premonitory stage of labour

8/13/2019 Premonitory Stage of Labour

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Premonitory Stage of Labour Definition of Premonitory stage of labour

A short time previous to the commencement of labour where certain symptoms manifestthemselves, which are looked upon as indications of the approaching event is termed as the

premonitory stage of labour.

Signs & Symptoms of Premonitory stage of labour

o A feeling of activity and lightness on the part of the patiento A diminution of the abdominal protuberanceo An increased vaginal secretiono Frequently a sympathetic irritability of the bladder, and sometimes of the rectum also.o Lightening: the mother would feel the descent of the fetus and changes the abdominal

contour.o Bra ton hicks contraction: painless irregular contractionso Bloody showo !udden rush of energy: due to change in levels of estrogen and progesteroneo "ncreased backache and sacroiliac pressureo #ipening of cervi : soft $as butter% feeling of the cervio #upture of the membrane: &bag of water'

First Stage of Labour


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(he first stage of labour is a stage of dilatation of the cervical os. "t beginswith the onset of true labour contractions to full dilatation of the cervi .)uration of first stage is an average of *+ hours for nullipara and .- hours

for multipara. (he first stage is clinically manifested by progressive uterinecontraction, progressive taking up of the cervi and ultimate rupture ofmembranes.

Phases of First stage of Labour

Latent Phase (he latent or preparatory phase begins at the onset of regularly

perceived uterine contractions and ends when rapid cervical dilatation

begins. ontractions during this phase are mild and short, lasting /0 to 10

seconds.

ervical effacement occurs, and the cervi dilatates from 0 to + cm.

(he phase lasts appro imately 2 hours in a nullipara and 1.- hours in amultipara.

Active Phase )uring the active phase of labor, cervical dilatation occurs more

rapidly, increasing from 1 to cm. ontractions grow stronger, lasting 10 to 20 seconds, and occur

appro imately every + to - minutes.

(his phase lasts appro imately + hours in a nullipara and / hours in amultipara.

!how $increased vaginal secretions% and perhaps spontaneous ruptureof the membranes may occur during this time. (his phase can be adifficult time for a woman because contractions grow so strong, lastlonger, and begin to cause true discomfort.

"t can be a frightening time as she reali3es labor is truly progressing andher life is about to change forever.


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Transition Phase )uring the transition phase, contractions reach their peak of intensity,

occurring every / to + minutes with a duration of 20 to 40 seconds and

causing ma imum dilatation of 5 to *0 cm. "f the membranes have not previously ruptured or been ruptured by

amniotomy, they will rupture as a rule at full dilatation $*0 cm%.

"f it has not previously occurred, show occurs as the last of the mucus plug from the cervi is released.

By the end of this phase, both full dilatation $*0 cm% and completecervical effacement have occurred.

Factors affecting First Stage of Labour

1. Uterine factors Fundal dominance: 6terine contraction strart from the fundus of the

uterus and moves downward. ontractions of the fundus are strong andintense and last for a longer time in the fundus.

Pollarity: "t is used to describe the neuromuscular harmony betweenupper uterine segment and the lower uterine segment. ontractions ofthe uterus takes place at the upper pole and there is slight contractionsand dilatation of the cervi taking place at the lower pole.

Contraction and retraction: As the contractions begin it will not relacompletely which is called as retraction. (his retraction will favour infurther contractions and e pulsion of the fetus.

Formation of upper and lo er uterine segment : (he uterus forms athick upper layer and thin lower muscular layer. (he upper longitudinalmuscles pull on the lower circular muscles situated in the lower uterinesegment which will aid in the descent of the presenting part.

!etraction ring: (his is a ridge formed between the upper and thelower uterine segment. "ts also called as Bandl7s #ing.

Cer"ical effacement: "t is the thinning out of the cervi which isaccomplished in the first stage of labour. "t is e pressed in terms of

percentage. *008 effaced means that the cervi is fully effaced. "n


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primi effacement preceeds the dilatation of the cervi . "n multigravidae, both occur simultaneously.

Cer"ical dilatation: "t is a process of enlargement of the e ternal oswhich is a tightly closed operture to an opening large enough to permitthe passage of the fetal head. (his is e pressed in centimeters andranges from 09*0cm.

Presence of sho : As the cervi dilates, operculum is discharged outwith light blood stains called as !how7. (his is due to the rupturedcapillaries of the deciduas, where the chorion detaches due to dilatationof the cervi .

#. $echanical factors Formation of fore aters: As the chorion detaches, a loosened sac of

amniotic fluid bulges downwards into dilating internal os. "n case ofcomplete fle ion where the presenting part gets completely fi ed, fluidcuts into two compartments. ;ne compartment with fetus and somefluid called hind waters7 and another compartment with fluid in frontof the presenting part called forewaters7. Forewaters when rupturedreleases prostaglandins causing uterine contractions.

!upture of membranes : "t occurs at the end of the first stage oflabour. "t can sometimes rupture before the dilation of the cervi .

%eneral fluid pressure:


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> #outine 6rine

$anagement*. (ake a brief history and assessment

/. Encourage the woman to have a warm bath or vulval toileting.+. ive a soap and water enema.1.


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+. )escent of head following rupture of membrane in early labour to e cludecord prolapse

1. )iagnosis of second stage9full dilatation of cervi

Diagnosis of poor progress of labour @rolonged bradycardia and meconium stained liquor @ossibility of foetal distress

@rolonged latent phase when more than eight hours in primigrvida andmore than si hours in multigravida

@rolonged latent phase may be due to fault in power, passage or passenger

@assage is small due to contracted pelvis @assenger, hydrocephalous, brow Iocciput not feltJ

Large baby, shoulder presentation

!ole of nurse in caring of the oman in the first stage of labour: Admitting client to birthing area after determining that client is in labor )etermining if clientKs membranes have ruptured

Encouraging family participation as appropriate with the labor process

@erforming Leopold maneuver and vaginal e ams as appropriate

?onitoring maternal vital signs and fetal heart rate and patterns,reporting any deviations or abnormalities

Applying electronic fetal monitor as appropriate

Assessing pain level, instituting positioning, breathing, rela ation, and

other methods for pain control administering analgesics as ordered @roviding ice chips, wet washcloth, or hard candy

Encouraging voiding at least every / hours

Assisting with anesthetic administration


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Assisting with amniotomy with assessment of fetal heart rate, fetal positioning, and fetal cord after amniotomy

leansing perineum and assisting with pad changes regularly

?onitoring progress including vaginal discharge, cervical dilation andeffacement, position, and fetal descent

@erforming vaginal e aminations as necessary

Assisting coach and supporting client and partner

@reparing supplies and equipment for delivery

Gotifying primary health care provider at appropriate time to scrub forattending delivery

Derifying maternal and fetal heart rate response to uterine contractionsduring intrapartal care

"nstructing client and partner about reasons for electronic monitoring

Applying tocotransducer snugly after determining fetal position viaLeopold maneuver

@alpating to determine contraction intensity

#eassuring client about normal fetal heart rates

Ad=usting monitor to achieve and maintain clear tracing

"nterpreting rhythm strips when at least a *09minute tracing has beenobtained


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Second Stage of Labour

!econd stage of labour is the stage of fetal e pulsion. "t begins with fulldilation of cervical os and ends with the birth of the baby. !econd stage lastsfor / hours for nullipara and /09+0 minutes in multipara.

Changes ta(ing place during the second stage of the labour:*. (he second stage is clinically manifested by increased frequency and intensity

of uterine contractions every /9+ minutes lasting for 20940minutes./. (he long a is of the fetus is parallel to the long a is of the pelvis.+. @elvic floor muscles e ert some pressure over the fetus as it descends down.1. (he mother e erts pressure with her abdominal muscles at the peak of

inspiration with glottis closed called as &bearing down' efforts with pursedlips, distension of neck veins, rapid pulse rate, increased respiratory rateandincreased perspiration which result in e pulsion of the fetus

-. (he mother may show features of e haustion.

)*uipments for conduction of deli"ery


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!terile gloves !terile drapes !terile leggings !terile towels !terile sponges !teel Basin ord clamp !uture cutting !cissors Allies (issue Forceps Episiotomy !cissors !uture material Bulb !yringe #ubber atheter Geedle holder !pot light

Signs of Deli"ery )istension of perineum which becomes tense and glistening Dulval opening looks like a slit through which scalp hairs are visible

Fetal head will not reside back even after the cessation of uterinecontraction called rowning7.

Anal sphincter gets stretched with visibility of anterior rectal wall.

$anagement of the Second Stage of Labour (he second stage of labor, as noted previously, is characteri3ed by

complete cervical dilation descent of the fetal verte and in patientswithout anesthesia, a sensation of pelvic pressure and the urge to beardown.

"nternal e amination should confirm complete dilation, as well as thefetal position and station, prior to the commencement of maternal

pushing efforts.


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Encouraging spontaneous bearing9down efforts for second stage

Evaluating pushing efforts and length of time in second stage

+hird stage of labour $echanism of placental seperation!eparation of the placenta is brought about by contraction and separationretraction retraction of the myometrium which thicken the uterine wall andreduces the si3e of the placental area. As the placental area becomes smaller,the placenta begins to tear off the uterine wall because, unlike the uterus, it is


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not elastic and cannot contract and retract. At the area of separation a clotforms. (his clot, known as a retroplacental clot, collects between the deciduaand the placenta and further promotes separation. !ubsequent uterinecontractions completely detach the placenta from the uterine wall and it

descends into the lower uterine segment and then into the vaginafrom where it is e pelled.

(here are two methods of separation of the placenta which have beendescribed by !chult3e and ?atthews )uncan. (hese methods are not underthe control of the birth attendant.

(he Schult,e method is said to be the more common. (he placenta detachesfrom a central point and slips down into the vagina through the hole in theamniotic sac the fetal surface appears at the vulva, with the membranestrailing behind like an inverted umbrella as they are peeled off the uterinewall. (he maternal surface of the placenta is not seen, and any blood clot isinside the inverted sac.

"n the $atthe s Duncan method, the placenta slides down sideways andcomes through the vulva with the lateral border first, like a button through a

buttonhole. (he maternal surface is seen, and the blood escapes as it is notinside the sac. "t is more likely that parts of the membranes will be left behindwith the ?atthews )uncan method, as they may not be peeled off ascompletely as in the !chult3e method. (he ?atthews )uncan method may beassociated with a placenta lying lower in the uterus. (he process of separationtakes longer and blood loss is greater $because there are fewer oblique fibresin the lower segment%.

Signs of placental separation*. (he fundus feels hard and globular, and rises abdominally to the level

of the umbilicus./. (he cord lengthens at the vulva.

+. A trickle of blood appears when the placenta separates.

Control of bleeding


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old the placenta in the palms of the hands $palms should be kept flat% allthe lobules on the maternal side should be present and they should fittogether. (here should be no irregularities on the margins. "f the maternalside is carefully rinsed with water and held to the light, a shiny layer should

be seen $the decidua%. "f it is not intact, it may indicate that some fragmentsof placenta are left behind. ;n the fetal side, the membranes should appearcomplete. old the umbilical cord in one hand and let the placenta hangdown: check that the membranes are complete, there should be one hole Hwhere the baby came through $if placenta e pelled by ?atthews )uncanmethod, the membrane may be torn in more than one place%. "t also gives youthe opportunity to look for free9ending vessels on the membranes which mayindicate the presence of an e tra lobe of placenta $placenta succenturiata or

bipartita% which is left behind in the uterus.

$- -%)$) + /F +0) +0'!D S+-%) /F L- /U! (he third stage of labour is the most dangerous time, because of the risk of

bleeding which can be life9threatening. (he active management of the thirdstage must be carried out correctly, otherwise serious complications mayoccur such as haemorrhage andCor inversion of the uterus.

-cti"e management:*. An o ytocic drug $such as o ytocin *0 "6 "? or ergometrine 0./ mg "?% isgiven after delivery of the baby and immediately after the midwife has

palpated the uterus to check that there is not a multiple pregnancy./. (he cord is clamped and cut, immediately after the drug is given.+.


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contract again before a second attempt. Apply ontrolled cord traction 9 toavoid inversion of the uterus, controlled cord traction should never be appliedwithout counter9traction

1. As the placenta is delivered, it should be caught in both hands at the vulvato prevent the membranes tearing and some being left behind.

Physiological management: Go o ytocics are used before delivery of the placenta. !igns of placental separation are awaited. )elivery of the placenta is by gravity and maternal effort. (he cord is clamped after delivery of the placenta $or sometimes when the

pulsations have ceased%, unless there is a need to clamp and cut the cord forneonatal reasons.m (his method should only be used in situations when noo ytocic drugs are available.

;nce signs of placental separation are visible, check that the uterus is wellcontracted and, if it is, ask the woman to bear down to push the placenta out.

atch the placenta in both hands as it emerges from the vagina. " f the placenta fails to deliver, check that the bladder is empty and, if not, ask

the woman to pass urine, then try again to deliver the placenta with the ne tuterine contraction.

Choice of o ytocic drugs ; ytocics cause the uterus to contract. (hey speedup the deliveryof the placenta and lessen the blood loss. (he choices are:A. ; ytocin.B. !yntometrine.

. Ergometrine.

-./ ytocin; ytocin is a pituitary $posterior lobe% e tract which can be preparedsynthetically:

causes contraction of smooth muscle and therefore has apowerfulaction on the uterine muscle

acts within /M minutes when given intramuscularly.


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Advantages of oxytocin: "t has a rapid action and does not cause side effectsin most cases. "t is also more stable in hot climates.

Disadvantages of oxytocin: "t does not have a sustained action.

. Syntometrine!yntometrine is a combined preparation, ergometrine and o ytocin which isgiven by intramuscular in=ection.

Advantages of syntometrine:"t has the combined effect of the rapid action of o ytocin and the sustainedaction of ergometrine.

Disadvantages of syntometrine:(here is a greater risk of producing temporary hypertension and vomiting.

C. )rgometrineErgometrine is a preparation of ergot which:

may be given orally, intramuscularly or intravenously. owever, oral preparation has been found to be ineffecti"e for acti"e managementof the third stage 9 and should not be used for this purpose

takes 2H minutes to take effect when given intramuscularly, and 1-seconds when given intravenously

causes marked spasm of the uterus by a series of rapid contractions

has an effect lasting appro imately /H1 hours.

Advantages of ergometrine:"t is the cheapest of the o ytocic drugs and it has a sustained action.

Disadvantages of ergometrine:eadache, nausea and vomiting, and hypertension. Ergometrine is therefore

definitely contraindicated and should ne"er be given to women with raised blood pressure andCor cardiac disease. Ergometrine stored at room temperature or e posed to light,maylose a lot of its potency.

!ecommendations for practice


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*. (he use of o ytocin is recommended.


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(he delivery of the placenta does not mark the end of risk for bleeding onthe contrary, the uterus may have a tendency to rela slightly following

placental delivery, and this is the point at which problems most commonly begin. (he prophylactic use of a uterotonic helps ensure that the uterus

continues to contract and retract, but the obstetrician must remain vigilant. Gearly every clinician can recount an episode of being briefly distracted atthis point only to have his or her attention abruptly reclaimed by a cascade of

blood.

Following delivery of the placenta, palpate the abdomen to assess andmonitor uterine tone and si3e. At this point, uterine massage is reasonable,especially if concern e ists regarding uterine tone. 6terine massage can beuncomfortable therefore, e plain the rationale to the patient. "f intravenousaccess is in place, a continuous infusion of o ytocin for a period followingdelivery is reasonable. "f ongoing concerns e ist regarding uterine tone, thenstart an o ytocin infusion or administer a longer9acting agent. Encourageearly breastfeeding to promote endogenous o ytocin release.

;nce good, sustained uterine tone has been established, the presence of any bleeding from the lower genital tract can be assessed. "f bleeding is minimal,assess the placenta for completeness. $First, manage any significant lowergenital tract bleeding.% Assessment of the placenta before repair of anepisiotomy or any lacerations is advised in order to avoid disrupting theserepairs if uterine e ploration or instrumentation is necessary.

E amine the fetal side for any evidence of vessels coursing to the edge of the placenta and into the membranes. !uch vessels suggest the presence of asuccenturiate placental lobe. "f the vessels are torn and the lobe is not present,it is quite likely retained and may subsequently lead to bleeding or infection."f this is the case, turn the placenta over and lay it on a flat surface toe amine the maternal side, with special attention to any defect suggestive of amissing, retained cotyledon. Gote other abnormalities of the placenta, andconsider whether pathological e amination is warranted. ultures of the

placenta seem to be of little value in the diagnosis or management of fetal oruterine infection.


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?anual removal of the placenta is warranted if significant bleeding occurs.(he retained or partially detached placenta interferes with uterine contractionand retraction and leads to bleeding. @erform manual removal with a level ofanalgesia that matches the clinical urgency of the situation. (he cessation of

an o ytocin infusion or the administration of uterine rela ants to promoteuterine e ploration and manual removal is of questionable value and maylead to increased bleeding. 6ltrasound may be useful in select cases.


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(his condition is very rare. (he risk of uterine inversion is increased inabnormalities of placentation, such as accreta, and is more likely with fundalcord insertions and any condition that predisposes patients to uterine atonyand prolapse. ord traction should never occur without countertraction or in

the absence of uterine contraction. Leave the placenta attached, and focusmanagement on maternal resuscitation and rapid return of the uterus to theabdominal cavity.

(he fingers are formed into a single cone9shaped unit and placed at the mostdependent portion of the protruding mass, which represents the inverteduterine fundus. entle upward pressure is e erted in the a is of the birthcanal with the fingers and thumb together to minimi3e the risk of uterine

perforation. (he action has been likened to that of placing the fingers at thetoe of an inside9out sock and pushing to make the sock right9side out.Following uterine replacement, vigorous massage and uterotonicadministration should undertaken.

?anual removal of the placenta may be performed when the motherKs vitalsigns are stable unless concern e ists regarding abnormal placentation.6terine rela ants, such as nitroglycerin, may be helpful.

Placenta accreta

@lacenta accreta and its variants are not complications of third9stagemanagement but are most commonly recogni3ed during the third stage. (heselife9threatening abnormalities of placentation may occur spontaneouslyhowever, they are much more common in situations in which the placenta hasimplanted over a previously scarred uterus. (he routine use and improvingcapabilities of ultrasound may suggest this diagnosis in the antepartum

period, and the diagnosis should be considered in high9risk situations. (he possibility of placenta accreta mandates that preparations for the management

of severe @@ are in place and, if suggested based on ultrasound findings,that e pertise is available to deal with the complications of placenta percreta.


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premonitory stage of labour

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