Chapter 15: Nursing Care During Labor and Birth

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Okay, picture this.

You are stepping onto the labor and delivery floor for your very first clinical shift.

Oh yeah, it is a completely unique environment.

Right, the monitors are chiming, the hallways are just moving at a rapid pace, and you are tasked with managing the care of two distinct patients simultaneously.

And one of whom you can't even see.

Exactly.

Welcome to our deep dive.

Our mission today is to take the foundational concepts of nursing care during labor and birth and, you know, translate them into a practical chronological clinical shift.

Right, because we are diving straight into chapter 15 of Foundations of Maternal Newborn in Women's Health the seventh edition.

Yes, specifically focusing entirely on nursing care during labor and birth, and we are going to bypass the rote memorization of textbook pages today.

Instead, we want to walk through the entire continuum of care from the moment a patient decides to head to the hospital through the physiological marathon of delivery all the way to the critical postpartum recovery phase.

What's fascinating here is how the nurse acts as the critical bridge.

You know, you are balancing this completely natural physiological process that the human body is designed to do with the highly technical world of acute medical interventions.

Exactly.

And just as a quick reminder, this deep dive will stay strictly grounded in the provided chapter.

No outside anecdotes, no random internet theories.

We are ensuring absolute accuracy for your upcoming exams and clinicals.

Perfect.

So let's start where the patient's journey usually begins.

The admission process.

Right, which actually kicks off before they even arrive at the birth facility.

Nurses spend a lot of time in the third trimester teaching patients exactly when to grab their bag and head to the hospital.

Yeah, and that guidance is highly dependent on whether the patient is a nullapara or a multipara.

It's a huge distinction.

A nullapara is a woman who is pregnant with her first child.

Her cervical tissue has never been fully dilated before, so typically takes much longer to efface, which means to thin out and to dilate.

So what do we tell her?

For a nullapara, the instruction is to come in when her contractions are regular, occurring every five minutes, lasting for one full minute each, and maintaining that consistent pattern for at least one hour.

Right, the classic 5 -1 -1 rule.

But then the instructions shift entirely for a multipara, right?

Because her body has done this before.

Exactly.

The cervix generally offers much less resistance for a multipara.

It dilates much more rapidly once active labor is established.

I mean, if she waits for the 5 -1 -1 pattern, she might literally deliver in the car.

She definitely might.

So we tell a multipara to head in when her contractions are 10 minutes apart, lasting for one minute for one hour.

Okay, but beyond just timing contractions, we also teach them about red flags, things that mandate immediate evaluation at the hospital no matter what the contractions are doing.

Yes, and the first major one is ruptured membranes, the water breaking.

Which we have to remind them isn't always this dramatic, cinematic gush of fluid on the floor.

It can be a really subtle trickle that a patient might just confuse with urinary incontinence.

Right, but any suspicion of ruptured membranes needs evaluation.

The amniotic sac is a sterile protective barrier.

Once that is breached, the clock starts ticking on the risk of an ascending infection like chorioamnionitis.

And there is a much more immediate physical danger too.

A prolapsed umbilical cord.

Yeah.

It is a life -threatening obstetric emergency.

The cord slips down past the fetal presenting part and can get completely crushed.

Another massive red flag is bleeding.

But we have to clearly educate the patient on the difference between normal physiological changes and pathological bleeding.

Because normal bloody show is incredibly common.

Right.

As the cervix softens and dilates, tiny capillaries rupture.

That mixes with the cervical mucus plug, creating this thick mucusy discharge that's pink or dark red.

That is totally normal.

But pathological bleeding presents as active bright red blood, usually unmixed with mucus and often accompanied by severe abdominal pain.

Which is a primary indicator of something like a placental abruption, where the placenta prematurely rips away from the uterine wall.

Or vasoprevia.

If she sees bright red blood, she bypasses the waiting room entirely.

The final red flag is a noticeable decrease in fetal movement.

If the baby's activity drops significantly, we have to evaluate fetal well -being immediately.

Okay.

So let's transition to the moment she actually walks through the doors of the labor and delivery unit.

The clinical text provides this really vital vignette to demonstrate therapeutic communication during admission.

The one with Sandra, Amy, and Jeff.

Yes.

Sandra is the nursing student, Amy is the laboring multi -para, and Jeff is her husband.

Amy walks in and she is already visibly anxious.

And Sandra's approach here is a master class in the difference between just collecting data and actively assessing emotional state.

Right.

Instead of asking a closed -ended question like, is this your first baby?

Which only gets a yes or no.

Sandra asks, is this your first baby, Amy, or have you had others?

That open -ended phrasing is an invitation.

It allows Amy to share that this is her second baby and she immediately volunteers that her first labor took forever.

And then Amy expresses this huge dread about the electronic fetal monitor.

She hates being tied down to the bed.

So Sandra uses a specific therapeutic communication technique here called reflecting.

She says, you seem to have mixed feelings about the monitor.

Exactly.

She does not dismiss the anxiety and she definitely doesn't offer false reassurance by saying something like, oh, monitors are great now.

You won't even notice it.

Which completely shuts down communication.

It damages trust.

By reflecting the statement back, Sandra validates Amy's feelings.

Then she offers concrete facts saying they will work together to find comfortable positions.

But Sandra is also doing a rapid clinical assessment at the exact same time.

She observes Amy is a multi -para with strong contractions every three minutes.

Sandra knows this means she is likely progressing rapidly.

So Sandra uses her critical thinking and immediately seeks out the experience RN because this patient needs priority evaluation.

Establishing that rapport is crucial and part of that safety involves clear communication.

The textbook is very explicit about this.

If a patient has limited English proficiency, you must secure a certified culturally acceptable interpreter.

You cannot use family members to interpret.

Never.

A family member might filter the information.

They might minimize the patient's pain or soften a concerning diagnosis based on their own emotional state.

It completely compromises informed consent.

We also have to do a cultural assessment.

How do they view physical touch?

You can't just assume a laboring patient wants to be massaged and the desire for touch changes constantly.

She might love a lower back massage at four centimeters and find any physical contact excruciatingly irritating at eight centimeters.

We also need to integrate cultural health practices like the hot and cold theory of illness mentioned in the text which is prevalent in many Asian and Hispanic cultures.

Right.

In this theory, birth involves the loss of blood and fluids so it's classified as a cold condition.

The body has lost its internal heat.

So if you offer her a pitcher of ice water, she will likely refuse it.

She will want room temperature or warm fluids like tea, extra blankets, maybe specific hot foods like soft boiled eggs after delivery.

The nurse's job is to respect that.

Okay.

So once rapport is established, we dive into the Intrapartum Assessment Guide, Table 15 .1.

It's a massive intake interview.

You need a tremendous amount of data, estimated date of delivery, the EDD, gravity, the total number of times pregnant, parity, pregnancies that reached viable age.

And abortions, making sure to specifically differentiate between spontaneous abortions, what we call miscarriages, and induced abortions.

Then we check allergies,

food, meds, latex.

But there is a very specific clinical nugget the expert points out here regarding dental anesthesia.

Yes.

You must ask, have you ever had a problem with anesthesia when you've had dental work?

Why is that so critical?

Because dental anesthetics like Novocaine or Litocaine are local anesthetics.

The medications used for epidurals and labor like Bupivacaine belong to the same family.

They end in the suffix cane.

So asking about dental work is this brilliant, indirect way to screen for a potentially life -threatening cross sensitivity before the anesthesia provider even walks in.

Exactly.

We also check recent food intake in case she needs emergency general anesthesia, current meds, and social history.

Which brings up the delicate questioning around illegal substances, tobacco, and alcohol.

This requires immense professionalism.

Patients fear legal repercussions.

So if you seem judgmental, they will withhold information.

But you need the truth.

Because if a patient is actively using opioids and you give her a certain narcotic pain relief, it could trigger acute withdrawal.

Or the newborn might need specialized resuscitation.

Okay.

All of this assumes we actually have time.

Box 15 .1 breaks down what happens when a patient rolls into triage and it looks like she's about to deliver right this second.

When birth is imminent, you abandon the comprehensive interview.

You shift to a focused assessment,

maternal vital signs, fetal heart rate, and immediate delivery prep.

The signs are distinct.

She's grunting, involuntarily bearing down, maybe sitting awkwardly on one buttock due to the pressure.

Or she just shouts, the baby is coming.

At that point, the nurse must stay completely calm.

You don't need gloves.

And clean gloves are actually fine here, right?

Yes, because you are receiving the infant,

not performing a sterile invasive procedure.

As the head emerges, you support the perineum.

Once the head is out, wipe the secretions and use a bulb syringe to clear the airway.

But sequence matters here.

Always suction the mouth first, then the nose.

Because if you do the nose first, the infant might reflexively gasp and aspirate fluid from their mouth deep into their lungs.

Mouth first, then nose.

Then thermoregulation.

Dry the baby, place them skin to skin on the mother's bare chest, and encourage immediate suckling.

That suckling stimulates the mother's pituitary gland to release endogenous oxytocin, which causes the uterus to contract firmly and controls maternal bleeding.

While managing all of this, we are watching the fetal heart rate.

The textbook reinforces that a normal baseline is 110 to 160 beats per minute.

With moderate variability and acceleration.

Exactly.

Okay.

Assuming we are not in a precipitous delivery, we perform a database assessment, which includes procedure 15 .1, Leopold's maneuvers.

This is a systematic four -step method of abdominal palpation to determine the presentation, position, and lie of the fetus.

But before you touch her abdomen, ask her to empty her bladder and position her supine with a critical adjustment.

You have to place a wedge under one hip.

The wedge is a non -negotiable safety step to prevent aortic cavity compression, also known as supine hypotensive syndrome.

If she lies flat, the heavy uterus compresses the inferior vena cava and descending aorta against her spine, which drops her blood pressure and severely compromises oxidated blood flow to the placenta.

So always use the wedge.

Okay.

First maneuver.

You face her head and palpate the uterine fundus at the top.

You're trying to figure out what's up there.

A soft, irregular mass that moves with the body is the buttocks, meaning the baby is head down or a cephalic.

But if it's hard, round, and moves independently, if you can ballot it, that's the head, which means breach.

Right.

The second maneuver, you move your hands down the sides of the abdomen.

You want to locate the smooth, convex fetal back on one side.

And the nodular, small part, arms and legs on the other side.

The third maneuver is Pallix grip.

You grasp the suprapubic area.

If the mass is movable, the presenting part is floating.

If it is fixed, it is engaged in the pelvis.

Finally, the fourth maneuver.

You turn and face her feet.

You slide your hands down the sides toward the pubic bone.

One hand will meet a hard obstruction,

the cephalic prominence.

If the head is flexed, meaning the chin is tucked to the chest, you'll feel that prominence on the same side as the small parts.

It's the baby's forehead.

If connect this to the bigger picture, Leopold's isn't just about position.

No.

It tells the nurse exactly where to place the fetal monitor.

The clearest heart tones transmit through the fetal upper back.

Find the back, find the heartbeat instantly.

Next is Procedure 15 .2, Palpating contractions.

Because the external monitor can't accurately measure true intensity.

The textbook gives us a great tactile analogy here.

Yes.

You place your fingertips on the fundus.

A mild contraction feels like pressing the tip of your nose.

A moderate contraction feels like pressing your chin.

And a firm contraction feels like pressing your forehead.

It is rigid and board -like.

We measure frequency, duration, and most importantly, relaxation time.

The relaxation period is everything.

During a contraction, the blood vessels to the placenta are compressed.

The fetus relies on its reserves.

The resting tone gives the placenta a fresh flush of oxygen.

If that resting tone is too high, the fetus becomes hypoxic.

To see how the cervix is responding, we look at Figure 15 .1, the vaginal examination.

The

Facement and Dilation.

A facement is the thinning of the cervix, measured from 0 to 100 percent.

Dilation is the opening, measured from 0 to 10 centimeters.

You're also feeling the fetal presenting part.

In a normal vertex presentation, you'll feel the smooth skull, and you locate the fontanels to see how the head is rotated.

The posterior fontanel is a small triangular depression.

The anterior fontanel is larger and diamond -shaped.

You also measure station, how far down the baby is.

Zero station means the head is level with the maternal ischial spines.

Minus means it's higher, plus means it's lower.

This ongoing data collection brings us to Section 3.

We have to continuously monitor for tachycystal.

Which is more than 5 contractions in 10 minutes, or contractions lasting over 120 seconds.

It's an emergency because it strips the fetus of recovery time.

We also check the bladder every 2 hours.

A full bladder physically blocks the baby's descent.

And we assess coping.

An inward focus and rhythmic breathing means she's coping.

Panic thrashing and tearfulness means she is not, and we need to intervene.

We also monitor the amniotic fluid.

Sram is spontaneous rupture.

Aerome is artificial rupture.

When the water breaks, what does it look like?

Clear with vernix is normal.

Green indicates meconium, the baby's first bowel movement, which happens during fetal stress.

Cloudy or foul -smelling fluid indicates chorioamniitis, the severe infection.

And let's talk about the big risks upon rupture, because there are two massive ones.

The absolute primary emergency is a prolapsed umbilical cord.

Because that gush of fluid can physically wash the cord down past the baby's head.

And then the head crushes it against the pelvic bones, cutting off all oxygen.

This is why you must check the fetal heart rate immediately before and for one full minute immediately after the membrane's rupture.

The second major risk is abruptio placenta.

If she had polyhydramnios, too much fluid, and it all gushes out, the uterus rapidly collapses, which can literally shear the placenta off the uterine wall.

That's why assisting with an amniotomy, shown in figure 15 .2, is so strict.

The provider uses an amnihook, but they must perform a vaginal exam first to confirm the head is firmly engaged.

Right, the head acts like a cork to prevent the cord from slipping past.

Exactly.

Moving into section four, application of the nursing process.

If a patient is just in false labor, contractions aren't changing the cervix.

We reassure her, validate her frustration, and give her discharge teaching.

But if it's true labor,

the paramount concern is fetal oxygenation.

Which brings us back to positioning, never supine.

Right, aortic cabel compression.

Always use a wedge.

We also watch for maternal hypotension, hypertension, or a fever.

A maternal fever increases fetal metabolic demand, causing fetal tachycardia.

So we focus on comfort measures.

Dim lighting, cool washcloths like in figure 15 .3, ice chips in figure 15 .4, a clean, dry bed.

And positions for labor.

Figure 15 .5.

Upright positions use gravity, they open the pelvic outlet, and they make contractions more efficient.

There's one specific position for back labor.

Yes.

Back labor is agonizing.

It's usually caused by an occiput posterior fetus the baby is facing forward, so the hard back of its skull grinds into the mother's spine with every contraction.

The fix is the hands and knees position.

Gravity pulls the baby's heavy abdomen toward the floor, pulling the head off the mother's spine and giving the baby room to rotate.

It is incredibly effective.

Okay, here is where it gets really interesting.

Evidence -based practice regarding pushing.

Historically, at 10 centimeters, we'd say, hold your breath and push.

Directed, immediate pushing.

But evidence shows that's often harmful.

The new standard is delayed pushing or laboring down.

We wait for the Ferguson reflex.

Right.

As the uterus contracts, it passively pushes the baby lower.

When the head stretches the pelvic floor muscles, it triggers a massive neuroendocrine response.

The maternal pituitary releases a huge surge of oxytocin, causing an overwhelming involuntary urge to bear down.

That's the Ferguson reflex.

Waiting for that reflex reduces maternal fatigue and actually shortens the active pushing time, even if the overall second stage takes a bit longer.

And when she does push, we teach open glottis breathing over Valsalva, or purple pushing.

Valsalva drops maternal cardiac output and cuts off placental perfusion.

She should slowly exhale or grunt as she bears down.

Now, preparing for delivery.

We set up the sterile instrument table, figure 15 .6, and then we hit the delivery sequence in figures 15 .7 and 8.

The head crowns.

The provider does the Richin maneuver, applying pressure to the chin through the perineum to control the head's exit and prevent severe tearing.

Once the head is out, they check for a neutral cord wrapped around the neck.

Then restitution and external rotation.

The baby's head naturally untwists to align with its shoulders inside the pelvis.

The provider guides the anterior shoulder out first, under the pubic symphysis, then the posterior shoulder.

The airway is suctioned, cord clamped, and the placenta delivers shortly after.

It's an incredible sequence.

But what happens when things go wrong?

Section 5 covers alterations in normal labor.

Let's start with version.

Fig 15 .9, external cephalic version, or ECV.

If the baby is breech or transverse, the provider uses their hands on the outside of the mother's abdomen to physically manipulate and turn the baby head down.

But there are strict contraindications.

You would never do this if she had a previous classical or vertical C -section right.

Never.

The manipulation could cause that vertical scar to rupture.

You also can't do it if there's oligohydramideous low fluid, because you need the fluid as a lubricant to turn the baby safely.

They use ultrasound, give tocolytics like Tributalin to relax the uterus so it doesn't fight the turning, and give Rogam if the mother is Rh negative.

Now if the baby is head down but we need to initiate labor, we talk about induction and augmentation.

You need a medical reason, like a hostile environment, post -term pregnancy, or infection.

But first, you check the Bishop's score, Table 15 .2.

The Bishop's score evaluates the cervix based on dilation, effacement, station, consistency, and position.

A score greater than 8 means a very high chance of a successful vaginal birth.

If the score is low, you have to ripen the cervix first.

Table 15 .3 covers this.

We use prostaglandins like dinoprostone, or the off -label but highly effective Mesoprostol, brand name Cytotec.

Mesoprostol is actually an ulcer medication, but as a prostaglandin it softens the cervix and stimulates contractions.

Given in very small doses, 25 to 50 micrograms.

Or mechanical methods like laminaria seaweed inserts that absorb fluid and expand the cervix.

Once ripe, we use oxytocin, or Piticin.

The drug guide rules for Piticin are extremely strict.

It is always a secondary piggyback line.

Insert it at the proximal port.

Yes, the port closest to the patient.

If tachycystality happens, you must turn off the pump.

And because it's at the proximal port, the medication stops entering the patient immediately.

Tachycystality is the biggest safety check here.

More than five contractions in 10 minutes, or durations over 120 seconds.

If that happens, what are the nursing actions?

Rapid sequence.

Turn the patient on her side.

Give an IV fluid bolus.

Administer oxygen.

Stop the dosage immediately.

And anticipate giving Turbutalane to stop the contractions.

Perfect.

Section 6 is operative vaginal birth and episiotomy.

Figures 15 .10 and 11 show the vacuum extractor and forceps.

The rules for these instruments are absolute.

The cervix must be fully dilated, membranes ruptured, and the maternal bladder must be empty.

A full bladder sits right in the path of the instruments.

And there's a strict limit on the vacuum.

Maximum of three pop -offs.

If the suction cup pops off three times, you stop and go to a C -section.

The complications are significant.

Maternal lacerations.

For the infant, forceps can cause temporary facial nerve injury.

The vacuum creates a chignon, a conehead swelling, and increases the risk of a cephalohematoma.

Which brings us to episiotomy, figure 15 .12.

There are two types.

Midline and medialateral.

It is a brutal but necessary trade -off.

A midline cut heals neater and is less painful.

But it carries a massive risk of tearing straight down through the anal sphincter.

A fourth degree laceration.

Yes.

A medialateral cut goes off at an angle.

It prevents the anal tearing, but it bleeds more, hurts significantly more during healing, and scars irregularly.

Section seven deals with cesarean birth.

Box 15 .2 covers VBAC vaginal birth after cesarean.

The major catch with VBAC is the prior uterine incision.

It is generally only safe if the previous incision was a low transverse cut.

Because if it was a classical vertical cut high on the uterus, the risk of uterine rupture during labor is too high.

And you cannot just look at the skin scar on her abdomen.

Figures 15 .13 and 14 show this.

A horizontal bikini skin scar doesn't guarantee the uterine cut underneath isn't vertical.

You have to check the surgical records.

Pre -op prep involves a timeout, antacids like Bicitra to neutralize stomach acid in case of aspiration,

prophylactic antibiotics, abdominal clipping, not shaving, a Foley catheter to drain the bladder out of the way, and SCDs on the legs to prevent blood clots.

And postpartum nursing care involves massive emotional support for the mother, a sense of failure, plus standard PACU care.

All right.

Section 8.

The final stage.

Nursing care after birth.

We're managing two patients now.

Let's start with the infant and the Apgar score.

Table 15 .4.

Scored at 1 in 5 minutes.

You evaluate heart rate, respiratory effort, muscle tone, reflex response, and color.

Each gets a 0, 1, or 2.

Then thermoregulation.

The head is 25 % of their body surface area.

You must dry the infant's head immediately.

If they get cold, cold stress occurs.

They burn brown fat, which rapidly consumes their oxygen and glucose stores.

We also apply matching identification bands snugly to the ankles, not wrists.

Okay, not care of the mother.

Table 15 .5 on hemorrhage.

This raises an important question.

How do we spot hemorrhage early?

You cannot rely on blood pressure.

The first sign of hypovolemia is a rising pulse, tachycardia.

The body compensates for blood loss before the blood pressure finally drops.

We check the fundus.

If it feels soft and boggy, she is actively bleeding inside.

We immediately massage the uterus until it's firm like a grapefruit.

And if the fundus is high and displaced to the right side of her abdomen, her bladder is completely full.

It's physically pushing the uterus out of the way, preventing it from clamping down.

You must empty that bladder.

We check the lochia, the bleeding.

Make sure to roll her over to check for blood pooling under her back.

And we evaluate the perineum using the RIDA acronym.

Redness, edema, ecumosis, which is bruising discharge, and approximation of the incision edges.

We use ice packs for 10 to 20 minute intervals.

Lastly, promoting attachment.

The golden first hour, skin -to -skin contact.

You observe the mother progressing from a hesitant fingertip touch to a flat palm touch to fully enfolding the infant against her chest.

It is a profound transition.

It really is.

We just summarized this incredible journey of Chapter 15.

We recapped how the nurse seamlessly manages dual patients, one visible, one invisible, while balancing natural physiology with acute medical interventions.

Consider how the nurse's role in the delivery room spans the entirety of human history.

You go from being a primal emotional anchor and physical support using gravity and movement to simultaneously interpreting highly complex electronic fetal telemetry and administering precise pharmacologic interventions.

It's an integration of ancient intuition and cutting edge science that literally shapes the first moments of human life.

That is perfectly said.

Thank you for listening and a warm thank you from the Last Minute Lecture Team.

See you next time.