Labor and postpartum care: the stages, the fetal heart rate and the checks after birth
NCLEX-RN topic: Ante-, intra-, postpartum and newborn care
- Labor stage 1 ends at 10 cm; the active phase starts at 6 cm.
- A normal fetal heart rate baseline is 110–160/min with moderate variability.
- Early = head, late = placenta, variable = cord.
- Late decelerations: stop oxytocin, left side, fluids for low BP, notify provider.
- A pad soaked within 1 hour or golf-ball clots suggest hemorrhage.
Key facts
- Latent phase: 0–6 cm, contractions 30–45 seconds every 5–10 minutes. Active phase: 6–10 cm, contractions 40–90 seconds every 2–5 minutes.
- The second stage runs from 10 cm to birth; the third stage runs from birth to delivery of the placenta, which should occur within 30 minutes.
- A normal fetal heart rate baseline is 110–160/min; moderate variability (6–25/min) and accelerations signal a well-oxygenated fetus.
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- Early decelerations mirror contractions (head compression); late decelerations start during the contraction and recover after it ends (uteroplacental insufficiency); variable decelerations are abrupt V or W shapes (cord compression).
- For late decelerations: stop oxytocin, turn the client to her left side, give fluids for maternal hypotension and notify the provider.
- After birth the fundus is near the umbilicus, firm and midline, then descends about 1 cm a day; lochia goes from rubra (days 1–3) to serosa (pinkish brown, to about day 10) to alba (yellow-white).
- Postpartum hemorrhage is blood loss of 1,000 mL or more within 24 hours of birth; uterine atony is the most common cause.
Quick check1 question · 2 more at the end
A client in active labor is receiving an oxytocin infusion. The nurse notes repeated decreases in the fetal heart rate that begin during each contraction and return to baseline only after the contraction ends. Which action should the nurse take?
Correct answer: A.
Decelerations that start during a contraction and recover only after it ends are late decelerations, which signal uteroplacental insufficiency and fetal hypoxia. Oxytocin can cause tachysystole, which reduces blood flow to the placenta. Nursing actions are to stop the oxytocin, turn the client to her left side, give fluids for maternal hypotension and notify the provider.
A Correct: for late decelerations, the nurse stops the oxytocin and changes the client to a left lateral position, then notifies the provider.
B Incorrect: more oxytocin can cause tachysystole and further reduce blood flow to the placenta.
C Incorrect: early decelerations from head compression mirror the contraction; these start late and recover after it ends.
D Incorrect: a left side-lying position improves placental blood flow; lying flat on the back does not.
Full lesson
Each part starts with its main idea. Open a part when you want the details.
The short answer: Labor has three stages: dilation to 10 cm (latent, then active phase), birth of the baby, and delivery of the placenta. During labor, a fetal heart rate baseline of 110–160/min with moderate variability is reassuring. After birth, the fundus should be firm and midline; a pad soaked within 1 hour or clots larger than a golf ball suggest hemorrhage.
1 What happens in each stage of labor?Labor moves through three stages, and each one has its own contraction pattern and nursing focus. 1 min
Labor moves through three stages, and each one has its own contraction pattern and nursing focus. The first stage runs from the start of true labor to full dilation at 10 cm and has a latent and an active phase.
| Stage | Starts → ends | What you see |
|---|---|---|
| First, latent phase | Regular contractions → 6 cm | Contractions 30–45 seconds, every 5–10 minutes; client often talkative |
| First, active phase | 6 cm → 10 cm | Contractions 40–90 seconds, every 2–5 minutes; client turns inward and can't talk through contractions |
| Second | 10 cm → birth of the baby | Strong contractions every 2–3 minutes with an urge to push |
| Third | Birth → delivery of the placenta | Usually 5–30 minutes; the placenta should deliver within 30 minutes |
| Fourth | First 1–4 hours after the placenta | Frequent checks of vital signs, fundus and bleeding |
Bloody show is pink or brownish mucus; bright red bleeding is not expected and is reported right away. Amniotic fluid should be clear, and green or yellow fluid suggests meconium.
2 How do you read the fetal heart rate?Start with the baseline and variability, because together they tell you whether the fetus is well oxygenated. 1 min
Start with the baseline and variability, because together they tell you whether the fetus is well oxygenated. A normal baseline is 110–160/min. Moderate variability (fluctuations of 6–25/min) and accelerations of at least 15/min lasting at least 15 seconds are reassuring.
| Deceleration | Shape and timing | Cause | Nurse's response |
|---|---|---|---|
| Early | Gradual dip that mirrors the contraction | Head compression | Common in active labor; check labor progress |
| Late | Starts during the contraction, recovers after it ends | Uteroplacental insufficiency | Stop oxytocin, left side, fluids for low maternal BP, notify provider |
| Variable | Abrupt V or W shape | Cord compression | Reposition, stop oxytocin, check for prolapsed cord, notify provider |
A baseline above 160/min for 10 minutes is fetal tachycardia, most often from maternal fever.
3 What does the postpartum assessment check?The BUBBLE-EE mnemonic keeps the postpartum check complete: breasts, uterus, bladder, bowels, lochia, episiotomy and perineum, extremities and emotional status. 1 min
The BUBBLE-EE mnemonic keeps the postpartum check complete: breasts, uterus, bladder, bowels, lochia, episiotomy and perineum, extremities and emotional status.
- Uterus: support the lower uterus near the symphysis pubis with one hand while the other finds the fundus. It should be firm, midline and near the umbilicus for the first day or two, then descend about 1 cm per day.
- Bladder: a full bladder pushes the fundus up or to one side and slows involution, so have the client void.
- Lochia: rubra (red) for days 1–3, serosa (pinkish brown) until about day 10, then alba (yellow-white). A musty odor is normal; a foul odor suggests infection.
- Emotional status: baby blues fade within a couple of weeks; symptoms that limit daily functioning suggest postpartum depression.
4 Which signs point to postpartum hemorrhage?Postpartum hemorrhage is blood loss of 1,000 mL or more within 24 hours of birth, and uterine atony is its most common cause. 1 min
Postpartum hemorrhage is blood loss of 1,000 mL or more within 24 hours of birth, and uterine atony is its most common cause.
Report right away a peripad saturated within 1 hour, clots larger than a golf ball or a boggy uterus. Early hypovolemia shows as a falling blood pressure, rising pulse and breathing rate, weakness, dizziness and anxiety. Blood volume is about 50% higher in pregnancy, so these signs may appear only after a large loss.
5 What the nurse doesThe nurse assesses on a schedule, acts early on warning signs and teaches the client what to report. 1 min
The nurse assesses on a schedule, acts early on warning signs and teaches the client what to report.
- Assess: contractions and fetal heart rate during labor; BUBBLE-EE and vital signs after birth.
- Priority action: for late decelerations, stop oxytocin, turn the client to her left side and notify the provider. For a boggy or displaced fundus, have the client void, massage the fundus if it stays boggy and report heavy bleeding.
- Teach: report heavy bleeding, a temperature of 100.4°F (38°C) or higher, or low mood lasting longer than 2 weeks.
Common mistakes
The traps students fall into most. Read these before you practice.
Watch out: Early decelerations from head compression are common in active labor, not a sign of fetal hypoxia like late decelerations.
Watch out: Variable decelerations come from cord compression, not from pressure on the fetal head.
Watch out: A fundus pushed up or off to one side can mean a full bladder, so have the client void and recheck rather than just documenting the finding.
Watch out: Normal vital signs soon after birth do not rule out heavy bleeding, because the extra blood volume of pregnancy can hide hypovolemia until a large amount is lost.
Watch out: Bloody show is pink or brownish mucus; bright red bleeding is not normal and is reported right away.
How to remember it
Two short hooks cover the decelerations and the bleeding limits. Memory hook: "Early = head, Late = placenta, Variable = cord." For bleeding, think "one pad, one hour, one golf ball."
Self-check:
- Name the cervical dilation that separates the latent and active phases.
- Describe how a late deceleration differs from an early one.
- List three findings that suggest postpartum hemorrhage.