UNIVERSITY OF CEBU – BANILAD

College of Nursing
Banilad, Cebu City

RESOURCE UNIT ON THE STAGES OF LABOR

GENERAL OBJECTIVES: After 2 hours and 30 minutes of varied-lecture discussion, the BSN III students will be able to acquire
beginning knowledge and skills and a positive attitude on the concept of the stages of labor.

SPECIFIC CONTENT METHODOLOGY TIME RESOURCES EVALUATION

OBJECTIVE ALLOTMENT

1. Define related
terms: 1. Labor-Labor is defined as the onset of rhythmic contractions Varied lecture- 10 minutes Books Paper and
and the relaxation of the uterine smooth muscles which results in discussion pencil test
effacement or progressive thinning of the cervix, and dilation or Cooperation
widening of the cervix.
of the class
2. Braxton Hicks Contraction- Braxton Hicks contractions, also
known as false labor or practice contractions are sporadic Time and
uterine contractions that usually start around 6 weeks however effort of the
are not usually felt until the second trimester or third group
trimester of pregnancy.

3.Cervical effacement refers to a thinning of the cervix. It is a

component of the Bishop score. It can be expressed as a
percent.

2. Identify signs
and symptoms of Before "true" labor begins, you may have "false" labor pains, Varied lecture- 10 minutes Paper and
false and true also known as Braxton Hicks contractions. These irregular discussion Books pencil test
labor. uterine contractions are perfectly normal and may start to occur
from your fourth month of pregnancy. They are your body s Cooperation
way of getting ready for the "real thing." of the class

Time and
What do Braxton Hicks contractions feel like?Braxton Hicks effort of the
contractions can be described as tightening in the abdomen group
that comes and goes. These contractions do not get closer
together, do not increase with walking, do not increase in how
long they last or how often they occur, and do not feel stronger
over time.

What do true labor contractions feel like?The way a

contraction feels is different for each woman and may feel
different from one pregnancy to the next. Labor contractions
cause discomfort or a dull ache in your back and lower
abdomen, along with pressure in the pelvis. Some women may
also feel pain in their sides and thighs. Some women describe
contractions as strong menstrual cramps, while others describe
them as strong waves that feel like diarrhea cramps.

Timing of contractions

• False Labor: Often are irregular and do not get closer

together
• True Labor: Come at regular intervals and as time goes on,
get closer together. Contractions last about 30-70 seconds.
Change with movement

• False Labor: contractions may stop when you walk or rest, or

may even stop when you change position
• True Labor: Contractions continue, despite movement or
changing positions
Strength of contractions

• False Labor: Contractions are usually weak and do not get

much stronger (may be strong first, then get weaker)
• True Labor: Contractions steadily increase in strength
Pain of contractions
 • False Labor: contractions are usually only felt in the front of
the abdomen or pelvic region
• True Labor: Contractions usually start in the lower back and
move to the front of the abdomen

3. Identify those Varied lecture- 10 minutes Paper and

factors that distinguish discussion pencil test
the three phases of the FIRST STAGE OF LABOR--THREE PHASES Books
first stage of labor.
a. Latent or Prodromal Phase (Early). In this phase, the mother Cooperation
feels slow, rhythmic contractions radiating from the lumbar region
to the anterior portion of her abdomen. The contractions last from
of the class
30 to 45 seconds with the intensity gradually increasing. The
frequency of contractions is from 5 to 20 minutes. There is some Time and
cervical effacement. Dilation is from 0 to 3 cm. "Bloody show" is effort of the
usually present. The mother is usually able to walk, talk, or laugh group
some during this phase. Diversion is usually welcomed during this
time. This phase may not be included as part of the first stage of
labor since it is before the onset of true labor. True labor is
considered to be at 4 cm. Duration of this phase varies,
sometimes as long as 24 hours and is referred to as the
"prolonged latent" phase. The mother may sometimes make some
progress dilating from 1 to 2 cm and will then stop. She is usually
not admitted to the hospital at this point unless the membranes are
ruptured.

b. Active or Accelerated Phase. In this phase, the contractions

become stronger and last longer, usually 45 to 60 seconds. The
frequency is from 3 to 5 minutes. The cervix dilates from 4 to 7 cm.
This phase is considered the onset of true labor. The mother is
admitted to the hospital at this point. She, then, becomes involved
with bodily sensations and tends to withdraw from the surrounding
environment. She is not able to walk, but, desires companionship
and encouragement.

c. Transient or Transitional Phase. In this phase, the

contractions are sharp, more intensified, and last from 60 to
90 seconds. The frequency is from 2 to 3 minutes. The cervix
dilates from 8 to 10 cm. Completion of this phase marks the
end of the first stage of labor. The mother may express
feelings of frustration, loss of control, and/or irritability. Her
 focus becomes internal. She has difficulty comprehending
surroundings, events, and instructions. There is an increase
in bloody show as a result of the rupture of capillary vessels
in the cervix and the lower uterine segment. The mother feels
an urge to push or to have a bowel movement. This is
considered the most severe and difficult phase for the Varied lecture- 10 minutes Paper and
mother. discussion pencil test

Books

a. Hospital Admission. After a physician or nurse has evaluated Cooperation

the patient, an admission order is written. At this point, your duties
as a practical nurse are as follows:
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(1) Establish a rapport with the patient and significant others. Time and
4. Identify the nursing effort of the
care given the patient
during the first stage (2) Explain all procedures or routines, which will be carried out group
of labor. prior to performing them. These include:(a) NPO except ice chips
while in labor.(b) Activities allowed and disallowed according to
ward policies (i.e. bathroom privileges). (c) Use of fetal monitors.
(d) Progress reports.(e) Visitation policies.(f) Where patient's
personal belongings will be maintained.

(3.) Review the information obtained originally in the exam room,

verify and transfer the OB health record to the labor chart per ward
policies. You will review the following information:

(a) Obstetric history 1 Gravida/para.2 Estimated date of

confinement (EDC) or due date.3 Duration of previous
labors.4 Problems with previous pregnancies/deliveries.

(b) General condition.1 Rh status.,2 Allergies.,3 History of medical

problems.

(c) Current pregnancy. 1 Onset of labor (contractions regular, 5

minutes or less) .2 Frequency, duration, and intensity of
contractions. 3 Membranes-ruptured or intact. 4 Amount and
character of show or vaginal bleeding. 5 Vital signs. 6 Rate,
location of fetal heart tones. 7 Plans to bottle or breast feed. 8 Any
problems with this pregnancy.
4. . Evaluation of Uterine Contractions Continued.

(1) The purpose of this evaluation is to assess the ability of the

uterus to dilate the cervix, help in determining the progress of
labor, help to detect abnormalities of uterine contractions (such as
lack of uterine relaxation), and help to evaluate any signs of fetal
distress.

(2) This evaluation will help you in identifying the frequency (how
often in minutes contractions occur), intensity (strength of
contractions when palpitations are identified as mild, moderate, or
strong [severe]), and duration(how long the contractions lasts in
seconds).

(3) When palpating for contractions, place your hand over the
fundal area of the patient's uterus. Contractions can be felt by your
fingers before the patient actually becomes aware of them. See
figure 2-3 for patient experiencing contractions.

5. Fetal Monitoring.

(1) Fetal monitoring is done to detect presence of fetal life at time

of admission and to detect development of fetal distress during
labor. A fetoscope or fetal monitor may be used to obtain FHTs

6. Vital Signs. Monitor the patient's vital signs.

(1) On admission.(2) Every hour during early labor.(3) Blood

pressure (BP), pulse (P), and respiratory rate (R) every 30 minutes
during active, transition, and the second stage of labor, to include
the temperature every hour.(4) Blood pressure, P, and R every 15
minutes while on Pitocin®, to include the temperature every hour. Varied lecture- 10 minutes Paper and
(5) More frequently if complications arise.
discussion pencil test
7.. Patient Given an Opportunity to Void

8. Prevention of Infection. Books

Cooperation
of the class
 Time and
effort of the
group
The second stage of labor begins when the cervix is completely
effaced and dilated and ends when the infant is born.

a. These signs of the second stage of labor are considered

imminent or impending signs.

(1) Imminent signs.

(a) Increased bloody show.

(b) Desire to bear down or have bowel movement (result of the

descent of the presenting part).

(c) Bulging of the perineum.

5. Select the signs of
(d) Dilatation of the anal orifice.
the second stage of
labor.
(2) Impending signs.

(a) Nausea and retching.

(b) Irritability and uncooperativeness.

Varied lecture-
(c) Complaints of severe discomfort.
discussion 10 minutes Paper and
pencil test
(d) Pleas for relief.

b. Once dilatation and effacement are complete, the patient is

instructed to push with each contraction to bring the presenting Books
part down into the pelvis.
Cooperation
of the class
2-8. NURSING CARE GIVEN WHILE IN THE DELIVERY ROOM
Time and
a. Never leave the patient alone once she has been transferred to effort of the
the delivery room. In addition, never turn your back on the group
perineum because the baby could push through the vaginal
opening while your back is turned.
 b. 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.

c. 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.
Positioning also depends upon the type of anesthesia to be used
Varied lecture- 10 minutes Paper and
and C-section delivery. Each case may be different.
discussion pencil test
d. 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 (see fig. 2-7). Begin cleaning at number
1 and proceed through number 7. Discard used sponges after
each step. Rinse area with the remaining solution.
Books

e. Monitor the patient's blood pressure and the fetal heart tones Cooperation
every 5 minutes and after each contraction. of the class
6. Identify the nursing
care given the patient
while in the delivery Time and
room. effort of the
2-9. NORMAL BIRTHING PROCESS (FIGURE 2-8) group
Even though most of the time the delivery remains in the hands of
the obstetrician, there may be times when a practical nurse will
have to assist the patient to give birth. In general, the activity of
the normal birthing process (see figure 2-8) is given below:

a. Crowning, the appearance of the infant's head on the perineum.

b. Delivery of the head. This includes suctioning of the infants

nose and mouth with a bulb syringe. A DeLee suction trap is used
if meconium is present.

c. Delivery of the anterior shoulder and the posterior shoulder.

d. Delivery of the trunk and lower body.

 e. Clamping and cutting of the umbilical cord.

INFORMATION TO BE RECORDED ABOUT THE DELIVERY

Record the following information.

a. Exact date and time of delivery.

b. Sex of the infant.

7. Know the normal
birthing process and
c. Condition of the infant (APGAR) after birth. APGAR is the most
the nursing
widely used method of evaluating the condition of a newborn baby.
responsibilities
A value of 0 to 2 is given for each observation (i.e., heart rate,
associated.
respiratory effort, muscle tone, reflex irritability, and color). The
values are added giving a total APGAR score (see table 2-2). A
baby in excellent condition would score 9 to 10 and a dead baby
would score 0. Most babies score 7 or better. The condition of the
infant will be taken at one (1) minute, at five (5) minutes, and at
thirty (30) minutes.

d. Position of the infant at delivery.

e. Type of episiotomy, lacerations.

f. Spontaneous or forceps delivery.

g. Use of oxygen and suction on the infant. Varied lecture- 10 minutes Paper and
discussion pencil test
h. Number of vessels in the cord.

i. Mother's name.

j. Any other pertinent facts about the delivery

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( SEE APPENDIX A FOR ILLUSTRATION) Cooperation

of the class

Time and
 effort of the
group

The third stage of labor is the period from birth of the baby through
delivery of the placenta. This is considered a dangerous time
because of the possibility of hemorrhaging. Signs of the placental
separation (see figure 2-9) are as follows:

a. The uterus becomes globular in shape and firmer.

b. The uterus rises in the abdomen.

c. The umbilical cord descends three (3) inches or more further out
of the vagina.

d. Sudden gush of blood.

NURSING CARE DURING THE THIRD STAGE

a. 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. Varied lecture- 10 minutes Paper and
discussion pencil test
b. Allow the mother to bond with the infant. Show the infant to the
mother and allow her to hold the infant

INFORMATION TO RECORD

Record the following information.

Books
a. Time the placenta is delivered.

b. How delivered (spontaneously or manually removed by the Cooperation

physician). of the class

c. Type, amount, time and route of administration of oxytocin. Time and

Oxytocin is never administered prior to delivery of the placenta effort of the
because the strong uterine contractions could harm the fetus.
group
8. Identify signs of d. If the placenta is delivered complete and intact or in fragments.
placental separation
and the nursing care to
be done during the third
stage of labor.
The fourth stage of labor, is the period from the delivery of the
placenta until the uterus remains firm on its own. In this
stabilization phase, the uterus makes its initial readjustment to the
nonpregnant state. The primary goal is to prevent hemorrhage
from the uterine atony and the cervical or vaginal lacerations.

NOTE: Atony is the lack of normal muscle tone. Uterine atony is

failure of the uterus to contract.

2-15. NURSING CARE DURING THE FOURTH STAGE OF

LABOR

a. 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.

b. 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.
Varied lecture- 10 minutes Paper and
c. 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 discussion pencil test
vital signs, evaluated the fundal height and firmness, and
evaluated the lochia.

d. Monitor the patient's vital signs and general condition.

e. Evaluate the perineal area for signs of developing edema

and/or hematoma.

(1) Predisposing conditions includes prolonged second stage, Books

delivery of a large infant, rapid delivery, forceps delivery, and
fourth degree lacerations. Cooperation
of the class
 Nursing considerations for perineal edema. Time and
effort of the
(a) Apply an ice pack to the perineum as soon as possible to group
decrease the amount of developing edema.
9. Know the
(b) Stress the importance of peri-care and use of "sitz-baths" on
fourth stage of the postpartum ward.
labor and the
nursing (c) Assess for urinary distention which is due to edema of the
responsibilities urethra.
during the
stage.

There are five essential factors that affect the process of labor and
delivery. They are easily remembered as the five Ps (passenger,
passage, powers, placenta, and psychology).

a. Passenger (Fetus).

(1) Presentation of the fetus (breech, transverse).

(2) Position of the fetus (ROP, LOP).

(3) Size of the fetus.

b. Passage (Birth Canal).

(1) Parity of the woman, if she has ever delivered before.

(2) Resistance of the soft tissues as the fetus passes through the
birth canal.

(3) Fetopelvic diameters.

c. Powers (Contractions).

(1) Force of the uterine contractions.

(2) Frequency of the uterine contractions.

 d. Placenta.

(1) Site of implantation.

(2) Whether it covers part of the cervical os.

e. Psychology (Psychological State of the Woman).

(a) Patient extremely anxious.

(b) Emotional factors related to the patient.

(c) Amount of sedation required for the patient.

10.Determine
factors
that may
extend or
influence
the
duration
of labor.
BIBLIOGRAPHY:

BOOK SOURCE:
Pilleteri, Adele ,Maternal & Child nursing; 4th edition, 2003 ,
Lippincott Williams & Wilkins, Hong Kong

INTERNET SOURCE:

http://www.brooksidepress.org/Products/Obstetric_and_Newborn_Care_II/lesson_3_Section_1.htm

http://en.wikipedia.org/wiki/Cervical_effacement

http://www.emaxhealth.com/40/1122.html
THE BIRTHING PROCESS: