1st STAGE OF LABOR

Nursing care during the first stage:

a. Hospital Admission. After a physician or nurse has evaluated the patient, an admission order is
written. At this point, your duties as a practical nurse are as follows:
(1) Establish a rapport with the patient and significant others.
(2) Explain all procedures or routines, which will be carried out prior to performing them. These
include:
(a) NPO except ice chips while in labor.
(b) Activities allowed and disallowed according to ward policies (i.e. bathroom privileges).
(c) Use of fetal monitors.
(d) Progress reports.
(e) Visitation policies.
(f) Where patient's personal belongings will be maintained.
(3) Orient the patient to the surroundings (that is, room, call bell).
(4) Initiate the patient's labor chart.
(5) Review the information obtained originally in the exam room, verify and transfer the OB health
record to the labor chart per ward policies. You will review the following information:
(a) Obstetric history.
b. Perineal Preparation. Shaving of pubic hair to prevent infection of perineal episiotomy/lacerations is
rarely done anymore. There must be a physician's order to perform this task.
c. Cleansing Enema.
d. Evaluation of Uterine Contractions Continued. The purpose of this evaluation is to assess the ability
of the uterus to dilate the cervix, help in determining the progress of labor, help to detect abnormalities of
uterine contractions (such as lack of uterine relaxation), and help to evaluate any signs of fetal distress.
This evaluation will help you in identifying the frequency (how often in minutes contractions
occur), intensity (strength of contractions when palpitations are identified as mild, moderate, or strong
[severe]), andduration (how long the contractions lasts in seconds).
When palpating for contractions, place your hand over the fundal area of the patient's uterus.
Contractions can be felt by your fingers before the patient actually becomes aware of them. See figure 23 for patient experiencing contractions.

2nd STAGE OF LABOR (DELIVERY STAGE)

Nursing care during the second stage:
a. Encourage the patient to rest between contractions and to push with contractions. Only one
person should coach. Verbal encouragement and physical contact help reassure and encourage the
patient.
b. Position the patient's legs in the stirrups for the lithotomy position. This is the most common
position for delivery. Facilities using birthing beds have the patient in an upright position. Positioning also
depends upon the type of anesthesia to be used and C-section delivery. Each case may be different.
c. Prep the patient's perineum. A Betadine scrub and water are used with 4x4's. Clean the perineum by
washing the pubic area, down each thigh, down each side of the labia, down the perineum, and down the
rectal area (see fig. 2-7). Begin cleaning at number 1 and proceed through number 7. Discard used
sponges after each step. Rinse area with the remaining solution.
d. Monitor the patient's blood pressure and the fetal heart tones every 5 minutes and after each
contraction.

3rd STAGE OF LABOR (PLACENTAL STAGE)

Nursing care during the third stage:
a. Continue observation. Following delivery of the placenta, continue in your observation of the fundus.
Ensure that the fundus remains contracted. Retention of the tissues in the uterus can lead to uterine
atony and cause hemorrhage. Massaging the fundus gently will ensure that it remains contracted.
b. Allow the mother to bond with the infant. Show the infant to the mother and allow her to hold the
infant.
c. Record the following information.
a. Time the placenta is delivered.
b. How delivered (spontaneously or manually removed by the physician).
c. Type, amount, time and route of administration of oxytocin. Oxytocin is never
administered prior to delivery of the placenta because the strong uterine contractions
could harm the fetus.
d. If the placenta is delivered complete and intact or in fragments.

4th STAGE OF LABOR (RECOVERY STAGE)

Nursing care during the fourth stage of labor:
a. Transfer the patient from the delivery table. Remove the drapes and soiled linen. Remove both legs
from the stirrups at the same time and then lower both legs down at the same time to prevent cramping.
Assist the patient to move from the table to the bed.
b. Provide care of the perineum. An ice pack may be applied to the perineum to reduce swelling from
episiotomy especially if a fourth degree tear has occurred and to reduce swelling from manual
manipulation of the perineum during labor from all the exams. Apply a clean perineal pad between the
legs.
c. Transfer the patient to the recovery room. This will be done after you place a clean gown on the
patient, obtained a complete set of vital signs, evaluated the fundal height and firmness, and evaluated
the lochia.
d. Ensure emergency equipment is available in the recovery room for possible complications.
(1) Suction and oxygen in case patient becomes eclamptic.
(2) Pitocin is available in the event of hemorrhage.
(3) IV remains patent for possible use if complications develop.