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