r e t p a h 1c 4 Nursing Management During Labor and Birth KeyTERMS LearningOBJECTIVES accelerations After studying the chapter content, the student should be able to artifact accomplish the following: baseline fetal heart rate baseline variability 1. Define the key terms. crowning 2. Describe the assessment data collected on admission to the perinatal unit. deceleration 3. Identify the measures used to evaluate maternal status during labor and birth. electronic fetal monitoring 4. Compare and contrast the advantages and disadvantages of external and episiotomy internal fetal monitoring, including the appropriate use for each. Leopold’s maneuvers 5. Describe appropriate nursing interventions to address nonreassuring fetal heart neuraxial rate patterns. analgesia/anesthesia 6. Outline the nurse’s role in fetal assessment. periodic baseline changes 7. Explain the various comfort-promotion and pain-relief strategies used during labor and birth. 8. Discuss the ongoing assessment involved in each stage of labor and birth. 9. Delineate the nurse’s role throughout the labor and birth process. wow Wise nurses are not always silent, but they know when to be during the miracle of birth. The laboring and birthing process pregnant women who attend a series of prepared child- is a life-changing event for many women. Nurses need to birth classes. (See Chapters 12 and 22 for more informa- be respectful, available, encouraging, supportive, and pro- tion on these objectives.) fessional in dealing with all women. The nursing manage- This chapter provides information about nursing ment for labor and birth should include comfort measures, management during labor and birth. It describes the nec- emotional support, information and instruction, advocacy, essary data to be obtained with the admission assessment and support for the partner (Simkin, 2002). and methods to evaluate labor progress and maternal and fetal status. The chapter also describes the major meth- ods for comfort promotion and pain management. The ConsiderTHIS! chapter concludes with a discussion of the nursing man- Since I was expecting my first child, I was determined to agement specific to each stage of labor, including key put my best foot forward and do everything right, for I was nursing measures that focus on maternal and fetal assess- an experienced OB nurse and in my mind it was expected ments and pain relief. behavior. I was already 2 weeks past my “calculated due date” and I was becoming increasingly worried. Today I went to work with a backache but felt no contractions. Admission Assessments I managed to finish my shift but felt wiped out. As I walked The nurse usually first comes in contact with the woman to my car outside the hospital, my water broke and I felt the warm fluid run down my legs. I went back inside to either by phone or in person. It is important to ascertain be admitted for this much-awaited event. whether the woman is in true or false labor and whether Although I had helped thousands of women go through she should be admitted or sent home. their childbirth experience, I was now the one in the bed If the initial contact is by phone, the nurse needs to and not standing alongside it. My husband and I had establish a therapeutic relationship with the woman. This practiced our breathing techniques to cope with the dis- is facilitated by speaking in a calm, caring tone. When comfort of labor, but this “discomfort” in my mind was completing a phone assessment, include questions about more than I could tolerate. So despite my best inten- the following: tions of doing everything right, within an hour I begged for a “painkiller” to ease the pain. While the medication • Estimated date of birth, to determine if term or preterm took the edge off my pain, I still felt every contraction • Fetal movement (frequency in the past few days) and truly now appreciate the meaning of the word • Other premonitory signs of labor experienced “labor.” Although I wanted to use natural childbirth • Parity, gravida, and previous childbirth experiences without any medication, I know that I was a full partici- • Time from start of labor to birth in previous labors pant in my son’s birthing experience, and that is what • Characteristics of contractions, including frequency, “doing everything right” was for me! duration, and intensity Thoughts: Doing what is right varies for each indi- • Appearance of any vaginal bloody show vidual, and as nurses we need to support whatever • Membrane status (ruptured or intact) that is. Having a positive outcome from the child- • Presence of supportive adult in household or if she birth experience is the goal, not the means it takes to is alone achieve it. How can nurses support women in mak- ing their personal choices to achieve a healthy out- When speaking with the woman over the telephone, come? Are any women “failures” if they ask for pain review the signs and symptoms that denote true versus medication to tolerate labor? How can nurses help false labor, and suggest various positions she can assume women overcome this stigma of being a “wimp”? to provide comfort and increase placental perfusion. Also suggest walking, massaging, and taking a warm shower to promote relaxation. Outline what foods and fluids are The health of mothers and their infants is of critical appropriate for oral intake in early labor. Throughout the importance, both as a reflection of the current health sta- phone call, listen to the woman’s concerns and answer tus of a large segment of our population and as a predictor any questions clearly. of the health of the next generation. Healthy People 2010 Reducing the risk of liability exposure and avoiding (DHHS, 2000) addresses maternal health in two objectives preventable injuries to mothers and fetuses during labor for reducing maternal deaths and for reducing maternal and birth can be accomplished by adhering to two basic illness and complications due to pregnancy. In addition, tenets of clinical practice: (1) use applicable evidence another objective addresses increasing the proportion of and/or published standards and guidelines as the foun- 332 Chapter 14 NURSING MANAGEMENT DURING LABOR AND BIRTH 333 dation of care, and (2) whenever a clinical choice is pre- example, the woman’s due date is still 2 months away, it sented, chose client safety (Simpson & Knox, 2003). With is important to establish this information so interventions this advice in mind, advise the woman on the phone to can be initiated to arrest the labor immediately or notify contact her healthcare provider for further instructions the intensive perinatal team to be available. In addition, or to come to the facility to be evaluated, since ruling out if the woman is a diabetic, it is critical to monitor her glu- true labor and possible maternal-fetal complications can- cose levels during labor, to prepare for a surgical birth if not be done accurately over the phone. dystocia of labor occurs, and to alert the newborn nurs- Additional nursing responsibilities associated with a ery of potential hypoglycemia in the newborn after birth. phone assessment include: By collecting important information about each woman they care for, nurses can help improve the outcomes for • Consult the woman’s prenatal record for parity status, all concerned. estimated date of birth, and untoward events. Be sure to observe the woman’s emotions, support • Call the healthcare provider to inform him or her of the system, verbal interaction, body language and posture, woman’s status. perceptual acuity, and energy level. Also note her cultural • Prepare for admission to the perinatal unit to ensure ade- background and language spoken. This psychosocial infor- quate staff assignment. mation provides cues about the woman’s emotional state, • Notify the admissions office of a pending admission. culture, and communication systems. For example, if the If the nurse’s first encounter with the woman is in per- woman arrives at the labor and birth suite extremely anx- son, an assessment is completed to determine whether she ious, alone, and unable to communicate in English, how should be admitted to the perinatal unit or sent home until can the nurse meet her needs and plan her care appropri- her labor advances. Entering a facility is often an intimi- ately? It is only by assessing each woman physically and dating and stressful event for women since it is an unfamil- psychosocially that the nurse can make astute decisions iar environment. Giving birth for the first time is a pivotal regarding proper care. In this case, an interpreter would be event in the lives of most women. Therefore, demonstrate needed to assist in the communication process between respect when addressing the client and thoroughly listen the healthcare staff and the woman to initiate proper care. and express interest and concern. Nurses must value and It is important for the nurse to acknowledge and try to respect women and promote their self-worth by allowing understand the cultural differences in women with cultural them to participate in making decisions and fostering a backgrounds different from that of the nurse. Attitudes sense of control (Matthews & Callister, 2004). toward childbirth are heavily influenced by the culture in An admission assessment includes maternal health which the woman has been raised. As a result, within every history, physical assessment, fetal assessment, laboratory society, specific attitudes and values shape the woman’s studies, and assessment of psychological status. Usually childbearing behaviors. Be aware of what these are. When the facility has a specialized form that can be used through- carrying out a cultural assessment during the admission out labor and birth to document assessment findings process, ask questions (Box 14-1) to help plan culturally (Fig. 14-1).