Learning Outcome
Recognize different stages of labor
Distinguish between normal and abnormal labor progression
Formulate nursing diagnoses related to preparation for childbirth
Administer analgesia as advised by the practitioner
Summarize basic medical and nursing therapy for abnormal labor
Understand the role of amniotomy
Understand the role of oxytocin in the induction of labor
Discuss the variability of maternal outcomes
Normal labor is characterized by regular and painful uterine contractions that conclude in progressive labor. A discussion on abnormal labor patterns is reviewed as abnormalities of the first stage (cervical dilation to complete cervical dilation) and the second stage (descent of the presenting part leading to delivery of the baby). The third stage of labor describes the expulsion of the placenta. An overview of labor abnormalities encompasses all the stages of labor. First and second-stage abnormalities are described either as protraction disorders (which means that delivery is progressing but is lower than normal) or as arrest disorders (complete cessation in progress). Abnormal third-stage labor meriting intervention is placenta retention beyond 30 minutes, as most third stages are concluded within the first 10 to 20 minutes of delivery.[1]
Normal labor is characterized by regular and painful contractions that conclude in delivering the fetus and placenta. Labor is divided into three stages and subsequent phases within each stage:
First Stage: 0-10 cm
Second Stage: decent of presenting part leading to the delivery of the fetus
Latent (complete cervical dilation to the onset of active maternal expulsive efforts)
Active (beginning of active maternal expulsive efforts to the expulsion of the fetus)
Third Stage: placental expulsion
Abnormal labor patterns in the first and second stage are defined as either protraction or arrest disorders. Protracted labor stages indicate that labor is progressing but at a slower pace than expected. Arrest disorders indicate the complete cessation of the progress of labor. Abnormal third-stage labor warrants intervention when the placenta is retained > 30 minutes. The following criteria should be kept in mind when labeling the labor as
First Stage Protraction and Arrest
Latent Phase
Protraction:
In nulliparas women: Not entered the active phase by 20 hours after onset of the latent phase.
In multiparas women: Not entered the active phase by 14 hours after the onset of the latent phase.
Arrest: Due to its slow progression, latent phase arrest is not considered a clinical entity.
Active Phase
Protraction: Women at ≥6 cm dilation, dilating less than approximately 1 to 2 cm/hour
Arrest: Cervical dilation ≥6 cm in a patient with ruptured membranes and
No change in the cervix for ≥4 hours despite adequate contractions (defined as >200 Montevideo units [MVU])
No change in the cervix for ≥6 hours with inadequate contractions
Second Stage Protraction
There is no appropriate length defined for the diagnosis. However, the following criteria can be utilized in the presence of favorable maternal and fetal condition:
For nulliparous women: More than four hours for the second stage or three hours of pushing.
For multiparous women: More than three hours for the second stage or two hours of pushing.
Nursing Diagnosis
Infections ( hospital-acquired or related to procedures)
Hypothermia due to loss of blood
Abnormal uterine contractions
The normal progression of labor requires the four "Ps," representing power from uterine contractions, adequate bony maternal pelvis as the passage, and finally, the fetus as a passenger presenting itself in a favorable presentation. The size of the fetus and the capacity of the maternal pelvis are tested as uterine contractions provide propulsion. A deficiency in the uterine contractions is addressed easily with the judicious use of oxytocin. However, labor abnormalities due to unfavorable fetal pelvic dynamics lead to true dystocia requiring a cesarean delivery.[2]
Risk Factors Associated with Abnormal Labor
Symptoms for the onset of preterm labor are reviewed, including a history of progressively stronger contractions and any history of leakage of fluid or passage of a mucous plug. Asking about recent vaginal bleeding is always a significant inquiry to exclude concerns for placental abruption. At admission to labor and delivery, prenatal records and obstetric history should be reviewed because these optimally inform the provider of the best intrapartum obstetric care. This care includes the determination of the static gestational age. Abdominal examination is a key component of an obstetric exam. It provides an estimated fetal weight of the fetus and informs the provider of the fetal presentation and the descent of the presenting part into the pelvis. The continuous monitoring of the external fetal heart rate provides insight into fetal well-being. A manual vaginal exam to evaluate maternal bony pelvis capacity and cervical dilation, as well as fetal pelvic dynamics, occurs at intervals.
The uterine activity is assessed by external tocometry and targeted at 3 to 5 contractions in the 10-minute window. The contractions should last 30 to 40 seconds to be effective. Internal intrauterine pressure assessment using a catheter could be utilized, in which case marked medial units are used and targeted at more than 200 Montevideo units in a 10-minute window. The monitoring of uterine contractions should be continuous during labor. The assessment of the fetal heart rate could be performed utilizing external or internal fetal heart rate monitoring. An alternative is fetal heart rate auscultation every 15 minutes in the first stage of labor and after each contraction during the second stage of labor. In interpreting the fetal heart rate, strip millimeters considered are baseline viability, basal heart rate, cardiac accelerations or decelerations, and endocrine activity. Strip abnormalities are characterized based on consideration of the above parameters.
The obstetric partogram is a composite graphic record of labor progress. Along with documentation of essential obstetric vital signs, it is used in developing confluent areas to control intrapartum care. The World Health Organization (WHO) recognizes this status as useful labor management that adequately draws attention to excessively prolonged labors.[3] Partogram has increasingly fallen out of use.
Most labor and delivery unit will have an established protocol for administration of oxytocin that entails the administration of the proper medication and dosage, as well as criteria for an incremental increase as clinically warranted. The protocols also include monitoring maternal and fetal vital signs, as well as the atria, for discontinuation of the medication in the event of concern for tachycardia systole all fetal well-being. Such protocols allow collaborative care between the nursing staff and the obstetrician.
Therapeutic rest and analgesia may be provided during a prolonged first stage of labor.
Oxytocin, as advised by the obstetrician, may be given when indicated, during all stages of labor.
In the case of maternal/fetal compromise, immediate intraoperative delivery is indicated.
Nursing Management
Review the history of labor, onset, and duration.
Obtain baseline lab investigations.
Assess uterine contractile pattern manually (palpation) or electronically, depending on the availability.
Evaluate the current level of maternal fatigue/emotional stress.
Observe any signs of infection.
Evaluate the degree of hydration. Note down the quantity and type of intake.
Place the client in a lateral recumbent position and encourage bed rest or sitting position/ambulation, as tolerated.
Note signs of fetal distress, cessation of uterine contractions, and presence of vaginal bleeding.
Alert the obstetrician of any warning signs.
Prepare client for amniotomy, and assist with the procedure, when indicated.
Administer narcotic or sedative, as indicated.
When To Seek Help
Nonreassuring fetal hearts tracing
Absence of uterine contractions
Signs of hypovolemia/hypothermia
Signs of maternal infection including a high temperature and raised white cell counts
Outcome Identification
Induction of labor at the appropriate time
Maternal rest and readiness for operative delivery
Reassuring fetal heart rates
The best management of labor requires a coordinated interprofessional effort between trained obstetric nurses, midwives, and providers. Team management may lower the average cesarean section rates and improve outcomes. [Level V]
Abnormal labor can be a daunting experience for women, especially during the first birth. However, patients must be aware that they can be managed both at home and at a maternity care clinic/hospital, depending on the stage and associated risk factors. As the labor progresses, the practitioners may advise rest and analgesia. When the time is due, patients may be under observation to induce labor and/or undergo operative delivery.
Discharge Planning
The patients should be discharged with appropriate analgesia and sedatives when they plan to wait for labor at home.
They should be encouraged to stay mobile, in the absence of any complications, as it may lead to better outcomes.
Patients should be on a high-calorie diet and have appropriate hydration.
The patient should have at least one caregiver at home. In the absence of a caregiver, social services should be contacted.
Complete blood counts should be obtained, in case of a need for blood transfusion.
In the case of abdominal pain or any other signs of labor, the patient should be instructed to get immediate help from the provider.
During labor complications, cesarean deliveries can be a life-saving procedure and may become medically necessary. Cesarean section rates among the nulliparous, singleton, term gestation, and vertex presentation (NSTV) are currently trending in most institutions and states. Diligent management of labor aspires to minimize variation between providers. Management may lower the average cesarean section rates in this population, and this can provide the best opportunity to improve outcomes and reduce costs. In 2012 the baseline NSTV cesarean birth rate was 27% in California, and the most recent rate available in 2015 was 25.6%. As an example, California aspires to reach its target rate of 23.9% or lower by 2022. Racial disparities such as non-Hispanic black women having disproportionately higher cesarean delivery also deserve an inquiry.[4]
Review Questions
1.
Clark SL, Garite TJ, Hamilton EF, Belfort MA, Hankins GD. "Doing something" about the cesarean delivery rate. Am J Obstet Gynecol. 2018 Sep;219(3):267-271. [PubMed: 29733840]
2.Zhang J, Troendle J, Reddy UM, Laughon SK, Branch DW, Burkman R, Landy HJ, Hibbard JU, Haberman S, Ramirez MM, Bailit JL, Hoffman MK, Gregory KD, Gonzalez-Quintero VH, Kominiarek M, Learman LA, Hatjis CG, van Veldhuisen P., Consortium on Safe Labor. Contemporary cesarean delivery practice in the United States. Am J Obstet Gynecol. 2010 Oct;203(4):326.e1-326.e10. [PMC free article: PMC2947574] [PubMed: 20708166]
3.Stokholm L, Talge NM, Christensen GT, Juhl M, Mortensen LH, Strandberg-Larsen K. Labor augmentation during birth and later cognitive ability in young adulthood. Clin Epidemiol. 2018;10:1765-1772. [PMC free article: PMC6263242] [PubMed: 30538580]
4.American College of Obstetrics and Gynecology Committee on Practice Bulletins-Obstetrics. ACOG Practice Bulletin Number 49, December 2003: Dystocia and augmentation of labor. Obstet Gynecol. 2003 Dec;102(6):1445-54. [PubMed: 14662243]
5.Zhang J, Troendle JF, Yancey MK. Reassessing the labor curve in nulliparous women. Am J Obstet Gynecol. 2002 Oct;187(4):824-8. [PubMed: 12388957]
6.Langston C, Kaplan C, Macpherson T, Manci E, Peevy K, Clark B, Murtagh C, Cox S, Glenn G. Practice guideline for examination of the placenta: developed by the Placental Pathology Practice Guideline Development Task Force of the College of American Pathologists. Arch Pathol Lab Med. 1997 May;121(5):449-76. [PubMed: 9167599]
7.Wathes DC, Borwick SC, Timmons PM, Leung ST, Thornton S. Oxytocin receptor expression in human term and preterm gestational tissues prior to and following the onset of labour. J Endocrinol. 1999 Apr;161(1):143-51. [PubMed: 10194538]
8.Lee HJ, Macbeth AH, Pagani JH, Young WS. Oxytocin: the great facilitator of life. Prog Neurobiol. 2009 Jun;88(2):127-51. [PMC free article: PMC2689929] [PubMed: 19482229]
9.Bailit JL, Dierker L, Blanchard MH, Mercer BM. Outcomes of women presenting in active versus latent phase of spontaneous labor. Obstet Gynecol. 2005 Jan;105(1):77-9. [PubMed: 15625145]
10.ACOG Committee Opinion No. 766 Summary: Approaches to Limit Intervention During Labor and Birth. Obstet Gynecol. 2019 Feb;133(2):406-408. [PubMed: 30681540]