Stages of Labor and Delivery

Stages of Labor and Delivery

• This unit expects students to identify labor stages, assess laboring families, and use critical thinking to make labor and birth more family-centered.
• It also aims to teach students how to find areas in labor and birth that could use more nursing research or evidence-based practices.

Affective Objectives

• Students should be able to listen in discussions, respectful of other opinions, and accept critique openly

Psychomotor Objectives

• Students should be able to analyze how nurses can improve labor and birth and combine knowledge of nursing in labor to achieve quality maternal and child healthcare

Required Readings

• Maternal and Child Health Nursing: Care of the Childbearing and Childrearing Family. (8 th Ed.) by Adele Pillitteri and JoAnne Silbert-Flagg (2018)
• Essentials of Maternity, Newborn, and Women's Health Nursing (4th Ed.) by Susan Scott Ricci

Stages of Labor Divisions

• Labor is divided into three stages
• Stage 1: Begins with true labor contractions and ends when the cervix is fully dilated
• Stage 2: Extends from full dilatation until the infant is born
• Stage 3: Placental stage
• The first 1-4 hours after birth is sometimes called the "fourth stage" to emphasize maternal observation
• Friedman (1978) used data to divide stages 1 and 2 into latent and active labor phases

First Stage of Labor

• It has three divisions: Latent, active, and the transition phase

Latent Phase (Preparatory)

• Begins at the onset of contractions, ends when rapid cervical dilatation begins
• Contractions: Mild, last 20-40 seconds
• Cervix: Effacement occurs, dilates from 0-3 cm
• Duration: ~6 hours for nulliparas, ~4.5 hours for multiparas
• Ripe cervix: A "nonripe" cervix means a longer latent phase, however analgesia can prolong the phase if given too early
• Cephalopelvic disproportion: Measuring the length of the latent phase is important to detect this condition
• Activity: Walking about and preparing for birth is encouraged
• In birth setting: Continue activity, begin alternative pain relief (aromatherapy/distraction)

Active Phase

• Cervical dilatation occurs more rapidly, from 4 to 7 cm
• Contractions last 40-60 seconds and occur every 3-5 minutes
• Duration: ~3 hours in a nullipara and ~2 hours in a multipara
• Rupture of membranes: Show (increased vaginal secretions) may occur with spontaneous rupture
• Discomfort: As contractions strengthen, this phase can be difficult, dramatic, and frightening as labor progresses
• Friedman graph: Active labor can be subdivided into acceleration (4-5 cm) and maximum slope (5-9 cm)
• Maximum slope: Cervical dilatation proceeds most rapidly, averaging 3.5 cm/hr in nulliparas and 5-9 cm/hr in multiparas
• Activity: Women should continue to be active in a comfortable position

Transition Phase

• Contractions: Peak intensity, every 2-3 min, 60-90 second duration, maximum cervical dilatation (8-10 cm)
• Membrane Rupture: Membranes rupture if not already
• Complete dilation (10 cm): Complete cervical effacement occurs
• Discomfort: Intense, potentially causing N/V
• Loss of Control: Feelings of anxiety, panic, or irritability
• Peak transition identification: slowing of cervical dilation when 9cm is reached
• Urge to push: At 10 cm of dilation, an irresistible urge may occur

Second Stage

• Period from full dilation and cervical effacement to birth
• Duration: ~1 hour (uncomplicated birth)
• Contractions: Change to an uncontrollable urge to push
• Nausea/Vomiting: May experience
• Perineum: Begins to bulge and tense as fetal head touches internally
• Anal changes: Eversion may occur & stool expelled
• Crowning: Fetal scalp appears & circle enlarges

Third Stage

• Begins with the birth of infant and ends with delivery of placenta
• Placental separation and expulsion are involved

Placental Separation

• Uterus: Contractions cause disproportion leading to placental folding/separation
• Bleeding: Begins on the maternal surface and helps separation
• Completed separation: Placenta sinks
• Signs of loosening include:
  • Cord lengthening
  • Gush of vaginal blood
  • Uterine shape change
  • Firm contraction
  • Placental visualization at vaginal opening

Placental Presentation

• Schultze presentation: Placenta separates first at the center, folds onto itself, presents fetal surface- shiny and glistening
• (~80% of placentas)
• Duncan presentation: Placenta separates first at edges, slides presenting maternal surface- looks raw, red, & irregular

Bleeding

• Normal consequence of placental separation, before uterine sealing

Placental Expulsion

• Natural bearing-down or Credé’s maneuver by provider: placenta delivered naturally this way
• Non-contracted uterus: Pressure should NEVER be applied or inversion/hemorrhage may occur
• Manual removal: Possible if no spontaneous delivery is possible

Physiological Effects of Labor on a Woman: Cardiovascular System

• Labor involves strenuous work requiring a cardiovascular response
• Contractions: Decrease uterine blood flow and increases blood in general circulation, leading to peripheral resistance and increases in systolic and diastolic blood pressure.
• Pushing: Increases cardiac output by 40-50%
• Post Birth: Decreases within the first hour
• Cardiac history: Requires close monitoring for complications

Physiological Effects of Labor on a Woman: Blood Pressure

• Systolic blood pressure rises ~15 mmHg with each contraction
• Abnormal increases: Could signify pathology
• Supine position: Uterine pressure on the vena cava can lead to hypotension

Physiological Effects of Labor on a Woman: Hemopoietic System

• Leukocytosis: WBC increases due to stress/exertion (average 25,000 to 30,000 cells/mm3, compared with 5,000 to 10,000 cells/mm3)

Physiological Effects of Labor on a Woman: Respiratory System

• Respiration rate increases to supply oxygen, total oxygen consumption nearly doubles
• Hyperventilation possible: Use breathing patterns

Physiological Effects of Labor on a Woman: Temperature Regulation

• Increased muscular activity: Slight elevation, Diaphoresis occurs to cool body

Physiological Effects of Labor on a Woman: Fluid Balance

• Insensible water loss increases from increased respiration/diaphoresis
• Intravenous fluid replacement: May be needed for prolonged labor due to increased fluid losses and decreased oral intake

Physiological Effects of Labor on a Woman: Urinary System

• Kidneys concentrate urine, specific gravity increases (1.020-1.030)
• Increased muscle activity: Trace protein is common due
• Bladder tone: Fetal head pressure reduces bladder tone/sense of filling

Physiological Effects of Labor on a Woman: Musculoskeletal System

• Joint softening: Relaxin hormone causes the symphysis pubis/sacral joints to soften/relax, increasing pelvic ring size

Physiological Effects of Labor on a Woman: Gastrointestinal System

• Digestive Inactivity: Fairly inactive due to shunting blood/uterine pressure, stomach emptying prolonged
• Bowel movement: Some loosen with strong contractions

Physiological Effects of Labor on a Woman: Neurologic/Sensory Responses

• Pain responses cause increased pulse/respiration rate
• Initial cause of pain: Uterus & cervix discomfort
• Pain concentrated on the perineum at moment of birth

Psychological Responses of a Woman to Labor: Fatigue

• A heavy burden can make labor loom as an overwhelming and unendurable experience unless they have competent support people with them.

Psychological Responses of a Woman to Labor: Fear

• Increased by labor moving faster/slower than anticipated, contractions are harder/longer than remembered
• A reminder can ease the mind as childbirth is predictable and a well-documented event

Psychological Responses of a Woman to Labor: Cultural Influences

• This has strong effects and every mother responds differently

Physiological Effects of Labor to a Fetus: Neurologic System

• Pressure on fetal head can causes decreased heart rate (FHR) by 5 bpm during contraction when strength reaches 40 mmHg
• Monitor: Fetal heart decreases appear as a normal or early deceleration pattern

Physiological Effects of Labor to a Fetus: Cardiovascular System

• Fetus unaffected by rate variations
• During contractions: Arteries constricted so filling of cotyledons halts, thus reducing oxygen/nutrients/ causing slight hypoxia

Physiological Effects of Labor to a Fetus: Integumentary System

• minimal petechiae or ecchymotic, and also edema of the presenting part (caput succedaneum)

Physiological Effects of Labor to a Fetus: Musculoskeletal System

• Uterine contractions push fetus into a position of full flexion

Physiological Effects of Labor to a Fetus: Respiratory System

• Labor aids surfactant production by alveoli in fetal lung
• Lung fluid passes easily due to chest pressure

Maternal Danger Signs: High or Low Blood Pressure

• Systolic > 140 mmHg, diastolic > 90 mmHg, or increase systolic > 30 mmHg, increase diastolic > 15 mmHg (pregnancy-induced hypertension criteria)
• Falling blood pressure: Sign of intrauterine hemorrhage

Maternal Danger Signs: Abnormal Pulse

• High (>100 bpm) may be indication of hemorrhage

Maternal Danger Signs: Inadequate or Prolonged Contractions

• Requires intervention in cases due to increased rest period being needed between contractions
• Contractions > 70 sec require reporting

Maternal Danger Signs: Pathologic Retraction Ring

• Indentation across abdomen at the joining of parts of the uterus may signal impending uterine rupture

Maternal Danger Signs: Abnormal Lower Abdominal Contour

• Bulge signal 1) injury of bladder from the head as it descends, 2) impeded the descent of the head
• Empty bladder 2 hours during labor

Maternal Danger Signs: Increasing Apprehension

• May indicate nearing second stage
• May need investigated due to oxygen deprivation or internal hemorrhage

Fetal Danger Signs: High or Low Fetal Heart Rate

• 160 bpm (tachycardia) or <110 bpm (bradycardia) is an indicator of fetal distress

• equally important is a late or variable deceleration pattern on a fetal monitor.
• False sense of security given if only assessed between contractions

Fetal Danger Signs: Meconium Staining

• Not always sign of distress when a amniotic fluid color turns green: may indicate rectal sphincter control and passage into amniotic fluid
• May indicate hypoxia: which promotes vagal reflex
• Breech: May be pressure on buttocks that causes stool loss

Fetal Danger Signs: Hyperactivity

• Indicates hypoxia

Fetal Danger Signs: Oxygen Saturation

• Low levels (under 40%) requires assessment of oxygen saturating with a catheter
• Blood pH of 7.2, suggests well-being and is compromised; Normal oxygen saturation in a fetus is normally 40% to 70%.

Care of a woman during the First Stage of Labor

• To keep the process natural, nurses can be helpful by keeping it as free of unnecessary interventions
• Labor begins on its own
• Women are able to move to move about freely
• Women receive continuous support during labor
• No interventions should be used, like intravenous fluids
• Nonsupine positions should be given women
• Give mother and baby unlimited time to be with each other

Respecting Contraction Time

• Exercises should resume when concentration is disrupted

Promote Change of Positions

• If ruptured: Lay on side until the monitor indicates that the umbilical cord may prolapse if the head is not engaged (firmly in the pelvic inlet)
• Medication: If dizzy, lay elevated for up to 15 after administration and lay on side, prefferably the left so that blood flow is free to limbs/placental filling/ circulation and tip away from the vena cava
• Breathing exercises: Some women need them on the side and should return after each contraction to lie supine

Offer & Respect/Promote Support

• Touch a woman.
• Show support for the woman

Pain Management

• Ask the woman on which pain management measures to take to help them resume their breathing exercises with success

Second Stage of Labor: Reactions

• Some may react by getting more argumentative/ angry/crying/ screaming
• Some react by tensing, which may make the sensation even more uncomfortable/frightening

Second Stage of Labor: Preparing the Place of Birth

• When cervix dilated 9–10 cm (multipara) for primipara when the head is crowned the size of a quarter or half dollar (full dilation and descent)
• Equipment such as sponges, drapes, scissors, basins, clamps, bulb syringe, vaginal packing, sterile gloves/towels ready

Second Stage of Labor: Positioning

• Woman can choose from lateral or Sims, dorsal recumbent, semi-sitting, and squatting Position top
• Table 30–60 degree angle: so that the woman can push effectively. Lying for longer than 1 hour in a lithotomy position; leads to intense pelvic congestion that may cause thrombophlebitis

Second Stage of Labor: Promoting Effective Pushing

• Wait for urge, rest during
• Use gravity by semi-Fowler’s, squatting, or all-fours
• Short or long pushes with each breath
• Avoid breath-holding and urge/breathe during pushes

Second Stage of Labor: Perineal Cleaning

• Iodophor
• Clean outward (away) from vagina

Second Stage of Labor: Introducing the Infant

• Infant is on parent
• Must be warm and safe

Postpartum Care

• Perineal Repair requires Placenta Delivery and Oxytocin Administration
• VS: Check pulse/respirations/BP every 15min for the first hour: Pulse= 80-90 bpm /20-24 per min and is slightly elevated d/t excitement and recent oxytocin administration
• Check location, size, tone of uterus and lochia characteristics
• Perineal care/pad after positioning birth bed Offer clean gown/warmed blanket: Chill/shaking 10-15min after
• Exhaustion may trigger high risks of hemorrhage during this fourth stage