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8/13/2019 maternalcarethefirststagelabourmonitoringandmanagement-120410032725-phpapp01

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8

The rst stage

of labour:

Monitoring andmanagement

Beore you begin this unit, please take thecorresponding test at the end o the book toassess your knowledge o the subject matter. Youshould redo the test afer youve worked throughthe unit, to evaluate what you have learned.

Objectives

When you have completed this unit you

should be able to:

Monitor and manage the rst stage of

labour.

Evaluate accurately the progress of

labour.

Know the importance of the alert and

action lines on the partogram.

Recognise poor progress during the rststage of labour.

Systematically evaluate a patient

to determine the cause of the poor

progress in labour.

Manage a patient with poor progress in

labour.

Recognise patients at increased risk of

prolapse of the umbilical cord.

Manage a patient with cord prolapse.

THE DIAGNOSIS

OF LABOUR

8-1 When is a patient in labour?

A patient is in labour when she has botho theollowing:

Regular uterine contractions with at leastone contraction every ten minutes.Cervical changes (i.e. cervical effacementand/or dilatation) orrupture o themembranes.

THE TWO PHASE S OF THE

FIRST STAGE OF LABOUR

Te rst stage o labour can be divided intotwo phases:

Te latent phase.Te active phase.

The rst stage of labour is divided into two

phases: the latent phase and the active phase.

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151THEFIRSTSTAGEOF LABOUR : MONITORINGANDMANAGEMENT

8-2 What do you understand by the latentphase of the rst stage of labour?

Te latent phase starts with the onset olabour and ends when the patients cervixis 3 cm dilated. With primigravidas thecervix should also be ully effaced toindicate that the latent phase has ended.However, in a multigravida the cervix neednot be ully effaced.During the latent phase, the cervix dilatesslowly. Although no time limit need be setor cervical dilatation, this phase does not

normally last longer than eight hours. Tetime taken may vary widely.During the latent phase there is aprogressive increase in the duration andthe requency o uterine contractions.

8-3 What do you understand by the

active phase of the rst stage of labour?

Tis phase starts when the cervix is 3 cmdilated and ends when the cervix is ullydilated.During the active phase, more rapid

dilatation o the cervix occurs.Te cervix should dilate at a rate o at least1 cm per hour.

NOTEThe average rate of dilatation of the cervix

during the active phase is at least 1.5 cm per hour

in multigravidas and 1.2 cm in primigravidas.Therefore, the lower limit of the normal rate

of cervical dilatation is 1 cm per hour.

The cervix should dilate at a rate of at least 1 cm

per hour in the active phase of labour.

MONITORING OF THE


8-4 What do you understand by a complete

physical examination during labour?

Te routine observations (usually donehourly or hal-hourly) o the condition o

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the mother, the condition o the etus, andthe contractions.A careul abdominal examination.A careul vaginal examination.

Tis examination is only complete when thendings have been charted on the partogram.I the ndings are abnormal, a plan must bemade regarding the urther management othe patient.

8-5 When should you do a complete

physical examination on a patient in labour?

On admission.During the latent phase: Four hours aferadmission or when the patient startsto experience more painul, regularcontractions.During the active phase: Four-hourly,provided all observations indicate thatprogress is normal. I there is poorprogress, the next complete examinationwill have to be done afer two hours inmost instances.

Afer the complete examination has been doneand an assessment made about the progress olabour, a decision is taken on when the nextcomplete examination should be done. Tetime o the next examination is marked on thepartogram with an arrow. Te next completeexamination may, i the circumstancesdemand it, be done sooner (but not later) thanthe time indicated.

8-6 How should progress during the

rst stage of labour be monitored?

Apartogramis used to monitor and record theprogress o labour.

8-7 What is a partogram?

A partogram is a chart on which the progresso labour over time can be presented. You willnotice that provision has been made on thechart to record all the important observationsregarding the condition o the mother, thecondition o the etus, and the progress olabour.

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152 MATERNALCARE

Figure 8-1:An example of a partogram


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An example o a partogram is shown ingure 8-1.

8-8 What is the rst oblique line

on the partogram called?

Te alert line. It represents a rate o cervicaldilatation o 1 cm per hour.

8-9 What is the importance of the alert line?

Te alert line represents the minimum progressin cervical dilatation which is acceptable during

the active phase o the rst stage o labour.

8-10 What is the second oblique

line on the partogram called?

Tis line is called the action line.

8-11 What is the importance

of the action line?

Any patient whose graph o the cervicaldilatation alls on or crosses the actionline must have a complete examination

by the doctor. Her urther managementmust be under the doctors supervisionand direction. I a patient is not alreadyin hospital, she will need to be transerredinto a hospital where there are acilitiesor instrumental delivery and Caesareansection.Te progress o labour is very slow whenthe graph o cervical dilatation crossesor alls on this line. When this occurs,action must be taken in order to hasten thedelivery o the inant.

If the cervical dilatation falls on, or crosses, the

action line of the partogram, a doctor must be

called to assess the patient.

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MANAGEMENT OF APATIE NT IN THE L ATENT

PHASE OF THE FI RST

STAGE OF LA BOUR

Te latent phase o labour should not lastlonger than eight hours.

8-12 What is the initial management of

a patient in the latent phase of labour?

When a patient is admitted in early labour,and on examination everything is ound to benormal, only routine observations are done. Tenext complete examination is done our hourslater, or sooner i the patient starts to experiencemore regular and painul contractions. Tepatient should eat and drink normally, andshould be encouraged to walk around. She neednot be admitted to the labour ward.

8-13 What should you do at the

second complete examination?

At this time, the ollowing must be assessed.

Te contractions: I the contractions havestopped the patient is no longer in labour,and i the maternal and etal conditions arenormal, she may be discharged. However,i the contractions have remained regular,then you must assess the cervix.Te cervix:

I the effacement and dilatation othe cervix have remained unchanged,the patient is probably not in truelabour. I she is experiencing painulcontractions, she should be given ananalgesic, e.g. pethidine 100 mg andpromethazine (Phenegan) 25 mgor hydroxyzine (Aterax) 100 mg byintramuscular injection and, providedthat all other observations are normal,the next complete physical examinationis planned or our hours later.I there has been progress in effacementand/or dilatation o the cervix, thepatient is in labour and, provided that

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154 MATERNALCARE

all other observations are normal, thenext complete examination is plannedor our hours later. I the cervix is 3 cmor more dilated, the patient has nowprogressed to the active phase o therst stage o labour.

8-14 What should you do if a patient has

not progressed to the active phase of

labour within eight hours after admission?

Te contractions may have stopped, inwhich case the patient is not in labour. I

the membranes have not ruptured and ithere is no indication to induce labour, thepatient should be discharged.Te patient may still be having regularcontractions. In this case, urthermanagement depends upon the state othe cervix:

I there has been no progress ineffacement and/or dilatation o thecervix, the patient is probably not inlabour. Te responsible doctor shouldsee and assess this patient, in order

to decide whether labour should beinduced.I there has been progressive effacementand/or dilatation o the cervix, thepatient is in labour. I the progresshas been slow during the latent phase,it may be necessary to rupture themembranes or commence an oxytocininusion i she is HIV positive asdescribed in 8-35.

MANAGEMEN T OF A

PATIENT IN THE ACTIVE

PHASE OF THE FIRS T

STAGE OF LA BOUR

When a patient is admitted in the activephase o labour, she will probably be innormal labour. However, the possibilityo cephalopelvic disproportion must beconsidered, especially i the patient isunbooked.

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8-15 How do you manage a patientwho is in normal labour?

When the condition o the mother and thecondition o the etus are normal, and thereare no signs o cephalopelvic disproportion,the next complete examination must be doneour hours later. Te cervical dilatation, incentimetres, is recorded on the alert line othe partogram.

8-16 What represents normal progress

during the active phase of the rst

stage of labour on the partogram?

Te recording o cervical dilatation at thevarious vaginal examinations lie on or tothe lef o the alert line. In other wordscervical dilatation is at least 1 cm per hour.Tere is also progressive descent o theetal head into the pelvis. Tis is detectedby assessing the amount o the etal headabove the brim o the pelvis on abdominalexamination. Descent o the head duringthe active phase o the rst stage o labourmay occur late, especially in multigravidas.

With normal progress during the active phase

of the rst stage of labour, the recording of the

dilatation of the cervix will lie on or to the left

of the alert line on the partogram. In addition,

there will be progressively less of the fetal head

palpable above the pelvic brim.

8-17 Why is it necessary to evaluate both

cervical dilatation and the descent of

the head in order to determine whether

there has been progress in the active

phase of the rst stage of labour?

Cervical dilatation without associateddescent o the head does not necessarilyindicate progress in labour.Cervical dilatation may occur when thereare good contractions, in association withincreasing caput succedaneum ormationand moulding o the etal skull, whilethe amount o etal head palpable abovethe brim o the pelvis remains the same.

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In these circumstances no real progresshas occurred, because the head is notdescending into the pelvis.Te station o the presenting part o thehead in relation to the spine, as elt onvaginal examination, can also improvewithout further descent of the head andwithout real progresshaving occurred.Tis is because o increasing caputsuccedaneum and moulding.

Descent of the head is assessed on abdominal

and not on vaginal examination.

8-18 What circumstances will make it

necessary to do vaginal examinations

more frequently than four- hourly in the

active phase of the rst stage of labour?

I cephalopelvic disproportion issuspected, the next vaginal examinationmust be done two hours later.I a complete examination has revealedpoor progress o labour, without the

presence o cephalopelvic disproportion,the next complete examination shouldalso be done two hours later, to assessthe effectiveness o the measures taken tocorrect the poor progress.I a patients cervix is more than 6 cmdilated, the next complete examinationwould normally be done when the cervixis expected to be ully dilated. However,the examination may need to be doneearlier i there are signs that the cervix isalready ully dilated.

8-19 When should you rupture

the patients membranes?

It is possible to reduce the risk otranserring HIV rom a mother to herinant by keeping the duration o rupturedmembranes as short as possible. Do notrupture the membranes o patients whoseHIV status is positive or unknown i theyare still intact at the start o the activephase o labour. Te ollowing vaginalexamination will not increase the risk o

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inection i the membranes are intact. Tenext complete examination should be doneafer two hours when the managementshould be as ollows:

With normal progress do not rupturethe membranes.With poor progress the membranesshould be ruptured and the nextexamination perormed our hours later.

A patient who is HIV negative and inlabour with a vertex presentation may haveher membranes ruptured with saety i:

She is in the active phase o labour.Te etal head is 3/5 or less palpableabove the brim o the pelvis.

Afer rupturing the membranes, careullyeel around the etal head to rule out thepossibility o a cord prolapse.

I the etal head is 4/5 or more above the pelvicbrim, and the cervix is 6 cm or more dilated,it is saer to careully rupture the membranesthan to allow them to rupture spontaneously.Tis will reduce the risk o cord prolapse.

8-20 What should you do if apatient ruptures her membranes

spontaneously during labour?

I the etal head is 4/5 or more palpableabove the pelvic inlet, or i there is abreech presentation, the patient is at highrisk or a cord prolapse. A sterile vaginalexamination must, thereore, be done torule out this possibility.I the etal head is 3/5 or less palpableabove the pelvic inlet, it is highlyunlikely that a cord prolapse might

happen. However, the etal heart must bemonitored to rule out the possibility oetal distress due to cord compression.

8-21 What are the advantages of

rupturing a patients membranes?

Rupture o the membranes acts as astimulus to labour, so that there is ofenbetter progress.Meconium staining o the liquor will bedetected.

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156 MATERNALCARE

I the cord prolapses when the membranesare ruptured, this can be detectedimmediately, and the appropriatemanagement can thereore be startedwithout delay.

It is important to make sure that the patient isin the active phase o the rst stage o labourbeore rupturing the membranes.

POOR PROG RESS IN THE

ACTIVE P HASE OF THEFIRST STAGE OF LABOUR

8-22 How would you recognise poor

progress in the active phase of labour?

Poor progress is present when the graphshowing cervical dilatation crosses the alertline. In other words, cervical dilatation in theactive phase o the rst stage o labour is lessthan 1 cm per hour.

8-23 What should you do if thegraph showing cervical dilatation

crosses the alert line?

A systematic assessment o the patient mustbe made in order to determine the cause o thepoor progress in labour.

8-24 How should you systematically

examine a patient with poor progress in

the active phase of the rst stage of labour?

Step 1

wo questions must be asked:

Is the patient in the active phase o the rststage o labour?Are the membranes ruptured?

I the answer to both questions is yes, proceedto step 2.

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Step 2

Te cause o the poor progress o labour mustbe determined by examining the patient usingthe Rule o the our Ps. Te our Ps are:

Te patient.Te powers.Te passenger.Te passage.

The cause of poor progress of the active phase

of the rst stage of labour is determined by

assessing the four Ps.

8-25 How may problems with the patient

cause poor progress of labour and how

should these problems be managed?

Any o the ollowing actors may interere withthe normal progress o labour.

Te patient needs pain relief. Patients whoexperience very painul contractions,especially i associated with excessiveanxiety, may have poor progress o labour

as a result. Pain relie, emotional support.and reassurance can be o great value inspeeding up the progress o labour.Te patient has a full bladder.A ull bladdernot only causes mechanical obstruction,but also depresses uterine muscle activity.A patient must be encouraged to pass urinerequently but may need catheterisation,and sometimes an indwelling catheter,until afer delivery.Te patient is dehydrated.Dehydrationis recognised by the act that the patient

is thirsty, has a dry mouth, passes smallamounts o concentrated urine and mayhave ketonuria. Dehydration must becorrected as it may be the cause o thepoor progress. With good care duringlabour the patient will not becomedehydrated, because she can eat and drinkduring the latent phase o labour andtake oral uids during the active phase olabour. I there is poor progress duringthe active phase o labour, an intravenousinusion must be started.

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8-26 How may problems with the powerscause poor progress of labour?

Te powers (i.e. the uterine contractions)may either be inadequate or ineffective. Anypatient in whom labour progresses normallyhas both adequate and effective contractions,irrespective o the duration and requency ocontractions.

Inadequate uterine contractions.Inadequateuterine contractions can be the cause opoor progress o labour. Such contractions:

Last less than 40 seconds, and/orTere are ewer than two contractionsper ten minutes.

Ineffective uterine contractions.Teuterine contractions may be adequate butnot effective, as poor progress can occureven in the presence o apparently good,painul contractions (i.e. two or morein ten minutes with each contractionlasting 40 seconds or longer), withoutdisproportion being present (i.e. nomoulding o the etal skull). Te problemo ineffective contractions occurs only in

primigravidas. Any patient whose labourprogresses normally must have effectiveuterine contractions.

NOTEDysfunctional uterine contractions

are diagnosed when the uterine

contractions appear to be ineffective.

8-27 How may problems with the

passenger cause poor progress

of labour and how should these

problems be managed?

Te cause o poor progress o labour maybe due to a problem with the passenger (i.e.the etus). Tese problems can be identiedby perorming an abdominal examinationollowed by a vaginal examination.

On abdominal examination the ollowingproblems causing poor progress may beidentied.

Te lie of the fetus is abnormal.I the lie othe etus is transverse the patient will needa Caesarean section.

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Te presenting part of the fetus is abnormal.With a breech presentation, the patientmust be assessed by a doctor to decidewhether a vaginal delivery will be possibleor whether a Caesarean section is required.I the presentation is cephalic, the parto the head which is presenting must bedetermined on vaginal examination.

NOTEFetuses who present by the breech and

who comply with the criteria for vaginal delivery,

are only delivered vaginally if there is normal

progress during the rst stage of labour.

Te fetus is large.A large etus (i.e. estimatedas 4 kg or more), with signs o cephalopelvicdisproportion (i.e. 2+ or 3+ moulding) mustbe delivered by Caesarean section.Tere are two or more fetuses.Poor progressmay also occur in a patient with a multiplepregnancy, usually due to inadequateuterine contractions.Te fetal head has not engaged.Te numbero fhs o the head palpable above thepelvis must always be assessed:

Engagement has occurred only when

2/5 or less o the head is palpable abovethe brim o the pelvis. In this case theproblem o cephalopelvic disproportionat the pelvic inlet is excluded.With 3/5 or more o the headabove the pelvic brim, plus 2+ or3+ moulding, a Caesarean sectionis indicated or cephalopelvicdisproportion at the pelvic inlet.

An abdominal examination, to assess the lie and

the presenting part of the fetus, as well as the

amount of fetal head palpable above the pelvic

brim, must always be done before performing a

vaginal examination.

On vaginal examination the ollowing problemscausing poor progress may be identied.

Te presenting part is abnormal.Vertex (i.e.occipital) presentation o the etal headis the most avourable presentation orthe normal progress o labour. With any

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158 MATERNALCARE

other presentation o the etal head in earlylabour (e.g. brow), there is no urgencyto interere, as the presentation maybecome more avourable when the patientis in established labour. However, inestablished labour, i moulding is presentin any presentation other than a vertex, aCaesarean section will have to be done.Te position of the fetal head in relation tothe pelvis is abnormal.An occipito-anterior(right or lef) is the most avourable positionor normal progress o labour. Positionsother than this (i.e. lef or right occipito-posterior) will progress more slowly. Labourcan be allowed to continue provided thereis progress, and no progressive evidence odisproportion. Te patient will also needadequate pain relie and an intravenousinusion to prevent dehydration.Cephalopelvic disproportion is present.

Te head is examined or the amounto caput succedaneum present.Caput is not an accurate indicator odisproportion as it can also be presentin the absence o disproportion, or

example, in a patient who bears downbeore the cervix is ully dilated.Te sutures are examined ormoulding, which is the best indicationo the presence o disproportion.3+ o moulding is a denite sign odisproportion. In a vertex presentation,the sagittal and lambdoid (occipito-parietal) sutures are examined. Teworst degree o moulding noted in anyo the sutures is that which is recordedon the partogram as the amount o

moulding present.Improvement in the station o thepresenting part (i.e. the level o thepresenting part relative to the ischialspines) is not a reliable method oassessing progress in labour, comparedto descent and engagement o the etalhead as determined on abdominalexamination.

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Improvement in the station of the presentingpart of the fetal head, in relation to the ischial

spines, is not a reliable method of assessing

progress in the rst stage of labour.

8-28 How may problems with the passage

cause poor progress in labour and how

should these problems be managed?

Te ollowing problems with the passage maycause poor progress in labour:

Te membranes are still intact.Should themembranes still be intact, they must beruptured and the patient reassessed aferour hours beore poor progress can bediagnosed.Te pelvis is small. A pelvic assessmentwhich shows a small pelvis, together with2+ or 3+ moulding o the etal skull meansthat there is cephalopelvic disproportion,and is an indication or Caesarean section.

8-29 What are the two important

causes of poor progress of labour?

Cephalopelvic disproportion. Tis is adangerous condition i it is not recognisedearly and not correctly managed.Inadequate uterine action. Tis is acommon cause o poor progress inprimigravidas. It can be easily correctedwith an oxytocin inusion.

8-30 What must be done after the

patient has been systematically

evaluated to determine the cause

of the poor progress of labour?Te nurse attending to the patient mustinorm the doctor about the clinicalndings. ogether they must decide on thecause o the slow progress and what actionmust be taken to correct this problem.A decision must also be made as to whenthe next complete examination o thepatient will be done. Usually this willbe in two hours, but sometimes in ourhours. Tis consultation may be done by

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telephone and it is not necessary or thedoctor to see the patient at this stage.I labour progresses satisactorily ollowingthe action taken, labour is allowed tocontinue. However, i poor progresscontinues, or i the action line has beenreached or crossed, the patient must beexamined by the responsible doctor whomust then decide on urther management.

Te ollowing are examples o causes opoor progress in labour together with theirmanagement:

Cause Action

Cephalopelvic

disproportion

Caesarean section

An anxious patient

unable to cope

with painful

contractions

Reassurance and

analgesia

Inadequate uterine

contractions

An oxytocin infusion

Occipito-posterior

position

Analgesia and an

intravenous infusionIneffective uterine

contractions

Analgesia followed

by an oxytocin

infusion

CEPHALOPELVIC

DISPROPORTION

8-31 How will you know when poor progress

is due to cephalopelvic disproportion?

Tis can be recognised by the ollowingndings:

On abdominal examination, the etal headis not engaged in the pelvis. Remember, thisis diagnosed by nding 3/5 or more o thehead palpable above the brim o the pelvis.On vaginal examination, there is severemoulding (i.e. 3+) o the etal skull. Severemoulding must always be regarded asserious, as it conrms that cephalopelvicdisproportion is present.

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Cephalopelvic disproportion may already bepresent when the patient is admitted.

A high fetal head (3/5 or more above the brim)

on abdominal examination, with 3+ moulding

on vaginal examination, indicates cephalopelvic

disproportion.

8-32 Does a patients cervix always dilate

at a rate slower than 1 cm per hour if

cephalopelvic disproportion is present?

When there is cephalopelvic disproportion, thecervix usually dilates at a rate slower than 1 cmper hour, but the cervix may dilate normally,even though the etal head remains highdue to cephalopelvic disproportion. Tis is adangerous situation as it may be incorrectlyconcluded that labour is progressing normally.

8-33 What features would make

you diagnose cephalopelvic

disproportion when the fetal head

is not descending into the pelvis?

Ofen, especially in multiparous patients, thehead does not descend into the pelvis until latein the active phase o the rst stage o labour.However, when the head does not descend intothe pelvis, you should look or possible causes:

A malpresentation, e.g. a ace or a browpresentation.Moulding (i.e. 2+ or 3+).

I either o these are present, there iscephalopelvic disproportion, and a Caesareansection should be done.

On the other hand, labour can be allowed tocontinue i:

Tere is no malpresentation.Tere is no more than 1+ moulding.Te maternal and etal conditions aregood.

Te next complete physical examination mustbe repeated within two hours.

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160 MATERNALCARE

8-34 What should you do if youdecide that the poor progress is due

to cephalopelvic disproportion?

Once the diagnosis o cephalopelvicdisproportion has been made, the inantmust be delivered as soon as possible. Tismeans that a Caesarean section will haveto be done.While the preparations or Caesareansection are being made, it is o value toboth the mother and etus to suppressuterine contractions. Tis is done by

giving three niedipine (Adalat) 10 mgcapsules by mouth (a total o 30 mg)or give 250 g (0.5 ml) salbutamol(Ventolin) slowly intravenously, the 0.5 mlsalbutamol is diluted with 9.5 ml sterilewater and given slowly intravenously overve minutes, provided that there are nocontraindications.

INADEQUATE

UTERINE ACTION

8-35 What should you do if you decide that

the poor progress is due to inadequate

or ineffective uterine contractions?

Provided there are no contraindications,the patient must be given an oxytocininusion in order to strengthen thecontractions.Te patients progress must be reassessedafer two hours.I cervical dilatation has proceeded at the

rate o 1 cm per hour or more, progresshas been satisactory and labour isallowed to continue.I cervical dilatation has been slowerthan 1 cm per hour once the patient hasadequate uterine contractions, the patientmust be reassessed by the responsibledoctor. Cephalopelvic disproportion maybe present.I at this stage the patient is still in aperipheral clinic, there should be enough

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time to reer her to hospital beore theaction line is crossed.Patients who complain o painulcontractions need analgesia beoreoxytocin is started.

8-36 What are the contraindications to

the use of oxytocin in order to strengthen

contractions in the rst stage of labour?

Evidence o cephalopelvic disproportion.Oxytocin must, thereore, notbe given ithere is already moulding (i.e. 2+ or 3+)

present.Any patient with a scar o the uterus, e.g.rom a previous Caesarean section.Any patient with a etus in whom thepresenting part is not a vertex.Multiparas with poor progress during theactive phase o labour o the rst stage olabour.Grande multiparity during the latent oractive phase o the rst stage o labour.When there is etal distress.Patients with poor kidney unction or

heart valve disease.

NOTEOxytocin has an antidiuretic effect, so

there is a danger of the patient developing

pulmonary oedema. Hyperstimulation

must be avoided if an oxytocin infusion

is used. Five or more contractions in tenminutes, or contractions lasting longer than

60 seconds, indicate hyperstimulation.

8-37 How must oxytocin be

administered when it is used

during the rst stage of labour?

Te ollowing is a good method:

Begin with one unit o oxytocin in onelitre o Plasmolyte B, Ringers lactate orrehydration uid.Use a giving set which delivers 20 dropsper ml.Start with 15 drops per minute andincrease the rate at intervals o 30 minutesto 30 drops, and then to 60 drops perminute, until the patient gets at least three

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contractions lasting at least 40 secondsevery ten minutes.I there are still inadequate contractionswith one unit o oxytocin per litre at60 drops per minute, a new litre ointravenous uid containing eight unitsper litre is started at a rate o 15 drops perminute. Te rate is increased in the sameway as above until 30 drops per minuteare being given. Tis is the maximumamount o oxytocin which should be usedduring the rst stage o labour.

NOTEThe starting dose of oxytocin is ONE

milliunit (mUnit) per minute and the maximum

dose 12 mU per minute which is line withinternational dose recommendations.

3-38 What are the effects of a long labour?

Both the mother and etus may be affected.

Te mother. A patient in whom theprogress o labour is slow is more likely tobecome anxious and to be dehydrated. Ithe poor progress is due to cephalopelvic

disproportion (i.e. obstructed labour), andlabour is allowed to continue, then there isthe danger o the mother developing any orall o the ollowing:

A ruptured uterus.A vesicovaginal stula.A rectovaginal stula.

Te etus. Te stress o a long labourresults in progressive etal hypoxia, whichcauses etal distress and eventually in intra-uterine death.

THE REFERRAL OFPATIENTS WITH POOR

PROGRESS DURING THE

ACTIVE PH ASE OF THE


Te guidelines or reerral will varyrom region to region, depending on thedistances between clinics and hospitals,

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and the availability o transport. In general,arrangements must be made so that the patientwill be under the care o the responsibledoctor by the time the graph depicting cervicaldilatation crosses the action line.

8-39 What arrangements should

you make to ensure the patients

safety during transfer to hospital, if

there is poor progress of labour?

An intravenous inusion must be started.Te patient must lie on her side while

being transerred to hospital.A nurse should accompany the patient,unless there is a trained ambulance crew.I cephalopelvic disproportion is thecause o the poor progress o labour, thecontractions must be stopped. o stopcontractions, three niedipine (Adalat)10 mg capsules (total o 30 mg) can betaken orally or 250 g (0.5 ml) salbutamol(Ventolin) slowly intravenously, the 0.5 mlsalbutamol is diluted with 9.5 ml sterilewater and given slowly intravenously over

ve minutes. I indicated, the same doseo salbutamol may be repeated afer 30minutes. Both drugs should only be used ithere are no contraindications.

PROLAP SE OF THE

UMBILICAL CORD

8-40 Why is prolapse of the umbilical

cord a serious complication?

Because the ow o blood between the etusand placenta is severely reduced and maystop completely, causing etal distress andpossibly etal death.

8-41 What is the difference between a

cord presentation and a cord prolapse?

With a cord presentation, the umbilicalcord lies in ront o the presenting partwith the membranes still intact.

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162 MATERNALCARE

With a cord prolapse, the cord lies in ronto the presenting part and the membraneshave ruptured. Te loose cord may liebetween the presenting part o the etusand the cervix, in the vagina or outsidethe vagina.

8-42 How should a cord

presentation be managed?

I the cord is elt between the membranes andthe presenting part o the etus, i the etusis alive and is viable and i the patient is in

labour, a Caesarean section must be done.Tis will prevent a cord prolapse when themembranes rupture.

8-43 Which patients are at risk

of a prolapsed cord?

Patients in labour with an abnormallie (e.g. transverse lie) or an abnormalpresentation (e.g. breech presentation).Patients who rupture their membraneswhen the etal head is still not engaged (i.e.4/5 or more above the pelvic brim, e.g. in agrande multipara).Patients with polyhydramnios where theincreased volume o liquor may wash thecord out o the uterus.Patients in preterm labour where thepresenting part is small relative to thepelvis when the membranes rupture.Patients with a multiple pregnancy,where preterm labour, abnormal lie andpolyhydramnios are common.

8-44 What should be done when a

patient, who is at high risk of prolapseof the cord, ruptures her membranes?

A sterile vaginal examination mustimmediately be done to determine whetherthe cord has prolapsed.

8-45 What is the management

of a prolapsed cord?

A vaginal examination must be doneimmediately.

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4.

5.

I the cervix is 9 cm or more dilated andthe etal head is on the perineum, thepatient must bear down and the inantmust be delivered as soon as possible.Otherwise the patient must be managed asollows:

Replace the cord careully into thevagina.Give the patient mask oxygen and give250 g (0.5 ml) salbutamol (Ventolin)slowly intravenously, the 0.5 mlsalbutamol is diluted with 9.5 ml sterilewater and given slowly intravenouslyover ve minutes to stop labour.Put a Foley catheter into the patientsbladder and ll the bladder with 500 mlsaline.I the ull bladder does not lif thepresenting part off the prolapsed cord,the presenting part must be pushed upby an assistants hand in the vagina, andby turning the patient into the knee-chest position.

8-46 Why should the cord carefully

be replaced in the vagina?

Te cord must not be allowed to becomecold or dry as this will produce vasospasmand, thereby, urther reduce the blood owthrough the cord.

8-47 Why are oxygen and salbutamol

given to a patient with a prolapsed cord?

Giving oxygen to the patient may improvethe oxygen supply to the etus.Stopping uterine contractions will reduce

the pressure o the presenting part on theprolapsed cord.

8-48 Should a Caesarean section be done

on all women with a prolapsed cord if the

infant cannot be rapidly delivered vaginally?

No. A Caesarean section is only done i theinant is potentially viable (28 weeks or more)and the cord is still pulsating. Otherwise theinant should be delivered vaginally as thechances o survival are then extremely small.

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CASE STUDY 1

A primigravida patient at term, who is HIVnegative, is admitted to the labour ward. She hasone contraction, lasting 30 seconds, every tenminutes. Te cervix is 1 cm dilated and 1.5 cmlong. Te maternal and etal observations arenormal. Afer our hours she is having twocontractions, each lasting 40 seconds, every tenminutes. On vaginal examination the cervix isnow 2 cm dilated and 0.5 cm long with bulgingmembranes. Te diagnosis o poor progress o

labour due to poor uterine contractions is madeand an oxytocin inusion is started to improvecontractions.

1. Do you agree with the diagnosis

of poor progress of labour?

Te diagnosis is incorrect as the patient is stillin the latent phase o the rst stage o labour.Poor progress o labour can only be diagnosedin the active phase o labour.

2. Why can it be said with certainty that the

patient is in the latent phase of labour?

Te cervix is still less than 3 cm dilated.Te cervix is dilating slowly.Te cervix is effacing.Te requency o the uterinecontractions is increasing.

3. What is your assessment of

the patients management?

Apart rom the wrong diagnosis, oxytocinshould not be given beore the membranes

have been ruptured.

4. Should the patients membranes have

been articially ruptured when the

second vaginal examination was done?

No. I the maternal and etal condition aregood, you should wait until the cervix is 3 cmor more dilated. Te membranes may also beruptured i the patient has been in the latentphase o labour or eight hours without anyprogress.

CASE STUDY 2

A patient at term is admitted in labour with avertex presentation. Te cervix is already 4 cmdilated. Te cervical dilatation is recorded onthe alert line. At the next vaginal examinationthe cervix has dilated to 8 cm. Caput can bepalpated over the etal skull. It is decided thatthe progress is avourable and that the nextvaginal examination should be done afer aurther our hours.

1. On admission, should thewomans cervical dilatation have

been entered on the alert line?

Yes. Te patient is in the active phase o therst stage o labour as her cervix is 4 cmdilated. Tereore, the cervical dilatationmust be plotted on the alert line. Te utureobservations should all on or to the lef othe alert line.

2. Do the ndings of the second

examination indicate normal

progress of labour?

Not necessarily, as no inormation is givenabout the amount o etal head palpable abovethe pelvic brim. Cervical dilatation withoutdescent o the head does not always indicatenormal progress o labour.

3. Is normal cervical dilatation with

improvement in the station of the

presenting part possible if cephalopelvic

disproportion is present?

Yes. Te uterine contractions cause anincreasing amount o caput and moulding,which is incorrectly interpreted as normalprogress o labour. In this case, caput wasnoted during the second examination.However, urther inormation about anymoulding and the amount o etal headpalpable above the pelvic brim are essentialbeore it can be decided whether normalprogress is present or not.


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4. Was the correct decision made at thetime of the second examination to repeat

the vaginal examination after four hours?

No. I the cervix is 8 cm dilated, the nextexamination must be done two hours later,or even sooner i there are indications thatthe womans cervix is ully dilated. I it isuncertain whether the progress o labour isnormal then the examination should also berepeated in two hours.

CASE STUDY 3

A primigravida patient at term is admitted inlabour. At the rst examination the etal headis 2/5 above the pelvic brim and the cervixis 6 cm dilated. Tree contractions in tenminutes, each lasting 45 seconds, are palpated.At the next examination our hours later, thehead is still 2/5 above the brim and the cervixis still 6 cm dilated. No moulding can be elt.Te patient is still having three contractionsin ten minutes, each lasting 45 seconds and

complains that the contractions are painul.Because there has been no progress in spiteo painul contractions o adequate requencyand duration, it is decided that cephalopelvicdisproportion is present and that, thereore, aCaesarean section must be done.

1. Do you agree that the poor

progress of labour is due to

cephalopelvic disproportion?

No. o diagnose poor progress due tocephalopelvic disproportion, severe moulding

(3+) must be present.

2. What is most probably the reason

for the poor progress of labour?

Te patient is a primigravida with strong,painul contractions and no signs ocephalopelvic disproportion. A diagnosis oineffective uterine contractions (dysunctionaluterine contractions) can, thereore, be madewith condence.

3. What should be the management ofthe patients poor progress of labour?

Firstly, the patient should be reassuredand given analgesia with pethidine andpromethazine (Phenegan) or hydroxyzine(Aterax). Ten an oxytocin inusion should bestarted to make the contractions more effective.

4. Why is reassuring the

patient so important?

Anxious patients ofen progress slowly

in labour and have painul contractions.Emotional support during labour is a veryimportant part o patient care.

5. When must the next vaginal

examination be done?

Te next vaginal examination should bedone two hours later to determine whetherthe treatment has been effective. During theexamination it is very important to excludecephalopelvic disproportion.

CASE STUDY 4

A patient who is in labour at term hasprogressed slowly and the alert line has beencrossed. During a systematic evaluation othe patient by the midwie or poor progresso labour, a diagnosis o an occipito-posteriorposition is made. As the patient is makingsome progress, she decides to allow labourto continue. Afer our hours, the cervicaldilatation alls on the action line. Although

there is still slow progress, she again decidesto allow labour to continue and to repeat thevaginal examination in a urther two hours.

1. Was the patient managed correctly

when she crossed the alert line?

Yes. She was systematically examined and adiagnosis o slow progress o labour due to anoccipito-posterior position was made.


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2. What should be done if a long rststage of labour is expected due to

an occipito-posterior position?

An intravenous inusion must be startedto ensure that the patient does not becomedehydrated. In addition, adequate analgesiamust 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 havebeen under his/her direction.

4. Under what conditions should thedoctor allow labour to progress further?

If there is steady progress of labour, the maternal

and fetal conditions are good, and there is less than

3+ moulding.

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