Chapter 14: Nursing Management During Labor and Birth

Key Terms Related to Fetal Heart Rate:

● Accelerations: abrupt increase in FHR above baseline that lasts for atleast 30
seconds from onset to peak
○ Visually apparent with elevations in FHR of more than 15 seconds but less
than 2 minutes
○ Considered reassuring and require no interventions → denote fetal
movement and well being; basis for nonstress testing

● Artifact: irregular variations or absence of FHR on fetal monitor record that

results from mechanical limitations of the monitor or electronic interface
○ Ex: may pick up transmissions from radios used by drivers nearby and
translate them into signals

● Baseline fetal heart rate: average FHR that occurs during 10 minute increments
exlcuing periodic or episodic rate changes (tachycardia and bradycardia)

● Baseline variability

● Deceleration: transient fall in FHR caused by stimulation of parasympathetic

nervous system; described by their shape and association to uterine contraction
○ Early decelerations: visually apparent with gradual decrease in FHR; nadir
(lowest point) occurs at peak contraction → decrease 30 to 40 bpm below
baseline
■ onset, nadir, & recovery of deceleration occur at the same time as
onset, peak, and nadir of contraction
■ Most often seen during active stage of labor: pushing, crowning, and
vacuum extraction
■ Result of fetal head compression that results in reflex of vagal
response with slowing FHR during contraction → NOT indicative of
fetal distress and do not require intervention

○ Late decelerations: visually apparent, symmetrical, transitory decreases in

FHR that occur after peak of contraction; have gradual waveforms
 ● Electronic fetal monitoring: detects the fetal pulse by sensing and analyzing tissue
movements via Doppler ultrasound
- can detect variability and types of decelerations in fetus
- Uses a transducer that is capable of both sending and receiving
ultrasound waves
- Fast reflections are analyzed and software in the machine are able to
determine the FHR; recommended method of intrapartum fetal
surveillance for high risk pregnancies

● Periodic baseline changes

Nursing Management of Laboring Women:

● Assessment
● Comfort measures
● Emotional support
● Information and instruction
● Advocacy
● Support for the partner

Maternal Assessment During Labor and Birth #1:

● Maternal status (vital signs, pain, prenatal record review)

- Assess maternal vital signs
- Review prenatal record to identify potential risk factors
- Evaluate pain and pain strategies throughout the birthing process

Vaginal examination (cervical dilation, effacement, membrane status, fetal descent, and
presentation) → If there is no bleeding upon admission, a vaginal exam or ultrasound
assessment may be performed to assess cervical dilation and monitored periodically.

● baseline variability, periodic changes (see Table 14.1):

- Findings are discussed with patient and their family along with being documented and
relayed to provider.
→ Assess the progress of labor → prior to the exam, a full explanation of
what it is going to entail, who will be performing it, and how the findings will
impact the labor plan should be discussed.
- A vaginal exam takes time and proper practice in order to become
efficient in the skill.
- Patient’s privacy and dignity should be maintained at all times.

- Purpose of the exam: assess amount of cervical dilation, percentage of cervical

effacement, and the fetal membrane status → also to gather information on
presentation, position, station degree of fetal head flexion, and presence of fetal
skull swelling or molding

- How: position the woman on their back for exam; initial exam should use water as a
lubricant
- Don sterile gloves and insert index and middle finger into vag.; palpate cervix
for dilation, effacement, and position (posterior or anterior)
- If cervix is open to any degree → presenting fetal part, position,
station, and molding can be assessed along with the membranes being
evaluated as either intact, bulging, or ruptured

- Cervical dilation and effacement: first stage of labor = cervix opening (dilation)
and thinning (effacement) → determines which stage if labor is actively happening
- Width of cervix opening = dilation
- 0 cm: external cervical os is closed
- 5 cm: external cervical os is halfway dilated
- 10 cm: external cervical os is fully dilated and ready for birth
- Length of cervix = effacement
- 0%: cervical canal is 2cm long
- 50%: cervical canal is 1 cm long
- 100%: cervical canal is obliterated

- Fetal descent and presenting parts: descent = station

 - Gloved index finger is used to palpate the fetal skull (vertex presentation)
or buttocks (if breech presentation) through the opened cervix.
- Station is assessed in relation to the mother's ischial spines and fetus
presenting parts. They are the landmarks which have been designated zero
stations.
- Presenting part is higher than ischial spines, the number assigned is
negative
- Presenting part is lower than ischial spines, the number assigned is
positive denoting how many centimeters below zero station (neutral/
even area)
- Progressive descent (-5 to 0 to +4) is expected outcome; moving downward
from negative to zero station to positive.

● Rupture of membranes: happens usually during the first stage of active labor. → to
confirm, a sample of fluid is taken from the vag.
■ Nitrazine yellow dye swab
● Vaginal ph is acidic and amniotic fluid is alkaline
- if intact, will feel like a soft bulge that is more prominent during a
contraction → nitrazine swab remains yellow to olive green and the pH is
between 5 and 6.
- If ruptured, the patient can report a feeling of sudden gush of fluids or a
slow trickle of fluids. → nitrazine swab turns blue green to deep blue with a
pH of 6.5 to 7.5.
- PRIORITY: checking the fetal heart rate to identify deceleration which
can indicate cord compression related to cord prolapse.
- Prolonged rupture of membranes can increase risk for
intrauterine infection!
- Signs: maternal fever, fetal and maternal tachycardia,
foul odor of vaginal discharge, and increase in wbc.

● Uterine contractions (see Figure 14.2): increase in intrauterine pressure causes

tension on the cervix. This in turn leads to dilation and thinning of the cervix which
eventually forces the fetus through the birth canal.
- Contraction (systole) and a relaxation (diastole) phase
 - Each contraction starts with a building up (increment), gradually reaching
an acme (peak intensity of contraction) with the greatest force at the
fundus, and then letting down (decrement).
- Each contraction series is followed by a period of rest and ends when
the next contraction begins.
- At the acme (greatest intensity), the entire uterus contracts with
the greatest intensity in fundal area.
- Monitored by palpation of fundus and by electronic monitoring
- Assessment includes duration of contractions, intensity, frequency, and
uterine resting tone
- Intensity: 30 mmHg or greater initiates cervical dilation; during active
labor it can reach 50 to 80 mmHg.
- Resting tone: normally 5 to 10 mmHg during early labor; during active
labor 12 to 18 mmHg

- How to palpate uterine contractions: for contraction intensity, pads of

fingers on fundus and describe what it feels like. → can also use internal
and external electronic monitoring, however external is not accurate
- Mild: feels like tip of nose
- Moderate: feels like a chin
- Strong: feels like a forehead

● Leopold maneuvers (see Nursing Procedure 14.1): determining the presentation,

position, and lie of the fetus
- Involves inspection and palpation of maternal abdomen
- How?: flat palmar surfaces of hands with fingers together, palpate uterus
- A longitudinal lie is an expected finding
- Presentation can include: cephalic, breech, or shoulder

1. Maneuver 1: What fetal part (head or butt) is located in the fundus (top of
uterus)?
2. Maneuver 2: On which maternal side is the fetal back located? (fetal heart
tones are best heard through back of fetus)
3. Maneuver 3: What is the presenting part?
4. Maneuver 4: Is the fetal head flexed and engaged in pelvis?
 Maternal Assessment During Labor and Birth #2

Fetal Assessment During Labor and Birth → assessment focuses primarily on determining
the fetal heart rate pattern!
● Amniotic fluid analysis: fluid should be clear when membranes have ruptured
- Cloudy or foul smelling amniotic fluid = infection
- Green fluid = fetus has passed their first meconium stool in utero secondary
to: hypoxia, prolonged pregnancy, cord compression, intrauterine growth
restriction, maternal hypertension, diabetes, or chorioamnionitis
- IF BREECH PRESENTATION: considered a normal occurrence
- Due to fetal hypoxia, the main priority is to prevent meconium aspiration
syndrome!
- Necessity to suction the head after is born before the infant takes
its first breath and direct tracheal suctioning after birth if apgar
score is low!
- Amnioinfusion: introduction of warmend, sterile lr or ns into the uterus used
to dilute moderate to heavy meconium released into utero to assist in
preventing meconium aspiration syndrome

● Fetal heart rate monitoring: essential to ensure well being of fetus and to optimize
outcomes; location changes as mother progresses with labor and fetus dispels
downward.
- Object: to reduce mortality and morbidity by ensuring that all fetal hypoxic
insults are identified in time to allow removal or alteration of reasoning
before irreversible damage can occur
- To not confuse with mom’s heart rate, palpate mom’s radial pulse
simultaneously while FHR is being auscultated through abdomen

● Handheld doppler: uses ultrasound waves to bounce off fetal heart,

producing an echo or clicks that reflect the rate of the fetal heart;
- acceptable for low risk women
- A small amount of water soluble gel is put on mother’s abdomen or
actual device to transmit sound waves → best heard in mom’s lower
abdomen quadrant
● Electronic: detects the fetal pulse by sensing and analyzing tissue movement
via doppler ultrasound; specifically for use of high risk pregnancies
- Uses a transducer that is capable of sending and receiving
ultrasound waves.
- Fast reflections are analyzed and software in the machine determines
the FHR → recommended for intrapartum fetal surveillance for high
risk pregnancies
- Indications: oxytocin infusion to induce labor, epidural
analgesics, variety of problems related to compromise of fetus
or mom → prolonged rupture of membranes (longer than 24
hrs), moderate hypertension (higher than 150/100 mmHg),
confirmed delay in first or scond stage of labor, presence of
meconium
- Seems to increase the number of preterm and surgical assisted births
with no effect on reducing incidence of intrapartum injury

● Intermittent FHR Monitoring: primary method; acceptable for low risk women
- Practice of using hand held doppler or fetoscope for periodic
assessment of fhr.
- Listens to FHR for short periods of time at regular intervals → this
allows for mom to be mobile for the first stage of labor. Mom is able to
change positions and move around due to not being hooked up to a lot
of wires and machines.
- Does not provide continuous monitoring nor can detect
variability and types of decelerations → no difference between
intermittent and continuous as they relate to apgar score,
cord blood gasses, etc.
- Can be used to detect FHR baseline, rhythm, and changes from baseline
→ to establish baseline, count the FHR for one full minute after a
contraction to locate any late decelerations. Unless there is a
problem such as ruptured membrane or bleeding, can count FHR for 30
seconds and multiply by 2.
 - Frequent assessment should occur after a period of
ambulation, after pain medication, or after a vaginal
examination.
- FHR is heard most clearly at the fetal back!
- Cephalic: lower quadrant of mother’s abdomen
- Breech: heard at or above the level of mom’s umbilicus
- Contractions should be assessed every 15 to 30 minutes in
active labor and every 5 to 15 minutes while pushing → as well
as before and after any digital vaginal exam, membrane
rupture, medication administration, and ambulation
- Not found quickly, try doing the leopold maneuver → locate fetus
back

● Continuous FHR Monitoring: efm uses a monitoring device that produces a

continuous tracking of the FHR; sound is produced with each heartbeat as
the device is in place along with a graphic record being produced
- Indications: mother receiving oxytocin infusion, mother who has
epidural analgesia, or if there are a variety of health problems for
both mom and fetus such as:
- Prolonged rupture of membranes (longer
than 24 hours)
- Moderate hypertension (above 150/100
mmHg)
- Confirmed delay of first or second stage
of labor
- Presence of meconium
- Increased use is associated with increased risk of c section
birth with no decrease in cerebraly palsy
- Using during labor helps determine whether the fetus is well
oxygenated → reducing risk of neonatal seizures or death
- Enables detection of fetal acidemia ealier and
interventions are able to be put in effect faster to
prevent injury
 - Can limit mom’s mobility and encourages mom to lie supine which
reduces placenta perfusion.
- Remains an accurate tool for determing fetal health by providing
moment by moment printout of FHRR status
- Goal: to identify fetus with increased risk of hypoxic injury so that
interventons can avoid adverse outcomes

External: indirectly with equipment attached to mom’s stomach wall; two ultrasound
transducers used → non invasive, can detect changes in abdominal pressure between
uterine resting tone and contractions; measures approximate duration and frequency of
contractions, providing permanent record of FHR
- Tocotransducer, pressure sensitive device, placed against fundus in the area of
greatest contractility to monitor uterine contractions → detects changes in
uterine pressure and converts the pressure registered into an electrical signal.

- Other transducer records baseline FHR, long term variability, accelerations, and
decelerations → positioned on mom’s abdomen in midline between umbilicus and
symphais pubis; diaphragm is moved to either side of abdomen to get the strongest
sound → converts heart movements into beeping sounds and records them on graph
paper
- Can be used while membranes are still intact and cervix has not yet dilated; can
also be used if membranes have ruptured and cervix is dilating
- CONS: restricts mother’s mobility, can not detect short term variability,
signal disruptions with no explanation aka artifact

Internal: directly with equipment attached to the fetus; for hish risk pregnanaices but can
also be used for moms with:
- Multiple gestations, decreased fetal movement, abnormal FHR, maternal
fever, IUGR, abnormal FHR on auscultation, preeclampsia, dysfunctional
labor, preterm birth, or if mom has diabetes or hypertension
- Involves placement of spiral electrode into fetal presenting part (usually
parietal bone on head) to assess FHR; a pressure transducer is placed
internally within the uterus to record uterine contractions
- Considerd the most accurate method of detecting fetal heart
characteristics and patterns → receiving signal directly from fetus
 - Fetal scalp electrode: used to monitor the fetal heartbeat without
montoring mother’s uterine contractions/ pressure
- FHR and duration and interval of uterine contractions are
recorded on graph paper → permits evaluation of baseline
heart rate and changes in rate and pattern

Can accurately detect both short term (moment to moment) changes in variability
(fluctuations in baseline) and FHR dysrrhythmias; maternal positioning and movement do not
interfere.

Specific criteria must be met in order to utilizes this assessment tool:

1. Ruptured membrane
2. Cervical dilation of atleast 2 cm
3. Presenting fetal part low enough to allow placement of
scalp electrodes
4. Skilled practitioner to insert electrodes
→ Effacacy depends on accurate interpretation of tracings not which method being used.

● Fetal heart rate patterns: must be able to interpret various parameters to

determine if FHR pattern’s category
1. Category 1: strongly predictive of normal fetal acid base balance. Needs no
interventions
2. Category 2: not predictive of abnormal fetal acid base balance. Requires
evaluation and follow up monitoring
3. Category 3: predictive of abnormal fetus acid base balance. Requirees
prompt interventon and evaluations
a. This would include: supplemental oxygen, changing positions,
discontinuing labor augmentation medication, and treatment of
maternal hypotension
● Baseline:
- Normal FHR is 110 to 160 bpm; obtained by auscultation, ultrasound, or
doppler
 - Fetal bradycardia: below 110 bpm that lasts for 10 minutes; can be benign if
isolated event; considered an ominous sign when accompanied by decrease in
baseline variability and late decelerations
- Causes: fetal hypoxia, prolonged maternal hypoglycemia, fetal
acidosis, administration of analgesics to mother, hypothermia,
anesthetic agents, maternal hypotension, fetal hypothermia,
prolonged umbilical cord compression, fetal congestive heart block

- Fetal tachycardia: above 160 bpm that lasts for 10 minutes; represents early
compensatory mechanism to asphyxia; considered an ominous sign when
accompanied by decrease in variability and late decelerations
- Causes: fetal hypoxia, maternal hyperthyroidism, maternal anxiety,
fetal anemia, prematurity, fetal infection, chronic hypoxiemia,
congenital anomalies, fetal heart failure, and fetal arrythmias

● baseline variability: irregular fluctuations in baseline FHR → measured by amplitude

of peak to trough in bpm; represents interplay between parasympathetic and
sympathetic nervous system (push and pull effect) and this produces a moment to
moment change in FHR.
○ Important clinical indicator that is predictive of fetal acid-base balance and
cerebral tissue perfusion; influenced by fetal oxygenation status, cardiac
output, and drug effects
○ The presence implies that both parasympathetic and sympathetic branches are
working and receiving adequate oxygen; MOST IMPORTANT
CHARACTERISITCS OF FHR
○ Four categories:
1. Fluctuation range undetectable
2. Range observed at fewer than 5 bpm
3. Range from 6 to 25 bpm
4. Range more than 25 bpm

→ Absent or minimal variability: caused by fetal acidemia secondary to uteroplacental

insufficiency, crod compression, preterm fetus, maternal hypotension, uterine
hyperstimulation, abruptio placenta, or fetal dysrhythmia.
 - Interventions to improve uteroplacental blood flow incude: lateral positioning,
increasing iv fluids, supplemental oxygen at 8 to 10 L per mask, internal fetal
monitoring, documenting findings, reporting change to md, prep for surgical birth if
no changes occur with interventions.

→ moderate viability: autonomic and central nervous system of fetus are well developed
and oxygenated; considered a good sign of fetal well being and correleates with absence of
metabolic acidosis

→ marked variability: there are more than 25 bpm fluctuations in FHR baseline
- Causes: cord prolapse of compression, maternal hypotension, uterine
hyperstimulation, and abruptio placenta
- Interventions: determing the cause if possible, increasing iv fluids,
supplemental oxygenation at 8 to 10 L via mask, discontinuing oxytocin,
internal fetal monitoring, communicating changes to md, preparing for
surgical birth if all else fails

● periodic changes (see Table 14.1): temporary or recurrent changes made in response
to a stimulus aka contraction.
-
● Other assessment methods
● Fetal scalp sampling, pulse oximetry, stimulation

Guidelines for Assessing Fetal Heart Rate

● Initial 10- to 20-minute continuous FHR assessment on entry into labor/birth area
● Completion of a prenatal and labor risk assessment on all clients
● Intermittent auscultation every 30 minutes during active labor for low-risk women
and every 15 minutes for high-risk women
● During second stage of labor intermittent auscultation every 15 minutes for
low-risk women and every 5 minutes for high-risk women

Question #1

According to the ACOG, ICSI, and AWHONN guidelines, how often should the fetal
heart rate be assessed for a high-risk laboring woman during the second stage of
labor?
a. Every 5 minutes
 b. Every 10 minutes
c. Every 15 minutes
d. Every 20 minutes
Answer to Question #1

a. Every 5 minutes
Rationale: During the second stage of labor, intermittent auscultation should be
done every 5 minutes for the high-risk woman and every 15 minutes for the low-risk
woman. (ACOG, ICSI, AWHONN guidelines)

Continuous Electronic Fetal Monitoring #1

● Uses a machine to produce a continuous tracing of the FHR

● Produce a graphic record of the FHR pattern
● Primary objective
● To provide information about fetal oxygenation and prevent fetal injury from
impaired oxygenation
● To detect fetal heart rate changes early before they are prolonged and profound

Continuous Electronic Fetal Monitoring #2

Criteria for Using Continuous Internal Monitoring of the FHR

● Ruptured membranes
● Cervical dilation of at least 2 cm
● Present fetal part low enough to allow placement of the scalp electrode
● Skilled practitioner available to insert spiral electrode (Murray et al., 2019).

Four Categories of Baseline Variability:

● Absent: fluctuation range undetectable

● Minimal: fluctuation range observed at <5 bpm
● Moderate: (normal) fluctuation range from 6 to 25 bpm
● Marked: fluctuation range >25 bpm
● Periodic baseline changes:
● Accelerations, decelerations

Interpreting FHR Patterns

Interventions for Category III Patterns

Comfort and Pain Management

● Pain as universal experience; intensity highly variable

 ● Mandate for pain assessment in all clients admitted to health care facility
● Numerous nonpharmacologic and pharmacologic choices available

Nonpharmacologic Measures for Pain Management

● Continuous labor support

● Hydrotherapy
● Ambulation and position changes (see Table 14.2, Figure 14.9)
● Acupuncture and acupressure
● Attention focusing and imagery
● Therapeutic touch and massage; effleurage
● Breathing techniques (e.g., patterned-paced breathing)

Question #2:

Is the following statement true or false?

Pain experienced by a woman in labor is fairly intense.
a. True
b. False
Answer to Question #2

b. False
Pain during labor is a universal experience, but the intensity varies.

Pharmacologic Measures

● Systemic analgesia
● Regional or local anesthesia
● Neuraxial analgesia/anesthesia techniques: use of analgesic or anesthetic,
continuously or intermittently into epidural or intrathecal space
● Shift in pain management: woman as an active participant during labor

Systemic Analgesia

● Route: typically administered parenterally through existing IV line

● Drugs (see Drug Guide 14.1)
● Opioids (butorphanol, nalbuphine, meperidine, fentanyl)
● Ataractics (hydroxyzine, promethazine)
● Benzodiazepines (diazepam, midazolam)

Regional Analgesia/Anesthesia
 ● Epidural block: continuous infusion or intermittent injection; usually started when
dilation >5 cm
● Combined spinal–epidural block (“walking epidural”)
● Patient-controlled epidural
● Local infiltration (usually for episiotomy or laceration repair)
● Pudendal block (usually for second stage, episiotomy, or operative vaginal birth)
● Intrathecal (spinal) analgesia/anesthesia (during labor and cesarean birth)

General Anesthesia

● Emergency cesarean birth or woman with contraindication to use of regional

anesthesia
● IV injection, inhalation, or both
● Commonly, first thiopental IV to produce unconsciousness
● Next, muscle relaxant
● Then intubation, followed by administration of nitrous oxide and oxygen; volatile
halogenated agent also possible to produce amnesia

First Stage of Labor: Phone Assessment

● Estimated date of birth

● Fetal movement; frequency in past few days
● Other premonitory signs of labor experienced
● Parity, gravida, and previous childbirth experiences
● Time frame in previous labors
● Characteristics of contractions
● Bloody show and membrane status (whether ruptured or intact)
● Presence of supportive adult in household or if she is alone

Nursing Care During First Stage of Labor

● General measures
● Obtain admission history
● Check results of routine laboratory tests and any special tests
● Ask about childbirth plan
● Complete a physical assessment
● Initial contact either by phone or in person

First Stage of Labor: Admission Assessment #1

 ● Maternal health history (see Figure 14.13 and Box 14.2)
● Physical assessment (body systems, vital signs, heart and lung sounds, height and
weight)
● Fundal height measurement
● Uterine activity, including contraction frequency, duration, and intensity
● Status of membranes (intact or ruptured)
● Cervical dilatation and degree of effacement
● Fetal heart rate, position, station
● Pain level

First Stage of Labor: Admission Assessment #2

● Fetal assessment
● Lab studies
● Routine: urinalysis, CBC
● Syphilis screening, HbsAg screening, GBS, HIV (with woman’s consent), and possible
drug screening if not included in prenatal history
● Assessment of psychological status

Question #3

Is the following statement true or false?

If a pregnant woman in labor calls the health care facility, the nurse should
strongly advise the woman to come to the facility to be evaluated.
a. True
b. False
Answer to Question #3

b. False
If the initial contact is made by phone, the nurse needs to ask the woman about her
signs and symptoms and what she is experiencing. The nurse would then instruct the
woman to remain at home or come to the facility based on the woman’s responses.
First Stage of Labor: Continuing Assessment

● Woman’s knowledge, experience, and expectations

● Vital signs
● Vaginal examinations
● Uterine contractions
 ● Pain level
● Coping ability
● FHR
● Amniotic fluid (see Table 14.3)

Nursing Management: Second Stage #1

● Assessment
● Typical signs of second stage
● Contraction frequency, duration, intensity
● Maternal vital signs
● Fetal response to labor via FHR
● Amniotic fluid with rupture of membranes
● Coping status of woman and partner

Question #4:

During the second stage of labor, assessment would include which of the
following?
a. Complaints of rectal or perineal pressure
b. Estimated date of birth
c. Fundal height
d. Fetal position
Answer to Question #4

a. Complaints of rectal or perineal pressure

During the second stage of labor, the nurse would assess for signs typical for this
stage, such as complaints of rectal or perineal pressure. Assessment of estimated
date of birth, fundal height, and fetal position are assessments for the first stage
of labor.
Nursing Management: Second Stage #2

● Interventions
● Supporting woman and partner in active decision making
● Supporting involuntary bearing-down efforts; encouraging no pushing until strong
desire or until descent and rotation of fetal head well advanced
● Providing instructions, assistance, pain relief
● Using maternal positions to enhance descent and reduce pain
 ● Preparing for assisting with delivery

Nursing Management: Second Stage #3

● Interventions with birth

● Cleansing of perineal area and vulva
● Assisting with birth, suctioning of newborn, and umbilical cord clamping
● Providing immediate care of newborn
● Drying
● Apgar score
● Identification

Nursing Management: Third Stage

● Assessment
● Placental separation; placenta and fetal membranes examination; perineal trauma;
episiotomy; lacerations
● Interventions
● Instructing to push when separation apparent; giving oxytocin if ordered; assisting
woman to comfortable position; providing warmth; applying ice to perineum if
episiotomy; explaining assessments to come; monitoring mother’s physical status;
recording birthing statistics; documenting birth in birth book

Nursing Management: Fourth Stage

● Assessment: vital signs, fundus, perineal area, comfort level, lochia, bladder status
● Interventions
● Support and information
● Fundal checks; perineal care and hygiene
● Bladder status and voiding
● Comfort measures
● Parent–newborn attachment
● Teaching
Chapter 14: Study Guide Questions:

Question 1: During the second stage of labor, a nurse should assess which of the following

signs?

a. Cervical effacement
b. Fetal movement
c. Complaints of rectal pressure
d. Fundal height
Answer: C. Complaints of rectal pressure → Rationale: Rectal or perineal pressure is a
typical sign in the second stage of labor, indicating fetal descent and readiness for birth.
Cervical effacement and fundal height are assessed during the first stage.

Question 2: A nurse is conducting a phone assessment with a woman who thinks she is in

labor. What should the nurse assess first?

a. Time of last meal

b. Presence of contractions and their frequency
c. Estimated date of birth
d. Her plan for pain management

Answer: B. Presence of contractions and their frequency → Rationale: Assessing

contractions and their frequency helps determine if the woman is in active labor and may
need to come to the facility. Other questions can be addressed based on this initial
assessment.

Question 3: Which nonpharmacologic comfort measure would a nurse likely recommend to a

laboring woman experiencing moderate pain?

a. Epidural block
b. IV opioid
c. Hydrotherapy
d. General anesthesia

Answer: C. Hydrotherapy → Rationale: Hydrotherapy, like a warm bath, can effectively

reduce pain during labor without medications. Epidural and general anesthesia are
pharmacologic options, while IV opioids are systemic analgesics.
Question 4: According to ACOG and AWHONN guidelines, how often should fetal heart rate

(FHR) be assessed for a high-risk laboring woman during the second stage of labor?

a. Every 5 minutes
b. Every 10 minutes
c. Every 15 minutes
d. Every 20 minutes

Answer: A. Every 5 minutes → Rationale: High-risk women in the second stage of labor
require FHR assessments every 5 minutes to monitor for fetal distress and ensure timely
interventions if needed.

Question 5: Which of the following FHR variability levels indicates the best oxygenation

status in the fetus?

a. Absent
b. Minimal
c. Moderate
d. Marked

Answer: C. Moderate → Rationale: Moderate variability (6–25 bpm) reflects a healthy,

well-oxygenated fetus, while absent, minimal, or marked variability may indicate potential
issues.

Question 6: During the first stage of labor, what would be the priority nursing intervention

for a woman reporting her membranes have ruptured?

a. Check cervical dilation

b. Assess FHR
c. Perform a Leopold maneuver
d. Provide pain relief

Answer: B. Assess FHR → Rationale: After rupture of membranes, assessing FHR is critical
to detect any signs of cord prolapse or fetal distress.

Question 7: Which of the following is a key purpose of continuous electronic fetal

monitoring (EFM)?

a. To ensure adequate maternal pain management

 b. To provide real-time maternal blood pressure monitoring
c. To monitor fetal oxygenation and detect distress early
d. To record maternal uterine contractions only

Answer: c. To monitor fetal oxygenation and detect distress early → Rationale: EFM is
primarily used to monitor fetal oxygenation status and identify signs of fetal distress for
timely intervention.

Question 8: The nurse observes a deceleration in FHR with contractions. What is the

priority intervention?

a. Call the provider immediately

b. Change the mother’s position
c. Increase IV fluid rate
d. Administer oxygen to the mother

Answer: B. Change the mother’s position → Rationale: Position changes can relieve cord
compression and improve blood flow, often reducing decelerations.

Question 9: A woman receiving an epidural during labor should be monitored for which

common side effect?

a. Hypertension
b. Hypotension
c. Tachycardia
d. Fever

Answer: B. Hypotension → Rationale: Epidurals often cause maternal hypotension due to

vasodilation, requiring close monitoring and possible IV fluids or medication.

Question 10: The nurse is evaluating a woman who is dilated to 8 cm and expressing

increased anxiety and pain. Which nonpharmacologic intervention would best help her at

this time?

a. Offering systemic analgesia

b. Encouraging patterned-paced breathing
c. Performing a vaginal exam
 d. Administering an epidural

Answer: B. Encouraging patterned-paced breathing → Rationale: Patterned breathing

helps manage pain and anxiety, especially in active labor stages where the woman is close to
full dilation.

Question 11: Which of the following assessments is most important immediately after

delivery of the placenta?

a. Checking fundal height

b. Assessing the newborn’s Apgar score
c. Evaluating perineal area for trauma
d. Administering an analgesic

Answer: a. Checking fundal height → Rationale: Fundal checks help ensure the uterus is
contracting appropriately, reducing the risk of postpartum hemorrhage.

Question 12: A woman in labor receives a pudendal block. What is this typically used for?

a. Pain relief during the first stage of labor

b. Emergency cesarean delivery
c. Episiotomy or operative vaginal birth
d. Continuous pain relief throughout labor

Answer: C. Episiotomy or operative vaginal birth → Rationale: Pudendal blocks are used
for local anesthesia in the perineal area, often during episiotomy or forceps-assisted
delivery.

Question 13: Which assessment finding would indicate potential fetal compromise?

a. FHR accelerations with movement

b. Moderate baseline variability
c. Marked FHR variability
d. FHR of 130 bpm

Answer: C. Marked FHR variability → Rationale: Marked variability may indicate fetal
hypoxia or distress, requiring further evaluation and possible intervention.
Question 14: If the nurse observes amniotic fluid that is greenish in color, what could this

indicate?

a. Normal amniotic fluid

b. Meconium staining
c. Preterm labor
d. Risk for infection

Answer: B. Meconium staining → Rationale: Greenish amniotic fluid often indicates meconium,
which can signify fetal stress and requires close monitoring for potential aspiration.

Question 15: Which pain management technique allows the laboring woman to remain an

active participant in labor?

a. General anesthesia
b. Neuraxial analgesia
c. Benzodiazepines
d. IV opioids

Answer: B. Neuraxial analgesia → Rationale: Neuraxial analgesia (e.g., epidural) allows for
pain relief while keeping the woman awake and able to participate in the birthing process.

Question 16: A patient in early labor asks if she should come to the hospital. Which

statement by the nurse is appropriate?

a. "Yes, it’s time to come in right away."

b. "How far apart are your contractions?"
c. "You should wait until your water breaks."
d. "Only come if you have intense pain."

Answer: B.. "How far apart are your contractions?" → Rationale: Contraction frequency
helps the nurse determine if the patient is in active labor and if she should come to the
facility.

Question 17: Which of the following is a priority for a nurse caring for a woman in the

fourth stage of labor?

a. Assessing fetal heart rate

 b. Ensuring complete cervical effacement
c. Monitoring for postpartum hemorrhage
d. Checking for rupture of membranes

Answer: C. Monitoring for postpartum hemorrhage → Rationale: Postpartum hemorrhage is

a primary concern immediately after delivery, so monitoring the fundus and lochia is
essential.

Question 18: For which stage of labor is a “walking epidural” most beneficial?

a. First stage of labor

b. Second stage of labor
c. Third stage of labor
d. Fourth stage of labor

Answer: A. First stage of labor → Rationale: A walking epidural allows the woman to remain
mobile and participate actively in labor management.

Question 19: A nurse observes the mother experiencing a sudden urge to push during the

second stage of labor. What is the nurse’s best action?

a. Encourage deep breathing

b. Assess fetal station
c. Inform the provider
d. Administer an analgesic

Answer: C. Inform the provider → Rationale: The urge to push signifies readiness for
delivery; notifying the provider ensures support during birth.

Question 20: What is a major benefit of intermittent FHR monitoring in low-risk

pregnancies?

a. Detects every deceleration

b. Allows for greater maternal mobility
c. Provides continuous data on fetal well-being
d. Is more accurate than EFM
Answer: B. Allows for greater maternal mobility → Rationale: Intermittent monitoring
enables movement, aiding comfort and labor progress in low-risk pregnancies.