Interventions: provide support, breathing techniques, encouragement, monitoring mother’s vitals and fetal heart rate (esp. May report intense pressure (bowel movement) due to baby pushing down…don’t want the mother to start pushing until fully dilated because it can cause swelling of the cervix…hence it won’t fully dilate.Mother will be concentrating, irritated, pain, nauseous, shivering.Contractions will be very intense and long (back to back contractions) 60-90 seconds length every 2-3 minutes.Lasts 30 minutes to 2 hours (longer for first time mothers).Shortest phase but most intense/painful.This phase will lead into Stage 2 where the baby will be delivered. Mother will be serious, anxious, and in pain.
Contraction intensity scale full#
Encourage frequent urination to keep bladder empty ( full bladder prevents uterus from contracting properly and can slow down labor), monitor vitals of mother and fetal heart rate. Non-pharmacological: changing positions, warm shower or bath, massages between contractions, breathing techniques, ice or fluids for dry mouth. Interventions: Provide comfort (non-pharmacological and pharmacology). Perform Nitrazine paper test to confirm the water has broke (turns blue if positive).Important to monitor for meconium -stained fluid which is greenish brown/yellowish ammonitic fluid…baby can aspirate this into lungs causing infection or blocking airway and this usually indicates fetal distress).If woman at home, time to go to the hospital.Contractions will be noticeably stronger and longer (45 to 60 seconds) every 3 to 5 minutes.*Starts at 6 cm (instead of 4 cm)…. (The American College of Obstetricians and Gynecologists) has recommended guideline changes for cervical dilation for the stages of labor.Cervix dilates to * 4 to 7 cm and thins.Woman will be talking, excited, and nervous. If woman at home, should monitor contraction duration and intensity…try to stay comfortable at home until water breaks or enters active phase of labor.Longest of the phases (especially first time mothers >20 hours vs >14 multipara)….some women notice contractions while others don’t (can gradually occur over 8-12 hours or 1-3 days).Contractions are less intense compared to other phases and stages.Contractions occur every 5 to 30 minutes and 30-45 seconds in length.*0-6 cm…. (The American College of Obstetricians and Gynecologists) has recommended guideline changes for cervical dilation for the stages of labor.Cervix dilates from 1 to 4 cm* and thins.Remember the mnemonic: “ Labor is Actively Transitioning” Phase 1: Early labor ( Latent) Phases: Early Labor (Latent), Active, and Transition Longest Stage (especially for first time mothers…nulliparous).Goal: Cervical dilation (opening) 0-10 cm & 100% effacement (thinning) due to contractions. Stages of Labor Nursing NCLEX Review Stage 1 of Labor Signs the placenta is about to be deliveredĪfter you review these notes, don’t forget to take the stages of labor quiz.changes in the perineum that the baby is about to be delivered.delivery mechanisms (Duncan or Schultz).cervical dilation ranges in each phase of stage 1 and contraction length and frequency.be able to identify each stage based on its description.These type of questions may be found on NCLEX and definitely on nursing lecture exams in maternity.įor exams it is important to remember the following about the stages of labor: As a nursing student, you must be familiar with each stage of labor and the nursing interventions based on the specific stage of labor.
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