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Labor is divided into four stages. What does this chapter cover?
Nursing care throughout each of the four stages of labor.
When does the first stage of labor begin and end?
Begins with onset of regular uterine contractions and ends with complete cervical effacement and dilation (10 cm).
What is effacement?
Thinning of the cervix.
What is dilation?
Enlargement of the cervix to 10 cm.
What are signs of true labor?
Regular, strong contractions; intensify with walking; cervical change occurs.
What are signs of false labor?
Irregular contractions; decrease with walking; no cervical change; may be due to recent exam, sex, bleeding, or semen.
What subjective data should be collected during labor assessment?
Reason for visit, contraction details (onset, frequency, duration), pain level, discharge or fluid leakage.
How is rupture of membranes confirmed?
Nitrazine test: blue if amniotic fluid (alkaline), yellow if vaginal secretions (acidic).
What can cause a false positive Nitrazine test?
Recent sex, bleeding, or vaginal exams.
What objective data is collected on admission in labor?
Physical exam, vital signs, fetal heart rate, uterine contractions, vaginal exam, bloodwork.
When should a vaginal exam be done during labor?
On admission and before pain meds; limited if membranes ruptured.
What blood tests are done during labor assessment?
Hemoglobin, hematocrit, type & screen, Group B Strep (if not done prenatally).
What is important to review from the prenatal record?
GTPAL, risk factors, history of sexual abuse.
What are key nursing interventions during labor?
Educate, support, encourage position changes, fluids, relaxation, advocate, maintain calm environment.
When does the second stage of labor begin and end?
Begins with full dilation and effacement; ends with birth of the baby.
What are the two phases of the second stage of labor?
Latent phase (passive descent), Active phase (pushing with Ferguson reflex).
How often are vital signs and fetal heart rate checked during second stage?
VS: every 5–30 min; FHR: every 5–15 min.
How often are vaginal exams done in second stage?
Every 10–15 minutes during active phase.
How many nurses are assigned during second stage?
One nurse during labor; two nurses at birth (one for mom, one for baby).
What is done to prepare for birth?
Positioning, pushing techniques, sterile supplies, warm baby table, suction and meds ready.
What is done immediately after the baby is born?
Skin-to-skin, dry baby, put on hat, delay cord clamping 1–5 min or until pulsation stops.
What is the benefit of delayed cord clamping?
Allows up to 30% more blood volume to transfer from placenta.
What is included in newborn initial assessment?
Apgar score, airway check, breathing monitor, cold stress prevention.
What happens if baby is stable after birth?
Apply ID bands and continue skin-to-skin contact.
What happens if baby is not stable?
Move baby to warming table for further assessment and resuscitation.
How is the perineum assessed after birth?
Check for soft tissue trauma and laceration degree.
What are the degrees of laceration?
1st: superficial; 2nd: perineal muscles; 3rd: through anal sphincter; 4th: through rectal mucosa.
What is an episiotomy?
Surgical incision to enlarge vaginal outlet; not routine.
When does the third stage of labor occur?
From birth of baby to delivery of placenta.
What are signs of placental separation?
Lengthening cord and vaginal blood gush.
What medication helps deliver placenta and control bleeding?
Pitocin (IV or IM).
What care is done after placenta delivery?
Perineal care, patient cleaning, breastfeeding encouraged.
When is the fourth stage of labor?
From placenta delivery to ~1–2 hours postpartum (stabilization period).
What is assessed during the fourth stage of labor?
Vital signs and fundus every 15 minutes for 2 hours.
What if the fundus is boggy?
Perform fundal massage and help empty bladder.
What else is monitored in the fourth stage?
Lochia (bleeding), perineum (laceration or episiotomy status).