First Stage of Labor

Latent Phase

The latent phase of the first stage of labor is variable in length, but usually less than 20 hours for a nullipara and 14 hours for a multipara. Little cervical dilation is seen, but cervical preparation for labor occurs with changes in consistency caused by changes in collagen and connective tissue. An increase in effacement as well as the anterior positioning of the cervix is also noted. Conduction anesthesia given in this phase may prolong or arrest progress. In normal pregnant women, latent-phase labor is best experienced at home. Clear liquids instead of heavy meals are encouraged during this time.

Table 21-12 Stages of Labor

Stage

Onset

Completion

First (latent and active phases)

Active labor

Complete dilation

Second

Complete dilation

Delivery of baby

Third

Delivery of baby

Delivery of placenta

Fourth"

Delivery of placenta

Contracted uterus

*Not always considered a stage.

Instructions for coming to the hospital include vaginal bleeding like a period, rupture of membranes, painful contractions at least 3 to 4 minutes apart, and decreased fetal movement. A subset of women may have a prolonged latent phase that can be treated with morphine in a hospital setting. Often this treatment accelerates transition to the active phase.

Active Phase

The active phase of the first stage of labor is the segment of rapid dilation, the progress of which is not affected by sedation or conduction anesthesia. This phase usually occurs at about 4 to 5 cm of cervical dilation. In general, nullipa-rous women dilate at least 1.2 cm per hour and multiparous 1.5 cm/hr (Friedman, 1978). Progress of the active phase depends on strength and frequency of uterine contractions, size, position, and attitude of the fetal head, as well as size and shape of the bony pelvis. Because of the different diameters of the pelvic inlet, midplane, and outlet, the fetal head must turn at different times of descent to negotiate the bony structure. Flexion of the fetal head during this process is crucial because this diminishes its anteroposterior (AP) diameter and permits easier descent. The cardinal movements of the fetal head during labor include engagement, descent, flexion, internal rotation, extension, external rotation, and expulsion.

Either continuous electronic fetal monitoring (EFM) or intermittent auscultation can be used to monitor the fetus in the active phase of labor (ACOG, 1995a). Instead of continuous EFM in this phase, in low-risk mothers with normal labor, the fetal heart may be auscultated after a contraction and recorded every 30 minutes; the frequency should be increased to every 15 minutes in higher-risk labors. Fetal heart rate decelerations should prompt even more frequent auscultation or continuous EFM. Auscultation rather than continuous EFM will allow mobility during labor, which may improve maternal comfort. IV fluids in the normal gravida can be reserved for women with long labor who become dehydrated despite oral liquids, those who require conduction anesthesia or large doses of pain medication, and those in whom complications develop or are suspected.

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