Stages of Labor • Attitude of the woman: Generally, feel

comfortable walking and sitting; Can usually

First Stage: Dilatation Stage talk or laugh during their contractions
• Begins with the onset of true labor contractions
to full dilatation & effacement of the cervix. Latent Phase
• 2 important events 1. Assess patient’s psychological readiness. Provide
 Cervical effacement continuous maternal support (compared to usual care).
 Cervical dilatation 2. Measure duration of latent phase.
• nulliparas, it should not be more than 6 hours.
The first stage is also called the Dilatation or cervical • multiparas, it should be within 4 to 5 hours
stage. It extends from the first true uterine contraction Determine if patient received anesthesia because it can
until the cervix is completely effaced & dilated. prolong latent phase. One of the most common cause of
prolonged latent phase is cephalopelvic disproportion
Cervical effacement* (CPD) and it requires cesarean birth.
Primiparas – dilatation begins when cervix is
completely effaced. Stages of labor
Multiparas – dilatation & effacement takes place at the 1st stage : Dilatation/Cervical Stage
same time. Phases: L – latent
Cervical effacement is the shortening or thinning of A - Active
the cervical canal from a bottleneck with a length of T - Transition
about 4 cm until it is paper thin. 2nd stage : Expulsion
3rd stage: Placental
Cervical dilatation 4th stage: Recovery
 Fully dilated – diameter 10 cm.
 Uterine contraction causes dilatation by 3. Allow patient to be continually active.
pulling the cervix over the presenting • Upright maternal positions are recommended
part for women on the first stage of labor.
 BOW & fetal head acts as a wedge in
dilating the cervix Patients without pregnancy complications can still walk
 Increased amount of show as dilatation around and make necessary birth preparations.
is completed*
4. Conduct interviews and filling in of forms (e.g., birth
Cervical dilatation refers to the enlargement/ opening certificate) at this phase while the patient experiences
or widening of the cervical os. Increased amount of minimal discomfort and has control over contraction
show as dilatation is completed since the last pains.
operculum (mucus plug) is dislodged and minute 5. Conduct health teaching on
capillaries rupture. • breastfeeding,
• newborn care,
Divided into 3 phases: • newborn screening and
1. Latent Phase • effective bearing down because during
Latent (Preparatory) Phase this time, patient’s anxiety is controlled
• Cervical dilatation – 0 to 4 cm Dilate only very and she is able to focus on nurse’s
slow. instructions.
• Interval: 3 to 5 minutes 6. Educate patient on different relaxation techniques. As
• Duration of 20 to 40 seconds early as this phase, encourage patient to begin
• intensity; mild to moderate alternative therapy of pain relief.
7. Ensure that the total number of internal examinations
Latent (Preparatory) Phase starts from the onset of true the woman receives in the entire course of labor is
labor contractions to 4 cm cervical dilatation. limited to 5 only.
8. Ensure that birthing companion of choice is present
• Have regular, frequent contractions that may or all throughout the course of labor.
may not be painful.
• Length of the latent Phase 2. Active Phase
Primis – 6 hours • cervical dilatation - 4 cm to 7 cm
Multis – 4 to 5 hours • intensity is moderate to strong
• interval shortens (2-3mins, and
 • duration lengthens (30 to 60 seconds). Here are nursing responsibilities in this phase:
• Length: 1.Inform patient on progress of her labor.
Primis – 3 hours 2. Assist patient with pant-blow breathing.
Multis – 2 hours 3. Monitor maternal vital signs and fetal heart rate
every 30 minutes -1 hour, or depending on the doctor’s
• This is where true discomfort is first felt by the order. Contraction monitoring is also continued.
patient so she is dependent and her focus is on
herself. Pant-blow breathing is done through the mouth. You
• Usually are not comfortable with talking or take several fast, shallow breaths and then you blow out
laughing during their contractions. The shallow breaths make a quiet "heh" sound. Choose
any rhythm that is best for you. Many women are
As intensity of contractions become stronger and start to comfortable with "heh, heh, heh, heh, and blow" (four
cause pain and much discomfort, the woman prefers to fast pants to one complete blow). You can also try other
stay in bed. She withdraws from her environment as her rhythms like "heh, heh, blow" (two fast pants to one
attention is focused on herself and the sensations on her complete blow) or "heh, heh, heh, blow" (three fast pants
body. to one complete blow)

Nursing responsibilities in this phase: 4. When perineal bulging is noticeable, prepare for
1. Inform patient on the progress of her labor to lessen delivery. Check room temperature (25-28⁰C and free of
her anxiety and obtain her trust and cooperation. air drafts).
2. Start monitoring progress of labor with the use of The nurse should also notify staff and prepare
WHO partograph, 2-hour action line. necessary supplies and equipment, including
3. Encourage patient to be continually active to resuscitation machine.
maximize the effect of uterine contractions. 5. Lastly, perform handwashing and double gloving.
Upright maternal positions are recommended if
tolerated. WHO do not recommend the following nursing
4.Assist patient in assuming her position of comfort. interventions during labor because they have low quality
For those who can’t stay upright, left-side lying is of evidence:
recommended to avoid disruption in fetal oxygenation.  Routine perineal shaving
5.Monitor maternal vital signs and fetal heart rate every  Routine use of enema
2 hours, or depending on the doctor’s order.  Admission cardiotocography (CTG) for low-risk
6. Anticipate patient needs (e.g., sponging face with cool women
cloth, keeping bed clean and dry, providing ice chips or  Vaginal douching
lip balm) to promote comfort.  Routine amniotomy for patients in spontaneous
7. Determine when patient last voided because a full labor
bladder* can hinder fast labor progress.  Massage and reflexology
8. Institute non-pharmacological pain measures (e.g.,
breathing exercises, distraction method, imagery, music Imagery: Guiding you through imaginary mental images
therapy, etc.) of sights, sounds, tastes, smells, and feelings can help
shift attention away from the pain.
Full bladder inhibits uterine contraction
Imagery: Guiding you through imaginary mental images Second Stage: Stage of Expulsion
of sights, sounds, tastes, smells, and feelings can help • starts when cervical dilatation reaches 10 cm
shift attention away from the pain. and ends when the baby is delivered*.
• At this stage, the patient feels an uncontrollable
3. Transition Phase urge to push.
• cervical dilatation 8 to 10 cm • The patient may also experience temporary
• cervical effacement – 100% nausea together with increased restlessness and
• Contractions: shaking of extremities.
- Interval - every 2-3 mins.
- Duration of 60-90 seconds Duration: Primi – 50 minutes
- Intensity-Strong Multi – 20 minutes
• patient may be exhausted and withdrawn or Transfer to DR: Primi- @ 10 cms.
aggressive and restless. Multi – @ 7-8 cm
• Patient’s urge to push is noticeable. Bulging of the perineun – surest sign of delivery
initiation
Mechanisms of labor
E – Engagement; D- descent; F- Flexion;
IR – internal rotation; E – extension; ER – external
rotation; E - extension

Delivery position
1. Lithotomy The nurse at this stage must coach quality pushing and
• is used when surgical procedures such as support delivery.
forceps or episiotomies are to be performed. 1. Instruct patient on quality pushing. The abdominal
2. Dorsal recumbent muscles must aid the involuntary uterine contractions to
• Head of bed is 35 to 45 degrees elevated deliver the baby out.
• knees are flexed and 2.Provide a quiet environment for the patient to
• Feet flat on bed concentrate on bearing down.
(side lying)left lateral 3. Provide positive feedback as the patient pushes.
Left lateral position
Indicated for women with heart disease Coach mother to push effectively: instruct her the
bearing down is like straining at stool, she must push
only when the urge to push is felt and relax completely
after contraction to replenish her energy.

4. Repeat doctor’s instructions. At this phase, the patient

barely hears the conversation around the room because
all her energy and thoughts are being directed toward
giving birth.
5. The woman may complain of leg cramps*

Leg cramps – pressure exerted by the fetal head against

Squatting the pelvic nerves.
Dorsiflex the affected foot and straighten the leg
Kneeling
6. When the head is crowning:
Instruct the mother to pant not to push to prevent rapid
expulsion of the baby and to avoid lacerations.

7. Ritgen’s maneuver is to be performed while delivery

the head.
- slows down delivery of the head
- lets the smallest diameter of the head to be born
- facilitates extension of the head
 Signs of placental separation:
• Fundus becomes firm and globular in shape;
rises to the abdomen – Calkin’s sign (1st sign)
• Lengthening of umbilical cord
• Sudden gush of vaginal blood

8.Take note of the time of delivery and proceed to

initiate essential newborn care. Delayed cord clamping
is recommended.
9. Assist in restrictive episiotomy for patients who had
vaginal births.

Episiotomy
• Prevents lacerations
• Widens the vaginal canal • Blood loss of 300-500 mL occurs as a normal
• Shortens the 2nd stage of labor consequence of placental separation.
• Rapid pulling of the cord may cause uterine
inversion

Mechanism of Placental separation

Mathew’s duncan –the leading edge of the placenta

WHO do not recommend the following interventions separates first and the placenta is delivered with its raw
during delivery because they provide low quality of surface exposed;
evidence: Duncan – separation begins from the edges of the
1. Perineal massage placenta. The maternal side is delivered first.
2. Use of fundal pressure Schultz – separation of the placenta starts from the
center. The shiny and smooth fetal side is delivered first;
Third Stage: Placental Stage
• starts from birth of infant to delivery of
placenta.
• It is divided into two separate phases:
- Placental separation
- Placental expulsion.
• 3 to 10 mins. after delivery of baby, the uterus
begins to contract again, and placenta starts to
separate from the contracting wall.
 • Utilize absorbable synthetic suture materials
(over chromic catgut) for primary repair of
episiotomy or perineal lacerations.

Fourth Stage: Recovery

• Immediate postpartum*,
• the nurse checks the vital signs and monitors for
excessive bleeding*.
• The first four hours after birth is sometimes
referred to as the Recovery stage of labor
because this is the most critical period for the
mother.

The mother and newborn recover from the physical

process of birth
The main danger during the 4th stage is hemorrhage
Nursing Considerations during Placental delivery
• Utilize controlled cord traction technique for • The nurse is set to perform nursing interventions
placental expulsion that would prevent the patient from infection
• Administer oxytocic drugs as ordered. and hemorrhage.
- Oxytocin • The fundus is checked every 15 minutes
- Methergin - fundus should be at the level of
- Carboprost the umbilicus*
• Massage uterus gently - if boggy or relaxed – massaged
gently
Oxytocin drugs – are drugs that stimulate uterine
contractions A high fundus or displaced to the right or left is usually
Carboprost is a form of prostaglandin (a hormone-like caused by a full bladder.
substance that occurs naturally in the body).
Prostaglandins help to control functions in the body such • The bladder should be assessed frequently to
as blood pressure and muscle contractions. Carboprost is prevent distention.
used to treat severe bleeding after childbirth • a full bladder displaces the uterus and prevents
(postpartum). effective uterine contraction thereby
predisposing the woman to hemorrhage.
• Coach in relaxation for delivery of placenta.
• Congratulate on delivery of baby. A high fundus or displaced to the right or left is usually
• Encourage skin-to-skin contact to facilitate caused by a full bladder.
bonding and early breastfeeding.
• The nurse is set to perform nursing interventions
Retained placental fragments can cause severe that would prevent the patient from infection
hemorrhage by preventing the uterus to contract and hemorrhage.
• they are being reminded of the importance of:
• Ask patient whether placenta is important to  breastfeeding,
them before it is disposed.  ambulation, and
• For those who want to take it home, ensure that  newborn care.
they understand and follow standard infection
precautions and hospital policy. WHO recommendations for immediate postpartum:
• Early (<6 hours) resumption of feeding for
Retained placental fragments can cause severe patients who have vaginal birth
hemorrhage by preventing the uterus to contract • Prophylactic antibiotics for women who
sustained third to fourth degree of perineal tear
• Inspect placental completeness during delivery
- 15 to 20 cotyledons* • In healthy women who delivered vaginally to
- 500 gms. term infants, early postpartum discharge is
recommended.
Interventions not recommended during immediate
postpartum:
• Routine use of ice packs
• Oral methylergometrine for patients who
delivered vaginally