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Home Notes Maternal and Child Health Nursing Labor

 Notes
 Maternal and Child Health Nursing

Labor
By
Marianne Belleza, RN
-
May 26, 2016
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The big day has finally arrived! Everyone must be in a state of panic and happiness, but the
pregnant woman, who is the center of everything, must stay focused so the entire labor process
would go by smoothly and safely.

Contents [hide]

 1 Assessment
 2 Diagnosis
o 2.1 First stage of labor
o 2.2 Second stage of labor
o 2.3 Third stage of labor
 3 Planning
 4 Implementation
 5 Evaluation
 6 Induction and Augmentation of Labor
o 6.1 Cervical Ripening
 o 6.2 Induction of Labor by Oxytocin
o 6.3 Augmentation by Oxytocin

Assessment

The key to a successful individualized care plan is the precise assessment and accurate obtaining
of data. The woman would be placed under observation during labor to monitor her progress and
ensure a safe delivery for her and the child.

 Assess for the signs of true labor. The signs of true labor are contractions that begin
irregularly but progresses regularly and predictably, the pain is felt first at the lower back
and circles towards the abdomen, continues to progress no matter what the woman’s
activity level is, increases in duration, frequency, and intensity and cervical dilation is
already present.
 Assess for the appearance of show, which is blood mixed with mucus and would be
present once the operculum or mucus plug is expelled.
 Assess for the rupture of membranes. This is the scanty or sudden gush of clear fluid
from the vagina.
 Assess for the engagement of the fetal head. Engagement refers to the settling of the
presenting part into the pelvis at the level of the ischial spines.
 Assess for the station. Station is the relationship of the presenting part to the level of the
ischial spines.
 Assess for the effacement and dilatation of the cervix. Effacement is the shortening
and thinning of the cervical canal. In cervical dilatation, the enlargement or widening of
the cervical canal is assessed.

Diagnosis

Main topic: Stages of Labor

During labor, a pregnant woman might encounter difficulties that could affect her progress.
These conditions should be prevented to ensure a smooth labor period and eventually, a safe
delivery.

First stage of labor

This stage of labor is divided into three phases.

 The latent phase starts during the onset of true labor contractions until cervical
dilatation.
 The active phase occurs when cervical dilatation is at 4 to 7 cm and contractions last
from 40 to 60 seconds with 3 to 5 minutes interval.
 The transition phase occurs when contractions reach their peak with intervals of 2 to 3
minutes and dilatation of 8 to 10 cm.

Second stage of labor

  This stage starts at full cervical dilatation until the birth of the infant.
 The woman may experience an uncontrollable urge to push and bear down with every
contraction.
 Crowning or the appearance of the fetal head on the vaginal opening occurs.

Third stage of labor

 The third stage begins with the birth of the infant until the delivery of the placenta.
 The signs of placental expulsion are lengthening of the umbilical cord, sudden gush of
vaginal blood, changes in the shape of the uterus and its firm contraction, and the
appearance of the placenta at the vaginal opening.

Planning

With all the data gathered during assessment and through an accurate diagnosis, a care plan for
the woman in labor would be made to aid her through her progress.

Care of a woman in the first stage of labor

 Labor should be allowed to start naturally, not artificially induced.

 The woman must also be allowed to move freely throughout the labor. Artificial
interventions should also be prohibited.
 Allow the woman to assume a non-supine position for delivery.
 Upon delivery of the newborn, mother and child should be given unlimited opportunity
for breastfeeding and bonding.

Care of a woman in the second stage of labor

 During the second stage of labor, the place of delivery of the woman must be prepared.
 The position of birth wherein the woman is most comfortable must also be determined at
this stage.
 Another important part is the promotion of second stage effective pushing.
 Perineal cleaning is also an integral part of the second stage.

Care of the woman in the third stage of labor

 Placental delivery should be given focus at this stage. Once the placenta is delivered,
oxytocin should be administered intramuscularly to promote uterine contractions.
 If there is episiotomy performed, perineal repair should be integrated into the care plan.

Implementation

Some interventions are implemented to give comfort and safety for the mother during and after
the labor period. These are essential in promoting the strength that the mother would need during
delivery.
  Encourage the client to void every 2 hours.
 Observe and review the client’s breathing techniques.
 Inform the client if c interventions are necessary.
 Create a birth plan with the client so she could integrate her preferences in the care plan.
 Provide ice chips, hard candies, or fluids to relieve dry mouth.
 Provide a comfortable environment to aid in the effective coping management of the
client.
 Allow the client to walk and move around freely during labor.
 Do not intervene with the client during a contraction to avoid disturbing her focus on her
technique.

Evaluation

After the labor has passed, delivery would commence immediately. And when the labor period
for the woman has gone smoothly, a great chance for a safe and healthy delivery is within reach.

 Client should exhibit no signs of bladder distention and have the ability to void every 2
hours.
 Client has a good to tolerable level of pain.
 Client can express her preferences during labor.
 Client has the ability to understand the usual process of labor.
 Client reports that her environment is comfortable and secure.
 Client would be able to verbalize her feelings about her experiences during her labor
period.

Induction and Augmentation of Labor

Cervical Ripening

 Cervical ripening must be complete during early labor.

 If there is no cervical ripening, there would be no dilatation and coordination of uterine
contractions.
 To determine whether the cervix is ripe, Bishop established criteria for scoring the cervix.
 If the woman’s score is 8 or greater, the cervix is already ready or birth and would
respond to induction.
 One of the ways to ripen the cervix is known as “stripping the membranes”, or separating
the membranes from the lower uterine segment manually using a gloved finger in the
cervix.
 Complications that may arise from this procedure include bleeding due to undetected
low-lying placenta, inadvertent rupture of membranes, and infection when the
membranes rupture.
 Another method that is also considered is the use of hygroscopic suppositories or
suppositories of seaweed that swell upon contact with cervical secretions.
 These suppositories gradually and gently urge dilatation.
 They are held in place by gauze sponges saturated with povidone iodine or an antifungal
cream.
  The number of sponges and dilators should be documented accordingly to avoid leaving
behind one of them inside the cervix.
 A more common method of speeding cervical ripening is the application of a
prostaglandin gel to the interior surface of the cervix by a catheter or suppository, or to
the external surface by applying it to a diaphragm and then replacing it against the cervix.
 Additional doses may be applied every six hours, but two or three doses are usually
enough to achieve ripening.
 Instruct the woman to remain in a side lying position to avoid leakage of the medication.
 Continuously monitor the FHR at least every 30 minutes after each complication.
 Side effects of this method include diarrhea, fever, hypertension, and vomiting.
 Oxytocin administration may also be started, but that would be 6 to 12 hours after the last
prostaglandin dose.
 Use prostaglandin with caution in women with asthma, renal or cardiovascular disease, or
glaucoma.
 Women who underwent cesarean birth in the past are contraindicated with prostaglandin
method.

Induction of Labor by Oxytocin

 Administration of oxytocin can initiate contractions in a uterus in pregnancy term.

 Oxytocin is administered intravenously so that when there is hyperstimulation, then it
could be quickly discontinued.
 The effects happen immediately because the half-life of oxytocin is approximately 3
minutes.
 Oxytocin is usually mixed with Ringer’s lactate, 10 units of oxytocin in 1000 mL of
Ringer’s lactate.
 The infusion could also be administered piggyback to a maintenance IV solution, so that
if the infusion would be discontinued, the main IV line could still be maintained.
 The oxytocin solution must always be attached to the port nearest to the woman so that
little solution remains in the tubing if it is discontinued.
 Use of an infusion pump is recommended to regulate the infusion rate and make sure that
the rate would not change even if the woman moves.
 Do not increase the rate without any further instructions because it can cause tetanic
contractions.
 Artificial rupture of membranes may be done when cervical dilatation reaches 4 cm to
further induce labor.
 Be aware of peripheral vessel dilatation, a side effect of oxytocin administration, which
can cause hypotension.
 Assess the woman’s pulse and blood pressure every 15 minutes to be certain of a safe
induction.
 Monitor uterine contractions and FHR accordingly.
 Contractions should occur no more often than every 2 minutes, should not be longer than
70 seconds, and not stronger than 50 mmHg.
 Stop the IV infusion if the contractions become more frequent or longer in duration than
the safe limits or if there are signs of fetal distress.
  Excessive stimulation of the uterus by oxytocin may lead to tonic uterine contractions
with fetal death or rupture of the uterus.
 In the event that hyperstimulation is not stopped even if the infusion has been
discontinued, a beta-adrenergic receptor drug or magnesium sulfate may be prescribed to
decrease myometrial activity.
 A complication of oxytocin infusion is water intoxication because oxytocin has an
antidiuretic effect that results in decreased urine flow.
 Symptoms of water intoxication are headache and vomiting.
 Water intoxication in its most severe form can cause seizures, coma, and even death
because of the large shift in interstitial tissue fluid.
 Monitor the intake and output appropriately and assess urine specific gravity to detect
fluid retention.
 Limit the amount of IV fluid to 150 mL/hr by making sure that the main line is infusing
at a rate not greater than 2.5 mL/min.
 Induced labor tends to have shorter first stage than the average unassisted labor.
 Assure the woman that uterine contractions in an induced labor are basically normal so
she can use her breathing techniques effectively.
 However, hyperbilirubinemia and jaundice in a newborn are possible because of
induction of labor with oxytocin.
 The infant should be observed closely for these conditions during the first few days of
life.

Augmentation by Oxytocin

 If labor contractions begin spontaneously but become weak, irregular, and ineffective,
augmentation of labor is required.
 Precautions for oxytocin administration are the same as for primary induction of labor.
 The uterus may respond effectively to oxytocin used as augmentation.
 The drug should be increased in small increments only and fetal heart sounds should be
monitored during the procedure.

The labor process is the gateway towards a safe delivery. Once the woman has undergone labor,
it is imminent that delivery would follow suit. It is important for the woman to have a smooth
labor process for this is where she would be gathering her strength to deliver her precious bundle
of joy.

 TAGS
 cervix
 crowning
 dilatation
 effacement
 engagement
 labor
 show
 station
 Vagina
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