STAGES OF LABOR

STAGE OG DILATATION (1ST STAGE), STAGE OF EXPULSION (2ND STAGE), PLACENTAL

EXPULSION (3RD STAGE), AND ONE TO FOUR HOURS AFTER DELIVERY (4TH STAGE).

Upon admission

Monitor labor Is the mother First stage of

NO YES
experiencing History taking
progress labor
true signs of
labor?

Physical Assessment
(Leopold's Maneuvers and IE)
a) Effacement, dilatation, and condition
of the membranes
Advise NPO. Start IVF Provide privacy b) Lie, presentation, attitude, position of
If contraction is
ass ordered, and Perineal and reassurance; the fetus
tolerable, provide
monitor intake and preparation establish and c)The fetal presenting part to the level of
bathing
output per hour. maintain rapport the ischial spines (station)
d)Location of the heart tone

Encourage the mother Monitor uterine

Instruct patient to Monitor vital signs
to change in contractions
Encourage the mother BP, FHR
bear down only (duration, interval,
to empty her bladder comfortable position. frequency, integrity) Active phase:every 30mins
during true labor
every 2-3 hours (Sim's position is Active phase:every 30mins Latent phase:every hour
contractions
recommended) Latent phase:every hour

Transfer of patient from

the labor room to the Look for signs of Administer
Second stage of delivery room. danger signals anesthetics Administer analgesics
labor Multiparas: at 7-9cm dilatation during labor and (Preferably regional (Narcotics, Demerol)
Primiparas: at full dilatation with delivery ansthesia)
perineal bulging

Encourage strong pushing Encourage strong pushing

with contractions with contractions
Position the mother
Provide bearing down Ask the mother to take 2 Ask the mother to take 2 Provide perineal
properly on the breaths then hold her breath breaths then hold her breath
techniques cleaning
delivery table and bear down and bear down
Also, use blow blow breathing Also, use blow blow breathing
patterns patterns

Apply pressure with the As soon as the head

palm against the rectum crowns, instruct to Position the mother
Gently press the head Care for the
while it slowly eases out to support perineum not to push longer. properly on the
during crowning.
Episiotomy Wound
Then, instruct her to delivery table
(Use sterile towel)
pant

As soon as the head has

As the head rotates,
been delivered, insert 2 Immediately hold the
gently push downward to Deliver the rest of the
fingers into the vagina.
deliver anterior shoulder, body while supporting the Note time of delivery baby below the level
Then feel a presence of a
then gently lift to deliver head and the neck of the mother's vulva
looped of cord around the
posterior shoulder
neck.

As soon as the signs of Encourage the mother

separation appear, tract to push with Cut the cord until
the cord slowly and Third Stage of Provide mother and
pulsations have
contractions to aid in
wind it around the clamp.
placental
Labor child initial contact
stopped
Then deliver the placenta
by rotating it expulsion

Imme- Is the placenta

diately
Inspect for Palpate the uterus to Is it relaxed,
delivered within 20 Note the time of YES
notify NO YES completeness of determine degree of boggy or non-
mins after the placental delivery
the delivery of the cotyledons contraction contracted?
doctor baby?

a)massage the fundus

No gently and properly
Administer Oxytocic b) apply an ice or ice
Assist the doctor in cap over the abdomen.
agents
Estimate the amount doing episiorrhaphy Inspect the perineum
(Monitor Blood
of blood loss (Administer local for lacerations
Pressure of the
anesthetic)
mother)

Provide comfort and

Take vital signs every 15
perineal care, apply clean
minutes for the first hour
sanitary. Soiled napkin
and palpate the uterine
should
fundus for size, and
be removed from front to
position
back
END
Assess the ff:
Transfer her back to room a) Fundus- palpate every 15 minutes during the
and position her to flat on
Fourth Stage of first hour postpartum then every 30 minutes for
bed without pillows labor the next four hours
b) Bladder- check every 2 hours during the first 8
hours postpartum then every 8 hours for 3 days
c) Vaginal discharge-check every 15 minutes
Provide comfort measures (if there is a presence of excessive flow,
a) Perineal care and apply sanitary napkin immediately refer to the doctor)
b) Give the mother a soothing sponge bath, d) Blood pressure & pulse rate- checke every 15
change her soiled gown dress and minutes during the first four hours postpartum
dirty linens then every 30 minutes until stable.
c) Provide additional blankets e) Perineum- inspect every 8 hours for 3 days.
d)Give the mother initial nourishment of coffee, Take note of the condition of episiorrhaphy:
tea, milk or soup
e) Provide a quiet and restful environment
f) Allow mother to take enough rest and sleep

XYRELLE GAMBALOZA
BSN 2-I

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