Stages of Labor

 1st Stage = true labor pain –full dilatation

 Pre-Labor
 Phase 1 - Early Labor/Latent
 Phase 2 - Active Labor
 Phase 3 – Transition
 2nd Stage- full dilatation – delivery of baby
 3rd Stage- delivery of baby – delivery of placenta
 4th Stage- delivery of placenta – 1st 4 hours after
Stage 1: Latent phase
From onset of labor to 4cm cervical dilatation
Assessment:
 Contractions: mild and irregular; 5-30 min. apart; last 10-
30 sec.
 Cervical dilatation: 0 – 4cm
 Duration: 8–10hrs
 Descent: Primi: 0 ; Multi: 0 – 2cm
 Show: brownish, mucus plug or pale, pink mucus,
scanty amount
 Behavior: Bubbly, excited. A little stage fright., wish to
tell the world. Gradually less sociable, more serious,
beginning to realize it’s work.
 Membranes: intact or ruptured
Assessment:
 FHR q 15 min; immediately after rupture of membrane
 Maternal v/s: temp q 2H if membranes ruptured; q 4H
if intact. PR and RR q 1H or prn. BP q 30min or prn
 Time of last ingestion of food
 Knowledge of labor process and birth plan

** BEST TIME TO TEACH BREATHING

TECHNIQUES BECAUSE THE WOMAN IS STILL
COMFORTABLE, COOPERATIVE & CAN
STILL CONCENTRATE ON A
CONVERSATION WELL.
Stage 1: Active phase
From 4cm to 8cm cervical dilatation
Assessment:
 Contractions: moderate; more regular; 3 – 5min
apart; 30 -45 sec
 Cervical dilatation: 4 – 8cm
 Duration: 3 hrs
 Descent: Primi and Multi: +1 to +2cm
 Show: pink to bloody mucus, scant to moderate
 Behavior: Working very hard. Serious, need to
concentrate. Intense pressure with contractions.
Backache may intensify or vanish. Pushing effort.
Very self-centered.
 Assess maternal and fetal v/s
 Membranes: intact or ruptured
** THIS PHASE LASTS APPROXIMATELY 3
HOURS IN A NULLIPARA & 2 HOURS IN A
MULTIPARA.

** ANESTHESIA IS GIVEN DURING THIS PHASE

AT 5- 6 CM DILATATION.
 Timing of anesthesia administration

1. Before 5 cm (latent phase)

- may retard or stop labor
2. From 5 to 7 cm (early active phase)
- may aid relaxation
3. After 8 cm (transition phase)
- may result in respiratory depression requiring
resuscitative measures in sedated neonate
Stage 1: Transition phase
From 8cm to 10 cm/full cervical dilatation
Assessment:
 Contractions: Strong to expulsive and regular; 2
-3min apart; 45 – 60sec (few to 90sec)
 Cervical dilatation: 8 – 10cm

 Duration: 1 – hr

 Descent: Primi and Multi: +2 to +3cm

 Show: bloody mucus, copious

 Behavior: Confused, irritable, not wanting to be

touched, afraid of losing control. Increased rectal
pressure. Increased backache.
Assessment:

 Signs of nausea, vomiting, trembling and

crying
 Maternal/fetal v/s
 Breathing patterns, may be hyperventilating
 Urge to bear down with contractions
*** A SURE SIGN THAT THE BABY IS
ABOUT TO BE BORN IS THE BULGING
OF THE PERINEUM. IN GENERAL,
PRIMIGRAVIDAS ARE TRANSPORTED
FROM LR TO DR WHEN THERE IS
BULGING OF THE PERINEUM (10 CM);
MULTIPARAS ARE TRANSPORTED AT 7-8
CM CERVICAL DILATATION OR AT
+1+2***
CHARACTERISTICS:
***IF SPONTANEOUS RUPTURE DOES NOT
OCCUR AT THIS TIME, AMNIOTOMY
(SNIPPING OF BOW WITH A STERILE
POINTED INSTRUMENT TO ALLOW
AMNIOTIC FLUID TO DRAIN) IS DONE
TO PREVENT FETUS FROM
ASPIRATING THE AMNIOTIC FLUID AS IT
MAKES ITS VARIOUS FETAL POSITION
CHANGES
***AMNIOTOMY HOWEVER CANNOT BE
DONE IF STATION IS STILL AT “MINUS”
AS THIS CAN LEAD TO CORD
COMPRESSION.
***THERE IS AN UNCONTROLLABLE URGE
TO PUSH WITH CONTRACTIONS, A
SIGN OF AN IMPENDING SECOND
STAGE OF LABOR.
***NOTE: CHECKING THE BLOOD PRESSURE
SHOULD BE DONE MIDWAY BETWEEN
CONTRACTIONS BECAUSE IT
NORMALLY INCREASES DURING A
CONTRACTION.
*** FHR SHOULD NOT BE TAKEN DURING
UTERINE CONTRACTIONS SINCE IT
TENDS TO SLOW DOWN AS INDUCED BY
THE COMPRESSION OF THE FETAL HEAD
DURING UTERINE CONTRACTIONS
REASONS FOR ADMIN. OF ENEMA:
a. TO PREVENT INFECTION TO BOTH THE
MOTHER & THE FETUS.
b. IT HELPS TO INCREASE UTERINE
CONTRACTIONS.
c. PREVENTS POSTPARTUM DISCOMFORT
d. TO FACILITATE THE DESCENT OF THE
FETUS TO THE BIRTH CANAL.
 CONTRAINDICATIONS OF ENEMA:
a. MALPRESENTATION & POSITION
b. VAGINAL BLEEDING
c. RUPTURED BAG OF WATERS
d. CROWNING
e. PLACENTA PREVIA
Stage 2
From full dilatation of cervix to birth of the baby
MECHANISM OF LABOR
7 CARDINAL MOVEMENTS/ MECHANISM
OF LABOR / FETAL POSITION CHANGES:
1.ENGAGEMENT = “STATION 0”
2. DESCENT = DOWNWARD MOVEMENT
OF THE BIPARIETAL DIAMETER OF THE
FETAL HEAD TO WITHIN THE PELVIC
INLET. (occurs due to the pressure on the
fetus by the uterine fundus) THE PRESSURE
OF THE FETUS ON THE SACRAL NERVES
CAUSES THE MOTHER TO EXPERIENCE A
PUSHING SENSATION.
3. FLEXION = AS FETAL HEAD REACHES PELVIC
FLOOR, PRESSURE FROM THE PELVIC FLOOR
CAUSES THE FETAL HEAD TO BEND FORWARD
ONTO THE CHEST. THIS PERMITS THE
SMALLEST AP DIAMETER
(SUBOCCIPITOBREGMATIC DIAMETER) TO
PRESENT IN THE OUTLET.
4. INTERNAL ROTATION – THE HEAD FLEXES &
THE OCCIPUT ROTATES UNTIL IT IS SUPERIOR,
OR JUST BELOW THE SYMPHYSIS PUBIS
BRINGING THE HEAD TO THE BEST
RELATIONSHIP TO THE OUTLET OF THE PELVIS.
(SMALLEST DIAMETER IS PRESENTED TO THE
PELVIC OUTLET).
5. EXTENSION = AS THE HEAD COMES OUT,
THE BACK OF THE NECK STOPS AT THE PUBIC
ARCH & ACTS AS A PIVOT FOR THE REST OF
THE HEAD. THE HEAD EXTENDS & THE
FOREHEAD, NOSE, MOUTH & FINALLY THE CHIN
APPEAR.
6. EXTERNAL ROTATION=
- AS THE HEAD IS BORN IT ROTATES BRIEFLY
BACK TO DIAGONAL OR TRANSVERSE
POSITION OF THE EARLY PART OF LABOR, (THE
POSITION IT OCCUPIED WHEN IT WAS
ENGAGED) BRINGING THE SHOULDER TO AN
Antero-Posterior POSITION.
** WHEN THE BIPARIETAL DIAMETER OF THE
FETAL HEAD HAS PASSED THE PELVIC INLET,
THE PALPABLE PORTION OF THE FETAL HEAD
IS APPROXIMATELY AT STATION +2). ONE
SHOULDER, IS ANTERIOR TO THE SYMPHYSIS
PUBIS & THE OTHER IS POSTERIOR TO THE
PELVIC FLOOR.)
7.EXPULSION = WITH THE DELIVERY OF THE
SHOULDERS, THE REST OF THE BABY IS BORN
EASILY & SMOOTHLY BECAUSE OF ITS
SMALLER SIZE & BIRTH IS COMPLETED.( END
OF PELVIC DIVISION OF LABOR).
NURSING CARE:
a.WHEN POSITIONING LEGS IN
LITHOTOMY POSITION, PUT THEM UP
AT THE SAME TIME TO PREVENT
INJURY TO THE UTERINE LIGAMENTS.
b. AS SOON AS THE FETAL HEAD
CROWNS, INSTRUCT THE MOTHER NOT
TO PUSH BUT TO PANT INSTEAD
( RAPID & SHALLOW BREATHING), TO
PREVENT RAPID EXPULSION OF THE
BABY.
c. IF PANTING IS DEEP & RAPID, CALLED
HYPERVENTILATION,THE PATIENT WILL
EXPERIENCE LIGHTHEADEDNESS &
TINGLING SENSATION OF THE FINGERS
LEADING TO CARPOPEDAL SPASMS
BECAUSE OF RESPIRATORY ALKALOSIS.
MX:
- LET THE PATIENT BREATHE INTO A
PAPER BAG TO RECOVER LOST CARBON
DIOXIDE.( A CUPPED HAND WILL SERVE
THE SAME PURPOSE)
d. ASSIST IN EPISIOTOMY – INCISION MADE
IN THE PERINEUM PRIMARILY TO:
1. PREVENT LACERATIONS
2. PREVENT PROLONGED & SEVERE
STRETCHING OF MUSCLES
SUPPORTING BLADDER OR RECTUM
3. REDUCE DURATION OF SECOND STAGE
OF LABOR WHEN THERE IS
HYPERTENSION & FETAL DISTRESS
4. ENLARGE OUTLET, AS IN BREECH
PRESENTATION
 TYPES OF EPISIOTOMY

1. MEDIAN - FROM MIDDLE PORTION

OF THE LOWER VAGINAL BORDER
DIRECTED TOWARDS THE ANUS.

2. MEDIOLATERAL – BEGINS IN THE

MIDLINE BUT DIRECTED LATERALLY
AWAY FROM THE ANUS.
e. APPLY THE MODIFIED RITGEN’S
MANEUVER
** COVER THE ANUS WITH STERILE
TOWEL & EXERT UPWARD & FORWARD
PRESSURE ON THE FETAL CHIN. WHILE
EXERTING GENTLE PRESSURE WITH
TWO FINGERS ON THE HEAD TO
CONTROL THE EMERGING HEAD.
RITGEN’S MANEUVER
 THIS WILL NOT ONLY SUPPORT THE
PERINEUM THUS PREVENTING
LACERATIONS BUT WILL ALSO FAVOR
FLEXION SO THAT THE SMALLEST
SUBOCCIPITOBREGMATIC DIAMETER OF
THE FETAL HEAD IS PRESENTED.
** EASE THE HEAD OUT IN-BETWEEN
CONTRACTIONS & IMMEDIATELY
SUCTION SECRETIONS FROM THE
MOUTH & NOSE TO ESTABLISH A PATENT
AIRWAY.
REMEMBER:
** THE FIRST PRINCIPLE IN THE CARE
OF THE NEWBORN IS TO ESTABLISH &
MAINTAIN A PATENT AIRWAY.**
- THE HEAD SHOULD BE DELIVERED
IN BETWEEN CONTRACTIONS.
** INSERT TWO FINGERS INTO THE
VAGINA SO AS TO FEEL FOR THE
PRESENCE OF A CORD LOOPED
AROUND THE NECK (NUCHAL CORD ).
IF SO, BUT LOOSE, SLIP IT DOWN THE
SHOULDERS OR UP OVER THE HEAD;
BUT IF TIGHT, CLAMP CORD TWICE AN
INCH APART, AND THEN CUT IN-
BETWEEN.
Clamp the umbilical cord
Cut between the clamps
Stage 3
From birth of the baby to expulsion of the placenta
Assessment:
 Observe for signs of placental separation:
 the uterus contracts
 the uterus changes from discoid to globular
shape
 a sudden gush of blood from the vagina
 lengthening of the umbilical cord by 3 more
inches
 displacement of the uterus upward to the level of
the umbilicus
 Determine placental separation and presentation
 Schultze (most common): shiny and glistening
from the fetal surface
 separates in the center (80%)

 Duncan: looks raw, red, irregular and dirty

(because of its cotyledons) from the
maternal surface
 descends sideways, separates at the edges

rather than center

 Determine if placental fragments do not remain in
uterus (INSPECT FOR COMPLETENESS)
NURSING CARE:
1. DO NOT HURRY THE EXPULSION OF THE
PLACENTA BY FORCEFULLY PULLING OUT
THE CORD OR DOING VIGOROUS
FUNDAL PUSH AS THIS CAN CAUSE
UTERINE INVERSION.
2. TRACT THE CORD SLOWLY, WINDING IT
AROUND THE CLAMP UNTIL THE
PLACENTA SPONTANEOUSLY COMES
OUT ,ROTATING IT SLOWLY SO THAT
NO MEMBRANES ARE LEFT INSIDE
THE UTERUS. A METHOD CALLED
“BRANDT ANDREW’S MANEUVER”
3. TAKE NOTE OF THE TIME OF PLACENTAL
DELIVERY. IT SHOULD BE DELIVERED
WITHIN 15 TO 20 MINUTES AFTER THE
DELIVERY OF THE BABY, OTHERWISE
REFER IMMEDIATELY TO THE PHYSICIAN AS
THIS CAN CAUSE SEVERE BLEEDING IN THE
MOTHER.

** IF BLEEDING OCCURS & THE PLACENTA

CANNOT BE DELIVERED, MANUAL
EXTRACTION OF THE PLACENTA IS
INDICATED **
 Duncan
Mechanism

Schultz
Mechanism
Inspect the placenta for
completeness.
5. PALPATE THE UTERUS TO DETERMINE
DEGREE OF CONTRACTION. IF RELAXED,
BOGGY OR NON CONTRACTED; THE FIRST
NURSING ACTION IS TO MASSAGE
GENTLY. AN ICE CAP OVER THE ABDOMEN
WILL ALSO HELP CONTRACT THE UTERUS
SINCE COLD CAUSES VASOCONSTRICTION.
6. INJECT OXYTOXICS, METHERGIN OR
SYNTOCINON (IM) TO MAINTAIN UTERINE
CONTRACTIONS, THUS PREVENTING
HEMORRHAGE.
7. INSPECT THE PERINEUM FOR
LACERATIONS. ANYTIME THE UTERUS IS
FIRM FOLLOWING PLACENTAL DELIVERY,
YET BRIGHT RED VAGINAL BLEEDING IS
GUSHING FORTH FROM THE VAGINAL
OPENING, SUSPECT LACERATIONS.
 CATEGORIES OF LACERATIONS
1.FIRST DEGREE – INVOLVES THE
FOURCHETTE, PERINEAL SKIN
VAGINAL MUCUS MEMBRANES
2. SECOND DEGREE – INCLUDES THE
MUSCLES OF THE PERINEAL BODY.
3. THIRD DEGREE – EXTENDS TO THE
ANAL SPHINCTER
4. FOURTH DEGREE – EXTENDS TO THE
MUCOSA OR LUMEN OF THE RECTUM.
Stage 4
Usually 1 - 2hrs after birth

- SAID TO BE THE MOST CRITICAL FOR THE

MOTHER BECAUSE OF UNSTABLE VITAL
SIGNS.

- STARTS IMMEDIATELY AFTER THE

DELIVERY OF THE FETUS UP TO 4 HOURS
& IS COMPLETED WHEN THE
REPRODUCTIVE TRACT HAS RETURNED
TO ITS NON PREGNANT CONDITION
Assessment:
 Assess firmness and position of fundus
 Assess vital signs including BP q 15 min: BP
returns to prelabor levels and pulse is slightly
lower than during labor
 return of B/P is due to increased volume of blood
returning to maternal circulation
 lowered B/P and rising pulse may reflect increased
blood loss
 Assess amount and character of vaginal blood
flow
 Inspect perineum
 Stages of Labor
Stage 1 Stage 2 Stage 3 Stage 4

From onset of labor From full dilatation From birth of the Time after birth
until full dilation of of the cervix to birth baby to expulsion of (usually 1-2 hours)
cervix of the baby the placenta (birth) of immediate
a. Latent = 0-4cm (pushing) recovery
b. Active = 4-8cm
c. Transition = 8-
10cm

Primi: 12 - 13 hr Primi: 1 hour Primi: 3 – 4 min Primi: 1 – 2 hr

Multi: Multi: 20 min Multi: 4 - 5 min Multi: 1 – 2 hours
8 hrs
Mech of labor:
Mech of labor: Internal rotation,
Engagement, Extension, External
Descent, Flexion, rotation, Expulsion
 The End

daisy jagna