ANGELES UNIVERSITY FOUNDATION Commented [1]: (SGD) MCT

Angeles City

College of Nursing

CARE OF MOTHER, CHILD AND ADOLESCENT WELL

NCM 0107
First Semester, Academic Year 2020-2021
MODULE 5
Stages of Labor

MODULE OVERVIEW

This self-instructional module is designed and prepared for BSN II students to provide
them with adequate knowledge and skills in preparing woman for childbirth physically,
emotionally, and psychologically thus making labor safe and comfortable for both the
mother and her family. It presents a knowledge on describing the different stages of labor
and nursing care of patients during labor and delivery.

Labor and delivery is the culmination of the childbearing cycle and is an intense period
during which the products of conception are expelled from the uterus. It calls for all the
psychological and physical coping methods that a woman has available to her. No matter
how much childbirth preparation she has had, nor how many times she has already gone
through the experience, the woman will require nursing care that is efficient and family
focused, because childbirth marks the beginning of a new family structure.

Nursing interventions to make labor and delivery safe, comfortable, and effective are vital.
Any support person should be treated with respect and should be included in all phases
of the process, whenever possible. Labor and delivery are enormous emotional and
physiologic accomplishments for a woman and her support person, and interventions that
make the experience more positive and memorable for them will mean a lot to future
family interactions.

In this module you will spend 8 hours discussion and activities . Below are the details of
the content, the activities that you need to accomplish and estimated time of completion:

PART OF THE MODULE ESTIMATED TIME OF

COMPLETION
Video Conference: Stages of labor 15 minutes
Asynchronous: Knowledge Check: 10 minutes
Video Conference: Nursing Care and Management during the First 20minutes
Stage of Labor:

Asynchronous: Video Viewing Fetal Position 5 minutes

Asynchronous: Knowledge Check Fetal Position 10 minutes

Video Conference: Fetal Station 15 minutes

Asynchronous: Video Viewing Fetal Station 5 minutes
Video conference: Location of the fetal heart tone in relation to the 15 minutes
presentation.

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 Video Conference: Continuation Nursing Care and Management 30 minutes
during the First Stage of Labor:
Asynchronous: Knowledge Check on 1st stage of labor 15 minutes
Video Conference: Second Stage of Labor, Mechanism of Labor 15 minutes
Asynchronous: Video Viewing Mechanism of labor 5 minutes
Asynchronous: Knowledge Check on mechanism of labor 15 minutes
Video Conference: Fetal Heart Monitor Interpretation 30 minutes
Asynchronous: Video Viewing Understanding the different changes 10 minutes
in fetal heart tone
Asynchronous: Knowledge Check Interpretation Fetal Monitor 30 minutes
Video Conference: Nursing care and Management during the second 45 minutes
stage of labor
Asynchronous: Video Viewing Normal delivery Process 3 minutes
Video Conference: Third Stage of Labor Nursing Care Management 45 minutes
Asynchronous: Video Viewing Mechanism of Separation and signs 4 minutes
of placental separation

Video Conference: Nursing Care and Management for Fourth Stage 45 minutes
of Labor
Assessment Check: REFLECTIVE WRITING 60 minutes

Summative Evaluation: 30 minutes

Quiz 30 points

TOTAL HOURS: 8 HOURS

MODULE LEARNING OUTCOME:

Pursuant to the Commission on Higher Education (CHED) Memorandum Order No. 15,
the required policies, standards and guidelines in the nursing program parallels this
module’s aim to satisfactorily meet the following learning outcomes.

LO1: Integrate concepts, theories and principles of sciences and humanities in the
formation and application of appropriate nursing care (of well mother, child, adolescent)
during childbearing and childrearing years (P01a);
LO3: Assess mother, child, adolescent’s health status with the use of specific methods
and tools to address existing health needs. (PO2a)
LO4: Formulate nursing diagnosis / es focusing on health promotion and disease
prevention related to mother, child, and adolescent’s health. (PO2b)
LO5: Implement safe and quality nursing interventions addressing health needs affecting
women from pregnancy to postpartum and children from perinatal to adolescent stage.
(PO2c)
LO6: Conduct individual/group health education activities based on the priority learning
needs of mother, child, adolescent. (PO2d)
LO7: Evaluate with the client the health outcomes of nurse-client working relationship.
(PO2e)

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Learning Objectives:
Upon completion of this module, the learner should be able to:

1. Identify the different stages of Labor

2. Compare the length of labor among Primigravida and Multigravida
3. Identify and differentiate the signs under the phases of labor
4. Identify Nursing care for mother’s in the 1 st stage of labor
5. Properly identify the fetal lie, presentation, attitude and position
6. Identify the location of the fetal heart tone in relation to the presenting part
7. Identify the nursing care for mother’s in the 2 nd stage of labor
8. Enumerate in order the Mechanism of labor and describe each mechanism
9. Interpret fetal heart monitor in relation to the maternal contraction
10. Identify the nursing interventions needed for the changes in the fetal monitor
tracing
11. Identify Nursing care for mother’s during the 3 rd stage of labor
12. Enumerate the signs of placental separation
13. Identify and differentiate the mechanism of placental separation
14. Identify Nursing care for mother’s during 4 th stage of labor

Recommended Preparation

The study of Maternity and Child Health Nursing makes use of the developmental
approach. It is therefore, suggested that prior to studying this program, the student should
read the modules on Pregnancy and Prenatal care. In addition, a review of the anatomy
of the female reproductive system and study of the fetal skull will facilitate the user's
understanding of this self- instructional module.

Key Terms: Please familiarize yourself with the following terms which will guide you in
understanding as you read the module for stages of labor.

Dilatation
Effacement
Engagement
Lie
Presentation
Position
Station
Attitude
Crowning
Episiotomy
Episiorrhapy

Assessment

PRETEST

I. Multiple Choice. Choose the best answer

1. Effacement is a characteristic referable to the:

a. widening of the cervical canal.
b. shortening and thinning of the cervical canal.
c. thickening of the uterine wall.
d. formation of a ridge dividing the uterus into two segments

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2. The relation of the long axis of the fetus to the long axis of the mother is termed:
a. station
b. position
c. presentation
d. attitude

3. The primary aim of doing a perineal incision or episiotomy is to:

a. prevent lacerations
b. reduce duration of second stage of labor
prevent prolonged and severe stretching of muscles supporting
the bladder
d. spare the infant's head from prolonged pressure and
pushing against the rigid perineum

4. Crowning is best defined as the:

a. accommodation of the fetal head to the pelvic shape
b. encirclement of the largest diameter of the fetal head by the
vulvar ring
c. enlargement of the fetal head
d. appearance of the fetal head at the vagina

5. Signs of placental separation include the following:

1. uterus becomes elongated

2. uterus rises to level of umbilicus
3. sudden gush of blood from vagina
4. shortening of the cord

a. 1 and 2
b. 1 and 3
c. 2 and 3
d. 3 and 4

6. Which of the following describes the Shultz mechanism of placental separation?

1. placenta separates first from its center

2. the shiny surfaces presents at vaginal opening
3. placenta separates first at its edges
4. the raw, red, irregular surface presents at the vaginal opening

a. 1 and 2
b. 2 and 3
c. 1 and 3
d. 3 and 4

7. The most common position for the fetus at birth is:

a. right sacroposterior (RSP)
b. left occipitoanterior (LOA)
c. right mentotransverse (RMT)
d. right acromiodorsoanterior (RADA)

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8. In a vertex presentation and an LOA position, the fetal heart rate can usually be heard
at the:
a. right lower quadrant
b. left lower quadrant
c. right upper quadrant
d. left upper quadrant

9. Voiding every 2-3 hours is encouraged in a woman in labor to:

1. facilitate fetal descent 2. lessen the weight of her abdomen

3. avoid urinary tract infection 4. stimulate contractions

a. 1 and 2
b. 1 and 3
c. 2 and 3
d. 3 and 4

10. Which of the following is a characteristic of true labor pains?

a. lack of cervical effacement or dilatation

b. cessation of uterine contractions
c. irregular, generally confined to the abdomen
d. intensification of uterine contractions with walking

11. The beginning of the second stage of labor can be recognized by the patient's desire
to:
a. blow during contractions
b. tense up during contractions
c. push during contractions
d. pant during contractions

12. The average length of time a primipara patient will be in labor is approximately:

a. 18
b. 20
c. 24
d. 14

13. When the placenta has been delivered, the first thing the nurse should do is to:

a. palpate the uterus if it is contracted

b. administer oxytocic agents as ordered
c. inspect the placenta for completeness of the cotyledon
d. estimate the blood loss to detect any bleeding

14. It is the relation of the fetal presenting part of a specific quadrant of the woman's
pelvis.

a. station
b. position
c. presentation
d. attitude

15. It is the relation of the fetal presenting part to the level of the ischial spines.

a. lie

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 b. station
c. presentation
d. position

16. The stage of expulsion in labor is also known as:

a. first stage of labor

b. second stage of labor
c. third stage of labor
d. fourth stage of labor

17. The stage of dilatation in labor is also known as:

a. first stage of labor

b. second stage of labor
c. third stage of labor
d. fourth stage of labor

18. The normal amount of blood loss during labor and delivery is:

a. 100 ml.
b. 250 ml - 350 ml
c. 600 ml
d. 1000 mL

19. It is the relation of the long axis of the fetus to the long axis of the mother.

a. presentation
b. station
c. position
d. attitude

20. It is synonymous to crowning which is the encirclement of the largest diameter of the
fetal head by the vulvar ring.

a. station +1 or +2
b. station -1 or -2
c. station -3 or -4
d. station +3 or +4

After accomplishing this pretest, we will be discussing the answers using

MENTIMETER.

DISCUSSION:

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 I. THE LABOR PROCESS

STAGES OF LABOR:
A. STAGE OF DILATATION (1st Stage)
B. STAGE OF EXPULSION (2ND Stage)
C. PLACENTAL EXPULSION (3rd Stage)
D. One to FOURS HOURS AFTER DELIVERY (4th Stage)

Length of Labor

Comparison of length of labor in Primigravida and Multigravida.

Stage of Labor Primigravida Multigravida

First stage 12 ½ hours 7 hrs. 20 minutes

Second stage 80 minutes 30 minutes
Third stage 10 minutes 10 minutes
Total 14 hours 8 hours

A. First stage of labor/dilatation stage.

This stage begins with the first symptoms of true labor and ends with the
complete dilatation of the cervix (10 cms.) The “force” or “power” at work during
this stage is the involuntary uterine contraction which is divided into 3 phases:

1. Latent phase – the phase begins with onset of regular contractions and ends
with complete effacement (100%) and cervical dilatation of about 3 cm. Mild
uterine contractions occur regularly 10-20 minutes apart and are of short
duration (20-40 seconds). The woman usually experiences low backaches,
and abdominal cramps and is general excited, alert talkative and in control.
This phase lasts approximately 6 hours in nullipara and 4.5 hours in multipara.
Analgesia given too early in labor will prolong this phase.

2. Active phase – this begins with complete effacement and cervical dilatation of
4-7 cms. Uterine contractions occur at 3-5 minutes apart and last 40-60
seconds. The contractions are stronger, last longer and begin to cause
discomfort. It is an exciting and frightening time because she realizes that labor
is truly progressing. This phase lasts approximately 3 hours in nullipara and 2
hours in a multipara.

Two Periods of Active Phase:

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 a. Acceleration (4-5 cm)
b. Maximum slops (5-9 cm)

At its most rapid pace at an average rate of 3.5 cm. Per hour in nulliparas
and 5-9 cm. per hour in multiparas.

3. Transition Phase – Maximum dilatation of 8 to 10 cm. occurs, and contractions

reaches their peak of intensity, occurring every 2-3 mins with a duration of 60-
90 secs. May experience a feeling of loss of control, anxiety, panic, and
irritability. Her focus is entirely inward on the task of birthing her baby. The peak
of this phase can be identified by a slight slowing in the rate of cervical dilatation
when 9cm is reached. As the woman reaches 10 cm of dilatation, an irresistible
urge to push begins to occur.

SUMMARY OF THE 3 PHASES:

PHASE ONSET MINUTES OF Manifestation

CONTRACTIONS s

LATENT onset of the Mild uterine Low backache,

Nulli = 6 hours regular contractions abdominal cramps,
Multi = 4.5 hours contractions and Interval: 10-20 mins excited, alert talkative
ends with Duration: 20-40 and in control
complete secs NR= aromatherapy,
effacement distraction,
(100%) accupressure;X
Cervical dilation: analgesics
0-3 cm = controlled breathing;
walk

ACTIVE complete Contractions are Begin to cause

Nulli = 3 hours effacement to stronger, last discomfort, exciting,
Multi = 2 hours Cervical dilatation: longer frightening, labor is
4-7cms Interval = 3-5 mins progressing
*Show Duration = 40-60 NR= active
secs participant;
comfortable position

Transition Maximum Maximum dilatation Experience feeling of

(peak of this dilatation until of 8-10cm occurs loss of control,
phase can be contractions and contractions anxiety, panic,
identified by a reaches their peak reached their peak irritability
slight slowing rate of Intensity of intensity *intense discomfort
of cervical *full dilatation Interval = 2-3 mins (NV)
dilatation when *full effacement

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 9cm reached and Duration = 60-70
10cm dilatation an secs
irresistible urge to
push begins to
occur

KNOWLEDG
E CHECK

Case Scenario: Anna, 34 years old, a gravida 4 patient went to the hospital with chief
complain of labor pains. She said the pain starts from her abdomen radiating to her back,
which can be relief by walking or change of position. Upon internal examination it revealed
80% effacement and a cervical dilatation of 3 cm. She was place in an external monitor
and her contraction are lasting for 30 seconds every 15 minutes.

1. Based from the signs and symptoms of the patient, what phase in the 1 st stage of
labor is she?
2. What are the signs and symptoms manifested by the patient that will defend your
answer in no. 1 question?
3. What are the interventions that a nurse can do during this phase?

Nursing Care and Management during the First Stage of Labor:

1. Upon admission, history taking should include a review of the

woman’s pregnancy, both physical and psychological events, and a
review of pregnancies, general health, and family medical information to
aid in planning other nursing care.

2. Physical Assessment. General physical examination, Leopold’s

maneuvers and/or internal examination are done to determine the
following:

a. Effacement, dilatation, and condition of the membranes

b. Lie: Refers to the relationship of the cephalocaudal axis (spinal column)

of the fetus to the cephalocaudal axis of the woman

Lie may either be vertical or horizontal lie is very rare(1%) and may be
due to a relaxed abdominal wall because of multiparity pelvic contraction
or placenta previa.

Longitudinal lie (99%) – cephalocaudal axis of the fetus is parallel to the woman’s
spine. It can be Cephalic or Breech Lie

Transverse lie – cephalocaudal axis of the fetal spine is at the right angles to the
woman’s spine

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 c. Presentation may either be cephalic, breech or shoulder. Presenting
part refers to the part of the fetus that presents at the internal cervical os
and may either be the head, the buttocks, the shoulder, brow, chin, face
or feet.

c.1: CEPHALIC PRESENTATION

● Vertex presentation: the most common type
- vertex (skull bones are capable of effective molding to accommodate
the cervix )
- the smallest diameter (suboccipitobregmatic) presents to the maternal
pelvis
- the occiput is the presenting part
⮚ Military presentation
- the fetal head is neither flexed or extended
- the occipitofrontal diameter presents to the maternal pelvis
- Brow / Sinciput becomes the presenting part

⮚ Brow presentation

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 - the fetal head is partially extended
- the sinciput is the presenting part

⮚ Face presentation
- the fetal head is hyperextended (complete extension)
- the face is the presenting part

c.2: BREECH PRESENTATION

⮚ Complete breech
- thighs tightly flexed on the abdomen;
- Presenting part: buttocks + tightly flexed feet

⮚ Frank breech -
-hips are flexed
- knees are extended to rest on the chest.
- PP: buttocks alone

⮚ Footling Breech
- Neither the thighs nor lower legs are flexed.
- If one foot presents, (single-footling breech)
- both present (double-footling breech)

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c.3: SHOULDER PRESENTATION:
- Fetus lies horizontally in the pelvis
- longest fetal axisc.3 is perpendicular to that of the mother.
- Presenting Part: Shoulders (acromion process), an iliac crest, a hand or an elbow

d. Attitude: Fetal attitude refers to the posture of a fetus during labor.

Mammalian fetuses have a tendency to assume a fully flexed posture
during development and during parturition. Flexion of the fetal head on
the chest allows for the delivery of the head by its smallest bony diameter.
A loss of this flexed posture presents a progressively larger fetal head to
the bony pelvis for labor and delivery. The fetal arms and legs also tend
to assume a fully flexed posture. The longitudinal posture of the fetus
likewise is flexed under normal circumstances.

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 Fig. 1. Importance of cranial flexion is emphasized by noting the increased diameters
presented to the birth canal with progressive deflection. A. Flexed head. B. Military
position. C, D. Progressive deflection.

f. Position – the relation of the fetal presenting part to a specific quadrant of the woman’s
pelvis. The woman’s pelvis is divided into 4 quadrants.

1. right anterior
2. right posterior
3. left anterior
4. left posterior

Consequently, four parts of the fetus have been chosen as points of direction.

1. occiput – in vertex presentations

2. chin (mentum) – in face presentations
3. sacrum – in breech presentations
4. scapula (acromion) – in shoulder presentations.

3 notations to describe the fetal position:

1. Right (R) or Left (L) side of the maternal pelvis
2. The landmark of the presenting part:
Vertex presentation: Occiput (O)
Face presentation: Chin (M) mentum
Breech presentation: Sacrum (Sa)
Shoulder presentation: Scapula / Acromion process (A)
3. Anterior (A), Posterior (P), or transverse (T) depending on whether the landmark
is in front, back, or side of the pelvis

Occiput of the fetus points to the left anterior quadrant in a vertex position, LOA; ROA =
born fastest
Occiput of the fetus points to the right posterior quadrant, ROP

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ROP/LOP = labor is extended; more painful for a woman because the rotation of the fetal
head puts pressure on sacral nerves

YOU MAY WATCH THIS VIDEO TO FURTHER UNDERSTAND HOW TO

LOCATE FETAL POSITION:
https://www.youtube.com/watch?v=EPo4WFC1g9Y

KNOWLEDGE
CHECK…
ACTIVITY: CASE SCENARIO FOR FETAL POSITION

ACTIVITY: Based from the images of ultrasound taken from different pregnant
mothers below, identify the right position of the fetal head.

Case 1: Maria is on her 37 weeks AOG, her ultrasound revealed:

What is the position of the baby?

Case 2: Hanna, 17 years old and is on her 39th week AOG , her ultrasound revealed:

What is the position of her baby?

Case 3: Joanna, 27 years old and is on her 37th week AOG , her ultrasound revealed:

What is the position of her baby?

Case 4: Marites, a 38 years old gravida 4 mother is on her 37th week AOG , her
ultrasound revealed:

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 What is the position of her baby?

Case 5: Cess, a 35 years old gravida 2 mother is on her 39th week AOG , her
ultrasound revealed:

What is the position of her baby?

g. Station the relation of the fetal presenting part to the level of the ischial spines.

1. Station 0 – when the fetal presenting part is at the level of the ischial
spines. Synonymous to engagement.
2. Station -1 or -2 – when the fetal presenting part is above the level of
the ischial spines.
3. Station +1 or +2 – when the fetal presenting part is 1 cm. or 2 cm.
Below the level of the ischial spines.
4. Station +3 or +4 – is synonymous to crowning. It is the encirclement
of the largest diameter of the fetal head by the vulvar ring.

The ischial spines can be palpated at about a finger-length into the vagina. They are felt
as bony prominences.

15 | MODULE 9 STAGES OF LABOR

Engagement – refers to the settling of the presenting part of a fetus far enough to the
pelvis to be at the level of the ischial spine.
Station - refers to the relationship of the presenting part of a fetus to
the level of the ischial spine
0 – level of the ischial spine (engagement)
-1 to -4 ( above the spines)
* -4 (floating)
+1 to +4(below the spines)
* +3 to +4 (crowning)

16 | MODULE 9 STAGES OF LABOR

 YOU MAY WATCH THE VIDEO ON STATION:
https://www.youtube.com/watch?v=ze53Ep-gwBQ

h. Location of the fetal heart tone in relation to the presentation.

In vertex presentation, fetal heart sound is best heard at the area of

the fetal back, usually located at the left lower quadrant (LLQ) or the
right lower quadrant (RLQ). In breech presentations fetal heart sound
are located at or above the level of the umbilicus; in face presentations
fetal heart sounds are best heard at the area of the fetal chest.

LOCATIONS OF THE FETAL HEART TONE

LOA
LOP ROA

ROP
LSA

You can locate the fetal heart tone by locating the fetal back using the Leopold’s
Maneuver. You may want to review how to perform Leopold’s maneuver. Please
READ page 369 of your Pillitteri book, Box 15.6.

The average fetal heart rate is between 110 and 160 beats per minute. It can vary
by 5 to 25 beats per minute. The fetal heart rate may change as your baby
responds to conditions in your uterus. An abnormal fetal heart rate may mean that
your baby is not getting enough oxygen or that there are other problems.

Fetal heart rate and Uterine contraction records:

• Moderate bradycardia
– 100-109 bpm; vagal response from compression of fetal head
• Marked bradycardia
17 | MODULE 9 STAGES OF LABOR
 – 🡫 100 bpm; hypoxia
• Moderate tachycardia
– 161-180 bpm
• Marked tachycardia
– 🡫 180 bpm; hypoxia, maternal fever, fetal arrhythmia, maternal
anemia or hypothyroidism

You can use the following in getting the fetal heart tone

Stethoscope:

Doppler :

NOTE: When using these two devices (stethoscope and Doppler) Do not take the
FHT once the uterus is contracted because it will give you unreliable result. You need to
simultaneously get the fetal heart tone and maternal pulse to determine if the sound you
are hearing comes from the baby and not from the mother’s heartbeat.

YOU MAY WATCH THIS VIDEO FOR GETTING THE FETAL

HEART TONE.
https://www.youtube.com/watch?v=voPoxY_a1_Q

Electronic Fetal Monitor

⮚ External Fetal monitor: is a test used during pregnancy. It measures
a baby's heart rate and the mother's contractions. The test uses
instruments placed on the mother's belly to make the measurements. The
results are viewed as graphs on a video screen.
⮚ The electrodes are place in the FUNDUS of the mother to record
uterine contraction
⮚ The other electrode is place on the FETAL BACK to record the FHT.

18 | MODULE 9 STAGES OF LABOR

 ⮚ Internal Fetal monitor: involves placing a electrode directly on the fetal scalp
through the cervix. This test is performed to evaluate fetal heart rate and variability
between beats, especially in relation to the uterine contractions of labor.
19 | MODULE 9 STAGES OF LABOR
Continuation Nursing Care and Management during the First Stage of Labor:

3. Provide privacy and reassurance; establish and maintain rapport with the patient and
family.

4. Bath, if contractions are tolerable to ensure cleanliness and provide comfort and
relaxation.

5. Perineal preparation. The perineum is cleansed from front to back using the no. 7 stroke
in order to disinfect the area surrounding the vagina. This helps to prevent contamination
of the birth canal and reduce possibilities of postpartum infection.

6. Advise patient not to eat anything by mouth (NPO). Start IVF regulated as ordered and
monitor intake and output hourly. Solid or liquid foods must be avoided for the following
reasons:
⮚ Digestion is delayed during labor.
⮚ A full stomach interferes with proper bearing down.
⮚ Aspiration may occur during the reflex nausea and vomiting of the transition phase
or if anesthesia will be used.

7. Encourage patient to empty her bladder every 2-3 hours because:

⮚ full bladder retards fetal descent
⮚ urinary stasis can lead to urinary tract infection
⮚ a full bladder may be traumatized during delivery

4. Instruct/Advise patient to bear down only during true labor contractions to

minimize maternal exhaustion and prevent cervical edema which may interfere
with labor progress. To minimize bearing down, the patient should be advised
to do abdominal breathing during contractions.

5. Encourage patient to change and assume comfortable position. Sim’s position

is the best because:
a. It favors anterior rotation of the head
b. It promotes relaxation between contractions
c. It prevents supine hypotensive syndrome

6. Monitor uterine contractions every hour during the latent phase and every 30
minutes during the active phase. The following aspects are to be considered:

20 | MODULE 9 STAGES OF LABOR

 a. Duration – from the beginning of one contraction to the end of the same
contraction. Early in labor, duration is 20-40 seconds; late in labor,
duration is 60-90 seconds because fetal well being will be compromised.
It must be remembered that there is no blood supply when uterine
muscles are contracted.
b. Interval – from the end of one contraction to the beginning of the next
contraction. Early in labor interval is 10-20 minutes; late in labor, interval
is only 2-3 minutes.
c. Frequency – from the beginning of the contraction to the beginning of the
next contraction. The nurse should time 3-4 contractions at a time to have
a good picture of the frequency of contractions.
d. Intensity – refers to the strength of contractions. It may be mild, moderate
or strong. When estimating intensity, the nurse should check the fundus
at the end of every contraction to ensure that there is a period of
relaxation between contractions. This relaxation period is important
because it is during this time that the uterine vessels refill with blood,
thereby maintaining continuous and adequate oxygen supply to the fetus.
Prolonged and sustained uterine contractions can lead not only to fetal
distress but also to rupture of the uterus.

7. Monitor vital signs. Blood pressure and fetal heart rate are taken every hour
during the latent phase and every 30 minutes during the active phase.
Definitely, BP and FHR should never be taken during contraction. During
uterine contractions, no blood goes to the placenta. The blood is pooled to the
peripheral blood vessels which results in increased blood pressure. On the
other hand, FHR tends to decrease during a contraction because of the
compression of the fetal head. When the fetal head is compressed by the
contracting uterus, the vagus nerve is stimulated, thus causing bradycardia.
Normal FHR is 120-160 per minute.

8. Administration of analgesics. Narcotics are the most commonly used

analgesics, specially Demerol (meperideine hydrochloride). Its dosage is
based on the patient’s weight, the status of labor, and the size and stage
gestation. Demerol acts to suppress the sensory portion of the cerebral cortex.

9. Administration of anesthetics. Regional anesthesia is preferred over any other

form because it does not enter maternal circulation and therefore does not
retard labor contractions nor cause respiratory depression in the newborn.

10. The nurse must be aware of the danger signals during labor and delivery. Signs
of fetal and maternal distress are as follows:

a. Signs of fetal distress:

i. Tachycardia – FHR more than 160/min.
Bradycardia – FHR less than 110/min.
ii. Meconium – stained amniotic fluid
iii. Fetal trashing or hyperactivity due to fetal struggling for more
oxygen.
iv. Fetal acidosis – blood ph below 7.2

b. Signs of maternal distress;

1. BP over 140/90,or falling BP associated with clinical signs of
shock such as pallor, restlessness, or apprehension, increase
respiratory rate and pulse rate.
2. Abnormal pulse of more than100 bpm may indicate hemorrhage.
3. Inadequate / prolonged contractions.
4. Abnormal lower abdominal contour.

21 | MODULE 9 STAGES OF LABOR

 5. Increasing apprehension could be a sign of O2 deprivation or
internal hemorrhage

11. Transfer of patient from the labor room to the delivery room. In general,
multiparas are transported to the delivery room when cervical dilatation is about
7-9cms. While primiparas are transferred to the delivery room at full dilatation
with perineal bulging when crowning is taking place.

Knowledge
check:

ACTIVITY: CASE SCENARIO FOR STAGE ONE OF LABOR:

Mrs. M. is a 27-y/o gravida 3, para 2, who was admitted at term at 6:30 p.m. She stated
that she had been having contractions at 7 to 10 minute intervals since 4 p.m. They
lasted 30 seconds. She also stated that she had been having "a lot of false labor" and
hoped that this was "the real thing". Her membranes were intact. Mrs. M.'s temperature,
pulse and respirations were normal and her blood pressure was 124/80. The fetal heart
tones were 134 and regular. The nurse midwife examined Mrs. M. and found that the
baby's head was at +1 station, and the cervix was 4 cm. dilated and 80 percent effaced.
She reported her findings to the doctor and he ordered Demerol 50 mg. with Phenergan
25 mg. to be given intravenously when needed.

1. What type of labor is Mrs. M experiencing? (TRUE OR FALSE LABOR)

Give reasons for your answer based on the assessment data of the patient.

2. As Mrs. M. was getting into bed, her membranes ruptured. What intervention will you
do as a student nurse caring for Mrs. M? Give the rationale for your interventions?

3. After her membranes ruptured, her contractions began coming every 4 minutes and
lasted 45 to 55 seconds. They were moderately strong. Upon internal examination it
revealed a cervical dilatation of 7 cm. Based from the assessment data of the patient,
what phase of the 1st stage of labor is the patient? Explain your answer by enumerating
the signs and symptoms that the patient presented.

4. Why is it important for Mrs. M. to relax during her contractions? How can you help
her to relax?
5. Do you think Mrs. M. should be given the medication ordered by the doctor? What
safety measures should be taken at the time the medication is given? What
observations should be made after it is given? Why?

6. A vaginal exam revealed that Mrs. M. is complete and +2. What is the interpretation
of this? What should be the nursing interventions at this time? Explain the rationale
behind your interventions

7. How would you know that Mrs. M. has entered the transition phase?

8. What are the interventions a nurse can do during the transition phase?

22 | MODULE 9 STAGES OF LABOR

 B. SECOND STAGE OF LABOR/STAGE OF EXPULSION

This stage begins from the time of full dilatation of the cervix and ends
with the delivery of the infant. It is often the pelvic division. This stage is
divided into two phase; deceleration and fetal descent.
1. Deceleration phase – is a misnomer for this phase in that the
progress of labor does not actually slow down; the final degree
of cervical dilatation are achieved and the cervix retracts over
the presenting part.
2. Fetal descent phase – with retracted of the cervix over the
presenting part, fetal descent and negotiation of the pelvis
occurs rapidly. As the fetus descent in the pelvic ring, being
pushed beyond the open cervix, woman’ perineum begins to
bulge, the labia part, and the vaginal introitus stretched apart.

MECHANISMS OF LABOR / FETAL POSITION CHANGES

Passage of fetus through the birth canal involve a number of different position
changes so that the smallest diameter of the fetal head will fit through the pelvic inlet and
outlet. These position changes are termed the CARDINAL MOVEMENTS OF LABOR,
they are:

1. Descent –is the downward movement of the biparietal diameter of the fetal head
to within the pelvic inlet. It occurs because of pressure on the fetus by the uterine
fundus: full descent may be aided by abdominal muscle contraction.

2. Flexion- as descent occurs, pressure from the pelvic floor causes the fetal head to
bend forward onto the chest. This brings the smallest diameter of fetal head into a
good position, which is termed. Attitude, therefore, is the degree of flexion that the
fetus assumed prior to delivery.

3. Internal Rotation- the wider anteroposterior (AP) diameter of the fetal head enters
the wider transverse diameter of the pelvic inlet and will rotate so that fetal head is
positioned at the wider AP diameter of pelvic outlet. The sequence therefore, is
from occipitoransverse (LOT) to left occipitoanterior (LOA) to occiput anterior (OA).
The occiput is now either superior to or just below the symphysis pubis.

4. Extension – as the occiput is born, the back of the neck stops beneath the pubic
arch and acts as a pivot for the head. The head thus extend and the foremost parts
of the head, the face and chin, are born.

5. External Rotation (Restitution) – after the head has been delivered, it rotates 45 to
left so that the anterior shoulder is just below pubic arch.

6. Expulsion-this consists of the delivery of the rest of the body.

23 | MODULE 9 STAGES OF LABOR

 For you to better understand the mechanisms of labor watch this 5
minute video. It will illustrate how the fetal head changes position as it
goes down from the pelvic inlet to the outlet up to the expulsion of the
baby. You need to take note in order the mechanism of labor because after watching
the video you will be asked to enumerate in order the mechanism and explain the
importance of each mechanism to achieve a successful delivery process.

https://www.youtube.com/watch?v=7lwgnWYzGWY

Knowledge
Check

Based from the discussion and the video provided for viewing on the mechanism of
labor, Enumerate in order the mechanism and explain the importance of each
mechanism to achieve a successful delivery process.

24 | MODULE 9 STAGES OF LABOR

 Electronic monitoring of FHT and Uterine contractions

a. Accelerations
● A short-term rises in the heart rate of at least 15 beats per minute,
lasting at least 15 seconds.
● Accelerations are normal and healthy. They tell the doctor that the
baby has an adequate oxygen supply
– Non-periodic; 🡫in FHR; 🡫 30 secs
– Caused by: Fetal movement, change in maternal position, analgesic
– Before 32 weeks; 10 bpm; 10 secs
– After 32 weeks; 15 bpm; 15 secs
b. Decelerations
● Decelerations are temporary drops in the fetal heart rate. There are three
basic types of decelerations: early decelerations, late decelerations, and
variable decelerations.
● Early decelerations are generally normal and not concerning. Late and
variable decelerations can sometimes be a sign the baby isn’t doing well.
– Symmetrical; periodic 🡫 in FHT

25 | MODULE 9 STAGES OF LABOR

 – CAUSED BY: Pressure on fetal head during contractions which stimulates
vagal nerve which caused Parasympathetic stimulation
b.1: Early Deceleration: Early decelerations begin before the peak of the
contraction and end when the contraction ends.. Early decelerations can happen
when the baby’s head is compressed. This often happens during later stages of
labor as the baby is descending through the birth canal. They may also occur
during early labor if the baby is premature or in a breech position. This causes the
uterus to squeeze the head during contractions. Early decelerations are generally
not harmful.
INVERSE OF CONTRACTION WAVES

b.2: Late Decelerations:

● Delayed 30-40 secs after the onset of contractions and continued beyond end of
contraction
● Caused by UTERO PLACENTAL INSUFFICENCY
● Late decelerations don’t begin until the peak of a contraction or after the uterine
contraction is finished. They’re smooth, shallow dips in heart rate that mirror the
shape of the contraction that’s causing them. Sometimes there is no cause for
concern with late decelerations, as long as the baby’s heart rate also shows
accelerations (this is known as variability) and quick recovery to normal heart rate
range.
Nursing Responsibility:
Position the mother in Left-lateral position
Initiate IV fluids and O2 inhalation with doctor’s order

26 | MODULE 9 STAGES OF LABOR

 ● Late decelerations can be a sign that the baby isn’t getting enough oxygen. Late
decelerations that occur along with a fast heart rate (tachycardia) and very little
variability can mean that the contractions may be harming the baby by depriving
them of oxygen. Your doctor may opt to begin an urgent (or emergent) cesarean
section if late decelerations and other factors indicate that the baby is in danger.

Prolonged decelerations:
• 🡫 in FHT of 15 bpm or more
• Lasts longer 2-3 minutes
• CAUSED BY: Cord compression / Maternal hypotension

b.3: Variable Decelerations

• Variable decelerations are irregular, often jagged dips in the fetal heart rate that
look more dramatic than late decelerations
• Decelerations at unpredictable times in relation to contractions

27 | MODULE 9 STAGES OF LABOR

 • Cord compression / ROM / Oligohydramnios
• Nursing Responsibilities
• Left lateral position
• O2
• Knee-chest position

For you to better understand the different changes in fetal heart tone as
reflected on the external monitor strip, the causes of these changes and
the interventions please watch this 10 minute video. Please take note of
the difference in the strips, what causes it and the interventions
because you will be using it in answering the knowledge check activity.
https://www.youtube.com/watch?v=ac14n5uD4_0

28 | MODULE 9 STAGES OF LABOR

 Knowledge
Check:

Case Scenario:

CASE 1: A 24 year old G3 P2 39 weeks AOG is in active labor. Her cervix is presently 5
cm dilated.

a. What is the interpretation of the External monitor tracing?

b. What might be the possible cause for it?
c. What management can a nurse do at this time?

CASE 2: A 35 year old G3 P1 mother is on transitional stage of labor. Her contractions

are 2-3 minutes apart. There is process in her cervical dilatation.

a. What is the interpretation of the External monitor tracing?

b. What might be the possible cause for it?
c. What management can a nurse do at this time?

29 | MODULE 9 STAGES OF LABOR

CASE 3. Joana, a G1P0 mother is on labor. She has moderate amount of vaginal
bleeding and bag of water ruptured 15 minutes ago.

a. What is the interpretation of the External monitor tracing?

b. What might be the possible cause for it?
c. What management can a nurse do at this time?

NURSING CARE AND MANAGEMENT DURING THE SECOND

STAGE OF LABOR

1. Proper positioning on the delivery table

Two alternative delivery positions are lateral Sim’s and

dorsal recumbent (on the back with knees flexed), semi sitting and
squatting, Nurse-midwives tend to favor these alternative birth
positions for their clients; with less tension on the perineum, women may have
fewer perineal tears.

2. Bearing Down Techniques

3. This is the best time to encourage strong pushing with contractions. At the
beginning of a contraction, the woman is asked to take two short breaths, then to
hold her breath and bear down at the peak of the contraction. She could also be
told to use BLOW_BLOW breathing patterns to prevent pushing between
contractions
4. Perineal Cleaning:
Rinse the perineal area with sterile water and clean the Vagina from inner to outer
part; clean compress with each stroke.

30 | MODULE 9 STAGES OF LABOR

 5. Care of the Episiotomy Wound

Episiotomy is a surgical incision of the perineum made to prevent tearing of

the perineum and to release pressure on the fetal head during delivery.

No anesthesia is necessary during episiotomy because the pressure of the

fetal presenting part against the perineum is so intense that the nerve endings for
pain are momentarily deadened, resulting in natural anesthesia.

The two types of episiotomy are:

a. Median – begun in the midline of the perineum and directed toward the
rectum.
b. Mediolateral – begun in the midline of the perineum but directed laterally
away from the rectum.

Mediolateral episiotomies have the advantage over midline cuts in

that, if tearing occurs beyond the incision, it will be away from the rectum
with less danger of complication from rectal muscosal tears. However,
midline episiotomies appear to heal more easily, cause less blood loss, and
result in less discomfort to a woman in the postpartal period.

31 | MODULE 9 STAGES OF LABOR

 6. Breathing Technique

As soon as the head crowns, the woman is instructed not to push any longer
because it can cause rapid expulsion of the fetus. Instead she should be advised
to pant (rapid and shallow breathing).

7. Ritgen’s Maneuver. The basic steps in applying this method of delivery are as
follows:

a. Support the perineum during crowning by applying pressure with the palm
against the rectum with the use of sterile towel. This will not only prevent
lacerations of the fourchette but will also bring the fetal chin down the chest
so that the smallest diameter of the fetal head is the one presented at the
birth canal.

b. The head should be pressed gently while it slowly eases out to prevent rapid
expulsion of the fetus, which could result not only lacerations, abruption
placenta, and uterine inversion but also shock because of sudden decrease
in intra abdominal pressure.

32 | MODULE 9 STAGES OF LABOR

 c. As soon as the head has been delivered, the nurse should insert two fingers
into the vagina to feel for the presence of a cord looped around the neck. If
it is so and is loose, it should be slipped down the shoulder, be clamped
twice, an inch apart, and cut in between.

d. As the head rotates, give a gentle, steady downward push in order to deliver
the anterior shoulder and then a gentle, upward lift to deliver the posterior
shoulder.

e. While supporting the body’s head and neck, the rest of the baby is delivered.

33 | MODULE 9 STAGES OF LABOR

 8. Time of delivery must be noted.

9. Proper handling of the newborn.

Immediately after delivery, the newborn should be held below the level of
the mother’s vulva so that blood from the placenta can enter the infant’s body on
the basis of gravity flow.

10. Cutting of the Cord

This is postponed until pulsations have stopped because 50-100 ml. of
blood is flowing from the placenta to the newborn at his time.

• Delayed cutting (Physiologic clamping)

– Continue to pulsate for a few minutes after birth
– Postponed the cutting until pulsations have stopped because 50-100
ml of blood is flowing from the placenta to the newborn at this time
– (+) Adequate RBCs and WBCs
– Delayed cutting can prevent Polycythemia and Hyperbilirubinemia
- Clamp the cord 8-10 inches from infant’s umbilicus with 2 hemostats
then cut in the middle of the hemostats.
- Check for 3 Vessels.
AVA: 2 arteries , 1 vein (larger diameter)

34 | MODULE 9 STAGES OF LABOR

 11. Initial Contact
Maternal – infant bonding is initiated as soon as the baby has been
suctioned and provided warmth. The mother is informed of the baby’s sex and
condition and allow her to hold onto her baby, maybe put to breast to suck, it can
help contract the uterus as well as the weight of the baby on her abdomen.

For you to understand and have an idea on the normal delivery

process please watch this 3 minute video. This will help you when
you will be having your actual duty in the Delivery Room
https://www.youtube.com/watch?v=ZDP_ewMDxCo

35 | MODULE 9 STAGES OF LABOR

C. THE THIRD STAGE OF LABOR/PLACENTAL STAGE

This stage begins with the delivery of the infant and ends with the
delivery of the placenta. It is divided into two phases: placental separation
phase and placental expulsion phase.

1. Placental separation phase – separation of the placental results from

the disproportion between the size of the placenta and the reduced size
of the site of placental attachment after the delivery of the baby. The signs
of placental separation are the following.
a. Sudden gush of blood from the vagina
b. Lengthening of the umbilical cord
c. The uterus becomes more firm and round in shape and rising high at the
level of the umbilicus. (CALKIN’S SIGN)
d. Placenta is visible at the vaginal opening

2. Placental expulsion – the placenta is delivered either by the natural bearing down
effort of the mother or by gentle pressure on the contracted uterine fundus by the
physician or nurse (Crede’s maneuver). Pressure must never be applied to a
uterus in a non-contracted state or the uterus may evert and hemorrhage. This is
a grave complication of delivery, because the maternal blood sinuses are open
and gross hemorrhage occurs.

If the placenta does not deliver spontaneously, it can be removed manually. There
are two mechanisms by which the placenta is separated and expelled from the
uterus:
a. Schultz – if the placenta separates first from its center so that it folds on
itself like an umbrella and its shiny and glistening fetal surface is presented
at the vaginal opening.

b. Duncan – if the placenta separates first at its edges, it slides along the
uterine surface evident. It looks raw, red, and irregular with the cotyledons
showing.

36 | MODULE 9 STAGES OF LABOR

 A single trick of remembering the presentations is associating “shiny” with
Schultz (the fetal membrane surface) and “dirty” with Duncan (the irregular
maternal surface).

NURSING CARE AND MANAGEMENT DURING THE THRID STAGE OF LABOR:

1. The delivery of the placenta is the main focus of nursing activity during the third
stage of labor.

Never hurry the delivery of the placenta by forcefully pulling out the cord or
by vigorous fundal push as this can leads to uterine inversion.

Encourage the mother to push with contractions to aid in placental

expulsion. As soon as the signs of separation appear, tract the cord slowly and
wind it around the clamp. Then deliver the placenta by rotating it so that no
placenta fragments are left inside the uterus. This method is called the Brandt
Andrews maneuver.

2. Take note of the time of placental delivery, should be delivered within 20

minutes after the delivery of the baby. If the placenta is not delivered within
this time, the doctor should be immediately notified as it could be a sign of
uterine atony, a condition that could lead to death due to hemorrhage.

3. Inspect for completeness of cotyledons. Incomplete cotyledons means that

some placental fragments may have been retained in the uterus. This will
prevent the uterus from contracting well and, therefore, cause excessive
bleeding.

4. Palpate the uterus to determine degree of contraction. If relaxed, boggy or

non-contracted, the immediate nursing actions are:
a) massage the fundus gently and properly
b) apply an ice or ice cap over the abdomen.
5. Administration of oxytocic agents. Oxytocic agents may be administered as
ordered to ensure uterine contractions, thus preventing hemorrhage.
Methergin (0.2 mg/ml) and Syntocinon (10 u/ml) via intramuscular (IM) are two
of the more commonly given oxytocics. Never administrered ocytocics before
placental delivery, it may cause placental entrapment. Also, a common side
effect of oxytocins is hypertension. The nurse should, therefore, assess or
monitor the blood pressure of mothers who have received oxytocics.

37 | MODULE 9 STAGES OF LABOR

 For you to better understand the mechanism of separation, signs of
placental separation, proper delivery of the placenta and nursing
management after the delivery of the placenta, please watch this 4
minute video. https://www.youtube.com/watch?v=WvKSKTahCss

6. Inspect the perineum for lacerations. Presence of bright red vaginal bleeding
following placental delivery and if uterus if firm, lacerations should be
suspected. Lacerations are ragged edge which heal more slowly and therefore
predispose the mother to infection.

Lacerations are classified into:

a) First-degree – involved the vaginal mucous membrane and the skin of

the perineum to the fourchette.
b) Second-degree – involve the vagina, perineal skin, fascia levator
animuscle and perineal body.
c) Third-degree – involves the entire perineum and external sphincter of
the rectum.
d) Fourth-degree – involve the entire perineum, rectal sphincter and some
of the mucous membrane of therectum.

7. Assist the doctor in doing episiorrhaphy, repair of episiotomy or lacerations. A

local anesthetic, usually Xylocaine is given in order to minimize pain during the
procedure. In episiorrhaphy, vaginal packing is done to maintain pressure on
the suture line and, therefore, prevent bleeding. The nurse should be aware
that this packing is usually removed after 24-48 hours.

38 | MODULE 9 STAGES OF LABOR

 8. Estimate the amount of blood loss. The normal amount of blood loss during
labor and delivery is around 300-500 ml. Any amount exceeding 500 ml. is
considered hemorrhage.

9. Provide comfort and perineal care, apply clean sanitary. Soiled napkin should
be removed from front to back.

10. Take vital signs every 15 minutes for the first hour and palpate the uterine
fundus for size, and position. Pulse may become rapid 80-90 min., respiration
20-24/min. and BP slightly elevated due to the excitement of the mother and
recent Oxytocin administration.

11. Transfer back to room (recovery room if she had undergone anesthesia) and
position flat on bed without pillows to prevent dizziness due to decrease in intra-
abdominal pressure. (Start of Fourth Stage of Labor or Puerperium)

D. THE FOURTH STAGE OF LABOR

This stage refers to the first one to four hours immediately after
delivery when the vital signs of the mother are quite unstable. Just like
the first three stages of labor, the stage is important and said to be critical
because of the possibility of postpartum complications, notably uterine
atony.

NURSING CARE AND MANAGEMENT DURING THE FOURTH STAGE OF

LABOR

Nursing interventions during the fourth stage of labor are focused mainly on
assessment of the newly delivered mother’s condition and the giving of comfort
measure.

1. Assessment. The nurse should carefully monitor the following aspects:

a. Fundus – should be palpated every 15 minutes during the first hour

postpartum and then every 30 minutes for the next four hours. The
fundus should be firm, at the midline and at the level of the umbilicus.

b. Bladder – should be checked every 2 hours during the first 8 hours

postpartum and then every 8 hours for 3 days. Suspect a full urinary
bladder if the fundus is not well contracted and is shifted to the right. A
full urinary bladder prevents good contraction of the uterus and therefore,
may cause hemorrhage.

c. Vaginal discharge. The amount of blood flow should be checked every

15 minutes and should be moderate. It is said that if a newly delivered
woman saturate a sanitary napkin more often than every 30 minutes, the
flow is excessive necessitating immediate referral to the doctor.

d. Blood pressure and pulse rate – should be checked every 15 minutes

during the first four hours postpartum and then every 30 minutes until
stable. BP and pulse rate are slightly increased from excitement and the
effort of delivery but normally stabilizes within one hour.

e. Perineum – should be inspected every 8 hours for 3 days. Take note of

the condition of the episiorrhaphy: the suture should be clean and intact.

39 | MODULE 9 STAGES OF LABOR

 The perineum may be edematous and discolored for several days
postpartum but will spontaneously resolve in several days’ time.

3. Comfort Measures. Helping the mother feel comfortable after delivery can be
effected by the following measures:

a. Perform perineal care gently and apply a sanitary napkin snugly.

Lower the legs simultaneously from the stirrups and position her flat on bed without
pillows to prevent dizziness due to sudden release if intra-abdominal pressure.
b. Give the mother a soothing sponge bath, change her soiled gown dress and
dirty linens.
c. Provide additional blankets if the mother suddenly complaints of chilling.
This is common complain immediately after delivery because of the sudden
release in intra-abdominal pressure the temperature of the delivery room,
or even fatigue.
d. Give the mother initial nourishment of coffee, tea, milk or soup.
e. Provide a quiet and restful environment.
f. Allow mother to take enough rest and sleep in order to regain lost energy

ASSESSMENT CHECK

1. REFLECTION WRITING: Because of the pandemic we are still not allowed to go

to the hospital and handle actual cases of mothers in the labor and delivery
process. In order for you to have an idea on the entire process please watch this
Vlog of Kara and Allan a couple who shared their experience during labor and
delivery.
https://www.youtube.com/watch?v=mlB2zfTtq7M
After watching it, make a reaction paper about their experience on Labor and Delivery
process integrating the concepts you have learned from the previous discussion.
Instructions and rubric will be posted on the discussion tab of MyClass.

2. FLOW CHART: Create a flowchart that will summarize the events that happened
from stage 1 to stage 4 of the labor process. Integrate in the flow chart the
nursing responsibilities a nurse must do in each process. Instructions and Rubric
will be provided in the assignment tab of MyCLass.

Answer to the Pretest and Post test:

40 | MODULE 9 STAGES OF LABOR

 1. B 6. B 11.C 16.B

2. B 7.B 12.D 17.A

3. A 8. B 13.C 18.B

4. B 9. B 14.B 19.C

5. C 10. D 15.B 20.D.

Note: If your score is 12 or higher, your understanding of Stages of labor is

satisfactory

REFERENCES:
Adopted From:
The Self – Instructional Modules in Maternal and Child Health Nursing
Author: Dr. Zenaida S. Fernandez

PRESCRIBED TEXT:

Silbert-Flagg, J. and Pilliteri, A. (2018). Maternal child health nursing: Care of the
childbearing and childrearing family. Volume 1 and 2 (Philippine edition); 8th edition.
Philadelphia: Lippincott
Books:
Leap, N. (2016). Supporting women for labour and birth: a thoughtful guide. London: Routledge/Taylor and Francis Group.

Leifer, G. (2015). Introduction to maternity and pediatric nursing. Boston: Pearson. .

PREPARED BY:
BRENDA B. POLICARPIO RN, RM, MN
NCM 0107 Instructor

PEER REVIEWED BY:

Ma. Corazon Tanhueco, RN, MAN
Sarah S. Nares, RN, MN Commented [2]: (SGD) SSN
NCM 0107 Instructors

Evaluated By:
Jennie C. Junio, RN, MAN
Level 2 Coordinator

APPROVED BY:

Zenaida S. Fernandez, RN, PhD

Dean, College of Nursing

41 | MODULE 9 STAGES OF LABOR

42 | MODULE 9 STAGES OF LABOR