SDM INSTITUTE OF NURSING

SCIENCES SATTUR, DHARWAD

CLINICAL SPECIALITY-1
OBSTETRIC AND GYNAECOLOGICAL
NURSING
UNIT-4
NORMAL LABOUR AND NURSING MANAGEMENT

SUBMITTED TO
Mrs. MRS. BIJLEE MUNDINMANI
ASST. PROFESSOR
HOD DEPT. OF OBSTETRIC &
GYNECOLOGICAL NURSING
SDM UNIVERSITY OF NURSING
SCIENCES, SATTUR, DHARWAD.

SUBMITTED BY:
MISS. SAVITA S. HANAMSAGAR
1ST YESR MSc. STUDENT
SDM UNIVERSITY OF NURSING
SCIENCES, SATTUR, DHARWAD.

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 Unit 4 normal labour and nursing management

TOPIC CONTENT:

1. Essential factors of labour

2. Stages and onset of labour

3. First stage : physiology of normal labour :

- Use of partograph : principles ,use and critical analysis

- Analgesia and anaesthesia in labour

- Nursing management

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 Unit 4 normal labour and nursing management
 Introduction:

Labour is characterized by the presence of regular uterine contractions with effacement and
dilatation of the cervix and fetal descent. A parturient is a patient in labor and parturition is
the process of giving birth. Delivery is the expulsion or extraction of a viable fetus out of the
womb. It is not synonymous with labor; delivery can take place without labor as in elective
cesarean section. Delivery may be vaginal, either spontaneous or aided, or it may be
abdominal.

 Normal labour:

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 (eutocia)
labour is called normal if it fulfils the following criteria
a) Spontaneous in onset and term.
b) With vertex presentation.
c) Without undue prolongation.
d) Natural termination with minimal aids.
e) Without having complications affecting the health of the mother and/or the baby.

Abnormal labour (dystocia)

Any deviation from the definition of normal labour is called abnormal labour.

 Essential factors of labour:

1. Passenger:

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Fetal head size- Cephalopelvic disproportion (CPD) baby's head or body is too large to fit
through the mother’s pelvis.

Attitude- Relationship of the fetal body parts to one and other (degree of flexion)
 Complete flexion- Most common; "the fetal position"; vertex presentation; chin
touches the chest
 Moderate flexion- Second most common; "military position"; sinciput presentation;
chin does not touch the chest
 Partial extension- Uncommon; brow presentation; can make birth difficult
 Complete extension- Relatively rare; face presentation; the occiput touches the fetuses
upper back

Lie- Relationship of the fetal spine to the maternal spine

longitudinal lie
 Fetal spine is parallel to maternal spine
 Fetuses line vertically
 Can be both cephalic or breach
 Most common, about 99%

Transverse lie
 Fetal spine is 90° to maternal fetuses line horizontally

Oblique lie
 Fetal spine is 45° to maternal spine
 Midway between longitudinal and transverse
 Rare and considered abnormal

2. Position-

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 Relationship of the presenting part of the fetus to a specific quadrant of the mother's
pelvis
 First letter- Which way the presenting part is facing
 Second letter- The presenting part of the fetus
 Third letter- Which way the presenting part is lying in relation to maternal pelvis
 Right occipital posterior
 Left occipital posterior
 Right occipital anterior
 Left occipital anterior

3. Presentation-
The part of the fetus that presents into the birth canal first. Determine by attitude, lie, and
position.
 Cephalic fetal presentation:
Vertex
 Parietal bones of the presenting part of the fetus
 Considered optimal for fetal descent
 Longitudinal lie with complete flexion attitude

Face
 Face is the presenting part of the fetus
 Longitudinal lie with partial extension attitude
 Severe edema and facial distortion occur from pressure
of uterine contractions

Brow & sinciput

 Brow or forehead is the presenting part of the fetus
 Longitudinal lie with moderate flexion attitude

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Mentum
 Chin is the presenting part of the fetus
 Longitudinal lie with partial extension attitude
 Severe edema and facial distortion occur from pressure
of uterine contractions
 Vaginal delivery is usually impossible

 Breech fetal presentation:

Complete
 Buttocks and feet are the presenting part of the fetus
 Longitudinal lie with complete flexion attitude
 Legs are crossed
 Least difficult breech position

Frank
 Buttocks are the presenting part of the fetus
 Longitudinal lie with moderate flexion attitude
 Both legs are drawn up

Incomplete & footling

 One or both of the knees and legs are the presenting part of the fetus
 Longitudinal lie
 Legs are extended with little or no hip flexion
 Most difficult breech position
Cord prolapsed is common

 Other fetal presentation:

Shoulder
 Shoulder, iliac crest, hand or elbow is the presenting part
 Transverse lie

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  Ranges from complete flexion to complete extension
 In multiparous it can be caused due to relaxation of the
abdominal walls
 Other causes: pelvic contraction, placenta previa

Compound
 Extremity presents with another major presenting part (usually head)
They present simultaneously

 STAGES AND ONSET:

 Uterine contraction and retraction :

 Retraction is the progressive shortening of the uterine smooth muscle cells in the upper
portion of the uterus as labour progresses.
 It is a major feature of uterine contractility during labour. - After the cells contract they
relax but they do not return to their original length.
 At the same time the lower segment of the uterus becomes thinner and more stretched.
 Eventually this results in the cervix being taken up into the lower segment of the uterus
and forming a continuum with the upper uterine segment.
 In labour, the lower uterine segment, cervix, vagina, pelvic floor and vulval outlet are
dilated until there is one continuous birth canal.
 Uterine contractions are involuntary in nature and there is relatively minimal extra-
uterine neuronal control.
 The frequency of contractions may vary during labour and with parity.
 They occur at intervals of 2-4 minutes.
 Their duration also varies during labour, from30-60 seconds or occasionally longer.

 Softening of the cervix occurs by:

1.Destruction of collagen fibers.
2.A decrease in dermatine sulphate ,which has strong affinity for collagen.

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 3.An increase in hyaluronic acid. All these changes happened within the cervical
tissues.
 Hormonal factors: -
 Progesterone maintains uterine quiescence by suppressing prostaglandin production,
inhibiting communication between myometrial cells and preventing oxytocin release.
Oestrogen opposes the action of progesterone.
 Prior to labour, there is a reduction in progesterone receptors and an increase in the
concentration of oestrogen relative to the progesterone.
 Prostaglandin synthesis by the chorion and the decidua is enhanced, leading to an
increase in calcium influx into the myometrial cells.
 This change in the hormonal milieu also increases gap junction formation between
individual myometrial cells, creating a functional syncytium, which is necessary for
coordinated uterine activity.
 The production of ACTH by the placenta increases in concentration towards term and
potentiates the action of prostaglandins and oxytocin on myometrial contractility.
 The fetal pituitary secretes oxytocin and the fetal adrenal gland produces cortisol,
which stimulates the conversion of progesterone to oestrogen. Which of these
hormonal steps initiates labour is unclear. As labour becomes established, the output
of oxytocin increases.

 STAGES OF LABOUR

 First stage - It starts from the onset of true labour pain with full dilatation of the
cervix. The average duration is 12 hours in primigravidae and 6 hours in multipara.
 Second stage – It starts from the full dilatation of the cervix (not from the rupture of
the rupture of the membranes) and ends expulsion of the fetus from the birth canal. It
average duration is 2 hours in primigravidae and 30 minutes in multipara.
 Third stage – It begins after expulsion of the fetus and ends with expulsion of the
placenta and membranes (after-birth). It average duration is about 15 minutes in both
primigravidae and multipara.
 Fourth stage – It is the stage of observation for at least one hour after expulsion of
the after-births.

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  FIRST STAGE OF LABOUR

PHASES OF FIRST STAGE OF LABOUR

Latent phase : It is prior to active phase and may last 6-8 hour in primigravidae when the
cervix dilates from 0cm to 3-4cms dilated and cervical canal shortens from 3cm long to less
than 0.5cm long.

Active phase: It is the time when the cervix undergoes more rapid dilatation. This begin
when the cervix is 3-4cms dilated and in the presence of rhythmic contraction, is complete
when the cervix is fully dilated(10cms).

Transitional phase: It is the stage of labour when the cervix is from around 8cm dilated (or
until the expulsive contraction during second stage are felt by the woman). There is often a
brief lull in the intensity of uterine activity at this time.

 PHYSIOLOGY OF FIRST STAGE OF LABOUR

DURATION
 The length varies widely and is influenced by parity, birth interval, physiological state,
presentation and position of the fetus.
 The average duration is 12 hours in primigravidae and 6 hours in multipara. In the
individual case, however averages can prove extremely misleading.

UTERINE ACTION

 FUNDAL DOMINANCE
 Each uterine contraction starts in the fundus near one of the cornua and spreads
across and downwards.
 The contraction last longer in the fundus where it is also more intense, but the peak
is reached simultaneously over the whole uterus and the contraction fades from all
parts together.

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  This pattern permits the cervix to dilate and the strongly contracted fundus to expel
the fetus.

 POLARITY
 It is the term used to describe the
neuromuscular harmony that prevails between
the two poles or segments of the uterus
throughout the labour.
 During each uterine contraction, these two
poles act in synchronization.
 The upper pole contracts strongly and retracts
to expel the fetus.
 The lower pole contracts slightly and dilates to allow the expulsion to take place.
 If polarity is disorganized then the progress of labour is inhibited.

 CONTRACTION AND RETRACTION

 During labour the contraction does not pass off entirely, but muscle fibers retain
some of the shortening of contraction instead of becoming completely relaxed. This
is termed as retraction.
 The longitudinal muscle fibers of the upper segment are attached with the circular
muscle fibers and the upper part of the cervix.
 With each contraction, not only the canal is opened up from down but it also
becomes shortened and retracted.
 The upper segment of the uterus becomes gradually shorter and thicker and its
cavity diminishes and this assists in the progressive expulsion of the fetus.

 FORMATION OF UPPER AND LOWER UTERINE SEGMENTS

 By the end of pregnancy, the body of the uterus is divided into two segments, which
are anatomically distinct.
 The thick and muscular upper uterine segment, having been formed from the body
of the fundus, is mainly concerned with contraction and retraction.

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  The lower uterine segment is formed of the isthmus and the cervix and is prepared
for distension and dilatation.
 When labour begins, the retracted longitudinal fibers in the upper segment pull on
the lower uterine segment causing it to stretch.
 This is aided by the force applied by the descending presenting part.

 RETRACTION RING
 A physiological ridge forms between the upper and lower uterine segments known
as the ‘retraction ring’.
 It is termed as ‘Bandl’s Ring’ when it is associated with mechanically obstructed
labour and fetal compromise.
 The physiological ring gradually rises as the upper segment contracts and retracts
and the lower segment thins out to accommodate the descending fetus.
 Once the cervix is fully dilated and the fetus can leave the uterus, the retraction ring
rises no further.

 CERVICAL EFFACEMENT
 It is the process by which the muscular fibers of the cervix are pulled upward and
merges with the fibers of the lower uterine segment.
 In primigravidae, effacement precedes dilatation of the cervix, whereas in
multipara, both occur simultaneously.
 Expulsion of the mucus plug (operculum) is caused by effacement.

 CERVICAL DILATATION
 Dilatation of the cervix is the process of enlargement of the cervical os from a
tightly closed aperture to an opening large enough to permit passage of the fetal
head.
 Full dilatation at term equates to about 10 cm.
 It occurs as a result of uterine action and the counter pressure applied by either the
intact bag of membranes or the presenting part or both.

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  Pressure applied equally to the cervix causes the uterine fundus to respond by
contraction and retraction.

 THE SHOW
 As a result of dilatation of the cervix, operculum is lost.
 The woman may see a blood-stained mucoid discharge few hours before or after the
labour starts.
 The blood is from the ruptured capillaries in the parietal decidua where the chorion
has detached from the dilating cervix.
 There should never be too much blood staining or frank bleeding.

MECHANICAL FACTORS

 FORMATION OF FOREWATER
 As the lower uterine segment forms and
stretches, the chorion becomes detached from
it and increased intrauterine pressure causes
the loosened part of the sac of fluid to bulge
downward in to the cervical os, to the depth
of 6-12 mm.
 The well flexed head fits snugly into the cervix cutting off the fluid in front of the
head from that which surrounds the body.
 The former is known as ‘forewaters’ and the latter is known as ‘hind waters’.
 The effect of separation of the forewaters prevents the pressure that is applied to the
hind waters during contractions from being applied to the forewaters causing it to
remain intact and thus a natural defense against ascending infection.

 GENERAL FLUID PRESSURE

 The pressure of the uterine contraction is exerted on the fluid and as the fluid is not
compressible, the pressure is equalized throughout the uterus and over the fetal
body.
 This is known as ‘general fluid pressure’.

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 RUPTURE OF MEMBRANE(ROM)
 It happens spontaneously at the end of the first stage of labour after the cervix is
fully dilated and no longer supports the bag of forewaters.
 Sometimes the membrane may rupture days before labour or during the first stage
of labour.
 Occasionally the membranes do not rupture even in the second stage of labour and
appear at the vulva as a bulging sac covering the fetal head as it is born; this is
known as the ‘caul’.
 FETAL AXIS PRESSURE

 During each contraction, the uterus rises forward and the force of the fundal
contraction is transmitted to the upper pole of the fetus, down the presenting part of
the fetus and is applied by the presenting part to the cervix.
 This is known as the ‘fetal axis pressure’.
 Becomes more prominent after ROM and during second stage of labour.

CLINICAL COURSE OF FIRST STAGE OF LABOUR

 PAIN
 The pains are felt more anteriorly with simultaneous hardening of the uterus.
 Initially, the pains are not strong enough to cause discomfort and come at varying
intervals of 15-20 minutes with duration of about 30 seconds.
 But gradually with increasing intensity and duration the contraction comes at interval of
3-5 minutes and lasts for about 45 seconds.
 Clinically, the pains are said to be good if they come at intervals of 3-5 minutes and at
the height of contraction the uterine wall cannot be indented by the fingers.

 DILATATION AND EFFACEMENT OF THE CERVIX

Friedman 1978 described graphical representation of cervical dilatation in cm against
duration of labour in hours. It is a sigmoid curve and first stage of labour is divided into
the following:

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 PHASES OF LABOUR PRIMI MULTI

LATENT PHASE (up to 3cm) 6-8 hrs. 4-6 hrs.

ACTIVE PHASE (3 to 10cm) 4 hrs. 2 hrs.

RATE OF DILATATION 1cm/hr. 1.5cm/hr.

 Active phase is further subdivided into:

 Acceleration phase: 3 to 4 cm
 Phase of maximum slope: 4 to 9 cm
 Phase of deceleration: 9 to 10 cm

 STATUS OF MEMBRANE
 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 labour but before full dilatation of
the cervix- when it is called early rupture.
 When membranes rupture before the onset of labour, it is called premature rupture.
 An intact membrane is best felt with fingers during uterine contraction when it
becomes tense and bulges out though the cervical opening.
 With rupture there is an acceleration of uterine contractions.

 MATERNAL SYSTEM
 General condition remains unaffected.
 A feeling of transient fatigue appears following a strong contraction.
 Pulse rate is increased by 10-15 beats per minute during contractions and settles down
to its previous rate in between contraction.
 Temperature remains unchanged.

 FETAL EFFECT

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 As long the membranes remain intact, there is hardly any adverse effect on the fetus.
 However, during contraction, there may be slowing of the fetal heart rate by 10-20
beats per minute.
 This soon returns to its normal rate of about 140 per minutes as the intensity of
contraction decreases.

 MANAGEMENT OF FIRST STAGE OF LABOUR

PRINCIPLES
1) Non-interference with the watchful expectancy so as to prepare the patient for natural
birth.
2) To monitor carefully the progress of labour, maternal conditions and fetal behavior so
as to detect any intrapartum complication.

GENERAL CONDITIONS
 Labour events have got great physiological, emotional and social impact to the
woman and her family.
 She experiences stress, physical pain and fears of danger.
 The caregiver should be tactful, sensitive and respectful to her.
 The woman is allowed to have her chosen companion.
 Privacy must be maintained.
 Provide comfortable environment.

COMMUNICATION
 During labour maintain communication with the woman and her companion.
 Maintaining communication means informing the woman whenever possible of
everything that is happening and everything that you are doing or planning.
 Explain all procedures that will be carried out, even minor ones. This will help to
minimize anxiety and provide reassurance that things are routine.

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 Before you carry out any procedure, seek permission. This is part of courtesy and
respect.
 You should also discuss any measurements or results and their implications with the
woman.
 Keep the woman and her family informed about the progress of the labour.
 Anything you have to say should be directed to the woman. If you need to talk about
her with colleagues or with the companion, go to place where she cannot overhear or
see.

COLLECTING PAST HISTORY

Of particular relevance at the onset of labour are:
 The birth plans
 Parity and age
 Gestational age and outcomes of previous labours
 Weights and condition of previous babies
 Any known problems- social and physical
 Onset of labour or leakage of liquor, if any
 Records of antenatal visits, investigation reports and any specific treatment, if
available, are to be reviewed.

BIRTH PLAN
Find out if the woman and her companion has decided a birth plan and explore the
following issues:
 The woman chosen birth companion
 Her choice of clothes for labour
 Ambulation and fetal monitoring(intermittent, electronic or a mixture)
 Pain relief
 Position of labour and at birth
 Cutting the umbilical cord
 Skin to skin contact and feeding the baby after birth

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 If any of the choice’s compromises labour or mothers or fetal condition, then the final
decision will be taken by the obstetrician.

PHYSICAL EXAMINATION
 See is their blood on her clothing or on the floor beneath her.
 Is she grunting, moaning, or bearing down.
 Ask her, or someone who is with her, whether she has now or has recently had:
 Vaginal bleeding
 Severe headache/blurred vision
 Convulsions or loss of consciousness

 Difficulty breathing
 Fever
 Severe abdominal pain
 Premature leakage of amniotic fluid.
 Maintain her privacy
 Examine her comprehensively (head to toe).
 Look for signs of anemia (paleness inside the eyelids, pale fingernails and gums).
 Look for yellowish discoloration of the eyes (jaundice), which indicates liver disease.
 Basic observation including pulse rate, temperature, and blood pressure are taken and
recorded.
(Pulse is recorded every 30 minutes, blood pressure every 4 hours and temperature is
recorded every 2 hours.)
 The woman’s hands and feet are examined for any signs of edema.
 Inspect size, shape and scar.
 Perform palpation of the abdomen using Leopold’s maneuver (fundal palpation, lateral
palpation, deep pelvic palpation and Pawlick's grip)
 Measure fetal heart rate using a fetoscope or stethoscope.

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  Measure contractions by putting your hand over the mother’s abdomen, around the
fundus. Count the frequency, i.e., number of contractions in 10 minutes, and the
duration.
 Record all your findings in a partograph.

 Use of partograph : principles ,use and critical analysis

PARTOGRAPH
 Friedman first devised it.
 It is a composite graphical record of cervical dilatation and descent of head against
duration of labour in hours.
 It also gives information about the fetal and maternal conditions.
 Components
a) Patient identification.
b) Time-recorded at hourly interval. Zero time for spontaneous labour is the time of
admission in the labour ward and for induced labour is the time of induction.
c) Fetal heart rate.
d) State of membranes and color of liquor: to mark ‘I’ for intact membranes, ‘C’ for clear
and ‘M’ for meconium-stained liquor.
e) Cervical dilatation and descent of the head.
f) Uterine contraction.
g) Drugs and fluids.
h) Blood pressure.
i) Oxytocin
j) Urine analysis.
k) Vital signs recorded.

 Partograph:
 It is a sigmoid curve and the first stage of labour has got two phases a latent phase and
an active phase.
 The active phase has got three components
1) Acceleration phase with cervical dilatation of 2.5-4cm.
2) Phase of maximum slope of 4-9cm dilation.

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 3) Phase of deceleration of 9-10cm dilation.

 Recording
 You start recording on the partograph when the labour is in active first stage
(cervical dilation of 4 cm and above).
 Your recordings should be clearly visible so that anybody who knows about the
partograph can understand and interpret the marks you have made.

 Cervical dilatation
- In the cervical dilatation section of the partograph, down the left side, are the numbers
0–10.
- Each number/square represents 1 cm dilatation.
- Along the bottom of this section are 24 squares, each representing 1 hour.
- The dilatation of the cervix is estimated by vaginal examination and recorded on the
partograph with an X mark every 4 hours.
- Cervical dilatation in multipara women may need to be checked more frequently than
every 4 hours in advanced labour, because their progress is likely to be faster than that
of women who are giving birth for the first time.
- If progress of labour is satisfactory, the recording of cervical dilatation will remain on,
or to the left, of the alert line.

 Descent of the fetal head

- For labour to progress well, dilatation of the cervix should be accompanied by descent
of the fetal head, which is plotted on the same section of the partograph, but using O as
the symbol.
- When the fetal head is at the same level as the ischial spines, this is called station 0. If
the head is higher up the birth canal than the ischial spines, the station is given a
negative number. At station –4 or –3 the fetal head is still ‘floating’ and not yet
engaged; at station –2 or –1 it is descending closer to the ischial spines.
- If the fetal head is lower down the birth canal than the ischial spines, the station is
given a positive number. At station +1 and even more at station +2.
- At station +3 the baby’s head is crowning, i.e., visible at the vaginal opening even
between contractions. The cervix should be fully dilated at this point.

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 CORRESPONDING MARK ON
STATION OF THE HEAD
THE PARTOGRAPH
-4 or -3 5
-2 or -1 4
0 3
+1 2
+2 1
 +3 0

Recording moulding on the partograph

 Use a scale from 0 (no moulding) to +3, and write them in the
row of boxes provided:
- 0 Bones are separated and the sutures can be felt easily.
- +1 Bones are just touching each other.
- +2 Bones are overlapping but can be separated easily with pressure by your finger.
- +3 Bones are overlapping but cannot be separated easily with pressure by your finger.

 Uterine contraction
Contractions become more frequent and last longer as labour progresses. Contractions are
recorded every 30 minutes on the partograph in their own section, which is below the
hour/time rows. At the left-hand side is written ‘Contractions per 10 mins and the scale is
numbered from 1–5. Each square represents one contraction, so that if two contractions
are felt in 10 minutes, you should shade two squares.

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  Assessment and recording of fetal wellbeing
- By counting the fetal heart beat every 30 minutes;

 Amniotic fluid as an indicator of fetal distress

- To mark ‘I’ for intact membranes
- ‘C’ for clear
- ‘M’ for meconium-stained liquor.
 Assessment of maternal wellbeing
During labour and delivery, after your thorough initial evaluation, maternal wellbeing is
followed by measuring the mother’s vital signs: blood pressure, pulse, temperature, and urine
output.
- Blood pressure is measured every four hours.
- Pulse is recorded every 30 minutes.
- Temperature is recorded every 2 hours.
- Urine output is recorded every time urine is passed.

FETAL WELLBEING

1) Monitoring fetal heart rate.

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2) Electronic fetal monitoring

Also called cardiotocography (CTG), is when the baby's heart rate is monitored with an
ultrasound machine while the mother's contractions are monitored with a pressure sensor.

3) Fetal blood sampling

It is a procedure to take a small amount of blood from an unborn baby (fetus) during
pregnancy. A fetal blood sample may be taken to:

- Diagnose genetic or chromosome abnormalities.

- Check for and treat severe anemia in the baby.
- Check for and treat other blood problems such as Rh disease.
- Check oxygen levels in the fetus.
- Check for infection in the fetus.
- Give certain medicines to the fetus.

Maternal distress
Evidence of maternal distress is:
1) Anxious look with sunken eyes
2) Dehydration, dry tongue
3) Acetone smell in breath
4) Rising pulse rate of 100 per minute or more
5) Hot, dry vagina often with offensive discharge
6) Scanty high colored urine with presence of acetone

VAGINAL EXAMINATION
 Indication
 Make a positive identification of presentation.
 Determine whether the head is engaged in case of doubt.
 Ascertain whether the forewaters have ruptured, or to rupture them artificially.
 Exclude cord prolapse after rupture after rupture of the forewaters, especially if
there is an ill-fitting presenting part or the fetal heart rate changes.
 Assess progress or delay in labour.
 Confirm full dilatation of the cervix.

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  Confirm the axis of the fetus and presentation of the second twin in multiple
pregnancies, and if necessary in order to rupture the second amniotic sac.
 Method
 Wash the hands properly before and after each vaginal examination.
 Wear plastic apron and surgical gloves.
 Explain the women about the procedure and always take consent before doing it.
 Clean perineum with anti-
septic swab; discard the soiled swab
in yellow container.
 Separate labia with non-
examining hands.
 Use middle and index finger of right/left hand and insert them into vagina at 12’O
clock-6’O clock position.
 Judge the dilatation of cervix in cms.
 Assess the adequacy of the pelvis by noting well curved sacrum and inability to
reach both ischial spines at the same time.
 Remove gloves and put them into 0.5% chlorine solution.
 Inform the woman about the progress of labour.

 Record the information on the partograph, if cervical dilatation is 4cm and above.
 Key points:

 Do P/V examination only when required/indicated to minimize the infection.

- At the onset of labour – to confirm the onset of labour and to detect
precisely the presenting part and its position.
- The progress of labour can be judged on periodic examinations at an interval
of 3-4 hours.

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 - Following the rupture of the membranes to exclude cord prolapse especially
where the head is not yet engaged.
- Whenever any interference is contemplated.
- To diagnose precisely the beginning of second stage.
 Maintain privacy and dignity of women at all times.
 Findings
- Observe the labia for any sign of varicosities, edema or vulval warts or sores.
- Observe whether the premium is scared from previous tear or episiotomy.
- Observe for any discharge or bleeding from the vaginal orifice.
- If the membrane has ruptured, observe the color and odor of any amniotic fluid or
discharge. Offensive liquor suggests infection and green fluid indicates the presence
of meconium or post maturity.
- Observe the length of cervical canal, effacement, consistency of cervix (soft, elastic
and closely applied to the presenting part) and dilatation of the cervix.
- Determine the presenting part, position of head and degree of flexion and note the
station of head in relation to the ischial spines.
- Also assess degree of moulding of head.

 Analgesia and anaesthesia in labour:

Analgesia in normal labor

Labor pain is experienced by most women with satisfaction at the end of a successful labor.
Antenatal classes, sympathetic care and encouraging environment during labor can reduce the
need of analgesia. The intensity of labor pain depends on the intensity and duration of uterine
contraction, degree of dilatation of cervix, distension of perineal tissue, parity and the pain
threshold of the subject. The most distressing time during the whole labor is just prior to the
full dilation of the cervix. The drug must be non-toxic and safe for both mother and fetus

METHODS OF PAIN RELIEF

 Sedatives and analgesics

 Inhalation agents
 Regional analgesia

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  Patient controlled analgesia (PCA)
 Transcutaneous electrical nerve stimulation (TENS)
 Psychoprophylaxis.
 General anesthesia.

Sedatives and Analgesics

The following factors are important to control the dose of sedatives and analgesics:

1. The threshold of pain

2. Primigravidae or multigravida – the multiparous women need less analgesia due to
added relaxation of the birth canal and rapid delivery.
3. Maturity of the fetus – minimal dose of drug is indicated while the fetus is thought to
be premature to avoid the risk of neonatal asphyxia.
Purpose of selecting an analgesic agent, labor is divided in to 2 phase.
First phase – corresponds up to 8cm dilation of cervix in primi and 6cm in multi.
Second phase – corresponds to dilation of the cervix beyond the above limits up to
delivery.
The first phase is controlled by sedatives and analgesics and the second phase is controlled
by inhalation agent. The idea is to avoid the risk of delivery of a depressed baby.

OPIOID ANALGESICS

 Pethadine : it has got strong sedative but less analgesic efficacy. Pethadine is
generally used in the first phase of labor and indicated when the discomfort of labor
merges into regular, frequent and painful contractions. The initial dose is 100mg i.m.
And repeated as the effect of the first dose begins to wane, without waiting for the re-
establishment of labor pain.

Side effects:-

For mother; nausea, vomiting, delayed gastric emptying.

For fetus; respiratory and suckling depression.

 Meptazinol has got similar similar analgesic and sedative property as that of
Pethadine. It causes less respiratory depression of the new-born

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  Pentazocine ( Fortwin ) : it is given I.M in a dose of 30-40 mg. Its duration is shorter
and causes some respiratory depression. It also causes drug dependence. Naloxone is
an efficient and reliable antagonist.
To antagonize the effect of narcotics given to mother when the labor proceeds more rapidly
than anticipated, naloxone in a dose of 0.4 mg should be given IV

 Tranquilisers :
 Diazepam : it is well tolerated by the patient.it does not produce
vomiting and helps in the dilation of cervix. It is metabolised in the
liver. The usual dose is 5-10mg. It may be used in larger doses in the
management of pre-eclampsia.
 Midazolam is more potent and neonatal side effects are less compared
to diazepam. It has good anxiolytic property. It is cleared from the
tissue more rapidly. Dose of 0.05 mg/kg is given IV
 Combination of narcotics and tranquilisers: narcotics may be used in
combination with promethazine, chlorpromazine, or promazine.

INHALATION METHOD

1. Nitrous Oxide and air: nitrous oxide has minimal effect on the fetus and does not
interfere with uterine contraction. This agent is used in the second phase. Now a days,
nitrous oxide and air are not used because this mixture produce hypoxia.
2. Premixed nitrous oxide and oxygen: cylinders contain 50 % nitrous oxide and 50%
oxygen mixture. Entonox apparatus has been approved for use by midwives. It can be
self-administered.
3. Trichloroethylene (trilene ): this is an useful drug in labor with high analgesic effect. It
gives better result in nervous and strung women than nitrous oxide. It is no longer used
these days.
4. Methoxyflurane, isoflurane, enflurane: they are good analgesic agents and more
effective than trichloroethylene.

REGIONAL ANAESTHESIA

When complete relief of pain is needed throughout labor, epidural analgesia is the safest
and simplest method for procuring it.

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1. Continuous lumbar epidural block :
A lumbar puncture is made between L2 and L3 with the epidural needle (Tuohy needle).
With the patient on her left side, the back of the patient is cleansed with antiseptics
before injection. When the epidural space is ensured, a plastic catheter is passed through
the epidural needle for continuous analgesia. Repeated dose of 4-5 ml of 0.5 percent
bupivacaine or 1 % lignocaine are used to maintain analgesia.
Contraindication to epidural analgesia:-
- Sepsis at the site of injection.
- Haemorrhage disease or anticoagulant therapy.
- Supine hypotension.
- Hypovolaemia.
- Neurological disease.
- Spinal deformity or chronic low back pain.

Complications of epidural analgesia:-

- Hypotension due to sympathetic blockade. Parturient should be well

hydrated with crystalloid solution beforehand.
- Pain at the insertion site.
- Post spinal headache due to leakage of cerebrospinal fluid through the
needle hole in the dura.
- Total spinal due to inadvertent administration of the drug in the
subarachnoid space.
- Injury to nerves.

2. Caudal epidural analgesia:

With the patient in left lateral position and after full aseptic precautions. The
sacral hiatus is identified and a malleable needle is pushed through it, first piercing
the skin and the Sacro-coccygeal ligament at right angle and then depressing the
needle towards the natal cleft so that the needle lies at an angle of 40 0 to the skin the
needle is gently advanced in to sacral canal. The stylet is withdrawn and an aspiration
test is carried out to ensure that the dura or vein is not punctured. An epidural nylon
catheter is passed through the needle and the needle is then withdrawn 16ml to 20 ml
of 1% lignocaine is passed and relief of pain becomes established within 10-20 mts.

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 Bupivacaine (0.5%) can be used for prolonged analgesia. Caudal analgesia is rapidly
falling into discus because the approach to the epidural space through sacral hiatus is
dirtier, harder and fails more often.

3. Paracervical nerve block:

It is useful for pain relief during the first stage of labor. Following the usual
antiseptic safe guards, a long needle(15cm or more) is passed in to the lateral fornix,
at the three and nine o’ clock position. 5-10 ml of 1% lignocaine with adrenaline are
injected at the site of the cervix and the procedure is repeated on the other
side.bupivacane is avoided due to its cardiotoxicity. Paracervical block should not be
used where placental insufficiency is present. Fetal bradycardia is a known
complication.

4. Prudential nerve block:

It is a safe and simple method of analgesia during delivery. Prudential nerve
block does not relieve the pain of labor but affords perineal analgesia and relaxation.
Prudential nerve block is mostly used for forceps and vaginal breech delivery. The
prudential nerve may be blocked by either the transvaginal or the trans perineal route.

5. Transvaginal route:
Transvaginal route is commonly preferred. A 20ml syringe/ one 15cm 17-20G
spinal needle and about 20ml of 1% lignocaine hydrochloride are required. The index
and middle fingers of one hand are introduced into the vagina, the fingertip are placed
on the tip of the ischial spine of one side. The needle is passed along the groove of the
finger and guided to pierce the vaginal wall on the apex of spine and thereafter to
push a little to pierce the sacrospinous ligament just above the ischial spine tip. After
aspirating to exclude blood, about 10ml of the solution is injected. The similar
procedure is adopted to block the nerve of the other side by changing the hands.
6. Spinal anesthesia:
Spinal anesthesia can be employed to alleviate the pain of delivery and
during the third stage of labor. For normal delivery or for outlet forceps with
episiotomy, block should extend to S1.
Procedure:

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 Spinal anesthesia can be obtained by injecting 1ml of hyperbaric lignocaine (5%)
into the subarachnoid space of the third or fourth lumbar interspace.
Advantages:
-less fetal hypoxia
-easy technique
-no inhalation anesthesia is require.
Disadvantages:
-hypotension due to block of sympathetic fibres leading to vasodilation and low
cardiac output.
-respiratory depression may occur.
-post spinal headache-due to low or high CSF pressure and leakage of CSF.
-meningitis due to faulty asepsis.
-transient or permanent paralysis.
-toxic reaction of local anesthetic drug.
-nausea and vomiting are not uncommon.
-urinary retention.

PATIENT CONTROLLED ANALGESIA (PCA)

Narcotics are administered by the mother herself from a pump at continuous or
intermittent demand rate through I.V route. This offers better pain control than high
doses given at a long interval by the midwife. Maternal satisfaction is high with this
method. Drug commonly used are pethidine, meperidine or fentanyl.
PSYCHOPROPHYLAXIS
It is psychological method of antenatal preparation designed to prevent or at
least to minimize pain and difficulty during labor. Relaxation and motivation can
reduce the fear and apprehension to a great extent. Patient is taught about the
physiology of pregnancy and labor in antenatal classes. Relaxation exercises are
practiced. Husband or the partner is also involved in the management. His presence in
labor would encourage the bearing down efforts. Need of analgesia would be less.

TRANSCUTANEOUS ELECTRIC NERVE STIMULATION (TENS)

It is a noninvasive procedure and is preferred by many women during labor,
electrodes are placed over the level of T 10-L1 and S2-4. Current strength can be

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 adjusted according to pain. It works by transmitter release through inter neurone level.
However , no change in pain score was observed when TENS was switched on.

PATIENT PREPARATION
 GENERAL
a) Support the labour
 Help her relax rather than fighting it.
 Encouragement, emotional support and assurance are given to keep up the morale.
 Constant supervision is ensured.
b) Guard the labour
 Keep rude and unkind people away.
 The patient should not worry about family problems.
 Helping the mother to manage her contractions
 In early labour she may be able to sleep.
 To save her strength, the mother should rest in between the contractions.
c) Touch
 Do not massage the belly.
 Reassuring the woman that the pain she has is normal.
 Touch can help a woman in labour, but find out what kind of touch she wants
 A firm, still hand pressing on the lower back during contractions
 Massage between contractions, especially on the feet or back
 Hot or cold cloths on the lower back or belly.
 If the mother is sweating, a cool wet cloth on the forehead usually feels good.

d) Sounds
 You can make low sounds yourself to guide her.
e) Breathing
 In the first stage of labour, there are many kinds of breathing that may make labour
easier.
 Encourage mothers to try different ways of breathing throughout labour:
 Slow blowing-Ask the woman to take a long, slow breath. To breathe out she should
make a kiss with her lips and slowly blow. Breathing in through the nose can help her
breathe slowly.

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  Hee breathing- The woman takes a slow deep breath and then blows out short, quick
breaths while she makes soft ‘hee, hee’ sounds.
 Panting- The woman takes quick, shallow breaths.
 Strong blowing- The woman blows hard and fast.
f) Encourage the woman to urinate at least once every 2 hours.
g) Emotional and psychological support for the woman in labour
 You do not have to work alone to give support to the mother during labour. There is
evidence that the presence of constant support from the woman’s husband, close
relatives or friends in labour favors good progress.
 Keep the woman informed about the progress of labour.

 BOWEL
 An enema with soap and water or glycerin 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 labour nor reduces the infection rate.

 REST AND AMBULATION

If membranes are intact, the mother is allowed to walk.
 This attitude prevents venacaval compression and encourages descent of the head.
 Ambulation can reduce the duration of labour, need for analgesia and improves
maternal comfort.
 Assist the woman to assume a position according to her own preference.
 Help the woman to squat, sit, kneel or take other positions.
 However, if labour is monitored
electronically or epidural is given, she
should be in bed.

 DIET

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  Food is withheld during active labour due to delayed emptying of the stomach and
high risk of aspiration.
 Fluids in the form of plain water, ice chips or fruit juice may be given in early
labour.
 During the first stage of labour, she should drink at least 1 cup every hour of a
high calorie fluid such as tea, soft drinks, soup, or fruit juice to prevent
dehydration.

 PROMOTING PHYSICAL SUPPORT AND CLEANLINESS

 General body wash.
 Mouth washing.
 Combing hair.
 Changing of soiled gowns or linen.
 Back rub.
 Perineal shave may or may not be done according to the institutional policy.

 RELIEF OF PAIN
 The common analgesic drug used is pethidine 50-100mg intramuscularly when
pains are well established in the active phase of labour.
 Pethidine is an effective analgesic as well as sedative.
 If necessary, it is repeated after 4 hours.
 Metoclopramide 10 mg IM is given to combat vomiting due to pethidine.
 Pethidine crosses the placenta and is a respiratory depressant to the neonate.
 The drug should not be given if delivery is anticipated within two hours.

 PREVENTION OF INFECTION
 Unnecessary people in the birthing environment should be avoided.
 The midwife or the physician should follow strict aseptic techniques before any
invasive procedure.
 Try to avoid unnecessary invasive procedure.

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  The fetal membranes should be preserved intact unless there is a positive
indication for their rupture that overweighs the advantage of their protective
functions.

 NURSING RESPONSIBILITIES OF FIRST STAGE OF LABOUR

Latent (Preparatory) Phase
1) Assess patient’s psychological readiness. Provide continuous maternal support
(compared to usual care).
2) Measure duration of latent phase.
3) Allow patient to be continually active.
4) Conduct interviews and filling in of forms (e.g. birth certificate) at this phase while
the patient experiences minimal discomfort and has control over contraction pains.
5) Conduct health teaching on breastfeeding, newborn care, and effective bearing down
because during this time, patient’s anxiety is controlled and she is able to focus on
nurse’s instructions.
6) Educate patient on different relaxation techniques. As early as this phase, encourage
patient to begin alternative therapy of pain relief.
7) Ensure that the total number of internal examinations the woman receives in the entire
course of labor is limited to 5 only.
8) Ensure that birthing companion of choice is present all throughout the course of labor.

Active Phase

1) Inform patient on the progress of her labor to lessen her anxiety and obtain her trust
and cooperation.
2) Start monitoring progress of labor with the use of WHO partograph, 2-hour action
line.
3) Encourage patient to be continually active to maximize the effect of uterine
contractions. Upright maternal positions are recommended if tolerated.

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 4) Assist patient in assuming her position of comfort. For those who can’t stay upright,
left-side lying is recommended to avoid disruption in fetal oxygenation.
5) Monitor maternal vital signs and fetal heart rate every 2 hours, or depending on the
doctor’s order.
6) Anticipate patient needs (e.g., sponging face with cool cloth, keeping bed clean and
dry, providing ice chips or lip balm) to promote comfort.
7) Determine when patient last voided because a full bladder can hinder fast labor
progress.
8) Institute non-pharmacological pain measures (e.g., breathing exercises, distraction
method, imagery, music therapy, etc.)

Transition Phase
1) Inform patient on progress of her labor.
2) Assist patient with pant-blow breathing.
3) Monitor maternal vital signs and fetal heart rate every 30 minutes -1 hour, or
depending on the doctor’s order. Contraction monitoring is also continued.
4) When perineal bulging is noticeable, prepare for delivery.
5) Check room temperature (25-280C and free of air drafts).
6) The nurse should also notify staff and prepare necessary supplies and equipment,
including resuscitation machine. Lastly, perform handwashing and gloving.

SUMMARY
Today we discussed about labour and stages of labour, Essential factors of labour, Stages and
onset of labour, First stage : physiology of normal labour ,Use of partograph ,Analgesia and
anaesthesia in labour and Nursing management. We discussed in detail about the first stage of
labour, its phases and physiology of first stage of labour and the contributing factors like
uterine action and mechanical factors. We listed down the clinical course of first stage of
labor. We also discussed in detail about management of first stage of labor including
principles, general considerations, physical and vaginal examination, patient preparation and
how to record all these information in a partograph.

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 CONCLUSION
The onset of labour is a complex physiological process and therefore it cannot be easily
defined by a single event. Nursing care for pregnant women in labor proves to be a
challenging task because it requires nurses to be fast in their assessment without sacrificing
the quality and accuracy of rendered nursing care. Promoting the health of women in labor is
one active way of reducing maternal mortality and ensuring universal access to reproductive
health services. To gain patient and family’s cooperation and trust, it is important that the
nurse should be able to establish a therapeutic relationship with them. The opportunity to
protect women and the privilege of being a part of their positive pregnancy experience is
rewarding.

BIBLIOGRAPHY

1. Dutta.D.C.Textbook of Obstetrics.7thed.London.New Central Book

Agency(P)Ltd;2011.113-135.
2. Elizabeth Midwifery for Nurses.2nded.New Delhi. CBS Publishers and Distributors
Pvt Ltd;2013. 101-126.
3. Seth.S.S.Essential of Obstetrics.2nded.Jaypee Brothers Medical
Publishers(P)Ltd;2011.393-409
4. Cooper.M,Fraser.D.Textbokk for Midwives.15thed.New York. Churchill Livingstone
Elsevier;2009. 459-490.
5. Kumud, Avinash K.R,Seema Coeffect of upright positions on the duration of first
stage of labour. Nursing and Midwifery Research Journal.2013 Jan;9(1):10-20

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