Intrapartum Care: Monitoring and management of the first stage of labour

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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 …

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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  • 1. 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.
  • 2. 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.
  • 3. 36 INTRAPAR TUM CARE3-7 What is a partogram? for instrumental delivery and Caesarean section.A partogram is a chart on which the progress 2. The progress of labour is very slow whenof labour over time can be presented. You will the graph of cervical dilatation crossesnotice that provision has been made on the or falls on this line. When this occurs,chart to record all the important observations action must be taken in order to hasten theregarding the condition of the mother, the delivery of the infant.condition of the fetus, and the progress oflabour.An example of a partogram is shown in If the cervical dilatation falls on, or crosses, thefigure 3-1. action line of the partogram, a doctor must be called to assess the patient.3-8 What is the first oblique lineon the partogram called?The alert line. It represents a rate of cervical MANAGEMENT OF Adilatation of 1 cm per hour. PATIENT IN THE LATENT PHASE OF THE FIRST3-9 What is the importance of the alert line?The alert line represents the minimum progress STAGE OF LABOURin cervical dilatation which is acceptable duringthe active phase of the first stage of labour. 3-12 What is the initial management of a patient in the latent phase of labour?3-10 What is the second obliqueline on the partogram called? When a woman is admitted in early labour, and on examination everything is foundThis line is called the action line. This line to be normal, only routine observationsfollows the same slope as the alert line. The are done. The next complete examinationtwo lines are spaced four hours apart. is done four hours later, or sooner if the woman starts to experience more regular NOTE If the travelling time between a clinic or and painful contractions. She should eat and district hospital without Caesarean section drink normally, and should be encouraged to facilities and the next level of care is one hour or more, a transfer line can be drawn walk around. She need not be admitted to the two hours after the alert line. This measure labour ward. will allow for earlier transfer of patients and The latent phase of labour should not last provide one to two hours for travelling time. longer than eight hours.3-11 What is the importanceof the action line? The latent phase of labour should not last longer than eight hours.1. Any woman whose graph of the cervical dilatation falls on or crosses the action line, must have a complete examination 3-13 What should you do at the by the doctor. Her further management second complete examination? must be under the doctor’s supervision At this time, the following must be assessed. and direction. If a woman is not already in hospital, she will need to be transferred 1. The contractions: If the contractions have into a hospital where there are facilities stopped the woman is no longer in labour, and if the maternal and fetal conditions are
  • 4. MONITORING AND MANAGEMENT OF THE FIRST STAGE OF LABOUR 37Figure 3-1: An example of a partogram
  • 5. 38 INTRAPAR TUM CARE normal, she may be discharged. However, has been slow during the latent if the contractions have remained regular, phase, it may be necessary to rupture then you must assess the cervix. the membranes or to commence an2. The cervix: oxytocin infusion if she is HIV positive. • If the effacement and dilatation of the cervix have remained unchanged, the woman is probably not in true MANAGEMENT OF A labour. If she is experiencing painful PATIENT IN THE ACTIVE contractions, she should be given an analgesic, e.g. pethidine 100 mg and PHASE OF THE FIRST promethazine (Phenegan) 25 mg STAGE OF LABOUR or hydroxyzine (Aterax) 100 mg by intramuscular injection. Provided that When a woman is admitted in the active all other observations are normal, the phase of labour, she will probably be in next complete physical examination is normal labour. However, the possibility planned for four hours later. of cephalopelvic disproportion must be • If there has been progress in effacement considered, especially if she is unbooked. and/or dilatation of the cervix, the woman is in labour and, provided that 3-15 How do you manage a woman all other observations are normal, the who is in normal labour? next complete examination is planned for four hours later. If the cervix is 3 cm When the condition of the mother and the or more dilated, the patient has now condition of the fetus are normal, and there progressed to the active phase of the are no signs of cephalopelvic disproportion, first stage of labour. the next complete examination must be done four hours later. The cervical dilatation, in3-14 What should you do if a woman has centimetres, is recorded on the alert line ofnot progressed to the active phase of the partogram.labour within eight hours after admission? 3-16 What represents normal progress1. The contractions may have stopped, in during the active phase of the first which case the woman is not in labour. If stage of labour on the partogram? the membranes have not ruptured and if there is no indication to induce labour, the 1. The recording of cervical dilatation at the woman should be discharged. She should various vaginal examinations lie on or to return when labour starts again. the left of the alert line. In other words2. The woman may still be having regular cervical dilatation is at least 1 cm per hour. contractions. In this case, further 2. There also is progressive descent of the management depends upon the state of fetal head into the pelvis. This is detected the cervix: by assessing the amount of the fetal head • If there has been no progress in above the brim of the pelvis on abdominal effacement and/or dilatation of the examination. Descent of the head during cervix, the woman is probably not in the active phase of the first stage of labour labour. The responsible doctor should may, however, occur late, especially in see and assess her, in order to decide multigravidas. whether labour should be induced. • If there has been progressive effacement and/or dilatation of the cervix, the woman is in labour. If the progress
  • 6. MONITORING AND MANAGEMENT OF THE FIRST STAGE OF LABOUR 39 the effectiveness of the measures taken to With normal progress during the active phase the correct the poor progress. recordings of cervical dilatation lie on or to the 3. If a woman’s cervix is more than 6 cm left of the alert line and there will be progressive dilated, the next complete examination descent of the fetal head. would normally be done when the cervix is expected to be fully dilated. However,3-17 Why is it necessary to evaluate both the examination may need to be donecervical dilatation and the descent of earlier if there are signs that the cervix isthe head in order to determine whether already fully dilated.there has been progress in the activephase of the first stage of labour? 3-19 When should you rupture the woman’s membranes?1. Cervical dilatation without associated descent of the head does not necessarily 1. It is possible to reduce the risk of indicate progress in labour. transferring HIV from a mother to her2. Cervical dilatation may occur when there infant by keeping the duration of ruptured are good contractions, in association with membranes as short as possible. Therefore increasing caput succedaneum formation do not rupture the membranes of women and moulding of the fetal skull, while whose HIV status is positive or unknown the amount of fetal head palpable above if the membranes are still intact at the start the brim of the pelvis remains the same. of the active phase of labour. The following In these circumstances no real progress vaginal examination will not increase the has occurred, because the head is not risk of infection if the membranes are descending into the pelvis. intact. The next complete examination3. The station of the presenting part of the should be done after two hours when the head in relation to the ischial spines, as felt management should be as follows: on vaginal examination, can also improve • With normal progress do not rupture without further descent of the head and the membranes. without real progress having occurred. • With poor progress the membranes This is because of increasing caput should be ruptured and the next succedaneum and moulding. examination performed four hours later. 2. A woman who is HIV negative and in Descent of the head is assessed on abdominal labour with a vertex presentation may have and not on vaginal examination. her membranes ruptured with safety if: • She is in the active phase of labour.3-18 What circumstances will make it • The fetal head is 3/5 or less palpablenecessary to do vaginal examinations above the brim of the pelvis.more frequently than four-hourly in the 3. After rupturing the membranes, carefullyactive phase of the first stage of labour? feel around the fetal head to rule out the possibility of a cord prolapse.1. If cephalopelvic disproportion is suspected, the next vaginal examination If the fetal head is 4/5 or more above the must be done two hours later. pelvic brim (the pelvic inlet), and the cervix2. If a complete examination has revealed is 6 cm or more dilated, it is safer to carefully poor progress of labour, without the rupture the membranes than to allow them presence of cephalopelvic disproportion, to rupture spontaneously. This will reduce the the next complete examination should risk of cord prolapse. also be done two hours later, to assess
  • 7. 40 INTRAPAR TUM CARE3-20 What should you do if a 3-23 What should you do if the graph showswoman ruptures her membranes cervical dilatation crossing the alert line?spontaneously during labour? A systematic assessment of the patient must1. If the fetal head is 4/5 or more palpable be made in order to determine the cause of the above the pelvic brim, or if there is a poor progress in labour. breech presentation, the woman is at high risk for a cord prolapse. A sterile vaginal 3-24 How should you systematically examination must, therefore, be done to examine a woman with poor progress in rule out this possibility. the active phase of the first stage of labour?2. If the fetal head is 3/5 or less palpable above the pelvic brim, it is highly Step 1 unlikely that a cord prolapse might Firstly two questions must be asked: happen. However, the fetal heart must be auscultated to rule out the possibility of 1. Is the woman in the active phase of the first fetal distress due to cord compression. stage of labour? 2. Are the membranes ruptured?3-21 What are the advantages of If the answer to both questions is ‘yes’, proceedrupturing a woman’s membranes? to step 2.1. Rupture of the membranes acts as a When patients are HIV negative with stimulus to labour, so that there is often intact membranes, artificial rupture of the better progress. membranes should be done and a systematic2. Meconium staining of the liquor will be assessment again made after two hours. detected. When patients are HIV positive with3. If the cord prolapses when the membranes intact membranes and with at least three are ruptured, this can be detected contractions of 40 seconds (strong) or immediately, and the appropriate more per 10 minutes present, a systematic management can therefore be started assessment is again made after two hours. without delay. Without contractions oxytocin can be usedIt is important to make sure that the woman is carefully to augment the contractions and ain the active phase of the first stage of labour systematic assessment again made two hoursbefore rupturing the membranes. after strong contractions have been achieved. NOTE An alternative method with HIV positivePOOR PROGRESS IN THE patients would be to rupture membranes and assess after two hours. With normal progress aACTIVE PHASE OF THE delivery would be achieved within four hours of rupture of membranes. With no progressFIRST STAGE OF LABOUR present a Caesarean section could be done within four hours of rupture of membranes. The transmission rate of HIV is significantly lower3-22 How would you recognise poor if babies are born within four hours of ruptureprogress in the active phase of labour? of membranes compared to longer periods of labour with rupture of the membranes.Poor progress is present when the graph showscervical dilatation crossing the alert line. In Step 2other words, cervical dilatation in the active The cause of the poor progress of labour mustphase of the first stage of labour is less than be determined by examining the woman using1 cm per hour. the ‘Rule of the four Ps’. The four Ps are:
  • 8. MONITORING AND MANAGEMENT OF THE FIRST STAGE OF LABOUR 411. The patient. 3-26 How may problems with the2. The powers. ‘powers’ cause poor progress of labour?3. The passenger. The ‘powers’ (i.e. the uterine contractions)4. The passage. may either be inadequate or ineffective. Any patient in whom labour progresses normally The cause of poor progress of the active phase has both adequate and effective contractions, of the first stage of labour is determined by irrespective of the duration and frequency of assessing the four Ps. contractions. 1. Inadequate uterine contractions: Inadequate3-25 How may problems with the ‘patient’ uterine contractions can be the cause ofcause poor progress of labour and how poor progress of labour. Such contractions:should these problems be managed? • Last less than 40 seconds, and/or • There are fewer than two contractionsAny of the following factors may interfere with per 10 minutes.the normal progress of labour. 2. Ineffective uterine contractions: The uterine1. The patient needs pain relief: Women who contractions may be adequate but not experience very painful contractions, effective, as poor progress can occur even especially if associated with excessive in the presence of apparently good, painful anxiety, may have poor progress of labour contractions (i.e. two or more in 10 minutes as a result. Pain relief, emotional support with each contraction lasting 40 seconds and reassurance can be of great value in or longer), without disproportion being speeding up the progress of labour. present (i.e. no moulding of the fetal skull).2. The patient has a full bladder: A full The problem of ineffective contractions bladder not only causes mechanical occurs only in primigravidas. Any woman obstruction, but also depresses uterine whose labour progresses normally must muscle activity. A woman must be have effective uterine contractions. encouraged to pass urine frequently but Dysfunctional uterine contractions are may need catheterisation, and sometimes diagnosed when the uterine contractions an indwelling catheter until after delivery. appear to be ineffective.3. The patient is dehydrated: Dehydration is recognised by the fact that the woman 3-27 How may problems with the is thirsty, has a dry mouth, passes small ‘passenger’ cause poor progress amounts of concentrated urine and may of labour and how should these have ketonuria. Dehydration must be problems be managed? corrected as it may be the cause of the poor progress. With good care during The cause of poor progress of labour may be labour the woman will not become due to a problem with the ‘passenger’ (i.e. dehydrated, because she can eat and drink the fetus). These problems can be identified during the latent phase of labour and by performing an abdominal examination take oral fluids during the active phase of followed by a vaginal examination. labour. If there is poor progress during On abdominal examination the following the active phase of labour, an intravenous problems causing poor progress may be infusion must be started. identified.
  • 9. 42 INTRAPAR TUM CARE1. The lie of the fetus is abnormal: If the lie of 1. The presenting part is abnormal: Vertex (i.e. the fetus is transverse the woman will need occipital) presentation of the fetal head a Caesarean section. is the most favourable presentation for2. The presenting part of the fetus is abnormal: the normal progress of labour. With any With a breech presentation, the woman other presentation of the fetal head in early must be assessed by a doctor to decide labour (e.g. brow), there is no urgency whether a vaginal delivery will be possible to interfere, as the presentation may or whether a Caesarean section is required. become more favourable when the patient If the presentation is cephalic, the part is in established labour. However, in of the head which is presenting must established labour, if moulding is present be determined on vaginal examination. in any presentation other than a vertex, a Fetuses who present by the breech and Caesarean section will have to be done. who comply with the criteria for vaginal 2. The position of the fetal head in relation to delivery, are only delivered vaginally if the pelvis is abnormal: An occipito-anterior there is normal progress during the first (right or left) is the most favourable stage of labour. position for normal progress of labour.3. Size of the fetus: A large fetus (i.e. estimated Positions other than this (i.e. left or as 4 kg or more), with signs of cephalopelvic right occipito-posterior) will progress disproportion (i.e. 2+ or 3+ moulding) must more slowly. Labour can be allowed to be delivered by Caesarean section. continue provided there is progress, and4. There are two or more fetuses: Poor progress no progressive evidence of cephalopelvic may also occur in a woman with a multiple disproportion. The patient will also need pregnancy, usually due to inadequate adequate pain relief and an intravenous uterine contractions. infusion to prevent dehydration.5. The fetal head has not engaged: The number 3. Cephalopelvic disproportion is present: of fifths of the head palpable above the • The fetal head is examined for the pelvic brim must always be assessed: amount of caput succedaneum present. • Engagement has occurred only when Caput is not an accurate indicator of 2/5 or less of the head is palpable above disproportion as it can also be present the brim of the pelvis. In this case the in the absence of disproportion, for problem of cephalopelvic disproportion example, in a woman who bears down at the pelvic inlet is excluded. before the cervix is fully dilated. • With 3/5 or more of the head above the • The sutures are examined for pelvic brim, plus 2+ or 3+ moulding, moulding, which is the best indication a Caesarean section is indicated for of the presence of cephalopelvic cephalopelvic disproportion at the disproportion. 3+ of moulding is a pelvic inlet. definite sign of disproportion. In a vertex presentation, the sagittal suture is examined for moulding. The degree An abdominal examination, to assess the lie and of moulding of the sagittal suture is the presenting part of the fetus, as well as the recorded on the partogram. amount of fetal head palpable above the pelvic • Improvement in the station of the brim, must always be done before performing a presenting part (i.e. the level of the vaginal examination. presenting part relative to the ischial spines) is not a reliable method ofOn vaginal examination the following problems assessing progress in labour. Rather,causing poor progress may be identified. the descent and engagement of the fetal head must be determined on abdominal examination.
  • 10. MONITORING AND MANAGEMENT OF THE FIRST STAGE OF LABOUR 43 3. If labour progresses satisfactorily following Improvement in the station of the presenting the action taken, labour is allowed to part of the fetal head, in relation to the ischial continue. However, if poor progress spines, is not a reliable method of assessing continues, or if the action line has been progress in the first stage of labour. reached or crossed, the woman must be examined by the responsible doctor who3-28 How may problems with the ‘passage’ must then decide on further management.cause poor progress in labour and how The following are examples of causes ofshould these problems be managed? poor progress in labour together with theirThe following problems with the ‘passage’ may management:cause poor progress in labour:1. The membranes are still intact: Should the Cause Action membranes still be intact, they must be Cephalopelvic Caesarean section ruptured and the patient reassessed after disproportion four hours before poor progress can be An anxious woman Reassurance and diagnosed. unable to cope analgesia2. The pelvis is small: A pelvic assessment with painful which shows a small pelvis, together with contractions 2+ or 3+ moulding of the fetal skull means Inadequate uterine An oxytocin infusion that there is cephalopelvic disproportion, contractions and is an indication for Caesarean section. Occipito-posterior Analgesia and an3-29 What are the two important position intravenous infusioncauses of poor progress of labour? Ineffective uterine Analgesia followed contractions by an oxytocin1. Cephalopelvic disproportion: This is a infusion dangerous condition if it is not recognised early and not correctly managed.2. Inadequate uterine action: This is a common cause of poor progress in CEPHALOPELVIC primigravidas. It can be easily corrected DISPROPORTION with an oxytocin infusion.3-30 What must be done after a woman has 3-31 How will you know when poor progressbeen systematically evaluated to determine is due to cephalopelvic disproportion?the cause of the poor progress of labour? This can be recognised by the following1. The nurse attending to the woman must findings: inform the doctor about the clinical 1. On abdominal examination, the fetal head findings. Together they must decide on the is not engaged in the pelvis. Remember, this cause of the slow progress and what action is diagnosed by finding 3/5 or more of the must be taken to correct this problem. head palpable above the brim of the pelvis.2. A decision must also be made as to when 2. On vaginal examination, there is severe the next complete examination of the moulding (i.e. 3+) of the fetal skull. Severe woman should be done. Usually this will moulding must always be regarded as be in two hours, but sometimes in four serious, as it confirms that cephalopelvic hours. This consultation may be done by disproportion is present. telephone and it is not necessary for the doctor to see the woman at this stage.
  • 11. 44 INTRAPAR TUM CARECephalopelvic disproportion may already be 3-34 What should you do if youpresent when the patient is admitted. decide that the poor progress is due to cephalopelvic disproportion? A high fetal head (3/5 or more above the brim) 1. Once the diagnosis of cephalopelvic on abdominal examination, with 3+ moulding disproportion has been made, the infant on vaginal examination, indicates cephalopelvic must be delivered as soon as possible. This, disproportion. therefore, means that a Caesarean section will have to be done. 2. While the preparations for Caesarean3-32 Does a woman’s cervix always dilate section are being made, it is of value toat a rate slower than 1 cm per hour if both the mother and fetus to suppresscephalopelvic disproportion is present? uterine contractions. This is done by givingWhen there is cephalopelvic disproportion, the three nifedipine (Adalat) 10 mg capsulescervix usually dilates at a rate slower than 1 cm by mouth (a total of 30 mg) provided thatper hour, but the cervix may dilate normally, there are no contraindications.even though the fetal head remains highdue to cephalopelvic disproportion. This is a INADEQUATEdangerous situation as it may be incorrectlyconcluded that labour is progressing normally. UTERINE ACTION3-33 What features would make 3-35 What should you do if you decide thatyou diagnose cephalopelvic the poor progress is due to inadequatedisproportion when the fetal head or ineffective uterine contractions?is not descending into the pelvis? 1. Provided there are no contraindications,Often, especially in multiparous patients, the the woman must be given an oxytocinhead does not descend into the pelvis until late infusion in order to strengthen thein the active phase of the first stage of labour. contractions.However, when the head does not descend into 2. The woman’s progress is reassessed afterthe pelvis, you should look for possible causes: two hours.1. A malpresentation, e.g. a face or a brow 3. If cervical dilatation has proceeded at the presentation. rate of 1 cm per hour or more, progress2. Moulding (i.e. 2+ or 3+). has been satisfactory and labour isIf either of these are present, there is allowed to continue.cephalopelvic disproportion, and a Caesarean 4. If cervical dilatation has been slowersection should be done. than 1 cm per hour once the woman has adequate uterine contractions she mustOn the other hand, labour can be allowed to be reassessed by the responsible doctor.continue if: Cephalopelvic disproportion may be • There is no malpresentation. present. • There is no more than 1+ moulding. 5. If at this stage the woman is still in a • The maternal and fetal conditions are peripheral clinic, there should be enough good. time to refer her to hospital before the action line is crossed.The next complete physical examination must 6. Patients who complain of painfulbe repeated within two hours. contractions need analgesia before oxytocin is started.
  • 12. MONITORING AND MANAGEMENT OF THE FIRST STAGE OF LABOUR 453-36 What are the contraindications to minute. The rate is increased in the samethe use of oxytocin in order to strengthen way as above until 30 drops per minutecontractions in the first stage of labour? are being given. This is the maximum amount of oxytocin which should be used1. Evidence of cephalopelvic disproportion. during the first stage of labour. Oxytocin must, therefore, not be given if there is already moulding (i.e. 2+ or 3+) NOTE The starting dose of oxytocin is ONE present. milliunit (mUnit) per minute and the maximum2. Any patient with a scar of the uterus, e.g. dose 12 mU per minute which is line with from a previous Caesarean section. international dose recommendations.3. Any patient with a fetus in whom the presenting part is not a vertex. 3-38 What are the effects of a long labour?4. Multiparas with poor progress during the active phase of labour of the first stage of Both the mother and fetus may be affected: labour. 1. The mother: A woman in whom the5. Grande multiparity during the latent or progress of labour is slow, is more likely to active phase of the first stage of labour. become anxious and to be dehydrated. If6. When there is fetal distress. the poor progress is due to cephalopelvic7. Patients with poor kidney function or disproportion (i.e. obstructed labour), and heart valve disease. labour is allowed to continue, then there isOxytocin has an antidiuretic effect, so that the danger that she may develop any or allthere is a danger of the patient developing of the following:pulmonary oedema. Hyperstimulation must • A ruptured avoided if an oxytocin infusion is used. • A vesicovaginal fistula.Five or more contractions in 10 minutes or • A rectovaginal fistula.contractions lasting longer than 60 seconds 2. The fetus: A long labour can result inindicate hyperstimulation. progressive fetal hypoxia, resulting in fetal distress and eventually in intra-uterine death.3-37 How must oxytocin beadministered when it is usedduring the first stage of labour? THE REFERRAL OF WOMENThe following is a good method: WITH POOR PROGRESS1. Begin with one unit of oxytocin in one DURING THE ACTIVE litre of Plasmolyte B, Ringer’s lactate or rehydration fluid. PHASE OF THE FIRST2. Use a giving set which delivers 20 drops STAGE OF LABOUR per ml.3. Start with 15 drops per minute and The guidelines for referral will vary increase the rate at intervals of 30 minutes from region to region, depending on the to 30 drops, and then to 60 drops per distances between clinics and hospitals, minute, until the patient gets at least three and the availability of transport. In general, contractions lasting at least 40 seconds arrangements must be made so that the every 10 minutes. woman will be under the care of the4. If there are still inadequate contractions responsible doctor by the time the graph shows with one unit of oxytocin per litre at cervical dilatation crossing the action line. 60 drops per minute, a new litre of intravenous fluid containing eight units per litre is started at a rate of 15 drops per
  • 13. 46 INTRAPAR TUM CARE3-39 What arrangements should This will prevent a cord prolapse when theyou make to ensure the woman’s membranes during transfer to hospital, ifthere is poor progress of labour? 3-43 Which women are at risk1. An intravenous infusion must be started. of a prolapsed cord?2. The woman must lie on her side while 1. Women in labour with an abnormal being transferred to hospital. lie (e.g. transverse lie) or an abnormal3. A nurse should accompany the woman, presentation (e.g. breech presentation). unless there is a trained ambulance crew. 2. Women who rupture their membranes4. If cephalopelvic disproportion is the when the fetal head is still not engaged (i.e. cause of the poor progress of labour, the 4/5 or more above the pelvic brim, e.g. in a contractions must be stopped. To stop grande multipara). contractions, three nifedipine (Adalat) 10 3. Women with polyhydramnios where the mg capsules per mouth (total of 30 mg) increased volume of liquor may wash the can be taken. cord out of the uterus. 4. Women in preterm labour where the presenting part is small relative to thePROLAPSE OF THE pelvis when the membranes rupture.UMBILICAL CORD 5. Women with a multiple pregnancy, where preterm labour, abnormal lie and polyhydramnios are common.3-40 Why is prolapse of the umbilicalcord a serious complication? 3-44 What should be done when aBecause the flow of blood between the fetus woman, who is at high risk of prolapseand placenta is severely reduced and may of the cord, ruptures her membranes?stop completely, causing fetal distress and A sterile vaginal examination mustpossibly fetal death. immediately be done to determine whether the cord has prolapsed.3-41 What is the difference between acord presentation and a cord prolapse? 3-45 What is the management1. With a cord presentation, the umbilical of a prolapsed cord? cord lies in front of the presenting part A vaginal examination must be done with the membranes still intact. immediately:2. With a cord prolapse, the cord lies in front of the presenting part and the membranes 1. If the cervix is 9 cm or more dilated and have ruptured. The loose cord may lie the fetal head is on the perineum, the between the presenting part of the fetus woman must bear down and the infant and the cervix, in the vagina or outside must be delivered as soon as possible. the vagina. 2. Otherwise the woman must be managed as follows: • Replace the cord into the vagina or3-42 How should a cord cover it with a warm, wet towel.presentation be managed? • Give the woman mask oxygen andIf the cord is felt between the membranes and three nifedipine (Adalat) 10 mgthe presenting part of the fetus, if the fetus capsules per mouth (total of 30 mg) tois alive and is viable and if the woman is in stop labour.labour, a Caesarean section must be done.
  • 14. MONITORING AND MANAGEMENT OF THE FIRST STAGE OF LABOUR 47 • Put a Foley catheter into the woman’s of labour, due to poor uterine contractions, is bladder and fill the bladder with made and an oxytocin infusion is started to 500 ml saline. improve contractions. • If the full bladder does not lift the presenting part off the prolapsed cord, 1. Do you agree with the diagnosis the presenting part must be pushed up of poor progress of labour? by an assistant’s hand in the vagina, and by turning the patient into the The diagnosis is incorrect as the woman is still knee-chest position in the latent phase of the first stage of labour. Poor progress of labour can only be diagnosed in the active phase of labour.3-46 Why should the cord be replaced inthe vagina or be covered by a warm towel? 2. Why can it be said with certainty that theThe cord must not be allowed to become woman is in the latent phase of labour?cold or dry as this will produce vasospasmand, thereby, further reduce the blood flow • The cervix is still less than 3 cm dilated.through the cord. • The cervix is dilating slowly. • The cervix is effacing. • The frequency of the uterine3-47 Why are oxygen and nifedipine given contractions is a patient with a prolapsed cord?1. Giving oxygen to the woman may improve 3. What is your assessment of the oxygen supply to the fetus. the woman’s management?2. Stopping uterine contractions will reduce the pressure of the presenting part on the Apart from the wrong diagnosis, oxytocin prolapsed cord. should not be given before the membranes have been ruptured.3-48 Should a Caesarean section be doneon all women with a prolapsed cord if the 4. Should the woman’s membranesinfant cannot be rapidly delivered vaginally? have been artificially ruptured when the second vaginal examination was done?No. A Caesarean section is only done if theinfant is potentially viable (28 weeks or more) No. If the maternal and fetal condition areand the cord is still pulsating. Otherwise the good, you should wait until the cervix is 3 cminfant should be delivered vaginally as the or more dilated. The membranes may also bechances of survival are then extremely small. ruptured if the woman has been in the latent phase of labour for eight hours without any progress.CASE STUDY 1A primigravida woman at term, who is HIV CASE STUDY 2negative, is admitted to the labour ward. She hasone contraction, lasting 30 seconds, every 10 A woman at term is admitted in labour with aminutes. Her cervix is 1 cm dilated and 1.5 cm vertex presentation. The cervix is already 4 cmlong. The maternal and fetal observations are dilated. The cervical dilatation is recorded onnormal. After four hours she is having two the alert line. At the next vaginal examinationcontractions, each lasting 40 seconds, every 10 the cervix has dilated to 8 cm. Caput can beminutes. On vaginal examination her cervix is palpated over the fetal skull. It is decided thatnow 2 cm dilated and 0.5 cm long with bulging the progress is favourable and that the nextmembranes. The diagnosis of poor progress
  • 15. 48 INTRAPAR TUM CAREvaginal examination should be done after a normal then the examination should also befurther four hours. repeated in two hours.1. On admission, should thewoman’s cervical dilatation have CASE STUDY 3been entered on the alert line?Yes. The patient is in the active phase of the A primigravida woman at term is admitted infirst stage of labour as her cervix is 4 cm labour. At the first examination the fetal headdilated. Therefore, the cervical dilatation was is 2/5 above the pelvic brim and the cervix iscorrectly plotted on the alert line. The future 6 cm dilated. Three contractions in 10 minutes,observations should fall on or to the left of each lasting 45 seconds, are palpated. At thethe alert line. next examination four hours later, the head is still 2/5 above the brim and the cervix is still 6 cm dilated. No moulding can be felt.2. Do the findings of the second The woman is still having three contractionsexamination indicate normal in 10 minutes, each lasting 45 seconds andprogress of labour? complains that the contractions are painful.Not necessarily, as no information is given Because there has been no progress in spiteabout the amount of fetal head palpable above of painful contractions of adequate frequencythe pelvic brim. Cervical dilatation without and duration, it is decided that cephalopelvicdescent of the head does not always indicate disproportion is present and that, therefore, anormal progress of labour. Caesarean section must be done.3. Is normal cervical dilatation with 1. Do you agree that the poorimprovement in the station of the progress of labour is due topresenting part possible if cephalopelvic cephalopelvic disproportion?disproportion is present? No. To diagnose poor progress due toYes. The uterine contractions cause an cephalopelvic disproportion, severe mouldingincreasing amount of caput and moulding, (3+) must be present.which is incorrectly interpreted as normalprogress of labour. In this case, caput was 2. What is most probably the reasonnoted during the second examination. for the poor progress of labour?However, further information about anymoulding and the amount of fetal head The patient is a primigravida with strong,palpable above the pelvic brim are essential painful contractions and no signs ofbefore it can be decided whether normal cephalopelvic disproportion. A diagnosis ofprogress is present or not. ineffective uterine contractions (dysfunctional uterine contractions) can, therefore, be made with confidence.4. Was the correct decision made at thetime of the second examination to repeatthe vaginal examination after four hours? 3. What should be the management of the woman’s poor progress of labour?No. If the cervix is 8 cm dilated, the nextexamination must be done two hours later, Firstly, the woman should be reassuredor even sooner if there are indications that and given analgesia with pethidine andthe woman’s cervix is fully dilated. If it is promethazine (Phenegan) or hydroxyzineuncertain whether the progress of labour is (Aterax). Then an oxytocin infusion should be started to make the contractions more effective.
  • 16. MONITORING AND MANAGEMENT OF THE FIRST STAGE OF LABOUR 494. Why is reassuring the 1. Was the woman managed correctlywoman so important? when she crossed the alert line?Anxious patients often progress slowly Yes. She was systematically examined and ain labour and have painful contractions. diagnosis of slow progress of labour due to anEmotional support during labour is a very occipito-posterior position was made.important part of patient care. 2. What should be done if a long first5. When must the next vaginal stage of labour is expected due toexamination be done? an occipito-posterior position?The next vaginal examination should be An intravenous infusion must be started todone two hours later to determine whether ensure that the woman does not becomethe treatment has been effective. During the dehydrated. In addition, adequate analgesiaexamination it is very important to exclude must be given.cephalopelvic disproportion. 3. Was the woman correctly managed when she reached the action line?CASE STUDY 4 No. A doctor should have evaluated the woman. Further management should haveA woman who is in labour at term has been under his/her direction.progressed slowly and the alert line has beencrossed. During a systematic evaluation by 4. Under what conditions should thethe midwife for poor progress of labour, a doctor allow labour to progress further?diagnosis of an occipito-posterior positionis made. As the woman is making some If there is steady progress of labour, if theprogress, she decides to allow labour to maternal and fetal conditions are good, andcontinue. After four hours the cervical there is less than 3+ moulding.dilatation falls on the action line. Althoughthere is still slow progress, she again decidesto allow labour to continue and to repeat thevaginal examination in a further two hours.