LABOUR

LABOUR

 It is the process by which the foetus,

placenta and membrane are expelled
through the birth canal after the 28th week of
pregnancy.
 Labour begins when there are regular,
painful contraction lasting at least 20sec
(timed by a trained observer), occurring at a
frequency of at least two contractions in
every 10min and with a cervical dilation of at
least 3cm.
 NORMAL LABOUR
 Labour is said to be normal when the process
begins spontaneously at term with fetus
presenting by the vertex and is completed
within 18hrs with no complications.
Signs and symptoms of true Labour
1. Premonitory signs of labour
These are signs which are to announce that
labour is approaching. They are very useful
where the gestational age of pregnancy is not
definite. They are
 Lightening
 Frequent micturation
 False pain or spurious labour
 Taking up of cervix
 Lightening
 This is sinking of the uterus into the pelvic.
 The head of the fetus descend into the pelvic
brim.
Frequency of micturation
 Due the fetal head pressing on the bladder
and limiting its capacity.
False pain or spurious labour
 Erratic and irregular pain confined chiefly to
the lower part of the abdomen.
 These type of pain do not cause dilatation of
the cervix.
Taking up of the cervix
 This is shortening of the cervical canal
because it is drawn to emerge into the lower
uterine segment
2. True labour
 Contractions
 Show
 Dilatation of the cervix
 STAGES OF LABOUR
 First stage
 Second stage
 Third stage
 Fourth stage
 First stage
 This stage starts from the onset of regular
uterine contractions to the full dilation of the
cervical os.
 It lasts 12hrs in primip and 6-12hrs in multips.
 The first stages of labour consist of
 Latent
 Active phase
• Latent phase
 Here, the contraction occurs less than 3 in
10mins and lasts less than 20sec
• Active phase
 This stage lasts 6hrs with contractions
occurring 3 to 4 times in 10mins, each lasting
40-60sec.
 The cervix dilate from 4cm to 10cm at an
average rate of 1cm in 1hr.
 Second stage
 Starts from full cervical dilatation to the
complete expulsion of the baby.
 It normally lasts 1-2hrs in primip and 30min in
multipara.
Third stage
 Starts from birth of the baby to the expulsion
of the placenta and membranes.
 Fourth stage
This is a period of six hours following the
expulsion of the placenta.

MANAGEMENT OF FIRST STAGE OF LABOUR

Objectives:
The goal of care during labour and delivery is to
ensure the most positive outcome, namely a
healthy mother and healthy baby
• Welcome and reassure her in a friendly manner
• Show concern and eagerness to help
• Explain procedures to her
• Observe condition of the client as you welcome her into the
clinic.
Collect and analyse antenatal record
The following routine care should be given during
the first stages;
A)Take history;
I. Onset and symptoms of labour
II. Danger symptoms- bleeding, foetal movement, fever,
offensive liquor
III. Review maternal health record if available if not, ask about
obstetric, medical/surgical history
B) Perform physical examination/assessment
(observe stringent aseptic procedures)
I. Thorough general physical examination
II. Abnormal examination
III. Vaginal examination check for;
-show
-cervical dilation
-presentation
C. Look for any abnormalities such as offensive
meconium-stained liquor

D. Record findings
E. Monitor labour

in the latent phase, monitor;

Contractions -1/2 hourly
Descent four hourly
Feotal heart -1/2 hourly
Cervical dilatation –four hourly
F) Record all findings on observation chart
I. Use partograph for client in active phase, there are
no contra-indication.
II. Monitor progress as plotted on partograph.
III. Identify any problems and take appropriate action.

perform vaginal examinations every

four hours unless otherwise indicated. If dilatation on
admission is 4cm or above, 2 to 3 hourly vaginal
examination may be necessary. Avoid too frequent
vaginal examinations to prevent infections.
.
G. Explain to mother and/or accompanying
person(s)
-progress of labour
-reasons for ;
 any intervention
 Referral

H. Give emotional support and reassurance

 GENERAL EXAMINATION
PHYSICAL EXAMINATION
• INSPECTION
- Appearance of the client like being pallor,
rashes on the skin or oedema
- Vulva examination- check on the anatomy of
the vulva and the presence of the following;
warts, varicose veins, oedema.
- Check the temperature, pulse, respiration, BP,
FH
- Urine R/E( routine examination )
• Palpation- abdominal examination
• Auscultation of foetal HR(pinard horn, doppler
foetal monitor)
All these are done to check on the lie,
presentation, position engagement and foetal
condition.

PHYSICAL CARE OF THE PATIENT

Position
A woman in labour should be allowed to assume
any position confortable to her. She should not be
confined to bed especially in first stage of labour
Personal hygiene
help her bath, mouth and teeth cleaned, bed
linen straightening and changed as and when
necessary. Observe aseptic techniques in your
care by washing hands before and after care. Eg.
After touching each patient . Wear gowns and
gloves, use sterile instrument for procedure.
Care of the bladder
Encourage frequent emptying of the bladder
through out labour. Catheterization should be a
last resort. Empty the bladder every 3 to 4
hours.
Nutrition
Light nourishing diet in every first stage. Give drinks.
Please follow hospital protocol for nutrition guideline
Rest and sleep
Encourage rest by making the environment quite and
with a conducive temperature.
Alleviate pain by sacral massages, some analgesics
like pethidine and sedatives like phenergan 12.5-
25mg are allowed in the early first stage of labour.
NB, these drugs are not given when cervical
dilatation is beyond 6cm.
Observation of the progress of labour
Timing of contraction
Observe vulva pads for show and greenish
colour.
Observe for decent
Elimination
Encourage emptying of the bowel. A full bladder
and bowel impedes uterine contractions.
Vaginal examination;
Indications;
• To decide whether she is in true labour
• To ascertain cervical dilation
• Confirm the lie of a second twin
• Confirm presentation and also after rapture of
membranes to ascertain the course of delay
and prolonged labour
CONTRAINDICATIONS OF V/E
 Antepartum haemorrhage
 In trial labour so as not to introduce infection
 INTERPRETATION OF V/E
• 1c…………..a tip of finger
• 2cm………..a large finger
• 3cm………..2 fingers
• 4cm…………3 fingers
• 5cm………..1/2 dilatation dilated
• 6cm……….1/2 dilated
• 7cm……….3/4 dilated
• 8cm………..rim of cervix
• 9cm…………almost fully dilated
• 10cm………. Fully dilated
CERVICAL DILATION BOARD
.
.
NB. Always conduct vaginal examination to confirm full
dilation before allowing and encouraging patient to
bear.

SECOND STAGE OF LABOUR

This stage of labour start from full cervical dilatation to

the complete expulsion of the baby
Signs and symptoms of the 2nd stage of labour
• Change in the characteristics of uterine contractions
ie they become regular and have a bearing down
effect or feeling on the woman
• Bulging of the perineum
• Anus dilate and has the appearance of capital
letter D
• Gapping of the vulva and the vertex is seen
peeping
• Pelvic floor is displaced
On V/E, cervix is not felt
Position in labour
 Squatting, kneeling, standing
 Left lateral position
 Upright position
 Lithotomy; this is the preferred one in Ghana
 MANAGEMENT OF SECOND STAGE OF LABOUR
The second stage start from full dilation of the cervix to the
birth of the baby.It usually lasts up to 30min in multipara,
and 60min in nullipara respectively. The clinical
signs/symptoms indicating that the second stage has started
include the following;
 contraction become stronger and are of longer durations,
lasting 40-60sec and occur at shorter intervals (3
contraction in ten minute)
 The woman feels pressure in the rectum accompanied by
the urge to defecate
 The perineum bulges and the anus dilate
 Nausea and retching may occur as the cervix reaches full
dilation .
 Delivery steps
Explain to patient what to expect during labour
Position patient according to her preference
Wear protective clothing( plastic apron, boot, goggles and mask)
Wash hands with soap and water and dry with sterile towel
Put on sterile gloves on both hands
Clean vulva/perineum with antiseptic solution eg.
Chlorhexidine/savlon.
Drape the woman appropriately for delivery
Check delivery trolley and instruments
Infiltrate the perineum with anaesthetics, if indicated
Maintain flexion of the head as it comes out of the vagina
Observe perineum for impending tear
Prepare and perform episiotomy when indicated
Prevent soiling of the perineum using a sanitary pad to cover the anus
Observation during the second stage of labor

1.Fetal condition : listening to fetal heart rate after every two

contractions or 15 minute.
the normal FHR is 120 to 160 beat per minute.
2. Maternal condition ; temperature, pulse , respiration , Bp.
Contraction for strength, frequency and duration of vagina
examination.
3. Bladder; the woman should not be allow to enter the
second stage with a full bladder because full bladder can
rupture bladder and can prevent decent of the head. It can
also cause poor uterine contraction and cause postpartum
haemorrhage.
 OTHER CARE STILL UNDER SECOND STAGE
• Reassurance
• Mop around the forehead
• Give sips of water to moisten the lips, tongue and throat
• Continue with education as to when to push, relax and about the right way of
bending down
Third stage of labour
This start with the delivery of the infant and ends with the delivery of the
placenta and it membranes.
physiology of the third stage of labour
• Separation of the placenta from the upper uterine segment .
• Descent and expulsion of the placenta
• Control of bleeding
Mode of placenta delivery
After separation of placenta had been seen, one hand is placed above the
symphysis pubis with the palms facing the umbilicus exerting pressure in and
upward direction. the outer hands grasp the cord winding it around the hand.
When the placenta is visible at the vulva, it is cupped in the
hands to ease pressure on the fragile membrane. It is
delivered gently into a receiver
Care of the patient after expulsion of the placenta
The patient is cleaned up after the delivery of the placenta
and the perineum posterior vaginal wall and vulva are
inspected for laceration. If the laceration needs suturing,
arrange and suture them immediately, tidy up the woman
and put a sterile pad in her vulva. IM Ergometrine 0-5mg
could be given to maintain good uterine contraction. Collect
all blood clot around, any clot in the uterus expelled. Provide
warmth by changing any wet cloth and make her comfortable
to rest. Congratulate her and serve her with a warm drink
after placenta have been examined and found to be
complete. observe TPR and BP.
 EXAMINATION OF THE PLACENTA AND MEMBRANES.
The 3rd stage of labour is never said to be completed until the
placenta and membranes are examined and found to be
complete.
Method
Collect all blood and clot into a measuring jug and measure.
Please add and estimate the amount of blood that wet the bed
linen.
Hold the by the cord like an inverted umbrella and membranes
inspected to see if any are torned or restrained. This can be
detected by inserting the second hand into the holes and
sweep around and when no whole is found, except from where
the baby, then it is passed and it is complete. In the case of
ragged membranes make attempt to look for them and put
pieces together to give an overall picture of completeness.
 CONT
Now lay the placenta on a flat surface and examine
minutely both placenta and membranes kill the
amnion from the chorion right up to the umbilica cord
so as to view fully the chorion. The presence of the
blood vessels and the hole other than one large
through which the baby came is suggestive of
succenturiate lobe.
Note the insertion of the cord. Fit all the cotyledon
together. If there is any suspicion that the placenta
and membranes are incomplete keep them and
inform doctor immediately. Weigh placenta and
record.
 RECORD THE BLOOD LOSS
Document in the folder also the state of the placenta
and its membrane. Consider the woman out of
danger after the above.
Please continue observing.
FOURTH STAGE OF LABOUR; this is the first hour
after delivery.
Observe mother and baby closely for any deviation
from normal, attention should be paid to blood loss
by recording after approximation.
 MANAGEMENT OF THE FOURTH STAGE
OF LABOUR
The fourth stage is the first six hours following the birth of the
placenta.
FIRST HOUR;
Put the baby to mother’s breast within half hour of delivery.
Do the following;
• Monitor mother BP and pulse every 15 minutes
• Palpate and massage the uterus every 15minutes for 1hour
to ensure it remains firmly contracted
• Inspect the introitus every 15minutes for any active bleeding.
• Check T.P.R., B.P, and record
• Palpate the fungus to see if uterus has contracted well.
 CONT”
EXAMINE THE BABY;
• Breathing
• Colour
• Muscle tone
• palate(cleft palate)
• Anus(inperforate anus)
• Continue to keep baby warm, especially the head 2-6hours

Do the following;

• Take the blood pressure and pulse every 2hours

• Take temperature at least once
• Encourage the woman to pass urine frequently
• Palpate the uterus. Palpate bladder and check vagina for bleeding for every hourly.
• Support mother to continue breast feeding. If mother is HIV positive and chooses not to
breastfeed support mother’s choice.
• Administer 1.0mg of vitamin K to the baby to prevent haemorrhagic disease for babies
weighing less than2.5kg give 0.5mg.
• Instil antibiotic drops-chloramphenical or tetracycline 0.5% into baby’s eyes.
 cont
• Carry out a detail examination of baby from head to toe to exclude
abnormalities
• Dry or wipe the baby ( do not bath the baby within the first 24hours).
• Offer supportive care
• Talk to mother and encourage her ask questions to express her feelings
• Advise birth companion to remain with the woman during the period
• Ensure woman has a clean bed
• Replace soiled and wet clothing and bedding
• Encourage the mother to pass urine when she feels the urge or if
bladder palpable.
• Encourage adequate fluid intake and appropriate food and sufficient
rest.
• Maintain a calm environment conducive to mother
• Provide continuous support to parent or relative about the well-being of
the baby and the mother.
 Group 6 members
• ISAIAH KWOFIE …….. RGN/18/060
• AWINBUGRI STEVEN….. RGN/18/039
• APPIAH BABA ABEL…….. RGN/18/026
• KYEI PRISCILLA…….RGN/18/061
• OSEI KISSIWAA ABIGAIL…… RGN/18/084
• ADUSEI GLORIA……. RGN/18/008
• OBENEWAH STELLA….. RGN/18/076
• AMOAH DEDE HENRIETTA…..RGN/18/018
• ASUBOAH KWAME KODUAH….. RGN/18/037
• AWINI JOSEPH……. RGN/18/040
• ACHEAMPONG SAMUEL……..RGN/18/002