LESSON 2-2
STAGES OF LABOR AND NURSING CARE

The goal of any mother and health care team is the successful, uncomplicated birth of a new infant. Your understanding of the process of labor and what it entails will allow you to provide adequate comfort measures to the patient and to assist her through this long awaited event. Although much pain or discomfort may be experienced by the mother and those concerned, labor and delivery of an infant is an eventful time after a long nine months of pregnancy.

Labor is defined as the onset of rhythmic contractions and the relaxation of the uterine smooth muscles which results in effacement or progressive thinning of the cervix, and dilation or widening of the cervix (see figure 2-1). This process culminates with the expulsion of the fetus and expulsion of the other products of conception (placenta and membranes) from the uterus.

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Figure 2-1. Stages of effacement and dilatation.

TRUE LABOR VS FALSE LABOR

Many women often experience "false labor" before "true labor" actually begins. False contractions may begin as early as three or four weeks before the termination pregnancy. Contractions, show, the cervix, and fetal movement all are vital in distinguishing between true and false labor (see Table 2-1).

Table 2-1. True verses false labor.

FACTOR

TRUE LABOR

FALSE LABOR

Contractions Produce progressive dilation and effacement of the cervix. Occur regularly and increase in frequency, duration, and intensity. Do not produce progressive dilatation and effacement. Are irregular and do not increase in frequency, duration, and intensity.
Show Is present. Not present. May have brownish discharge that may be from vaginal exam if within the last 48 hours.
Cervix Becomes effaced and dilates progressively. Usually uneffaced and closed.
Fetal Movement No significant change, even though fetus continues to move. May intensify for a short period or it may remain the same.

a. Contractions.

(1) True labor. The contractions of true labor produce progressive dilatation and enfacement of the cervix. These contractions occur regularly and increase in frequency, duration, and intensity. The discomfort of true labor contractions usually starts in the back and radiates around to the abdomen and is not relieved by walking.

(2) False labor. False labor contractions are referred to as Braxton Hicks contractions. They do not produce progressive cervical effacement and dilatation. They are irregular and do not increase in frequency, duration, and intensity. Discomfort is located chiefly in the lower abdomen and groin area. Walking often offers relief.

b. Show. This is another sign of impending labor. After the discharge of the mucous plug that has filled the cervical canal during pregnancy, the pressure of the descending presenting part of the fetus causes the minute capillaries in the cervix to rupture. This blood is mixed with mucus and therefore has a pink tinge.

(1) True labor. Show is usually present in true labor. There will be pinkish mucus or a bloody discharge. This mucus or discharge may also be from the mucous plug from the cervix.

(2) False labor. Show is not present in false labor. However, the mother may have an old, brownish discharge especially if she had a vaginal exam within the last 48 hours.

c. Cervix.

(1) True labor. In true labor, the cervix becomes effaced and dilates progressively. This change can be identified within an hour or two.

(2) False labor. In false labor, the cervix is usually un-effaced and closed. There is no change identified if the cervix is rechecked in an hour or two.

d. Fetal Movement.

(1) True labor. There is no significant change in fetal movement even though the fetal continues to move.

(2) False labor. Fetal movement may intensify for a short period or it may remain the same.

OVERVIEW OF THE LABOR PROCESS-FOUR STAGES

a. First Stage of Labor. The first stage of labor is referred to as the "dilating" stage. It is the period from the first true labor contractions to complete dilatation of the cervix (10cm) (see figure 2-2). The forces involved are uterine contractions. The first stage of labor is divided into three phases:

(1) Latent (early) or prodromal.

(2) Active or accelerated.

(3) Transient or transitional.

b. Second Stage of Labor. The second stage of labor is referred to as the "delivery or expulsive" stage. This is the period from complete dilatation of the cervix to birth of the baby. The forces involved are uterine contractions plus intra-abdominal pressure.

c. Third Stage of Labor. The third stage of labor is referred to as the "placental" stage. This is the period from birth of the baby until delivery of the placenta. The forces involved are uterine contractions and intra-abdominal pressure.

d. Fourth Stage of Labor. The fourth stage of labor is referred to as the "recovery or stabilization" stage. This period begins with the delivery of the placenta and ends when the uterus no longer tends to relax. The forces involved are uterine contractions

Figure 2-2. Cervical dilatations.

 First Stages of Labor

FIRST STAGE OF LABOR--THREE PHASES

a. Latent or Prodromal Phase (Early). In this phase, the mother feels slow, rhythmic contractions radiating from the lumbar region to the anterior portion of her abdomen. The contractions last from 30 to 45 seconds with the intensity gradually increasing. The frequency of contractions is from 5 to 20 minutes. There is some cervical effacement. Dilation is from 0 to 3 cm. "Bloody show" is usually present. The mother is usually able to walk, talk, or laugh some during this phase. Diversion is usually welcomed during this time. This phase may not be included as part of the first stage of labor since it is before the onset of true labor. True labor is considered to be at 4 cm. Duration of this phase varies, sometimes as long as 24 hours and is referred to as the "prolonged latent" phase. The mother may sometimes make some progress dilating from 1 to 2 cm and will then stop. She is usually not admitted to the hospital at this point unless the membranes are ruptured.

b. Active or Accelerated Phase. In this phase, the contractions become stronger and last longer, usually 45 to 60 seconds. The frequency is from 3 to 5 minutes. The cervix dilates from 4 to 7 cm. This phase is considered the onset of true labor. The mother is admitted to the hospital at this point. She, then, becomes involved with bodily sensations and tends to withdraw from the surrounding environment. She is not able to walk, but, desires companionship and encouragement.

c. Transient or Transitional Phase. In this phase, the contractions are sharp, more intensified, and last from 60 to 90 seconds. The frequency is from 2 to 3 minutes. The cervix dilates from 8 to 10 cm. Completion of this phase marks the end of the first stage of labor. The mother may express feelings of frustration, loss of control, and/or irritability. Her focus becomes internal. She has difficulty comprehending surroundings, events, and instructions. There is an increase in bloody show as a result of the rupture of capillary vessels in the cervix and the lower uterine segment. The mother feels an urge to push or to have a bowel movement. This is considered the most severe and difficult phase for the mother.

NURSING CARE DURING THE FIRST STAGE OF LABOR

a. Hospital Admission. After a physician or nurse has evaluated the patient, an admission order is written. At this point, your duties as a practical nurse are as follows:

(1) Establish a rapport with the patient and significant others.

(2) Explain all procedures or routines, which will be carried out prior to performing them. These include:

(a) NPO except ice chips while in labor.

(b) Activities allowed and disallowed according to ward policies (i.e. bathroom privileges).

(c) Use of fetal monitors.

(d) Progress reports.

(e) Visitation policies.

(f) Where patient's personal belongings will be maintained.

(3) Orient the patient to the surroundings (that is, room, call bell).

(4) Initiate the patient's labor chart.

(5) Review the information obtained originally in the exam room, verify and transfer the OB health record to the labor chart per ward policies. You will review the following information:

(a) Obstetric history.

1 Gravida/para.

2 Estimated date of confinement (EDC) or due date.

3 Duration of previous labors.

4 Problems with previous pregnancies/deliveries.

(b) General condition.

1 Rh status.

2 Allergies.

3 History of medical problems.

(c) Current pregnancy.

1 Onset of labor (contractions regular, 5 minutes or less).

2 Frequency, duration, and intensity of contractions.

3 Membranes-ruptured or intact.

4 Amount and character of show or vaginal bleeding.

5 Vital signs.

6 Rate, location of fetal heart tones.

7 Plans to bottle or breast feed.

8 Any problems with this pregnancy.

(6) Evaluate the patient's current emotional status.

(7) Evaluate the patient's preparation for labor through classes.

(8) Evaluate for possible danger signs.

(a) Increased pulse or temperature.

(b) Excessive vaginal bleeding.

(c) Presence of meconium (fetal feces) in the amniotic fluid of a mother with a vertex position.

(d) Alteration in fetal heart tones (FHT's) above 160 or below 120.

(e) Obvious change in the character of uterine contractions.

(9) Perform the admission physician's orders to include but not limited to the following:

(a) Administer and maintain intravenous fluids--per physician's order and SOP. This is usually done on all patients.

(b) Draw lab work--CBC, serologic testing, type and screen, or per SOP.

(c) Send uterine activity (UA) which was obtained prior to admission to the lab.

b. Perineal Preparation. Shaving of pubic hair to prevent infection of perineal episiotomy/lacerations is rarely done anymore. There must be a physician's order to perform this task.

c. Cleansing Enema.

(1) A cleansing enema may range from "mini-" or "Fleets" to a full, soap-suds enema. Giving an enema is no longer considered routine. There must be a physician's order to perform this task.

(2) The patient must be evaluated to determine if she has had a recent bowel movement.

(3) If a cleansing enema is given, it is usually a small fleet.

(4) Some physicians consider giving fleets to:

(a) Prevent fecal contamination of the perineum during delivery.

(b) Cleanse the bowel. This provides more room for fetal passage.

(c) Stimulate uterine contractions.

(5) Some physicians consider not giving fleets because the following factors may be present or begin:

(a) Vaginal bleeding.

(b) Premature labor.

(c) Presenting part not engaged.

(d) Abnormal presentation--breech or transverse.

(e) Already rapid moving labor.

(f) Advanced labor.

(g) Membranes are ruptured or danger of prolapsed cord.

(h) Results of enema may produce unmanageable amounts of loose stool at delivery.

d. Evaluation of Uterine Contractions Continued.

(1) The purpose of this evaluation is to assess the ability of the uterus to dilate the cervix, help in determining the progress of labor, help to detect abnormalities of uterine contractions (such as lack of uterine relaxation), and help to evaluate any signs of fetal distress.

(2) This evaluation will help you in identifying the frequency (how often in minutes contractions occur), intensity (strength of contractions when palpitations are identified as mild, moderate, or strong [severe]), and duration (how long the contractions lasts in seconds).

(3) When palpating for contractions, place your hand over the fundal area of the patient's uterus. Contractions can be felt by your fingers before the patient actually becomes aware of them. See figure 2-3 for patient experiencing contractions.

Figure 2-3. Uterus between and during contractions.

e. Monitoring and Recording Color and Amount of Show. As labor progresses, the show becomes more blood-tinged. A sharp increase in the amount of bloody show coupled with frequent severe contractions may indicate labor is progressing too rapidly. Report this immediately to the Charge Nurse or physician and be prepared for possible delivery.

f. Fetal Monitoring.

(1) Fetal monitoring is done to detect presence of fetal life at time of admission and to detect development of fetal distress during labor. A fetoscope or fetal monitor may be used to obtain FHTs. Normal fetal heart rate ranges from 120 to 160 beats per minute (BPM). The rate may increase or decrease by 30 BPM during a contraction. It should return to the baseline immediately after the contraction. A continued fetal heart rate of greater than or less than 30 BPM from the normal baseline after contractions may be indicative of fetal distress as defined by:

(a) Fetal tachycardia--FHTs sustained at greater than 160 BPM.

(b) Fetal bradycardia--FHTs sustained at less than 120 BPM.

(2) Fetal distress may be indicated by FHT's, between contractions that are consistently abnormal. Any variations should be reported immediately.

(3) The FHTs should be checked and recorded on admission, every 15 minutes during the first stage of labor, every 5 minutes during the second stage of labor, and immediately after rupture of membranes. This helps to identify the location of the prolapsed cord.

NOTE: The prolapsed cord is referred to as the umbilical cord that protrudes beside or ahead of the presenting part of the fetus. Pressure of the presenting part on the umbilical cord can endanger fetal circulation.

(4) Fetal monitoring continued. According to the National Institute of Health (NIH), electronic fetal monitoring of the fetus is not necessary during normal labor. However, if either the mother or fetus is considered at risk, a more precise measurement of fetal response is indicated.

(5) Candidates for continuous fetal monitoring includes a patient with a multiple pregnancy, a patient with obstetric complications, a patient receiving oxytocin infusions, any high risk patient, a patient with meconium stained amniotic fluid, or any patient whose pregnancy is not progressing normally.

(6) Most medical facilities are using continuous fetal monitoring during labor. Alternative birth centers often use intermittent monitoring.

(7) Methods of fetal monitoring (see figures. 2-4 and 2-5). A transducer is placed on the abdomen over the uterus for external monitoring. An electrode is attached to the presenting part of the fetus, but NOT placed on the sutures, fontanels, face, or scrotum for internal monitoring.

Figure 2-4. External fetal monitoring,

Figure 2-5. Internal fetal monitoring.

g. Vital Signs. Monitor the patient's vital signs.

(1) On admission.

(2) Every hour during early labor.

(3) Blood pressure (BP), pulse (P), and respiratory rate (R) every 30 minutes during active, transition, and the second stage of labor, to include the temperature every hour.

(4) Blood pressure, P, and R every 15 minutes while on Pitocin®, to include the temperature every hour.

(5) More frequently if complications arise.

h. Patient Given an Opportunity to Void. You should offer the patient an opportunity to void every 2 hours during labor. The discomfort of contractions often causes the patient to be unaware that her bladder is full. A full bladder may impede the progress of labor.

i. Patient is NPO During Labor. The patient may have ice chips to prevent drying and chapping of the lips. Vaseline may be applied to her lips to prevent chapping. Gastric emptying time is prolonged once labor is established. The administration of analgesics also prolongs gastric emptying. The patient may vomit and aspirate since her stomach contents may not be absorbed. Being unaware of when possible complications could arise could necessitate an emergency C-section with general anesthesia.

j. Positioning During Labor. Assist the patient in turning from side to side. Elevate the head of the bed 30 degrees; this makes it easier for the patient to breathe. Try to keep the patient off her back to prevent supine hypotensive syndrome. This syndrome results in pressure of the enlarged uterus on the vena cava, reduces blood supply to the heart, decreases blood pressure, and reduces blood circulation to the uterus and across the placenta to the fetus. The patient may complain of being nauseated and feeling cool and clammy. The best position for the patient is on her left side since this increases fetal circulation.

k. Prevention of Infection. Handwashing is essential before and after performing any procedure. Fresh, clean scrub suits should be worn in the delivery area. Unauthorized persons should not be allowed in the area. A patient with infections should be separated from other patients.

l. Vaginal Exams. Only the physician or a trained nurse performs this exam.

It is done to evaluate cervical effacement, cervical dilatation, status of membranes, and station of presenting part. Care must be taken to perform good perineal cleansing before and after the procedure (vaginal exam). Once membranes rupture, the exam should be limited even further to prevent the risk of infection. See figure 2-6 for vaginal palpation of cervical dilatation, effacement, amniotic membranes, and presenting part.

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Figure 2-6. Vaginal exam.

m. Artificial Rupture of Membranes.

(1) Rupture of the membranes is done by the physician to induce or hasten labor. Apply an internal fetal monitor lead or a uterine catheter.

(2) The FHTs should be checked immediately following rupture. Determining fetal distress is secondary to compression of the cord. The cord may be displaced by the sudden "gush" of waters, which may yield a prolapsed cord.

(3) Fluids should be carefully examined for meconium if the fetus is in the vertex presentation, (that is, head first). You should check for:

(a) Slight green color--called light meconium.

(b) Green to dark color--called moderate meconium.

(c) Dark green with chucks of meconium--called heavy meconium.

(4) Record the following information:

(a) Time of the procedure (rupture of membranes).

(b) Amount of fluid expelled (small, moderate, or large).

(c) Color--clear or meconium stained (extent of staining--light, moderate, or heavy).

(d) Fetal heart rate immediately after the procedure and five minutes after the procedure.

(e) Instrument used, if other than an amnihood, to provide a slow, controlled release of fluid. Other instruments may be a fetal scalp electrode or spinal needle.

NOTE:

The amnihood is used to tear a small opening in the amniotic sac.

n. Emotional Support.

(1) First phase--latent. Offer support and explanations. Instruct or reinforce breathing techniques (breathe slowly and deeply and use deep chest or abdominal breathing). Remind the patient to not push down during the first stage since it could causes cervical edema. It could also cause cervical lacerations and fetal hypoxia.

(2) Second phase--active. Continue to give support, offer encouragement, and give explanations. Include significant other in these procedures. Reinforce breathing and relaxation techniques. Accelerated shallow panting may be used, and also, effleurage (stroking movement used in massage, usually of the abdomen).

(3) Third phase--transition. Encouragement is especially important now since the patient is most likely losing control at this point. She may be nauseated or flushed and may vomit. Assist the patient to turn on her side or to sit up to prevent aspiration. Wipe her face and mouth with a cool cloth. Be aware that the patient may want to be left alone, but don't leave; stay and support her. Remind the patient that this is the shortest stage and that the baby will be born soon. Encourage her to concentrate on relaxation and breathing techniques. Use more intensive breathing techniques (high chest, pant-blow). Make sure to give instructions in short, simple phrases. Remind the patient that she still can't push even though she may have a strong urge to do so.

o. Preparation of the Delivery Room. Preparation is usually done by the paraprofessional on duty if the scrub technicians are not employed. Strict aseptic technique is maintained. The room is prepared while the patient is in the first stage of labor. The local SOP will determine how soon before anticipated delivery the room can be set up. It is usually 2 to 12 hours if the tables are covered and rooms are closed.

 SECOND STAGE OF LABOR (DELIVERY STAGE)

 As previously mentioned, the second stage of labor begins when the cervix is completely effaced and dilated and ends when the infant is born.

a. These signs of the second stage of labor are considered imminent or impending signs.

(1) Imminent signs.

(a) Increased bloody show.

(b) Desire to bear down or have bowel movement (result of the descent of the presenting part).

(c) Bulging of the perineum.

(d) Dilatation of the anal orifice.

(2) Impending signs.

(a) Nausea and retching.

(b) Irritability and uncooperativeness.

(c) Complaints of severe discomfort.

(d) Pleas for relief.

b. Once dilatation and effacement are complete, the patient is instructed to push with each contraction to bring the presenting part down into the pelvis.

 TRANSFER OF THE LABOR PATIENT TO THE DELIVERY ROOM

Transfer the mother to the delivery room and prepare her for delivery when delivery seems imminent. Timing is dependent on the parity of the patient, size of the infant, effectiveness of the patient's pushes, arrival of the physician, familiarity of the staff with equipment, and need for additional preparation time. Parity refers to the condition of the woman with respect to her having borne children.

a. Primigravida patients are transferred when the cervix is completely effaced and dilated and the head or presenting part is crowning.

b. Multipara patients are transferred when the cervix is completely effaced and dilated. The patient usually pushes (i.e., bears down) in the delivery room. She may be transferred prior to complete dilatation (8 to 9 cm) if she is progressing rapidly and the presenting part is descending. These patients are normally not encouraged to push when in the labor room since delivery occurs more rapidly in the multipara patient.

 NURSING CARE GIVEN WHILE IN THE DELIVERY ROOM

a. Never leave the patient alone once she has been transferred to the delivery room. In addition, never turn your back on the perineum because the baby could push through the vaginal opening while your back is turned.

b. Encourage the patient to rest between contractions and to push with contractions. Only one person should coach. Verbal encouragement and physical contact help reassure and encourage the patient.

c. Position the patient's legs in the stirrups for the lithotomy position. This is the most common position for delivery. Facilities using birthing beds have the patient in an upright position. Positioning also depends upon the type of anesthesia to be used and C-section delivery. Each case may be different.

d. Prep the patient's perineum. A Betadine® scrub and water are used with 4x4's. Clean the perineum by washing the pubic area, down each thigh, down each side of the labia, down the perineum, and down the rectal area (see fig. 2-7). Begin cleaning at number 1 and proceed through number 7. Discard used sponges after each step. Rinse area with the remaining solution.

e. Monitor the patient's blood pressure and the fetal heart tones every 5 minutes and after each contraction.

Figure 2-7. Cleaning the patient's perineum.

 NORMAL BIRTHING PROCESS (FIGURE 2-8)

Even though most of the time the delivery remains in the hands of the obstetrician, there may be times when a practical nurse will have to assist the patient to give birth. In general, the activity of the normal birthing process (see figure 2-8) is given below:

a. Crowning, the appearance of the infant's head on the perineum.

b. Delivery of the head. This includes suctioning of the infants nose and mouth with a bulb syringe. A DeLee suction trap is used if meconium is present.

c. Delivery of the anterior shoulder and the posterior shoulder.

d. Delivery of the trunk and lower body.

e. Clamping and cutting of the umbilical cord.

 INFORMATION TO BE RECORDED ABOUT THE DELIVERY

Record the following information.

a. Exact date and time of delivery.

b. Sex of the infant.

c. Condition of the infant (APGAR) after birth. APGAR is the most widely used method of evaluating the condition of a newborn baby. A value of 0 to 2 is given for each observation (i.e., heart rate, respiratory effort, muscle tone, reflex irritability, and color). The values are added giving a total APGAR score (see table 2-2). A baby in excellent condition would score 9 to 10 and a dead baby would score 0. Most babies score 7 or better. The condition of the infant will be taken at one (1) minute, at five (5) minutes, and at thirty (30) minutes.

Figure 2-8. Birthing process (continued).

Figure 2-8. Birthing process (continued).

Figure 2-8. Birthing process (concluded).

d. Position of the infant at delivery.

e. Type of episiotomy, lacerations.

f. Spontaneous or forceps delivery.

g. Use of oxygen and suction on the infant.

h. Number of vessels in the cord.

i. Mother's name.

j. Any other pertinent facts about the delivery.

Table 2-2. Sample APGAR scoring chart.

SIGN

0 1 2 1 min 5 min 30 min

Heart Rate

Absent Less Than 100 Over

100

Respiratory

Effort

Absent Slow

Irregular

Good

Cry

Muscle

Tone

Limp Some

Flexion

Active

Motion

Reflex

Irritability

No

Response

Grimace Cry

Color

Pale Body Pink

Extr. Blue

All

Pink

TOTAL SCORE

 THIRD STAGE OF LABOR (PLACENTAL STAGE)

As previously mentioned, the third stage of labor is the period from birth of the baby through delivery of the placenta. This is considered a dangerous time because of the possibility of hemorrhaging. Signs of the placental separation (see figure 2-9) are as follows:

a. The uterus becomes globular in shape and firmer.

b. The uterus rises in the abdomen.

c. The umbilical cord descends three (3) inches or more further out of the vagina.

d. Sudden gush of blood.

Figure 2-9. Placental separation and delivery.

 NURSING CARE DURING THE THIRD STAGE

a. Continue observation. Following delivery of the placenta, continue in your observation of the fundus. Ensure that the fundus remains contracted. Retention of the tissues in the uterus can lead to uterine atony and cause hemorrhage. Massaging the fundus gently will ensure that it remains contracted.

b. Allow the mother to bond with the infant. Show the infant to the mother and allow her to hold the infant.

 INFORMATION TO RECORD

Record the following information.

a. Time the placenta is delivered.

b. How delivered (spontaneously or manually removed by the physician).

c. Type, amount, time and route of administration of oxytocin. Oxytocin is never administered prior to delivery of the placenta because the strong uterine contractions could harm the fetus.

d. If the placenta is delivered complete and intact or in fragments.

 FOURTH STAGE OF LABOR (RECOVERY STAGE)

 FOURTH STAGE OF LABOR

The fourth stage of labor, as previously mentioned, is the period from the delivery of the placenta until the uterus remains firm on its own. In this stabilization phase, the uterus makes its initial readjustment to the nonpregnant state. The primary goal is to prevent hemorrhage from the uterine atony and the cervical or vaginal lacerations.

NOTE:

Atony is the lack of normal muscle tone. Uterine atony is failure of the uterus to contract.

 NURSING CARE DURING THE FOURTH STAGE OF LABOR

a. Transfer the patient from the delivery table. Remove the drapes and soiled linen. Remove both legs from the stirrups at the same time and then lower both legs down at the same time to prevent cramping. Assist the patient to move from the table to the bed.

b. Provide care of the perineum. An ice pack may be applied to the perineum to reduce swelling from episiotomy especially if a fourth degree tear has occurred and to reduce swelling from manual manipulation of the perineum during labor from all the exams. Apply a clean perineal pad between the legs.

c. Transfer the patient to the recovery room. This will be done after you place a clean gown on the patient, obtained a complete set of vital signs, evaluated the fundal height and firmness, and evaluated the lochia.

d. Ensure emergency equipment is available in the recovery room for possible complications.

(1) Suction and oxygen in case patient becomes eclamptic.

(2) Pitocin® is available in the event of hemorrhage.

(3) IV remains patent for possible use if complications develop.

e. Check the fundus.

(1) Ensure the fundus remains firm.

(2) Massage the fundus until it is firm if the uterus should relax (see figure 2-10).

Figure 2-10. Massaging the fundus.

(3) Massage the fundus every 15 minutes during the first hour, every 30 minutes during the next hour, and then, every hour until the patient is ready for transfer.

(4) Chart fundal height. Evaluate from the umbilicus using fingerbreadths. This is recorded as two fingers below the umbilicus (U/2), one finger above the umbilicus (1/U), and so forth. The fundus should remain in the midline. If it deviates from the middle, identify this and evaluate for distended bladder.

(5) Inform the Charge Nurse or physician if the fundus remains boggy after being massaged.

NOTE:

A boggy uterus many indicate uterine atony or retained placental fragments. Boggy refers to being inadequately contracted and having a spongy rather than firm feeling. This is descriptive of the postdelivery of the uterus.

f. Monitor lochia flow. Lochia is the maternal discharge of blood, mucus, and tissue from the uterus. This may last for several weeks after birth.

(1) Keep a pad count. Record the number of pads soaked with lochia during recovery.

(2) Identify presence of bright red bleeding or blood clots.

(3) Document thick, foul-smelling lochia.

(4) Observe for constant trickle of bright red lochia. This may indicate lacerations.

(5) Identify lochia amounts as small, moderate, or heavy (large) (see figure 2-11).

(6) Document lochia flow when the fundus is massaged.

(a) Every fifteen (15) minutes times one hour.

(b) Every thirty (30) minutes times one hour.

(c) Every hour until ready for transfer.

g. Observe the mother for chills. The cause of the mother being chilled following birth is unknown. However, it refers primarily to the result of circulatory changes after delivery. The best means of relief is to cover the mother with a warm blanket.

Figure 2-11. Assessing lochia flow.

h. Monitor the patient's vital signs and general condition.

(1) Take BP, P, and R every 15 minutes for an hour, then every 30 minutes for an hour, and then every hour as long as the patient is stable. Take the patient's temperature every hour.

(2) Observe for uterine atony or hemorrhage.

(3) Observe for any untoward effects from anesthesia.

(4) Orient the patient to the surroundings (bathroom, call bell, lights, etc.).

(5) Allow the patient time to rest.

(6) Encourage the patient to drink fluids.

i. Observe patient's urinary bladder for distention. Be able to recognize the difference between a full bladder and a fundus.

(1) Characteristics of a full bladder.

(a) Bulging of the lower abdomen (see figure 2-12).

Figure 2-12. Bulging of the lower abdomen.

(b) Spongy feeling mass between the fundus and the pubis.

(c) Displaced uterus from the midline, usually to the right.

(d) Increased lochia flow.

(2) Full bladders may actually cause postpartum hemorrhage because it prevents the uterus from contracting appropriately.

(3) Nerve blocks may alter the sensation of a full bladder to the patient and prevent her from urinating.

(4) If at all possible, ambulate the patient to the bathroom.

(5) Urine output less than 300cc on initial void after delivery may suggest urinary retention.

(a) Document the fundal height and bladder status before the patient urinates.

(b) Reevaluate and document the fundal height and bladder status after the patient urinates to accurately document an empty bladder.

j. Evaluate the perineal area for signs of developing edema and/or hematoma.

(1) Predisposing conditions includes prolonged second stage, delivery of a large infant, rapid delivery, forceps delivery, and fourth degree lacerations.

(2) Nursing considerations for perineal edema.

(a) Apply an ice pack to the perineum as soon as possible to decrease the amount of developing edema.

(b) Stress the importance of peri-care and use of "sitz-baths" on the postpartum ward.

(c) Assess for urinary distention which is due to edema of the urethra.

(3) Assessment for perineal hematoma.

(a) Look for discoloration of the perineum.

(b) Listen for the patient's complaints or expression of severe perineal pain.

(c) Observe for edema of the area.

(d) Observe/listen for patient's feeling the need to defecate if forming hematoma is creating rectal pressure.

(e) Observe for patient's sensitivity of the area by touch (by sterile glove).

k. Observe for signs of hemorrhage.

(1) Uterine atony.

(2) Vaginal or cervical lacerations.

(3) Retained placental fragments.

(4) Bladder distention.

(5) Severe hematoma in vagina or surrounding perineum.

l. Assess for ambulatory stability.

(1) The patient is at risk of fainting on initial ambulation after delivery due to hypovolemia from blood loss at delivery and hypoglycemia from prolonged nothing by mouth (NPO) status.

(2) The patient should be accompanied on the first ambulation and observed for stability.

(3) Ammonia ampuls should be readily available.

(4) The patient should be closely monitored while in the bathroom to prevent injury if fainting does occur.

(5) The patient who received regional anesthesia at deliver (that is, pudendal block) should be assessed for possible loss of sensation in the lower extremities.

m. Observe C-section patients. Most C-section patients are still initially recovered in the recovery room. If not, monitor the patient as you would any patient in a recovery room immediately during post delivery. Include monitoring of the fundus and lochia flow. Times are consistent with the normal vaginal delivery patient.

n. Instruct the patient in the proper perineal care. The patient should use the peribottle after each void and bowel movement, wipe from front to back to avoid contamination, and apply the perineal pad from front to back.

o. Discontinue IV on a normal patient once she is stable and the physician has ordered removal.

p. Complete notes and transfer the stable patient to the ward (on normal vaginal delivery--others require physician clearance).

 FACTORS THAT MAY EXTEND OR INFLUENCE THE DURATION OF LABOR--5 Ps

There are five essential factors that affect the process of labor and delivery. They are easily remembered as the five Ps (passenger, passage, powers, placenta, and psychology).

a. Passenger (Fetus).

(1) Presentation of the fetus (breech, transverse).

(2) Position of the fetus (ROP, LOP).

(3) Size of the fetus.

b. Passage (Birth Canal).

(1) Parity of the woman, if she has ever delivered before.

(2) Resistance of the soft tissues as the fetus passes through the birth canal.

(3) Fetopelvic diameters.

c. Powers (Contractions).

(1) Force of the uterine contractions.

(2) Frequency of the uterine contractions.

d. Placenta.

(1) Site of implantation.

(2) Whether it covers part of the cervical os.

e. Psychology (Psychological State of the Woman).

(a) Patient extremely anxious.

(b) Emotional factors related to the patient.

(c) Amount of sedation required for the patient.