1st stage managment

management of first stage of labour

1. Management of first stage of labour Prepared by: Nirsuba Gurung Assistant Lecturer MSON

2. Nursing care of women in first stage of labour General : Clean and safe environment Use of aseptic technique Trimming of vaginal hair Constant observation Communication/emotional support

3. Position

4. Bending in back ,Sitting in low chair or bed leaning forward –help in engagement Upright and walking helps in fetal descent Lateral facilitate kidney function and promote blood circulation to fetus

5. Diet In the latent phase of labour allow diet as desired and encourage oral hydration(Uterine muscle contraction requires glucose and, if depleted, muscle inertia may occur. Eating and drinking in early labour has not been shown to significantly affect labour progress, or cause adverse maternal or infant ) Allow a light, low fat, low roughage diet in labour for women at low risk for anaesthesia (Hunger and thirst can lead to ketonuria , which may increase the length of labour and need for interventions)

6. • Women at risk for having a general anaesthetic should have sips of clear fluid only. Consider administration of intravenous fluids for: - Women at risk of dehydration - Fasting women

7. Bladder Encourage women to pass urine every two hourly If women is not able to pass urine for six hour and bladder is found full as suprapubic bulging ,sterile catheter should insert to passed the urine from bladder

8. Bowel Enema should not be given at the end of the first stage of labour Emptying the rectum prevents soiling of the perineum in second stage of labour

9. Rest and sleep Mild sedation and analgesic Ensure adequate sleep

10. Pain management Position Ambulation Small feeding Back massage Breathing technique Warm bath and shower buscopan , morphine

11. Provide comfort and assistance Assist in daily care Praise and reassure her Give detail of progress of labour

12. Teaching bearing down or pushing effort

13. Medication Epidocin –for cervical dilation and effacement

14. Infection control measures

15. Proper recording

16. To note progress of labour Progressive descent of fetal head as measured by one-fifth examination

17. What is a partogram (partograph) ?

18. Definition The partogram Is a graph used in labour to monitor the parameters of progress of labour , maternal and fetal wellbeing, and treatment administration

19. PRACTICAL VALUE OF USING THE PARTOGRAM Offers an objective basis for overtime monitoring the progress of labour, maternal and fetal wellbeing. Enables early detection of abnormalities of labour Prevention of obstructed labour and ruptured uterus .

20. PRACTICAL VALUE OF PARTOGRAM cont Complications of obstructed labour and ruptured uterus contribute up to 30% of maternal deaths in some areas. Proper use of partogram has proved so useful in reduction of both maternal and perinatal mortalities and morbidities

21. Advantage A single sheet of paper can provide details of necessary information at a glance No need to record labour event repeatedly Gives clear picture of normality and abnormality in loabour It can predict deviation from duration of labour ,so appropriate stepscould betaken in time

22. It facilitate handover procedure of staff Save working time of staff against writing labour notes in long hand Educational value for all staff

23. RECOMMENDATIONS ON THE USE OF PARTOGRAM Based on the evidence-based reports on its effectiveness in monitoring of labour . WHO R ecommends its use in all labour wards and for all women (WHO 1994)

24. PRINCIPLES USED TO DESIGN THE PARTOGRAM The partogram depends on the principles that; The latent phase should not last longer than 8 hours The latent phase ends and active phase starts when the cervix is 3cm (4cm is sometimes used) During active phase – the cervix should dilate at not less than 1 cm per hour

25. PRINCIPLES cont A lag time of 4 hours is usually acceptable the slowing of labour and the need to intervene; this is the distance between alert line and the action line .

26. PRINCIPLES OF USING THE PARTOGRAM Basic health facilities Used to monitor labour which is expected to be normal . Those with risk factors should already have been referred. Referral is decided when the progress line of the cervical dilatation deviates to the right of an alert line. 2. Health facilities with comprehensive EmOC. Used to monitor both high and low risk labour

27. PROTOCOL FOR LABOUR MANAGEMENT WITH THE WHO PARTOGRAM

28. EXCLUSIONS Don’t complete the partogram in case of: Prematurity (<34/40) Cervical dilatation 9 -10 cm on admission Elective CS Emergency CS on admission

29. Fetal distress Severe pre- eclampsia Diagnosed CPD Multiple pregnancy Malpresentation

30. STARTING THE PARTOGRAM Latent phase Contractions at least 2 in 10, lasting ≥ 20 sec Active phase Contractions at least 1 in 10, lasting ≥ 20 sec SRM but no contractions When oxytocin is started or when labour commences Inductions At ARM ± oxytocin When induction is medical start when labour commences (see 1 and 2) or membranes rapture.

31. DESIRED UTERINE CONTRACTIONS The desired rates of uterine contractions in labour = 4 - 5 in 10 minute, each lasting 40-50 seconds. It may be maintained at that rate throughout 2 nd and 3 rd stage of labour

32. TIMING OBSERVATIONS IN LATENT PHASE AND ACTIVE PHASE UP TO ACTION LINE Parameter Ideal in both phases (hrs) Minimum acceptable Latent phase Active phase Vaginal examination 4 8 4 Descent of head 4 8 4 Contractions ½ 4 2 Fetal heart beats ½ 4 1 Temperature, PR, BP, urine 4 4 4

33. TIMING OBSERVATIONS IN LATENT PHASE AND ACTIVE PHASE Vaginal examination may be carried out more frequently in advanced first stage 7+cm or if problems develop

34. Part 1 : Fetal condition this part of the graph is used to monitor and assess fetal condition 1 - Fetal heart rate 2 - membranes and liquor 3 - molding the fetal skull bones. Caput

35. Fetal heart rate < 160 beats/min =tachycardia > 120 beats/min = bradycardia > 100beats/min=severe bradycardia Decelerations? yes/no Relation to contractions? Early Variable Late

36. membranes and liquor intact membranes ……………………………………… .I ruptured membranes + clear liquor …………………… .C ruptured membranes + meconium- stained liquor …… ..M ruptured membranes + blood – stained liquor ………… B ruptured membranes + absent liquor ………………… ....A

37. Molding the fetal skull bones Molding is an important indication of how adequately the pelvis can accommodate the fetal head. Increasing molding with the head high in the pelvis is an ominous sign of Cephalopelvic disproportion. separated bones . sutures felt easily ……… .O bones just touching each other …………… ..+ overlapping bones …………… ………… ...++ severely overlapping bones ( notable ) …… ..+++

38. Part 2 – progress of labour . Cervical dilatation Descent of the fetal head Uterine contractions this section of the paragraph has as its central feature a graph of cervical dilation against time it is divided into a latent phase and an active phase

39. latent phase : it starts from onset of labour until the cervix reaches 3 cm dilatation once 3 cm dilatation is reached , labour enters the active phase lasts 8 hours or less each lasting < 20 seconds at least 2/10 min contractions

40. Active phase : Contractions at least 3 / 10 min each lasting < 40 seconds The cervix should dilate at a rate of 1 cm / hour or faster

41. Action line ( hospital line ) The action line is drawn 4 hour to the right of the alert line and parallel to it This is the critical line at which specific management decisions must be made at the hospital

42. Cervical dilatation It is the most important information and the surest way to assess progress of labour , even though other findings discovered on vaginal examination are also important when progress of labour is normal and satisfactory , plotting of cervical dilatation remains on the alert line or to left of it if a woman arrives in the active phase of labour , recording of cervical dilatation starts on the alert line when the active phase of labor begins , all recordings are transferred and start by platting cervical dilatation on the alert line

43. When labor goes from latent to active phase , plotting of the dilatation is immediately transferred from the latent phase area to the alert line

44. Descent of the fetal head It should be assessed by abdominal examination immediately before doing a vaginal examination, using the rule of fifth to assess engagement The rule of fifth means the palpable fifth of the fetal head are felt by abdominal examination to be above the level of symphysis pubis When 2/5 or less of fetal head is felt above the level of symphysis pubis , this means that the head is engage , and by vaginal examination , the lowest part of vertex has passed or is at the level of ischial spines

45. Assessing descent of the fetal head by vaginal examination; 0 station is at the level of the ischial spine (Sp).  

46. Uterine contractions Observations of the contractions are made every hour in the latent phase and every half-hour in the active phase frequency how often are they felt ? Assessed by number of contractions in a 10 minutes period duration how long do they last ? Measured in seconds from the time the contraction is first felt abdominally , to the time the contraction phases off Each square represents one contraction

47. Palpate number of contraction in ten minutes and duration of each contraction in seconds Less than 20 seconds:   Between 20 and 40 seconds: More than 40 seconds:

48. Part 3: maternal condition Name / Age /Gestation Medical / Obstetrical issues Assess maternal condition regularly by monitoring : drugs , IV fluids , and oxytocin , if labour is augmented pulse , blood pressure, Temperature, Urine volume , analysis for protein and acetone

49. Thank you