Phase

Length of time

Physical changes

Fetus does

Psychological changes

Nurse does:

Patient does:

Support person does:

Latent

6-8 hrs

0-3 cms

Contractions: mild/mod, q. 2-30 min, last 30-45 seconds

ROM (clear!)

Dil: usually complete in P. simultaneous in M.

FHR: 110-160, periodic & episodic changes, early decels (head compression), accelerations: Table 20-5: Figure 20-8 (506-507)

Station: N: 0 M: -2-0

mild anxiety, coping ok, can focus

VS/FHR/contractions/pain: T: q. 4, q- 30-60 min

Record: ROM, vag exams, meds given, care provided

Remind pt/support person to do activities in next 2 columns

Pain management: non-pharm

Keep pt/partner informed

Uses relaxation techniques, rest/sleep, change positions, ambulate, eat light food & drink,

void q. 2 hrs.

Pain: mild/mod

Remind woman to do activities in column to left.

Eat/drink/void

Active

3-6 hrs

4-7 cms

Contractions: mod/strong, q. 3-5 min, last 40-70 seconds

ROM (usual)

FHR: 110-160, early decels, accelerations

Station: +1- +2

Becomes more serious, “can I do this?”, focus more inward, fatigue,

VS/FHR/contractions/pain: T: q. 4. q. 15-30 min

Record: ROM, vag exams, meds given, care provided,

Position changes

Comfort measures: relaxation techniques, massage, breathing, counter pressure (esp back labor), heat/cold, hydrotherapy, intradermal H20 block

May have urge to push: teach to blow through the urge, change position

Watch for hyperventilation

Reduce distractions

Hygiene

Keep pt/partner informed

Pain: mod.

Uses comfort measures

Nutrition: eat light food & drink,

void q. 2 hrs.

Remind woman to do activities in column to left.

Comfort measures for symptoms to left

Eat/drink/void

Transition

20-40 minutes

8-10 cms Maybe 6 in M., cx lip.

Contractions: strong, q. 2-3 min, last 45-90 seconds

ROM

FHR: 110-160

Station: +1- +2

Loss of control, irritable, confused, narrow focus,

VS/FHR/pain: T: q. 4. q. 10-15 min

Record: ROM, vag exams, meds given, care provided,

Reduce distractions

Hygiene

Provide relief/assistance for partner; may need to take charge

Encourage: not long now, 1 contraction at a time

Keep pt/partner informed

Prepare for birth

Pain: severe

N&V, perspires, shaky, narrow focus, vocal, hyperventilates R. alkalosis), need to defecate,

Nutrition: fluids

void q. 2 hrs.

Remind woman to do activities in column to left.

Comfort measures for symptoms to left

Not take what she says personally!

Drink fluids

Summary

1-20 hours

Complete dil, complete effacement, clear amniotic fluid

Needs 02! FHT 110-160, early decels, nl accels, clear AF, descends

Coping adequately

Nursing process, plan, anticipate, proactive

Pain managed, hydrated, O2 and metabolic needs met, bladder empty

Supported in his/her role, metabolic needs met

Phase

Length of time

Physical changes

Fetus does

Psychological changes

Nurse does:

Patient does:

Support person does:

Latent

10-30 min

Contractions: variable: q. 5 min.

FHR: 110-160

Station: 0 to +2

May wonder why contractions “stopped”

VS: q. 5-30 min; FHR: q. 15 min.

Document care given: VS, FHR, labor progress, interventions and pt response

May sleep

Rests too!

Put on gown, cap, show covers, mask if required

Descent

Varies (5-15 minutes)

Contractions: Q. 1 -21/2 min last 90 seconds; > bloody show Episiotomy: if needed: mediolateral or midline.

Perineal laceration controlled: 1 st, 2 nd or 3 rd or 4 th degree.

FHR: 110-160

Station: +2-+4 to birth

Can be overwhelming

VS: q. 5-30 min; FHR: q. 5 min.

Document care given: VS, FHR, labor progress, interventions and pt response

Encourage open glottis pushing

Assist with comfortable pushing position (left lateral if going to fast)

Remind to relax between contractions

Hygiene: change chux when soiled

Keep pt/partner informed

VS: q. 5-30 min; FHR: q. 5 min.

Document care given: VS, FHR, labor progress, interventions and pt response

Encourage open glottis slow pushing; instruct not to push (blow) when crowning

Help Relax throat and mouth

May need to quite directive: if pt out of control

Keep pt/partner informed (make sure support person is not going to faint!)

Warm compresses to perineum

Hygiene: change chux when soiled

Will soon have two patients to care for soon so make sure everything set up

Grunting; vocalization

Increase urge to push ( Ferguson reflex), hold breath 4-5 seconds

May have difficulty following directions

Ring of fire

Eat, drink

Comfort measures for symptoms to left

Will probably need some guidance from nurse/midwife/MD

Comfort measures for symptoms to left

Will probably need some guidance form nurse/midwife/MD

Don’t faint!

Summary

Usually < 1 hr

Controlled birth; no injury to woman or child; no tears

Needs 02!

Apgar score: > 6

“That wasn’t so bad”

Nursing process, plan, anticipate, proactive

Excitement and relief, shaking

Supported in his/her role, metabolic needs met