Labor is a transformative process, marked by a series of uterine contractions that facilitate cervical dilation and effacement, ultimately enabling the fetus to descend through the birth canal. While the expected date of delivery (EDD) provides an estimated timeframe, the precise onset of labor remains unpredictable.
Stages of Labor: A Nursing Perspective
Labor is classically divided into three distinct stages, each requiring specific nursing assessments and interventions:
Stage 1: Early and Active Labor. This protracted initial phase is characterized by progressive uterine contractions. Early labor contractions gradually intensify and become more frequent. When contractions reach a pattern of occurring every five minutes, the patient is typically advised to proceed to the hospital. During this phase, the cervix dilates to approximately 4-6 centimeters. Active labor ensues with contractions becoming stronger, longer, and more closely spaced. As the fetus descends further into the birth canal, the patient may experience an urge to push.
Stage 2: Delivery of the Baby. This stage commences once the cervix is fully dilated to 10 centimeters. Contractions become even more intense and frequent. The mother is instructed to actively push with each contraction to facilitate the baby’s passage through the birth canal. This stage culminates in the birth of the newborn.
Stage 3: Delivery of the Placenta. Following the delivery of the baby, the uterus continues to contract, leading to the separation and expulsion of the placenta. This final stage concludes with the delivery of the placenta and fetal membranes.
The mode of delivery, whether vaginal or via Cesarean section, is determined by various factors. Vaginal delivery is generally preferred due to its lower risk of complications and faster maternal recovery. However, a Cesarean section, involving surgical incisions in the abdomen and uterus, may be necessary. C-sections can be planned or performed emergently during labor in response to complications such as fetal distress, placental abruption, umbilical cord prolapse, or excessive maternal bleeding.
The Nursing Process in Intrapartum Care
Labor and delivery nurses are pivotal in providing holistic care to women and their newborns throughout the perinatal period. They serve as a vital link between the patient and the medical team, offering continuous support, education, comfort measures, and timely updates on labor progress and potential interventions. In Cesarean deliveries, nurses may also participate directly in the surgical procedure.
Comprehensive Nursing Assessment During Labor
The initial step in providing effective nursing care is a thorough nursing assessment. This involves gathering comprehensive data encompassing the patient’s physical, psychosocial, emotional, and diagnostic status.
Review of Health History: Essential Data Collection
1. Prenatal Care Review: A meticulous review of the patient’s prenatal record is paramount. Confirmation of the estimated delivery date is a crucial component of the initial labor assessment.
2. Detailed Patient History: Obtain a comprehensive history from the patient, including fetal movement patterns, contraction frequency and timing, the status of amniotic membranes (ruptured or intact), and the presence or absence of vaginal bleeding. A review of the mother’s medical, surgical, and obstetric history, along with recent laboratory results and imaging studies, is also essential.
3. Differentiation of True Labor: It is critical to differentiate true labor contractions from Braxton-Hicks contractions. Braxton-Hicks contractions are irregular, less intense, and typically subside with changes in activity, unlike true labor contractions which are progressive and intensify over time.
Physical Assessment: Identifying Key Labor Signs
1. Assessment for Labor Signs: The signs of labor can vary, but common indicators include:
- Progressive, regular uterine contractions
- Spontaneous rupture of amniotic membranes (“water breaking”)
- Bloody show (blood-tinged mucus discharge)
- Abdominal and lower back pain
Image alt text: A pregnant woman in a hospital bed, demonstrating the physical discomfort and intensity of labor contractions.
2. Leopold’s Maneuvers: These systematic abdominal palpations are performed to determine fetal position and presentation:
- First maneuver: Identifies the fetal part occupying the uterine fundus.
- Second maneuver: Determines the location of the fetal back to differentiate it from limbs.
- Third maneuver: Confirms fetal presentation and aids in estimating fetal weight and amniotic fluid volume.
- Fourth maneuver: Assesses the extent of fetal descent into the maternal pelvis.
Abnormal fetal presentations, such as breech, brow, face, or shoulder, can lead to delivery complications and may necessitate interventions.
3. Vital Signs Monitoring: Elevated blood pressure may be indicative of preeclampsia or eclampsia, serious conditions that pose risks to both mother and fetus during labor and delivery.
4. Pelvic Examination: A pelvic exam assesses cervical dilation (opening) and effacement (thinning). If membrane rupture is suspected, a sterile speculum examination may be performed to visually confirm amniotic fluid in the cervix.
5. Contraction Pattern Monitoring: As labor advances, contractions become stronger and more frequent. In the second stage of labor, contractions may occur every two to five minutes and last 60-90 seconds. The mother is instructed to push during contractions and rest in between.
6. Fetal Station Determination: Fetal station describes the descent of the presenting fetal part in relation to the ischial spines of the maternal pelvis. It is measured in centimeters from -5 to +5. A station of -5 indicates the fetal head is still high in the pelvis, while +5 means the fetal head is at the vaginal opening. Station 0 signifies engagement, where the fetal head is at the level of the ischial spines, typically occurring about two weeks before labor.
7. Pain Assessment: Utilizing a numeric pain scale, the nurse frequently assesses the patient’s pain level to guide pain management interventions.
Diagnostic Procedures: Supporting Intrapartum Management
1. Pelvic Evaluation Assistance: Clinical pelvimetry (physical examination) and radiographic methods (CT or MRI) may be used to evaluate pelvic dimensions and shape, helping to predict potential delivery complications. This evaluation can be performed during prenatal visits or upon admission for labor.
2. Specimen Collection for Lab Tests: Routine laboratory tests for laboring patients include:
- Complete blood count (CBC)
- Blood typing and antibody screen
- Urinalysis
3. Uterine Contraction Monitoring: External tocodynamometry should be initiated upon admission to labor and delivery to monitor the onset, frequency, and duration of uterine contractions.
4. Fetal Heart Rate Assessment: Fetal heart tones and heart rate are assessed using Doppler devices, external transducers, or internal fetal scalp electrodes.
5. Bedside Ultrasound Assistance: Bedside ultrasonography can confirm fetal presentation and position and identify potential complications that might necessitate Cesarean delivery.
Nursing Interventions: Enhancing Labor and Delivery Outcomes
Nursing interventions are critical for optimizing maternal and fetal well-being during labor and delivery.
Management of Patient and Fetus During Labor: Evidence-Based Practices
1. Explanation of Cervical Examinations: Clearly explain the purpose of frequent cervical exams, which are performed to monitor labor progress by assessing cervical dilation and effacement. Typically, sterile cervical exams are conducted every 2 to 3 hours, unless complications warrant more frequent assessments. Emphasize the increased risk of infection associated with more frequent exams, especially after membrane rupture.
2. Promotion of Ambulation and Position Changes: Encourage women to ambulate and change positions freely throughout labor, as tolerated. Mobility facilitates fetal descent and can alleviate pain.
3. IV Line Insertion: Establish an intravenous (IV) line to allow for administration of medications or fluids as needed.
4. Oral Intake Encouragement: Unless contraindicated, oral intake should not be restricted during labor. Intravenous fluids may be necessary if oral intake is insufficient, particularly for prolonged labor.
5. Labor Pain Management: Offer a range of pain management options, including intravenous opioids, inhaled nitrous oxide, and epidural analgesia, according to patient eligibility and preference. Non-pharmacological pain relief methods, such as massage, breathing techniques, and position changes, should also be readily available.
6. Implementation of Comfort Measures: Comfort measures play a significant role in reducing discomfort and anxiety during labor. Recommend and facilitate:
- Creating a calming environment: dim lighting, quiet surroundings, soothing music, and privacy.
- Encouraging movement: walking, slow dancing with a partner, pelvic rocking, utilizing a birth ball, or rocking chair.
- Promoting tactile comfort: massage, acupressure, or counterpressure to the lower back.
- Thermal therapies: applying heat packs, warm showers or baths, or cold compresses.
Image alt text: A labor and delivery nurse attentively assisting a patient in labor, offering support and comfort.
7. Preparation for Amniotomy (if indicated): Explain amniotomy, the artificial rupture of membranes (AROM), and its potential role in inducing or augmenting labor. Emphasize that amniotomy is not always necessary or beneficial.
8. Oxytocin Administration (if indicated): If labor progress stalls, oxytocin may be administered intravenously to stimulate uterine contractions.
9. Prevention of Complications: Be vigilant for potential labor complications that can affect maternal and fetal well-being.
- First stage complications: Arrest of labor may necessitate Cesarean section.
- Second stage complications:
- Fetal: Asphyxia, brain damage, acidemia, shoulder dystocia, bone fractures, fetal injury, nerve palsies, scalp hematoma.
- Maternal: Uterine rupture, vaginal or cervical lacerations, uterine hemorrhage, amniotic fluid embolism.
- Third stage complications: Hemorrhage, cord avulsion, retained placenta, incomplete placental evacuation.
Postpartum Monitoring: Ensuring Maternal Recovery
1. Pain Management: Post-Cesarean delivery pain may require NSAIDs or narcotic analgesics. Post-vaginal delivery, mothers may experience afterpains (uterine contractions) and perineal soreness, especially if episiotomy or lacerations occurred. Offer comfort measures:
- Donut pillow for sitting
- Warm sitz baths
- Ice packs or chilled sanitary pads to the perineum
- Acetaminophen or ibuprofen for inflammation
2. Vaginal Discharge Monitoring: Lochia, the postpartum vaginal discharge, progresses through three stages:
- Lochia rubra: Dark red, lasts ~4 days.
- Lochia serosa: Pink, lasts ~10 days.
- Lochia alba: White or yellow, lasts up to 2 weeks.
Heavy bleeding (soaking a pad hourly or passing large clots) is abnormal and requires immediate assessment.
3. Constipation Prevention: Postpartum bowel movements can be uncomfortable. Recommend strategies to prevent constipation:
- Stool softeners or laxatives
- High-fiber diet and increased fluid intake
- Over-the-counter hemorrhoid creams
- Witch hazel pads
- Sitz baths
4. Hygiene Education: Demonstrate proper perineal care and handwashing techniques to reduce infection risk. Wiping from front to back after voiding or defecating is crucial for perineal wound healing.
5. Mood and Emotional Assessment: Postpartum emotional lability is common. Monitor for mood swings, anxiety, insomnia, and crying spells. Persistent symptoms, loss of appetite, anhedonia, or withdrawal from the newborn may indicate postpartum depression requiring intervention.
6. Breastfeeding Promotion: Encourage breastfeeding initiation as soon as the mother is ready. Provide lactation support and education on positioning, latch, and managing common breastfeeding challenges like engorgement, nipple pain, and breast discomfort.
7. Postpartum Checkup Reminders: Emphasize the importance of postpartum follow-up visits within a few weeks of delivery to monitor maternal well-being, discuss contraception, and assess healing.
Nursing Care Plans: Addressing Common Intrapartum Nursing Diagnoses
Nursing care plans are essential tools for prioritizing assessments and interventions based on identified nursing diagnoses. Common nursing diagnoses in intrapartum care include:
Acute Pain
Labor pain arises from uterine contractions and cervical pressure, manifesting as intense cramps in the abdomen, groin, and back.
Nursing Diagnosis: Acute Pain
Related to: Muscle contractions, tissue trauma
As evidenced by: Restlessness, moaning, crying, wincing, verbal pain reports, pain facies, diaphoresis, tachycardia, tachypnea
Expected outcomes: Pain reduction verbalization, demonstrated comfort and relaxation, utilization of pain-reducing techniques.
Assessments:
- Pain level assessment using a numeric pain scale.
- Pain assessment concurrent with vital sign monitoring.
Interventions:
- Establish rapport with the patient and support person.
- Instruct in breathing techniques.
- Discuss pain relief options.
- Assist with positioning for comfort.
- Provide comfort measures (back rubs, pillows, ice).
- Administer analgesics as ordered (e.g., epidural).
Anxiety
Anxiety is common during labor, particularly for first-time mothers, stemming from fear of the unknown, concerns about fetal well-being, and anticipation of pain.
Nursing Diagnosis: Anxiety
Related to: Perceived threat to baby, fear of outcomes, surgical intervention (C-section), threat to health, fear of pain
As evidenced by: Increased tension, feelings of inadequacy, expressed concerns, vital sign changes, restlessness
Expected outcomes: Verbalized reduction in worry and stress, expression of feelings, effective utilization of support systems.
Assessments:
- Psychological and emotional state assessment.
- Identification of specific patient concerns and anxieties.
Interventions:
- Acknowledge and validate patient feelings.
- Involve and support the patient’s support system.
- Maintain a calm demeanor and provide clear explanations.
- Encourage relaxation techniques (deep breathing, effleurage, massage).
- Provide a calm and restful environment.
Risk for Decreased Cardiac Output
Labor-related physiological changes, such as increased cardiac output during contractions, can be compromised by complications like hemorrhage, hypertension, and fluid imbalances, increasing the risk for decreased cardiac output.
Nursing Diagnosis: Risk for Decreased Cardiac Output
Related to: Labor and delivery complications, bleeding, uterine atony, dehydration, fluid/electrolyte imbalance, decreased fluid volume, hypertension, hypotension, cardiac conditions, childbirth process
As evidenced by: (Risk diagnosis – no defining characteristics)
Expected outcomes: Absence of signs of decreased cardiac output (arrhythmias, dyspnea, vital sign alterations), fetal heart rate within normal limits.
Assessments:
- Regular vital sign monitoring, including between contractions.
- Continuous fetal heart rate monitoring.
Interventions:
- Position patient in left lateral side-lying position.
- Monitor for signs of bleeding.
- Administer supplemental oxygen as needed.
- Monitor vital signs post-anesthesia.
- Perform continuous fetal heart monitoring.
Risk for Imbalanced Fluid Volume
Labor and delivery can predispose women to fluid volume imbalance due to blood loss, dehydration, and nausea/vomiting.
Nursing Diagnosis: Risk for Imbalanced Fluid Volume
Related to: Altered fluid intake, bleeding, nausea and vomiting, dehydration
As evidenced by: (Risk diagnosis – no defining characteristics)
Expected outcomes: Urine output and lab values within normal limits, stable vital signs and oxygen saturation.
Assessments:
- Medical history and risk factor assessment for fluid imbalance.
- Monitor laboratory values (CBC).
- Frequent vital sign assessment.
Interventions:
- Monitor blood pressure and pulse during oxytocin infusion.
- Encourage oral fluid intake.
- Administer IV fluids as indicated.
- Monitor intake and output.
Risk for Infection
Rupture of amniotic membranes and invasive procedures increase the risk of infection during labor and postpartum.
Nursing Diagnosis: Risk for Infection
Related to: Repetitive vaginal exams, ruptured membranes, fecal contamination, umbilical cord prolapse
As evidenced by: (Risk diagnosis – no defining characteristics)
Expected outcomes: Patient verbalizes signs of infection, demonstrates aseptic practices, remains free from infection.
Assessments:
- Assessment of vaginal secretions and amniotic fluid characteristics.
- Fetal heart rate monitoring (tachycardia may indicate infection).
- Maternal vital sign and WBC count monitoring.
Interventions:
- Limit vaginal examinations.
- Utilize aseptic technique during invasive procedures.
- Demonstrate perineal care and hand hygiene.
- Administer antibiotics as prescribed.
- Administer oxytocin as prescribed (to expedite labor).
