Management of first stage of labour

Prepared by:Nirsuba Gurung

Assistant LecturerMSON

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

Position

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

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 labour and need for interventions)

• 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

Bladder Encourage women to pass urine

every two hourlyIf 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

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

Rest and sleep Mild sedation and analgesic Ensure adequate sleep

Pain management PositionAmbulation Small feedingBack massageBreathing techniqueWarm bath and showerbuscopan, morphine

Provide comfort and assistance Assist in daily carePraise and reassure her Give detail of progress of labour

Teaching bearing down or pushing effort

Medication Epidocin –for cervical dilation and

effacement

Infection control measures

Proper recording

To note progress of labour

Progressive descent of fetal head as measured by one-fifth examination

What is a partogram (partograph) ?

DefinitionThe partogramIs a graph used in labour to monitor the parameters of progress of labour, maternal and fetal wellbeing, and treatment administration

PRACTICAL VALUE OF USING THE PARTOGRAM

Offers an objective basis for overtime monitoring the progress of labour, maternal and fetal wellbeing.

Enables early detection of abnormalities of labour Prevention of obstructed

labour and ruptured uterus.

PRACTICAL VALUE OF PARTOGRAM cont

Complications of obstructed labour and ruptured uterus contribute up to 30% of maternal deaths in some areas.

Proper use of partogram has proved so useful in reduction of both maternal and perinatal mortalities and morbidities

Advantage 1. A single sheet of paper can provide

details of necessary information at a glance

2. No need to record labour event repeatedly

3. Gives clear picture of normality and abnormality in loabour

4. It can predict deviation from duration of labour ,so appropriate stepscould betaken in time

5. It facilitate handover procedure of staff

6. Save working time of staff against writing labour notes in long hand

7. Educational value for all staff

RECOMMENDATIONS ON THE USE OF PARTOGRAM

Based on the evidence-based reports on its effectiveness in monitoring of labour.

WHO Recommends its use in all labour

wards and for all women (WHO 1994)

PRINCIPLES USED TO DESIGN THE PARTOGRAM

The partogram depends on the principles that;

1. The latent phase should not last longer than 8 hours

2. The latent phase ends and active phase starts when the cervix is 3cm (4cm is sometimes used)

3. During active phase – the cervix should dilate at not less than 1 cm per hour

PRINCIPLES cont

4. A lag time of 4 hours is usually acceptable the slowing of labour and the need to intervene; this is the distance between alert line and the action line.

PRINCIPLES OF USING THE PARTOGRAM

1. Basic health facilities Used to monitor labour which is expected

to be normal. Those with risk factors should already have

been referred. Referral is decided when the progress line

of the cervical dilatation deviates to the right of an alert line.

2. Health facilities with comprehensive EmOC.

Used to monitor both high and low risk labour

PROTOCOL FOR LABOUR MANAGEMENT WITH THE WHO

PARTOGRAM

EXCLUSIONS

Don’t complete the partogram in case of:

Prematurity (<34/40)Cervical dilatation 9 -10 cm on admission

Elective CSEmergency CS on admission

Fetal distress Severe pre-eclampsia Diagnosed CPD Multiple pregnancy Malpresentation

STARTING THE PARTOGRAM

1. Latent phase◦ Contractions at least 2 in 10, lasting ≥ 20 sec

2. Active phase◦ Contractions at least 1 in 10, lasting ≥ 20 sec

3. SRM but no contractions◦ When oxytocin is started or when labour

commences4. Inductions

◦ At ARM ± oxytocin◦ When induction is medical start when labour

commences (see 1 and 2) or membranes rapture.

DESIRED UTERINE CONTRACTIONS

The desired rates of uterine contractions in labour = 4 - 5 in 10 minute, each lasting 40-50 seconds.

It may be maintained at that rate throughout 2nd and 3rd stage of labour

TIMING OBSERVATIONS IN LATENT PHASE AND ACTIVE PHASE UP TO ACTION LINE

ParameterIdeal in both phases(hrs)

Minimum acceptable

Latent phase

Active phase

Vaginal examination 4 8 4

Descent of head 4 8 4

Contractions ½ 4 2Fetal heart beats ½ 4 1

Temperature, PR, BP, urine 4 4 4

TIMING OBSERVATIONS IN LATENT PHASE AND ACTIVE PHASE

Vaginal examination may be carried out more frequently in advanced first stage 7+cm or if problems develop

Part 1 : Fetal conditionthis part of the graph is used to

monitor and assess fetal condition1 - Fetal heart rate2 - membranes and liquor3 - molding the fetal skull bones.

Caput

FETAL HEART RATE< 160 beats/min =tachycardia > 120 beats/min = bradycardia >100beats/min=severe bradycardiaDecelerations? yes/noRelation to contractions?

n Earlyn Variablen Late

membranes and liquor

intact membranes ……………………………………….Iruptured membranes + clear liquor

…………………….Cruptured membranes + meconium- stained liquor

……..Mruptured membranes + blood – stained liquor

…………Bruptured membranes + absent

liquor…………………....A

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……….Obones just touching each other……………..+overlapping bones …………… …………...++severely overlapping bones ( notable ) ……..

+++

Part 2 – progress of labour . Cervical dilatationDescent of the fetal headUterine 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

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 lesseach lasting < 20 secondsat least 2/10 min contractions

Active phase :Contractions at

least 3 / 10 mineach lasting < 40

secondsThe cervix should

dilate at a rate of 1 cm / hour or faster

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

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

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

Descent of the fetal 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

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

Uterine contractions Observations of the contractions are made every

hour in the latent phase and every half-hour in the active phase

frequency how often are they felt ? Assessed by number of contractions in a 10

minutes period duration how long do they last ? Measured in seconds from the time the

contraction is first felt abdominally , to the time the contraction phases off

Each square represents one contraction

Palpate number of contraction in ten minutes and duration of each contraction in seconds

Less than 20 seconds:  Between 20 and 40 seconds: More than 40 seconds:

Part 3: maternal conditionName / 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

Thank you