Stages and Phases of Labor and Delivery
1. Name the stages and phases of labor. What happens in each stage?
Stage 1:
Contractions - The first stage of labor starts with contractions that are considered the
onset of labor. Once the cervix is dilated to 10 cm and 100% effaced this stage has
ended. For a client who has not had any children the labor typically lasts 10 to 14 hours.
The first stage becomes shorter for subsequent births.
The Latent/Early Phase (cervix dilates from 1 to 4 cm) The longest phase of labor.
During the Early Phase contractions are more than 5 minutes apart, 15 to 45 seconds,
and are uncomfortable.
The Active Phase (cervix dilates to 5 to 7 cm) Contractions are 3 to 5 minutes apart and
last 45 to75 seconds. These contractions become stronger and pressure can be felt in
the pelvis against the cervix. During this time SROM occurs, and bloody show increases.
Transitional Phase (cervix dilates to 8 to 10 cm) The shortest phase of labor.
Contractions during the transitional phase are very intense and last 75 to 90 seconds.
The contractions appear to be nearly on top of each other with less than a minute
between. There is an increase in bloody show an intense urge to push. The client is
expected to feel nauseous, have chills and hot flashes.
Stage 2:
Delivery of the Baby - The contractions start to fall farther apart than the previous
contractions in the transition phase. The mother feels the urge to push.
Stage 3:
Delivery of the Placenta - The delivery of the placenta takes 5 to 20 minutes and is
assessed for intactness and the umbilical cord is assess for three vessels.
Stage 4:
Stabilization and Recovery during this time preventing postpartum hemorrhage is the
top concern and vitals signs, fundus, lochia, perinuem, and urinary output are to be
assessed. Oxytocin may be prescribed to help the uterus contract and control bleeding.
The nurse should assess for maternal-infant bonding as well.
2. What is the priority nursing diagnosis for Stage IV?
Risk for bleeding related to uterine atony or retention of placenta fragments.
3. How does a nurse know a client has true labor contractions?
True contractions will become longer and stronger with increase in pain. When there are
cervical changes this indicates true labor.
Hypertensive Disease in Pregnancy
1. What is the primary expected outcome for a client who has
preeclampsia after magnesium sulfate is administered? What are toxic
manifestations for this medication?
Magnesium Sulfate is expected to prevent seizures in clients who have preeclampsia by
depressing the CNS. Signs of toxicity include the absence of patellar DTR, U/O less than
30 mL/hr, RR less than 12/min, decreased LOC, and cardiac dysrhythmias.
2. What manifestations indicate to a nurse that a client may become
Eclamptic?
Possible signs of convulsions include headaches, severe epigastric pain, hyperreflexia
This study source was downloaded by 100000836551366 from CourseHero.com on 03-02-2022 12:16:56 GMT -06:00
https://www.coursehero.com/file/36637660/Stages-and-Phases-of-Labor-and-Deliverydocx/
1. Name the stages and phases of labor. What happens in each stage?
Stage 1:
Contractions - The first stage of labor starts with contractions that are considered the
onset of labor. Once the cervix is dilated to 10 cm and 100% effaced this stage has
ended. For a client who has not had any children the labor typically lasts 10 to 14 hours.
The first stage becomes shorter for subsequent births.
The Latent/Early Phase (cervix dilates from 1 to 4 cm) The longest phase of labor.
During the Early Phase contractions are more than 5 minutes apart, 15 to 45 seconds,
and are uncomfortable.
The Active Phase (cervix dilates to 5 to 7 cm) Contractions are 3 to 5 minutes apart and
last 45 to75 seconds. These contractions become stronger and pressure can be felt in
the pelvis against the cervix. During this time SROM occurs, and bloody show increases.
Transitional Phase (cervix dilates to 8 to 10 cm) The shortest phase of labor.
Contractions during the transitional phase are very intense and last 75 to 90 seconds.
The contractions appear to be nearly on top of each other with less than a minute
between. There is an increase in bloody show an intense urge to push. The client is
expected to feel nauseous, have chills and hot flashes.
Stage 2:
Delivery of the Baby - The contractions start to fall farther apart than the previous
contractions in the transition phase. The mother feels the urge to push.
Stage 3:
Delivery of the Placenta - The delivery of the placenta takes 5 to 20 minutes and is
assessed for intactness and the umbilical cord is assess for three vessels.
Stage 4:
Stabilization and Recovery during this time preventing postpartum hemorrhage is the
top concern and vitals signs, fundus, lochia, perinuem, and urinary output are to be
assessed. Oxytocin may be prescribed to help the uterus contract and control bleeding.
The nurse should assess for maternal-infant bonding as well.
2. What is the priority nursing diagnosis for Stage IV?
Risk for bleeding related to uterine atony or retention of placenta fragments.
3. How does a nurse know a client has true labor contractions?
True contractions will become longer and stronger with increase in pain. When there are
cervical changes this indicates true labor.
Hypertensive Disease in Pregnancy
1. What is the primary expected outcome for a client who has
preeclampsia after magnesium sulfate is administered? What are toxic
manifestations for this medication?
Magnesium Sulfate is expected to prevent seizures in clients who have preeclampsia by
depressing the CNS. Signs of toxicity include the absence of patellar DTR, U/O less than
30 mL/hr, RR less than 12/min, decreased LOC, and cardiac dysrhythmias.
2. What manifestations indicate to a nurse that a client may become
Eclamptic?
Possible signs of convulsions include headaches, severe epigastric pain, hyperreflexia
This study source was downloaded by 100000836551366 from CourseHero.com on 03-02-2022 12:16:56 GMT -06:00
https://www.coursehero.com/file/36637660/Stages-and-Phases-of-Labor-and-Deliverydocx/
