CRITICAL PATHWAY for Intrapartal Stages
Category	First Stage	Second and Third Stage	Fourth Stage Birth to 1 Hour Past Birth
Referral	Review prenatal record Advise CNM/physician of admission	Labor record for first stage	Report to recovery room nurse
Assessments	Admission assessments: Ask about problems since last prenatal visit; labor status (contraction frequency and duration), membrane status (intact or ruptured); coping level; support; woman’s desires during labor and birth; ability to verbalize needs; laboratory testing (blood and UA) Intrapartal assessments: Cervical assessment: from 1 to 10 cm dilation; nullipara (1.2 cm/hour), multipara (1.5 cm/hour) Cervical effacement: from 0% to 100% Fetal descent: progressive descent from -4 to+4 Membrane assessment: intact or ruptured; when ruptured, Nitrazine and Fem positive, fluid clear, no foul Comfort level: woman states is able to cope with contractions Behavioral characteristics: facial expressions, tone of voice and verbal expressions are consistent with comfort level and ability to cope Latent Phase: BP, P, R q1h if in normal range (BP 90-140/60-90 or not >30 mm Hg systolic or 15 mm Hg diastolic over baseline; pulse 60-90; respirations 12-20/minutes, quiet, easy) Temp q4h unless >37.6°C (99.6°F) or membranes ruptured >q2h Uterine contractions q30min (contractions q5-10minutes, 15-40seconds, mild intensity) FHR q60min (for low-risk women) and q30min (for high-risk women) if reassuring (reassuring FHR has baseline 110-160, LTV average, accelerations with fetal movement, no late or variable decelerations); if nonreassuring, position on side, start O2, assess for hypotension, monitor continuously, notify CNM/physician Active Phase: BP, P, R qlh if WNL Temp as above Uterine contractions q30minutes: contractions q2-3minutes, 60 seconds, moderate to strong FHR q30min (for low-risk women) and ql5min (for high-risk women) if reassuring; if nonreassuring, institute interventions Transition: BP, P, R, q30min	Second stage assessments: BP, P, R q5-15min Uterine contraction palpated continuously FHR q15min (for low-risk women) and q5min (for high-risk women) if reassuring; if nonreassuring, monitor continuously Fetal descent: descent continues to birth Comfort level: woman states is able to cope with contractions and pushing Behavioral characteristics: response to pushing, facial expressions, verbalization Third Stage Assessments: BP, P, R q5min Uterine contractions, palpate occasionally until placenta is delivered, fundus maintains tone and contraction pattern continues to birth of placenta Newborn Assessments: Assess Apgar score of newborn Respirations 30-60, irregular Apical pulse: 120-160 and somewhat irregular Temperature: skin temp above 36.5°C (97.8°F) Umbilical cord: two arteries, one vein (if one artery, assess for anomalies and urine output) Gestational age: 38-42 wk	Expected Outcomes: Appropriate resources identified and used Immediate postbirth assessments of mother ql5min for 1 hr: BP: 90-140/60-90; should return to pre-labor level Pulse: slightly lower than in labor; range is 60-90 Respirations: 12-20/min; easy; quiet Temperature: 36.2-37.6°C (98-99.6°F) Fundus: firm, in midline, at the umbilicus Lochia: rubra; moderate amount; < 1 pad/hr; no free flow or passage of clots with massage Perineum: sutures intact; no bulging or marked swelling; minimal bruising may be present; no do severe pain or rectal pain Bladder: nondistended; spontaneous void of >100 ml clear, straw-colored urine; bladder nondistended following voiding If hemorrhoids present, no tenseness or marked engorgement; <2 cm diameter Comfort level: <3 on scale of 1 to 10Energy level: awake and able to hold newborn Newborn assessments if newborn remains with parents: Respirations: 30-60; irregular Apical pulse: 120-160 and somewhat irregular Temperature: skin temp above 36.5°C (97.8°F); skin feels warm to touch Skin color: noncyanotic Mucus: small amount, clear, easily suctioned with bulb syringe without skin color change Behavioral: newborn opens eyes widely if room is slightly darkened Movements: rhythmic; no hand tremors present Expected Outcomes: Findings indicate normal progression with absence of complications