STAGES OF LABOR

Nursing Care, Management and Responsibilities

OBJECTIVES

 Define each Stage of Labor

 Identify the measures used to evaluate maternal status during labor and
birth.
 Outline the nurse’s role in fetal assessment.
 Explain the various comfort-promotion and pain-relief strategies used during
labor and birth.
 Discuss the ongoing assessment involved in each stage of labor and birth.
 Define the nurse’s role throughout the labor and birth process.
TEACHING LEARNING ACTIVITY

EERGNOTOEPSR
TEACHING LEARNING ACTIVITY

PROGESTERONE
TEACHING LEARNING ACTIVITY

RNOOMHE
TEACHING LEARNING ACTIVITY

HORMONE
TEACHING LEARNING ACTIVITY

LBROA
TEACHING LEARNING ACTIVITY

LABOR
TEACHING LEARNING ACTIVITY

RIUTCNETOO
TEACHING LEARNING ACTIVITY

UTEROTONIC
TEACHING LEARNING ACTIVITY

USPNEOTNSAO
TEACHING LEARNING ACTIVITY

SPONTANEOUS
TEACHING LEARNING ACTIVITY

ITTGANQSU
TEACHING LEARNING ACTIVITY

SQUATTING
TEACHING LEARNING ACTIVITY

CALIHO
TEACHING LEARNING ACTIVITY

LOCHIA
TEACHING LEARNING ACTIVITY

NOONRIACTTSC
TEACHING LEARNING ACTIVITY

CONTRACTIONS
TEACHING LEARNING ACTIVITY

LIVPEC LROOF
TEACHING LEARNING ACTIVITY

PELVIC FLOOR
TEACHING LEARNING ACTIVITY

NFLADLU IHHGET
TEACHING LEARNING ACTIVITY

FUNDAL HEIGHT
TEACHING LEARNING ACTIVITY

EDERC RAMENUVE
TEACHING LEARNING ACTIVITY

CREDE MANEUVER
TEACHING LEARNING ACTIVITY

BNTRAD DWSRANE AMREEVNU

TEACHING LEARNING ACTIVITY

BRANDT ANDREWS MANEUVER

TEACHING LEARNING ACTIVITY

OTDRCLNLOE RCDO ANRTCIOT

TEACHING LEARNING ACTIVITY

CONTROLLED CORD TRACTION

STAGES OF LABOR
Nursing Care, Management and Responsibilities
DEFINITION OF LABOR

 Labor is the process by which the fetus and the placenta leave the uterus
(National Institute of Child Health and Development, 2017.)
 Labor is a physiologic process during which the product of contraception
(Fetus, Umbilical Cord, Membranes and Placenta) are expelled outside the
uterus (ENE, 2019).
 Labor is a series of events by which uterine contractions and abdominal
pressure expel a fetus and placenta from the uterus (Lippincott, Williams and
Wilkins, 2018).
THE STAGES OF LABOR

Labor is traditionally divided into three stages:

First Stage of Labor

 This is the cervical dilatation stage.
 Starts with true labor pain and ends with full dilatation of the cervix (10 cm)
 Duration: 10-14 hours for primigravida (12 hours in other scources) and 6-8
hours multipara
 This is divided into three segments: Latent, Active and Transition Phase.
THE STAGES OF LABOR

Labor is traditionally divided into three stages:

Second Stage of Labor

 Stage of fetal expulsion
 Begins with full dilatation and fetal expulsion
 Duration: 1 hour primigravida and ½ hour for multipara
THE STAGES OF LABOR

Labor is traditionally divided into three stages:

Third Stage of Labor

 Stage of placental and membrane expulsion.
 Begins after the delivery of the fetus and ends in the expulsion of the
placenta and membranes
 Duration: 10-20 minutes for both primipara and multipara
THE STAGES OF LABOR

Labor is traditionally divided into three stages:

Fourth Stage of Labor

 Early recovery stage
 The 1st 1 – 4 hours after the delivery of the placenta
 This stage is emphasized in order to identify the importance of close maternal
observation. Usually at this stage routine uterine massage is usually done
every 15 minutes.
THE FIRST STAGE OF LABOR

This is the longest stage of labor averaging for about 12 hours. This stage is
divided into three segments: Latent, Active and Transition phase.

The Latent Phase

 This begins at the onset of regularly perceived uterine contractions and ends
with rapid cervical dilatation.
 Contractions: 20-40 seconds long
 Cervix dilates from 0-3 cm
 This phase lasts from 6 (six) hours in nullipara and 4.5 (four and a half) hours
in multipara
THE FIRST STAGE OF LABOR

This is the longest stage of labor averaging for about 12 hours. This stage is
divided into three segments: Latent, Active and Transition phase.

The Active Phase

 Cervix dilates from 4 (four) -7 (seven) cm per hour
 Contractions: 40-60 seconds every 3-5 minutes
 This phase lasts 3 hours in nullipara and 2 hours in multipara
THE FIRST STAGE OF LABOR

This is the longest stage of labor averaging for about 12 hours. This stage is
divided into three segments: Latent, Active and Transition phase.

The Transition Phase

 Cervix dilates from 8 to 10 cm
 Contractions: Every 2-3 minutes lasting 60-70 seconds
THE SECOND STAGE OF LABOR

 Starts from full cervical dilatation and effacement to the birth of the infant
 Feeling of constant urge to push
 At this stage the fetus begins to descend, the fetus passes through the birth
canal via the 7 cardinal movement
 Crowning is imminent in this stage
THE SECOND STAGE OF LABOR

Perineal Cleaning and Massage

 Massaging the perineum helps to prevent it from tearing

 Clean the perineum with WARM antiseptic solution (Iodaphor) and rinse with
sterile water.
 Remember to ALWAYS clean from the vagina outward.
THE SECOND STAGE OF LABOR

 Perineal Cleaning and Massage

THE SECOND STAGE OF LABOR

THE BIRTH

 RITGENS MANEUVER
 When the head distends the vulva and the perineum enough to open the
vaginal introtius in a diameter of 5cm or more.
 One hand: Draped, gloved hand may exert forward pressure to the chin of the
fetus through the perineum just in front of the coccyx.
 The othe Hand: Exerts pressure superiorly against the occiput.
THE SECOND STAGE OF LABOR

The Birth
THE SECOND STAGE OF LABOR

Cord Cutting and Clamping

Physiologic Clamping
 This is done by delaying the cutting of the umbilical cord until the pulsation
ceases.
 Maintain the infant at uterine level

 The cord is clamped with two hemostats:

 1. First clamp is placed 2 cm from the umbillicus
 2. Second clamp is placed 5cm from the infants umbilicus.
THE SECOND STAGE OF LABOR

Cord Cutting and Clamping

Physiologic Clamping
THE SECOND STAGE OF LABOR

Unang Yakap (Essential Newborn Care)

Is a package evidenced based practice recommended by the DOH, PhilHealth and
WHO as a standsard care for all births by skilled practitoners in public or private
setting.

The following steps are chronologically orderd and standard steps that an infant
recieves upon birth. (Time Bounded Innterventions)
1. Immidiate and thorough Drying
2. Skin to skin contact
3.Proper cord clamping and cutting
4. Non seperation of baby from mother for Breast Feeding.
THE SECOND STAGE OF LABOR

Unang Yakap (Essential Newborn Care)

IMMEDIATE AND THOROUGH DRYING

Use a clean, dry cloth, thoroughly dry the baby, wiping the face, eyes, head,
font and back, arms and legs.
THE SECOND STAGE OF LABOR

Unang Yakap (Essential Newborn Care)

SKIN TO SKIN CONTACT

If the baby is crying and breathing normally, avoid any manipulation

Place the newborn prone on the mother’s abdomen or chest skin-to-skin.
Cover newborn’s back with a blanket and head with a bonnet.
Place Identification band on the ankle
THE SECOND STAGE OF LABOR

Unang Yakap (Essential Newborn Care)

PROPER CORD CLAMPING AND CUTTING

Clamp the cord after cord pulsations have stopped (1-3 min)
Put ties tightly around the cord at 2 centimeters and at 5 centimeters from the
newborn’s abdomen.
Cut between ties with sterile instrument
Observe for oozing of blood.
Do not milk the cord towards the newborn
After Cord Clamping administer oxytocin 10 IU IM to the mother
THE SECOND STAGE OF LABOR

Unang Yakap (Essential Newborn Care)

NON SEPARATION OF BABY FROM MOTHER FOR BREAST FEEDING

Observe the newborn. Only when the newborn shows feeding cues, make verbal
suggestions to the mother to encourage her newborn to move toward the breast.
Counsel on positioning and attachment
THE SECOND STAGE OF LABOR

Unang Yakap (Essential Newborn Care)

NON SEPARATION OF BABY FROM MOTHER FOR BREAST FEEDING

When the baby is ready, advise the mother to:

A. Make sure the NB neck is neither flexed of twisted

B. Make sure the NB is facing the breast with the NB nose opposite her nipple and chin touching
the breast.
C. Hold the NB body close to her body.
D. Support the NB whole body
E. Wait until the NB mouth is open wide
F. Move her NB onto her breast aiming the infants lower lip well below the nipple
THE SECOND STAGE OF LABOR

Unang Yakap (Essential Newborn Care)

NON SEPARATION OF BABY FROM MOTHER FOR BREAST FEEDING

When the baby is ready, advise the mother to:

G. Look for signs of good attachment and suckling:

Mouth wide open
Lower lip turned outward
Baby’s chin touching the breast
Suckling is slow, deep with some pauses
THE THIRD STAGE OF LABOR

The Placental Stage

 Begins with the birth of the fetus and the delivery of the placenta.
 Divided into 2 (two) separate phases: Placental Expulsion and Placental
Delivery
THE THIRD STAGE OF LABOR

The Placental Stage

Placental Separation
 Active bleeding on the maternal surface of the placenta begins with separation.
 
Signs of placental separation
 1. The uterus becomes globular and firmer
 2. There is often a sudden gush of blood
 3. The placenta passing down into the lower uterine segment, where its bulk
pushes the uterus upward
 4. The umbilical cord protrudes further out of the vagina
THE THIRD STAGE OF LABOR

The Placental Stage

Placental Expulsion
 Traction on the umbilical cord must not be used to pull the placenta out of
the uterus
 Manual removal of the placenta
 Active management of the third stage
 Oxytocin
 Controlled cord tractions to the lower uterine segment or the upper vagina.
THE THIRD STAGE OF LABOR

The Placental Stage

Placental Expulsion
 CREDE MANEUVER – apply a gentle pressure on the contracted fundus by the
primary health care provider
 This is done used to void urine from the bladder from the bladder
THE THIRD STAGE OF LABOR

The Placental Stage

Placental Expulsion
 Brandt-Andrews Technique
 Forceps are placed on the umbilical cord as close to the vulva as possible
 One hand is on the forceps
 The other hand is on the abdomen so that the palmar surface of the fingers is over
the anterior surface of the uterus approximately at the junction of the corpus uteri
with the lower segment.
 The uterus in now gently pressed backwards and upwards towards the patients
umbilicus at the same time steady but not too strong
NURSING CARE, MANAGEMENT AND
RESPONSIBILITIES
CARE OF A WOMAN DURING THE FIRST, SECOND & THIRD STAGE OF
LABOR
CARE OF A WOMAN DURING THE FIRST STAGE OF
LABOR

Nursing care during this stage will include taking an admission history (reviewing
the prenatal record); checking the results of routine laboratory tests and any
special tests such as chorionic villi sampling, amniocentesis, genetic studies, and
biophysical profile done during pregnancy; asking the woman about her childbirth
preparation (birth plan, classes taken, coping skills); and completing a physical
assessment of the woman to establish a baseline of values for future comparison.
CARE OF A WOMAN DURING THE FIRST STAGE OF
LABOR

Key nursing interventions include:

 Identifying the estimated date of birth from the client and the prenatal chart
 Validating the client’s prenatal history to determine fetal risk status
 Determining fundal height to validate dates and fetal growth
 Performing Leopold’s maneuvers to determine fetal position, lie, and
presentation
CARE OF A WOMAN DURING THE FIRST STAGE OF
LABOR

Key nursing interventions include:

 Checking FHR
 Performing a vaginal examination (as appropriate) to evaluate effacement
and dilation progress
 Instructing the client and her partner about monitoring techniques and
equipment
 Assessing fetal response and FHR to contractions and recovery time
 Interpreting fetal monitoring strips to provide optimal fetal care
 Checking FHR baseline for accelerations, variability, and decelerations
 Repositioning the client to obtain optimal FHR pattern
CARE OF A WOMAN DURING THE FIRST STAGE OF
LABOR

Key nursing interventions include:

 Recognizing FHR problems and initiating corrective measures
 Checking amniotic fluid for meconium staining, odor, and amount
 Comforting client throughout testing period and labor
 Supporting client’s decisions regarding intervention or avoidance of
intervention
 Assessing client’s support system and coping status frequently
CARE OF A WOMAN DURING THE FIRST STAGE OF
LABOR

Teaching for Positioning During the First Stage of Labor

 Semi-sitting in bed or on a couch leaning against the partner
 Sitting in a chair with one foot on the floor and one on the chair
 Leaning forward by straddling a chair, a table, or a bed or kneeling over a
birth ball
 Sitting in a rocking chair or on a birth ball and shifting weight back and forth
 Lunge by rocking weight back and forth with foot up on chair during
contraction
 Open knee–chest position
CARE OF A WOMAN DURING THE FIRST STAGE OF
LABOR

Teaching for Positioning During the First Stage of Labor

 Walking with support from your partner
 Slow-dancing position with your partner holding you
 Side-lying with pillows between the knees for comfort
CARE OF A WOMAN DURING THE FIRST STAGE OF
LABOR

Other key Interventions:

 Assist woman to change positions frequently to increase comfort and promote

labor progress.
 Encourage use of distraction to reduce focus on contraction pain.
 Suggest pelvic rocking, massage, or counter back pressure to reduce pain.
 Assist with use of relaxation and breathing techniques to promote relaxation.
 Use touch appropriately (backrub) when desired by the woman to promote
comfort.
CARE OF A WOMAN DURING THE FIRST STAGE OF
LABOR

Other key Interventions:

 Integrate use of nonpharmacological measures of pain relief, such as warm
water, birthing ball, or other techniques to facilitate pain relief.
 Administer pharmacologic agents as ordered when requested to control pain.
 Provide reassurance and encouragement between contractions to foster self-
esteem and continued participation in labor process.
CARE OF A WOMAN DURING THE SECOND STAGE OF
LABOR

Assessment is continuous during the second stage of labor

Assessment involves identifying the signs typical of the second stage of labor,
including:
 Increase in apprehension or irritability
 Spontaneous rupture of membranes
 Sudden appearance of sweat on upper lip
 Increase in blood-tinged show
 Low grunting sounds from the woman
 Complaints of rectal and perineal pressure
 Beginning of involuntary bearing-down efforts
CARE OF A WOMAN DURING THE SECOND STAGE OF
LABOR

Nursing interventions during this stage focus on motivating the woman,

encouraging her to put all her efforts to pushing this newborn to the outside
world, and giving her feedback on her progress.
CARE OF A WOMAN DURING THE SECOND STAGE OF
LABOR

Teaching for Positioning During the Second Stage of Labor

 Lithotomy with feet up in stirrups: most convenient position for caregivers
 Semi-sitting with pillows underneath knees, arms, and back
 Lateral/side-lying with curved back and upper leg supported by partner
 Sitting on birthing stool: opens pelvis, enhances the pull of gravity, and helps
with pushing
 Squatting/supported squatting: gives the woman a sense of control
 Kneeling with hands on bed and knees comfortably apart
CARE OF A WOMAN DURING THE SECOND STAGE OF
LABOR

Other important nursing interventions during the second stage include:

Providing continuous comfort measures such as mouth care, position changes,
changing bed linen and under pads, and providing a quiet, focused environment.

 Instructing the woman on the following bearing-down positions and

techniques:
 Pushing only when she feels an urge to push
 Using abdominal muscles when bearing down
 Using short pushes of 6 to 7 seconds
CARE OF A WOMAN DURING THE SECOND STAGE OF
LABOR

Other important nursing interventions during the second stage include:

Providing continuous comfort measures such as mouth care, position changes,
changing bed linen and under pads, and providing a quiet, focused environment.

 Instructing the woman on the following bearing-down positions and

techniques:
 Focusing attention on the perineal area to visualize the newborn
 Relaxing and conserving energy between contractions
 Pushing several times with each contraction
 Pushing with an open glottis and slight exhalation
CARE OF A WOMAN DURING THE SECOND STAGE OF
LABOR

Continuing to monitor contraction and FHR patterns to identify problems

 Continuing in assessment measurements: blood pressure, pulse, respirations,

uterine contractions, bearing down efforts, FHR, coping status of the client
and her partner
 Providing pain management if needed
 Providing a continuous nursing presence
 Offering praise for the client’s efforts
CARE OF A WOMAN DURING THE SECOND STAGE OF
LABOR

Continuing to monitor contraction and FHR patterns to identify problems

 Providing brief, explicit directions throughout this stage

 Continuing to provide psychosocial support by reassuring and coaching
 Facilitating the upright position to encourage the fetus to descend
CARE OF A WOMAN DURING THE SECOND STAGE OF
LABOR

Preparing for and assisting with delivery by:

 Preparing the delivery bed and positioning client

 Preparing the perineal area according to the facility’s protocol
 Offering a mirror and adjusting it so the woman can watch the birth
 Explaining all procedures and equipment to the client and her partner
 Setting up delivery instruments needed while maintaining sterility
 Receiving newborn and transporting him or her to a warming environment, or
covering the newborn with a warmed blanket on the woman’s abdomen
 Providing initial care and assessment of the newborn
CARE OF A WOMAN DURING THE THIRD STAGE OF
LABOR

The Delivery of the Placenta

Monitoring placental separation by looking for the following signs:

 Firmly contracting uterus
 Change in uterine shape from discoid to globular ovoid
 Sudden gush of dark blood from vaginal opening
 Lengthening of umbilical cord protruding from vagina
CARE OF A WOMAN DURING THE THIRD STAGE OF
LABOR

The Delivery of the Placenta

 Examining placenta and fetal membranes for intactness (Duncan/Schultz)

The Perineal Inspection

 Assessing for any perineal trauma, such as the following, before allowing the
birth attendant to leave:
 Firm fundus with bright-red blood trickling: laceration
 Boggy fundus with red blood flowing: uterine atony
 Boggy fundus with dark blood and clots: retained placenta
CARE OF A WOMAN DURING THE THIRD
STAGE OF LABOR
Interventions during the third stage of labor include:
 Cleaning and assisting client into a comfortable position after birth, making
sure to lift both legs out of stirrups (if used) simultaneously to prevent strain
 Repositioning the birthing bed to serve as a recovery bed if applicable
 Assisting with transfer to the recovery area if applicable
 Providing warmth by replacing warmed blankets over the woman
CARE OF A WOMAN DURING THE THIRD
STAGE OF LABOR
Interventions during the third stage of labor include:
 Describing the process of placental separation to the couple
 Instructing the woman to push when signs of separation are apparent
 Administering an oxytocic if ordered and indicated after placental expulsion
(10 units IM or per 1000 ml fluid IV)
 Providing support and information about episiotomy and/or laceration
CARE OF A WOMAN DURING THE THIRD
STAGE OF LABOR
Monitoring maternal physical status by assessing:
 Vaginal bleeding: amount, consistency, and color
 Vital signs: blood pressure, pulse, and respirations taken every 15 minutes
 Uterine fundus, which should be firm, in the midline, and at the level of the
umbilicus
CARE OF A WOMAN DURING THE FOURTH
STAGE OF LABOR
Immediate Postpartum Assessment and Nursing Care

During this time the uterus is unable to maintain contractions – High Risk for
hemorrhage
Obtain Vital Signs every 15 minutes for the 1st hour
If applicable, wash the perineum with designated solution
Palpate the woman’s fundus size, consistency and position.
Observe the amount of lochia each time you record the mothers vital signs
The focus of nursing management during the fourth stage of labor involves frequent
close observation for hemorrhage, provision of comfort measures, and promotion of
family attachment.
CARE OF A WOMAN DURING THE FOURTH
STAGE OF LABOR
TYPE COLOR DURATION COMPOSITION

Lochia Rubra Red 1-3 days Blood, Fragments

of Decidua, mucus

Lochia Serosa Pink 3-10 days Blood, Mucus and

Leukocytes

Lochia Alba White 10-14 days Largely Mucus

CARE OF A WOMAN DURING THE FOURTH
STAGE OF LABOR
Assessment

 Assessments during the fourth stage center on the woman’s vital signs, status
of the uterine fundus and perineal area, comfort level, lochia amount, and
bladder status
 Assess fundal height, position, and firmness every 15 minutes during the first
hour following birth. If the fundus is displaced to the right of the midline,
suspect a full bladder as the cause
 Assess the perineum, including the episiotomy if present, for possible
hematoma formation
CARE OF A WOMAN DURING THE FOURTH
STAGE OF LABOR
Assessment

 Assess vaginal discharge (lochia) every 15 minutes for the first hour and every
30 minutes for the next hour. Palpate the fundus at the same time to
ascertain its firmness and help to estimate the amount of vaginal discharge.
 Assess the woman’s comfort level frequently
 Ask the woman to rate her pain on a scale of 1 to 10; it should be less than 3.
If it is higher, further evaluation is needed.
CARE OF A WOMAN DURING THE FOURTH
STAGE OF LABOR
Nursing Interventions
 Providing support and information to the woman regarding episiotomy repair
and related pain-relief and self-care measures
 Applying an ice pack to the perineum to promote comfort and reduce swelling
 Assisting with hygiene and perineal care; teaching the woman how to use the
perineal bottle after each pad change and voiding; helping the woman into a
new gown
 Monitoring for return of sensation and ability to void
CARE OF A WOMAN DURING THE FOURTH
STAGE OF LABOR
Nursing Interventions
 Encouraging the woman to void by ambulating to bathroom, listening to
running water, or pouring warm water over the perineal area with the
peribottle
 Monitoring vital signs and fundal and lochia status every 15 minutes and
documenting them
 Promoting comfort by offering analgesia for after pains and warm blankets to
reduce chilling
 Offering fluids and nourishment if desired
 Encouraging parent–infant attachment by providing privacy for the family
CARE OF A WOMAN DURING THE FOURTH
STAGE OF LABOR
Nursing Interventions
 Being knowledgeable and sensitive to typical cultural practices after birth
 Assisting the mother to nurse, if she chooses, during the recovery period to
promote uterine firmness due to the release of oxytocin from the posterior
pituitary gland, which stimulates uterine contractions
 Teaching the woman how to assess her fundus for firmness periodically and to
massage it if it is boggy
 Describing the lochia flow and normal parameters to observe for postpartum
 Teaching safety techniques to prevent newborn abduction
CARE OF A WOMAN DURING THE FOURTH
STAGE OF LABOR
Nursing Interventions

 Demonstrating the use of the portable sitz bath as a comfort measure for her
perineum if she had a laceration or an episiotomy repair
 Explain comfort/hygiene measures and when to use them
 Assisting with ambulation when getting out of bed for the first time
 Providing information about the routine on the mother–baby unit or nursery
for her stay
 Observing for signs of early parent–infant attachment: fingertip touch to palm
touch to enfolding of the infant
THE WOMAN WITH UNIQUE CONCERNS IN LABOR

The Woman who will be placing her baby for adaptation

 Even if the woman decided to place her baby for adaptation, she needs to be
an active participant in her labor and be allowed to hold her child afterward.
 The decision of placing the baby for adaption is painful than she relies. Offer
support no matter what decision she eventually makes. Also offer support as
to whether she wants to hold the child or begin breast feeding.
 Be certain that you do not offer influencing advice, because the woman is the
only person who knows whether keeping this child will be right for her or for
the future of the child.
THE WOMAN WITH UNIQUE CONCERNS IN LABOR

The Woman without a Support Person

 Some women choose to labor without their partner
 Often the partner is not around due to work and other commitments
 Such woman ask a family member or a close friend to be their support person
 This situation will make the woman more fearful about being alone and asked
to begin a new life role.
End