by Nancy Haun, AN, SCM

Today, many "traditional"procedures which were oncethought to be necessary forsafe childbirth are beingexamined and discarded asunnecessary or even harmful.

when fathers or "significant others" electto stay with the mother during labor, thenurse often feels she is free to do otherthings, forgetting that the couple mayneed professional support and encour-agement through the event. By stayingwith them during the first stage, the nursecan develop the rapport and trustingrelatio~ship which is so valuable throughtransition and the second stage of labor.The nurse is there to provide comfort, toteach, to praise and to assess the progressof labor.

women receiving a perineal shave com-plain of discomfort, burning and itchingafterwards.2 At St. Joseph's Hospital,London, Ontario, routine shave prepsfor vaginal and abdominal deliverieswere discontinued about seven years agowithout any rise in the infection rate. Ifhair does make perineal repair difficultafter birth, it may be clipped.

There also was much concern thatpassage of stool during the second stageof labor might contaminate the area andcause embarassment for the woman.However, soapsuds enemas have bee~reported to cause rectal irritation3 andallergic reactions.4 Furthermore, studieshave shown that the incidence of fecalcontamination at delivery is not influ-enced by giving an enema.5 Of still moreinterest is a recent British study whichrevealed that fecal contamination doesnot increase the infection rate.6 Mahanand McKay state that "continued routineuse of enemas cannot be justified exceptwhen circumstances clearly indicate aneed."7 Today, the admission nurse isbetter occupied obtaining a: thoroughpatient history and data base and orient-ing the patient and her coach to their newsurroundings.

hildbirth is usually ajoyous fam-ily event. It is the culmination of

.months of dreams and hopesand the beginning of life for a new familymember. For the nurse, the first priorityremains maternal and infant safety,through continuous assessment of motherand fetus for any signs of deviations fromthe norm in order to provide promptintervention. But today, another equallyimportant role is that of ensuring asatisfying experience for the birthingfamily.

The first stage of labor1. Routine 'preps'. Until recently, thelaboring patient was greeted by theadmissions nurse with an enema in onehand, "high, hot and a hell of a lot", and arazor in the other. These p~oceduresgenerally went unquestioned as neces,.sary methods to ensure a sterile field forbirth. Ho.wever, as early as 1922, studiesshowed that infection rates were in factlower in patients who did not receive aperineal shave.' It is difficult to performan adequate shave without multiplesmall abrasions and a high percentage of

3. Position. During labor the supinerecumbent position should be stronglydiscouraged as it allows the gravid uterusto compress the abdominal aorta andinferior vena cava possibly causing mat-ernal supine hypotension and fetal dis-tress. We recommend encouraging thewoman to assume any other position ofcomfort for labor. Rupture of the mem-branes during labor does not automati-cally mean bed rest if the vertex is pres-enting, is engaged and well applied to thecervix. Some women find that backacheis relieved by being on "all fours" espe-cially when the fetus is in an "occipitoposterior" position.

Solid foods are best avoided as gas-trointestinal motility slows during partu-rition. Oral intake for the low-riskpatient should be limited to fluids (juices,clear soups) and hard candies. Obviously,if there is a likelihood that the womanwill require a general anesthetic, she willbe given parenteral rather than oralfluids.

2. Support persons. At the time of theadmission, assessment of the goals of thelaboring mother and her spouse is impor-tant for the formulation of an individual-ized plan of care. Fathers are encouragedto stay throughout the birth, to providethe mother with comfort and support.No longer are fathers requested to leavewhile "procedures" ~ carried out.Instead, they are recognized as playing avery necessary supportive role in thelabor/delivery process. Unfortunately,

Nancy Haun is a clinical instructor with theUniversity of Western Ontario Perinatal OutreachProgram, London. Ont

4.

Maternal and fetal well-being(table one). The n\lrse must continuallyassess the maternal and fetal response to

Parameter Frequency

MaternalTemperaturePulseBlood pressureUrinalysisContractions

4 HourlyHourlyHourly2 HourlyEvery 15 minutes

FetalFetal heart rate -Latent phase-Active

phaseSecond stage

Every 30 minutesEvery 15 minutesEvery 5 minutes -

26 October 1984 The Canadian NtJrse

bleeding, an active herpetic lesion, or fol-lowing premature rupture of the mem-branes before the onset of labor. Aseptictechnique must be maintained whenexamining the l~boring woman to min-imize ascending infection. Use of theFriedman Curve is strongly recom-mended as a tool to monitor labor pro-gress (see figure one). The findings fromvaginal examinations including extent ofcervical dilatation, station in relation tothe ischial spines and position of thepresenting part are plotted on the graphagainst the number of hours in labor.Cervical dilatation and descent of thepresenting part follow a recognizedsequence and use of the Friedman Curvepermits a quick and reliable means ofinterpretation and evaluation of the pro-gress of normal labor and identificationof deviations.

labor. She must be able to swiftly identifyany deviations from the normal andinitiate prompt intervention.

Take maternal temperature every fourhours throughout labor. A slight eleva-tion is often attributed to dehydration,but if it persists beyond two hours, regardit as a sign of infection and report it.Check the pulse hourly and between con-tractions. It should not exceed 100 bpm.

beginning of the next and should notexceed four or five in a ten-minuteperiod. The uterus should relax com-pletely between contractions. Failure todo so indicates increased resting tone andmay result in fetal distress.

Observe the vaginal discharge. Bleed-ing other than "show" should be reportedto the physician, as should the presenceof meconium-stained amniotic fluid.

The second stageTypically, the onset of the second stage ischara:cterized by a heavier bloody show,and an overwhelming urge to push dur-ing contractions. However, the onlyaccurate indication of second stage iscomplete dilatation of the cervix felt onvaginal examination.

Traditionally, once the woman hadachieved full dilatation, she was proppedup, instructed with each contraction totake a big breath, hold it, and "Push,push, push, push". Not uncommonly themother's face was distorted and red, neckveins became distended, petechiae deve-loped, and even small conjunctivalhemorrhages appeared. We congratu-lated ourselves on our success withcoaching the delivering woman when wesaw these signs of her effort. In fact, abetter position for the second stage oflabor is a semi-sitting position in whichthe back is supported by pillows, a backrest, or with the back of the bed elevated.9Wrist straps are no longer used and are tobe condemned. The mother's knees arebent and apart and her feet are best keptflat on the bed as the action of drawingher legs up to push (or placing the legs instirrups) may put tension on the peri-neum, tightening the introitus. 10 Periodicchange of position during the secondstage may be helpful. Some womenprefer to push in a side-lying position,others sql:latting. However, with the lat-ter position, control of the actual deliveryis often difficult to maintain.

Prolonged breath holding while bear-ing down may lead to decreased cardiacoutput and hypotension. Although this isusually tolerated by the healthy partur-ient it can adversely affect the fetus bydecreasing placental perfusion, leadingto hypoxia and fetal distress. I I It is nowrecommended that several deep breathsbe taken at the beginning of a contrac-tion and that the breath be held no longerthan seven seconds while the motherpushes. 12 Her mouth should be openslightly and she should slowly exhale

The fetal heart rate should be assessedevery 30 minutes during the latent phaseof labor and every 15 minutes in theactive phase. Count the rate betweencontractions and at the same time assessthe maternal pulse as it may be mistakenfor the fetal heart rate. The normal fetalheart rate is 120 to 160 bpm.Fetal tachy-cardia may be a sign of infection and/ orfetal distress and should be reportedimmediately as should fetal bradycardia.A slight deceleration in the fetal heartrate may occur with a contraction but itshould return quickly to a normal base-line as the contraction finishes. Persist-ence of fetal bradycardia for more than20 seconds after the contraction hasceased is an important sign of fetal dis-tress and must be reported.

Tachycardia, another important sign,may indicate dehydration, infection, orhemorrhage. Take the blood pressurehourly between contractions, with themother either sitting up or lying on herside.

Attention to the urinary bladder isvery important throughout labor. A fullbladder can impede descent of the pre-senting part, inhibit uterine contraction,cause discomfort, and predispose thewoman to urinary retention and cystitisin the postpartum period.8 If a woman isallowed to enter the third stage of laborwith a full bladder, she risks hemorrhageand delay of placental expulsion.8 Sheshould be encouraged to void at leastevery two hours. If voiding is difficultand bladder distention is evident, themother should be catheterized. Test theurine every two hours for ketones, pro-tein and glucose. The presence of ketonesin the urine is indicative of dehydrationand glycogen depletion and an intraven-ous infusion may be required. More thana trace of protein may be an early indica-tion of pregnancy-induced hypertension.

The frequency and duration of con-tractions should be assessed every 15 to20 minutes. The duration of a contrac-tion is measured in seconds and whenpalpated abdominally, a contractionshould not exceed 60 seconds. Fre-quency of contractions is estimated fromthe beginning of one contraction to the

The Canadian Nurse

5. Assessing progress: The FriedmanCurve. Vaginal examination permits amore accurate assessment of labor pro-gress than rectal examination (see tableone). Vaginal examinations are indicatedat admission (to establish a data base), atrupture of the membranes or with signsof fetal distress (to rule out cord pro-lapse), prior to giving medication forpain relief (to confirm progress), beforeallowing the woman to push (to deter-mine full dilation), and periodically todetermine progress (see table two). Vagi-nal and rectal examinations are con-traindicated in the presence of vaginal

action in the sensitive time after birth.The mother is encouraged to relax andnot to bear down during the third stage.Offering the baby the breast will stimu-late the release of oxytocin and promoteplacental separation in addition to theobvious emotional benefits for themother.

provide a satisfying experience for thechild-bearing couple while maintainingsafety. They are welcome and a source ofjoy to all involved. .

through the bearing-down effort.

Caldeyro-Barcia suggests that the secondstage will proceed more slowly with thismethod but that the fetus will be in bettercondition. 13 The woman is encouraged to

push in the direction of the vaginal orificeand to relax her face and lowerextremities.

The fetal heart rate should be assessedat least every five minutes after contrac-tions in the second stage of labor and themother should not be left. alone at anytime. Today, the mother with noidentifi-able risk, labors and gives birth in thesame room which may be equipped witha birthing bed. She is encouraged to con-centrate on the work at hand and mayfind the atmosphere less tense than in theusual "delivery" room. The father is

encouraged to remain with his partnerfor the birth be it normal or "high risk",to provide support and comfort and to

share in the joy of the event.

The third stageImmediately after the birth the baby isdried quickly ~nd given to the mother.Routine suctioning of the healthy new-born is not necessary; if done vigorously,it may be harmfu1 by causing a reflex

bradycardia. Ophthalmic prophylaxisand vitamin K, are withheld until thebaby is admitted to the nursery in ordernot to interfere with parent-infant inter-

The Canadian Nurse

The fourth stageThe first hour after birth is commonly

referred to as the fourth stage of labor. Itis a time when one is observing for signsof hemorrhage. The temperature is taken

once, and the pulse, blood pressure, fun-

dus, lochia, and perineum are assessedevery 15 minutes. A bedpad should beoffered to encourage the woman to keepher bladder empty.

This is a very special hour for motherand baby and the family as a whole. Thebaby is usually alert and begins toexplore the new environment. If siblingshave not been present previously, theyand the grandparents are welcomed inthe recovery room to greet and hold thenew arrival, and congratulate the new

parents,Childbirth today has again become a

family-oriented event. The <':hangeswhich are taking place in maternity carehave less to do with wallpaper and

expensive equipment, than with attitudesof medical and nursing staff who seek to

References

I Johnston, R.A., and Sidall, R.S. I~ the usualmethod of preparing patients for deliverybeneficial or necessary? American Journalof Obstetrics and Gynecology 4: 645-650,

Dec. 1922.2. Romney, M.L. Predelivery Shaving: an unjus-

tified assault? Obste!. Gynecol. I: 33, 1980.3. Barker, C.S. Acute colitis rLsulting from soap-

suds enema. Canadian Medical AssociationJournal 52: 285,1945.

4. Smith, D. Severe anaphylactic reaction after asoap enema. British Medical Journal4: 215, 1964.

5. Whitley, N., and Mack, E. Are enemas justifiedfor women in labor? American Journal ofNursing 80: 1339, Jul. 1980.'

6. Romney, M.L. and Gordon, H. Is your enema

really necessary? British Medical Journal282: 1269-71, Apr. 1981.

7. Mahan, C.S., and McKay, S. Preps and ene-mas -Keep or discard? ContemporaryOB/GYN 22: 5,241-8,1983.

8. Myles, M. Textbook for Midwives. 9th ed.Edinburgh, Churchill Livingstone, 1981.

9. McKay, S.R. Second stage labor: has tradition

replaced safety? American Journal of Nurs-ing81: 1016-9, May 1981.

10. Ibid.II. Cadeyro-Barcia, R. The influence of maternal

bearing-down efforts during second stageon fetal well-being;. Birth Fam. J. 6: 17-22,Spring 1979.

12. McKay, Op. cit.13. Ibid.

October 1984 29