Labour 1st stage

UNIT 4 OBG

1. NORMAL LABOUR

2. NORMAL LABOUR Series of events that takes place in the genital organs, in an effort to expel the viable products of conception out of the womb through the vagina into the outer world.

3. STAGES OF LABOUR Ist STAGE :- From onset of true labour pains till the full dilatation of cervix. Its 12 hrs in primigravida and 6 hrs in multiparae .

4. Contd… IInd STAGE :- From full dilatation of cervix till fetus is delivered. Its 2 hrs in primigravidae and 30 min . in multiparae .

5. Contd… IIIrd STAGE :- From delivery of fetus till delivery of placenta . Its of average 15 mins in PGR.

6. 4 TH STAGE It is the stage of observation for at least 1 hour after expulsion of the after birth. During this period, general condition of the patient and the behavior of uterus are to be care fully watched

7. First stage of labour The first stage of labour starts with the onset of labour pains to the full dilatation of the cervix. This stage takes about 12 hours in primi-gravida and half that time for subsequent deliveries.

8. EVENTS IN 1 ST STAGE OF LABOUR FACTORS Predisposing Actual factors factors

9. Pre-disposing factors Softening of the cervix Fibro- musculo -glandular hypertrophy Increase vascularity Accumulation of fluid in between collagen fibres Breaking down of collagen fibrils by enzymes collagenase and elastase .

10. ACTUAL/MAIN EVENTS Dilatation and effacement of cervix. Full formation of lower uterine segment.

11. Actual factors 1)Uterine contractions and retractions The longitudnal muscle fibres of upper segment are attached with circular muscle fibres of lower segment and upper part of cervix in a bucket holding fashion .

12. 2)Bag of memberanes The memberanes are attached loosely to the decidua lining the uterine cavity expect over the internal os . In vertex presentation girdle of head fit in to lower uterine segment and divides amnotic cavity in to two parts that are forewater and hindwater . This generates hydrostatic pressure and dilates the cervical canal

13. Fetal axis pressure: in longitudnal lie there is tendency of straightening out of the fetal vertebral column due to contractions of circular muscles of the body of uterus, this exerts pressure on cervix and dilates cervical canal.

14. Vis-a- tergo : it is the downward thrust of the presenting part of fetus and upward pull of cervix over lower uterine segment.

15. Effacement It is the process by which the muscular fibres of the cervix are upward and merges with fibres of the lower uterine segment.

16. Lower uterine segment As the labour progresses wall of upper segment becomes thickened and there is thining of lower segment. A distinct ring is produced at the junction of two, called physiological retraction ring.

17. NURSING CARE DURING THE FIRST STAGE OF LABOR:

18. NURSING CARE DURING THE FIRST STAGE OF LABOR: A. Hospital Admission . After a physician or nurse has evaluated the patient, an admission order is written. At this point duties of nurse are: (1) Establish a rapport with the patient and significant others. (2) Remove nail paint from hands, feet, jewelry and handover all belongings to significant relatives (3) Change the clothes of the women according to policy

19. ( 4) Taking history Present labour – name Case number When labour started Membranes ruptured or intact Frequency or strength of contractions

20. Past history Parity Character of previous labour Weight and condition of previous babies Evidence of cephalopelvic disproportion Maternal disease Rh - isoimmunization

21. (5) Perineal Preparation Shaving of pubic hair to prevent infection of perineal episiotomy/lacerations. (6) Enema The purposes of enema are: To stimulate uterine contractions To assure a clean field without fecal contamination at the time of delivery

22. (7) Rest and ambulation Intact membranes- allowed to walk Ruptured membranes - bed rest in left lateral position. (8) Diet- Food is withheld during active labour Fluids in the form of plain water, fruit juice may be given in early labour In DMC & H Semi solid diet and liquids are allowed during first stage

23. (9) Bladder care – Patient is encouraged to pass urine by herself as full bladder often inhibits uterine contractions. (10) Explain all procedures or routines, which will be carried out prior to performing them. These include: (a)Explain activities allowed and disallowed according to ward policies (i.e. bathroom privileges). (b) Use of fetal monitors to know the fetal well being

24. 11 ) Initiate the patient's labor chart. 12 ) Orient the patient to the surroundings. 13) Explain visiting hours or policies to patient and relatives: IN DMC&H One female attendant is allowed for 24 hours No male attendant is allowed .

25. 14) Use of partograph to assess progress of labor as well as fetal status and well being. NOTE: In Partograph nurse has to assess: i ) Fetal heart rate ii) Status of liquor C - clear MS -meconium stained Amniotic fluid should be carefully examined for meconium if the fetus is in the vertex presentation, (that is, head first).

26. VAGINAL EXAMINATION . Only the physician or a trained nurse performs this exam. It is done to evaluate cervical effacement, cervical dilatation , status of membranes, & station of presenting part . Care must be taken to perform good perineal cleansing before and after the procedure (vaginal examination). Once membranes rupture, the exam should be limited even further to prevent the risk of infection.

27. CONTRACTIONS When palpating for contractions, place hand over the fundal area of the patient's uterus. Contractions can be felt by fingers before the patient actually becomes aware of them.

28. Contractions The purpose of this evaluation is to assess the ability of the uterus to dilate the cervix, help in determining the progress of labor 1.FREQUENCY(how often in minutes contraction occurs 2. INTENSITY: (Strength of Contractions as:-) MILD- <20 seconds MODERATE- 20-40 seconds SEVERE- 40-60 seconds 3. DURATION:(How long the contraction lasts in Seconds)

29. Vital Signs Monitor the patient's vital signs. (1) On admission. (2) Every hour during early labor. (3)Blood pressure (BP), pulse (P), and respiratory rate (R) every 30 minutes during active, to include the temperature every hour. (4) More frequently if complications arise.

30. General measures Rest and ambulation Vaseline may be applied to her lips to prevent chapping. Assist the patient in turning side to side Elevate the bed at 30 to enhance breathing Avoid supine position Prefer left lateral position

31. Criteria for shifting the patient to delivery table After full dilatation ( 10 cm dilatation ) shift the patient to delivery table.

32. EVIDENCE BASED STUDIES

33. Use of birthing ball for comfort in pregnancy & labour This will help to keep the deep muscles of the spine in good working conditions. The ball has many uses in late pregnancy when sitting can become so uncomfortable. The ball support perineal muscles without a lot of pressure and keep the fetus aligned in the pelvis.

34. Ambulation during labour Ambulation in women during labour is very necessary during the labour. It should be free to adopt any position unless there is any medical or obstetrical contraindication. It helps to reduce the time period means shorter the labour with less labour pain.

35. Vaginal examination It should be performed by trained personnel only. It should be done every 4 hourly not more frequently and should be carried out under strict asepsis during labour.

36. Support during labour According to evidenced based practices the presence of second person of the women own choice during the labour. The second Should be an experienced women who has some understanding of the birthing process.

37. Use of enemas There is no evidence that enemas will shorter the length of labour and also reduce in infection rate in post delivery . It should be given when there is clear indication and women has to wish to take it.