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Michelle Acuavera Maternal/Newborn - Clinical Harvey STAGES OF LABOR AND CHILDBIRTH Labor and birth is divided into four stages: Stage 1 begins with onset of labor and ends with complete cervical dilation. Stage 2 begins with complete dilation of cervix and ends with delivery of baby. Stage 3 begins after delivery of baby and ends with delivery of placenta. Stage 4 begins after delivery of the placenta and is completed 4 hours later; it is the immediate postpartum period.

Stage 1 defined as the progression of cervical changes divided into three phases: latent phase, active phase, and transition Characteristics of the first stage of labor are: it begins with onset of true labor and ends with complete cervical dilation (10 cm) and complete effacement (100%). longest stage, typically lasting 12 hours for primigravidas and 8 hours for multigravidas normally tremendous variations in lengths of labor fetal membranes usually ruptures during this stage maternal cardiac output increases maternal pulse may increase gastrointestinal motility decreases, which leads to increase in gastric emptying time the woman experiences pain associated with UCs that result in the dilation and effacement of the cervix

Assessment during all phases of the first stage of labor includes: Maternal vital signs FHR and UCs Cervical changes Fetal position and descent in the pelvis The womans response to labor and pain

Nursing actions during all phases of the first stage of labor are related to: Diet and hydration Activity and rest Elimination Comfort Support and family involvement Education Safety 1

J. Michelle Acuavera Maternal/Newborn - Clinical Harvey Documentation of labor admission and progression

First Phase (Latent Phase) early and slower part of labor with an average length of 8.6 hours for primiparous and 5.3 hours for multiparous woman women are usually both excited and apprehensive about the start of labor - they are talkative and able to relax with the contractions some women choose to stay home during this phase, although some women are admitted to the birth center during this time

Characteristics of this phase are: cervical dilation from 0 to 3 cm with effacement from 0 to 40% contractions occur every 5 to 10 minutes, lasting 30 to 45 seconds, and mild intensity and are often describe as feeling like strong menstrual cramps

Medical Interventions: laboratory tests (may include complete blood count (CBC), blood type and Rh, urinalysis, syphilis screening, HBsAg, HIV, and possible drug screening) order IV or saline lock order intermittent fetal monitoring or continuous fetal and uterine monitoring

Nursing Actions: admit to the labor unit and orient the woman, her partner, and family to the labor room review prenatal record for: estimated date of delivery (EDD) prior obstetrical history (pregnancy, births, abortions and living children) allergies medications trends in vital signs and weight gain chronic conditions or pregnancy-related complications biochemical and infectious disease laboratory test results review childbirth plan and discuss the womans expectations teach and reinforce relaxation and breathing techniques obtain laboratory tests as per orders start IV or insert saline lock, if ordered review the womans report of onset of labor assess and record the following maternal vital signs FHR 2

J. Michelle Acuavera Maternal/Newborn - Clinical Harvey uterine contractions cervical dilation and effacement fetal presentation, position, and station by performing a sterile vaginal examination status of membranes amniotic fluid for color, amount, consistency, and odor vaginal bleeding or bloody show for amount and characteristics of vaginal discharge fetal position with Leopold maneuver deep tendon reflexes signs of edema heart and lung sounds maternal emotional status pain and discomfort review laboratory results for blood Rh status, hematocrit, hemoglobin, and check urine for glucose and protein document allergies, history of illnesses, and last dietary intake encourage fluid intake; food may or may not be restricted provide comfort measures, incorporating methods in delivering plan if feasible encourage the woman to walk as much as possible by: explaining the importance of walking in facilitating labor progression and fetal descent and rotation and in making UCs more efficient walking with the woman, which can provide a comforting and reassuring presence and distraction assess cultural needs and incorporate beliefs in the nursing care and delivery plan establish a therapeutic relationship through active listening and providing labor support incorporate understanding of the couples maturity level, educational level, and previous experience into nursing care review the labor plan with the woman and her partner inquire about concerns and questions the woman and/or her partner have concerning the labor and birth process provide clear explanations and updates on progress

Second Phase (Active Phase) averages 3 to 6 hours in length. It is typically shorter for multigravidas women in this phase may have decreased energy and increased fatigue women often become more serious and turn attention to internal sensations, turning inward as labor progresses

Characteristics of this phase are: the cervix dilates, on average, 1.2 cm/hr for primiparous women and 1.5 cm/hr for multiparous women 3

J. Michelle Acuavera Maternal/Newborn - Clinical Harvey cervical dilation progresses from 4 cm to 7 cm with effacement of 40% to 80% continued fetal descent contractions become more intense, occurring every 2 to 5 minutes with a duration of 45 to 60 seconds discomfort increases and this is typically the time the woman comes to the birth center or hospital if she has not done so already

Medical Interventions: rupture membranes if not previously ruptured perform internal monitoring with application of internal fetal electrode and/or uterine transducer, if necessary order pain medication or epidural anesthesia evaluate progression in labor evaluate fetal status

Nursing Actions: monitor FHR and contractions every 15 to 30 minutes monitor maternal vital signs every 2 hours; every 1 hour if ROM perform intrapartal vaginal exam as needed to assess cervical changes and fetal descent assess pain (location and degree) administer analgesia as per orders and desire of woman evaluate effectiveness of epidural or other pain medication monitor intake and output (I&O), hydration status, and for nausea and vomiting encourage intake of fluids and ice chips offer clear explanations and updates of progress promote comfort measures assist with elimination needs as bladder distension can hinder fetal descent encourage breathing and relaxation methods review and reinforce relaxation techniques maintain eye contact and physical proximity to the woman develop a rhythm and breathing style to deal with each contraction use a direct and gentle voice and have a calm and confident manner use touch of massage if acceptable to the woman. communicate the womans progress and status with the care provider incorporate the support person in care of patient by: role modeling supportive behaviors offering support and praise assisting partner with food and rest providing breaks if desired or needed 4

J. Michelle Acuavera Maternal/Newborn - Clinical Harvey explain procedures being done assess the environment for adjustments to be made; typically decrease stimulation with dim lighting and decrease noise and interruptions provide reassurance, updates on progress, and positive reinforcement

Third Phase (Transition Phase) usually the most difficult but shortest of the first stage of labor women are easily discouraged, irritable, and may be overwhelmed and panic easily they often feel and act out of control.

Characteristics of this phase are: cervical dilation from 8 to 10 cm with complete (100%) effacement contractions every 1 to 2 minutes lasting 60 to 90 seconds and intense exhaustion and increased difficulty concentrating increase of bloody show nausea and vomiting backache trembling diaphoresis strong urge to bear down or push

Medical Interventions: perform amniotomy (AROM) if not previously done order pain medications, if desired

Nursing Actions: assess FHR and UCs every 15 minutes encourage woman to breathe during contractions and rest between contractions by staying with patient and breathing with her assess I&O assess for bladder distention and assist the with voiding if necessary promote comfort measures attend to the hygiene needs of the woman such as blotting her brow and face, providing pericare, and changing chux pad assist with breathing and relaxation methods by demonstrating breathing through demonstration and reinforcement communicate the womans progress and status with the care provider prepare the room and couple for delivery

J. Michelle Acuavera Maternal/Newborn - Clinical Harvey familiarize the woman and support people with usual routine and keep informed of what to expect open the delivery tray turn on the infant radiant warmer use brief explanations, as the womans focus is narrowed remain in the room with the woman and family provide encouragement and reassurance to the woman and her support person(s) keep them apprised of labor progress, such as changes in cervical dilation compliment them on their effective breathing and relaxation techniques

Stage 2 cervical dilation is complete (10 cm) stage ends with the delivery of the baby women in the second stage may have a burst of energy, be more focused, and may feel like they are able to actively participate in facilitating birth with active pushing efforts

Characteristics of this stage are: typically last 50 minutes for primigravidas and 20 minutes for multigravidas, although a second stage of several hours is normal woman may feel an intense urge to push or bear-down when the baby reaches the pelvic floor bearing-down in the second stage is usually less tiring and more effective when begun after the woman has the urge to do so contractions are intense, occurring every 2 minutes and lasting 60 to 90 seconds in duration bloody show increases the perineum flattens and the rectum and vagina bulge

Medical Interventions: prepare for delivery perform episiotomy if necessary assist the woman in the birthing of her child

Nursing Actions: instruct the woman to bear down with the urge to push monitor for fetal response to pushing; check FHR 5-15 minutes or after each contraction provide comfort measures support and encourage womans spontaneous pushing efforts attend to perineal hygiene as needed, as the woman may pass stool with pushing give praise and encouragement of progress made encourage rest between contractions by breathing with the patient and therapeutic touch 6

J. Michelle Acuavera Maternal/Newborn - Clinical Harvey review and reinforce pushing technique by: maintaining eye contact developing a rhythm and pushing style to deal with each contraction that maximizes the woman urge to push use direct, simple, and focused communication, avoiding unnecessary conversation. advocate on the womans behalf for her desires of the delivery plan assist the support person and partner role model supportive behaviors offer support, praise, and encouragement assist with food and rest and provide breaks

Third Stage begins immediately after the delivery of the fetus involves separation and expulsion of the placenta and membranes the uterus spontaneously contracts around its diminishing contents this sudden decrease in uterine size is accompanied by a decrease in the area of placental implantation the decidual layer separating from the uterine wall Placental separation typically occurs within a few minutes after delivery once the placenta separates, the uterus continues to contract until the placenta is expelled (usually takes 5 to 20 minutes post delivery of the baby and occurs spontaneously)

Signs that signify the impending delivery of the placenta include: upward rising of the uterus into a ball shape lengthening of the umbilical cord at the introitus sudden gush of blood from the vagina (approximately 500 mL)

Medical Interventions: at delivery, the neonate is often placed skin to skin on mothers abdomen for bonding await delivery of the placenta inspect the placenta after delivery order pain medications if necessary

Nursing Actions: assess maternal vital signs every 15 minutes. encourage the woman to breathe with contractions and relax between contractions encourage motherbaby interactions by providing immediate newborn contact, if the newborn is stable administer pain medications as per order 7

J. Michelle Acuavera Maternal/Newborn - Clinical Harvey complete documentation of the delivery documentation of delivery includes labor summary, delivery summary for mother and baby, infant information, infant resuscitation and documentation of personnel in attendance explain all forthcoming procedures stay with the woman and her family

Fourth Stage begins with the delivery of the placenta typically ends within 4 hours or with the stabilization of the mother the primary mechanism is vasoconstriction produced by a well contracted myometrium this stage also begins the postpartum period

Medical Interventions: repair the episiotomy or laceration inspect the placenta assess the fundus for firmness order oxytocin, Methergine, or prostaglandin as needed order pain medications, if necessary

Nursing Actions: assess the uterus for: position tone and location intervene with fundal massage as necessary assess lochia for color, amount, and clots administer oxytocin as per orders explain all procedures assist the care provider with repair of lacerations and/or episiotomy assess maternal vital signs every 15 minutes monitor perineum for unusual swelling or hematoma formation apply ice packs to the perineum monitor for bladder distention assist the woman to the bathroom assess for return of full motorsensory function if epidural or spinal anesthesia is used assess pain and medicate as per orders stay with the mother and family offer congratulations and reassurance on a job well done to the woman and family encourage motherbaby interaction by: 8

J. Michelle Acuavera Maternal/Newborn - Clinical Harvey providing immediate newborn contact assisting with early breastfeeding, if desired pointing out the newborns quiet, alert state monitor newborn status every 30 minutes: temperature heart and respiratory rates skin color adequacy of peripheral circulation type of respiration level of consciousness tone provide an opportunity for the support person to interact with newborn