THE FIRST STAGE

The first stage, which takes about 12 hours to complete, is divided into three segments: a latent,
an active, and a transition phase. Traditionally the Freidman’s curve, an algorithm for
determining normal labor progress, has been utilized in labor settings everywhere. However, new
research is discovering that a normal labor can actually take a great deal longer than previously
thought (Zhang, Landy, Branch, et al., 2010).

The Latent Phase

The latent or early phase begins at the onset of regularly perceived uterine contractions and ends
when rapid cervical dilatation begins. Contractions during this phase are mild and short, lasting
20 to 40 seconds. Cervical effacement occurs, and the cervix dilates minimally. A birthing parent
who is multiparous usually progresses more quickly than a nullipara. A woman who enters labor
with a “nonripe” cervix will probably have a longer than average latent phase. If a woman wants
analgesia at this point, she shouldn’t be denied of it, but analgesia given too early in labor is a
factor that tends to prolong this phase.
In a woman who is psychologically prepared for labor and who does not tense at each tightening
sensation in her abdomen, latent phase contractions cause only minimal discomfort and can be
managed by controlled breathing. During this phase, encourage women to continue to walk about
and make preparations for birth, such as doing lastminute packing for her stay at the hospital or
birthing center, preparing older children for her departure and the upcoming birth, or giving
instructions to the person who will take care of them while she is away. If desired, she could
begin alternative methods of pain relief such as aromatherapy, distraction, or acupressure (Steel,
Adams, & Sibbritt, et al., 2014). If the woman should come to a birthing setting this early,
encourage her to continue to be active and to use any nonpharmacotherapeutic measures she
finds effective.

The Active Phase

During the active phase of labor, cervical dilatation occurs more rapidly. Contractions grow
stronger, lasting 40 to 60 seconds, and occur approximately every 3 to 5 minutes. Show
(increased vaginal secretions) and perhaps spontaneous rupture of the membranes may occur
during this time. Encourage women to be active participants in labor by keeping active and
assuming whatever position is most comfortable for them during this time, except flat on their
back (Iravani, Janghorbani, Zarean, et al., 2015). This phase can be difficult for a woman
because contractions grow so much stronger and last so much longer than they did in the latent
phase that she begins to experience true discomfort. It is also both an exciting and a frightening
time because it is obvious something dramatic is definitely happening. In a few hours, a woman
will have a new baby. Her life will never be the same again.
The Transition Phase
During the transition phase, contractions reach their peak of intensity, occurring ever 2 to 3
minutes with a duration of 60 to 70 seconds, and a maximum cervical dilatation of 8 to 10 cm
occurs. If it has not previously occurred, show will occur as the last of the mucus plug from the
cervix is released. If the membranes have not previously ruptured, they will usually rupture at
full dilatation (10 cm). By the end of this phase, both full dilatation (10 cm) and complete
cervical effacement (obliteration of the cervix) have occurred.
During this phase, a woman may experience intense discomfort that is so strong, it might be
accompanied by nausea and vomiting. She may also experience a feeling of loss of control,
anxiety, panic, and/or irritability. Because of the intensity and duration of the contractions, it
may seem as though labor has taken charge of her. A few minutes before, she may have enjoyed
having her forehead wiped with a cool cloth or her back rubbed. Now, she may knock a partner’s
hand away from her. Her focus turns entirely inward to the task of birthing her baby. As a
woman reaches the end of this stage at 10 cm of dilatation, unless she has been administered
epidural anesthesia, a new sensation, the irresistible urge to push, usually begins.

THE SECOND STAGE

The second stage of labor is the time span from full dilatation and cervical effacement to birth of
the infant. A woman typically feels contractions change from the characteristic crescendo–
decrescendo pattern to an uncontrollable urge to push or bear down with each contraction as if to
move her bowels. She may experience momentary nausea or vomiting because pressure is no
longer exerted on her stomach as the fetus descends into the pelvis. She pushes with such force
that she perspires and the blood vessels in her neck become distended.
The fetus begins descent and, as the fetal head touches the internal perineum to begin internal
rotation, her perineum begins to bulge and appear tense. The anus may become everted, and stool
may be expelled. As the fetal head pushes against the vaginal introitus, this opens and the fetal
scalp appears at the opening to the vagina and enlarges from the size of a dime, to a quarter, then
a half-dollar. This is termed crowning. It takes a few contractions of this new type for a woman
to realize everything is all right, just different, and to appreciate it feels better and less
frightening, to push with contractions. As she concentrates on pushing, she may become unaware
of the conversation in the room. Pain may disappear as all of her energy and thoughts are
directed toward giving birth. As the fetal head is pushed out of the birth canal, it extends and
then rotates to bring the shoulders into the best line with the pelvis. The body of the baby is then
born.

THE THIRD STAGE

The third stage of labor, the placental stage, begins with the birth of the infant and ends with the
delivery of the placenta. Two separate phases are involved: placental separation and placental
expulsion. After the birth of the infant, the uterus can be palpated as a firm, round mass just
below the level of the umbilicus. After a few minutes of rest, uterine contractions begin again,
and the organ assumes a discoid shape. It retains this new shape until the placenta has separated,
approximately 5 minutes after the birth of the infant.

Placental Separation
As the uterus contracts down on an almost empty interior, there is such a disproportion between
the placenta and the contracting wall of the uterus that folding and separation of the placenta
occur. Active bleeding on the maternal surface of the placenta begins with separation, which
helps to separate the placenta still further by pushing it away from its attachment site. As
separation is completed, the placenta sinks to the lower uterine segment or the upper vagina.
The placenta has loosened and is ready to deliver when:
• There is lengthening of the umbilical cord.
• A sudden gush of vaginal blood occurs.
• The placenta is visible at the vaginal opening.
• The uterus contracts and feels firm again.
If the placenta separates first at its center and lastly at its edges, it tends to fold on itself like an
umbrella and presents at the vaginal opening with the fetal surface evident. Approximately 80%
of placentas separate and present in this way. Appearing shiny and glistening from the fetal
membranes, this is called a Schultze presentation. If, however, the placenta separates first at its
edges, it slides along the uterine surface and presents at the vagina with the maternal surface
evident. It looks raw, red, and irregular, with the ridges or cotyledons that separate blood
collection spaces evident; this is called a Duncan presentation. Although there is no difference in
the outcome, record which way the placenta presented. A simple trick of remembering the
presentations is remembering that, if the placenta appears shiny, it is a Schultze presentation. If it
looks “dirty” (the irregular maternal surface shows), it is a Duncan presentation. This stage can
take anywhere from 1 to 30 minutes and still be considered normal. Because bleeding occurs as
the placenta separates, before the uterus contracts sufficiently to seal maternal capillaries, there is
a blood loss of about 300 to 500 ml, not a great amount in relation to the extra blood volume that
was formed during pregnancy

Placental Expulsion
Once separation has occurred, the placenta delivers either by the natural bearing-down effort of
the mother or by gentle pressure on the contracted uterine fundus by the primary healthcare
provider (a Credé maneuver). Pressure should never be applied to a uterus in a noncontracted
state because doing so could cause the uterus to evert (turn inside out), accompanied by massive
hemorrhage (Bienstock et al., 2015). If the placenta does not deliver spontaneously, it can be
removed manually. It needs to be inspected after delivery to be certain it is intact and part of it
was not retained (which could prevent the uterus from fully contracting and lead to postpartal
hemorrhage). In recognition of cultural preferences, be certain to ask if a woman wants to take
home the placenta because this can be a strong cultural tradition you don’t want to break (Box
15.3)
Some women choose to have a cord blood sample withdrawn from the cord to be banked for
stem cell transplantation in the future. In some major health centers, women may be asked to
donate a placental blood sample for a community stem cell banking program