1. 5/31/2018
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Chapter 17
Stages of labor
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2. Stages of Labor First Stage Latent phase Active phase Transition phase
5/31/2018
chapter 17
Stages of Labor
First Stage
Latent phase
Active phase
Transition phase
Second Stage
Third Stage
Fourth Stage
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3. First stage of labor:(Stage of Dialtion)
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First stage of labor:(Stage of Dialtion)
It begins with the onset of true labor contractions and ends with complete dilation (10cm) and effacement (100%) of the cervix.
It is the longest stage for both nulliparous and parous women.
It has three phases: latent (early), active, and transition.
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4. 5/31/2018
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1. Latent phase:
Lasts from the beginning of labor until about 3cm of cervical dilation.
The woman is usually sociable and excited during this phase of labor.
Uterine contraction initially mild and infrequent progress to moderate strength every 5 min.
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5. 2. Active phase: The cervix dilates from 4 to 7 cm
5/31/2018
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2. Active phase:
The cervix dilates from 4 to 7 cm
Effacement is completed
The fetus descends to the pelvis
Internal rotation begins
Increase discomforts
The woman becomes more anxious and feel helpless
Serious inward focus
Uterine contraction every 2-5 minute
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6. 3. Transition phase: - Short but intense phase
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3. Transition phase:
- Short but intense phase
The cervix dilate from 8 to 10cm
The fetus descends further into the pelvis
Bloody show increase
Strong contractions
The woman may have the urge to push down
Leg tremors nausea and vomiting are common
The woman is irritable and lose control
Contraction every 1.5-2minute
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7. Second stage of labor (expulsion):
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Second stage of labor (expulsion):
Begins with complete dilation (10cm) and full effacement(100%) end with the birth of the baby.
involuntary pushing response
The mother may said that she needs to have a bowel movement or the baby is coming
Crowning of the fetal head
Feeling of stretching or splitting sensation
Contractions are strong
Woman exerts intense effort to push her baby
May appear sleepy between contraction
The word “labor” describe this phase
Feels tremendous relief and excitement as the second stage ends with the birth of baby
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8. Third stage of labor (placental)
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Third stage of labor (placental)
Begins with the birth of the baby and ends with the expulsion of the placenta
Length 5-10 min up to 30 min
Four Signs suggest placental separation:
1.Spherical shape of uterus
2.The uterus rises upward in the abdomen
3.The cord descends further from the vagina
4.a gush of blood appears as blood trapped behind placenta is released
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9. 5/31/2018
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The uterus must contract firmly and remain contracted after placenta is expelled to compress open vessels
During this stage pain results from uterine contractions and brief stretching of cervix as placenta passes through it
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10. Fourth stage of labor (physical recovery):
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Fourth stage of labor (physical recovery):
It lasts from the delivery of the placenta through the first 1 to 4 hours after birth
The uterus at or below the level of umbilicus ,firm contracted and rounded mass about 10 to 15cm in diameter
Lochia is rubra
Women may have chill lasts for 20 minutes, warm blanket or hot drink may be helpful
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11. Ice packs on perineum decrease discomfort and limit hematoma formation
5/31/2018
chapter 17
After pains or birth trauma are the main causes of discomforts in this stage
Ice packs on perineum decrease discomfort and limit hematoma formation
After pains are more intense in multiparous or in women who breast feed, in women who have uterine over distention( large baby) and full bladder or clot that remain in uterus
The woman is exhausted and need rest
This stage is the ideal time for bonding and to start breast feeding
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12. Nursing care during labor and birth
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Nursing care during labor and birth
Assessment on admission
Focused assessment
1. Fetal assessment
Gestational age of the fetus
Leopold’s maneuver
Fetal movement and FHR
Status of membrane( color ,odor and clarity of fluid)
2. Maternal assessment (vital signs) especially for infection or hypertension
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13. Data base assessment Reason for coming to hospital Prenatal care EDD
5/31/2018
Data base assessment
chapter 17
Reason for coming to hospital
Prenatal care
EDD
# of pregnancies term and abortion
Allergies
Last time of food intake
Medical surgical and pregnancy history
Recent illness and treatment
Medication, drug smoking and alcohol
Mother subjective evaluation of labor
Birth plan, pain management method and support person
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14. 3.Determine labor status
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2.Fetal assessment
Presentation ,position and FHR
Time of rupture membrane and characteristics of amniotic fluids
3.Determine labor status
Assess contraction
Cervix dilitation and effacement, station ,presentation and position
Membrane status
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15. 4. Physical exame(brief) 5. Laboratory data
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4. Physical exame(brief)
5. Laboratory data
Hematocrite and blood group and CBC
Blood glucose levels
Blood type and RH factor
Midstream urine(protein and glucose)
Syphilis ,hepatitis and HIV
6.IV access
Continuous infusion prevent dehydration
Isotonic electrolyte is preferable
Glucose is avoided
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16. Assessment after admission
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1.Fetal assessment
FHR electronic or Doppler
Amniotic fluid AROM OR SROM
Assess FHR at least one min after rupture of membrane
Record the time of rupture,FHR and character of fluid
cloudy, yellow or foul odor suggest infection
Green color suggest meconium passage (transient hypoxia)
Amount more than 1000ml is large, between is moderate and scant if only trickle barely enough to detect
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17. 5/31/2018
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2. Maternal assessment
Vital signs( hyper or hypotension , increased pulse increased resp. increased temp are all abnormal
Contraction
Progress of labor , vaginal exam should be limited to prevent infection
Intake and output ,check for bladder fullness every 2 hour
LOOK AT THE MOTHER’S PERINIUM FOR CROWNING OF FETAL HEAD IF SHE EXPERIENCE A NEED TO DEFECATE
Mother response to labor
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18. Nursing care for woman in true labor
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Nursing care for woman in true labor
1. Fetal oxygenation
Assessment of fetal well being include:
FHR,contraction,aminiotic fluid and vital signs
Intervention
1.promote placental function( position rather than supine)
2. observe for condition associated with fetal compromise
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19. Conditions Associated with Fetal Compromise
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Fetal heart rate outside the normal range
Little or no variability in heart rate
Persistent slowing of heart rate after contractions
Meconium-stained amniotic fluid
Cloudy, yellowish, or foul odor to amniotic fluid
Contractions longer than 90 seconds
Incomplete uterine relaxation, intervals between contractions shorter than 60 seconds
Maternal hypotension
Maternal hypertension
Maternal fever
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20. 1. providing comfort measures
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2. Discomfort
Intervention
1. providing comfort measures
Lightening: soft indirect lighting is soothing
Temperature; Cool damp cloths on woman's face and neck promote comfort, an electric fan circulate air in the room is appropriate
Cleanliness: change gown and linen when needed
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21. Positioning: use any comfortable position but avoid supine
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Mouth care: ice chips and hard candy reduce discomfort of dry mouth, avoid excessive sugar and if oral intake is contraindicated brushing teeth or rinsing mouth
Bladder emptying; Remined woman to empty bladder at least every 2 hours, catheterization is often needed
Positioning: use any comfortable position but avoid supine
Water( shower, tub, pool): enhance relaxation . Nipple stimulation by water current release oxytocin and make contraction more productive
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22. 5/31/2018
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2. Teaching
First stage
Pushing in response only to her spontaneous urge
Pushing without full dilitation leads to
cervix become lacerated and edematous and progress is blocked
Second stage
Laboring down
Position( curve body around uterus in C shape)
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23. Breathing pattern: avoid holding breath more than 6-8 second
5/31/2018
Breathing pattern: avoid holding breath more than 6-8 second
Provide encouragement
Giving of self
Pharmacologic management and support and care
3. Preventing injury
assessment ; observe mother’s perineum to determine when to make final preparation
Final preparation for primipara is done when crowning reach a diameter of 3-4cm but in multipara when cervix is fully dilated
chapter 17
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24. Intervention 1. transfer to delivery room 2. positioning of birth
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Intervention
1. transfer to delivery room
2. positioning of birth
3. observing perineum
Nursing care during Birth
1.Preparation of table
2.Perineal cleansing preparation
3.Initial care and assessment of newborn
4.Administration of medication such as oxytocin to control blood loss
5.Use universal precaution
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25. Responsibilities after birth
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Care of infant
1. maintain cardiopulmonary function
prepare neonatal resuscitation equipment
Assess Apgar score
Suctioning of secretion
2. supporting thermoregulation
dry infant
place under radiant warmer
Skin to skin contact
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26. Care of the mother 3. Identifying the infant Identifying band
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3. Identifying the infant
Identifying band
Care of the mother
1. observing for hemorrhage
Vs,fundus,lochia,bladder
Vital signs : assess temp. in recovery and before transfer to postpartum ward
Assess other vital signs every 15 min for first hour and 30 min in the next hour
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27. The first two or three voiding must be at least 300-400ml each voiding
5/31/2018
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Fundus should be firm midline and at or below umbilicus .If not firm massage and encourage mother to breast feeding
Bladder: full bladder is suspected when fundus is above umbilicus and or displaced to one side usually the right
The first two or three voiding must be at least ml each voiding
Lochia is rubra, small clot is okay but large clot is abnormal
Saturation of one pad within the first hour is the maximum normal lochia flow
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28. ice backs, analgesics , warmth
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2. Relieving discomfort
ice backs, analgesics , warmth
Ice packs: to reduce edema and limit hematoma formation
Analgesics:after pain and perineal pain may relieved by mild analgesics. Regular urination reduce after pain because uterus contract effectively
Warmth warm blanket is soothing and shorten the chills that is common after birth promoting early family attachment :
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29. Leopold's Maneuvers (1 of 4)
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Leopold's Maneuvers (1 of 4)
Unn Fig Procedure 17-1
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30. Leopold's Maneuvers (2 of 4)
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Leopold's Maneuvers (2 of 4)
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31. Leopold's Maneuvers (3 of 4)
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Leopold's Maneuvers (3 of 4)
Unn Fig Procedure 17-1
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32. Leopold's Maneuvers (4 of 4)
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Leopold's Maneuvers (4 of 4)
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