Nursing care for pregnant women in labor proves to be a challenging task because it requires nurses to be fast in their assessment without sacrificing the quality and accuracy of rendered nursing care. Now, why should care of women in various stages of labor be taken seriously?
Four Stages of Labor
Stage 1: Latent phase
Description:
Stage 1 is the longest. A labor curve, often called a Friedman curve, may be used to identify whether a woman’s cervical dilation is progressing at the expected rate.
Assessment
- Cervical dilation is 1 to 4 cm.
- Uterine contractions occur every 15 to 30 minutes, are 15 to 30 seconds in duration, and are of mild intensity.
Interventions
- Encourage mother and partner to participate in care.
- Assist with comfort measures, changes of position, and ambulation.
- Keepmother and partner informed of progress.
- Offer fluids and ice chips.
- Encourage voiding every 1 to 2 hours.
Stage 1: Active phase
Assessment
- Cervical dilation is 4 to 7 cm.
- Uterine contractions occur every 3 to 5 minutes, are 30 to 60 seconds in duration, and are of moderate intensity.
Interventions
- Encourage maintenance of effective breathing patterns.
- Provide a quiet environment.
- Keepmother and partner informed of progress.
- Promote comfort with back rubs, sacral pressure, pillow support, and position changes.
- Instruct partner in effleurage (light stroking of abdomen).
- Offer fluids and ice chips and ointment for dry lips.
- Encourage voiding every 1 to 2 hours.
Stage 1: Transition phase
Assessment
- Cervical dilation is 8 to 10 cm.
- Uterine contractions occur every 2 to 3 minutes, are 45 to 90 seconds in duration, and are of strong intensity.
Interventions
- Encourage rest between contractions.
- Wake mother at beginning of contraction so she can begin breathing pattern.
- Keepmother and partner informed of progress.
- Provide privacy.
- Offer fluids and ice chips and ointment for dry lips.
- Encourage voiding every 1 to 2 hours.
Interventions throughout stage 1
- Monitor maternal vital signs.
- Monitor FHR via ultrasound Doppler, fetoscope, or electronic fetal monitor.
- Assess FHR before, during, and after a contraction, noting that the normal FHR is 120 to 160 beats/min.
- Monitor uterine contractions by palpation or tocodynamometer, determining frequency, duration, and intensity.
- Assess status of cervical dilation and effacement.
- Assess fetal station presentation and position by Leopold’s maneuvers.
- Assist with pelvic examination and prepare for a fern test.
Stage 2
Assessment
- Cervical dilation is complete.
- Progress of labor is measured by descent of fetal head through the birth canal (change in fetal station).
- Uterine contractions occur every 2 to 3 minutes, lasting 60 to 75 seconds, and are of strong intensity.
- Increase in bloody show occurs.
- Mother feels urge to bear down; assist mother in pushing efforts.
Interventions
- Perform assessments every 5 minutes.
- Monitor maternal vital signs.
- Monitor FHR via ultrasound Doppler, fetoscope, or electronic fetal monitor.
- Assess FHR before, during, and after a contraction, noting that normal FHR is 120 to 160 beats/min.
- Monitor uterine contractions by palpation or tocodynamometer, determining frequency, duration, and intensity.
- Provide mother with encouragement and praise and provide for rest between contractions.
- Keepmother and partner informed of progress.
- Maintain privacy.
- Provide ice chips and ointment for dry lips.
- Assist mother into a position that promotes comfort and facilitates pushing efforts, such as lithotomy, semisitting, kneeling, sidelying, or squatting.
- Monitor for signs of approaching birth, such as perineal bulging or visualization of the fetal head.
Prepare for birth (expulsion of the fetus). F. Stage 3
Assessment
- Contractions occur until the placenta is expelled.
- Placental separation and expulsion occur.
- Expulsion of the placenta occurs 5 to 30 minutes after the birth of the infant.
- Schultze mechanism: Center portion of the placenta separates first, and its shiny fetal surface emerges from the vagina.
- Duncan mechanism: Margin of the placenta separates, and the dull, red, rough maternal surface emerges from the vagina first.
Interventions
- Assess maternal vital signs.
- Assess uterine status.
- Provide parents with an explanation regarding expulsion of the placenta.
- After expulsion of the placenta, uterine fundus remains firm and is located 2 fingerbreadths below the umbilicus.
- Examine placenta for cotyledons and membranes to verify that it is intact.
- Assess mother for shivering and provide warmth.
- Promote parental-neonatal attachment.
Stage 4
Description:
Period 1 to 4 hours after delivery
Assessment
- Blood pressure returns to prelabor level.
- Pulse is slightly lower than during labor.
- Fundus remains contracted, in the midline, 1 or 2 fingerbreadths below the umbilicus.
Interventions
- Performmaternal assessments every 15minutes for 1 hour, every 30 minutes for 1 hour, and hourly for 2 hours (or as per agency policy).
- Provide warm blankets.
- Apply ice packs to the perineum.
- Massage the uterus if needed, and teach the mother to massage the uterus.
- Provide breast-feeding support as needed.
- See Chapter 30 for information on caring for the newborn.
