# Situation: A 25-year-old primigravida at 40 weeks' gestation is in labor at a birthing facility that follows the Department of Health (DOH) Essential Intrapartum and Newborn Care (EINC) protocol. Her companion of choice stays with her, and her labor has been uncomplicated. Later, the client says she feels a strong urge to push and rectal pressure. Vaginal examination shows the cervix 8 cm dilated and fully effaced, with the head at +1 station. What is the nurse's BEST interpretation?

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> subject: Nursing Practice II — Maternal and Child Health Nursing

## 문제

Situation: A 25-year-old primigravida at 40 weeks' gestation is in labor at a birthing facility that follows the Department of Health (DOH) Essential Intrapartum and Newborn Care (EINC) protocol. Her companion of choice stays with her, and her labor has been uncomplicated.

Later, the client says she feels a strong urge to push and rectal pressure. Vaginal examination shows the cervix 8 cm dilated and fully effaced, with the head at +1 station. What is the nurse's BEST interpretation?

## 보기

1. She is in the second stage, since the head is already below the spines
2. She is in the second stage, as the urge to push signals full dilation
3. She is in the transition period; pushing now can cause cervical swelling **✔ 정답**
4. She is in the transition period; pushing now will shorten the second stage

**정답: 3**

## 해설

The second stage begins only at complete (10 cm) dilation. At 8 cm she is in the transition period of the active phase, when rectal pressure and an early urge to push are common. Pushing before full dilation can cause cervical edema and maternal exhaustion, so she is helped to breathe through contractions until full dilation is confirmed.

## 심화 해설

The correct interpretation is that this client remains in the first stage of labor, specifically the transition phase, and should not begin active pushing yet.

The urge to push is a powerful clinical cue, but it must always be correlated with cervical dilation. The second stage of labor begins only when the cervix is fully dilated at 10 cm. At 8 cm with complete effacement and a fetal station of +1, the presenting part is descending and exerting pressure on the rectum, which triggers the familiar sensation of needing to defecate or push. However, the cervix still has 2 cm of dilation remaining.

The transition period of the active phase is characterized by strong contractions, rectal pressure, and an early urge to push before full dilation is achieved. If the client pushes against a cervix that is not completely dilated, the fetal head can compress the anterior cervical lip against the symphysis pubis, leading to cervical edema, lacerations, and prolonged labor due to maternal exhaustion.

The management priority is to help the client avoid bearing down until full dilation is confirmed by vaginal examination. Strategies include positioning changes such as side-lying or hands-and-knees, and coaching her to exhale or pant through contractions instead of holding her breath and pushing. This approach protects the cervix and conserves maternal energy for the active pushing phase.

Watch out! Do not equate the urge to push with the onset of the second stage. The urge can appear before 10 cm dilation, especially when the fetal head is low in the pelvis.

Key point! The second stage begins at 10 cm dilation, not at +1 station or with the first sensation of rectal pressure.

The distinction between the passive and active phases of the second stage is also relevant here. A retrospective cohort study of nulliparous women defined the passive second stage as the interval from complete cervical dilation until the start of active pushing . In the current scenario, the client has not yet reached complete dilation, so she is not even in the passive second stage. She is still in the transition period of the first stage.

The clinical rationale for delaying pushing is supported by the understanding that the passive second stage allows the fetal head to descend and rotate without active maternal effort, which may reduce the risk of operative delivery and maternal fatigue . However, this evidence applies only after full dilation is confirmed. Before that point, the priority is to prevent cervical injury.

| Clinical finding | Interpretation | Nursing action |
| --- | --- | --- |
| Cervix 8 cm dilated, fully effaced | Transition phase of the first stage | Continue monitoring; do not initiate pushing |
| Fetal head at +1 station | Head is below the ischial spines but cervix is not fully open | Position changes to reduce pressure; encourage panting |
| Strong urge to push with rectal pressure | Expected response to fetal descent, not a sign of full dilation | Coach to breathe through contractions until 10 cm is confirmed |

The incorrect options conflate fetal station or the urge to push with the onset of the second stage. Station describes descent, not cervical readiness. A head at +1 station can occur while the cervix is still 8 cm dilated. Similarly, the urge to push is a sensory response to pressure, not a reliable indicator of complete dilation. Only a vaginal examination confirming 10 cm dilation marks the transition to the second stage.

The EINC protocol emphasizes evidence-based, low-intervention care that supports physiologic labor while preventing unnecessary complications. Delaying pushing until full dilation is consistent with this principle because it reduces the risk of cervical edema, which can obstruct descent and prolong labor. The nurse’s role is to provide reassurance, reposition the client to relieve pressure, and guide her breathing until the cervix is fully dilated.

## 임상 시나리오

Urge to Push Before Full DilationTransition Phase Management in EINC
The second stage begins only at 10 cm dilation. At 8 cm with full effacement and +1 station, the client is in the transition phase of the first stage.

Rectal pressure and an early urge to push are common during transition due to descent of the presenting part, but they do not confirm full dilation.

Help the client avoid bearing down by coaching panting or exhaling through contractions and using positions such as side-lying or hands-and-knees until full dilation is confirmed.

CautionPushing before 10 cm can compress the anterior cervical lip, causing cervical edema, lacerations, and maternal exhaustion. Always correlate the urge to push with vaginal examination findings.

## 핵심 개념

- **Transition phase** — The last part of the active phase of the first stage of labor, from about 8 cm to 10 cm dilation, marked by strong contractions and an early urge to push.
- **Second stage of labor** — Begins at complete cervical dilation (10 cm) and ends with delivery of the fetus.
- **Cervical edema** — Swelling of the cervix that can result from pushing against an incompletely dilated cervix, potentially prolonging labor.
- **Fetal station** — Relationship of the fetal presenting part to the ischial spines; +1 means the head is 1 cm below the spines.
- **EINC** — Essential Intrapartum and Newborn Care, a DOH protocol promoting evidence-based, low-intervention labor and delivery practices.

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