Stages of Labor

First Stage (True contraction to full dilatation and cervical effacement) Latent Phase: Or preparatory phase begins at the onset of regularly perceived uterine contractions and ends with rapid cervical dilatation begin. Contraction during this phase is mild and soft, lasting 20 to 40 seconds. Cervical effacement occurs and the cervix dilates from 0 to 3cm. The phase lasts approximately 6 hours in a nullipara and 4.5 hours in a multipara. Active Phase: Cervical dilatation occurs more rapidly, going from 4 to 7cm. Contractions are stronger, lasting 40 to 60 seconds and occurring approximately every 3-5 minutes. This phase lasts approximately 3 hours in nullipara and 2 hours in multipara. Transition Phase: Maximum dilatation of 8-10 cm occurs, and contractions reach their peak of intensity, occurring every 2-3 minutes with duration of 60 to 90 seconds. Dilatation continues at a rapid rate. Membranes will rupture as a rule at full dilatation and show will be present at the last of the mucus plug from the cervix is released. Nursing Management: Hospital Admission. After a physician or nurse has evaluated the patient, an admission order is written. At this point, your duties are to establish rapport with your patient and significant others, explain and orient the patient on all the procedures/ routines that will be done and evaluate the present condition of the patient and her baby. Perineal Preparation. Shaving of pubic hair to prevent infection of perineal episiotomy/lacerations is rarely done anymore. There must be a physician's order to perform this task. Cleansing Enema. Evaluation of Uterine Contractions Continued. Monitoring and Recording Color and Amount of Show. As labor progresses, the show becomes more blood-tinged. A sharp increase in the amount of bloody show coupled with frequent severe contractions may indicate labor is progressing too rapidly. Report this immediately to the Charge Nurse or physician and be prepared for possible delivery. Fetal Monitoring. Patient Given an Opportunity to Void. You should offer the patient an opportunity to void every 2 hours during labor. The discomfort of contractions often causes the patient to be unaware that her bladder is full. A full bladder may impede the progress of labor. Patient is NPO During Labor. The patient may have ice chips to prevent drying and chapping of the lips. Vaseline may be applied to her lips to prevent chapping. Gastric emptying time is prolonged once labor is established. The administration of analgesics also prolongs gastric emptying. The patient may vomit and aspirate since her stomach contents may not be absorbed. Being unaware of when possible complications could arise could necessitate an emergency C-section with general anesthesia. Positioning During Labor. Assist the patient in turning from side to side. Elevate the head of the bed 30 degrees; this makes it easier for the patient to breathe. Try to keep the patient off her back to prevent supine hypotensive syndrome. This syndrome results in

pressure of the enlarged uterus on the vena cava, reduces blood supply to the heart, decreases blood pressure, and reduces blood circulation to the uterus and across the placenta to the fetus. The patient may complain of being nauseated and feeling cool and clammy. The best position for the patient is on her left side since this increases fetal circulation. Prevention of Infection. Handwashing is essential before and after performing any procedure. Fresh, clean scrub suits should be worn in the delivery area. Unauthorized persons should not be allowed in the area. A patient with infections should be separated from other patients. Vaginal Exams. Artificial Rupture of Membranes. Emotional Support. Preparation of the Delivery Room. Preparation is usually done by the paraprofessional on duty if the scrub technicians are not employed. Strict aseptic technique is maintained. The room is prepared while the patient is in the first stage of labor. The local SOP will determine how soon before anticipated delivery the room can be set up. It is usually 2 to 12 hours if the tables are covered and rooms are closed.

Second Stage (full dilatation and cervical effacement to birth of the infant) Contractions change from the characteristic crescendo-decrescendo pattern to an overwhelming, uncontrollable urge to push or bear down with contractions as if she had to move her bowels. As the fetal head is pushed still tighter against the perineum, the vaginal introitus opens and the fetal scalp becomes visible at the opening to the vagina. At first, this is a slit like opening, which then becomes oval, then circular. The circle enlarges from the size of a dime to that of a quarter to that of a half-dollar which is called crowning. As she pushes, using her abdominal muscles and the involuntary uterine contractions, the fetus is pushed out of the birth canal. Ritgen maneuver- an obstetric procedure used to control delivery of the fetal head. It involves applying upward pressure from the coccygeal region to extend the head during actual delivery, thereby protecting the musculature of the perineum. Nursing Management: Never leave the patient alone once she has been transferred to the delivery room. In addition, never turn your back on the perineum because the baby could push through the vaginal opening while your back is turned. Encourage the patient to rest between contractions and to push with contractions. Only one person should coach. Verbal encouragement and physical contact help reassure and encourage the patient. Position the patient's legs in the stirrups for the lithotomy position. This is the most common position for delivery. Facilities using birthing beds have the patient in an upright position. Prep the patient's perineum. A Betadine scrub and water are used with 4x4's. Clean the perineum by washing the pubic area, down each thigh, down each side of the labia, down the perineum, and down the rectal area. Rinse area with the remaining solution.

 Monitor the patient's blood pressure and the fetal heart tones every 5 minutes and after each contraction. Third Stage (birth of the infant to the delivery of the placenta) Placental separation It occurs automatically as the uterus resumes contractions. As the uterus contracts down on an almost empty interior, there is such a disproportion between the placenta and the contracting wall of the placenta occur. Signs that indicate placental separation: Lengthening of the umbilical cord Sudden gush of vaginal blood Change in the shape of the uterus Schultzes placenta- It looks shiny and glistening from the fetal membranes. Duncan placenta- It looks raw, red, and irregular with ridges or cotyledons that separate blood collection spaces showing. Placental Expulsion The placenta is delivered either by the natural bearing-down effort of the mother or by gentle pressure on the contracted uterine fundus by the physician or nure-midwife (credes maneuver). Pressure must never be applied to a uterus in a non contracted state or it will evert and hemorrhage. Nursing Management: Continue observation. Following delivery of the placenta, continue in your observation of the fundus. Ensure that the fundus remains contracted. Retention of the tissues in the uterus can lead to uterine atony and cause hemorrhage. Massaging the fundus gently will ensure that it remains contracted. Allow the mother to bond with the infant. Show the infant to the mother and allow her to hold the infant. Fourth Stage (delivery of the placenta to first 2-4 hours of recovery) The hour or two after delivery when the tone of the uterus is established and the uterus contracts down again expelling any remaining contents. These contractions are hastened by breast-feeding, which stimulates production of the hormone oxytocin. Nursing Management: Transfer the patient from the delivery table. Remove the drapes and soiled linen. Remove both legs from the stirrups at the same time and then lower both legs down at the same time to prevent cramping. Assist the patient to move from the table to the bed. Provide care of the perineum. An ice pack may be applied to the perineum to reduce swelling from episiotomy especially if a fourth degree tear has occurred and to reduce swelling from manual manipulation of the perineum during labor from all the exams. Apply a clean perineal pad between the legs. Transfer the patient to the recovery room. This will be done after you place a clean gown on the patient, obtained a complete set of vital signs, evaluated the fundal height and firmness, and evaluated the lochia.

 Ensure emergency equipment is available in the recovery room for possible complications. Check the fundus. Monitor lochia flow. Lochia is the maternal discharge of blood, mucus, and tissue from the uterus. This may last for several weeks after birth. Monitor the patient's vital signs and general condition. Observe patient's urinary bladder for distention. Be able to recognize the difference between a full bladder and a fundus. Evaluate the perineal area for signs of developing edema and/or hematoma. Observe C-section patients. Most C-section patients are still initially recovered in the recovery room. If not, monitor the patient as you would any patient in a recovery room immediately during post delivery. Include monitoring of the fundus and lochia flow. Times are consistent with the normal vaginal delivery patient. Instruct the patient in the proper perineal care. The patient should use the peribottle after each void and bowel movement, wipe from front to back to avoid contamination, and apply the perineal pad from front to back. Discontinue IV on a normal patient once she is stable and the physician has ordered removal. Complete notes and transfer the stable patient to the ward (on normal vaginal delivery-others require physician clearance).

Signs of Labor
Preliminary Signs of Labor Lightening Descent of the fetal presenting part into the pelvis occurs approximately 10 to 14 days before labor begins. This change the womans abdominal contour as the uterus becomes lower and more anterior. It gives the woman relief from the diaphragmatic pressure and shortness of breath she has been experiencing and thus lightens her load. Increase in Level of Activity It is due to an increase in epinephrine release that is initiated by a decrease in progesterone produced by the placenta. Additional epinephrine prepares the womans body for the work of labor ahead. Braxton Hicks Contraction Is a tightening of the uterine muscles for one to two minutes and are thought to be an aid to the body in its preparation for birth. Not all expectant mothers feel these contractions. They are not thought to be part of the process of effacement of thecervix. Ripening of the Cervix It is an internal sign seen only on pelvic examination. (Goodells sign) softening of the cervix. Signs of True Labor Uterine Contraction- Initiation of effective, productive, involuntary uterine contractions

Show- the mucus plug that filled the cervical canal during pregnancy is expelled. The blood, mixed with mucus, takes on a pink tinge and is referred to as show or bloody show. Rupture of Membrane- a sudden gush or scanty, slow seeping of clear liquid from the vagina. Components of Labor A. Passenger: the fetus Attitude - relationship of fetal body parts to each other, normal uterine posture is completely flexed Lie - relationship of fetal spine to maternal spine. Longitudinal or vertical is when fetus is parallel to mother's spine, transverse or horizontal if fetus is at right angle to mother's spine. Presentation - portion of fetus that enters pelvis first: presenting part could be cephalic or breech (frank, footling) Position - relationship of fetal reference point to one or four quadrants or sides of mother's pelvis. Maternal pelvis side: L-left, R-right; Fetal Reference points: O-occiput, M-mentum, B-brow, S-sacrum; Maternal Pelvis Quadrant: Aanterior, T-transverse, P-posterior Station - degree of engagement from presenting part to ischial spine; Station 0 means at ischial spine, minus station means above spine, and plus station is below the spine. B. Passageway Pelvis- Gynecoid, Android, Anthropoid, Platypelloid Soft tissues - lower uterine segment, cervix, vagina, and introitus C. Power - forces acting to expel fetus; primarily by involuntary uterine contractions, secondarily by voluntary bearing down. - Functions of uterine contraction are effacement and dilation D. Psyche - response to contraction, perceptions and beliefs, pre-natal care and education, support systems and communication skills