Management of a Woman in First Stage of.pptx

First stage of labor

1. Management of a Woman in First Stage of Labour Bugando SON Midwifery 1 ALICE SHALUA RN/NM, ADNE,BScN , MNEd

2. By the end of this session, students are expected to be able to: Explain the signs and symptoms of labour Describe and demonstrate a vaginal examination Describe normal and abnormal findings on a vaginal examination Explain the management of a woman during the first stage of labour Learning Tasks

3. Recognition by the Mother woman herself usually diagnoses the onset of labour Show pink jelly-like discharge lost at the beginning of labour. It is the sign that labour is imminent or underway Contractions True labour contractions exhibit a pattern of rhythm and regularity usually increasing in length Contractions will be short initially, lasting 30 to 40 seconds and may be as much as half an hour apart . Signs and Symptoms of First Stage of Labour

4. Rupture of membranes May be difficult for woman to recognize a sudden gush of fluid as rupture of membranes and she should be instructed to inform the midwife immediately if this happens Recognition by the Midwife How? Abdominal exam to assess firmness, frequency and length of contractions PV exam to assess dilatation, effacement and station Signs and Symptoms of First Stage of Labour continued…

5. 5 Ps Passage Passenger Position Power or Physiological forces Psychosocial factors Labour Assessment

6. Abdominal Exam: Leopolds Fundal Height Lie Attitude Presentation Presenting part Engagement Fetal Heart tones Labour Assessment continued…

7. Descent of fetal head measured abdominally in terms of fifths or finger lengths above the brim: Labour Assessment continued…

8. A vaginal examination should be preceded by an abdominal examination Give an explanation and the obtain verbal consent Repeat in 4 hourly intervals and record on the partograph The woman’s bladder should be empty as the head may be displaced by a full bladder Vaginal Exam

9. Make a positive identification of presentation Determine whether the head is engaged Ascertain whether the fore waters have ruptured, or to rupture them artificially (no evidence this actually decreases time of labour) Exclude cord prolapse after rupture of fore waters, especially if there is an ill-fitting presenting part or fetal heart rate changes Assess progress or delay in labour Confirm full dilatation of the cervix Indications for a Vaginal Exam

10. A woman with history of repeated vaginal bleeding during pregnancy or obvious vaginal bleeding during labour. A woman for elective caesarian section A woman with genital warts and or genital herpes Contraindications to a vaginal Exam

11. The external genitalia: This is obtained by observation, normal findings include Discharges i.e. liquor and show. Abnormal findings include: Varicose veins Blood or pus or meconium stained discharges Warts and ulcers Old scars from tears and episiotomy or clitoridectomy Smell (offensive smell) Findings of Vaginal Exam

12. Normal findings: The walls should feel soft and stretchable. Vagina should feel warm and moist Abnormal findings: Hot and dry vagina is a sign of obstructed labour. In high temperatures it will feel warm but remains moist. Firm rigid walls may indicate type 3 female genital mutilation (FGM) and it indicates prolonged labour A cystocele may be felt anteriorly in multiparous women and stool in the rectum rectum may be felt on the posterior Condition of the Vagina

13. Normal findings: In established labour the effacement is complete and is closely applied to the presenting part. The consistency of the cervix should be soft and elastic in established labour The degree of dilatation of the uterine os is estimated by centimeters across the opening. A diameter of 10 cm indicates fully dilatation of the cervix. Cervix and Cervical Os

14. Abnormal findings: If the cervix is 2.5 cm long and is closed labour is not established. A tough hard un-dilatable cervix indicates unyielding cervix (rigid) especially if the woman has been in labour for some time. Edematous cervix which may be found on anterior part may be due to obstructed labour . Dilatation less than 1 cm per hour in active phase (some flexibiity between 4 and 7 centimeters) Cervix and Cervical Os continued…

15. Normal finding ; Intact membranes Abnormal findings ; Rupture of membranes in early labour Bulging membranes/elongated membranes. This may indicate that the membranes will rupture early or badly fitting presenting part Forewaters

16. It is assessd in relation to the maternal ischial spines to determine descent of the presenting part . Level or Station

17. The midwife should bear in mind about caput succedaneum and moulding which may give wrong interpretation of the level of the presenting part Abnormal findings; Excessive caput Excessive moulding No descending presentation in spite of good contractions The ischial spines Level or Station continued…

18. 99 % of all pregnant women present their fetuses by vertex. This is recognized by feeling the hard cephalic bone, the fontanelles and sutures . Identification of the Presentation

19. Abnormal findings; Feeling the buttocks, the limbs, face, shoulder or brow in the lower pole of the uterus Identification of the Presentation continued…

20. P osition is detected by feeling the features of the presenting part The vertex has the fewest diagnostic features , and is the most common presentation S agittal suture C ommonly felt in the right or left oblique diameter of the pelvis S ometimes during the process of labour it may be felt in the transverse diameter Towards the end of the 1st stage after rotation of the head it may be felt in the anterior posterior diameter. Fontanelles The anterior is a diamond shaped membranous space with 4 sutures leaving it In a well flexed head the posterior fontanel will be detected by its triangular shape with 3 sutures leaving it Identification of the fontanels will help the midwife find the occiput to detect the position. The Position

21. Moulding is judged by the degree of overlapping of the fetal skull bones e.g. parietal bones to override the occipital bones The Moulding

22. If the pelvic capacity was not assessed before, the midwife should do it during vaginal examination during labour Try to reach the sacropromontory to assess the anterior posterior diameter of the brim The Pelvic Capacity

23. The ischial spines should be blunt The sacral curve should be curved. Check the pubic angle; it should accommodate the two examining fingers that is 90 degrees angle. The Pelvic Capacity continued…

24. PV Demonstration

25. Explain the procedure to the woman and give her an opportunity to ask questions. Vaginal examination is an aseptic procedure. Wash hands with soap and water before preparing the equipments . Method

26. Sterile bowl with antiseptic solutions Sterile swabs Sterile gloves Perineal pad Sterile hand towel A receiver for soiled swabs A cocher forceps if the indication is to rupture the membranes Prepare Tray

27. Explain the procedure to the mother Let her ask the questions to allay anxiety Ask her to empty the bladder Screen the bed to provide privacy P erform and record findings for abdominal exam Ask the woman to lie on her back If she is dirty wash her thighs and the vulva with soap and water Scrub hands and put on sterile gloves Ask the woman to flex her knees and separate the thighs Procedure

28. Swab the vulva using the right hand while holding the swabs with the left hand The number of swabs depends on the condition of the vulva i.e. with much show etc usually 3 Swab the left labia minora then the right labia minora . Separate the labia minora with the first finger and thumb of left hand and swab the vestibule and the vaginal orifice with the right hand without contaminating the hands. Use only one strip. Do not remove the left hand Procedure continued…

29. Dip the first two fingers of the right hand into a lubricant and gently insert them into the vagina in a downward and backward direction avoiding touching the anus. While exploring avoid pressing the clitoris as it may cause discomfort to the mother . Procedure continued…

30. Do not remove the fingers until you have obtained all necessary information about the following; Condition of the vagina The cervix and cervical os The bag of waters The level of the presenting part Presentation and position Degree of moulding Abnormalities Procedure continued…

31. On completion of the exam withdraw fingers and check the discharge from the vagina. Place 4 knuckles between the ischial tuberosities and see if all can be accommodated. After the examination the results should be explained to the woman. Procedure continued…

32. Remove the gloves and put them in the dust bin marked highly infectious. Immerse the used equipments in chlorine 0.5% for 10 minutes. Remove them and wash them in soapy water. Rinse them in clean water, air dry then sterilize ready for another use next time Immediately record the findings before forgetting. Procedure continued…

33. Welcome the woman and her companion Review the woman’s antenatal records (if available), if not, take her history Perform quick assessment Perform physical examination and per vaginal examination (if signs of true labour are present) Record all findings of the latent and/or active1 st stage in the partograph . Allow a companion to remain with the woman (if possible), and continue monitoring the progress of labour, fetus and the woman (using partograph ) Management During 1 st Stage of L abour

34. Skills in inspiring confidence and establishing a trusting relationship with a woman is an integral part of good midwifery care. A n understanding that each individual woman/couple will respond differently to the onset of labour. A welcoming attitude and a comfortable environment will encourage the couple to relax and respond positively to the forces of labour, and the labour is likely to progress normally until the end . Best Practices in Midwifery Care

35. Respectful Care What can you do to prevent potential disrespect and abuse of women in childbirth? (brainstorm) You can become an agent for change… Best Practices in Midwifery Care continued…

36. Ideas to promote respectful care in childbirth Caring behavior Increased self esteem Good interpersonal counseling skills Creating respectful environment Teamwork Protecting privacy Welcoming birth companion Best Practices in Midwifery Care continued…

37. The midwife must make an immediate assessment of whether delivery is imminent and, if so, admission procedures are curtailed and preparation is made for the birth Refer to the handout for detailed care: Nurse Midwife Care in First Stage of Labour Best Practices in Midwifery Care continued…

38. The active phase of labour is completed within 12 hours. On average, the primigravida will take most of the time while the multigravida might expect to reach second stage within 6 hours. The midwife should avoid unnecessary vaginal examinations. Under no circumstances should a midwife make a vaginal examination if there is any frank bleeding unless the placenta is positively known to be in the upper uterine segment Key Points

39. Recording and reporting findings to the appropriate person is mandatory After the examination the results should be explained to the woman. During admission, the midwife must make an immediate assessment of whether delivery is imminent and, if so, admission procedures are curtailed and preparation is made for the birth The Midwife must understand and practice respectful care in childbirth Key Points continued…

40. 1. Break into 6 small groups with at least two students who have had 2 weeks of labour ward rotation 2. Each group is to review and discuss each point on handouts: Nurse M idwife C are in First S tage of Labour and Potential Contributors to and Impact of Disrespect and Abuse In Childbirth On Skilled Care Utilization Compare and contrast the potential abuse and disrespect and the best practices as listed in the handouts with the reality in the labour wards 3. Each group will come up one by one to practice PV exam on model Activities