FIRST STAGE OF LABOUR

INTRODUCTION

Series of events that takes place in the genital organ in an effort to expel the viable products of
conception out of the womb through the vagina in to the outer world is called labour.

Delivery is the expulsion or extraction of viable fetus out of the womb. The normal labour is otherwise
known as eutocia. The events of labor are divided in to four stages :

1. First stage

2. Second stage

3. Third Stage

4. Fourth Stage

FIRST STAGE OF LABOR

This starts from onset of regular uterine contraction and ends with full dilatation of cervix. It is also
known as “cervical Stage “ of labor. This stage is chiefly concerned with the preparation of the birth
canal so as to facilitate the expulsion of fetus in the second stage.

DEFINITION

“The stage which starts with the onset of true labor pain and ends with full dilatation of cervix is known
as first stage of labor.”

Duration- The average duration is 12 hours in primi gravida and 6 hours in multigravida.

PHYSIOLOGICAL CHANGES OR EVENTS IN FIRST STAGE OF LABOUR

The factors responsible for first stage of labour can be divided in to 2 groups:

1. Uterine Factors: It includes the following event

i. Fundal Dominance
ii. Contraction and Retraction of Uterine Muscle
iii. Formation of Upper and lower segment
iv. Development of retraction ring
v. Effacement & dilatation of cervix
vi. Ripening of the cervix
2. Mechanical factors: The mechanical factors include
i. Formation of Fore water
ii. General Fluid Pressure
iii. Rupture of membranes
iv. Fetal Axis Pressure
Uterine Factors
 Fundal Dominance: Each uterine contraction starts in the fundus and spreads across
and downwards. It permits the cervix to dilate and the fundus to expel the fetus.
 Polarity: The co-ordination between fundal contraction and cervical dilatation is called
“polarity of uterus”. The upper pole contracts strongly and retracts to expel the fetus.
The lower pole contracts slightly and dilates to allow expulsion of the fetus.
 Contraction and Retraction of Uterine Muscle: Contraction means the temporary
reduction in length of fibers which attain their full length during relaxation. Retraction
means the permanent shortening of the muscle fibers. It helps in formation of the lower
uterine segment, dilatation and effacement of cervix, separation of placenta,
maintenance of effective homeostasis. If the contraction lasts for < 20secs, it is called
mild contraction, if it lasts for 20-40secs , is called moderate contraction, >40secs it is
called strong contraction.
 Formation of upper and Lower uterine Segment: By the end of the pregnancy the body
of the uterus has divided in to two anatomically distinct segments- Uppr and Lower
Uterine segment .
 Development of Retraction ring: A ridge forms between the upper and lower uterine
segment, known as retraction ring. In normal labour retraction ring gradually rises as the
upper segment contracts and retracts ad the lower segment thins out to accommodate
the descending fetus.
 Effacement and Dilatation of the Cervix: The longitudinal muscle fibers of the upper
segment are attached with circular muscle fibers of the lower segment in a bucket
holding manner. Dilatation of the cervix is the process of enlargement of the external
cervical os from a tightly closed aperture to an opening large enough to permit passage
of the fetal head. Full dilatation of cervix is 10cm.
 Ripening of the Cervix: The cervix moves from its posterior position during pregnancy to
an anterior position, and the normally firm tissue softens considerably.
Mechanical Factors
 Formation of bag of water: As the lower uterine segment stretches , the chorionic
becomes detached from it, the increased intrauterine pressure causes the loosen part of
the sac of fluid herniated downwards in ton dilating internal OS and forms Bag of
membrane. In vertex presentation the part of water in front of presenting part is called
fore water and part above the griddle of contact is hind water.
 General Fluid Pressure: While the membranes remain intact, the pressure of the
uterine contraction is exerted on the fluid and as fluid is not compressible, the pressure
is equalized throughout the uterus and the fetal body which is known as general fluid
pressure.
 Rupture of Membranes: It occurs at the end of the 1 st stage of labour when the cervix is
fully dilated. It may be spontaneous or artificially done some times.
  Fetal Axis Pressure: During each contraction the uterus rears forward and the force of
the fundal contraction is transmitted to the upper pole of uterus, down the long axis of
the uterus and is applied by the presenting part to the cervix. This is known as Fetal Axis
Pressure.
PHASES OF FIRST STAGE
The first stage of labor is further subdivided in to3 phases:
a. Latent Phase(Early Labor)
b. Active Phase(Active Labor)
c. Transition Phase
a) Latent Phase/ Prodermal Phase: It begins with the onset of true labor contraction ,
which are usually mild, when the cervix is dilated 4cm. The frequency of contraction
ranges between 5-10minutes with duration of 30-45seconds. This stage usually lasts
for 8-10hours for primi gravida and 5-8 hours in multipara.
b) Active Phase: It begins at 4cm cervical dilatation and ends at 8cm dilatation.
Contractions occur in every 2-5minutes, last for 45-60seconds, and are moderate to
strong in intensity. This is characterized by progressive cervical dilatation and fetal
descent.
c) Transition Phase: It is the most difficult part of labour when the cervix is dilated 8cm
and it ends with full dilatation of cervix. The contractions are of strong intensity,
occur every 2-3minutes and lasts for 60-90seconds.

MANAGEMENT OF FIRST STAGE

AIM OF MANAGEMENT

1. Minimal observation with minimal active assistance.

2. To maintain the normalcy & to detect any deviation from the normal the earliest possible
moment.

ANTISEPTICS AND ASEPSIS

1. Surgical cleanliness and asepsis on the part of patient and attendant involve in the delivery
process are to be maintained
2. Antiseptic and aseptic precautions are to be taken during vaginal examination and during
conduction of delivery.

PRINCIPLES

1. Temperature of the room should be 25-28 0 c.

2. Noninterference with watchful expectancy so as to prepare the client for natural birth.
3. To monitor carefully the progress of labor, maternal condition and fetal behavior and to detect
any intra-partum complication early.
ACTUAL MANAGEMANT OF PATIENT

1. Admission of woman when she is in true labor

2. History taking
3. Records of antenatal visits, investigation reports and specific treatment given if available are to
be reviewed.
4. If she is not booked, file the record with mark on booked, she is inquired all about of her labor
pain, time of on set and frequency, water discharge or ROM.
5. Thorough general or obstetrical examination is to be done to diagnose on set of true labor,
maternal wellbeing, fetal position and presentation, fetal heart rate to know cephalopelvic
disproportion.
6. The patient should have a general body wash and wear laundry gown.

PSYCHOLOGICAL PREPARATION

1. Emotional support is provided by exercising skill in imparting confidence, expressing caring and
dependability being advocate for further child bearing.
2. The nurse should display a tolerant non- judgmental attitude ensuring the woman is accepted
with whatever may be her reaction and behavior
3. Encouragement and assurance is given to keep up the moral
4. Support should be provided by giving information about the labor events and explanation
should be given before performing and examination and procedure
5. Constant supervision is ensured so that the patient may not feel that she is alone.
6. Ensure privacy, respect and dignity of the patient.
7. Discuss the finding with her, take informed consent for all procedures.
8. Reassure that all is well.
9. Allow the birth companion to massage the patient’s back, hold the woman’s hand and sponge
the woman’s face.

PHYSICAL PREPARATION

1. Rest: If membranes are intact the patient is allowed to walk, to seat or to lie down during pain,
which prevent venacaval compression & encourages descent of head. In case of early rupture of
membrane the patient should be in bed.
2. Diet: Allow low light low fat food, encourage have to her plenty of fluid in the form of plane
water , lemon juice, soup, juice may be given in early stage of labor, and with held as soon as
active labor is established. If it is anticipated that la our is going to be prolonged , an active
management is necessary, I.V fluid management with 5% dextrose should be started.Bowel:
Enema should not be given routinely as it may cause infection or injury.
3. Bladder Care: The patient is encouraged to empty the bladder herself frequently (2hrly). If
patient fails to pass urine in late first stage catheterization is to be done with strict aseptic
technique.
 4. Relief of Pain: The no pharmacological methods of pain relief should adopted. Speaking in calm
& gentle voice, offering encouragement and reassurance to the woman , relaxation techniques,
placing a cool cloth on woman’s forehead. Monitor the client by using partograph.

RECENT STUDIES
He result of 25 studies (involving 5218 women) shown that the first stage of labour may be
approximately one hour and twenty minutes shorter for women who are upright or walk around. Indeed
other important outcomes for women who were upright and mobile compared with lying down in bed
included a reduction in the risk of caesarean birth, less use of epidural as a method of pain relief, and
less chance of their babies being admitted to the neonatal unit. More research of better quality is still
needed to validate these results for all women in labor.

(Cochrane Library, 9 Oct2013)

CONCLUSION
First stage of labor as the starting of child birth process plays a crucial role both for the health of mother
and the baby. If it is not managed properly it may lead to various complications in the next stages of
labor.