Labor and Labor Complications

What Labor Is

Labor is the process of childbirth: rhythmic uterine contractions that progressively open the cervix and end in delivery of the baby. It signals the end of pregnancy.

Admission

Build trust fast. Introduce yourself, settle the patient and family, and find out their birth expectations and cultural values up front. They are anxious. Calm and confident sets the tone for the whole admission.

Take the health history at admission: personal data (blood type, allergies), previous illness, pregnancy complications, labor and delivery preferences, and childbirth preparation, plus standard obstetric, medical, and social history. Then assess vital signs, do a physical exam, and document the contraction pattern (frequency, interval, duration, intensity). Check membrane status by vaginal exam and assess fetal wellbeing through fetal heart rate, amniotic fluid characteristics, and contractions. Perform Leopold's maneuver to determine the fetal presenting part, point of maximum impulse, fetal descent, and engagement.

Admit to the labor room only when the patient is in active labor.

Stages of Labor

Cervical effacement, cervical dilatation, and descent of the presenting part define the stages.

First Stage

Three sub-phases: latent, active, and transition.

Latent (Preparatory) Phase

Onset of true labor contractions to 3 cm dilatation. Responsibilities:

1. Assess psychological readiness and provide continuous maternal support (better than usual care).
2. Track the duration of the latent phase. For nulliparas it should not exceed 6 hours; for multiparas, 4.5 hours. Check whether the patient received anesthesia, which can prolong this phase. A common cause of a prolonged latent phase is cephalopelvic disproportion (CPD), which requires cesarean birth.
3. Keep the patient active. Upright positions are recommended in the first stage. Patients without complications can walk and finish birth preparations.
4. Handle interviews and forms (birth certificate) now, while discomfort is minimal and the patient still controls her contraction pain.
5. Teach breastfeeding, newborn care, and effective bearing down now, while anxiety is low and she can focus.
6. Teach relaxation techniques and start alternative pain relief early.
7. Limit total internal exams across the entire labor to 5.
8. Keep the chosen birthing companion present throughout labor.

Active Phase

4 cm to 7 cm dilatation. Contractions get stronger, intervals shorten, duration lengthens. This is where real discomfort starts, so the patient turns inward. Responsibilities:

1. Tell her how labor is progressing to lower anxiety and keep her cooperation.
2. Start tracking progress with the WHO partograph, 2-hour action line.
3. Keep her active to maximize the effect of contractions. Upright positions if tolerated.
4. Help her into a position of comfort. If she cannot stay upright, left-side lying protects fetal oxygenation.
5. Monitor maternal vital signs and fetal heart rate every 2 hours, or per order.
6. Anticipate needs: cool cloth to the face, clean dry bed, ice chips, lip balm.
7. Find out when she last voided. A full bladder slows labor.
8. Use nonpharmacological pain measures (breathing, distraction, imagery, music).

Transition Phase

8 cm to 10 cm (full) dilatation with full effacement. The patient may be exhausted and withdrawn or aggressive and restless, and the urge to push shows. Responsibilities:

1. Keep her informed of progress.
2. Coach pant-blow breathing.
3. Monitor maternal vital signs and fetal heart rate every 30 minutes to 1 hour, or per order, and continue contraction monitoring.
4. When perineal bulging appears, prepare for delivery. Check that the room is 25-28°C and free of air drafts, notify staff, prepare supplies and equipment including the resuscitation machine, then perform handwashing and double gloving.

WHO does not recommend these during labor (low-quality evidence): routine perineal shaving, routine enema, admission cardiotocography (CTG) for low-risk women, vaginal douching, routine amniotomy in spontaneous labor, and massage and reflexology.

Second Stage

Starts at 10 cm dilatation, ends with delivery of the baby. The patient feels an uncontrollable urge to push and may have transient nausea, restlessness, and shaking extremities. Coach quality pushing and support the delivery:

1. Coach quality pushing. The abdominal muscles aid the involuntary uterine contractions to deliver the baby.
2. Keep the environment quiet so she can concentrate on bearing down.
3. Give positive feedback as she pushes.
4. Repeat the provider's instructions. She barely hears the room because all her energy is on the birth.
5. Note the time of delivery and start essential newborn care. Delayed cord clamping is recommended.
6. Assist with restrictive episiotomy for vaginal births.

WHO does not recommend these during delivery (low-quality evidence): perineal massage and fundal pressure.

Third Stage (Placental Stage)

Birth of the infant to delivery of the placenta, in two phases: placental separation and expulsion. 5 minutes after delivery the uterus contracts again and the placenta separates from the contracting wall. Blood loss of 300-500 mL is normal with placental separation. The placenta sinks to the lower uterine segment or upper vagina, then is delivered with gentle cord traction.

Signs of placental separation: lengthening umbilical cord, sudden gush of vaginal blood, a uterus that changes to a globular shape, firm uterine contractions, and the placenta appearing at the vaginal opening.

Nursing care:

1. Coach relaxation for delivery of the placenta.
2. Congratulate her on the birth.
3. Encourage skin-to-skin contact for bonding and early breastfeeding.
4. Ask whether the placenta matters to her before it is destroyed. For those taking it home, confirm they follow standard infection precautions and hospital policy.
5. Give prophylactic oxytocin as ordered.
6. Use controlled cord traction for placental expulsion.
7. Use absorbable synthetic suture (over chromic catgut) for primary repair of episiotomy or perineal lacerations.

For immediate postpartum, check vital signs and watch for excessive bleeding. The first 4 hours after birth, sometimes called the fourth stage of labor, is the most critical period for the mother. Work to prevent infection and hemorrhage, and reinforce breastfeeding, ambulation, and newborn care.

WHO recommendations for immediate postpartum: early (<6 hours) resumption of feeding after vaginal birth; prophylactic antibiotics for women with third to fourth degree perineal tears; and early postpartum discharge for healthy women who delivered term infants vaginally.

Not recommended in immediate postpartum: routine ice packs, and oral methylergometrine for women who delivered vaginally.

Assessment

Accurate assessment drives the care plan. The patient stays under observation through labor to track progress and keep delivery safe.

Assess for the signs of true labor: contractions that begin irregularly but progress regularly and predictably, pain felt first in the lower back that circles toward the abdomen, progression regardless of activity level, increasing duration, frequency, and intensity, and cervical dilation already present. Assess for show (blood mixed with mucus, present once the mucus plug is expelled), rupture of membranes (scanty or sudden gush of clear fluid), and engagement of the fetal head (the presenting part settling into the pelvis at the level of the ischial spines). Assess station (relationship of the presenting part to the ischial spines), effacement (shortening and thinning of the cervical canal), and dilatation (widening of the cervical canal).

Planning

First stage

Let labor start naturally rather than by artificial induction. Let her move freely and avoid artificial interventions. Allow a non-supine position for delivery. After birth, give mother and child unlimited opportunity for breastfeeding and bonding.

Second stage

Prepare the place of delivery. Determine her most comfortable birth position, promote effective second-stage pushing, and keep up perineal cleaning.

Third stage

Focus on placental delivery. Once the placenta is out, give oxytocin intramuscularly to promote uterine contractions. If episiotomy was performed, build perineal repair into the plan.

Implementation

These interventions give comfort and safety and build the strength she needs for delivery. Encourage voiding every 2 hours. Review her breathing techniques. Tell her when interventions are necessary. Build a birth plan with her so her preferences are in the care plan. Offer ice chips, hard candies, or fluids for dry mouth. Keep the environment comfortable to support coping. Let her walk and move freely. Do not interrupt her during a contraction, which would break her focus.

Evaluation

When labor has gone smoothly, the odds of a safe, healthy delivery are good. Look for no signs of bladder distention and the ability to void every 2 hours, a tolerable pain level, the ability to express her labor preferences, an understanding of the normal labor process, a comfortable and secure environment, and the ability to verbalize her feelings about the experience.

Induction and Augmentation of Labor

Cervical Ripening

Ripening must complete during early labor. Without it there is no dilatation or coordination of contractions. Use the Bishop criteria to score the cervix: a score of 8 or greater means the cervix is ready and will respond to induction.

One ripening method is stripping the membranes, separating them from the lower uterine segment manually with a gloved finger in the cervix. Complications include bleeding from an undetected low-lying placenta, inadvertent rupture of membranes, and infection if the membranes rupture.

Another option is hygroscopic suppositories (seaweed) that swell on contact with cervical secretions and gently urge dilatation. They are held in place by gauze sponges saturated with povidone iodine or an antifungal cream. Document the number of sponges and dilators so none is left inside the cervix.

A more common method is prostaglandin gel applied to the interior surface of the cervix by catheter or suppository, or to the external surface on a diaphragm replaced against the cervix. Additional doses may be applied every 6 hours, but two or three doses usually achieve ripening. Keep the woman side lying to avoid leakage. Monitor FHR at least every 30 minutes after each application. Side effects include diarrhea, fever, hypertension, and vomiting. Oxytocin may start 6 to 12 hours after the last prostaglandin dose. Use prostaglandin with caution in asthma, renal or cardiovascular disease, or glaucoma. Prior cesarean birth contraindicates the prostaglandin method.

Oxytocin

Oxytocin can initiate contractions in a uterus at term. Give it intravenously so it can be stopped quickly if hyperstimulation occurs. Effects are immediate: the half-life is approximately 3 minutes. Mix 10 units of oxytocin in 1000 mL of Ringer's lactate. Run it piggyback to a maintenance IV so the main line stays open if the infusion is stopped, and attach the oxytocin to the port nearest the woman so little solution remains in the tubing if discontinued. Use an infusion pump to hold the rate steady even when she moves. Do not increase the rate without further orders, as it can cause tetanic contractions. Artificial rupture of membranes may be done at 4 cm dilatation to further induce labor.

Watch for peripheral vessel dilatation, an oxytocin side effect that causes hypotension. Check pulse and blood pressure every 15 minutes for a safe induction, and monitor uterine contractions and FHR. Contractions should occur no more often than every 2 minutes, last no longer than 70 seconds, and be no stronger than 50 mmHg. Stop the infusion if contractions exceed those limits or there are signs of fetal distress. Excessive stimulation can cause tonic contractions with fetal death or uterine rupture. If hyperstimulation continues after the infusion is stopped, a beta-adrenergic receptor drug or magnesium sulfate may be ordered to decrease myometrial activity.

Oxytocin has an antidiuretic effect, so water intoxication is a complication: decreased urine flow, headache, and vomiting, and in severe form seizures, coma, and death from the large shift in interstitial fluid. Monitor intake and output and assess urine specific gravity for fluid retention. Limit IV fluid to 150 mL/hr, keeping the main line no faster than 2.5 mL/min.

Induced labor tends to have a shorter first stage than unassisted labor. Reassure the woman that induced contractions are basically normal so she can use her breathing effectively. Watch the newborn closely in the first few days for hyperbilirubinemia and jaundice, which are possible after oxytocin induction.

Augmentation

If spontaneous contractions become weak, irregular, and ineffective, augmentation is needed. Oxytocin precautions match those for primary induction. The uterus may respond effectively. Increase the drug in small increments only and monitor fetal heart sounds throughout.

Labor Complications

Assess early in pregnancy to head off labor complications.

Uterine Rupture

Rare but serious: the uterus cannot sustain the strain. Contributing factors are abnormal presentation, prolonged labor, multiple gestation, improper oxytocin use, and trauma from forceps or traction. Immediate cesarean birth can prevent fetal death.

The warning is a sudden, severe pain during a contraction or a tearing sensation. Rupture is complete or incomplete. Complete rupture goes through endometrium, myometrium, and peritoneum, and contractions stop immediately; signs include hemorrhage, shock, fading fetal heart sounds, and distinct swellings of the retracted uterus and extrauterine fetus. Incomplete rupture goes through endometrium and myometrium only with the peritoneum intact; signs include localized tenderness, persistent aching pain in the lower uterine segment, and absent contractions and fetal heart sounds. Confirm with ultrasound.

Anticipate emergency fluid replacement and IV oxytocin as ordered. Laparotomy controls the bleeding and repairs the rupture. Cesarean hysterectomy or tubal ligation may be done with consent. Disclose fetal outcome, the woman's safety, and the extent of surgery, and allow time for emotions. Advise against future pregnancy after rupture unless it is in the inactive lower segment. Fetal viability and maternal prognosis depend on the extent of the rupture.

Inversion of the Uterus

The uterus turns inside out during delivery of the fetus or placenta. Factors: traction on the cord to remove the placenta, pressure on the fundus while the uterus is not contracting, or a placenta attached to the fundus that pulls it down during birth. Signs: sudden gush of a large amount of blood, a non-palpable fundus, signs of blood loss (hypotension, dizziness, paleness), and exsanguination if bleeding continues.

Never replace the inversion yourself and never remove an attached placenta. Oxytocic drugs only worsen the inversion and tense the uterus, making it harder to replace. Establish an IV line with a large-gauge needle to restore fluid volume, start oxygen, assess vital signs, and begin CPR if she arrests. Nitroglycerin or a tocolytic is given IV to relax the uterus while the physician replaces the fundus manually, then oxytocin afterward to keep it contracted and in place. Antibiotics are ordered because the exposed endometrium risks infection. Tell her future pregnancies will need cesarean delivery, as inversion can recur.

Amniotic Fluid Embolism

Amniotic fluid is forced into an open maternal uterine blood sinus after membrane rupture or partial premature separation of the placenta. The likely cause is an anaphylactoid or humoral response. It cannot be predicted or prevented. Risk factors: abruptio placentae, hydramnios, and oxytocin administration. The woman has sharp chest pain, inability to breathe, pallor, and poor blood flow. Emergency measures: oxygen and CPR. Prognosis depends on how fast it is detected, the skill and speed of intervention, and the size of the embolism. Endotracheal intubation and fibrinogen therapy are needed because DIC risk is high. Fetal prognosis is uncertain because a severe maternal blood pressure drop reduces placental perfusion.

Prolapse of the Umbilical Cord

A loop of cord slips down in front of the presenting part. Factors: a small fetus, placenta previa, CPD, premature rupture of membranes, hydramnios, and multiple gestation. The cord may be felt on vaginal exam, and ultrasound can diagnose it. Cesarean section should happen before membrane rupture, or the cord slides into the vagina. Prolapse is usually found after rupture, when the fetal heart rate shows variable deceleration, so assess fetal heart sounds after every rupture of membranes to rule it out.

The goal is to relieve cord compression and prevent fetal anoxia: manually lift the fetal head off the cord through the vagina or place the woman in Trendelenburg. Start oxygen to improve fetal oxygenation and reduce uterine activity and fetal pressure with a tocolytic. Once the cord is exposed to air it dries and the umbilical vessels atrophy, so cover any exposed portion with a sterile saline compress. With complete dilatation the physician can deliver the baby; without it, emergency cesarean birth is needed because of reduced blood flow. Amnioinfusion (adding sterile fluid into the uterus) can prevent further cord compression. During infusion, monitor fetal heart rate and uterine contractions internally and record maternal temperature hourly to detect infection.

Multiple Gestation

A multiple birth needs extra personnel. The mother may be more frightened than excited, so attend to her needs. The second fetus often faces anoxia, so cesarean birth is often preferred over vaginal delivery. Anemia and pregnancy-induced hypertension are common, so assess blood pressure and hematocrit. For a planned vaginal birth, advise her to come in early in labor. Teach breathing techniques to minimize analgesia or anesthesia and the respiratory difficulties immature lungs can face.

Head engagement may not be firm because the babies are small. Common conditions include abnormal fetal presentation, an overstretched uterus, premature placental separation, and uterine dysfunction from long labor. Twins usually have vertex presentations; with three or more fetuses, presentations vary. Give oxytocin after the birth of the last fetus, unlike singleton pregnancies, to avoid compromising the remaining fetuses. If the next fetus is not vertex, external version may be attempted or cesarean birth performed. An oxytocin infusion can shorten the time between births, and nitroglycerin can relax the uterus.

If the first infant's placenta separates before the second birth, sudden profuse vaginal bleeding puts the mother at great risk. If that separation loosens the other placentas, or there is a common placenta, the other fetuses' heart rates will signal distress. Most multiple gestations not in vertex presentation are delivered by cesarean so they can be born together and survive. Let parents view and inspect their fetuses to dispel fears that the infants are imperfect. Assess the mother thoroughly right after birth: an overdistended uterus may contract poorly, raising her hemorrhage risk from uterine atony. Assess the infants for gestational age and any unusual conditions.

Ineffective Uterine Force

Ineffective labor occurs when contractions, the basic force moving the fetus through the canal, become abnormal.

Hypotonic Contractions

Unusually slow or infrequent, only two or three contractions in a 10-minute period, with strength not rising above 10 mmHg, mostly during the active phase. They follow analgesia, bowel or bladder distention, an overstretched uterus (multiple gestation, large fetus, hydramnios), or a uterus lax from grand multiparity. They raise the risk of postpartal hemorrhage. In the first hour after birth following hypotonic labor, palpate the uterus and assess the lochia every 15 minutes to catch bleeding the contractions are too weak to halt.

Hypertonic Contractions

Marked by a resting tone above 15 mmHg, occurring more frequently and during the latent phase. They are more painful than usual and defeat her breathing techniques. Lack of relaxation between contractions can starve the uterine artery filling and cause fetal anoxia. Apply a uterine and fetal external monitor for at least 15 minutes to check the resting phase and rule out late deceleration. Cesarean birth is needed for late deceleration, an abnormally long first stage, or lack of progress with pushing. Explain to the woman and partner that the strong contractions are ineffective and not dilating the cervix.

Uncoordinated Contractions

More than one pacemaker may be firing, or myometrial receptors may act independently of the pacemaker. Rest between contractions is hard because they come erratically. Attach a fetal and uterine external monitor for at least 15 minutes to assess rate, pattern, resting tone, and fetal response. Oxytocin can stimulate a more effective, consistent pattern with a better, lower resting tone.

Dysfunctional Labor

First-stage dysfunction includes prolonged latent phase, protracted active phase, prolonged deceleration phase, and secondary arrest of dilatation. Manage a prolonged latent phase by resting the uterus and providing fluid for hydration and pain relief. Oxytocin augments a protracted active phase. A prolonged deceleration phase needs cesarean birth. In secondary arrest of dilatation, no progress for more than 2 hours means cesarean birth.

Second-stage dysfunction includes prolonged descent and arrest of descent. Descent slower than 1 cm/hr in a nullipara or 2.0 in a multipara is prolonged descent: encourage rest and increase fluids, and IV oxytocin may help the uterus contract effectively. A semi-Fowler's position, squatting, kneeling, or more effective pushing may speed descent. No descent for 1 hour in a multipara or 2 hours in a nullipara is arrest of descent; the likely cause is CPD, so cesarean birth is necessary. Oxytocin may assist if there is no contraindication to vaginal birth.

Precipitate Labor

Contractions so strong the woman delivers after only a few rapid contractions. Grand multiparity facilitates it, and it can follow oxytocin induction or amniotomy. The fetus risks subdural hemorrhage from rapid release of pressure on the head, and the woman risks lacerations of the birth canal from the forceful birth. A rate greater than 5 cm per hour in a nullipara or 10 cm/hr in a multipara means precipitate labor. Caution a multipara by her 28th week that labor may be brief again if she had a brief labor before, so she can plan transportation. Convert the birthing room to readiness before full dilatation.

Comfort and Pain Management

Etiology and Physiology of Pain

Pain warns that something threatening is happening in the body. Involuntary muscles usually do not hurt when contracting, which makes uterine contractions unique. During contractions, blood vessels constrict and reduce blood supply to uterine and cervical cells, causing anoxia of the muscle fibers, the same mechanism as a heart attack. Ischemia and anoxia increase as labor progresses, intensifying the pain. Stretching of the cervix and perineum adds to it. Once cervical stretching is complete, the urge to push takes over and the pain fades as she pushes. Pressure of the presenting part on the tissues also contributes, and cultural differences shape how she perceives the pain.

Pain starts in nociceptors stimulated by mechanical, chemical, or thermal stimuli. Chemical mediators carry the impulse along myelinated and unmyelinated fibers to the spinal cord, neurotransmitters move it across the synapse between peripheral and spinal nerves, and it ascends to the brain cortex where it is interpreted as pain. The Melzack-Wall gate control theory holds that pain can be halted at three points: the peripheral end terminals, the synapse points, or where the impulse is interpreted. Pain medications mainly block spinal cord neurotransmitters to stop the impulse from crossing to the spinal nerve.

Comfort Measures

Relaxation, taught in childbirth classes, keeps the abdominal wall loose so the uterus can rise during contractions without pressing against it, and doubles as distraction. Help her find her position of comfort and offer music or aromatherapy.

Focusing means concentrating on an object as a distraction, which keeps sensory input from reaching the cortex. A photograph works well; avoid asking questions that break her concentration.

Prayer and worship objects (Bibles, rosaries, crosses) comfort some women. Be careful changing the sheets so these sacred objects are not thrown away.

Breathing techniques relax the abdomen and distract from pain by focusing on slow-paced breathing. Teach them before labor when possible, but you can still coach them during labor.

Herbal preparations have little evidence behind them but are still widely used. Examples: raspberry leaves, life root, and fennel.

Heat or cold: warm application to the lower back soothes back pain in labor; a cool cloth to the forehead helps after exertion; ice chips relieve a dry mouth.

Therapeutic touch and massage: therapeutic touch uses touch to comfort and relieve pain, working on the idea that the body holds energy fields, plentiful fields meaning good health and few meaning ill health, and redirecting them through laying on of hands. Touch and massage increase endorphin release and reduce pain. Effleurage, taught in Lamaze, helps especially during the first and second stages.

Pharmacologic Measures

Narcotic analgesics are potent but used cautiously because they cause fetal CNS depression. Avoid narcotics in preterm labor because of fetal lung immaturity. Meperidine is useful in labor for its sedative and antispasmodic effects that relieve pain and relax the cervix, and it is given 3 hours before birth so its peak action in the fetus passes by delivery.

Regional anesthesia injects a local anesthetic to block specific nerve pathways. Some fetal effects include fetal heart rate decelerations and newborn flaccidity, bradycardia, and hypotension. It keeps the woman awake and aware, and it helps prevent postpartum hemorrhage because it does not depress uterine tone, so the uterus can still contract after birth.

Local anesthesia reduces local nerve fibers' ability to conduct pain. Local infiltration injects anesthetic into the superficial perineal nerves; the effect lasts 1 hour, allowing a pain-free birth and episiotomy suturing. The pudendal nerve block injects anesthetic near the right and left pudendal nerves at the level of the ischial spine, giving pain relief after 2 to 10 minutes that lasts 1 hour. Check FHR and maternal blood pressure right after injection to detect maternal hypotension.

Fetal Position, Presentation, Size, and Passage

Occipitoposterior Position

The usual fetal position is posterior rather than anterior. With a vertex presentation, the occiput points diagonally and posteriorly, to the left or right. During internal rotation in these positions, the fetal head must rotate through an arc of approximately 135 degrees. Rotation from a posterior position is aided by a hands-and-knees position, squatting, or side lying, though these tire the laboring woman. Posterior positions occur with android, anthropoid, and contracted pelvis, and in dysfunctional patterns such as prolonged active phase, arrested descent, or fetal heart sounds heard best at the lateral abdomen.

A posterior head does not fit the cervix the way an anterior head does. Confirm by vaginal exam or ultrasound, since it can cause umbilical cord prolapse. Labor is prolonged because the rotation arc is greater. Lower back pain comes from sacral nerve compression as the head rotates against the sacrum; relieve it with counterpressure on the sacrum and heat or cold. To help the fetus rotate, have her lie on the side opposite the fetal back or assume hands and knees. Have her void every 2 hours to keep the bladder empty and avoid impeding descent. She may need an oral sports drink or IV glucose to replace energy stores. Maternal exhaustion causes uterine dysfunction, so a 135-degree rotation may not happen if contractions are ineffective or the fetus is larger than average. The head may arrest in the transverse position or not rotate at all, requiring cesarean birth. Reassure her that even though labor is not "by the book," it is still within safe limits.

Oversized Fetus

Macrosomia (an oversized fetus) weighs more than 4000 to 4500 g, and that size can be a problem. Macrosomic babies are usually born to women with diabetes or gestational diabetes, and to multiparas. The oversized fetus overstretches the myometrial fibers and can cause uterine dysfunction. Wide shoulders cause fetal-pelvic disproportion or uterine rupture from obstruction. Cesarean birth is necessary if the fetus is too oversized for vaginal delivery. Pelvimetry or ultrasound compares fetal size with pelvic capacity. A macrosomic baby born vaginally carries high risk of cervical nerve palsy, diaphragmatic injury, or fractured clavicle from shoulder dystocia. The woman is at risk for hemorrhage from the overdistended uterus and uterine atony.

Shoulder dystocia happens in the second stage when the head is born but the shoulders are too broad to pass the pelvic outlet. The woman risks vaginal and cervical tears; the fetus risks cord compression between its body and the bony pelvis. Forcing the birth can fracture the clavicle or injure the brachial plexus. It usually occurs with maternal diabetes, in multiparas, and in post-date pregnancies, and is found when the head is born and the shoulders lock beneath the symphysis pubis. Suspect it with a prolonged second stage, arrest of descent, or a head that retracts instead of protruding with each contraction. Have her flex her thighs sharply on her abdomen (McRobert's maneuver) to widen the outlet and free the anterior shoulder, and apply suprapubic pressure to help the shoulder out from beneath the symphysis pubis.

Breech Presentation

Most fetuses are breech early in pregnancy but turn cephalic by week 38. The fetal head is the widest single diameter, but the buttocks and legs take up more space, so the fetus turns head-down because the fundus is the largest part of the uterus. Types: complete, frank, and footling. Breech raises fetal risk for anoxia, head trauma, fracture of the spine or arm, dysfunctional labor, and early rupture of membranes. Meconium in the amniotic fluid signals buttock pressure and can lead to meconium aspiration. Fetal heart sounds are heard high in the abdomen. Leopold's maneuver and vaginal exam confirm breech. Monitor FHR and contractions continuously to catch fetal distress early.

In a breech birth, delivery of the head is the most dangerous part because a loop of cord passing down beside the head may be compressed. Intracranial hemorrhage is another danger from the spontaneous pressure changes. An infant born from a frank breech often extends the legs continuously for the first 2 or 3 days of life, so reassure parents this is normal.

Face Presentation

Face and brow presentations are asynclitism, a fetal head presenting at a different angle than expected. In face presentation the head diameter presenting to the pelvis is often too large for birth, and the back is hard to outline because it is concave. Confirm by vaginal exam when the nose, mouth, or chin is the presenting part, or by ultrasound. It usually occurs with a contracted pelvis or placenta previa, a relaxed multiparous uterus, prematurity, hydramnios, or fetal malformation. If the chin is anterior and pelvic diameters are normal, vaginal birth is possible; if the chin is posterior, cesarean birth is the choice. Facial edema and ecchymosis appear on the baby afterward, so assess airway patency closely and reassure parents the edema is transient.

Brow Presentation

The rarest presentation. It occurs in multiparas or with relaxed abdominal muscles. Obstructed labor results as the head jams in the pelvic brim with the occipitomental diameter presenting. Cesarean birth is necessary unless it corrects spontaneously. Extreme facial ecchymosis appears on the infant; reassure parents the bruising over the anterior fontanelle is normal.

Inlet Contraction

Narrowing of the anteroposterior diameter to less than 11 cm or the transverse diameter to 12 cm or less. The usual cause is rickets in early life or an inherited small pelvis. If the fetal head engages during the 36th to 38th week, the inlet is adequate. No engagement in a primigravida suggests a fetal or pelvic abnormality. Every primigravida should have pelvic measurements taken and recorded before week 24 so a birth decision can be made. In CPD the fetus stays in a floating position, and if membranes rupture the risk of cord prolapse rises sharply.

Outlet Contraction

Narrowing of the transverse diameter at the outlet to less than 11 cm, the distance between the ischial tuberosities. It is easy to measure at a prenatal visit, so a narrow diameter can be anticipated before labor, and it is easily assessed during labor as well.

Trial Labor

Trial labor gauges the progress of labor in a woman with a borderline inlet measurement but good fetal lie and position. It continues as long as descent of the presenting part and cervical dilatation continue. Monitor fetal heart sounds and contractions continuously and have her void every 2 hours to aid descent. After rupture of membranes, assess FHR closely; a still-high fetal head raises the danger of cord prolapse and fetal anoxia. If there is no progress after 6 to 12 hours, cesarean birth is necessary. If trial labor fails, explain why cesarean birth is best, and reassure her and her support person that cesarean is an alternative, not an inferior, method.

External Cephalic Version

Turning a fetus from breech to cephalic before birth. It can be done as early as 34 to 35 weeks, but the usual time is 37 to 38 weeks. Record FHR and ultrasound continuously during the procedure. Give a tocolytic to relax the uterus. The examiner locates and grasps the breech and vertex transabdominally with hands on the abdomen. The procedure can reduce the number of cesarean births from breech presentations. Contraindications: multiple gestation, severe oligohydramnios, prior vaginal birth complications, cord coil, and unexplained third-trimester bleeding that could be placenta previa. The pressure may feel uncomfortable. Rh-negative women should receive Rh immunoglobulin afterward in case bleeding occurs.

Nursing Process During Labor and Delivery

Assessment

Assessment for delivery starts in the second stage, from full dilatation to the birth of the baby, when the mother must deliver with her strength intact for a normal vaginal delivery. Assess her response to the intensity and duration of contractions, her comfort with the birthing position, and whether her breathing techniques help or add to the difficulty. Assess the support person's ability to assist, the fetal heart sounds for any cord occlusion that could hinder fetal circulation, and whether the environment is comfortable for mother and baby.

Diagnosis

Deliveries do not always go smoothly, so be ready to form a diagnosis and care plan fast. A common one: pain related to the intensity of uterine contractions.

Planning

Prepare the place of birth before delivery. For multigravidas, start when the cervix has dilated to 9 to 10 cm; for primiparas, when the head has crowned to the size of a quarter. Prepare the newborn care area in the same room with supplies for eye care, suction and resuscitation equipment, a radiant heat warmer, sterile towels, and newborn identification. Let her choose her most comfortable position. Alternative positions include dorsal recumbent, lateral Sim's, squatting, and semi-sitting. Position a provider at the foot of the birthing table so a precipitous birth does not let the infant fall.

Implementation

If she has a birth plan, make sure every provider knows her preferences. Encourage her to void before delivery to reduce discomfort. Offer ice chips or hard candies for dry mouth. Keep the environment comfortable. Let her assume a birthing position of her choice unless contraindicated, and help her vent any emotions about the experience.

Evaluation

Look for the ability to manage discomfort with nonpharmacologic methods, the ability to identify other pain relief measures, no signs of bladder distention with the ability to void every 2 hours, reduced or no mouth discomfort, a comfortable environment, and a report that the delivery was a tolerable and meaningful part of her life.

Frequently Asked Questions

What are the four stages of labor?

The first stage runs from the onset of true labor to full (10 cm) cervical dilatation and has three phases: latent, active, and transition. The second stage runs from full dilatation to delivery of the baby. The third stage runs from delivery of the baby to delivery of the placenta. The first hours after birth are sometimes called a fourth stage, the most critical recovery period for the mother (MedlinePlus).

How much blood loss is normal after a vaginal birth?

Blood loss with placental separation is expected and should not exceed about 500 mL for a vaginal birth; loss beyond that threshold is treated as postpartum hemorrhage. Because the maternal blood volume rises by roughly 50% during pregnancy, the body is prepared to tolerate this normal loss.

How does oxytocin induction differ from augmentation?

Induction uses IV oxytocin to start contractions in a uterus at term that has not begun effective labor. Augmentation uses the same drug, with the same precautions, to strengthen contractions that started on their own but became weak, irregular, and ineffective. In both cases you increase the rate only in small increments and monitor fetal heart rate and uterine activity continuously.

What practices does WHO no longer recommend during routine labor?

For low-risk labor, WHO advises against routine perineal shaving, routine enema, admission cardiotocography, vaginal douching, routine amniotomy in spontaneous labor, and routine fundal pressure during the second stage. WHO instead emphasizes continuous labor companionship, effective communication, and respectful, woman-centered care (WHO Intrapartum Care).

Which labor complications are true emergencies?

Uterine rupture, uterine inversion, amniotic fluid embolism, and umbilical cord prolapse are the ones you cannot afford to miss. Each can rapidly threaten the life of the mother, the fetus, or both, and each calls for immediate provider notification, large-bore IV access, oxygen, and preparation for emergency surgery.

What is the priority nursing action for a prolapsed umbilical cord?

Relieve pressure on the cord at once. Manually lift the presenting part off the cord through the vagina or place the patient in Trendelenburg or knee-chest position, start oxygen, cover any exposed cord with a sterile saline compress, and prepare for emergency cesarean birth if the cervix is not fully dilated.