1. Participatory childbirth techniques
    1. Psychoprophylaxis-Lamaze method
      1. Premise-conditioned responses to stimuli occupy nerve pathways, reducing perception of pain. Emphasis is on childbirth as a natural event, with an informed woman as the active participant. The ability to relax effectively reduces the perception of pain, and the involvement of the coach fosters the family concept.
      2. Childbirth partners are taught:
        1. Anatomy and physiology of labor.
        2. Psychology of man and woman.
        3. What to expect in the birthing setting.
        4. Conditioned responses to labor stimuli.
          1. Concentration on focal point.
          2. Breathing techniques.
          3. Need for active coaching to enable woman to:
            1. Use techniques appropriate to present stage of labor.
            2. Avoid hyperventilation.
        5. Specific stage-appropriate techniques:
          1. First stage of labor-early: slow, deep chest breathing; active: patterned breathing.
          2. Transition (8-10 cm)-rapid, shallow breathing pattern, to prevent pushing prematurely.
            1. Panting.
            2. Pant-blow.
            3. “He-he” pattern.
          3. Second stage of labor
            1. Pushing (or bearing-down) - aids fetal descent through birth canal.
            2. Panting-aids relaxation between contractions; prevents explosive birth of head.
        6. Effects on labor behaviors/coping:
          1. Help mother cope with and assist contractions.
          2. Prevent premature bearing-down efforts; reduce possibility of cervical lacerations, edema due to pushing on incompletely dilated cervix.
          3. When appropriate, improve efficiency of bearing-down efforts.
    2. Other methods-include parent classes, classes for siblings, multiparas, and those who plan cesarean birth.
  2. Nursing actions during first stage of labor
    1. Assessment: careful evaluation of:
      1. Antepartal history
        1. EDB
        2. Genetic and familial problems.
        3. Preexisting and coexisting medical disorders, allergies.
        4. Pregnancy-related health problems (hyperemesis, bleeding, etc.).
        5. Infectious diseases (past and present herpes, etc.).
        6. Past obstetric history, if any.
        7. Pelvic size estimation.
        8. Height.
        9. Weight gain.
        10. Laboratory results:
          1. Blood type and Rh factor.
          2. Serology.
          3. Urinalysis.
          4. Hepatitis.
          5. Rubella.
        11. Prenatal care history.
        12. Use of medications.
      2. Admission findings
        1. Emotional status.
        2. Vital signs.
        3. Present weight.
        4. Fundal height.
        5. Estimated fetal weight.
        6. Edema.
        7. Urinalysis (for protein and glucose).
      3. FHR-normal, 110-160 beats/minutes.
        1. Check and record every 15-30 minutes- monitor fetal response to physiological stress of labor.
        2. Bradycardia (mild, 100-110 beats/minutes, or 30 beats/minutes lower than baseline reading).
        3. Tachycardia (moderate, 160-179 beats/ minutes, or 30 beats/minutes above baseline reading lasting 5+ minutes).
      4. Contractions-every 15-30 minutes.
        1. Place fingertips over fundus, use gentle pressure; contraction felt as hardening or tensing.
        2. Time: frequency and duration.
        3. Intensity/strength at acme:
          1. Weak-easily indent fundus with fingers.
          2. Moderate-some tension felt, fundus indents slightly with finger pressure.
          3. Strong-unable to indent fundus.
      5. Maternal response to labor-assess for effective coping, cooperation, and using effective breathing techniques.
      6. Maternal vital signs-between contractions.
        1. Response to pain or use of special breathing techniques alters pulse and respirations.
        2. B/P, P, RR-if normotensive: on admission, and then every hour and pm; after regional anesthesia: every 30 minutes (every 5 minutes first 20 minutes).
        3. Temp-if within normal range: on admission, and then every 4 hr and pm. Every 2 hours after rupture of membranes.
        4. Before and after analgesia/anesthesia.
        5. After rupture of membranes.
      7. Character and amount of bloody show.
      8. Bladder status: encourage voiding every 1-2 hours, monitor output.
        1. Determine bladder distention-palpate just above symphysis (full bladder may impede labor progress or result in trauma to bladder).
        2. Admission urinalysis-check for protein and glucose.
      9. Signs of deviations from normal patterns.
      10. Status of membranes:
        1. Intact.
        2. Ruptured (nitrazine paper turns blue on contact with alkaline amniotic fluid). Fluid may be placed on a glass slide to dry; a fernlike crystallization of sodium chloride will appear. Note, record, and report:
          1. Time-danger of infection if ruptured more than 24 hours.
          2. FHR stat and 10 minutes later-to check for prolapsed cord.
          3. Character and color of fluid.
      11. Amniotic fluid.
        1. Amount-polyhydramnios (>2000 mL)- associated with congenital anomalies/ poorly controlled diabetes.
        2. Character-thick consistency or odor associated with infection.
        3. Color-normally clear with white specks.
          1. Yellow-presence of bilirubin; Rh or ABO incompatibility.
          2. Green or meconium stained; if fetus in vertex position, indicates recent fetal hypoxia secondary to respiratory distress in fetus.
          3. Port wine-may indicate abruptio placentae.
      12. Labor progress:
        1. Effacement.
        2. Dilatation.
        3. Station.
        4. Bulging membranes.
        5. Molding of fetal head.
      13. Perineum-observe for bulging.
    2. Analysis/nursing diagnosis:
      1. Anxiety, fear related to uncertain outcome, pain.
      2. Ineffective individual coping related to lack of preparation for childbirth or poor support from coach.
      3. Altered nutrition: less than body requirements related to physiological stress of labor.
      4. Altered urinary elimination related to pressure of presenting part.
      5. Altered thought processes related to sleep deprivation, transition, analgesia.
      6. Fluid volume deficit related to anemia, excessive blood loss.
      7. Impaired (fetal) gas exchange related to impaired placental perfusion.
    3. Nursing care plan/implementation:
      1. Goal: comfort measures.
        1. Maintain hydration of oral mucosa. Encourage sucking on cool washcloth, ice chips, lollipops, clear liquids.
        2. Reduce dryness of lips. Apply lip balm.
        3. Relieve backache. Apply sacral counterpressure (particularly with occiput posterior [OP] presentation).
        4. Encourage significant other to participate, Encourage ambulation when presenting part engaged.
      2. Goal: management of physical needs.
        1. Encourage frequent voiding to prevent full bladder from impeding oncoming head.
        2. Encourage ambulation throughout labor; lateral Sims’ position with head elevated to: Encourage relaxation.
          1. Allow gravity to assist in anterior rotation of fetal head.
          2. Prevent compression of inferior vena cava and descending aorta (supine hypotensive syndrome).
          3. Promote placental perfusion.
        3. Perineal prep, if ordered to promote cleanliness.
        4. Fleet’s enema, if ordered-to stimulate peristalsis, evacuate lower bowel. Note: contraindicated if:
          1. Cervical dilation (4 cm or more) with unengaged head-due to possibility of cord prolapse.
          2. Fetal malpresentation/malposition- due to possible fetal distress.
          3. Preterm labor-may stimulate contractions.
          4. Painless vaginal bleeding-due to possible placenta previa.
      3. Goal: management of psychosocial needs. Emotional support:
        1. Encourage verbalization of feelings, fears, concerns.
        2. Explain all procedures.
        3. Reinforce self-concept (“You’re doing well!”).
      4. Goal: management of discomfort.
        1. Analgesia or anesthesia-may be required or desired-to facilitate safe, comfortable birth.
        2. Support/enhance/teach childbirth techniques.
          1. Reinforce appropriate breathing techniques for current labor status.
            1. If woman is hyperventilating, to increase Paco2, minimize fetal acidosis, and relieve symptoms of vertigo and syncope, suggest:
              1. Breathe into paper bag.
              2. Breathe into cupped hands.
            2. Demonstrate appropriate breathing for several contractions-to reestablish rate and rhythm.
      5. Goal: sustain motivation.
        1. Offer support, encouragement, and praise, as appropriate.
        2. Keep informed of status and progress.
        3. Reassure that irritability is normal.
        4. Serve as surrogate coach when necessary (if no partner, before partner arrives, while partner changes clothes, during needed breaks); assist with effleurage, breathing, focusing.
        5. Discourage bearing-down efforts by pant-blow until complete (10 cm) dilation to avoid cervical edema/laceration.
        6. Facilitate informed decision making regarding medication for relaxation or pain relief.
        7. Minimize distractions: quiet, relaxed environment; privacy.
    4. Evaluation/outcome criteria:
      1. Woman manages own labor discomfort effectively.
      2. Woman maintains control over own behavior.
      3. Woman successfully completes first stage of labor without incident.