4. Labour - 1st Stage - Management-1.pptx

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1. Labor – First Stage Management Dr. S. Kalavathi Professor RMCON, AU.

2. Introduction Labor is a unique experience in women’s life. Labor events have got great psychological, emotional and social impact to the woman and her family. The knowledge of physiological changes during labor , ensures appropriate care to the mothers. Labor pain is real and the mothers are sensitive. Mother experiences pain, stress and fear of unknown/danger. 2

3. Introduction The main aim of MCH is reduction of Maternal & Perinatal morbidity and mortality The function of midwifery is preventive Every mother would like to deliver a healthy baby Every midwife should aim to fulfil her wish

4. General Considerations Caregivers need to be tactful, sensitive & respect mother’s feelings. Privacy, and explanation is to be given. Mother can choose her birth companion. Continuous emotional support reduces the need for analgesia & operative delivery. Keep her informed her about the progress of labour . Environment should be so, that she can birth with dignity. 5

5. Aims of management in Normal Labor Maximal observation with minimal active intervention. Maintain normalcy. Detect deviation from normal at the earliest possible moment. Take necessary action like informing seniors or referring, etc. 6

6. Admission of the Mother Quick history collection, assessment need to be done. Refer medical records, & learn the condition of the mother. Care according to the stage of labour . Make her feel comfortable by showing a welcome attitude & by giving reassurance. Admission bath may be given & dress, jewels, artificial dentures, lenses, need to be taken care. Consent form… 7

7. Antisepsis & Asepsis Strict asepsis and antisepsis should be maintained. Shaving/hair clipping of the vulva or perineal care as per policy. Shower or bath & wear laundered gown. Strict aseptic technique to be followed during vaginal examinations & during conduction of delivery. 8

8. Vaginal examinations in labor Vaginal examination findings serve as a baseline data. Frequent PV exam should be avoided. PV exams can be done every 4 hourly in normal labor to assess the progress of labor. Even if the proper aseptic techniques are followed there is chance of introducing infection, specially after rupture of membranes. 10

9. Vaginal examinations in labor [Cont..] Indications Vaginal examination is done on admission by a senior doctor: to confirm the onset of labor & the onset of II stage of labor, to confirm the presenting part & station, to confirm the position, to assess pelvic adequacy ( Primi ), Following rupture of membranes, to exclude cord prolapse . 11

10. Management of First Stage Principles Non interference with watchful expectancy so as to prepare the patient for natural birth. To monitor carefully the progress of labor, maternal conditions and fetal behavior, so as to detect any intra partum complications early. Maintain privacy. 12

11. Management of First Stage General Care Admission of the mother. Confirm the stage in which she is & care accordingly. Constant supervision. Avoid supine position in bed to avoid vena caval congestion. 13

12. Management of First Stage Bowel Care Traditionally an enema with soap and water or glycerine suppository is given early in labor. Enema reduce the load in the rectum & contamination in second stage. Studies have proved that enema does not shortens the 2 nd stage or the rate of infection. Giving enema – Follow the Institution Policy 14

13. Management of First Stage [Cont..] Rest and Ambulation Mother can be ambulated in first stage if, The membranes are intact. Not given any analgesia. Ambulation may reduce the duration of labor and the need of analgesics & improve the maternal comfort. 15

14. Management of First Stage [Cont..] Diet Emptying of the stomach is delayed in labor. Gastric content pH is low. Fluids (Juices, water) may be given in early labor. Intravenous infusion may be started where any intervention is anticipated or patient is under regional anesthesia. Food is withheld in active labor. 16

15. Management of First Stage [Cont..] Bladder Care Encourage mother to empty the bladder by herself frequently [Full bladder inhibits contractions and may cause infection]. If fails to urinate on her own, catheterize following aseptic precautions. If women can not go to the toilet, bedpan is to be provided. Maintain privacy. 17

16. Management of First Stage [Cont..] Relief of Pain Pain relief is an important aspect in care of mother in labour . Pain relief is achieved by Pharmacological or Non Pharmacological methods. Explanation, reassurance, relaxation, back massage, etc. are useful pain relief. Common analgesic drug used is Pethidine , 50 to 100mg IM given in well established labour , and can be repeated after 4 hours. Pethidine crosses the placenta, causes respiratory depression to the neonate. Pethidine should not be given if delivery is anticipated within 2 hours. 18

17. Management of First Stage – Observation Maintain partograph Maternal Vitals – Pulse, Respiration, BP, Temperature Observe the tongue periodically for hydration Uterine contractions – duration & interval Urine output

18. Partograph Partograph is a paper-based tool developed by the W.H.O. . According to standard W.H.O. protocol, different labour vitals need to be monitored at a different intervals based on the stage of labour. The partograph or partogram has been established as the “gold standard” labor monitoring tool universally. A partogram or partograph is a composite graphical record of key data (maternal and fetal ) during labour entered against time on a single sheet of paper. It includes, relevant measurements such as cervical dilation , fetal heart rate , duration of labour and vital signs . It is intended to provide an accurate record of progress in labour, & to detect quickly, deviation from normal & to treat it accordingly.

19. Components of Partograph Patient identification data. Time: It is recorded at an interval of one hour. Zero time (for spontaneous labour) is time of admission in the labour ward. For induced labour is time of induction. Fetal heart rate is recorded every thirty minutes. State of membranes and colour of liquor: "I" designates intact membranes, "C" designates clear and "M" designates mecconium stained liquor.

20. Components of Partograph Cervical dilatation and descent of head. Uterine contractions: Squares in vertical columns are shaded according to duration and intensity. Drugs and fluids Blood pressure : is recorded in vertical lines at an interval of 2 hours. Pulse rate : is also recorded in vertical lines at an interval of 30 minutes. Oxytocin : Concentration is noted down in upper box; while dose is noted in lower box. Urine analysis Temperature recordings

21. Advantages of using Partograph The use of the partograph is recommended as an important indicator for monitoring intrapartum care. Partograph includes several labour vitals including cervix dilatation of the mother. Plotting the cervix dilatation against time can help in predicting early, deviation from the normal progress of labour. Provides information on single sheet of paper at a glance. Improvement in maternal morbidity , perinatal morbidity and mortality . A partograph is contained in the Perinatal Institute's "Birth notes’’. Use of a partograph in established labour is recommended by the National Institute for Clinical Excellence (NICE) in the " Intrapartum Care" guidelines.

22. Limitations of Partograph Partograph requires a skilled healthcare worker to fill and interpret the findings. Often paper - partograph and the equipment required to complete it are unavailable in low resource settings. Despite decades of training and investment, implementation rates and capacity to correctly use the partograph are very low. According to some recent literature, cervical dilatation over time is a poor predictor of severe adverse birth outcomes. This raises questions around the validity of a partograph alert line.

23. ADVANTAGES OF PARTOGRAPH Provides information on single sheet of paper at a glance Early prediction of deviation from normal progress of labour Improvement in maternal morbidity , perinatal morbidity and mortality . Usage A partograph is contained in the Perinatal Institute's "Birth notes “ . Use of partograph in labour is recommended by the National Institute for Clinical Excellence (NICE) in the " Intrapartum Care" guidelines.

24. Limitations It requires a skilled healthcare worker who can fill and interpret the partograph . Recent studies have shown there is no evidence that partograph use is detrimental to outcomes. Often paper- partograph and the equipment required to complete it are unavailable in low resource settings. Despite decades of training and investment, implementation rates and capacity to correctly use the partograph are very low. Some recent literature found that, cervical dilatation over time is a poor predictor of adverse birth outcomes. This raises questions around the validity of a partograph alert line.

25. Digital Partograph A digital partograph is an electronic implementation of the standard paper-based partograph / partogram that can work on a mobile or tablet PC. Partograph is a paper-based tool developed by the W.H.O. to monitor labour during pregnancy. The use of the partograph is recommended as an important indicator for monitoring intrapartum care. Partograph includes several labour vitals including cervix dilatation of the mother. Plotting the cervix dilatation against time can help in predicting deviation from the normal progress of labour. In order to overcome the limitations of paper-based partograph , various researchers have suggested the use of digital partograph . Much literature is available regarding the feasibility of a digital partograph .

26. Digital Partograph A digital partograph is an electronic implementation of the standard paper-based partograph that can work on a mobile or tablet PC.

27. DIGITAL PARTOGRAM

28. Advantages of Digital Partograph Allows easy data analysis Data is essential in healthcare & electronic partograph makes a digital copy of the data. Partograph itself is a very basic form of A I & with more data, we can improve the underlying algorithm to predict complications, adverse outcomes during labour. Availability A common reason for low partograph use is non-availability of paper-based partograph . The limitations, can be overcome by use of digital partograph . The feasibility of digital partograph is high, provided an adequate power supply. Ease of use Plotting paper partograph requires training. Digital photographs are made highly simple to use by taking advantage of advances in human-computer interaction except that Non-tech savvy users might find it overwhelming.

29. Advantages of Digital Partograph Mitigating human errors Electronic partograph remind the midwives to enter labour vitals in case they forget the standard protocol. In some cases, such small aid can be life-saving by decreasing the delay in decision making. Increased accountability & preventing false data entry. Often the partograph is filled after delivery only for record keeping purpose. With electronic records, it is impossible to temper the data. Actual time of data entry can be logged easily. This allows obtaining a correct metric of protocol adherence for the labour monitoring process.

30. Management of First Stage – Observation Descend of presenting part – by Abdominal palpation, Pelvic grip, PV examination & Shifting of maximal intensity of FHS

31. Management of I Stage- Assessment of Fetal Wellbeing Check the FHR – Rate, rhythm, and intensity Counted every half an hour in early labour ; Every 15 minutes in late labour ; and every 5 minutes in second stage of labour Count FHR for full 1 minute; The count immediately following uterine contractions is valuable. Normal FRH – 110 to 160 beats per minute Continuous Electronic Fetal Monitoring – is done in high risk pregnancies

32. Clinical Fetal Monitoring 37

33. Clinical Fetal Monitoring 38

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35. Management of First Stage [Cont..] Assessment of Progress of Labor Pain – duration and interval. As the labour advances, the duration increases and the interval decreases. Station of the head – can be assessed by abdominal palpation & PV examination. Cervical dilatation & effacement. After latent phase, in Primi – 1 cm/hour & in Multi – 1.5 cm/hour is the rate of dilatation. 40

36. Management of First Stage [Cont..] Preparation for Second Stage of Labor The mother may be anxious of labour , because of pain and fear of unknown, Fear of outcome of labour etc. Physical Preparation of the mother. Psychological preparation of the mother. Preparation of delivery tray, resuscitation tray etc. 42

37. Evidence of Maternal Distress Anxious look with sunken eyes, Rising pulse rate of 100 per minute or more, Dehydration, dry tongue, Hot, dry vagina often with offensive discharge, Acetone smell in breath, Scanty high colour urine with presence of acetone. 43

38. Management of First Stage – Observation Descend of presenting part – by Abdominal palpation, Pelvic grip, PV examination & Shifting of maximal intensity of FHS

39. Management of I Stage- Assessment of Fetal Wellbeing Check the FHR – Rate, rhythm, and intensity Counted every half an hour in early labour ; Every 15 minutes in late labour ; and every 5 minutes in second stage of labour Count FHR for full 1 minute; The count immediately following uterine contractions is valuable. Normal FRH – 110 to 160 beats per minute Continuous Electronic Fetal Monitoring – is done in high risk pregnancies

40. Clinical Fetal Monitoring 46

41. Clinical Fetal Monitoring 47

42. 48

43. Management of First Stage [Cont..] Assessment of Progress of Labor Pain – duration and interval. As the labour advances, the duration increases and the interval decreases. Station of the head – can be assessed by abdominal palpation & PV examination. Cervical dilatation & effacement. After latent phase, in Primi – 1 cm/hour & in Multi – 1.5 cm/hour is the rate of dilatation. 49

44. Management of First Stage [Cont..] Preparation for Second Stage of Labor The mother may be anxious of labour , because of pain and fear of unknown, Fear of outcome of labour etc. Physical Preparation of the mother. Psychological preparation of the mother. Preparation of delivery tray, resuscitation tray etc. 50

45. Evidence of Maternal Distress Anxious look with sunken eyes, Rising pulse rate of 100 per minute or more, Dehydration , dry tongue, Hot , dry vagina often with offensive discharge, Acetone smell in breath, Scanty high colour urine with presence of acetone. 51

46. Summary & Conclusion Thank You… 52