What is Labor?
Labor refers to the process of childbirth, during which a pregnant
woman experiences rhythmic uterine contractions that lead to the
progressive opening of the cervix and the eventual delivery of the
baby. It is a natural and dynamic process that signifies the end of
pregnancy and the beginning of motherhood.
Establishing Therapeutic Relationship
To gain the patient and family’s cooperation and trust, it is important that
the nurse should be able to establish a therapeutic relationship with them.
The nurse should introduce himself and make them feel welcome. At this
point, they are all anxious and it is best for the nurse to convey his message
gently and confidently. Expectations of the family about birth should be
determined and it is also the best time to ascertain cultural values.
Admission Assessment
When a patient arrives at the labor floor, pertinent information about the
pregnant woman’s health history is taken during admission. These include
personal data (e.g. blood type, allergies, etc.), previous illness, pregnancy
complications, preferences for labor and delivery, and childbirth
preparations. Standard obstetric, medical, and social history taking is also
done.
In addition, the nurse assesses the following: vital signs, physical exam,
contraction pattern (frequency, interval, duration, and intensity), intactness
of membranes through a vaginal exam, and fetal well-being through
fetal heart rate, characteristic of amniotic fluid, and contractions. The nurse
performs Leopold’s maneuver to determine the fetal presenting part, point
of maximum impulse, fetal descent, and engagement.
Admission into the labor room is only done when the patient is in active
labor.
Stages of Labor
The progress of cervical effacement, cervical dilatation, and descent of the
fetal presenting part dictate stages of labor. Here are the stages of labor
and significant events that mark their beginning and end:
Duration
Stages of
Start End
Labor
Nullipara Multipara
10-12 hr but 6-20
Full cervical 6-8 hrs but 2-12 hrs
First Stage True labor contractions hrs is the normal
dilatation is the normal limit
limit
Onset of regularly perceived uterine
3 cm cervical
Latent phase contractions (mild contractions lasting 6 hrs 4.5 hrs
dilatation
20-40 sec)
Stronger uterine contractions lasting 7 cm cervical
Active phase 3 hrs 2 hrs
40-60secs dilatation
Uterine contractions reaching their
Transitional 10 cm cervical
peak, occurring every 2-3 minutes for 3 hrs 1.5-2 hrs
phase dilatation
60-90 s
<2 hrs 0.5-1 hrs
Second Stage Full cervical dilatation Infant birth
3 hrs with epidurals 2 hrs with epidurals
Placental
Third Stage Infant birth Maximum of 30 min.
delivery
First Stage of Labor
As mentioned above, the first stage of labor is divided into three sub-phases,
namely: latent, active, and transitional phases.
A. Latent (Preparatory) Phase starts from the onset of true labor contractions to 3
cm cervical dilatation. Here are nursing responsibilities during this phase:
1. Assess patient’s psychological readiness. Provide continuous maternal
support (compared to usual care).
2. Measure duration of latent phase. For nulliparas, it should not be more
than 6 hours. On the other hand, for multiparas, it should be within 4.5
hours. Determine if patient received anesthesia because it can prolong
latent phase. One of the most common cause of prolonged latent
phase is cephalopelvic disproportion (CPD) and it requires cesarean
birth.
3. Allow patient to be continually active. Upright maternal positions are
recommended for women on the first stage of labor. Patients without
pregnancy complications can still walk around and make necessary
birth preparations.
4. Conduct interviews and filling in of forms (e.g. birth certificate) at this
phase while the patient experiences minimal discomfort and has
control over contraction pains.
5. Conduct health teaching on breastfeeding, newborn care, and
effective bearing down because during this time, patient’s anxiety is
controlled and she is able to focus on nurse’s instructions.
6. Educate patient on different relaxation techniques. As early as this
phase, encourage patient to begin alternative therapy of pain relief.
7. Ensure that the total number of internal examinations the woman
receives in the entire course of labor is limited to 5 only.
8. Ensure that birthing companion of choice is present all throughout the
course of labor.
B. Active Phase starts from 4 cm cervical dilatation to 7 cm cervical
dilatation. During this phase, contraction intensity is stronger, interval
shortens, and duration lengthens. This is where true discomfort is first
felt by the patient so she is dependent and her focus is on herself. Here
are nursing responsibilities in this phase:
1. Inform patient on the progress of her labor to lessen
her anxiety and obtain her trust and cooperation.
2. Start monitoring progress of labor with the use of WHO
partograph, 2-hour action line.
3. Encourage patient to be continually active to maximize the
effect of uterine contractions. Upright maternal positions are
recommended if tolerated.
4. Assist patient in assuming her position of comfort. For those
who can’t stay upright, left-side lying is recommended to avoid
disruption in fetal oxygenation.
5. Monitor maternal vital signs and fetal heart rate every 2
hours, or depending on the doctor’s order.
6. Anticipate patient needs (e.g. sponging face with cool cloth,
keeping bed clean and dry, providing ice chips or lip balm) to
promote comfort.
7. Determine when patient last voided because a full bladder can
hinder fast labor progress.
8. Institute non-pharmacological pain measures (e.g. breathing
exercises, distraction method, imagery, music therapy, etc.)
C. Transition Phase starts from 8 cm cervical dilatation to 10 cm
(full) cervical dilatation and full cervical effacement. During this
time, patient may be exhausted and withdrawn or aggressive
and restless. Patient’s urge to push is noticeable. Here
are nursing responsibilities in this phase:
1. Inform patient on progress of her labor.
2. Assist patient with pant-blow breathing.
3. Monitor maternal vital signs and fetal heart
rate every 30 minutes -1 hour, or depending on
the doctor’s order. Contraction monitoring is also
continued.
4. When perineal bulging is noticeable, prepare for
delivery. Check room temperature (25-280C and
free of air drafts). The nurse should also notify
staff and prepare necessary supplies and
equipment, including resuscitation machine.
Lastly, perform handwashing and double gloving.
WHO do not recommend the following nursing interventions during
labor because they have low quality of evidence:
1. Routine perineal shaving
2. Routine use of enema
3. Admission cardiotocography (CTG) for low-risk women
4. Vaginal douching
5. Routine amniotomy for patients in spontaneous labor
6. Massage and reflexology
Second Stage of Labor
Second Stage of Labor starts when cervical dilatation reaches 10 cm and
ends when the baby is delivered. At this stage, the patient feels an
uncontrollable urge to push. The patient may also experience
temporary nausea together with increased restlessness and shaking of
extremities. The nurse at this stage must coach quality pushing and support
delivery.
Here are nursing care tips for this stage:
1. Instruct patient on quality pushing. The abdominal
muscles must aid the involuntary uterine contractions
to deliver the baby out.
2. Provide a quiet environment for the patient to
concentrate on bearing down.
3. Provide positive feedback as the patient pushes.
4. Repeat the doctor’s instructions. At this phase, the
patient barely hears the conversation around the room
because all her energy and thoughts are being directed
toward giving birth.
5. Take note of the time of delivery and proceed to initiate
essential newborn care. Delayed cord clamping is
recommended.
6. Assist in restrictive episiotomy for patients who had
vaginal births.
WHO do not recommend the following interventions during delivery because
they provide low quality evidence:
1. Perineal massage
2. Use of fundal pressure
Third Stage of Labor
Third Stage of Labor or the placental stage starts from birth of infant to
delivery of placenta. It is divided into two separate phases: placental
separation and placental expulsion. Five minutes after delivery of baby,
the uterus begins to contract again, and placenta starts to separate from
the contracting wall. Blood loss of 300-500 mL occurs as a normal
consequence of placental separation. Placenta sinks to the lower uterine
segment or upper vagina. The placenta is then expelled using
gentle traction on the cord.
Here are the signs of placental separation:
1. Lengthening of umbilical cord
2. Sudden gush of vaginal blood
3. Change in the shape of uterus (globular in shape)
4. Firm uterine contractions
5. Appearance of placenta in vaginal opening
At this stage, here are the nursing care tips:
1. Coach in relaxation for delivery of placenta.
2. Congratulate on delivery of baby.
3. Encourage skin-to-skin contact to facilitate bonding and early
breastfeeding.
4. Ask patient whether placenta is important to them before it is
destroyed. For those who want to take it home, ensure that they
understand and follow standard infection precautions and
hospital policy.
5. Administer prophylactic oxytocin as ordered.
6. Utilize controlled cord traction technique for placental
expulsion.
7. Utilize absorbable synthetic suture materials (over chromic
catgut) for primary repair of episiotomy or perineal lacerations.
For immediate postpartum, the nurse checks the vital signs and monitors for
excessive bleeding. The first four hours after birth is sometimes referred to as
the fourth stage of labor because this is the most critical period for the mother. The
nurse is set to perform nursing interventions that would prevent the patient from
infection and hemorrhage. Also, they are being reminded of the importance of
breastfeeding, ambulation, and newborn care.
Here are WHO recommendations for immediate postpartum:
1. Early (<6 hours) resumption of feeding for patients who have vaginal birth
2. Prophylactic antibiotics for women who sustained third to fourth degree of
perineal tear during delivery
3. In healthy women who delivered vaginally to term infants, early
postpartum discharge is recommended.
On the other hand, here are interventions not recommended during immediate
postpartum:
1. Routine use of ice packs
2. Oral methylergometrine for patients who delivered vaginally
