Labor & Delivery Study Guide

The first stage is from the onset of regular uterine contractions to full effacement and dilation of the cervix. It is much longer than the second and third stages combined. Parity is a strong factor in the length of the first stage. Full dilation may occur in less than 1 hour in a woman who has had a lot of pregnancies. In first time mothers, it can take 20 hours or more. Variations can also occur in different client populations. There are three different phases of the first stage of labor.

They include the latent phase, active phase, and a transition phase. The latent phase includes progress in effacement of the cervix and a little increase in descent. The active phase and transition phase includes rapid dilation of the cervix and increased rate of descent of the presenting part. When a woman is obese prior to pregnancy, the active phase of labor can be longer. Nursing interventions would be to assist the woman with breathing exercises, reassure her, emphasize positive aspects of the situation, provide continuous emotional support, and respect contraction time. Some other interventions include respecting her activities, her pain management efforts, respect her contraction time, and promote change of position, and voiding and bladder care.

The second stage of labor lasts from the time the cervix is fully effaced and dilated to the birth of the fetus. It usually takes anywhere from 20 minutes to 50 minutes. Labor of up to 2 hours can be considered normal, and ethnicity plays a role in that. It is composed of two phases: the latent phase and the active pushing (descent) phase. During the latent phase, the fetus continues to descend passively through the birth canal and rotate to an anterior position as a result of uterine contractions. Some women do not experience the urge to bear down during this phase. The next phase is the active pushing phase and they do have the urge to bear down. Nursing interventions for the second stage would be to assess and record the temperature, pulse, respirations, FHR, and contractions, provide support, prepare the place of birth, turn on the radiant heat warmer, begin the sterile field, position the woman into the stirrups, place legs in lithotomy position, and promote effective second stage pushing. Also, the nurse may do perineal cleansing, aspirate the newborns nose and mouth, cut the cord, place the infant in the warmer, and apply prophylactic eye ointment. She may also cover the infants head and allow the mother the breastfeed if she wishes.

The third stage of labor lasts from the birth of the fetus until the placenta is delivered. It normally separates with the third or fourth strong uterine contraction after the birth of the baby. After separation, it can be delivered with the next contraction. It’s usually expelled within 15 minutes. This stage usually lasts 30 minutes, but the longer the stage, the greater the risk of hemorrhage. Nursing interventions are to inspect the placenta, obtain a baseline blood pressure, document the administration of oxytocics, perform perineal stitching, and obtain vitals every 15 minutes.

The fourth stage lasts 1-2 hours after delivery of the placenta. It is the recovery period and homeostasis is reestablished. It’s an important period to observe for complications such as abnormal bleeding. Nursing interventions would be to continue the vitals, perform more perineal care, offer a clean gown and warm blanket, and palpate the fundus for size, consistency, and position.

2. List the cardinal movements (mechanisms) of normal labor and delivery and define each of the cardinal movements (12.5)

The cardinal movements of normal labor and delivery include: engagement, descent, and flexion, internal rotation to occipitoanterior position, extension, external rotation beginning restitution, and external rotation. Engagement is when the biparietal diameter of the head passes the pelvic inlet. This usually occurs before the onset of active labor. Asynclitism occurs sometimes during engagement. It is when the head is deflected anteriorly or posteriorly in the pelvis. Descent refers to the progress of the presenting part through the pelvis. It depends on four different forces. They include pressure exerted by the amniotic fluid, direct pressure exerted by the contracting fundus on the fetus, force of the contraction of the stage of labor, and extension and straightening of the fetal body. The degree is measured by the station of the presenting part. It accelerates during the active phase when the cervix has dilated to 4-7 centimeters. In first time pregnancies, descent is usually slow but steady, but in subsequent pregnancies, it is faster.

Flexion is when the descending head meets resistance from the cervix, pelvic wall, or pelvic floor. It normally flexes, so that the chin is brought into closer contact with the fetal wall. It permits the smaller diameter rather than larger diameters.

Internal rotation is when the maternal pelvic inlet is widest in the transverse diameter, so that the fetal head passes the inlet into the true pelvis in the occipitotransverse position. The outlet is wide for the fetus to exit, and the head must rotate. It begins at the level of the iscial spines, but isn’t completed until it reaches the lower pelvis. The face also rotates posteriorly, and is guided by each contraction.

Extension is when the fetal head reaches the perineum for birth and it is deflected anteriorly by the perineum. It occiput goes under the lower border of the symphysis pubus and then the head emerges. First the occiput, then the face, and finally the chin emerges from the perineum.

Restitution is when the head rotates briefly to the position it occupied while it was in the inlet. It’s usually a 45 degree turn and it realigns the infant’s head with her or his back and shoulders. The external rotation occurs as the shoulders engage and descend in the same way that the head did. The shoulders descend first and then they rotate to the midline and deliver from under the pubic arch.

Lastly, expulsion is when the head and shoulders are lifted up toward the mother’s pubic bone and the trunk of the baby is born by flexing it laterally in the direction of the pubis. When the baby has emerged, the second stage of labor is finished.

3. Identify the following terms relating to fetal monitoring and provide nursing interventions for the terms early, variable, and late decelerations.

a. Frequency (Contractions) (1.5)
How often the uterine contractions occur; the time that elapses from the beginning of one contraction to the beginning of the next contraction

b. Duration (Contractions) (1.5)
The time that elapses between the onset and then end of the contraction

c. Fetal heart rate range (1)
The normal fetal heart rate usually varies somewhere between 120 and 160 beats per minute throughout pregnancy, but in the early part of the first trimester, the heart rate can be slower.

d. Beat to beat variability (1)
Variability of fetal heart rate measured in changes in the QRS-QRS interval from heart beat to heart beat. It is measured with electronic internal fetal heart rate monitors.

e. Reassuring fetal heart rate (1.5)
It is associated with fetal well-being and lack of acute distress. They include periodic accelerations, mild variable decelerations lasting less than 30 seconds, or early decelerations that mirror contractions in duration and timing.

f. Non-reassuring fetal heart rate (1.5)
They are patterns that suggest fetal compromise or a declining ability to cope with the stress of labor. The y include a significant decrease in baseline variability or baseline heart rate, progressive fetal tachycardia or bradycardia, persistent late decelerations, or recurrent late return to baseline after deceleration.

g. Early, variable, and late decelerations (4.5)

Early decelerations of the FHR are a visual apparent gradual decrease in and return to baseline FHR associated with UCs. They are thought to be caused by transient fetal head compression and are a normal and benign finding. Interventions are not necessary for early decelerations because it’s benign.

Variable deceleration of the FHR is defined as a visually abrupt decrease in FHR below the baseline. It is at least 15 beats per minute or more below the baseline, lasts at least 15 seconds, and returns to the baseline in less than 2 minutes from the time of onset. Nursing interventions include change maternal position, discontinue oxytocin, administer oxygen, notify physician, assist with vaginal examination, assist with amnioinfusion if ordered, and assist with birth if pattern cannot be corrected.

Late decelerations are a visually apparent gradual decrease in and return to baseline FHR associated with UC’s. It begins after the contraction has started, and the lowest point of the deceleration occurs after the peak of the contraction. Nursing interventions include changing the maternal position, correcting hypotension by elevating legs, increase the rate of IV solution, palpate the uterus, discontinue oxytocin if infusing, administer oxygen by nonrebreather face mask, notifying the physician, considering internal monitoring, and assisting with the birth if pattern cannot be corrected.

4. Look up the following medications used in labor & delivery. Identify indications fur use, usual dosage, desired effects, side effects, and nursing considerations. *Make sure the information pertains to labor and delivery.