Mindanao State University Buug Campus

College of Arts and Sciences

NURSING DEPARTMENT

Labor and Birth

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? In 2000, the United Nations Millennium Summit included the
improvement of maternal health as one of the Millennium Development Goals (MDGs) to be
adapted by the international community composed of over 42 countries. Promoting the
health of women in labor is one active way of reducing maternal mortality and ensuring
universal access to reproductive health services.

The progression of labor is traditionally divided into three phases, and each phase
deals with different concerns and considerations. Having gained mastery of this, nurses are
able to implement nursing interventions to safeguard the welfare of both the mother and
the baby.

Establishing Therapeutic Relationship

To gain patient and family’s cooperation and trust, it is important that

the nurse should be able to establish a therapeutic relationship with them. The nurse
should introduce himself and make them feel welcome. At this point, they are all anxious
and it is best for the nurse to convey his message gently and confidently. Expectations of
the family about birth should be determined and it is also the best time to ascertain cultural
values.

Admission Assessment

When a patient arrives at the labor floor, pertinent information about the pregnant
woman’s health history is taken during admission. These include personal data
(e.g. blood type, allergies, etc.), previous illness, pregnancy complications, preferences for
labor and delivery, and childbirth preparations. Standard obstetric, medical, and social
history taking is also done.

In addition, the nurse assesses the following: vital signs, physical exam, contraction
pattern (frequency, interval, duration, and intensity), intactness of membranes through
vaginal exam, and fetal well-being through fetal heart rate, characteristic of amniotic fluid,
and contractions. The nurse performs Leopold’s maneuver to determine fetal presenting
part, point of maximum impulse, fetal descent and engagement.
 Admission into labor room is only done when the patient is in active labor.

Stages of Labor

The progress of cervical effacement, cervical dilatation, and descent of fetal presenting part
dictate stages of labor. Here are the stages of labor and significant events that mark their
beginning and end:

Stages of Start End Duration

Labor
Nullipara Multipara

First Stage True labor contractions Full cervical 10-12 hr but 6-8 hrs but 2-12 hrs
dilatation 6-20 hrs is is the normal limit
the normal
limit

Latent phase Onset of regularly perceived uterine 3 cm cervical 6 hrs 4.5 hrs
contractions (mild contractions dilatation
lasting 20-40 sec)

Active phase Stronger uterine contractions lasting 7 cm cervical 3 hrs 2 hrs

40-60secs dilatation

Transitional Uterine contractions reaching their 10 cm cervical 3 hrs 1.5-2 hrs

phase peak, occurring every 2-3 minutes for dilatation
60-90 s

Second Stage Full cervical dilatation Infant birth <2 hrs 0.5-1 hrs

3 hrs with 2 hrs with epidurals

epidurals

Third Stage Infant birth Placental Maximum of 30 min.

delivery

First Stage of Labor

As mentioned above, the first stage of labor is divided into three sub-phases, namely: latent,
active, and transitional phases.

Latent Phase

Latent (Preparatory) Phase starts from the onset of true labor contractions to 3 cm

cervical dilatation. Here are nursing responsibilities during this phase:

1. Assess patient’s psychological readiness. Provide continuous maternal support

(compared to usual care).
2. Measure duration of latent phase. For nulliparas, it should not be more than 6 hours.
On the other hand, for multiparas, it should be within 4.5 hours. Determine if patient
received anesthesia because it can prolong latent phase. One of the most common
cause of prolonged latent phase is cephalopelvic disproportion (CPD) and it
requires cesarean birth.
3. Allow patient to be continually active. Upright maternal positions are recommended
for women on the first stage of labor. Patients without pregnancy complications can
still walk around and make necessary birth preparations.
4. Conduct interviews and filling in of forms (e.g. birth certificate) at this phase while
the patient experiences minimal discomfort and has control over contraction pains.
5. Conduct health teaching on breastfeeding, newborn care, and effective bearing
down because during this time, patient’s anxiety is controlled and she is able to
focus on nurse’s instructions.
6. Educate patient on different relaxation techniques. As early as this phase, encourage
patient to begin alternative therapy of pain relief.
7. Ensure that the total number of internal examinations the woman receives in the
entire course of labor is limited to 5 only.
8. Ensure that birthing companion of choice is present all throughout the course of
labor.

Active Phase

Active Phase starts from 4 cm cervical dilatation to 7 cm cervical dilatation. During this

phase, contraction intensity is stronger, interval shortens, and duration lengthens. This is
where true discomfort is first felt by the patient so she is dependent and her focus is on
herself. Here are nursing responsibilities in this phase:

1. Inform patient on the progress of her labor to lessen her anxiety and obtain her
trust and cooperation.
2. Start monitoring progress of labor with the use of WHO partograph, 2-hour action
line.
3. Encourage patient to be continually active to maximize the effect of uterine
contractions. Upright maternal positions are recommended if tolerated.
4. Assist patient in assuming her position of comfort. For those who can’t stay
upright, left-side lying is recommended to avoid disruption in fetal oxygenation.
 5. Monitor maternal vital signs and fetal heart rate every 2 hours, or depending
on the doctor’s order.
6. Anticipate patient needs (e.g. sponging face with cool cloth, keeping bed clean and
dry, providing ice chips or lip balm) to promote comfort.
7. Determine when patient last voided because a full bladder can hinder fast labor
progress.
8. Institute non-pharmacological pain measures (e.g. breathing exercises, distraction
method, imagery, music therapy, etc.)

Transition Phase

Transition Phase starts from 8 cm cervical dilatation to 10 cm (full) cervical dilatation and

full cervical effacement. During this time, patient may be exhausted and withdrawn or
aggressive and restless. Patient’s urge to push is noticeable. Here are nursing
responsibilities in this phase:

1. Inform patient on progress of her labor.

2. Assist patient with pant-blow breathing.
3. Monitor maternal vital signs and fetal heart rate every 30 minutes -1 hour, or
depending on the doctor’s order. Contraction monitoring is also continued.
4. When perineal bulging is noticeable, prepare for delivery. Check room temperature
(25-280C and free of air drafts). The nurse should also notify staff and prepare
necessary supplies and equipment, including resuscitation machine. Lastly,
perform handwashing and double gloving.

WHO do not recommend the following nursing interventions during labor because they

have low quality of evidence:

1. Routine perineal shaving

2. Routine use of enema
3. Admission cardiotocography (CTG) for low-risk women
4. Vaginal douching
5. Routine amniotomy for patients in spontaneous labor
6. Massage and reflexology

Second Stage of Labor

Second Stage of Labor starts when cervical dilatation reaches 10 cm and ends when the
baby is delivered. At this stage, the patient feels an uncontrollable urge to push. The patient
may also experience temporary nausea together with increased restlessness and shaking of
extremities. The nurse at this stage must coach quality pushing and support delivery.

Here are nursing care tips for this stage:

 1. Instruct patient on quality pushing. The abdominal muscles must aid the
involuntary uterine contractions to deliver the baby out.
2. Provide a quiet environment for the patient to concentrate on bearing down.
3. Provide positive feedback as the patient pushes.
4. Repeat doctor’s instructions. At this phase, the patient barely hears the conversation
around the room because all her energy and thoughts are being directed toward
giving birth.
5. Take note of the time of delivery and proceed to initiate essential newborn care.
Delayed cord clamping is recommended.
6. Assist in restrictive episiotomy for patients who had vaginal births.
WHO do not recommend the following interventions during delivery because they
provide low quality of evidence:

1. Perineal massage
2. Use of fundal pressure

Third Stage of Labor

Third Stage of Labor or the placental stage starts from birth of infant to delivery

of placenta. It is divided into two separate phases: placental separation and placental
expulsion. Five minutes after delivery of baby, the uterus begins to contract again, and
placenta starts to separate from the contracting wall. Blood loss of 300-500 mL occurs as a
normal consequence of placental separation. Placenta sinks to the lower uterine segment
or upper vagina. The placenta is then expelled using gentle traction on the cord.

Here are the signs of placental separation:

1. Lengthening of umbilical cord

2. Sudden gush of vaginal blood
3. Change in the shape of uterus (globular in shape)
4. Firm uterine contractions
5. Appearance of placenta in vaginal opening

At this stage, here are the nursing care tips:

1. Coach in relaxation for delivery of placenta.

2. Congratulate on delivery of baby.
3. Encourage skin-to-skin contact to facilitate bonding and early breastfeeding.
4. Ask patient whether placenta is important to them before it is destroyed. For those
who want to take it home, ensure that they understand and follow
standard infection precautions and hospital policy.
5. Administer prophylactic oxytocin as ordered.
 6. Utilize controlled cord traction technique for placental expulsion.
7. Utilize absorbable synthetic suture materials (over chromic catgut) for primary
repair of episiotomy or perineal lacerations.

For immediate postpartum, the nurse checks the vital signs and monitors for
excessive bleeding. The first four hours after birth is sometimes referred to as the fourth
stage of labor because this is the most critical period for the mother. The nurse is set to
perform nursing interventions that would prevent the patient from infection and
hemorrhage. Also, they are being reminded of the importance of breastfeeding, ambulation,
and newborn care.

Here are WHO recommendations for immediate postpartum:

1. Early (<6 hours) resumption of feeding for patients who have vaginal birth
2. Prophylactic antibiotics for women who sustained third to fourth degree of perineal
tear during delivery
3. In healthy women who delivered vaginally to term infants, early postpartum
discharge is recommended.

On the other hand, here are interventions not recommended during immediate

postpartum:

1. Routine use of ice packs

2. Oral methylergometrine for patients who delivered vaginally

Nursing care for women in labor is a routine that takes a while to fall into. After all, it is
overwhelming for beginner nurses to do their responsibilities in front of a woman writhing
in pain. However, the opportunity to protect women and the privilege of being a part of
their positive pregnancy experience is rewarding.

References:

1. Clinical Practice Guidelines on Intrapartum and Immediate Postpartum Care 2012

by Department of Health and Philippine Obstetrical and Gynecological Society.
Retrieved
from: [Link]
ines_einc.pdf
2. Callahan, T. (2013). Blueprints Obstetrics and Gynecology. (6th ed.). Baltimore, MD:
Lippincott William & Wilkins.
3. Pillitteri, A. (2010). Maternal & Child Health Nursing: Care of the Childbearing and
Childrearing Family (6th ed.). PA: Lippincott William & Wilkins.