Stages of Labor and Delivery

• These notes cover the stages of labor, signs of labor, fetal heart rate (FHR) monitoring, labor complications, and interventions.

Stage 1 of Labor

• Consists of latent, active, and transitional phases.
• Latent phase: longest stage and cervix dilates to 4 cm.
• Active phase: cervix dilates to 6-7 cm.
• Transitional phase: cervix effaces to 10 cm.

Labor Stages in Detail

• Latent Phase:
  • Length: 6-12 hours.
  • Contractions: 5-15 min frequency, 10-30 sec duration, mild intensity.
  • Station: -2 to 0, membrane usually intact.
  • Biological Response: Excitement, anxiousness, talkativeness.
  • Personal Response: Thoughts centered on self, labor, and baby.
• Active Phase:
  • Length: 1-6 hours.
  • Contractions: 3-5 min frequency, 30-45 sec duration, moderate to strong intensity.
  • Station: increasing, membrane intact or ruptured 0 to +2.
  • Biological Response: Restlessness, labored respiration, increasing fears.
  • Personal Response: Needs human presence.
• Transitional Phase:
  • Length: 1-2 hours (up to 4 hours can be normal).
  • Contractions: 1-2 min frequency, 40-60 sec duration, strong intensity.
  • Station: heavy, usually ruptured 0 to +2.
  • Biological Response: Leg cramps, nausea, vomiting, panic, emotional response to external stimuli.
  • Personal Response: Limited control, uncooperative, thoughts on self, dependent.

Stage 2 of Labor

• Expulsive phase.
• Length: 2-4 hrs for first-time mothers, less than 1 hr for multiparous.
• Cervix is fully dilated to 10 cm.
• Contractions: 1-2 min frequency, 50-90 sec duration, less painful, expulsive.
• Station: heavy, ruptured, +4.

Stage 3 of Labor

• Placenta delivery.
• Length: 1-20 min.
• Cervix is closing.
• Contractions: less painful.
• Uterus rises, umbilical cord lengthens, cramping occurs.
• The individual's system is relieved.
• Oxytocin is administered to prevent hemorrhage.

Stage 4 of Labor

• Immediate postpartum.
• Length: 2-4 hours.
• Cervix is closing.
• Contractions are cramping.
• Fundal massage is performed.

Non-Pharmacological Labor Induction

• Ambulation and position changes.

Pushing Techniques

• Open Glottis:
  • Pushing occurs only with the urge.
  • Consistent breathing to keep the glottis open.
  • 3-4 pushes per contraction for 6-8 seconds.
• Closed Glottis:
  • Deep breath followed by pushing for 10 seconds.
  • 2-3 pushes per contraction.

Signs of True Labor

• Cervical changes (effacement, dilation, station).
• Patterned contractions when laying down.

Signs of False Labor

• Irregular contractions cease with ambulation, position changes, and/or laying down.

Acronym COAT

• Color, odor, amount, and time describe and assess amniotic fluid.

Tests to Confirm Amniotic Fluid

• Fern test (ferns under microscope).
• Amnisure (non-invasive test for amniotic protein).
• Nitrazine paper (turns blue if amniotic fluid is present).

Post Water Breaking

• Ambulation should be avoided to progress labor.
• It is Important to know rupture time to avoid risks of infection

Amnioinfusion Reasons

• Indicated for thick meconium, low amniotic fluid, and cord compression.

Fetal Heart Rate (FHR) Monitoring

• FHR 1:
  • Baseline 110-160 bpm; moderate variability; absent late/variable decelerations.
• FHR 2:
  • Bradycardia without absent baseline variability indicates intervene immediately.
  • Baseline rate: Tachycardia

FHR Variability

• Absent variability without recurrent decelerations, or marked variability.
• Absence of induced accelerations requires fetal stimulation.
• Recurrent variable decelerations with minimal or moderate variability indicates intervention.

Interventions for FHR Issues

• Variable decelerations with "slow return to baseline” require repositioning.

More Notes on FHR

• FHR 3:
  • Absent variability with recurrent late decelerations/variable decelerations/bradycardia requires intervention

Managing FHR Issues

• Minimal or Absent Variability:
  • Promote fetal oxygenation through:
    • Lateral positioning.
    • IV fluid bolus.
    • Oxygen administration at 10 L/min.
    • Modification of pushing.
• Recurrent Variable Decelerations:
  • Alleviate umbilical cord compression by:
    • Repositioning.
    • Amnioinfusion.
    • Modification of pushing.
• Maternal Hypotension:
  • Correct maternal hypotension through:
    • Lateral positioning.
    • IV fluid bolus.
    • Ephedrine if no response.

Emergency Scenarios

• Category 3 FHR and labor dystocia.
• Category 3 FHR is more urgent, needing immediate surgery.

Fetal Tachycardia Causes

• Fever and infection.
• Intervention includes cooling with towels and ice.

Tachysystole Contractions

• More than 5 contractions in 10 minutes, lasting over 120 seconds, increased resting tone, and less than one minute apart

Fetal Bradycardia Causes

• Perfusion issues (uterine detachment, cord compression).

SROM/AROM Risks

• Placenta abruptio or cord prolapse.
• In case of cord prolapse, push the head back to relieve pressure.

Labor Dystocia

• Dilation of ≥ 6 cm with membrane rupture, ≥ 6 hours of inadequate contractions, and no cervical change.
• New moms or those with uterine abnormalities are most at risk
• Suprapubic pressure and McRoberts maneuver are interventions.

Turtle Sign

• Indicates shoulder dystocia.
• The baby's is coming out and then goes back in because anterior shoulder is stuck on mom's bone
• Do not apply fundal pressure

Precipitous Delivery

• Fast delivery within 3 hours of labor onset increases risk of tears and cervical lacerations.
• A baby can have a bruised face and broken vessels in the eyes
• Those with history of precipitous deliveries should notify the provider each time.

Thick Meconium

• Perform amnioinfusion and bulb syringe suctioning.

Meconium Aspiration Syndrome (MAS)

• Abnormal inhalation of meconium by the fetus/newborn.

Anaphylactic Syndrome

• Also known as amniotic fluid embolism, leads to a high mortality rate.
• Mom's system gets injected with amniotic fluid

Triage Interventions

• Requires fetal heart rate monitoring, vitals, and timing.

Types of Cesarean Sections

• Scheduled:
  • Before birth onset.
  • Due to previous C-section or risk conditions.
• Non Urgent:
  • Related to complications or failure to progress.
• Urgent:
  • A need for rapid delivery.
  • Malrepresentation.
  • Placenta previa with bleeding and Category I FHR.
• Emergent:
  • Immediate need of delivery.
    • Umbilical cord prolapse.
    • Uterine rupture.

Post C-Section Care

• Splinting with pillow, showers only, watch incision, report infection signs, remove staples, avoid heavy lifting and driving.
• Ambulation, medications, heating pads, and carbonated drinks help gas pain move around.
• Sodium citrate neutralizes stomach acid.

Epidural Administration

• Prioritize assessing BP and fluid bolus
• C-shaped position while administering

Epidural Interventions

• Keep bladder empty and change position every hour.

Acronym: VC, EH, AO, LP

• Indicate interventions for cord compression (VC), head compression (EH), oxygen okay (AO), and expedite delivery (LP). External Cephalic Version (ECV).

External Cephalic Version (ECV)

• A manipulation of the fetus for vaginal birth.
• Done at the hospital due to risk for ROM (Rupture of Membranes)
• Dangerous and painful

TOLAC & VBAC

• Trial of labor after cesarean & Vaginal birth after cesarean (TOLAC/VBAC).
• Contraindications include pelvic abnormalities, transverse fetus, prior C-sections, and vertical incision

Bishop Score

• The bishop score assesses cervical readiness.

Bishop Score Results

• If ≥ 8, it is favorable for induction, you may give Pitocin
• If < 6, use cervical ripening (such as cervidil and cytotec) to soften cervix.

Operative Vaginal Delivery

• Vacuum assist or forceps to deliver the baby faster.

3 Pull Rule

• The 3 pull rule with vacuum assist can lead to more than 3 tries in 15 minutes leading to increased risk of brain bleeds for baby, lacerations, and/or hemorrhage for mom.

Latent Labor Actions

• Ambulation and position changes.

Stage 2 Nursing Role During Labor

• Encourage pushing (3-4 times/6-8 seconds when there’s an urge).

Ferguson Reflex

• Maternal urge to push.

Signs of Labor Progression

• The urge to push.

Prolapsed Cord Action

• Relieve pressure on cord by elevating presenting part.

Cardinal Movements of Labor

1. Engagement
2. Descent
3. Flexion
4. Internal Rotation
5. Extension
6. External Rotation
7. Expulsion

Vacuum Extraction Assistance

• A nurse should push with vacuum traction.

Priority Action after ROM

• Check FHR to rule out cord prolapse.

Characteristics of Active Labor

• Internal focus/breathing, contractions every 3-5 minutes, pain 5-8, and breathing techniques.

AROM and Meconium Noted

• Notify NICU.

Post Delivery Contractions

• The mother will still feel contractions.

Ideal Position for Stage 2 Labor

• Elevate HOB (Head of Bed) and squatting bar use.

Chorioamnionitis Signs

• Maternal fever, foul amniotic fluid, and fetal tachycardia.

Interventions for Chorioamnionitis

• Cool mom off, start antibiotics for mom and baby, blood culture, and Tylenol.

Fetal Tachycardia Definition

• A baseline of 190 bpm.

Local Anesthesia

• Pain control for stitches.

Nitrate Oxide Administration

• 30 seconds before a contraction.

Placenta Previa

• Bright red bleeding that is painless, a drop in BP, and late decelerations.

Placenta Abruption

• Painful, dark red bleeding, late decelerations.

Risk for Uterine Rupture

• Previous C-section scar.

Water Breaking Guidelines

• Break the water when the baby's head is engaged.

Signs of Approaching Labor

• Nesting, lightning, mucus plug loss, weight loss, persistent backache, and increased Braxton Hicks.

Leopold's Maneuvers

• Determine fetal position in the uterus.

The 5 P's of Labor

• Passenger (fetus and placenta).
• Passageway (birth canal).
• Powers (contractions).
• Position (of the mother).
• Psychology.

Questions cover cervical dilation, labor stages, contraction patterns, and interventions for complications such as shoulder dystocia and meconium aspiration. Focus on understanding the phases of labor, expected physiological responses, and appropriate clinical management.