Chapter 6: Labour & Birth: Nursing Care of Mother & Infant

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Welcome back to The Deep Dive.

Today we are shifting gears and doing something that I think is going to be incredibly valuable for a specific slice of our audience, but honestly fascinating for everyone else too.

We are calling this a last minute lecture.

It's a bit of a survival guide.

Exactly.

So if you are a nursing student currently staring at, you know, a wall of text,

frantically trying to cram for an obstetrics exam and feeling that panic rising,

just take a deep breath.

We gotcha.

We are here for you.

Or if you are just someone who wants to understand the absolute biological miracle, and I mean the intense gritty mechanics of how a human being actually enters the world, you have come to the right place.

It is, and I don't think this is an exaggeration, arguably the most intense physiological event a human body can endure.

Wow.

And for the nurse standing in that room, it is a high stakes balancing act that requires a massive amount of skill, intuition, and knowledge.

So today we are diving deep into chapter six of Lifer's Introduction to Maternity and Pediatric Nursing in Canada.

The title of this chapter is Nursing Care of the Mother and Infant During Labor and Birth.

Right.

And our mission today is pretty straightforward.

We are going to walk through this chapter chronologically.

We aren't skipping around.

We are going to try to translate those, you know, those dry textbook concepts into a clear audio friendly guide for the intrapartum period.

And just so everyone is on the same page right from the jump, intrapartum specifically refers to the time during labor and birth.

Okay.

Not the pregnancy before and not the recovery weeks after, just the main event.

Right.

So before we get into the nitty gritty of contractions and dilation and all that, let's set the stage.

The text opens by making a really strong claim that obstetrical nursing is unique compared to every other discipline in healthcare.

How so?

Well, just think about a standard hospital floor for a second.

In almost every field,

cardiac, orthopedics, oncology, you have one primary patient in the bed.

One person.

You treat that one patient.

In labor and birth, you have two patients simultaneously.

You have the mother and you have the fetus.

And here is the kicker.

Their needs are, you know, they're intertwined, but they are distinct.

That adds a layer of complexity right off the bat.

Oh, it does.

Every single intervention you do for the mom affects the baby and vice versa.

Like what?

Well, if you give mom medication for pain, it crosses the placenta.

If you position mom on her back, it changes blood flow to the baby.

It's a symbiotic high wire act.

And the text mentions that because of this, it requires a

massive interdisciplinary skill set.

It really is the decathlon of nursing.

I mean, you need the technical high acuity skills of an ICU or med -cert nurse because things can go wrong and they can go wrong, fast bleeding, blood pressure issues.

Then you need the developmental knowledge of a pediatric nurse because the second that baby is out,

you are doing newborn care instantly.

And perhaps most importantly, you need incredible psychosocial communication skills because emotions are running higher than anywhere else in the hospital.

You are dealing with pain, fear, joy, and family dynamics all at once.

Speaking of those psychosocial skills and dynamics, the text spends a significant amount of time on cultural competence right at the start.

It really emphasizes that we cannot make assumptions about behavior.

That is such a crucial point for anyone entering this field.

You just can't view the labor room through your own cultural lens.

The text gives a really specific common example regarding the role of the father or partner.

Right.

The scenario where a nurse might walk into the waiting room and see a father just sitting there while the mother is in labor down the hall.

Exactly.

And the knee -jerk reaction, especially in a Western context where we expect the partner to be holding the hand and coaching the breathing,

might be to judge him, to assume he's disinterested or unsupportive or checking out.

But the text warns us against that.

It does.

Because in some cultures, it is strictly forbidden for the father to attend the birth.

It's seen as women's business.

So it's a norm, not a choice about his feelings.

It's a cultural norm, not a lack of love.

If we judge that behavior through our own cultural lens, we damage the therapeutic relationship immediately.

We have to ask, not assume.

We have to understand their plan and their values.

Now, there is also a very specific and quite heavy section in this chapter regarding female genital mutilation or FGM.

It's a tough topic, but the text is very clear on the nurse's responsibility here.

Yes.

And this is something Canadian nurses absolutely need to be aware of, given that we serve such a diverse global population.

FGM involves the removal of parts of the female genitalia or, in some cases, the stitching of the labia.

And the text is clear on its steps.

Very clear.

It states, this is recognized internationally as a human rights violation and a harmful practice.

There is no ambiguity there at all.

But the nurse's role in the delivery room isn't to be a judge or a lawyer.

Correct.

When a woman presents in labor who has undergone FGM,

our role is medical care and dignity.

It is not the moment for judgment or stigmatization.

The text outlines specific medical implications we need to be ready for.

So what are those implications?

I mean, how does it actually change the birth?

They are significant.

The scar tissue from FGM can be very, very rigid.

Normal tissue stretches to let the baby pass.

Scar tissue does not.

So it's like a barrier.

It's a barrier.

This puts a woman at a high risk for obstructed labor, where the baby simply cannot get out and severe lacerations are tearing.

And there is a critical nursing note in the text here regarding what happens if that tissue tears or has to be cut.

Yes.

If a woman has been infibulated, that's where the opening has been narrowed by stitching and it has to be cut, or it tears during birth to let the baby out.

Yeah.

We do not resusher it back to its previous state.

Because that would just be perpetuating the harm.

Precisely.

The text says clearly.

Repairing the previous infibulation is declined on medical grounds.

Repetitive cutting and suturing causes massive scar tissue.

It can lead to painful intercourse, chronic infections, and voiding difficulties.

So what's the goal then?

The focus is on repairing the birth trauma, ensuring pain relief, which you will likely need more of, and maintaining her dignity.

It's about leaving her in a safe functional state, not restoring a harmful one.

That is a really, really important distinction for students to memorize.

The text also moves into caring for LGBTQ2 patients.

I found the language here really progressive for a standard textbook.

It talks about how the anatomy doesn't always match the gender identity.

Yeah.

It's all about establishing safety.

For example, the text discusses the scenario of a trans man giving birth.

Okay.

So this is someone who is assigned female at birth but identifies as a man.

He might still have reproductive organs and become pregnant, but that doesn't mean he identifies with the term mother.

That seems like a small semantic thing, but I imagine it's huge for the patient.

It's huge.

The text suggests using terms like chest feeding instead of breastfeeding, if that's what the patient prefers.

It's all about mirroring the patient's language.

So just asking,

what would you like to be called?

Exactly.

He might want to be called dad or parent.

And you have to think physically for a trans man.

He likely had to stop taking testosterone to carry this pregnancy.

Oh, that would be incredibly difficult.

Incredibly distressing.

Feminine characteristics might return during the pregnancy.

The text notes they might worry deeply about losing their gender identity.

The nurse needs to be that anchor of support, respecting his identity, even when the biological process seems to contradict it.

It comes back to that therapeutic relationship.

If the patient doesn't feel safe, the labor won't go well.

That's the bottom line.

Okay, let's move from the who to the where.

The physical setting.

The text outlines three main settings.

Hospitals, freestanding birth centers, and home.

Hospitals are still the most common setting in Canada.

But even there, the architecture has changed to match the philosophy of care.

How so?

Well, we used to move women around like an assembly line labor in one room, deliver in a cold operating theater, recover in another.

That sounds exhausting.

And stressful.

It was incredibly disruptive.

Now we see LBR rooms, labor, birth, recovery, or even LBRP rooms where you stay for the postpartum period too.

It's all designed to be more home -like, but with high -tech backup, hidden away in the cupboards.

Then you have birth centers, which are usually midwife -led.

Right.

These are for low -risk women.

It's a middle ground.

It's home -like, usually no epidurals available, but it's separate from the hospital environment.

It really emphasizes a natural approach.

And then home birth.

I feel like this is always a huge debate in the media, but the text actually cites a specific study here to settle the safety question.

It does.

The Hutton et al.

study.

This is a key piece of evidence for Canadian practice.

It showed that for low -risk women,

home births attended by midwives in an integrated system.

What does integrated system mean?

It means they can easily transfer to a hospital if things go wrong.

There's a clear pathway.

In that context, home births have safety outcomes similar to hospital births.

So no increase in mortality or severe outcomes for the baby or mom.

Correct.

But, and this is the really interesting part, they have significantly fewer intrapartum interventions.

Like what?

Less oxytocin, fewer tears, fewer C -sections.

So for the right candidate, it's a very valid and safe option.

That is a key takeaway.

The environment really dictates the level of intervention.

Absolutely.

Okay, let's get into the mechanics.

The text structures the entire physiological process around a framework called the five P's.

The five P's, yes.

If you're a nursing student, tattoo this on your brain, you will use it every single day.

It's the checklist for why labor is or isn't progressing.

Okay, what are they?

They are.

The powers, the passage, the passenger, maternal position, and the psyche.

I love a good framework.

It makes it so much easier to organize the information.

Let's start with the first P, the powers.

This sounds like a superhero movie, but we're talking about the engine of labor, right?

We are.

In the first stage of labor, the power is the uterine contraction.

This is involuntary smooth muscle.

The mom can't control it, she can't start it, and she can't stop it.

It's just the uterus waking up and doing its job.

The text has this great visual of the contraction cycle.

It looks like a bell curve.

It does.

And understanding that shape is key to assessing it.

You have three phases in that curve.

First, the increment, that's the hill going up, second,

the peak, or the acme, that's the top, the hardest part of the squeeze, and third, the decrement, the relaxation as it goes down the other side.

But then, crucially, you have the resting interval, the flat line between the bumps.

That rest period is so important.

It's not just for the mom to catch her breath, though that's part of it.

It's vital for the baby.

Why?

Think of the uterus as a massive muscle squeezing a sponge.

When it squeezes during a contraction, blood flow to the placenta stops, completely.

Wow.

So the baby is essentially holding its breath.

The rest period is when the placenta refills with oxygenated blood.

That puts it in perspective if the uterus never relaxes.

The blood flow and the oxygen never returns.

That's why we obsess over that resting tone.

So how do nurses measure these powers?

Because you can't just ask how much does it hurt,

right?

No, that's too subjective.

We use three specific technical terms,

frequency, duration, and intensity.

Okay, let's break those down.

Frequency.

Frequency is measured from the start of one contraction to the start of the next.

Start to start, not the gap in between.

Correct.

A lot of people confuse that.

If a contraction starts at 10 .00 and the next starts at 10 .05, the frequency is five minutes.

Got it.

And duration.

Duration is how long the tightening itself lasts, measured in seconds.

Usually somewhere between 45 to 90 seconds.

And intensity.

This one seems tricky because unless you have an internal monitor, you can't see a number for intensity.

Right.

So if you are using your hands palpating, you use the nose, chin, forehead trick.

Walk us through that.

Okay.

So you put your hand on the fundus, the top of the uterus.

During the peak of a contraction,

if it feels soft like the tip of your nose, you can push it in easily.

Yeah.

That's a mild contraction.

Okay.

Nose is mild.

If it's firmer like your chin, there's a bit of give, but it's mostly hard.

That's moderate.

Chin is moderate.

And if it's hard like your forehead and you can't indent it at all, it's like a rock.

That's a strong contraction.

That is so practical.

Love those bedside tricks.

Now there is a massive safety alert in this section regarding something called tachycystally.

Yes.

This is a major red flag.

Tachycystal means fast uterus.

It means the uterus is working too hard.

It's hyper stimulated.

What are the numbers for that?

When do we worry?

If contractions are coming more often than every two minutes, or if they're lasting longer than 90 seconds, or, and this is the big one, if that resting time between them is less than 60 seconds.

Because as you said, no rest means no oxygen.

Exactly.

If you seek tachycystally, the fetus can become hypoxic.

You have to intervene immediately to slow things down.

But you do.

Turn off the oxytocin if it's running, turn the mom to her side, maybe give medication to relax the uterus.

It's a top safety priority.

And the whole point of these powers, these contractions, is to change the cervix.

The text uses an analogy of pushing a ball out of a balloon.

Yeah.

It's a great way to explain effacement and dilation.

Imagine a ping pong ball inside the neck of a deflated balloon.

Yeah.

The neck is long and thick.

Right.

As you push the ball down, the neck of the balloon gets shorter and thinner.

That's effacement.

We measure it in percentage.

From 0 to 100 % effaced, or paper thin.

And dilation.

Eventually the neck disappears completely into the balloon.

Then the hole itself opens up.

That's dilation, measured from 0 to 10 cm.

You need both to get the baby out.

And once we hit 10 cm, the powers change, right?

We enter the second stage of labor.

Yes.

Now the powers are combined.

You still have the involuntary uterine contractions, but now you add the voluntary maternal pushing.

The mom adds her abdominal strength to the uterus to physically push the baby out.

Becomes a team effort between the mom and her uterus.

Okay.

That's the first P.

Let's move to the second and third, which kind of go together.

The passage and the passenger.

So the passage is the mom's pelvis.

Right.

And it's not just a simple tunnel.

It's a bony cage.

The text distinguishes between the false pelvis at the top, which just supports the weight of the pregnant uterus.

It's like a big funnel.

Okay.

And the true pelvis at the bottom.

That's the tight squeeze the baby has to navigate.

It has an inlet, a mid pelvis, and an outlet.

And unfortunately, not all pelvises are created equal.

The text talks about different shapes.

No.

Genetics plays a big role here.

There were four classic shapes.

First is gynochoid.

This is the classic female shape.

It's round, roomy, and has blunt ischial spines.

It is the absolute best for birth because it matches the shape of the fetal head.

So gynochoid is ideal.

Then you have android.

Android is heart -shaped.

This is more typical of male anatomy.

It's narrower and that heart shape at the inlet forces the baby's head into tight corners.

The baby has a much, much harder time fitting through.

Then there are the, uh, the weirder ones.

Right.

You have anthropoid, which is an oval shape, like an egg standing on its end.

It's narrow side to side, but deep front to back.

What does that mean for the baby?

Babies often come out sunny side up or facing the mom's front in this one,

in an occiput posterior position because there's more room that way.

And finally, platypilloid, which is flat and wide.

This is the rarest and generally very difficult for a vaginal birth because the baby just can't get past the inlet.

So the passage provides the constraints.

The passenger is the fetus.

And the text goes into a lot of detail about the fetal head.

It's not just a solid bowling ball.

No, thank goodness.

If it were, birth would be impossible.

The skull bones are not fused yet.

They have sutures, which are flexible joints, and fontanels, the soft spots between them.

This allows for something called molding.

That's where the plates literally slide over each other to make the head smaller.

Right.

We've all seen those conehead babies.

Exactly.

It looks a little weird at first, but it's a brilliant survival mechanism.

The head changes shape to fit the tunnel.

It usually resolves in a day or two.

And nurses can use those soft spots to figure out which way the baby is facing inside.

Yes.

During a vaginal exam,

the anterior fontanel, the one on top, is diamond -shaped.

The posterior one, at the back, is a tiny triangle.

So if you feel a little triangle...

You know, you're feeling the back of the head.

Yeah.

If you feel the big diamond, you're feeling the front of the head, which means the baby might be in a less ideal position.

That leads us to presentation and position.

This is like a secret code language in obstetrics.

L -O -A -R -O -P -L -S -A.

Let's decode this because students often get mixed up here.

It is a GPS coordinate system for the baby.

But before you get to the three -letter code, you have to know two other things.

Lie and presentation.

Okay.

What's a lie?

Lie is simple.

Is the baby's spine parallel to the mom's spine?

That's longitudinal.

Or is it sideways?

Perpendicular.

That's transverse.

And a transverse lie is a problem.

It's a C -section.

You cannot push a baby out sideways.

So we want longitudinal, then presentation.

What body part is leading the way?

Exactly.

Cephalic means head first, which is what we want.

Vertex is the best version of that chin tucked to chest, presenting the smallest part of the head.

But you can have breech bottom or feet first.

The text mentions frank breech, full breech, footling breech.

It sounds like dance moves.

It does.

Frank is legs straight up by the ears, like a V.

Full is cross -legged, like a little Buddha.

Footling is one or two feet dangling down.

Generally, breech leads to a C -section, although the text does note that selected vaginal breech births can be safe if the provider is highly skilled.

But for most students, you should think breech surgical consult.

Okay.

Now the three -letter code, like LOA or ROP, I remember seeing this on charts.

What does it actually mean?

It describes the exact rotation of the head.

Let's bring it down to three questions.

Go for it.

Question one for the first letter.

Is the landmark on the baby's body pointing to the mom's left L or her right R?

Oxford right.

Got it.

Question two for the second letter.

What is that landmark?

Usually it's O for occiput, the back of the fetal head, but it could be S for sacrum if the baby is breech.

Okay.

O for occiput.

And question three for the last letter.

Is that landmark pointing towards the mom's front, which is anterior A, her back, which is posterior P, or to the side, transverse T?

Okay.

So let's test this.

If a nurse says the baby is LOA.

Left occiput anterior.

So the back of the baby's head, the occiput, is on the mom's left side and it's facing her front anterior.

This is the gold standard.

It's the smoothest, easiest position for birth.

The baby dives under the pubic bone perfectly.

And what about the dreaded ROP?

Occiput posterior.

So the baby is on the right side, but the back of its hard head, the occiput, is grinding against the mother's spine, her sacrum.

That sounds incredibly painful.

It is.

This is the cause of back labor, that intense continuous pain in the lower back that doesn't go away between contractions.

And it takes longer because the baby has to rotate much further, almost 135 degrees to get out.

That connects perfectly to the fourth P, maternal position.

Because if you have an OP baby causing back labor, sitting on your back in bed is probably the worst thing you can do.

100%.

Gravity is the unsung hero of labor.

Upright positions, walking, squatting, kneeling, being on hands and knees, all help the baby descend and rotate into a better position.

And the text is very firm on this.

The supine position, flat on your back, is generally bad.

It is.

It's not just about comfort.

It causes physiological problems.

The heavy uterus compresses the aorta and the vena cava, the big blood vessels in your back.

And that leads to what?

It causes hypotension in the mom, which makes her feel dizzy and sick.

And more importantly, it reduces blood flow and oxygen to the baby.

It's called supine hypotension.

So we want mom upright, side lying, or on hands and knees to take that pressure off.

And finally, the fifth P, the psyche.

This isn't just stay positive, toxic positivity.

There's actual physiology here.

There is.

It's the fear, tension, pain cycle.

If a woman is terrified, her body releases catecholamines, stress hormones like adrenaline and cortisol.

The fight or flight hormones.

Exactly.

And what do those hormones do to the uterus?

They fight it.

They fight it.

They inhibit uterine contractions and divert blood flow away from the uterus to the skeletal muscles.

It's the body saying, it is not safe to give birth right now.

There's a tiger nearby.

So being scared literally makes labor longer and harder.

Yes.

The nurse's role isn't just hand holding.

It's protecting the physiological process by reducing fear.

If the mom feels safe and supported, she releases oxytocin, which helps labor progress.

It's a chemical game as much as it is a mechanical one.

Let's fast forward a bit in our timeline.

A woman is at home.

She thinks, is this it?

The text lists a bunch of signs of impending labor.

How does she know?

Okay.

There's a checklist of what we call promontory signs.

First, Blackstone Hicks.

Those practice contractions.

They might get regular for a bit, but they don't get stronger or longer or closer together, and they don't change the cervix.

Okay.

Practice contractions.

Second, lightning, where the baby drops down into the pelvis.

Suddenly, mom can breathe again because the baby is off her lungs.

A relief.

But now she has to pee constantly because the baby's head is sitting on her bladder.

Third, the text mentions a sudden burst of energy.

The nesting urge, yes.

She might suddenly decide to scrub all the floors or organize the entire nursery at three in the morning.

It's a classic sign.

And the bloody show.

Which sounds like a horror movie title, I know, but it's just the mucus plug coming loose.

It seals the cervix during pregnancy.

As the cervix starts to soften and open a little, that plug falls out, and it's usually streaked with a bit of pink or brown blood.

It means things are happening.

And then the big one, rupture of membranes, ROM, the water breaking.

Which is an immediate reason to get assessed by your provider.

The text warns about infection risk if the water is broken for too long.

Usually, we want the baby out within 24 hours.

And there's another risk, right?

Yes, the risk of cord compression or prolapse.

If the baby's head isn't engaged in the pelvis yet, the umbilical cord can slip out before the baby when the water gushes.

That's a major emergency.

So if the water breaks, you go in.

So labor starts.

The baby has to navigate that pelvic obstacle course we talked about.

The text outlines the mechanisms of labor or cardinal movements.

It's a specific dance sequence the baby has to do.

Can you walk us through the steps?

Sure.

It helps to visualize the baby acting like a diver or a corkscrew, trying to find the path of least resistance.

Step one is descent.

The baby moves down through the pelvis.

We measure this by station.

Station zero is at the level of the ischial spines.

That's the narrowest part of the pelvis.

Minus numbers are high up.

Plus numbers are low.

So plus four on the floor means the baby is about to be born.

Exactly.

Step two is engagement.

The head has officially passed the pelvic inlet.

Step three is flexion.

This is so key.

The baby tucks its chin to its chest.

This presents the smallest possible diameter of the head to the birth canal.

If the head is extended, it gets stuck.

Okay, so chin down.

Then what?

Step four is internal rotation.

The head hits the pelvic floor, which is shaped kind of like a gutter.

It forces the baby to twist so the face is looking at the mom's spine.

The head has to be vertical to get under the pubic bone.

It's like a key in a lock.

Perfect analogy.

Step five is expansion.

The head pivots under the pubic bone and lifts up.

The chin lifts off the chest and the head is born.

The face sweeps across the perineum.

Amazing.

Step six is restitution and external rotation.

The head is out, but the shoulders are still twisted inside.

So the head turns back to the side to align with the shoulders.

Looks like the baby is looking at the nurse's thigh.

And the final step.

Step seven is expulsion.

The anterior shoulder slips out under the pubic bone and the posterior shoulder, and the rest of the body just slides out easily.

It's incredible that it happens automatically.

The baby knows the moves.

But how does a woman know it's true labor versus just pre -labor?

The text has a table for this.

Yes.

And the definitive difference, the only one that really matters clinically is cervical change.

If the cervix isn't opening and thinning, it's not true labor.

But you can't check your own cervix at home easily.

Right.

So the test you can do at home is activity.

What should she do?

Walk.

In pre -labor, or false labor, walking often makes the contractions stop or get milder.

It distracts the uterus.

In true labor, walking makes them stronger and more regular.

Gravity intensifies it.

What about the pain?

True labor pain usually starts in the back and wraps around to the front like a big belt.

Pre -labor is often just felt in the groin or lower abdomen.

So she comes to the hospital.

Admission time.

What are the key assessments?

What's the first thing a nurse does?

We triage quickly.

First, listen to the baby.

Fetal heart rate.

Is the baby okay?

That's priority one.

Second, check the mom's vital signs.

Is she stable?

And third, check nearness to birth.

Is the baby coming right now?

Do I need to get gloves and catch or do we have time?

And to check the baby's position from the outside, we use our hands.

The Leopold maneuver.

This is a four -step process of palpating the abdomen systematically to map out the baby.

That's where we'll put the heart rate monitor for the best signal.

Where is the head?

Is the baby breached?

It saves us from hunting for the heartbeat.

And labs.

What are we looking for?

A standard panel.

Urine for protein to check for preeclampsia and for sugar.

Blood for a type and screen in case she bleeds and needs a transfusion.

And we check her GBS group B strep status.

What is GBS?

It's a type of bacteria that lives naturally in many women's vaginas.

It's harmless to the mom, but it can be deadly to a newborn if they inhale it during birth.

It can cause sepsis or pneumonia.

So what do you do?

If she's GBS positive, she needs IV antibiotics, usually penicillin, at least four hours before birth to protect the baby.

Now let's talk about monitoring the baby during labor.

This is a huge part of the nurse's job.

Fetal health surveillance.

Two main ways to do it.

Intermittent auscultation, or IA, and continuous electronic fetal monitoring,

or EFM.

The text emphasizes that for healthy, low -risk women,

IA is actually preferred.

IA is just listening with a handheld Doppler.

Yes, listening every 15 to 30 minutes in active labor.

Why would that be better?

Wouldn't seeing the monitor all the time be safer?

Not necessarily for a low -risk person.

IA allows the mom to walk around, get in the shower, and use all those gravity -friendly positions we talked about.

Being tethered to an EFM machine often keeps her in bed, which can slow labor down.

But EFM is necessary for high -risk situations.

Absolutely.

Or whenever we are using oxytocin to induce or augment labor, because oxytocin can stress the baby, so we need to watch it constantly.

When we look at that EFM strip, the paper coming out of the machine, we are looking for a few specific things.

The text breaks down the patterns really well.

Right.

It's like reading the baby's nervous system.

Yeah.

First, you look at the baseline.

What's the average heart rate?

It should be between 110 and 160 beats per minute.

Okay, 110 to 160.

Second, you look at variability.

That's the jag, and that's the line.

We want to see moderate variability changes of 6 to 25 beats per minute from the baseline.

That creates a sawtooth pattern.

What does that mean?

It means the baby's central nervous system is awake, happy, and well oxygenated.

A flat line or minimal variability is a bad sign.

And then the decelerations when the heart rate drops.

These are the stress tests.

Students memorize the mnemonic VLAL CHOP.

Let's break that down.

Okay.

VLAL CHEEP.

It's a lifesaver.

V goes with C.

Variable decels are caused by cord compression.

What does a variable look like on the strip?

A sharp V shape,

an immediate abrupt drop, and immediate abrupt return.

It doesn't have a consistent relationship with the contraction.

And what do you do?

You move the mom.

If she turns over to a different side or gets on her hands and knees, the baby usually rolls off the cord and the decel goes away.

Okay, next.

E goes with H.

Early decels are caused by head compression.

What does it look like?

A shallow U shape that mirrors the contraction perfectly.

The contraction starts.

The heart rate dips gradually.

The contraction ends.

The heart rate returns to baseline.

And what does that mean?

Is it bad?

No.

It's benign.

It just means the baby's head is being squeezed in the birth canal as it comes down.

It stimulates the vagus nerve.

It's actually a sign of progress.

You don't do anything but document it.

Okay, then A goes with O.

Accelerations are...

okay.

An acceleration is when the heart rate goes up by 15 beats for 15 seconds.

It's a sign of a well -oxygenated fetus.

We love to see accelerations.

And the bad one.

L goes with P.

Late decels are caused by placental insufficiency.

What does it look like?

This is subtle but critical.

The heart rate drops after the contraction peaks and it takes a long time to recover.

The whole deceleration is shifted to the right of the contraction.

And what does that mean?

It means the placenta isn't giving the baby enough oxygen during the contraction.

The baby is running out of reserve.

This is the most ominous pattern.

And the text gives a list of interventions for late decels.

This is a drill nurses practice constantly.

It's called intrauterine resuscitation.

You are trying to revive the fetus while it's still inside.

What are the steps?

First, you reposition the mom, usually to her left side, to get pressure off those big vessels.

Second, you give her oxygen via a face mask to supersaturate her blood.

Third, you give her a bolus of IV fluids wide open to boost blood volume and flow to the placenta.

And fourth, if oxytocin is running, you stop it immediately.

And if that doesn't work...

If the lates continue, you're looking at an urgent or emergency c -section.

We also check the amniotic fluid.

It should be clear, like water.

Right.

If it's green or brownish, that's meconium.

The baby has passed its first stool inside.

It can be a sign of long -term stress or post -maturity.

We worry about the baby inhaling that thick tar into their lungs at birth, which is called meconium aspiration syndrome.

And if it smells bad...

That's a sign of an infection, like coreaminitis.

And if we aren't sure if the water actually broke, maybe she just peed a little.

We use nitrosine paper.

The litmus test.

Literally.

If it turns blue, it's amniotic fluid, because fluid is alkaline.

Urine is acidic, so the paper would stay yellow or green.

Moving on to the actual stages of labor.

Section six of our outline, stage one, is from zero to ten centimeters, but it's divided into latent and active phases.

Yes.

The latent phase is from zero to three centimeters.

This is the excited phase.

Mom is usually chatty, happy, maybe a bit nervous.

She can walk, talk, and follow instructions easily.

This is the best time for education and hydration.

She's calling her friends and posting on social media.

And then it shifts.

The active phase, which detects groups from four to ten centimeters, is a totally different world.

The mood shifts drastically.

She becomes introverted, focused.

She might not answer questions.

The pain increases significantly.

The jokes stop.

There's a safety alert in the book here about behavior changes.

Yes.

If a woman suddenly gets really irritable, starts shaking, maybe vomits, or says things like, I can't do this anymore, or I need to go home, that is usually the sign she is in transition.

And transition is what?

It's the tail end to the first stage, roughly from eight to ten centimeters.

It's the hardest part.

She's almost there.

Don't argue with her.

Don't try to reason.

Just support her.

That loss of control is physiological.

It means the baby is coming soon.

Then we hit ten centimeters.

Second stage.

Pushing time.

The text discourages Valsalva.

Pushing.

That's where you hold your breath and bear down.

Turning purple.

Why is that bad?

It reduces oxygen to the baby.

It recommends open glottis, pushing, exhaling, or grunting while pushing.

It's better for oxygenation and for the health of the pelvic floor.

And there's a concept mention called laboring down.

This is great for moms with an epidural.

If she is ten centimeters but has no urge to push because she's dumb, don't force her.

Let her rest for an hour or two.

Let the uterus bring the baby down naturally until the head is visible.

It saves her a ton of energy.

Then comes crowning the ring of fire and potentially the episiotomy.

Or a laceration.

An episiotomy is a surgical cut to widen the opening.

It used to be routine but it's not anymore.

The evidence shows we get better outcomes by letting the tissue stretch and tear naturally if it's going to.

And if it tears, we grate it.

Right.

A first degree is just the skin.

A second degree goes into the muscle.

A third degree tear goes into the anal sphincter.

And a fourth degree goes all the way through the rectum into the mucosa.

The nursing focus here is anticipating pain.

Having the right supplies ready for the provider to repair it and maintaining a clean field to prevent infection.

Baby is out.

But we aren't done.

Third stage.

Delivery of the placenta.

And you don't pull on the cord.

You wait for signs of separation.

The cord suddenly lengthens.

The fundus rises up in the abdomen and you see a gush of blood.

And it comes out in two different ways and nurses love these names.

Yes.

The mechanisms.

You can have the Schultz mechanism where the shiny fetal side with the membranes comes out first.

The mnemonic is shiny Schultz.

And the other one.

The Duncan mechanism.

Where the rough red maternal side comes out first.

The mnemonic for that is dirty Duncan.

Dirty Duncan and shiny Schultz.

It sounds like a comedy duo.

It's a classic nursing mnemonic.

You'll never forget it.

And on the fourth stage.

The first one to two hours of recovery.

The book frames this as a critical observation period.

Arguably the most dangerous time for the mother.

The risk of postpartum hemorrhage is highest right here.

The uterus is tired.

It wants to relax.

If it relaxes the placental site can bleed like an open wound.

So what are you checking?

We check vital signs for shock.

A high pulse and a low blood pressure are late ominous signs.

Most importantly we check the fundus.

It must be firm and midline.

What does that mean firm?

It should feel like a hard grapefruit right under her belly button.

If it's boggy or squishy it means it's filling with blood.

We have to massage it aggressively until it firms up.

It's painful for her but it's life -saving.

What if it's pushed to the side?

If the fundus is firm but displaced to the side, usually to her right, it means her bladder is full.

A full bladder acts like a wedge.

It stops the uterus from clamping down effectively.

So we have to get her to pee or catheterize her to prevent or stop the bleeding.

And we check the lochia, the bleeding.

Right.

The first type is called rubra.

It's dark red blood.

It should not be more than one pad an hour.

If you're soaking a pad in 15 minutes that is a hemorrhage.

You need to call for help immediately.

Finally, let's look at the new little patient.

Care of the newborn.

The priority is the golden hour.

Skin -to -skin contact on the mom's chest immediately after birth.

This isn't just for bonding or vibes.

It's critical physiology.

What does it do?

It regulates the baby's heart rate.

It stabilizes their breathing.

And crucially, it maintains their temperature.

Thermo regulation is huge.

It is the number one priority after breathing.

Babies lose heat incredibly fast.

They are wet and have a large surface area.

If they get cold stress, they burn through all their glucose to stay warm, leading to hypoglycemia or low blood sugar.

And that causes more problems.

Yes, it's a domino effect.

Hypoglycemia leads to respiratory distress.

So you dry the baby immediately, especially the head.

You put a hat on, you keep them on, mom.

Warmth equals oxygen for a newborn.

What about the cord?

Delayed cord clamping is the standard of care in Canada now for one to three minutes.

It gives the baby a huge boost of iron -rich blood from the placenta, which can prevent anemia for months.

And the Apgar score.

This is the first test a human takes.

Yep, done at one minute and five minutes of life.

It scores five things.

Heart rate, respiratory effort, muscle tone, reflex irritability, and color.

Each gets a zero, one, or two.

And what's a good score?

A score of eight to ten is great.

Four to seven means the baby needs some stimulation, rub their back, maybe give some blow by oxygen.

Less than three means they need full resuscitation.

The text notes something about their color.

Yes.

Most babies lose a point on color because of acrocynosis blue hands and feet.

That's perfectly normal in the first 24 hours as their circulation adapts.

Don't panic about blue hands and feet.

Last thing, meds.

We put goop in their eyes.

Erythromycin eye ointment.

It's to prevent blindness from gonorrhea or chlamydia that could have been passed during birth.

It's a condition called ophthalmia neonaturum.

And the book mentions a legal nuance here.

Right.

It notes that in Ontario, parents can opt out.

The Canadian Pediatric Society actually questions the evidence for mandatory universal use, given how effective STI screening is now.

But it is still standard practice in most places to give it within two hours of birth.

And vitamin K.

An injection into the thigh, the vastus lateralis muscle, to prevent a rare but serious bleeding disorder.

Newborns can't clot blood well yet because their gut is sterile, so they don't make their own vitamin K yet.

This shot buys them time until their gut bacteria kick in and start producing it.

We have unpacked a massive amount of information.

From that unique two -patient dynamic to the five P's, the mechanisms of the cardinal movements, reading the EFM strips, and that precious golden hour.

It's a journey from pure physiology to family dynamics.

To wrap up, I want to highlight a quote from the intro of this chapter that really stuck with me.

It says that families remember the details of this experience for a long, long time.

Absolutely.

In medicine, we often focus on the outcome.

Healthy mom, healthy baby.

And that is priority number one, always.

But the experience matters too.

Did they feel safe?

Did they feel heard?

Did they feel respected?

And that's the nurse's domain.

That's the art of nursing.

A nurse can't always control the labor path.

Complications happen.

C -sections happen.

But a nurse can control the support.

That presence, that hand on the shoulder during a tough contraction, that calm voice during a scary deceleration explaining what is happening.

That is what the family remembers 20 years later.

That is the art of nursing.

Thank you so much for listening to this last minute lecture on the Dean Dive.

Good luck with your studies and go be that supportive presence.

See you next time.