Labor & Delivery Nursing: Core Concepts & Clinical Care

Labor & Delivery Essentials for Nurses

Maternal & Fetal Assessments

• RhoGAM Administration: For Rh-negative mothers with Rh-positive babies.
• Direct Coombs Test: Performed on cord blood at delivery to detect antibodies on infant's red blood cells.
• Rupture of Membranes (ROM) Assessment:
  • BLUE Test: Positive pH (6.5 to 7.5) indicates amniotic fluid.
  • Typical amniotic fluid volume: 700-1000 mL.
• Fetal Station: Describes the descent of the fetal head in relation to the mother's ischial spines.
  • -1 to -5: Fetal head is above the ischial spines (pelvic inlet).
  • 0: Fetal head is at the ischial spines; baby is level and engaged in the pelvis.
  • +1 to +5: Fetal head is below the ischial spines, progressing towards crowning and emergence.
• Contraction Stress Test (CST): Evaluates fetal well-being during contractions.
  • Procedure: Obtain a 10-20 minute baseline. Observe for 3 contractions within 10 minutes.
  • Positive CST: Fetus shows signs of distress (e.g., late decelerations).
  • Negative CST: No signs of fetal distress observed.

Key Concepts in Labor

• Cardinal Movements of Labor: The seven essential movements the fetus undergoes to pass through the birth canal.
  1. Engagement
  2. Descent
  3. Flexion
  4. Internal Rotation
  5. Extension
  6. External Rotation
  7. Expulsion
• The 5 Ps of Labor: Critical factors influencing the labor process.
  1. Passenger: The fetus and placenta.
  2. Powers: Uterine contractions.
  3. Passageway: The birth canal, including the pelvis, cervix, pelvic floor, and vagina.
  4. Position: The relationship of the presenting fetal part (e.g., occiput, mentum, sacrum) to the mother's pelvic inlet.
     • Persistent Occiput Posterior (POP): Can lead to increased back labor pain and longer labor duration.
  5. Psyche: The mother's psychological response to labor.
• Placental Separation:
  • Shiny Schultz: Fetal side of the placenta, connected to the baby, emerges first.
  • Dirty Duncan: Maternal side of the placenta, connected to the mother, emerges first.

Labor Interventions & Pain Management

• Amniotomy: Artificial rupture of membranes.
  • Priority Assessment: Immediately assess Fetal Heart Rate (FHR) after the procedure.
• Cervical Ripening Medications (Prostaglandins): Used to soften the cervix.
  • Procedure: Obtain informed consent. Position client supine or in a wedge side-lying position for 30 minutes after administration.
  • Monitoring: Monitor FHR and uterine activity every 15 minutes.
• Effleurage: A light, gentle, circular stroking of the client's abdomen with fingertips, often used for pain relief during labor.
• Epidural Considerations: Ensure adequate platelet count before epidural administration.

Stages of Labor & Postpartum Care

Stages of Labor

• Stage 1: Begins with the onset of regular uterine contractions and ends with full cervical dilation (10 cm).
  • Latent Phase: 0-3 cm dilation; contractions every 5-30 minutes, lasting 30-45 seconds.
  • Active Phase: 4-7 cm dilation; contractions every 3-5 minutes, lasting 40-70 seconds.
  • Transition Phase: 8-10 cm dilation; contractions every 2-3 minutes, lasting 45-90 seconds.
• Stage 2: From full cervical dilation to the birth of the baby.
  • Assessments: Monitor FHR every 15 minutes. Assist with breathing techniques. Record delivery time, medications administered, and any episiotomies or lacerations.
• Stage 3: From the birth of the baby to the birth of the placenta.
  • Assessments: Monitor vital signs, bleeding, and fundus. Provide immediate care for the newborn.
• Stage 4: Recovery phase, 1-2 hours after placental delivery.
  • Assessments: Monitor vital signs, fundus, and lochia every 15 minutes for the first hour (x4), then every 30 minutes for the second hour (x2), then hourly.
  • Priority Concern: Hemorrhage is the primary concern during this stage.

Postpartum Considerations

• Uterine Atony: Lack of muscle tone in the uterus, a common cause of postpartum hemorrhage.
• Fundal Massage: Performed to stimulate uterine contractions and prevent hemorrhage.
  • Frequency: Every 15 minutes for the first hour postpartum, every 30 minutes for the second hour, then hourly as needed.
• Perineal Lacerations:
  • 1st Degree: Involves skin and vaginal mucosa.
  • 2nd Degree: Extends through skin, mucous membrane, and fascia of the perineum; may include midline and clitoral tears.
  • 3rd Degree: Extends to the rectal mucosa and exposes the lumen of the rectum.
  • 4th Degree: A complete tear from front to back, involving the rectal sphincter and rectal mucosa.
• Postpartum Hemorrhage (PPH):
  • Warning Sign: Tachycardia in an OB client should prompt immediate assessment for hemorrhage.
  • Medications: Oxytocin, Carboprost, Methylergonovine.