15.3: Stages of Labor
By the end of this section, you will be able to:
- Explain the events occurring in the phases of the first stage of labor
- Describe the events within the second stage of labor
- Explain the mechanisms of labor
- Describe the events within the third stage of labor
- Explain the events occurring in the first hour after labor and birth
Labor progresses in a multistage process that can follow the typical pattern or deviate significantly in a variation of normal or in a pathologic deviation. The latter warrants nursing interventions or recognition of the deviation and the need to consult with the provider for interventions outside the scope of nursing. To understand when to intervene, the nurse must first understand the normal progression through the stages of labor. The first stage begins with uterine contractions and cervical change that progress through the early and active phase. The routine time frames for first stage labor include the latent phase of labor, up to 14 hours in multiparous persons and up to 20 hours for nulliparous persons. Active labor begins when the laboring person’s cervix reaches 6 cm dilated; multiparous persons progress faster to complete dilation (Olsen & Ramus, 2022). Lack of cervical dilation in 4 hours with consistent contractions or 6 hours without consistent contractions indicates an arrest of labor, leading to interventions such as augmentation and/or cesarean birth (Olsen & Ramus, 2022).
In the second stage , the cervix is completely dilated, and maternal pushing efforts begin, ending in vaginal birth as the presenting part rotates through the birth canal and is expelled from the vagina. The average time frame for the second stage is less than 4 hours for birthing persons having their first child and less than 3 in multiparous persons (Olsen & Ramus, 2022). The third stage begins with the completion of birth of the newborn and ends when the placenta is delivered. The average time frame for this stage is between 5 and 30 minutes (Olsen & Ramus, 2022). The 1 to 4 hours after birth of the placenta are also referred to as the fourth stage of labor, which often requires one-to-one patient ratios for in-depth nursing care due to the need for more support and monitoring for both the birthing person and their newborn.
First Stage of Labor
The first stage of labor begins with uterine contractions resulting in cervical change. These contractions are often reported as mild uterine cramping that builds in intensity and frequency throughout early labor until it reaches a pattern. The nurse assesses cervical effacement and dilation consistent with active labor. When effacement and dilation are complete, labor transitions into the second stage, and pushing can begin. Early labor is often better tolerated with minimal support from nurses and support people. However, laboring people vary in their tolerance of discomfort and should be treated according to their wishes, no matter what stage of labor is present. Nurses should know and offer support and both nonpharmacologic and pharmacologic pain relief options for each stage and phase of labor.
Early Phase
The early phase of stage 1 of labor begins with uterine contractions that elicit cervical change within 4 hours or less and ends when cervical dilation progresses to 6 cm (Olsen & Ramus, 2022). To encourage labor progression during the early phase, mobility and upright positioning are helpful for both comfort and cervical dilation. Comfort techniques include ambulation, frequent position changes, massage (light or firm based on patient preference), counter pressure on hips or low back, hydrotherapy done in a shower with upright positioning, narcotic pain medications, nitrous oxide, and even epidural anesthesia if ordered by the health-care provider.
If a laboring person has an epidural in the early phase of labor, it is crucial for the nurse to continue position changes every 20 to 30 minutes or more frequently to facilitate fetal rotation and descent. The laboring person is not getting the physiologic signals to do this because of the medication present for pain control. Positions that are helpful with an epidural in place include side-lying release on each side, exaggerated runners, upright with symmetric and asymmetric leg positioning, hands and knees (be sure to get lift support and position legs securely to protect patient and nurse body mechanics), and pelvic tilts to encourage engagement of the presenting fetal part (Tilden et al., 2022) (Figure 15.11).
Active Phase
The active phase begins when the early phase ends (6 cm dilation) and ends when the second stage of labor begins (10 cm dilation). The active phase is often associated with contractions occurring every 2 to 5 minutes, each lasting 60 seconds, with an intensity that requires more support of the laboring person to cope with the pain. This phase progresses more quickly than the early phase of labor for most laboring people.
Other signs that a laboring person is reaching the active phase of labor can be nausea and vomiting, becoming more focused and internal, being unable to answer questions or converse during contractions, and feeling rectal pressure. Asking laboring people to recline or lie in a bed during the active phase without epidural anesthesia can significantly increase pain. Upright positioning and free movement are necessary coping techniques for this phase of labor. Nurses can support this physiologic process and assist laboring people by advocating for intermittent auscultation instead of continuous fetal monitoring, if appropriate based on risk factors. Nurses should encourage movement and ambulation and remind laboring persons to urinate, drink water, and eat small nutritious snacks. If fatigue is a concern for the laboring person, restful positions that prevent severe pain include (Garbelli & Lira, 2021):
- hands and knees with a peanut-shaped birth ball under the arms to allow passive or active movement without strain on the hands and wrists,
- seated position with legs supported alternately with a peanut-shaped birth ball, and/or
- side lying with a peanut shaped birth ball with counter pressure as needed to the hips and low back.
Heat or ice can be applied in these positions as well, for comfort to allow for rest. Breathing techniques, progressive pelvic floor muscle relaxation, and positive affirmations are also helpful during the active phase.
If epidural anesthesia is being used, the nurse must continue to be diligent with position changes every 20 to 30 minutes and use of the peanut ball to encourage fetal rotation and descent (Grenvik et al., 2023). The nurse should discuss the laboring person’s preferences for the second stage of labor and review the benefits of different pushing techniques and positions. Throughout labor, the nurse should answer any questions and address any fears surrounding the birth to prepare the laboring person’s mind as their body prepares.
Second Stage of Labor
When the cervix is 10 cm dilated and 100 percent effaced, it is completely or fully dilated, and the second stage begins. Pushing efforts can begin immediately or can be delayed until the birthing person feels the urge to push. Pushing efforts can be spontaneous, without coaching or direction if signs of progress are observed (ACOG, 2023). Perineal bulging with maternal efforts, visualization of the fetal presenting part, and passing of maternal stools are signs that progress is being made. Use of these signs avoids the risk for infection and perineal edema associated with multiple or prolonged vaginal examinations. If progress is unclear within the first 30 minutes, the nurse should consider having the birthing person change positions and directing the maternal effort down toward the rectum or changing between open-glottis and closed-glottis pushing to find what works for the birthing person. Research has shown benefits for changing positions during the second stage, with upright or side-lying positions showing improved outcomes for the birthing person and fetus, and lithotomy or supine positions causing increased risk for perineal tearing, longer pushing time, more pain, and increased fetal heart rate abnormalities (Huang et al., 2019). Open-glottis pushing and closed-glottis pushing should be determined by the birthing person. Research shows that nurses who are educated on optimal position changes and pushing techniques reduce cesarean rates compared to those who do not complete this additional education (Dent et al., 2023).
The average nulliparous person without an epidural will need to push effectively for 2 to 3 hours to birth their newborn. With an epidural, the expected time frame expands to 3 to 4 hours. For the average multiparous person, the second stage could last an hour, or 2 hours with an epidural. When pushing efforts exceed 3 hours in a multiparous birthing person and 4 hours in a nulliparous birthing person, there is a small but statistically significant increase in risk for postpartum hemorrhage, chorioamnionitis, endometritis, postpartum fever, obstetric anal sphincter injury, persistent occiput posterior position, shoulder dystocia, neonatal intensive care unit admission, and neonatal sepsis (Pergialiotis et al., 2020). The nurse should take a shared decision-making approach with the provider and the birthing person when discussing prolonged pushing efforts. The risks, benefits, and indications for interventions and alternatives that accommodate the birthing person’s preferences and risk tolerance should be discussed. ACOG recommends considering operative vaginal deliveries as a strategy for reducing the risk for cesarean birth due to national increases in cesarean birth without improved outcomes (2023).
Shared Decision-Making
The incidence of medical errors resulting in poor patient outcomes led to the Quality and Safety Education for Nurses (QSEN) project. The objective of the QSEN project is to educate nurses at the prelicensure level with the knowledge, skills, attitudes, and values required to increase the quality and safety of the system of health care, improving patient outcomes (Sherwood & Barnsteiner, 2021). Integration of the QSEN competency of patient-centered care has also led to improved patient satisfaction when providing compassionate care.
An essential part of the patient-centered care QSEN competency is shared decision-making. Shared decision making means the patient and health-care team work together to make the health-care decisions best for the birthing person and fetus. The patient’s preferences, needs, and beliefs are respected, leading to the development of a partnership between the health-care team and the patient. For many pregnant patients, shared decision-making starts with a birth plan . During the labor and birth process, the patient’s and support persons’ preferences, needs, and beliefs expressed in the birth plan are respected by health-care personnel when providing patient care, following standards of care, and implementing health-care provider orders. For example, during labor and birth, decisions are made regarding the use of intermittent or continuous fetal and contraction monitoring and external or internal monitoring, need for IV access or continuous IV fluid infusion, induction and augmentation of labor, extending the length of second stage bearing down efforts, use of vacuum extractor or forceps, and need for cesarean birth.
Mechanisms of Labor
When crowning of the fetal head is noted, the nurse should prepare for imminent birth even though it may take some time with slow, controlled expulsive efforts by the birthing person. The provider attending the birth should be present with hands poised to assist with any emergencies or to provide perineal support. A meta-analysis of seven studies found that perineal massage during the second stage prevented episiotomy and decreased the duration of pushing but was not effective in decreasing the severity or incidence of perineal tears (Marcos-Rodríguez et al., 2023). Once the fetal head delivers, the provider will check for the presence of a nuchal cord. Also, after delivery of the head, the restitution of the fetal shoulders occurs, which means the shoulders turn to the left or right oblique diameter of the pelvis to allow easier passage of the shoulders under the maternal pubic arch. This is where a shoulder dystocia may develop with incomplete restitution or impaction of the fetal shoulder despite adequate restitution. Restitution is then followed by external rotation of the fetal head for the fetal face to be directed toward the left or right thigh of the birthing person. After external rotation, the fetal shoulders are typically delivered with gentle downward traction on the anterior shoulder followed by upward traction on the posterior shoulder, then lifting the newborn toward the birthing person’s abdomen. The nurse must consider the position of the birthing person, as these movements will differ if the anatomy is reversed in the hands-and-knees or kneeling position. Once the fetal shoulders are delivered, the remainder of the body should follow smoothly without traction placed under the fetal axilla or neck. Support of the body can be done gently to guide the remaining body with flat hands to prevent tissue trauma in the newborn. The mechanisms of labor are summarized in Figure 15.12.
Third Stage of Labor
Birth has occurred, and the third stage of labor begins. Placental delivery should occur within 30 minutes of the time of birth to reduce the risk for hemorrhage (Begley, 2019). Reports of cramping from the birthing person, lengthening of the umbilical cord, change in the shape of the uterus due to involution as the placenta detaches from the uterus and moves out of the uterus and into the vaginal canal, and increased vaginal bleeding are signs that the placenta has detached and subsequent delivery is imminent. To facilitate the birth of the placenta, allowing the newborn to latch to the breast and stay skin-to-skin can increase physiologic maternal oxytocin levels (Vittner et al., 2018).
If the placenta has not delivered within the expected 30 minutes or significant bleeding is occurring, gentle cord traction with one hand and pressure on the uterus with the opposite hand by the provider attending the birth can lead to the birth of the placenta. See 19.9 Complications in the Third Stage of Labor for interventions for retained placenta.
Table 15.2 summarizes cervical dilation in the stages of labor.
| Stage of Labor | Cervical Dilation |
|---|---|
| First stage (early phase) | 0–6 cm |
| First stage (active phase) | 6–10 cm |
| Second stage | 10 cm to birth |
| Third stage |
Birth to placenta delivery
Cervix begins to close |
Fourth Stage of Labor
The fourth stage begins after the birth of the placenta. This stage includes the time to repair any perineal trauma and ends 1 to 4 hours after delivery of the placenta. This time is of the utmost importance and requires the continued presence of a skilled attendant or nurse to monitor closely for complications. Complications during this time include an increased risk of maternal hemorrhage; uterine atony; bladder distention; pain from perineal trauma or breast-feeding attempts; fatigue; hypotension or the development of a fever; and difficulty in ambulating due to birth, blood loss, perineal trauma, or epidural anesthesia . Frequent taking of vital signs and assessment of fundal height/tone/vaginal bleeding are necessary. The nurse should keep the room warm, keep the baby blankets dry, consider a hat if the newborn has hair that is staying wet, prevent interruptions in skin-to-skin contact and initiation of breast-feeding for 1 to 2 hours before weighing, measuring, or administering medications to the newborn.
Nurse:
Courtney, BSN, RN, C-EFM
Years in practice:
6
Clinical setting:
Labor and delivery unit
Geographic location:
Texas
A few years ago, a patient arrived in obvious distress in what appeared to be active labor. The patient was thrashing in the EMS transport stretcher and restraints, screaming for help, saying, “The baby is coming.” I arrived to receive the transport and assume care for the patient’s triage in labor and delivery. I first helped transfer the patient to a labor and delivery bed without restraints and calmly coached the patient to take deep, slow breaths to allow for oxygen for both them and their fetus. The patient responded with deep breathing attempts while still trying to ask for relief. I explained the need to ask basic medical questions and obtained vital signs for the patient and their fetus prior to administering pain relief. I quickly and effectively addressed major health problems, medications, allergies, and pregnancy history while obtaining maternal and fetal vital signs. The patient denied any pertinent medical history and reported this was their third pregnancy, currently at 38 weeks’ gestation with two previous term vaginal births without complications. The patient was receiving care from an OB/GYN who was credentialed at our facility and who sent prenatal records at 36 weeks’ gestation for review on admission to labor and delivery. These records were being obtained by the unit secretary at that time. Contractions appeared on the monitor every 2 to 3 minutes, each lasting 1 minute, and were strong on palpation. The fetal baseline was 125 bpm, with moderate variability, positive for accelerations, and negative for decelerations. The maternal vitals were as follows: BP 122/76, pulse 95, PO 2 96%, temperature 98.0° F, and pain 10/10 with contractions. The cervical exam showed 9/100/0 station with LOA fetus. I notified the provider that the patient was progressing quickly with birth imminently expected. The provider was en route to delivery and requested an anesthesia consult to consider epidural anesthesia, as this was the patient’s preference for birth. Anesthesia as presented and recommended for the patient was too close to the time of delivery; further, laboratory test results had not come back and the IV fluid bolus was not yet administered, so epidural anesthesia was contraindicated. IV medication was contraindicated as well due to fetal risk at birth, and nitrous oxide was not available at our facility. I then continued to increase the patient’s access to nonpharmacologic pain relief options by moving the patient to the shower to allow for hydrotherapy and intermittent auscultation. This provided significant relief, and the patient was able to speak clearly between contractions. I then explained the information again about epidural access in the patient’s case and recommended continued hydrotherapy, deep breathing, and counterpressure when needed for pelvic pressure. The patient began spontaneously pushing, and because our facility policy did not allow for birth utilizing hydrotherapy, I had the patient move to the toilet for expulsive efforts. The OB/GYN arrived and entered the bathroom, where the patient expelled the fetal head, stood, and delivered the rest of the fetal body, which was then passed through the maternal legs for skin-to-skin contact and delayed cord clamping while the patient was transported back to the labor bed for the third stage of labor.