Management during first stage of Labour

1. Heera KC
Lecturer,
Maternal Health Nursing (BPKIHS)
MANAGEMENT OF NORMAL LABOR

2. OBJECTIVES
• Aims of management of normal labor
• Purposes of management of first stage of labor
• Principles of management of first stage of labor
• Preliminaries
• Management of first stage of labor

3. Aims of management of normal labor
• Maximal observation with minimal active intervention.
• To maintain the normalcy and to detect any deviation from
the normal at the earliest possible moment.

4. MANAGEMENT OF THE FIRST STAGE
• To conduct safe and clean delivery.
• To prevent woman from over exhaustion, injuries, bleeding
and other complications( eg: maternal and fetal distress) and
provide necessary help when required.
Purposes

5. MANAGEMENT OF THE FIRST STAGE
• For maintenance of normal delivery at normal time interval.
• For delivery of healthy, live and normal baby.
• To identify deviation and take corrective measures at the earliest.
Purposes Cont…

6. Principles of first stage management
(1) Noninterference with watchful expectancy so as to prepare the
patient for natural birth.
(2) To monitor carefully the progress of labor, maternal conditions and
fetal behavior so as to detect any intrapartum complication early.

7. PRELIMINARIES
• History taking
• Thorough general and obstetrical examinations including
vaginal examination.
• Record review
• Health teaching

8. Actual management of first stage of labor
• Supportive care
• Positioning and mobility
• Rest and Ambulation
• Nutrition
• Bladder care
• Bowel elimination
care
• Prevention of
infection
• Relief of pain
• Observations

9. Actual management of first stage of labor
• Companion of her choice and, same health care provider
throughout labor and childbirth if possible.
• Ensure good communication and support by staff.
• Ensure privacy and confidentiality
SUPPORTIVE CARE

10. SUPPORTIVE CARE
Cont…
• Advice to avoid dorsal supine
position to avoid aortocaval
compression. (pressure of the
uterus against blood vessels
decreases blood supply and oxygen
to the fetus.)
Positioning and mobility

11. Rest and Ambulation
If membranes intact – walk, sit or to lie down during pains.
• This attitude prevents vena-caval compression and encourage
descent of head.
• Ambulation reduce the duration of labor, need of analgesia and
improve maternal comfort.
If membrane rupture early or when an analgesic drug is given, the
women should be in bed.

12. Nutrition
• An adequate intake of fluids and calories required to met the energy
demand and fluid losses.
• Plain water, salty lemon water, soup, fruit juice is given.
• Intravenous fluid with ringer solution if regional anesthesia or if
unable to take pr oral or dehydrated.

13. Bladder care
• Empty every 1-2 hours during labor.
• Provide bed pan if required.
• Privacy and comfort.
• Catheterisation with strict aseptic precaution.
• Careful record regarding amount and time of voiding should be kept.

14. Bowel elimination care
• Stools formed in the large intestine is moved downward toward the
anorectal area by pressure exerted by the fetal presenting part as it
descends.
• The stool is expelled during second stage pushing.
• Increases the risk of infection, may embarrasses the woman thereby
reducing the effectiveness of these efforts.

15. Prevention of infection
• Visitor should be control
• Personal hygiene- hand
washing.
• Strict aseptic technique.
• Maternal temperature and
vaginal discharge are
assessed frequently (every
1-2 hrs)

16. Relief of pain
• Suggest changes of position.
• Encourage mobility.
• Encourage her companion to massage her back or hold her hand,
sponge her face between contractions and place a cool cloth at the back
of her neck.

17. Relief of pain cont…
• Encourage the woman to use the breathing techniques.
• Encourage the woman to take a warm bath or shower.
• If necessary, offer morphine 0.1 mg/kg body weight IM, informing the
woman of the advantages and disadvantages and obtaining consent.

18. Avoid the following practices
X Do not routinely shave the perineal/pubic area prior to a vaginal
birth.
X Do not routinely cleanse the vagina with an antiseptic (e.g.
chlorhexidine) during labor for the purpose of preventing infectious
morbidities, even in women with documented Group B streptococcus
colonization.
X Do not routinely give an enema to women in labor.

19. OBSERVATIONS
1) Vital signs
During the latent phase of the first stage of labour
• Check maternal mood and behaviour (distressed, anxious) at least
once every hour;
• Check blood pressure, pulse and temperature at least once every four
hours.
ASSESSMENT OF MATERNAL CONDITION

20. ASSESSMENT OF MATERNAL CONDITION
During the active phase of first stage of labor
• Maternal mood and behavior (distressed, anxious) at least
once every 30 minutes;
• Blood pressure at least once every four hours.
Temperature at least once every two hours and
Pulse once every 30 minutes.

21. Alert if
• Pulse rate>100 b.p.m: anxiety, pain and infection, ketoacidosis and
hemorrhage.
• Temperature >38°C- infection, dehydration (at least every two
hours.)
• Supine position, shock, epidural anesthesia, suspect occult or frank
haemorrhage: hypotension.

22. Alert if cont…
• Pre-eclampsia: hypertension during pregnancy.
• Rate over 20 respirations/min: severe anxiety or other
pathologies.

23. 2. Urinalysis
• May be tested for glucose, ketones and proteins.
• Ketones may occur as a result of starvation, dehydration or maternal
distress when all available energy has been utilized. (Give dextrose
IV.)
• Trace of protein: rupture of membrane/urinary infection.

24. 3. Fluid analysis
4. Abdominal examination and contractions
• Is carried out when midwife first examines the mother.
• Should be repeated at intervals throughout labor in order to assess the
length, strength and frequency of contraction and descent of
prescribing part.

25. ASSESSMENT OF FETAL CONDITION
Fetal heart rate: 110 to 160 per minute.
• During the latent phase: full minute count at least once every hour.
• During the active phase : every 30 minutes
• During second stage : every five minutes.
Note: If there are fetal heart rate abnormalities (less than 100 or more
than 180 beats per minute), suspect fetal distress.
(IMPAC revised edition)

26. Reassess the fetal heart rate after
• Rupture of membranes
• Vaginal examination
• Ambulation (before and after)
• Change in infusion rate of
oxytocin administration of
drugs (before and after)
• Urinary catheterization
• Expulsion of the fetus
• Recognition of abnormal
uterine activity
• Decrease in fetal activity as
felt by the mother

27. Status of the membrane
• Note the color of the draining amniotic fluid.
• Presence of thick meconium - need for close monitoring and possible
intervention for management of fetal distress such as keeping women
in prop-up position and stop the oxytocin drip.
• Absence of fluid draining after rupture of the membranes is an
indication of reduced volume of amniotic fluid, which may be
associated with fetal distress.

28. Progress of labor
The progress is best assessed using partograph.

30. SUMMARY