Which is the priority nursing action for a client in the second stage of labor?

This NCLEX review will discuss the stages of labor. In maternity nursing, you will learn the stages of labor.

As a nursing student, you must be familiar with each stage of labor and the nursing interventions based on the specific stage of labor.

These type of questions may be found on NCLEX and definitely on nursing lecture exams in maternity.

For exams it is important to remember the following about the stages of labor:

•   what occurs in each stage
•   be able to identify each stage based on its description
•   cervical dilation ranges in each phase of stage 1 and contraction length and frequency
•   nursing interventions for each stage
•   delivery mechanisms (Duncan or Schultz)
•   changes in the perineum that the baby is about to be delivered
•   Signs the placenta is about to be delivered

After you review these notes, don’t forget to take the stages of labor quiz.

Lecture on the Stages of Labor

Stage 1 of Labor

Goal: Cervical dilation (opening) 0-10 cm & 100% effacement (thinning) due to contractions.

Facts:

• Longest Stage (especially for first time mothers…nulliparous)
• Has 3 Phases
• Starts with TRUE Labor

Phases: Early Labor (Latent), Active, and Transition

Remember the mnemonic: “ Labor is Actively Transitioning”

Phase 1: Early labor (Latent)

• Cervix dilates from 1 to 4 cm* and thins
  • *0-6 cm….ACOG.org (The American College of Obstetricians and Gynecologists) has recommended guideline changes for cervical dilation for the stages of labor.
• Contractions occur every 5 to 30 minutes and 30-45 seconds in length
• Contractions are less intense compared to other phases and stages
• Longest of the phases (especially first time mothers >20 hours vs >14 multipara)….some women notice contractions while others don’t (can gradually occur over 8-12 hours or 1-3 days)
• If woman at home, should monitor contraction duration and intensity…try to stay comfortable at home until water breaks or enters active phase of labor.

Woman will be talking, excited, and nervous.

Phase 2: Active Labor

• • Cervix dilates to *4 to 7 cm and thins
    • *Starts at 6 cm (instead of 4 cm)….ACOG.org (The American College of Obstetricians and Gynecologists) has recommended guideline changes for cervical dilation for the stages of labor.
  • Contractions will be noticeably stronger and longer (45 to 60 seconds) every 3 to 5 minutes
  • Lasts about 4 to 8 hours
  • If woman at home, time to go to the hospital.
  • Water may break (if hasn’t already)
    • Important to monitor for meconium -stained fluid which is greenish brown/yellowish ammonitic fluid…baby can aspirate this into lungs causing infection or blocking airway and this usually indicates fetal distress)
    • Perform Nitrazine paper test to confirm the water has broke (turns blue if positive)

Interventions: Provide comfort (non-pharmacological and pharmacology). Non-pharmacological: changing positions, warm shower or bath, massages between contractions, breathing techniques, ice or fluids for dry mouth. Pharmacological: epidural etc. Encourage frequent urination to keep bladder empty (full bladder prevents uterus from contracting properly and can slow down labor), monitor vitals of mother and fetal heart rate.

Mother will be serious, anxious, and in pain.

Phase 3: Transition

This phase will lead into Stage 2 where the baby will be delivered.

• Cervix dilates to 8 to 10 cm and thins
• Shortest phase but most intense/painful
• Lasts 30 minutes to 2 hours (longer for first time mothers)
• Contractions will be very intense and long (back to back contractions) 60-90 seconds length every 2-3 minutes.
• Mother will be concentrating, irritated, pain, nauseous, shivering.
• May report intense pressure (bowel movement) due to baby pushing down…don’t want the mother to start pushing until fully dilated because it can cause swelling of the cervix…hence it won’t fully dilate.

Interventions: provide support, breathing techniques, encouragement, monitoring mother’s vitals and fetal heart rate (esp. during contractions, and before, and after…want heart rate 110 to 160), mother’s contractions (length, frequency) monitoring status of cervix (dilation and effacement), assessing fetal position and station (station 0 baby head is engaged and at ischial spine). The ischial spine is the narrowest part of the pelvis.

Stage 2 of Labor

Starts when cervix has fully dilated and ends when baby is fully delivered.

• Cervix is fully dilated so baby can start descending into the birth canal (woman will have intense pressure in rectum as baby descending)…watch fetal station +1 to 5+ (5+ is head crowning).
• Contractions will be strong and intense like in the transition period…. 60-90 seconds length every 2-3 minutes).
• For first-time mothers this stage lasts approximately 1 hour (may last 3 hours) and 20 minutes for multipara.

Interventions: Monitor mother’s vital and baby heart during, after, and before contractions with continuous fetal monitoring (assessing for signs of distress).

Watch for changes in perineum that represents birth of baby is approaching:

• Bulging perineum and rectum
• Parts of baby present
• Increase in bloody show

Teach mom how to push: exhale when pushing and positioning (High-fowler and lithotomy), squatting, side-lying , maintain comfort measures, encouragement and praise, record exact time birth of the baby.

Stage 3 of Labor

Starts with full delivery of baby and ends with full delivery of the placenta.

Lasts 5 to 15 minutes…the longer the stage the increased risk for hemorrhage and retained placenta (which can cause infection/hemorrhage).

Signs that the placenta is about to be delivered:

• Umbilical cord starts to lengthen
• Trickling/gush of blood and uterus changes from an oval shape to globular
  • With these signs mother will give a gently push

Delivery Mechanisms of the Placenta:

• Schultz Mechanism: REMEMBER “Shiny Schultz”. This is the “shiny” side from the side of the baby…remember shiny and new which is the baby…this part comes out first.
• Duncan Mechanism: REMEMBER “Dull/Dirty Duncan”. This side is “dull”, red, and rough and is the side from the mother. Also, try to remember the mother is dirty from labor and is in rough condition, so it is the maternal side.

Interventions: monitor BP before and after delivery of placenta, administer oxytocin “Pitocin” as ordered by the physician AFTER delivery of the placenta…helps uterus contract after delivery of placenta and prevents hemorrhage, assess placenta to make sure it is enact (cord should have two arteries and one vein), make mother comfortable and encourage bonding with baby (breastfeeding), change linens, peri-care.

Stage 4 of Labor

1 to 4 hours after the delivery of placenta

Goal: monitor mother’s health status after birth due to risk for hemorrhage, infection (retaining placenta), and uterine atony etc.

• Monitoring vital signs (especially blood pressure and heart rate due to risk of hemorrhage and an increased temperature due to risk of infection).
• Monitor discharge “Lochia”:  red, moderate, may have small clots, however large clots not normal…assess how many peri-pads are being used…if changing every 15 minutes…this is abnormal.
• Monitor the fundus of the uterus for firmness: it should be firm and midline, and at or slightly below the umbilicus….if soft/boggy or displaced perform:  fundus massage and want to make sure bladder is empty so have the patient void (will be checking fundus  every 15 minutes for 1 hour then 30 minutes for 2 hours).
• The fundus of the uterus will decrease 1 cm a day and after 10 days post-delivery cannot be felt.
• Administering pain relief as ordered by MD.
• Apply witch hazel to perineum and ice pack due to edema, tearing, or episiotomy.
• Promote bonding with parents and baby and help with breastfeeding.

More Maternity NCLEX Reviews

References:

Labor and birth | womenshealth.gov. (2017). womenshealth.gov. Retrieved 4 January 2017, from https://www.womenshealth.gov/pregnancy/childbirth-and-beyond/labor-and-birth

6cm is the new 4cm: evaluating the definition of active phase of labor and its potential effect on cesarean rates and mortality. (2014). Retrieved 7 February 2020, from http://ajog.org/article/S0002-9378(13)01690-6/abstract