Management of first stage labour

LABOUR AND ITS MANAGEMENT

1. 1 st stages consist of 3 stages A. Latent phase: cervical dilations is 0-3 cm Begins with regular contractions (labor pains). pains are similar to painful menstrual cramping and are usually accompanied by low back pain. Contractions during this phase are more than 5 minutes apart, last 25 to 35 seconds , and are considered to be mild. usually, woman is excited about labor and talkative. B. Active phase: cervical dilation is 4-7 cm. more active contractions. The contractions become more frequent (every 3 to 5 minutes), last longer (60 seconds), and are of a moderate to strong intensity .

2. Cervical dilation become advances more quickly nulliparous women abut 1 cm of dilation per hour and multiparas at 1.5cm of cervical dilation per hour C. Transitional phase: cervical dilation is 7-10 cm The transition phase is the most intense phase of labor . Transition is characterized by frequent strong contractions that occur every 2 to 3 minutes and last 60 to 90 seconds on average. That a woman may feel during transition include rectal pressure, an increased urge to bear down, an increase in bloody show, and spontaneous rupture of the membranes (if they have not already ruptured).

3. TRUE AND FALSE LABOR CONTRACTIONS True and false labor contractions 

4. Duration: primigravida = 8-12 h multigravida = 6-8h Phases of the first stage: - Latent phase: started when the cervix dilatated slowly reached to about 3cm. in primigravida = 4-6hrs in multigravida = 4 . 8 h - Active phase: rapid dilatation of the cervix to reach 10cm in primigravda = 4h in multigravida =2h THE FIRST STAGE OF LABOUR

5. Phase Primiparous Multiparous Latent phase 4-8 hrs 4-6 hrs Active phase 4hrs 2hrs

6. The determination of whether a woman is in labor is made within one hour of admission . Diagnosis of labor is made only when painful contractions are accompanied by any one of the following : Bloody show Rupture of the membranes Full cervical effacement . Cervical dilatation is not part of the criteria Meet the criteria Rest & observation Until next day Antenatal ward Didn’t meet the criteria Diagnosis of labour

7. MANAGEMENT OF LABOUR The management of labour should be commenced during the antenatal period the women should be classified as high or low risk pregnancy. The medical or surgical problems should be corrected as in case of (anaemia, hypertension, urinary tract infection) and all investigations should be performed and prepared such as (HIV, HCV, Hbs Ag, blood grouping…….etc).

8. AIM OF FIRST STAGE MANAGEMENT: . Achieve delivery of normal healthy child with with minimal physical and psychological maternal effect. 2. Early anticipation, recognition and management of any abnormalities during labour.

9. ADMISSION TO LABOUR Welcoming the woman Review the referral note or pregnancy card to review history. Check and record the vital sign: BP-RR-Temp Auscultate fetal heart sound. Assess uterine contraction. Ask to woman to empty bladder and give urine spacemen.

10. 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

11. 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

12. 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

13. • 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

14. 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

15. 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

16. Rest n sleep Mild sedation and analgesic Ensure adequate sleep

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

18. Provide comfort n assist in her care Assist in daily care Praise and reassure her Give detail of progress of labour

19. Teaching bearing down or pushing effort

20. Artificial rupture of membrane: 1- perform artificial rupture of membrane if woman is 4 cm or more. Head is engaged The AROM is don by physician and it can be done by midwife under doctor supervision or if the dilatation is 6 cm or more Follow-up 1- follow the progress of labour utilizing the partogram . 2- conduct vaginal examination in following condition: Upon admition . After AROM Q 2-4 hr Document all of procedure, assessment finding on partogram .

21. cervical examination should be kept to a minimum to avoid promoting intraamniotic infection. In general, vaginal examinations are performed: On admission At one to four hour intervals in the first stage and at one hour intervals in the second stage At rupture of membranes to evaluate for cord prolapse Prior to intrapartum administration of analgesia When the parturient feels the urge to push to determine whether the cervix is fully dilated If the FHR falls, to evaluate for conditions such as cord prolapse or uterine rupture.

22. Establish good rapport and trus t beginning with the f i rst contact and maintain i t throughout the woman’s s tay . Follow the woman’s wishes on including her husband or relatives. Explain a l l procedures and processes. Keep the woman informed about all decisions. Listen respectfully to questions and answer her calmly and reassuringly. Respect the woman’s privacy . Provide continuous emotional support . Allow the woman to drink f luids , eat l ight meals and walk.

23. Maternal well-being Foetal well-being Progression of labour Adequate hydration Pain relief Components of management

24. What is a partogram (partograph) ?

25. partograph Definition: it is graphical record of key data of labor progress with both maternal and fetal data. it is the process by which normal and abnormal progress of labor and also fetal response in labor can be defined.

26. importance It allows an instant visual assessment of the rate of Cervical dilatation and comparison with an expected So that slow progress can be recognized Early and appropriate actions taken to correct it Where possible.

27. Components of partogram Maternal well being Vital signs Urine Hydration Fetal well being FHR Character of liquor Moulding

28. Progression of labour Cervical dilatation Station Uterine contractions Medications Oxytocin Pain relief

29. 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

30. Heart rate auscultation

31. 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

32. 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 …………… …………...++ Severly over lapping bones ( notable ) ……..+++

33. 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

34. 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

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

36. Action 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

37. Progression of labour 2 main components Abdominal examination PV examination

38. Abdominal examinations Uterine contractions Can be felt by palpation Maximum expected is 3 in 10min One lasting >40 sec 2min relaxation in between

39. Palpate the number of contractions in 10 minutes and calculate the duration of one contraction Less than 20sec Between 20 and 40sec More than 40sec

40. Recording of uterine contractions

41. 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

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

43. Descent of 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

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

45. If contractions are not satisfactory, Oxytocin infusion 5U for primi 2U for multi Starting 15drops/min Can increase by 15drops/min every ½ hour Up to max. of 60drops/min

46. Use of oxytocins The midwife will obtain the physician order before initiating and oxytocin infusion: perform vaginal examination. commence oxytocin via dropper machine follow the following standard of oxytocin initiation. add 5 unit to 500 ml R/l increase the drip rate according to IOL protocol at 30 minutes interval until contraction lasting until contraction lasting for 40- 45 sec. and occurring 3-4/10 minute. the maximum dose is 20 milliunits per minutes i.e. 24 dpm (72ml/hr)

47. Keep woman under continues fetal monitoring. Reduce oxytocin if good contractions have been established to prevent hyper stimulation Reassess progress by vaginal examination q/ 2 hr Discontinue oxytocin in case of: 1- hypertonic uterine contraction. 2- Prolong fetal deceleration 3- Persistent fetal bradycardia. 4- Document .

48. PV examinations Routinely done every 4 hourly Important to determine progression 4 main things to check Cervical dilatation Effacement Descent Moulding

49. ABNORMAL LABOR INDICATORS Prolong Latent phase : A failure of thinning of the lower segment, effacement and dilation of the cervix despite several hours of painful contractions. Management: Simple analgesia Encourage mobilization Reassurance AROM and oxytocin will cause poor progress

50. Prolong active phase Protracted active phase dilation is a common dysfunctional labor pattern → Most common in first labour. → Implies slow progress during the active phase of labour. → Usually with inefficient uterine contractions. → Abnormalities of passenger It seems to be associated with mild cephalopelvic disproportion.

51. Primary dysfunctional labour Slow progression in active phase Falls to right of action line Possibilities –Uterine Inertia (ineffective uterine contraction) – Malposition (2 nd commenest ) – Cephalopelvic disproportion

52. Secondary arrest Progression normal in latent and early active phase and arrest of cervical dilatation during late active phase. No cervical dilatation > 2hrs at any point beyond 6cm dilatation Possibilities –CPD –OP position –Inadequate uterine contraction

53. Non pharmacological Psychoprophylaxis Psycotherapy Physical methods

54. Music therapy Accupressure Accupunture Touch n Massage on back Heat application Aromatherapy Transcutaneous electrical nerve block

55. Pharmacological Pethidine 1mg/kg Primi – 1 st when cx is 3cm, 2 nd after 4hrs of 1 st dose Multi – single dose when cx is 3cm Morphine 10mg SC or IM Preferred in heart disease Nitrous oxide gas (Entonox) Mixed with oxygen 1:1 Given via face mask