WEEK 8: STAGES OF LABOR AND
5
DELIVERY, DANGER SIGNS OF
LABOR
OBJECTIVE
1. Describe common theories explaining the onset of
labor
2. Assess a family in labor, identifying the woman’s
readiness, stage and progression.
3. Use critical thinking to analyze ways that nurses can
make labor and birth more family centered
4. Identify areas related to labor and birth that could
benefit from additional nursing research or
application of evidence-based practice.
STAGES OF LABOR
Divided into three stages:
1. A first stage of dilatation which begins with the
initiation of true labor contractions and ends when
the cervix is full dilated;
2. A second stage, extending from the time of full
dilatation until the infant is born; and
3. A third or placental stage, lasting from the time the
infant is born until after the delivery of the placenta
4. The first 1 to 4 hours after birth of the placenta is
sometimes termed the “fourth stage” to emphasize
the importance of the close maternal observation
needed at this time.
→ It’s helpful in planning nursing interventions
to ensure the safety of the woman and her
fetus
I. FIRST STAGE
The latent, the active, and the transition phase.
A. Latent/Preparatory Phase
• Begins at the onset of regularly perceived uterine
contractions and ends when rapid cervical
dilatation begins
• Contractions are mild and short, lasting 20 to 40
seconds. Cervical effacement occurs, and the cervix
dilates from 0 to 3 cm.
→ Multipara progress more quickly than
nullipara
Page 1 of 7 NCMA 217 LEC (MIDTERMS)
• Lasts approximately 6 hours in a nullipara and 4.
hours in a multipara
• A woman who enters labor with a “nonripe” cervix
will have a longer than usual latent phase
→ Nonripe cervix is not yet ready to dilate
• Although women should not be denied analgesia at
this point, analgesia given too early may prolong
this phase
→ It should be given later than the latent phase
• Measuring the length of the latent phase is
important because a reason for a prolonged latent
phase is cephalopelvic disproportion that could
require a cesarean birth
→ If disproportion between the fetus and the
pelvis occur, the pelvis is at fault
→ if the fetus is the cause of disproportion, it is
not because the fetal head is too large but it’s
presenting to the birth canal at less than its
enormous diameter
• A woman can (and should) continue to walk about
and make preparations for birth, such as:
▪ Doing last minute packing for her stay at the
hospital or birthing center
→ Preparing baby dresses or diapers;
kakailanganin nya during her stay sa hospital
or birth centers
▪ Preparing older children for her departure
and the upcoming birth
→ Pag bibilinan ang mga anak to stay safe,
especially the eldest son/daughter
▪ Giving instructions to the person who will
take care of them while she is away
▪ In a birth setting, allow her to continue to be
active (Greulich & Tarrant, 2007). Encourage
her to continue or begin alternative methods
or pain such as aromatherapy or distraction
→ Aromatherapy – aromatic essential oils to
improve the health of the body,mind and
spirits
→ Distraction – mental distraction, it can really
reduce pain and the effect is just in the mind.
It means that you use your brain to focus
attention on something else. You can put
your pain in the background and focus on
playing games, counting, using breathing
techniques and many other activities.
Annotated by: C. Danting
B. Active Phase • During this phase, a woman may experience intense
discomfort, so strong that it is accompanied by
• Cervical dilatation occurs more rapidly, increasing
nausea and vomiting
from 4 to 7 cm
• A woman may also experience a feeling of loss
• Contractions grow stronger, lasting 40 to 60
control, anxiety, panic or irritability
seconds, and occur approximately every 3 to 5
→ because of the intense and duration of the
minutes
contractions. It may seem as though labor
• Lasts approximately 3 hours in a nullipara and 2
has been taken charge of her
hours in a multipara. Show (increased vaginal
→ A few minutes before, gusting gusto ng mga
secretions) and perhaps spontaneous rupture of the
mother ang pinupunasan ang kanilang
membranes may occur during this time.
forehead ng cool cloth or na rrub ang
kanilang back.
• Difficult time
→ She may knock a partner’s hand away from
• Exciting time
her also.
• Frightening time
→ Her focus is entirely to the birthing of her
→ This phase can be difficult to a woman
baby
because contractions grow so much stronger
• The peak of the transition phase can be identified
and longer than latent phase. Can experience
by a slight slowing in the rate of cervical dilatation
discomfort
when 9 cm is reached. As a woman reaches the end
→ It’s also exciting time because something
of this stage at 10 cm of dilatation, a new sensation
dramatic is happening.
occurs and that’s the irresistible urge to push
→ Frightening time – as a woman realizes labor
is truly progressive and her life is about to II. SECOND STAGE
change forever. In a few minutes the woman
• The period from full dilatation and cervical
will have a new baby and life will never be
effacement to birth of the infant; this stage takes
the same
about 1 hour (Archie, 2007).
• Encourage women to remain active participants in
• A woman feels contractions change from the
labor by assuming what position is most
characteristic crescendo-decrescendo pattern to an
comfortable for them during this time (Albers,
overwhelming, uncontrollable urge to push or bear
2007)
down with each contraction as if to move her
→ Except, flat on back - this may lead to supine
bowels
hypotension syndrome
• She may experience momentary nausea or vomiting
C. Transition Phase • She pushes with such force that she perspires and
the blood vessels in her neck may become
• Contractions – peak of intensity, occurring – 2 to 3
distended
minutes/duration of 60 to 90 seconds and
• As the fetal head touches the internal side of the
maximum cervical dilatation of 8 to 10 cm
perineum, the perineum begins to bulge and
→ Strongest intensity
appears tense. The Anus may become everted, and
• If the membranes have not previously ruptured or still may be expelled
been ruptured by amniotomy (artificial rupture of
• As the fetal head pushes against the perineum, the
membrane), they will rupture as a rule of full
vaginal introitus opens and the fetal scalp appears
dilatation (10 cm). If it has not previously occurred,
at the opening to the vagina. At first, the opening is
show occurs as the last of the mucus plug from the
slitlike, then becomes oval, and then circular. The
cervix is released
circle enlarges from the size of a dime, then a
• Both full dilatation (10 cm) and complete cervical quarter, then a half-dollar. This is called crowning.
effacement (obliteration of the cervix) have
occurred

Page 2 of 7 NCMA 217 LEC (MIDTERMS) Annotated by: C. Danting

 III. THIRD STAGE
• Begins with the birth of the infant and ends with the
delivery of the placenta.
• Two separate phases are involved:
▪ placental separation
▪ placental expulsion
A. Placental Separation
→ As separation seems completed, the
placenta seems to follow uterine segments of
the upper vagina. The placenta has loosened
and ready to deliver when there’s:
• Lengthening of the umbilical cord
• Sudden gush of vaginal blood
→ Not complete separation
• Change in the shape of the uterus
• Firm contraction of the uterus
• Appearance of the placenta at the vaginal opening
Schultze
• If the placenta separates first at its center and last
at its edges, it tends to fold onto itself like an
umbrella and presents at the vaginal opening wit h
the fetal surface evident.
• Appearing shiny and glistening from fetal
membranes
→ Schultze presentation
→ Approximately 80% of placenta separates
this way
Duncan
• The placenta separates first at its edges, it slides
along the uterine surface and presents at the vagina
with the maternal surface evident
• It looks raw, red, and irregular, with the ridges or
cotyledons that separate blood collection spaces
evident;
• “shiny” with Schultze (the fetal membrane surface)
and “dirty” with Duncan (the irregular maternal
surface
• Normal blood loss – 300 to 500 ml
→ And not great amount in relation to the extra
blood falling that was formed during
pregnancy
→ This stage can be any in 1 to 30 minutes. And
can still be considered normal
Page 3 of 7 NCMA 217 LEC (MIDTERMS)
B. Placental Expulsion
• After separation, the placenta is delivered either by
the natural bearing-down effort of the mother or by
gentle pressure on the contracted uterine fundus by
a physician or nurse midwife
→ Creed’s maneuver
• Pressure must never be applied to a uterus in a
noncontracted state
• If the placenta does no deliver spontaneously, it can
be removed manually.
→ With the deliver of the placenta, the third
stage of labor is already complete
MATERNAL AND FETAL RESPONSES TO LABOR
→ Labor Is a local process that involve the
abdomen and the reproductive organs but
because it’s such an intense process it has
systematic physiologic effects on both
women and her fetus
→ Intensity is so great that almost all body
systems are affected by it.
1. Physiologic Effects of Labor on a woman
A. Cardiovascular System
Cardiac Output
• Each contraction greatly decreases blood flow to
the uterus. This increases the amount of blood that
remains in a woman’s general circulation, leading to
an increase in peripheral resistance, which in turn
results in an increase systolic and diastolic blood
pressure.
• The work of pushing during labor increase cardiac
output 40% to 50% above the prelabor level.
Cardiac output then gradually decreases from this
high level, within the first hour after birth, by about
50%.
Blood Pressure
With the increased cardiac output caused by contractions
during labor,
• Systolic blood pressure rises an average of 15 mm
Hg with each contraction
• When a woman lies in a supine position and pushes
during the second stage of labor, pressure of the
Annotated by: C. Danting
 uterus on the vena cava causes her blood pressure
to drop precipitously, leading to hypotension
• An upright or side-lying position during the second
stage of labor not only makes pushing more
effective but also can help avoid such a problem.
B. Hemopoietic System
• Development of leukocytosis, or a sharp increase in
the number of circulating white blood cells.
→ Possibly as a result of stress and heavy
exertion
• At the end of labor, the average woman has a white
blood cell count of 25,000 to 30,000 cells/mm3,
compared with a normal count of 5000 to 10,000
cells/mm3
C. Respiratory System
• Total oxygen consumption increases by about 100%
during the second stage of labor. Women adjust
well to this change, which is comparable to that of
a person performing a strenuous exercise. It can
result in hyperventilation. Using appropriate
breathing patterns during labor can help avoid
severe hyperventilation.
C. Temperature Regulation
• The increased muscular activity associated with
labor can result in a slight elevation (1 F) in
temperature
• Diaphoresis occurs with accompanying evaporation
to cool and limit excessive warming:
D. Fluid Balance
• Insensible water loss increases during labor
• Fluid balance is further affected if a woman eats
nothing but sips of fluid or ice cubes or hard candy
• Although not a concern in usual labor, the
combination of increased fluid losses and decreased
oral intake may make intravenous fluid
replacement necessary if labor becomes prolonged.
F. Urinary System
With the decrease in the fluid intake during labor and
the increase insensible water loss,
• The kidneys begin to concentrate urine to preserve
both fluid and electrolytes
Page 4 of 7 NCMA 217 LEC (MIDTERMS)
• Specific gravity may rise to a high normal level of
1.020 to 1.030
• It is not unusual for protein (trace to 1) to be evident
in urine
→ Because of the breakdown of the protein
caused by the increased muscle activity
• Pressure of the fetal head as it descends in the birth
canal against the anterior bladder reduces bladder
tone or the ability of the bladder to sense filling.
G. Musculoskeletal System
• Relaxin, has acted to soften the cartilage between
the bones.
→ Relaxin – ovarian released hormone
• In the week before labor, considerable additional
softening causes the symphysis pubis and the
sacral/coccyx joints to become even more relaxed
and movable, allowing them to stretch apart to
increase the size of the pelvic ring by as much as 2
cm
H. Gastrointestinal System
• Inactive during labor, probably because of the
shunting of blood to more life sustaining organs and
also because of pressure on the stomach and
intestines from the contracting uterus. Digestive
and emptying time of the stomach-prolonged
• Some women experience a loose bowel movement
as contractions grow strong.
→ Just like similar to what they may experience
with the menstrual cramps
I. Neurologic and Sensory Responses
• The neurologic responses that occur during labor
are responses related to pain
→ Increase pulse and respiratory rate
• Early in labor, the contraction of the uterus and
dilatation of the cervix cause the discomfort
• At the moment of birth, the pain is centered on the
perineum as it stretches to allow the fetus to move
past it
2. Psychological Responses of a Woman to Labor
A. Fatigue
• By the time a date of birth approaches, a woman is
generally tired from the burden of carrying so much
extra weight
Annotated by: C. Danting
 • Most women do not sleep well during the last → To make labor positive experience be
month of pregnancy (Beebe & Lee, 2007) prepared to adapt care of women’s specific
→ Because of the discomfort needs. If a woman has a traditional that run
→ Side-lying position causes backache; pag nag counter to the hospital protocols, you’re
turn sa back yung fetus gagalaw/magkikick going to address these differences and make
at magigising ang mother, pag bumalik sa arrangement to accommodate her desires.
side-lying mag cause ulit backache Ex. Advocating for special foods to eat or
• It can make the process of labor loom as an saving the placenta in order for the mother
overwhelming, unendurable experience unless they to take it home.
have competent support people with them.
3. Physiologic Effects of Labor to a fetus
B. Fear
A. Neurologic system
• Women appreciate a review of the labor process
→ The pressure in circulatory changes that
early in labor as a reminder that childbirth is not a
occur with contractions not only affect the
strange, bewildering event but a predictable and
mother but also detectable physiologic
well-documented one
changes in the fetus as well.
• Being taken by surprise-labor moving faster or
• Uterine contractions exert pressure on the fetal
slower than the woman thought it would or
head, so the same response that is involved with
contractions harder and longer than she
any instance of increased intracranial pressure
remembers from last time-can lead a woman to feel
occurs.
out of control and increase the pain she experiences
→ The baby who has a hydrocephalus, yung
▪ Explain that labor is predictable, but also
pressure na naccause doon sa fetal head
variable, to limit this kind of fear
during uterine contraction is the same ang
→ It depends upon individual because some
naicause na pressure ng fluid doon sa brain
women have a low pain tolerance, yung iba
sa mga structures and it will cause ICP
mataas ang pain tolerance.
• The fetal heart rate (FHR) decreases by as much as
→ Must consider of being a multipara or
5 beats per minute (bpm) during contraction, as
nullipara and how is the attitude of the
soon as contractions strength reaches 40 mm Hg
women to the labor
• This decrease appears on a fetal heart monitor as a
▪ Explain that contractions last a certain length
normal or early deceleration pattern.
and reach a certain firmness but always have
a pain-free rest period in between B. Cardiovascular System
→ During interval, it allows placental perfusion
• The ability to respond to cardiovascular changes is
C. Cultural Influences usually mature enough that the fetus is unaffected
by the continual variations of heart rate that occur
• Cultural factors can strongly influence a woman’s
with labor- a slight slowing and then return to
experience of labor
normal (baseline) levels
• Women are educated to help plan their care
• During a contraction, the arteries of the uterus are
→ Internet, books, knowledge and information
sharply constricted and filling of nutrients of
they’ve taken during labor classes or
cotyledons almost completely halts, the amount of
prenatal classes
nutrients, including oxygen, exchanged during this
• Every woman responds to cultural cues in some time is reduced, causing a slight but inconsequential
way. This makes her response to pain, her choice of fetal hypoxia.
nourishment, her preferred birthing position, the
→ So filling of blood or oxygenation temporarily
proximity and involvement of a support person, and
stop during contraction because of arteries
customs related to the immediate postpartal period
are constricted
individualized (Price, Noseworthy, & Thornton,
2007)
Page 5 of 7 NCMA 217 LEC (MIDTERMS) Annotated by: C. Danting
 C. Integumentary System
• The pressure involved in the birth process is often
reflected in minimal petechiae (tiny purple, red or
brown spot on the skin) or ecchymotic(flat blue or
purple patch measuring 1 cm occur when the blood
leaks on a broken capillary into the surrounding
tissue around the skin) areas on a fetus (particularly
the presenting part).
• There may also be edema of the presenting part
(caput succedaneum) edema of the skull
D. Musculoskeletal System
• The force of uterine contractions tends to push a
fetus into a position of full flexion, the most
advantageous position for birth
→ It presents the narrowest AP diameter of
fetal head
E. Respiratory System
• The process of labor appears to aid in the
maturation of surfactant production by alveoli in
the fetal lung
• The pressure applied to the chest from contractions
and passage through the birth canal helps to clear it
of lung fluid
• An infant born vaginally is usually able to establish
respirations more easily than a fetus born by
cesarean birth
MATERNAL DANGER SIGNS
1. High or Low Blood Pressure
• Normally, a woman’s blood pressure rises slightly in
the second (pelvic) stage of labor (because of her
pushing effort)
• A systolic pressure greater than 140 mm Hg and a
diastolic pressure greater than 90 mm Hg, or an
increase in the systolic pressure of more than 30
mm Hg or in diastolic pressure of more than 15 mm
Hg (the basic criteria for pregnancy-induced
hypertension), should be reported
• Important to report is a falling blood pressure,
because it may be the first sign of intrauterine
hemorrhage (excessive blood loss)
Page 6 of 7 NCMA 217 LEC (MIDTERMS)
2. Abnormal Pulse
• Most pregnant women have a pulse rate of 70 to 80
bpm. This rate normally increases slightly during the
second stage of labor – due to exertion that’s
involved
• A maternal pulse rate greater than 100 bpm during
the normal course of labor is unusual and should be
reported. It may be another indication of
hemorrhage
3. Inadequate of Prolonged Contractions
• If uterine contractions become less frequent, less
intense, or shorter in duration, this may indicate
uterine exhaustion (inertia). If this problem cannot
be corrected, a cesarean birth may be necessary
→ Hypotonic inertia
→ Uterine contractions are infrequent, weak
and short in duration. Some factors include
multigravida, elderly generally pwedeng
anemia, improper use of analgesia,
malpresentation/malposition or over
distention of the uterus.
• A period of relaxation must be presented between
contractions so that the intervillous spaces of the
uterus can fill and maintain an adequate supply of
oxygen and nutrients for the fetus. As a rule, uterine
contractions lasting longer than 70 seconds should
be reported
→ Dapat kinukuha ung duration of contraction,
and interval para malaman kung nag
kakaroon ng placental perfusion or rest
period between contraction because interval
causes placental perfusion or it will allow
blood flow to the placenta and to the fetus to
supply adequate oxygen and nutrients
→ Should be reported especially in the early
phase of labor
4. Pathologic Retraction Ring
• An indentation across a woman’s abdomen, where
the upper and lower segments of the uterus join,
may be a sign of extreme uterine stress and possible
impending uterine rupture. For this reason, it is
important to observe the contours of a woman’s
abdomen periodically during labor
• Fetal heartbeat auscultation automatically provides
a regular opportunity to assess a woman’s abdomen
Annotated by: C. Danting
 → Physiologic retraction ring = normal it’s a lign
of demarcation between upper and lower
uterine segment that’s present during
normal labor and cannot usually be felt
abdominally pero kung yung retraction ring
is pathologic hindi dapat iniignore it can be a
sign of extrauterine stress/ and impending
uterine rupture
5. Abnormal Lower Abdominal Contour
• If a woman has a full bladder during labor, a round
bulge on her lower anterior abdomen may appear.
This is a danger signal for two reasons:
▪ First, the bladder may be injured by the
pressure of a fetal head
▪ Second, the pressure of the full bladder may
not allow the fetal head to descend
❖ To avoid a full bladder, women need to
try to void about every 2 hours during
labor
6. Increasing Apprehension
→ Anxiety, fear of something unpleasant will
happen
• Warnings of a psychological danger during labor are
as important to consider in assessing maternal well-
being as are physical signs
• A woman who is becoming increasingly
apprehensive despite clear explanations of
unfolding events may not be “hearing because she
has a concern that has not been met
• Increasing apprehension also needs to be
investigated for physical reasons, because it can be
a sign of oxygen deprivation or internal
hemorrhage.
FETAL DANGER SIGNS
1. High or Low Fetal Heart Rate
• As a rule, an FHR of more than 160 bpm (fetal
tachycardia) or less than 110 bpm (fetal
bradycardia) is a sign of possible fetal distress
• An equally important sign is a late or variable
deceleration pattern on a fetal monitor
→ Variable deceleration occurs when the FHR
decrease greater than or equal to 15 BPM.
Page 7 of 7 NCMA 217 LEC (MIDTERMS)
→ Last longer than or equal to 15 seconds or
less than 2 minutes from the onset to return
to baseline
• The FHR may return to a normal range in between
these irregular patterns, giving a false sense of
security if FHR is assessed only between
contractions
2. Meconium Staining
• Meconium staining, a green color in the amniotic
fluid, is not always a sign of fetal distress but is
highly correlated with its occurrence
• The fetus has had loss of rectal sphincter control,
allowing meconium to pass into the amniotic fluid.
It may indicate that a fetus has or is experiencing
hypoxia, which stimulates the vagal reflex and leads
to increased bowel motility
• Although meconium staining may be normal in a
breech presentation, it should always be reported
immediately so that its cause can be investigated
3. Hyperactivity
• Ordinarily, a fetus is quiet and barely moves during
labor. Fetal hyperactivity may be a sign that hypoxia
is occurring, because frantic motion is a common
reaction to the need for oxygen.
4. Oxygen Saturation
• If a fetus is assessed for oxygen saturation level by
a catheter inserted next to the check, a low oxygen
saturation level (under 40%) or if fetal blood was
obtained by scalp puncture, the finding of acidosis
(blood pH 7.2O) suggests that fetal well-being is
becoming compromised
• Oxygen saturation in a fetus is normally 40% to 70%
Annotated by: C. Danting