Introduction to the 4 Stages of Labor

By recognizing the signs and symptoms of each stage, nurses can monitor the progress of labor and identify any potential complications. Additionally, nurses can provide emotional support and education to help clients cope with physical and emotional changes during childbirth.

The stages of labor are typically divided into four distinct parts, each with its own set of characteristics and changes in the body.

Stage 1: From the beginning of contractions until 10 cm has been achieved.

Stage 2: Cervix is fully dilated, and the baby is delivered.

Stage 3: Placenta delivery.

Stage 4: Don’t let your client bleed to death.

1. First Stage of Labor

Early labor is the first stage of labor, which can last a few hours to a few days. During this stage, the cervix dilates and thins out, or effaces. Contractions may begin, but they are typically mild and irregular. Clients may experience lower back pain, cramping, and a bloody show as the cervix begins to open.

Early or Latent Phase 

The client is relaxed and contractions are mild. This is the time for early education and encouragement.

Some important notes for this phase include:

• 0 – 3 cm cervix dilation
• 0 – 30% Effaced (thinner cervix)
• Irregular Contractions (Short & far apart)
  • Frequency: 5 – 30 min
  • Duration: 30 seconds
• Oxytocin stimulates uterine contractions. 
• Monitor fetal heart rate.
• Assess for late decelerations (not enough oxygen getting to the baby)

Active Phase 

Contractions begin to be stronger and longer, breathing techniques are needed, and the mother may be irritable. Breathing techniques and pain management are needed at this stage

Some important notes for this phase include:

• 4 – 7 cm cervix dilation (Goal = 10 cm)
• Contractions (stronger & longer)
• 100% effaced (fully thinned cervix)
• Pain Medications:
  •  Epidural
  •  IV narcotics: Give slowly during the peak of the contractions. 

Transition Phase 

This phase occurs when the cervix dilates to a ten. It’s all about keeping focus and staying in control.

Some important notes for this phase include:

• 8 – 10 cm cervix dilation
• 100% effaced (fully thinned cervix)
• Contractions (strongest & closer)
• Assess the color of amniotic fluid (water break).
• Monitor for signs of fetal distress or hypoxia aspiration.

2. Second Stage of Labor

This Stage of Labor (delivery of the baby) is also called the descent phase or the pushing stage, because the baby is pushed out of the birth canal.

Active labor is the second labor stage, typically lasting from three to eight hours. During this stage, the cervix continues to dilate, and the contractions become stronger and more regular. Clients may experience increased pressure and pain as the baby moves down the birth canal. The urge to push may also become stronger during this stage.

The cervix must be 100% effaced and 10 cm dilated.

Signs to look for:

• Increase in contractions and urge to bear down to have a bowel movement.
• Ferguson reflex: Spontaneous urge to push during labor. It occurs when the presenting part of the fetus reaches the pelvic floor.

Nursing Interventions

• Positioning of the mother is priority:
  • High Fowlers, Lithotomy, Side-lying
• Push properly:
  • Avoid holding the breath or tightening the abdomen.
  • Push when feeling the urge.
  • Breathe in deep.
  • Breathe out slowly through the mouth and keep the mouth open while pushing down.

Nursing Assessments

• Fetal heart rate before, during, and after the contraction
• Frequency of contractions
• Duration of contractions
• Uterine tone between contractions

5 Ps of Labor

Passenger (Baby)

Passenger refers to the baby that is being delivered. The baby’s size, position, and presentation can impact the delivery process. For example, a baby in a breech position (feet or buttocks first) may present more challenges during delivery than a baby in the head-down position.

Nurses can monitor the passenger by using ultrasound to assess the baby’s position and monitoring the baby’s heart rate during labor.

Passageway

This refers to the birth canal through which the baby must pass during delivery. The passageway is the muscular canal that goes from the uterus to the outside of the body. The size and shape of the mother’s pelvis and the baby’s head can affect the ease or difficulty of delivery. 

Nurses can assess the passage by performing pelvic exams and monitoring the baby’s descent during labor.

Power

This refers to the strength and effectiveness of the contractions that the mother experiences during labor. The power of the contractions is measured by their frequency, duration, and intensity. Nurses can assess the power of contractions by monitoring the mother’s uterine contractions using a fetal monitor. 

Techniques used to assist with painful contractions consist of breathing exercises, relaxation techniques such as massage, calming music, or aromatherapy, in addition to pain medication (if needed).

Position

Position refers to the mother’s position during labor and delivery. The mother’s position can affect the progression of labor and the ease of delivery. For example, a mother lying flat on her back may experience more pain and discomfort than a mother in an upright position. 

Nurses can encourage mothers to try different positions during labor and delivery to help facilitate progress and promote comfort.

Psychological Response of the Mother (Psyche)

This refers to the mother’s emotional state during labor and delivery. The mother’s emotional well-being can impact the progression of labor and her ability to cope with pain and stress. Nurses can provide emotional support and encouragement to mothers during labor and delivery to help reduce stress and promote positive emotional well-being.

3. Third Stage of Labor

In the 3rd Stage of Labor (Placenta Delivery) – the uterus contracts & the placenta spontaneously detaches from the uterine wall. The placenta must be delivered carefully.

This typically occurs within 5-30 minutes after the baby is born. During this stage, the uterus continues to contract, causing the placenta to separate from the uterine wall. Clients may experience mild contractions and discomfort during this stage.

NEVER pull on the cord to deliver the placenta! There’s a high risk of tearing the placenta and leaving behind portions of it, along with possible uterine inversion. This is when the uterus flips inside out, putting the client at risk for hemorrhage and infection. 

4. Fourth Stage of Labor

The Recovery stage lasts around two to four hours after birth. At this point, we encourage skin-to-skin and breastfeeding for multiple reasons.

This stage of labor is the recovery stage, which typically lasts for a few hours after the delivery of the placenta. During this stage, the uterus continues to contract, which helps to prevent excessive bleeding. Clients may experience shaking, sweating, and fatigue during this stage.

Breastfeeding stimulates maternal oxytocin release (to help the uterus contract). It provides nourishment and supports the blood sugar of the newborn.

Normal Fundus:

• Firm
• Midline
• Level with the umbilicus (belly button) 

Abnormal Fundus:

• Displaced fundus above umbilicus or to one side = bladder distension
• Soft or boggy (uterine atony) = increased risk for hemorrhaging

Nursing Assessment

• Infection (temperature over 100.4 ° F (38 °C))
• Hemorrhage
• Priority Assessments:
• Peri pads count
  • Fully saturated in less than one hour
• Decreasing blood pressure
• Increasing heart rate

Nursing Interventions

• Fundus check first. Fundus Assessment:
  • Assess three times, every five minutes, then every 15 minutes for an hour
• Void or use a catheter (in and out).
• Administer Pitocin (oxytocin): IV or IM control bleeding after childbirth.
• Stimulate the release of natural oxytocin for breastfeeding.

4 Signs of True Labor

1. “Bloody show”: mucus and blood
2. Water breaking: Amniotic sac rupture
3. True Labor Contractions

• Increased Frequency (regular & rhythmic)
• Increased Intensity & Duration

1. Cervix
2. Dilatation: how wide is the cervix (goal = 10cm) 
3. Effacement: cervix gets thinner & shorter

True Signs of Labor Chart

Braxton Hicks Contractions

Braxton Hicks contractions, also known as practice contractions or false labor, are a normal and common occurrence during pregnancy. They are named after John Braxton Hicks, an English physician who first described them in 1872. 

Braxton Hicks contractions are characterized by a tightening sensation in the uterus that lasts up to a minute. They are usually painless but can be uncomfortable.

They’re different from true labor contractions in that they are irregular, infrequent, and do not progress in intensity or frequency. True labor contractions, on the other hand, are regular, become closer together, and increase in intensity over time. 

Braxton Hicks contractions can begin as early as the second trimester, but are more commonly experienced in the third trimester of pregnancy.

• False labor contractions
• No dilatation of cervix
• Disappear with walking or position change

Labor Nursing Interventions

• Apply counterpressure to the sacrum during contractions
• Reposition the mother on her hands & knees with birth ball & encourage to change position every 30 – 60 minutes
• Assist with pain management by working with the mother to manage pain during labor and delivery. This may include techniques such as breathing exercises, massage, and medication administration.
• Administer medications as ordered by the health care provider (HCP)  including pain medications and medications to help augment or induce labor.
• Provide education to the mother and her partner about the labor and delivery process. This includes what to expect during each stage of labor and delivery, as well as breastfeeding and newborn care.
• Monitor progress of labor, including the mother’s cervical dilation and effacement, as well as the baby’s descent and position in the birth canal.
• Assist the HCP during delivery, including preparing the delivery room, assisting with the delivery of the baby, and caring for the baby immediately after birth.
• Perform postpartum assessments on both the mother and the baby immediately after birth to ensure that they are both stable and healthy.