Active phase

During the active phase of labor, the contractions are stronger, each lasting about 40 to
60 seconds and recurring about every 3 to 5 minutes. The increased strength of the
contractions commonly causes pain. Assess FHR and uterine activity every 30 minutes
for a low-risk patient and every 15 minutes for a high-risk patient.

Cervical dilation occurs more rapidly, increasing from about 3 to 7 cm, and the fetus
begins to descend through the pelvis at an increased rate.

Transition phase

During the transition phase, contractions reach maximum intensity. They each last 60 to
90 seconds, and they occur every 2 to 3 minutes.

The cervix dilates from about 7 to 10 cm to become fully dilated and effaced.

If the membranes aren’t already ruptured, they usually rupture when the woman is 10
cm dilated and the remainder of the mucus plug is expelled from the cervix.

When in the transition phase, the woman may experience intense pain or discomfort.
Nursing care during the transition phase includes monitoring vital signs and FHR,
encouraging proper breathing techniques, and administering medications, as ordered.

Second stage

The second stage of labor starts with full dilation and effacement of the cervix and ends
with the delivery of the baby.

During the second stage, the frequency of the contractions slows to about one every 3
to 4 minutes; however, they continue to last 60 to 90 seconds and are accompanied by
the uncontrollable urge to push or bear down. The decreased frequency of the
contractions gives the woman a chance to rest. During the second stage of labor
(including pushing), assess FHR every 15 minutes for a low-risk patient and every 5
minutes for a high-risk patient.

The second stage involves moving the fetus through the birth canal and out of the body.
As the uterine contractions work to accomplish this movement, the fetal scalp becomes
visible at the opening to the vagina (crowning). The mother’s oxytocin level increases,
which helps to intensify the contractions. The cardinal movements of labor occur in this
order: descent, flexion, internal rotation, extension, external rotation, and expulsion.

Labor complications

Dystocia, a slow or abnormal progression of labor, may occur (e.g., shoulder dystocia).

When a baby's head emerges from the birth canal during delivery, the first action to
ensure the baby's safety and well-being that a healthcare provider should take is to
check for a nuchal cord (umbilical cord wrapped around the baby's neck) and, if present,
gently slip the cord over the head or shoulder to prevent compression.

Lacerations

First degree is a tear that only involves the skin and vaginal mucosa.

Second degree is a tear that involves the skin, vagina mucosa, and perineal muscles.

Third degree is a tear that involves the skin, vagina mucosa, perineal muscles, and anal
sphincter.

Fourth degree is a tear that involves the skin, vagina mucosa, perineal muscles, anal
sphincter, and rectal mucosa.

Open glottis pushing

Open glottis pushing allows a woman to make noise and only bear down for 6 to 8
seconds at a time, resulting in less fetal stress and better fetal oxygenation. Pushing is
also encouraged in a variety of positions to help the fetus navigate the pelvis.

Traditional closed glottis pushing (making no noise, holding one’s breath for a count of
10, and quickly gasping in air and repeating) is a common occurrence in many labor
rooms that has not proven to be the most effective method of pushing.
Decreased venous return from the extremities, which is a result of closed glottis
pushing, makes less blood available for the transport of oxygen to the fetus
resulting in a greater likelihood of a nonreassuring FHR pattern.

Controlled Breathing
Breathing is important because it helps relax the muscles between contractions and
pushing, which allows for a safer progression of labor. It also helps manage pain and
keeps the mother’s oxygen supply up, which keeps the fetus’ oxygen supply up.

Gate control theory of pain

According to the gate control theory of pain, local physical stimulation can interfere with
pain stimuli by closing a hypothetical gate in the spinal cord, thus blocking pain signals
from reaching the brain. Examples of this type of non-pharmacologic intervention, which
can be effective in reducing labor pain, include non-invasive techniques like massage,
hydrotherapy, relaxation, breathing, or acupressure.

Third stage

The third stage of labor occurs after delivery of the fetus and ends with the delivery of
the placenta. It consists of two phases: placental separation and placental expulsion.

Active management of the third stage is when the mother is given oxytocin (Pitocin) to
increase uterine contractions and minimize bleeding. Having extra oxytocin speeds up
delivery of the placenta, which usually happens within 30 minutes.

A placenta that remains in place may cause hemorrhage, shock, infection, or even
death, so manual removal of the placenta may be indicated if it doesn’t deliver
spontaneously within 30 minutes of delivery.

In the third stage of labor, during the first hour, the nurse should be assessing the
patient’s vital signs and fundus every 15 minutes.

Blood loss

Quantitative blood loss (QBL) is a more accurate method for determining blood loss
during delivery, as it involves direct measurement of blood volume using calibrated
containers, compared to estimated blood loss (EBL), which involves a visual estimation.

Fourth stage

The fourth stage of labor initiates the postpartum period and occurs immediately after
the delivery of the placenta.
It usually lasts for about 1 to 4 hours. During this stage, the woman should be monitored
closely. Risks associated with the fourth stage of labor include hemorrhage, bladder
distention, and venous thrombosis. Nurses should monitor the woman’s vital signs
every 15 minutes for a minimum of 1 hour, then as ordered.

After delivery, the uterus gradually descends into its pre-pregnancy position in the pelvis
and decreases in size, a process called uterine involution. To evaluate this process,
palpate the uterine fundus and determine size, degree of firmness, and rate of descent
(measured in fingerbreadths above or below the umbilicus). Involution normally begins
immediately after delivery when the firmly contracted uterus lies almost at the umbilicus.

If the woman is breastfeeding, the release of natural oxytocins should help to maintain
or stimulate contraction of the uterus. If it doesn’t remain contracted, gently massage
the uterus or administer medications as ordered.

Encourage the woman to void because a full bladder displaces the uterus, causing it to
deviate from its normal position and increasing the risk of uterine atony (the failure of
the uterus to contract adequately following delivery), which can lead to excessive
postpartum bleeding.

Observe the amount, color, and consistency of the lochia and watch for its absence,
which may indicate that a clot is blocking the cervical os. A woman has an additional
risk of clot formation if she had a cesarean delivery.

A firm uterus indicates an appropriate uterine tone which helps prevent excessive
bleeding by compressing blood vessels at the placental site. Lochia assessment is
critical as bleeding is an indication of potential complications postpartum such as
infection and hemorrhage.

If a postpartum woman is undergoing an assessment by a healthcare provider 3 days

Electronic Fetal Monitoring (EFM)

In EFM, two devices, an ultrasound transducer and a toco transducer, are placed on the
mother’s abdomen to evaluate fetal well-being and uterine contractions.