MANAGEMENT of first stage of LABOUR ppt

The management of the first stage of labour involves:

Providing basic care and support to low-risk women at home or hospital
Encouraging mobility and optimum positions during the latent and active phases
Allowing labouring in water if desired
Following current guidance regarding maternal nutrition and monitoring vital signs
Helping women cope with labour pains by suggesting deep breathing, hydration, hydrotherapy, and self-care

2. Management on admission
Patient preparation — There is no evidence that
routine enemas or perineal shaving is beneficial .
A urinary catheter is not necessary unless the
woman is unable to void, but she should be
encouraged to empty her bladder regularly as a
full bladder can impede fetal descent.
Fluids and oral intake — There is no consensus
on acceptable maternal oral intake during
uncomplicated labor

3. Management on admission
Placement of an intravenous line or a hep-
lock at the time admission is recommended.
Interestingly, one randomized trial found that
women who received intravenous hydration at
250 mL/h had fewer labors persisting for over 12
hours and less need for oxytocin augmentation
than those who received 125 mL/h

4. Management on admission
Antibiotic prophylaxis  : (in some centers)
to prevent early-onset neonatal infection is
appropriate patients;
the agent of choice is intravenous penicillin. A
minimum of four hours of intrapartum therapy
has been recommended prior to delivery
Although normal labor and vaginal delivery is
not an indication for prophylaxis against
infective endocarditis, some centers generally
administer antibiotic prophylaxis during labor to
pregnant women with underlying valvular heart
disease.

5. Management on admission
Monitoring — All pregnant women require
surveillance (eg, monitoring of vital signs and
FHR) since 20 to 25 % of all perinatal morbidity
and mortality occurs in pregnancies with no
underlying risk factors for adverse outcome .
Assessment of the quality of the uterine
contractions and cervical examinations are
repeated at appropriate intervals to follow the
progress of labor.

6. Management on admission

7. Active management of labor
  It refers to active control, rather than passive
observation, over the course of labor by the
obstetrical provider.
It includes three essential elements
I.Careful diagnosis of labor by strict criteria
II.Constant monitoring of labor with specific standards
for normal progression
III.Prompt intervention (eg, amniotomy, high dose
oxytocin) according to established guidelines if
progress is unsatisfactory .

8. Active management of labor
The active management of labor is generally
limited to women who meet the following
criteria:
1)Nulliparous
2)Term pregnancy
3)Singleton infant in cephalic presentation
4)No pregnancy complications
5)Experiencing spontaneous onset of labor.

9. Active management of labor
Nulliparous labor tends to be more subject to
failure to progress .
 administration of oxytocin, sometimes at high
dosages, is one of the interventions involved in
active management. This is safer in nulligravid
women since the nulligravid uterus is virtually
immune to rupture (except as a result of
manipulation or previous surgery)

10. Active management of labor
Recommendation on routine amniotomy
Limited evidence showed no substantial benefit
for early amniotomy and routine use of oxytocin
compared with conservative management of
labor.
In normally progressing labor, amniotomy
should not be performed routinely.
 Combined early amniotomy with use of oxytocin
should not be used routinely.

11. Active management of labor
  Interventions with amniotomy and/or high dose
oxytocin are initiated if progress does not proceed
according to the defined standards.
Rutpure of the fetal membranes provides
information about fetal status, but does not appear
to significantly accelerate labor . In the Dublin
protocol, rupture must be performed before
treatment with oxytocin, which is administered
only in the presence of clear amniotic fluid .

12. Active management of labor
If membranes are ruptured when there is
polyhydramnios or an unengaged fetal presenting
part, it is prudent to use a small gauge needle, rather
than a hook, to puncture the fetal membranes in one
or more places, and to perform the procedure in the
operating room. This "controlled amniotomy“
permits emergency cesarean delivery in the event of
an umbilical cord prolapse .
Routine amniotomy should not be performed in
women with active hepatitis B & C or HIV in order
to minimize exposure of the fetus to ascending
infection.

13. Active management of labor

So usually, Amniotomy is indicated to further
evaluate fetal status (eg, placement of a fetal
scalp electrode) or uterine contractions (eg,
placement of an intrauterine pressure catheter).

14. Active management of labor
Slower progress in the nulliparous patient is
most often the result of inefficient uterine
action .
In the absence of medical contraindications,
labor that fails to progress is treated with
oxytocin

15. Pain Control:
The pain of childbirth is likely to be the most severe pain
that a woman experiences during her lifetime.

16. Non-pharmacological
methods

17. Pain relief techniques
Water birthing
Music
Heat and cold
Massage
Relaxation
Breathing
Intra dermal injections
of sterile water
Hypnotism
Acupressure / Shiatsu
Acupuncture
Electro-acupuncture
TENS

18. WATER BIRTHING
Provides pain relief and a less traumatic birth
experience for the baby
Redistribution of blood volume, which stimulates
the release of oxytocin and vasopressin (Katz
1990)
Exerts gravitational pull
Aid stretching of the perineum, slows crowning
of the infant's head, reduces the use of
episiotomy

19. Music
ancient Greeks played soothing instrumental
music to women in labour
alters mood, reduces stress and promotes
positive thoughts
a trigger for a breathing response or as a cue for
relaxation.
used as a distraction

20. TENS
TENS (transcutaneous electrical nerve
stimulation
stimulates the release of endorphins
Most useful in labour before the pain becomes
too intense
drug dose requirements may be less

21. Hypnotherapy
Mongan method (also known as HypnoBirthing),
Hypnobabies, the Lamaze method, Natal
Hypnotherapy and the GentleBirth program
Useful for heartburn, high blood pressure and
postnatal depression
can significantly shorten labor, reduce pain and
reduce the need for intervention, produced
higher apgar scores, reduce the incidence of
postpartum depression and increase the
incidence of spontaneous deliveries

22. Relaxation techniques
Providing a stress-free period during the
antenatal period helping in preparing the
woman and also in growth of the foetus.
Decreasing the tension, fatigue, discomfort and
pain of labour. It also increases the oxygen going
to the baby.
Helps in providing a stress-free period during
pueperium (i.e.:after delivery). Thus helping in
lactation and bonding between the couple and
little one.

23. Breathing techniques
In some women, relaxation alone may not be
sufficient to counter the discomfort of labour. In
such cases breathing techniques can be used to
augment the efficacy of relaxation techniques
used only during contraction

24. Acupressure
For relieving head / neck and upper backache
apply circular pressure on the muscles at the top
of the shoulder in vertical line with the nipples
near the back.
Massaging the center of the sole, below the ball
of the feet will relax the lower body.
To relieve low backache, pelvic discomfort or
pain, press firmly in an inward direction on
either side of the vertebral column, below the
waist level. Circular pressure is applied during
contraction and intermittent pressure between
contractions.

25. Acupuncture
Traditional Chinese therapy
Releases endorphins and enkephalins

26. Physical therapy
Massage
Counter pressure
Hot and Cold Compresses
Light stroking or “Effleurage”

27. Massage
Touch has been associated with the power of
healing
Examples; Therapeutic massage (eg: shiatsu),
perineal massage

28. Methods of touch and massage
lightly stroking the abdomen
firm circular massage using the palm of the hand
over the centre of the back or sacrum.
a long stroke down the length of the back,
buttocks and down the back of the legs
stroking across the forehead, down the neck and
down the arms
simply holding hands!

29. Intra dermal injections of sterile
water
intense stinging followed by relief of backache for 60 – 90
minutes
may be due to release of endorphins or by counterirritation
0.1 ml of sterile water is
injected into four locations on
the lower back, two over each
posterior superior iliac spine
(PSIS) and two 3 cm below
and 1 cm medial to the PSIS.
The injections should raise a
bleb below the skin.

30. Pharmacological methods

31. Pain Control:
patient-controlled epidural analgesia (PCEA)
empowers the parturient by giving her direct
control of her pain relief, and this may increase
maternal satisfaction .

32. Pain Control:
First stage of labor  
 Visceral or cramp-like
 source :
uterus and cervix, produced by distention of uterine
and cervical mechanoreceptors and by ischemia of
uterine and cervical tissues///. The pain signal enters
the spinal cord after traversing the T10, T11, T12, and
L1 .
abdominal wall, lumbosacral region, iliac crests,
gluteal areas, and thighs.///
Transition refers to the shift from the late first stage
(7 to 10 cm cervical dilation) to the second stage of
labor. Transition is associated with greater
nociceptive input as the parturient begins to
experience somatic pain from vaginal distention.

33. Pain Control:
Hyperventilation —  consistently accompanies
labor pain. Arterial CO2 partial pressures less
than 20 mmHg are not uncommon, and profound
hypocarbia may inhibit ventilatory drive
between contractions and result in maternal
hypoxemia, lightheadedness, and loss of
consciousness . respiratory alkalosis, which
impairs oxygen transfer from the maternal to
fetal circulation, may occur.

34. Pain Control:
Psychological effects — unrelieved pain may also
be a factor that contributes to the development
of postpartum psychological trauma. This may
negatively influence the mother's postpartum
adjustment, and in its most severe form, result in
post-traumatic stress disorder (PTSD) which
shouldn’t be underestemated.

35. ANALGESIA FOR THE FIRST STAGE
OF LABOR
 :
classified as either
systemic
locoregional

36. Systemic:
Intravenous
Intramuscular
inhalation routes
 most popular agents are opioids (eg, morphine,
fentanyl, meperidine)

37. Systemic:
Newer opioid analgesics  — Fentanyl, a
synthetic opioid, and its congeners (eg,
sufentanil, alfentanil, and remifentanil) have
also been used to provide labor pain relief. These
drugs have a short duration of action, so they are
best administered using the intravenous, rather
than the intramuscular route.

38. Systemic
Inhalation agents — Nitrous oxide . The
parturient self-administers the anesthetic gas
using a hand-held face mask. The safety of this
technique is that the parturient will be unable to
hold the mask if she becomes too drowsy . A
systematic review on nitric oxide for relief of
labor pain concluded it was inexpensive, easy to
administer, and safe for both mother and fetus.
The analgesic effect was better than that
produced by opioids, but less than with epidural
analgesia

39. Regional techniques:
Epidurals and Spinals are the most popular
modalities
Regional techniques are widely acknowledged to
be the only consistently effective means of
relieving the pain of labor and delivery. Local
injection may also be administered to achieve
paracervical or pudendal nerve block.

40. Pain control:
Epidural analgesia provided better pain relief
than parenteral opioids. However, opioids
were associated with a shorter duration of
labor, less oxytocin augmentation, and fewer
instrumental deliveries compared to epidural
analgesia.
Side effects- epidural: Nausea, vomiting, and
sedation & Respiratory depression which was the
major neonatal concern

41. THANK YOU