Normal labour.pptx

1st stage of normal labour and nursing management

1. FIRST STAGE OF NORMAL LABOUR AND NURSING MANAGEMENT BY – PREETI KULSHRESTHA M.SC. NURSING PREVIOUS YEAR

2. Normal labour

3. LABOUR Labour is described as the process by with fetus, placenta and membranes are expelled through the birth canal.

4. NORMAL LABOUR ( EUTOCIA )- Labour is called normal if it fulfils the following criteria- Spontaneous in onset and at term. With vertex presentation. Without undue prolongation. Natural termination with minimal aids. Without having any complications affecting the health of the mother and /Or baby

5. STAGES OF LABOUR Events of labour are divided into 4 stages – First stage Second stage Third stage Fourth stage

6. 1. FIRST STAGE – Also called “CERVICAL STAGE” Starts From the onset of true labour pain and ends with full dilatation of the cervix DURATION - 12 hrs in primigravidae - 6hrs in multiparae 2. SECOND STAGE – Starts from the full dilatation of the cervix and ends with expulsion of the fetus from the birth canal. DURATION – 2 hrs in primigravidae - 30 mins in multiparae

7. 3 . THIRD STAGE- Begins after expulsion of the fetus and ends with expulsion of the placenta and membranes DURATION – 15 mins in both primigravidae and multiparae 4. FOURTH STAGE – Stage of observation for at least 1 hr. General condition and behaviour of uterus are to be monitored.

8. PHYSIOLOGY OF NORMAL LABOUR OR EVENTS OF 1 ST STAGE OF LABOUR Following are the major events during labour- Gradually increasing uterine contractions Retraction Dilatation of the cervix Effacement of the cervix or taking up of cervix Formation of lower uterine segment

9. Gradually increasing Uterine contraction There is irregular uterine contractions which are painless (BRAXTON – HICKS) and no effect on dilatation of the cervix. During contraction, uterus becomes hard. Patient experiences pain. The pain of uterine contraction is distributed along the cutaneous nerve distribution of T10 to L1.

10. There are wide variations in – frequency Intensity Duration a)Frequency- in the early stage of labour, the contractions come at intervals of 10 to 15 mins. The intervals gradually shorten with advancement of labour until in the 2 nd stage, when it comes every 2 or 3 mins.

11. b) intensity- The intensity gradually increases with advancement of labour until it becomes max. in the 2 nd stage during delivery of the baby. Intrauterine pressure is raised to 40-50 mmhg during 1 st stage and abt 100-120 mmhg in the 2 nd stage of labour during contraction. c) Duration- In the 1 st stage, the contractions last for about 30 sec initially but gradually increases in duration with the progress of labour. Thus in the 2 nd stage, the contractions last longer than in the 1 st stage.

12. VARIATION OF PAIN

13. RETRACTION Retraction is a phenomenon of the uterus in which the muscle fibers are permanently shortened.

14. Retraction results in permanent shortening and the fibers are shortened once and for all. The net effect of retraction on normal labour are – Essential property in the formation of lower uterine segment and dilatation and effacement up of the cervix. To maintain the advancement of the presenting part made by the uterine contraction and to help in ultimate expulsion of the fetus. To reduce the surface area of the uterus favouring separation of placenta. Effective haemostasis after the separation of the placenta.

15. DILATATION OF THE CERVIX Dilatation of the cervix depends upon 2 factors – Predisposing factors Actual factors A. PREDISPOSING FACTORS- Softening of the cervix. Fibro-Musculo -glandular hypertrophy. Increased vascularity. Accumulation of fluid in between collegen fibers. Breaking down of collegen fibrils by enzymes collagenase and elastase.

16. Contd . B. ACTUAL FACTORS- Uterine contraction and retraction. Bag of membranes. Fetal axis pressure. Vis-a- tergo (1)UTERINE CONTRACTION AND RETRACTION=

17. Contd. The longitudinal muscle fibers of the upper segment are attached with circular muscle fibers of the lower segment and upper part of the cervix in a bucket holding fashion. Muscle becomes shortened and retracted. There is some co-ordination between fundal contraction and cervical dilatation called “ polarity of uterus ”. While the upper segment contracts, retracts and pushes the fetus, the lower segment and the cervix dilated.

18. Contd. (2) BAG OF MEMBRANE= The membranes are attached loosely to the decidua lining the uterine cavity except over the internal os. In vertex presentation girdle of head fit in the lower uterine segment and divides amniotic cavity into 2 parts that are hind waters and fore waters . This generates hydrostatic pressure and dilates the cervical canal.

19. contd. (3) FETAL AXIS PRESSURE = In longitudinal lie, there is tendency of straightening out of the fetal vertebral column due to contraction of circular muscles of the body of uterus. This allows the fundal contraction to transmit into the fetal axis and mechanical stretching of the lower segment and opening up of the cervical canal. In transverse lie, fetal axis pressure is absent.

20. Contd. (4) VIS-A-TERGO= It is the final phase of dilatation and retraction of the cervix It is downward thrust of the presenting part of the fetus upward pull of the cervix over the lower segment.

21. EFFACEMENT OR TAKING UP OF CERVIX Effacement is the process by which the muscular fibers of the cervix are pulled upward and mixed with the fibers of the lower uterine segment. The cervix becomes thin during first stage of labour.

22. FORMATION OF LOWER UTERINE SEGMENT During labour the wall of upper segment becomes progressively thickened with progressive thinning of the lower segment A distinct ridge is produced at the junction of the two, called physiological retraction ring.

23. CLINICAL COURSE OF FIRST STAGE OF LABOUR (1) PAIN- initially, pains are come at varying intervals of 15 to 30 mins. With duration of about 30 secs. but gradually the interval become shortened with increasing intensity and duration comes at intervals of 3 to 5 mins. And lasts for about 45 secs. (2) DILATATION AND EFFACEMENT OF THE CERVIX- cervix dilatation is expressed either in terms of fingers – 1,2,3 or fully dilated (10cm) or better in terms of cm. effacement of the cervix is expressed in terms of % i.e. 25%, 50% or 100%. (3) STATUS OF THE MEMBRANES – membranes usually remain intact until full dilatation of the cervix or sometimes even beyond, in the 2 nd stage .it may rupture any time after the onset of labour but before full dilatation of cervix –when it is called early rupture . When the membranes rupture before the onset of labour it is called premature rupture membrane.

24. Contd. (4) MAERNAL SYSTEM- pulse rate is increased by 10-15 b per min. during contraction . Systolic B.P. is raised by about 10mmhg during contraction. temperature remains unchanged. (5) FETAL EFFACT – during contraction there may be slowing of FHR by 10-20 b per min which soon returns to its normal rate of about 140 per min.

25. PHASES OF 1 ST STAGE OF LABOUR This stage is subdivide into 3 phases- Latent phase (early labour) Active phase (active labour) Transition phase Latent phase (early labour)- Starts – with contraction of true labour Ends – when cervix is dilated 4 cm. Intensity – mild frequently occurs every 30 mins. Frequency – 5-10 mins. Duration – 30-45 sec. Dilatation – 0-3 cm

26. Contd. ACTIVE PHASE ( ACTIVE LABOUR) – Starts – at 4 cm of cervix dilatation Ends – when the cervix is dilated 8 cm Intensity – moderate in every 2-5 mins. Dilatation – in primiparous women – 1.2 cm per hr. - in multiparous women – 1.5 cm per hr. TRANSITION PHASE – Starts – when cervix is dilated 8 cm. Ends – full dilatation of cervix . Intensity – strong occurs every 2-3 mins. Duration – 60-90 sec.

27. Nursing management

28. Nursing management during the first stage of labour GENERAL – emotional support and encouragement. BOWEL – enema with soap and water or glycerin suppository is given in early stage. REST AND AMBULATION – when membranes are intact women is encouraged for ambulation, when ruptured women advised for rest. DIET – fruit juice, soup, salt lemon juice is recommended . ice chips or plain water may be given in early labour. BLADDER CARE – encourage the women to empty the bladder, if failed the catheterization is to be done with aseptic techniques.

29. CONTD. RELIEF OF PAIN – Pethidine 50-100 mg I.M. (analgesic) Metoclopramide10 mg I.M. (Antiemetic) PARTOGRAPH – monitor the progress of the labour by plotting the partograph. Abdominal palpation = 1. uterine contraction = 2. pelvic grip FHR.

30. THANK YOU