Name:AMT October 4,2022
BSN2A
In the first Stage of Labor, Cervical dilation (opening) 0-10 cm & 100% effacement (thinning)
due to contractions.It is the longest Stage (especially for first time mothers as nulliparous.It has
Has 3 phases which are Latent,Active and Transition,this stage starts with TRUE Labor.
The Signs and Symptoms of the Stage 1 in a Latent Phase or early labor are: Contraction:
dilate is in 0.3 cm,mild, Duration is in 30-45 seconds,Frequency is 5-20 minutes, Scant
pinkish discharge, bloody show.The mother’s response in this phase are: Surge of energy and
excited,Talkative, outgoing, and low anxiety. This is also the best time to do teaching.
Nursing Care Stage 1 – Latent Phase
Welcome the patient to the Hospital, Assess goals for this labor,Assess Psychological
response,Orient to common procedures, Check Vital signs and FHT’s, Enema,IV, NPO,and
Assessment of Labor Progress – dilation, effacement, station, lie, etc.
Stage 1 Active Phase Signs and Symptoms are; Contractions – dilate 4-7
cm,Moderate,Duration is 45-60 seconds,Frequency is in 2-5 minutes, The mother’s responses
are more serious ,determined,dependent, restless and focuses on self.
Nursing Care Stage 1 – Active Phase
Non-Pharmacological Measures and Pharmacological Measures should be performed. In
Non-Pharmacological nurse Anticipate Needs,Sponge face with cool cloth,Keep bed clean
and dry and change chux,Provide with mouth care – lip balm to lips,fluids for dry
mouth,Assess voiding, modified breathing, Effleurage, and play Music or Tv. In
Pharmacological: Analgesia and epidural anesthesia depending on doctors order. Nurse
should encourage the mother to frequently urinate to keep the bladder empty (full bladder
prevents uterus from contracting properly and can slow down labor), monitor vitals of mother
and fetal heart rate.
The last phase in stage 1 is the Transition Phase. Signs and Symptoms of this phase are
Contractions is in 7-10 cm, it is Strong, Irregular with multiple peaks and its duration is in
60-90 seconds and its frequency is in 2 minutes.The Mother’s response are withdrawn,
drowsy,nausea,trembling of legs,Irritable,aggressive and urge to push.
Nursing Care Stage 1 – Transition Phase
Nurses provide support it may need to breathe with the patient,encouragement is necessary,
Back rub and Assist with pant-blow breathing. Nurse should watch for hypervention – have a
breath mask and slow down the breathing, Do NOT allow the patient to push by having the
patient blow-blow-blow with urge and do not be offended by irritability.Monitoring mother’s
vitals and fetal heart rate especially during contractions, before, and after with a heart rate
120 to 160, mother’s contractions (length, frequency) monitoring status of cervix (dilation
and effacement), assessing fetal position and station (station 0 baby head is engaged and at
ischial spine). The ischial spine is the narrowest part of the pelvis.
The Stage 2 of Labor Starts when the cervix has fully dilated and ends when the baby is fully
delivered.
Cervix is fully dilated so baby can start descending into the birth canal (woman will have intense
pressure in rectum as baby descending)…watch fetal station +1 to 5+ (5+ is head
crowning).Contractions will be strong and intense like in the transition period…. 60-90 seconds
length every 2-3 minutes).For first-time mothers this stage lasts approximately 1 hour (may last 3
hours) and 20 minutes for multipara.Signs and Symptoms that the patient is in stage 2 are
sudden Appearance of sweat on upper lip,shaking of extremities and Increased restlessness.
Stage 2 Nursing Care
Nurses should Monitor mother’s vital and baby heart during, after, and before contractions with
continuous fetal monitoring (assessing for signs of distress).Watch for changes in perineum that
represents birth of baby is approaching:Pressure on rectum; involuntary bearing down,Bulging of
perineum and Increase in bloody show.
The key to care during this stage is to teach QUALITY PUSHING.Teach mother how to
push: exhale when pushing and positioning (High-fowler and lithotomy), squatting,
side-lying.Keep perineum clean and dry,maintain comfort measures- Provide quiet
environment, Support with positive feedback--encouragement and praise, Repeat doctors
instructions and record exact time birth of the baby. Allow to hold the baby.
Stage 3 of Labor starts with full delivery of the baby and ends with full delivery of the
placenta.It lasts 5 to 15 minutes…the longer the stage the increased risk for hemorrhage and
retained placenta (which can cause infection/hemorrhage).Signs that the placenta is about to be
delivered:Umbilical cord starts to lengthen,Trickling/gush of blood and uterus changes from an
oval shape to globular.With these signs mother will give a gently pushThe delivery mechanisms
of the Placenta have two types.Schultz Mechanism: This is the “shiny” side from the side of the
baby, shiny and new which is the baby…this part comes out first.Duncan Mechanism:
“Dull/Dirty Duncan”. This side is “dull”, red, and rough and is the side from the mother. Also,
try to remember the mother is dirty from labor and is in rough condition, so it is the maternal
side.
Stage 3 – Nursing Care
Nurses should Congratulate on delivery of baby,and coach in relaxation for delivery of the
placenta, Monitor Blood Pressure before and after delivery of placenta, Administer oxytocin
“Pitocin” as ordered by the physician AFTER delivery of the placenta cause it helps uterus
contract after delivery of placenta and prevents hemorrhage.Assess placenta to make sure it is
enact (cord should have two arteries and one vein), Nurses should make mother comfortable
and encourage bonding with baby (breastfeeding), change linens, peri-care.
Stage 4 of Labor is 1 to 4 hours after the delivery of placenta.Nurses should monitor a
mother's health status after birth due to risk for hemorrhage, infection (retaining placenta),
uterine atony etc.
Stage 4 – Nursing Care
Monitoring vital signs (especially blood pressure and heart rate due to risk of hemorrhage and an
increased temperature due to risk of infection).Monitor discharge “Lochia”: red, moderate, may
have small clots, however large clots not normal…assess how many peri-pads are being used…if
changing every 15 minutes…this is abnormal.Monitor the fundus of the uterus for firmness: it
should be firm and midline, and at or slightly below the umbilicus….if soft/boggy or displaced
perform: fundus massage and want to make sure bladder is empty so have the patient void (will
be checking fundus every 15 minutes for 1 hour then 30 minutes for 2 hours).The fundus of the
uterus will decrease 1 cm a day and after 10 days post-delivery cannot be felt.Administering pain
relief as ordered by MD.Apply witch hazel to the perineum and ice pack due to edema, tearing,
or episiotomy.Promote bonding with parents and baby and help with breastfeeding.
