Labor and Delivery is one of the most unique places in the hospital. Where else in the hospital do you get to go to birthday parties all day long?
While Labor and Delivery is an exciting place, many nurses new to Labor and Delivery are nervous because there is so much to learn, especially when it comes to procedures and interventions unique to Labor and Delivery!
In nursing school, you learn how to perform basic nursing skills. But there is a whole set of skills it’s likely you never learned in nursing school because they are specific to the care of a laboring patient.
I remember how nervous I was when I first dove into the world of Labor and Delivery. So, to help ease your nerves about Labor and Delivery, I have outlined common procedures, skills and interventions you won’t find on any other unit in the hospital. Let’s dive into the most common procedures, skills and interventions unique to Labor and Delivery!
An amniotomy is when the physician or midwife breaks the patient’s amniotic sac (commonly called the bag of water) to help with the progression of labor. The nurse won’t perform this procedure independently, but will assist by getting the hook (it looks like a crochet needle!)
After the water is broken, the nurse will be responsible for assessing the water color periodically through the rest of labor. Clear fluid is ideal. If you see yellow tinged fluid or thick yellow goop that’s an indication that there is meconium (the feces of the baby). With meconium, the baby will need to be assessed and possibly suctioned by a NICU team immediately after delivery to prevent aspiration.
Nursing Assessments: Fluid color, fluid amount, fetal status
Once the bag of water is broken, an amnio infusion might be needed if there is cord compression. Instilling fluid back into the uterus cushions the baby’s cord, which hopefully stops fetal distress.
An amnio infusion is performed by instilling fluid into the uterus via an intrauterine pressure catheter (IUPC). The IUPC has a port where IV tubing can be connected. To instill the fluid, you set your IV tubing in a similar fashion as other IV therapies. Typically, I place tape over each port and label it “AMNIO” to prevent a medication administration error. (Since the tubing is similar, you don’t want someone to accidentally administer medications into the uterus instead of the vein)!
After setting up a IUPC, a bolus of fluid is immediately administered in the uterus to cushion the baby’s cord. After the initial bolus, the nurse will assess for fluid leaking out of the uterus. If you see fluid return, you will adjust the therapy to a slow continuous drip per doctor’s orders. In this case, you want fluid to slowly come out after being administered because you don’t want to blow up the uterus like a balloon!
Assessments: Adequate fluid return, fluid color, uterine contractions, fetal status
Vaginal exams are necessary to check the progress of a laboring patient. During a vaginal exam, you will assess three things: Dilation, Station and Effacement.
To perform a vaginal exam, you will don sterile gloves, apply lubricant to your gloved fingers, and gently insert your fingers into the vagina.
Dilation is how open the patient’s cervix is. This is measured from 0 (completely closed) to 10 cm (completely open).
Effacement is an assessment of the thickness of the cervix, measuring from 0-100%. A measurement of 0% means the cervix is at its full thickness. When the cervix is 50% effaced, it means the cervix is half its ordinary thickness. A 100% effaced means the cervix is thinned out completely (it feels like a thin rubber band).
Lastly, station is the position of the baby’s head in relationship to the ischial spines (or the pelvis). For instance, If the baby’s head is not engaged in the pelvis, the baby is -3 or -2 station. As labor progresses, the baby’s head sitting right at the ischial spines would be 0 station. When the baby’s head is crowning (or coming out of the vagina), it would be +3 station.
Assessments: Dilation, Effacement, Station
When you typically think about placing a foley, most people immediately think about draining the bladder. While Labor and Delivery nurses do place foley catheters into the bladder, we also use a foley catheter set for another purpose.
If the patient is dilated less than 3cm, a foley catheter can be inserted into the vaginal canal. Once inside the canal, the provider finds the cervix and inflates the balloon inside the cervix. Typically, we insert 30ml of saline into the balloon. So, a special catheter is used to accommodate for this much fluid. The inflated balloon puts pressure on the cervix and helps dilate the patient to 3cm. When the balloon falls out, you know your patient has made it to 3cm dilated.
As the nurse you will help by instilling the fluid. After the balloon is in place, the catheter is pulled tight and taped to the patient’s leg to create tension.
Assessments: Balloon position (still inside or expelled), Amount of tension on catheter
Once the baby is born, the baby will be immediately assessed. The APGAR score is a tool used to assess the newborn’s overall well being at 1 minute and 5 minutes after birth.
APGAR stands for appearance, pulse, grimace, activity, and respiration. Each of these 5 assessments gets a score from 0-2. A 2 is a perfect score for a category, and your total score is out of 10.
At the 1 minute assessment, scores ranging from 7-10 indicate the newborn will need routine post delivery care. A score of 4-6 may indicate the newborn needs some assistance with breathing. Scores less than 4 require immediate lifesaving measures. At the five minute assessment, scores less than 7 means the newborn needs frequent monitoring and possible interventions.
Fetal monitoring and interpretation of fetal heart rate is one of the many important things for a Labor and Delivery nurse to master. Many interventions performed on a laboring patient rely on accurate interpretations of the baby’s heart rate and the mother’s contraction pattern. This book is a good reference for anyone wanting to learn more in depth about fetal monitoring interpretation.
There are 2 ways to monitor the fetus: Internally and Externally.
External monitoring is preferred because it is non-invasive, leading to less risk of infection and complication. With external monitoring, two monitors are attached to the outside of the patient’s abdomen. One monitor (called the Sono) is placed to listen to the baby’s heartbeat. The other monitor (called the Toco) is placed on the top of the fundus (the uterus) to assess contractions.
Internal monitors are used when monitoring externally becomes difficult and accurate interpretation is not possible. Reasons for internal monitoring include: large patient habitus, fetal positioning making it difficult for a continuous heart beat tracing, and/or a need for an accurate assessment of uterine contraction strength for the titration of medications.
Sono (also called a Doppler transducer): When applying the monitor, gel is placed on the monitor to help conduct sound waves. Then, the nurse places the monitor over the baby’s heart. To find the placement for the monitor, the position of the baby is palpated using Leopold’s maneuvers. For instance, if the baby is cephalic (head down), the monitors will be in the lower quadrants of the abdomen. If the baby is breech (head up), the sono will be placed higher up on the abdomen.
Toco (also called a Tocodynamometer): The toco works by pressure. The monitor is placed at the top of the patient’s abdomen (on top of the fundus). On the monitor, there is a button that touches the patient’s belly. During contractions, the button is compressed and helps to translate the duration of contractions.
A disadvantage to external contraction monitoring is if a patient coughs, or moves, you might see a spike on the tracing. The toco can only tell when and how long a contraction is. You cannot tell the strength of the contraction using an external monitor.
Fetal Scalp Electrode (FSE): A FSE is a tiny transducer that is placed on the baby’s head. The nurse will perform a vaginal exam prior to placement. It is important that the FSE is not placed over the fontanel of the baby.
Once you find a place on the baby’s head, you slide the FSE into the vaginal canal, place the tip against the skull and turn the end to attach it. The tip of the FSE looks like a small hook. The small hook sits underneath the skin on the baby’s head and gives continuous accurate feedback on the baby’s heart rate.
Intrauterine pressure catheter (IUPC): An IUPC is a flexible tube that sits inside of the uterus. Placing an IUPC it is very similar to an FSE.
The nurse will first perform a vaginal exam. The IUPC tube is then slid past the baby’s head and sits inside the uterus. With an IUPC, it is possible to tell the exact strength of a contraction. This is helpful for titrating Pitocin, helping to prevent the over stimulating the uterus.
Another use of the IUPC is that fluid can be instilled into the uterus via a port. This would be indicated if the monitor showed fetal distress caused by cord compression.
McRoberts Maneuver and Suprapubic Pressure:
In the event of a shoulder dystocia (where the baby’s shoulder gets stuck in the birth canal), there are two maneuvers the nurse can perform to help the shoulder dislodge.
The first is the McRoberts maneuver. The nurse will assist the patient in pulling their legs back as far as possible. This can open up the pelvis to allow the baby’s shoulder to move through the birth canal.
The other thing the nurse might assist with is applying suprapubic pressure (achieved by the nurse either standing on a stool or climbing on top of the patient’s bed)! The goal is to apply pressure slightly above the pubic bone, which helps to push the baby’s shoulder under the bone. This helps the baby move safely through the birth canal.
Both the McRoberts Maneuver and applying suprapubic pressure help the baby move safely through the birth canal. However, in the event the baby cannot progress with these interventions, an emergent procedure called the Zavanelli maneuver is used.
This procedure involves pushing the baby back into the uterus and performing an emergent cesarean section. The Zavanelli maneuver is very uncommon and is associated with great risk to both the mother and baby.
Spontaneous Rupture of Membranes (SROM) Check
When a patient arrives complaining of leaking or are suspicious her water has broken, a spontaneous rupture of membranes (SROM) check is performed.
The fluid the patient is complaining about needs to be examined, which can be done in various ways. Nitrazine paper is used to test the pH of the fluid coming from the vagina. If the paper turns a certain color indicating a positive reading for amniotic fluid, you can deduct that the bag of water is broken.
Another method used to check if fluid is amniotic fluid is to check for ferning. The fluid is smeared on a slide, allowed to dry, and examined under a microscope. If the sample is amniotic fluid, it will dry looking like fern branches.
Lastly, if these methods are inconclusive the doctor might order an Amnisure test. To perform the test, the nurse will insert a special swab into the vagina and hold it inside the canal following the instructions on the package. Once complete, this is sent to the lab and results should confirm if the water has broken.
Fundal Checks and Massage
After delivery, the uterus is assessed frequently and the patient is checked for signs of hemorrhage. The nurse will do a fundal check to see the height of the fundus, or uterus. The fundus is massaged or rubbed to check for firmness. A firm, hard uterus is a good indication that the patient is currently not at risk of hemorrhage. A boggy or soft uterus needs to be massaged or rubbed until it becomes firm. If the uterus stays boggy, it is more likely to bleed, possibly causing a hemorrhage.
While you are massaging the fundus, you will check your patient’s pad to assess if blood is expelled. If you see gushes of blood or large clots, this requires further assessment. As you’re rubbing the uterus, if the blood doesn’t stop you might need to measure the amount and contact a provider to notify them of a hemorrhage so the appropriate medication can be administered.
Labor and Delivery is a unique area of practice and involves many procedures you probably didn’t learn in nursing school! These procedures are usually taught during staff orientation or on the job.
Because of its uniqueness, Labor and Delivery is a fun area to work in. If you’re interested in learning more about Labor and Delivery nursing or have just started your job, I recommend this book.
I remember as a new nurse on Labor and Delivery, I was completely lost with the nursing verbiage and abbreviations specific to this area! To help you understand what is going on in Baby Land, I created a cheat sheet that includes common Labor and Delivery nursing verbiage and abbreviations. You can check out my blog post about Labor and Delivery lingo here and get your free cheat sheet of verbiage and abbreviations here!
Also, if you’re interested in being a nurse in Baby Land, take a peek at my other article at FreshRN where I describe what it’s like to be a Labor and Delivery nurse!
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