Labor and Delivery Nursing: A Study Guide

Labor and delivery is two patients at once, and sometimes three when the baby arrives. The mother's blood pressure, her uterus, and her bleeding are tied directly to the baby's oxygen. This lesson walks through the stages of labor, fetal monitoring, preeclampsia and magnesium, postpartum hemorrhage, Rh status, newborn assessment, and neonatal resuscitation, with the why behind every rule so you can reason through any NCLEX question instead of memorizing it.

Stages of laborFetal monitoringPreeclampsiaMagnesiumPostpartum hemorrhageRh and RhIGNewborn assessmentAPGARNRPPPV

The stages of labor

Labor is divided into four stages. Knowing the stage tells you what is normal, what to watch, and what the biggest danger is right now.

Fetal heart rate monitoring

The fetal heart rate (FHR) tracing is the best window you have into the baby's oxygen supply. Oxygen travels from the mother's lungs, through her blood, across the placenta, and down the cord. A problem at any point in that path shows up on the strip.

Baseline

Normal baseline: 110 to 160 beats per minute, judged over a 10 minute window, ignoring accelerations and decelerations.

• Tachycardia (over 160 for 10 minutes or more): think maternal fever or infection (chorioamnionitis), maternal dehydration, drugs like terbutaline, or early fetal hypoxia. Why: fever raises the baby's metabolic rate and heart rate, just like it does in adults.
• Bradycardia (under 110 for 10 minutes or more): think cord compression, maternal hypotension, or late fetal hypoxia. Why: a baby's heart slows when its oxygen supply drops, because the baby has less ability than an adult to compensate.

Variability

Variability is the small up-and-down wiggle of the baseline. It shows that the baby's brain and nervous system are well oxygenated and actively controlling the heart. Moderate variability is the single most reassuring finding on a strip.

Accelerations

An acceleration is a brief rise above baseline: at term, at least 15 bpm for at least 15 seconds (before 32 weeks, 10 bpm for 10 seconds). Accelerations are reassuring. Why: a baby that can speed up its heart in response to movement has a healthy, oxygenated nervous system.

Decelerations and VEAL CHOP

The three FHR categories

Preeclampsia

Preeclampsia is a pregnancy disorder of the blood vessels that starts with an abnormal placenta. The placenta releases substances that injure the lining of the mother's blood vessels all over her body. That is why it affects so many organs: the vessels in the brain, liver, kidneys, and lungs are all injured at once. The only cure is delivery of the placenta, and it can still develop up to 6 weeks after birth.

Severe features

• BP 160 systolic or higher, or 110 diastolic or higher. Why it matters: pressures this high can cause a stroke. Severe range BP that lasts 15 minutes or more should be treated within 30 to 60 minutes, usually with IV labetalol, IV hydralazine, or immediate-release oral nifedipine per order.
• Platelets under 100,000. Why: damaged vessel walls use up platelets as they try to repair themselves, which raises bleeding risk.
• Liver enzymes twice normal or severe right upper quadrant or epigastric pain. Why: the liver swells inside its capsule. Epigastric pain can warn of liver rupture.
• Creatinine over 1.1 mg/dL or doubling. Why: the kidneys are losing function.
• Pulmonary edema. Why: leaky vessels let fluid into the lungs.
• New headache that does not go away with medication, or visual changes (spots, blurring). Why: these signal brain involvement and can come right before a seizure.

HELLP syndrome

HELLP is a severe form of preeclampsia: Hemolysis, Elevated Liver enzymes, Low Platelets. The BP may be only mildly high, and the patient may just say she has nausea or feels like she has the flu, with epigastric or right upper quadrant pain. Why it is dangerous: low platelets and a damaged liver can lead to bleeding, liver rupture, and DIC. Do not dismiss "the flu" in a third-trimester patient.

Why seizures happen (eclampsia)

Injured blood vessels in the brain lose their ability to regulate blood flow. Very high pressure pushes fluid out of the vessels and causes brain swelling and irritability. That irritated brain tissue can fire a seizure. Hyperreflexia and clonus are signs the brain and nerves are irritable. A seizure is called eclampsia and can happen before, during, or after birth.

Nursing care

• BP with the correct cuff size, sitting or in a side-lying position with the arm at heart level. Why: a cuff that is too small or an arm held above the heart gives a falsely high or low reading.
• Assess for headache, visual changes, epigastric pain, reflexes, and clonus. Why: these are the warning signs of progression to eclampsia or HELLP.
• Strict intake and output; watch for urine under 30 mL/hr. Why: low output shows kidney injury, and it also means magnesium will build up.
• Lung sounds and SpO2. Why: leaky vessels and IV fluids raise the risk of pulmonary edema, so fluids are often limited per order.
• Seizure precautions: padded side rails, suction and oxygen at the bedside, low stimulation (dim lights, quiet room). Why: stimulation can trigger a seizure in an irritable brain.
• During a seizure: stay with her, call for help, turn her on her side, protect from injury, do not put anything in her mouth, note the time, and give magnesium as ordered. Then check the FHR. Why: side lying protects the airway and keeps the uterus off the vena cava; the baby often shows bradycardia during and after the seizure that may recover as the mother reoxygenates.
• Fetal monitoring. Why: the abnormal placenta can cause growth restriction and late decelerations.

Magnesium sulfate

Why it is given: magnesium sulfate is the drug of choice to prevent and treat seizures in preeclampsia with severe features and eclampsia. It calms nerve and muscle activity, partly by blocking calcium at the nerve-muscle junction. It is not a blood pressure drug, so severe BP still needs an antihypertensive. It is also given before 32 weeks for fetal neuroprotection, because it lowers the risk of cerebral palsy in very preterm babies.

Toxicity: know the order

As the magnesium level rises, signs appear in a predictable order. That is why reflexes are checked so often: they disappear before breathing slows.

1. Loss of deep tendon reflexes (patellar reflex). The earliest sign. Why: magnesium blocks nerve signals to muscles, and reflexes are the first to fade.
2. Respiratory depression: RR under 12. Why: the same nerve-muscle block now weakens the breathing muscles.
3. Urine output under 30 mL/hr. Why: magnesium leaves the body only through the kidneys. Low urine output means the drug is building up, so this is both a cause and a warning sign of toxicity.
4. Decreased level of consciousness (very drowsy, slurred speech, confusion), progressing to cardiac arrest at very high levels.

Hourly checks while magnesium is running

• Deep tendon reflexes and clonus
• Respiratory rate, SpO2, and lung sounds (pulmonary edema risk)
• Level of consciousness
• Urine output (indwelling catheter is common)
• BP and heart rate, FHR
• Serum magnesium levels and creatinine as ordered

Also know: magnesium relaxes smooth muscle, including the uterus, so watch for postpartum hemorrhage. It crosses the placenta, so tell the newborn team; the baby may be floppy (low tone) or slow to breathe at birth. Flushing, warmth, and feeling sluggish are expected side effects, not toxicity.

Postpartum hemorrhage

Quantitative blood loss (QBL)

Measure blood loss instead of guessing: weigh pads, chux, and sponges (1 gram of weight is about 1 mL of blood, after subtracting the dry weight) and use graduated collection drapes. Why: visual estimates routinely underestimate large blood loss, and a missed hemorrhage is a delayed response.

The 4 Ts: causes of PPH

Nursing actions, in order

1. Fundal massage for a boggy uterus, with one hand cupping and supporting the lower uterine segment just above the pubic bone. Why: massage stimulates the muscle to contract and clamp down on bleeding vessels. Supporting the lower segment keeps the uterus from being pushed down or turned inside out.
2. Empty the bladder (help her void or catheterize per order). Why: a full bladder pushes the uterus up and to one side (usually the right) and keeps it from contracting.
3. Call for help and notify the provider, start or follow the hemorrhage protocol, and keep measuring QBL.
4. Two large-bore IVs, fluids, labs (CBC, type and crossmatch, coagulation studies) and blood products as ordered. Why: replace lost volume and oxygen-carrying capacity, and look for a clotting cause.
5. Give uterotonics as ordered (table below).
6. Monitor vital signs, SpO2, urine output, and level of consciousness frequently.

Rh status and RhIG

If the mother is Rh negative and the baby is Rh positive, some of the baby's blood can enter her bloodstream, especially at birth. Her immune system can then make antibodies against Rh positive red blood cells. The first baby is usually not harmed, because the antibodies form after exposure. In the next pregnancy with an Rh positive baby, those antibodies cross the placenta and destroy the baby's red blood cells (hemolytic disease of the fetus and newborn), causing anemia, jaundice, and in severe cases heart failure and fetal death.

Newborn assessment

At birth the baby has to switch from placental oxygen to breathing air in a matter of minutes. Your first assessment answers one question: is this baby making the transition?

• Caput succedaneum vs cephalohematoma: caput is swelling of the scalp that crosses suture lines and goes away in a few days. A cephalohematoma is bleeding under the skull's covering that does not cross suture lines. Why the difference matters: the trapped blood breaks down into bilirubin, so a cephalohematoma raises jaundice risk.
• Jaundice in the first 24 hours is pathologic and must be reported. Why: normal (physiologic) jaundice appears after 24 hours as the baby breaks down extra fetal red blood cells; early jaundice suggests hemolysis, such as Rh or ABO incompatibility.
• Vitamin K IM. Why: newborns have sterile guts with none of the bacteria that make vitamin K, so they are at risk for bleeding.
• Erythromycin eye ointment. Why: it prevents eye infection from bacteria such as gonorrhea picked up in the birth canal.
• Hepatitis B vaccine within 24 hours per guidelines, plus hepatitis B immune globulin if the mother is positive.
• Glucose checks for at-risk babies (diabetic mother, large or small for gestational age, preterm). Why: babies of diabetic mothers make extra insulin before birth and keep making it after the mother's glucose supply is cut off.
• Skin to skin and early feeding. Why: skin to skin warms the baby, steadies glucose and breathing, and supports breastfeeding.

APGAR scoring

The APGAR score is done at 1 minute and 5 minutes after birth. Each of 5 signs gets 0, 1, or 2 points, for a total of 0 to 10. If the 5 minute score is under 7, repeat it every 5 minutes up to 20 minutes.

• 7 to 10: reassuring. 4 to 6: moderately abnormal. 0 to 3: low.
• Most healthy babies score 8 or 9 at 1 minute, because hands and feet are usually still blue.
• Do not wait for the APGAR to start resuscitation. Why: the decision to help a baby breathe is made in the first 30 to 60 seconds, before the 1 minute score exists. The score describes how the baby is doing and how it responded, it does not decide treatment.

Neonatal resuscitation (NRP)

About 1 in 10 newborns needs some help to start breathing, and only a small number need chest compressions or medications. The Neonatal Resuscitation Program (NRP) from the American Academy of Pediatrics and the American Heart Association teaches the steps.

Before birth and the first questions

Before every birth: check risk factors, assemble the team, and check the equipment (warmer, bag-mask or T-piece, suction, oxygen blender, pulse oximeter). At birth, ask: Is the baby term? Good muscle tone? Breathing or crying? If yes to all, the baby stays with the mother skin to skin for routine care, and cord clamping can be delayed at least 30 to 60 seconds in babies who do not need resuscitation.

Initial steps

1. Warm (radiant warmer, or skin to skin). Why: cold babies use more oxygen and become hypoglycemic and acidotic. Preterm babies may be placed in a plastic wrap or bag without drying.
2. Dry the baby and remove wet linens. Why: wet skin loses heat fast through evaporation.
3. Stimulate by rubbing the back or flicking the soles of the feet. Why: touch can trigger breathing. If gentle stimulation does not work within seconds, do not keep stimulating; move to ventilation.
4. Position the airway in the "sniffing" position, head slightly extended. Why: a newborn's large back of the head can bend the neck forward and kink the airway; too much extension also blocks it.
5. Clear secretions only if needed (mouth first, then nose; "M before N"). Why: suctioning the nose first can make the baby gasp and inhale what is in the mouth. Routine suctioning is not recommended because it can cause bradycardia. Non-vigorous babies with meconium are no longer routinely intubated for suctioning; they get the same initial steps and PPV if needed.

Positive pressure ventilation (PPV)

Positive pressure ventilation means breathing for the baby with a bag-mask (self-inflating or flow-inflating bag) or a T-piece resuscitator, delivering breaths under pressure that push air into the lungs.

• Rate: 40 to 60 breaths per minute. Say "Breathe, two, three, breathe, two, three." Why: this rate inflates the lungs and lets air out between breaths without trapping air.
• Mask fit: covers the chin, mouth, and nose, but not the eyes. Why: a good seal is needed for air to enter the lungs; pressure on the eyes can slow the heart.
• Oxygen to start: 21% (room air) for babies 35 weeks or more. For preterm babies, start higher: current guidelines say it is reasonable to begin with 30% or more for babies under 32 weeks (21% to 30% for 32 to 34 weeks, per NRP). Then titrate to the target SpO2 table. Why start low: too much oxygen creates oxygen free radicals that can damage tissue, and room air works as well as 100% for term babies.
• Check the heart rate after 15 seconds of PPV. A rising heart rate is the best sign the breaths are working.

Why the targets are low at first: before birth, a healthy baby's SpO2 is only about 60%, and it rises slowly over about 10 minutes as the lungs fill with air. Pushing it to 100% right away is not normal and can cause harm.

Chest compressions

• When: heart rate under 60/min after at least 30 seconds of PPV that moves the chest (an alternative airway is strongly recommended by this point). Why wait for effective ventilation: in most babies the slow heart rate is caused by low oxygen, so fixing breathing comes first. Compressions take time away from breaths.
• Ratio: 3 compressions to 1 breath (90 compressions and 30 breaths per minute), with oxygen increased to 100%. Why 3:1 and not the adult 30:2: newborn arrest is a breathing problem, so the baby still needs frequent breaths.
• Technique: two thumbs on the lower third of the breastbone, hands encircling the chest, depth about one third of the chest. Recheck the heart rate after 60 seconds.

Epinephrine basics

• When: heart rate still under 60/min after 60 seconds of compressions with 100% oxygen and effective ventilation.
• Route: IV (umbilical venous catheter) or IO is preferred, 0.02 mg/kg (range 0.01 to 0.03 mg/kg) of the 0.1 mg/mL concentration, flushed with normal saline. A larger endotracheal dose may be given while IV access is placed. Repeat every 3 to 5 minutes if the heart rate stays under 60. Why IV is preferred: endotracheal absorption in newborns is unreliable, partly because the lungs may still hold fluid.
• Volume: normal saline 10 mL/kg may be ordered if blood loss is suspected (for example, placental abruption or cord bleeding) and the baby is not responding.

Quick check

Evidence and sources

Now playing: Shock Run has a Labor and Delivery, Mother-Baby, and NICU unit where you watch the strip, catch the bleed, and make the call when a mother or baby crashes.

For education only. Follow your program, current guidelines, provider orders, and facility policy.