Stages of Labor

●First Stage
●Latent phase
●Active phase
●Transition phase
●Second Stage
●Third Stage
●Fourth Stage
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First stage of labor:(Stage
of Dilation)
● It begins with the onset of true labor contractions and
ends with complete dilation (10cm) and effacement
(100%) of the cervix.
● It is the longest stage for both nulliparous and parous
women.
● It has three phases: latent (early), active, and
.
transition

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1. Latent phase:
● Lasts from the beginning of
labor until about 3cm of cervical
dilation.
● The woman is usually sociable
and excited during this phase of
labor.
● Uterine contraction initially
mild and infrequent progress to
moderate strength every 5 min.

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2. Active phase:
●The cervix dilates from 4 to 7 cm
●Effacement is completed
●The fetus descends to the pelvis
●Internal rotation begins
●Increase discomforts
●The woman becomes more anxious and
feel helpless
●Serious inward focus
●Uterine contraction every 2-5 minute

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3. Transition phase:
● Short but intense phase
● The cervix dilate from 8 to 10cm
● The fetus descends further into the pelvis
● Bloody show increase
● Strong contractions
● The woman may have the urge to push down
(Ferguson reflex)
● Leg tremors nausea and vomiting are common
● The woman is irritable and lose control
● Contraction every 1.5-2minute

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Uterine action
• Contractions become expulsive as the fetus descends
further into the vagina
• Ferguson reflex: pressure from the presenting part
stimulates nerve receptors in the pelvic floor. As a
consequence, the woman experiences the need to push.
– This reflex may initially be controlled to a limited extent but
becomes increasingly compulsive, overwhelming & and
involuntary.
– Mother’s response is to employ her secondary powers of
expulsion by contracting her abdominal muscles & and
diaphragm.
 Second stage of labor (Expulsion)
● Begins with complete dilation (10cm) and full effacement(100%)
end with the birth of the baby.
● Involuntary pushing response
● The mother may said that she needs to have a bowel movement
or the baby is coming
● Crowning of the fetal head

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●Feeling of stretching or
splitting sensation
●Contractions are strong
●Woman exerts intense
effort to push her baby
●May appear sleepy
between contraction
●The word “labor”
describe this phase
●Feels tremendous relief
and excitement as the
second stage ends with
the birth of baby
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 Third stage of labor (Placental)
● Begins with the birth of the baby and ends with the
expulsion of the placenta
● Length 5-10 min up to 30 min
● Four Signs suggest placental separation:
● 1.The spherical (globular) shape of uterus
● 2. The uterus rises upward in the abdomen
● 3. The cord descends further from the vagina
● 4. Gush of blood appears as blood trapped behind the
placenta is released

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●The uterus must contract firmly
and remain contracted after
placenta is expelled to compress
open vessels
●During this stage pain results
from uterine contractions and
brief stretching of cervix as
placenta passes through it
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Placenta

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 Fourth stage of labor (Physical
recovery):
● It lasts from the delivery of the placenta through the first 1
to 4 hours after birth
● The uterus at or below the level of umbilicus ,firm
contracted and rounded mass about 10 to 15cm in diameter
● Lochia is rubra
● Women may have chill lasts for 20 minutes, warm blanket
or hot drink may be helpful

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● After pains or birth trauma are the main causes of
discomforts in this stage
● Ice packs on perineum decrease discomfort and
limit hematoma formation
● After pains are more intense in
● multiparous
● or in women who breast feed,
● in women who have uterine over distention (large baby)
● and full bladder
● or clot that remain in uterus
● The woman is exhausted and need rest
● This stage is the ideal time for bonding and to start
breast feeding

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 Nursing care during labor and
birth
● Assessment on admission
● Focused assessment
● 1. Fetal assessment
● Gestational age of the fetus
● Leopold’s maneuver
● Fetal movement and FHR
● Status of membrane( color, odor and clarity of
fluid)
● 2. Maternal assessment (vital signs)
● especially for infection or hypertension

● CONSENT FORMS:

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 Data base assessment

● Reason for coming to hospital

● Prenatal care
● EDD
● # of pregnancies term and abortion
● Allergies
● Last time of food intake
● Medical surgical and pregnancy history
● Recent illness and treatment
● Medication, drug smoking and alcohol
● Mother subjective evaluation of labor
● Birth plan, pain management method and
support person

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2. Fetal assessment
• Presentation, position, and FHR
• Time of rupture membrane and characteristics of
amniotic fluids

3. Determine labor status

• Assess contraction
• Cervix dilatation and effacement, station,
presentation and position
• Membrane status

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4. Physical Exame (brief)
5. Laboratory data
– Hematocrite,blood group and CBC
– Blood glucose levels
– Blood type and RH factor
– Midstream urine (protein and glucose)
– Syphilis, hepatitis, and HIV

6. Intravenous (IV) access

– Continuous infusion prevents dehydration
– Isotonic electrolyte is preferable
– Glucose is avoided (to void neonatal hypoglycemia).

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 Assessment after Admission
1. Fetal assessment
• FHR electronic or Doppler
• Amniotic fluid AROM OR SROM
• Assess FHR at least one minute after rupture of membrane
• Record the time of rupture, FHR and character of fluid
Cloudy, yellow or foul odor suggests infection
The green color suggests meconium passage (transient
hypoxia)
• Amount more than 1000ml is large, between 500-1000 is
moderate and scant if only trickle barely enough to detect

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2. Maternal assessment
• Vital signs( hyper or hypotension , increased pulse
increased resp. increased temp are all abnormal
• Contraction
• Progress of labor, vaginal exam should be limited to
prevent infection
• Intake and output ,check for bladder fullness every 2
hour
• LOOK AT THE MOTHER’S PERINEUM FOR
CROWNING OF THE FETAL HEAD IF SHE
EXPERIENCE A NEED TO DEFECATE
• Mother’s response to labor
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Nursing care for woman in true labor
1. Fetal oxygenation
• Assessment of fetal well-being include:
– FHR,
– Uterine contraction,
– aminiotic fluid
– and vital signs
Intervention
• 1. Promote placental function (position rather than
supine)
• 2. Observe for condition associated with fetal
compromise

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 Conditions Associated with Fetal
Compromise
• Fetal heart rate outside the normal range

• Little or no variability in heart rate

• Persistent slowing of heart rate after contractions

• Meconium-stained amniotic fluid

• Cloudy, yellowish, or foul odor to amniotic fluid

• Contractions longer than 90 seconds

• Incomplete uterine relaxation, intervals between contractions

shorter than 60 seconds

• Maternal hypotension
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• Maternal hypertension
2. Discomfort
Intervention
1. Providing comfort measures
● Room Light: soft indirect lighting is soothing
● Temperature; Cool moist damp cloths on
woman's face and neck promote comfort, an
electric fan circulate air in the room is
appropriate (should be turned off before
delivery of the newborn)
● Cleanliness: change gown and linen when
needed

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● Mouth care: ice chips and hard candy reduce the discomfort
of dry mouth, avoid excessive sugar, and if oral intake is
contraindicated brushing teeth or rinsing mouth
● Bladder emptying; Remind woman to empty bladder at
least every 2 hours, catheterization is often needed
● Positioning: use any comfortable position but avoid supine

● Water( shower, tub, pool): enhance relaxation . Nipple

stimulation by water current releases oxytocin and makes
contraction more productive

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3. Teaching
First stage
•Pushing in response only to her spontaneous urge
•Pushing without full dilatation leads to:

1. The cervix becomes lacerated and edematous

2. Labor progress is blocked

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3. Teaching cont.
Second stage
• Laboring down: researchers recognized that a second stage
longer than 2 hours is safe if the mother and fetus show no signs
of compromise.
• Women push most effectively when they feel the reflex urge to
do so.
• Closed-glottis pushing or the Valsalva maneuver can reduce
maternal cardiac output and reduce fetal oxygenation.
• Position: the mother may push in any preferable position.
Change position. curve body around the uterus in C shape with
her chin on her chest. For most effectiveness, teach her to pull
on her knees, hand-holds, or a squatting bar while pushing.

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3. Teaching cont.
• Breathing pattern:

– discourage holding breath for more than 4 seconds per push

– discourage pushing more than four times per contraction.

– Deep breath helps her relax at the end of contraction.

– Women may grunt or groan (!‫ )ان‬when pushing reassure her that this is normal.

• Provide encouragement

• Giving of self: the nurse’s caring presence is crucial. Gentle coaching and encouragement
improve a laboring woman’s confidence in her own body to give birth.

• Pharmacologic management and support and care

• Caring for the birth partner: woman’s support person

4. Preventing injury
Assessment
observe the mother’s perineum to determine
when to make the final preparation
Final preparation for primipara is done when
crowning reaches a diameter of 3-4cm but in
multipara when the cervix is fully dilated

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Intervention
1. transfer to the delivery room or modified bed to the delivery
bed.
2. positioning of birth
3. observing perineum
Nursing Care During Birth
1. Preparation of table
2. Perineal cleansing preparation
3. Initial care and assessment of the newborn
4. Administration of medication such as oxytocin to control blood
loss
5. Use universal precaution

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 Responsibilities after birth

Care of infant
1. Maintain cardiopulmonary function
• Prepare neonatal resuscitation equipment
• Assess Apgar score
• Maintain clear airway: Suctioning of secretion accordingly

2. Supporting thermoregulation
• Dry infant
• Place under radiant warmer
• Skin-to-skin contact
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InRev
1 The Apgar
Scale
Scor

Characteristic 0 1 e 2

Heart rate Absent Less than 100 beats More that 100 beats
per minute per minute

Efforts to Absent Slow, irregular Good; baby is crying

breathe
Flaccid,limp Weak, inactive Strong, active motion
Muscle tone
Body pale Body pink, extremities Body and extremities
Skin color or blue blue pink

Vigorous crying,
No Frown, grimace coughing, sneezing
Reflex irritability response

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3. Identifying the infant
•Identifying band
4. Prophylactic medications
Care of the mother
1. Observing for hemorrhage
VS, uterus, lochia, bladder
•Vital signs: assess temp. in recovery and before
transfer to the postpartum ward
•Assess other vital signs every 15 minutes for the first
hour and 30 minutes in the next hour

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•Fundus should be firm midline and at or below the
umbilicus. If not firm massage and encourage the
mother to breastfeed
•Bladder: A full bladder is suspected when the fundus
is above the umbilicus and or displaced to one side
usually the right
•The first two or three voidings must be at least 300-
400ml each voiding

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•Lochia is rubra, small clot is okay but large clot is
abnormal

•Saturation of one pad within the first hour is the

maximum normal lochia flow

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2. Relieving discomfort
• ice backs, analgesics, warmth

• Ice packs: to reduce edema and limit hematoma formation

• Analgesics: after pain and perineal pain may relieved by mild analgesics.
Regular urination reduces after pain because the uterus contracts effectively:
• Warmth warm blanket is soothing and shortens the chills that is common after
birth

3. Promoting early family attachment

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