When the pregnancy is coming to an end, around gestational age of 40 weeks, the body prepares for labor. The fetus has grown and is prepared to survive outside of the uterus. Labor represents the end of the pregnancy and it is divided into four stages. During these stages, it is at the utmost importance to closely monitor both mother and fetus, watching for any signs of distress or complications. The labor process is divided into four main stages which are then divided into phases.
The Four Stages of Labor
The first stage of labor begins when the first regular contraction is felt until full dilation of the cervix. Many women, especially those who are expecting for the first time, have difficulty of determining the onset of labor, as they might feel false labor or Braxton Hicks contractions. According to Women’s Health, the first stage is the longest stage of labor, usually lasting about 12 to 19 hours (Womens Health, 2018). Stage one is furthermore divided into three phases, latent, active and transition. Latent, or early labor, is the first phase of stage one. The latent phase lasts until the cervix is dilated to 3cm. Most nulliparous women seek immediate admission to the hospital because they do not know what the right time is to come in as this is their first pregnancy. Contractions in the latent phase should last 10-30 seconds every 5-30 minutes apart. (Perry, 2014) The next part of this stage is the active phase. This is when multiparous women come in the hospital. The have experience from previous birth and are less anxious. (Perry, 2014). This phase lasts approximately while the mother is dilated from 3cm-7cm. This phase requires more energy as the contractions increase from moderate to strong lastingn30-40 seconds and are coming at 3-5 minutes apart. At this time the cervix is rapidly dilating, and rupture of membranes can occur. The last phase in the first stage of labor is the transition phase. This is when the cervix dilates rapidly from 8cm-10 cm. Contractions are very strong, and they are on top of one another, every 2-3 minutes and they last 45-90 seconds. Many women find this phase as the most difficult part of labor. Women may feel irritated, tired, and may think that they are not able to make it through (James Greene, 2019).
With the end of transition phase of the first stage of labor, the second stage of labor begins. This is the stage when the infant is born (Perry, 2014). This stage begins with full dilation of the cervix, 10 cm, and it ends with the baby’s birth. The second stage lasts about 50-60 minutes for nulliparous women and about 20-30 minutes for multiparous women. The second stage is also broken down into two phases, the latent phase and the active pushing phase. The latent phase is calmer and there is a little bit of rest for the laboring mother. During this phase the fetus continues to descend through the birth canal as a result of ongoing uterine contractions. During the active pushing phase, the mother has strong urges to start pushing. The urge to bear down intensifies, and the woman may be more vocal about her pain level. Once the baby’s head is born, most of the hard work is over, and the rest of the baby’s body is born quite quickly. (Perry, 2014)
The third stage of labor begins immediately after the baby is born and lasts until the placenta is expelled (Perry, 2014). This is the shortest stage, as it takes anywhere between 5-30 minutes for the placenta to be expelled from the uterine cavity. Immediately after delivery, small contractions begin again, signaling that the placenta is separating from the uterine wall, ready for delivery. Women may experience some discomfort, even pain during this stage, as the provider applies pressure to the uterus and tugs gently on the umbilical cord to expel the placenta. The delivery of the placenta is also called the afterbirth (William’s Obstetrics Twenty-Second Ed. Cunningham, n.d.).
The first 1-2 hours after birth is called the fourth stage of labor. This is the recovery time for both mother and newborn. This is also a time where both the mother and the newborn become acquainted of each other, and maternal organs readjust to the nonpregnant state (Perry, 2014). The fourth stage is the most important and crucial for the new mother and the newborn. Assessment of the new mother, such as vital signs, fundus, bladder, lochia and perineum are all assessed and observed to avoid any postpartum complications. This is the stage that most parents/families enjoy holding, exploring and bonding with the newborn. (Perry, 2014)
Fetus distress during labor
Labor is a very stressful period for the fetus and frequent monitoring of the fetal status is necessary during labor. Fetal oxygen and heart rate are closely monitored during labor and it must be maintained to prevent fetal compromise and allow for a healthy baby after delivery. Fetal distress occurs when the fetus is nor receiving adequate oxygen during pregnancy or labor (HIE Help Center , n.d.). Fetal distress is usually diagnosed based on fetal heart rate which is monitored by fetal heart rate monitor. Fetal heart rate should be maintained between 110-160 beats per minute during the third trimester, as well as during labor. One of the ways we can identify fetus destress is there is tachycardia or abnormally fast heart rate present during labor. This is when the heart rate is greater than 160 beats per minutes. This can indicate maternal or fetal infection, or it is responding to certain medications (Perry, 2014). Also, if the fetus is bradycardic or abnormally slow heart rate, it is an indication that the fetus is in distress. This is when the heart rate is less than 110 beats per minute and is often caused by fetal cardiac problems (Perry, 2014). Another indication of distress would be variable and late decelerations on the FHR monitor. Variable deceleration is when there is an abrupt decrease in heart rate. Late deceleration is the late return of heart rate to the baseline after a contraction.
When there is an indication that the fetus is in distress during labor, close monitoring and further assessment will aid the nursing personnel and provider of the safest way to deliver the fetus. The main goal would be to return the fetal heart rate to normal as soon as possible to avoid injury (HIE Help Center , n.d.). When a fetus is in distress medical personnel must quickly assess and intervene. The first intervention includes administration of oxygen by nonrebreather face mask for approximately 15-30 minutes. Assisting the woman into a side lying position will also relieve pressure and aid in the heart rate returning to baseline. IV fluids should be increased to increase maternal blood volume, aiding in more blood volume to be delivered to fetus and increasing the heart rate of the fetus. Many times, and in many cases the best way to alleviate fetal distress is to deliver the fetus via C-Section. (Perry, 2014).
Umbilical Cord Prolapse
Prolapse of the umbilical cord occurs when the cord lies bellow the presenting part of the fetus (Perry, 2014). This may be due a long cord, malpresentation of the fetus or an unengaged presenting part. Early detection of cord prolapse is quite crucial in a delivery, because the outcome can be very dangerous for the fetus. One of the signs of cord prolapse is a change in the fetus heart rate, or variable decelerations. These changes in heart rate, as well as lack of oxygen to the fetus, can also cause fetus blood pressure changes. This occurs because the compression in the cord also compresses the vein in the umbilical cord leading to carbon dioxide accumulating in the fetus heart, causing respiratory acidosis (American Pregnancy Association , n.d.). Prolonged cord compression for longer than 5 minutes will result in central nervous system damage, risk of brain damage, fetal hypoxia, or death to the fetus (Perry, 2014).
When a prolapse of the umbilical cord occurs, the goal is to relieve the pressure of the cord, allowing more oxygen flow to the fetus, and safe delivery of the fetus. If the woman is not fully dilated and the provider has been notified, the next most important thing is relieving the pressure by assisting the client in a Trendelenburg position as well as insertion of two gloved fingers into the vagina to the cervix, pressuring against the presenting part, not moving the hand until the client is sent in for a cesarean delivery. Oxygen should be increased and administered to the client by nonrebreather mask at 8 to 10 L/ min until birth is accomplished. Fetal heart rate must be continually monitored, and education to client and support person should be provided during this time. If the client is fully dilated, a forceps or vacuum assisted birth can be performed for the fetus in a cephalic presentation, or an emergency cesarean birth will be performed.
Meconium in the amniotic fluid
While the fetus grows in the womb, the liquid that surrounds the fetus in the placenta is called amniotic fluid. Meconium is the sticky, thick, green first stool that the baby passes after birth. Sometimes this could happen inside utero, within the amniotic fluid, staining the amniotic fluid green, which helps the provider to determine if the fetus has aspirated meconium stained fluid and intervene. The major risk associated with meconium stained amniotic fluid is MAS or meconium aspiration syndrome (Perry, 2014). It causes severe form of pneumonia, which can cause death.
Before birth the amniotic fluid, if membranes have ruptured, is assessed for the presence of meconium. If the amniotic fluid shows presence of meconium, equipment is gathered, and the neonatal unit is informed. After the delivery of the infant’s head, the oro-nasopharynx should be suctioned by the provider before the delivery of the shoulders. If the newborn shows signs of depressed respirations, bluish skin color, grunting sounds when breathing, the provider will proceed with intubation immediately after suctioning (Stanford Childrens Hospital , n.d.). In the nursery or NICU the infant should be closely monitored for respiratory distress, cyanosis, tachypnea, and labored breathing. In the meantime, arterial blood gases and pH should be monitored for evidence of either metabolic or respiratory acidosis. A chest x-ray may be obtained to rule out any air trapping in the alveoli.
Benefits and adverse effects of epidural
During labor one of the most popular choice of drug for pain relief is the epidural injection. Epidural anesthesia is administered between the fourth and fifth lumbar vertebrae, providing analgesia or pain block, as well as pain relief, which then would lead to a total lack of feeling in that particular area. There are many benefits of using epidural block during childbirth, but one of the most important that women find during this period is that it allows them for a more pleasant and less painful birth experience, while allowing them to be fully awake and aware of their surroundings. Another benefit of the epidural is that it can help the laboring woman deal with exhaustion, allowing for rest, and giving strength to the mother in being active in the childbirth process (Perry, 2014).
Of course, like many other medications while it has great benefits, the epidural can have adverse reactions as well. One of the few adverse reactions is that epidural can cause a sudden drop of blood pressure of the laboring mother. Blood pressure is routinely checked and if any changes, client is treated with IV fluids, medications or oxygen. Another side effect of the epidural anesthesia is that for few hours after delivery, lower limbs might feel limb. Nursing assistance for ambulation, assistance to use the bathroom and frequent check for edema should be performed by the assigned nurse or assistive personnel. One of the major complication or side effect that can happen from an epidural block, is headache. This is caused by aspiration or leakage of spinal fluid where the epidural block is injected. If the headaches are consistent, a blood patch into the fluid gap can be administered to avoid pooling of spinal fluid into the empty space, causing the headache (Epidural Anesthesia, n.d.).
Internal fetal and uterine monitoring
During labor it is very important to monitor both fetus and laboring mother to prevent any complications. If the provider is unable to get good results from external fetal monitoring, to closely monitor the fetus, the provider will use internal fetal monitoring. If the membrane is ruptured and the cervix dilated at least 2-3 cm, the provider will use intrauterine pressure catheter and spiral electrode near the head of the fetus. When the catheter is compressed during a contraction, the pressure is converted to measure frequency, duration and intensity.
Most common monitoring during labor is the external mode, which uses external transducers attached to the laboring woman’s abdomen, assessing fetal heart rate and uterine contractions. The transducer works by reflecting high frequency sound waves. To monitor uterine contractions a tocotransducer is placed over the fundus above the umbilicus and is held in place by an elastic belt. As monitoring of the fetus and contractions are very important during labor, they can indicate fetal distress or intensity of contractions, presenting that it might be time to prepare the woman for birth (Perry, 2014).
When a provider is periodically listening to the fetal heartbeat during labor, it is called intermittent auscultation. This is done with a Pinard stethoscope or a doppler transducer placed on the client’s abdomen. Fetal auscultation is checked at set times during labor, and more frequently if there are any risk factors present. Fetal auscultation is done to document the fetal heart rate, as well as any accelerations and decelerations, and their timing and duration. Interchangeably while auscultating the fetal heartrate, the provider can also assess the contractions of the laboring mother by placing the hand on the abdomen, feeling the intensity, frequency and duration of the contractions. Intermittent auscultation is usually done for at least a full minute, and every 15-30 minutes during the active stage of labor, and every 5-15 minutes during the pushing phase of the second stage of labor. Fetal hear auscultation is done at the first assessment when the client is admitted in the labor and delivery department and should continue every hour during early labor. By doing so, the provider can avoid any complications, and assess and intervene if a complication might occur during the labor process (Holschuh, December 2018).
Waiting for nine months for labor to be initiated, women get anxious, prepare a birth plan, but can never be sure of what the outcome would be. Starting from the first stage, when labor is initiated, down to the last stage of labor when a new mother holds her infant for the first time, the labor process can be a scary and at the same time a pleasurable experience for many women. One can never be sure that the labor process would be a smooth ride, as there are many complications that can happen during this period with the mother as well as the fetus. Patient centered care and evidence-based practice is very important aspect of the labor and delivery process. Knowing the status of the patient and the fetus, frequent monitoring, frequent assessment will prevent any complications as well as prevent fetus mortality.