Clinical Teaching

A MATERIAL ON
FIRST STAGE OF
LABOR

SUBMITTED TO SUMBITTED BY
MADAM MRS SMITHA MS. ANURADHA
ASSISTANT PROFESSOR MSc. NURSING 1ST YEAR
HFCON HFCON
 FIRST STAGE OF LABOUR
INTRODUCTION

For many pregnant women, concerns about labor pain are second only to concerns about their
baby's health and well-being. However, women's labor pain experiences are often quite
different from other experiences of physical pain. Labor pain doesn’t have to involve
suffering. In fact, working through your labor can bring a sense of satisfaction and
accomplishment.

When a woman feels she is successfully meeting a challenge and is the center of loving
attention, she may feel exhilarated even while in great pain. If she feels helpless and unable to
cope or that people are not treating her with respect, she will suffer regardless of her pain
level. And there are many ways to get help and increase your comfort at this time and for this
you must have knowledge regarding the first stage of labor.

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.
NORMAL LABOUR
Labour is called normal if it fulfils the following criteria
1. Spontaneous in onset and at term
2. With vertex presentation
3. Without undue prolongation
4. Natural termination with minimal aids
5. Without having any complication affecting the health of the mother and baby.
STAGES OF LABOUR
It is divided in 4 stages:
 First stage- it starts from the onset of true labour pain and ends with the full dilation of
the cervix. It is in other words, the “cervical stage” of labor. Its average duration is 12
hours in primigravida and 6 hours in multiparae
 Second stage: it starts from the full dilatation of the cervix (not from the rupture of the
membranes) and ends with expulsion of the fetus from the birth canal.
It has two phases-
The propulsive phase- Starts from the full dilation upto the descent of the presentating
part to the pelvic floor.
The expulsive phase: distinguished by, maternal bearing down efforts with the
delivery of the baby, its average duration is 2 hours in primigravida and 30 minutes in
multiparae.
 Third stage: it begins after expulsion of the fetus and ends with expulsion of the
placenta and membranes(after-birth). Its average duration is about 15 minutes in both
primigravidae and multiparae. The duration is however, reduced to 5 minutes in active
management.
  Fourth stage: it is the stage of observation for at least one hour after the expulsion of
the after-births. During this period, general condition of the patient and the behavious
of the uterus are to be carefully watched.
PHYSIOLOGY OF NORMAL LABOR
During pregnancy there is marked hypertrophy and hyperplasia of the uterine muscle and the
enlargement of the uterus is more: beyond and the attachment of round ligament. At term, the
length of the uterus measures about 35cm including cervix and the fundus is much wider both
transversely and anteroposteriorly than the lower segment.
The uterus is pyriform or ovoid shape. The cervical canal is occluded by a thick, tenacious,
mucus plug.
UTERINE CONTRACTION IN LABOR
 Throughout the pregnancy there is rhythmic involuntary spasmodic uterine contractions
which are painless and have no effect on dilation of the cervix.
 The character of the contractions changes with the onset of labor.
 The pacemaker of the uterine contraction is probably situated in the region of the tubal
ostia from where waves of contractions spread downwards.
Where there is wide variation in frequency, intensity and duration of concentration, tey remain
usually within normal limits and following patterns.
 There is good synchronisation of the contraction waves of both halves of the uterus.
 There is fundal dominance with the gradual diminishing contraction wave through mid-
zone down to lower segment which takes about 10-20 seconds.
 The waves of contraction follow a regular pattern.
 Intra amniotic pressure rises beyond 20 mm Hg with the onset of true labor pains during
contraction.
 Good relaxation occurs in between of contraction to bring down the intra-amniotic
pressure to less than 8 mm Hg. Contraction of the fundus last longer than that of the
midzone.
During contraction the uterus becomes hard and push anteriorly to make the long axis of the
uterus in line with that of pelvic axis. Simultaneously, the patient experiences pain which is
situated more on the hypogastric region often radiating to the thigs.
Probable causes of pain are; -
 Myometrial hypoxia during contraction
 Stretching of the peritoneum over the fundus.
 Stretching of the cervix during dilatation.
 Compression of then nerve ganglion.
The pain of the uterine contraction is distributed along the cutaneous nerve distribution to T10
to L1.
Pain of the cervical dilataion and starching is reffred to the back through the sacral plexus.
TONUS:
  It is the intrauterine pressure contraction in between contraction.
 During pregnancy, as the uterus is relatively inactive, the tonus is of 2-3 mm Hg.
 During the first stage of labor, it varies from 8-10 mm Hg.
 It is inversely proportional to the relaxation.
 The factors which govern the tonus are- contractility of uterine muscle, intra-
abdominal pressure, over distension of the uterus as in twin’s pregnancy and
hydraminos.
INTENSITY:
 The intensity of the uterine contraction describes the degree of the uterine systole.
 The intensity gradually increases with advancement of labor until it becomes maximum
in the second stage during delivery of the baby
 Intensity is initially influenced probably by hormones but subsequently depend on
multiple origin of contraction.
 Intrauterine pressure is raised to 40-50 mm Hg during first stage and about 100-200
mmHg in second stage of labor during contraction.
DURATION:
 In the first stage of labor, the contractions last for about 30 sec initially but gradually
increases in duration with the progress of labor. Thus in the second stage, the
contraction last longer than in the first stage.
FREQUENCY:
 In the early stage of labor, the contractions come at intervals of ten to fifteen minutes.
The intervals gradually shorten with advancement of labor until in the second stage,
when it comes every two or three minutes.
NOTE: it is important to note that all the feature of uterine contractions mentioned are very
effective only when they are in combination.
RETRACTION:
 Retraction is a phenomenon of the uterus in labor in which the muscle fibres are
permanently shortened.
 Contraction is a temporary reduction in length of the fibres, which attains their full
length during relaxation. In contrast, retraction results in permanent shortening and the
fibres are shortened once for all.
The net effect of retraction in normal labor are:
 Essential property in the formation of lower uterine segment and dilation 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.
 PHASES IN FIRST STAGE OF LABOR:
I. Latent phase:
 from onset of labor to the 3-4 cm dilatation of cervix.
 Cervix fully EFFACED
 Mild, irregular contractions become more rhythmic and stronger
 Cervical dilatation starts
 Can last even up to 12-16 hour
II. Active phase:
 from end of the latent phase to the full dilation of the cervix.
 Cervix dilates rapidly up to 10cm
 At a rate of 1cm/hour or more
 Foetal descent begins
 Lasts for 2 – 6 hours
First phase Duration is shorter in multi and Considered as prolonged if, – >12hrs in
primigravida >8hrs in multi
EVENTS IN FIRST STAGE OF LABOR
The first stage is chiefly concerned with the preparation of the birth canal so as to facilitate
expulsion of fetus in the second stage.
The main events of first stage are-
a) Cervical Dilation and effacement
b) Full formation of the lower uterine segment

i. CERVICAL DILATION
Prior to the onset of labor, in the prelabor phase(phase-1) there may be a certain amount of
dilation of cervix, specially in multiparae and in some primigravidae. Important structural
components of the cervix are-
 Smooth muscle(5-20%)
 Collagen
 The ground substance
Pre-disposing factors which favour smooth muscle dilation are: -
  Softening of the cervix
 Fibro-musculo-glandular hypertrophy
 Increased vascularity
 Accumulation of fluid in between collagen fibres
 Breaking down of collagen fibrils by enzymes collagenase and elastase.
 Change in the various glycosaminoglycans (e.g. increase in hyaluronic acid, decrease
in dermatan sulphate) in the matrix of the cervix.
These are under the action of hormones
 Estrogen
 Progesterone
 Relaxin
Too much fibrosis as in chronic cervicitis or prolapse or organic lesion in the cervix as in
carcinoma, results in deficiency of these factors. As a result, cervix may fail to dilate.
Actual factors responsible are:
a) Uterine Contraction and retraction:
 The longitudinal muscle fibres of the upper segment are attached with circular
muscle fibres of the lower segment and upper part of the cervix in a bucket holding
fashion.
 With each contraction, not only the canalis opened up from above down but it also
becomes shortened and retracted. There is some co-ordination between fundal
contraction and cervical dilation called “polarity of uterus”.
 While the upper segment contract, retracts and pushes the fetus, the lower segment
and the cervix dilate in response to the forces of contraction of upper segment.

b) Bag of membrane
 The membranes (amnion and chorion) are attached loosely to the decidua lining the
uterine cavity except over the internal os.
 In vertex presentation, the girdle of the contact of the head (that part of the
circumference of the head which first comes in contact with the pelvic brim) being
spherical, may well fit with the wall of the lower uterine segment.
 This result in dividing amniotic cavity in two compartment. The part above the girdle
of contact contains the fetus with the bulk of the liquor called hindwaters and the one
below it containing small amount of liquor called forewaters.
 With the onset of labor, the membranes attached to the lower uterine segment are
detached and with the rise of intrauterine pressure during contraction there is herniation
of the membranes through the cervical canal. There is ball-valve like action by the well
flexed head.
 Uterine contraction generate hydrostatic pressure in the forewaters that in turn dilate
the cervical canal like a wedge. When the bag of forewater is absent (PROM) the
pressure of the presenting part pushes the cervix centrifugally.
 c) Fetal axis pressure
 In labor with longitudinal lie, there is a tendency of straightening out of the fetal
vertebral column due to contraction of circular muscles of the body of the uterus.
 This allows the fundal contraction to transmit through the podalic piole into the fetal
axis and hence allows mechanical stretching of the lower segment and opening up of
the cervical canal.
 With each uterine contraction, there is elongation of the uterine ovoid and decrease in
the transverse lie fetal axis pressure is absent.
d) Vis-a-tergo
 The final phase of dilation and retraction of the cervix is achieved by downward thrust
of presenting part of the fetus and upward pull of the cervix over the lower segement.
This phenomenon is lacking in transverse lie where a thin cervical film to disappear.

ii. EFFACEMENT OR TAKING UP OF CERVIX

 Effacement is the process by which the muscular fibers of the cervix are pulled upward
and merges with the fibers to the lower uterine segment.
 The cervix becomes thin during first stage of labor or even before that in primigravidae.
 In primigravidae, effacement precedes dilation of the cervix, whereas in multiparae,
both occur simultaneously. Expulsion of mucus plug is caused by effacement.

iii. LOWER UTERINE SEGMENT

 Before the onset of the labor, there is no complete anatomical or functional division of
the uterus.
 During labor, the demarcation of an active upper segment and are relatively passive
lower segment is more pronounced
 The wall of the upper segment becomes progressively thickened with progressive
thinning of the lower uterine segment.
  This is pronounced in late stage, specially after ruptured of the membranes and attains
it maximum in second stage.
 A distinct ridge is produced at the junction of the two called physiological retraction
ring which should not be confused with the pathological retraction ring- a feature of
obstructed labor.
 The lower uterine segment is thus limited superiorly by the physiological retraction ring
and inferiorly by the fibromuscular junction of cervix and uterus.
 Anatomically, the lower uterine segment corresponds with the part of the uterus to
which the peritoneum is loosely attached to the anterior wall.
 When fully formed, it measures 7.5-10cm from the internal os. It is hemispherical in
shape at the beginning but becomes cylindrical when fully formed in second stage.
 Thinning of the wall is achieved by –
a) Relaxation of the muscle fibres causing elongation as it is entirely passive
b) Contraction and retraction of the muscle fibres of the upper segment thereby
drawing up and elongating the lower segment and cervix
 At the same time fetus is pushed down causing further stretching of the wall - “receptive
relaxation”. However, unlike the upper segment, it has got poor retractile property.
It develops gradually as pregnancy advances and progressively thin s out during labor. It
developed from the isthmus- that portion of the non-pregnant uterus situated in between
anatomical and histological internal os, the former being higher.
CLINICAL IMPORTANCE
 The phenomenon of receptive relaxation, enables expulsion of the fetus by formation
of complete birth canal along with the fully dilated cervix.
 Implantation of placenta in lower segment gives rise to an important clinical entity-
placenta praevia.
 It is through this segment that caesarean section is performed.
 Because of poor retractile property, there is chance of post-partum haemorrhage if
placenta is implanted over the area.
 Poor decidual reaction facilitates morbid adherent placenta.
 In obstructed labor, the lower uterine segment is very much starched and thinned out is
likely to give way specially in multiparae.

CLINICAL COURSE OF FIRST STAGE OF LABOR

  The first symptom to appear is intermittent painful uterine contractions followed by
expulsion of blood stained mucus (show) per vaginam.
 Only few drops of blood mixed with mucus is expelled and any excess should be
considered abnormal.
PAIN
 The pains are felt more anteriorly with simultaneously hardening of the uterus which is
bodily pushed forwards.
 Initially, the pains are not strong enough to cause discomfort and come at varying
intervals of 15-30 minutes with the duration of about 30 seconds.
 But gradually the interval becomes shortened with increasing intensity and duration so
that in late first stage the contraction comes at interval of 3-5minutes and lasts for about
45 seconds. The relation of pain with the uterine contraction is of great clinical
significance.
 In normal labor, pains are usually felt shortly after the uterine contraction begins and
pass off before complete relaxation of the uterus. Clinically., the pains are said to be
good if they come at intervals of 3-5 minutes and at the height of contraction of the
uterine wall cannot be indented by the fingers.
DILATATION AND EFFACEMENT OF THE CERVIX
 Progressive anatomical changes in the cervix such as dilatation and effacement are
inferred through vaginal examination.
 Cervical dilatation relates with dilatation of the external os and effacement is
determined by the length of the cervical canal in the vagina.
 In primigravidae, the cervix may be completely effaced, feeling like a paper although
not dilated enough to admit a fingertip. It may be mistaken for one that is fully dilated.
 When in multiparae, dilatation and taking up occur simultaneously which are more
abrupt following rupture of the membranes. The anterior lip of the cervix is the last to
be effaced. The first stage is said to be completed only when the cervix is completely
retracted over the presenting part during contraction.
 Cervical dilatation is expressed either in term of fingers- 1,2,3 or fully dilated; or
better in term of centimetres (10cm when fully dilated). Usually measured with fingers
but recorded in cm. One fingers equals to 1.6 cm on average. Effacement of the cervix
in terms of percentage i.e. 25%,50% or 100%.
 The term ‘rim’ is used when the depth of the cervical tissue surrounding the os is about
0.5-1 cm.
Partograph: Freidman (1954) first devised it.
it composite graphical record of cervical dilatation and descent of the head against duration of
labor in hours. It also gives information about fetal and maternal condition, which are all
recorded on a single sheet of paper.
Cervical dilation is the sigmoid curve and the first stage of labor has got two phases-
a) A latent phase
b) Active phase
The active phase got three components.
i) Acceleration phase with cervical dilatation of 2.5-4 cm.
ii) Phase of maximum slope of 4-9cm dilatation.
iii) Phase of deceleration of 9-10cm dilatation.
 In primigravidae, the latent phase is often long (about 8 hours) during which effacement
occurs. The cervical dilatation averaging only 0.35cm/hour.
 In multiparae, the latent phase is short (about 4 hours) and effacement and dilatation
occur simultaneously.
 Dilation of the cervix at the rate of 1 cm per hour in primigravidae and 1.5 cm in
multigravidae beyond 3 cm dilatation is considered satisfactory.
STATUS OF THE MEMBRANES
 Membranes usually remain intact until full dilatation of the cervix or sometimes even
beyond, in the second stage. However, it may rupture any time after the onset of labor
but before full dilatation of cervix-when it is called early rupture.
 When the membranes rupture before the onset of labor, it is called premature rupture.
 An intact membrane is best felt with fingers during uterine contraction when it becomes
tense and bulges out through the cervical opening
 In between contractions, the membranes get relaxed and lies in contact with the head.
 With the rupture of the membranes, variables amounts of liqor escape out through the
vagina and other there is acceleration in the uterine contraction.
MATERNAL SYSTEM
 General condition remains unaffected although, a feeling of transient fatigue appears
following a strong contraction.
 Pulse rate is increased by 10-15 beats per minute during contraction which settles down
to its previous rate in between contraction.
 Systolic blood pressure is raised by about 10mm Hg during contraction.
 Temperature remains unaffected.
FETAL EFFECT
 So long as the membranes are intact, there is hardly any adverse effect on the fetus.
 During contraction, there may be slowing heart rate by 10-20 beats per minute which
soon returns to its normal rate of about 140 per minute as the intensity of contraction
diminishes provided the fetus is not compromised.
 MANAGEMENT
Principles
 non-interference with watchful expectancy so as to prepare the patient for natural
birth.
 To monitor carefully the progress of labor, maternal conditions and fetal behaviour so
as to detect any intrapartum complication early.
Preliminaries
 This consist of basic evaluation of the current condition.
 Enquiry is to be made about the onset of labor pains or leakage of liqor, if any.
 Through general and obstetrical examinations including vaginal examination are to be
carried out and recorded.
 Records of antenatal visits, investigation reports and specific treatment given, if
available, are to be reviewed
Actual Management
a) General
 Antiseptic dressing
 Encouragement and assurance are given to keep up the morale.
 Constant supervision
b) Bowel
An enema with soap and water or glycerine suppository is traditionally given in early
stage. This may be given if the rectum feels loaded on vaginal examination. But enema
neither shortens the duration of labor nor reduces the infection rate.
c) Rest and ambulation
If the membranes are intact, the patient is allowed to walk about. This attitude prevents
venecaval compression and encourages descent of the head. Ambulation can reduce the
duration of labor, need of analgesia and improves maternal comfort. If however, labor
is monitored electronically or analgesic drug (epidural analgesia) is given, she should
be in bed.
d) Diet
There is delayed emptying of the stomach in labor. Low PH of the gastric contents is a
real danger if aspirated following general anaesthesia when needed unexpectedly. So
food is withheld during active labor. Fluids in the forms of plain water, ice chips or fruit
may be given in early labor. Intravenous fluid with ringer lactate solution is started
where any intervention is anticipated or the patient is under regional anaesthesia.
e) Bladder care
Patient is encouraged to pass urine by herself as full bladder often inhibits uterine
contraction and may lead to infection. If the woman cannot go to the toilet, she is given
a bed pan. Privacy must be maintained and comfort must be ensured. If the patient fails
to pass urine specially in late first stage, catherisation is to be done with strict aseptic
precautions.
f) Relief of pain
Common analgesic drug used is pethidine 50-100 mg intravenously when pain is well
established in active stage of labor. If necessary it is repeated after 4 hours. Pethidine
 is an effective analgesic as well as a sedative. Metoclopramide 10mg I.M. is commonly
given to combat vomiting due to pethidine. Pethidine crosses the placenta and is a
respiratory depressant to the neonate. So, the drug should not be given when the
delivery is anticipated within two hours.
g) Assessment of progess of labor and partograph recording
Abdominal findings-
Uterine contraction- as regards the frequency, intensity and duration are assessed. The
number of contraction in 10 minutes and duration of each contraction in seconds are
recorded in the partograph.
Pelvic grip- gradual disappearance of the poles of the head (sinciput and occiput) which
were felt previously palpable above the pelvic brim).
Shifting the maximal impulse of the fetal heart beat downwards and medially.
To note the fetal well being
 Fetal heart rate: along with its rhythm and intensity should be noted every hour in the
first and every 15 minutes in second stage of following rupture of the membranes. To
be of value, the observation should be made immediately following uterine contraction.
The count should be made for 60 seconds
for outline clinical observation, ordinarily stethoscope is quite suitable
Doppler ultrasonic cardiography (Popplex), is helpful in case of obesity and
polyhydramnios.
To avoid confusion of maternal and fetal heart arte, maternal pulse should be counted,
otherwise maternal tachycardia may be wrongly treated as fetal heart rate. Normal fetal
heart rate ranges from 110-150 per minute.
Continuous electric fetal monitoring: the device consist of simultaneous recording of fetal
heart action by fetal electro-cardiography and uterine contraction by tocography. It is
commonly used in high risk pregnancy.
Vaginal examination
 Dilatation of cervix in centimetres in relation to hours of labor is a reliable index to note
the progress of labor.
 To note the position of the head and degree of flexion.
 To note the station of the head in relation to the ischial spines.
 Color of the liquor (clear or meconium stained) if the membranes are ruptured.
 Degree of moulding of the head- moulding occurs first at the junction of occipito-
parietal bones and then between the parietal bones
 Caput formation- progressive increase is more important than its mere prescence.
Fetal distress factors must be check out for hypoxia
TO CHECK THE MATERNAL CONDITION
Routine check-up includes
a) To record two hourly maternal pulse, blood pressure and temperature.
b) To observe the tongue periodically for hydration
c) To note the urine output, urine for acetone, glucose and I.V. Fluids, drugs
Evidence of maternal distress are:
 Dehydration, dry tongue
 Acetone smell in breath
 Rising pulse rate of 100 per minute or more
 Hot dry vagina often with offensive discharge
 Scanty high coloured urine with presence of acetone
 Anxious look with sunken eye
SUMMARY AND CONCLUSION
First stage of labor starts from the onset of true labor pain ends with full dilatation of the cervix.
Its average duration is about 12 hours in primigravida and 6 hours in multiparae. First stage
consists of latent phase (upto 4 cm of cervical dilatation) and active phase upto 10cm. this stage
is chiefly concerned with dilatation and effacement of the cervix. The stage is clinically
manifested by progressive uterine contraction by progressive uterine contraction; progressive
dilation and except during uterine contraction.
BIBLIOGRAPHY
 Dutta D.C., Textbook of obstetrics, New Central Book agency publication 6th edition
page no: 114-144
 Manocha Sneh Lata, Procedure and practices in Midwife, Kumar publishing house,
page no. 64-74
 Sharma JB, Textbook of Obstetrics, Avichal publishing Company, 2nd edition, page
no. 120-140
 Daftary N. S., Chakaravarti Sudip, Holland and Brews Manual of Obstetrics, Elsevier
publication, 3rd edition, page no. 246-257
 Whilson Robert, Beecham Clayton M., Carrington Elise Ried, Obstetrics and
Gynecology, The C.V. Mobsy Company, 5th edition page no.184-203
 Bookmiler Mae M, Bowen George L., Textbook of obstetrics and Obstetric Nursing,
W.B. Saunders Company publication, 4th edition page no.110-118