management of first stage of labour

1. Management of first stage of
labour
Prepared by:
Nirsuba Gurung
Assistant Lecturer
MSON

2. Nursing care of women in first
stage of labour
 General :
◦ Clean and safe environment
◦ Use of aseptic technique
◦ Trimming of vaginal hair
◦ Constant observation
◦ Communication/emotional support

3. Position

4.  Bending in back ,Sitting in low chair or
bed leaning forward –help in
engagement
 Upright and walking helps in fetal
descent
 Lateral facilitate kidney function and
promote blood circulation to fetus

5. Diet
 In the latent phase of labour allow diet as
desired and encourage oral
hydration(Uterine muscle contraction
requires glucose and, if depleted, muscle
inertia may occur. Eating and drinking in
early labour has not been shown to
significantly affect labour progress, or cause
adverse maternal or infant )
 Allow a light, low fat, low roughage diet in
labour for women at low risk for
anaesthesia(Hunger and thirst can lead to
ketonuria, which may increase the length of

6.  • Women at risk for having a general
anaesthetic should have sips of clear
fluid only.
 Consider administration of
intravenous fluids for:
- Women at risk of dehydration
- Fasting women

7. Bladder
 Encourage women to pass urine every
two hourly
 If women is not able to pass urine for
six hour and bladder is found full as
suprapubic bulging ,sterile catheter
should insert to passed the urine from
bladder

8. Bowel
 Enema should not be given at the end
of the first stage of labour
 Emptying the rectum prevents soiling
of the perineum in second stage of
labour

9. Rest and sleep
 Mild sedation and analgesic
 Ensure adequate sleep

10. Pain management
 Position
 Ambulation
 Small feeding
 Back massage
 Breathing technique
 Warm bath and shower
 buscopan, morphine

11. Provide comfort and
assistance
 Assist in daily care
 Praise and reassure her
 Give detail of progress of labour

12. Teaching bearing down or
pushing effort

13. Medication
 Epidocin –for cervical dilation and
effacement

14. Infection control measures

15. Proper recording

16. To note progress of labour
Progressive descent of fetal head as measured by one-fifth examination

18. What is a partogram
(partograph) ?

19. Definition
The partogram
Is a graph used in labour to
monitor the parameters of
progress of labour, maternal
and fetal wellbeing, and
treatment administration

21. PRACTICAL VALUE OF USING THE
PARTOGRAM
 Offers an objective basis for
overtime monitoring the progress of
labour, maternal and fetal wellbeing.
 Enables early detection of
abnormalities of labour
 Prevention of obstructed labour
and ruptured uterus.

22. PRACTICAL VALUE OF PARTOGRAM cont
 Complications of obstructed labour
and ruptured uterus contribute up to
30% of maternal deaths in some
areas.
 Proper use of partogram has proved
so useful in reduction of both
maternal and perinatal mortalities and

23. Advantage
1. A single sheet of paper can provide
details of necessary information at
a glance
2. No need to record labour event
repeatedly
3. Gives clear picture of normality and
abnormality in loabour
4. It can predict deviation from duration
of labour ,so appropriate stepscould
betaken in time

24. 5. It facilitate handover procedure of
staff
6. Save working time of staff against
writing labour notes in long hand
7. Educational value for all staff

25. RECOMMENDATIONS ON THE USE OF
PARTOGRAM
Based on the evidence-based reports on
its effectiveness in monitoring of labour.
WHO
Recommends its use in all labour wards
and for all women (WHO 1994)

26. PRINCIPLES USED TO DESIGN THE PARTOGRAM
The partogram depends on the principles
that;
1. The latent phase should not last longer
than 8 hours
2. The latent phase ends and active phase
starts when the cervix is 3cm (4cm is
sometimes used)
3. During active phase – the cervix should
dilate at not less than 1 cm per hour

27. PRINCIPLES cont
4. A lag time of 4 hours is usually
acceptable the slowing of labour and
the need to intervene; this is the
distance between alert line and the
action line.

28. PRINCIPLES OF USING THE PARTOGRAM
1. Basic health facilities
 Used to monitor labour which is expected to be
normal.
 Those with risk factors should already have been
referred.
 Referral is decided when the progress line of
the cervical dilatation deviates to the right of an
alert line.
2. Health facilities with comprehensive EmOC.
 Used to monitor both high and low risk labour

29. PROTOCOL FOR LABOUR
MANAGEMENT WITH THE WHO
PARTOGRAM

30. EXCLUSIONS
Don’t complete the partogram in case
of:
 Prematurity (<34/40)
 Cervical dilatation 9 -10 cm on
admission
 Elective CS

31.  Fetal distress
 Severe pre-eclampsia
 Diagnosed CPD
 Multiple pregnancy
 Malpresentation


32. STARTING THE PARTOGRAM
1. Latent phase
◦ Contractions at least 2 in 10, lasting ≥ 20 sec
2. Active phase
◦ Contractions at least 1 in 10, lasting ≥ 20 sec
3. SRM but no contractions
◦ When oxytocin is started or when labour
commences
4. Inductions
◦ At ARM ± oxytocin
◦ When induction is medical start when labour
commences (see 1 and 2) or membranes rapture.

33. DESIRED UTERINE CONTRACTIONS
 The desired rates of uterine
contractions in labour = 4 - 5 in 10
minute, each lasting 40-50 seconds.
 It may be maintained at that rate
throughout 2nd and 3rd stage of labour

34. TIMING OBSERVATIONS IN LATENT PHASE AND
ACTIVE PHASE UP TO ACTION LINE
Parameter
Ideal
in both
phases
(hrs)
Minimum acceptable
Latent
phase
Active
phase
Vaginal examination 4 8 4
Descent of head 4 8 4
Contractions ½ 4 2
Fetal heart beats ½ 4 1
Temperature, PR, BP, urine 4 4 4

35. TIMING OBSERVATIONS IN LATENT
PHASE AND ACTIVE PHASE
Vaginal examination may be
carried out more frequently in
advanced first stage 7+cm or if
problems develop

36. Part 1 : Fetal condition
 this part of the graph is used to monitor and
assess fetal condition
 1 - Fetal heart rate
 2 - membranes and liquor
 3 - molding the fetal skull bones. Caput

37. FETAL HEART RATE
< 160 beats/min
=tachycardia
> 120 beats/min =
bradycardia
>100beats/min=sev
ere bradycardia
Decelerations?
yes/no
Relation to
contractions?
 Early
 Variable
 Late

38. membranes and liquor
 intact membranes
……………………………………….I
 ruptured membranes + clear liquor
…………………….C
 ruptured membranes + meconium- stained liquor
……..M
 ruptured membranes + blood – stained liquor
…………B
 ruptured membranes + absent
liquor…………………....A

39. Molding the fetal skull bones
 Molding is an important indication of how
adequately the pelvis can accommodate the fetal
head. Increasing molding with the head high in the
pelvis is an ominous sign of Cephalopelvic
disproportion.
 separated bones . sutures felt easily……….O
 bones just touching each other……………..+
 overlapping bones …………… …………...++
 severely overlapping bones ( notable ) ……..+++

40. Part 2 – progress of labour
. Cervical dilatation
 Descent of the fetal head
 Uterine contractions
 this section of the paragraph has as its central
feature a graph of cervical dilation against time
 it is divided into a latent phase and an active
phase

41. latent phase :
 it starts from onset of labour until the cervix
reaches 3 cm dilatation
 once 3 cm dilatation is reached , labour
enters the active phase
 lasts 8 hours or less
 each lasting < 20 seconds
 at least 2/10 min contractions

42. Active phase :
 Contractions at least 3
/ 10 min
 each lasting < 40
seconds
 The cervix should
dilate at a rate of 1 cm /
hour or faster

43. Action line ( hospital line )
 The action line is drawn 4 hour to the
right of the alert line and parallel to it
 This is the critical line at which specific
management decisions must be made
at the hospital

44. Cervical dilatation
 It is the most important information and the
surest way to assess progress of labour ,
even though other findings discovered on vaginal
examination are also important
 when progress of labour is normal and
satisfactory , plotting of cervical dilatation
remains on the alert line or to left of it
 if a woman arrives in the active phase of labour ,
recording of cervical dilatation starts on the alert
line
 when the active phase of labor begins , all
recordings are transferred and start by platting
cervical dilatation on the alert line

45.  When labor goes from latent to active phase , plotting
of the dilatation is immediately transferred from the
latent phase area to the alert line

46. Descent of the fetal head
 It should be assessed by
abdominal examination
immediately before doing a
vaginal examination, using
the rule of fifth to assess
engagement
 The rule of fifth means the
palpable fifth of the fetal
head are felt by abdominal
examination to be above the
level of symphysis pubis
 When 2/5 or less of fetal
head is felt above the level of
symphysis pubis , this means
that the head is engage , and
by vaginal examination , the
lowest part of vertex has
passed or is at the level of
ischial spines

47. Assessing descent of the fetal head by
vaginal examination;
0 station is at the level of the ischial spine
(Sp).

48. Uterine contractions
 Observations of the contractions are made every
hour in the latent phase and every half-hour in the
active phase
 frequency how often are they felt ?
 Assessed by number of contractions in a 10
minutes period
 duration how long do they last ?
Measured in seconds from the time the contraction
is first felt abdominally , to the time the contraction
phases off
 Each square represents one contraction

49. Palpate number of contraction in
ten minutes and duration of each
contraction in seconds
 Less than 20 seconds:
 Between 20 and 40 seconds:
 More than 40 seconds:

50. Part 3: maternal condition
Name / Age /Gestation
Medical / Obstetrical issues
Assess maternal condition regularly by monitoring :
 drugs , IV fluids , and oxytocin , if labour is
augmented
 pulse , blood pressure, Temperature, Urine volume
, analysis for protein and acetone