A nurse is caring for a client who is in labor and reports increasing rectal pressure. She is experiencing contractions 2 to 3 min apart, each lasting 80 to 90 seconds, and a vaginal examination reveals that her cervix is dilated to 9 cm. The nurse should identify that the client is in which of the following phases of labor?
A Active
B Transition
C Latent
D Descent
The Correct answer and Explanation is:
The correct answer is B: Transition.
In the context of labor, the phases are generally categorized into three stages: the latent phase, active phase, and transition phase, followed by the descent (or second stage) of labor.
- Latent Phase: This is the early stage of labor, where the cervix dilates from 0 to about 3 cm. Contractions are typically mild and irregular, and this phase can last for many hours or even days.
- Active Phase: In this phase, the cervix dilates from 4 to 7 cm. Contractions become more regular, occurring every 3 to 5 minutes and lasting about 60 seconds. Women may begin to focus more on the labor process, and pain management may become more necessary.
- Transition Phase: This is characterized by rapid cervical dilation, from 8 to 10 cm. The contractions are very strong and can occur every 2 to 3 minutes, lasting 60 to 90 seconds, as described in the scenario. During this phase, women often experience significant discomfort, including increased rectal pressure, which the client is reporting. This phase is often the most intense, both physically and emotionally, as the body prepares for the descent of the baby.
- Descent Phase: Also known as the second stage of labor, this phase begins when the cervix is fully dilated (10 cm) and involves the baby’s descent through the birth canal.
Given that the client is at 9 cm dilation with contractions occurring every 2 to 3 minutes and lasting 80 to 90 seconds, these signs clearly indicate that she is in the transition phase of labor. It’s essential for the nurse to provide supportive care and prepare for imminent delivery, as transition can lead quickly into the descent phase, where the baby will be born.