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Nur 3125 Stages of Labor Template
- Course
- NUR 3125
- Institution
- Florida Southwestern State College
This is a comprehensive and detailed template on;Stages of Labor for Nur 3125. *Essential Study Material!!
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Stages of laborFirst stage: Begins with the onset of true labor and
Second Stage of Labor: Expulsion of the Fetus
ends with full dilation of the cervix at 10 cm.
Assessment
1. Early labor
❖ Monitor the blood pressure, pulse, and respirations every 15
2. Active labor
to 30 minutes
3. Transition
❖ Assess the contraction pattern every 15 minutes
Latent Phase (Early Labor): Contractions during
❖ Assess fetal status
early labor are typically five to 10 minutes apart, last
❖ Assess the woman’s report of an uncontrollable urge to
30 to 45 seconds, and are of mild intensity. The
push
cervix is dilated from 1 to 3 cm, and effacement has
❖ Check the FHR every 15 minutes for the low-risk woman,
begun. Possible spontaneous rupture of membranes
every five minutes for woman at risk for labor complications
Assessment
❖ Assess FHR and contractions at least once
every hour
❖ Assess maternal status
❖ Assess status of fetal membranes
❖ Assess the woman’s psychosocial state
Goals, expected outcomes
❖ Goal: The woman and fetus remain free
from injury
❖ Goal: The woman’s anxiety is reduced
❖ Goal: The woman’s pain is manageable
Third Stage of Labor: Delivery of Placenta
❖ Goal: The woman and partner have
adequate knowledge of labor process Assessment
Active Labor: contractions occur every two to five ❖ Assess the woman’s psychosocial
minutes, last 45 to 60 seconds, and are of moderate state after she gives birth
to strong intensity. The cervix should dilate ❖ Monitor for signs of placental
progressively from 4 to 8 cm.contractions are regular separation
moderate and strong. Rapid effacement. Fetal Selected nursing diagnoses
descent begins.
Assessment ❖ Risk for deficient fluid volume related
to blood loss in the intrapartum period
❖ Assess woman’s psychosocial
❖ Risk for trauma: Hemorrhage, amniotic
state
fluid embolism, retained placenta, or
❖ Assess labor progress
uterine inversion related to delivery of
❖ Assess fetal status the placenta
❖ Assess maternal status
Transition Phase of Labor: contractions should
occur every two to three minutes, last 60 to 90 Fourth Stage of Labor: Recovery
seconds, and be of strong intensity. The uterus Assessment
should relax completely between uterine ❖ Continue to assess for hemorrhage
contractions. Cervical examination during transition ❖ Assess the lochia: Color, quantity
reveals dilation between 8 and 10 cm. ❖ Monitor for signs of infection
The client may be nauseous, vomiting or reporting ❖ Monitor for suprapubic distention
the need to have a bowel movement. Urge to push ❖ Assess comfort level
and bloody show. ❖ Assess mother’s psychosocial state during the
Assessment
fourth stage
❖ Assess for signs that woman has reached
transition phase ❖ Assess initial bonding behaviors of the new
❖ Assess woman’s ability to cope family
❖
❖
Assess maternal status
Assess fetal status
Pushing
❖ She will often express irritability, ❖ Vigorous pushing: take a deep breath, hold the breath, and push while
restlessness, and will feel out of control. counting to 10. She is encouraged to complete three “good” pushes in
She may tremble, vomit, or cry. It is this manner with each contraction.
important to assess for hyperventilation ❖ open-glottis pushing: method of expelling the fetus that is
characterized by pushing with contractions using an open glottis so that
air is released during the pushing effort.
❖ urge-to-push method, in which the woman bearsdown only when she
g any technique that feels right for her
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