At what time is the laboring client encouraged to push?

An epidural is the most common type of anesthetic used for pain relief during labor. Here’s what you should know before having an epidural, including information that dispels some common myths.

How and when is an epidural for labor pain administered?

If you choose to have an epidural, an anesthesiologist will insert a needle and a tiny tube, called a catheter, in the lower part of your back. The needle is removed and the catheter left in place for delivery of the medication through the tube as needed. You can begin an epidural at any time during your labor — in the beginning, in the middle, or even toward the end — in consultation with your physician.

Does it hurt when the epidural is administered?

The anesthesiologist will numb the area where the epidural is administered, which may cause a momentary stinging or burning sensation. But because of this numbing, there is very little pain associated with an epidural injection. Instead, most patients will feel some pressure as the needle is inserted.

What does an epidural do?

An epidural provides anesthesia that creates a band of numbness from your bellybutton to your upper legs. It allows you to be awake and alert throughout labor, as well as to feel pressure. The ability to feel second-stage labor pressure enables you to push when it’s time to give birth to your baby. It can take about 15 minutes for the pain medication to work.

How long does the pain relief last?

You can continue to receive pain relief through an epidural for as long as you need it. The amount of medication you receive through the epidural can be increased or decreased as necessary.

Can an epidural slow labor or lead to a cesarean delivery (C-section)?

There is no credible evidence that it does either. When a woman needs a C-section, other factors usually are at play, including the size or position of the baby or slow progression of labor due to other issues. With an epidural, you might be able to feel contractions — they just won’t hurt — and you’ll be able to push effectively. There is some evidence that epidurals can speed the first stage of labor by allowing the mother to relax.

Can epidurals harm the baby?

The amount of medication that reaches the baby from the epidural is very small, and there is no evidence that it causes any harm.

Are there risks and side effects?

Epidurals are very safe; serious complications are extremely rare. However, as with all medications and medical procedures, there are potential side effects:

• Decrease in blood pressure – The medication may lower your blood pressure, which may slow your baby’s heart rate. To make this less likely, you will be given extra fluids through a tube in your arm (IV), and you may need to lie on your side. Sometimes, your anesthesiologist will give you a medication to maintain your blood pressure.
• Sore back – Your lower back may be sore where the needle was inserted to deliver the medication. This soreness should last no more than a few days. There is no evidence that an epidural can cause permanent back pain.
• Headache – On rare occasions, the needle pierces the covering of the spinal cord, which can cause a headache that may last for a few days if left untreated. If this situation arises, discuss the treatment options with your anesthesiologist.

What is combined spinal-epidural anesthesia?

A spinal block is sometimes used in combination with an epidural during labor to provide immediate pain relief. A spinal block, like an epidural, involves an injection in the lower back. While you sit or lie on your side in bed, a small amount of medication is injected into the spinal fluid to numb the lower half of the body. It brings good relief from pain and starts working quickly, but it lasts only an hour or two and is usually given only once during labor. The epidural provides continued pain relief after the spinal block wears off.

Anesthesiologists are committed to patient safety and high-quality care, and have the necessary knowledge to understand and treat the entire human body.

Nursing care for pregnant women in labor proves to be a challenging task because it requires nurses to be fast in their assessment without sacrificing the quality and accuracy of rendered nursing care. Now, why should care of women in various stages of labor be taken seriously? In 2000, the United Nations Millennium Summit included the improvement of maternal health as one of the Millennium Development Goals (MDGs) to be adapted by the international community composed of over 42 countries. Promoting the health of women in labor is one active way of reducing maternal mortality and ensuring universal access to reproductive health services.

The progression of labor is traditionally divided into three phases, and each phase deals with different concerns and considerations. Having gained mastery of this, nurses are able to implement nursing interventions to safeguard the welfare of both the mother and the baby.

Establishing Therapeutic Relationship

To gain patient and family’s cooperation and trust, it is important that the nurse should be able to establish a therapeutic relationship with them. The nurse should introduce himself and make them feel welcome. At this point, they are all anxious and it is best for the nurse to convey his message gently and confidently. Expectations of the family about birth should be determined and it is also the best time to ascertain cultural values.

Admission Assessment

When a patient arrives at the labor floor, pertinent information about the pregnant woman’s health history is taken during admission. These include personal data (e.g. blood type, allergies, etc.), previous illness, pregnancy complications, preferences for labor and delivery, and childbirth preparations. Standard obstetric, medical, and social history taking is also done.

In addition, the nurse assesses the following: vital signs, physical exam, contraction pattern (frequency, interval, duration, and intensity), intactness of membranes through vaginal exam, and fetal well-being through fetal heart rate, characteristic of amniotic fluid, and contractions. The nurse performs Leopold’s maneuver to determine fetal presenting part, point of maximum impulse, fetal descent and engagement.

Admission into labor room is only done when the patient is in active labor.

The progress of cervical effacement, cervical dilatation, and descent of fetal presenting part dictate stages of labor. Here are the stages of labor and significant events that mark their beginning and end:

First Stage of Labor

As mentioned above, the first stage of labor is divided into three sub-phases, namely: latent, active, and transitional phases.

Latent Phase

Latent (Preparatory) Phase starts from the onset of true labor contractions to 3 cm cervical dilatation. Here are nursing responsibilities during this phase:

1. Assess patient’s psychological readiness. Provide continuous maternal support (compared to usual care).
2. Measure duration of latent phase. For nulliparas, it should not be more than 6 hours. On the other hand, for multiparas, it should be within 4.5 hours. Determine if patient received anesthesia because it can prolong latent phase. One of the most common cause of prolonged latent phase is cephalopelvic disproportion (CPD) and it requires cesarean birth.
3. Allow patient to be continually active. Upright maternal positions are recommended for women on the first stage of labor. Patients without pregnancy complications can still walk around and make necessary birth preparations.
4. Conduct interviews and filling in of forms (e.g. birth certificate) at this phase while the patient experiences minimal discomfort and has control over contraction pains.
5. Conduct health teaching on breastfeeding, newborn care, and effective bearing down because during this time, patient’s anxiety is controlled and she is able to focus on nurse’s instructions.
6. Educate patient on different relaxation techniques. As early as this phase, encourage patient to begin alternative therapy of pain relief.
7. Ensure that the total number of internal examinations the woman receives in the entire course of labor is limited to 5 only.
8. Ensure that birthing companion of choice is present all throughout the course of labor.

Active Phase

Active Phase starts from 4 cm cervical dilatation to 7 cm cervical dilatation. During this phase, contraction intensity is stronger, interval shortens, and duration lengthens. This is where true discomfort is first felt by the patient so she is dependent and her focus is on herself. Here are nursing responsibilities in this phase:

1. Inform patient on the progress of her labor to lessen her anxiety and obtain her trust and cooperation.
2. Start monitoring progress of labor with the use of WHO partograph, 2-hour action line.
3. Encourage patient to be continually active to maximize the effect of uterine contractions. Upright maternal positions are recommended if tolerated.
4. Assist patient in assuming her position of comfort. For those who can’t stay upright, left-side lying is recommended to avoid disruption in fetal oxygenation.
5. Monitor maternal vital signs and fetal heart rate every 2 hours, or depending on the doctor’s order.
6. Anticipate patient needs (e.g. sponging face with cool cloth, keeping bed clean and dry, providing ice chips or lip balm) to promote comfort.
7. Determine when patient last voided because a full bladder can hinder fast labor progress.
8. Institute non-pharmacological pain measures (e.g. breathing exercises, distraction method, imagery, music therapy, etc.)

Transition Phase

Transition Phase starts from 8 cm cervical dilatation to 10 cm (full) cervical dilatation and full cervical effacement. During this time, patient may be exhausted and withdrawn or aggressive and restless. Patient’s urge to push is noticeable. Here are nursing responsibilities in this phase:

1. Inform patient on progress of her labor.
2. Assist patient with pant-blow breathing.
3. Monitor maternal vital signs and fetal heart rate every 30 minutes -1 hour, or depending on the doctor’s order. Contraction monitoring is also continued.
4. When perineal bulging is noticeable, prepare for delivery. Check room temperature (25-280C and free of air drafts). The nurse should also notify staff and prepare necessary supplies and equipment, including resuscitation machine. Lastly, perform handwashing and double gloving.

WHO do not recommend the following nursing interventions during labor because they have low quality of evidence:

1. Routine perineal shaving
2. Routine use of enema
3. Admission cardiotocography (CTG) for low-risk women
4. Vaginal douching
5. Routine amniotomy for patients in spontaneous labor
6. Massage and reflexology

Second Stage of Labor

Second Stage of Labor starts when cervical dilatation reaches 10 cm and ends when the baby is delivered. At this stage, the patient feels an uncontrollable urge to push. The patient may also experience temporary nausea together with increased restlessness and shaking of extremities. The nurse at this stage must coach quality pushing and support delivery.

Here are nursing care tips for this stage:

1. Instruct patient on quality pushing. The abdominal muscles must aid the involuntary uterine contractions to deliver the baby out.
2. Provide a quiet environment for the patient to concentrate on bearing down.
3. Provide positive feedback as the patient pushes.
4. Repeat doctor’s instructions. At this phase, the patient barely hears the conversation around the room because all her energy and thoughts are being directed toward giving birth.
5. Take note of the time of delivery and proceed to initiate essential newborn care. Delayed cord clamping is recommended.
6. Assist in restrictive episiotomy for patients who had vaginal births.

WHO do not recommend the following interventions during delivery because they provide low quality of evidence:

1. Perineal massage
2. Use of fundal pressure

Third Stage of Labor

Third Stage of Labor or the placental stage starts from birth of infant to delivery of placenta. It is divided into two separate phases: placental separation and placental expulsion. Five minutes after delivery of baby, the uterus begins to contract again, and placenta starts to separate from the contracting wall. Blood loss of 300-500 mL occurs as a normal consequence of placental separation. Placenta sinks to the lower uterine segment or upper vagina. The placenta is then expelled using gentle traction on the cord.

Here are the signs of placental separation:

1. Lengthening of umbilical cord
2. Sudden gush of vaginal blood
3. Change in the shape of uterus (globular in shape)
4. Firm uterine contractions
5. Appearance of placenta in vaginal opening

At this stage, here are the nursing care tips:

1. Coach in relaxation for delivery of placenta.
2. Congratulate on delivery of baby.
3. Encourage skin-to-skin contact to facilitate bonding and early breastfeeding.
4. Ask patient whether placenta is important to them before it is destroyed. For those who want to take it home, ensure that they understand and follow standard infection precautions and hospital policy.
5. Administer prophylactic oxytocin as ordered.
6. Utilize controlled cord traction technique for placental expulsion.
7. Utilize absorbable synthetic suture materials (over chromic catgut) for primary repair of episiotomy or perineal lacerations.

For immediate postpartum, the nurse checks the vital signs and monitors for excessive bleeding. The first four hours after birth is sometimes referred to as the fourth stage of labor because this is the most critical period for the mother. The nurse is set to perform nursing interventions that would prevent the patient from infection and hemorrhage. Also, they are being reminded of the importance of breastfeeding, ambulation, and newborn care.

Here are WHO recommendations for immediate postpartum:

1. Early (<6 hours) resumption of feeding for patients who have vaginal birth
2. Prophylactic antibiotics for women who sustained third to fourth degree of perineal tear during delivery
3. In healthy women who delivered vaginally to term infants, early postpartum discharge is recommended.

On the other hand, here are interventions not recommended during immediate postpartum:

1. Routine use of ice packs
2. Oral methylergometrine for patients who delivered vaginally

Nursing care for women in labor is a routine that takes a while to fall into. After all, it is overwhelming for beginner nurses to do their responsibilities in front of a woman writhing in pain. However, the opportunity to protect women and the privilege of being a part of their positive pregnancy experience is rewarding. Read and share this to your nurse friends because women’s and children’s lives deserve only the best care.

References:

1. Clinical Practice Guidelines on Intrapartum and Immediate Postpartum Care 2012 by Department of Health and Philippine Obstetrical and Gynecological Society. Retrieved from: https://www.wpro.who.int/philippines/publications/clinical_practical_guidelines_einc.pdf
2. Callahan, T. (2013). Blueprints Obstetrics and Gynecology. (6th ed.). Baltimore, MD: Lippincott William & Wilkins.
3. Pillitteri, A. (2010). Maternal & Child Health Nursing: Care of the Childbearing and Childrearing Family (6th ed.). PA: Lippincott William & Wilkins.