Stages of Labor Start End Duration

Nullipara Multipara

First Stage True labor Full cervical dilatation 10-12 hr 6-8 hrs but
contractions but 6-20 2-12 hrs is
hrs is the the normal
normal limit limit

Latent phase Onset of regularly 3 cm cervical 6 hrs 4.5 hrs

perceived uterine dilatation
contractions (mild
contractions lasting
20-40 sec)

Active phase Stronger uterine 7 cm cervical 3 hrs 2 hrs

contractions lasting dilatation
40-60secs

Transitional Uterine contractions 10 cm cervical 3 hrs 1.5-2 hrs

phase reaching their peak, dilatation
occurring every 2-3
minutes for 60-90 s

Second Stage Full cervical Infant birth <2 hrs 0.5-1 hrs
dilatation

3 hrs with 2 hrs with

epidurals epidurals

Third Stage Infant birth Placental delivery Maximum of 30 min.

First Stage of Labor

- Period from the onset of labor until complete dilatation of the cervix has occurred
- NURSING CARE: Monitor FHR; determine fetal position with abdominal (leopold's maneuver) and
pelvic exams (palpation of sutures or fontanelles); regular assessments of cervical dilatation and
descent of fetal head

1. Latent Phase - from onset of true labor contractions to 3 cm

2. Active Phase - 4 cm - 7 cm
- contraction intensity is stronger, interval shortens, and duration lengthens.
- true discomfort is first felt so she is dependent and her focus is on herself
3. Transition Phase - 8 cm to 10 cm (full cervical dilatation and full effacement)
- patient may be exhausted and withdrawn or aggressive and restless.
- urge to push is noticeable
Second Stage of Labor
- starts when cervical dilatation reaches 10 cm and ends when the baby is delivered
- INTERVENTIONS: warm compresses and perineal massage; assist mother to find comfortable
and safe position; delay cord clamping for 1 min until pulsation stops;

Third Stage of Labor

- starts from birth of infant to delivery of placenta
- Two parts: placental separation and placental expulsion
- 5 mins. after delivery of baby, uterus begins to contract again, and placenta starts to separate
from the contracting wall.
- NURSING CARE: Fundal massage to induce its contraction and stop bleeding; examine
placenta to confirm completeness w/c should consist of umbilical cord, complete amniotic
membranes, 3 blood vessels and repair any lacerations

Signs of placental separation:

 Lengthening of umbilical cord
 Sudden gush of vaginal blood
 Change in the shape of uterus (globular in shape)

Fourth Stage of Labor

- stage occurs 2 hrs after delivery when tone of uterus is established as the uterus contracts
again
- NURSING CARE: monitoring to rule out hemorrhage or preeclampsia

MECHANISMS OF LABOR
 ENGAGEMENT
○ Largest diameter of the fetal head fits into the large diameter of the maternal pelvis.
○ Head moves towards pelvic brim in with L/R OT position
● DESCENT
○ Head descends through the pelvic inlet towards pelvic floor.
○ Due to uterine contractions, pressure from amnio fluid, abdominal muscle contraction
● FLEXION
○ Fetal head comes into contact with the pelvic floor, cervical flexion occurs
○ Flexion where chin touches the chest
● INTERNAL ROTATION
○ Pelvic floor has gutter shape with forward/downward slope THUS head rotates from left/right
occipito-transverse to occipito-anterior.
● EXTENSION
○ Head slips beneath SUPRAPUBIC ARCH causing extension of the head
○ Extension causes premium to stretch
● EXTERNAL ROTATION & RESTITUTION
○ Head externally rotates to face right or left medial thigh of mother (L/R occipito-transverse)
○ At the same time, shoulder rotates
○ RESTITUTION - alignment of head and shoulders
● DELIVERY
○ Nurse applies downward traction followed by upward traction to assist in delivery shoulder
below suprapubic arch

3 PHASES OF CONTRACTION
 LATENT PHASE - Onset of regularly perceived uterine contractions (mild contractions lasting 20-40
sec)
○ Phase lasts Nullipara - 6 hrs ; Multipara - 4.5 hrs
● ACTIVE PHASE - Stronger uterine contractions lasting 40-60secs
○ Phase lasts Nullipara - 3 hrs ; Multipara - 4.5 hrs
● TRANSITIONAL PHASE - Uterine contractions reaching their peak, occurring every 2-3 minutes for 60-
90 s
BRADYCARDIA - FHR lower than 120 bpm for 10 mins
- Sign of possible hypoxia

TACHYCARDIA - FRH greater than 180 bpm for 10 mins

- Caused by fetal hypoxia, fetal arrhythmias, maternal fever, maternal
anemia/hyperthyroidism

CERVICAL EFFACEMENT
- Gradual thinning, shortening and drawing up of the cervix measured by percentages (0 to 100%)
- Nurse wears surgical glove and insert 2 fingers into the vagina and feel for effacement
DILATATION
- Gradual opening of the cervix measured in cm (0 to 10 cm)

3 MAIN CAUSES OF POSTPARTUM HEMORRHAGE

TTT mnemonic
 Uterine atony [Tone] - uterus fails to contract after the delivery of the baby
 Laceration (cervical /vaginal tear), hematoma, inversion, rupture [Trauma];
 Retained tissue or invasive placenta [Tissue];
 Coagulopathy [Thrombin]

TREATMENT/MANAGEMENT
 Medication e.g. oxytocin (to stimulate uterine contractions)
 Fundal massage (to stimulate contractions)
 Removal of placental pieces that remain in the uterus
 Examination of the uterus and other pelvic tissues
 suturing perineal tears; suturing an episiotomy; repair of cervical and high vaginal tears; and
manual removal of the placenta.

CEPHALOPELVIC DISPROPORTION
- Complication in w/c there is a size mismatch between mother’s pelvis and head of the baby
- Vaginal delivery is DANGEROUS or NOT POSSIBLE, thus caesarian birth is required if vaginal is
unsuccessful

EPISIOTOMY - surgical cut made in the perineum during childbirth (mayo scissors)
EPISIORRHAPHY - surgical repair of injury to the vulva by suturing (metzenbaum)

FALSE LABOR - contractions are often irregular and do not get closer together
TRUE LABOR - contractions come at regular intervals and get closer together as time goes on (Contractions
last about 30-70 secs)
FACTORS AFFECTING LABOR (4P’s)

1. Passenger - the fetus (size, presentation, moldability of skull)

2. Passageway - pelvis and birth canal
3. Powers - uterine contractions (quality, foce, frequency)
4. Psyche - response of the mother (mother's attitude toward labor and her prep for labor

FRIEDMAN CURVE
- Used to determine whether the labor is progressing normally or abnormally
- used as the gold standard for rates of cervical dilation and fetal descent during active labour

INTRAPARTUM COMPLICATIONS

 Cord prolapse – place in trendelenburg position to reduce compression of the cord

 Fetal distress – bradycardia/tachycardia, meconium-staining of non-breech
o changing the mother’s position
o increasing maternal hydration
o maintaining oxygenation for the mother
o amnioinfusion, where fluid is inserted into the amniotic cavity to relieve pressure on the umbilical
cord
o tocolysis, a temporary stoppage of contractions that can delay preterm labor

 Hydromnios -
 Maternal exhaustion – results from unnecessary pushing and bearing down during latent phase
 Shoulder dystocia - when one or both of a baby's shoulders get stuck inside the mother's pelvis during
labor; management: change positions, manually turning baby’s shoulders, episiotomy to widen vagina
 Cephalopelvic disproportion – mismatch between mother’s pelvis and baby’s head
 Excessive bleeding - more than 500 ml for primigravida
o the use of medication
o uterine massage
o removal of retained placenta
o uterine packing
o tying off bleeding blood vessels
o surgery, possible a laparotomy, to find the cause of the bleeding, or hysterectomy, to remove
the uterus
PRESENTATION

1. CEPHALIC - fetal head occupies lower segment of uterus

a. Vertex - occiput
b. Brow - chin is untucked; neck is slightly extended backward
c. Face - chin (mentum)
2. BREECH - when buttocks/sacrum occupies the lower segment of the uterus
3. SHOULDER - scapula comes in the lower segment of uterus

It is used to determine the position, presentation, and engagement of the fetus in utero.

1ST MANEUVER - Used to determine fetal lie and which fetal pole (cephalic or podalic) occupies fundus;
Palpate fundus; Head: round, more mobile; Breech: large, soft

2ND MANEUVER - Used to determine position of fetal back; Place palms on either side of abdomen, exert
gentle deep pressure;

3RD MANEUVER - Used to confirm fetal presentation (cephalic vs breech); the thumb and fingers of 1 hand
grasp the lower portion of abdomen above pubic symphysis; Not engaged- movable mass is felt
4TH MANEUVER - Used to determine the degree of descent; Face pt’s feet, position fingertips of both hands
on either side of the presenting part à exert inwards pressure, slide caudad along the axis of pelvic inlet; When
the head has descended, can feet anterior shoulder or the space created by the neck from the head

PREMONITORY SIGNS OF LABOR

● A small bloodstained discharge as the cervix thins and the mucus plug drops out (this is called a
‘show’)
● Bag of water breaks; seen as a gush or trickle of water as the membranes break
● Increased uterine contractions
● Period-like cramps
● Backache
● Diarrhea

BODY CHANGES DURING LABOR

 Head of baby pushes against cervix
 Nerve impulses from cervix transmitted to brain
 Brain stimulates pituitary gland to secrete oxytocin
 Oxytocin carried in bloodstream to uterus
 Oxytocin stimulates uterine contractions and pushes baby towards cervix

SHOULDER DYSTOCIA - birth injury that happens when one or both of a baby's shoulders get stuck inside
the mother's pelvis during labor; head is delivered vaginally but the shoulders remain inside the mother.

RUPTURE OF THE MEMBRANE (BOW)

- Seen as a sudden gush or slow seeping of amniotic fluid from the vagina
- If BOW have ruptured, LABOR IS INEVITABLE & labor pain will set in w/in next 24 hrs
- NSG ACTION: Put to bed right away, take FHR. She should be allowed to remain sitting or standing
because the possibility of cord compression is high.

CORD PROLAPSE
- Cord comes out before the baby; happens when water breaks before baby has moved to birth canal
- woman in labor feels a loop of the cord coming out of her vagine
- IMMEDIATE ACTION: Place in TRENDELENBURG POSITION to reduce cord compression
- NOTE: Only 5 mins of cord compression leads to CNS damage and even death
- Apply warm saline solution OS on the cord to prevent crying of the cord

PLACENTAL SEPARATION
 Schultz - center portion of placenta separates first; shiny surface emerges from vagine
 Duncan - margin of placenta separates; red, dull, dirty surface emerges from the vagina with ridges
of cotyledons

SIGNS OF PLACENTAL SEPARATION

 Uterus becoming globular
 Gushing of blood
 Lengthening of the cord

MONITORING BP
- BP should NOT be taken during contraction because it INCREASES because all the blood is in the
periphery (no blood supply goes to placenta during contraction)

NPO (Nothing by mouth)

  WHY NPO? To prevent aspiration that may occur during reflex nausea and vomiting when anesthesia
is used or during transition phase

VOIDING
 Woman should EMPTY BLADDER every 2-3 hrs because:
○ Full bladder retards fetal descent
○ May cause UTI
○ Full bowel may be traumatized during delivery

BREATHING TEACHNIQUE
- Woman in 1st stage should be instructed NOT TO PUSH OR BEAR DOWN during contractions
because it will lead to MATERNAL EXHAUSTION AND CERVICAL EDEMA (because of the excessive
pounding of fetal presenting part of the pelvic floor)

SIM’S POSITION
 Encourage mother because:
○ Favors anterior rotation of the head
○ Promotes relaxation between contractions
○ Prevents supine hypotensive syndrome

LEFT LATERAL DECUBITUS POSITION

- It prevents pressure in inferior vena cava located in the right

CONTRACTIONS
 LATENT PHASE: Monitored every hour
 ACTIVE PHASE: every 30 mins

SIGNS OF FETAL DISTRESS

 Bradycardia and tachycardia
 Meconium-stained amniotic fluid
 Fetal hyperactivity due to fetal struggling for more O2

SIGNS OF MATERNAL DISTRESS

 BP over 140/90 & FALLING BP with signs of shock (paloor, restlessness, increase RR and PR)
 Bright red vaginal bleeding or HEMORRHAGE (blood loss > 500 cc)
 Abnormal abdominal contour

ADMINISTRATION OF ANALGESICS
Narcotics: DEMEROL
● DEMEROL acts to suppress the sensory portion of cerebral cortex
● Given at 25-100 mg
● Takes effect in 20 mins
● Patient experiences sense of well being and euphoria

ANESTHETICS
- Regional anesthesia is PREFERRED because DOES NOT ENTER MATERNAL CIRCULATION so it
DOES NOT CAUSE RESP DEPRESSION IN NEWBORN

Problems with the umbilical cord. The umbilical cord may get caught on an arm or leg as the infant travels
through the birth canal. Typically, a provider intervenes if the cord becomes wrapped around the infant's neck,
is compressed, or comes out before the infant.5

Abnormal heart rate of the baby. Ask the woman to switch positions to help the infant get more blood flow;
immediate delivery; more likely to need an emergency cesarean delivery, or the health care provider may need
to do an episiotomy to widen the vaginal opening for delivery.
Perinatal asphyxia. This condition occurs when the fetus does not get enough oxygen in the uterus or the
infant does not get enough oxygen during labor or delivery or just after birth.

Shoulder dystocia. Infant's head has come out of the vagina, one of the shoulders becomes stuck.

Excessive bleeding. If delivery results in tears to the uterus, or if the uterus does not contract to deliver the
placenta, heavy bleeding can result. Use of misoprostol to reduce bleeding, especially in resource-poor
settings.