BALKEEJ KAURM.SC(N) 2ND YEAR
AIMS,CONSRI MUKTSAR SAHIB
PUNJAB
Contents:IntroductionStages of labourDiagnosisManagement on admissionActive management of labourMonitoringPartogramAbnormalitiesPain control
IntroductionLabor : 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 beginsContractions are mildLasting 20-40 secondsCervical effacement occurs,cervix dilate 0-3 cm6 hours in nullipara and 4.5 hours in multipara.
.ACTIVE PHASECervical dilatation increasing from 4-7 cmContractions last 40-60 seconds and occur
every 3-5 minutes3 hours in nullipara and 2 hours in multiparaShow and spontaneous ruptures of
membranes may occur
ACTIVE PHASE DIVIDED INTO THREE ADDITIONAL PHASES:-Acceleration phase-phase of maximum slope-deceleration phase
TRANSITION PHASECONTRACTIONS REACH THEIR PEAK OF
INTENSITYCERVICAL DILATATION INCREASE FROM
8- 10CMCONTRACTIONS LASTS FOR 60- 90
SECONDSOCCUR EVERY 2-3 MINUTESIF 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 DOMINENCEPOLLARITY
CONTD……CONTRACTION AND RETRACTIONFORMATION OF UPPER AND LOWER
UTERINE SEGMENTRETRACTION RING
CONT…..CERVICAL EFFACEMENTCERVICAL DILATATION
CONTD…PRESENCE OF SHOW
2.MECHANICAL ACTORS-FORMATION OF FOREWATERS
CONTD….RUPTURE OF MEMBRANES
CONTD…..GENERAL FLUID PRESSUREFETAL 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
Didn’t meet the
criteria
Rest & observationUntil next
day
Antinatal ward
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 LABOUROBJECTIVE-TO HAVE A WATCHFUL EXPECTANCY
AND TO MONITOR THE PROGRESS OF LABOUR AND TO PREVENT COMPLICATIONS
INITIAL ASSESSMENT-Onset of contractionFrequencyDuration MemebraneLiquorPresent and previous obstetric history,drug history
Contd……CLINICAL EXAMINATIONPallorJaundiceHydrationPulse/bp/temp,/resp. ratechest,/cvsoedema
Contd……oOEDEMA
PER ABDOMEN EXAMINATIONUterine contractionFrequency and duration in 10 minFundal hieght
Contd…..
LIE/PRESENTATION
Contd….FHR to be noted every 15 minutes with fetal
doppler
PER VAGINAL EXAMINATIONDischarge showAbsence or presence of membranesStation of head
Contd….EffacementDilatationCaput/moulding
investigationsBasic pre op
MANAGEMENTGENERAL-emotional support and assurance are givenBOWEL-encourage women for warm bath,soap enemaREST 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 should be done
Contd…..PARTOGRAPH-monitor the progress of the
labour by plotting the partograph
Partogram:Maternal statusFetal heart rate Dilatation & descentUterine contractions
Contd….
Cont…..Watch for maternal and fetal well being.Psychological preparation of the motherP/V examination should be done :1 to 4 hours in the first stage and at 1 hour intervel
at the second stageAt rupture of membranes to evaluate for cord
prolapsePrior to intrapartum administration of analgesiaWhen the parturient feels the urge to pushWhen 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 laborThe 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 laborNulliparous 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 laborRecommendation 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 LABOURInterventions 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 LABOURIf 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 LABOURSlower 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.
MONITORINGIt 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 & Emotional2)Vitals & Urinalysis3)Uterine contractions4)Abdominal examination_Leopold manouvers5)Vaginal loss – show, liquor, blood6)Vaginal examination....when necessary7) Pain control8)FHR
DIAGNOSIS OF POOR PROGNOSIS OF LABOURProlonged bradycardia and meconium stained liquorPossibility of foetal distressProlonged 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 pelvisPassenger, hydrocephalous, brow [occiput not felt]Large baby, shoulder presentation
ROLE OF NURSE IN CARING OF THE WOMAN IN THE FIRST STAGE OF LABOURAdmitting client to birthing area after
determining that client is in laborDetermining if client's membranes have rupturedEncouraging family participation as appropriate
with the labor processPerforming Leopold maneuver and vaginal exams
as appropriateMonitoring maternal vital signs and fetal heart
rate and patterns, reporting any deviations or abnormalities
CONTD…..Applying electronic fetal monitor as appropriateAssessing pain level, instituting positioning,
breathing, relaxation, and other methods for pain control; administering analgesics as ordered
Providing ice chips, wet washcloth, or hard candyEncouraging voiding at least every 2 hoursAssisting with anesthetic administrationAssisting 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 intensityReassuring 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