| Phases of First Stage | Assessment: Expected Maternal Behaviors | Nursing Care Plan/Implementation |
|---|
| 0–4 cm: Latent Phase and Early Active Phase |
| 1. Time: multipara 5–6 hours; nullipara 8–10 hours, average | 1. Usually comfortable, euphoric, excited, talkative, and energetic, but may be fearful and withdrawn | 1. Provide encouragement, feedback for relaxation, companionship, hydration, nutrition |
| 2. Contractions: regular, mild, 5–10 minutes apart, 20–30 seconds’ duration | 2. Relieved or apprehensive that labor has begun | 2. Coach during contractions: signal beginning of contraction, mark the seconds, signal end of contraction; “Follow my breathing,” “Watch my lips,” etc. |
| 3. Low-back pain and abdominal discomfort with contractions | 3. Alert, usually receptive to teaching, coaching, diversion, and anticipatory guidance | 3. Comfort measures: position change for comfort; praise; keep aware of progress; maintain hydration |
| 4. Cervix thins: some bloody show | | |
| 5. Station: Multipara –2 to +1; nullipara 0. | | |
| 4–8 cm: Midactive Phase,Phase of Most Rapid Dilation |
| 1.Average time: nullipara 1–2 hours; multipara 1½–2 hours | 1. Tired, less talkative, and less energetic | 1. Coach during contractions; partner (coach) may need some relief |
| 2. Contractions: 2–5 minutes apart, 30–40 seconds’ duration, intensity increasing | 2. More serious, malar flush between 5 and 6 cm, tendency to hyperventilate, may need analgesia, needs constant coaching | 2. Comfort measures (to partner too—as needed): position for comfort while preventing hypotensive syndrome; encourage relaxation, focusing her on areas of tension; provide counterpressure to sacrococcygeal area, prn; praise; keep aware of progress; minimize distractions from surrounding environment (loud talking, other noises); offer analgesics and anesthetics, as appropriate; provide hygiene: mouth care, ice chips, clean perineum; warmth, as needed |
| 3. Membranes may rupture now | | 3. Monitor progress of labor and maternal/fetal response, color of fluid, time of rupture of membranes (ROM) |
| 4. Increased bloody show | | 4. If monitors are in use, attention on mother; periodically check accuracy of monitor readouts |
| 5. Station: –1 to 0 | | |
| 8–10 cm: Transition, Deceleration Period of Active Phase |
| 1. Average time: nullipara 40 minutes–1 hour; multipara 20 minutes | 1. If not under regional anesthesia, more introverted; may be amnesic between contractions | 1. Stay with woman (couple) and provide constant support |
| 2. Contractions: 1½–2 minutes apart, 60–90 seconds’ duration, strong intensity | 2. Feeling she cannot make it; increased irritability, crying, nausea, vomiting, and belching; increased perspiration over upper lip and between breasts; leg tremors; and shaking | 2. Continue to coach with contractions: may need to remind, reassure, and encourage her to reestablish breathing techniques and concentration with each contraction; coach panting or “he-he” respirations to prevent pushing |
| 3. Increased vaginal show; rectal pressure with beginning urge to bear down | 3. May have uncontrollable urge to push at this time | 3. Comfort measures; remind her and partner her behavior is normal and “OK”; coach breathing to quell nausea; offer ice chips |
| 4. Station: +13 to +14 | | 4. Assist with countertension techniques woman requested |
| | 5. Monitor contractions, FHR (after each contraction), vaginal discharge, perineal bulging, maternal vital signs; record every 15 minutes |
| | 6. Assess for bladder filling |
| | 7. Keep mother (couple) aware of progress |
| | 8. Prepare partner for birth (scrub, gown, etc.) |