NORMAL LABOR

Labor is described as the process by which the fetus,

placenta and membranes are expelled through the

birth canal.

Normal labor occurs at term and is spontaneous in

onset with the fetus presenting by the vertex. the

process is completed within 18 hours and no

complications arise.

These labor abnormalities are best described as protraction

disorders ( ie, slower than normal progress) or arrest disorders

(ie, complete cessation of progress).

STAGES OF LABOR

1-The 1st stage is that of dilation of the cervix

2-The 2nd stage of labor and is the expulsion of the fetus.

3-The 3rd stage of labor icludes separation and expulsion

of placenta and membranes.

4-The 4th stage lasts from delivery of the placenta until the

postpartum condition of the woman has become stabilize

' 'usually 1-2 hour after delivery''

STAGES OF LABOR

THE 1ST STAGE CONSISTS OF 3 PHASES

A. Latent phase: cervical dilations is 0-3 cm1- Begins with regular contractions (labor pains).

2- pains are similar to painful menstrual cramping and are usually

accompanied by low back pain.

3-Contractions during this phase are more than 5 minutes apart,

last 25 to 35 seconds, and are considered to be mild. usually, woman is

excited about labor and talkative.

B. Active phase: cervical dilation is 4-7 cm. 1- more active contractions.

2- The contractions become more frequent (every 3 to 5 minutes), last

longer (60 seconds), and are of a moderate to strong intensity.

THE 1ST STAGE CONSISTS OF 3 PHASES

3- Cervical dilation become advances more quickly

4- nulliparous women abut 1 cm of dilation per hour and

multiparas at 1.5cm of cervical dilation per hour

C. Transitional phase: cervical dilation is 7-10 cm

1- The transition phase is the most intense phase of labor.

Transition is characterized by frequent

2- strong contractions that occur every 2 to 3 minutes and

last 60 to 90 seconds on average.

3- That a woman may feel during transition include rectal

pressure, an increased urge to bear down, an increase in

bloody show, and spontaneous rupture of the membranes

(if they have not already ruptured).

True and false labor contractions

TRUE AND FALSE LABOR CONTRACTIONS

THE FIRST STAGE OF LABOUR

Duration:primigravida = 8-12 hmultigravida = 6-8 h

Phases of the first stage:Latent phase: started when the cervix dilatated slowly -

reached to about 3cm.

in primigravida = 4-6hin multigravida = 4.8 h

- Active phase: rapid dilatation of the cervix to reach 10cm

in primigravda = 4hin multigravida =2h

Prolong Latent phase : A failure of thinning of the lower

segment, ef facement and dilation of the cervix despite

several hours of painful contractions.

Management:

Simple analgesia

Encourage mobilization

Reassurance

AROM and oxytocin will cause poor progress

ABNORMAL LABOR INDICATORS

Nulliparous Multiparous

Latent phase 4.6 h 4.8 h

Abnormal 20 h 14 h

Protracted active phase ( Prolong active phase)

Protracted active phase dilation is a common dysfunctional labor pattern

→ Most common in first labour.

→ Implies slow progress during the active phase of labour.

→ Usually with inefficient uterine contractions.

→ Abnormalities of passenger

It seems to be associated with mild cephalopelvic disproportion.

ABNORMAL LABOR INDICATORS

Arrest of labor

absence of progress of active labor (as defined by cervical dilation and descent of the presenting part) for 2 hours or longer.

There is a well-recognized relationship of arrest with fetopelvic disproportion.

It has been suggested that the diagnosis not be made unless labor is active ,

The cervix is dilated greater than 4 cm, and there has been 2 hours of no cervical change with 200 Montevideo units or more per 10-minute interval .

ABNORMAL LABOR INDICATORS

LABOR INDICATORS

Idication Nullipara Multipara

Prolonged latent phase >20 h >14 h

Average second stage 50 min 20 min

Prolonged second stage without

(with) epidural

>2 h (>3 h) >1 h (>2 h)

Protracted dilation < 1.2 cm/h < 1.5 cm/h

Protracted descent < 1 cm/h < 2 cm/h

Arrest of dilation* >2 h >2 h

Arrest of descent* >2 h >1 h

Prolonged third stage >30 min >30 min

*Adequate contractions >200 Montevideo units [MVU] per 10 minutes for 2 hours. (Please refer to the

Pathophysiology for information regarding adequate contractions.)

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 painful contractions are accompanied by any one of the following :

Bloody show

Rupture of the membranes

Full cervical ef facement .

Cervical dilatation is not part of the criteria

Meet the criteria

Rest &

observation

Until next day

Antenatal

wardDidn’t meet the

criteria

MANAGEMENT OF LABOUR

The management of labour should becommenced during the antenatal period

the women should be classified as high or lowrisk pregnancy.

The medical or surgical problems should becorrected as in case of (anaemia,hypertension, urinary tract infection) and allinvestigations should be performed andprepared such as (HIV, HCV, Hbs Ag, bloodgrouping…….etc).

AIM OF FIRST STAGE MANAGEMENT:

1- achieve delivery of normal healthy child with with minimal

physical and psychological maternal effect.

2- early anticipation, recognition and management of any

abnormalities during labour.

ADMISSION TO LABOUR

Welcoming the woman

Review the referral note or pregnancy card to review history.

Check and record the vital sign: BP -RR-Temp

Auscultate fetal heart sound.

Assess uterine contraction.

Ask to woman to empty bladder and give urine spacemen.

MIDWIFERY CARE

Nutrition and fluid :

1- encourage intake of oral fluid and come candies.

2- Encourage voiding every 2 hr.

Ambulation and position:

1- encourage ambulation if continues monitoring is not required.

2- encourage woman to avoid lying on her back.

3- if lying back encourage to be on left lateral position.

Hygiene:

1- offer to woman have a shower upon admission if she desire.

2-encourage and assess having warm shower if woman is not active

phase.

3- assist woman to keep Perineal clean after vaginal examination.

4-change wet linen whatever possible .

MIDWIFERY CARE (CONT.)

Artificial rupture of membrane :

1- perform artificial rupture of membrane if woman is 4 cm or more.

2- head is well applied.

3- Head is engaged

The AROM is don by physician at MOH hospital and it can be don my midwife under doctor supervision or if the woman is 6 cm or more

Follow-up

1- follow the progress of labour utilizing the partogram.

2- conduct vaginal examination in following condition:

a. Upon admotion.

b. After AROM

c. Q 2-4 hr

Document all of procedure, assessment finding on partogram.

MIDWIFERY CARE (CONT.)

cervical examination should be kept to a minimum to avoid promoting intraamniotic infection.

In general, vaginal examinations are performed:

• On admission

• At one to four hour intervals in the first stage and at one hour intervals in 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 to determine whether the cervix is fully dilated

• If the FHR falls, to evaluate for conditions such as cord prolapse or uterine rupture.

MIDWIFERY CARE (CONT.)

A. Establ ish good rapport and trus t beg inning with the f irst contact and maintain i t

throughout the woman ’s s tay.

B. Fol low the woman ’s w ishes on inc luding her husband or re la t ives .

C. Explain a l l procedures and processes .

D. Keep the woman informed about a l l dec i s ions .

E. Lis ten respectful ly to quest ions and answer her ca lmly and reassuringly.

F. Respect the woman ’s pr ivacy.

G. Provide continuous emot ional support .

H. Al low the woman to dr ink f luids , eat l ight meals and walk.

PAIN RELIEVE FOR WOMAN IN ACTIVE

PHASE

Changing of body positions: lying down, walking, sitting etc.

Vocalization: reading Quran and chanting.

Breathing exercise

Touch and massage.

Hot/cold packs.

Warm shower: if possible may relieve her pain & increase her

labour contraction.

Relaxation techniques.

Document alternative measures & any medication given.

PARTOGRAM

Definition:

it is graphical record of key data of labor progress

with both maternal and fetal data.

it is the process by which normal and abnormal

progress of labor and also fetal response in labor

can be defined.

IMPORTANCE

It allows an instant visual assessment of the rate

of

Cervical dilatation and comparison with an

expected

Norm , so that slow progress can be recognized

Early and appropriate actions taken to correct it

Where possible.

it is a graphic representation of cervical

dilatation and descent of the presenting part .

* it is an essential part of the partogram .

it offers the chance of early detection of slow progress of

labor

* first ,we set an alert line at 1cm/h. for the active

phase dilatation to represent the ideal progress.

then.

PART 1 : PROGRESS OF LABOR CERVICOGRAM ):

Starting a Pantograph

A pantograph should be started only when a

woman is in active phase of labour

Contractions must be 1 or more in 10mins, each

lasting for 20secs or more

Cervical dilatation must be 4cms or more

PART 1 : PROGRESS OF LABOR CERVICOGRAM ):

The plot of first digital examination should be put on alert line

It should be at alert line or at the left of it

If it moves to the right of the alert line, labour may be prolonged

Normal Latent and Active Phases

Latent phase is less than 8 hrs. and active phase remains to the left of or on the alert line

Do not augment with oxytocin or intervene unless complications develop

ARM may be done at any time in the active phase

PART 1 : PROGRESS OF LABOR CERVICOGRAM ):

Between Alert and Action lines ( moving to the right)

I t i s 4 hours to the r ight of Aler t l ine

Assess the cause of s low progress and take act ion

Action should be taken in a p lace wi th faci l i ty for deal ing wi th obs tetr ic

emergencies i s avai lable

It indicate prolong act ive phase of labour

In a Health Centre:

1- Transfer to hospital wi th faci l i t ies for Cesarean sect ion, unless Cervix i s a lmost

fu l ly d i la ted

2- ARM may be performed i f membranes are s t i l l in tact and observe labour for a shor t

per iod before t ransfer

In Hospital:

Perform ARM if membranes are in tact and continue routine observat ions

PART 1 : PROGRESS OF LABOR CERVICOGRAM ):

PART 1 : PROGRESS OF LABOR CERVICOGRAM ):

At or Beyond Active Phase Action Line

Full medical assessment

Consider IV infusion/bladder catheterization/analgesia

Options:

Delivery if fetal distress or obstructed labour

Oxytocin augmentation if no contraindication

digital examination after 3 hr , then in 2 or more hr: then in 2

or more hr

failure to have progress which mean delivery is indicated

Under supervision of physician:

Undersupervioin of doctor:

Perform Aminotomy if the membrane is

intact

Augment uterine contraction by oxytocin

in absence of contraction

Perform vaginal examination Q2 hr

If no progress after 6 hr of augmentation

, LSCS is indicated14األول، كانون30

APPLICATION OF PARTOGRAM

PARTOGRAM IN FIRST STAGE

OF LABOUR Star partogram for every woman in active phase of labour.

Record fetal condition include:

Assess fetal heart Q 30 mint.

Use the following keys in documentation:

I= intact membrane.

C= clear

B= blood staining

M= meconium

Moulding:

0= bon are normally separated.

+ = bon touching each other.

++ = bone overlapping but easily separated.

+++ = bone overlapping but can not separated.

PARTOGRAM IN FIRST STAGE OF

LABOUR

BP= 2 hr

Puls=30 minutes

Temp= 2 hr

Check and record all rein passed for albumin

Drug administration include oxytocin

IV fluid.

Record progress of labour:

Cx dilatation = Q2-4 hr

Uterine contraction if is week, moderate or strong

It should to be assessed about frequency and duration.

14األول، كانون30

USE OF OXYTOCIN:

The midwife will obtain the physician order before

initiating and oxytocin infusion:

1- perform vaginal examination.

2- commence oxytocin via dropper machine

3- follow the following standard of oxytocin initiation.

6- add 5 unit to 500 ml R/l

7- increase the drip rate according to IOL protocol at 30

minutes interval until contraction lasting until

contraction lasting for 40- 45 sec. and occurring 3-4/10

minute.

8- the license maximum dose is 20 milliunits per

minutes i.e. 24 dpm ( 72ml/hr)

USE OF OXYTOCIN

Keep woman under continues fetal monitoring.

Reduce oxytocin if good contractions have been

established to prevent hyper stimulation

Reassess progress by vaginal examination q/2 hr

Discontinue oxytocin in case of:

1- hypertonic uterine contraction.

2- Prolong fetal deceleration

3- Persistent fetal bradycardia.

4- Document .