Guide — Maternal-Newborn
Labor and Delivery Overview
Labor is divided into four stages, each with distinct cervical changes, maternal adaptations, fetal heart rate patterns, and nursing priorities. This guide provides a systematic overview of normal labor progress, assessment parameters, and nursing interventions from admission through the immediate postpartum period.
12 min read · Maternal-Newborn
Educational use only. Labor management protocols vary by facility and clinical presentation. This guide reflects general principles for nursing students and NCLEX preparation. Always follow provider orders, facility policies, and current ACOG/AWHONN guidelines. This material supports nursing education and exam review. It is not medical advice and is not a substitute for clinical judgment, institutional policy, or medical direction. Always follow facility protocols and current provider orders.
Overview
Labor is the process by which regular uterine contractions cause progressive cervical effacement (thinning) and dilation (opening), resulting in the birth of the infant and expulsion of the placenta. True labor contractions are regular, increase in frequency and intensity, and cause cervical change. Braxton Hicks contractions are irregular, do not increase in intensity, and do not cause cervical change.
The four stages of labor:
Stage 1 (Onset–Full Dilation) → Stage 2 (Full Dilation–Delivery) → Stage 3 (Delivery–Placenta) → Stage 4 (Recovery)
First Stage — Onset to Full Dilation (10 cm)
The first stage is the longest stage of labor and is subdivided into latent, active, and transition phases.
Latent Phase (0–6 cm)
- Contractions: mild to moderate, 5–20 minutes apart, 30–45 seconds duration
- Cervix effaces and dilates to 6 cm
- Duration: up to 20 hours in nulliparous; up to 14 hours in multiparous
- Patient typically talkative; able to breathe through contractions
Active Phase (6–10 cm)
- Contractions: moderate to strong, 2–5 minutes apart, 45–60 seconds duration
- Normal dilation rate: ≥1 cm/hour in active labor
- Patient focused on breathing; may request pain management
- AROM or SROM may occur; fetal station descends
Transition Phase (8–10 cm)
- Contractions: strong, 2–3 minutes apart, 60–90 seconds duration
- Most intense phase; patient may feel urge to push, nausea, shaking
- Duration: 30 minutes to 2 hours; briefer in multiparous women
First stage nursing priorities:
- Monitor FHR per AWHONN guidelines (intermittent auscultation or continuous EFM)
- Assess contractions: frequency (onset to onset), duration (onset to end), intensity, and resting tone
- Vital signs every 4 hours in latent phase; every 1–2 hours in active phase
- Assess cervical dilation per provider orders; document fetal station and presentation
- Support comfort measures: position changes, ambulation, hydrotherapy, breathing techniques
- Maintain IV access; monitor fluid intake/output
Second Stage — Full Dilation to Birth
The second stage begins at complete dilation (10 cm) and ends with delivery of the infant. Duration: up to 3 hours in nulliparous (longer with epidural); up to 2 hours in multiparous.
Pushing patterns:
- Open-glottis (physiologic) pushing is associated with less maternal fatigue and better fetal oxygenation
- Spontaneous pushing when patient feels urge; directed pushing per provider guidance
- Passive descent (laboring down) supported when epidural in place and fetal status reassuring
Nursing priorities:
- Continuous FHR monitoring; report any late or prolonged decelerations immediately
- Coach and support effective pushing effort
- Prepare delivery field; ensure neonatal resuscitation equipment available and warmer ready
- Assess maternal vital signs every 5–15 minutes
- Document delivery time; call APGAR at 1 and 5 minutes
Third Stage — Birth to Placental Delivery
The third stage begins after birth of the infant and ends with delivery of the placenta. Duration: 5–30 minutes. Retained placenta beyond 30 minutes is an obstetric emergency.
Signs of placental separation:
- Gush of blood from vagina
- Umbilical cord lengthens
- Uterus rises in the abdomen and becomes globular
Active management of third stage (AMTSL):
- Oxytocin (Pitocin) 10–40 units IV/IM after delivery of anterior shoulder or after placenta delivers — reduces PPH risk
- Controlled cord traction with uterine counter-pressure
- Uterine massage after placenta delivers
Nursing priorities:
- Monitor for signs of placental separation; never apply fundal pressure before separation
- Administer oxytocin per order; monitor for uterine tone
- Assess blood loss; normal delivery blood loss ≤500 mL vaginal, ≤1000 mL cesarean
- Inspect placenta for completeness (retained fragments cause PPH)
Fourth Stage — Recovery (First 1–2 Hours Postpartum)
The fourth stage encompasses the first 1–2 hours after placental delivery. This is the highest-risk period for postpartum hemorrhage. Uterine atony accounts for the majority of PPH cases.
BUBBLE-LE assessment (every 15 minutes × 4, then every 30 minutes):
- Breasts — engorgement, nipple integrity, breastfeeding initiation
- Uterus — fundus firm, midline, at or 1 cm above umbilicus; boggy uterus requires massage
- Bladder — urinary distension displaces uterus and causes atony; encourage voiding
- Bowel — assess for return of bowel function
- Lochia — rubra expected; excessive clots or saturation of >1 pad/hour is abnormal
- Episiotomy/lacerations — intact, no hematoma, ice as needed
- Emotional/bonding — assess maternal-infant attachment, mood
Contraction Assessment
| Parameter | Definition | Normal Active Labor |
|---|---|---|
| Frequency | Onset of one contraction to onset of next | Every 2–5 minutes |
| Duration | Onset to end of same contraction | 45–90 seconds |
| Intensity | Strength at peak (palpation or IUPC) | Moderate to strong; fundus firm at peak |
| Resting tone | Uterine tone between contractions | Soft, relaxed (not rigid) |
Tachysystole — report immediately:
>5 contractions in 10 minutes averaged over 30 minutes; may cause fetal hypoxia. Reposition patient, discontinue oxytocin if infusing, notify provider, administer oxygen.
NCLEX Pearls
- True labor contractions cause cervical change; Braxton Hicks do not
- Normal active phase dilation rate: ≥1 cm/hour
- A boggy uterus in the fourth stage = uterine atony → massage the fundus, administer oxytocin
- Never apply fundal pressure to deliver the placenta before signs of placental separation
- Retained placenta beyond 30 minutes = obstetric emergency
- Tachysystole (>5 contractions/10 min): stop oxytocin, reposition, O2, notify provider
- Postpartum hemorrhage (current ACOG definition) = cumulative blood loss ≥1000 mL OR loss with signs/symptoms of hypovolemia within 24 h, regardless of delivery route; >500 mL after vaginal birth is still considered excessive and warrants close monitoring
Related Resources
Standards & sources
Fact-checked Jun 20, 2026This page is written to align with American College of Obstetricians and Gynecologists (ACOG) · AWHONN · American Academy of Pediatrics (AAP) — newborn. It is an educational summary, not a citation of any single document — always verify specific doses, values, and protocols against current guidelines and your facility policy. How we source content →