LESSON

STAGES OF
2
LABOR
LEARNING CONTENTS

Let’s start…

STAGES OF LABOR

A. First Stage (Stage of Dilatation) – begins with true

labor pains and ends with complete dilatation
of the cervix.
1. Power/Forces: Involuntary uterine contractions
2. Phases:
a. Latent – early time in labor
 Cervical dilatation is minimal
because effacement is occurring
 Cervix dilates 3-4 cm. only
 Contractions are of short duration
and occur regularly 5-10 minutes
apart (during which time the
pregnant woman may seek
admission to the hospital)
 Mother is excited, with some degree
of apprehension but still with ability
to communicated
 Takes up 8 of the 12-hour first stage
b. Active/accelerated
 Cervical dilatation reaches 4-8 cm.
 Rapid increase in duration, frequency and intensity of contractions
 Mother fears losing control of herself
3. Nursing Care

a. Hospital admission – provide privacy and reassurance from the very start
 Personal data – name, age, address, civil status
  Obstetrical data – determine EDC; obstetrical score; amount and
character of show; and whether or not membranes have ruptured
b. General physical examination, internal exam and Leopold’s maneuvers are
done to determine:
 Effacement and dilatation
Station – relationship of the fetal presenting part to the level of the ischial
spines
▪ Station 0 – at the level of the ischial spines; synonymous to
engagement
▪ Station -1 – presenting part above the level of the ischial spines
▪ Station +1 – presenting part below the level of the ischial spines \
▪ Station +3 or +4 – synonymous to crowning (= encirclement of the
largest diameter of the fetal had by the vulvar ring)
 Presentation – relationship of the long axis of the fetus to the long axis
of the mother; also known as lie
Presenting part – the fetal part which enter the pelvis first and covers the
internal cervical os

Types of Presentation

I. VERTICAL
A. Cephalic – he is the presenting part
1. Vertex – head sharply flexed, making
the parietal bone the presenting part
2. Face)
3. Brow) if in poor flexion
4. Chin )

B. Breech – buttocks are the presenting

parts
1. Complete – thighs flexed on the
abdomen and legs are on thighs
2. Frank – thighs are flexed and
legs are extended, resting on the
anterior surface of the body
3. Footling
a. Single – one leg unflexed
and extended; one foot
presenting
b. Double – legs unflexed and extended; feet are presenting

II. HORIZONTAL – Transverse lie – Shoulder presentation

 In vertex and breech presentations, fetal heart sounds are best heard, at the area
of the fetal back; in face presentations, at the area of the fetal chest
 In vertex presentations, FHS are usually located in either the left or right lower
quadrant (RLQ or LLQ); in breech presentation, at or above the level of the
umbilicus (RUQ or LUQ)  Hazards of breech delivery: o Cord compression o
Abruptio placenta o Erb-duchenne paralysis
 Horizontal lie is very rare (1%) and maybe due to a relaxed abdominal wall
because of multiparity, pelvic contraction or placenta previa
 Position – relationship of the fetal presenting part to a specific quadrant of the
mother’s pelvis
 The pelvis is divided into four quadrants
o Right anterior
o Right posterior
o Left anterior
o Left posterior
o Posteriors positions result in more backaches
because of pressure fetal presenting part on the
maternal sacrum
 Points of direction in the fetus:
o Occiput – in vertex presentations
o Chin (mentum) – in face presentations
o Buttocks/feet – in breech presentations
o Scapula (acromic) – in horizontal presentation
 Possible fetal positions
o Vertex
 LOA – left occipitoancetior (most
common and favorable position at
birth)
 LOP – left occipitoposterior
 LOT – left occipitoetransverse
 ROA – right occipitoanterior
 ROP – right occipitoposterior
 ROT – right occipitotransverse o
Breech
 LSA – left sacroanterior
 LSP – left sacroposterior
 LST – left sacrotransverse
 RSA – right sacroanterior
 RSP – right sacroposterior
 RST – right sacrotransverse o Face
 LMA – left mentoanterior
 LMP – left mentoposterior
 LMT – left mentotransverse
 RMA – right mentoanterior
  RMP – right mentoposterior
 RMT – right mentotransverse
o Shoulder
 LADA – left acromiodorsoanterior
 LADP – left acromiodorsoposterior
 RADA – right acromiodorsoanterior
 RADP – right acromiodorsotransverse

c. Monitoring and evaluation of important aspects

 Uterine contractions – fingers should be spread lightly over the fundus
o Duration – from the beginning of one contraction to the end of the same
contraction (A to B)
 Duration during early labor – 20-30 seconds
 Duration late in labor – 60 to 70 seconds (SHOULD NEVER
BE LONGER)
o Interval – from the end of one contraction to the beginning of the next
contraction (B to C)
 Interval early in labor – 40-45 minutes
 Interval late in labor – 2-3 minutes
o Frequency – from the beginning of one contraction to the beginning of the
next contraction (A to C) Time 3-4 contractions to have a good picture of
the frequency of contractions
o Intensity – strength of contractions. May be mild, moderate or string.
Intensity is measured by the consistency of the fundus at the acme of the
contraction. When estimating intensity, check fundus at the end of
contractions to determine whether it relaxes.
o Blood pressure – should not be taken during a contraction as it tends to
increase. Because no blood supply goes to the placenta during a
contraction, all of the blood is in the periphery that is why there is
increased BP during uterine contractions.
 BP readings should be taken at least every half hour during
active labor
 When a woman in labor complains of a headache, the first
nursing action is to take the BP. If it is normal, it is only
stress headache; if the BP is increased, refer immediately to
the doctor (it could be a sign of toxemia)
o Fetal heart rate – should not be mistaken for uterine soufflé (synchronizes
with maternal pulse rate)
 Normally 120-160 per minute
 Should not be taken also during a uterine contraction
because it tends to decrease. Compression of the fetal head
when the uterus contracts stimulates the vagal reflex which,
in turn, caused bradycardia
  Should be taken every hour during the latest phase of labor;
every half hour during the active phase and every 15
minutes during the transition phase
 For any abnormality in FHR, the initial nursing action is to
change the mother’s position.
o Signs of fetal distress:
▪ Bradycardia (= FHR less than 100/minute) or
tachycardia
▪ (=FHR more than 180/minute) o Meconium-
stained amniotic fluid in non-breech presentation
▪ Fetal thrashing – hyperactivity of the fetus as it
struggles for more oxygen
d. Emotional support is provided for the woman in labor by keeping her constantly
informed of the progress in labor.
e. Healthy Teachings
 Bath – is advisable if contractions are tolerable or not too close to one
another. Will make the mother feel more comfortable
 Ambulation – during the latent phase of labor helps shorten the first stage
of labor. But definitely not allowed anymore if membranes have ruptured.
 Solid or liquid foods are to be avoided because:
o Digestion is delayed during labor
o A full stomach interferes with proper bearing down
o May vomit and cause aspiration
 Enema – NOT a routine procedure
o Purposes:
 A full bowel hinders the progress of labor- effectiveness of
enema in labor is shown by evaluating change in uterine tone
and amount of show
 Expulsion of feces during second stage of labor predisposes
mother and baby to infection.
 Full bowel predisposes to post-partum discomfort o Procedure
of enema administration
 Enema solution may either be soap suds or fleet enema
 Optimal temperature of the enema solution – 105oF to 115oF (
40.5oC – 46.1oC)
 Patient on side-lying position
 When there is resistance while inserting the rectal catheter,
withdraw the tube slightly while letting a small amount of
solution enter
 Clamp rectal tube during s contraction
 Important nursing action: Check FHR after enema
administration to determine fetal distress
o Contraindications to enema in labor :
 Vaginal bleeding
  Premature labor
 Abnormal fetal presentation or position
 Ruptured membranes
 Crowning
 Encourage the mother to void very 2-3 hours by offering the bedpan
because:
 A full bladder retards fetal descent
 Urinary stasis can lead to urinary tract infection
 A full bladder can be traumatized during delivery
PERINEAL PREP  Perineal Prep – done aseptically
Use “No.7” method, always from front to back.
 Perineal shave – maybe done to provide a clean area for
delivery. Muscles at the symphysis pubis should be kept
taut and razor
moved along the direction of hair growth
 Encourage Sim’s position because :
 It favors anterior rotation of the fetal head
 It promotes relaxation between contractions
 It prevents continual pressure of the gravid uterus on the inferior
vena cava ( the blood vessel which brings unoxygenated blood
back to the heart), pressure results in Supine Hypotensive
Syndrome, also called Vena Cava Syndrome. Hypotension is
due to the reduced venous return resulting in decreased cardiac
output and therefore, a fall in arterial BP.

 Woman in labor should not be allowed to push or bear

down unnecessarily during contractions of the first stage
because:
 It leads to unnecessary exhaustion
 Repeated strong pounding of the fetus against the pelvic floor
will lead to cervical edema, thus interfering with dilatation
 Abdominal breathing – is advised for contractions during
the first stage in order to reduce tension and prevent hyperventilation.

f. Administer analgesics as ordered. The dosage is based on the patient’s weight,

status of labor and size and stage of gestation.
 Narcotics are the most commonly used, specifically Demerol.
 Pharmacologic effect: Depresses the sensory portion of the
cerebral cortex. It is not only a potent analgesic, it is also a
sedative and an antispasmodic.
 It is not given early in labor because it can retard labor progress
( is an antispasmodic), but cannot also be given if delivery is only
one hour away because it causes respiratory depression in the
newborn ( that is why it can
 be given only if cervical dilatation is 6-8cm.)
 Given 25-100mg.,depending on the body weight
 Takes effect in 20 minutes – patient experiences a sense of well-
being and euphoria
 Narcotic antagonists (e.g. Narcan or Nalline) are given to
counteract the toxic effects of Demerol

g. Assist in administration of regional anesthesia – preferred over any other form of

anesthesia because it does not enter maternal circulation and thus does not affect
the fetus. Patient is completely awake and aware of what is happening. Does not
depress uterine tone, thus optimal uterine contraction is
achieved.
 Xylocaine is anesthesia of choice
 Patient on NPO with IV to prevent dehydration, exhaustion
and aspiration and because glucose aids uterine muscles in
proper functioning.

 Types of Anesthesia:

 Paracervical – transvaginal
injection into either side of
the cervix. Patient on
lithotomy position. Coupled
with a local anesthetic,
results in “painless childbirth”
( uterine contractions are not
felt by mother)

 Pudendal – through the sacro-spinous

ligament into the posterior areolar
tissues to reduce perception of pain
during second stage and make mother
comfortable. Patient on lithotomy. Side
effect : an ecchymotic (purplish
discoloration of the skin due to blood
in the subcutaneous tissues) area or
hematoma in the right of the perineum
may be an aftermath. No special
treatment is needed: ice bag applied to the area on the first day may reduce the
swelling

 Low Spinal
 Epidural –
injection of local
anesthetic at the
lumbar level
outside the dura
mater
 Saddle block
– injection into
th
the 5 lumbar
space, causing anesthesia into the parts of the body
that come in contact with a saddle (perineum, upper
thighs and lower pelvis). Blocks nerves that transmit
pain of first stage of labor. In sitting or side-lying
position, with back flexed.

 Forceps are generally needed in delivery of patient under anesthesia

because of loss of coordination in second-stage pushing
 Postspinal headaches maybe due to leakage of anesthetic into the
CSF or injection of air at time of needle insertion. Management : Flat
on bed for 12 hours and increase fluid intake  Common side-effects:
 Hypotension – because Xylocaine is a vasodilator. Management
: turn to side; prompt elevation of legs;
administration of vasopressor and oxygen, as ordered
 Fetal bradycardia
 Decreased maternal respirations

h. A sure sign that the baby is about to be born is the bulging of the perineum. In
general, primigravidas are transported from LR to the DR when the cervix is
fully dilated or when there is bulging of the perineum; multiparas are
transported at 7-8cm cervical dilatation.

B. Transition Period – when the mood of the woman suddenly changes and the
nature of the contractions intensify.
1. Characteristics :
a) If membranes are still intact, this period is marked by a sudden
gush of amniotic fluid as fetus is pushed into the birth canal. If
spontaneous rupture does not occur, amniotomy (snipping of BOW
with a sterile pointed instrument e.g. Kelly or Allis forceps or
amniohook to allow amniotic fluid to drain), is done to prevent fetus
from aspirating the amniotic fluid as it makes its different fetal
 position changes. Amniotomy, however cannot be done if station is
still “minus” as this (can lead to cord compression).
b) Show becomes prominent.
c) There is an uncontrollable urge to push with contractions, a sign of
impending second stage of labor. Profuse perspiration and
distention of neck veins are seen.
d) Nausea and vomiting is a reflex reaction due to decreased gastric
motility and absorption.
e) In primis, baby is delivered within 20 contractions (=40 minutes); in
multis, in 10 contractions (=20 mintues)

2. Nursing actions are primarily comfort measures:

a) Sacral pressure ( applying pressure with the heel of the hand
on the sacrum) relieves discomfort from contractions
b) Proper bearing down techniques: push with contractions
c) Controlled chest ( costal) breathing during contractions
d) Emotional support

C. Second Stage (stage of Expulsion) – begins with

complete dilatation of the cervix and ends with
delivery of the baby.
1. Power/forces: In voluntary uterine
contractions and contractions of the
diaphragmatic and abdominal muscles

2. Mechanisms of Labor/ Fetal Position

Changes : (D FIRE ERE)
a. Descent (may be preceded by engagement)

b. Flexion – as descant occurs, pressure from the pelvic floor causes

the chin to bend forward onto the chest
 c. Internal
Rotation – from
AP to
transverse, then
AP to AP

d. Extension – as
head comes out,
the back of the
neck stops beneath
the pubic arch. The
head extends and
the forehead, nose,
mouth and chin
appear

e. External
Rotation (also
called
restitution) -
anterior
shoulder
rotates
externally to
the AP position
f. Expulsion – delivery of the rest of the body

3. Nursing Care
a. When positioning legs or lithotomy, put them up at the same
time to prevent injury to the uterine ligaments

b. As soon as the fetal head crowns, instruct mother not to

push, but to pant instead ( rapid and shallow breathing) to
prevent rapid expulsion of the baby. If panting is deep and
rapid, called hyperventilation the patient will experience
lightheadedness and tingling sensation of the fingers leading
to carpopedal spasms, because of respiratory alkalosis.
Management: let the patient breath into brown paper bag to
recover lost carbon dioxide; a cupped hand will serve the
same purpose.

c. Assist in episiotomy – incision made in the perineum primarily to

prevent lacerations.
 Other purpose of episiotomy:
o Prevent prolonged and severe stretching of muscles
supporting bladder or rectum
o Reduce duration of second stage when there is
hypertension or fetal distress
o Enlarge outlet, as in breech presentation or forceps
delivery
 Types of episiotomy:
o Median – from middle portion of the lower vaginal
border directed towards the anus
o Mediolateral – begun in the midline but directed
laterally away from the anus
 Natural anesthesia is used in episiotomy, i.e., no anesthetic is
injected because pressure of fetal presenting part against the
perineum is so intense that nerve endings for pain are
momentarily deadened.

d. Apply the Modified Ritgen’s Maneuver:

  Cover the anus with sterile towel and exert upward and
forward pressure on the fetal chin, while exerting gentle
pressure with two fingers on the head to control emerging
head. This will not only support the perineum, thus
preventing lacerations, but will also favor flexion so that the
smallest sub-occipitobregmatic diameter of the fetal head is
presented.
 Ease the head out and immediately wipe the nose and
mouth of secretions to establish and maintain a patent
airway (REMEMBER: the first principle in the care of the
newborn is establish and maintain a patent airway).
(The head should be delivered in between
contractions.)
 Insert 2 fingers into the vagina so as to feel for the presence
of a cord looped around the neck (nuchal cord). If so, but
loose, slip it down the shoulders or up over the head; but if
tight; clamp cord twice, an inch apart, and then cut in
between.
 As the head rotates, deliver the anterior shoulder by exerting a
gentle downward push and then slowly give an upward lift to deliver
the posterior shoulder
 While supporting the head and the neck, deliver the rest of the
body. Take note of the exact time of delivery of the baby.
a. Immediately after delivery, newborn should be held below
the level of the mother’s vulva for a few minutes to
encourage flow of blood from the placenta to the baby.
b. The infant is held with his head in a dependent position (-
head lower than the rest of the body) to allow for drainage of
c. secretions. REMEMBER: Never stimulate a baby to cry
unless you have drained him out of his secretions first.
d. Wrap the bay in a sterile diaper to keep him warm.
REMEMBER: Chilling increases the body’s need for oxygen.
e. Put the bay on the mother’s abdomen. The weight of the
baby will help contract the uterus.
f. Cutting of the cord is postponed until the pulsations have
stopped because it is believed that 50 – 100 ml of blood is
flowing from the placenta to the baby at this time. After cord
pulsations have stopped, clamp it twice, an inch apart, and
then cut in between
g. Show the baby to the mother, inform her of the sex and time
of delivery then give the baby to the circulating nurse.

D. Third Stage (Placental Stage) – begins with the delivery of the baby and ends with
the delivery of the placenta.
1. Signs of placental separation:
a. Uterus becoming round and firm again, rising high to the level of the
umbilicus (Calkin’s sign) – the earliest sign of placental separation
b. Sudden gush of blood from the vagina
c. Lengthening of the cord from the vagina

2. Types of placental delivery:

a. Schultz – if placenta separates
first at its center and last at its
edges, it tends to fold on itself
like an umbrella and presents the
fetal surface which is shiny. 80%
of placentas separate in this
manner (“Shiny” for Schultz)

b. Duncan – if placenta separates

first at its edges, it slides along
the uterine surface and presents
with the maternal surface which
is raw, red, beefy, irregular and
“dirty”. Only about 20% of
placentas separate this way.
(”Dirty” of Duncan)

3. Nursing Care
a. Do not hurry the expulsion of the placenta by forcefully pulling out the
cord or doing vigorous fundal push as this can cause uterine inversion.
Just watch for the signs of placental separation.
b. Tract the cord slowly, winding it around the clamp until placenta
spontaneously comes out, rotating it slowly so that no membranes are
left inside the uterus, a method called Brandt-Andrews maneuver.
c. Take not of the time of placental delivery; it should be delivered within
20 minutes after the delivery of the baby. Otherwise, refer immediately
to the doctor as this can cause severe bleeding in the mother.
d. Inspect for completeness of cotyledons; any placental fragment retained
can also cause severe bleeding and possible death
e. Palpate the uterus to determine degree of contraction. If relaxed, boggy
or non-contracted, first nursing action is to massage gently and properly.
An ice cap over the abdomen will also help contract the uterus since
cold causes vasoconstriction.
f. Inject oxytocin (Methergin – 0.2. mg/ml or Syntocinon = 10 U/ml) – IM to
maintain uterine contractions, thus prevent hemorrhage. Note:
oxytocins are not given before placental delivery because placental
entrapment can occur.
 Categories of lacerations
(tend to heal more slowly
because of ragged
edges):
o First degree – involves the vaginal
mucous membranes and skin
o Second
degree –
involves not
only the
vaginal
mucous
membranes
and skin, but
also the muscles
o Third degree – involves not only the muscles, vaginal
mucous membranes and skin, but also the external
sphincter of the rectum
o Fourth degree – involves not only the external
sphincter of the rectum, the muscles, vaginal mucous
membranes and skin, but also the mucous
membranes of the rectum

 Assist the doctor in doing episiorrhaphy (- repair of episiotomy or

lacerations). In vaginal episiorrhaphy, packing is done to
maintain pressure on the suture line, thus prevent further
bleeding. Note: Vaginal packs have to be removed after 24 – 48
hours
g. Make mother comfortable by perineal care and applying clean sanitary
napkin snugly to prevent its moving forward from the anus to the
vagina. Soiled napkins should be removed from front to back.
h. Position the newly-delivered mother flat on bed without pillows to
prevent dizziness due to decrease in intra-abdominal pressure.
i. The newly-delivered mother may suddenly complain of chills due to the
rapid decrease of pressure, fatigue or cold temperature in the delivery
room. Management: Provide additional blankets to keep her warm.
j. May give initial nourishment, e.g., milk, coffee, or tea
k. Allow patient to sleep in order to regain lost energy
E. Fourth Stage – first 1 – 2 hours after delivery which is said to be the most critical
stage for the mother because of unstable vital signs.
1. Assessment:
a. Fundus – should be checked every 15 minutes for 1 hour then every 30
minutes for the next 4 hours. Fundus should be firm, in the midline and,
during the first 12 hours postpartum, is a little above the umbilicus. First
nursing action for a non-contracted uterus: massage.
b. Lochia – should be moderate in amount. Immediately after delivery, a
perineal pad can be completely saturated after 30 minutes.
c. Bladder – a full bladder is evidenced by a fundus which is to the right of
the midline, dark-red bleeding with some clots.
d. Perineum – is normally tender, discolored and edematous. It should be
clean, with intact sutures.
e. Blood pressure and pulse rate – may be slightly increased from
excitement and effort of delivery, but normalize within one hour.

2. Lactation-suppressing agents – estrogen-androgen preparation given

within the first hours postpartum to prevent breastmilk production in
mothers who will not (or cannot) breastfeed.
E.g., diethylstilbestrol, TACE or deladumone. These drugs tend to increase
uterine bleeding and retard menstrual return.

3. Rooming-in concept – mother and baby are together while in the hospital.
The concept of a family, therefore, is felt at the very beginning because
parents have the baby with them, thus providing opportunities for
developing a positive relationship between parents and newborn. Eye-to-
eye contact is immediately established, releasing maternal caretaking
responses.