Intrapartum Care: Introduction


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Intrapartum Care was developed for doctors and advanced midwives who care for women who deliver in district hospitals. It contains theory chapters and skills workshops adapted from the labour chapters of Maternal Care. Monitoring the mother, fetus, and progress of labour, the second and third stages of labour, managing pain, the puerperium and family planning

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Intrapartum Care: Introduction

  1. 1. IntrapartumCareA learning programmefor professionalsDeveloped by thePerinatal Education Programme
  2. 2. Intrapartum CareA learning programmefor professionalsDeveloped by thePerinatal Education
  3. 3. VERY IMPORTANTWe have taken every care to ensure that drugdosages and related medical advice in this bookare accurate. However, drug dosages can changeand are updated often, so always double-checkdosages and procedures against a reliable,up-to-date formulary and the given drug‘sdocumentation before administering it.Intrapartum Care:A learning programme for professionalsUpdated 18 May 2010First published by EBW Healthcare in 2009Text © Perinatal Education Programme 2009Illustrations by Anne WestobyGetup © Electric Book Works 2009ISBN (print edition): 978-1-920218-38-6ISBN (PDF ebook edition): 978-1-920218-39-3All text in this book excluding the tests andanswers is published under the Creative CommonsAttribution Non-Commercial No DerivativesLicense. You can read up about this license at multiple-choice tests and answers in thispublication may not be reproduced, stored in aretrieval system, or transmitted in any form or byany means without the prior permission of ElectricBook Works, 87 Station Road, Observatory, CapeTown, 7925.Visit our websites at www.electricbookworks.comand
  4. 4. ContentsContents 3 Case study 2 32 Case study 3 33Acknowledgements 7 3 Monitoring and management of theIntroduction 9 first stage of labour 34 About the EBW Healthcare series 9 The diagnosis of labour 34 Why decentralised learning? 9 The two phases of the first stage of labour 34 Books in the EBW Healthcare series 9 Monitoring of the first stage of labour 35 Format of the courses 11 Management of a patient in the latent Contributors 12 phase of the first stage of labour 36 Updating the course material 13 Management of a patient in the active Contact information 13 phase of the first stage of labour 38 Poor progress in the active phase of the1 Monitoring the condition of the mother first stage of labour 40during the first stage of labour 15 Cephalopelvic disproportion 43 Monitoring labour 15 Inadequate uterine action 44 Assessing the general condition of the The referral of women with poor mother 16 progress during the active phase of Assessing the temperature 17 the first stage of labour 45 Assessing the pulse rate 19 Prolapse of the umbilical cord 46 Assessing the blood pressure 19 Case study 1 47 Assessing the urine 20 Case study 2 47 Maternal exhaustion 21 Case study 3 48 Case study 1 22 Case study 4 49 Case study 2 22 3A Skills workshop: Examination of the2 Monitoring the condition of the fetus abdomen in labour 50during the first stage of labour 24 Abdominal palpitation 50 Monitoring the fetus 24 Assessing contractions 53 Fetal heart rate patterns 26 Assessing the fetal heart rate 53 Managing a woman with an abnormal fetal heart rate pattern 30 The liquor 31 Case study 1 32
  5. 5. 4 INTRAPAR TUM CARE3B Skills workshop: Vaginal examination Case study 3 103in labour 54 Case study 4 104 Preparation for a vaginal examination in labour 54 6 Managing pain during labour 105 Procedure of examination 55 Pain relief in labour 105 The vulva and vagina 55 Use of analgesics in labour 106 The cervix 55 Naloxone 108 The membranes and liquor 56 Sedatation in labour 109 The presenting part 56 Inhalational analgesia 109 Moulding 60 Local anaesthesia 110 Epidural anaesthesia 1103C Skills workshop: Recording General anaesthesia 111observations on the partogram 62 Case study 1 111 The partogram 62 Case study 2 112 Recording the condition of the mother 62 Case study 3 113 Recording the condition of the fetus 62 Case study 4 113 Recording the progress of labour 64 Exercises on the correct use of the 7 The puerperium 115 partogram 66 The normal puerperium 115 Case study 1 66 Management of the puerperium 117 Case study 2 69 Puerperal pyrexia 120 Case study 3 70 Thromboembolism 123 Puerperal psychiatric disorders 1244 The second stage of labour 73 Secondary postpartum haemorrhage 125 The normal second stage of labour 73 Self-monitoring 125 Managing the second stage of labour 74 Case study 1 126 Episiotomy 77 Case study 2 126 Prolonged second stage of labour 78 Case study 3 127 Management of impacted shoulders 79 Case study 4 127 Managing the newborn infant 80 Case study 1 80 8 Family planning after pregnancy 130 Case study 2 81 Contraceptive counselling 130 Case study 3 82 Contraception after delivery 132 Case study 4 82 Case study 1 136 Case study 2 1364A Skills workshop: Performing and Case study 3 137repairing an episiotomy 84 Case study 4 137 Performing an episiotomy 84 Repairing an episiotomy 85 Tests 139 Test 1: Monitoring the condition of the5 The third stage of labour 90 mother during the first stage of labour 139 The normal third stage of labour 90 Test 2: Monitoring the condition of the Managing the third stage of labour 91 fetus during the first stage of labour 141 Examination of the placenta after birth 94 Test 3: Monitoring and management The abnormal third stage of labour 94 of the first stage of labour 143 Managing a postpartum haemorrhage 95 Test 4: The second stage of labour 146 Protecting the staff from HIV infection Test 5: The third stage of labour 149 during labour 102 Test 6: Managing pain during labour 152 Case study 1 102 Test 7: The puerperium 155 Case study 2 103 Test 8: Family planning after pregnancy 157
  6. 6. AcknowledgementsIntrapartum Care has been edited from Editor-in-Chief of the Perinatal Educationselected units of the Maternal Care manual Programme: Prof D L Woodsof the Perinatal Education Programme. This Editors of Intrapartum Care: Prof G B Theronlearning programme for professionals is and Prof R C Pattinsondeveloped by the Perinatal Education Trustand funded by Eduhealthcare. Contributors to Intrapartum Care: Prof H van C de Groot, Dr D H Greenfield, Ms H Louw,We acknowledge all the participants of the Prof G B Theron, Prof D L WoodsPerinatal Education Programme who havemade suggestions and offered constructivecriticism. It is only through constant feedbackfrom colleagues and participants that thecontent of the Perinatal Education Programmecourses can be improved.
  7. 7. IntroductionABOUT THE EBW WHY DECENTRALISEDHEALTHCARE SERIES LEARNING?EBW Healthcare publishes an innovative Continuing education for healthcare workersseries of distance-learning books for traditionally consists of courses and workshopshealthcare professionals, developed by the run by formal trainers at large central hospitals.Perinatal Education Trust, Eduhealthcare, These teaching courses are expensive to attend,the Desmond Tutu HIV Foundation and the often far away from the healthcare workers’Desmond Tutu TB Centre, with contributions family and places of work, and the contentfrom numerous experts. frequently fails to address the real healthcare requirements of the poor, rural communitiesOur aim is to provide appropriate, affordable who face the biggest healthcare challenges.and up-to-date learning material forhealthcare workers in under-resourced areas, To help solve these many problems, a self-so that they can manage their own continuing help decentralised learning method has beeneducation courses which will enable them to developed which addresses the needs oflearn, practise and deliver skillful, efficient professional healthcare workers, especiallypatient care. those in poor, rural communities.The EBW Healthcare series is built onthe experience of the Perinatal EducationProgramme (PEP), which has provided BOOKS IN THE EBWlearning opportunities to over 60 000 nurses HEALTHCARE SERIESand doctors in South Africa since 1992. Manyof the educational methods developed by PEPare now being adopted by the World Health Maternal Care addresses all the commonOrganisation (WHO). 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
  8. 8. 10 INTRAPAR TUM CAREthe progress of labour, specific medical glucose concentration, insertion of an umbilicalproblems during pregnancy, labour and the vein catheter, phototherapy, apnoea monitorspuerperium, family planning and regionalised and oxygen therapy.perinatal care. Skills workshops teach clinicalexamination in pregnancy and labour, routine Primary Newborn Care was writtenscreening tests, use of an antenatal card specifically for nurses and doctors whoand partogram, measuring blood pressure, provide primary care for newborn infants indetecting proteinuria and performing and level 1 clinics and hospitals. Primary Newbornrepairing an episiotomy. Care addresses the care of infants at birth, care of normal infants, care of low-birth-weightMaternal Care is aimed at healthcare workers infants, neonatal emergencies, and commonin level 1 hospitals or clinics. minor problems in newborn infants.Primary Maternal Care addresses the Mother and Baby Friendly Care describesneeds of healthcare workers who provide gentler, kinder, evidence-based ways of caringantenatal and postnatal care, but do not for women during pregnancy, labour andconduct deliveries. It is adapted from theory delivery. It also presents improved methodschapters and skills workshops from Maternal of providing infant care with an emphasisCare. This book is ideal for midwives and on kangaroo mother care and exclusivedoctors providing primary maternal care level 1 district hospitals and clinics,and complements the national protocol of Saving Mothers and Babies was developed inantenatal care in South Africa. response to the high maternal and perinatal mortality rates found in most developingIntrapartum Care was developed for doctors countries. Learning material used in the book isand advanced midwives who care for women based on the results of the annual confidentialwho deliver in district hospitals. It contains enquiries into maternal deaths and the Savingtheory chapters and skills workshops adapted Mothers and Saving Babies reports published infrom the labour chapters of Maternal Care. South Africa. It addresses the basic principlesParticular attention is given to the care of mortality audit, maternal mortality,of the mother, the management of labour perinatal mortality, managing mortalityand monitoring the wellbeing of the fetus. meetings and ways of reducing maternal andIntrapartum Care was written to support perinatal mortality rates. This book shouldand complement the national protocol of be used together with the Perinatal Problemintrapartum care in South Africa. Identification Programme (PPIP).Newborn Care was written for healthcare Birth Defects was written for healthcareworkers providing special care for newborn workers who look after individuals with birthinfants in regional hospitals. It covers defects, their families, and women who are atresuscitation at birth, assessing infant size and increased risk of giving birth to an infant with agestational age, routine care and feeding of both birth defect. Special attention is given to modesnormal and high-risk infants, the prevention, of inheritance, medical genetic counselling,diagnosis and management of hypothermia, and birth defects due to chromosomalhypoglycaemia, jaundice, respiratory distress, abnormalities, single gene defects, teratogensinfection, trauma, bleeding and congenital and multifactorial inheritance. This bookabnormalities, as well as communication with is being used in the Genetics Educationparents. Skills workshops address resuscitation, Programme which trains healthcare workers insize measurement, history, examination and genetic counselling in South Africa.clinical notes, nasogastric feeds, intravenousinfusions, use of incubators, measuring blood
  9. 9. INTRODUCTION 11Perinatal HIV enables midwives, nurses and nurses with wide experience in the careand doctors to care for pregnant women and of adults with HIV, through the auspices oftheir infants in communities where HIV the Desmond Tutu HIV Foundation at theinfection is common. Special emphasis has University of Cape Town.been placed on the prevention of mother-to-infant transmission of HIV. It covers the basicsof HIV infection and screening, antenatal FORMAT OF THE COURSESand intrapartum care of women with HIVinfection, care of HIV-exposed newborninfants, and parent counselling. 1. Objectives The learning objectives are clearly stated at theChildhood HIV enables nurses and doctors start of each chapter. They help the participantto care for children with HIV infection. It to identify and understand the importantaddresses an introduction to HIV in children, lessons to be learned.the clinical and immunological diagnosisof HIV infection, management of childrenwith and without antiretroviral treatment, 2. Pre- and post-testsantiretroviral drugs, opportunistic infections There is a multiple-choice test of 20 questionsand end-of-life care. for each chapter at the end of the book. Participants are encouraged to take a pre-testChildhood TB was written to enable before starting each chapter, to benchmarkhealthcare workers to learn about the primary their current knowledge, and a post-test aftercare of children with tuberculosis. The book each chapter, to assess what they have learned.covers an introduction to TB infection,and the clinical presentation, diagnosis, Self-assessment allows participants to monitormanagement and prevention of tuberculosis in their own progress through the course.children and HIV/TB co-infection. ChildhoodTB was developed by paediatricians with 3. Question-and-answer formatwide experience in the care of children with Theoretical knowledge is presented in atuberculosis, through the auspices of the question-and-answer format, which encouragesDesmond Tutu Tuberculosis Centre at the the learner to actively participate in theUniversity of Stellenbosch. learning process. In this way, the participant is led step by step through the definitions,Child Healthcare addresses all the common causes, diagnosis, prevention, dangers andand important clinical problems in children, management of a particular problem.including immunisation, history andexamination, growth and nutrition, acute Participants should cover the answer for a fewand chronic infections, parasites, and skin minutes with a piece of paper while thinkingconditions, as well as difficulties in the home about the correct reply to each question. Thisand society. Child Healthcare was developed method helps learning.for use in primary care settings. Simplified flow diagrams are also used, where necessary, to indicate the correct approach toAdult HIV covers an introduction to HIV diagnosing or managing a particular problem.infection, management of HIV-infected adultsat primary-care clinics, preparing patients forantiretroviral (ARV) treatment, ARV drugs, Each question is written in bold,starting and maintaining patients on ARV like this, and is identified with thetreatment and an approach to opportunistic number of the chapter, followed by theinfections. Adult HIV was developed by doctors number of the question, e.g. 5-23.
  10. 10. 12 INTRAPAR TUM CARE4. Important lessons Participants need to achieve at least 80% in the examination in order to successfully complete the course. Successful candidates Important practical lessons are emphasised by will be emailed a certificate which states placing them in a box like this. that they have successfully completed that course. EBW Healthcare courses are5. Notes not yet accredited for nurses, but South African doctors can earn CPD points on the NOTE Additional, non-essential information is successful completion of an examination. provided for interest and given in notes like this. These facts are not used in the case studies or Please contact or included in the multiple-choice questions. +27 021 44 88 336 when you are ready to take the exam.6. Case studiesEach chapter closes with a few case CONTRIBUTORSstudies which encourage the participantto consolidate and apply what was learned The developers of our learning materials are aearlier in the chapter. These studies give the multi-disciplinary team of nurses, midwives,participant an opportunity to see the problem obstetricians, neonatologists, and generalas it usually presents itself in the clinic or paediatricians. The development and review ofhospital. The participant should attempt to all course material is overseen by the Editor-answer each question in the case study before in-Chief, emeritus Professor Dave Woods,reading the correct answer. a previous head of neonatal medicine at the University of Cape Town who now consults to7. Practical training UNICEF and the WHO.Certain chapters contain skills workshops,which need to be practised by the participants Perinatal Education Trust(preferably in groups). The skills workshops, Books developed by the Perinatal Educationwhich are often illustrated with line drawings, Programme are provided as cheaply as possible.list essential equipment and present step-by- Writing and updating the programme is bothstep instructions on how to perform each funded and managed on a non-profit basis bytask. If participants aren’t familiar with a the Perinatal Education Trust.practical skill, they are encouraged to ask anappropriate medical or nursing colleague todemonstrate the clinical skill to them. In this Eduhealthcareway, senior personnel are encouraged to share Eduhealthcare is a non-profit organisationtheir skills with their colleagues. based in South Africa. It aims to improve health and wellbeing, especially in poor communities,8. Final examination through affordable education for healthcare workers. To this end it provides financialOn completion of each course, participants support for the development and publishing ofcan take a 75-question multiple-choice the EBW Healthcare series.examination on the EBW Healthcare website,when they are ready to. The Desmond Tutu HIV FoundationAll the exam questions will be taken fromthe multiple-choice tests from the book. The The Desmond Tutu HIV Foundation at thecontent of the skills workshops will not be University of Cape Town, South Africa, is aincluded in the examination. centre of excellence in HIV medicine, building
  11. 11. INTRODUCTION 13capacity through training and enhancing CONTACT INFORMATIONknowledge through research.The Desmond Tutu Tuberculosis Centre EBW HealthcareThe Desmond Tutu Tuberculosis Centre at Website: www.ebwhealthcare.comStellenbosch University, South Africa, strives Email: info@ebwhealthcare.comto improve the health of vulnerable groupsthrough the education of healthcare workers Telephone: +27 021 44 88 336and community members, and by influencing Fax: +27 088 021 44 88 336policy based on research into the epidemiologyof childhood tuberculosis, multi-drug- Post: 87 Station Road, Observatory, 7925,resistant tuberculosis, HIV/TB co-infection Cape Town, South Africaand preventing the spread of TB and HIV insouthern African. Editor-in-Chief: Professor Dave Woods Website: THE Email: MATERIAL Telephone: +27 021 786 5369 Fax: +27 021 671 8030EBW Healthcare learning materials Post: Perinatal Education Programme, PO Boxare regularly updated to keep up with 34502, Groote Schuur, Observatory, 7937,developments and changes in healthcare South Africaprotocols. Course participants can makeimportant contributions to the continualimprovement of EBW Healthcare booksby reporting factual or language errors,by identifying sections that are difficult tounderstand, and by suggesting additions orimprovements to the contents. Details ofalternative or better forms of managementwould be particularly appreciated. Please sendany comments or suggestions to the Editor-in-Chief, Professor Dave Woods.
  12. 12. 1 Monitoring the condition of the mother during the first stage of labourBefore you begin this unit, please take the MONITORING LABOURcorresponding test at the end of the book toassess your knowledge of the subject matter. Youshould redo the test after you’ve worked through 1-1 What is labour?the unit, to evaluate what you have learned Labour is the process whereby the fetus and the placenta are delivered. The uterine Objectives contractions cause the cervix to dilate and eventually push the fetus and placenta through the cervix and out of the vagina. Traditionally When you have completed this unit you labour is divided into different stages. should be able to: • Monitor the condition of the mother 1-2 What are the stages of labour? during the first stage of labour. Labour is divided into three stages: • Record the clinical observations on the 1. The first stage of labour. partogram. 2. The second stage of labour. • Explain the clinical significance of these 3. The third stage of labour. observations. Each stage of labour is important as it must • Manage any problems which are be correctly diagnosed and managed. There detected. are dangers to the mother in each of the three stages of labour. Labour is divided into three stages.
  13. 13. 16 INTRAPAR TUM CARE1-3 What is the first stage of labour? 3. Finally you must ask the question: ‘What must I do about the problem?’.The first stage of labour starts with the onsetof regular uterine contractions and ends whenthe cervix is fully dilated. 1-9 How is the condition of the mother monitored?1-4 What must be monitored in By regular observations of the following:the first stage of labour? 1. The general condition of the mother.1. The condition of the mother. 2. Temperature.2. The condition of the fetus. 3. Pulse rate.3. The progress of labour. 4. Blood pressure. 5. Urine output and urinalysis for protein and1-5 What four questions should be asked ketones.about each of these observations? Therefore, the general condition of the mother,1. How often must the observations be done? as well as observations of her temperature,2. How are the findings recorded? pulse rate, blood pressure, urine volume and3. What is the clinical significance of the chemistry must be recorded on the partogram. findings?4. What should be done if an observation is abnormal? ASSESSING THE GENERAL CONDITION1-6 What is the partogram? OF THE MOTHERThe partogram is a chart which shows theprogress of labour over time. It also displaysobservations reflecting the maternal and fetal 1-10 Why is it important to observecondition as well as the progress of labour. The the general condition of the motherobservations of every woman in the first stage during the first stage of labour?of labour must be charted on a partogram. If the general condition of the mother is not normal, there will usually be further abnormal1-7 What maternal observations findings when the other observations are made.are recorded on the partogram?All the maternal observations must be 1-11 When can the general condition ofcarefully recorded on the partogram. the mother be regarded as normal? A woman in the first stage of labour will All the observations of every mother in the first normally appear calm and relaxed between stage of labour must be recorded on a partogram. contractions and does not look pale. During contractions, her respiratory rate will increase and she will experience pain. However, she1-8 How should each should not have pain between contractions.observation be assessed? When a woman’s cervix is fully dilated, orAt the completion of any set of observations, almost fully dilated, she becomes restless, mayyou must ask yourself the following questions: vomit, and has an uncontrollable urge to bear down with contractions.1. Is everything normal? If the answer is no, then you must ask:2. What is not normal and why is it not normal?
  14. 14. MONITORING THE CONDITION OF THE MOTHER DURING THE FIRST STAGE OF LABOUR 171-12 How often should the general 1-17 When may severe exhaustioncondition of the mother be observed? or dehydration occur?The general condition of the mother should With a prolonged labour, e.g. withbe observed continuously, but noted specially cephalopelvic disproportion.when other observations are made. 1-18 What may cause a pale face1-13 When is the general condition and mucous membranes?of the mother abnormal? This is usually due to either of the following:When any of the following are present: 1. Chronic anaemia, e.g. iron deficiency,1. Excessive anxiety. malaria, etc.2. Severe, continuous pain. 2. Blood loss, e.g. placenta praevia, abruptio3. Severe exhaustion. placentae or rupture of the uterus.4. Dehydration.5. Marked pallor of the face and mucous 1-19 Where must abnormalities in the membranes. mother’s general condition be recorded? If the general condition of the woman1-14 What causes severe anxiety? becomes abnormal, this must be noted inAnxiety is usually seen in primigravidas who: the appropriate space at the bottom of the partogram as shown in figure 1-1.1. Are not prepared for the process of labour and the labour ward.2. Are not accompanied by a friend or family member in the labour ward. ASSESSING THE3. Cannot communicate due to language TEMPERATURE differences.1-15 What should you do if the mother 1-20 What is a normal temperature?is very anxious and is experiencing The normal range of oral temperature is 36.0 tovery painful contractions? 37.0 °C. Therefore, a temperature higher than1. She must be comforted and reassured. If 37.0 °C is abnormal and is regarded as pyrexia. possible, someone she knows should stay with her. 1-21 How often should you2. She must be offered appropriate pain relief. monitor the temperature? Four hourly, unless there is a particular reason1-16 What causes severe, continuous to do so more frequently.pain in the first stage of labour?Severe, continuous pain always indicates that a 1-22 How is the temperature recorded?complication is present, such as: The temperature is recorded in the appropriate1. Abruptio placentae. space on the partogram as shown in figure 1-1.2. Rupture of the uterus.3. An infection, such as acute pyelonephritis 1-23 What are the causes of and chorioamnionitis. pyrexia during labour? There are two main causes of a high maternal temperature:
  15. 15. 18 INTRAPAR TUM CAREFigure 1-1: Recording maternal observations on the partogram1. Infection: This will most probably be in the 1-25 What are the dangers of pyrexia? urogenital tract, e.g. acute pyelonephritis 1. To the mother: The temperature, on its or chorioamnionitis. However, it must own, does not constitute a risk. However, be remembered that any other infection, if the pyrexia is caused by an infection, the unrelated to the pregnancy, may be present infection may be dangerous to the mother. during labour, e.g. pneumonia, viral Fever may cause a woman to go into labour. infections or malaria. 2. To the fetus: A high temperature can cause2. Maternal exhaustion: Dehydration causes fetal tachycardia (fast heart rate). Preterm pyrexia. delivery with complications of immaturity in the newborn infant may also result. If1-24 How should you manage the pyrexia is due to chorioamnionitis, thematernal pyrexia? fetus is at high risk of becoming infected1. The cause of the high temperature must and may present with pneumonia. be found and treated. It is particularly important to look for acute pyelonephritis, chorioamnionitis and evidence of maternal exhaustion.2. The temperature may be brought down with paracetamol (e.g. Panado).
  16. 16. MONITORING THE CONDITION OF THE MOTHER DURING THE FIRST STAGE OF LABOUR 19ASSESSING THE 1-32 How often should you monitor the blood pressure?PULSE RATE Blood pressure is monitored two-hourly during the latent phase of labour and hourly1-26 What is the normal during the active phase of labour.maternal pulse rate? 1-33 How is the blood pressure recorded?The normal range of the maternal pulse rate is80 to 100 beats per minute. The blood pressure is recorded in the appropriate space on the partogram as shown1-27 How often should you in figure 1-1.monitor the pulse rate? 1-34 What are the causes ofThe pulse rate is monitored two-hourly during hypertension (high blood pressure)?the latent phase of labour, and hourly duringthe active phase of the first stage of labour. 1. Anxiety. 2. Pain.1-28 How is the pulse rate recorded? 3. Any one of the hypertensive disorders of pregnancy.The pulse rate is recorded in the appropriatespace on the partogram as shown in figure 1-1. 1-35 What are the causes of hypotension (low blood pressure)?1-29 What are the causes ofa rapid pulse rate? 1. Some women may normally have a low blood pressure. Therefore, the bloodThe commonest causes of a rapid pulse rate pressure during labour must be compared(tachycardia) are: with that recorded during the antenatal1. Anxiety. visits.2. Pain 2. Pressure of the uterus on the inferior vena3. Pyrexia. cava when the woman lies on her back may4. Exhaustion. decrease the venous return to the heart5. Shock. and, thereby, cause the blood pressure to fall. This is called supine hypotension.1-30 What action should be taken if 3. Shock. This is usually due to blood loss.the mother has a fast heart rate? 1-36 What are the risks of hypotension?The cause of the tachycardia should bedetermined and treated. 1. To the mother: If hypotension is due to shock, the mother may suffer kidney damage. Severe and uncorrectedASSESSING THE hypotension may result in maternal death. 2. To the fetus: A fall in blood pressure resultsBLOOD PRESSURE in decreased blood flow to the placenta, reducing the supply of oxygen to the fetus. This may cause fetal distress due to hypoxia.1-31 What is a normal blood pressure?The normal range of blood pressure during thefirst stage of labour is 100/60 mm Hg or above,but less than 140/90 mm Hg.
  17. 17. 20 INTRAPAR TUM CARE1-37 What should you do for a 1-41 How often should you test the urine?mother with hypotension? 1. Every four hours during the latent phase of1. Establish the cause of the hypotension. labour.2. If the hypotension is due to the woman 2. Every two hours during the active phase of lying on her back, she should be turned labour. onto her side. The blood pressure usually 3. Each time the woman passes urine, if more returns to normal within one to two frequently than above. minutes. The fetal heart rate should then be checked again. 1-42 How are the urinary3. If the hypotension is due to haemorrhage, observations recorded? the woman must be resuscitated urgently and be managed according to the cause of The observations are recorded on the the bleeding. partogram: 1. Volume in ml.1-38 How do you recognise shock? 2. Protein and ketones are recorded as 0 if absent and 1+ to 4+ if present.Shock presents with one or more of thefollowing features: The urinary observations should be recorded on the partogram as shown in figure 1-1.1. Tachycardia.2. Hypotension. NOTE If the reagent strip also tests for blood and3. The skin feels cold and sweaty. glucose, this information should be recorded on the partogram. However, microscopic1-39 What are the common causes of hematuria is often present during labour andshock in the first stage of labour? most women with an infusion containing 5% dextrose will have glucosuria present.1. Shock during the first stage of labour is almost always due to haemorrhage, for 1-43 What volume of urine passed indicates example: oliguria (decreased urine output)? • Abruptio placentae. • Placenta praevia. An amount of less than 20 ml per hour. • A ruptured uterus.2. Infection as a cause of shock must always 1-44 What are the causes of oliguria? be considered. 1. Dehydration. 2. Severe pre-eclampsia.ASSESSING THE URINE 3. Shock. Women suffering from any of these conditions must have their urinary output accurately1-40 What urine tests should monitored. An indwelling urinary catheterbe done during labour? must, therefore, be passed.1. Volume. The cause of the oliguria must be diagnosed2. Protein. and treated.3. Ketones.The presence and degree of proteinuria and 1-45 How can normal hydrationketonuria is measured and graded with a during labour be ensured?reagent strip, e.g. Dipstix. 1. If a vaginal delivery is expected, the woman should be encouraged to eat and
  18. 18. MONITORING THE CONDITION OF THE MOTHER DURING THE FIRST STAGE OF LABOUR 21 drink during the latent phase of the first 1-48 How do you recognise stage of labour. maternal exhaustion?2. If a Caesarean section is expected during The following physical signs of maternal labour, the woman must be kept nil per exhaustion may be present: mouth while being prepared for surgery.3. Women who are at low risk of problems 1. Tachycardia. must continue taking fluids, while women 2. Pyrexia. with risk factors should be kept nil per 3. A dry mouth. mouth, during the active phase of the first 4. Oliguria. stage of labour. Intravenous fluids must be 5. Ketonuria. given to women with risk factors as well as to women with long labours. 1-49 What causes maternal exhaustion? A long labour with an insufficient supply of Always ensure that a mother in labour has an fluid and energy to the woman. adequate fluid intake. Fluids should be given intravenously if necessary. 1-50 What are the effects of maternal exhaustion?1-46 What is the significance of proteinuria? 1. On the mother: Inadequate progress of labour due to poor uterine action in the firstProteinuria of more than a trace is never stage, and poor maternal effort in bearingnormal. It is an important sign of: down during the second stage of labour.1. Pre-eclampsia. 2. On the fetus: Fetal distress due to hypoxia.2. Urinary tract infection. This often results from incorrectly3. Renal disease. managed cephalopelvic disproportion.When there is proteinuria, the urine mustalways be examined for evidence of infection. 1-51 How can you preventHowever, infection alone will not cause more maternal exhaustion?than 1+ proteinuria. Proteinuria of 2+ or more 1. Make sure that the woman gets anshould always be regarded as indicating pre- adequate intake of fluid and energy duringeclampsia or chronic renal disease. labour. It may be necessary to give fluid intravenously. Ringer’s lactate with 5%1-47 What is the clinical dextrose will also ensure an adequatesignificance of ketonuria? energy supply to the woman.Ketonuria is common in labour and may be 2. Ensure that the woman gets adequatenormal. However, if a woman has ketonuria, analgesia during is important to look for signs of maternal 3. Ensure that labour does not becomeexhaustion. prolonged. 1-52 How do you treat a motherMATERNAL EXHAUSTION with maternal exhaustion? If a woman has signs of maternal exhaustionMaternal exhaustion is a term used to then she should receive:describe a clinical condition, consisting of 1. An intravenous infusion, giving two litresdehydration and exhaustion during prolonged of Ringer’s lactate with 5% dextrose. Thelabour. It should not be confused with pain, first litre must be given quickly and theanxiety or shock. second litre given over two hours. It is
  19. 19. 22 INTRAPAR TUM CARE contraindicated to give a woman in labour 5. What are the dangers of 50 ml of 50% dextrose intravenously as this maternal pyrexia to the fetus? may be harmful to the fetus. Pyrexia may cause preterm labour, resulting2. Adequate analgesia. in the delivery of a preterm infant with all the complications of immaturity. If the pyrexia Maternal exhaustion may result in poor progress is due to chorioamnionitis a preterm infant of labour, while poor progress of labour may will be born with a high risk of congenital result in maternal exhaustion. pneumonia.1-53 Is it necessary for every mother to CASE STUDY 2receive intravenous fluid during labour?No. Low risk women who are progressing A woman is admitted to hospital with a historywell in labour do not need intravenous fluid, of labour for 24 hours. On admission sheeven if 1+ or 2+ ketonuria is present. If there appears anxious, has a dry mouth and a pulseare no contraindications, women should be rate of 120 beats per minute. She is able to passencouraged to take oral fluids during labour. only 30 ml of urine which is dark in colour. She had not passed any urine for the previous few hours.CASE STUDY 1 1. What is the probable diagnosis?A woman is admitted at 32 weeks gestation. Maternal exhaustion due to a long labourShe complains of lower abdominal pain and with an inadequate fluid and energy intake.fever. On general examination her temperature The diagnosis is confirmed by the presence ofis 38 °C. maternal tachycardia and a dry mouth.1. Does this woman have a 2. What other findings wouldnormal temperature? help confirm this diagnosis?No. She is pyrexial as her temperature is Pyrexia and ketonuria.higher than 37 °C. 3. Does this woman have oliguria?2. Where should hertemperature be recorded? Yes, as she obviously has passed less than 20 ml per hour during the past number of hours.In the appropriate space on the partogram. 4. Is ketonuria always abnormal?3. What are the most likelycauses of her pyrexia? No, ketonuria on its own may be normal.Acute pyelonephritis or chorioamnionitis asshe has pyrexia with lower abdominal pain. 5. How could maternal exhaustion be avoided?4. How should you manage By making sure that every woman receivesthis woman’s pyrexia? an adequate intake of fluid and energy during labour. If a vaginal delivery is expected and noDiagnose and treat the cause of the high high risk factors are present, a woman shouldtemperature. The temperature should be continue to take fluids orally during the activebrought down with paracetamol. phase of the first stage of labour. Any woman
  20. 20. MONITORING THE CONDITION OF THE MOTHER DURING THE FIRST STAGE OF LABOUR 23with prolonged labour should receive fluidsintravenously.6. How should the woman’sexhaustion be treated?She should be given two litres of Ringer’slactate with 5% dextrose intravenously. Thefirst litre must be given quickly and the secondlitre over two hours. In addition, adequateanalgesia should be given if needed.
  21. 21. 2 Monitoring the condition of the fetus during the first stage of labourBefore you begin this unit, please take the MONITORING THE FETUScorresponding test at the end of the book toassess your knowledge of the subject matter. Youshould redo the test after you’ve worked through 2-1 Why should you monitorthe unit, to evaluate what you have learned the fetus during labour? It is essential to monitor the fetus during Objectives labour in order to assess the response to the stresses of labour. The stress of a normal labour usually has no effect on a healthy fetus. When you have completed this unit you should be able to: 2-2 What may stress the • Monitor the condition of the fetus fetus during labour? during labour. 1. Compression of the fetal head during • Record the findings on the partogram. contractions. • Understand the significance of the 2. A decrease in the supply of oxygen to the findings. fetus. • Understand the causes and signs of fetal 2-3 How does head compression distress. stress the fetus? • Interpret the significance of different fetal heart rate patterns and meconium- Uterine contractions may compress the fetal head and cause slowing of the fetal heart rate. stained liquor. Head compression usually does not harm the • Manage any abnormalities which are fetus. detected. NOTE Slowing of the fetal heart is due to vagal stimulation. With a long labour due to cephalopelvic disproportion, compression
  22. 22. MONITORING THE CONDITION OF THE FETUS DURING THE FIRST STAGE OF LABOUR 25 of the fetal head can be severe and 2-6 When do uterine contractions reduce repeated. This may result in fetal distress. the supply of oxygen to the fetus? Usually uterine contractions do not reduce2-4 What may reduce the supply the supply of oxygen to the fetus, as there is anof oxygen to the fetus? adequate store of oxygen in the placental blood1. Uterine contractions: Uterine contractions to meet the fetal needs during the contraction. are the commonest cause of a decrease Normal contractions in labour do not affect in the oxygen supply to the fetus during the healthy fetus with a normally functioning labour. placenta, and, therefore, are not dangerous.2. Abnormal uterine blood vessels: The However, contractions may reduce the oxygen placenta may fail to provide the fetus with supply to the fetus when: enough oxygen and nutrition due to a decrease in the blood flow through the 1. There is placental insufficiency. uterine blood vessels to the placenta, i.e. 2. The contractions are prolonged or very placental insufficiency. Women with pre- frequent. eclampsia have poorly formed, narrow 3. There is compression of the umbilical cord. spiral arteries that provide inadequate amounts of maternal blood to the 2-7 How does the fetus respond placenta. Maternal smoking can also cause to a lack of oxygen? narrowing of the uterine blood vessels. A reduction in the normal supply of oxygen to3. Abruptio placentae: Part or all of the the fetus causes fetal hypoxia. This is a lack of placenta stops functioning because it oxygen in the cells of the fetus. If the hypoxia is separated from the uterine wall by a is mild the fetus will be able to compensate retroplacental haemorrhage. There is also and, therefore, show no response. However, spasm of the uterus which reduces the severe fetal hypoxia will result in fetal distress. amount of maternal blood reaching the Severe, prolonged hypoxia will eventually placenta. As a result the fetus does not result in fetal death. receive enough oxygen.4. Cord prolapse or compression: This stops the fetal blood flow and transport of 2-8 How is fetal distress oxygen from the placenta to the fetus. recognised during labour? Fetal distress caused by a lack of oxygen results Uterine contractions are the commonest cause in a decrease in the fetal heart rate. The fetus responds to hypoxia with a bradycardia to of a decreased oxygen supply to the fetus conserve oxygen. during labour. 2-9 How do you assess the condition2-5 How do contractions reduce the of the fetus during labour?supply of oxygen to the fetus? Two observations are used:Uterine contractions may: 1. The fetal heart rate pattern.1. Reduce the maternal blood flow to the 2. The presence or absence of meconium in placenta due to the increase in intra- the liquor. uterine pressure.2. Compress the umbilical cord.
  23. 23. 26 INTRAPAR TUM CAREFETAL HEART RATE 2-12 How often should you monitor the fetal heart rate?PATTERNS Low risk patients who have had normal observations on admission:2-10 What devices can be used to 1. Two hourly during the latent phase ofmonitor the fetal heart rate? labour.Any one of the following three pieces of 2. Half hourly during the active phase ofequipment: labour.1. A fetal stethoscope. Women with a high risk of fetal distress should2. A ‘doptone’ (Doppler ultrasound fetal heart have their observations done more frequently. rate monitor). The following women would be regarded as at3. A cardiotocograph (CTG machine). higher risk:In most low risk labours the fetal heart rate is 1. Intermediate risk patients.determined using a fetal stethoscope. However, 2. High risk patients.a doptone is helpful if there is difficulty 3. Patients with abnormal observations onhearing the fetal heart, especially if distress or admission.intra-uterine death is suspected. If available, 4. Patients with meconium-stained liquor.a doptone is the preferred method in primary These women need more frequent recording ofcare clinics and hospitals. Cardiotocograph the fetal heart rate:is not needed in most labours but is animportant and accurate method of monitoring 1. Hourly during the latent phase of labour.the fetal heart in high risk pregnancies. 2. Half hourly during the active phase of labour. 3. At least every 15 minutes if fetal distress is A doptone is the preferred method of assessing suspected. the fetal heart rate in primary care clinics and hospitals. 2-13 What features of the fetal heart rate pattern should you2-11 How should you monitor always assess during labour?the fetal heart rate? There are two features that should always beBecause uterine contractions may decrease assessed:the maternal blood flow to the placenta, and 1. The baseline fetal heart rate: This is thethereby cause a reduced supply of oxygen to heart rate between contractions.the fetus, it is essential that the fetal heart rate 2. The presence or absence of decelerations: Ifshould be monitored during a contraction. In present, the relation of the deceleration topractice, this means that the fetal heart pattern the contraction must be determined:must be checked before, during and after the • Decelerations that occur only during acontraction. A comment on the fetal heart contraction (i.e. early decelerations).rate, without knowing what happens during • Decelerations that occur duringand after a contraction, is almost valueless. and after a deceleration (i.e. late decelerations) The fetal heart rate must be assessed before, • Decelerations that have no fixed relation to contractions (i.e. variable during, and after a contraction. decelerations).
  24. 24. MONITORING THE CONDITION OF THE FETUS DURING THE FIRST STAGE OF LABOUR 27 NOTE In addition, the variability of the fetal heart 2-16 What are early decelerations? rate can also be evaluated if a cardiotocograph is available. Good variability gives a spiky trace Early decelerations are characterised by a while poor variability gives a flat trace. slowing of the fetal heart rate starting at the beginning of the contraction, and returning2-14 What fetal heart rate patterns to normal by the end of the contraction. Earlycan be recognised with a fetal decelerations are usually due to compressionstethoscope or doptone? of the fetal head which causes the heart rate to slow during the contraction.1. Normal.2. Early deceleration. 2-17 What is the significance3. Late deceleration. of early decelerations?4. Variable deceleration.5. Baseline tachycardia. Early decelerations do not indicate the6. Baseline bradycardia. presence of fetal distress. However, these fetuses must be carefully monitored as they areThese fetal heart rate patterns (with the at an increased risk of fetal distress.exception of variable decelerations) canbe easily recognised with a stethoscope NOTE When early decelerations are seen on aor doptone. However, cardiotocograph CTG trace, normal variability of the fetal heartrecordings (figures 2-1, 2-2 and 2-3) are rate is reassuring that the fetus is not hypoxic.useful in learning to recognise the differencesbetween the three types of deceleration. 2-18 What are late decelerations?It is common to get a combination of A late deceleration is a slowing of the fetalpatterns, e.g. a baseline bradycardia with late heart rate during a contraction, with the ratedecelerations. It is also common to get one only returning to the baseline 30 seconds orpattern changing to another pattern with more after the contraction has ended.time, e.g. early decelerations becoming latedecelerations. With a late deceleration the fetal heart rate only NOTE The variation in fetal heart rate normally returns to the baseline 30 seconds or more after exceeds five beats or more per minute, giving the contraction has ended. the baseline a spiky appearance on a CTG trace. A loss or reduction in beat-to-beat variation to below five beats per minute gives NOTE When using a cardiotocograph, a late a flat baseline (a ‘flat trace’) which suggests deceleration is diagnosed when the lowest fetal distress. However a flat baseline may also point of the deceleration occurs 30 seconds occur if the fetus is asleep or as the result of or more after the peak of the contraction. the administration of analgesics (pethidine, morphine) or sedatives (phenobarbitone). 2-19 What is the significance of late decelerations?2-15 What is a normal fetal Late decelerations are a sign of fetal distressheart rate pattern? and are caused by fetal hypoxia. The degree to1. No decelerations during or after which the heart rate slows is not important. It is contractions. the timing of the deceleration that is important.2. A baseline rate of 100 – 160 beats per minute. Late decelerations indicate fetal distress.
  25. 25. 28 INTRAPAR TUM CAREFigure 2-1: An early deceleration Figure 2-2: A late deceleration2-20 What are variable decelerations? 2-22 What are the causes of aVariable decelerations have no fixed baseline tachycardia?relationship to uterine contractions. Therefore, 1. Maternal pyrexia.the pattern of decelerations changes from one 2. Maternal exhaustion.contraction to another. Variable decelerations 3. Hexoprenaline (Ipradol) administration.are usually caused by compression of the 4. Chorioamnionitis (infection of theumbilical cord and do not indicate the placenta and membranes).presence of fetal distress. However, these 5. Fetal haemorrhage or anaemia.fetuses must be carefully monitored as they areat an increased risk of fetal distress. There is an increased risk of fetal distress if a fetal tachycardia is present.Variable decelerations are not easy torecognise with a fetal stethoscope or doptone. 2-23 What is a baseline bradycardia?They are best detected with a cardiotocograph. A baseline fetal heart rate of less than 100 NOTE Variable decelerations accompanied by beats per minute. loss of variability of the fetal heart rate may indicate fetal distress. Variable decelerations 2-24 What is the cause of a with good variability is reassuring. baseline bradycardia?2-21 What is a baseline tachycardia? A baseline bradycardia of less than 100 beats per minute usually indicates fetal distressA baseline fetal heart rate of more than 160 which is caused by severe fetal hypoxia. Ifbeats per minute. decelerations are also present, a baseline bradycardia indicates that the fetus is at great risk of dying.
  26. 26. MONITORING THE CONDITION OF THE FETUS DURING THE FIRST STAGE OF LABOUR 29 These fetal heart rate patterns do not indicate fetal distress but warn that the fetal heart rate must be closely observed as fetal distress may develop. If electronic monitoring (a cardiotocograph) is available, the fetal heart rate pattern must be monitored. 2-28 What fetal heart rate patterns indicate fetal distress during labour? 1. Late decelerations. 2. A baseline bradycardia. NOTE On cardiotocography loss of variability of the fetal heart rate lasting more than 60 minutes also suggests fetal distress. 2-29 How should the fetal heart rate pattern be observed during labour?Figure 2-3: Variable decelerations The fetal heart rate must be observed before, during and after a contraction. The following questions must be answered and recorded on2-25 How should you assess the the partogram:condition of the fetus on the basisof the fetal heart rate pattern? 1. What is the baseline fetal heart rate? 2. Are there any decelerations?1. The fetal condition is normal if a normal 3. If decelerations are observed, what is their fetal heart rate pattern is present. relation to the uterine contractions?2. The fetal condition is uncertain if the fetal 4. If the fetal heart rate pattern is abnormal, heart rate pattern indicates that there is an how must the patient be managed? increased risk of fetal distress.3. The fetal condition is abnormal if the fetal 2-30 Which fetal heart rate pattern heart rate pattern indicates fetal distress. indicates that the fetal condition is good?2-26 What is a normal fetal heart 1. The baseline fetal heart rate is normal.rate pattern during labour? 2. There are no decelerations.A normal baseline fetal heart rate without anydecelerations.2-27 Which fetal heart rate patternsindicate an increased risk of fetaldistress during labour?1. Early decelerations.2. Variable decelerations.3. A baseline tachycardia.
  27. 27. 30 INTRAPAR TUM CAREFigure 2-4: Recording fetal observations on the partogramMANAGING A WOMAN and stop the oxytocin infusion to prevent uterine overstimulation.WITH AN ABNORMAL 2. If the fetal bradycardia persists, intra-FETAL HEART uterine resuscitation of the fetus must be given and the fetus delivered as quick asRATE PATTERN possible. 2-33 How is fetal resuscitation given?2-31 What must be done ifdecelerations are observed? 1. Turn the woman onto her side. 2. Give her 40% oxygen through a face mask.First the relation of the decelerations to the 3. Start an intravenous infusion of Ringer’suterine contractions must be observed to lactate and give 250 μg (0.5 ml) salbutamoldetermine the type of deceleration. Then (Ventolin) slowly intravenously, aftermanage the patient as follows: ensuring that there is no contraindication1. If the decelerations are early or variable, to its use. (Contraindications to salbutamol the fetal heart rate pattern warns that are heart valve disease, a shocked patient there is an increased risk of fetal distress or patient with tachycardia). The 0.5 ml and, therefore, the fetal heart rate must be salbutamol is diluted with 9.5 ml sterile checked every 15 minutes. water and given slowly intravenously over2. If late decelerations are present, the five minutes. management will be the same as the 4. Deliver the infant by the quickest possible management of fetal bradycardia. route. If the woman’s cervix is 9 cm or more dilated and the head is on the pelvicThe observations of the fetal heart rate must floor, proceed with an assisted deliverybe recorded on the partogram as shown in (forceps or vacuum). Otherwise, perform afigure 2-4. A note of what management is Caesarean section.decided upon must also be made under the 5. If the patient cannot be deliveredheading ‘Management’ at the bottom of the immediately (i.e. there is another patientpartogram. in theatre) the dose of salbutamol can be repeated if contractions start again, but not2-32 What must be done if a fetal within 30 minutes of the first dose or if thebradycardia is observed? maternal pulse is 120 or more beats perFetal distress due to severe hypoxia is present! minutes.Therefore, you should immediately do the It is important that you know how to give fetalfollowing: resuscitation, as it is a life-saving procedure when fetal distress is present, both during the1. Exclude other possible causes of antepartum period and in labour. bradycardia, e.g. turn the woman onto her side to correct supine hypotension,
  28. 28. MONITORING THE CONDITION OF THE FETUS DURING THE FIRST STAGE OF LABOUR 31Always prepare to resuscitate the infant after distress may be present. If not, the fetus isbirth if fetal distress is diagnosed during labour. at high risk of distress. 2. There is a danger of meconium aspiration NOTE Salbutamol (a beta2 stimulant) can also at delivery. be given from an inhaler but this method is less effective than the parenteral administration. Give four puffs from a salbutamol inhale. This Meconium-stained liquor warns that either fetal can be repeated every 10 minutes until the distress is present or that there is a high risk of uterine contractions are reduced in frequency fetal distress. and duration, or the maternal pulse reaches 120 beats per minute. Uterine contractions can also be suppressed with nifedipine (Adalat). Nifedipine 2-37 How should you monitor the 30 mg is given by mouth (one capsule = 10 mg). fetus during the first stage of labour The three capsules must be swallowed and not if the liquor is meconium stained? used sublingually. This method is slower than using intravenous salbutamol and the uterine 1. Observe carefully for late decelerations. contractions will only be reduced after 20 minutes. If present, then fetal distress must be diagnosed. 2. If late decelerations are absent, thenTHE LIQUOR observe the fetal heart rate pattern carefully during labour as about a third of fetuses with meconium-stained liquor will2-34 Is the liquor commonly develop fetal distress.meconium-stained? 3. If electronic monitoring (CTG) is available,Yes, in 10–20% of patients the liquor is yellow the fetal heart rate pattern must beor green due to meconium staining. The carefully monitored.incidence of meconium-stained liquor isincreased in the group of women that go into 2-38 How must the delivery be managedlabour after 42 weeks gestation. if there is meconium in the liquor? 1. The infant’s mouth and pharynx must2-35 Is it important to distinguish be thoroughly suctioned after deliverybetween thick and thin, or yellow of the head but before the shouldersand green meconium? and chest are delivered, i.e. before theAlthough fetal and neonatal complications infant breathes. This must be doneare more common which thick meconium, irrespective of whether a vaginal deliveryall cases of meconium-stained liquor should or Caesarean section is managed the same during the first stage 2. Anticipate that the infant may need to beof labour. The presence of meconium is resuscitated at delivery. If the infant criesimportant and the management does not or breathes well no further suctioning isdepend on the consistency of the meconium. needed. However if the infant does not cry well, suction the infant again before starting mask ventilation. If intubation is2-36 What is the importance of needed, suction via the endotracheal tubemeconium in the liquor? before starting ventilation.1. Meconium-stained liquor usually indicates the presence of fetal hypoxia or an episode 2-39 How and when are the of fetal hypoxia in the past. Therefore, fetal liquor findings recorded? Three symbols are used to record the liquor findings on the partogram:
  29. 29. 32 INTRAPAR TUM CAREI = Intact membranes (i.e. no liquor draining). late decelerations, labour may be allowed to continue. However, very careful observationC = Clear liquor draining. of the fetal heart rate pattern is essential,M = Meconium-stained liquor draining. especially if oxytocin is to be restarted. The fetal heart should be listened to every 15The findings are recorded in the appropriate minutes or fetal heart rate monitoring with aspace on the partogram as shown in figure 2-4. cardiotocograph should be started.The liquor findings should be recorded when:1. The membranes rupture.2. A vaginal examination is done. CASE STUDY 23. A change in the liquor findings is noticed, e.g. if the liquor becomes meconium A woman who is 38 weeks pregnant presents stained. with an antepartum haemorrhage in labour. On examination, her temperature is 36.8 °C, her pulse rate 116 beats per minute, herCASE STUDY 1 blood pressure 120/80 mm Hg, and there is tenderness over the uterus. The baselineA primigravida with inadequate uterine fetal heart rate is 166 beats per minute. Thecontractions during labour is being treated fetal heart rate drops to 130 beats per minutewith an oxytocin infusion. She now has during contractions and then only returns tofrequent contractions, each lasting more than the baseline 35 seconds after the contraction40 seconds. With the woman in the lateral has ended.position, listening to the fetal heart rate revealslate decelerations. 1. Which of the maternal observations are abnormal and what is the probable1. What worries you most cause of these abnormal findings?about this woman? A maternal tachycardia is present and there isThe late decelerations indicate that fetal uterine tenderness. These findings suggest andistress is present. abruptio placentae.2. Should the fetus be 2. Which fetal observations are abnormal?delivered immediately? Both the baseline tachycardia and the lateNo. Correctable causes of poor oxygenation of decelerations.the fetus must first be ruled out, e.g. posturalhypotension and overstimulation of the uterus 3. How can you be certain thatwith oxytocin. The oxytocin infusion must these are late decelerations?be stopped and oxygen administered to thewoman. Then the fetal heart rate should be Because the deceleration continues forchecked again. more than 30 seconds after the end of the contraction. This observation indicates fetal distress. The number of beats by which the3. After stopping the oxytocin the fetal heart slows during a deceleration is notuterine contractions are less frequent. important.No further decelerations of the fetalheart rate are observed. What furthermanagement does this patient need?As overstimulation of the uterus withoxytocin was the most likely cause of the
  30. 30. MONITORING THE CONDITION OF THE FETUS DURING THE FIRST STAGE OF LABOUR 334. Why should an abruptio 3. How would you decide whetherplacentae cause fetal distress? this fetus is distressed?Part of the placenta has been separated from By listening to the fetal heart rate. Latethe wall of the uterus by a retroplacental clot. decelerations or a baseline bradycardia willAs a result, the fetus has become hypoxic. indicate fetal distress. 4. How should the fetus be monitoredCASE STUDY 3 during the remainder of the labour? The fetal heart rate pattern must beDuring the first stage of labour a woman’s liquor determined carefully every 15 minutes in orderis noticed to have become stained with thin to diagnose fetal distress should this meconium. The fetal heart rate pattern isnormal and labour is progressing well. 5. What preparations should be made for the infant at delivery?1. What is the importance of thechange in the colour of the liquor? The infant’s mouth and pharynx must be well suctioned immediately after the head has beenMeconium in the liquor indicates an episode delivered. No further suctioning is neededof fetal hypoxia and suggests that there may be if the infant cries or breathes well. However,fetal distress or that the fetus is at high risk of if the infant does not breathe well directlyfetal distress. after delivery, suctioning should be repeated before mask ventilation is started. If the infant2. Can thin meconium be a is intubated, further suctioning of the largersign of fetal distress? airways via the endotracheal tube should beYes. All meconium in the liquor indicates either done before ventilation is started.fetal distress or that the fetus is at high risk offetal distress. The management does not dependon whether the meconium is thick or thin.
  31. 31. 3 Monitoring and management of the first stage of labourBefore you begin this unit, please take the THE DIAGNOSIScorresponding test at the end of the book toassess your knowledge of the subject matter. You OF LABOURshould redo the test after you’ve worked throughthe unit, to evaluate what you have learned 3-1 When is a woman in labour? A woman 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 10 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 woman 1. The latent phase. to determine the cause of the poor 2. The active phase. progress in labour. • Manage a woman with poor progress in The first stage of labour is divided into the latent labour. phase and the active phase. • Recognise women at increased risk of prolapse of the umbilical cord. • Manage a woman with cord prolapse.
  32. 32. MONITORING AND MANAGEMENT OF THE FIRST STAGE OF LABOUR 353-2 What do you understand by the latent MONITORING OF THEphase of the first stage of labour? FIRST STAGE OF LABOUR1. The latent phase starts with the onset of labour and ends when the patient’s cervix is 3 cm dilated. With primigravidas the 3-4 What do you understand by a complete cervix should also be fully effaced to physical examination during labour? indicate that the latent phase has ended. However, in a multigravida the cervix need 1. The routine observations (usually done not be fully effaced. hourly or half hourly) of the condition of2. During the latent phase, the cervix dilates the mother, the condition of the fetus, and slowly. Although no time limit need be set the contractions. for cervical dilatation, this phase does not 2. A careful abdominal examination. normally last longer than eight hours. The 3. A careful vaginal examination. time taken may vary widely. This examination is only complete when the3. During the latent phase there is a findings have been charted on the partogram. progressive increase in the duration and If the findings are abnormal, a plan must be the frequency of uterine contractions. made regarding the further management of the patient.3-3 What do you understand by theactive phase of the first stage of labour? 3-5 When should you do a complete physical1. This phase starts when the cervix is 3 cm examination on a woman in labour? dilated and ends when the cervix is fully 1. On admission. dilated. 2. During the latent phase: Four hours after2. During the active phase, more rapid admission or when the woman starts dilatation of the cervix occurs. to experience more painful, regular3. The cervix should dilate at a rate of at least contractions. 1 cm per hour. 3. During the active phase: Four hourly, provided all observations indicate that NOTE Cervical dilatation of 4 cm rather than 3 progress is normal. If there is poor cm is sometimes used to indicate progression progress, the next complete examination to the active phase of the first stage of labour. will usually have to be done after two hours.The average rate of dilatation of the cervixduring the active phase is at least 1.5 cm After the complete examination has been doneper hour in multigravidas and 1.2 cm in and an assessment made about the progressprimigravidas. However, the lower limit of of labour, a decision must be taken on whenthe normal rate of cervical dilatation is 1 cm the next complete examination should beper hour. done. The time of the next examination is marked on the partogram with an arrow. The next complete examination may, if the The cervix should dilate at a rate of at least 1 cm circumstances demand it, be done sooner, but per hour in the active phase of labour. not later than the time indicated. 3-6 How should progress during the first stage of labour be monitored? A partogram is used to monitor and record the progress of labour.