate labor and birth are most at risk.

Associated maternal risks include trauma to maternal tissues, postpartum hemorrhage secondary to cervical lacerations, maternal anxiety, and fear of loss of control. Fetal and neonatal risks include fetal hypoxia due to decreased periods of uterine relaxation between contractions and neonatal intracranial hemorrhage secondary to a rapid birth.

Women with a history of precipitate labor and birth must be closely monitored for cervical change during the final weeks of pregnancy to ensure a controlled and safe delivery.

As the nurse, you should be able to recognize those at risk of a precipitate labor or birth, such those with as a sudden onset of intense contractions. Promotion of comfort and emotional support are also important aspects of the care provided to these women. Client education regarding measures that are being taken to ensure her safety and comfort, as well as allowing the woman to

verbalize her fears and concerns, will go far in dispelling her anxiety. Applicable nursing diagnoses include:

Risk for injury, maternal or fetal, related to the rapid progression of labor and birth

Acute pain related to intense uterine contractions Anxiety or fear related to the rapid progression of labor and

birth

Expected client outcomes include:

Birth occurs safely with no injury to mother or newborn. Mother is able to utilize available measures to manage pain

effectively. Mother reports a decrease in anxiety.

24. Obstetric Emergencies: Prolapsed Umbilical Cord

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A prolapsed umbilical cord occurs when the cord becomes trapped between the fetal presenting part and the cervix, resulting in compression, which can lead to fetal compromise. It can be a visual prolapse, protruding from the vagina after rupture of membranes, able to be palpated on vaginal exam, or an occult prolapse that is only evident by changes in the FHR such as variable decelerations or sustained bradycardia. Risk factors for umbilical cord prolapse include high fetal station, a footling breech presentation, transverse fetal lie, small fetus, and hydramnios.

Management priority is to decrease or alleviate the cord compression. This can be accomplished by placing the woman in a Trendelenburg or knee-chest position or manually lifting the fetal presenting part from the cord with a gloved hand. If the cord is protruding from the vagina, no attempt should be made to replace it to avoid additional restriction of blood flow. Saline moistened sponges can be applied to keep the cord from drying out prior to delivery. Birth is accomplished via cesarean section.

Nursing responsibilities will center on strategies to improve fetal oxygenation including administering oxygen to the mother via face mask at 8–10 L/min. The nurse will also be responsible for preparing the woman for surgery. Alleviating the anxiety and fear that the woman and her family may experience is also a priority nursing measure.

Applicable nursing diagnoses include:

Risk for impaired gas exchange (fetus) related to decreased umbilical blood flow

Fear related to unknown pregnancy outcome

Expected client outcomes include:

The mother verbalizes her understanding of her conditions and the corrective measures taken.

The mother safely delivers her newborn. The mother feels emotionally supported throughout the

experience.

25. Obstetric Emergencies: Shoulder Dystocia

Shoulder dystocia occurs when the anterior fetal shoulder becomes impacted above the symphysis pubis bone. Risk factors for shoulder dystocia include fetal macrosomia, cephalopelvic disproportion, or maternal pelvic abnormalities. A telltale sign of shoulder dystocia occurs after the head is delivered and it retracts against the perineum, much like a turtle in its shell (“turtle sign”). Normal gentle traction will not release the shoulder from the symphysis. This is an emergent situation that requires prompt action from the entire health care team to ensure a favorable outcome.

Risks to the mother include trauma to maternal perineal tissues at birth. Risk to the fetus/newborn includes asphyxia, brachial plexus injury, Erb’s palsy, and clavicle fracture.

Management requires quick recognition of the situation and implementation of appropriate maneuvers to free the fetal shoulder. The McRoberts maneuver involves having the woman flex her knees to her chest. This provides more room in the pelvic floor and decreases the force necessary to extract the shoulders. Suprapubic pressure can be applied directly over the maternal symphysis pubis to assist in dislodging the anterior fetal shoulder. Additionally, fundal pressure should be avoided as it will only further wedge the shoulder against the symphysis. The Woods maneuver requires the health care provider to rotate the affected

shoulder 180° to the posterior position. If these measures are unsuccessful, the health care provider may elect to break the fetal clavicle to facilitate birth of the fetus.

Nursing responsibilities center on assisting the woman in positions that will facilitate birth, assisting the health care provider or midwife with those maneuvers, and providing reassurance and explanations to the woman regarding the actions being taken. Once delivery has been accomplished, the nurse should monitor the mother for signs of excessive bleeding, and the newborn should also be monitored for signs of brachial plexus injury or clavicle crepitus and the ability to adapt to extrauterine life. Applicable nursing diagnoses include:

Risk for injury, maternal or fetal, related to trauma during the birth process

Risk for infection related to maternal tissue trauma during the delivery process

Expected client outcomes include:

The mother safely delivers her newborn. The mother shows no signs of infection postpartum.

26. Obstetric Emergencies: Amniotic Fluid Embolism

Amniotic fluid embolism (AFE), also known as anaphylactoid syndrome of pregnancy, is a rare emergent condition characterized by sudden onset respiratory distress and circulatory collapse. It is caused by amniotic fluid, fetal cells, hair, or other debris entering the maternal circulation and lungs. AFE occurs in 1 in 8,000 to 1 in 30,000 pregnancies and has a 60–80% mortality rate. The exact cause is unknown but is thought to be the result of very strong uterine contractions that force amniotic fluid into

open uterine vessels. AFE can occur during labor or immediately postpartum.

Management involves prompt recognition of the signs of AFE, including severe respiratory distress, depressed cardiac function, disseminated intravascular coagulation (DIC), and cardiac arrest. Interventions center on maintaining maternal cardiorespiratory status and blood volume replacement. If the mother is in cardiac arrest, immediate cesarean delivery is indicated to ensure survival of the fetus.

Nursing responsibilities include the administration of blood products, assisting in the insertion of central lines, preparation for an emergent cesarean delivery, and the transfer of the mother to the intensive care unit post delivery. Nurses can also provide reassurance and emotional support to the mother’s family. Applicable nursing diagnoses include:

Impaired gas exchange, maternal or fetal, r/t decreased blood flow

Fluid volume deficit (maternal) r/t excessive blood loss Fear r/t unknown labor outcome Knowledge deficit r/t disease process

Expected client outcomes include:

Fetus is delivered safely. Maternal status is appropriately stabilized. The family remains informed and supported throughout the

process.