Editing Maternal and Newborn Nursing (section)

== Intrapartum Care ==

=== Onset and the five P's ===

Premonitory signs include lightening, increased Braxton Hicks contractions, cervical ripening, bloody show, a small weight loss, a burst of energy (nesting), and rupture of membranes. '''True labor''' produces regular contractions that increase in frequency, duration, and intensity, are usually felt in the back radiating to the abdomen, are not relieved by walking or rest, and '''produce cervical dilation and effacement'''. '''False labor''' is irregular, felt mostly in the abdomen, often relieved by walking, position change, or hydration, and does not change the cervix. Cervical change is the deciding criterion.

The '''five P's''' are '''passenger''' (fetal size, lie, presentation, attitude, position), '''passageway''' (pelvis and soft tissues), '''powers''' (contractions and maternal pushing), '''position''' (maternal position), and '''psyche''' (emotional state and support). Fetal '''station''' is the relationship of the presenting part to the ischial spines: 0 is engaged, negative numbers are above the spines, positive numbers are below.

=== Stages of labor ===

* '''First stage''' - onset of true labor to full dilation (10 cm).
** '''Latent phase''' (0 to about 5 or 6 cm): contractions mild to moderate, patient talkative and sociable. Nursing focus is orientation, ambulation, hydration, and teaching.
** '''Active phase''' (about 6 cm to 10 cm): contractions every 2 to 5 minutes, strong, patient inwardly focused, may become irritable, nauseated, and shaky in transition. Nursing focus is comfort, coaching, and closer fetal and maternal monitoring.
* '''Second stage''' - full dilation to birth of the infant. Encourage pushing with the urge; support spontaneous rather than prolonged breath-holding pushing when possible.
* '''Third stage''' - birth of the infant to delivery of the placenta, usually within 5 to 30 minutes. Signs of placental separation are a gush of blood, lengthening of the cord, and a globular firming uterus. '''Do not pull on the cord'''; traction risks uterine inversion.
* '''Fourth stage''' - the first 1 to 4 hours after delivery of the placenta, the highest-risk window for postpartum hemorrhage. Assess fundus, lochia, vital signs, bladder, and perineum on a frequent schedule per facility protocol (a common pattern is every 15 minutes for the first hour).

'''Cardinal movements''': engagement, descent, flexion, internal rotation, extension, external rotation (restitution), and expulsion.

=== Contraction assessment ===

* '''Frequency''': beginning of one contraction to the beginning of the next.
* '''Duration''': beginning to end of one contraction.
* '''Intensity''': by palpation (mild feels like the tip of the nose, moderate like the chin, firm like the forehead) or in Montevideo units with an intrauterine pressure catheter.
* '''Resting tone''': the uterus must relax fully between contractions; that is when the placenta refills and the fetus is oxygenated.
* '''Tachysystole''' is more than 5 contractions in 10 minutes averaged over 30 minutes. If oxytocin is infusing and tachysystole or a nonreassuring fetal heart rate occurs, '''stop or decrease the oxytocin''' as the first action.

=== Electronic fetal monitoring ===

Interpret in this order: '''baseline rate, variability, accelerations, decelerations, and uterine activity'''.

* '''Baseline''' 110 to 160 bpm. Above 160 for 10 minutes or more is '''tachycardia''' (maternal fever, infection, dehydration, medications, fetal hypoxia). Below 110 is '''bradycardia''' (cord compression or prolapse, rapid descent, maternal hypotension, abruption).
* '''Variability''' is the most important single indicator of fetal central nervous system oxygenation. Absent (undetectable), minimal (5 bpm or less), '''moderate (6 to 25 bpm, the reassuring finding)''', marked (more than 25 bpm). Fetal sleep cycles, narcotics, and magnesium reduce variability without necessarily meaning hypoxia.
* '''Accelerations''' are reassuring and essentially rule out fetal acidemia at that moment.
* '''Decelerations''':
** '''Early''' - gradual, mirror the contraction, nadir with the peak. Cause is '''head compression'''. Benign; no intervention.
** '''Variable''' - abrupt drop of 15 bpm or more for 15 seconds or more, variable in shape and timing. Cause is '''cord compression'''. Interventions: reposition, and consider amnioinfusion for repetitive variables.
** '''Late''' - gradual, begin after the contraction starts, nadir after the peak, return after the contraction ends. Cause is '''uteroplacental insufficiency'''. Always concerning.
** '''Prolonged''' - 15 bpm or more below baseline lasting 2 minutes to less than 10 minutes.
* Memory aid '''VEAL CHOP''': '''V'''ariable = '''C'''ord compression, '''E'''arly = '''H'''ead compression, '''A'''ccelerations = '''O'''K, '''L'''ate = '''P'''lacental insufficiency.
* '''Category I''' is normal (baseline 110 to 160, moderate variability, no late or variable decelerations, early decelerations and accelerations may be present or absent). '''Category III''' is abnormal and requires prompt intervention: '''absent variability with recurrent late decelerations, recurrent variable decelerations, or bradycardia; or a sinusoidal pattern'''. '''Category II''' is everything in between, is the most common category, and requires evaluation and continued surveillance.

'''Intrauterine resuscitation''' for a nonreassuring pattern: '''reposition the patient to a lateral position''' (usually the first and fastest action), '''stop oxytocin''', give an IV fluid bolus of isotonic solution, give oxygen by nonrebreather mask as indicated by facility protocol, perform a vaginal exam to rule out cord prolapse and assess rapid descent, correct maternal hypotension, and notify the provider. Consider terbutaline for tachysystole and amnioinfusion for recurrent variables.

=== Obstetric emergencies ===

* '''Umbilical cord prolapse''' - suspect with sudden prolonged deceleration or variable decelerations right after rupture of membranes, especially with a high presenting part, malpresentation, polyhydramnios, or a long cord. '''Actions: call for help, place a gloved hand in the vagina and hold the presenting part off the cord, place the patient in knee-chest or steep Trendelenburg or exaggerated Sims position, give oxygen, stop oxytocin, and prepare for emergency cesarean birth. Do not attempt to push the cord back in.''' If the cord is visible, keep it moist with warm sterile saline gauze. The nurse's hand stays in place until delivery.
* '''Shoulder dystocia''' - the head delivers and retracts against the perineum (turtle sign). '''McRoberts maneuver''' (hyperflex the maternal thighs sharply onto the abdomen) plus '''suprapubic''' pressure. '''Never apply fundal pressure''', which worsens impaction and risks uterine rupture. Watch for postpartum hemorrhage and for neonatal brachial plexus injury or clavicle fracture.
* '''Uterine rupture''' - sudden severe abdominal pain often described as tearing, loss of fetal station, an abnormal fetal heart rate or loss of tracing, cessation of contractions, and signs of shock. Highest concern with a prior classical uterine incision or trial of labor after cesarean. Immediate surgical delivery.
* '''Amniotic fluid embolism''' - abrupt hypoxia and respiratory distress, cardiovascular collapse, and DIC, typically in labor or just after birth. Care is immediate cardiopulmonary resuscitation and support, oxygen, and massive transfusion.
* '''Chorioamnionitis''' - maternal fever, maternal and fetal tachycardia, uterine tenderness, foul-smelling fluid. Antibiotics and delivery.

=== Comfort and anesthesia ===

Nonpharmacologic measures include position changes and ambulation, hydrotherapy, counterpressure to the sacrum for back labor, breathing techniques, effleurage, heat and cold, and continuous labor support.

'''Epidural analgesia''': the most common serious immediate complication is '''maternal hypotension''' with resulting decreased uteroplacental perfusion and fetal heart rate change. Nursing care: IV access with a fluid bolus per protocol before placement, position the patient sitting or side-lying with the back curved, monitor blood pressure frequently (a common pattern is every 2 to 5 minutes for the first 15 to 20 minutes), have the patient void or place a catheter because bladder sensation is lost, keep the patient off her back, and implement fall precautions. Treat hypotension with lateral positioning, a fluid bolus, oxygen, and a vasopressor such as ephedrine or phenylephrine per order. Other risks are pruritus, fever, urinary retention, and postdural puncture headache.

'''Opioids''' given close to birth can cause neonatal respiratory depression; naloxone should be available, and it is not given to a newborn of an opioid-dependent mother because it can precipitate withdrawal and seizures.

=== Induction, augmentation, and cesarean birth ===

'''Oxytocin''' is titrated to an adequate contraction pattern with a full resting tone. Nursing responsibility is continuous fetal monitoring, watching for tachysystole and Category II or III patterns, monitoring intake and output (oxytocin has an antidiuretic effect and high-dose prolonged infusion risks water intoxication), and knowing that '''the nurse independently stops or decreases the infusion for tachysystole or a nonreassuring tracing'''. Cervical ripening agents include prostaglandins (dinoprostone, misoprostol) and mechanical methods such as a Foley balloon. Bishop score estimates readiness for induction; a higher score predicts success.

'''Amniotomy''': assess and document the fetal heart rate immediately before and after, note fluid color, odor, and amount, and watch for cord prolapse. Meconium-stained fluid warrants readiness for neonatal resuscitation. Time from rupture matters for infection risk.

'''Cesarean birth''' care includes the standard perioperative sequence plus a wedge under the right hip to displace the uterus off the vena cava, and postoperatively the same fundal, lochia, incision, and VTE assessments as vaginal birth. Cesarean patients still have lochia and still need fundal assessment.