First Stage

Stage 1: Latent Phase

Power: Contractions palpate mild, every 5-10 minutes, lasting
30-45 seconds
Psyche: Patient is usually excited about the start of labor Measuring progress in labor: Cervical
dilation (0-3 cm)
Passageway: Encourage frequent position changes that optimize
fetal descent, rotation, and widen pelvic outlet
Ambulation (with intact amniotic sac) Squatting
Hands and knees position
Rocking chair Side-lying
Check bladder status and encourage patient to void every 2 hours
Nursing considerations Monitor vital signs every 30-60 minutes
Fetal heart tones every 30-60 minutes

Hydration

• Oral fluids as ordered

• Monitor intake and output

Pain management

Pain medication usually avoided until in active labor Techniques for pain management

• Hydrotherapy

- Shower - Labor tub

• Massage - Effluerage: light, circular stroking of gravid abdomen

Counter-pressure to Relaxation techniques back

Progressive relaxation - Patterned breathing

Soft music and lighting - Distraction

Stage 1: Active Phase

Power: Contractions palpate moderate to strong, every 2-5 minutes lasting 40-60 seconds
Psyche: Patient may have greater difficulty coping with the pain of contractions

Measuring progress in labor: Cervical dilation (4-7 cm) Passageway

Encourage frequent position changes Check bladder status and encourage patient to void every

2 hours

Nursing considerations

Monitor vital signs every 30 minutes

Fetal heart tones every 15-30 minutes

Pain management Continue with effective techniques used in latent

phase Systemic medications to decrease pain perception

• Document and report maternal and fetal response to

systemic medications

• Neonatal side effects related to both dose and timing of administered medication

Systemic Pain Medications in Labor

Drug Action

Medication Class

Opioid

Reduce pain perception

analgesics

Meperidine Butorphanol fentanyl Nalbuphine

Nursing Considerations

Side effect: nausea and

vomiting

Long-acting active metabolite.

may cause respiratory depression (in the neonate) Caution with women who are

opiate dependent, may cause

withdrawal IV push dosing should be at the beginning of a contraction to limit transfer to fetus

No analgesic effect

May have prolonged

depressant effect on neonate

Adjunct drugs Promethazine Hydroxyzine Sedatives

Reduce nausea Reduce anxiety

Promotes rest with prolonged latent phase

Epidurals in labor

Oxygen, suction equipment, emergency medications

should be at bedside Document vital signs and monitor fetal heart rate prior to

procedure

Encourage patient to void Administer IV bolus prior to epidural insertion (500 cc to

1000 cc of saline or lactated Ringer's solution) to prevent

maternal hypotension

Position and support patient during insertion of epidural catheter

Note maternal vital signs before and after test dose, then every 5 minutes with administration;
thereafter, monitor

vital signs and FHR per hospital protocol

Evaluate bladder status every hour and encourage to

void; catheterize if unable to void or bladder overdi-

stended

Assess for level of anesthesia

Monitor for comfort with contractions

Monitor progress of labor

Assist with position changes • Report adverse effects

Hypotension

Pruritis (itching) Pyrexia (fever)

Respiratory depression.

Stage 1: Transition

Power Contractions palpate strong, every 1.5-3 minutes lasting 45-90 seconds

Psyche. Patient may feel a loss of control; provide encourage

ment to patient Measuring progress in labor

Cervical dilation (8-10 cm) Fetal descent (0/+1 station)

Physical changes common with transition Urge to push if presenting part is low

Nausea/vomiting Trembling limbs

Beads of sweat on upper lip Increased bloody show

Passageway: Activity more restricted, however, encourage

positions that promote fetal rotation and descent Squatting

Hands and knees position

Side-lying Nursing considerations

Encourage patient to void

Monitor vital signs and fetal heart tones every 5-15 minutes Pain management

Continue with effective techniques used in active phase If systemic medications are given,
consider amount of time

estimated until birth and potential for newborn effects (respiratory depression)

Have naloxone hydrochloride (Narcan) available to reverse effects if needed

Document maternal and fetal response to medications

Second Stage of Labor: Expulsion

10 cm dilated until the birth of the baby Power: Contractions palpate strong, every 2-3 minutes
lasting

60-90 seconds

Psyche: Patient may be eager or afraid to push Measuring progress in labor Descent of fetus:
from +1 station to crowning

Cardinal movements of labor (changes in fetal position that

facilitate birth)

Engagement/Descent/Flexion

Internal rotation

• Extension

External rotation: • Expulsion

Passageway

Promote effective pushing • Wait for urge to bear down called the "Ferguson reflex"

Discourage prolonged breath-holding Encourage open glottis pushing

Position for pushing • Squatting

• Side-lying

• Modified Lithotomy

Encourage patient to void Patient may pass stool with pushing

Nursing considerations Monitor vital signs every 15-30 minutes

■Fetal heart tones every 5-15 minutes

Pain management per primary health-care provider

Pudendal block: Local anesthetic that blocks pudendal nerve to numb lower vagina and perineum
for vaginal birth; useful with forcep delivery

Local anesthesia to perineum: Numbs perineum for

episiotomy/laceration repair Prepare for the birth of the baby

■Cleanse the perineum Check working order of suction equipment, oxygen, radiant warmer

Neonatal resuscitation equipment should be readily avail- able for every delivery

■ Prepare delivery instruments

Note precise time of birth Provide immediate care of the newborn

Assess airway and suction as needed

Remove excess fluid from infant's nose and mouth (infants are obligate nose breathers)

If meconium is noted in nose or mouth, endotracheal intubation and suctioning must be

performed imme- diately

Assess breathing effort (rate of at least 30 per minute) If respiratory effort is not observed, gently
stimulate

infant by tapping sole of foot or stroking the back

• Positive pressure ventilate if tactile stimulation does not result in respiratory effort

Assess circulation: heart rate >100 BPM Temperature regulation

• Dry infant

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• Place infant under prewarmed radiant warmer with temperature probe applied

• Remove wet towels and lay infant on warm blankets • Keep temperature of labor room warm
Once infant is stabilized, encourage skin-to-skin contact

with mother

Assign Apgar Score at 1 and 5 minutes • Score of 10 possible; Score of at least 8 desirable

Apgar Score

Score

Heart Rate

Respiratory Effort

Muscle Tone

Reflex irritability Color

Absent

Absent

Limp
No response
Blue or pale
Less than 100
Slow, irregular
Some flexion of extremities
Grimace
Body pink; extremities blue
2
Greater than 100 Good; crying
Active motion
Cough, sneeze or vigorous cry Completely pink
Assess for abnormalities that may need immediate attention (example: neural tube defects, open
lesions, or
birth injuries) Examine umbilical cord and count number of vessels: 2
arteries and 1 vein; place plastic clamp on cord
Identification
• Fingerprint mother and footprint newborn • Apply identification bands to both mother and
newborn
before leaving birthing room Medications
Administer eye prophylaxis; ophthalmic antibiotic ointment (based on hospital protocol) to
prevent chlamydial or gonococcal eye infection clotting
Administer vitamin K, IM to boost production of factor (needed due to sterile gut at birth)

Weigh and measure infant (head, chest, and abdominal circumference as well as length) Assess
skin for lacerations, bruising, or edema
Note passage of stool/urine
Third Stage: Delivery of Placenta
Power: Strong uterine contractions cause the placenta to detach from the uterine wall
Psyche: Patient may be exhausted; encourage bonding with baby
Signs of placental separation Sudden gush or trickle of blood from vagina
Lengthening of visible umbilical cord at introitus
Contraction of the uterus Nursing considerations
Instruct patient to push when appropriate
Note time of placenta delivery After placenta expelled:
• Monitor amount of bleeding • Monitor vital signs
Assess fundus
- Height - Location
- Tone
Administer oxytocic medication as ordered Stimulates uterus to contract
Prevents hemorrhage
Cleanse and apply ice pack to the perineum
Provide clean linen under patient Provide warm blanket: patients often tremble/shiver
immediately after the birth
Assess level of consciousness/comfort Place newborn in arm of mother, encouraging skin-to-skin
contact ■Assist with positioning for breastfeeding and bonding