Stages of Labor and Delivery

• Study notes for the Nur 335 exam 2 on Maternal Health Theory & Application

Stage 1 of Labor

• Consists of latent, active, and transitional phases; a mnemonic to remember labor actively transitioning exists

Stages of Labor

Latent Phase

• The longest stage
• Lasts 6-12 hours
• Causes cervical effacement and dilation to 4 cm
• Contractions occur every 5-15 minutes, lasting 10-30 seconds at a mild intensity
• May or may not have show/membrane/station intact, usually at -2-0
• Biological response includes cramps, backache, excitement, anxiety, happiness, relief, curiosity, quietness, or talkativeness, and the need for information and reassurance
• Personal response includes thoughts centered on self, labor, and baby

Active phase

• Lasts 1-6 hours
• Causes cervical effacement and dilation to 6-7 cm
• Contractions occur every 3-5 minutes, lasting 30-45 seconds at a moderate/strong intensity
• Show/membrane/station increases, intact or ruptured at 0 - +2
• Biological response includes restlessness, labored respiration, hyperventilation, increasing fears and anxieties, and feeling threatened and inwardly focused
• Requires human presence

Transitional phase

• Lasts 1-2 hours, or 4 hours can be normal
• Causes cervical effacement to 10 cm
• Contractions occur every 1-2 minutes, lasting 40-60 seconds with strong intensity
• Show/membrane/station is heavy, usually ruptured at 0 - +2
• Causes leg cramps, nausea, vomiting, hiccups, belches, perspiration, and a pulling or stretching sensation deep in the pelvis, as well as panic, emotional, and irritable responses to external environment stimuli
• Personal response becomes limited, losing control; thoughts are on self, uncooperative, amnesic between contractions, and dependent

Interventions

• Involves lab tests, IV, fetal monitoring, assessing VS, GBS status, SVE, support, and comfort measures

Second Stage of Labor: Expulsive Phase

• Length for primiparas is 2-4 hours; for multiparas, less than 1 hour
• Cervix is fully dilated to 10 cm
• Contractions occur every 1-2 minutes, lasting 50-90 seconds, and are less painful and expulsive
• Show/membranes/station is heavy, ruptured at +4
• Intra-abdominal pressure is exerted (bearing down), urge to push, perineum bulges and flattens, perineal burning and stretching.
• Desires to sleep between contractions, amnesic between contractions

Interventions

• Instruct the woman to bear down with the urge to push, check Fetal Heart Rate (FHR), and provide comfort measures

Third Stage of Labor: Placenta

• Length is 1-20 minutes, with cervix closing
• Contractions are less painful
• Uterus rises and becomes globular shape, gush or flood as placenta separates, umbilical cord lengthens, cramping.
• May want to sleep, proud, happy, relief, may or may not display emotions
• Personal system is relieved

Interventions

• Oxytocin administration prevents hemorrhage

Fourth Stage of Labor: Immediate Postpartum

• Highest risk for hemorrhage
• Length is 2-4 hours, with the cervix closing
• Contractions cause cramping
• Biological response includes post-partum chills, hunger, thirst, drowsiness, moderate to heavy lochia, and usually painless uterine contractions

Interventions

• Fundal massage

Non-Pharmacological Ways to Induce Labor

• Ambulation and position changes

Two Different Pushing Techniques

Open Glottis

• Mom pushes only when she has the urge by continuing to breathe, which keeps the glottis open
• 3-4 times per contraction for 6-8 seconds

Closed Glottis

• Mom takes a deep breath and pushes for 10 seconds
• 2-3 times per contraction

Signs of Labor

• True labor presents with cervical changes (effacement, dilation, station), patterned contractions, and contractions while laying down
• False labor presents with irregular contractions, and contractions go away with ambulation, position changes, and laying down

COAT Acronym

• Describes and assesses amniotic fluid (Color, Odor, Amount, Time)

Tests to Confirm Amniotic Fluid

• Fern test (looking for ferns under a microscope)
• Amnisure (non-invasive test looking for amniotic protein)
• Nitrazine paper (will turn blue if amniotic fluid is present)

Management After Water Breaks

• No ambulation to progress labor

Reasons to Monitor Rupture Time

• Risk of infection and a small window of time for the baby to remain in the mom after rupture exists

Reasons to do Amnioinfusion

• Thick meconium
• Low amniotic fluid
• Variables and cord compression

Fetal Heart Rate Monitoring (FHR 1)

• Desirable findings include a baseline of 110-160, moderate variability, absent late or variable decelerations, absent or present early decelerations, and absent or present accelerations

FHR 2

• Undesirable findings include a baseline rate of Bradycardia not accompanied by absent baseline variability, or a baseline rate of Tachycardia

• Minimal variability

• Absent variability without recurrent decelerations

• Marked variability

• Absence of induced accelerations after fetal stimulation

• Recurrent variable decelerations with minimal or moderate variability

• Prolonged deceleration

• Recurrent late decelerations with moderate variability

• Variable decelerations with “slow return to baseline," “overshoots," or "shoulders"

Intervention

• Reposition the mom

FHR 3

• Contains absent variability with, recurrent late decelerations, recurrent variable decelerations, bradycardia, and sinusoidal pattern

Clinical Situations and Interventions

• Minimal or absent variability/Recurrent late decelerations: Promote fetal oxygenation by lateral positioning, IV fluid bolus of lactated Ringer's solution, and oxygen administration at 10 L/min via nonrebreather face mask.

• Recurrent variable decelerations: Modification of pushing efforts; pushing with every other or every third contraction or discontinuation of pushing temporarily (during second stage labor)

• Tachycardia Bradycardia: Decrease in oxytocin rate

• Variable, late or prolonged decelerations occurring with maternal pushing efforts: Discontinuation of oxytocin / removal of Cervidil insert/withholding next dose of misoprostol

• Tachysystole: Reduce uterine activity with IV fluid bolus of lactated Ringer's solution, lateral positioning, decrease/discontinuation of oxytocin

• Recurrent variable decelerations: Alleviate umbilical cord compression with Amnioinfusion

• Maternal hypotension: Correct maternal hypotension with lateral positioning and IV fluid bolus of lactated Ringer's solution

Prioritization

• A mom having a category 3 VS is more urgent and would go to surgery first, compared to a mom having labor dystocia and not progressing

Fetal Tachycardia Causes

• Fever and infection

Tachysystole interventions

• Cool mom down with towels and ice

Tachysystole Contractions

• 5 contractions in 10 minutes
• Lasting longer than 120 seconds
• Resting tone is increased
• Less than one minute apart

Fetal Bradycardia Causes

• Perfusion issues; uterine detachment and cord compression

Pressure After SROM and AROM Causes

• Placenta abruptio (detachment) or cord prolapse

Management of a Prolapsed Cord

• Push the head back with fingers to relieve pressure off the cord

Labor Dystocia

• Dilation of more than or equal to 6 cm dilation with membrane rupture and 6 hours or more of inadequate contractions and no cervical change
• New moms and uterine abnormalities are at most risk

Intervention

• Suprapubic pressure (use stool for higher ground) and McRoberts maneuver (mom's thighs towards abdomen)

Actions for Labor Dystocia That Isn't Progressing

• C-section

Turtle Sign

• Indicates shoulder dystocia, where the baby's head starts coming out and then goes back in because the anterior shoulder is stuck on the mom's bone

Warning

• Never do a fundal pressure

Precipitous Delivery

• Fast delivery within 3 hours of the onset of labor

Risk Factors

• Tearing and cervical lacerations

Baby Risks

• A bruised face and broken vessels in the eyes

Action for History of Precipitous Deliveries

• Yes, because deliveries can become quicker each time and nurses need to prepare and know if mom is feeling any sensation of pressure

Thick Meconium Noted When BOW is Ruptured

• Amnioinfusion in labor and bulb syringe suctioning (mouth first and then nose)

Meconium Aspiration Syndrome (MAS)

• Abnormal inhalation of meconium (first stool) produced by a fetus or newborn

Anaphylactic Syndrome

• Emergent and has a high mortality rate
• Amniotic fluid gets into mom's system and causes an embolism

Triage Interventions

1. Fetal heart rate monitoring
2. Vitals
3. Time of

Types of C-Section

Scheduled

• Occurs before the onset of birth due to a previous c-section or conditions that can put the mom/baby at risk during birth (malpresentation)

Non-Urgent

• Relates to complications such as failure to progress and failure to descend with category 1 FHR

Urgent

• Indicates a need for rapid delivery
• Malpresentation diagnosed after onset of labor or placenta previa with mild bleeding diagnosed after labor. and fetal heart rate with Category 1 FHR

Emergent

• Indicates an immediate need to deliver the fetus b/c of prolapse of umbilical cord or rupture of uterus

Care Instructions After C-Section

• Splinting with pillow
• No baths or swimming, only showers
• Watch the incision
• Report signs of infection
• Removed staples
• Lift nothing heavier than the baby
• No driving
• Ambulation
• For gas pain, ambulation, medications, use heating pad and carbonated drink

Medication Before C-Section

• Sodium citrate to neutralize stomach acid

Epidural

• 1st priority: assess BP and give a liter bolus of fluids

Interventions

• Keep the bladder empty with a straight cath
• Position changes every hour (turning side to side)
• Place mom in C shape position when giving epidural

V-C

• Variable decels and cord compression
• Interventions: This is not okay? Position changes and move on

E-H

• Early decels and Head compression
• Interventions: Okay sign and identify the process of labor

A-O

• Accelerations and oxygen okay
• Interventions: Okay sign and No intervention needed

L-P

• Late decels and perfusion
• Interventions: Not good expedite delivery, intrauterine resuscitation and evaluate why

External Cephalic Version (ECV)

• An attempt to manipulate and turn the fetus externally from a breech presentation to vertex presentation to allow for vaginal birth

Risks of ECV

• The procedure is done at the hospital because is risk for ROM, dangerous, painful

TOLAC & VBAC

• Trial of labor after cesarean & Vaginal birth after cesarean

Contraindications for TOLAC/VBAC

• Pelvic abnormalities that are not conducive for a vaginal birth
• Fetus lies transverse In mom's stomach
• History of 2 previous c/s
• vertical c-section incision

Bishop Score Assessment

• Assesses cervical readiness

High Bishop Score

• 8 or higher
• Favorable for induction! give Pitocin

Low Bishop Score

• Less than 6
• Give cervical ripening medication (cervidil, cytotec) to soften cervix

Operative Vaginal Delivery

• Vacuum assist or use of forceps to help deliver baby faster

Vacuum Assist Rule

• More than 3 or more attempts in 15 minutes can put baby at risk for increased brain bleeds, jaundice and puts mom at risk for lacerations and hemorrhage

Management of Category 1 FHR in Latent Labor w/ ROM

• Ambulation and position changes

Nursing Role During Stage 2 of Labor

• Encourage the patient to push 3-4 times with 6-8 seconds between urges

Ferguson Reflex

• Maternal urge to push

Sign of Labor Progression

• From stage 1 to 2
• The urge to push

Prolapsed Cord Priority Action

• Relieve pressure on cord by elevating presenting part

Seven Cardinal Movements of Labor

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

Vacuum Extraction Assistance

• Patient will push with vacuum traction

Priority Action After ROM

• Assess the fetal heart rate to rule out cord prolapse

Characteristics of Active Labor

• Include internal focus and breathing, contractions every 3-5 minutes, pain 5-8, and using breathing techniques

Nursing Priority With AROM and Meconium Noted

• Notify NICU

Postpartum Contractions

• Contractions will be felt after the baby is born

Best Position in Stage 2 of Labor

• Elevate HOB and use of the squatting bar

Signs of Chorioamnionitis

• Maternal fever, foul-smelling amniotic fluid, fetal tachycardia

Interventions

• Cool the mom off, start antibiotics for mom and baby, do CBC and blood culture. - Tylenol to get fever down

Fetal Tachycardia Baseline

• A fetus with a baseline of 190 has tachycardia

Action for Controlling Pain

• Use local anesthesia to helps controlling pain with stitches

When To Give Nitrate Oxide

• Give 30 seconds before a contraction

Placenta Previa Signs and Symptoms

• Bright red bleeding that is painless
• Drop in BP
• Baby has late decelerations

Placenta Abruption Signs and Symptoms

• Painful, dark red bleeding, late deceleration

Risk for Uterine Rupture

• Previous c-section due to uterus scarring,

Rupturing Bag of Water

• Rupture the bag of water when the baby's head is engaged

Signs Mom Is Going Into Labor

• Nesting, lightening, loss of mucus plug, weight loss, persistent backache, increased Braxton hicks

Leopold’s Maneuvers: Determining Fetal Position

• 1st maneuver: determine what part of the fetus is located in the fundus of the uterus
• 2nd maneuver: determine location of the fetal back
• 3rd maneuver: determine the presenting part
• 4th maneuver: determine the location of the cephalic prominence.

The 5 P’s of Labor: Factors Affecting Labor Progress

• Passenger (fetus and placenta), passage (birth canal), powers (contractions), position (of the mother), and psychology

These flashcards cover the stages of labor and delivery, including typical contraction patterns, biological responses, and expected durations. Key interventions and signs of placental separation are also addressed. The scenarios focus on recognizing different stages and appropriate responses during childbirth.