BALKEEJ KAUR

M.SC(N) 2ND YEAR

AIMS,CON
SRI MUKTSAR SAHIB
PUNJAB
Contents:
Introduction
Stages of labour
Diagnosis
Management on admission
Active management of labour
Monitoring
Partogram
Abnormalities
Pain control
Introduction
Labor : Uterine contractions resulting in progressive
dilation and effacement of the cervix and
accompanied by descent and expulsion of the fetus.

Abnormal labor, dystocia, and failure to progress are

terms used to describe a difficult labor pattern

Approximately 20 % of labors involve dystocia

Stages of labor

NORMAL LABOR — divided into Four stages

First stage: time from the onset of labor until
complete cervical dilatation
Second stage: time from complete cervical dilatation
to expulsion of the fetus
Third stage: time from expulsion of the fetus to
expulsion of the placenta
Fourth stage: the 1st post partum hour..
Recommendations on definitions of
the first stage of labor:
The first stage is further subdivided into the latent
active ,and transition phase

latent phase-
 onset of regularly perceieved contractions and ends
when rapid cervical dilatation begins
Contractions are mild
Lasting 20-40 seconds
Cervical effacement occurs,cervix dilate 0-3 cm
6 hours in nullipara and 4.5 hours in multipara.
.ACTIVE PHASE
Cervical dilatation increasing from 4-7 cm
Contractions last 40-60 seconds and occur every 3-5
minutes
3 hours in nullipara and 2 hours in multipara
Show and spontaneous ruptures of membranes may
occur
ACTIVE PHASE DIVIDED INTO
THREE ADDITIONAL PHASES:
-Acceleration phase
-phase of maximum slope
-deceleration phase
TRANSITION PHASE
CONTRACTIONS REACH THEIR PEAK OF
INTENSITY
CERVICAL DILATATION INCREASE FROM 8- 10CM
CONTRACTIONS LASTS FOR 60- 90 SECONDS
OCCUR EVERY 2-3 MINUTES
IF THE MEMBRANES ARE NOT RUPTURED
PREVIOUSLY THEY WILL RUPTURE AT 10 CM
CERVICAL EFFACEMENT AND
DILATATION DURING LABOUR
….
Recommendations on definitions of
the first stage of labor:
FACTORS AFFECTING FIRST
STAGE OF LABOUR:
1.UTERINE FACTORS:
FUNDAL DOMINENCE
POLLARITY
CONTD……
CONTRACTION AND RETRACTION
FORMATION OF UPPER AND LOWER UTERINE
SEGMENT
RETRACTION RING
CONT…..
CERVICAL EFFACEMENT
CERVICAL DILATATION
CONTD…
PRESENCE OF SHOW

2.MECHANICAL ACTORS-
FORMATION OF FOREWATERS
CONTD….
RUPTURE OF MEMBRANES
CONTD…..
GENERAL FLUID PRESSURE
FETAL AXIS PRESSURE
 Diagnosis of labor
The determination of whether a woman is in labor is made
within one hour of admission .
Diagnosis of labor is made only when painfull contractions
are accompanied by any one of the following :
Bloody show
Rupture of the membranes
Full cervical effacement.
 Cervical dilatation is not part of the criteria

Meet the criteria

Rest &
Didn’t meet the Antinatal
observation
criteria ward
Until next day
Diagnosis of labor
The correct diagnosis of labor is considered to be the
single most important determination in the
management of labor because an incorrect diagnosis
of active labor will lead to inappropriate
interventions and an increased likelihood of cesarean
delivery.
MANAGEMENT OF FIRST STAGE
OF LABOUR
OBJECTIVE-TO HAVE A WATCHFUL EXPECTANCY
AND TO MONITOR THE PROGRESS OF LABOUR
AND TO PREVENT COMPLICATIONS
INITIAL ASSESSMENT-
Onset of contraction
Frequency
Duration
Memebrane
Liquor
Present and previous obstetric history,drug history
Contd……
CLINICAL EXAMINATION
Pallor
Jaundice
Hydration
Pulse/bp/temp,/resp. rate
chest,/cvs
oedema
Contd……oOEDEMA
PER ABDOMEN EXAMINATION
Uterine contraction
Frequency and duration in 10 min
Fundal hieght
Contd…..
LIE/PRESENTATION
Contd….
FHR to be noted every 15 minutes with fetal doppler
PER VAGINAL EXAMINATION
Discharge show
Absence or presence of membranes
Station of head
Contd….
Effacement
Dilatation
Caput/moulding
investigations
Basic pre op
MANAGEMENT
GENERAL-emotional support and assurance are
given
BOWEL-encourage women for warm bath,soap
enema
REST AND AMBULATION-when membranes are
intact women is encouraged for ambulation,when
ruptured women advised for rest.
DIET-fruit juice ,soup,salt lemon juice is
recommended.NPO 6-8 hours prior to surgery
BLADDER CARE-encourage the women to empty the
bladder,if failed catheterization with aseptic tecniques
Contd…..
PARTOGRAPH-monitor the progress of the labour by
plotting the partograph
Partogram:
Maternal status
Fetal heart rate
Dilatation & descent
Uterine contractions
Contd….
Cont…..
Watch for maternal and fetal well being.
Psychological preparation of the mother
P/V examination should be done :
1 to 4 hours in the first stage and at 1 hour intervel at
the second stage
At rupture of membranes to evaluate for cord
prolapse
Prior to intrapartum administration of analgesia
When the parturient feels the urge to push
When the FHR falls,to evaluate the conditions like
uterine rupture or cord prolapse
 Contd….
Placement of intravenous line at the time of admission is
recommended.-it is found that women who received
Intravenous hydration at 250ml/hr had fewer labors
persisting for over 12 hours and less need for oxytocin
augmentation than those who received 120ml/hr.
ANTIBIOTIC PROPHYLAXIS –in some centers to prevent
early onset neonatal infection intravenous penicillin is given
Active management of labor
It refers to active control, rather than passive observation,
over the course of labor by the obstetrical provider.

It includes three essential elements

I. Careful diagnosis of labor by strict criteria
II.Constant monitoring of labor with specific standards for
normal progression
III.Prompt intervention (eg, amniotomy, high dose
oxytocin) according to established guidelines if progress
is unsatisfactory .
Active management of labor
The active management of labor is generally limited to
women who meet the following criteria:
1) Nulliparous
2)Term pregnancy
3) Singleton infant in cephalic presentation
4)No pregnancy complications
5)Experiencing spontaneous onset of labor.
Active management of labor
Nulliparous labor tends to be more subject to failure
to progress .
 administration of oxytocin, sometimes at high
dosages, is one of the interventions involved in active
management. This is safer in nulligravid women since
the nulligravid uterus is virtually immune to rupture
(except as a result of manipulation or previous
surgery)
Active management of labor
Recommendation on routine amniotomy

Limited evidence showed no substantial benefit for

early amniotomy and routine use of oxytocin
compared with conservative management of labor.
In normally progressing labor, amniotomy should not
be performed routinely.

 Combined early amniotomy with use of oxytocin

should not be used routinely.
ACTIVE MANAGEMENT OF
LABOUR
Interventions with amniotomy,and/or high dose
oxytocin are initiated if progress does not succeed
according to the defined standards.
Rupture of the fetal membranes provides
information
About fetal status,but does not appear to significantly
accelerate labour.In the dublin protocol,rupture must
be performed before treatment with oxytocin which is
administered only in the presence of clear amniotic
fluid.
ACTIVE MANAGEMENT OF
LABOUR
If membranes are ruptured when there is
polyhydramnios or an inengaged fetal presenting
part,it is prudent to use a small gauze needle,rather
than a hook,to puncture the fetal membranes in one
or more places,and to perform the procedure in the
operating room.This controlled amniotomy permits
emergency cesarean delivery in the event of an
umbilical cord prolapse.
Routine amniotomy should not be performed in
women with active hepatitis B and C or HIV inoreder
to minimize exposure of the fetus to ascending
infection.
ACTIVE MANAGEMENT OF
LABOUR
Slower progress in the nulliparous patient is most
often the result of inefficient uterine action.

In the absence of medical contraindications,labour

that falls to progress is treated with oxytocin.
MONITORING
It is desirable that all examinations should be done by
single individual to minimize interobservor
variations.

A vaginal examination during labour often raises

anxiety and interrupts the women focus

Increased number of vaginal examination is

associated with neonatal sepsis
Monitoring:
Recommendations on monitoring during the
established first stage of labor

 A pictorial record of labor (partogram) should be used once labor is established.

 4 hourly temperature and blood pressure

 hourly pulse

 half-hourly documentation of frequency of contractions

 frequency of emptying the bladder

 vaginal examination offered 4 hourly, or when there is concern about progress

 Intermittent auscultation of the fetal heart after a contraction should occur for at least
1 minute, at least every 15 minutes, and the rate should be recorded as an average.
Monitoring:
Recommendations on initial monitoring:
1) Psychological & Emotional
2)Vitals & Urinalysis
3) Uterine contractions
4)Abdominal examination_Leopold manouvers
5)Vaginal loss – show, liquor, blood
6)Vaginal examination....when necessary
7) Pain control
8)FHR
DIAGNOSIS OF POOR
PROGNOSIS OF LABOUR
Prolonged bradycardia and meconium stained liquor
Possibility of foetal distress
Prolonged latent phase when more than eight hours
in primigrvida and more than six hours in
multigravida
Prolonged latent phase may be due to fault in power,
passage or passenger
Passage is small due to contracted pelvis
Passenger, hydrocephalous, brow [occiput not felt]
Large baby, shoulder presentation
ROLE OF NURSE IN CARING OF THE WOMAN IN
THE FIRST STAGE OF LABOUR
Admitting client to birthing area after determining
that client is in labor
Determining if client's membranes have ruptured
Encouraging family participation as appropriate with
the labor process
Performing Leopold maneuver and vaginal exams as
appropriate
Monitoring maternal vital signs and fetal heart rate
and patterns, reporting any deviations or
abnormalities
CONTD…..
Applying electronic fetal monitor as appropriate
Assessing pain level, instituting positioning,
breathing, relaxation, and other methods for pain
control; administering analgesics as ordered
Providing ice chips, wet washcloth, or hard candy
Encouraging voiding at least every 2 hours
Assisting with anesthetic administration
Assisting with amniotomy with assessment of fetal
heart rate, fetal positioning, and fetal cord after
amniotomy
CONTD….
Assisting with amniotomy with assessment of fetal
heart rate, fetal positioning, and fetal cord after
amniotomy
 Cleansing perineum and assisting with pad changes
regularly
 Monitoring progress including vaginal discharge,
cervical dilation and effacement, position, and fetal
descent
Performing vaginal examinations as necessary
 Assisting coach and supporting client and partner
CONTD…..
 Palpating to determine contraction intensity
Reassuring client about normal fetal heart rates
 Adjusting monitor to achieve and maintain clear
tracing
 Interpreting rhythm strips when at least a 10-minute
tracing has been obtained
CONTD…..
 Preparing supplies and equipment for delivery
 Notifying primary health care provider at appropriate
time to scrub for attending delivery
 Verifying maternal and fetal heart rate response to
uterine contractions during intrapartal care
 Instructing client and partner about reasons for
electronic monitoring
 Applying tocotransducer snugly after determining
fetal position via Leopold maneuver