Labor and Childbirth Stages

• Labor and childbirth is a series of events that works to expel a viable infant from the uterus
• Nurses are an important care provider, offering assessment, monitoring, and support during labor and delivery
• A supportive nursing presence can significantly impact a woman's labor experience and outcomes

Stages of Labor

• First stage: From onset of regular uterine contractions to full effacement and dilation of the cervix
  • Latent phase: Cervix dilates 0 to 3 cm; contractions are irregular, mild to moderate
  • Active phase: Cervix dilates 4 to 7 cm; contractions become more regular, moderate to strong
  • Transition phase: Cervix dilates 8 to 10 cm; contractions are strong to very strong, and the woman feels the urge to push
• Second stage: Full cervical dilation to the birth of the infant
  • Latent phase: Fetus descends passively through the birth canal and rotates to an anterior position as a result of ongoing uterine contractions
  • Active phase: Woman experiences urges to bear down
• Third stage: Begins immediately after the birth of the fetus and ends when the placenta is delivered
• Fourth stage: Begins after the delivery of the placenta and including at least the first 2 hours after birth

Factors Affecting Labor (The 5 P's)

• Passenger: Fetus and placenta, including factors like fetal size, presentation, lie, attitude, and position
• Passageway: The birth canal, including the bony pelvis, cervix, pelvic floor muscles, and vagina
• Powers: Uterine contractions and maternal pushing efforts
• Position: Maternal positions during labor
• Psychological response: Woman's emotional state and psychological preparation

Fetal Presentation

• Cephalic: Head first, the most common presentation
• Breech: Buttocks or feet first
• Shoulder: Shoulder first

Fetal Lie

• Longitudinal (vertical): Fetus is parallel to the mother's spine (cephalic or breech)
• Transverse (horizontal): Fetus is at a right angle to the mother's spine

Fetal Attitude

• Flexion: Chin to chest, extremities flexed is desirable
• Extension: Chin away from chest, extremities extended

Fetal Position

• Indicated by a three-part abbreviation
  • Right (R) or Left (L): Whether the fetal presenting part is oriented to the right or left side of the maternal pelvis
  • Occiput (O), Sacrum (S), Mentum (M), or Scapula (Sc): The fetal presenting part, such as occiput (head), sacrum (breech), mentum (chin), or scapula (shoulder)
  • Anterior (A), Posterior (P), or Transverse (T): Whether the presenting part is anterior, posterior, or transverse in relation to the maternal pelvis
• LOA (Left Occiput Anterior) is the most common and favorable position

Maternal Physiological Changes During Labor

• Cardiovascular: Cardiac output increases, blood pressure rises during contractions
• Respiratory: Increased oxygen consumption
• Renal: Proteinuria may occur
• Gastrointestinal: Gastric motility decreases
• Endocrine: Metabolism increases, blood glucose levels may decrease

Pain Management During Labor

• Non-pharmacological:
  • Breathing techniques: Lamaze, patterned breathing
  • Relaxation techniques: Massage, imagery, music
  • Effleurage: Light stroking of the abdomen
  • Counterpressure: Applying pressure to the sacrum
  • Heat or cold applications
  • Hydrotherapy: Whirlpool or shower
• Pharmacological:
  • Systemic analgesia: Opioids like fentanyl and morphine
  • Regional analgesia/anesthesia:
    • Epidural: Provides pain relief from contractions and birth, numbing from umbilicus to thighs
    • Spinal: Provides pain relief for cesarean birth, numbing from nipples to feet
    • Pudendal block: Provides pain relief in the perineal area during the second stage of labor, birth, and episiotomy repair
  • Local anesthesia: Used for episiotomy or laceration repair

Nursing Assessment During Labor

• Maternal assessment:
  • Vital signs: Temperature, pulse, respirations, blood pressure
  • Contractions: Frequency, duration, intensity
  • Cervical dilation and effacement
  • Fetal heart rate (FHR) monitoring
  • Pain level
  • Emotional status
• Fetal assessment:
  • FHR: Baseline, variability, accelerations, decelerations
  • Fetal presentation, position, and lie
  • Amniotic fluid: Color, odor, amount

Fetal Heart Rate Monitoring

• Baseline FHR: Average FHR over a 10-minute period, excluding accelerations and decelerations; normal range is 110-160 bpm
• Variability: Fluctuations in the FHR baseline
  • Absent: Non-reassuring
  • Minimal: 0-5 bpm
  • Moderate: 6-25 bpm (normal)
  • Marked: >25 bpm
• Accelerations: Abrupt increases in FHR above the baseline that peak in less than 30 seconds are reassuring
• Decelerations: Decreases in FHR below the baseline
  • Early decelerations: Gradual decrease mirroring contractions caused by head compression (normal)
  • Late decelerations: Gradual decrease beginning after the peak of the contraction caused by placental insufficiency (non-reassuring)
  • Variable decelerations: Abrupt decrease, U, V, or W shaped, caused by umbilical cord compression (potentially non-reassuring)
  • Prolonged deceleration: Decrease in FHR of at least 15 bpm below the baseline and lasting more than 2 minutes but less than 10 minutes

Nursing Interventions During Labor

• First stage:
  • Encourage ambulation if not contraindicated
  • Provide comfort measures: Back rubs, sacral pressure, position changes
  • Encourage voiding every 2 hours
  • Provide clear liquids or ice chips
  • Monitor maternal vital signs and FHR
  • Assess cervical dilation and effacement
  • Assist with breathing and relaxation techniques
• Second stage:
  • Encourage pushing when the urge is felt
  • Provide support and encouragement
  • Monitor maternal vital signs and FHR
  • Assist with positioning for pushing
  • Prepare for delivery
• Third stage:
  • Observe for signs of placental separation
  • Administer oxytocin as prescribed
  • Assist with placental delivery
• Fourth stage:
  • Assess fundal firmness and location
  • Monitor lochia (vaginal discharge)
  • Assess perineum for edema and hematoma
  • Monitor maternal vital signs
  • Encourage breastfeeding
  • Promote bonding between mother and infant

Complications During Labor

• Fetal distress: Non-reassuring FHR patterns include late decelerations, severe variable decelerations, bradycardia
• Prolapsed umbilical cord: The umbilical cord precedes the fetus
• Shoulder dystocia: Difficulty delivering the fetal shoulders
• Uterine rupture: Tearing of the uterus
• Amniotic fluid embolism: Amniotic fluid enters the maternal circulation
• Postpartum hemorrhage: Excessive bleeding after delivery

Cesarean Birth

• Surgical delivery of the fetus through an incision in the abdomen and uterus
• Indications: Fetal distress, cephalopelvic disproportion, malpresentation, placental abnormalities, previous cesarean birth, maternal medical conditions
• Nursing care:
  • Preoperative: Assess maternal and fetal status, provide education, administer medications
  • Intraoperative: Assist with positioning and monitoring
  • Postoperative: Monitor vital signs, assess incision, manage pain, promote bonding

Induction and Augmentation of Labor

• Induction of labor is the artificial stimulation of uterine contractions before the spontaneous onset of labor, with or without ruptured fetal membranes
• Augmentation of labor is stimulation of uterine contractions when spontaneous contractions have failed to result in progressive cervical dilation or descent of the fetus

Learn about the stages of labor and childbirth, including the latent, active, and transition phases of the first stage. Understand the role of uterine contractions and cervical dilation throughout the process. Also, learn about the second stage of labor.