POST BASIC B.

Sc NURSING

Midwifery and Obstetrical Nursing

Unit: IV - Assessment &

management of intranatal period
First stage of labour

DR.S. RAJESWARI
READER& HOD, OBG NSG
 Objectives

At the end of the class, you will be able to:

• Define labour
• Enlist the stages of labour
• Describe the causes for onset of labour
• Enumerate premonitory labour signs
• Describe the physiology of first stage care
• Explain care of mother during Ist stage of labour
• Frame the nursing process for I22st stage of
labour

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 Labour

• Labor is a physiologic process during which the

fetus, membranes, umbilical cord, and placenta
are expelled from the uterus.

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 Terms

• Parturition- process of giving birth

• Parturient- mother who in labour
• Delivery- may be normal or AVD OR CS
• Eutocia -normal labour
• Dystocia- abnormal labour

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 Normal labour

• Spontaneous in onset and at term

• With vertex presentation
• Without undue prolongation
• Natural termination with minimal aids
• Without having any complications affecting
mother and foetus

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 First stage of labor

• Begins with regular uterine contractions and ends

with complete cervical dilatation at 10 cm
• 6-8 -multi 10 -12 hrs for primi
• Divided into a latent phase and an active phase
• The latent phase begins with mild, irregular uterine
contractions that soften and shorten the cervix
• Contractions become progressively more rhythmic
and stronger
• The active phase usually begins at about 3-4 cm of
cervical dilation and is characterized by rapid
cervical dilation and descent of the presenting fetal
part

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 Second stage of labor

• Begins with complete cervical dilatation and

ends with the delivery of the fetus
• In nulliparous women, the second stage should
be considered prolonged if it exceeds 3 hours if
regional anesthesia is administered or 2 hours in
the absence of regional anesthesia
• In multiparous women, the second stage should
be considered prolonged if it exceeds 2 hours
with regional anesthesia or 1 hour without it

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 Third stage of labor

• The period between the delivery of the fetus and

the delivery of the placenta and fetal membranes
• Delivery of the placenta often takes less than 10
minutes, but the third stage may last as long as
30 minutes

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 Fourth stage

• 2-6 hrs following birth

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Causes for labour

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Causes for labour

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 Feto- placental contribution for
labour onset
• Stimulation of Fetal pituitary
↓
• Increased ACTH- stimulates the foetal adrenal
glands
↓
• increased cortisol secretion
↓
• accelerated production of estrogen and
prostaglandins from placenta

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 Feto- placental contribution for
labour onset (cont…)
• ↑ the release of oxytocin from maternal pituitary
• Promote synthesis of receptors for oxytocin in the
myometrium and decidua
• Accelerates lysosome disintegration inside the
decidual cells resulting increased prostaglandin
synthesis
• Stimulates the synthesis of myometrial contractile
protein-actomysoin through activation of ATP
• Increase the excitability of myometrial cell
membrane

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Premonitory signs of labour

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Premonitory signs of labour

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Premonitory signs of labour

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Premonitory signs of labour

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Premonitory signs of labour

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Premonitory signs of labour

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Premonitory signs of labour

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Recognition of I st stage of labour

• Show
• Contraction
• Rupture of membrane

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False Vs True labour

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False Vs True labour

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Signs of true labour

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Signs of true labour

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Signs of true labour

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 Physiology of first stage

Uterine contraction
❑ Fundal dominance
❑ Polarity
❑ Contraction and retraction

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Fundal dominance

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Polarity

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Contraction and retraction

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 Physiological changes

Physiological changes • Mechanical factor

in uterus
• Formation of Upper • Formation of fore
and lower uterine water
segment • Rupture of
• The retraction ring membranes
• Cervical effacement • General fluid pressure
• Cervical dilatation • Fetal axis pressure
• Show

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 Admission process

• History: Present labour- pains,show, rupture of

membranes ,booked or unbooked, G,P,L,A,SB,D
• Past history- nature of delivery, weight and
condition of the baby, pre-medical h/o and RH
iso immunization
• Abdominal assessment-leopold maneuver

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 Pervaginal examination

• Perineum
• Vagina
• Cervix
• cervical os
• Fore water
• Station
• Position
• Molding
• Pelvic capacity

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 Admission Care

• Bowel preparation
• Perineal shave
• Bath
• Clothing

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 Diagnosis of stage& phase
Symptoms and Stage Phase Salient features
Signs
• Cervix dilated First Latent lasts 8 hours or less
less than 3 cm at least 2/10 min
each contractions
lasting < 20 seconds
• Cervix dilated First Active Contractions at least 3 / 10 min
4–8 cm Each contractions
lasting < 40 seconds
The cervix should dilate at a rate
of 1 cm / hour or faster
• Fetal descent begins
•Cervix dilated 8-10 First Transition ”
cm

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 On going care
• Environment
• Emotional support
• Prevention of infection
• Position and mobility
• Nutrition
• Bladder care
• Pain management
Observation
• Reaction to labour
• Vital signs
• Fluid balance
• Progress
Contractions- 2/20”/10’
Decent of presenting part
Foetal well being- FHR,
liquor, moulding, caput, PH
continuous, intermittent,
remote monitoring
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 Assessment-Labour progress

• Partograph

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 Partograph 
• It is a composite graphical
record of cervical dilatation and
decent of head against duration
of labor in hour.
• It also gives the maternal and
fetal condition that all are
recorded on a single sheet of
paper

• It was developed and extensively

tested by the world health
organization (WHO)

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 Advantages
• A single sheet of paper can provide details of
necessary information at a glance

• No need to enter record events repeatedly

• It facilitates hand over procedures

• It has reduced the incidence of prolonged labor

and cesarean section and thereby reduction
maternal morbidities and mortalities

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 Advantages (contd…)

• Recognize cephalopelvic disproportion long before

obstructed labor

• Assist in early decision on transfer , augmentation , or

termination of labor

• Increase the quality and regularity of all observations of

mother and fetus

• Highly effective in reducing complications from prolonged

labor for the mother (postpartum hemorrhage, sepsis, uterine
rupture and its sequelae) and for the newborn (death, anoxia,
infections, etc.).

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 Functions
• The partograph is designed
for use in all maternity
settings , but has a different
level of function at different
levels of health care

• In health center, the

partograph - gives early
warning if labour is likely to
be prolonged and to
indicate that the woman
should be transferred to
hospital (ALERT LINE
FUNCTION )

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 Functions (contd…)
• In hospital settings, moving to the right of alert
line serves as a warning for extra vigilance , but
the action line is the critical point at which
specific management decisions must be made

• other observations on the progress of labour are

also recorded on the partograph and are
essential features in management of labour

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 Components of the partograph 

• Part I: fetal condition

( at top )

• Pqrt II : progress of
labour ( at middle )

• Part III : maternal

condition ( at bottom )

• Outcome : ………………

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 Part 1 : Fetal condition 

This part of the graph is used to monitor and assess

fetal condition

1 - Fetal heart rate

2 - membranes and liquor
3 - moulding the fetal skull bones &Caput

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 Fetal heart rate

• Basal fetal heart rate =120 – 160 beats/min

• < 160 beats/min =tachycardia
• > 120 beats/min = bradycardia
• >100 beats/min = severe bradycardia
• Decelerations? yes/no

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• Relation to contractions?

– Early deceleration

– Variable deceleration

– Late deceleration

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 Membranes and liquor 

• intact membranes …………………. I

• ruptured membranes + clear liquor
……………………. C
• ruptured membranes + meconium - stained
liquor ……..M
• ruptured membranes + blood – stained liquor
…………B
• ruptured membranes + absent
liquor…………………....A

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 Moulding the fetal skull bones 

• Molding is an important indication of how adequately the pelvis

can accommodate the fetal head

• increasing moulding with the head high in the pelvis is an

ominous sign of cephalopelvic disproportion

• separated bones . sutures felt easily ……………….…. O

• bones just touching each other ……………………….. +

• overlapping bones ( reducible ) ……………………... ++

• severely overlapping bones ( non – reducible ) …….+++

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 Part II – Progress of labor 

• Cervical dilatation
• Descent of the fetal head
• Uterine contractions

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 Cervical dilatation (contd..)

• Dilatation of the cervix is plotted ( recorded ) with an

X
• descent of the fetal head is plotted with an O ,
• when the woman arrives in the active phase , time of
admission is 0 time

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 Cervical dilatation (contd..)

• Alert line ( health facility line)

drawn from 3 cm dilatation
represents the rate of
dilatation of 1 cm / hour

• Action line ( hospital line )

The action line is drawn 4
hour to the right of the alert
line and parallel to it

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 Cervical dilatation (contd..) 
• When progress of labor is
normal and satisfactory ,
plotting of cervical dilatation
remains on the alert line or
to left

• a woman whose cervical

dilatation moves to the right
of the alert line must be
transferred and managed in
an institution with adequate
facilities for obstetric
intervention, unless delivery
is near

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Abdominal palpation for descent of
the fetal head 

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 Assessing descent of the fetal head
by vaginal examination;

0 station is at the level of the ischial spine

vaginal examination should be performed infrequently as

this is compatible with safe practice ( once every 4 hours is
recommended )

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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

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 Duration of Uterine contractions are plotted
with differential shading

• Less than 20 seconds:

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

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 Part III: Maternal condition

• 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

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 Pain management
Non- Pharmacological :Complementary or
Alternative treatment
• Mind–body interventions - Breathing exercises ,
Biofeedback ,Yoga, music, meditation
• Bioelectromagnetic –tens
• Physical methods : position,massage, heating
pads, warm bath
• Alternative medication : Acupuncture, acue
pressure ,hypnosis

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 Pharmacological

• Systemic analgesia/opiods : inhalational •

local/Regional techniques -PCEA• General
anesthesia
• Parenteral opioids
• Pethidine Fentanyl Remifentanyl
Tramadol Diamorphine Nalbuphine
Butorphanol

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 Inhalational Agents

Entonox (N2O:O2 50:50)

Isoflurane (0.2-0.25%)
Desflurane (1-4.5% in O2 or Entonox)
Sevoflurane (0.5 -3%)

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 Nursing diagnoses

• Anxiety related to labour process

• Acute pain RT tissue dilation , pressure of
adjacent structure Secondary to labour process
• Risk for fluid volume deficit RT more loss due
to labour process
• Risk for maternal infection RT invasive
procedure
• Risk for foetal injury –foetal distress RT alerted
uteroplacental perfusion

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 Nursing diagnoses

• Altered urinary elimination-retention RT

mechanical compression of bladder
• Risk for ineffective coping RT inadequate
support system
• Deficient knowledge related to labour and
available option

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 References
• Dutta, D. C., & Konar, H. (2015). Text book of Obstetrics: Including
perinatology and contraception (8th ed.). Calcutta, India: New
Central Book Agency.
• Dawn, C.S., (2003). Textbook of obstetrics and neonatology (16th
ed.). Calcutta, India: Dawn Book.
• Fraser, D., & Cooper, M. A. (2010). Myles textbook for midwives
(15th ed.). Edinburgh: Churchill Livingstone.
• Lowdermilk, D. L., Perry, S. E., & Bobak, I.M. (2014). Maternity &
women’s health care (8th ed.). St. Louis, MO: Mosby.
• Pillitteri, A. (2007). Maternal & child health nursing: Care of the
childbearing & childrearing family (5th ed.). Philadelphia, PA:
Lippincott Williams & Wilkins.
• Reeder, S. J., Martin, L. L., & Koniak, D. (2014). Maternity nursing:
Family, newborn, and women’s health care (19th ed.).
Philadelphia: Lippincott.
• Shashank .V.P.,(1995). Textbook for Midwives (2nd ed.). Mumbai:
Vora Publications.

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