STAGES OF LABOR

FIRST

STAGE- Dilatation stage

Begins with true labor contractions and

ends with complete dilatation of the
cervix.

PHASES
1. LATENT - Early time of labor.

Takes up 6 of the 12-hour first stage

Cervical dilatation is minimal up 3 cms
only because effacement is occurring.
Contractions are mild and short, lasting
20-40 second.
Woman in labor is excited with some
degree of apprehension but still with
ability to communicate.

2. ACTIVE - Cervix 4-7cm, complete effacement

Contractions are stronger.

Duration 40-60`secs
Frequency 3-5 mins
Lasts approximately 3 hours in nullipara and 2
hours in multipara.
SHOW and perhaps spontaneous rupture of
the membranes may occur.
Contractions cause true discomfort.
Exciting time because the mother realizes that
something dramatic is happening. .
Frightening time because she realizes that
labor is truly progressing and her life is about
to change.

3. TRANSITION Very important period

between the first and second stages of
labor.
- maximum dilatation of 8-10 cms
occurs
cervix 8-10 cm
frequency 2-3 mins
duration 60-90 seconds
The mood of the woman suddenly
changes and the nature of the
contractions intensify.

If membranes are still intact, this period is

marked by a sudden gush of amniotic
fluid as the fetus is pushed into the birth
canal. If spontaneous rupture of the BOW
does not occur, amniotomy (snipping of
the BOW with a sterile, pointed
instrument) is done by the doctor to
prevent fetus from aspirating the
amniotic fluid into the lungs as he makes
different positions changes. Amniotomy
is done if station is still minus because
this can lead to cord compression

 SHOW becomes prominent.

There is uncontrollable urge to push
with contractions (a sign that second
stage of labor is very near) so that
profuse perspiration and distention of
neck veins are seen.
Nausea and vomiting is a reflex
reaction due decreased gastric
motility and absorption.
In primis, baby is delivered within 20
contractions (40 mins) in multis, after
about 10 contractions (20 mins).

Nursing care is focused

primarily on giving comfort
measures:

Sacral

pressure (applying pressure with

the heel of the hand on the sacrum)
relieves discomfort from contractions.
Proper bearing down technique: push
with contractions.
Controlled chest (costal) breathing
during contractions.
Emotional support.

SECOND STAGE of
LABOR
Begins with the complete
dilatation of the cervix and
ends with the delivery of the
baby.

POWERS/Forces at work
Involuntary uterine
contractions as well as
contractions of the
diaphragmatic and abdominal
muscles.

MECHANISMS OF LABOR

The changes of position are termed as

CARDINAL MOVEMENTS OF LABOR
1. DESCENT Refers to the progress of the
presenting part through the pelvis.
- Downward movement of the
biparietal diameter of the fetal head
within the pelvic inlet.
- Descend depends on four forces
a. amniotic fluid pressure
b. direct fundal pressure
c. abdominal muscle contraction
fetal body extension and straightening

2. FLEXION As descent occurs, pressure

from the pelvic floor causes the Fetal head
bend forward onto the chest.
3. INTERNAL ROTATION The descent and
flexion bring the shoulders, coming next
into the optimal position to enter the inlet
or put the widest diameter of the shoulders
in line with the wide transverse diameter of
the inlet.
4. EXTENSION As the occiput is born, the
back of the neck stops beneath the pubic
arch and acts as a pivot for the rest of the
head. The head thus extends and the
foremost parts of the head, the face and the
chin are born.


5. EXTERNAL ROTATION - Almost
immediately after the head is born,
the head rotates back to the
diagonal or transverse position of
the early part of the labor. The
anterior shoulder is born first,
assisted b downward flexion of the
infants head.
6. EXPULSION Once the shoulders
are born, the rest of the baby is born
easily and smoothly because of its
smaller size.

NURSING CARE
NURSING CARE:
A. When positioning legs onto the stirrups, put
them up at the same time in order to prevent
injury to the uterine ligaments.
B. As soon as the head crowns, instruct mother
not to push, but to pant (rapid and shallow
breathing), so as to prevent rapid expulsion of
the baby.
If
panting
is
deep
and
rapid
called
hyperventilation, the patient will suffer
respiratory alkalosis and will eventually complain
of: Pallor, dizziness, lightheadedness, with
tingling sensation in the finger tips and lips.

Hyperventilation is due to the direct

effect of progesterone in the
respirator center in the brain.
Nsg. Intervention:
where she can
cuffed hands to
carbon dioxide.

offer paper bag

breath into or
recover the lost

C. Assist episiotomy incision made in the

perineum primarily to prevent laceration.
Other reasons for doing episiotomy:
1.To
prevent
prolonged
and
severe
stretching of muscles supporting the
bladder and rectum.
2. To reduce the second stage of labor
when there is hypertension, fetal distress
orr other problems which necessitate
immediate delivery of the baby.
3.
To
enlarge
outlet
in
breech
presentation of forceps delivery.

 TYPES
1.

OF EPISIOTOMY:

MEDIAN From middle

portion of the lower vaginal border
directed towards the anus.
2. MEDIOLATERAL Begun in
the midline but directed laterally
from the anus

D. Apply the MODIFIED

RITGENS MANEUVER
As soon as crowning is taking place,
cover the anus with sterile towel and exert
upward and forward pressure on the fetal
chin, at the time exerting gentle pressure on
the head to prevent rapid expulsion. This
will not only support the perineum, thus
preventing lacerations, but will also favor
flexion so the smallest suboccipitobregmatic
diameter of the fetal head is the one
presented at the birth canal.

Ease the head out and

immediately wipe the mouth and
nose of secretions to establish patent
airway.
After head delivery, insert two
fingers into the vagina to feel for the
presence of a cord around the neck
(nuchal cord). If there is and is quite
loose, slip it down the shoulders or up
over the head; but if it is tight, clamp
the cord twice, an inch apart, and cut.

As the head rotates, deliver

the anterior shoulder by giving it a
gentle, downward push and then
deliver the posterior shoulder by
giving it a gentle, upward lift.
While supporting the head
and the neck, deliver the rest of
the body. Take note of the time of
delivery as soon as the entire body
has been expelled.

 E.

Immediately after delivery, the

infant should be held with his head in
a dependent position ( head lower
than the rest of the body) to allow
drainage of secretions.
F. The newborn should be held
below the level of the mothers vulva
for a few seconds so that the blood
from the placenta can enter the
infants body on the basis of gravity
flow.


G. Wrap the baby in a sterile
diaper to keep him warm; chilling
increases the bodys need for
oxygen.
H. Put the baby on the mothers
abdomen, the weight of the baby
will help contract the uterus.


I. Cutting of the cord is postponed
until the pulsations have stopped
because it is believed that 50-100 ml
of blood is still flowing from the
placenta to the baby at this time.
Then, clamp twice, an inch apart and
cut between.
J. Show the baby to the mother,
inform her of the sex and time of
delivery and hand baby to the
circulating nurse.

THIRD STAGE: PLACENTAL

STAGE
From the delivery of the baby to the
delivery of the placenta

SIGNS OF PLACENTAL SEPARATION

1.CALKINS SIGN Uterus becomes
round and firm again, rising high to
the level of the umbilicus. It is the
earliest time of separation.
2. Sudden gush of blood from vagina
3. Lengthening of the cord.


TYPES OF PLACENTAL
DELIVERY
SCHULTZES MECHANISM If placenta
separates first at its center and last at its
margin, it tends to fold on itself like an
inverted umbrella and presents shiny fetal
surface. Shiny clean side first delivered.
- More common, 80% of placental
delivery.
- Less external bleeding because it is
usually concealed first behind the
placenta
1.


2.DUNCANS

MECHANISM If
placenta separates first at its
margin/edges, it slides along the
uterine surface, which is red, beefy,
irregular and dirty.
3. Its the maternal surface
- side out first
- umbrella shaped
- more external bleeding so it
appears bloody.

NURSING CARE
A. Do not hurry the expulsion of the placenta
by forcefully pulling out the cord or doing
vigorous fundal push as this can cause uterine
inversion. Just watch for the signs of placental
separation.
B. Deliver the placenta with BRANTANDREWS MANEUVER - Tract the cord slowly
and gently; winding it around the clamp until
the placenta spontaneously disengages,
rotating it slowly so that no membranes are
left inside the uterus.

 C.Take note of the time of placental

delivery. It should be delivered with in
20 minutes from the
delivery of the baby. If it fails to deliver
within this time, refer to the doctor
immediately because it could mean
uterine atony (soft, boggy, nonpalpable)
D.Inspect the placenta for the
completeness of the cotyledons, any
placental fragment retained can lead to
severe bleeding and possible death.

 E.The most important aspect of care

after the delivery of the baby and placenta
is maintenance of uterine contractions. The
fundus should be palpated; anytime at all
that is relaxed, non-contracted or boggy;
1.Massage carefully initial nursing
reaction.
2. Apply an ice over the abdomen to help
contract the uterus 1.
2.3.
Inject oxytocin/syntocinon to
maintain uterine contractions. ( it should
not be given before placental delivery
because placental entrapment can occur.)


F.

Inspect for the perineum for

lacerations. Anytime the uterus is
well contracted or firm following
placental delivery, yet bright red
blood is gushing in spurts,
suspects lacerations.
They tend to heal more slowly
because of ragged edges of the
tears.

CATEGORIES
First degree involves the vaginal mucous
membrane and perineal skin.
Second degree Involves not only the vaginal
mucous and perineal skin, but also the muscles.
Third degree Involves not only the vaginal
mucous membrane, perineal skin and muscles
but
also the external sphincter of the rectum.
Fourth degree Involves not only the vaginal
mucous membrane, perineal skin, muscles and
rectal sphincter, but also the mucous
membrane of the rectum.

 EPISIORRHAPHY

Repair of the
episiotomy, in vaginal
episiorrhaphy, a vaginal pack is
inserted to maintain pressure on
the suture line, thus preventing
further bleeding. Vaginal pack is
usually removed 24-48 hours
postpartum.

 G.Make

mother comfortable by
perineal care and applying clean
sanitary snugly to prevent its
moving forward from the anus to
the vaginal opening. Soiled napkins
should be removed from the front
to back.
H. Position the newly delivered
mother flat on her back without
pillows to prevent dizziness due to
decrease in abdominal pressure

FOURTH STAGE First 1-2

hours after the delivery which
is said to be dangerous stage
of the mother because her
vital signs are still unstable.

ASSESSMENT

1.FUNDUS Should be checked every 15

minutes for one hour then every 30 minutes
for the next 4 hours. Fundus should be firm in
the midline and during the first 12 hours
postpartum is slightly above the umbilicus.
2.LOCHIA Should be moderate in amount. If
napkin saturates more than 30 minutes,
suspect postpartum hemorrhage.
LOCHIA RUBRA 1-3 days. Red, moderate
LOCHIA SEROSA 4-10, brownish
LOCHIA ALBA 10-14days, 21 upper limit

3. BLADDER A full bladder is

evidenced by a fundus which is to the
right of the midline. Dark red bleeding
and some clots are expressed.
4. PERINEUM Should be tender,
discolored and edematous. It should be
clean with intact sutures.
5. EPISIOTOMY Note for bleeding
or edema. Ice bag to perineum
immediately can reduce edema or
swelling.

Promote comfort:
- keep warm, chills are common
because of excitement, sudden drop in
maternal hormones, release of intraabdominal pressure, fetal blood in
circulation.
- Give partial bath, peri-care,
change wet linens
- Assess for after pains; reassure
that it is secondary to uterine
contractions. Ice cap for relief or
analgesics as ordered.

 H.

The newly delivered mother

may suddenly complain of chills,
this is normal immediate after the
delivery and may only be due to
the decrease in intraabdominal
pressure, fatigue, cold delivery
room temperature. Provide
additional blankets.
I.Give initial nourishment e.g.
milk, coffee, soup, or tea.
J. Allow patient to sleep in order to
regain lost energy.

FOURTH STAGE First 1-2

hours after the delivery
which is said to be
dangerous stage of the
mother because her vital
signs are still unstable.

ASSESSMENT
FUNDUS

Should be checked every

15 minutes for one hour then every
30 minutes for the next 4 hours.
Fundus should be firm in the midline
and during the first 12 hours
postpartum is slightly above the
umbilicus.

 LOCHIA

Should be moderate in
amount. If napkin saturates more
than 30 minutes, suspect postpartum
hemorrhage.

LOCHIA RUBRA 1-3 days. Red,

moderate

LOCHIA SEROSA 4-10, brownish

LOCHIA ALBA 10-14days, 21

upper limit

 BLADDER

A full bladder is evidenced

by a fundus which is to the right of the
midline. Dark red bleeding and some
clots are expressed.
PERINEUM Should be tender,
discolored and edematous. It should be
clean with intact sutures.
EPISIOTOMY Note for bleeding or
edema. Ice bag to perineum
immediately can reduce edema or
swelling.

Promote comfort
Keep warm, chills are common because
of excitement, sudden drop in maternal
hormones, release of intra-abdominal
pressure, fetal blood in circulation.
Give partial bath, peri-care, change wet
linens
Assess for after pains; reassure that it is
secondary to uterine contractions. Ice
cap for relief or analgesics as ordered.