🏁 The Stages of Labor
Four stages, what happens in each, and the nursing priority that changes at every transition.
🧬 True labor vs false
Labor is measured by the cervix, not by the contractions. A woman contracting hard with no cervical change is not in labor.
| TRUE labor | FALSE labor | |
|---|---|---|
| Cervix | Dilates and effaces — the deciding factor | No change |
| Contractions | Regular; closer, longer, stronger | Irregular, do not intensify |
| Pain starts | In the back, radiating to the front | Front or abdomen only |
| With walking | Gets stronger | Often eases |
| With rest/bath | Continues | Settles |
🏁 The four stages
First stage, in three phases
| Phase | Dilation | She is | You |
|---|---|---|---|
| Latent | 0–5 cm | Talkative, excited, sociable | Encourage walking, eating lightly, resting |
| Active | 6–7 cm | Serious, inward, focused | Breathing support, position changes, epidural often here |
| Transition | 8–10 cm | Irritable, nauseated, shaking, "I can't do this" | Firm calm reassurance; it is nearly over |
"I can't do this any more" is the classic transition line - and the correct response is to tell her this is the shortest phase and the baby is nearly here.
Second stage
- Full dilation to birth; urge to push, often involuntary
- Crowning — the head stays visible between contractions
- Encourage open-glottis pushing with contractions; rest between
- Monitor fetal heart rate every 5–15 minutes depending on risk
- Maternal vital signs every 5–30 minutes — not hourly; this is the stage where hypotension and exhaustion show up fastest
🚶 Keep her moving in second stage
Encourage her to change position often. There is no one correct pushing position, and staying in one for the whole stage is what stalls descent. Each position does something different:
- Squatting or supported standing — opens the pelvic outlet the most; uses gravity
- Hands and knees — takes the pressure off the back, helps a baby rotate out of occiput-posterior
- Side-lying — slows a fast descent, protects the perineum, good with an epidural
- Semi-Fowler’s or upright in bed — the default, easy to monitor from
Never leave her flat on her back. Supine puts the uterus on the vena cava, drops her cardiac output, and drops placental perfusion.
Empty the bladder before pushing — but with a straight catheter or a bedpan. Once she is fully dilated and pushing, she does not get walked to the bathroom. She may deliver there, and she may not be safe to stand.
🚨 Open-glottis, not breath-holding
| Open-glottis (do this) | Valsalva / breath-holding (avoid) |
|---|---|
| She pushes while breathing out — grunting, groaning, air moving | Deep breath held 10 seconds while bearing down, three times per contraction |
| Pushes when she feels the urge, for as long as it lasts | Coached to a count, whether or not she feels anything |
| Intrathoracic pressure stays near normal, so venous return holds | Intrathoracic pressure rises, venous return falls, cardiac output falls |
| Fetal oxygenation is maintained | Placental perfusion drops — late decelerations, fetal acidosis |
| Less perineal trauma and less maternal exhaustion | More perineal tearing, more pelvic floor injury |
Test answer: teaching a client to take a breath and hold it for 10 seconds while pushing is wrong. It is the old coached-pushing method and it is what the question is testing you on.
Third stage — placenta
Signs of separation: a gush of blood, the cord lengthens, the uterus becomes globular and rises.
Never pull on the cord. Traction can invert the uterus, which is a catastrophic emergency.
After delivery, inspect the placenta for completeness — retained fragments cause hemorrhage and infection.
🚨 Fourth stage — the hemorrhage window
The most dangerous hours. Assess every 15 minutes for the first hour:
- Fundus — firm, midline, at or below the umbilicus
- Lochia — amount, clots
- Bladder — a full bladder prevents contraction
- Vital signs — watch the pulse, it rises before the BP falls
- Perineum — swelling, hematoma
🩺 Care across labor
🚨 When the membranes rupture
The very first action is to check the fetal heart rate - rupture is when cord prolapse happens.
Then note TACO: Time · Amount · Colour · Odour.
- Clear = normal
- Green = meconium — possible fetal distress; prepare for suction at birth
- Foul = infection
- Port-wine = abruption
⭐ The 5 Ps
Passenger · Passageway · Powers · Position · Psyche
When labor stalls, the question is always which P has failed.
💉 Comfort measures
- Position changes — upright and mobile shortens labor
- Counter-pressure on the sacrum for back labor
- Warm shower or bath; breathing techniques; a focal point
- Empty the bladder every 2 hours — a full bladder slows descent and hurts
- Epidural: fluid bolus first, then BP every 5 minutes; hypotension is the main risk
🎯 NCLEX traps
- Cervical change defines true labor
- Irritable and saying she cannot cope = transition, nearly there
- FHR immediately after rupture of membranes
- Never pull the cord in the third stage
- Fourth stage: assess every 15 minutes; check the bladder
- Second stage: encourage frequent position changes — that is the answer far more often than any single position
- Open-glottis pushing, never a 10-second breath-hold
- Fully dilated and pushing = no trips to the bathroom