OB | Nursing Management of Labor

Fetal Heart Rate (FHR) Monitoring and Assessment A primary objective of labor management is tracking the FHR to detect changes early, ensure adequate fetal oxygenation, and prevent fetal injury. Initial continuous FHR assessment spans 10 to 20 minutes upon entry.

Baseline variability is a key indicator and is categorized as absent, minimal, moderate (a normal fluctuation of 6 to 25 bpm), or marked. FHR patterns are evaluated in three tiers:

• Category I (Normal): Predictive of normal fetal acid-base status and requires no intervention.
• Category II (Indeterminate): Requires evaluation and continued surveillance.
• Category III (Abnormal): Predictive of abnormal acid-base status and requires immediate intervention. Essential interventions include notifying the health care provider, discontinuing oxytocin, repositioning the client (left or right lateral, knee-chest), administering oxygen via nonrebreather mask, increasing IV fluids, and preparing for an expeditious surgical birth if the pattern is not corrected within 30 minutes.

Maternal Pain Management Pain during labor is a universal experience with highly variable intensity, and pain assessment is mandated for all clients. The modern nursing approach emphasizes the woman as an active participant in her pain management.

• Nonpharmacologic measures: Include continuous labor support, hydrotherapy, ambulation, position changes, acupressure, massage (effleurage), and patterned-paced breathing.
• Pharmacologic measures: Include systemic analgesia (IV opioids, ataractics, benzodiazepines) and regional/neuraxial anesthesia (epidural blocks, combined "walking" spinal-epidurals, and pudendal blocks for the second stage). General anesthesia is typically reserved for emergency cesarean births or when a woman has a contraindication to regional anesthesia.

Stage-by-Stage Nursing Interventions

• First Stage: Initial contact often involves a phone assessment detailing the estimated date of birth, fetal movement, contraction characteristics, and membrane status. Admission requires a comprehensive health history and physical assessment, including vital signs, Leopold maneuvers, monitoring uterine contraction frequency/duration/intensity, checking cervical dilation and effacement, and determining fetal position. Routine lab studies (urinalysis, CBC) and necessary screenings (syphilis, HbsAg, GBS, HIV) are also collected.
• Second Stage (Birth): Care shifts to tracking the fetal response to labor and supporting involuntary bearing-down efforts. Nurses must encourage the mother not to push until she has a strong desire or until the descent and rotation of the fetal head are well advanced. Immediately following birth, newborn care involves drying, suctioning, clamping the umbilical cord, assigning the Apgar score, and identification.
• Third Stage (Placental Delivery): The nurse assesses for placental separation, administers ordered oxytocin, examines the placenta and fetal membranes, checks for perineal trauma, and documents birthing statistics.
• Fourth Stage (Recovery): Critical post-birth assessments demand frequent checks of vital signs, fundus firmness, lochia, perineal area, and bladder status/voiding. Promoting parent-newborn attachment, providing comfort measures, and initiating teaching are fundamental priorities during this final phase.