Stages of labor

First stage: Begins with the onset of true labor and

Second Stage of Labor: Expulsion of the Fetus
ends with full dilation of the cervix at 10 cm.
Assessment
1. Early labor
❖ Monitor the blood pressure, pulse, and respirations every 15
2. Active labor
to 30 minutes
3. Transition
❖ Assess the contraction pattern every 15 minutes
Latent Phase (Early Labor): Contractions during
❖ Assess fetal status
early labor are typically five to 10 minutes apart, last
❖ Assess the woman’s report of an uncontrollable urge to
30 to 45 seconds, and are of mild intensity. The
push
cervix is dilated from 1 to 3 cm, and effacement has
❖ Check the FHR every 15 minutes for the low-risk woman,
begun. Possible spontaneous rupture of membranes
every five minutes for woman at risk for labor complications
Assessment
❖ Assess FHR and contractions at least once
every hour
❖ Assess maternal status
❖ Assess status of fetal membranes
❖ Assess the woman’s psychosocial state
Goals, expected outcomes
❖ Goal: The woman and fetus remain free
from injury
❖ Goal: The woman’s anxiety is reduced
❖ Goal: The woman’s pain is manageable
Third Stage of Labor: Delivery of Placenta
❖ Goal: The woman and partner have
adequate knowledge of labor process Assessment
Active Labor: contractions occur every two to five ❖ Assess the woman’s psychosocial
minutes, last 45 to 60 seconds, and are of moderate state after she gives birth
to strong intensity. The cervix should dilate ❖ Monitor for signs of placental
progressively from 4 to 8 cm.contractions are regular separation
moderate and strong. Rapid effacement. Fetal
Selected nursing diagnoses
descent begins.
Assessment ❖ Risk for deficient fluid volume related
to blood loss in the intrapartum period
❖ Assess woman’s psychosocial
❖ Risk for trauma: Hemorrhage, amniotic
state
fluid embolism, retained placenta, or
❖ Assess labor progress
uterine inversion related to delivery of
❖ Assess fetal status
the placenta
❖ Assess maternal status

Transition Phase of Labor: contractions should

occur every two to three minutes, last 60 to 90
seconds, and be of strong intensity. The uterus
should relax completely between uterine
contractions. Cervical examination during transition
reveals dilation between 8 and 10 cm.
The client may be nauseous, vomiting or reporting
the need to have a bowel movement. Urge to push
and bloody show.
Assessment
❖ Assess for signs that woman has reached
transition phase
Fourth Stage of Labor: Recovery
Assessment
❖ Continue to assess for hemorrhage
❖ Assess the lochia: Color, quantity
❖ Monitor for signs of infection
❖ Monitor for suprapubic distention
❖ Assess comfort level
❖ Assess mother’s psychosocial state during the
fourth stage
❖ Assess initial bonding behaviors of the new

❖ Assess woman’s ability to cope
❖ Assess maternal status
❖ Assess fetal status
❖ She will often express irritability,
restlessness, and will feel out of control.
She may tremble, vomit, or cry. It is
important to assess for hyperventilation
during this phase.
Pushing
family
❖ Vigorous pushing: take a deep breath, hold the breath, and push while
counting to 10. She is encouraged to complete three “good” pushes in
this manner with each contraction.
❖ open-glottis pushing: method of expelling the fetus that is
characterized by pushing with contractions using an open glottis so that
air is released during the pushing effort.
❖ urge-to-push method, in which the woman bearsdown only when she
feels the urge to do so using any technique that feels right for her