Learning Objectives
By the end of this section, you will be able to:
- Explain the nursing actions during obstetric triage
- Identify the content of the admission history of the laboring person during the first stage of labor
- Perform the admission physical exam on the laboring person during the first stage of labor
- Explain the nursing actions when monitoring a laboring person and fetus during the first stage of labor
- Provide comfort measures to the laboring person during the first stage of labor
Labor places physical and emotional demands on the laboring person and their support persons. The nursing care required during the process of labor and birth is based on the laboring person’s progress, their ability to meet the physical and psychosocial demands of labor and birth, and fetal adaptation. The nurse also follows standards of care, ensuring safety and meeting the needs of both the laboring person and the fetus from admission to the labor and birth unit through the postpartum period.
Unfolding Case Study
Labor and Delivery: Part 1
Brianne is a 36-year-old, G1 P0, high school teacher who is being admitted to the Labor and Birth Unit at 39 weeks’ gestation for induction of labor due to gestational diabetes and possible macrosomia. Brianne states she and her partner, Trey, have attended a childbirth education class. Trey has come with Brianne and plans to provide support to Brianne throughout the labor and birth process.
| Past medical history (PMH) | Medical history:
Social history: Brianne and Trey live in a two-bedroom apartment on the second floor in a building with only a freight elevator. They have a small dog named Candy. Trey works for a construction company and is 40 years old. Neither Candy nor Trey smokes. Trey does drink an occasional beer. Brianne does not drink alcoholic beverages. Prenatal history BP range, 110–128/60–80 Fundal height at 39 weeks, 40 cm Gestational diabetes (diet controlled) No current medications and allergy to penicillin |
| Flowchart | Height: 5 ft 3 in. Weight at first prenatal visit: 135 lb Vital signs Admission to Labor and Birth unit BP, 128/74; Temp, 98.2 (F); Pulse, 84; Resp, 18 |
| Lab results | Initial prenatal labs A negative, antibody screen negative Rubella nonimmune Negative tests for STIs at initial prenatal visit Urine positive for GBS Genetic and neural tube defect screening labs Screening and diagnostic tests for genetic and neural tube abnormalities negative 28-week prenatal labs 1-hour GCT, 150 3-hour GTT, FBS, and 2-hour glucose levels elevated 36-week prenatal labs Negative tests for STIs at 36 weeks’ gestation |
| Diagnostic tests/imaging results | Initial prenatal visit Intrauterine pregnancy Fetal heart rate 154 6 weeks’ gestation 20 weeks’ gestation Ultrasound negative for congenital anomalies and showed fundal placenta Fetal heart rate 148 36 weeks’ gestation Ultrasound indicates EFW 3,150 g (7 lb) Fetal heart rate 148 Vertex presentation Amniotic fluid index, 10 |
| Provider’s orders | Admit to Labor & Birth Unit for induction of labor Blood type, Rh, antibody screen CBC Start IVFs of 1,000 LR at 100 mL/hr Pitocin 15 units in 250 mL of LR IVPB, start at 2 milliunits/min and increase 2 milliunits/min every 30 minutes up to 20 milliunits/min to establish labor |
Obstetric Triage
The rapid assessment and prioritization of care based on the specific obstetric and gynecologic needs, or obstetric triage, occurs when a patient at 16 weeks’ gestation, or later, arrives at a hospital for care related to the pregnancy. When the patient presents to the hospital, they will be evaluated by health-care providers who specialize in obstetric care to determine the urgency of the care required. While some patients present for ruling out labor or rupture of membranes, obstetric triage also serves a primary role in evaluating for obstetric emergencies or concerning symptoms throughout a pregnancy. The more common emergencies and symptoms include new onset vaginal bleeding, decreased fetal movement, abdominal pain, swelling, and elevated blood pressure (American College of Obstetricians and Gynecologists [ACOG], 2023a). Other obstetric triage patients may be sent to another unit, such as the emergency department, within the hospital for follow-up evaluation of non–pregnancy-related conditions. If the patient’s situation does not require observation or admission, as in false labor, the patient is discharged with instructions and follow-up with their obstetric care provider (ACOG, 2023a).
When a patient arrives for obstetric triage, the nurse will obtain the presenting symptoms, complete a focused physical assessment, and gather information about the pregnancy. The nurse will also obtain the patient’s vital signs and fetal heart rate (FHR) and contraction patterns to prioritize the patient’s need for care. This information will be entered into the electronic health record (EHR). The nurse will also interview the patient about their current health-care provider for obstetric care. If the patient’s obstetric provider is on staff at the facility, the nurse will notify the health-care provider of the patient’s arrival, presenting symptoms, and other priority information obtained during the triage process. If the patient’s health-care provider is not on staff at the facility or if the patient does not have a preexisting relationship with a provider who has privileges at the facility, the nurse will notify a hospital-based provider (ACOG, 2023b).
During the initial interaction with the patient, the nurse will ascertain the patient’s estimated date of delivery (EDD) to determine the gestational age of the fetus. Based on facility-specific policies, those who are less than 20 weeks’ pregnant are often triaged in the emergency department. Medical decisions related to the patient’s complaint and assessment will vary based on the gestational age. In addition, the nurse needs to obtain an obstetric history for the patient, including the number of pregnancies, term and preterm deliveries, abortions, and current living children (Moudi et al., 2020). These initial interview questions are obtained with succinct questioning by the nurse while the initial stages of the physical assessment are being conducted.
Initial vital signs are obtained upon arrival on the unit to detect any abnormal values that require an immediate report to the health-care provider. Elevated blood pressure can be indicative of a serious complication—pre-eclampsia or eclampsia—and require a prompt response by the health-care team. An elevated temperature along with an increased pulse rate can be indicative of infection.
Initial assessment also includes assessment of the fetal heart rate. The type of fetal and uterine monitoring equipment is facility-specific and will vary based on the clinical situation. The nurse will perform Leopold’s maneuvers to determine the fetal position and the placement of any external fetal monitoring equipment. Fetal monitoring, fetal monitoring equipment, and Leopold’s maneuvers are discussed in depth in Chapter 16 Electronic Fetal and Uterine Contraction Monitoring.
Review of Prenatal Record
When a patient arrives for obstetric triage with symptoms of labor, prior to the initial assessment, the nurse will review the prenatal record of the patient to obtain a baseline understanding of the patient’s obstetric and medical history to provide a high level of individualized patient care (Moudi et al., 2020). When the prenatal record is available, the nurse will review the prenatal history, medical and surgical history, and labs to create a plan of care reflective of the findings in the patient’s chart. When a prenatal record is not available, a thorough interview of the patient is necessary to obtain a complete history, and laboratory and diagnostic testing may be performed during their visit. Whether the patient has a prenatal record available or not, it is important to confirm information with the patient and clarify any incomplete information.
Obstetric History
The obstetric history of the patient may have a direct impact on the care provided, requiring a thorough assessment of the history through the patient’s chart and personal interview. The nurse will obtain information on the patient’s history of any previous pregnancies, including the dates, outcomes, type of delivery, and any complications (Tukisi et al., 2022). The nurse will also inquire about any complications with any of the previous pregnancies and the types of deliveries. This information is often found in the prenatal record but should always be verified with the patient. It is important to remember that the patient’s pregnancy history is confidential and should be discussed in private. For more information on the complete assessment of obstetric history, see Chapter 11 Prenatal Care.
Labor and Birth Unit Admission History and Physical Exam
When a patient presents to the labor and birth unit in possible labor or a condition related to pregnancy requiring inpatient care, the nurse first performs an obstetric triage assessment (Moudi et al., 2020). Sometimes, early labor can be challenging to distinguish from false labor or prodromal labor. The nurse will need to use clinical judgment and a combination of the assessment criteria in Table 18.1 to determine whether a patient is in true labor and ready to be admitted for active labor management and delivery (Tukisi et al., 2022).
| Assessment | Data |
|---|---|
| Clinical assessment of contractions |
|
| Cervical examination | A cervical examination is performed to assess the dilation (opening) and effacement (thinning) of the cervix. In true labor, the cervix typically starts to dilate and efface. |
| Assessment of progression | Nurses observe the progression of labor over time. True labor involves a progressive change in contractions, cervical dilation, and effacement. |
| Rupture of membranes (amniotic sac) | The presence of amniotic fluid in or leaking from the vagina can be confirmed through visual inspection or testing. |
| Bloody show | A small amount of bloody discharge or mucus plug is often expelled as the cervix begins to dilate. This is known as a “bloody show” and is a common sign of labor. |
| Patient’s pain and perception | The patient’s description of their pain and discomfort can provide valuable information. Contractions during labor are often more painful and rhythmic compared to Braxton Hicks contractions. True labor contractions also cause cervical change. |
| Assessment of other signs | Nurses assess other signs, such as the urge to push, pressure in the lower back or pelvis, and changes in bowel movements. |
Admission History of the Person in Labor
Once the obstetric triage nurse has received the order from the health-care practitioner (HCP) to admit the laboring person, a more thorough history will be completed per facility protocol. A thorough admission history includes the laboring person ’s medical, surgical, obstetric and gynecologic, and genetic history (Milton, 2024).
Medical History
In reviewing the prenatal history, the nurse will carefully review the list of preexisting conditions and conditions related to the pregnancy that may impact the care of the laboring person and fetus. The nurse will review any pertinent diagnostic tests, including ultrasound results, mainly reviewing the placental placement and fetal positioning or abnormalities. It is important to note any medications that the laboring person is currently taking and document the last time the medication was taken.
A series of laboratory tests are ordered as part of normal prenatal care and should be reviewed by the nurse. The nurse should review the baseline prenatal laboratory tests and any subsequent lab results to identify trends or changes throughout the pregnancy or during the current visit. The nurse will closely assess the laboring person ’s complete blood cell count (CBC), blood typing and antibody screen, rubella titers, hepatitis B and C, human immunodeficiency virus (HIV), and sexually transmitted infection (STI) screenings for abnormal findings that require notification to the provider. Routine prenatal monitoring for gestational diabetes (GDM) should be reviewed, and GDM protocol initiated if the laboring person received a diagnosis during pregnancy. A full overview of prenatal care, including lab work, is available in Chapter 11 Prenatal Care.
Surgical History
The surgical history of the laboring person is reviewed by the nurse and should specifically include any past surgical births, surgery to the abdomen or uterus, and any previous cervical procedures that affect the cervix and create scar tissue, such as punch and cone biopsies. The nurse should also inquire about any previous experiences or complications associated with anesthesia.
Obstetric and Gynecologic History
The nurse reviews the obstetric and gynecologic history of the laboring person. The obstetric history includes number of pregnancies, their outcomes, and any complications. The gynecologic history includes any history of cervical or vaginal cytology, gynecologic complications, such as uterine fibroids and cervical cerclage, or past or current STIs that could impact the labor process (Milton, 2024).
In a laboring person with a history of an STI during the current pregnancy, the nurse investigates whether treatment was initiated and completed, whether all sexual partners were concurrently treated, and whether the test of cure was completed with negative results (Milton, 2024). Any STI diagnosed during the pregnancy, its treatment, and verification of the effectiveness of the treatment are reported to the health-care provider and the team assigned to the care of the newborn.
Psychosocial History
During the admission process, the nurse will review and ask questions about the psychosocial history of the laboring person (O’Connor, 2022). The information obtained that is related to the physical environment at home includes housing, transportation restrictions, access to phone, utilities, and appliances. The nurse also assesses the availability of support persons, preparation for labor and birth, and newborn care knowledge. Evaluation of the laboring person’s and newborn’s safety at home as well as the risk for depression are also responsibilities of the nurse. The nurse will enter this information into the EHR.
Genetic History
The nurse also reviews and confirms the genetic history of the laboring person and other biological parent of the fetus from the prenatal record. Prenatal screenings and diagnostics during pregnancy are optional medical tests and procedures performed to monitor the health of both the pregnant person and the developing fetus (ACOG, 2020b). These tests help identify and manage potential risks, ensure a healthy pregnancy, and enable timely interventions when necessary. The information is obtained directly from the laboring person and other biological parent, if present, when prenatal records are not available. Some genetic disorders that affect blood clotting or bleeding increase the risk of morbidity and mortality during labor and should be addressed during the initial admission intake. The medical team will need to be notified of a family history that includes birth defects, newborn screening disorders, or any genetic disorders that could affect the care of the laboring person or fetus (Centers for Disease Control and Prevention [CDC], 2023). These disorders can be inherited from one or both parents or may arise due to spontaneous mutations. Here are some genetic disorders that can impact pregnancy:
- Down Syndrome (Trisomy 21): Down syndrome is a chromosomal disorder caused by an extra copy of chromosome 21. It can lead to intellectual disabilities and physical abnormalities in the affected child. Prenatal screening tests, such as noninvasive prenatal testing (NIPT) and amniocentesis, can detect the presence of an extra chromosome 21.
- Cystic Fibrosis: Cystic fibrosis is a genetic disorder that affects the respiratory and digestive systems. Carriers of the cystic fibrosis gene may pass it on to their children. Prenatal carrier screening can identify couples at risk of having a child with cystic fibrosis.
- Sickle Cell Disease: Sickle cell disease is a genetic blood disorder that can cause anemia, pain episodes, and other complications. It is more common in people of African, Mediterranean, and Middle Eastern descent. Prenatal genetic testing can determine if both parents carry the sickle cell trait, increasing the risk of having an affected child.
- Tay-Sachs Disease: Tay-Sachs is a rare genetic disorder that affects the nervous system. It is more common in people of Ashkenazi Jewish descent. Prenatal carrier screening can identify couples at risk of having a child with Tay-Sachs disease.
- Hemophilia: Hemophilia is a genetic disorder that impairs blood clotting. It primarily affects males, and carriers of the gene can pass it on to their children. Genetic testing can determine the risk of having a child with hemophilia.
- Neural Tube Defects: Conditions like spina bifida and anencephaly are congenital neural tube defects that can have genetic components. Folic acid supplementation and prenatal screening can help mitigate the risk and manage these conditions.
- Congenital Heart Defects: Some congenital heart defects have a genetic basis, and a family history of heart problems can increase the risk of these disorders in offspring. Prenatal ultrasound and genetic testing can help identify these conditions.
It is important to note that advances in genetic testing and prenatal screening have improved the ability to detect and manage many of these genetic disorders during pregnancy. Genetic counseling and testing are recommended for couples with a family history of genetic disorders or other risk factors to assess the likelihood of having an affected child and to make informed decisions about prenatal care and interventions (CDC, 2023).
Physical Exam of the Person in Labor
Performing a physical examination during labor is a critical aspect of obstetric care, allowing the close monitoring of the progression of labor and the well-being of both the birthing person and the fetus. This hands-on assessment involves a systematic evaluation of various physical parameters and vital signs to ensure a safe and healthy labor and delivery process (Milton, 2024).
General Survey
The nurse will conduct a general survey of the laboring person upon admission. The nurse will observe the laboring person’s appearance and behavior. Deviations from the expected findings should be documented, and further action may be required.
Heart, Lungs, and Extremities
Upon admission, the laboring person’s heart, lungs, and extremities should be evaluated. The nurse should auscultate for heart and lung sounds and report any abnormal findings to the provider. The nurse should visually inspect the extremities for edema, bearing in mind that dependent edema can be a normal finding related to increased fluid volume during pregnancy. Generalized edema of the face, hands, and feet may be indicative of preeclampsia if accompanied by physical symptoms of preeclampsia (Rana et al., 2020). If the laboring person presents with any signs of preeclampsia, including headache and visual disturbances, the nurse should perform an assessment of the laboring person’s deep tendon reflexes (DTRs) and clonus. Any abnormal findings should be immediately reported to the provider.
Obstetric Exam
An obstetric examination, a medical assessment by a health-care provider to evaluate and monitor the health and progress of the pregnant person and their developing fetus throughout pregnancy, will be completed upon admission of the laboring person to the facility. The exam is relatively consistent for term and preterm labor, except where noted (Milton, 2024). The nurse will establish the fetal heart rate and contraction pattern through auscultation and palpation or external fetal monitoring. The status of the membranes will be assessed to determine whether the membranes are intact or ruptured. The assessment may include the laboring person’s report of a gush or leaking of fluid before arrival, visual inspection of the vagina for pooling, or laboratory testing of the fluid for ferning or pH. The nurse should document the time of the rupture of membranes and identify the color of the fluid through visual inspection or patient report and assess for any odor associated with the fluid. Amniotic fluid is expected to be clear. Green or yellow color is associated with meconium-stained fluid. Bloody fluid is associated with placenta previa or abruption.
The nurse will then conduct a vaginal examination to determine cervical dilation, effacement, cervical position, station, and presenting part and position of the fetus. The vaginal exam may be deferred in the preterm laboring person to allow for additional testing, including fetal fibronectin testing. Additionally, the nurse should defer the vaginal examination in laboring persons with vaginal bleeding, a documented placenta previa, or other factors where a vaginal examination may result in complications. Before performing the vaginal examination, the nurse must consider the following complications that may arise from performing the examination.
- Infection: Frequent vaginal examinations can introduce bacteria into the birth canal, potentially increasing the risk of infection, especially if strict aseptic technique is not followed. This can lead to conditions like urinary tract infections or chorioamnionitis (infection of the fetal membranes).
- Ruptured Membranes: Overly forceful or poorly timed vaginal examinations can cause unintended premature rupture of membranes (PROM) or artificial rupture of membranes (AROM), which may increase the risk of infection and potentially lead to complications for both the laboring person and the fetus.
- Discomfort and Pain: Vaginal examinations can be uncomfortable and painful for the laboring person, causing anxiety and distress. Repeated examinations may exacerbate this discomfort.
- Cervical Edema and Bleeding: Frequent or aggressive cervical checks can cause irritation, swelling (cervical edema), and bleeding, potentially leading to cervical injury or hematoma formation.
Clinical Safety and Procedures (QSEN)
Performing a Sterile Vaginal Exam
Explain the procedure to the patient and obtain consent using a trauma-informed approach/language with all patients.
Drape a sheet to maintain the patient’s privacy during the exam.
Don a sterile glove on your dominant hand.
Lubricate the index and middle fingers of your dominant hand.
Inform the patient you will be inserting two fingers into the vagina, and they will feel pressure.
After inserting your fingers into the vagina, locate the cervix.
Check the cervix for the following:
- Cervical Dilation: Estimate the distance between one side of the cervix and the other, documented in centimeters (see Figure 15.3).
- Cervical effacement: Estimate the length of the cervix. A cervix is 0 percent effaced when it is 2 cm long and 100 percent effaced when it is paper thin. Estimate the percentage between 2 cm and paper thin.
- Cervical position: A cervix that “points” toward the patient’s back is in a posterior position, whereas an anterior position is oriented toward the vaginal introitus. If the cervix is located somewhere between the two, it is in the midposition.
Check the presenting part for the following:
- Presentation: Assess the part of the fetus that is presenting in the maternal pelvis: cephalic (vertex), breech (frank).
- Station: Determine the level of the presenting part in relation to the ischial spines of the pelvis.
- Fetal Position: Palpate the relationship of the presenting fetal part (skull if cephalic and sacrum if breech) in relation to the maternal pelvis).
Monitoring the Physical Response during the First Stage of Labor
The assessment of the patient in labor includes obtaining regular maternal vital signs and monitoring the fetal heart rate as outlined in (Table 18.2). Hospital policies are created to reflect the guidelines for fetal monitoring and vital signs, based on the recommendations of professional organizations. These policies dictate the minimum frequency of vital signs, contraction patterns and labor progress, pain, and emotional response checks to be performed by the nurse (Milton, 2024). The nurse should use discretion based on the laboring person’s situation and may complete the assessment more frequently than the minimal policy standard.
| Assessment Data | Early Phase of Labor | Active Phase of Labor |
|---|---|---|
| Vital signs | Every 1 hour | Every 1 hour |
| Contraction pattern | Intermittently every 15–60 minutes or continuously based on low- or high-risk labor status, and documented at the same interval as FHR (refer to Chapter 16 Electronic Fetal and Uterine Contraction Monitoring for both intermittent and continuous monitoring) | Intermittently every 15 minutes or continuously based on low- or high-risk labor status, and documented at the same interval as FHR (refer to Chapter 16 Electronic Fetal and Uterine Contraction Monitoring for both intermittent and continuous monitoring) |
| FHR pattern | See Table 18.3 | See Table 18.3 |
| Labor progress | As indicated based on significant changes in patient behavior, uterine contraction pattern, or abnormalities in the FHR | As indicated based on the patient’s presentation, the feeling of pressure, significant changes in patient behavior, uterine contraction pattern, or abnormalities in the FHR |
| Pain | Hourly or as needed | Hourly or as needed |
| Emotional response | Continuous | Continuous |
Monitoring the Fetal Response to the First Stage of Labor
The Association of Women’s Health, Obstetric and Neonatal Nurses [AWHONN] (2018) recommends fetal heart rate monitoring of uncomplicated pregnancies be reviewed every 15 to 30 minutes during the first stage of labor when electronic monitoring is in place (Table 18.3). When intermittent auscultation is in place, fetal monitoring in the early phase of labor is at the recommendation of the health-care provider and every 15 to 30 minutes in the active phase. See Chapter 16 Electronic Fetal and Uterine Contraction Monitoring for more information on fetal heart rate during labor. In patients who present with or develop complications during labor, the recommendation is for a review of the heart rate every 15 minutes during the first stage of labor. Laboring persons with risk factors should be monitored continuously, allowing for prompt intrauterine resuscitation or delivery.
| FHR Assessment Data | Early Phase of Labor (cervix < 4 cm dilated) |
Early Phase of Labor (cervix 4–5 cm dilated) |
Active Phase of Labor (cervix ≥ 6 cm dilated) |
|---|---|---|---|
| FHR baseline FHR variability Periodic changes |
Frequency at the discretion of the midwife or physician | Low risk without oxytocin: every 30 minutes With risk factors or oxytocin: every 15 minutes |
Low risk without oxytocin: every 30 minutes With risk factors or oxytocin: every 15 minutes |
Monitoring for Complications of the First Stage of Labor
Consistent monitoring for complications begins during the first stage of labor and continues through the succeeding stages of labor and into the postpartum period. During the first stage of labor, the most common complications are related to periodic fetal heart rate changes and labor progress that deviates from normal. The nurse will regularly assess the fetal heart rate, contraction pattern, and labor progress, and watch for any signs of complications during the first stage of labor (Milton, 2024).
Monitoring of the fetus during the first stage of labor will depend on the phase of labor and hospital policy or provider order. The nurse may auscultate the fetal heart rate intermittently or apply external fetal monitors for continuous monitoring. If the nurse detects any abnormalities in the fetal heart rate during auscultation or continuous fetal monitoring, the nurse will perform interventions and notify the provider immediately. Complications and nursing actions are covered in more detail in Chapter 19 Complications of Labor and Birth.
Nursing Interventions during the First Stage of Labor
During the first stage of labor, the nurse will support and educate the laboring person and their partner on comfort measures, mobility, pain relief, and emotional support. These needs will be constant during labor, but the role of the nurse will change as the labor progresses.
Encouraging Position Changes of the Person in Labor
Whenever possible, the nurse should encourage the laboring person to change positions and ambulate during the first stage of labor. The nurse should educate the laboring person on the benefits of position change and ambulation and demonstrate how the partner can assist during the labor process (see Figure 15.11). The laboring person should be advised that lying flat on their back can result in hypotension related to the compression of the vena cava. Walking and upright positions have been shown to decrease the duration of the first stage of labor. Compared to semirecumbent or supine positions, upright positions during labor often result in shorter labors, fewer interventions, and decreased pain for laboring persons. In addition, upright positions allow gravity to assist in bringing the fetus down. No matter the position, frequent position changes create slight movement in the pelvic bones and help the fetus find the best fit into the pelvis (Ondeck, 2019).
The position and station of the fetus during labor can impact the progress of labor and the comfort of the laboring person. Table 18.4 lists specific position changes recommended based on fetal position and station (Dhekra et al., 2020; Garbelli & Lira, 2021).
| Goal | Fetal Position | Recommended Laboring Person Positions |
|---|---|---|
| Changing fetal position during labor | Occiput anterior (OA): This is the most favorable position for labor. | Encourage the laboring person to try the following position changes to facilitate labor progress (Garbelli & Lira, 2021):
|
| Occiput posterior (OP): The fetus’s head is facing the laboring person’s front. | Labor can be more challenging, and position changes can help:
|
|
| Occiput transverse or asynclitic: When the fetus’s head is not well aligned with the pelvis, these positions can lead to prolonged labor. | Recommended position changes include (Garbelli & Lira, 2021):
|
|
| Changing fetal station during labor | High station (above 0 station) | When the fetus’s head is high in the pelvis, position changes can help engage the head in the pelvis and encourage descent (Dhekra et al., 2020):
|
| Low station (below 0 station) | If the fetus’s head is low but not progressing, these position changes can help facilitate descent (Dhekra et al., 2020):
|
|
| Changing fetal position at the pelvic outlet | When the fetus’s head is at the outlet (crowning), position changes focus on guiding the head through the birth canal (Huang et al., 2019):
|
Remember that every labor is unique, and the effectiveness of position changes may vary from person to person. Continuous communication with the laboring person, monitoring the baby’s heart rate, and working collaboratively with the health-care team are essential for safe and effective labor progress in different fetal positions and stations.
Encouraging Breathing and Relaxation of the Person in Labor
The nurse should encourage the laboring person to try to relax and breathe during the first stage of labor. Breathing techniques distract from pain, help in the relaxation of muscles in the pelvis to allow descent of the fetus, and maintain blood oxygen levels for the laboring person and fetus (Heim & Makuch, 2023). Pain management is discussed in detail in Chapter 17 Pain Management During Labor and Birth.
Providing Emotional Support to the Person in Labor
The onset of labor can be a time of excitement and anxiety for new parents. The nurse can provide emotional support to the laboring person and partner by answering questions that they may have. The nurse can ease the laboring person’s anxiety by explaining the expected progression of labor and creating a plan of care with the laboring person and the partner. The nurse should ask the laboring person how they envision their labor and how their wishes can be accommodated while discussing any potential barriers to their desired birth plan. Throughout the labor and delivery, the nurse should discuss any changes with the laboring person and their partner and continually explain what is happening.
Providing Measures for Pain Relief to the Person in Labor
Pain management during the first stage of labor varies based on the patient’s preferences. The nurse is an integral part of the laboring person’s pain management plan. Some laboring persons may opt for nonpharmacologic pain management strategies in which the nurse will provide support with positioning, room ambiance, and management of staff and visitors (Heim & Makuch, 2023). When a laboring person desires analgesia, the nurse may provide options for the laboring person, obtain an order from the provider, administer the medication, and monitor the laboring person following administration. Many facilities offer epidural anesthesia for persons in labor. The nurse will assist the laboring person in proper positioning and will support and monitor the laboring person following the initiation of the epidural. For a more detailed comparison of pain management options, benefits, and risks, refer to Chapter 17 Pain Management During Labor and Birth.
Assisting with Amniotomy
The nurse’s role during an amniotomy, known as breaking of water or artificial rupture of membranes (AROM), is to assist the laboring person and the health-care provider. The nurse’s duties take place before, during, and after the procedure.
Clinical Safety and Procedures (QSEN)
Assisting during an Amniotomy
Informed Consent: The nurse witnesses that the procedure, as well as the reasons for the amniotomy, potential benefits, risks, and alternatives, has been explained to the patient.
Preparation: The nurse ensures that all necessary supplies and equipment are readily available. Such items include sterile gloves, a sterile amniotomy hook or instrument, sterile drapes, and a waterproof pad or absorbent materials to manage amniotic fluid.
Positioning: The patient is positioned comfortably in bed, typically in the lithotomy position (lying on the back with knees bent and feet in stirrups) or another position that allows easy access to the perineal area.
Assisting the Provider: The nurse assists the health-care provider (usually an obstetrician or midwife) during a vaginal examination in which the provider evaluates the cervix’s position, dilation, and effacement.
Performing the Amniotomy: The health-care provider uses a sterile amniotomy hook or instrument to puncture a small opening in the amniotic sac, causing the slow release of amniotic fluid. The nurse may assist by holding the drape or offering support to the patient during the procedure.
Assessing Amniotic Fluid: After the amniotomy, the nurse monitors the characteristics of the amniotic fluid, including color, odor, and the presence of meconium (fetal stool). Any abnormal findings are reported to the health-care provider.
Monitoring Contractions and Fetal Heart Rate: The nurse closely monitors the patient’s uterine contractions and fetal heart rate patterns before and after the amniotomy. Changes in these patterns may indicate the need for further intervention or adjustments in labor management.
Comfort and Emotional Support: Throughout the procedure and in the postamniotomy period, the nurse provides emotional support to the patient, addressing any concerns or questions.
Documentation: Accurate and detailed documentation of the procedure, including the date, time, provider’s name, amniotic fluid characteristics, and maternal and fetal assessments, is essential in the patient’s medical record.
Postamniotomy Care: The nurse continues to monitor the patient’s progress, ensuring they remain comfortable and well hydrated. Frequent assessments of vital signs, contractions, and fetal well-being are maintained.
Education during the First Stage of Labor
The nurse should be a continual resource for educating the patient during labor. The laboring person should be encouraged to ask questions to clarify any information presented by the nurse or health-care team (Milton, 2024). To ease the stress of labor, the nurse should always explain what is happening to the laboring person and their partner and immediately notify them of changes or concerns about the plan of care.
When the nurse applies the external fetal monitoring equipment or auscultates the fetal heart rate, the nurse should educate the laboring person and their partner on the importance of and reason for fetal monitoring during labor (AWHONN, 2018). The nurse can give a brief description of what the health-care team is looking for on the fetal monitor and assure the laboring person that the monitoring is being continually watched so that the health-care team will respond immediately when necessary.
Upon admission, the nurse should discuss the process of labor and birth. The laboring person and their partner should understand the first stage of labor begins with early dilation and ends at full dilation and effacement. The nurse should educate the laboring person on what pain management options are available during the first stage, the value of position changes and rest and relaxation, and the importance of being hydrated during labor. The laboring person should be educated on the differences in pain medication and pushing during the second stage, complete dilation to delivery, when and how pushing will occur, and the team members who will be present for the delivery (Milton, 2024).
Nursing care plays a crucial role in decreasing the cesarean birth rate by promoting and supporting safe and healthy vaginal births. Table 18.5 lists ways in which nursing care can contribute to reducing the cesarean birth rate, with references to evidence-based practices and guidelines.
| Nursing Care | Nursing Intervention | Specific Details of the Intervention |
|---|---|---|
| Labor support and education | Continuous labor support | Nurses will provide continuous emotional support, comfort measures, and encouragement to laboring persons (ACOG, 2019). |
| Frequent position changes and movement | Encourage mobility | Nurses can encourage laboring persons to change positions frequently, such as walking, swaying, or using a birthing ball. ACOG recommends movement and position changes during labor to reduce the risk of cesarean births (ACOG, 2024). |
| Pain management and comfort measures | Nonpharmacologic pain relief | Nurses can offer nonpharmacologic pain relief methods, including relaxation techniques, massage, warm compresses, and hydrotherapy, to help manage pain and discomfort during labor. Effective pain management can reduce the need for epidurals and other interventions associated with cesarean births. |
| Monitoring fetal well-being | Intermittent auscultation and continuous fetal monitoring | Nurses can use intermittent auscultation or continuous electronic fetal monitoring (EFM) to assess fetal well-being during labor. Appropriate and judicious use of EFM can help detect and address fetal distress promptly, potentially avoiding unnecessary cesarean births (AWHONN, 2018). |
| Labor progress assessment | Regular cervical examinations | Nurses can perform cervical examinations at appropriate intervals to assess labor progress. However, they should avoid unnecessary or frequent cervical checks, as they can increase the risk of infection and interventions (ACOG, 2021). |
| Supporting physiologic birth | Promotion of physiologic birth | Nurses can advocate for and support physiologic birth, including spontaneous labor onset and the avoidance of unnecessary interventions. ACOG emphasizes the importance of supporting low-intervention births when appropriate (ACOG, 2019). |
By implementing evidence-based nursing care practices and promoting physiologic birth, nurses can contribute to reducing the cesarean birth rate and ensuring safe and positive birthing experiences for laboring persons.
Legal and Ethical Issues
Adoption
A patient may present for delivery with a legal adoption plan or may decide upon arrival to place their newborn up for adoption. The decision to place a newborn for adoption is a personal one, and the patient may change their mind multiple times during the labor and birth. The nurse should support the patient through decisions and emotional changes during their stay. When a patient presents with a prearranged adoption plan, the nurse should discuss the plan with the patient and any intended parents who are present. It is important to have a clear understanding ahead of time of whether adopting parents will be present in the room/hospital at the time of delivery, whether the patient wants to see or hold the newborn, skin-to-skin, whether any of that should be offered after delivery according to patient desire, and so forth. If a patient does not have a prearranged legal plan or decides during their stay to surrender the newborn, legal arrangements can be initiated. The nurse should consult a social worker to provide resources to the patient and arrange for postdelivery care of the newborn.