Maternity · Intrapartum
Labor & Delivery: Stages, Pain Management, Induction
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Prepared for Pass the Shift (owner: Kristina, RN). Always follow your facility’s protocols, provider orders, and current references.
1. Overview: The 5 Ps of Labor
Labor is regular uterine contractions that cause progressive cervical change ( and dilation). Progress depends on the 5 Ps:
- Powers — contractions (frequency, duration, intensity) and pushing
- Passage — the bony pelvis and soft tissues
- Passenger — fetal size, presentation (cephalic, breech, shoulder), position (e.g., LOA = occiput toward the parent’s left front, ideal; OP = “sunny-side up,” causes back labor), attitude (flexion), and (−5 to +5; 0 = at the ischial spines = engaged)
- Passageway/placenta — placenta and membranes
- Psyche — fear, support, and culture affect pain and progress
True vs. false labor: true labor contractions get stronger, longer, and closer, don’t stop with rest or hydration, and change the cervix. False (Braxton Hicks) contractions are irregular, ease with walking/hydration, and the cervix doesn’t change.
Leopold maneuvers (palpation to find fetal lie and position) help place the Doppler: FHR is best heard over the fetal back — below the umbilicus for cephalic, above it for breech.
2. Stages of Labor
| Stage | Starts → ends | Key features | Nursing focus |
|---|---|---|---|
| First – latent | Onset → ~6 cm | Mild–moderate contractions; can last hours | Comfort, ambulation, hydration, education |
| First – active | ~6 cm → 10 cm | Stronger, closer contractions; faster cervical change | Monitor FHR and contractions per protocol, pain management, void every 2 h (full bladder blocks descent) |
| Transition (end of active) | ~8 → 10 cm | Intense; nausea/vomiting, shaking, irritability, rectal pressure, “I can’t do this” | Constant support, short simple directions; don’t let the client push until fully dilated (unless ordered) |
| Second | 10 cm → birth of baby | Urge to push; crowning | Coach pushing (open-glottis is often preferred), monitor FHR closely, prepare for birth and newborn care |
| Third | Baby → placenta | Usually ≤ 30 min. Signs of separation: gush of blood, cord lengthens, uterus rises and becomes globular | Oxytocin after birth per protocol (active management lowers PPH), inspect placenta (3 vessels in cord: 2 arteries, 1 vein) |
| Fourth | Placenta → ~1–4 h after | Recovery; highest PPH risk | Fundus, lochia, VS (often every 15 min for the first hour), bladder, perineum, skin-to-skin, breastfeeding |
: remember COAT — Color (clear is normal; green = ; bloody, cloudy, or foul = concern), Odor, Amount, Time. Check the FHR immediately after ROM (cord prolapse risk). Nitrazine (fluid turns paper blue, pH alkaline) and ferning help confirm.
3. Pain Management
Nonpharmacologic: continuous labor support (doula), position changes, birthing ball, hydrotherapy, massage/counterpressure (great for back labor), breathing patterns, heat/cold, hypnosis, TENS, nitrous oxide where available.
| Option | Key points | Nursing considerations |
|---|---|---|
| IV opioids (fentanyl, butorphanol, nalbuphine) | Short relief; may dull, not erase, pain | Respiratory depression in parent and newborn if given close to birth; reduced FHR variability. Have naloxone available (for the parent; neonatal use per resuscitation protocol). Mixed agonist-antagonists (butorphanol, nalbuphine) can cause withdrawal in opioid-dependent clients |
| Most effective; continuous local anesthetic ± opioid into epidural space | Before: consent, IV access, fluid preload/co-load per protocol, platelets/coagulation as ordered, baseline VS/FHR. After: BP every few minutes initially (hypotension is the most common side effect → lateral position, fluids, vasopressor per order), FHR, bladder distension (may need a catheter), fall risk, itching, fever, sensory level | |
| Spinal | Single injection; used for cesarean | Hypotension; post-dural puncture headache (worse upright; may need blood patch) |
| Pudendal / local | For birth or repair | Doesn’t relieve contraction pain |
| General anesthesia | Emergency cesarean | Aspiration risk; neonatal depression |
Contraindications to neuraxial anesthesia (examples): client refusal, coagulopathy or low platelets (threshold per anesthesia), infection at site, uncorrected hypovolemia, some anticoagulant timing.
4. Induction and Augmentation
Induction starts labor; augmentation strengthens labor that has started. Common reasons: post-term pregnancy, preeclampsia, diabetes, PROM, fetal growth restriction, chorioamnionitis.
Contraindications (examples): placenta previa, vasa previa, transverse lie, prior classical (vertical) uterine incision or certain uterine surgery, active genital herpes, cord prolapse.
rates cervical readiness (dilation, effacement, station, consistency, position). ≥ 8 = favorable (induction likely to succeed); low scores → cervical ripening first.
| Method | Nursing considerations |
|---|---|
| Prostaglandins: misoprostol (PGE1), dinoprostone (PGE2) | Monitor for tachysystole; client stays recumbent briefly after insertion per protocol; misoprostol generally avoided with prior uterine scar; wait the specified interval before starting oxytocin |
| Mechanical: balloon catheter, membrane stripping | Discomfort, bleeding, infection |
| Amniotomy (artificial ROM) | Check FHR before and after (cord prolapse); COAT; infection risk increases with time |
| IV infusion | See below |
Oxytocin safety (high-alert medication):
- Give as a piggyback on a pump into the primary line at the port closest to the client
- Titrate per protocol (low and slow); continuous EFM
- Goal: adequate labor without tachysystole — e.g., contractions every 2–3 min, lasting ~60–90 s, with uterine relaxation between
- Stop/reduce oxytocin for tachysystole, Category II/III tracing, or a uterus that doesn’t relax; then lateral position, IV bolus, notify provider, tocolytic (terbutaline) per order
- Water intoxication (antidiuretic effect at high doses/long infusions): headache, nausea, confusion, low Na⁺, low urine output → monitor I&O
- Risks: uterine rupture, PPH from uterine fatigue
5. Priority Nursing Assessments in Labor
- FHR pattern and contraction pattern per protocol (frequency depends on risk and stage)
- Maternal VS — temp every 2–4 h (more often after ROM), BP for preeclampsia and epidural
- Cervical change and fetal descent
- Bladder, hydration, pain and coping
- Signs of complications: bleeding, fever, abnormal fluid, abnormal pain
6. Complications and Emergencies
- : head delivers then retracts (“turtle sign”). Call for help; McRoberts maneuver (sharply flex thighs to the abdomen) and suprapubic pressure (never fundal pressure). Risks: macrosomia, diabetes. Newborn: assess for brachial plexus injury and clavicle fracture
- Cord prolapse, uterine rupture: see the fetal monitoring guide
- Precipitous birth: stay with the client, call for help, support the head with gentle pressure to prevent rapid expulsion, check for nuchal cord, dry and warm the baby
- Amniotic fluid embolism: sudden dyspnea, hypotension, hypoxia, cardiac arrest, then DIC. Code response, airway, CPR with left uterine displacement
- Dystocia / failure to progress: reposition, empty bladder, augmentation, operative birth
- Preterm labor (< 37 weeks): tocolytics (e.g., nifedipine, indomethacin < 32 weeks) for short delays, betamethasone for fetal lung maturity (24–34 weeks, per guidance), magnesium sulfate for fetal neuroprotection < 32 weeks, GBS prophylaxis as indicated
Cesarean birth nursing: consent, NPO/antacid per protocol, IV, Foley, abdominal prep, lateral tilt, antibiotics within 60 min before incision; postop: fundus (gently), lochia, incision, pain, early ambulation, VTE prevention, bowel sounds.
7. Memory Aids
- 5 Ps: Powers, Passage, Passenger, Placenta, Psyche
- ROM = COAT, and FHR right after ROM
- Stage 3 signs: “Gush, Lengthen, Rise”
- Cord vessels “AVA”: Artery, Vein, Artery
- Oxytocin trouble? “Turn it off, turn her over, fluids up, call.”
- Epidural first problem = hypotension
8. NCLEX-Style Practice Questions
1. A client receives an epidural. Ten minutes later BP is 86/50 (baseline 124/78) and the FHR shows a late deceleration. What should the nurse do first?
A. Place the client supine with legs elevated
B. Turn the client to a lateral position and increase IV fluids
C. Remove the epidural catheter
D. Give an opioid for comfort
Answer: B. Epidural sympathetic blockade causes vasodilation and hypotension, which reduces placental perfusion. Lateral positioning relieves vena cava compression and fluids restore volume; give a vasopressor if ordered. Supine (A) worsens compression.
2. A client on oxytocin has contractions every 1.5 minutes lasting 90 seconds, with an FHR baseline of 140 and moderate variability. What is the priority?
A. Increase oxytocin to strengthen contractions
B. Stop the oxytocin infusion
C. Encourage pushing
D. Document a normal labor pattern
Answer: B. This is tachysystole (> 5 contractions in 10 min, with too little rest between). Even with a reassuring FHR, stop or reduce oxytocin per protocol to protect placental blood flow.
3. Right after membranes rupture, which assessment does the nurse perform first?
A. Maternal temperature
B. Fluid color
C. Fetal heart rate
D. Cervical dilation
Answer: C. Cord prolapse can follow ROM, so check the FHR first. Then assess COAT and temperature trends.
4. During birth, the fetal head delivers and then pulls back tightly against the perineum. Which actions does the nurse anticipate? Select all that apply.
A. Apply fundal pressure
B. Help the client into McRoberts position
C. Apply suprapubic pressure as directed
D. Call for additional help
E. Prepare to assess the newborn for clavicle fracture
Answer: B, C, D, E. This is shoulder dystocia. McRoberts and suprapubic pressure help free the anterior shoulder. Fundal pressure (A) worsens impaction and can cause uterine rupture.
5. A client in labor is 9 cm dilated, shaking, nauseated, and says, “I can’t do this anymore.” How should the nurse interpret this?
A. She needs an immediate cesarean
B. These are expected signs of transition
C. She is having a reaction to the epidural
D. She should begin pushing now
Answer: B. Transition (about 8–10 cm) commonly brings shaking, nausea/vomiting, irritability, and loss of confidence. Give close support and simple coaching. Pushing (D) usually waits for full dilation.
References
American College of Obstetricians and Gynecologists. (n.d.). Labor induction [Patient FAQ]. Retrieved October 15, 2026, from https://www.acog.org/womens-health/faqs/labor-induction
American College of Obstetricians and Gynecologists. (n.d.). Medications for pain relief during labor and delivery [Patient FAQ]. Retrieved October 15, 2026, from https://www.acog.org/womens-health/faqs/medications-for-pain-relief-during-labor-and-delivery
Avila Hernandez, A. N., & Hendrix, J. M. (2025). Epidural anesthesia. In StatPearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK542219/
Hutchison, J., Mahdy, H., & Jenkins, S. M. (2025). Normal labor: Physiology, evaluation, and management. In StatPearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK544290/
Jenkins, S. M., & Van Hook, J. W. (2023). Induction of labor. In StatPearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK459264/
Osilla, E. V., Patel, P., & Sharma, S. (2025). Oxytocin. In StatPearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK507848/