Mastering Maternal-Newborn Practice: A Comprehensive Guide
This article is designed to provide a comprehensive understanding of key concepts and practices in maternal-newborn health, drawing upon a range of clinical scenarios and evidence-based guidelines. It addresses critical aspects of labor and delivery, postpartum care, and potential complications, aiming to equip healthcare professionals and students with the knowledge and skills necessary to provide safe and effective care.
Understanding Fetal Heart Rate Patterns
Fetal heart rate (FHR) monitoring is a crucial aspect of assessing fetal well-being during labor. Different patterns can indicate various conditions, and understanding these patterns is essential for timely intervention.
Variable Decelerations and Cord Compression
Variable decelerations are abrupt decreases in FHR that vary in timing and shape relative to uterine contractions. They are often caused by umbilical cord compression, which is a significant risk factor immediately following the rupture of membranes, as the fluid cushion around the cord is reduced.
Early Decelerations and Fetal Head Compression
Early decelerations are gradual decreases in FHR that mirror uterine contractions. They are thought to be caused by fetal head compression and are generally considered benign. Fetal head compression during a contraction leads to vagal nerve stimulation, causing a transient decrease in the fetal heart rate. This deceleration is typically gradual in onset and recovery, mirroring the contraction pattern, and is considered a benign finding.
Accelerations as Reassuring Signs
Non-periodic accelerations are abrupt increases in FHR above the baseline, typically lasting less than 30 seconds. They are usually a reassuring sign, often occurring with fetal movement or stimulation. An increase in baseline variability is generally considered a reassuring sign of fetal well-being, indicating a responsive central nervous system and adequate oxygenation. Normal baseline variability ranges from 6 to 25 beats per minute.
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Addressing Postpartum Hemorrhage
Postpartum hemorrhage (PPH) is a significant concern in the immediate postpartum period. Prompt recognition and management are critical to prevent adverse outcomes.
Uterine Atony and Fundal Massage
Uterine atony, a soft and boggy uterus that does not contract effectively, is the most common cause of early PPH. Massaging the fundus is the highest priority because stimulating uterine contraction by massage can help to compress the blood vessels at the placental site and reduce bleeding. Assessing the client's blood pressure is important in evaluating the extent of blood loss, but it is not the initial action to take. Addressing the likely cause of the bleeding should precede further assessment of vital signs.
Addressing a Displaced Fundus
A firm fundus displaced to the right and above the umbilicus often indicates a full bladder. The bladder, when distended, can push the uterus out of its midline position and interfere with its ability to contract effectively, potentially leading to increased bleeding. Having the client void will relieve the pressure on the uterus, allowing it to return to its midline position and remain firm.
Recognizing and Managing Magnesium Sulfate Toxicity
Magnesium sulfate is used to prevent seizures in pre-eclampsia and tocolysis in pre-term labor. However, it can lead to toxicity if not monitored carefully.
Signs of Magnesium Toxicity
Magnesium sulfate is a central nervous system depressant. Respiratory depression (respiratory rate less than 12 breaths per minute), hypotension (systolic blood pressure less than 90 mmHg or a significant drop from baseline), and absent deep tendon reflexes are signs of magnesium toxicity and require immediate intervention to prevent serious adverse effects.
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Prioritizing Nursing Actions During Labor and Delivery
Effective nursing care during labor and delivery requires prioritizing actions based on the clinical situation.
Addressing Concerning Vital Signs
The client's low blood pressure (82/54 mm Hg) and elevated maternal heart rate (128/min) in the presence of contractions with a duration of 1 minute and a frequency of 3 minutes are concerning findings that warrant immediate notification of the provider for further evaluation and management. These vital signs could indicate maternal hypovolemia, dehydration, or other complications. While addressing the client's pain is important, the priority action should be to assess the underlying cause of the concerning vital signs before offering pain medication.
Optimizing Maternal Positioning During Labor
Supine positioning can compress the vena cava, leading to decreased venous return, reduced cardiac output, and potential maternal hypotension, which can compromise fetal oxygenation. Alternative positions like lateral or semi-recumbent are generally preferred during labor to optimize blood flow.
Recognizing Warning Signs in Late Pregnancy
Monitoring fetal movement is a crucial teaching point at 31 weeks gestation. A decrease in fetal movement can be an early indicator of fetal compromise and requires prompt evaluation.
Understanding the Stages of Labor
Labor progresses in a multistage process that can follow the typical pattern or deviate significantly in a variation of normal or in a pathologic deviation. The latter warrants nursing interventions or recognition of the deviation and the need to consult with the provider for interventions outside the scope of nursing. To understand when to intervene, the nurse must first understand the normal progression through the stages of labor.
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First Stage of Labor
The first stage begins with uterine contractions and cervical change that progress through the early and active phase. The routine time frames for first stage labor include the latent phase of labor, up to 14 hours in multiparous persons and up to 20 hours for nulliparous persons. Active labor begins when the laboring person’s cervix reaches 6 cm dilated; multiparous persons progress faster to complete dilation.
Early Phase of Stage 1
The early phase of stage 1 of labor begins with uterine contractions that elicit cervical change within 4 hours or less and ends when cervical dilation progresses to 6 cm. To encourage labor progression during the early phase, mobility and upright positioning are helpful for both comfort and cervical dilation. If a laboring person has an epidural in the early phase of labor, it is crucial for the nurse to continue position changes every 20 to 30 minutes or more frequently to facilitate fetal rotation and descent.
Active Phase of Stage 1
The active phase begins when the early phase ends (6 cm dilation) and ends when the second stage of labor begins (10 cm dilation). The active phase is often associated with contractions occurring every 2 to 5 minutes, each lasting 60 seconds, with an intensity that requires more support of the laboring person to cope with the pain. Other signs that a laboring person is reaching the active phase of labor can be nausea and vomiting, becoming more focused and internal, being unable to answer questions or converse during contractions, and feeling rectal pressure. Asking laboring people to recline or lie in a bed during the active phase without epidural anesthesia can significantly increase pain. Upright positioning and free movement are necessary coping techniques for this phase of labor.
Second Stage of Labor
In the second stage, the cervix is completely dilated, and maternal pushing efforts begin, ending in vaginal birth as the presenting part rotates through the birth canal and is expelled from the vagina. The average time frame for the second stage is less than 4 hours for birthing persons having their first child and less than 3 in multiparous persons.
Pushing Techniques and Positions
The nurse should discuss the laboring person’s preferences for the second stage of labor and review the benefits of different pushing techniques and positions. When the cervix is 10 cm dilated and 100 percent effaced, it is completely or fully dilated, and the second stage begins. Pushing efforts can begin immediately or can be delayed until the birthing person feels the urge to push. Pushing efforts can be spontaneous, without coaching or direction if signs of progress are observed. Perineal bulging with maternal efforts, visualization of the fetal presenting part, and passing of maternal stools are signs that progress is being made. Use of these signs avoids the risk for infection and perineal edema associated with multiple or prolonged vaginal examinations. If progress is unclear within the first 30 minutes, the nurse should consider having the birthing person change positions and directing the maternal effort down toward the rectum or changing between open-glottis and closed-glottis pushing to find what works for the birthing person.
Research has shown benefits for changing positions during the second stage, with upright or side-lying positions showing improved outcomes for the birthing person and fetus, and lithotomy or supine positions causing increased risk for perineal tearing, longer pushing time, more pain, and increased fetal heart rate abnormalities. Open-glottis pushing and closed-glottis pushing should be determined by the birthing person.
Prolonged Pushing Efforts
When pushing efforts exceed 3 hours in a multiparous birthing person and 4 hours in a nulliparous birthing person, there is a small but statistically significant increase in risk for postpartum hemorrhage, chorioamnionitis, endometritis, postpartum fever, obstetric anal sphincter injury, persistent occiput posterior position, shoulder dystocia, neonatal intensive care unit admission, and neonatal sepsis. The nurse should take a shared decision-making approach with the provider and the birthing person when discussing prolonged pushing efforts. The risks, benefits, and indications for interventions and alternatives that accommodate the birthing person’s preferences and risk tolerance should be discussed.
Third Stage of Labor
The third stage begins with the completion of birth of the newborn and ends when the placenta is delivered. The average time frame for this stage is between 5 and 30 minutes. Placental delivery should occur within 30 minutes of the time of birth to reduce the risk for hemorrhage.
Signs of Placental Detachment
Reports of cramping from the birthing person, lengthening of the umbilical cord, change in the shape of the uterus due to involution as the placenta detaches from the uterus and moves out of the uterus and into the vaginal canal, and increased vaginal bleeding are signs that the placenta has detached and subsequent delivery is imminent.
Fourth Stage of Labor
The fourth stage begins after the birth of the placenta. This stage includes the time to repair any perineal trauma and ends 1 to 4 hours after delivery of the placenta. This time is of the utmost importance and requires the continued presence of a skilled attendant or nurse to monitor closely for complications. Complications during this time include an increased risk of maternal hemorrhage; uterine atony; bladder distention; pain from perineal trauma or breast-feeding attempts; fatigue; hypotension or the development of a fever; and difficulty in ambulating due to birth, blood loss, perineal trauma, or epidural anesthesia. Frequent taking of vital signs and assessment of fundal height/tone/vaginal bleeding are necessary.
QSEN and Shared Decision-Making
The incidence of medical errors resulting in poor patient outcomes led to the Quality and Safety Education for Nurses (QSEN) project. The objective of the QSEN project is to educate nurses at the prelicensure level with the knowledge, skills, attitudes, and values required to increase the quality and safety of the system of health care, improving patient outcomes. An essential part of the patient-centered care QSEN competency is shared decision-making. Shared decision making means the patient and health-care team work together to make the health-care decisions best for the birthing person and fetus. The patient’s preferences, needs, and beliefs are respected, leading to the development of a partnership between the health-care team and the patient. For many pregnant patients, shared decision-making starts with a birth plan. During the labor and birth process, the patient’s and support persons’ preferences, needs, and beliefs expressed in the birth plan are respected by health-care personnel when providing patient care, following standards of care, and implementing health-care provider orders.
Management of Shoulder Dystocia
When crowning of the fetal head is noted, the nurse should prepare for imminent birth even though it may take some time with slow, controlled expulsive efforts by the birthing person. The provider attending the birth should be present with hands poised to assist with any emergencies or to provide perineal support. A meta-analysis of seven studies found that perineal massage during the second stage prevented episiotomy and decreased the duration of pushing but was not effective in decreasing the severity or incidence of perineal tears. Once the fetal head delivers, the provider will check for the presence of a nuchal cord. Also, after delivery of the head, the restitution of the fetal shoulders occurs, which means the shoulders turn to the left or right oblique diameter of the pelvis to allow easier passage of the shoulders under the maternal pubic arch. This is where a shoulder dystocia may develop with incomplete restitution or impaction of the fetal shoulder despite adequate restitution. Restitution is then followed by external rotation of the fetal head for the fetal face to be directed toward the left or right thigh of the birthing person. After external rotation, the fetal shoulders are typically delivered with gentle downward traction on the anterior shoulder followed by upward traction on the posterior shoulder, then lifting the newborn toward the birthing person’s abdomen. The nurse must consider the position of the birthing person, as these movements will differ if the anatomy is reversed in the hands-and-knees or kneeling position. Once the fetal shoulders are delivered, the remainder of the body should follow smoothly without traction placed under the fetal axilla or neck. Support of the body can be done gently to guide the remaining body with flat hands to prevent tissue trauma in the newborn.
Case Study: Applying Knowledge in a Clinical Setting
A few years ago, a patient arrived in obvious distress in what appeared to be active labor. The patient was thrashing in the EMS transport stretcher and restraints, screaming for help, saying, “The baby is coming.” I arrived to receive the transport and assume care for the patient’s triage in labor and delivery. I first helped transfer the patient to a labor and delivery bed without restraints and calmly coached the patient to take deep, slow breaths to allow for oxygen for both them and their fetus. The patient responded with deep breathing attempts while still trying to ask for relief. I explained the need to ask basic medical questions and obtained vital signs for the patient and their fetus prior to administering pain relief. I quickly and effectively addressed major health problems, medications, allergies, and pregnancy history while obtaining maternal and fetal vital signs. The patient denied any pertinent medical history and reported this was their third pregnancy, currently at 38 weeks’ gestation with two previous term vaginal births without complications. The patient was receiving care from an OB/GYN who was credentialed at our facility and who sent prenatal records at 36 weeks’ gestation for review on admission to labor and delivery. These records were being obtained by the unit secretary at that time. Contractions appeared on the monitor every 2 to 3 minutes, each lasting 1 minute, and were strong on palpation. The fetal baseline was 125 bpm, with moderate variability, positive for accelerations, and negative for decelerations. The maternal vitals were as follows: BP 122/76, pulse 95, PO2 96%, temperature 98.0° F, and pain 10/10 with contractions. The cervical exam showed 9/100/0 station with LOA fetus. I notified the provider that the patient was progressing quickly with birth imminently expected. The provider was en route to delivery and requested an anesthesia consult to consider epidural anesthesia, as this was the patient’s preference for birth. Anesthesia as presented and recommended for the patient was too close to the time of delivery; further, laboratory test results had not come back and the IV fluid bolus was not yet administered, so epidural anesthesia was contraindicated. IV medication was contraindicated as well due to fetal risk at birth, and nitrous oxide was not available at our facility. I then continued to increase the patient’s access to nonpharmacologic pain relief options by moving the patient to the shower to allow for hydrotherapy and intermittent auscultation. This provided significant relief, and the patient was able to speak clearly between contractions. I then explained the information again about epidural access in the patient’s case and recommended continued hydrotherapy, deep breathing, and counterpressure when needed for pelvic pressure. The patient began spontaneously pushing, and because our facility policy did not allow for birth utilizing hydrotherapy, I had the patient move to the toilet for expulsive efforts.
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