Normal Labour & Nursing Management of First stage of Labour

Definition of normal labor, Terminology , events of labour, causes of labour, signs , stages of labour , signs and symptoms of labour, diagnosis in first stage of labour, Partograph, difference between true labour and false labour ,nursing management of first stage of labour.

1. NORMAL LABOUR AND NURSING MANAGEMENT OF FIRST STAGE OF LABOUR PREPARED BY: NEHA PARMAR ASSISTANT PROFESSOR DPCN NADIAD

2. TERMINOLOGIES. LABOUR: series of movements that occur on the head and the foetal trunk in the process of adaptation during its journey through the pelvis. INDUCTION OF LABOUR: is the stimulation of uterine contraction d uring pregnancy before labour begins on its own to achieve a vaginal birth. Or it is the process or treatment that stimulates childbirth and delivery. PARTOGRAPH: the graphic representation used to assess the progress of labour and to identify when intervention is necessary.

3. FIRST STAGE OF LABOUR: it starts from the onset of labour pains to the full dilatation of the cervix, also called as “cervical stage”. LATENT PHASE: it is prior to active first stage of labour and may last for 6-8 hours in primigravidae . ACTIVE PHASE: here the cervix undergoes rapid dilatation. It begins when cervix 3-4 cm dilated is complete when the cervix is fully dilated (10cm).

4. TRANSITIONAL PHASE: is the stage when the cervix is from around 8cm dilated until it is fully dilated (or until the expulsive contractions during second stage are felt by the woman) LIGHTENING: it is the welcome sign, occurs due to the active pulling of the lower pole of the uterus and widening of the symphysis pubis, the presenting part sinks into the true pelvis few weeks before the onset of labour in primigravidae

5. SHOW: there is presence of blood stained cervical secretion with the onset of labour. Or expulsion of cervical mucus plug , mixed with blood is called “ show” EFFACEMENT OF THE CERVIX: effacement is the process of thinning out. It is measured as percentage of shortness of cervical canal.

6. ARTIFICIAL RUPTURE OF MEMBRANES: amniotomy involves splitting of the amnion and chorion to release the liquor. EPISIOTOMY: is a surgical incision into the perineum to enlarge the space at the outlet, thereby facilitating the birth of the child.

7. DEFINITION OF LABOUR Series of events that take 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 is called labour. D.c dutta

8. CONTD.. Labour may be defined as rhythmic contraction & relaxation of the uterine muscles with progressive effacement (thinning) & dilatation (opening) of the cervix, leading to expulsion of the products of conception. Clausen etal , 1973   Labour is described as the process by which the foetus, placenta & membranes are expelled through the birth canal. Cassidy, 1999

9. NORMAL LABOUR (EUTOCIA): Labour is called normal if it fulfils the following criteria; [1] Spontaneous in onset & at term. [2] With vertex presentation [3] Without undue prolongation. [4] Natural termination with minimal aids. [5] Without having any complications affecting the health of the mother & /or the baby.

10. ABNORMAL LABOUR [DYSTOCIA]: Any deviation from the definition of normal labour is called abnormal labour. Thus a labour in a case with presentation other than vertex or having some complications even with vertex presentation affecting the course of labour or modifying the nature of termination or adversely affecting the maternal & or foetal prognosis is called an abnormal labour.

11. THE THREE P’S OF NORMAL LABOUR The labour process involves a relationship between the three Ps”; the powers, the passages the passengers

12. CONTD.. The primary powers are the contractions and retractions of the uterine muscle. The secondary powers are the contractions of the abdominal muscles and diaphragm. the passages are the pelvis, uterus, vagina and the pelvic floor the passenger is mainly the fetus,but placenta, membranes and liquor amnii are also passengers

13. CAUSES FOR THE ONSET OF LABOUR : ThE onset of labour is said to be multifactoral in origin, i.e. hormonal, mechanical and neuronal factorS Hormonal factors- The hormones responsible for the onset of labour are oxytocin, progesterone and prostaglandins. Progesterone -it has a relaxant effect on the uterus. It is first produced by the corpus luteum and then by placenta. It inhibits uterine contractibility. When the estrogen level increases, the progesterone level decrease. This decreases at the end of pregnancy.

14. Contd.. Oxytocin : this hormone is released by the posterior pituitary gland of the mother. It has a stimulating action on the pregnant uterus. The oxytocin released acts directly on the myometrium and causes the uterus to contract. Prostaglandins : the major sites of synthesis of prostaglandins are placenta, foetal membrane, decidual cells, and myometrium. They act on the uterine muscles and causes it to contract

15. Contd.. Mechanical factors : this is due to the mechanical stimulation of the uterus and cervix: Uterus: as pregnancy advances, its contractility increases and it becomes more susceptible to stimulation. Cervix : the presence of the presenting part on the nerve ending of the cervix causes the onset of labour

16. Contd.. Neuronal factors : α and β adrenergic receptors are present in the myometrium . When progesterone gets withdrawn, onset of labour takes place. Labour is likely to be initiated by a combination of all the above mechanisms

17. FALSE PAIN (SPURIOUS PAIN) it is found in primigravida than in parous women. It usually appears prior to the onset of true labour pain, by one or two weeks in primi and by a few days in multiparea . The women feels pain and discomfort in the abdomen and these are mistaken for labour pain.

18. False pain has the following features: Dull in nature & usually confined to the lower abdomen and groin Continuos and unrelated with hardening of uterus Without any effect on dilation of cervix Usually relieved by enema and administration of sedatives. Such pains are probably due to stretching of the cervix and lower uterine segment.

19. THE PREMONITARY SIGNS OF LABOUR That starts from two or three weeks before onset of true labour. lightening frequency of micturation cervical changes appearance of false pains Vaginal secretions may increase SHOW Membranes may rupture

20. DIFFERENCE BETWEEN TRUE LABOUR AND FALSE LABOUR TRUE LABOUR FALSE LABOUR Painful uterine contractions come at regular intervals. Uterine contractions always present Intensity of pain progress with advancement of labour Interval between pain gradually becomes short in true labour Irregular intervals in false labour Not always present  Intensity remains same Remains same

21. Presence of bulging fore waters in true labour   Pain felt in true labour is in abdomen ,back & groin   Cervical dilatation & effacement is present Show is usally present   Pain is not relived by sedatives or enema Absent   Pain usually felt in lower abdomen   Absent   Not present   Pain is usually relieved by medication.  

22. STAGES OF LABOUR Labour is divided into four stage First Stage of Labour:- The first stage of labour is referred to as the "dilating" stage. It is the period from the first true labour contractions to complete dilatation of the cervix (10cm) . The forces involved are uterine contractions. The first stage of labour is divided into three phases: Latent (early) or prodromal . Active or accelerated. Transient or transitional

23. Second Stage of Labor :- The second stage of labor is referred to as the "delivery or expulsive" stage. This is the period from complete dilatation of the cervix to birth of the baby. The forces involved are uterine contractions plus intra-abdominal pressure. Third Stage of Labor . The third stage of labor is referred to as the "placental" stage. This is the period from birth of the baby until delivery of the placenta. The forces involved are uterine contractions and intra-abdominal pressure.

24. Fourth Stage of Labor . The fourth stage of labor is referred to as the "recovery or stabilization" stage. This period begins with the delivery of the placenta and ends when the uterus no longer tends to relax. The forces involved are uterine contractions

25. PHYSIOLOGY OF NORMAL LABOUR During pregnancy there is marked hypertrophy and hyperplasia of the uterine muscle and the enlargement of uterus are more; beyond the attachment of round ligaments. At term, the length of the uterus measures about 35cm including the cervix and the fundus is much wider both transversely and anteroposteriorly than the lower segment. The uterus assumes pyriform or ovoid shape. The cervical canal is occluded by a thick, tenacious(sticky) mucus plug.

26. Uterine contraction in labour : Throughout pregnancy there is rhythmic involuntary spasmodic uterine contractions are painless and have no effect on dilatation of cervix.which changes with the onset of labour; the complexity of the mechanism of the onset has previously been described. While there are wide variations in frequency, intensity & duration of contractions, they remain unusually within normal limits & follow the following patterns There is good synchronisation of the contraction waves of both halves off the uterus There is fundal dominance with gradual diminishing contraction wave through midzone down to lower segment which takes about 10-20 seconds The waves of contraction follow a regular pattern

27. Intra-amniotic pressure rises beyond 20mm Hg with the onset of true labour pains during contraction Good relaxation occurs in between contraction to bring down the intra-amniotic pressure to less than 8mmHg contractions of the fundus last longer than that of midzone . During contraction, uterus becomes hard & somewhat pushed anteriorly to make the long axis of the uterus in line with that of pelvic axis. Simultaneously, the patient experience pain which is situated more on the hypo gastric region, often radiating to the thighs.

28. PROBABLE CAUSES OF PAIN : Myometrial hypoxia during contractions (as in angina) Stretching of the peritoneum over the fundus Stretching of the cervix during dilatation Compression of the nerve ganglion. The pair of uterine contractions is distributed along the cutaneous nerve distribution of T10 & L1 pain of cervical dilatation & stretching is referred to the back through the sacral plexus.

29. TONUS: it is intrauterine pressure in between contraction. During pregnancy ,as the uterus is relatively in active the tonus of 2-3mmHg . During the first stage of labour it varies from 8-10mm Hg .The factors which govern the tonus are – Contractility of uterine muscles Intra abdominal pressure Over distension of uterus as in twins & hydraminos

30. INTENSITY: the intensity gradually increases with advancement labour until it becomes maximum in the stage during delivery DURATION: in the first stage, the contractions last for about 30 seconds initially but gradually increase in duration with progress in labour .Thus in the second stage the contraction last longer than in the first stage. FREQUENCY: in the early stage of labour the contraction come at intervals of ten to fifteen minutes .the intervals gradually shorten with advancement of labour until in the second stage when it comes every 2 or 3 minutes

31. Retraction : it is a phenomenon of the uterus in labour in which the muscle fibres are permanently shortened Unlike any other muscles of the body the uterine muscles have this property to become shortened once & for all. contraction is a temporary reduction in length of the fibres which attains their full length during relaxation

32. THE NET EFFECTS OF RETRACTION IN NORMAL LABOUR Essential property in the formation of lower uterine segment & dilatation & effacement up of the cervix. To maintain the advancement of the presenting part made by the uterine contractions & to help in ultimate expulsion of the foetus. To reduce the surface area of the uterus favouring separation of placenta. Effective haemostasis after the separation of the placenta

33. EVENTS IN THE FIRST STAGE OF LABOUR

34. UTERINE ACTION : FUNDAL DOMINANCE Each uterine contraction starts in the fundus near one of the cornua & spreads across & downwards. Each contraction is longest & intense in the fundus , but the peak is reached simultaneously over the whole uterus & fades from all parts together. This pattern permits the cervix to dilate & the fundus to expel the foetus.

35. POLARITY A neuromuscular harmony prevails between the two poles or segments of uterus throughout labour, which is termed as polarity During each contraction, these two poles act harmoniously. The upper pole contracts stronger & retracts to expel the foetus, lower pole contracts & slightly & dilates to allow expulsion to occur. If polarity is disorganized, the progress of labour is inhibited.

36. CONTRACTION & RETRACTION: During labour the contraction does not pass off entirely, the muscle fibres retain some of the shortening of contraction instead of becoming completely relaxed. This is termed as retraction , which is a unique property of the uterine muscle.

37. Because of this, upper segment of the uterus becomes gradually shorter &thicker & its cavity diminishes assisting in the progressive expulsion of the foetus. FORMATION OF UPPER AND LOWER SEGMENTS: By the end of pregnancy, the body of the uterus has divided into two anatomically distinct segments upper & lower uterine segments. The upper uterine segment is mainly concerned with contraction and is thick & muscular. The lower segment is prepared for distension & dilatation & is thinner. The lower segment develops from the isthmus & is about 8 to 10 cm in length.

38. THE RETRACTION RING The ridge forms between the upper and lower uterine segments, which is known as retraction ring. The physiological retraction ring gradually rises as the upper uterine segment contracts and retracts and the lower uterine segment thins out to accommodate the descending foetus. Once the cervix is fully dilated & the foetus can leave the uterus, the retraction ring rises no further. The retraction ring is normally not visible over the abdomen. When the phenomenon is exaggerated in an obstructed labour, the retraction ring becomes visible above the symphysis pubis; it is termed as bandl’s ring .

39. CERVICAL EFFACEMENT/ TAKING UP OF THE CERVIX 'Effacement' refers to the inclusion of the cervical canal into the lower uterine segment. Cervical effacement is the process by which the muscular fibres of the cervix are pulled upward & merges with the fibres of the lower uterine segment A

40. CERVICAL DILATION Dilatation of the cervix is the process of enlargement of the external cervical as from an orifice of a few mm to an opening large enough for the baby to pass through . dilatation is effected primarily by the hydrostatic action of the amniotic fluid under the influence of contractions, causing the membranes to serve as a dilating wedge in the area of least resistance in the uterus If the membranes have ruptured, the pressure of the presenting part on the cervix and the lower uterine segment has a dilating effect.

41. CONTD.. Dilatation is clinically evaluated by measuring the diameter of the cervical opening in centimetres, with 0 centimetre being a closed external cervical os and 10 centimetres being complete dilatation. SHOW: Because of the dilatation of the cervix, the operculum, which formed the cervical plug during pregnancy, is lost. This blood stained mucoid discharge is termed as the Show. The blood comes from the ruptured capillaries in the parietal deciduas where the chorion has become detached from the dilating cervix..

42. MECHANICAL FACTORS FORMATION OF THE FORE WATERS: As the lower uterine segment stretches, the chorion becomes detached from it and the increased intrauterine pressure causes this loosened part of the sac of fluid to bulge downwards into the dilating internal so, to the depth of 6-12mm. The fluid in front of the head is termed as fore waters and that which surrounds the body as hind waters . The effect of separation of fore water is to keep the membranes intact during the first stage by preventing the pressure applied to the hind waters during uterine contractions from being applied to the fore water.

43. GENERAL FLUID PRESSURE While the membranes remain intact, the pressure of the uterine contraction s exerted on the fluid and as fluid is not compressible, the pressure is equalized through the uterus and over the foetal body, which is known as general fluid pressure. RUPTURE OF THE MEMBRANES The physiological moment for the membranes to rupture is at the end of the first stage of labour when the cervix becomes fully dilated and no longer supports the bag of waters. Spontaneous rupture of membranes may sometimes occur days or hours before labour begins or during the first stage

44. Membranes may sometimes rupture days before labour begins or during the first stage. If for any reason there is a badly fitting presenting part and the fore-waters are not cut off effectively then the membranes may rupture early. Ocassionally the membranes do not rupture even in 2 nd stage and appear at the vulva as bulging sac covering the fetal head as it is born: This is known as the ‘ Caul ’.

45. FETAL AXIS PRESSURE During each contraction the uterus rears forward (becomes upright) and the force of the fundal contraction s transmitted to the upper pole of the uterus, down the long axis of the foetus and is applied by the presenting part to the cervix. This is known as foetal axis pressure. It becomes more significant after rupture of the membranes and during the second stage of labour

46. PARTOGRAPH It was first devised by Friedman (1954) Definition Partograph is a composite graphical record of cervical dilation & descent of head against duration of labour in hours it is also gives information about foetal & maternal condition. It is been recorded on a single sheet of paper.

47. THE COMPONENTS OF A PARTOGRAPH ARE: Components of the partograph Part I : fetal condition( at top ) Part II : progress of labour( at middle) Part III : maternal condition( at bottom) Outcome : ……………… Patient identification Time-recorded at hourly interval zero time spontaneous labour is the time of admission & for induced labour is the timr of induction Foetal heart rate recorded hourly. State of membranes & colour of liquor: to mark of ‘I’ for intact membranes ‘c’ for clear ‘m’ for meconium stained liquor. Cervical dilatation & descent of the head.

48. CONTD.. Uterine contractions the square in the vertical columns are shaded according to duration & intensity. Drugs & fluids. Blood pressure –every 2 hour & pulse at every 30 minutes. Oxytocin – concentration in the upper box & dose is the lower box. Urine analysis. Temperature record.

49. Cervical dilatation It is divided into a latent phase and an active phase Latent phase : It starts from onset of labour until the cervix reaches 3 cm diltation Once 3 cm diltation is reached , labour enters the active phase Lasts 8 hours or less Each lasting < 20 sceonds At least 2/10 min contractions Active phase : Contractions at least 3 / 10 min Each lasting < 40 sceonds The cervix should dilate at a rate of 1 cm / hour or faster

50. Alert line ( health facility line ) The alert line drawn from 3 cm diltation represents the rate of diltation of 1 cm / hour Moving to the right or the alert line means referral to hospital for extra vigilance Action line ( hospital 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

51. ADVANTAGES: A single sheet of paper can provide details of necessary information at a glance. No need to record labour event repeatedly It can predict deviation from normal duration of labour early If facilitates handover procedure Introduction of partograph and the management of labour (WHO 1944) has reduced the incidence of prolonged in maternal morbidity perinatal mortality & morbidity.

52. FIRST STAGE OF LABOUR (STAGE OF CERVICAL DILATATION ) Begins with the 1 st true labour contraction and ends with complete effacement and dilatation of the cervix(10 cm dilatation). The 1 st stage of labour averages about 13 ½ hours for a nullipara and about 7 ½ hours for a multipara . Latent phase(early ) Dilates from 0-3 cm. Contractions are usually every 5 to 20 minutes, lasting 20 to 40 sec, and of mild intensity. The contractions progress to about every 5 mts and establish a regular pattern

53. Active phase: Dilates from 4 to 7 cm. Contractions are usually every 2 to 5 mts ; lasting 20 to 50 sec and of mild to moderate intensity. After reaching the active phase, dilatation averages 1.2cm/hr in the nullipara and 1.5 cm/hr in the multipara . Transitional phase : Dilates from 8 to 10 cm . Contractions are every 2 to 3 mins , lasting 50 to 60 sec and of moderate to strong intensity. Some contraction may last upto (but not exceed) 90 sec

54. NURSING ASSESSMENT AND INTERVENTONS History and baseline data Establish baseline information Establish baseline maternal and fetal vital signs Obtain urine specimen – test the results for glucose and protein.

55. VAGINAL EXAMINATION Explain the procedure. Place her in lithotomy position. Conduct examination under aseptic technique. Evaluate : Condition of cervix Presentation Position Membranes : intact or ruptured Perineum

56. PREPRATION OF LABOUR ROOM AND WOMEN PREPARATION OF LABOUR ROOM PREPARATION OF WOMEN

57. PREPARATION OF TROLLEY Sponge holding forceps – 2 Dissecting forceps, toothed – 1 Dissecting forceps, non-toothed – 1 Scissors, straight – 1 Small artery forceps, curved – 4 Needle holder – 1 Episiotomy scissors – 1 Kidney tray – 1 Sterile drapes Towel clips Syringe 5 cc, with needle Local anaesthesia Anti septic solution Gauze swabs Sterile pads Sutures and ligaments( chromic catgut no.0,1)

58. ACTIVE MANAGEMENT OF LABOUR -1 st STAGE OF LABOUR The main points which have to be taken care of during the active management of first stage of labour are as follows EMOTIONAL SUPPORT PREVENTION OF INFECTION CAREFUL EXAMINATION PERINEAL PREPARATION ENEMA

59. Contd.. BLADDER REST & POSITION DIET VAGINAL EXAMINATION ABDOMINAL PALPATION MONITORING THE FETAL WELL –BEING

60. INDUCTION OF LABOUR DEFINITION : this is deliberate initiation of labour before spontaneous onset after 28 weeks of pregnancy TYPES OF INDUCTION Elective induction-it is the indication of labour for the convenience of woman, the physician or the hospital Indicated induction – it is the induction of labour for the high risk pregnancies

61. CERVICAL RIPENING: Maturation of the cervix starts around 5-6 weeks prior to the labour in which the cervix start getting dilated effaced & soft The methods which can be employed for ripening of the cervix are: Use of prostaglandin cervical gel ( cerviprime ) Stripping of the membranes Oxytocin infusion This method for induction is chosen by assessing the cervix with the help of bishop’s SCORE

62. BISHOP’S SCORE: It was introduced by Bishop in 1964. It is practical method of predicting the success before induction of labour The score is mainly useful in multiparous patient. It is done by cervical assesment as shown

63. Parameter Score Description 1 2 3 Cervical position Posterior Middle Anterior – The position of the cervix changes with menstrual cycles and also tends to become more anterior (nearer the opening of the vagina) as labour becomes closer. Cervical consistency Firm Medium Soft – In  primigravid  women, the cervix is typically tougher and resistant to stretching, much like a balloon that has not been previously inflated (it feels like the bottom of a chin). With subsequent vaginal deliveries, the cervix becomes less rigid and allows for easier dilation at term. Cervical effacement 0-30% 40-50% 60-70% 80+% Effacement translates to how 'thin' the cervix is. The cervix is normally approximately three centimetres long, as it prepares for labour and labour continues the cervix will efface till it is 'fully effaced' (paper-thin). Cervical dilation Closed 1–2 cm 3–4 cm 5+cm Dilation is a measure of how open the cervical os is (the hole). It is usually the most important indicator of progression through the first stage of labour. Fetal station −3 −2 −1, 0 +1, +2 Fetal station describes the position of the fetus's head in relation to the distance from the  ischial spines , which are approximately 3-4 centimetres inside the vagina and are not usually felt. Health professionals visualise where these spines are and use them as a reference point. Negative numbers indicate that the head is further inside than the ischial spines and positive numbers show that the head is below the level of the ischial spines.

64. METHODS OF INDUCTION There are mainly three methods of induction Medical Surgical Combined Medical induction –under medical induction two drugs are discussed – Oxytocin induction Prostaglandins Surgical induction Artificial rupture of membranes Stripping of the membranes

65. ANALGESICS AND ANAESTHESIA ANALGESICS- The analgesics can be given by subcutaneous intramuscular or intravenous route commonly used analgesic are: Pethidine Meperidine hydrochloride (Demerol) MEPTAZINAL Pentazocin ( fortwin ) Diamorphine Inhalation analgesia

66. ANAETHESIA Regional anaesthesia - In the regional anaesthesia, injection is given to block the transmission of painful stimuli from the uterus, cervix, vagina and perineum to the local anaesthetic can be given one time or continuously.METHOD USED: ---Para cervical block-In par cervical block, local anaesthetic injection is given transvaginally , near to the outer rim of the cervix when the injection is given during labour mother achieves the relief from the pain caused by cervical dilatation

67. EPIDURAL ANALGESIA It can be given by a single injection or by continuous injection into the epidural space at the second third or fourth lumbar interspaces the pain relief is obtained by blocking the condition of impulses along the sensory nerves as they enter spinal cord to avoid the risk of supine hypotension mother is positioned in left lateral for the procedure the foetal heart & blood pressure of mother are to be examined throughout the procedure

68. Site:

69. Position

70. The advantages of epidural anaesthesia are: it gives effect pain relief & does not depress respiratory centre of foetus it also enhance the woman’s rest relaxation ability to cope. The disadvantages include the vital signs have to be monitored more frequently and there can be lengthening of the first and second stage of labour. On addition to this, mother is less able to adapt different birth positions, it may cause infection

71. SPINAL ANAESTHESIA It provides anaesthesia for vaginal or caesarean delivery The anaesthesia is directly given into the spinal fluid Spinal anaesthesia has effect on the bearing down reflex of the mother There is no effects on the foetal respiration but can cause maternal headache & temporary hypotension It should not be given in the cases where the mother is having infection at the puncture site hypovolemia hypotension or hypertension CPD & central nervous system diseases

72. PERINEAL INFITRATION Perinal infiltration is done 2-5 minutes before performing episiotomy around 10 ml of 1% lignocaine is taken in a syringe The perineum on the proposed episiotomy site is infiltrated One should always aspirate before infiltration In case of application of forceps or ventouse perineal & labial infiltration is done

73. FIRST STAGE OF LABOUR- LATENT PHASE (0 to 3 cm ) NURSING DIAGNOSIS Deficient fluid volume related to decreased oral intake, lack of eating, and the energy requirement of labour. Anxiety related to concern for self and the foetus. Acute pain related to uterine contraction or position of the foetus

74. FIRST STAGE OF LABOUR- ACTIVE AND TRANSITION PHASE NURSING DIAGNOSIS Anxiety related to concern for self and foetus. Acute pain related to uterine contraction and nausea and vomiting. Impaired urinary elimination related to epidural anaesthesia or from pressure of the foetus. Ineffective coping related to discomfort Risk for related to rupture of membranes. Impaired physical mobility related to medical intervention and discomfort. Ineffective breathing pattern related to pain and fatigue.

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