Stages of Labor
Four stages — know the timing, cervical dilation, and nursing priorities for each.
- Stage 1: Dilationlongest stage
- Onset of regular contractions → full cervical dilation (10 cm). Monitor FHR, contractions, cervical progress, comfort measures, emotional support.
- Stage 2: Expulsionnullipara up to 2 hrs
- Full dilation (10 cm) → delivery of the baby. Coach pushing, monitor FHR continuously, prepare for delivery, perineal support.
- Stage 3: Placental5–30 minutes
- Delivery of baby → delivery of placenta. Monitor for placental separation signs (gush of blood, lengthening cord, globular uterus). Inspect placenta for completeness.
- Stage 4: Recovery1–2 hours
- First 1–2 hours after placental delivery. Monitor VS q15min, fundal checks, assess lochia, bonding, breastfeeding initiation. HIGHEST risk for PPH.
Stage 1 — Three Phases
- Latent0–6 cm
- Mild, irregular contractions 5–30 min apart, 30–45 sec. Talkative, excited, can walk and eat. May be sent home if early.
- Active6–8 cm
- Moderate-strong contractions 3–5 min apart, 40–70 sec. More serious, focused on breathing, needs support. Epidural usually placed here.
- Transition8–10 cm
- Strong contractions 2–3 min apart, 60–90 sec. Most intense. Irritable, nausea, rectal pressure, feeling of "I can't do this." Do NOT leave patient alone.
If a question describes a laboring patient who is irritable, nauseous, says "I can't take this anymore," and has rectal pressure → she's in transition (8–10 cm). The nurse should stay with her, provide encouragement, and prepare for delivery. Transition is the shortest but most intense phase.
Every key point in this guide fits on one free printable page. Jump to the free cheatsheet PDF →
Fetal Heart Rate Monitoring
Normal FHR: 110–160 bpm. Know the baseline, variability, and patterns.
- Baseline110–160 bpm
- <110 = bradycardia (cord compression, medications). >160 = tachycardia (infection, fever, dehydration, anxiety).
- Variabilitymoderate = 6–25 bpm
- Indicates healthy autonomic nervous system. Absent variability = ominous (fetal distress, acidosis). Minimal = concerning.
- Accelerations↑15 bpm for ≥15 sec
- REASSURING. Sign of fetal well-being. Basis for reactive NST.
- Decelerations
- Drops in FHR — type determines intervention needed. See section 03.
Accelerations are ALWAYS reassuring — they mean the baby's nervous system is responding appropriately. If you see accelerations on the monitor, the baby is doing well. No intervention needed. This is what makes an NST "reactive."
Decelerations — The Most Tested FHR Topic
Early = benign. Variable = cord. Late = ominous. Know the differences.
- Earlymirrors contraction
- Starts and ends WITH the contraction. Cause: Head compression (normal during pushing). Benign — no intervention. Continue monitoring. Reassure the mother.
- VariableV or W shape, abrupt
- Variable timing — can occur anytime. Cause: Cord compression (cord around neck, oligohydramnios). Reposition mother (side to side). O₂ if persistent. Amnioinfusion may be ordered. Notify provider if recurrent.
- Latedelayed after peak
- Starts AFTER the contraction peak, doesn't recover until after contraction ends. Cause: Uteroplacental insufficiency. OMINOUS — act immediately. Left lateral position, O₂ 8–10 L/min NRB, STOP oxytocin, increase IV fluids, notify provider.
- Prolonged≥2 min, <10 min
- Drop ≥15 bpm sustained. Causes: cord prolapse, uterine rupture, maternal hypotension. Emergency. Same as late + assess for cord prolapse. If >10 min = terminal bradycardia → emergency C-section.
If you see late decelerations → think the placenta is failing to oxygenate the baby. Immediate actions: 1) Turn to LEFT side (improves placental perfusion), 2) O₂ via non-rebreather, 3) STOP Pitocin, 4) Increase IV fluids, 5) Notify the provider. Remember: "STOP" → Side (left), Turn off Pitocin, Oxygen, Provider.
Early = Everything's fine (head compression — benign). Variable = V shape = cord (Variable = Cord). Late = Last thing you want to see (uteroplacental insufficiency — ominous).
? The monitor shows decelerations that mirror the contraction, starting and ending with it — what type and what do you do?
Rupture of Membranes (ROM)
When the water breaks — the FIRST thing you check is fetal heart rate.
Types of ROM
- SROM: Spontaneous rupture of membranes (natural)
- AROM: Artificial rupture (amniotomy — provider breaks the bag)
- PROM: Premature ROM — membranes rupture BEFORE the onset of labor (at term)
- PPROM: Preterm premature ROM — membranes rupture before 37 weeks AND before labor
Confirmation Tests
- Nitrazine paper: turns BLUE = positive for amniotic fluid (alkaline, pH 7.0–7.5). False positive: blood, semen, infection.
- Fern test: amniotic fluid dried on a slide shows a fern-like crystallization pattern under microscope.
Nursing Priorities After ROM
If the question says "the patient's membranes just ruptured" → the FIRST nursing action is to check fetal heart rate. Not assess fluid, not call the provider — FHR first. Cord prolapse can occur when membranes rupture, especially if the presenting part is not engaged.
Pain Management in Labor
Non-pharmacological first, then medications as labor progresses.
Non-Pharmacological
- Breathing techniques (Lamaze — patterned breathing)
- Position changes (walking, birth ball, rocking, side-lying)
- Hydrotherapy (warm shower/bath — before ROM)
- Massage, counterpressure on sacrum
- Focal point concentration
- Support person presence
Pharmacological
- IV opioidsfentanyl, nalbuphine
- Given in early-active labor. Avoid within 1 hour of delivery (neonatal respiratory depression). Have naloxone ready for baby. Causes maternal sedation.
- Epiduralmost common method
- Placed in active labor (usually ≥4–6 cm). Continuous or PCEA. Monitor: hypotension (#1 side effect — give IV fluid bolus before), decreased sensation, urinary retention, fever. Keep HOB ≥30°. Monitor FHR after placement. Cannot ambulate (fall risk).
- Spinal blockused for C-section
- Single injection into subarachnoid space. Rapid onset. Post-procedure: keep flat to prevent spinal headache.
- Local/Pudendal block
- Numbs perineum for episiotomy repair or forceps delivery. No effect on labor pain or fetus.
Epidural causes sympathetic blockade → vasodilation → hypotension. Prevention: give 500–1,000 mL IV fluid bolus BEFORE placement. Treatment: turn to left side (improves venous return), increase IV fluids, ephedrine if severe. Monitor BP every 5 minutes for the first 20 minutes after placement.
Dystocia & Labor Complications
When labor doesn't progress normally — know the complications and interventions.
Shoulder Dystocia
- Definition: After the head delivers, the anterior shoulder gets stuck behind the pubic bone
- Turtle sign: The baby's head delivers and then retracts back against the perineum (like a turtle pulling into its shell) — classic recognition sign
- McRoberts maneuver: Sharply flex the mother's thighs against her abdomen (hyperflexion). This is the FIRST intervention.
- Suprapubic pressure: Apply firm downward pressure just above the pubic bone (NOT fundal pressure — that worsens impaction)
- This is an emergency — risk of brachial plexus injury, clavicle fracture, asphyxia
Precipitous Labor
- Labor lasting <3 hours from start to delivery
- Risks: cervical/perineal lacerations, uterine rupture, PPH, neonatal injury
- Priority: do NOT leave the patient. Support the baby. Control delivery.
Uterine Rupture
- Most common in patients with prior C-section scar (VBAC attempts)
- Signs: sudden severe abdominal pain ("tearing" sensation), cessation of contractions, fetal distress (late decelerations/bradycardia), maternal tachycardia, hypotension, change in uterine shape, referred shoulder/scapular pain
- Action: Emergency C-section. Large-bore IV, type and crossmatch, prepare for surgery immediately.
If you see "turtle sign" or "the head delivered but the shoulders are stuck" → McRoberts maneuver (hyperflex thighs to abdomen) is the FIRST nursing action. NEVER apply fundal pressure — it pushes the shoulder further into the pelvis and can cause uterine rupture.
Cord Prolapse
An obstetric emergency — the cord delivers before the baby, compressing fetal blood supply.
Risk Factors
- ROM with unengaged presenting part
- Malpresentation (breech, transverse lie)
- Polyhydramnios (excessive fluid)
- Preterm infant (smaller, higher station)
- Multiparity, long cord
Immediate Nursing Actions
Once you have your hand pushing the presenting part off the cord, do NOT release until the baby is delivered by C-section. Someone else should prep the patient for surgery while you maintain pressure. The cord is the baby's lifeline — if it's compressed, the baby gets no oxygen.
Cesarean Section
Surgical delivery — know the indications and the post-op priorities.
Common Indications
- Fetal distress (non-reassuring FHR pattern)
- Failure to progress (labor stalls despite augmentation)
- Cephalopelvic disproportion (baby too large for pelvis)
- Malpresentation (transverse, breech in some cases)
- Placenta previa (placenta covering the cervix)
- Placental abruption (placenta separating prematurely)
- Cord prolapse
- Prior classical (vertical) uterine incision
- Active genital herpes at time of labor
Post-Op Care (Same as Vaginal + Surgical Care)
- All standard post-op care: respiratory assessment, IS, early ambulation, pain management
- Monitor incision site for infection (redness, warmth, drainage, dehiscence)
- Fundal assessment (may be palpated gently — the uterus still involutes after C-section)
- Lochia assessment (same stages as vaginal delivery)
- DVT prophylaxis (SCDs, early ambulation, anticoagulants if ordered)
- Foley catheter — usually removed within 12–24 hours
- Diet: clear liquids → advance as tolerated after bowel sounds return
- Bonding: encourage skin-to-skin and breastfeeding as soon as mother is able
- Typical hospital stay: 3–4 days (vs 48 hours for uncomplicated vaginal)
VBAC (Vaginal Birth After Cesarean)
- May be attempted if the prior incision was low transverse (most common type)
- Contraindicated if prior classical (vertical) incision — high risk of uterine rupture
- Continuous fetal monitoring required during VBAC
- Must deliver in a facility with immediate C-section capability
- Misoprostol (Cytotec) is CONTRAINDICATED for induction in VBAC patients (uterine rupture risk)
Frequently Asked Questions
Common student questions on this topic.
What are the stages of labor?
How do I interpret fetal heart rate decelerations?
What is the normal fetal heart rate range?
What are the priority nursing actions if cord prolapse occurs?
What are the signs that delivery is imminent?
What is the difference between an epidural and a spinal block?
Quick-Reference Cheatsheet
Every key point from this guide on a single printable page.
Intrapartum (Labor & Delivery) Cheatsheet
Free, printable PDF · no spam · returning visitors skip the email step.