Refersher Course For Nurses

Management of Normal Labour

Mrs. Sarita Dubey
 Normal Labour

• Labor is defined as regular and painful

uterine contractions that cause
progressive effacement and dilation of the
cervix.
• The World Health Organization (WHO)
defined normal birth as "spontaneous in
onset, low-risk at the start of labor and
remaining so throughout labor and
delivery of product of conception
(fetus, placenta & membrane)
 Essential Factors Affecting Labour

• Passenger
• Passage
• Power
• Position of Mother
• Psychology of mother
 Physiohological Changes During labour

• Cardiovascular Changes
– Cardiac output increases
– Slight pulse changes- may increases more
than 100 beats as a result of exhaustion or
dehydration
– Blood pressure changes: very little
– Hypotension may seen due to hypotension
– White blood cells count increases up to
20,000/mm3
• GI Changes: Mobility and absorption
decreases
• Nausea Vomiting is Common
• Renal changes: discomfort increases
• Proteinuria may increases
• Increases metabolic activity
 Stages of labour
• I stage: The intrapartum period of pregnancy
begins with the first stage’s uterine contraction
and the progressive dilatation of the cervix.
• II Stage: From complete dilatation of cervix to
the infant delivery is the second stage of labour.
• The third stage of labour is complete with the
expulsion of the placenta and membranes.
• The fourth stage of labour is the first hour of
the postpartum.
 Comparison of true and false Labour pain

True labour pain False labour pain

Contraction are at regular intervals. Contraction are irregular

Intervals between contractions Usually no change

gradually shorten.
Contraction increases in duration and Usually no change
intensity.
Discomfort begins at back and radiate Discomfort usually at abdomen
to abdomen
Intensity usually increases with walking Walking has no effect or
lessens the contraction

Cervical dilatation and effacement are No effect on cervix

progressive and lead to bloody show
appearance
 Characteristic of Labour

First Stage of Labour Second Stage of Third Stage of

Labour Labour
Latent Active Transition
Phase Phase Phase

Nullipara 81\2 Hour 6 hour 1 -2 hours 15 – 30 mints

Multi Para 5 hrs 4 hrs 30 to 1 hrs 5 to 15 mints

Cervical 0 to 3 cm 4 to 8 cm 8to 10 cm Full dilatation to Delivery of baby to

dilatation delivery of baby delivery of placenta
Contractions First Stage of Second Third
Labour Stage of Stage of
Labour Labour
Frequency Every 10 to 20 Every 2 to 3 Every 1 Every 1 Every 5
mints at beginning mints – 2 mints – 2 mints mints
and progressive to
every 5 to 7 mints

Duration 15 to 20 seconds 60 seconds 60 -90 60 -90 1 -2

progressing to 30 to seconds seconds mints
40 seconds

Intensity Begins at mild and Begins at Strong Strong Strong

progress to moderate and
moderate progress to strong
 Provision of Care in First Stage of Labour

• Normal progress, Physiological

Characteristics, and Nursing Support
During First Stage and Second Stage of
labour
Phase Cervical Uterine Women’s Support Measures
Dilatation Contractions Response
STAGE 1-4 cm Every 15 -30 Usually happy, Establish rapport on admission and
I mints, 15 – 30 talkative, and
continue to build during care.
Latent sec duration eager to be in
Phase Mild Intensity labour Assess information base and learning
Exhibits need needs. Be available to consult
for regarding breathing technique if
independence
needed; teach breathing technique if
by taking care
of own bodily needed and in early labour.
needs and Orient family to room, equipment,
seeking monitors, procedures. Encourage
information
woman and partner to ask. Provide
needed information.
Assist woman into position of
comfort; encourage frequent change of
position; and encourage ambulation
during early labour.
Offer fluids/ice chip.
Keep informed of progress.
Encourage woman to void every one to
two hours.
Phase Cervical Uterine Women’s Response Support Measures
Dilatation Contractions
Active 4-7 cm Every 3-5 May experience Encourage woman to maintain
phase mints feelings of
30 – 60 helplessness; breathing patterns; provide quiet
second exhibits increased environment to reduce external
duration fatigue and may stimuli.
Moderate begin to feel restless
Provide reassurance,
intensity and anxious as
contractions become encouragement, support; keep
stronger; expresses couple informed of progress.
fear of abandonment
Promote comfort by giving
Become more
dependent as she is backrubs, scaral massage or
less able to meet her pressure, cool coths on forehead,
needs. assistance with position changes,
support with pillows, effleurage.
Provide ice chip, ointment to
prevent dry mouth and lips.
Encourage to void every one to two
hours.
Phase Cervical Uterine Women’s Response Support Measures
Dilatation Contractions
Tansitio 8 – 10 cm Every 2 – 3 Tires and may • Encourage woman to rest
n Phase mints exhibits increased between contration; if she sleep
45 – 90 restlessness and between contraction, wake her at
second irritability; may feel beginning of contraction so she
duration she cannot keep up can begin breathing pattern
Strong with labour process (increases feeling of control).
intensity and is out of control • Provide support, encouragement,
Physical discomforts and praise for efforts, Keep
fear of being left mother informed of progress
alone encourage continued
May fear tearing participation of support persons.
open or splitting • Promote comfort as list above
apart with but recognize many women do
contraction not want to be touched when
transition
• Provide privacy ice chips,
ointment for lips. Encourage to
void every one to two hours.
 Analgesia & Anestheia

• Pain receptors: affect by past experiences

cultural expectations , psychosexual
development Fatigue anemia, emotional
stress, Environment , support system
• Local anesthesia can be used but only
lower uterine segment will be affected, fetus
may have bradycardia.
• Epidural / Caudal : may hypotension,
potential distress in fetus
 Non-pharmacological Methods

• TENS(Tanscutaneous electrical nerve

stimulation)
• Touch : Acupressure, Cutaneous
stimulation by effleurage, massage, hot &
cold application
• Relaxation technique: Biofeedback, visual
Imagery, controlled breathing pattern etc..
Partograph
• A partogram or partograph is a composite graphical
record of key data (maternal and fetal) during labour
entered against time on a single sheet of paper
• A partograph is a tool used to monitor labor and
prevent prolonged and obstructed labor focusing on
observations related to maternal, fetal condition and
labor progress.
• The partograph was first introduced in 1954 by Friedman
graphically depicting the dilatation of the cervix during
labour.
• Philpott and Castle in 1972 developed Friedman's
concept into a tool for monitoring labour by adding the
action and alert lines2
Observations Charted on the Partograph

• A) The Foetal Condition

• 1) Foetal Heart Rate
• 2) Colour and Amount of Liquor
• 3) Moulding of the Foetal skull
 The Foetal Condition

• Foetal Heart Rate

• Observing the foetal heart rate is a safe
and reliable clinical way of knowing that
the foetus is well.
• The best time to listen to the foetal heart is
just after the contraction has passed off its
strongest phase.
• Listen to the foetal heart for 1 minute with
the woman in the lateral position if
possible.
• The foetal heart rate is recorded at the top
of the partograph.
• It is recorded every half hourly and each
square represents half hour.
• The lines for 120 and 160 are darker to
remind the recorder that these are the
limits of the normal foetal heart rate.
 Abnormal Foetal Heart Rates

• i) A rate >160 beats/min (tachycardia) and

<120 beats/min (bradycardia) may indicate
foetal distress.
• If an abnormal heart rate is heard, listen
every 15 minutes for at least 1 minute
immediately after a contraction.
• If the heart rate remains abnormal over
three observations action should be taken
unless delivery is very close.
 Membranes and Liquor

• The state of the liquor can assist in

assessing the foetal condition.
• There are four observations which are
recorded on the partograph immediately
below the foetal heart rate recordings.
They are:
• If the membranes are intact : Record as the
letter ‘I’ for intact
• If membranes are ruptured:
– a) Liquor is clear : Record as the letter ‘C’ for clear
– b) If the liquor is meconium stained : Record as the
letter ‘M’ for meconium
– c) The liquor is absent : Record as the letter ‘A’ for
absent
 Moulding of the Foetal Skull Bones

• Moulding is an important indication as to how

adequate the pelvis is to accommodate the
foetal head.
• Increasing moulding with the head high in the
pelvis is an ominous sign of cephalo-pelvic
disproportion.
• Recordings are made immediately beneath
those of the state of liquor.
• Key:
– 0 = Bones are separated and the sutures can be felt
easily
– + = Bones are just touching each other
– ++ = Bones are overlapping
– +++ = Bones are overlapping severely
• Moulding may be difficult to assess in the
presence of a large caput,
• but that in itself should alert to possible
cephalo-pelvic disproportion.
 Point to Remember

• Listen to the foetal heart rate immediately after

the peak of a contraction with the woman in the
lateral position.
• Recordings are made half hourly in the first
stage of normal labour.
• Normal foetal heart rate is between 120-160
beats/minute.
• Increasing moulding with a high head is a sign
of disproportion.
• B) The Progress of Labour
– 1) Cervical Dilatation
– 2) Descent of Head
– abdominal palpation of fifths of head palpable
– 3) Uterine Contraction
– Frequency/10 min.
– Duration—shown by differential shading
• 20 sec
• 40 sec
• 90 sec
 The Progress of Labour

• The first stage of labour is divided into the latent

and active phase:
• The latent phase (slow period of cervical
dilatation) is from 0-3 cms with gradual Normal
Labour shortening of the cervix.
• The active phase (faster period of cervical
dilatation) is from 4 cm to 10 cm (full cervical
dilatation). In the centre of the partograph is a
graph; along the left side are the figure 0-10
against squares.
• Each square represents 1 cm dilatation.
Along the bottom of the graph are numbers.
• Each square represents one hour.
• Rate of cervical dialation
– Primipara: 1.2 cm / hrs
– Multipara: 1.5 cm/hrs
• Dilatation of the cervix is measured in
centimetres (cm). The dilatation of the cervix
is plotted (recorded) with an ‘X’.
• The first vaginal examination on admission,
includes a pelvic assessment and the findings
are recorded.
• Vaginal examinations are made every four
hours, unless contraindicated.
• However, in advanced labour, women may be
assessed more frequently, particularly the
multipara.
• If progress is satisfactory the plotting of
cervical dilatation will remain on or to the left
of the alert line.
• Plotting cervical dilatation when admitted in the
Latent phase.
• The latent phase normally should not take
longer than 8 hours.
• When admission is in the latent phase dilatation
of the cervix is plotted at zero time and vaginal
examination made every 4 hours.
 Descent of the Foetal Head
• For labour to progress well, dilatation of the cervix
should be accompanied by descent of the head.
• However, descent may not take place until the
cervix has reached about 7 cm dilatation.
• Descent of the head is measured by abdominally
in fifths above the pelvic brim.
• It is found to be a more reliable way of gauging
descent than a vaginal examination.
• when large caput formation often leads to the
inexperienced to confuse scalp descent as
opposed to skull descent
Fetal Station
• The level of the foetal head measured
by abdominal palpation and expressed
in terms of fifths above the brim. S =
sinciput, 0 = occiput
• Descent of the head should always be
assessed by abdominal examination
immediately before doing a vaginal
examination.
• It is generally accepted that the head is
engaged when the portion above the brim is
represented by 2 fingers width or less
• Plotting of Descent of the Head
• On the left hand side of the graph is the word
‘descent’ with lines going from 5-0.
• Descent is plotted with an ‘0’ on the
cervicograph
 POINT TO BE REMENBER

• Assessing descent of the head assists in

detecting progress of labour.
• Descent is assessed abdominally in fifths
felt above the pelvic brim.
• Immediately before a vaginal examination,
an abdominal examination must always be
done
 Uterine Contractions
• Practical Manual There are two observations
made of the contractions:
– The frequency—how often are they felt?
– The duration—how long do they last?
• The frequency of contractions is assessed by
the number of contractions in a ten-minutes
period.
• The duration of the contractions: is from the
time, the contraction is first felt abdominally to
the time when the contraction passes off
measured in seconds.
• Recording on the Partograph
– Below the time line there is a blank of five squares
going across the length of the graph
– At the left hand side is written ‘contractions per 10
minutes’.
– Each square represents one contraction
– 2 contractions are felt in 10 minutes two squares
will be shaded.
– Duration—shown by differential shading
• 20 sec
• 40 sec
• 90 sec
• First Half Hour In the last ten minutes of that half
hour there were two contractions lasting less than
20 seconds
• Third Half Hour In the last ten minutes of that half
hour there were three contractions lasting less
than 20 seconds.
• Sixth Half Hour In the last ten minutes of that half
hour there were four contractions lasting between
20 and 40 seconds.
• Seventh Half Hour In the last ten minutes of that
half hour there were five contractions lasting more
than 40 seconds.
 Points to Remember
Contractions are observed for frequency and duration.
• The number of contractions in 10 minutes is
recorded.
• The 3 ways of shading in duration of contractions
represent:
i) up to 20 seconds,
ii) 20-40 seconds,
iii) more than 40 seconds.
• Recording must be made beneath the correct time
entry on the partograph.
 C) The Maternal Condition

C) The Maternal Condition

1) Pulse, Blood Pressure and Temperature
2) Urine—volume, protein, acetone
3) Drugs and I/V fluids
4) Oxytocin regime
 The Maternal Condition

• All the recordings for the maternal

condition are entered at the foot of the
partograph below the recording of uterine
contractions.
• Pulse, Blood Pressure and Temperature
– Pulse rate : half-hourly
– Blood pressure : 4 hourly or more frequently, if
indicated
– Temperature : 4 hourly or more frequently, if
indicated
• Urine—Volume, Protein and Acetone
– Protein or acetone in the urine
– Urine volume—encourage woman to pass urine 2-4
hourly 1 and 2 are charted in that order from top to
bottom on the chart.
Drugs and IV Fluids
• These are charted in the appropriate column
under the contractions.
• For any fluid and drug administrations.
Oxytocin Regimens
• There is a separate column for oxytocin titration
above the column for I/V fluids and drugs.
• All entries are made in relation to the time at
which the observations are made.
 Points to Remember
• Time of admission is zero time, when the
woman comes in the latent phase of labour.
• When the active phase of labour begins all
recordings are transferred, plotting the cervical
dilatation on the alert line.
• When progress of labour is normal plotting of
the cervical dilatation remains on the alert line
or to the left of it.
Thank you for listening