Before proceeding with a physical assessment, the nurse should check the clients

weight gain reported in her prenatal record. The clients ethnicity and religion
should be noted before physical assessment. This allows the nurse to proceed in a
culturally sensitive manner. The clients age should also be noted before the
physical assessment is begun. The type of insurance the woman has is not relevant
to the nurse. The clients gravidity and parityhow many times she has been
pregnant and how many times she has given birth should also be noted before a
physical assessment is begun. The prenatal record is a summary of the womans
history from the time she entered prenatal care until the record was sent to the
labor room (usually at about 36 weeks gestation). Virtually all of the physical and
psychosocial information relating to this woman is pertinent to the care by the
nurse. For example, if a woman has gained very little weight during her pregnancy,
the baby may be small for the gestational age. The nurse may also have to change
his or her care in relation to the womans ethnicity and religion, etc. A vaginal
examination will provide the nurse with the best information about the status of
labor. Leopolds maneuvers, although performed on a woman in labor, assess for
fetal position, not the progress of labor. Fundal contractility will assess for uterine
contractions, but this is not the most valuable information for labor. Assessment of
the fetal heart is critically important in relation to fetal well-being, but it will not
determine the progress of labor. Each of the assessments listed is performed on a
woman who enters the labor suite for assessment. However, the only assessment
that will determine whether or not a woman is in true labor is a vaginal
examination. Only when there is cervical changedilation and/or effacementis it
determined that a woman is in true labor. The nurse should assess the fetal heart
before reporting the clients status to the health care provider. The nurse should
assess the contraction pattern before reporting the clients status. A complete
urinalysis would likely be ordered by the primary health care practitioner once the
client has been officially admitted, but the test would not be performed during the
initial assessment process. The nurse should assess the womans vital signs before
reporting her status. A biophysical profile is performed only if ordered by a health
care practitioner. The fetal heart, contraction pattern, and maternal vitals all should
be assessed to provide the health care practitioner with a picture of the health
status of the mother and fetus. In some institutions, the nurse may also do a vaginal
examination to assess for cervical change. With the findings of a hard round mass
in the fundal area and soft round mass above the symphysis, the nurse can
conclude that the fetal lie is vertical. Station is assessed by palpating the ischial
spines. Station is determined by creating an imaginary line between the ischial
spines. The descent of the presenting part of the fetus is then compared with the
level of that line. When a fetus is in the occiput posterior position, mothers
frequently complain of severe back pain. The fetoscope should be placed in the left
lower quadrant for a fetus positioned in the LOA position as described in the
question. The fetal heart is best heard through the fetal back. Because, as
determined by doing Leopolds maneuvers, the baby is LOA, the fetal back (and,
hence, the fetal heart) is in the left lower quadrant. In a 7 cm dilated primipara, with
a baby at plus 3 station, vaginal delivery is not imminent, but the fetal head is well
past engagement and descent is progressing well. External rotation has not yet
occurred because the babys head has not yet been birthed. Muscle relaxation is an

integral part of Lamaze childbirth education. Pelvic rocking is taught in Lamaze

classes as a way of easing back pain during pregnancy and labor. Abdominal
massage, called efeurage, is also an integral part of Lamaze childbirth education.
Some of the techniques learned at childbirth education classes are meant to break
the fear-tension-pain cycle. The alternate pant-blow technique is used during stage
1 of labor. Rhythmic, shallow breaths are used during stage 1 of labor. Open glottal
pushing is used during stage 2 of labor. Slow chest breathing is used during stage 1.
Open glottal pushing is recommended because pushing against a closed glottis can
decrease the mothers oxygen saturation. The pant-blow breathing technique is
usually used during the transition phase of labor. Rapid, deep breathing is rarely
used in labor. Grunting and pushing is often the method that women instinctively
use during the second stage of labor. Most women find slow chest breathing
effective during the latent phase. Because the latent phase is the first phase of the
first stage of labor, the contractions are usually mild and they rarely last longer than
30 seconds. A slow chest breathing technique, therefore, is effective and does not
tire the woman out for the remainder of her labor. Efeurage is a light massage
that can soothe the mother during labor. There are a number of actions that
mothers can take that can support their breathing during labor. Walking, swaying,
and rocking can all help a woman during the process. Effleurage, the light
massaging of the abdomen or thighs, is often soothing for the mothers. The normal
fetal heart rate is 110 to 160 beats per minute. A rate of 152, therefore, is within
normal limits. No further action is needed at this time. Whenever a laboring woman
complains of severe back labor, it is very likely that the baby is lying in the occiput
posterior position. Every time the woman has a contraction, the head is pushed into
the coccyx. When direct pressure is applied to the sacral area, the nurse is providing
counteraction to the pressure being exerted by the fetal head. Although the test
taker may see in practice that women are encouraged to begin to push as soon as
they become fully dilated, it is best practice to wait until the woman exhibits signs
of rectal pressure. Pushing a baby that is not yet engaged may result in an overly
fatigued woman or, more significantly, a prolapsed cord. Women may contract
without being in true labor. Once the cervix begins to dilate, a client is in true labor.
Membranes can rupture before true labor begins. Engagement can occur before
true labor begins. Although laboring women experience contractions, contractions
alone are not an indicator of true labor. Only when the cervix dilates is the client in
true labor. False labor contractions are usually irregular and mild, but, in some
situations, they can appear to be regular and can be quite uncomfortable. True
labor contractions often begin in the back and, when the frequency of the
contractions is every 5 minutes or less, it is usually appropriate for the client to
proceed to the hospital. Even if the woman is not having labor contractions, rupture
of membranes is a reason to go to the hospital to be assessed. Expelling the
mucous plug is not sufficient reason to go to the hospital to be assessed. Greenish
liquid is likely meconiumstained uid. The client needs to be assessed. The latent
phase of labor can last up to a full day. In addition, Braxton Hicks contractions can
last for quite a while. Even though a woman may feel cramping for 4 hours or more,
she may not be in true labor. The mucous plug protects the uterine cavity from
bacterial invasion. It is expelled before or during the early phase of labor. In fact, it
may be hours, days, or even a week after the mucous plug is expelled before true

labor begins. Pregnant women are very protective of themselves and of the babies
they are carrying. Any time a change that might portend a problem occurs, a
pregnant woman is likely to become concerned and frightened. Certainly, seeing
any kind of blood loss from the vagina can be scary. The nurse must acknowledge
that fear before asking other questions or making other comments. Frequency is
defined as the time from the beginning of one contraction to the beginning of the
next, while duration is defined as the beginning of the increment of a contraction to
the end of the decrement. : Lie is concerned with the relationship between the
fetal spine and the maternal spine. When the spines are parallel, the lie is vertical
(or longitudinal). When the spines are perpendicular, the lie is horizontal (or
transverse). It is physiologically impossible for a baby in the horizontal lie to be
delivered vaginally. First, descent and exion must occur. If the baby does not
descend into the birth canal and the baby does not ex the head so that his or her
chin is on the chest, the baby simply will not be able to traverse through the bony
pelvis. Second, internal rotation (rotation of the fetal body when the fetal head is
still inside the mothers pelvis) must occur before external rotation (rotation of the
fetal body after the fetal head is outside the mother). In between the rotational
moves is extension, the delivery of the head. And, finally, expulsion must be last
because the delivery of the babys body is simply the last movement. a baby is
crowning when the mothers perineal tissues are stretched around the fetal head at
the same location where a crown would sit. The station at this time is past +5
station (or 5 cm past the ischial spines). The obstetric conjugate is measured by
the health care practitioner to estimate the potential for the fetal head to fit through
the anterior-posterior diameter of the maternal pelvis. It is the internal distance
between the sacral promontory and the symphysis pubis. The obstetric conjugate is
the shortest anterior to posterior diameter of the pelvis. When it is of average size,
it will accommodate an average-sized fetal head. There are three main breech
positions: frank, where the buttocks present and both feet are located adjacent to
the fetal head; single footling, when one leg is extended through the cervix and
vagina while the remaining leg is bent; and double footling, when both legs are
extended through the cervix and vagina. It is likely that a woman carrying a breech
in any position will have a cesarean section. Flexion is one of the first of the
cardinal moves of labor. Internal rotation occurs while the baby is still in utero.
During extension, the babys head is birthed. The baby rotates externally after the
birth of the head. The baby must move through the cardinal moves because the
fetal head is widest anterior-posterior but the fetal shoulders are widest laterally. On
the other hand, the maternal pelvis is widest laterally in the inlet but anterior
posterior at the outlet. During second stage labor, the woman should push on an
open glottis to prevent the vasovagal response. Research has shown that when
women push without being coached, they do not hold their breath to bear down, but
instead grunt during the second stage. By taking a slow, cleansing breath before
pushing, the woman is waiting until the contraction builds to its peak. Her pushes
will be more effective at this point in the contraction. The bulging perineum is an
indication that the baby is descending in the birth canal and the bloody show results
from injury to the capillaries in the mothers cervix. Because this woman is a
primigravida, she will likely need to push for many more minutes so it is not
necessary to notify the health care provider until additional signs are noted. The

average length of the second stage of labor for multiparas is about 15 minutes,
whereas the average time for an epidural to be inserted and to take effect is
approximately 20 minutes. In addition, the fetus in the scenario has already
descended to +3 station and is in the optimal position for deliveryLOA. It is very
likely that this baby will be born in a few contractions. The nurse should encourage
the client to continue pushing with her contractions. The contraction of the uterus
after delivery of the baby is the first step in the third stage of labor. As the uterus
contracts, its surface area decreases more and more. A hematoma forms behind
the placenta as the placenta separates from the uterine wall after the uterus has
contracted and its surface area has decreased. The membranes separate from the
uterine wall after the placenta separates and begins to be born. Once the baby is
born, the uterus contracts. When it does so, the surface area of the internal uterine
wall decreases, forcing the placenta to begin to separate. As the placenta
separates, a hematoma forms behind it, further promoting placental separation.
Once the placenta separates and begins to be born, the membranes peel off the
uterine wall and are delivered last. Rectal pressure is usually a sign of fetal
descent. Once the second stage is complete, the baby is no longer in utero. During
contractions, the blood from the placenta is forced into the peripheral vascular
system and there is an increase in cardiac output. As a result, the womans blood
pressure rises: an average of 35 mm Hg systolic and 25 mm Hg diastolic. The blood
pressure should never be assessed during a contraction because the reading will be
a marked distortion of the womans true blood pressure. For the anesthesiologist
to be able to insert the epidural catheter into the epidural space, the woman must
be placed in either the fetal position or sitting with her chin on her chest and her
back convex. In both of those positions, the womans vertebrae separate, providing
the anesthesiologist access to the required space. Before any medication, whether
analgesia or anesthesia, is administered during labor, the fetal heart should be
assessed to make sure that the baby is not already compromised. Before regional
anesthesia administration, a liter of uid should be infused to increase the womans
vascular uid volume. This will help to maintain her blood pressure after the
epidural insertion. And the womans bladder should be emptied because she will not
have the sensation of a full bladder once the epidural is in place. Hypotension is a
very common side effect of regional anesthesia. If no other therapeutic
interventions are performed, virtually all women will show signs of hypotension after
epidural administration. The change is related to two phenomena: dilation of the
vessels in the pelvis and increased compression of the vena cava. One of the most
important reasons for this is the compression of the vena cava by the pregnant
uterus. When a wedge is placed under the womans side usually the right side
the uterus is tilted, relieving the pressure on the great vessels. Massaging of the
perineum with mineral oil does help to reduce perineal tearing. During labor, nurses
and nurse midwives often massage a womans perineum to increase the elasticity of
the tissue. Because the tissue is more elastic, it is less inclined to tear during the
delivery. During pregnancy and early labor, the cervix is closed, long, and thick.
During the labor process, however, the cervix changes shape, becoming paper thin
and dilating to 10 cm. This is a universal finding. No matter how tall or short, old or
young a woman is, her cervix will dilate to 10 cm and efface 100% if she has a
vaginal delivery. Peristalsis slows dramatically during labor. Because of this, women

rarely become hungry during labor, but they do need uids and some nourishment.
Clear uids, including ice chips, water, tea, and bouillon, are often allowed.
Ultimately, though, it is the health care practitioners decision what and how much
the client may consume.