Stages of Labor Nursing Intervention: First Stage

Give at least 3 nursing intervention in the different stages of labor.
List different measures to relieve the perineal laceration.
Stages of Labor Nursing Intervention

FIRST STAGE
 Assess patient’s psychological
readiness. Provide continuous
maternal support.
 Measure duration of latent phase.
For nulliparas, it should not be
more than 6 hours. On the other
hand, for multiparas, it should be
Latent (Preparatory) Phase within 4.5 hours. Determine if
Starts from the onset of true labor patient received anesthesia
contractions to 3 cm cervical dilatation. because it can prolong latent
phase. One of the most common
causes of prolonged latent phase
is cephalopelvic disproportion
(CPD) and it requires cesarean
birth.
 Allow patient to be continually
active. Upright maternal positions
are recommended for women on
the first stage of labor. Patients
without pregnancy complications
can still walk around and make
necessary birth preparations
 Inform patient on the progress of
her labor to lessen her anxiety and
obtain her trust and cooperation.
Active Phase
 Encourage patient to be
Starts from 4 cm cervical dilatation to 7 cm
cervical dilatation. During this phase, continually active to maximize the
contraction intensity is stronger, interval effect of uterine contractions.
shortens, and duration lengthens. This is Upright maternal positions are
where true discomfort is first felt by the recommended if tolerated.
patient so she is dependent and her focus is  Assist patient in assuming her
on herself. position of comfort. For those who
can’t stay upright, left-side lying is
recommended to avoid disruption
in fetal oxygenation.
Transition Phase  Inform patient on progress of her
Starts from 8 cm cervical dilatation to 10 cm labor.
(full) cervical dilatation and full cervical  Assist patient with pant-blow
effacement. During this time, patient may be
breathing.
exhausted and withdrawn or aggressive and
 Monitor maternal vital signs and
restless. fetal heart rate every 30 minutes
-1 hour, or depending on the
doctor’s order. Contraction
monitoring is also continued.
SECOND STAGE  Instruct patient on quality pushing.
The abdominal muscles must aid
Starts when cervical dilatation reaches 10 the involuntary uterine
cm and ends when the baby is delivered. At contractions to deliver the baby
this stage, the patient feels an uncontrollable out.
urge to push. The patient may also
 Provide a quiet environment for
experience temporary nausea together with
increased restlessness and shaking of the patient to concentrate on
extremities. The nurse at this stage must bearing down.
coach quality pushing and support delivery.  Provide positive feedback as the
patient pushes.
WHO do not recommend the following

interventions during delivery because
they provide low quality of evidence:
 Perineal massage
 Use of fundal pressure
THIRD STAGE (PLACENTAL STAGE)  Lengthening of umbilical cord
 Sudden gush of vaginal blood
Starts from birth of infant to delivery of  Change in the shape of uterus
placenta. It is divided into two separate (globular in shape)
phases: placental separation and  Firm uterine contractions
placental expulsion. Five minutes after  Appearance of placenta in vaginal
delivery of baby, the uterus begins to opening
contract again, and placenta starts to
separate from the contracting wall. Blood
loss of 300-500 mL occurs as a normal
consequence of placental separation.
Placenta sinks to the lower uterine
segment or upper vagina. The placenta
is then expelled using gentle traction on
the cord.
Different Measures to Relieve the Perineal Laceration

To relieve pain or discomfort
 Keep an ice pack on your perineal area

 Try an anesthetic spray
 Have regular sits baths in a tub of warm, shallow water
 Take pain medicine. Some pain medicines can be constipating, so ask your health
professional for a formulation that includes a stool softener.
 Take stool softeners and drink lots of fluids to help soften stools and ease pain.
 Use warm water from a squeeze bottle to keep the perineal area clean. Pat it dry with
gauze or a sanitary wipe. Only wipe your perineal area from front to back
To help the area heal:
 Avoid using a hairdryer on the area as this can damage the tissue. The dust and hair
particles can also blow off the hairdryer and get stuck in the wound and cause
infection. Use a clean towel to pat the area dry instead.
 Wear breathable materials, such as cotton. Disposable briefs with loose clothing can
also help.
 Do your pelvic floor exercises. This helps increase the blood flow to the area and
speed up the healing process. Doing pelvic floor exercises will also help strengthen
the muscles around the vagina and the anus, which should help improve any issues
controlling your bowels.
 Avoid smoking as this can affect how well the wound heals.
 Avoid heavy lifting or strenuous exercise for 4-6 weeks after childbirth
REFERENCE
https://nurseslabs.com/stages-of-labor/#first_stage_of_labor
https://www.uofmhealth.org/health-library/zx3823
https://www.tommys.org/pregnancy-information/after-birth/recovering-perineal-tear

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Give at least 3 nursing intervention in the different stages of labor.

List different measures to relieve the perineal laceration.

Stages of Labor Nursing Intervention

WHO do not recommend the following

Different Measures to Relieve the Perineal Laceration

 Keep an ice pack on your perineal area

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