12.4 Labor Analgesia, Induction, and Operative Birth
Key Takeaways
- Hypotension is the most common complication of epidural analgesia; pre-load or co-load with intravenous crystalloid, position the woman laterally, and treat sustained hypotension with fluids and a prescribed vasopressor.
- Oxytocin induction is stopped immediately for tachysystole, defined as more than five contractions in ten minutes averaged over thirty minutes, or for any category III fetal heart rate pattern.
- Misoprostol and other prostaglandin cervical ripening agents are contraindicated in women with a previous caesarean or uterine scar because of the risk of uterine rupture.
- Sudden severe abdominal pain, loss of the fetal station, a change in uterine contour, and fetal bradycardia during a trial of labour after caesarean indicate uterine rupture and require immediate preparation for emergency laparotomy.
- After caesarean birth, prioritise uterine tone and lochia assessment alongside the standard postoperative airway, circulation, and thromboprophylaxis priorities, because postpartum haemorrhage remains the leading early complication.
12.4 Labor Analgesia, Induction, and Operative Birth
This material generates a high proportion of the intrapartum questions because it combines pharmacology, fetal surveillance, and emergency recognition in a single scenario. The recurring pattern is: a drug is running, something changes on the monitor, and the nurse must act before calling for help.
Non-Pharmacological Labour Support
Never treat these as filler. Continuous labour support measurably shortens labour and reduces intervention rates, and examiners include it as the correct answer in early-labour scenarios.
- Positioning and movement: upright positions, walking, birthing ball, hands-and-knees — the last is particularly useful for occiput-posterior back pain because it encourages fetal rotation.
- Counter-pressure to the sacrum and the double hip squeeze for back labour.
- Breathing and relaxation, patterned breathing, and focal points.
- Hydrotherapy: a warm shower or immersion, generally once active labour is established.
- Heat and cold, massage, and effleurage.
- Continuous presence of a support person, and an environment the woman controls.
Many women in Qatar labour with a female relative present and prefer female caregivers; accommodate this actively and offer a female chaperone for every examination.
Pharmacological Analgesia
Systemic opioids
Used in early or mid-labour where regional analgesia is not chosen. The essential timing rule is neonatal respiratory depression: administer with caution when birth is expected within one to four hours, depending on the agent, and ensure naloxone is available for the neonate. Naloxone is contraindicated in the neonate of an opioid-dependent mother because it precipitates acute withdrawal and seizures.
Epidural analgesia
The most effective labour analgesia and the source of most exam items.
Before placement: confirm informed consent, establish intravenous access and give a crystalloid pre-load or co-load, obtain a baseline blood pressure and fetal heart rate, ensure a recent platelet count, and position the woman in a curved side-lying or sitting position with the back arched.
Contraindications: maternal refusal, coagulopathy or therapeutic anticoagulation, thrombocytopenia below the anaesthetic threshold, infection at the insertion site, uncorrected hypovolaemia, and raised intracranial pressure.
Complications and nursing responses:
| Complication | Recognition | Nursing action |
|---|---|---|
| Hypotension (most common) | Systolic fall, maternal lightheadedness, fetal bradycardia or late decelerations | Turn to left lateral, increase IV fluids, give oxygen, notify anaesthesia, give prescribed vasopressor (ephedrine or phenylephrine) |
| Urinary retention | Bladder distension, uterus displaced, no urge sensation | Assess bladder routinely; catheterise as needed |
| Post-dural-puncture headache | Severe positional headache worse upright | Lie flat, hydrate, analgesia, caffeine, anaesthetic review for blood patch |
| Inadequate or one-sided block | Persistent pain, asymmetrical sensory level | Reposition to the unblocked side; notify anaesthesia |
| Fever | Maternal temperature rise without infection | Assess for chorioamnionitis; do not assume it is benign |
| High or total spinal | Rapidly rising block, dyspnoea, hand numbness, hypotension | Emergency: airway support, call anaesthesia immediately |
| Local anaesthetic systemic toxicity | Perioral tingling, tinnitus, metallic taste, seizures, arrhythmia | Stop infusion, call for help, intravenous lipid emulsion per protocol |
Monitor blood pressure frequently in the period after insertion or any top-up, and continue continuous fetal monitoring. Assess sensory level and motor block, keep the woman off her back, and implement fall precautions before any attempt to stand.
Pudendal block anaesthetises the perineum for the second stage and for repair; local perineal infiltration covers episiotomy and laceration repair. General anaesthesia for caesarean carries a higher risk of aspiration and failed intubation in pregnancy, so it is reserved for emergencies and is preceded by a non-particulate antacid, aspiration prophylaxis, and left lateral tilt.
Induction and Augmentation of Labour
Bishop score predicts the likelihood of successful induction from dilation, effacement, station, cervical consistency, and position. A higher score indicates a more favourable cervix; a low score usually prompts cervical ripening first.
Cervical ripening agents. Prostaglandin E2 (dinoprostone) and prostaglandin E1 (misoprostol) soften the cervix. Both are contraindicated with a previous caesarean or other uterine scar because of the risk of uterine rupture. Monitor fetal heart rate and uterine activity continuously after administration, and know how the agent can be removed or reversed if hyperstimulation occurs. Mechanical methods such as a transcervical balloon catheter are an alternative, particularly where prostaglandins are contraindicated.
Oxytocin infusion. Always administered as a secondary infusion via an infusion pump into a mainline, so it can be stopped instantly without losing venous access. Titrate against uterine response, not against a target rate.
Stop the oxytocin immediately for:
- Tachysystole: more than 5 contractions in 10 minutes, averaged over 30 minutes.
- Contractions lasting longer than 90 seconds, or a resting interval shorter than 60 seconds.
- Resting tone that fails to return to baseline.
- Any category III fetal heart rate tracing, recurrent late decelerations, or prolonged deceleration.
The accompanying intrauterine resuscitation is the same package used elsewhere: stop the oxytocin, reposition to left lateral, give an intravenous fluid bolus, give oxygen, and notify the provider; a tocolytic such as terbutaline may be prescribed.
Oxytocin at high doses has an antidiuretic effect, so monitor intake and output and watch for water intoxication — headache, nausea, confusion, and hyponatraemia — during prolonged high-dose infusion.
Amniotomy carries three specific risks that define the nursing response: cord prolapse (assess the fetal heart rate immediately before and after, and confirm the presenting part is engaged), infection (limit examinations and monitor temperature), and abruption with rapid decompression of a polyhydramnios. Document the time of rupture and the colour, odour, and amount of fluid.
Assisted Vaginal and Caesarean Birth
Vacuum extraction and forceps require a fully dilated cervix, ruptured membranes, an engaged and correctly positioned head, and an empty bladder. Neonatal considerations: vacuum is associated with cephalohaematoma and subgaleal haemorrhage (which crosses suture lines and can cause hypovolaemic shock — monitor head circumference and vital signs); forceps are associated with facial bruising and transient facial nerve palsy. Maternal risks include extended perineal laceration and haematoma.
Caesarean nursing care. Pre-operatively: consent, fasting where elective, aspiration prophylaxis, urinary catheter, antibiotic prophylaxis, and left lateral tilt to prevent aortocaval compression. Post-operatively, combine standard post-surgical priorities with obstetric ones:
- Airway, oxygenation, and level of consciousness, especially after general anaesthesia or spinal.
- Fundal tone and lochia — postpartum haemorrhage remains the leading early complication and the fundus must be assessed even through a dressed abdominal incision.
- Vital signs, incision and dressing, and urine output.
- Pain management, which enables early mobilisation.
- Thromboprophylaxis: pregnancy plus surgery plus immobility is a high-risk combination; early mobilisation, compression devices, and prescribed anticoagulation.
- Respiratory: deep breathing, incentive spirometry, splinted coughing.
- Early skin-to-skin contact and breastfeeding support, which are frequently delayed after caesarean and should be facilitated actively.
Trial of labour after caesarean (TOLAC). Requires continuous fetal monitoring, immediate availability of theatre and anaesthesia, and avoidance of prostaglandin ripening agents. Uterine rupture is the feared complication: sudden severe abdominal pain often described as tearing, loss of the fetal station on examination, a palpable change in the abdominal contour, cessation of contractions, fetal bradycardia or prolonged deceleration, and maternal signs of hypovolaemic shock. Fetal heart rate abnormality is frequently the earliest sign. The nursing response is immediate: stop any oxytocin, call for emergency help, give oxygen and fluids, position the woman, and prepare for immediate laparotomy.
Ten minutes after an epidural is sited, a labouring woman's blood pressure falls from 118/72 to 82/48 mmHg and the fetal heart rate tracing shows a prolonged deceleration to 90 bpm. What is the nurse's priority sequence of actions?
A woman at 41 weeks is receiving an oxytocin infusion for induction. Over the last 30 minutes the nurse counts an average of seven contractions per 10 minutes, and the uterine resting tone does not return to baseline between contractions. The fetal heart rate baseline is 140 bpm with minimal variability and recurrent late decelerations. What should the nurse do first?
A multipara attempting a trial of labour after a previous caesarean suddenly reports severe tearing abdominal pain between contractions. Contractions cease, the fetal heart rate drops to 70 bpm, the presenting part is no longer palpable at the previously documented station, and the maternal pulse rises to 130 with a blood pressure of 84/50 mmHg. What is the nurse's interpretation and priority action?