STAGES OF LABOR

STAGES OF LABOR
 STAGES OF LABOR
FIRST STAGE(DILATION AND EFFACEMENT STAGE)
1. Latent Phase- 6 to 8 hours
• begins at the onset of regular contractions & ends when
rapid cervical dilatation begins
• Cervical effacement begins
• Cervix dilates from 0 to 3 cm
• Frequency q5-30 min; Duration 20-40 secs; intensity mild to
moderate
• mother excited, talkative, feels comfortable sitting and
walking
Management(latent phase)
•Encourage walking and making preparations for
birth, frequent emptying of the bladder q2h,
•chest breathing,
•Assess:q4h(cervix, v/s)hourly(uterine
contraction, FHT)
•Encourage verbalization
•Orient patient and SO to surroundings
•Explain all procedures before
carrying them out

•Best time to give instructions

1st stage of LABOR
The First Stage of Labor
2. Active phase-3 to 6 hrs
•Cervix 4-7 cm; moderate contractions
•duration 40-60 seconds
•frequency every 3-5 minutes;
•mother less talkative
•BEST PHASE to give Meperidine Hcl
•encourage to void every 2 hours
Active phase
•Show (inc. vaginal secretions) & perhaps rupture of
the membranes occur at this time
•Contractions are very strong, lasts longer, & begin
to cause discomfort
•It can be frightening & dramatic for the woman
•Administration of analgesic at this stage has no
effect on labor progress
•Coach woman on breathing
and relaxation patterns
•Give short explanations only
•MUST stay in bed if BOW
ruptures and check FHT
•Discourage from bearing down
Active Phase
4-7 cm
q 3-5 min. contractions
30-60 seconds duration

•M Medications
•A Assess
Anticipate physical needs
•D Dry lips – ointment
Dry Linens
Side Effects of Pitocin
•P Pressure(BP) is elevated
•I Intake and output
•T Tetanic contractions
•O Oxygen decrease in fetus
•C Cardiac arrhythmia
•I Irregularity in fetal heart rate
•N Nausea and Vomiting
The First Stage of Labor
3. Transition phase
• cervix 8-10 cm;
• strong contractions
• duration 60-90 sec.
• frequency every 2-3 minutes
• experiences intense discomfort, N/V, loss of
control, anxiety, panic or irritability
• pant-blow; not push
• at 10 cm, a new sensation, the irresistible urge
to push, occurs.
 Transition
8-10 cm
q 2-3 mins contractions
45-90 seconds duration

•T Tires easily
•I Inform of progress
•R Restless
•E Encourage and praise
•D Discomfort
Management of Transition Phase
•Narcotics cannot be given as it will affect breathing
of newborn

•Discourage bearing down if less than 10cm:

lacerations, edema(pant-blow to decrease urge)

•If with N/V, left side-lying to prevent aspiration

Assessment BP, PR, RR Temperature FHR

Latent q 30min – 1 hr q 4 hours q 30 min- 1

Phase hour

Active Phase q 30 min q 4 hours q 15 – 30

mins
Transition Q 15 – 30 min q 4 hours q 15 – 30
Phase mins
 Transfer to Delivery Room

•Primiparas when cervix is 10cm dilated

and perineum is bulging
•Multiparas when cervix is 8cm dilated
2nd STAGE OF LABOR/ EXPULSIVE STAGE- 30-60
mins
•It is the period from full dilatation & cervical
effacement(unable to feel the cervix) to the birth of the
infant
•Duration 50-90 sec; frequency q 3 to 4 mins; intensity
is severe
•The pattern changes to an overwhelming,
uncontrollable urge to push or bear down with each
contraction as if to move her bowels
Imminent signs of 2nd Stage of Labor

1. Increased bloody show

2. Desire to bear down or have bowel
movement
3. Bulging of the perineum
4. Dilatation of the anal orifice
• Ferguson reflex- the urge to bear down as the presenting
part presses on the stretch receptors on the pelvic floor
causing release of oxytocin
• Combination of contractions & the CARDINAL
MOVEMENTS of labor helps expel the fetus
• At first, the opening is slit-like, then becomes oval then
circular.
• The circle enlarges & this is called CROWNING
What is RITGEN’S Maneuver?
As soon as the fetal head is
prominent (8cm),
Physician/nurse-midwife places a
sterile towel over the rectum and
press forward on the fetal chin
while the other hand is pressed
downward on the occiput
 Management of 2nd Stage
•Position of comfort
•May push when the urge is felt & relaxes
after uterine contraction or push during
uterine contraction with open glottis to
release air
•May push no longer than 5 or 6 secs
•When crowning, pant but not push to prevent
rapid expulsion
•Perform Ritgen’s maneuver
•Ask pt to pant or give only small pushes as the
head delivers. Then ask her not to push
•Allow baby’s head to turn spontaneously and
support baby’s head.
•Deliver 1 shoulder at a time
•Once whole body is out, call out the TOB
The Second Stage of Labor
THIRD STAGE OF
LABOR/Placental stage- 3 to 5
mins up to 1 hour
•It begins with the birth of the infant & ends
with the delivery of the placenta

•2 separate phases occurs: PLACENTAL

SEPARATION & PLACENTAL EXPULSION
•After birth of the infant, the placenta is palpated
as a firm, round mass just below the level of the
umbilicus.

•After a few minutes of rest, contractions begin

again & the placenta assumes a discoid shape
and retains this shape until it has separated,
about 5 minutes up to 1 hour after the birth of
the infant.
Placental Separation
•Active bleeding on the maternal surface of the
placenta begins with separation; the bleeding
helps push it away from the attachment site

•As separation is completed, the placenta sinks to

the lower uterine segment or the upper vagina
Signs of placental separation:
•lengthening of the umbilical cord
•sudden gush of vaginal blood
•change in the shape of the uterus; globular
(CALKIN’S SIGN)- 1st sign
•firm contraction of the uterus
•appearance of the placenta at the vaginal
opening
Types of Placental Presentation
•placenta separates first at its center & lastly at its
edges, it will fold on itself like an umbrella & present
with the FETAL SURFACE, appearing shiny &
glistening from the fetal membranes called a
SCHULTZ PRESENTATION (80%)

•If the placenta separates with the MATERNAL SIDE

(raw, red, & irregular with the cotyledons) showing,
it is called a DUNCAN PRESENTATION.
•Normal blood loss of placental separation= 300 to 500
ml until the uterus contracts with enough force to seal
the blood collection spaces

• Oxytocin (PITOCIN) or IM Methylergonovine

(METHERGINE) is given to minimize bleeding after
delivery of the baby(side effects: headache,
dizziness, HPN, vomiting)- CHECK BP before
giving
Placental Expulsion

•After separation, the placenta is

delivered by the natural bearing-down
effort of the mother.
•NO FUNDAL PUSH!!!!!!!!
• BRANDT-ANDREWS MANEUVER- winding of the
umbilical cord around the clamp & slowly & gently
pulling it up & down and side- to side to facilitate
separation & expulsion of the cord(not done according to
EINC- just simple traction w/ counterpressure)

• Never apply pressure on a postpartal uterus in a

noncontracted state because it may cause the uterus to
evert & hemorrhage
•If it does not deliver spontaneously, it can be
removed manually

•After delivery, inspect the placenta to make sure

it is intact & normal in weight & appearance (15
TO 28 COTYLEDONS)

•With the delivery of the placenta, the 3rd stage is

over
FOURTH STAGE OF
LABOR
•Lasts from 1 to 4 hours after birth &
initiates postpartum period
•It is a stage of recovery & bonding
•Fundus: firm, level of navel,
midline
Massage until firm
• Give oxytocin thru IM AFTER
PLACENTAL EXPULSION- to prevent
bleeding from atony and subinvolution

(side effect- headache, dizziness, HPN,

vomiting)
• CHECK BP before giving
Nursing care
•monitor VS q 15 mins for 1 hour
•Offer emotional support
•Perineal care- check lochia
•Offer regular diet as soon as she
requests for food
•Encourage full ambulation as soon as
possible
•Comfort measures-blanket for chills
•Check perineum for REEDA (redness, edema,
ecchymosis, discharges, approximation)
•Observe for complications: hemorrhage, bladder
distention, thrombosis
•Encourage voiding because a full bladder
interferes with contractions
Fourth Stage of labor
Fundic height Evaluation
• Immediately after delivery- below the umbilicus
• After 1 hour- above the umbilicus
• After 12 hours- level of umbilicus
• After 1 day- 1 fingerbreadth below the umbilicus
Postpartum Assessment
•B Breast
•U Uterus
•B Bladder
•B Bowel
•L Lochia
•E Episiotomy

•H Homan’s sign
•E Emotional
•B Bonding
Postpartum Assessment
1. Breast
Determine if Breastfeeeding or Not
Palpate for engorgement or tenderness
Inspect nipples for cracks, redness and erectility if nursing
2. UTERUS
Firm, midline (Fundal location with descent of 1cm/day)
Care for the breast
Engorgement:
1. BF frequently
2. Before feeding, WARM packs
3. Between feedings, COLD packs
4. Massage
Cracked nipples:
Expose, Rotation, Properly latched on.
Postpartum Assessment
Inspect any incision for REEDA
BLADDER
Voiding within 6-8 hours
Assess for frequency, burning or urgency
BOWEL
Assess for passage of flatus
POSTPARTUM ASSESSMENT
LOCHIA
Inspect quantity, type, odor, amount
CS-amount of lochia

Episiotomy or perineal lacerations

Inspect REEDA
Homan’s Sign
MANAGING COMMON DISCOMFORTS OF
PUERPERIUM
• Breast engorgement- lactating- warm compress; non-
lactating-cold compress
• After pains- due to uterine contractions- ice cap, pain
reliever
• Urinary retention- regular voiding, increase fluids
• Painful Episiotomy- flushing with warm water,
perilamp,analgesics, sitz bath
•Constipation- early ambulation, more fluids;
reassurance that defecating won’t hurt (no
suppository)
•Hemorrhoids- hot sitz bath; prevent constipation
MATERNAL AND FETAL RESPONSES TO LABOR
PHYSIOLOGIC EFFECTS OF LABOR ON A WOMAN
CARDIOVASCULAR SYSTEM
1. Cardiac Output- contractions decrease blood
flow to the uterus & increases blood in maternal
circulation increasing peripheral resistance (↑
BP, ↑Cardiac output by 40% to 50%)
•blood loss with birth (300-500ml)
compensated by increase in blood volume
during pregnancy

2. Blood pressure rises by an average of 15

mm Hg with every contraction
HEMATOPOIETIC SYSTEM
• Leukocytosis- sharp increase in circulating
WBC’s due to stress and exertion
• At end of labor, 25,000 to 30,000 cells/mm

RESPIRATORY SYSTEM
• ↑RR to supply enough O2
• Observe appropriate breathing patterns to
prevent hyperventilation
TEMPERATURE REGULATION
•Slight elevation by 1°F
•Diaphoresis occurs to prevent excessive warming
FLUID BALANCE
•Increase in RR and diaphoresis leads to insensible
water loss
URINARY SYSTEM
•Pressure of fetal head on the bladder reduces bladder
tone and the ability to sense filling
•Ask pt to void every 2 hours during labor
MUSKULOSKELETAL SYSTEM
• RELAXIN- from the ovaries soften cartilage and sacrococcygeal joint
increasing the size of the pelvic ring by as much as 2 cm
• Pubic flexibility may cause increasing or nagging back pain

GASTROINTESTINAL SYSTEM
• Inactive during labor due to shunting of blood to vital systems and the
pressure on GIT from contracting uterus
• LBM in some women as contractions increase
NEUROLOGIC & SENSORY
RESPONSES
•Neuro responses are related to
pain
PSYCHOLOGICAL RESPONSES OF A
WOMAN TO LABOR
• PAIN- reduces her ability to cope
• FEAR- lack of control and fear of the
outcome
• Cultural Influences-adapt cere to
woman’s specific circumstances
DANGER SIGNS OF
LABOR
Maternal Danger Signs

1. High or Low BP- systolic pressure >140 mm Hg, diastolic

pressure >90 mm Hg or increase of 30 mm Hg may be a
sign of PIH
• sudden drop in BP may be the 1st sign of intrauterine
bleeding
2. Abnormal Pulse (PR = 70-80bpm)- >100 bpm may be a
sign of hemorrhage
3. Inadequate or Prolonged Contractions- uterine
exhaustion
4. Pathologic Retraction Rings- indentation
across a woman’s abdomen where the upper
and lower segments join, may be a sign of
extreme uterine stress and possible
impending rupture

5. Increasing apprehension- O2 deprivation or

internal hemorrhage
6. Abnormal Lower Abdominal Contour-
with a full bladder, a round bulge on the
lower abdomen may appear
•danger sign for 2 reasons: bladder may be
injured due to pressure, full bladder may
prevent fetal head descent
• void every 2 hrs during labor
 Fetal Danger Signs
1. High or Low fetal Heart Rate- >160 bpm (fetal
tachycardia), < 110 bpm (fetal bradycardia),
decelerations may be a sign of fetal distress
2. Meconium Staining
•Green color of AF due to loss of sphincter control
may be due to fetal hypoxia
3. Hyperactivity- sign of hypoxia

4. Poor Oxygen saturation (40% to 70%)-

assessed by a catheter inserted next to the
cheek (<40% is low); plus acidosis (pH <7.2)
suggests fetus is being compromised
THE END!!!