EXPECTED BEHAVIOR
STAGE SIGNS AND SYMPTOMS
First Stage
Latent Phase
• Regular perceived uterine contraction
• Rapid cervical dilatation begins
• Tightening sensation in the woman’s
abdomen
Active Phase
• Cervical dilatation occurs more rapidly
• Contractions are stronger
• Increased vaginal secretions
• Spontaneous rupture of the membrane
Transition Phase
• Contractions reach their peak of
intensity,occurring every 2 to 3 minutes
with a duration of 60 to 90 seconds.
• Dilatation continues at a rapid rate
• Rupture of the membrane at full
dilatation
• Mucus plug from cervix is released
• Nausea and vomiting
• A feeling of loss of control, anxiety,
panic and irritability
• Intense sensation in the abdomen
NURSING INTERVENTIONS
OF THE MOTHER
• Feeling of • Assess couple for contributing factors related to feelings of loss of control
excitement and fear • Assist couple with using controlled breathing exercises and position
• Feeling of loss of changes. Reinforce information learned in childbirth education classes.
control • Slowly and clearly explain the events and changes occurring with the
• Anxiety active stage of labor. Inform the couple of things that can and cannot be
• Irritability controlled.
• Powerlessness • Reassure, as appropriate, that labor is proceeding without problems.
• Tensed • Allow opportunities for the couple to manipulate the environment. Offer
• Panic couple options from which they can choose.
• Emphasize positive aspects of situation and what can be controlled
• Provide continued emotional support throughout labor and provide privacy
as appropriate. Encourage the husband to continue actively support the
wife.
• Respect contraction time
• Promote change of positions
• Promote voiding and provide bladder care
• Offer Support
• Respect and promote the support person’s activities
• Support the woman’s pain management efforts
Second • Full dilatation
Stage • Cervical effacement
• Overwhelming, uncontrollable urge to
push
• Momentary nausea or vomiting
• Perineum begins to bulge and appear
tense
• Stool might also expelled
• Vaginal introitus opens
• Fetal scalp becomes visible at the
opening of the vagina
• Crowning
• Involuntary uterine contraction
• Feeling to push • Assess and record the temperature, pulse, respirations, blood pressure,
becomes strong FHR, Contractions
• Argumentative • Provide Support
• Angry • Prepare the place of Birth
• Crying or screaming • Convert the room to a birth room by opening the sterile packs of supplies
• Focus on the babies on waiting tables.
birth • Open the partition at the end of the room to reveal the “baby island” or
newborn care area.
• Turn on the radiant heat warmer in advance.
• Place sterile towels and a blanket on the warmer.
• Position the woman into the stirrup
• Raise both legs at the same time.
• Secure straps holding the legs in the stirrup
• Pad stirrup with abdominal pads if woman has ankle edema
• Top portion of the table is raised to 30—60 degrees angle.
• Place woman’s leg in a lithotomy position only at the last moment.
• Make sure that there is always someone at the foot of the broken delivery
room table.
• Promote effective second stage pushing
• Do perineal cleaning
• At birth, place a sterile towel over the rectum and press forward on the
fetal chin while the other hand is pressed downward on the occiput.
• Aspirate the newborn’s mouth and nose.
• Cut the cord and place infant to a sterile basket with the radiant heat
warmer
• Cover the infants head with a wrapped towel or cap
• Take infant to the parents
• Apply prophylactic eye ointment.
• Allow mother to breastfeed baby if she wishes.
Third and • Uterus resumes contraction
Fourth • Active bleeding on the maternal
Stage surface of the placenta
• Placenta sinks to the lower uterine
segment or the upper vagina
• Lengthening of the umbilical cord
• Sudden gush of vaginal blood
• Change in the shape of the uterus
• Bleeding occurs
• Excited • Inspect the placenta to ensure that it is intact and without gross
• Feeling anticlimactic abnormalities and check the number of cotyledons.
• Obtain a baseline blood pressure before handling oxytocic to the patient.
• Document the administration of oxytocics given in delivery or birthing
room on the maternal record.
• Perform perineal stitching.
• Be certain to include her in explanations and appreciate how anticlimactic
she may feel.
• Obtain vital signs every 15 minutes for 1 hour and according to the
agency’s policy.
• Palpate fundus for size, consistency, and position and observe the amount
and characteristics of the lochia.
• Perform perineal care
• Offer a clean gown and a warmed blanket..