A review of the patient’s prenatal records should always take place upon admittance to the facility. The nurse should take careful note of the patient’s obstetric history, including:

• Gravidity and Parity

• Problems

  • History of vaginal bleeding

  • Gestational hypertension

  • Anemia

  • Pregestational or gestations diabetes

  • Infections (e.g., bacterial, viral, sexually transmitted) and immunodeficiency status

  • Expected date of birth (EDB), which should be confirmed

• Patterns of maternal weight gain

• Physiologic measurements

  • • Maternal vital signs (blood pressure, temperature, pulse, respirations)

    • Fundal height

    • Baseline fetal heart rate (FHR)

    • Laboratory and diagnostic test results

• Common diagnostic and fetal assessment tests performed prenatally

  • Amniocentesis

  • Nonstress testing (NST)

  • Biophysical profile (BPP)

  • Ultrasound examination

If this labor and birth experience is not the patient’s first, the nurse must note the characteristics of previous experiences. These characteristics would include the duration of previous labors, types of pain relief measures, types of birth (spontaneous vaginal, forceps-assisted, vacuum-assisted, or cesarean birth), the condition of the newborn, and the patient’s perception of the previous labor and birth.

The woman’s general appearance and behavior (and that of her partner, family member, or other support people) can provide valuable clues as to the type of supportive care she will need.

Verbal Interactions

• Does the patient ask questions?

• Can she ask for what she needs?

• Does she talk to her support person(s)?

• Does she talk freely with the nurse or respond only to questions?

Body Language

• Does she change positions or lie rigidly still?

• What is her anxiety level?

• How does she react to being touched by the nurse or support person?

• Does she avoid eye contact?

• Does she look tired? If she appears tired, ask her how much rest she has had in the past 24 hours.

Perceptual Ability

• Is there a language barrier?

• Are repeated explanations necessary because her anxiety level interferes with her ability to comprehend?

• Can she repeat what she has been told or otherwise demonstrate her understanding?

Discomfort Level

• To what degree does the woman describe what she is experiencing, including her pain experience?

• How does she react to a contraction?

• How does she react to assessment and care measures?

• Are any nonverbal pain messages noted?

• Can she ask for comfort measures?

The way in which patients, partners, and family members approach labor is related to the manner in which they have been prepared for and socialized to childbearing, as well as how they deal with other stressors in their lives. Reactions during labor reflect their physical, social, cultural, and religious life experience regarding labor and birth.

Society communicates its expectations regarding acceptable and unacceptable maternal behaviors during labor and birth. These expectations may be used by some patients as the basis for evaluating their own actions. An idealized perception of labor and birth may be a source of guilt and cause a sense of failure if the patient finds the process less than joyous, especially when the pregnancy is unplanned or is the product of a dysfunctional or terminated relationship. Often patients have heard horror stories or have seen friends or relatives going through labors that were difficult and painful. Multiparous women often base their expectations of the current labor on their previous labor and birth experiences.

The nurse should encourage the patient to express her feelings about the pregnancy and her concerns and fears related to labor and birth. This discussion is especially important if the patient is a primigravida who has not attended birthing classes but has obtained information on labor and birth from the internet or reality television shows. Multiparous patients who have had a previous negative birth experience will also benefit from this kind of discussion.

Patients in labor usually have a variety of concerns that they will voice if asked but may not volunteer. Major fears and concerns relate to the process and effects of labor and birth on maternal and fetal well-being, and the attitude and actions of the health care staff. Every effort should be made to provide support and encourage those with her to be supportive. Patients who have continuous labor support are more likely to have a spontaneous vaginal birth and are less likely to have intrapartum analgesia or anesthesia, a cesarean or an operative vaginal birth, a baby with a low 5-minute Apgar score, or to report dissatisfaction with their labor and birth experiences (American College of Obstetricians and Gynecologists, 2019).

A partner, coach, or significant other also experiences stress during labor. The nurse can assist and support these individuals by identifying their needs and expectations, helping to make sure these are met, and interpreting events that are occurring. The degree of involvement and participation in labor support varies; therefore, it is important to determine the intended role of the support person and whether or not that person is prepared to fulfill their role.

Above all, however, the nurse must demonstrate sensitivity to the needs of support people and provide teaching and support as appropriate.

The initial physical examination includes a general systems assessment and an assessment of fetal status. During the examination, uterine contractions are assessed, and a vaginal examination is performed.

The findings of the admission physical examination serve as a baseline for assessing the patient’s progress in labor from that point. The initial examination findings serve as the basis for determining whether the patient should be admitted and what her ongoing care should be. It is important to explain assessment findings to the patient and her partner whenever possible.

Throughout labor, accurate documentation following facility policy is done as soon as possible after a procedure has been performed.

General Systems Assessment

Upon admission, the nurse should perform a general systems assessment. This includes an assessment of the heart, lungs, and skin, and an examination to determine the presence and extent of edema of the face, hands, sacrum, and legs. Testing of deep tendon reflexes and for clonus, if indicated, should be performed. Patient weight should also be measured and recorded.

Vital Signs

The nurse assesses vital signs (temperature, pulse, respiration, and blood pressure using a cuff of the correct size) on admission. The initial values are used as the baseline for comparison with all future measurements.

If the blood pressure is elevated, it should be reassessed 30 minutes later or per facility policy between contractions to obtain a reading after the woman has relaxed. The woman is encouraged to lie on her side to prevent supine hypotension and the resulting fetal hypoxemia. Body temperature is monitored in an effort to identify signs of infection or a fluid deficit (e.g., dehydration associated with inadequate fluid intake).

Urinalysis

A clean catch specimen may be obtained to gather further information about:

• Hydration status (e.g., specific gravity, color, amount)

• Nutritional status (e.g., ketones)

• Infection status (e.g., leukocytes)

• Possible complications such as preeclampsia (e.g., proteinuria)

Blood Tests

• Blood tests performed vary with facility protocol and the patient’s health status. A hematocrit or complete blood count (CBC) will likely be ordered. CBC measures hematocrit as well as other parameters including white blood cell count, red blood cell count, hemoglobin level, and platelet count.

• If HIV status is undocumented at the time of labor, it should be screened with a rapid HIV test unless the patient declines. “Type and screen” or “clot to hold” tests are used to determine the patient’s blood type, Rh status, and antibodies.

• If the patient had no prenatal care or if her prenatal records are not available, blood for a prenatal screen will likely be drawn on admission.

Other Tests

If the patient’s group B streptococcus status is not known, a rapid test may be done on admission.

• Showers, bed baths, tub baths, or whirlpool baths

  • Nursing action: Assess for progress in labor

    • Rationale: Determines appropriateness of the activity

  • Nursing action: Supervise showers or baths closely if woman is in true labor

    • Rationale: Prevents injury from fall; labor may be accelerated

  • Nursing action: Suggest warm water to flow over back

    • Rationale: Aids relaxation; increases comfort

• Perineum

  • Nursing action: Cleanse frequently, especially after rupture of membranes and when show increases

    • Rationale: Enhances comfort and reduces risk for infection

• Oral hygiene

  • Nursing action: Offer toothbrush or mouthwash, or wash teeth with an ice-cold wet washcloth as needed

    • Rationale: Refreshes mouth; helps counteract dry, thirsty feeling

• Hair

  • Nursing action: Brush, braid per patient’s wishes

    • Rationale: Improves morale; increases comfort

• Handwashing

  • Nursing action: Offer washcloths or cleansing foam before and after voiding and as needed

    • Rationale: Maintains cleanliness; prevents infection

• Face

  • Nursing action: Offer cool washcloth

    • Rationale: Provides relief from diaphoresis; cools and refreshes

• Gowns and linens

  • Nursing action: Change as needed

    • Rationale: Improves comfort; enhances relaxation

• Voiding

  • Nursing action: Encourage voiding at least every two hours

    • Rationale: A full bladder may impede descent of presenting part; overdistention may cause bladder atony and injury as well as postpartum voiding difficulty

• Ambulation

  • Nursing action: Allow ambulation to the bathroom according to orders of the nurse, midwife, or physician if:

    • The presenting part is engaged

      • Rationale: Reinforces normal process of urination

    • The membranes are not ruptured

      • Rationale: Precautionary measure to protect against prolapse of umbilical cord

    • The patient is not medicated

      • Rationale: Precautionary measure to protect against injury from a fall

• Bed rest

  • Nursing action: Offer bedpan

    • Rationale: Prevents complications of bladder distention and ambulation

  • Nursing action: Encourage upright position on bedpan, allow tap water to run; place patient’s hands in warm water; pour warm water over vulva; give positive suggestion

    • Rationale: Encourages voiding

  • Nursing action: Provide privacy

    • Rationale: Shows respect for woman

  • Nursing action: Put up side rails on bed

    • Rationale: Prevents injury from a fall

  • Nursing action: Place call bell and telephone within reach

    • Rationale: Reinforces safe care

  • Nursing action: Offer washcloth or cleansing foam for hands

    • Rationale: Maintains cleanliness; prevents infection

  • Nursing action: Cleanse vulvar area

    • Rationale: Maintains cleanliness; enhances comfort; prevents infection

• Urinary catheterization

  • Nursing action: Catheterize according to orders of nurse–midwife, physician, or hospital protocol if measures to facilitate spontaneous voiding are ineffective

    • Rationale: Prevents complications of bladder distention

  • Nursing action: Insert catheter between contractions

    • Rationale: Minimizes discomfort

  • Nursing action: Avoid force if obstacle to insertion is noted

    • Rationale: “Obstacle” may be caused by compression of urethra by presenting part

• Bowel elimination or sensation of rectal pressure

  • Nursing action: Perform vaginal examination

    • Rationale: Prevents misinterpretation of rectal pressure from presenting part as need to defecate; determines degree of descent of presenting part

  • Nursing action: Help the patient ambulate to the bathroom or offer a bedpan if rectal pressure is not from presenting part

    • Rationale: Reinforces normal process of bowel elimination and safe care

  • Nursing action: Cleanse perineum immediately after passage of stool

    • Rationale: Reduces risk of infection and sense of embarrassment

Supportive nursing care for a woman in labor includes the following:

• Providing continuity of care by the same nurse throughout the shift.

• Providing care that is nonjudgmental and respectful of the patient’s cultural and religious values and beliefs.

• Helping the patient meet her expected outcomes for her labor.

• Listening to patient concerns and encouraging her to express her feelings.

• Acting as the patient’s advocate, supporting her decisions, respecting her choices as appropriate, and relating her wishes as needed to other health care providers.

• Acknowledging the patient’s efforts during labor, including the strength and courage and those of her partner, and providing positive reinforcement.

• Protecting the patient’s privacy, modesty, and dignity.

• Helping the patient maintain control and participate to the extent she wishes in the birth of her infant.

• Teach simple breathing and relaxation techniques during the early phase of labor.

• Helping the patient conserve energy and cope effectively with pain and discomfort using a variety of acceptable comfort measures.

  • Maintaining a comfortable, calm, supportive atmosphere

  • Using touch therapeutically (e.g., heat or cold applied to the lower back in the event of back labor, a cool cloth applied to the forehead, massage)

  • Provide nonpharmacologic measures to relieve discomfort (e.g., hydrotherapy)

  • Just being there

  • Back massage and counterpressure, especially if the patient is experiencing back labor

The doula is a professional or lay labor support person who is present during labor in addition to the labor and birth nurse.

• The primary role of the doula is to focus on the laboring patient and provide physical and emotional support by using soft, reassuring words of praise and encouragement, touching, stroking, and hugging.

  • Administers comfort measures to reduce pain and enhance relaxation and coping, walks with the patient, helps her to change positions, and coaches her bearing-down efforts

  • Provides information about the progress of labor and explains procedures and events

  • Advocates for the patient’s right to participate actively in managing her labor

  • Supports the patient’s partner, who may feel overwhelmed or unqualified