Objectives for topic 4.

3
So you’re in labor…what happens at the hospital?
Contractions
Ongoing assessments in labor-mom & fetus
Informed consent
Induction vs. augmentation
Laceration vs. episiotomy
Assisted deliveries
Vaginal vs.Cesarean deliveries
LPN Scope of Practice in
Intrapartum Care
Refer to CLPNA Continuing Competency Profile
Category L – Maternal & Newborn Care
http://www.clpna.com/wp-content/uploads/2013/02/AB%20LPN
%20Competency%20Profile%20-%20K-Maternal%20Newborn%2
0Care.pdf
Signs of Labour
Initial Assessment of Woman in
Labour
When arrive at hospital:
Fetal Condition (FHR, amniotic fluid)
Maternal Condition (Vitals, urinalysis)
Impending Birth, grunting, pushing, show++
Waters broken? Very important to know this!!
If the water broke at home need to know odor, time,
color. NEED TO KNOW WHEN
Contractions
Frequency, length, intensity
Ongoing assessment & Nursing
Care of Mother
Assess vitals, comfort, observe behaviour
Contractions (duration, frequency, strength)
Time the contractions from beginning of one contraction to
beginning of next
Observe for “waters breaking” and show
Test amniotic fluid if unsure of waters breaking (nitrazine test)
Cervical dilatation – this should not be done DURING a contraction
Fetal station – where baby is
Provide ongoing comfort and support during this time.
Encourage her to walk and move about is she is able
Encourage changing position
Respect her contractions and try to not disrupt her focus
Assessment of the Fetus
Auscultation of the Fetal Heart Sounds
Electronic Monitoring
External
Internal
Fetal Heart Rate Patterns
Baseline Fetal Heart Rate
Variability – one of the best indicators of fetal well being
 When fetus moves baseline increase 5-15BPM
 If no variability then could be d/t narcotics in labor, fetal hypoxia

 Brady fetal: less than 110 for 10 min

 Trachy fetal more than 160 for 10 min

Fetal Decelerations
Decelerations are a drop in the fetal heart rate.
Baseline heart rate in labour is 110 – 160bpm
There are 3 types of decelerations.
1)Early decelerations – slowing of the fetal heart rate
early in the contraction denoting compression of the
fetal head.
Fetal Decelerations
2) Late decelerations - Late decelerations don’t begin
until the peak of a contraction or after the uterine
contraction is finished. They’re smooth, shallow dips in
heart rate that mirror the shape of the contraction
that’s causing them.

Late decelerations are triggered by a fall in the fetal

oxygen supply!
hypertension, diabetes, prolonged contractions,
abruptions
Variable Decelerations
3)Variable decelerations - irregular, often jagged dips in the fetal
heart rate that look more dramatic than late decelerations.
Variable decelerations happen when the baby’s umbilical cord is
temporarily compressed.

Variable – cord complciation

Early – head compression
Accelerations – okay
Late – placental insufficiency

VEAL CHOP
Contraction cycle

F
Vaginal Exams
Determines:
Cervical effacement
Cervical dilatation
Fetal presentation, position and station
Do not do vaginal exams when fresh bleeding is
present! Can be an indicator placenta previa

Should be kept to a minimum to prevent infection

STERILE
Assessment & Nursing Care of
Mother- Stage 2 (Pushing)
Preparing for birth
 Ensure delivery supplies are ready
 Prepare baby warmer
Position for birth
 Encourage to assume to most comfortable position for birth
Effective Pushing
 Wait until she has the urge to push…push with contraction and
rest between
Birth
 Clean perineum frequently
Assessment & Nursing Care
During Stage 3 & 4
Third and fourth stages of labor
Oxytocin
Placental delivery
Perineal repair
Assessment
Immediate postpartum care
Documentation in Labour &
Delivery
See Intrapartum Delivery Care Record on Moodle
Induction vs. Augmentation
Induction: labour is started artificially
Why would we induce labor? Old, risk factors, not
advancing, eclamptic, mom or baby is at risk.
Before inducing labor what should be assessed? Fetal
position, cervical ripening, presenting part engaged, fetus is
deemed mature
Augmentation: labour has begun, medication is used to
assist “ineffective” labor
In what cases would we augment labor? Help progress labor
Oxytocin or AROM
*Always remember to assess fetal well being
Forceps delivery
Used only in about 4-8 % of deliveries
Can be used in:
 Physical inability to push with contractions
 Halt in second stage of labor
 Abnormal fetal position
 Prolapsed cord
 Marks are often left on baby’s face – disappear in 1 – 2 days
 FHR must be taken before forceps are applied and after as
there is a risk of cord compression
Forceps
Delivery
Forceps
marks-will
disappear in
1-3 days
Vacuum Extraction
Nicer than a forceps delivery
Fetus has to be in birth canal, vacuum applied to
posterior fontanelle
Leads to caput on newborn
Vacuum Extraction
Cannot be used with
premature infants, face
presentation
Or when mom is unable
to assist with the delivery
process
Amniotomy
The artificial rupture of membranes
Allows fetal head to contact cervix directly
Cervix must be dilated at least 3 cm
Can happen accidently when performing a vaginal
exam
Assess amniotic fluid
There is a risk for cord prolapse
Assess Fetal heart rate before and after
Episiotomy
Midline and Mediolateral Episiotomy
done by doctor or midwife
not many episiotomies performed now. Research
shows that tears heal well.
Only done if perineum is not stretching (rigid) or if
doing an instrumental delivery for a big baby
Episiotomy
Surgical enlargement of the vagina during birth

F
Perineal lacerations
First degree – vaginal mucous membrane and skin of
perineum
Second degree – above and involves the muscle
Third degree – above and extends to the anal
sphincter
Fourth degree – above and extends through the anal
sphincter
Informed Consent
What is it?
Who can be a witness on informed consent
documents?
In maternity nursing, what do we need to get consent
for? Everything
Cesarean Birth
Cesarean Section
Surgical delivery of fetus through incisions in the
mother’s abdomen and uterus
Cesarean Birth
May be very little teaching done if the Cesarean is an
emergency
If ELECTIVE that is a “planned” cesarean then
teaching would include usual pre-surgical teaching.
Pre-op teaching to prevent complications
NPO, choice of anesthetic, husband can come in to OR,
baby may go to NICU or stay with Mom, foley catheter,
IV, skin prep, oral antacid, when to see/hold baby, pain
management
Consent
Cesarean Birth
Many women need debriefing after a cesarean birth,
especially if it was an emergency. They will always
feel grateful that their baby is safe but labor has not
progressed as they had hoped and they may still be
disappointed,
Mother is now POST – OP but is also a new mother.
Not just herself to think about.
Vaginal vs. Caesarean Delivery
Think about the advantages & disadvantages of each
delivery… If you were given the choice of type of
delivery, what would you choose?