Stage One
The process of labor can be mentally and physically exhausting for the woman going through it. It is divided into four stages; the first stage being the longest. This stage is further broken down into three phases known as the latent phase, active phase, and transition phase. The first stage of labor can last longer for one who has never had a baby than those who have had one or more children (Ward & Hisley, 2016).
The first stage begins when contractions start and ends when the cervix has dilated ten centimeters also known as fully dilated.
Within the first stage of labor, the first phase is termed the latent phase. This phase begins when regular contractions also known as labor pains commence. The contractions that occur in this phase last for about 30 – 45 seconds and take place about every 5 – 10 minutes. These contractions are noted to be mildly intense and the woman will most likely still be excited and talkative about having the baby.
The woman at this point in the process of labor may complain of having low back pain or abdominal cramping. The pain normally can be easily controlled in this phase. Early dilation and cervical effacement will occur during this phase also. The cervix will dilate around 0 – 3 centimeters and be effaced about 0 – 40 percent. This phase lasts about 8 hours or less but can last for around 10 – 14 hours and may take place before one ever goes to the hospital (Ward & Hisley, 2016).
Place tocometer and ultrasound monitors on the patient’s abdomen. Rationale: This lets the nurse determine the frequency and duration of contractions along with examining the fetal heart rate for any variability, accelerations, or decelerations (Ward & Hisley, 2016).
Ask history questions about previous pregnancies and births along with assessing how far along she is with the current pregnancy. Rationale: The nurse should ask questions to figure out one’s gravidity and parity and how previous births of children went in order to have a better understanding of how the current delivery may go. The nurse should also determine the gestational age of the fetus to interpret how well developed the baby will be.
Perform Leopold’s maneuvers on the patient. Rationale: These maneuvers will help the nurse determine how the baby is lying in the uterus and if the doctor needs to be informed in case any further interventions should occur such as trying to flip a baby who is breach.
Perform a general head to toe assessment including pain and a cervical assessment on the mother in labor. Rationale: A head to toe assessment is used to look for any signs of complications caused by the pregnancy and a cervical assessment is performed to determine the progress of labor.
Teach the patient about breastfeeding and newborn care during this phase since the patient is still talkative, excited, calm, and more likely to listen to the nurse’s instructions.
Teach the patient who does not have any current complications of pregnancy such as ruptured membranes to remain ambulatory due to the fact that this may promote the progression of labor (Ward & Hisley, 2016).
The second phase of labor within the first stage is called the active phase. This phase will last about 4 – 8 hours. In this phase, the contractions start to occur more frequently and last longer. They will happen about every 3 – 5 minutes and last for about 40 seconds to a full minute. These contractions will also be moderately or strongly intense. Due to the contractions becoming more intense and occurring more often, the laboring patient may not be as talkative and may focus on being uncomfortable and in pain more than they did in the latent phase. They may also complain of having a backache during this phase. The patient will use more coping strategies such as having their pain managed and having the nurse coach her through the contractions. Along with having more contractions, the cervix dilates further and becomes more effaced. The cervix will dilate to about 4 – 7 centimeters and will be effaced anywhere from 40 – 80 percent. These actions take place faster than they did in the latent phase and will continue to get faster as the patient progresses through the labor and birthing process (Ward & Hisley, 2016).
Provide anticipatory guidance about what is expected to happen as she progresses through labor. Rationale: Informing the laboring woman about what to expect in the next few hours will help diminish their anxiety or fears and prepare them emotionally.
Perform a cervical assessment and inform the patient on their progression of labor. Rationale: The cervical exam helps the nurse determine how many centimeters the cervix has dilated and how effaced it is. This measurement informs the nurse at what point the mother is in the laboring process and if she has progressed at all.
Help place the patient into different body positions. Rationale: This will help provide comfort to the mother by letting her relax her muscles during the physically exhausting progression of labor along with making sure the baby is still receiving oxygen.
Assist the patient with breathing and relaxation techniques. Rationale: These techniques can help one calm down, provide pain relief, and help the patient relax their muscles to promote fetal descent (Green, 2016).
Teach the patient different position changes that are beneficial in providing comfort and helping the fetus descend (Ward & Hisley, 2016).
Teach the patient to void at least every two hours since a full bladder can prevent the fetus from descending and cause more pain with every contraction (Ward & Hisley, 2016).
The final phase within the first stage of labor is known as the transition phase. This is the shortest phase, but also the most intense. It can last from about 30 minutes to two hours. In this phase the contractions become even more intense than in the previous phases. The frequency and duration of the contractions is also increased. They will last for about 60 – 90 seconds, occur around every 2 – 3 minutes, and are strong when palpated. Dilation of the cervix happens at the same rate as it does in the active phase or faster. For women who have never given birth, their cervix will dilate at a rate of 1 centimeter per hour and for the women who have given birth to one or more babies progress at a rate of 1.5 centimeters per hour. The cervix will dilate from 8 – 10 centimeters and effaced about 80 – 100 percent. During this phase, the women are in an excruciating amount of pain with only a little amount of time to rest in between each contraction and because of this, they do not believe they will be able to keep progressing through the contractions. The patient may also feel an increase in many different emotions along with rectal pressure and having the urge to push. They will need many words of encouragement and praise to help them get through this process (Ward & Hisley, 2016).
Use the tocometer and ultrasound monitors to assess for changes within the mother or fetus. Rationale: Assessing these monitors frequently will ensure that if any changes occur such as no resting tone is showing up between contractions or the baby’s heart rate decreases dramatically, adjustments will be made appropriately.
Perform vaginal examination to assess the progress through labor and for any signs and symptoms of complications. Rationale: A vaginal examination is used to determine cervical effacement, fetal presentation, position and station. It is also used to check for the color and characteristic of amniotic fluid and the time of rupture.
Provide emotional support and words of encouragement and praise. Rationale: This will help the patient continue to push through the painful contractions even when they feel like they cannot continue.
Distract the patient from focusing on the pain and change their body position. Rationale: This will increase comfort of the mother as well as promote fetal descent (Ward & Hisley, 2016).
Teaching topics for the transition phase
Teach the patient deep breathing exercises and to focus on breathing rather than anything else to relax the muscles and let their body lead.
Teach the patient to ask for help when they need it because we are here to advocate for them and coach them through the tough times of labor.
The second stage of labor starts when the cervix is fully dilated and stops when the patient has given birth to their infant. This stage may last anywhere from about 1 – 3 hours for a nulliparous woman and about 20 minutes for a multiparous woman. It is usually identified that the patient is in this stage due to involuntarily bearing down and having the urge to push. The contractions that occur in this phase are similar to those that occur in the transition phase of stage one. They are still extremely intense and occur for about 60 – 90 seconds every 2 – 3 minutes. The laboring woman in this stage will express and feel many different emotions. Some may feel like they cannot keep going through these intense contractions or may feel fearful or nervous of new sensations such as burning due to the baby crowning. Others may feel as if they have gotten a “second wind” or energy to help them get through this stage. The mother may feel a burning sensation when the baby’s head is crowning and lacerations or episiotomies may occur in this stage also. The nurse should not leave the patient’s side during this stage (Ward & Hisley, 2016).
Assess the abdomen for bladder distention every 30 minutes during this stage. Rationale: A full and distended bladder may make the contractions more painful than if it were not distended (Ward & Hisley, 2016).
Place the patient in high fowler’s and lithotomy positions or squatting or side laying and watch for changes in the perineal area that show that the baby is coming. Rationale: Having the head and chest of the mother up promotes blood flow and oxygen between the mother and the baby and spreading the legs with the knees bent prepares the perineal area for when the baby is crowning. Also, watch for signs of the baby crowning such as the perineum bulging, parts of the baby can be seen, or there is an increase in bloody show.
Promote effective pushing while resting in between each push. Rationale: Pushing with one’s mouth open will prevent the blood flow from the placenta to the baby from decreasing. Also, resting between each push gives the mom a break and the ability to regain their strength before pushing again.
Provide preventative infection measures after the birth. Rationale: An infection may appear after birth if lacerations or episiotomies occurred and were not taken care of.
Teach the mom when to push and when to rest. Also, teach her why she needs to be in one of the birthing positions.
Teach the mother to take deep breaths between each push.
The third stage of labor begins when the baby has been fully delivered and ends when the placenta has been delivered. This stage takes about 5 – 10 minutes, but it can take up to 30 minutes. At this time, the uterus should be firmly contracted, and the placenta should start to separate from it. The placenta will be delivered either by the Schultze mechanism or by the Duncan mechanism The Schultze mechanism is when the placenta presents with the shiny side up also known as the fetal side and the Duncan mechanism is when the placenta rolls up and presents sideways. The mother will feel a little discomfort or cramps as the placenta is delivered. In this stage, the mother will focus on the well-being of their infant and will be very emotional. Crying is the most common, but they will also show signs of relief (Ward & Hisley, 2016).
Palpate and assess the uterus to make sure it is globelike and rises upward into the abdomen. Also, assess that the umbilical cord has descended into the vagina and that a gush of blood has expelled. Rationale: These are signs that the placenta has separated from the uterus.
Administer a dose of oxytocin IV or IM once the placenta has been delivered. Rationale: Oxytocin is given to enhance uterine contractions which helps decrease the bleeding at the placental site and reduce the risk having a hemorrhage (Ward and Hisley, 2016).
Assess for the volume of blood lost and monitor the patient’s vital signs. Rationale: The patient may lose an excessive amount of blood upon delivery of the placenta which can cause their heart rate to increase and their blood pressure to decrease. The nurse will have to provide immediate care for these complications.
Provide emotional support for the mother by promoting skin to skin contact with the newborn. Rationale: The patient has gone through a very emotional experience and providing support can help her get through these times. Skin to skin contact with the mother and baby promotes attachment between the two.
Teach the parents how to hold the baby if it is their first child.
Teach the patient that their uterus will continue to mildly contract in order for it to go back to its normal size (Mayo Clinic Staff, 2016).
The fourth and final stage occurs after the delivery of the placenta and about 1 – 2 hours after birth. It is a time of maternal physiological adaptation or adjustment. During this stage, the uterus should feel firm and contracted. Some women may feel a little uncomfortable or some pain in the perineal area. This is usually related to a laceration or episiotomy or hemorrhoids. The mother will feel excited and tired during this stage. She will begin to bond with her infant and start breastfeeding or giving the newborn a bottle (Ward & Hisley, 2016).
Assess the uterus for firmness, height, and position. Rationale: If the uterus feels boggy or soft upon palpation, this is a sign that an excessive amount of blood has pooled up into the uterus, and action needs to be taken immediately. Also, if the uterus is deviated from its normal location and the bladder is not distended, the patient may be hemorrhaging.
Palpate the fundus and perform a fundal massage. Rationale: This action helps clear out the blood clots in the uterus and reduce the amount of bleeding and cramps (Ward & Hisley 2016).
Assess the vaginal discharge also known as lochia and document the color, amount, consistency, and odor. Rationale: By assessing this, the nurse can determine if there were any complications that occurred during the pregnancy such as green lochia which is a sign of infection or the patient is bleeding excessively which may be a sign of trauma to the perineum or birth canal (Ward & Hisley, 2016).
Provide the patient with a heated blanket or warm beverage and give them a light meal and some fluids. Rationale: The patient may be cold and shivering during this stage and the meal and fluids will help replenish the calories and fluids lost during the delivery.
Teach the mother how to monitor her own vaginal discharge and what the different types may indicate.
Teach the mother about breastfeeding and how to get the baby to latch on correctly.
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