Nursing Care of a Family During Labor and 

Birth

This chapter adds information about the process of labor and how we can offer effective support and education to our
patient who is currently in labor. Because without this type of support, labor can be a frightening rather than an
enjoyable event.

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What is labor?

Labor is the series of events by which uterine contractions and abdominal pressure expel a fetus and placenta from the
uterus.

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Let’s discuss the stages in Labor:

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First stage is consist of 4 parts.

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First part is Early labor or Latent Phase:: The patient’s cervix opens to 4 centimeters. She will probably spend most of
early labor at home. Contractions may go away if she change activity, but over time they'll get stronger. When the
patient notice a clear change in how frequent, how strong, and how long her contractions are, and when you she can no
longer talk during a contraction, she is probably moving into active labor.

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Second part is active labor: The patient’s cervix opens from 4 to 7 centimeters. This is when she should head to the
hospital. When she have contractions every 3 to 4 minutes and they each last about 60 seconds, it often means that her
cervix is opening faster (about 1 centimeter per hour).

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As her labor progresses, a reddish mucous discharge might be seen, which could be the mucous plug at the opening of
the patient's cervix.

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When this happen, the patient starts "water breaking", which is the rupture of the amniotic sac causing a gush of fluid
that signals that her baby is almost ready to be born. If this happens, the patient will begin to undergo stage 2 of her
labor.

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The third part is Transition to second stage:

The patient’s cervix opens from 7 to 10 centimeters. For most women, this is the hardest or most painful part of labor.
This is when your cervix opens to its fullest. Contractions last about 60 to 90 seconds and come every 2 to 3 minutes. So,
how does it happens?

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Second stage of labor

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The patient’s baby moves through the birth canal. The second stage of labor begins when the cervix is completely
dilated (open), and ends with the birth of your baby. Contractions push the baby down the birth canal, and the patient
may feel intense pressure, similar to an urge to have a bowel movement.

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During a vaginal childbirth, the first stage of labor lasts about 12 to 19 hours and starts when the patient's baby settles
lower into her pelvis. In response, Oxytocin, which is a hormone produced by the hypothalamus and secreted by the
pituitary gland, stimulates the uterine muscles to contract, so labor begins. It also increases the production of
prostaglandins, which move labor along and increases the contractions even more. Because of this effect, synthetic
oxytocin (pitocin) is sometimes used to induce a woman to start labor if she cannot start naturally, or it can be given to
make contractions stronger if a woman's labor is slowing.

When the cervix dilates from 7 to 10 centimeters, the pattern changes to where contractions last 60 to 90 seconds, with
just 30 seconds to 2 minutes of rest between. During this time, the patient may feel strong regular contractions and
extreme lower back pain. Why lower back pain?

In a normal delivery the baby's head will rotate to face the patients back. The patient's uterus is divided into an active
segment that contracts pushing the baby downward and a flexible passive segment that remains relaxed stretching to
provide more room for the baby to pass through. If the baby is facing the patient’s tummy, the back of the baby’s head,
which is the hardest part, pushes down on the patients spine and tailbone. This presses on the nerves in the spine,
causing pain. The doctor would formally call this the “Occipito Posterior Position”.

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When the top of your baby's head appears or crowns "also called crowning", the doctor may make a small cut called an
episiotomy to enlarge the vaginal opening. Then she will continue pushing her baby out as the baby's head passes
through the birth canal.

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The head molds into an elongated shape which will resolve itself within a few days as the skull bones shift back into
place.

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After the baby's head exits the birth canal, the baby's shoulders will rotate. To help the shoulders pass through the birth
canal, the baby's shoulders are delivered one after the other in order to fit through the patients pelvis. Once the
shoulders emerge, the rest of the baby slides out easily. After the baby is born, his or her umbilical cord will be cut.

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Third stage of labor is also called afterbirth.

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After the birth of the baby, the patients uterus continues to contract to push out the placenta. The placenta usually
delivers about 5 to 15 minutes after the baby arrives. Mild contractions will help push the placenta out of the uterus.

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During this stage, the patient and her baby may begin their bonding through skin-to-skin contact and breastfeeding
(Unang Yakap).

Once the baby is born, oxytocin promotes lactation by moving the milk into the breast. When the baby sucks at the
mother's breast, oxytocin secretion causes the milk to release so the baby can feed. At the same time, oxytocin is
released into the brain to stimulate further oxytocin production. Once the baby stops feeding, the production of the
hormone stops until the next feeding. Nursing right after birth will help the patients uterus to contract and will decrease
the amount of bleeding.

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Labor and birth are unique events, requiring a woman to employ all the psychological and physical coping methods she
has available. Regardless of the amount of childbirth preparation or the number of times a woman has been through the
birth experience, family-centered nursing care is the approach that best supports the woman as she focuses on the
beginning of her new family.

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Nursing Process Overview For the Woman in Labor

Assessment

A woman in labor is keenly aware of both nonverbal and verbal expressions around her ( not only words spoken
but gestures such as eye rolling or sighing). Because of this sensitivity, an assessment must be done quickly yet
thoroughly and gently because she may have difficulty being patient, for example, while admission information is
obtained or relaxing for a vaginal examination. Remember that pain is a subjective symptom. Only the woman can
evaluate how much she is experiencing or how much she wants to endure. Assess how much discomfort she is
experiencing and how she feels about her labor not only by what she scores on a pain scale but also by subtle signs of
pain such as facial tenseness, fl ushing or paleness of the face, hands clenched in a fi st, rapid breathing, or rapid pulse
rate. Appreciate that the fetus as well as the mother is under stress from the process of labor, so both need vital sign
assessments.

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Nursing Diagnosis

Nursing diagnoses in labor generally relate to a woman’s reaction to labor.

Common nursing diagnoses include:

● Pain related to labor contractions

● Anxiety related to process of labor and birth

● Health-seeking behaviors related to management of discomfort of labor

● Situational low self-esteem related to inability to use planned childbirth method

Although the discomfort of labor contractions is commonly referred to as “contractions” rather than “pain,” do
not omit the word “pain” from a nursing diagnosis because the term strengthens an understanding of the problem.

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Outcome Identification and Planning

When establishing expected outcomes for a woman in labor and her partner, be certain they are realistic and
that they can be met. Although labor usually takes place over a relatively short time frame (average, 12 hours), it is
important not to project a definite time limit for labor to be completed because the length of labor can vary greatly from
woman to woman and still be within normal limits. It is necessary also to appreciate the magnitude of labor. It is unlikely
all the fear or anxiety experienced during a woman’s labor can be completely alleviated. Often, because it is such an
unusual and significant experience, the average couple may need guidance in order to be able to employ additional
coping measures. Be certain to incorporate a support person as well as the woman in planning so the experience is a
shared one. Although a couple may have learned about the stages of labor and what to expect at each stage during
pregnancy, the reality of labor may seem very different from what they imagined. Be certain also that planning is fl
exible and individualized, allowing the woman to experience the full significance of the event. You may recommend
helpful web sites for them to learn more about birth.

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Implementation

As much as possible, interventions during labor should always be carried out between contractions so the
woman can use a prepared childbirth technique to limit the discomfort of contractions. This calls for good coordination
of care among health care providers and the woman and her support person. The person a woman chooses to stay with
her during childbirth is often culturally determined and varies from being a husband, a significant other or partner, the
father of the child, a sister, a parent, or a close friend.

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1. TENS - stands for Transcutaneous Electrical Nerve Stimulation, and is a small electrical device that reduces pain
signals sent to the brain.The battery-operated TENS machine has thin wires that are connected to four
electrodes, or sticky pads, which are taped to the lower back. The machine is thought to work by sending
electrical pulses from the machine along nerve roots to the pain pathways in the brain, thereby blocking pain
impulses.
2. Activity - Staying active during labor can help women deal with pain and reduce the length of labor.
3. Hypnosis -Self-hypnosis, using visualization and breathing techniques to induce a state of deep relaxation and
banish fear, is an increasingly popular way to deal with labor.
4. Water - Many women find being in warm water during labor very soothing and an excellent way to cope with
labor pain. The warmth of the water relaxes muscles, and being in water aids buoyancy, which can help relieve
the pressure on your pelvis.
5. Relaxation and Breathing Techniques - If you're relaxed, it will be easier to stay calm and in tune with your body.
There are various techniques you can use to help you relax during labor. These techniques include focusing on
your breathing, listening to music and listening to a meditation CD.
6. Acupuncture - Acupuncture uses fine needles placed at specific points on the body to reduce pain by stimulating
the production of endorphins.
7. Aromatherapy - Aromatherapy (essential) oils are derived from plants and used for their therapeutic properties.
The use of these oils in childbirth can stimulate, refresh and soothe you and, to some extent, your partner.
8. Reflexology - Reflexology involves massaging reflex zones on your feet that correspond with different parts of
your body to improve your blood circulation and relax any tension you may be feeling. Because many women
naturally want to be active and move around during their labor, it may be more helpful in between early
contractions.

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Outcome Evaluation

An evaluation during labor should be ongoing to preserve the safety of the woman and her newborn. After birth,
an evaluation helps to determine the woman’s opinion of her experience with labor and birth. Ideally, the experience
should not only be one she was able to endure but also one that allowed her self-esteem to grow and the family bond to
intensify through a shared experience. It is advantageous to talk to women following birth about their labor experience
because doing so serves as a means of evaluating nursing care during labor. It also provides a woman the chance to
“work through” the experience and incorporate it into her self-image.

Possible outcome criteria include:

 Client states pain during labor was tolerable because of her advance preparation.
 Client verbalizes that her need for nonpharmacologic comfort measures was met.
  Client and family members state the labor and birth experience was a positive growth experience for them, both
individually and as a family.

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THEORIES OF WHY LABOR BEGINS

Labor normally begins between 37 and 42 weeks of pregnancy, when a fetus is sufficiently mature to adapt to
extrauterine life, yet not too large to cause mechanical difficulty with birth. In some instances, labor begins before a
fetus is mature (preterm birth). In others, labor is delayed until the fetus and the placenta have both passed beyond the
optimal point for birth (postterm birth). Although in animals it has been shown that progesterone withdrawal is the
trigger that stimulates labor, the association that converts the random, painless Braxton Hicks contractions of pregnancy
into strong, coordinated, productive labor contractions in women is still largely undocumented. A number of theories,
including a combination of factors originating from both the woman and fetus, have been proposed to explain why
progesterone withdrawal begins.

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Some of the theories include:

 The uterine muscle stretches from the increasing size of the fetus, which results in release of prostaglandins.
 The fetus presses on the cervix, which stimulates the release of oxytocin from the posterior pituitary.
 Oxytocin stimulation works together with prostaglandins to initiate contractions.
 Changes in the ratio of estrogen to progesterone occurs, increasing estrogen in relation to progesterone, which
is interpreted as progesterone withdrawal.
 The placenta reaches a set age, which triggers contractions.
 Rising fetal cortisol levels reduce progesterone formation and increase prostaglandin formation.
 The fetal membrane begins to produce prostaglandins, which stimulate contractions

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THE COMPONENTS OF LABOR

A successful labor depends on four integrated concepts, often referred to as the four P’s:

1. The passage (a woman’s pelvis) is of adequate size and contour.

2. The passenger (the fetus) is of appropriate size and in an advantageous position and presentation.

3. The powers of labor (uterine factors) are adequate.

4. A woman’s psychological outlook is preserved, so afterward, labor can be viewed as a positive experience

All of these must work together in synchronicity to achieve a successful, vaginal birth. Think of them as gears in a
machine. If one of the gears is misaligned, then the whole machine malfunctions.

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Dystocia 

Normal labor is characterized by progress. Dysfunctional labor is one that does not result in normal progress of
cervical effacement (thinning of the cervix), dilation (enlargement of the cervix), and fetal descent (downward passage
of the baby through the pelvis). Dystocia is a general term that describes any difficult labor or birth. A dysfunctional
labor may result from problems with the powers of labor, the passenger, the passage, the psyche, or a combination of
these. Dysfunctional labor is often prolonged but may be unusually short and intense. Combined medical and nursing
care is indicated for care of the woman having dysfunctional labor.
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The first P is the passageway aka the birth canal. The passage refers to the route a fetus must travel from the
uterus through the cervix and vagina to the external perineum. This is consist of the pelvis or the bones, the soft tissues
of the cervix, and the vagina.

A small (contracted) or abnormally shaped pelvis may retard labor and obstruct fetal passage. The danger
of uterine rupture (tear in the uterine wall) is greater with thinning of the lower uterine segment, especially if
contractions remain strong.

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There are four types of pelvises that our patient might have.

1. Gynecoid

2. Android

3. Anthropoid

4. Platypelloid

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Gynecoid

This is the most common pelvis structure. It is round, cylindric shape throughout with wide pubic arch (90
degrees or greater). It is the most favorable pelvis for vaginal delivery. This is because the wide, open shape give the
baby plenty of room during delivery. Approximately 40% to 50% of women has this kind of pelvis.

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Android

This type of pelvis bears more resemblance to the male pelvis. It’s narrower than the gynecoid pelvis and is
shaped more like a heart or a wedge. The narrower shape of the android pelvis can make labor difficult. It is because the
baby might move more slowly through the birth canal. Some pregnant women with an android pelvis may require a C-
section. Android pelvis occurs in approximately 20%

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Anthropoid

An anthropoid pelvis occurs in approximately 25% of all women. It has a long, narrow oval shape with narrow
pubic arch. Its shape is similar to an upright egg or oval. The elongated shape of the anthropoid pelvis makes it roomier
from front to back than the android pelvis. But it’s still narrower than the gynecoid pelvis. Some pregnant women with
this pelvis type may be able to have a vaginal birth, but their labor might last longer.

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Platypelloid

The platypelloid pelvis is also called a flat pelvis. This is the least common type. It’s wide but shallow, and it
resembles an egg or oval lying on its side. The shape of the platypelloid pelvis can make a vaginal birth difficult. It is
because the baby may have trouble passing through the pelvic inlet. Many pregnant women with a platypelloid pelvis
need to have a C-section. But this one is super rare. The platypelloid pelvis occurs in only 2% to 5% of women.
 A special note that I want to bring up. You cannot determine the size and shape of a woman's pelvis just by
looking at her. That's kind of an old-fashioned thing. You cannot tell somebody's pelvis or how they're going to do in
labor just by looking at them.

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Second P: The Passenger

Yep. This would be the baby. Mom carries the baby, hence the term passenger. The body part of the fetus that
has the widest diameter is the head, so this is the part least likely to be able to pass through the pelvic ring. Whether a
fetal skull can pass depends on both its structure (bones, fontanelles, and suture lines) and its alignment with the pelvis.

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Structure of the Fetal Skull

The cranium, the uppermost portion of the skull, is composed of eight bones. The four superior bones—the frontal
(actually two fused bones), the two parietal, and the occipital are the bones important in childbirth. The other four
bones of the skull (sphenoid, ethmoid, and two temporal bones) lie at the base of the cranium and so are of little
significance in childbirth because they are never presenting parts. The chin, referred to by its Latin name mentum, can
be a presenting part. The bones of the skull join together at suture lines. The sagittal suture joins the two parietal bones
at the top of the skull. The coronal suture is the line of juncture between the frontal bones and the two parietal bones.
The lambdoid suture is the line of juncture between the occipital bone and the two parietal bones.

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Molding

The suture lines are important in birth because they allow the cranial bones to move and overlap , causing
cranial molding or a diminishing size of the skull so it is able to pass through the birth canal more readily. Significant
membrane-covered spaces called the fontanelles (soft spot or hubon) are found at the junction of the main suture lines.
The anterior fontanelle (sometimes referred to as the bregma) lies at the frontal junction of the coronal and sagittal
sutures. It closes and can no longer be felt when the infant reaches 12 to 18 months of age. The posterior fontanelle lies
at the rear of the skull at the junction of the lambdoidal and sagittal sutures. It is smaller than the anterior fontanelle.
Because of its small size, it closes when an infant is about 2 months of age. The space between the two fontanelles is
referred to as the vertex. The area over the frontal bone is referred to as the sinciput. The area over the occipital bone is
referred to as the occiput. Fontanelle spaces compress during birth to aid in molding of the fetal head. Their presence
can be assessed manually through the cervix after the cervix has dilated during labor. Palpating for fontanelle spaces
during a pelvic examination helps to establish the position of the fetal head and whether it is in a favorable position for
birth. No skull molding occurs when a fetus is breech, because the buttocks, not the head, present fi rst. Babies born by
cesarean birth when there is no preprocedure labor also typically have no molding.

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Fetal Presentation and Position

Other factors that play a part in whether a fetus is properly aligned in the pelvis and is in the best position to be born are
fetal attitude, fetal lie, fetal presentation, and fetal position.

Fetal Attitude

Attitude describes the degree of flexion (movement that decreases the angle between two body parts) a fetus
assumes during labor or the relation of the fetal parts to each other. A fetus in good attitude is in complete flexion.

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 The fetus in full flexion presents the smallest anteroposterior diameter (suboccipitobregmatic) of the skull to the
inlet in this good attitude (vertex presentation).

A fetus in good attitude is in complete flexion: the spinal column is bowed forward, the head is flexed forward so much
that the chin touches the sternum, the arms are flexed and folded on the chest, the thighs are flexed onto the abdomen,
and the calves are pressed against the posterior aspect of the thighs. This usual “fetal position” is advantageous for birth
because it helps a fetus present the smallest anteroposterior diameter of the skull to the pelvis and also because it puts
the whole body into an ovoid shape, occupying the smallest space possible.

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The fetus is not as well flexed (military attitude) and presents the occipitofrontal diameter to the inlet
(sinciput presentation).

A fetus is in moderate flexion if the chin is not touching the chest but is in an alert or “military position”. This position
causes the next widest anteroposterior diameter, the occipitofrontal diameter, to present to the birth canal. A fair
number of fetuses assume a military position early in labor. This does not usually interfere with labor, however, because
later mechanisms of labor (descent and flexion) force the fetal head to fully flex.

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The fetus in partial extension (brow presentation).

A fetus in partial extension presents the “brow” of the head to the birth canal.

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The fetus in complete extension presents a wide (occipitomental) diameter (face presentation).

If a fetus is in complete extension, the back is arched and the neck is extended, presenting the occipitomental diameter
of the head to the birth canal. This unusual position usually presents too wide a skull diameter to the birth canal for
vaginal birth. Such a position may occur in an otherwise healthy fetus or may be an indication there is less than the usual
amount of amniotic fluid present (oligohydramnios), which is not allowing the fetus adequate movement space. It also
may reflect a neurologic abnormality in the fetus causing spasticity (muscles stiffen or tighten).

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Fetal Lie

Lie is the relationship between the long (cephalocaudal) axis of the fetal body and the long (cephalocaudal) axis
of a woman’s body—in other words, whether the fetus is lying in a horizontal (transverse) or a vertical (longitudinal)
position.

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Fetal Presentation

Fetal presentation denotes the body part that will first contact the cervix or be born first and is determined by
the combination of fetal lie and the degree of fetal flexion (attitude). There are three common presentations, cephalic
(most common), breech and shoulders (malpresentations).

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Cephalic Presentation

A cephalic presentation is the most frequent type of presentation, occurring as often as 95% of the time. With
this type of presentation, the fetal head is the body part that first contacts the cervix. The vertex (baby's head-down) is
the ideal presenting part because the skull bones are capable of effectively molding to accommodate the cervix. This
exact fit may actually aid in cervical dilatation as well as prevent complications such as a prolapsed cord (a portion of the
cord passes between the presenting part and the cervix and enters the vagina before the fetus).

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Breech Presentation.

A breech presentation means either the buttocks or the feet are the first body parts that will contact the cervix. Breech
presentations occur in approximately 3% of births and are affected by fetal attitude the same as vertex presentations

• A good attitude brings the fetal knees up against the fetal abdomen.

• A poor attitude means the knees and legs are extended.

Three types of breech presentation (complete, frank, and footling) are possible and described in Table 15.2.

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Complete: The fetus has the thighs tightly flexed on the abdomen; both the buttocks and the tightly flexed feet present
to the cervix

Frank: Neither the thighs nor lower legs are flexed. If one foot presents, it is a single-footling breech; if both present, it is
a double-footling breech.

Footling: Attitude is moderate because the hips are flexed, but the knees are extended to rest on the chest. The buttocks
alone present to the cervix.

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Shoulder Presentation

In a transverse lie, a fetus lies horizontally in the pelvis so the longest fetal axis is perpendicular to that of the
mother. The presenting part is usually one of the shoulders (acromion process), an iliac crest, a hand, or an elbow . The
usual contour of the mother’s abdomen at term may appear fuller side to side rather than top to bottom. Fewer than 1%
of fetuses lie transversely. This presentation may be caused by pelvic contractions, in which the horizontal space is
greater than the vertical space or by the presence of a placenta previa (the placenta is located low in the uterus,
obscuring some of the vertical space). It also can be caused by relaxed abdominal walls from grand multiparity, which
allow the unsupported uterus to fall forward. If an infant is preterm and smaller than usual, an attempt to turn the fetus
to a horizontal lie (external fetal version) may be made. Most infants in a transverse lie must be born by cesarean birth,
however, because they can neither be turned or born vaginally due to this “wedged” position. Discovering a shoulder
presentation during labor is an important assessment because it almost always identifies a birth position that puts both
mother and child in jeopardy unless skilled health care personnel are available to complete a cesarean birth.

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Fetal Position

Fetal position is the relationship of the presenting part to a specific quadrant and side of a woman’s pelvis. For
convenience, the maternal pelvis is divided into four quadrants according to the mother’s right and left: (a) right
anterior, (b) left anterior, (c) right posterior, and (d) left posterior. Four parts of a fetus are typically chosen as landmarks
to describe the relationship of the presenting part to one of the pelvic quadrants.
• In a vertex presentation, the occiput (O) is the chosen point.

• In a face presentation, it is the chin (mentum [M]).

• In a breech presentation, it is the sacrum (Sa).

• In a shoulder presentation, it is the scapula or the acromion process (A).

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Position is indicated by an abbreviation of three letters. The middle letter denotes the fetal landmark (O for occiput, M
for mentum, Sa for sacrum, and A for acromion process). The fi rst letter defi nes whether the landmark is pointing to
the mother’s right (R) or left (L). The last letter defi nes whether the landmark points anteriorly (A), posteriorly (P), or
transversely (T).

Position is important because it can influence both the process and efficiency of labor. Typically, a fetus is born
fastest from an ROA or LOA position. Labor can be considerably extended if the position is posterior (ROP or LOP) and
may be more painful for a woman because the rotation of the fetal head puts pressure on sacral nerves. Encouraging a
woman to rest in a Sims position on the same side as the fetal spine or use a hands and knees position may encourage
rotation from an occipitoposterior to an occipitoanterior position prior to and during labor

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Engagement

Engagement is a medical term often referred to as “baby dropping.” This means that the infant's head or
buttocks have settled into the pelvis prior to labor. If this is your first pregnancy, engagement will usually occur about
two or three weeks prior to the onset of labor. In a primipara, nonengagement of the head at the beginning of labor
suggests that a possible complication such as an abnormal presentation or position, abnormality of the fetal head, or
cephalopelvic disproportion exists. In multiparas, engagement may or may not be present at the beginning of labor. The
degree of engagement is established by a vaginal and cervical examination.

• A presenting part that is not engaged is said to be “floating.”

• One that is descending but has not yet reached the ischial spines may be referred to as “dipping.”

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Station

Station refers to the relationship of the presenting part of the fetus to the level of the ischial spines

• When the presenting fetal part is at the level of the ischial spines, it is at a 0 station (synonymous with engagement).

they are right there, they are right at the level of ischial spots.

• If the presenting part is above the spines, the distance is measured and described as minus stations, which range from
–1 to –4 cm.

it means they're still kind of high, they're floating up there.

• If the presenting part is below the ischial spines, the distance is stated as plus stations ( 1 to 4 cm).

it means they're engaged and they're ready to start pushing.

• At a 3 or 4 station, the presenting part is at the perineum and can be seen if the vulva is separated (i.e., it is crowning).

In a perfect world, we would let all women labor down and get to, plus two station or plus to positive before they
started pushing. That would be great. That would be so much easier on the mom and us the nurse.
We don't want to push at the negative numbers or zero, there's no point in that. She's just gonna get exhausted, it's not
gonna help her make progress.

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Mechanisms (Cardinal Movements) of Labor

Effective passage of a fetus through the birth canal involves not only position and presentation but also a number of
different position changes in order to keep the smallest diameter of the fetal head (in cephalic presentations) always
presenting to the smallest diameter of the pelvis. These position changes are termed the cardinal movements of labor:
descent, flexion, internal rotation, extension, external rotation, and expulsion.

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Descent

The baby's head moves deep into the pelvic cavity and is commonly called lightening. Full descent occurs when the fetal
head protrudes beyond the dilated cervix and touches the posterior vaginal floor. Descent occurs because of pressure on
the fetus by the uterine fundus. As the pressure of the fetal head presses on the sacral nerves at the pelvic floor, the
mother will experience the typical “pushing sensation,” which occurs with labor. As a woman contracts her abdominal
muscles with pushing, this aids descent.

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Flexion.

As descent is completed and the fetal head touches the pelvic floor, the head bends forward onto the chest, causing the
smallest anteroposterior diameter to present to the birth canal. Complete flexion places the fetal head in optimal
smallest diameter to fit through the pelvisFlexion is also aided by abdominal muscle contraction during pushing.

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Internal Rotation

During descent, the biparietal diameter of the fetal skull was aligned to fit through the anteroposterior diameter of the
mother’s pelvis. As the head flexes at the end of descent, the occiput rotates so the head is brought into the best
relationship to the outlet of the pelvis. This movement brings the shoulders, coming next, into the optimal position to
enter the inlet, or puts the widest diameter of the shoulders (a transverse one) in line with the wide transverse diameter
of the inlet.

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Extension

As the occiput of the fetal head is born, the back of the neck stops beneath the pubic arch and acts as a pivot for the rest
of the head. The head extends, and the foremost parts of the head, the face and chin, are born.

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External Rotation.

In external rotation, almost immediately after the head of the infant is born, the head rotates a final time back to the
diagonal or transverse position of the early part of labor. This brings the aftercoming shoulders into an anteroposterior
position, which is best for entering the outlet. The anterior shoulder is born first, assisted perhaps by downward flexion
of the infant’s head.

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Expulsion.

Once the shoulders are born, the rest of the baby is born easily and smoothly because of its smaller size. This
movement, called expulsion, is the end of the pelvic division of labor. For a view of the complete birth sequence

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Now lets go to the third P is for powers or the power of labor or contractions.

Contractions are incredibly important in labour because they cause the cervix to get thinner and shorter. This is called
effacement, to dilate refers to the enlargement or widening of the cervical canal.

Forces acting to expel fetus:

• Primary force - involuntary uterine muscular contractions causing complete effacement and dilatation of
cervix (during first stage of labor).

• Secondary force - use of abdominal muscles to push during the second stage of labor (voluntary bearing
down).

So as the contraction is getting stronger, increasing in the intensity, it's called the increment. Increment = increase. Its
strongest point, is the peak or the Acme, and it's going down, which is decreasing, that's called the decrement
=decrease.

And then the point in between contractions is called the interval.

So why do you need to know all that information? because think about it, what point would be the best time to
encourage mom to push? The peak, right. So her body is involuntarily doing this. So we're gonna encourage voluntary
pushing and bearing down at this point because this is gonna help Mom push baby out, a little bit faster and a little bit
easier.

We should definitely not be pushing during the interval. The interval is the time, in which baby is getting reoxeginated.

Some other words related to the contractions are frequency, intensity, and duration.

Frequency is the one I'm sure you already know. Where they say, I'm having contractions every two to three minutes.
That's how frequent you're having them. So from the start of one contraction, to the start of another contraction. How
often are you having them? that's the frequency.

The intensity, is how strong are they. So are they really really strong contractions, are they're really great or they really
like weak piddly little ones that aren't doing much which doesnt cause much cervical change. So how strong, how
intense are the contractions

And the duration is how long does one contraction last. So the duration is from the start of one contraction, to the end
of that very same contraction. So how long does it last. 30 seconds that's not great, 60 seconds that's great right.

So all this stuff matters and it's all gonna help Mom and it's gonna help us, as the nurse to coach mom in the second
stage of labor which is the pushing stage.

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Our fourth and final P is the psyche and this is the one that people tend to forget about. You know, the other ones they
make sense, you have your birth canal, you have the baby, you have the contractions, that all make sense right. But the
psyche is actually really important too. This is moms, like mental state during labor. And it can affect things in a negative
way if we don't have a good understanding of it.

A woman who is relax, aware and participating in the birth process usually has a shorter, less intense labor.
A woman who is fearful has high levels of adrenaline which shows uterine contractions

So what are some things that can affect the woman's psyche?

1. Her culture. Some cultures, when they're in labor they're having those sort of pains, we express it freely and we
scream and yell and all that stuff. Were other cultures, they're taught to be more reserved and stoic during labor.

2. Preparation for labor. So has she read any books, seen any videos, has she taken a birthing class, or has she had no
preparation whatsoever. Those people are gonna go into this situation very differently.

3. Support system. Does she have a support system? is the father of the baby involved? is he present? is grandma there?
does she have a lot of people with her? or is she all by herself?

4. Previous births. So this can include having other children in the past, or attending the birth of somebody else. So
maybe like her older sister had a baby and she was there. And there were complications and now she's terrified because
what happened to her sister's baby is gonna happen to her baby, that kind of thing. Or it could be a positive thing where
she's had babies in the past and they were uncomplicated, easy breezy, no problems. She's probably gonna go into this
thinking, this is gonna be exactly the same,easy no problems.

5. Current pregnancy. So has she had an uncomplicated, no issues pregnancy? If she's had that, she's probably gonna
assume, she's gonna have an uncomplicated, no issues delivery. Or has she had issues? she been preeclamptic, has she
been put on bed rest, that kind of stuff, that's gonna affect the way she goes into the delivery. And the way she kind of
feels about the delivery.

6. and then finally I kind of put him all together, PAIN. Is she distracted by pain, FEAR. Is she afraid what's gonna happen
to her, the baby and then ANXIETY. All of these things, believe It or Not, can actually stop your labor, so even if you're
coming in and you're in good labor, you're you know four centimeters and you're an active labor and you're ready to
have this baby. But you're in so much pain or you're so worried and afraid about what's gonna happen, it can actually
cause your contractions to stop. And take you out of labor. And we don't want that, we don't want to put people out of
labor, who are term and ready to be in labor, right.

So it's our job as the nurse to assess mom's emotional mental status during labor and if there's any issues to help fix
those issues, as best as we can. So if she's all alone, you're gonna be her support system. You're gonna do that anyway
cuz you're her advocate as the nurse. If she has a culture where they expressed pain freely let her scream and yell.
You're not gonna go in there and just rush her and say stop. Let her do it. Or if she just wants you to hold her hand, so
she can squeeze your hand, let her do that. So assessing mom's psyche is also really important and we shouldn't forget
about this.

MATERNAL AND FETAL RESPONSES TO LABOR

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Physiologic and psychologic effects of labor on the mother.

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Physiologic Effects on Woman

Cardiovascular system

Strenuous work on the heart causing increased cardiac output, blood pressure and pulse rate. During a
contraction blood flow to the uterus decreases which leads to increase blood amount in the general circulation and thus
increase in the peripheral resistance and resulting in increase in blood pressure (systole and diastole). Blood volume
increases substantially during pregnancy, so that by childbirth, it exceeds its preconception volume by 30 percent, or
approximately 1–2 liters. The greater blood volume helps to manage the demands of fetal nourishment and fetal waste
removal. In conjunction with increased blood volume, the pulse and blood pressure also rise moderately during
pregnancy. As the fetus grows, the uterus compresses underlying pelvic blood vessels, hampering venous return from
the legs and pelvic region. As a result, many pregnant women develop varicose veins or hemorrhoids.

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Blood loss (300 – 500 ml) aids in reducing blood volume.

Blood pressure: with the increased cardiac output during contractions, systolic blood pressure rises an average of 15mm
Hg with each contraction.

When lying in supine position and pushes, her BP can drop leading to hypotension (upright or side lying position during
the second stage can help avoid such a problem

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Hemopoietic system:

Leukocytosis or sharp increase in WBCs possibly due to stress and heavy exertion (reaching 25,000/mm³ to 30,000/mm³
cells.

Respiratory system:

With increased cardiovascular output, the body responds with increased respiratory rate to provide oxygen leading to
hyperventilation

Consumption of Oxygen is up to 100% during the second stage (similar to running)

During the second half of pregnancy, the respiratory minute volume (volume of gas inhaled or exhaled by the lungs per
minute) increases by 50 percent to compensate for the oxygen demands of the fetus and the increased maternal
metabolic rate. The growing uterus exerts upward pressure on the diaphragm, decreasing the volume of each inspiration
and potentially causing shortness of breath, or dyspnea. During the last several weeks of pregnancy, the pelvis becomes
more elastic, and the fetus descends lower in a process called lightening. This typically ameliorates dyspnea.

The respiratory mucosa swell in response to increased blood flow during pregnancy, leading to nasal congestion and
nose bleeds, particularly when the weather is cold and dry. Humidifier use and increased fluid intake are often
recommended to counteract congestion.

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Temperature Regulation:
Increased muscular activity during labor leads to increased body temperature (1 degree)

Diaphoresis and evaporation helps the body to lose temperature

Fluid balance:

Factors affecting fluid balance:

Increased rate of respiration

Diaphoresis (insensible water loss)

Withholding fluid during labor

All may necessitate IV fluid replacement

Urinary system
With decreased fluid intake, kidneys begin concentration urine to preserve fluid and electrolytesIncreased specific
gravity

Protein in urine due to protein breakdown (muscle exertion)

Loss of sense of bladder filling (tone) which leads to overfilling. (During labor a woman must void every 2 hours)

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Musculoskeletal system:
Relaxin (released from ovaries) during pregnancy resulted in softening cartilage between bones (symphysis pubis and
sacro coccyx joints) lead to backache and pain at pubis during walking

Gastrointestinal system:

Fairly inactive during labor

Prolonged time of stomach emptying explain why food intake is restricted during labor

Loose bowel movements

Neurologic and sensory responses:

Responses related to pain (increased pulse and respiratory rate)

Pain due to contraction and perineal stretching

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The Psychological Responses of a Woman to Labor

The Response to Pain

Cultural factors can strongly influence a woman’s experience and satisfaction with labor. In the past, American women
were accustomed to expecting hospital procedures and a medical model of care; based on this, they followed
instructions with few questions. Today, women are encouraged to help plan their care. In addition, every woman
responds to cultural cues in some way. This makes her response to pain, her choice of nourishment, her preferred
birthing position, the proximity and involvement of a support person, and customs related to the immediate postpartal
period highly individualized. To make labor a positive experience, be prepared to adapt care to the woman’s specific
needs. If a woman has traditions that run counter to hospital protocols, address these differences and make
arrangements to accommodate her desires, beliefs or customs, if possible, such as advocating for special foods to eat,
ballroom dancing in order to remain upright, or saving the placenta for the mother to take home.

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The Response to Fatigue

By the time the date of birth approaches, a woman is generally tired from the burden of carrying so much extra weight
and has not slept well for the past month. For example, a side-lying position caused backache; when she turned onto her
back, her fetus kicked and wakened her; when she turned back to her side, her back ached again. Sleep hunger from this
type of discomfort can make it diffi cult for a woman to perceive situations clearly or to adjust rapidly to new situations.
It can make a small deficiency such as a wrinkled sheet appear as a major threatening discrepancy in her care. It can
make the process of labor loom as an overwhelming, unendurable experience unless she has competent people with her
to offer support, reassurance, and comfort.

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The Response to Fear

Women appreciate a review of the labor process early in labor as a reminder that childbirth is not a strange, bewildering
event but a predictable and well-documented one. Being taken by surprise—labor moving faster or slower than the
woman thought it would or contractions harder and longer than she remembers from last time—can lead a woman to
feel out of control and increase the level of pain she experiences. This sense of lack of control combined with pain may
cause her to begin to worry for her infant and may make her afraid she will not meet her own behavioral expectations.
Explain and repeat as necessary that labor is predictable, but also variable. Contractions last a certain length and reach a
certain intensity, but always have a rest period in between so she can have a break from pain. Fear of labor this way
releases adrenaline, and adrenaline interferes with oxytocin release and so can limit the effectiveness of uterine
contractions

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Fetal responses to labor:

Neurologic system: uterine contractions exert pressure on fetal head results in increased intracranial pressure.

Decreased fetal heart rate by 5 bpm during a contraction. This decrease appears on the fetal monitor as an early
deceleration pattern (normal during labor)

Cardiovascular system:

With contractions the uterus is arteries are sharply constricted and cotyledons filling halts leading to reduced oxygen
and nutrients

Integumentary system:

Minimal petachiae or echymotic areas on the fetus, caput succedaneum

Musculoskeletal system:

Contractions encourage full flexion attitude

Respiratory system:

Labor assists in the maturation of surfactant production by alveoli

Pushing aids in clearing the lung fluid

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Maternal Danger Signs of Labor

Wide variation exists among individuals in their response to labor and their pattern of labor contractions.
Certain signs, however, indicate that the course of events is deviating from usual.

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High or Low Blood Pressure

Normally, a woman’s blood pressure rises slightly in the second (pelvic) stage of labor because of her pushing
effort A systolic pressure greater than 140 mmHg and a diastolic pressure greater than 90 mmHg, or an increase in the
systolic pressure of more than 30 mmHg or in the diastolic pressure of more than 15 mmHg (the basic criteria for
gestational hypertension), should be reported. Just as important to report is a falling blood pressure because it may be
the first sign of intrauterine hemorrhage, although a falling blood pressure from hemorrhage is often associated with
other clinical signs of hypovolemic shock, such as apprehension, increased pulse rate, and pallor.

Abnormal Pulse
 Most women during pregnancy have a pulse rate of 70 to 80 beats/min. This rate normally increases slightly
during the second stage of labor because of the exertion involved. A maternal pulse rate greater than 100 beats/min
during labor is unusual and should be reported because it may be another indication of hemorrhage.

Inadequate or Prolonged Contractions

Uterine contractions normally become more frequent, intense, and longer as labor progresses. If they become less
frequent, less intense, or shorter in duration, this may indicate uterine exhaustion (inertia). This problem may be
correctable but needs augmentation or other interventions to accomplish this. Observe also if there is a period of
relaxation between contractions so the intervillous spaces of the uterus can fill and maintain an adequate supply of
oxygen and nutrients for the fetus. As a rule, uterine contractions lasting longer than 70 seconds are becoming long
enough to compromise fetal well-being because this interferes with adequate uterine artery filling.

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Abnormal Lower Abdominal Contour

If a woman has a full bladder during labor, a round bulge appears on her lower anterior abdomen. This is a
danger signal for two reasons: fi rst, the bladder may be injured by the pressure of the fetal head pressing against it; and
second, the pressure of the full bladder may not allow the fetal head to descend. To avoid a full bladder, ask women to
try to void about every 2 hours during labor.

Increasing Apprehension

Warnings of psychological danger during labor are as important to consider in assessing maternal well-being as are
physical signs. As she approaches the second stage of labor, a woman who is becoming increasingly apprehensive
despite clear explanations of unfolding events may not be “hearing” because she has a concern that has not been met.
Using an approach such as, “You seem more and more concerned. Could you tell me what is worrying you?” may be
helpful. Increasing apprehension also needs to be investigated for physical reasons, because it can be a sign of oxygen
deprivation or internal hemorrhage.

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Fetal Danger Signs of Labor

As well as observing for a woman’s danger signs of pregnancy, observing fetal danger signs is equally important. These
fetal danger signs include the following.

High or Low Fetal Heart Rate

As a rule, an FHR of more than 160 beats/min (fetal tachycardia) or less than 110 beats/min (fetal bradycardia) is
a sign of possible fetal distress. An equally important sign is a late or variable deceleration pattern revealed on a fetal
monitor. Frequent monitoring by a fetoscope, Doppler, or a monitor is necessary to detect these changes as they fi rst
occur.

Meconium Staining

This is not always a sign of fetal distress but is highly correlated with its occurrence . Meconium staining, a green
color in the amniotic fl uid, reveals the fetus has had a loss of rectal sphincter control, allowing meconium to pass into
the amniotic fluid. It may indicate a fetus has or is experiencing hypoxia, which stimulates the vagal refl ex and leads to
increased bowel motility. Although meconium staining may be usual in a breech presentation because pressure on the
buttocks causes meconium loss, it should always be reported immediately even with breech presentations so its cause
can be investigated.

Hyperactivity

Ordinarily, a fetus remains quiet and barely moves during labor. Fetal hyperactivity may be a subtle sign that
hypoxia is occurring because frantic motion is a common reaction to the need for oxygen.

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Low Oxygen Saturation

Oxygen saturation in a fetus is normally 40% to 70%. A fetus can be assessed for this by a catheter inserted next to the
cheek (under 40% oxygenation needs further assessment). If fetal blood is obtained by scalp puncture, the finding of
acidosis (blood pH lower than 7.2) suggests fetal well-being is becoming compromised and that further investigation is
also necessary.

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MATERNAL AND FETAL ASSESSMENTS DURING LABOR

The Immediate Assessment of a Woman in First Stage of Labor

• The Initial Interview and Physical Examination

The Detailed Assessment During the First Stage of Labor

• The History

• The Physical Examination

• Leopold Maneuvers

• The Vaginal Examination

• Sonography

• Assessing Rupture of Membranes

• Assessment of Pelvic Adequacy

• Vital Signs

• Laboratory Analysis

• The Assessment of Uterine Contractions

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The Initial Fetal Assessment

• Auscultation of Fetal Heart Sounds

Electronic Monitoring

• Initial Electronic Monitoring

Fetal Heart Rate and Uterine Contraction Records

Fetal Heart Rate Parameters

 • The Baseline Fetal Heart Rate

• Variability

• Periodic Changes

• The Sinusoidal Pattern

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THE CARE OF A WOMAN DURING THE FIRST STAGE OF LABOR

Nursing Interventions

• Help Empower Women

Help each woman express her feelings in her own way or in the way that works best for her.

• Respect Contraction Time

Do not interrupt a woman who is in the middle of breathing exercises during labor to perform a procedure or
ask questions because, once her concentration is disrupted, she will feel the pain of the contraction and, if she
has been successfully using breathing exercises to reduce pain, suddenly feeling the full force of a contraction
can be extremely frightening

• Promote Change of Positions

In early labor, however, a woman should be out of bed walking or sitting in a chair, kneeling, squatting, on all
fours, or in whatever position she prefers because active movement can shorten the beginning stage of labor

• Help With Fetal Alignment

A birthing sling is a long piece of fabric that can be slipped under a woman’s back as she lies supine or over the
abdomen if she is in a hands-and-knees position (Simkin, 2010). A support person uses the sling to gently rock
the mother’s abdomen, a technique which is advocated as also helping a fetus move into good alignment with
the pelvis.

• Promote Voiding and Provide Bladder Care

A full bladder or bowel can impede fetal descent, so encourage a woman to void, if possible, at least every 2 to 4
hours during labor.

• Offer Support

Patting an arm while telling a woman she is progressing in labor, brushing away a wisp of hair from her
forehead, and wiping her forehead with a cool cloth are indispensable methods of conveying support and
produce several benefits.

• Respect and Promote the Support Person

Be certain to admit a woman’s support person to the birthing area along with the woman and encourage him or
her to remain with the woman throughout the birth because having someone familiar with her during labor
helps to counteract the sensation everything is new and unexpected

• Support a Woman’s Pain Management Needs

Because pain is subjective, only the woman knows how much pain she can endure and whether she needs some
supplemental help to make childbirth the experience she planned

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THE CARE OF A WOMAN DURING THE SECOND STAGE OF LABOR

• Preparing the Place of Birth

For a multipara, convert a birthing room into a birth room by opening the sterile packs of supplies on waiting
tables when the cervix has dilated to 7 to 8 cm. For a primipara, this can be delayed until the head has crowned
to the size of a quarter or half-dollar (full dilatation and descent). Be certain drapes and materials used for birth
are sterile so no microorganisms can be accidentally introduced into the uterus. A table arranged with
equipment such as sponges, drapes, scissors, basins, clamps, vaginal packing, and sterile gowns, gloves, and
towels can be left, if covered, for up to 8 hours. A birthing bed is “broken” or the foot folded down to allow the
primary care provider ready access to support a crowning newborn head. Be certain that once a bed is broken,
someone remains continuously at the foot of the bed so if the fetus is born suddenly, the head and body can be
supported and born safely. To provide for baby care, open the partition at the end of the room to reveal the
“baby island,” or newborn care area. Such areas include a radiant heat warmer, equipment for suction and
resuscitation, and supplies for eye care and identifi cation of the newborn. Turn on the radiant heat warmer in
advance, so the bottom mattress is pleasantly warm to the touch at the time of birth. Place sterile towels and a
blanket on the warmer so they will also be warm when used to dry and cover the infant to help prevent
hypothermia.

• Positioning for Birth

Women can choose a variety of positions for birth. It can be lithotomy, lateral or Sims position, a dorsal
recumbent position. Using these positions plus warm compresses to the perineum place less tension on the
perineum and result in fewer perineal tears. They can also opt to water birth. Women may not only use a warm
water tub for labor comfort and relaxation but also to give birth under water. The increased buoyancy they feel
from the water helps them change positions easily; a sitting posture helps with fetal descent

• Promoting Effective Second-Stage Pushing

For the most effective pushing during the second stage of labor, a woman should wait to feel the urge to push
even though a pelvic exam has revealed she is fully dilated. Pushing is usually best done from a semi-Fowler’s
position with legs raised against the abdomen, squatting, or on all-fours rather than lying fl at to allow gravity to
aid the effort. Make sure the woman pushes with contractions and rests between them.

• Perineal Cleaning and Massage

Massaging the perineum as the fetal head enlarges the vaginal opening helps to keep it supple and prevent
tearing. To remove vaginal or rectal secretions and prepare the cleanest environment for the birth of the baby,
the care provider may clean the perineum with a warmed antiseptic such as Iodaphor (cold solution causes
cramping), and then rinse the area with sterile water.

• The Birth

As soon as the head of a fetus is prominent (approximately 8 cm across) at the vaginal opening, one technique
to help the fetus achieve extension and allow the smallest head diameter to present is for the care provider to
place a sterile towel over the rectum and press forward on the fetal chin while the other hand presses
downward on the occiput (a Ritgen maneuver)

• Cutting and Clamping the Cord

Cutting the cord is part of the stimulus that initiates a fi rst breath or marks the newborn’s most important
transition into the outside world, the establishment of independent respirations. The timing of cord clamping,
however, varies depending on the parent’s preference and the maturity of the infant

• Introducing the Infant

 After the cord is cut, it is time for the new parents to spend quality time with their newborn. The infant can
remain on the mother’s abdomen for skin-to-skin contact. If the woman’s partner or support person wants to
hold the infant, dry the infant well with a warmed towel, wrap him or her in a sterile blanket, and cover the
head with a wrapped towel or cap. Be certain to handle newborns gently but fi rmly as they are slippery from
amniotic fl uid and vernix.
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• The Delivery of the Placenta

The placenta will deliver spontaneously following most births. If the placenta has not delivered spontaneously
after about 10 minutes, the primary care provider will ask the new mother to bear down gently or else the
provider will apply gentle pressure on the contracted uterine fundus along with gentle traction on the umbilical
cord. If these measures are not successful, a placenta can be removed manually to limit the amount of
postpartum bleeding

• The Perineal Inspection

To be certain a woman’s perineum did not tear from the pressure of the fetal head, the perineum is carefully
inspected after birth.

• The Immediate Postpartum Assessment and Nursing Care

Because the uterus may be so exhausted from labor that it cannot maintain contraction, there is a high risk for
hemorrhage during this time (it is the most dangerous time of birth for the mother). Obtain vital signs (pulse,
respirations, and blood pressure) every 15 minutes for the fi rst hour and then according to agency policy or the
woman’s condition. Pulse and respirations may be fairly rapid immediately after birth (80 to 90 beats/min and
20 to 24 breaths/min), and blood pressure may be slightly elevated due to exertion and excitement of the
moment or recent oxytocin administration. Wash the perineum with the agency-designated solution and apply a
perineal pad. Palpate a woman’s fundus for size, consistency, and position and observe the amount and
characteristics of lochia each time you record vital signs.

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THE WOMAN WITH UNIQUE CONCERNS IN LABOR

• The Woman Without a Support Person

A woman who brings no support person with her needs a supportive nurse to remain with her continuously
during labor. A woman whose acceptance of her pregnancy was slow to develop due to lack of adequate
support people may not have completed the psychological tasks of pregnancy by the time she is in labor. This
could make her more apprehensive about being alone and being asked to begin a new life role. Increased
assessment of parent–child bonding may be necessary in the immediate postpartal period to be certain her
loneliness does not affect her relationship with her child.

• The Woman Who Will Be Placing Her Baby for Adoption

Although this decision may have seemed easier to make during pregnancy, once a woman holds the baby in her
arms, the prospect of giving up the child may be more painful than she realized. Offer support no matter what
decision she eventually makes; also offer support as to whether she wants to hold the child or begin
breastfeeding. Be certain you do not offer influencing advice, because the woman is the only person who knows
whether keeping this child will be right for her or for the child in the future.

• The Woman With Cultural Concerns

 A number of women from countries where female circumcision is allowed may have difficulty with a successful
second stage of labor because their perineum has so much scar tissue that their vagina cannot dilate adequately
for a fetal head to pass. They may need an episiotomy to avoid extensive perineal tearing. Some women are
scheduled for cesarean births because their perineum is so strictured. Help a woman accept these surgical
interventions as necessary in order to preserve her own health and limit pressure on the fetal head.

• The Woman Who Is Morbidly Obese

Care of women with a high body mass index (BMI) requires a number of special interventions in labor and birth.
On admission, a woman may be unusually fatigued from her efforts to keep active in early labor. Because many
overweight women have elevated blood pressure, be certain to assess this on admission (but then repeat it
about 15 minutes later when she is more rested to be certain an elevated pressure was not from anxiety).
Assess her ankles carefully for edema because this is common from overworked circulation in her lower
extremities. Be certain to assess her urine for protein and glucose because gestational diabetes occurs more
often in obese women than in others