The process of

labor (part 1)
Associate Professor:
Shahnaz Ayasrah

1
Outline
• The process of labor: first stage, second stage,
third stage and fourth stage.
• Maternal and fetal adaptation to labor.
• Nursing care and roles during labor stages.
• Brief overview of labor complications: prolonged
labor, lacerations, instrumental delivery and C/S.

2
 Introduction
• Labour is divided into 3 stages. The first stage is the
dilation of the cervix, the second stage is the birth
of the baby, and the third stage is the delivery of
the placenta. For first-time mothers, labour takes
around 12 to 14 hours. Women who have
undergone childbirth before can expect about 7
hours of labour.

3
Purpose of Leopold maneuver
• Fetal position (fetal position is described as fetal presentation
in relation to mother’s pelvis. For example, right occiput
anterior [ROA], left occiput anterior [LOA], left sacrum anterior
[LSA], and more…).
• Fetal lie (fetal lie is described as where the fetus lies in relation
to the mother’s back. For example, longitudinal lie, transverse
lie, and oblique lie)
• Fetal presentation (first fetal part that presents into the
maternal pelvis) Cephalic presentation, breech presentation.
• Fetal attitude (fetal attitude can be determined after head is
engaged) the relationship of the fetal body parts to each other.
flextion
• Fetal malposition
• Approximate fetal weight and amount of amniotic fluid
Stages of Labor
• First Stage
Latent phase
Active phase
Transition phase
• Second Stage
• Third Stage
• Fourth Stage

6
First stage of labor:(Stage of Dilation)
 It begins with the onset of true labor
contractions and ends with complete
dilation (10cm) and effacement (100%)
of the cervix.

 It is the longest stage for both

nulliparous and parous women.

 It has three phases: latent (early), active,

and transition.
7
1. Latent phase:
 Lasts from the beginning of labor
until about 3 cm of cervical dilation.

 The woman is usually sociable and

excited during this phase of labor.


 Uterine contraction initially mild and

infrequent progress to moderate
strength every 5 min.
8
2. Active phase:
 The cervix dilates from 4 to 7 cm
 Effacement is completed

 The fetus descends to the pelvis

 Internal rotation begins

 Increase discomforts

 The woman becomes more anxious and

feel helpless
 Serious inward focus

 Uterine contraction every 2-5 minute

9
3. Transition phase:
 Short but intense phase
 The cervix dilate from 8 to 10cm

 The fetus descends further into the pelvis

 Bloody show increase

 Strong contractions

 The woman may have the urge to push

down
 Leg tremors nausea and vomiting are
common
 The woman is irritable and lose control

 Contraction every 1.5-2 minute

10
 Second stage of labor (Expulsion)
 Begins with complete dilation (10cm) and
full effacement(100%) end with the birth of
the baby.

 involuntary pushing response

 The mother may said that she needs to have

a bowel movement or the baby is coming

 Crowning of the fetal head 11

Second stage of labor (Expulsion)
 Feeling of stretching or splitting sensation
 Contractions are strong
 Woman exerts intense effort to push her
baby
 May appear sleepy between contraction
 The word “labor” describe this phase
 Feels tremendous relief and excitement as
the second stage ends with the birth of baby

12
 Third stage of labor (Placental)
 Begins with the birth of the baby and ends with the
expulsion of the placenta
 Length 5-10 min up to 30 min
- Four Signs suggest placental separation:
1. Spherical shape of uterus
2. The uterus rises upward in the
abdomen
3. The cord descends further from the
vagina
4. Gush of blood appears as blood
trapped behind placenta is released 13
Third stage of labor (Placental)

The uterus must contract firmly and

remain contracted after placenta is
expelled to compress open vessels
During this stage pain results from

uterine contractions and brief

stretching of cervix as placenta
passes through it
14
 Fourth stage of labor (Physical recovery):
 It lasts from the delivery of the placenta

through the first 1 to 4 hours after birth

 The uterus at or below the level of

umbilicus ,firm contracted and rounded

mass about 10 to 15cm in diameter
 Lochia is rubra

 Women may have chill lasts for 20

minutes, warm blanket or hot drink may

be helpful

15
Fourth stage of labor
(Physical recovery):
 After pains or birth trauma are the main causes of
discomforts in this stage
 Ice packs on perineum decrease discomfort and limit
hematoma formation
 After pains are more intense in multiparous or in women
who breast feed, in women who have uterine over
distention( large baby) and full bladder or clot that
remain in uterus
 The woman is exhausted and need rest
 This stage is the ideal time for bonding and to start
breast feeding 16
17
Nursing care during labor and birth

• Assessment on admission
• Focused assessment
• 1. Fetal assessment
• Gestational age of the fetus
• Leopold’s maneuver
• Fetal movement and FHR
• Status of membrane( color ,odor and clarity of
fluid)
• 2. Maternal assessment
(vital signs) especially for infection or hypertension

18
Data base assessment
• Reason for coming to hospital
• Prenatal care
• EDD
• # of pregnancies term and abortion
• Allergies
• Last time of food intake
• Medical surgical and pregnancy history
• Recent illness and treatment
• Medication, drug smoking and alcohol
• Mother subjective evaluation of labor
• Birth plan, pain management method and support
person
19
2.Fetal assessment
• Presentation , position and FHR
• Time of rupture membrane and characteristics of
amniotic fluids

3.Determine labor status

• Assess contraction
• Cervix dilitation and effacement, station
,presentation and position
• Membrane status

20
4. Physical Exam (brief)

5. Laboratory data
• Hematocrite ,blood group and CBC
• Blood glucose levels
• Blood type and RH factor
• Midstream urine(protein and glucose)
• Syphilis ,hepatitis and HIV

6.IV access
• Continuous infusion prevent dehydration
• Isotonic electrolyte is preferable
• Glucose is avoided 21
 Assessment after Admission
• 1.Fetal assessment
• FHR electronic or Doppler
• Amniotic fluid artificial rupture of membranes ( AROM)
OR spontaneous rupture of membranes (SROM in
60-80 %)Assess FHR at least one min after rupture of membrane
• Record the time of rupture, FHR and character of fluid
 Normal is clear
 Cloudy, yellow or foul odor suggest infection
 Green color suggest meconium passage (transient hypoxia) (normal
in breech presentation)

• Amount more than 1000ml is large, between 500-1000 is moderate

and scant if only trickle barely enough to detect 22
•2. Maternal assessment
• Vital signs( hyper or hypotension ,
increased pulse increased resp. increased
temp are all abnormal
• Contraction
• Progress of labor , vaginal exam should be
limited to prevent infection
• Intake and output ,check for bladder
fullness every 2 hour
• LOOK AT THE MOTHER’S PERINIUM FOR
CROWNING OF FETAL HEAD IF SHE
EXPERIENCE A NEED TO DEFECATE
• Mother response to labor
23
Nursing care for woman in true labor
• 1. Fetal oxygenation
• Assessment of fetal well being include:
FHR,contraction,aminiotic fluid and vital
signs
• Intervention
• 1.Promote placental function( position
rather than supine)
• 2.Observe for condition associated with
fetal compromise
24
Conditions Associated with Fetal
Compromise
• Fetal heart rate outside the normal range
• Little or no variability in heart rate
• Persistent slowing of heart rate after contractions
• Meconium-stained amniotic fluid
• Cloudy, yellowish, or foul odor to amniotic fluid
• Contractions longer than 90 seconds
• Incomplete uterine relaxation, intervals between
contractions shorter than 60 seconds
• Maternal hypotension
• Maternal hypertension
• Maternal fever 25
• 2. Discomfort
• Intervention
1. Providing comfort measures
Lightening: soft indirect lighting is
soothing
Temperature; Cool damp cloths on
woman's face and neck promote
comfort, an electric fan circulate air in
the room is appropriate
Cleanliness: change gown and linen
when needed 26
 Mouth care: ice chips and hard candy reduce
discomfort of dry mouth, avoid excessive sugar and if
oral intake is contraindicated brushing teeth or rinsing
mouth
 Bladder emptying; Remined woman to empty bladder
at least every 2 hours, cathetrization is often needed
 Positioning: use any comfortable position but avoid
supine
 Water( shower, tub, pool): enhance relaxation . Nipple
stimulation by water current release oxytocin and make
contraction more productive
27
•2. Teaching

• First stage
• Pushing in response only to her spontaneous urge
• Pushing without full dilatation leads to
1. cervix become lacerated and edematous and
2. progress is blocked

28
• Second stage
• Laboring down
• Position( curve body around uterus in C shape)
• Breathing pattern: avoid holding breath more than
6-8 second
• Provide encouragement
• Giving of self
• Pharmacologic management and support and care

29
3. Preventing injury
• Assessment ; observe mother’s perineum to
determine when to make final preparation
• Final preparation for primipara is done when
crowning reach a diameter of 3-4cm but in
multipara when cervix is fully dilated
• Intervention
1. transfer to delivery room
2. positioning of birth
3. observing perineum
30
• Nursing care during Birth
1.Preparation of table
2.Perineal cleansing preparation
3.Initial care and assessment of newborn
4.Administration of medication such as oxytocin
to control blood loss
5.Use universal precaution

31
Responsibilities after birth
•Care of infant
1.Maintain cardiopulmonary function
• Prepare neonatal resuscitation equipment
• Assess Apgar score
• Suctioning of secretion
2.Supporting thermoregulation
• Dry infant
• Place under radiant warmer
• Skin to skin contact
3. Identifying the infant
• Identifying band
32
• Care of the mother
1. Observing for hemorrhage, fundus,
vaginal discharge (lochia), bladder
• Fundus should be firm midline and at or below
umbilicus .If not firm massage and encourage
mother to breast feeding
• Bladder: full bladder is suspected when fundus
is above umbilicus and or displaced to one
side usually the right
• The first two or three voiding must be at least
300-400ml each voiding
33
• Vaginal discharge (Lochia): is rubra, small
clot is okay but large clot is abnormal
• Saturation of one pad within the first hour is
the maximum normal lochia flow
2. Vital signs : assess temp. in recovery and
before transfer to postpartum ward
• Assess other vital signs every 15 min for first
hour and 30 min in the next hour

34
• 2. Relieving discomfort
ice backs, analgesics , warmth
• Ice packs: to reduce edema and limit
hematoma formation
• Analgesics: after pain and perineal pain may
relieved by mild analgesics. Regular urination
reduce after pain because uterus contract
effectively.
• Warmth warm blanket is soothing and shorten
the chills that is common after birth
• 3. Promoting early family attachment
35