What is a recommended labor care guide for a woman in labor?

Labor Care Guide for Women in Labor

A laboring woman should receive continuous one-to-one support from a trained professional, with intermittent auscultation as the preferred fetal surveillance method for healthy pregnancies, hourly motor block assessment if epidural analgesia is used, and freedom of movement with upright positioning throughout labor. 1, 2, 3

Initial Assessment Upon Presentation

When a woman presents in labor, obtain the following specific information:

• Contraction characteristics: Document onset timing, current frequency (contractions per 10 minutes), duration (in seconds), and intensity (mild/moderate/strong by palpation) 1
• Multiparity status and history: Previous rapid deliveries, non-hospital births, or complications 1
• Symptoms requiring immediate attention: Vaginal bleeding, severe headache, visual disturbances, decreased fetal movement, or urge to push 1
• Medical comorbidities: Cardiovascular disease, hypertension, diabetes, or respiratory conditions 4, 1

Perform cervical examination to determine dilation, effacement, station, position, and consistency; calculate Bishop score 1. If the woman appears to be in latent labor (irregular contractions, cervical dilation <6 cm without progressive change), discharge home is appropriate with instructions to return when contractions occur every 3-5 minutes, lasting 45-60 seconds, for 1-2 hours 5.

Continuous Labor Support and Positioning

Provide continuous one-to-one nursing care throughout active labor - this is the single most important intervention for improving outcomes 2, 6.

Encourage upright positions and ambulation for women without epidural analgesia; women with epidurals may adopt any comfortable position 3, 6. Position women in lateral decubitus during contractions to optimize hemodynamics 1.

Do not restrict oral intake of fluids or light solids during labor 3. If oral restriction is medically necessary, administer IV dextrose-containing fluids at 250 mL/hour 3.

Fetal and Maternal Monitoring

For Low-Risk Women Without Epidural

Use intermittent auscultation as the primary surveillance method 2:

• Assess fetal heart rate every 15-30 minutes during active first stage 2
• Assess every 5 minutes during second stage with pushing 1, 2
• Normal baseline: 110-160 bpm 1

For Women With Epidural or High-Risk Conditions

Implement continuous electronic fetal monitoring for: oxytocin augmentation, labor induction, increased perinatal risk, or epidural analgesia 2:

• Inspect and document tracings every 15 minutes in active labor 2
• Inspect every 5 minutes during second stage 1, 2
• Assess contraction frequency, duration, intensity, and resting tone 2

Monitor motor block hourly using straight-leg raise test (ability to lift heel off bed against gravity) 4. Alert the anesthesiologist immediately if the woman cannot perform straight-leg raise, as this may indicate extensive block requiring urgent evaluation 4.

After spinal or epidural top-up for procedures, assess straight-leg raise at 4 hours post-dose; escalate care if motor block persists beyond this timeframe to investigate reversible neurological complications 4.

Maternal Vital Signs

• Monitor blood pressure, heart rate, respiratory rate, temperature, and oxygen saturation every 4 hours during first stage 1, 6
• Increase to hourly monitoring during second stage 6
• Treat blood pressure ≥160/110 mmHg urgently in a monitored setting 1
• Maintain maternal temperature 36.5-37.5°C; implement active warming with forced-air devices if shivering occurs 7

Pain Management

Offer epidural analgesia with low-dose local anesthetic-opioid combinations as the preferred pharmacologic option 4. For women with respiratory disease, cautiously titrated epidural is preferred over systemic opioids due to respiratory depression risks 4.

Provide non-pharmacologic options: aromatherapy with essential oils, water immersion, back massage, and position changes 3, 6.

For women on chronic corticosteroids (≥7.5 mg daily for ≥2 weeks), administer stress-dose hydrocortisone IV during active labor to prevent adrenal crisis 4.

Labor Progress Management

Perform vaginal examinations every 2-4 hours during active first stage, or sooner if the woman requests or clinical signs indicate 6.

Do not diagnose labor arrest unless: ≥6 cm dilation with ruptured membranes AND either 4 hours of adequate contractions (≥200 Montevideo units) OR 6 hours of inadequate contractions despite oxytocin 3.

For slow progress in spontaneous active labor, initiate oxytocin augmentation 3:

• Start at 1-2 mU/min IV 8
• Increase by 1-2 mU/min increments until adequate contraction pattern established 8
• Higher-dose protocols may be considered for faster progress 3
• Monitor continuously with electronic fetal monitoring 2

Amniotomy combined with oxytocin is recommended for prevention and treatment of dysfunctional labor, but routine amniotomy alone in normally progressing labor should be avoided 3.

Intrauterine Resuscitation for Abnormal Fetal Heart Rate

When non-reassuring patterns develop, implement the following sequence:

• Change maternal position (lateral positioning preferred) 1
• Assess maternal vital signs 1
• Discontinue oxytocin immediately if infusing 8
• Administer supplemental oxygen 4
• Perform vaginal examination to assess for cord prolapse or rapid descent 1
• Consider fetal scalp stimulation or scalp blood sampling if pattern persists 2

Third Stage and Immediate Postpartum

Administer oxytocin for active management of third stage 4:

• Give 10-40 units in 1000 mL non-hydrating solution IV at rate to control atony 8
• Avoid ergometrine in women with asthma or lung disease due to bronchospasm risk 4
• Avoid prostaglandin F2α in women with asthma due to bronchoconstriction 4
• Administer oxytocin as slow IV infusion (<2 U/min) to prevent hypotension 1

Continue hemodynamic monitoring for ≥24 hours postpartum in women with structural heart disease 1.

Ensure early mobilization to reduce venous thromboembolism risk; consider thromboprophylaxis with low-molecular-weight heparin if immobility expected 4.

Critical Safety Considerations

Common pitfalls to avoid:

• Do not intervene with oxytocin during latent phase - this increases cesarean risk without benefit 5
• Do not diagnose arrest prematurely before meeting strict time and dilation criteria 3
• Do not delay warming interventions for shivering - hypothermia increases complications 7
• Do not ignore persistent motor block beyond 4 hours post-neuraxial anesthesia - this requires urgent investigation for epidural hematoma (8-12 hour window for intervention) 4
• Do not use skin temperature monitoring alone with epidurals - it underestimates core temperature by 2-4°C 7

For women with chronic respiratory disease, provide oxygen to maintain normal saturations, continue usual asthma medications, assist with sputum clearance, and have ICU backup available 4.