The most accurate definition of labor is contractions with cervical dilation.  If the woman is contracting and her cervix is not dilating or she is dilated or without contractions, she is not in labor. 

The second stage of labor is the stage at which the infant is born. It begins with full cervical dilation (10 centimeters) and complete effacement (100%) and ends with the baby’s birth.  Contractions remain at every 2-3 minutes, lasting about 50-60 seconds, and are strong to palpation.  The mother may have spontaneous bearing down efforts which becomes stronger as fetus descends to vaginal introitus and reaches perineum.  She may be quiet or vocalize with grunting or screaming.  Women often experience a sense of relief that she has some control over the progress of pushing and the "worst is over."  Pushing may diminish the pain especially while the introitus stretches with crowning (a sensation described as the "ring of fire").  Senses increased urge to push and describes increasing pain; describes ring of fire (burning sensation of acute pain as vagina stretches and fetal head crowns).  She will show a decreased ability to listen to or concentrate on anything but giving birth.  Her respiratory pattern will change with pushing as she holds her breath at regular intervals between 3 to 5 times per contraction.  Continued position changes are helpful to guide the baby through the cardinal movements through the pelvis.  She will often show excitement and relief immediately after birth of head.  

The force exerted by a combination of uterine contractions, gravity, and maternal bearing-down efforts (pushing) facilitates the achievement of an uncomplicated spontaneous vaginal birth. The length of second-stage labor varies considerably among women and is affected by parity and the use of epidural anesthesia.  Variations in pushing time are dependent on the size and shape of the mother's pelvis, the mother's pushing efforts, the size of the fetus, and the position of the presenting part in the pelvis.  Other factors that influence the length of second-stage labor include: the patient’s age, her body mass index (BMI), her emotional state, her fatigue, and the adequacy of her support systems.  The upper limit of second-stage labor is set at three hours for primiparous patients without an epidural; with an epidural, it extends slightly to four hours. For multiparous patient, the limits are set at two hours without an epidural and three hours with an epidural. A prolonged second stage is diagnosed once these time limits have been exceeded.

Interventions

Latent Phase

• Help the patient to rest in a position of comfort; encourage relaxation to conserve energy.

• Promote progress of fetal descent and the onset of the urge to bear down by encouraging position changes (especially upright), pelvic rock, ambulation, and showering

Active Pushing Phase

• Provide 1:1 nursing care. Do not leave the patient alone.

• Help the patient to change position and encourage spontaneous bearing-down efforts. Bearing-down consists of prolonged breath-holding, or sustained, directed bearing down. The Valsalva maneuver or closed glottis pushing is discouraged as it causes an increase in intrathoracic and cardiovascular pressure, thus reducing cardiac output and decreasing perfusion of the uterus and placenta. Spontaneous open glottis pushing (bearing down while exhaling) for six to eight seconds at a time is encouraged. The patient is encouraged to control the urge to bear down at certain points in these pushing efforts

• Encourage relaxation to conserve energy between contractions.

• Provide comfort and pain relief measures as needed.  Be aware that opioid medications are often avoided at this stage to avoid respiratory depression in the newborn if it is born with the medication still in its system

• Cleanse the perineum promptly if fecal material is expelled.

• Provide emotional support, encouragement, and positive reinforcement of efforts.

• Keep the patient informed regarding progress.

• Create a calm and supportive environment.

• Coach the patient to pant during contractions and to gently push between contractions when the head is emerging (crowning).

• Offer a mirror to watch birth.

• Encourage the patient to touch the fetal head when it is visible at the perineum.

Preparing for Birth

• Necessary supplies, instruments, and equipment should be gathered and prepared for use well before the anticipated time of birth.

• Positions for Labor and Birth:  No single ideal position for labor and birth exists. The patient may want to assume various positions for labor and birth. Encourage the patient to change positions frequently and help to attain and maintain their positions of choice. Some options are supine, semirecumbent, lithotomy positions, upright positions (shortens labor), squatting, side-lying, and hands-and-knees.

Introduction

The fourth stage of labor begins with the expulsion of the placenta and lasts until the patient is stable in the immediate postpartum period, usually within the first 1-2 hours after birth.  The immediate postpartum recovery period lasts longer. Based on maternal statues, the fourth stage of labor usually includes the first two hours after birth at a minimum. During this time maternal organs undergo their initial readjustment to the nonpregnant state, and the functions of body systems begin to stabilize.

Care Management

• Blood pressure:  Assess every 15 minutes for the first two hours 

• Pulse:  Assess rate and regularity every 15 minutes for the first two hours

• Temperature:  Assess at the beginning of the recovery period. The temperature should then be assessed every 4 hours for the first 8 hours after birth and then at least every 8 hours 

• Fundus:  Position the patient with knees flexed and head flat

  • • Just below the umbilicus, cup your hand and press it firmly into the patient’s abdomen. At the same time, stabilize the uterus at the symphysis pubis with the opposite hand

    • If the fundus is firm (and bladder is empty), with uterus in midline, measure its position relative to the patient’s umbilicus. 

    • If the fundus is not firm, massage it gently to contract and expel any clots before measuring the distance from the umbilicus

      • Place your hands appropriately; massage gently only until the fundus is firm

      • Expel clots with your upper hand, firmly apply pressure downward toward the vagina; observe the perineum for the amount and size of expelled clots

    • Lay your fingers flat on the patient’s abdomen under the umbilicus; measure how many fingerbreadths (fb) or centimeters (cm) fit between the umbilicus and the top of the fundus. 

      • Fundal height is documented according to agency guidelines. 

      • For example, if the fundus is 1 fb or 1 cm above the umbilicus, fundal height may be recorded as either +1, u+1, or 1/u. If the fundus is 1 fb or 1 cm below the umbilicus, fundal height may be recorded as either −1, u−1, or u/1.

• Bladder:  Assess its distention by noting the location and firmness of the uterine fundus and by observing and palpating the bladder. A distended bladder is seen as a suprapubic rounded bulge that is dull to percussion and fluctuates like a water-filled balloon. When the bladder is distended, the uterus is usually boggy in consistency, well above the umbilicus, and to the patient’s right side.  A full bladder increases the incidence of postpartum hemorrhage.  

  • • Assist the patient to void spontaneously

    • Measure and record the amount of urine voided

    • Catheterize as necessary

    • Reassess after voiding or catheterization to make sure the bladder is not palpable, and that the fundus is firm and in the midline

• Lochia:  Observe the lochia on perineal pads and on the linen under the patient’s buttocks

  • • Determine its amount and color; note the size and number of clots; note the odor

    • Observe the perineum for sources of bleeding (e.g., episiotomy, lacerations)

• Perineum:  Ask or assist the patient to turn onto her side and flex her upper leg on her hip

  • • Lift her upper buttock

    • Observe the perineum in good lighting

    • Assess the episiotomy or laceration repair for redness (erythema), edema, ecchymosis (bruising), drainage, and approximation (REEDA)

    • Assess for the presence of hemorrhoids

Postanesthesia Recovery

Obstetric recovery areas are held to the same standard of care that would be expected of any other postanesthesia recovery (PAR) unit.  A PAR score is determined for each woman on arrival and is updated as part of every 15-minute assessment. Components of the PAR score include activity, respiration, blood pressure, level of consciousness, and color.  If the patient received general anesthesia, she should be awake, alert, and oriented to time, place, and person. Her respiratory rate should be within normal limits and oxygen saturation level at least 95%, as measured by a pulse oximeter.  If epidural anesthesia is administered, the nurse may be responsible for removing the epidural catheter from the patient's back.  Care should be taken to assess that the tip of the epidural is intact and none of the tube remains in the patient.  

Nursing Interventions

Care of the New Mother

If food and fluids were restricted, especially if excessive fluid loss (blood, perspiration, or emesis) occurred during the birth, the patient will be very hungry and thirsty soon after the birth.  In the absence of complications, a patient who has given birth vaginally may have fluids and a regular diet as soon as she likes. In the immediate postpartum period, women who give birth by cesarean are usually restricted to clear liquids and ice chips.  Most new mothers are capable of self-care or are assisted in these activities by family members or support people.  When a woman is able to ambulate to the bathroom and return to bed steadily and without syncope, she is allowed to perform complete self-care.  Women who had epidural anesthesia may take longer due to sensations returning after anesthesia is discontinued.  

Care of the Family

Most parents enjoy being able to hold, explore, and examine the baby immediately after birth. Both parents can assist with thoroughly drying the infant. Skin-to-skin contact is encouraged for bonding and to assist in newborn thermoregulation.  Before being held by the partner, the newborn is wrapped snugly in a receiving blanket, and caps are often used to keep the newborn’s head warm and prevent heat loss.  Many women wish to begin breastfeeding their newborns immediately after birth to take advantage of the infant’s alert state (first period of reactivity) and to stimulate the production of oxytocin, which promotes contraction of the uterus and prevents hemorrhage.

Family–Newborn Relationships

Maternal exhaustion can affect the response to the newborn.  When the nurse is evaluating parent–newborn interactions after birth, they should consider the cultural characteristics of the woman and her family and the expected behaviors of that culture. For example, in some cultures the birth of a male child is preferred, and patients may grieve when a female child is born. Whatever the reaction and its cause, the patient needs continuing acceptance and support from members of the health care team. Appropriate nursing actions include:

• making a notation in the recovery record regarding the parents’ reaction to the newborn

• assessing this reaction by asking questions such as, “What do the parents say?” and “What do they do?” 

• conducting further assessments of the parent–newborn relationship during the recovery and postpartum period.

The interprofessional health care team, through their interest and concern, can provide the environment for making this a satisfying experience for parents, family, and significant others.

There are many ways the interprofessional health care team can help support normal labor and birth. 

• Allow labor to begin on its own: encourage spontaneous labor rather than fostering elective labor inductions. 

• Encourage freedom of movement throughout labor to facilitate the progress of labor and enhance maternal comfort and control of the labor process. 

• Provide support beginning early in labor and continuing throughout the process of childbirth to relieve maternal anxiety and stress 

• Provide support for pain relief measures to decrease the use of epidural anesthesia which increases the likelihood of cesarean birth. Support can also be provided by someone not employed by the hospital (e.g., doula). 

• Avoid routine implementation of interventions (e.g., intravenous fluids, oral intake restrictions, continuous electronic fetal monitoring, labor augmentation measures (e.g., amniotomy, oxytocin administration, and epidural anesthesia). 

• Support the practice of spontaneous nondirected pushing in nonsupine positions (e.g., lateral, squatting, standing, kneeling, and semi-sitting) to facilitate the progress of fetal descent and shorten the second stage of labor. 

• After birth, avoid separation of the mother from her healthy baby. Encourage skin-to-skin contact to keep the baby warm, prevent neonatal infection, enhance the newborn’s physiologic adjustment to extrauterine life, and foster early breastfeeding. 

Support of the Partner

The nurse also specifies support measures that can be used for the laboring patient and points out areas of the room in which the partner can move freely. The nurse encourages partners to assist with comfort measures and be present at the birth of their infant.  Consideration of cultural and personal expectations and beliefs is important.