7/27/2019 Stages of Labor and Its Management

1/3

STAGES OF LABOR

STAGES OF LABOR ANDUTERINE CONTRACTIONS

WOMANS RESPONSE NURSING INTERVENTIONS

STAGE I:DILATIONMAIN GOALS: COMPLETEDILATION OF CERVIX, DESCENTOF FETUS

Latent phase: cervix 0-3 cmContractions every 10-20 min,15- to 30-sec duration,mild intensity; progressingto every 5-7 min, 30- to 40-secduration, mild to moderateintensity

-Happy, excited-Talkative and eager to be in labor

-Exhibits need for independence-Attempts to care for own bodilyneeds-Seeks information about hercare-Some apprehension

-Establish rapport-Monitor maternal vital signs and

FHR-Assess status of amniotic fluid; ifmembranesintact or ruptured-Observe voiding time and amount-Assess coping ability, anxiety-Teach breathing techniques ifneeded-Encourage walking if membranesare intact-Encourage woman and supportperson to participatein care-Encourage relaxation if lying down(assist with

techniques such as effleurage) orsacral pressure-Offer fluids/ice chips-Woman is kept NPO to preventaspiration-Keep couple informed

STAGE 1:

Active phase: cervix 4-7 cmContractions every 2-3 min, 50-to 60-sec duration, moderateto strong intensity

ApprehensiveIll-defined doubts and fears-Exhibits increased fatigue andmay feel restless-As contractions becomestronger, becomes anxious-Becomes more dependent asshe is less able to meet herneeds

-Desire for companionship-Becomes uncertain if she cancope with contractions-Ritual activities or motions duringcontractions may indicatestrong coping strategies are inplace

-Continue to assess and documentmaternalvital signs and FHR every 30 min-Provide support and encouragement-If on electronic fetal monitor,observe fornormal/abnormal signs; explainmonitor towoman and support person

-Assess status of membranes-Encourage to void every 1-2 hr toavoid bladderdistention-Observe for full bladder (womanloses urge tovoid with epidural block)-Assess progress of labor (cervicaldilation)-Registered nurse may performvaginal examination(see Figure 8-3)-Provide comfort and safetymeasures:moisten lips, apply ointment, provideicechips-Apply cool cloth to womansforehead-Provide back rubs, sacral pressure,effleurage,attention-focusing activities-Assist with oral hygiene-Keep bed linens dry and bedrails up-Provide assistance with position

7/27/2019 Stages of Labor and Its Management

2/3

changes,support with pillows, or walking-Protect woman from infection withfrequentperineal care-Inform couple about labor progress

STAGE 1:

Transition: cervix 8-10 cmContractions every 2-3 min, 60-to 90-sec duration, strongintensity

-Marked restlessness and

irritability-Amnesia between contractions-Generalized discomfort, crampsin legs-Sometimes hiccupping andbelching-Nausea and vomiting-Perspiration on face-Trembling of legs-Increased vaginal show-May feel tearing open or splittingapart with contractions-Desires medication-May feel out of control-Fear of being alone

-Continue nursing interventions from

activephase-Encourage woman to rest betweencontractions-Talk woman through the contractionby maintainingbreathing pattern-Assess monitor strip fornormal/abnormalsigns (if on monitor); if not onmonitor, assess-FHR and blood pressure every 15min-Recognize woman may not want tobe

touched during transition period;recognizethis is a difficult time for woman-Do not leave woman alone-Accept behavior of throwing offcovers, etc.-Get blanket if woman feels cold;assist tochange positions-Apply cool cloth to head whenwomanfeels hot-Encourage voiding, assess for fullbladder-Provide support, praise, and

encouragementfor her efforts-Provide privacy

STAGE 2:

EXPULSION OF FETUSMAIN GOAL: DESCENT TO BIRTHOF BABY, COMPLETE DILATION10 CM

Contractions every 1.5-2 min,60- to 90-sec duration,strong intensity

-Desire to push-Satisfaction if told baby is almosthere-Complete exhaustion-Pushes with contractions-May feel helpless, out of control,panicky-Rectal and vaginal bulging andflattening of perineum

-Encourage open-glottis gruntingpush techniquewhen bearing down is spontaneous-Encourage deep breathing betweencontractions-Assess FHR after each contraction(if not onmonitor)-Assess monitor strip fornormal/abnormalfindings

-Assess contraction for frequency,duration,and intensity-Assess progress of labor; informwoman andpartner-Encourage continued support-Remain with woman at all times-Cleanse perineal area (strokedownward)-Provide necessary materials and

7/27/2019 Stages of Labor and Its Management

3/3

equipmentfor delivery-After birth, give immediate care tonewborn-Assess woman for potentialhemorrhage

STAGE 3:

EXPULSION OF PLACENTAMAIN GOALS: EXPULSION OFPLACENTA, PREVENTION OFHEMORRHAGE

Contractions temporarily cease2-3 contractions to expel placentaUpward rise of uterus in abdomenVisible lengthening of umbilical cordTrickle or gush of blood

-Eager to get acquainted with

baby-Sense of relief

-Assess womans vital signs

-Assess for excessive bleeding-Provide nurse-midwife/physicianwith necessarymaterials (for possible episiotomyrepair)-Take woman to recovery room (if intraditionalfacility)-Encourage parent-newborn bonding

STAGE 4:

IMMEDIATE RECOVERY PERIOD(MINIMUM 1 HR)MAIN GOALS: PREVENTHEMORRHAGE, FACILITATEMATERNAL-NEWBORN BONDING

-Exhausted but happy labor isover-Eager to feed baby-Hungry-Thirsty-Sleepy

-Nursing assessment is directedtoward preventionof hemorrhage-Assess every 15 min for 1 hrminimum: funduslocation (height) and consistency (ifnotfirm, massage and report); lochiaamount,color, odor; vital signs: bloodpressure,pulse, temperature; perineum:episiotomyfor edema, hematoma; state ofhydration;bladder for distention; fatigue andexhaustion(provide atmosphere for rest)-Encourage mother-newborn

bonding: holdbaby, breastfeed-Provide privacy for woman, partner,and babyto get acquainted

REFERENCE:

http://www.eu.elsevierhealth.com/media/us/samplechapters/9780721604787/Chapter%208%20Nursin

g%20Care%20During%20Labor%20and%20Pain%20Management.pdf, retrieved October 15, 2013

http://www.eu.elsevierhealth.com/media/us/samplechapters/9780721604787/Chapter%208%20Nursing%20Care%20During%20Labor%20and%20Pain%20Management.pdfhttp://www.eu.elsevierhealth.com/media/us/samplechapters/9780721604787/Chapter%208%20Nursing%20Care%20During%20Labor%20and%20Pain%20Management.pdfhttp://www.eu.elsevierhealth.com/media/us/samplechapters/9780721604787/Chapter%208%20Nursing%20Care%20During%20Labor%20and%20Pain%20Management.pdfhttp://www.eu.elsevierhealth.com/media/us/samplechapters/9780721604787/Chapter%208%20Nursing%20Care%20During%20Labor%20and%20Pain%20Management.pdfhttp://www.eu.elsevierhealth.com/media/us/samplechapters/9780721604787/Chapter%208%20Nursing%20Care%20During%20Labor%20and%20Pain%20Management.pdf