Stages of Labor • nulliparas, it should not be more than 6

1st stage : Dilatation/Cervical hours.

Stage Cervical dilatation refers to the enlargement/ • multiparas, it should be within 4 to 5
Phases: L – latent opening or widening of the cervical os. hours
A - Active Increased amount of show as dilatation is • Latent Phase
completed since the last operculum (mucus • Determine if patient received
T - Transition
nd
plug) is dislodged and minute capillaries anesthesia because it can prolong
2 stage : Expulsion rupture. latent phase. One of the most common
3rd stage: Placental Divided into 3 phases: cause of prolonged latent phase is
4th stage: Recovery 1. Latent Phase cephalopelvic disproportion (CPD) and
First Stage: Dilatation Stage 2. Active Phase it requires  cesarean birth.
Begins with the onset of true labor contractions 3. Transition Phase 3. Allow patient to be continually active.
to full dilatation & effacement of the cervix.
1. Latent Phase • Upright maternal positions are
• 2 important events recommended for women on the first
Latent (Preparatory) Phase
 Cervical effacement stage of labor.
• Cervical dilatation – 0 to 4 cm Dilate
 Cervical dilatation • Patients without pregnancy
only very slow.
complications can still walk around and
The first stage is also called the Dilatation or • Interval: 3 to 5 minutes make necessary birth preparations.
cervical stage. It extends from the first true
• Duration of 20 to 40 seconds 4. Conduct interviews and filling in of forms
uterine contraction until the cervix is completely
effaced & dilated. • intensity; mild to moderate (e.g. birth certificate) at this phase while the
Cervical effacement* • Latent (Preparatory) Phase starts from patient experiences minimal discomfort and has
the onset of true labor contractions to 4 control over contraction pains.
Primiparas – dilatation begins when cervix is
cm cervical dilatation. 5. Conduct health teaching on
completely effaced.
• Have regular, frequent contractions • breastfeeding,
Multiparas – dilatation & effacement takes
that may or may not be painful. • newborn care,
place at the same time.
• Length of the latent Phase • newborn screening and
Cervical effacement is the shortening or
thinning of the cervical canal from a bottleneck Primis – 6 hours • effective bearing down because
with a length of about 4 cm until it is paper thin. Multis – 4 to 5 hours during this time, patient’s
Cervical dilatation* • Attitude of the woman: Generally feel anxiety is controlled and she is
comfortable walking and sitting; Can able to focus on nurse’s
-Fully dilated – diameter 10 cm.
usually talk or laugh during their instructions.
-Uterine contraction causes dilatation by pulling
contractions 6. Educate patient on different relaxation
the cervix over the presenting part
Latent Phase techniques. As early as this phase, encourage
-BOW & fetal head acts as a wedge in dilating patient to begin alternative therapy of pain
the cervix 1. Assess patient’s psychological readiness.
Provide continuous maternal support relief.
-Increased amount of show as dilatation is
(compared to usual care).
completed*
2. Measure duration of latent phase.
7. Ensure that the total number of internal
examinations the woman receives in the entire
course of labor is limited to 5 only.
8. Ensure that birthing companion of choice is
present all throughout the course of labor.
Active Phase
• cervical dilatation - 4 cm to 7 cm
• intensity is moderate to strong
• interval shortens (2-3mins, and
• duration lengthens (30 to 60 seconds).
• Length:
Primis – 3 hours
Multis – 2 hours
Active Phase
• This is where true discomfort is first felt
by the patient so she is dependent and
her focus is on herself.
• Usually are not comfortable with
talking or laughing during their
contractions.
• As intensity of contractions become
stronger and start to cause pain and
much discomfort, the woman prefers to
stay in bed. She withdraws from her
environment as her attention is focused
on herself and the sensations on her
body.
Nursing responsibilities in this phase:
1. Inform patient on the progress of her labor to
lessen her anxiety and obtain her trust and
cooperation.
2. Start monitoring progress of labor with the
use of WHO partograph, 2-hour action line.
3. Encourage patient to be continually active to
maximize the effect of uterine contractions.
Upright maternal positions are
recommended if tolerated.
4.Assist patient in assuming her position of
comfort.
For those who can’t stay upright, left-side lying
is recommended to avoid disruption in fetal
oxygenation.
5.Monitor maternal vital signs and fetal heart
rate every 2 hours, or depending on the doctor’s
order.
6. Anticipate patient needs (e.g. sponging face
with cool cloth, keeping bed clean and dry,
providing ice chips or lip balm) to promote
comfort.
7. Determine when patient last voided because
a full bladder* can hinder fast labor progress.
8. Institute non-pharmacological pain measures
(e.g. breathing exercises, distraction method,
imagery, music therapy, etc.)
Full bladder inhibits uterine contraction
Imagery: Guiding you through imaginary mental
images of sights, sounds, tastes, smells, and
feelings can help shift attention away from the
pain.
Transition Phase
• cervical dilatation 8 to 10 cm
• cervical effacement – 100%
• Contractions:
- Interval - every 2-3 mins.
- Duration of 60-90 seconds
- Intensity-Strong
Transition Phase
• patient may be exhausted and
withdrawn or aggressive and restless.
• Patient’s urge to push is noticeable.
Here are nursing responsibilities in this
phase
1.Inform patient on progress of her labor.
2. Assist patient with pant-blow breathing.
3. Monitor maternal vital signs and fetal heart
rate every 30 minutes -1 hour, or depending on
the doctor’s order. Contraction monitoring is
also continued.
Pant-blow breathing is done through the
mouth. You take several fast, shallow breaths
and then you blow out
The shallow breaths make a quiet "heh" sound.
Choose any rhythm that is best for you. Many
women are comfortable with "heh, heh, heh,
heh, and blow" (four fast pants to one complete
blow). You can also try other rhythms like "heh,
heh, blow" (two fast pants to one complete
blow) or "heh, heh, heh, blow" (three fast pants
to one complete blow)
4. When perineal bulging is noticeable, prepare
for delivery. Check room temperature (25-28⁰C
and free of air drafts).
The nurse should also notify staff and prepare
necessary supplies and equipment, including
resuscitation machine.
Lastly, perform handwashing and double
gloving.
WHO do not recommend the following nursing
interventions during labor because they have
low quality of evidence:
 Routine perineal shaving
 Routine use of enema
 Admission cardiotocography (CTG) for
low-risk women
 Vaginal douching
  Routine amniotomy for patients in
spontaneous labor
 Massage and reflexology
Second Stage: Stage of Expulsion
• starts when cervical dilatation reaches
10 cm and ends when the baby is
delivered*.
• At this stage, the patient feels an
uncontrollable urge to push.
• The patient may also experience
temporary nausea together with
increased restlessness and shaking of
extremities.
• Duration: Primi – 50 minutes
Multi – 20 minutes
• Transfer to DR: Primi- @ 10 cms.
Multi – @ 7-8 cm
Bulging of the perineun – surest sign of delivery
initiation
Mechanisms of labor
E – Engagement; D- descent; F- Flexion;
IR – internal rotation; E – extension; ER –
external rotation; E - extension
Delivery position
Lithotomy
is used when surgical procedures such as The nurse at this stage must coach quality
forceps or episiotomies are to be performed. pushing and support delivery.
Dorsal recumbent 1. Instruct patient on quality pushing. The
Head of bed is 35 to 45 degrees elevated abdominal muscles must aid the involuntary
knees are flexed and uterine contractions to deliver the baby out.*
Feet flat on bed* 2.Provide a quiet environment for the patient to
This facilitates the pushing efforts of the concentrate on bearing down.
mother 3. Provide positive feedback as the patient
pushes.
Coach mother to push effectively: instruct her
the bearing down is like straining at stool, she
must push only when the urge to push is felt
and relax completely after contraction to
replenish her energy.
4. Repeat doctor’s instructions. At this phase,
the patient barely hears the conversation
around the room because all her energy and
thoughts are being directed toward giving birth.
(side lying)left lateral 5. The woman may complain of leg cramps*-
dorsiflex the affected foot and straighten the
leg
Leg cramps – pressure exerted by the fetal head
against the pelvic nerves.
6. When the head is crowning:
- instruct the mother to pant not to push to
.
prevent rapid expulsion of the baby and to
Left lateral position avoid lacerations.
Indicated for women with heart disease 7. Ritgen’s maneuver is to be
performed while delivery the
Squatting
head.
- slows down delivery of the head
Kneeling
- lets the smallest diameter of
the head to be born
- facilitates extension of the head
 • It is divided into two separate phases: Mathew’s duncan –the leading edge of the
- Placental separation placenta separates first and the placenta is
- Placental expulsion. delivered with its raw surface exposed;
• 3 to 10 mins. after delivery of baby, the Duncan – separation begins from the edges of
uterus begins to contract again, and the placenta. The maternal side is delivered
placenta starts to separate from the first.
contracting wall. Schultz– separation of the placenta starts from
the center. The shiny and smooth fetal side is
8.Take note of the time of delivery and proceed delivered first;
Signs of placental separation:
to initiate essential newborn care. Delayed cord
clamping is recommended. • Fundus becomes firm and globular in
shape; rises to the abdomen – Calkin’s
9. Assist in restrictive episiotomy for patients
sign (1st sign)
who had vaginal births.
• Lengthening of umbilical cord
Episiotomy
• Sudden gush of vaginal blood
• Prevents lacerations
• Widens the vaginal canal
• Shortens the 2nd stage of labor

Nursing Considerations during Placental

delivery
• Utilize controlled cord traction
technique for placental expulsion
• Administer oxytocic drugs as ordered.
- Oxytocin
- Methergin
• Blood loss of 300-500 mL occurs as a
- Carboprost
normal consequence of placental
separation. • Massage uterus gently
• Rapid pulling of the cord may cause Oxytocin drugs – are drugs that stimulate
WHO do not recommend the following uterine inversion uterine contractions
interventions during delivery because they Carboprost is a form of prostaglandin (a
Mechanism of Placental separation
provide low quality of evidence: hormone-like substance that occurs
1. Perineal massage naturally in the body). Prostaglandins help
2. Use of fundal pressure to control functions in the body such as
Third Stage: Placental Stage blood pressure and muscle contractions.
Carboprost is used to treat severe bleeding
• starts from birth of infant to delivery of
after childbirth (postpartum).
placenta.
• Coach in relaxation for delivery
 of placenta. • The fundus is checked every 15 minutes • Oral methylergometrine for patients
• Congratulate on delivery of baby. - fundus should be at the level of who delivered vaginally
• Encourage skin-to-skin contact to the umbilicus*
facilitate bonding and early - if boggy or relaxed – massaged gently
breastfeeding. A high fundus or displaced to the right or
Reatained placental fragments can cause severe left is usually caused by a full bladder.
hemorrhage by preventing the uterus to • The bladder should be assessed
contract
frequently to prevent distention.
• Ask patient whether placenta is
• a full bladder displaces the uterus and
important to them before it is disposed.
prevents effective uterine contraction
• For those who want to take it home, thereby predisposing the woman to
ensure that they understand and follow hemorrhage.
standard infection precautions and
• The nurse is set to perform nursing
hospital policy.
interventions that would prevent the
• Inspect placental completeness patient from infection and hemorrhage.
- 15 to 20 cotyledons* • they are being reminded of the
- 500 gms. importance of:
• Utilize absorbable synthetic suture • breastfeeding,
materials (over chromic catgut) for • ambulation, and
primary repair of episiotomy or perineal
• newborn care.
lacerations.
WHO recommendations for immediate
postpartum:
Fourth Stage: Recovery
• Here are
• Immediate postpartum*,
• Early (<6 hours) resumption of feeding
• the nurse checks the vital signs and for patients who have vaginal birth
monitors for excessive bleeding*.
• Prophylactic antibiotics for women who
• The first four hours after birth is sustained third to fourth degree of
sometimes referred to as the Recovery perineal tear during delivery
stage of labor because this is the most
• In healthy women who delivered
critical period for the mother.
vaginally to term infants, early
The mother and newborn recover from the postpartum discharge is recommended.
physical process of birth
The main danger during the 4th stage is
Interventions not recommended during
hemorrhage
immediate postpartum:
• The nurse is set to perform nursing
• Routine use of ice packs
interventions that would prevent the
patient from infection and hemorrhage.