NCP LABOR Stage I—Transition Phase (Deceleration)

The transition phase is typically the most intense of the three phases of stage I labor. It is also the shortest phase, lasting an average of 2–3 hr in nulliparas and 1 hr in multiparas. The cervix dilates 8–10 cm as the fetus descends approximately 1 cm/hr in nulliparas and 2 cm/hr in multiparas.

CLIENT ASSESSMENT DATA BASE

Circulation

BP elevated 5–10 mm Hg above client’s normal level
Pulse elevated

Ego Integrity

Irritable behavior, difficulty communicating/answering queries
May have difficulty maintaining control, requiring reminders about breathing/comfort techniques
May state, “I can’t stand it anymore,” or may desire to “leave the hospital and come back later”
May be amnesic

Elimination

Urge to void or defecate throughout phase (may indicate fetus in posterior position)

Food/Fluid

Nausea or vomiting may occur
Belching/hiccuping

Pain/Discomfort

Strong uterine contractions occurring every 2–3 min and lasting 60+ sec (unmedicated state).
Intense level of discomfort in abdominal/sacral area.
May become very restless, thrash with pain, or be fearful.
May report being “too hot”; tingling sensation of fingertips, toes, and face.
Leg tremors may occur.

Safety

Diaphoretic
FHTs heard just above symphysis pubis.
FHR may display variable decelerations (cord compression), late decelerations (uteroplacental insufficiency), or early decelerations (head compression).

Sexuality

Cervix dilates 8–10 cm.
Fetus descends 12–14 cm.
Copious amounts of bloody show.

NURSING PRIORITIES

1. Promote fetal and maternal well-being.
2. Provide physical and emotional support.