The Four P's
A laboring client is anxious and tense, stating, “I can’t do this anymore.” Her contractions have slowed, and cervical dilation has stopped. Which “P” is most likely affecting her labor progress?
A. Passenger
B. Passageway
C. Powers
D. Psyche
D. Psyche
Emotional stress and anxiety can inhibit oxytocin release, slowing labor progress.
Contractions are irregular, do not increase in frequency, duration and intensity
False labor
What is the difference between efface and dilate.
What is considered complete effacement and complete dilation?
Efface- thin (Complete effacement is 100%)
Dilate- Open (Complete dilation is 10 cm)
Known as false labor. Prepares the cervix and helps adjust the fetal position in the uterus.
Braxton Hicks Contractions
What should baseline FHR be for at least a 2-minute period.
110-160 beats/minute
What is the meaning of variable decelerations? What nursing intervention should be done for this?
C – Cord compression. Reposition mother (side to side, knee-chest), give O₂, stop oxytocin, possible amnioinfusion.
What does the nurse note when measuring the frequency of a laboring woman’s contractions?
The time between the beginning of one contraction and the beginning of the next
The nurse notes that a fetus is in breech presentation. Which “P” does this finding primarily involve?
A. Passenger
B. Passageway
C. Powers
D. Psyche
A. Passenger
Breech presentation involves fetal position, part of the “Passenger” factor.
Walking makes the contractions become stronger and more effective.
True labor
The amount of time the uterus relaxes between contractions.
Interval.
Fundus (top of uterus) no longer presses on diaphragm because baby drops into the pelvic inlet.
Lightening and Increased Vaginal Discharge.
What is considered fetal bradycardia?
110 beats/minutes (for10 minutes or longer)
What is the meaning for Early Decelerations? What nursing intervention should be done for this?
H – Head compression. Normal, benign – continue to monitor
What contraction duration and interval does the nurse recognize could result in fetal compromise?
Duration longer than 90 seconds, interval shorter than 60 seconds
A client in active labor has strong contractions every 2–3 minutes, each lasting 60 seconds. The cervix remains at 4 cm for several hours. Which factor is most likely the cause of slow labor progress?
A. Ineffective uterine contractions (Powers)
B. Anxiety and fear (Psyche)
C. Pelvic contracture (Passageway)
D. Fetal macrosomia (Passenger)
C. Pelvic contracture (Passageway)
When contractions are strong but dilation doesn’t progress, obstruction of the passageway is suspected.
Bloody show is often present. Bloody show is a mixture of blood and mucous.
True labor
What are the 3 phases of contractions?
Increment, Peak, Decrement
Thick mucus mixed with pink or dark brown blood. May begin a few days before labor, or a woman may not have this until labor is under way.
Bloody show
What is considered fetal tachycardia?
When the FHR is greater than 160 beats/min (that lasts 2-10 minutes or longer).
What is the meaning for accelerations? What nursing intervention should be done for this?
O – OK! Oxygenated fetus. No intervention needed.
The nurse observes the patient bearing down with contractions and crying out, “The baby is coming!” What is the best nursing intervention?
Stay with the woman and use the call bell to get help.
The nurse observes that the fetus remains high in the pelvis despite strong contractions and full cervical dilation. Which “P” is most likely responsible?
A. Passenger
B. Passageway
C. Powers
D. Psyche
B. Passageway
A high fetal station despite full dilation suggests an inadequate or contracted pelvis.
No change in effacement and dilation of the cervix
False labor
Frequency is the time from the beginning of one contraction until the beginning of the next contraction.
A woman should not have contractions every ___ minutes or less.
2 minutes.
Amniotic sac (bag of waters) sometimes ruptures before labor begins.
Rupture of Membranes
Abrupt increases in FHR. This is a sign of a fetus that is well oxygenated.
Acceleration. This is good!
What is the meaning for Late Decelerations? What nursing intervention should be done for this?
P – Placental insufficiency. Turn patient to left side, stop oxytocin, give O₂, increase IV fluids, notify provider.
The nurse observes on the fetal monitor a pattern of a 15-beat increase in the fetal heart rate that lasts 15 to 20 seconds. What does this pattern indicate?
A well-oxygenated fetus
During assessment, the nurse notes that the client’s contractions are every 1 minute and last 90 seconds with minimal rest between them. Which nursing action is most appropriate?
A. Encourage the patient to continue pushing with each contraction.
B. Increase IV fluids to maintain hydration.
C. Notify the provider because uterine tachysystole may impair fetal oxygenation.
D. Reposition the patient to left lateral position and continue monitoring.
C. Notify the provider
Contractions that are too frequent/intense indicate uterine tachysystole (excessive “Power”), which decreases fetal oxygenation and requires prompt action.
Discomfort is felt in the lower back and the lower abdomen, feels like menstrual cramps at first.
True.
Duration is how long the contractions last. Report contractions that last longer than ___ seconds.
90 seconds.
Known as nesting. Tell women to try and conserve energy- labor is coming.
Energy spurt
FHR changes that look like early decelerations except that they begin AFER the beginning of the contraction and do not return to baseline until after the contraction ends.
Late Decelerations. This is a BAD sign and must be dealth with immediately.
A nurse observes variable decelerations on the FHR monitor. What is the priority nursing intervention?
A. Increase IV fluids
B. Apply oxygen by mask
C. Change the mother’s position
D. Prepare for immediate delivery
C
Rationale: Variable decels = cord compression; first step is position change (side to side or knee–chest).
What is the most important nursing intervention during the fourth stage of labor?
Assess for hemorrhage