Management of the First Stage of Labour Lecture

8/6/2019 Management of the First Stage of Labour Lecture

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MANAGEMENT OF THEFIRST STAGE OF LABOUR

FNP LECTURE

THEME 4Lecturer : Ms Aliti Qarikau



Objectives

� At the end of this theme students would beable to :

� Discuss normal labour

� Define terminologies� Describe the management of first stage of

labour� describe events/ care of the first stage of

labour� Discuss promotion and maintenance of

aseptic technique



Introduction� Care during labour should be aimed towards achieving the

best possible physical, emotional and psychologicaloutcome for the woman and baby.

� The onset of labour is a complex physiological process andtherefore it cannot be easily defined by a single event.Although labour is a continuous process, it is convenient to

divide it into stages.

� Definitions of the stages of labour need to be clear in orderto ensure that women and the staff providing their carehave an accurate and shared understanding of the conceptsinvolved, enabling them to communicate effectively.



1- Latent Phase of Labor:

�

Uterine contractionmay be very mild,irregular

� not forceful enough tocause much pressure

on the cervix.� the cervix slowlybecomes shorter andsofter. This is knownas 'Effacement'.

� Dilation of the cervixoccurs from 0 cm to 4cm.

� frequency at thisstage is from 1-3 per 10minutes and eachcontraction lasts forless than a minute.

� The uterus maybecome firm and moreprominent with everycontraction.



� In some women, the labor pains start at the

back. This is more likely if the head of the fetusis more posteriorly placed and presses on themother's spine or ligaments.



2.Active Phase of Labor:

� uterus contractsmore frequently andthe pain ismaximum.

� Uterine contractionoccurs after every 3-5

minutes and lasts formore than a minute.

� The uterus becomeshard and moreprominent as thepain increases andsofter as the uterusrelaxes



� The pains sometimes start at the back and

radiates down to the thighs. Later on, at theend of this stage, the pains come even morefrequently and appear to run into each other inquick succession.

� The cervix dilates from 4 cm to 8 cm. Womenwhose waters have not ruptured at the onset oflabour, can experience a gush of water flowing

out of the vagina at this stage.



3.Transitional Phase of Labor:

� marks the transitionfrom the first stage oflabour to the secondstage of labour.

� The cervix dilates from8 cm to 10 cm

� At full dilatation at theend of the first stage oflabour, the cervix isabout 10 cm in diameter

� ( the maximum diameterof the fetal head is also10 cm when it is in anormal position, the

baby can be born easilythrough the cervix)



Characteristics of T/phase

� Restlessness

� Hyperventilation

� Bewilderment andsometimes anger

� Difficulty followingdirections

� Focus on self

� Irritability

� Statements like ´don·ttouch meµ

� Nausea, occasionallyvomiting

� Very warm feeling

�

Perspiration on upperlips

� Increasing rectalpressure



ADMISSION OF CLIENT IN LABOUR

� May be different foreach person

� Each client must be

cared for individuallybased on herparticular situation

� Assessing thecondition of mother

and fetus may beundertaken in a

sequential order ormay need to beperformed

simultaneously.� It is important todetermine whichstage of labour thewoman may be in

at the time ofadmission



When a woman is admitted in early labour,time can be taken to establish the nurse client

relationship by:� Making the woman

and her partner orfamily feel welcome

� Determining theirexpectations aboutthe birth (did theyattend childbirthclasses/)

� Identifying culturalvalues andpreferences related to

the birth process



Initial assessment

� A copy of the prenatal record is added to theclient·s admission record

� Clients who have not received prenatal care

will need more extensive assessment.



When a woman is admitted in active labour, ahistory is taken and an examination undertaken.

The examination includes:�temperature�pulse�Respiration�

blood pressure�Auscultation of heart and lungs�Fetal heart rate (FHR), continuous fetal monitoring-

CTG



� Contractions monitored for frequency,

duration and intensity

� state of hydration

� the urine should be tested for glucose, ketone

bodies and protein� Inspection for signs of edema of face, hands,

legs and sacrum



Examination of the abdomen:�

inspection, palpation and auscultation todetermine: the fetal lie, presentation and position,and the station of the presenting part, as well asto determine the presence of a fetal heartbeat�(The FH beat may be heard in various places on

the mother·s abdomen depending on the positionof the fetus)



VAGINAL EXAMINATION :should be performed only after cleansing of the

vulva and introitus and using an aseptic techniquewith sterile gloves and an antiseptic cream.



The following factors should be noted:

�

the consistency, effacement and dilatation of the cervix�whether the membranes are intact or rupturedand,

if ruptured, the colour of the amniotic fluid�presence of bloody show�nature and presentation of the presenting part�its relationship to the level of the ischial spines�

assessment of the bony pelvis and in particularof the pelvic outlet



CONTRACTIONS:� are assessed by

placing the fingers ofone hand on thefundus of the uterus,and using a light

pressure to keep thefingers still

� begin in the fundusand spreads down

the uterus

� Person assessing the

uterine contractionscan feel thetightening of theuterus before the

woman is aware of it



� At least 3 contractions ina row should be assessed

� The time eachcontraction begins andends (duration) and the

time lapse betweencontractions (frequency),should be noted.

� The intensity can beestimated by how easilythe uterus can be

indented during acontraction.



Mild contraction Uterus is easily indentedwith the fingertips; feels

like the tip of the nosemoderatecontraction

Uterus is more difficult toindent with the fingertips;feels similar to the chin

Strong contraction Uterus unable to beindented with fingertips;feels like the forehead



� Station is a term used to describe the descent ofthe baby into the pelvis. An imaginary line isdrawn between the ischial spines. This is the

"zero" line, and when the baby reaches this line itis considered to be in "zero station."

� When the baby is above this imaginary line it isin a minus station.

�

When the baby is below, it is in a "plus" station.� Stations are measured from -5 at the pelvic inlet

to +4 at the pelvic outlet



Nursing interventions

Focuses on continuous assessment of :� labour progress and fetal well-being

� providing maternal physical care

�

Assisting the client and her supportperson

� Providing and assisting withpharmacological comfort measures



1) Continuous assessment of labour and fetalwell-being

� The nurse personally assess labourprogress, times the contractions and

listens to the FHR at regular intervals� Records findings on the partogram

� One to one continuous support



Electronic fetal monitoring

� 2Types

- 1) intermittent auscultation(sonicaid/doppler)

2) continuous EFM (CTG)

� EFM provides a visual record of the FHR inrelation to the uterine contractions

� It allows early detection of fetal distressand abnormal uterine activity



Changing from intermittent auscultation to

continuous EFM

� Significant meconium stained liquor (alsoconsidered for light meconium stained

� Abnormal FHR detected by intermittent

auscultation-less than 110bpm greater than160bpm, any decelerations after contractions

� Maternal pyrexia defined > 38°C/once or

37.5°C on 2 occasions 2 hrs apart.� Fresh bleeding developing in labour



� External indirectmonitoring (CTGcardiotocograph

procedure:� A tocodynamometer

(for uterine activity) isplaced on the mother·sabdomen near the

fundus� A strap around the

mother holds it inplace

� A doppler transducer(ultrasonic device) isplaced on the mother·sabdomen and movedaround until the fetalheart is heard the best-this is also strapped inplace

� Sound waves are

bounced off the fetalheart and picked up anddisplayed by themonitor



2- Providing maternal physical care

Includes:

� comfort measures

� hygiene measures� ambulation and position

� food and fluid intake

� elimination



a) Comfort measures

� Offering the clientfluids

� Providing oral care� Assisting the client

with frequent position

changes- (encourageside-lying or uprightpositions)

� Providingencouragement and

praise



� Suggesting the use ofcold wash cloth on

the forehead or napeof the neck

� Keeping clientinformed of theprogress

� Giving back rub

� Assist client in

walking to showers� Offering analgesics as

ordered



b) Hygiene measures

� Offer showers if not contraindicated for theclient

� Bed linens should be clean and dry

� Change mackintosh frequently if needed

� Perineal care/changing of sanitary padswhen soaked

�

Oral care



c) Ambulation and position

� May increase uterine

activity, providedistraction from thediscomforts of labour,enhance maternalcontrol of the situation

� Encourage client towalk only if: themembranes are stillintact

� Presenting part is

engaged after ROM� If she has not had

pain medication.

� Side- lying position

promotes utero-placental blood flow

� Upright position-

place pillow underone hip to keep

uterus fromcompressing theaorta and vena cava



d) Food and fluid intake

� Clear fluids are all that is offered

� Sometimes I.V fluids are started on clients

� Keep an accurate I&O record if I.V fluid sare infusing

� (danger of hypervolemia)



Elimination

�

Encourage client to void every2

hours� Allow to walk to bathroom if not

contraindicated

� Catheterize if client cannot void and

bladder is distended� Monitor input & output



Assisting client and support persons

� S/P can be : the baby·s father or may beanother man or woman

� Should be treated with respect regardless of

relationship to the mother or fetus� Breathing techniques 3 types:-

� Slow deep breathing

� Shallow breathing

� Pant- blow breathing



Providing pharmacologicalcomfort measures

� Non- pharmacological ² (as discussed earlier)

� Pharmacological- systemic medications,regional blocks, general anesthesia

�

Systemic medications should be administeredonly if:

� The client is willing to receive them and vitalsigns are stable



� The fetus is :

�

term� exhibits normal

movement, FHR is120-160bpm with no

late or variabledecelerations

� Amniotic fluid is notmeconium stained

� Contractions:

- Are well established- Cervix dilated at

least 4-5cm in anullipara, 3-4cm in a

multipara,presenting part isengaged

- No complications areidentified



� Effects on the fetus depends on:

� The dosage given, timing and route of

administration and the pharmacokinetics of thedrug (best avoided if there is less than 3 hoursbefore delivery).



Assessment Latentphase

Activephase

Transitionphase

2nd stage

BP,P, R q1h q1h q30min q5min

temperature q4h q4h q4h

(if ROM) q2h q2h q2h

FHR q1h q3omin q15min q5min

contractions q1h q30min q15min continuously

Suggested time frame for selected assessments

Promotion and maintenance of aseptic



Promotion and maintenance of aseptictechnique

� Wear disposal gloves

anytime hands mightcome in contact withamniotic fluid, bloodyshow, urine or feces

� Wear splash aprons and

eye-covering (goggles orface masks) when thesplashing of body fluidsis possible

� Wash hands before

putting on gloves and

immediately afterremoving them

� Before catheterization-cleanse vulva andperineum thoroughly toremove any amniotic

fluid and bloody show� Avoid unnecessary V.E

� Use of sterile trays/instruments



Referencing

� White. L, (2005). F oundations of Maternal & pediatric nursing.(2nd ed.). Thomson, Delmarlearning

� Fraser, D. M, Cooper, A. (2003). Myles text book for Midwives (14th ed.).Churchill Livingston,Elsevier.

� Olds, London, Ladewig.(1992).Maternal-

Newborn Nursing A

family- centeredapproach.(4th ed.).Addison Wesley. RedwoodCity.

Management of the First Stage of Labour Lecture

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