Maternal Care addresses all the common and important problems that occur during pregnancy, labour, delivery and the puerperium. It covers: the antenatal and postnatal care of healthy women with normal pregnancies, monitoring and managing the progress of labour, specific medical problems during pregnancy, labour and the puerperium, family planning, regionalised perinatal care

1. 8
The first stage
of labour:
Monitoring and
management
Before you begin this unit, please take the THE DIAGNOSIS
corresponding test at the end of the book to
assess your knowledge of the subject matter. You OF LABOUR
should redo the test after you’ve worked through
the unit, to evaluate what you have learned.
8-1 When is a patient in labour?
A patient is in labour when she has both of the
Objectives following:
1. Regular uterine contractions with at least
When you have completed this unit you one contraction every ten minutes.
should be able to: 2. Cervical changes (i.e. cervical effacement
• Monitor and manage the first stage of and/or dilatation) or rupture of the
membranes.
labour.
• Evaluate accurately the progress of
labour. THE TWO PHASES OF THE
• Know the importance of the alert and FIRST STAGE OF LABOUR
action lines on the partogram.
• Recognise poor progress during the first The first stage of labour can be divided into
stage of labour. two phases:
• Systematically evaluate a patient 1. The latent phase.
to determine the cause of the poor 2. The active phase.
progress in labour.
• Manage a patient with poor progress in The first stage of labour is divided into two
labour. phases: the latent phase and the active phase.
• Recognise patients at increased risk of
prolapse of the umbilical cord.
• Manage a patient with cord prolapse.

2. THE FIRST STAGE OF LABOUR : MONITORING AND MANAGEMENT 151
8-2 What do you understand by the latent the mother, the condition of the fetus, and
phase of the first stage of labour? the contractions.
2. A careful abdominal examination.
1. The latent phase starts with the onset of
3. A careful vaginal examination.
labour and ends when the patient’s cervix
is 3 cm dilated. With primigravidas the This examination is only complete when the
cervix should also be fully effaced to findings have been charted on the partogram.
indicate that the latent phase has ended. If the findings are abnormal, a plan must be
However, in a multigravida the cervix need made regarding the further management of
not be fully effaced. the patient.
2. During the latent phase, the cervix dilates
slowly. Although no time limit need be set 8-5 When should you do a complete
for cervical dilatation, this phase does not physical examination on a patient in labour?
normally last longer than eight hours. The
time taken may vary widely. 1. On admission.
3. During the latent phase there is a 2. During the latent phase: Four hours after
progressive increase in the duration and admission or when the patient starts
the frequency of uterine contractions. to experience more painful, regular
contractions.
3. During the active phase: Four-hourly,
8-3 What do you understand by the
provided all observations indicate that
active phase of the first stage of labour?
progress is normal. If there is poor
1. This phase starts when the cervix is 3 cm progress, the next complete examination
dilated and ends when the cervix is fully will have to be done after two hours in
dilated. most instances.
2. During the active phase, more rapid
After the complete examination has been done
dilatation of the cervix occurs.
and an assessment made about the progress of
3. The cervix should dilate at a rate of at least
labour, a decision is taken on when the next
1 cm per hour.
complete examination should be done. The
NOTE The average rate of dilatation of the cervix
time of the next examination is marked on the
during the active phase is at least 1.5 cm per hour partogram with an arrow. The next complete
in multigravidas and 1.2 cm in primigravidas. examination may, if the circumstances
Therefore, the lower limit of the normal rate demand it, be done sooner (but not later) than
of cervical dilatation is 1 cm per hour. the time indicated.
The cervix should dilate at a rate of at least 1 cm 8-6 How should progress during the
first stage of labour be monitored?
per hour in the active phase of labour.
A partogram is used to monitor and record the
progress of labour.
MONITORING OF THE
8-7 What is a partogram?
FIRST STAGE OF LABOUR
A partogram is a chart on which the progress
of labour over time can be presented. You will
8-4 What do you understand by a complete notice that provision has been made on the
physical examination during labour? chart to record all the important observations
regarding the condition of the mother, the
1. The routine observations (usually done condition of the fetus, and the progress of
hourly or half-hourly) of the condition of labour.

3. 152 MATERNAL CARE
Figure 8-1: An example of a partogram

4. THE FIRST STAGE OF LABOUR : MONITORING AND MANAGEMENT 153
An example of a partogram is shown in MANAGEMENT OF A
figure 8-1.
PATIENT IN THE LATENT
8-8 What is the first oblique line PHASE OF THE FIRST
on the partogram called?
STAGE OF LABOUR
The alert line. It represents a rate of cervical
dilatation of 1 cm per hour. The latent phase of labour should not last
longer than eight hours.
8-9 What is the importance of the alert line?
The alert line represents the minimum progress 8-12 What is the initial management of
in cervical dilatation which is acceptable during a patient in the latent phase of labour?
the active phase of the first stage of labour. When a patient is admitted in early labour,
and on examination everything is found to be
8-10 What is the second oblique normal, only routine observations are done. The
line on the partogram called? next complete examination is done four hours
This line is called the action line. later, or sooner if the patient starts to experience
more regular and painful contractions. The
patient should eat and drink normally, and
8-11 What is the importance
should be encouraged to walk around. She need
of the action line?
not be admitted to the labour ward.
1. Any patient whose graph of the cervical
dilatation falls on or crosses the action 8-13 What should you do at the
line must have a complete examination second complete examination?
by the doctor. Her further management
must be under the doctor’s supervision At this time, the following must be assessed.
and direction. If a patient is not already 1. The contractions: If the contractions have
in hospital, she will need to be transferred stopped the patient is no longer in labour,
into a hospital where there are facilities and if the maternal and fetal conditions are
for instrumental delivery and Caesarean normal, she may be discharged. However,
section. if the contractions have remained regular,
2. The progress of labour is very slow when then you must assess the cervix.
the graph of cervical dilatation crosses 2. The cervix:
or falls on this line. When this occurs, • If the effacement and dilatation of
action must be taken in order to hasten the the cervix have remained unchanged,
delivery of the infant. the patient is probably not in true
labour. If she is experiencing painful
contractions, she should be given an
If the cervical dilatation falls on, or crosses, the
analgesic, e.g. pethidine 100 mg and
action line of the partogram, a doctor must be
promethazine (Phenegan) 25 mg
called to assess the patient. or hydroxyzine (Aterax) 100 mg by
intramuscular injection and, provided
that all other observations are normal,
the next complete physical examination
is planned for four hours later.
• If there has been progress in effacement
and/or dilatation of the cervix, the
patient is in labour and, provided that

5. 154 MATERNAL CARE
all other observations are normal, the 8-15 How do you manage a patient
next complete examination is planned who is in normal labour?
for four hours later. If the cervix is 3 cm
When the condition of the mother and the
or more dilated, the patient has now
condition of the fetus are normal, and there
progressed to the active phase of the
are no signs of cephalopelvic disproportion,
first stage of labour.
the next complete examination must be done
four hours later. The cervical dilatation, in
8-14 What should you do if a patient has centimetres, is recorded on the alert line of
not progressed to the active phase of the partogram.
labour within eight hours after admission?
1. The contractions may have stopped, in 8-16 What represents normal progress
which case the patient is not in labour. If during the active phase of the first
the membranes have not ruptured and if stage of labour on the partogram?
there is no indication to induce labour, the
1. The recording of cervical dilatation at the
patient should be discharged.
various vaginal examinations lie on or to
2. The patient may still be having regular
the left of the alert line. In other words
contractions. In this case, further
cervical dilatation is at least 1 cm per hour.
management depends upon the state of
2. There is also progressive descent of the
the cervix:
fetal head into the pelvis. This is detected
• If there has been no progress in
by assessing the amount of the fetal head
effacement and/or dilatation of the
above the brim of the pelvis on abdominal
cervix, the patient is probably not in
examination. Descent of the head during
labour. The responsible doctor should
the active phase of the first stage of labour
see and assess this patient, in order
may occur late, especially in multigravidas.
to decide whether labour should be
induced.
• If there has been progressive effacement With normal progress during the active phase
and/or dilatation of the cervix, the of the first stage of labour, the recording of the
patient is in labour. If the progress dilatation of the cervix will lie on or to the left
has been slow during the latent phase, of the alert line on the partogram. In addition,
it may be necessary to rupture the
there will be progressively less of the fetal head
membranes or commence an oxytocin
infusion if she is HIV positive as
palpable above the pelvic brim.
described in 8-35.
8-17 Why is it necessary to evaluate both
cervical dilatation and the descent of
MANAGEMENT OF A the head in order to determine whether
PATIENT IN THE ACTIVE there has been progress in the active
phase of the first stage of labour?
PHASE OF THE FIRST
1. Cervical dilatation without associated
STAGE OF LABOUR descent of the head does not necessarily
indicate progress in labour.
When a patient is admitted in the active 2. Cervical dilatation may occur when there
phase of labour, she will probably be in are good contractions, in association with
normal labour. However, the possibility increasing caput succedaneum formation
of cephalopelvic disproportion must be and moulding of the fetal skull, while
considered, especially if the patient is the amount of fetal head palpable above
unbooked. the brim of the pelvis remains the same.

6. THE FIRST STAGE OF LABOUR : MONITORING AND MANAGEMENT 155
In these circumstances no real progress infection if the membranes are intact. The
has occurred, because the head is not next complete examination should be done
descending into the pelvis. after two hours when the management
3. The station of the presenting part of the should be as follows:
head in relation to the spine, as felt on • With normal progress do not rupture
vaginal examination, can also improve the membranes.
without further descent of the head and • With poor progress the membranes
without real progress having occurred. should be ruptured and the next
This is because of increasing caput examination performed four hours later.
succedaneum and moulding. 2. A patient who is HIV negative and in
labour with a vertex presentation may have
her membranes ruptured with safety if:
Descent of the head is assessed on abdominal • She is in the active phase of labour.
and not on vaginal examination. • The fetal head is 3/5 or less palpable
above the brim of the pelvis.
8-18 What circumstances will make it 3. After rupturing the membranes, carefully
necessary to do vaginal examinations feel around the fetal head to rule out the
more frequently than four- hourly in the possibility of a cord prolapse.
active phase of the first stage of labour? If the fetal head is 4/5 or more above the pelvic
1. If cephalopelvic disproportion is brim, and the cervix is 6 cm or more dilated,
suspected, the next vaginal examination it is safer to carefully rupture the membranes
must be done two hours later. than to allow them to rupture spontaneously.
2. If a complete examination has revealed This will reduce the risk of cord prolapse.
poor progress of labour, without the
presence of cephalopelvic disproportion, 8-20 What should you do if a
the next complete examination should patient ruptures her membranes
also be done two hours later, to assess spontaneously during labour?
the effectiveness of the measures taken to
1. If the fetal head is 4/5 or more palpable
correct the poor progress.
above the pelvic inlet, or if there is a
3. If a patient’s cervix is more than 6 cm
breech presentation, the patient is at high
dilated, the next complete examination
risk for a cord prolapse. A sterile vaginal
would normally be done when the cervix
examination must, therefore, be done to
is expected to be fully dilated. However,
rule out this possibility.
the examination may need to be done
2. If the fetal head is 3/5 or less palpable
earlier if there are signs that the cervix is
above the pelvic inlet, it is highly
already fully dilated.
unlikely that a cord prolapse might
happen. However, the fetal heart must be
8-19 When should you rupture monitored to rule out the possibility of
the patient’s membranes? fetal distress due to cord compression.
1. It is possible to reduce the risk of
transferring HIV from a mother to her 8-21 What are the advantages of
infant by keeping the duration of ruptured rupturing a patient’s membranes?
membranes as short as possible. Do not
1. Rupture of the membranes acts as a
rupture the membranes of patients whose
stimulus to labour, so that there is often
HIV status is positive or unknown if they
better progress.
are still intact at the start of the active
2. Meconium staining of the liquor will be
phase of labour. The following vaginal
detected.
examination will not increase the risk of

7. 156 MATERNAL CARE
3. If the cord prolapses when the membranes Step 2
are ruptured, this can be detected
The cause of the poor progress of labour must
immediately, and the appropriate
be determined by examining the patient using
management can therefore be started
the ‘Rule of the four Ps’. The four Ps are:
without delay.
1. The patient.
It is important to make sure that the patient is
2. The powers.
in the active phase of the first stage of labour
3. The passenger.
before rupturing the membranes.
4. The passage.
POOR PROGRESS IN THE The cause of poor progress of the active phase
of the first stage of labour is determined by
ACTIVE PHASE OF THE assessing the four Ps.
FIRST STAGE OF LABOUR
8-25 How may problems with the patient
8-22 How would you recognise poor cause poor progress of labour and how
progress in the active phase of labour? should these problems be managed?
Poor progress is present when the graph Any of the following factors may interfere with
showing cervical dilatation crosses the alert the normal progress of labour.
line. In other words, cervical dilatation in the 1. The patient needs pain relief. Patients who
active phase of the first stage of labour is less experience very painful contractions,
than 1 cm per hour. especially if associated with excessive
anxiety, may have poor progress of labour
8-23 What should you do if the as a result. Pain relief, emotional support.
graph showing cervical dilatation and reassurance can be of great value in
crosses the alert line? speeding up the progress of labour.
2. The patient has a full bladder. A full bladder
A systematic assessment of the patient must
not only causes mechanical obstruction,
be made in order to determine the cause of the
but also depresses uterine muscle activity.
poor progress in labour.
A patient must be encouraged to pass urine
frequently but may need catheterisation,
8-24 How should you systematically and sometimes an indwelling catheter,
examine a patient with poor progress in until after delivery.
the active phase of the first stage of labour? 3. The patient is dehydrated. Dehydration
Step 1 is recognised by the fact that the patient
is thirsty, has a dry mouth, passes small
Two questions must be asked: amounts of concentrated urine and may
1. Is the patient in the active phase of the first have ketonuria. Dehydration must be
stage of labour? corrected as it may be the cause of the
2. Are the membranes ruptured? poor progress. With good care during
labour the patient will not become
If the answer to both questions is ‘yes’, proceed dehydrated, because she can eat and drink
to step 2. during the latent phase of labour and
take oral fluids during the active phase of
labour. If there is poor progress during
the active phase of labour, an intravenous
infusion must be started.

8. THE FIRST STAGE OF LABOUR : MONITORING AND MANAGEMENT 157
8-26 How may problems with the powers 2. The presenting part of the fetus is abnormal.
cause poor progress of labour? With a breech presentation, the patient
must be assessed by a doctor to decide
The powers (i.e. the uterine contractions)
whether a vaginal delivery will be possible
may either be inadequate or ineffective. Any
or whether a Caesarean section is required.
patient in whom labour progresses normally
If the presentation is cephalic, the part
has both adequate and effective contractions,
of the head which is presenting must be
irrespective of the duration and frequency of
determined on vaginal examination.
contractions.
1. Inadequate uterine contractions. Inadequate NOTE Fetuses who present by the breech and
uterine contractions can be the cause of who comply with the criteria for vaginal delivery,
poor progress of labour. Such contractions: are only delivered vaginally if there is normal
progress during the first stage of labour.
• Last less than 40 seconds, and/or
• There are fewer than two contractions 3. The fetus is large. A large fetus (i.e. estimated
per ten minutes. as 4 kg or more), with signs of cephalopelvic
2. Ineffective uterine contractions. The disproportion (i.e. 2+ or 3+ moulding) must
uterine contractions may be adequate but be delivered by Caesarean section.
not effective, as poor progress can occur 4. There are two or more fetuses. Poor progress
even in the presence of apparently good, may also occur in a patient with a multiple
painful contractions (i.e. two or more pregnancy, usually due to inadequate
in ten minutes with each contraction uterine contractions.
lasting 40 seconds or longer), without 5. The fetal head has not engaged. The number
disproportion being present (i.e. no of fifths of the head palpable above the
moulding of the fetal skull). The problem pelvis must always be assessed:
of ineffective contractions occurs only in • Engagement has occurred only when
primigravidas. Any patient whose labour 2/5 or less of the head is palpable above
progresses normally must have effective the brim of the pelvis. In this case the
uterine contractions. problem of cephalopelvic disproportion
at the pelvic inlet is excluded.
NOTE Dysfunctional uterine contractions • With 3/5 or more of the head
are diagnosed when the uterine above the pelvic brim, plus 2+ or
contractions appear to be ineffective.
3+ moulding, a Caesarean section
is indicated for cephalopelvic
8-27 How may problems with the disproportion at the pelvic inlet.
passenger cause poor progress
of labour and how should these
problems be managed? An abdominal examination, to assess the lie and
the presenting part of the fetus, as well as the
The cause of poor progress of labour may
amount of fetal head palpable above the pelvic
be due to a problem with the passenger (i.e.
the fetus). These problems can be identified brim, must always be done before performing a
by performing an abdominal examination vaginal examination.
followed by a vaginal examination.
On vaginal examination the following problems
On abdominal examination the following
causing poor progress may be identified.
problems causing poor progress may be
identified. 1. The presenting part is abnormal. Vertex (i.e.
occipital) presentation of the fetal head
1. The lie of the fetus is abnormal. If the lie of
is the most favourable presentation for
the fetus is transverse the patient will need
the normal progress of labour. With any
a Caesarean section.

9. 158 MATERNAL CARE
other presentation of the fetal head in early
Improvement in the station of the presenting
labour (e.g. brow), there is no urgency
part of the fetal head, in relation to the ischial
to interfere, as the presentation may
become more favourable when the patient spines, is not a reliable method of assessing
is in established labour. However, in progress in the first stage of labour.
established labour, if moulding is present
in any presentation other than a vertex, a 8-28 How may problems with the passage
Caesarean section will have to be done. cause poor progress in labour and how
2. The position of the fetal head in relation to should these problems be managed?
the pelvis is abnormal. An occipito-anterior
(right or left) is the most favourable position The following problems with the passage may
for normal progress of labour. Positions cause poor progress in labour:
other than this (i.e. left or right occipito- 1. The membranes are still intact. Should the
posterior) will progress more slowly. Labour membranes still be intact, they must be
can be allowed to continue provided there ruptured and the patient reassessed after
is progress, and no progressive evidence of four hours before poor progress can be
disproportion. The patient will also need diagnosed.
adequate pain relief and an intravenous 2. The pelvis is small. A pelvic assessment
infusion to prevent dehydration. which shows a small pelvis, together with
3. Cephalopelvic disproportion is present. 2+ or 3+ moulding of the fetal skull means
• The head is examined for the amount that there is cephalopelvic disproportion,
of caput succedaneum present. and is an indication for Caesarean section.
Caput is not an accurate indicator of
disproportion as it can also be present 8-29 What are the two important
in the absence of disproportion, for causes of poor progress of labour?
example, in a patient who bears down
before the cervix is fully dilated. 1. Cephalopelvic disproportion. This is a
• The sutures are examined for dangerous condition if it is not recognised
moulding, which is the best indication early and not correctly managed.
of the presence of disproportion. 2. Inadequate uterine action. This is a
3+ of moulding is a definite sign of common cause of poor progress in
disproportion. In a vertex presentation, primigravidas. It can be easily corrected
the sagittal and lambdoid (occipito- with an oxytocin infusion.
parietal) sutures are examined. The
worst degree of moulding noted in any 8-30 What must be done after the
of the sutures is that which is recorded patient has been systematically
on the partogram as the amount of evaluated to determine the cause
moulding present. of the poor progress of labour?
• Improvement in the station of the
1. The nurse attending to the patient must
presenting part (i.e. the level of the
inform the doctor about the clinical
presenting part relative to the ischial
findings. Together they must decide on the
spines) is not a reliable method of
cause of the slow progress and what action
assessing progress in labour, compared
must be taken to correct this problem.
to descent and engagement of the fetal
2. A decision must also be made as to when
head as determined on abdominal
the next complete examination of the
examination.
patient will be done. Usually this will
be in two hours, but sometimes in four
hours. This consultation may be done by

10. THE FIRST STAGE OF LABOUR : MONITORING AND MANAGEMENT 159
telephone and it is not necessary for the Cephalopelvic disproportion may already be
doctor to see the patient at this stage. present when the patient is admitted.
3. If labour progresses satisfactorily following
the action taken, labour is allowed to
continue. However, if poor progress
A high fetal head (3/5 or more above the brim)
continues, or if the action line has been on abdominal examination, with 3+ moulding
reached or crossed, the patient must be on vaginal examination, indicates cephalopelvic
examined by the responsible doctor who disproportion.
must then decide on further management.
The following are examples of causes of 8-32 Does a patient’s cervix always dilate
poor progress in labour together with their at a rate slower than 1 cm per hour if
management: cephalopelvic disproportion is present?
When there is cephalopelvic disproportion, the
Cause Action
cervix usually dilates at a rate slower than 1 cm
Cephalopelvic Caesarean section per hour, but the cervix may dilate normally,
disproportion even though the fetal head remains high
An anxious patient Reassurance and due to cephalopelvic disproportion. This is a
unable to cope analgesia dangerous situation as it may be incorrectly
with painful concluded that labour is progressing normally.
contractions
Inadequate uterine An oxytocin infusion 8-33 What features would make
contractions you diagnose cephalopelvic
disproportion when the fetal head
Occipito-posterior Analgesia and an
is not descending into the pelvis?
position intravenous infusion
Ineffective uterine Analgesia followed Often, especially in multiparous patients, the
contractions by an oxytocin head does not descend into the pelvis until late
infusion in the active phase of the first stage of labour.
However, when the head does not descend into
the pelvis, you should look for possible causes:
CEPHALOPELVIC 1. A malpresentation, e.g. a face or a brow
presentation.
DISPROPORTION 2. Moulding (i.e. 2+ or 3+).
If either of these are present, there is
8-31 How will you know when poor progress cephalopelvic disproportion, and a Caesarean
is due to cephalopelvic disproportion? section should be done.
This can be recognised by the following On the other hand, labour can be allowed to
findings: continue if:
1. On abdominal examination, the fetal head • There is no malpresentation.
is not engaged in the pelvis. Remember, this • There is no more than 1+ moulding.
is diagnosed by finding 3/5 or more of the • The maternal and fetal conditions are
head palpable above the brim of the pelvis. good.
2. On vaginal examination, there is severe
The next complete physical examination must
moulding (i.e. 3+) of the fetal skull. Severe
be repeated within two hours.
moulding must always be regarded as
serious, as it confirms that cephalopelvic
disproportion is present.

11. 160 MATERNAL CARE
8-34 What should you do if you time to refer her to hospital before the
decide that the poor progress is due action line is crossed.
to cephalopelvic disproportion? 6. Patients who complain of painful
contractions need analgesia before
1. Once the diagnosis of cephalopelvic
oxytocin is started.
disproportion has been made, the infant
must be delivered as soon as possible. This
means that a Caesarean section will have 8-36 What are the contraindications to
to be done. the use of oxytocin in order to strengthen
2. While the preparations for Caesarean contractions in the first stage of labour?
section are being made, it is of value to 1. Evidence of cephalopelvic disproportion.
both the mother and fetus to suppress Oxytocin must, therefore, not be given if
uterine contractions. This is done by there is already moulding (i.e. 2+ or 3+)
giving three nifedipine (Adalat) 10 mg present.
capsules by mouth (a total of 30 mg) 2. Any patient with a scar of the uterus, e.g.
or give 250 μg (0.5 ml) salbutamol from a previous Caesarean section.
(Ventolin) slowly intravenously, the 0.5 ml 3. Any patient with a fetus in whom the
salbutamol is diluted with 9.5 ml sterile presenting part is not a vertex.
water and given slowly intravenously over 4. Multiparas with poor progress during the
five minutes, provided that there are no active phase of labour of the first stage of
contraindications. labour.
5. Grande multiparity during the latent or
active phase of the first stage of labour.
INADEQUATE 6. When there is fetal distress.
UTERINE ACTION 7. Patients with poor kidney function or
heart valve disease.
8-35 What should you do if you decide that NOTE Oxytocin has an antidiuretic effect, so
the poor progress is due to inadequate there is a danger of the patient developing
or ineffective uterine contractions? pulmonary oedema. Hyperstimulation
must be avoided if an oxytocin infusion
1. Provided there are no contraindications, is used. Five or more contractions in ten
the patient must be given an oxytocin minutes, or contractions lasting longer than
infusion in order to strengthen the 60 seconds, indicate hyperstimulation.
contractions.
2. The patient’s progress must be reassessed 8-37 How must oxytocin be
after two hours. administered when it is used
3. If cervical dilatation has proceeded at the during the first stage of labour?
rate of 1 cm per hour or more, progress
The following is a good method:
has been satisfactory and labour is
allowed to continue. 1. Begin with one unit of oxytocin in one
4. If cervical dilatation has been slower litre of Plasmolyte B, Ringer’s lactate or
than 1 cm per hour once the patient has rehydration fluid.
adequate uterine contractions, the patient 2. Use a giving set which delivers 20 drops
must be reassessed by the responsible per ml.
doctor. Cephalopelvic disproportion may 3. Start with 15 drops per minute and
be present. increase the rate at intervals of 30 minutes
5. If at this stage the patient is still in a to 30 drops, and then to 60 drops per
peripheral clinic, there should be enough minute, until the patient gets at least three

12. THE FIRST STAGE OF LABOUR : MONITORING AND MANAGEMENT 161
contractions lasting at least 40 seconds and the availability of transport. In general,
every ten minutes. arrangements must be made so that the patient
4. If there are still inadequate contractions will be under the care of the responsible
with one unit of oxytocin per litre at doctor by the time the graph depicting cervical
60 drops per minute, a new litre of dilatation crosses the action line.
intravenous fluid containing eight units
per litre is started at a rate of 15 drops per 8-39 What arrangements should
minute. The rate is increased in the same you make to ensure the patient’s
way as above until 30 drops per minute safety during transfer to hospital, if
are being given. This is the maximum there is poor progress of labour?
amount of oxytocin which should be used
during the first stage of labour. 1. An intravenous infusion must be started.
2. The patient must lie on her side while
NOTE The starting dose of oxytocin is ONE being transferred to hospital.
milliunit (mUnit) per minute and the maximum 3. A nurse should accompany the patient,
dose 12 mU per minute which is line with unless there is a trained ambulance crew.
international dose recommendations. 4. If cephalopelvic disproportion is the
cause of the poor progress of labour, the
3-38 What are the effects of a long labour? contractions must be stopped. To stop
contractions, three nifedipine (Adalat)
Both the mother and fetus may be affected.
10 mg capsules (total of 30 mg) can be
1. The mother. A patient in whom the taken orally or 250 μg (0.5 ml) salbutamol
progress of labour is slow is more likely to (Ventolin) slowly intravenously, the 0.5 ml
become anxious and to be dehydrated. If salbutamol is diluted with 9.5 ml sterile
the poor progress is due to cephalopelvic water and given slowly intravenously over
disproportion (i.e. obstructed labour), and five minutes. If indicated, the same dose
labour is allowed to continue, then there is of salbutamol may be repeated after 30
the danger of the mother developing any or minutes. Both drugs should only be used if
all of the following: there are no contraindications.
• A ruptured uterus.
• A vesicovaginal fistula.
• A rectovaginal fistula. PROLAPSE OF THE
2. The fetus. The stress of a long labour UMBILICAL CORD
results in progressive fetal hypoxia, which
causes fetal distress and eventually in intra-
uterine death. 8-40 Why is prolapse of the umbilical
cord a serious complication?
THE REFERRAL OF Because the flow of blood between the fetus
and placenta is severely reduced and may
PATIENTS WITH POOR stop completely, causing fetal distress and
PROGRESS DURING THE possibly fetal death.
ACTIVE PHASE OF THE 8-41 What is the difference between a
FIRST STAGE OF LABOUR cord presentation and a cord prolapse?
1. With a cord presentation, the umbilical
The guidelines for referral will vary cord lies in front of the presenting part
from region to region, depending on the with the membranes still intact.
distances between clinics and hospitals,

13. 162 MATERNAL CARE
2. With a cord prolapse, the cord lies in front 1. If the cervix is 9 cm or more dilated and
of the presenting part and the membranes the fetal head is on the perineum, the
have ruptured. The loose cord may lie patient must bear down and the infant
between the presenting part of the fetus must be delivered as soon as possible.
and the cervix, in the vagina or outside 2. Otherwise the patient must be managed as
the vagina. follows:
• Replace the cord carefully into the
8-42 How should a cord vagina.
presentation be managed? • Give the patient mask oxygen and give
250 μg (0.5 ml) salbutamol (Ventolin)
If the cord is felt between the membranes and slowly intravenously, the 0.5 ml
the presenting part of the fetus, if the fetus salbutamol is diluted with 9.5 ml sterile
is alive and is viable and if the patient is in water and given slowly intravenously
labour, a Caesarean section must be done. over five minutes to stop labour.
This will prevent a cord prolapse when the • Put a Foley catheter into the patient’s
membranes rupture. bladder and fill the bladder with 500 ml
saline.
8-43 Which patients are at risk • If the full bladder does not lift the
of a prolapsed cord? presenting part off the prolapsed cord,
1. Patients in labour with an abnormal the presenting part must be pushed up
lie (e.g. transverse lie) or an abnormal by an assistant’s hand in the vagina, and
presentation (e.g. breech presentation). by turning the patient into the knee-
2. Patients who rupture their membranes chest position.
when the fetal head is still not engaged (i.e.
4/5 or more above the pelvic brim, e.g. in a 8-46 Why should the cord carefully
grande multipara). be replaced in the vagina?
3. Patients with polyhydramnios where the The cord must not be allowed to become
increased volume of liquor may wash the cold or dry as this will produce vasospasm
cord out of the uterus. and, thereby, further reduce the blood flow
4. Patients in preterm labour where the through the cord.
presenting part is small relative to the
pelvis when the membranes rupture.
8-47 Why are oxygen and salbutamol
5. Patients with a multiple pregnancy,
given to a patient with a prolapsed cord?
where preterm labour, abnormal lie and
polyhydramnios are common. 1. Giving oxygen to the patient may improve
the oxygen supply to the fetus.
8-44 What should be done when a 2. Stopping uterine contractions will reduce
patient, who is at high risk of prolapse the pressure of the presenting part on the
of the cord, ruptures her membranes? prolapsed cord.
A sterile vaginal examination must
8-48 Should a Caesarean section be done
immediately be done to determine whether
on all women with a prolapsed cord if the
the cord has prolapsed.
infant cannot be rapidly delivered vaginally?
8-45 What is the management No. A Caesarean section is only done if the
of a prolapsed cord? infant is potentially viable (28 weeks or more)
and the cord is still pulsating. Otherwise the
A vaginal examination must be done infant should be delivered vaginally as the
immediately. chances of survival are then extremely small.

14. THE FIRST STAGE OF LABOUR : MONITORING AND MANAGEMENT 163
CASE STUDY 1 CASE STUDY 2
A primigravida patient at term, who is HIV A patient at term is admitted in labour with a
negative, is admitted to the labour ward. She has vertex presentation. The cervix is already 4 cm
one contraction, lasting 30 seconds, every ten dilated. The cervical dilatation is recorded on
minutes. The cervix is 1 cm dilated and 1.5 cm the alert line. At the next vaginal examination
long. The maternal and fetal observations are the cervix has dilated to 8 cm. Caput can be
normal. After four hours she is having two palpated over the fetal skull. It is decided that
contractions, each lasting 40 seconds, every ten the progress is favourable and that the next
minutes. On vaginal examination the cervix is vaginal examination should be done after a
now 2 cm dilated and 0.5 cm long with bulging further four hours.
membranes. The diagnosis of poor progress of
labour due to poor uterine contractions is made 1. On admission, should the
and an oxytocin infusion is started to improve woman’s cervical dilatation have
contractions. been entered on the alert line?
Yes. The patient is in the active phase of the
1. Do you agree with the diagnosis
first stage of labour as her cervix is 4 cm
of poor progress of labour?
dilated. Therefore, the cervical dilatation
The diagnosis is incorrect as the patient is still must be plotted on the alert line. The future
in the latent phase of the first stage of labour. observations should fall on or to the left of
Poor progress of labour can only be diagnosed the alert line.
in the active phase of labour.
2. Do the findings of the second
2. Why can it be said with certainty that the examination indicate normal
patient is in the latent phase of labour? progress of labour?
• The cervix is still less than 3 cm dilated. Not necessarily, as no information is given
• The cervix is dilating slowly. about the amount of fetal head palpable above
• The cervix is effacing. the pelvic brim. Cervical dilatation without
• The frequency of the uterine descent of the head does not always indicate
contractions is increasing. normal progress of labour.
3. What is your assessment of 3. Is normal cervical dilatation with
the patient’s management? improvement in the station of the
presenting part possible if cephalopelvic
Apart from the wrong diagnosis, oxytocin
disproportion is present?
should not be given before the membranes
have been ruptured. Yes. The uterine contractions cause an
increasing amount of caput and moulding,
4. Should the patient’s membranes have which is incorrectly interpreted as normal
been artificially ruptured when the progress of labour. In this case, caput was
second vaginal examination was done? noted during the second examination.
However, further information about any
No. If the maternal and fetal condition are moulding and the amount of fetal head
good, you should wait until the cervix is 3 cm palpable above the pelvic brim are essential
or more dilated. The membranes may also be before it can be decided whether normal
ruptured if the patient has been in the latent progress is present or not.
phase of labour for eight hours without any
progress.

15. 164 MATERNAL CARE
4. Was the correct decision made at the 3. What should be the management of
time of the second examination to repeat the patient’s poor progress of labour?
the vaginal examination after four hours?
Firstly, the patient should be reassured
No. If the cervix is 8 cm dilated, the next and given analgesia with pethidine and
examination must be done two hours later, promethazine (Phenegan) or hydroxyzine
or even sooner if there are indications that (Aterax). Then an oxytocin infusion should be
the woman’s cervix is fully dilated. If it is started to make the contractions more effective.
uncertain whether the progress of labour is
normal then the examination should also be 4. Why is reassuring the
repeated in two hours. patient so important?
Anxious patients often progress slowly
CASE STUDY 3 in labour and have painful contractions.
Emotional support during labour is a very
important part of patient care.
A primigravida patient at term is admitted in
labour. At the first examination the fetal head
5. When must the next vaginal
is 2/5 above the pelvic brim and the cervix
examination be done?
is 6 cm dilated. Three contractions in ten
minutes, each lasting 45 seconds, are palpated. The next vaginal examination should be
At the next examination four hours later, the done two hours later to determine whether
head is still 2/5 above the brim and the cervix the treatment has been effective. During the
is still 6 cm dilated. No moulding can be felt. examination it is very important to exclude
The patient is still having three contractions cephalopelvic disproportion.
in ten minutes, each lasting 45 seconds and
complains that the contractions are painful.
Because there has been no progress in spite CASE STUDY 4
of painful contractions of adequate frequency
and duration, it is decided that cephalopelvic A patient who is in labour at term has
disproportion is present and that, therefore, a progressed slowly and the alert line has been
Caesarean section must be done. crossed. During a systematic evaluation of
the patient by the midwife for poor progress
1. Do you agree that the poor of labour, a diagnosis of an occipito-posterior
progress of labour is due to position is made. As the patient is making
cephalopelvic disproportion? some progress, she decides to allow labour
No. To diagnose poor progress due to to continue. After four hours, the cervical
cephalopelvic disproportion, severe moulding dilatation falls on the action line. Although
(3+) must be present. there is still slow progress, she again decides
to allow labour to continue and to repeat the
vaginal examination in a further two hours.
2. What is most probably the reason
for the poor progress of labour?
1. Was the patient managed correctly
The patient is a primigravida with strong, when she crossed the alert line?
painful contractions and no signs of
cephalopelvic disproportion. A diagnosis of Yes. She was systematically examined and a
ineffective uterine contractions (dysfunctional diagnosis of slow progress of labour due to an
uterine contractions) can, therefore, be made occipito-posterior position was made.
with confidence.

16. THE FIRST STAGE OF LABOUR : MONITORING AND MANAGEMENT 165
2. What should be done if a long first 4. Under what conditions should the
stage of labour is expected due to doctor allow labour to progress further?
an occipito-posterior position?
An intravenous infusion must be started If there is steady progress of labour, the maternal
to ensure that the patient does not become and fetal conditions are good, and there is less than
dehydrated. In addition, adequate analgesia 3+ moulding.
must be given.
3. Was the patient correctly managed
when she reached the action line?
No. A doctor should have evaluated the
patient. Further management should have
been under his/her direction.