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: After you review these notes, don’t forget to take the stages of labor quiz. Stage 1 of LaborGoal: Cervical dilation (opening) 0-10 cm & 100% effacement (thinning) due to contractions. Facts:
Phases: Early Labor (Latent), Active, and Transition Remember the mnemonic: “ Labor is Actively Transitioning” Phase 1: Early labor (Latent)
Woman will be talking, excited, and nervous. Phase 2: Active Labor
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: TransitionThis phase will lead into Stage 2 where the baby will be delivered.
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 LaborStarts when cervix has fully dilated and ends when baby is fully delivered.
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:
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 LaborStarts 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:
Delivery Mechanisms of the Placenta:
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 Labor1 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.
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 Which signs are considered warning signs in labor that should be reported to the health care provider?Urgent Maternal Warning Signs. Feels like the worst headache of your life.. Lasts even after treatment with medication and fluid intake.. Starts suddenly with severe pain – like a clap of thunder.. Throbs and is on one side of your head above your ear.. Comes with blurred vision or dizziness.. What is the most appropriate nursing action when there is fetal distress and dysfunctional labor?Place the client in a lateral recumbent position and encourage bed rest or sitting position/ambulation, as tolerated. Note signs of fetal distress, cessation of uterine contractions, and presence of vaginal bleeding. Alert the obstetrician of any warning signs.
Which finding would lead the nurse to suspect that the fetus of a woman in labor is in a persistent occiput posterior position?Clinical signs of occiput posterior position include accentuated maternal backache, persistent anterior cervical lip, ineffective contractions, and a prolonged second stage.
Which assessment would the nurse complete when a woman is in active labor?Admission Assessment
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.
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