Labor and delivery are intricate processes, marked by uterine contractions facilitating cervical dilation and effacement, ultimately leading to fetal expulsion through the birth canal. While labor typically commences around the expected due date (EDD), its precise onset remains unpredictable. This article delves into the stages of labor, the crucial role of nursing care, and, with a specific focus, the nursing diagnosis and management of cord prolapse, a critical obstetric emergency.
Stages of Labor
Labor progresses through three distinct stages:
Stage 1: Early and Active Labor: The longest phase, early labor is characterized by initial contractions that gradually intensify, becoming regular and closer together. Patients are typically advised to proceed to the hospital when contractions occur every five minutes. During this phase, the cervix dilates to approximately 4-6 centimeters. Active labor ensues with stronger, more frequent contractions, and the cervix continues to dilate. As the baby descends further into the birth canal, the mother may experience an urge to push.
Stage 2: Delivery of the Baby: Commencing when the cervix reaches full dilation (10 centimeters), this stage involves active pushing by the mother during contractions. These contractions are more intense and frequent. Stage 2 culminates in the birth of the baby.
Stage 3: Delivery of the Placenta: Following the baby’s delivery, the placenta detaches from the uterine wall and is expelled through the vagina.
Delivery methods vary based on circumstances, with vaginal delivery being the most common and preferred route due to its lower complication risk and faster recovery. Cesarean sections (C-sections), involving surgical incisions in the abdomen and uterus, are performed when vaginal delivery poses risks. C-sections may be planned or emergent, indicated by situations such as fetal distress, placental abruption, umbilical cord prolapse, or excessive bleeding.
The Nursing Process in Labor and Delivery
Labor and delivery nurses are pivotal in providing holistic care to women and their newborns throughout the perinatal period. They act as a vital link between the patient and the physician, offering continuous support, education, comfort, and updates on labor progression and potential interventions. In C-section deliveries, nurses may also participate directly in the surgical procedure.
Nursing Assessment
The nursing assessment, the initial step in the nursing process, involves gathering comprehensive data encompassing physical, psychosocial, emotional, and diagnostic aspects.
Review of Health History
1. Prenatal Care Review: A thorough review of prenatal records, including confirmation of the expected delivery date, is essential at the beginning of labor assessment.
2. Comprehensive History Taking: Nurses should inquire about fetal movements, contraction frequency and timing, amniotic membrane status (ruptured or intact), and the presence of vaginal bleeding. The mother’s medical, surgical, and obstetric history, along with recent laboratory and imaging results, should also be reviewed.
3. Differentiating True Labor: It’s crucial to distinguish true labor contractions from Braxton-Hicks contractions, which are irregular, less intense, and typically subside with activity changes. True labor contractions are progressive and do not diminish with movement.
Physical Assessment
1. Identifying Signs of Labor: Common signs of labor include:
- Regular, progressive contractions
- Rupture of amniotic membranes (“water breaking”)
- Bloody show (blood-tinged mucus)
- Abdominal and lower back pain
2. Leopold’s Maneuvers: These abdominal palpation techniques determine fetal position:
- First maneuver: Identifies the fetal part in the uterine fundus.
- Second maneuver: Determines the location of the fetal back.
- Third maneuver: Confirms fetal presentation and estimates fetal weight and amniotic fluid volume.
- Fourth maneuver: Assesses fetal presenting part engagement in the pelvis.
Abnormal fetal presentations can lead to complications requiring medical intervention.
3. Vital Signs Monitoring: Elevated blood pressure may indicate preeclampsia, a serious condition requiring immediate attention.
4. Pelvic Examination: Assesses cervical dilation and effacement. Sterile speculum examination confirms amniotic fluid presence if membrane rupture is suspected.
5. Contraction Pattern Monitoring: Labor progression is marked by increasingly stronger and more frequent contractions.
6. Fetal Station Determination: Fetal station indicates the descent of the presenting part relative to the ischial spines, ranging from -5 to +5 cm. Station 0 signifies engagement.
7. Pain Level Assessment: Using a numeric pain scale, nurses regularly assess and document the patient’s pain level to guide pain management strategies.
Diagnostic Procedures
1. Pelvic Evaluation Assistance: Clinical pelvimetry and radiographic methods (CT or MRI) may be employed to assess pelvic dimensions and predict potential delivery complications.
2. Routine Lab Sample Collection: Standard labor and delivery lab tests include:
- Complete blood count (CBC)
- Blood typing and screening
- Urinalysis
3. Uterine Contraction Monitoring: External tocometry monitors contraction onset and duration.
4. Fetal Heart Rate Assessment: Doppler devices, external belts, or internal electrodes are used to monitor fetal heart tones and rate, crucial for identifying fetal distress, including that associated with cord prolapse.
5. Bedside Ultrasound Assistance: Ultrasound can confirm fetal presentation and position and identify potential complications.
Nursing Interventions
Nursing interventions are crucial for ensuring maternal and fetal well-being throughout labor and delivery.
Managing Patient and Fetus During Labor
1. Explaining Cervical Exams: Regular cervical exams monitor labor progress. Frequency is typically every 2-3 hours unless complications necessitate more frequent assessment.
2. Encouraging Ambulation and Position Changes: Maternal movement promotes fetal descent and pain relief.
3. IV Line Insertion: Intravenous access allows for medication and fluid administration.
4. Allowing Oral Intake: Unless contraindicated, oral intake is permitted to maintain energy levels.
5. Pain Management: Options include pharmacological (opioids, nitrous oxide, epidural blocks) and non-pharmacological methods (massage, breathing techniques, positioning).
6. Comfort Measures: Creating a calming environment, massage, thermal therapies, and position support enhance comfort and relaxation.
7. Amniotomy Preparation (if indicated): Artificial rupture of membranes may be used to augment labor.
8. Oxytocin Administration (if indicated): Oxytocin stimulates contractions in cases of stalled labor.
9. Complication Prevention and Management, Including Cord Prolapse: Nurses are vigilant in monitoring for and managing potential complications, with umbilical cord prolapse being a critical obstetric emergency requiring immediate recognition and intervention.
Cord Prolapse: A Critical Obstetric Emergency and Nursing Diagnosis
Umbilical cord prolapse occurs when the umbilical cord descends below the fetal presenting part and into the vagina, preceding fetal delivery. This is an obstetric emergency because the presenting part can compress the cord against the pelvis, obstructing blood flow to the fetus and causing fetal hypoxia and distress.
Risk Factors for Cord Prolapse:
- Premature rupture of membranes (PROM)
- Malpresentation (breech, transverse lie)
- Prematurity
- Multiparity
- Polyhydramnios
- Unengaged presenting part
Nursing Diagnosis: Risk for Fetal Compromise related to Umbilical Cord Prolapse
Assessment Findings Indicating Potential Cord Prolapse:
- Sudden fetal bradycardia or variable decelerations on fetal heart rate monitoring, especially following amniotomy.
- Palpation of the umbilical cord during vaginal examination.
- Visualization or palpation of the cord protruding from the vagina.
Immediate Nursing Interventions for Suspected or Confirmed Cord Prolapse:
- Call for Help Immediately: Activate the emergency obstetric protocol.
- Elevate the Presenting Part: Manually elevate the fetal presenting part off the umbilical cord during vaginal examination and maintain this position. Do not attempt to replace the cord into the uterus.
- Position the Mother: Place the mother in the knee-chest position, Trendelenburg position, or deep Sims position to use gravity to relieve pressure on the cord.
- Administer Oxygen: Apply oxygen at 8-10 L/min via face mask to the mother to maximize fetal oxygenation.
- Monitor Fetal Heart Rate Continuously: Closely monitor fetal heart rate and pattern for signs of ongoing distress.
- Prepare for Immediate Delivery: Vaginal delivery may be possible if delivery is imminent. However, Cesarean section is often the safest and quickest route of delivery in cord prolapse cases to minimize fetal hypoxia and injury.
- Inform and Reassure the Patient and Family: Provide clear and concise information about the situation and the plan of care, offering reassurance and support.
- Avoid Handling the Cord Excessively: Minimize manipulation of the prolapsed cord to prevent vasospasm and further compromise blood flow.
- Prepare for Neonatal Resuscitation: Alert the neonatal team to be present at delivery as the infant may require resuscitation due to potential hypoxia.
Monitoring in the Postpartum Period
1. Pain Control: Postpartum pain management includes NSAIDs or narcotics for C-sections and comfort measures for vaginal deliveries (donut pillows, sitz baths, ice packs, analgesics).
2. Vaginal Discharge Monitoring (Lochia): Nurses assess lochia rubra, serosa, and alba, monitoring for abnormal bleeding.
3. Constipation Prevention: Strategies include stool softeners, high-fiber diet, hydration, hemorrhoid creams, and sitz baths.
4. Hygiene Education: Perineal care and handwashing education minimizes infection risk.
5. Mood and Emotion Assessment: Postpartum emotional changes are common, but nurses monitor for signs of postpartum depression.
6. Breastfeeding Promotion: Lactation support and education are provided.
7. Postpartum Checkup Reminders: Nurses ensure patients understand the importance of postpartum follow-up appointments.
Nursing Care Plans
Nursing care plans guide prioritized care based on identified nursing diagnoses. Examples include:
Acute Pain
Nursing Diagnosis: Acute Pain related to muscle contractions and tissue trauma, as evidenced by restlessness, moaning, verbalization of pain, and physiological responses.
Interventions: Pain assessment, rapport building, breathing technique instruction, pain relief option discussion, positioning assistance, comfort measures, and analgesic administration.
Anxiety
Nursing Diagnosis: Anxiety related to perceived threats, fear of pain and unexpected outcomes, as evidenced by tension, expressed concerns, and altered vital signs.
Interventions: Psychological state assessment, concern identification, acknowledging feelings, support system inclusion, calm demeanor, relaxation techniques, and a calm environment.
Risk for Decreased Cardiac Output
Nursing Diagnosis: Risk for Decreased Cardiac Output related to labor complications and physiological stressors.
Interventions: Vital signs monitoring, fetal heart rate assessment, left lateral positioning, bleeding monitoring, supplemental oxygen administration, post-anesthesia monitoring, and continuous fetal heart monitoring.
Risk for Imbalanced Fluid Volume
Nursing Diagnosis: Risk for Imbalanced Fluid Volume related to fluid shifts, blood loss, and potential dehydration.
Interventions: Medical history assessment, lab value monitoring, vital signs assessment, oxytocin infusion monitoring, fluid intake encouragement, IV fluid administration, and intake and output monitoring.
Risk for Infection
Nursing Diagnosis: Risk for Infection related to membrane rupture and invasive procedures, including the risk associated with prolonged labor in situations like cord prolapse if delivery is delayed.
Interventions: Vaginal secretion assessment, fetal heart rate monitoring, vital signs and WBC count monitoring, limiting vaginal exams, aseptic technique, hygiene education, and antibiotic and oxytocin administration as prescribed.
Conclusion
Labor and delivery nursing encompasses a wide spectrum of care, from supporting physiological childbirth to managing critical obstetric emergencies. Understanding the stages of labor, implementing thorough nursing assessments, and executing timely and effective interventions are paramount to ensuring positive maternal and fetal outcomes. Specifically, recognizing the signs and symptoms of umbilical cord prolapse and initiating immediate, protocol-driven nursing actions are crucial in mitigating fetal risk and promoting the well-being of both mother and child. Continuous education and preparedness are essential for nurses to confidently and competently manage all aspects of labor and delivery, including rare but life-threatening complications like cord prolapse.
