Module 6: The First Stage of Labor (1-22 Guided Questions) Flashcards
List the components of an admission history and physical and appropriate admission lab tests when a woman is in labor.
*Personal information, past obstetric history, past medical and primary healthcare history, and family history should be reviewed.
*Present pregnancy history should be reviewed to confirm gestational age and estimated date of delivery, significant prenatal events, and presence of a personalized plan for birth.
*P/E
*Pelvic/Cervical Exam
*Labs
Describe the component “pregnancy history” of an admission history and physical and appropriate admission lab tests when a woman is in labor.
o Age Parity
o Estimated date of delivery and estimated weeks of gestational age
o Complications of current pregnancy, including group B Streptococcus status
o Major complications of previous pregnancies, including prenatal, intrapartum, and postpartum periods
o Previous labor experience, including duration
o Mode of previous births/deliveries
o Size of previous babies Fetal movement pattern Vaginal bleeding
o Status of membranes
o Time of onset of contractions, and character of contractions from onset to the present, including frequency, duration, intensity, and aggravating and relieving factors
o Last oral intake
Describe the component “P/E” of an admission history and physical and appropriate admission lab tests when a woman is in labor.
o Vital signs: blood pressure, temperature, pulse, respirations
o Auscultation of heart and lungs
o Abdominal palpation to determine contraction pattern and fetal lie, presentation, position, and engagement
o Abdominal palpation to determine estimated fetal weight and fundal height
o Visual inspection for abdominal scars
o Assessment for presence of peripheral or facial edema
Describe the component “pelvic/cervical exam” of an admission history and physical and appropriate admission lab tests when a woman is in labor.
o Cervical effacement and dilatation
o Position of the cervix
o Station of fetal presenting part
o Presence of molding or caput succedaneum
o Fetal lie, presentation, and position
o Tone and elasticity of vagina and length of perineum
o Confirmation of membrane status
o Visual inspection of perineum
o Assessment of fetal heart rate
Describe the component “labs” of an admission history and physical and appropriate admission lab tests when a woman is in labor.
o Available prenatal records can be reviewed to identify the woman’s blood type and Rh status, anemias, glucose tolerance testing, and specific perinatal infections including GBS carrier status, hepatitis B infection or carrier status, and HIV status.
Complete blood count (CBC)
Blood type, Rh status, and antibody screen
Urinalysis
o In the case of a woman presenting with no prenatal record, all routine prenatal laboratory tests will be obtained to provide a baseline for development of a management plan.
Know the recommended frequency for the assessment of maternal vital signs in the first stage of labor.
- The following schedule for checking vital signs is frequently encountered as policy for a woman (without epidural anesthesia) during the first stage of labor who does not have a specific condition that would require more frequent monitoring:
o Blood pressure, pulse, and respirations: every hour
o Temperature: every 2 to 4 hours when the temperature is normal and the membranes are intact, and
every 1 to 2 hours if the temperature is abnormal and/or after the membranes have ruptured.
Know the recommended frequency for the assessment of maternal bladder/urine in the first stage of labor.
o A distended bladder can impede the progress of labor by preventing fetal descent as well as increasing the discomfort and pain in the lower abdomen that women frequently experience during labor.
o A woman in labor should be encouraged to empty her bladder at least every 2 hours during the active phase of the first stage of labor.
o This provides an opportunity for the clinician to evaluate maternal hydration status.
o Presence of ketones or protein in the urine may be helpful in developing the management plan and can be assessed as indicated.
Evaluate maternal well-being based on vital signs
As a woman’s status may change over the course of her labor, the frequency of assessing vital signs should be adjusted to match her unique situation
Review the recommendations for the frequency of fetal heart rate assessment during labor.
*CEFM:
o No complications: First stage q30/Second stage q15
o Complications: First stage q15/Second stage q5
*IA:
o ACOG: First stage q15/Second stage q5
o ACNM: First stage q15-30/Second stage no pushing q15/Second stage pushing q5
o AWHONN: Active phase of First stage q15-30/Active pushing of Second stage q5-15
Understand maternal adaptations in labor of the cardiovascular system and apply to labor management
o Increased blood volume by about 40% in early third trimester increased CO and SV
o Increased RBC production (Maximize oxygen delivery to mom & baby)
o Significant shifts in blood volume during contractions
Understand maternal adaptations in labor of the hematologic system and apply to labor management
o Levels of coagulation factors are markedly increased during active labor
Promote rapid hemostasis after placental separation.
o Clot development leads to reduced circulating fibrinogen and platelets ->decreased fibrolytic activity
Enhances clot development after delivery of placenta.
o Uterine contraction and compression of uterine vessels serve to promote accumulation of clotting factors and hemostasis after placental separation
Reduces risk of excessive maternal blood loss.
o Peak WBCs during labor (as high as 20,000)
Not accurate to determine presence of infection in labor.
Understand maternal adaptations in labor of the respiratory and system and apply to labor management
o Increased O2 consumption as muscular activity increases during uterine contractions.
o Failure to restore oxygenation to uterine muscle cells (during relaxation) over time can lead to anaerobic metabolism, production of lactic acid, and subsequent ischemic pain that is theorized to contribute to uterine pain felt during labor.
o Pain can lead to increased respiratory rate and hyperventilation respiratory alkalosis
pain management, PRN O2
Understand maternal adaptations in labor of the gastrointestinal system and apply to labor management
o Decreased gastric motility, relaxation of gastroesophageal sphincter, increased intraabdominal pressure increased risk for emesis & aspiration if laboring woman is sedated or intubated
o Transient nausea/vomiting may occur during active labor, especially during transition.
Antiemetics PRN
o Consider nutritional needs during labor – hypoglycemia due to fasting leads to use of alternative metabolic pathways accumulation of byproducts like lactate & ketones
Intake of isotonic sports drinks and a light diet
Apply criteria for normal and slow labor progress to clinical situations. (Review module 4 content)
- 0.5 cm per hour or
- 0.5-0.7/0.5-1.3 cm per hour (nullips/multips, with faster dilation as labor progresses)
- Longer labors are not associated with an increase in any complications.
- Although a longer second stage was not shown to result in increased perinatal complications, the research did consistently show an increase in cesarean birth, operative vaginal birth, and third- and fourth-degree lacerations.
- Some researchers argue that the problem with longer second stages is the tendency for providers to intervene with treatments that are the cause for higher rates of maternal morbidity.
Review recommendations for the appropriate use of vaginal exams during the first stage of labor.
During normal first-stage labor, a cervical examination may be indicated in the following situations:
o To establish an informational baseline that can be used for appropriately timing further examinations to establish labor status prior to admission or labor interventions (prelabor, latent, or active labor).
o As an appropriately timed second examination to determine the woman’s labor state prior to labor admission (prelabor, latent, or active labor).
o To inform management decisions related to management of labor pain.
o To verify complete dilation.
o To check for a prolapsed cord after spontaneous rupture of membranes if a prolapsed cord is a suspected risk (e.g., ballottable presenting part or fetal heart rate decelerations that do not resolve with usual maneuvers).
Be familiar with the history of the policy of withholding foods and oral fluids during labor.
*Contemporary management of labor in the United States typically involves limited oral nutritive intake and noncaloric intravenous fluid administration.
o The primary rationale cited for withholding food and fluid during labor is the decreased risk of gastric content aspiration during general anesthetic induction—an extremely rare but serious syndrome first described by Mendelson in 1946.
o Moreover, fasting does not guarantee an empty stomach or less acidity.
Understand current evidence regarding encouraging or withholding foods or oral fluids during labor and apply it in clinical situations.
- Overall, modern evidence shows no benefits or harms associated with oral intake during labor, so there is no justification for the restriction of fluids and food in labor for women at low risk for complications.
- Adequate hydration during labor would seemingly assist in the delivery of oxygen and nutrients as well as facilitate the elimination of waste from the contracting uterus, akin to how proper hydration benefits the skeletal muscle of athletes.
List indications for IV access and/or IV fluids.
*The decision to initiate and maintain intravenous access during labor should be based on actual or potential risk factors for each woman.
o Women who cannot tolerate oral fluid intake may require intravenous fluids.
o Intravenous access is also necessary for administration of some medications, such as antibiotic prophylaxis for women who are carriers of GBS, pain medications, or oxytocin augmentation.
o Prior to initiation of epidural anesthesia, establishing intravenous access allows for administration of isotonic fluid blood volume expanders to mitigate epidural-related hypotension.
Continuing access after epidural placement allows for ongoing fluid administration and medication administration should complications develop.
Understand the significance of ketonuria to the laboring woman.
- Inadequate caloric intake leads to breakdown of stored fat instead of glucose for energy. Ketones are a byproduct of fat breakdown. Helps assess current nutrition status and promote nutrition interventions as needed.
- Ketones can remain in the urine after serum ketones have been cleared, and this finding may lead to unnecessary intervention.
- In a Cochrane review, the authors concluded that there is no information on which to base practice regarding treatment of women with ketosis during labor.
- Management decisions are further complicated by a high false-positive rate in methods to test for ketonuria (eg, Ketostix/Multistix).
Know the potential hazards to the newborn of giving dextrose containing intravenous hydration to a laboring woman. This information can be found in the ACNM Clinical Bulletin “Providing Oral Nutrition to Women in Labor” at the end of the section called “The effects of fasting during labor.”
In large doses, intravenous dextrose caused fetal lactic acidosis, newborn jaundice and hypoglycemia.
Know the disadvantages of a supine maternal position during labor.
- Increased duration of labor, risk of caesarean birth, and the need for epidural, and may be associated with increased intervention and negative effects on mothers’ and babies’ well-being. Increased likelihood of NICU admissions.
- When resting in bed is necessary or desired, lateral recumbent positions are preferred to supine positions because they reduce the potential for aortic/venae cavae compression with resulting maternal hypotension and potential fetal compromise. Lateral positions also facilitate kidney function and do not interfere with coordination and efficiency of uterine contractions.
Know the impact of maternal position on:
- In the supine position contractions are more frequent and painful, yet less likely to improve labor progress!
Know the impact of squatting and “hands and knees” positions on pelvic dimensions.
- In both squatting and hand-to-knee (leaning forward while kneeling) positions, the sagittal outlet and interspinous diameter were significantly greater than when women were supine.
- In addition, squatting increased the intertuberous diameter and decreased the obstetric conjugate diameter.
List different positions and movements for labor and indicate their proposed benefit. Please note that you are not required to memorize exactly what part of the pelvis moves in which direction with each position or movement. This information is included to provide you with a repertoire of position suggestions for women in a wide variety of situations.
- Side lying positions
- Sitting positions
- Sitting upright
- Kneeling positions
- Squatting positions
- Supine positions
- Semisitting and side lying positions are restful and gravity neutral. They may help an exhausted woman save her energy, especially if she has been up and walking for a long period. Also, if progress is rapid, neutralizing gravity may slow the labor to a more manageable pace.
- Upright positions take advantage of gravity to apply the presenting part to the cervix, improve the quality of the contractions, and enhance the descent of the fetus.
- Positions in which the woman leans forward are thought to enhance fetal rotation or help maintain the favorable occiput anterior (OA) position and reduce back pain.
- Asymmetrical positions, in which the woman flexes one hip and knee, change the shape of the pelvis, enhance rotation, and reduce back pain.
- The exaggerated lithotomy position, used for several contractions in the second stage, may facilitate the passage of a “stuck baby” beneath the pubic symphysis.
- Dorsal positions tend to cause supine hypotension and increase back pain. Contractions are more frequent and painful, yet less likely to improve labor progress!
