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Maternal Care: The first stage labour Monitoring and management


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Maternal Care addresses all the common 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 the progress of labour, specific medical problems during pregnancy, labour and the puerperium, family planning, regionalised perinatal care

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Maternal Care: The first stage labour Monitoring and management

  1. 1. 8 The first stage of labour: Monitoring and managementBefore 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. 8-1 When is a patient in labour? A patient 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 ten 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 patient 1. The latent phase. to determine the cause of the poor 2. The active phase. progress in labour. • Manage a patient with poor progress in The first stage of labour is divided into two labour. phases: the latent phase and the active phase. • Recognise patients at increased risk of prolapse of the umbilical cord. • Manage a patient with cord prolapse.
  2. 2. THE FIRST STAGE OF LABOUR : MONITORING AND MANAGEMENT 1518-2 What do you understand by the latent the mother, the condition of the fetus, andphase of the first stage of labour? the contractions. 2. A careful abdominal examination.1. The latent phase starts with the onset of 3. A careful vaginal examination. labour and ends when the patient’s cervix is 3 cm dilated. With primigravidas the This examination is only complete when the cervix should also be fully effaced to findings have been charted on the partogram. indicate that the latent phase has ended. If the findings are abnormal, a plan must be However, in a multigravida the cervix need made regarding the further management of not be fully effaced. the patient.2. During the latent phase, the cervix dilates slowly. Although no time limit need be set 8-5 When should you do a complete for cervical dilatation, this phase does not physical examination on a patient in labour? normally last longer than eight hours. The time taken may vary widely. 1. On admission.3. During the latent phase there is a 2. During the latent phase: Four hours after progressive increase in the duration and admission or when the patient starts the frequency of uterine contractions. to experience more painful, regular contractions. 3. During the active phase: Four-hourly,8-3 What do you understand by the provided all observations indicate thatactive phase of the first stage of labour? progress is normal. If there is poor1. This phase starts when the cervix is 3 cm progress, the next complete examination dilated and ends when the cervix is fully will have to be done after two hours in dilated. most instances.2. During the active phase, more rapid After the complete examination has been done dilatation of the cervix occurs. and an assessment made about the progress of3. The cervix should dilate at a rate of at least labour, a decision is taken on when the next 1 cm per hour. complete examination should be done. The NOTE The average rate of dilatation of the cervix time of the next examination is marked on the during the active phase is at least 1.5 cm per hour partogram with an arrow. The next complete in multigravidas and 1.2 cm in primigravidas. examination may, if the circumstances Therefore, the lower limit of the normal rate demand it, be done sooner (but not later) than of cervical dilatation is 1 cm per hour. the time indicated. The cervix should dilate at a rate of at least 1 cm 8-6 How should progress during the first stage of labour be monitored? per hour in the active phase of labour. A partogram is used to monitor and record the progress of labour.MONITORING OF THE 8-7 What is a partogram?FIRST STAGE OF LABOUR A partogram is a chart on which the progress of labour over time can be presented. You will8-4 What do you understand by a complete notice that provision has been made on thephysical examination during labour? chart to record all the important observations regarding the condition of the mother, the1. The routine observations (usually done condition of the fetus, and the progress of hourly or half-hourly) of the condition of labour.
  3. 3. 152 MATERNAL CAREFigure 8-1: An example of a partogram
  4. 4. THE FIRST STAGE OF LABOUR : MONITORING AND MANAGEMENT 153An example of a partogram is shown in MANAGEMENT OF Afigure 8-1. PATIENT IN THE LATENT8-8 What is the first oblique line PHASE OF THE FIRSTon the partogram called? STAGE OF LABOURThe alert line. It represents a rate of cervicaldilatation of 1 cm per hour. The latent phase of labour should not last longer than eight hours.8-9 What is the importance of the alert line?The alert line represents the minimum progress 8-12 What is the initial management ofin cervical dilatation which is acceptable during a patient in the latent phase of labour?the active phase of the first stage of labour. When a patient is admitted in early labour, and on examination everything is found to be8-10 What is the second oblique normal, only routine observations are done. Theline on the partogram called? next complete examination is done four hoursThis line is called the action line. later, or sooner if the patient starts to experience more regular and painful contractions. The patient should eat and drink normally, and8-11 What is the importance should be encouraged to walk around. She needof the action line? not be admitted to the labour ward.1. Any patient whose graph of the cervical dilatation falls on or crosses the action 8-13 What should you do at the line must have a complete examination second complete examination? by the doctor. Her further management must be under the doctor’s supervision At this time, the following must be assessed. and direction. If a patient is not already 1. The contractions: If the contractions have in hospital, she will need to be transferred stopped the patient is no longer in labour, into a hospital where there are facilities and if the maternal and fetal conditions are for instrumental delivery and Caesarean normal, she may be discharged. However, section. if the contractions have remained regular,2. The progress of labour is very slow when then you must assess the cervix. the graph of cervical dilatation crosses 2. The cervix: or falls on this line. When this occurs, • If the effacement and dilatation of action must be taken in order to hasten the the cervix have remained unchanged, delivery of the infant. the patient is probably not in true labour. If she is experiencing painful contractions, she should be given an If the cervical dilatation falls on, or crosses, the analgesic, e.g. pethidine 100 mg and action line of the partogram, a doctor must be promethazine (Phenegan) 25 mg called to assess the patient. or hydroxyzine (Aterax) 100 mg by intramuscular injection and, provided that all other observations are normal, the next complete physical examination is planned for four hours later. • If there has been progress in effacement and/or dilatation of the cervix, the patient is in labour and, provided that
  5. 5. 154 MATERNAL CARE all other observations are normal, the 8-15 How do you manage a patient next complete examination is planned who is in normal labour? 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, in8-14 What should you do if a patient has centimetres, is recorded on the alert line ofnot progressed to the active phase of the partogram.labour within eight hours after admission?1. The contractions may have stopped, in 8-16 What represents normal progress which case the patient is not in labour. If during the active phase of the first the membranes have not ruptured and if stage of labour on the partogram? there is no indication to induce labour, the 1. The recording of cervical dilatation at the patient should be discharged. various vaginal examinations lie on or to2. The patient may still be having regular the left of the alert line. In other words contractions. In this case, further cervical dilatation is at least 1 cm per hour. management depends upon the state of 2. There is also progressive descent of the the cervix: fetal head into the pelvis. This is detected • If there has been no progress in by assessing the amount of the fetal head effacement and/or dilatation of the above the brim of the pelvis on abdominal cervix, the patient is probably not in examination. Descent of the head during labour. The responsible doctor should the active phase of the first stage of labour see and assess this patient, in order may occur late, especially in multigravidas. to decide whether labour should be induced. • If there has been progressive effacement With normal progress during the active phase and/or dilatation of the cervix, the of the first stage of labour, the recording of the patient is in labour. If the progress dilatation of the cervix will lie on or to the left has been slow during the latent phase, of the alert line on the partogram. In addition, it may be necessary to rupture the there will be progressively less of the fetal head membranes or commence an oxytocin infusion if she is HIV positive as palpable above the pelvic brim. described in 8-35. 8-17 Why is it necessary to evaluate both cervical dilatation and the descent ofMANAGEMENT OF A the head in order to determine whetherPATIENT IN THE ACTIVE there has been progress in the active phase of the first stage of labour?PHASE OF THE FIRST 1. Cervical dilatation without associatedSTAGE OF LABOUR descent of the head does not necessarily indicate progress in labour.When a patient is admitted in the active 2. Cervical dilatation may occur when therephase of labour, she will probably be in are good contractions, in association withnormal labour. However, the possibility increasing caput succedaneum formationof cephalopelvic disproportion must be and moulding of the fetal skull, whileconsidered, especially if the patient is the amount of fetal head palpable aboveunbooked. the brim of the pelvis remains the same.
  6. 6. THE FIRST STAGE OF LABOUR : MONITORING AND MANAGEMENT 155 In these circumstances no real progress infection if the membranes are intact. The has occurred, because the head is not next complete examination should be done descending into the pelvis. after two hours when the management3. The station of the presenting part of the should be as follows: head in relation to the spine, as felt on • With normal progress do not rupture vaginal examination, can also improve the membranes. without further descent of the head and • With poor progress the membranes without real progress having occurred. should be ruptured and the next This is because of increasing caput examination performed four hours later. succedaneum and moulding. 2. A patient who is HIV negative and in labour with a vertex presentation may have her membranes ruptured with safety if: Descent of the head is assessed on abdominal • She is in the active phase of labour. and not on vaginal examination. • The fetal head is 3/5 or less palpable above the brim of the pelvis.8-18 What circumstances will make it 3. After rupturing the membranes, carefullynecessary to do vaginal examinations feel around the fetal head to rule out themore frequently than four- hourly in the possibility of a cord phase of the first stage of labour? If the fetal head is 4/5 or more above the pelvic1. If cephalopelvic disproportion is brim, and the cervix is 6 cm or more dilated, suspected, the next vaginal examination it is safer to carefully rupture the membranes must be done two hours later. than to allow them to rupture spontaneously.2. If a complete examination has revealed This will reduce the risk of cord prolapse. poor progress of labour, without the presence of cephalopelvic disproportion, 8-20 What should you do if a the next complete examination should patient ruptures her membranes also be done two hours later, to assess spontaneously during labour? the effectiveness of the measures taken to 1. If the fetal head is 4/5 or more palpable correct the poor progress. above the pelvic inlet, or if there is a3. If a patient’s cervix is more than 6 cm breech presentation, the patient is at high dilated, the next complete examination risk for a cord prolapse. A sterile vaginal would normally be done when the cervix examination must, therefore, be done to is expected to be fully dilated. However, rule out this possibility. the examination may need to be done 2. If the fetal head is 3/5 or less palpable earlier if there are signs that the cervix is above the pelvic inlet, it is highly already fully dilated. unlikely that a cord prolapse might happen. However, the fetal heart must be8-19 When should you rupture monitored to rule out the possibility ofthe patient’s membranes? fetal distress due to cord compression.1. It is possible to reduce the risk of transferring HIV from a mother to her 8-21 What are the advantages of infant by keeping the duration of ruptured rupturing a patient’s membranes? membranes as short as possible. Do not 1. Rupture of the membranes acts as a rupture the membranes of patients whose stimulus to labour, so that there is often HIV status is positive or unknown if they better progress. are still intact at the start of the active 2. Meconium staining of the liquor will be phase of labour. The following vaginal detected. examination will not increase the risk of
  7. 7. 156 MATERNAL CARE3. If the cord prolapses when the membranes Step 2 are ruptured, this can be detected The cause of the poor progress of labour must immediately, and the appropriate be determined by examining the patient using management can therefore be started the ‘Rule of the four Ps’. The four Ps are: without delay. 1. The patient.It is important to make sure that the patient is 2. The the active phase of the first stage of labour 3. The passenger.before rupturing the membranes. 4. The passage.POOR PROGRESS IN THE The cause of poor progress of the active phase of the first stage of labour is determined byACTIVE PHASE OF THE assessing the four Ps.FIRST STAGE OF LABOUR 8-25 How may problems with the patient8-22 How would you recognise poor cause poor progress of labour and howprogress in the active phase of labour? should these problems be managed?Poor progress is present when the graph Any of the following factors may interfere withshowing cervical dilatation crosses the alert the normal progress of labour.line. In other words, cervical dilatation in the 1. The patient needs pain relief. Patients whoactive phase of the first stage of labour is less experience very painful contractions,than 1 cm per hour. especially if associated with excessive anxiety, may have poor progress of labour8-23 What should you do if the as a result. Pain relief, emotional support.graph showing cervical dilatation and reassurance can be of great value incrosses the alert line? speeding up the progress of labour. 2. The patient has a full bladder. A full bladderA systematic assessment of the patient must not only causes mechanical obstruction,be made in order to determine the cause of the but also depresses uterine muscle activity.poor progress in labour. A patient must be encouraged to pass urine frequently but may need catheterisation,8-24 How should you systematically and sometimes an indwelling catheter,examine a patient with poor progress in until after delivery.the active phase of the first stage of labour? 3. The patient is dehydrated. DehydrationStep 1 is recognised by the fact that the patient is thirsty, has a dry mouth, passes smallTwo questions must be asked: amounts of concentrated urine and may1. Is the patient in the active phase of the first have ketonuria. Dehydration must be stage of labour? corrected as it may be the cause of the2. Are the membranes ruptured? poor progress. With good care during labour the patient will not becomeIf the answer to both questions is ‘yes’, proceed dehydrated, because she can eat and drinkto step 2. during the latent phase of labour and take oral fluids during the active phase of labour. If there is poor progress during the active phase of labour, an intravenous infusion must be started.
  8. 8. THE FIRST STAGE OF LABOUR : MONITORING AND MANAGEMENT 1578-26 How may problems with the powers 2. The presenting part of the fetus is abnormal.cause poor progress of labour? With a breech presentation, the patient must be assessed by a doctor to decideThe powers (i.e. the uterine contractions) whether a vaginal delivery will be possiblemay either be inadequate or ineffective. Any or whether a Caesarean section is required.patient in whom labour progresses normally If the presentation is cephalic, the parthas both adequate and effective contractions, of the head which is presenting must beirrespective of the duration and frequency of determined on vaginal examination.contractions.1. Inadequate uterine contractions. Inadequate NOTE Fetuses who present by the breech and uterine contractions can be the cause of who comply with the criteria for vaginal delivery, poor progress of labour. Such contractions: are only delivered vaginally if there is normal progress during the first stage of labour. • Last less than 40 seconds, and/or • There are fewer than two contractions 3. The fetus is large. A large fetus (i.e. estimated per ten minutes. as 4 kg or more), with signs of cephalopelvic2. Ineffective uterine contractions. The disproportion (i.e. 2+ or 3+ moulding) must uterine contractions may be adequate but be delivered by Caesarean section. not effective, as poor progress can occur 4. There are two or more fetuses. Poor progress even in the presence of apparently good, may also occur in a patient with a multiple painful contractions (i.e. two or more pregnancy, usually due to inadequate in ten minutes with each contraction uterine contractions. lasting 40 seconds or longer), without 5. The fetal head has not engaged. The number disproportion being present (i.e. no of fifths of the head palpable above the moulding of the fetal skull). The problem pelvis must always be assessed: of ineffective contractions occurs only in • Engagement has occurred only when primigravidas. Any patient whose labour 2/5 or less of the head is palpable above progresses normally must have effective the brim of the pelvis. In this case the uterine contractions. problem of cephalopelvic disproportion at the pelvic inlet is excluded. NOTE Dysfunctional uterine contractions • With 3/5 or more of the head are diagnosed when the uterine above the pelvic brim, plus 2+ or contractions appear to be ineffective. 3+ moulding, a Caesarean section is indicated for cephalopelvic8-27 How may problems with the disproportion at the pelvic inlet.passenger cause poor progressof labour and how should theseproblems be managed? An abdominal examination, to assess the lie and the presenting part of the fetus, as well as theThe cause of poor progress of labour may amount of fetal head palpable above the pelvicbe due to a problem with the passenger (i.e.the fetus). These problems can be identified brim, must always be done before performing aby performing an abdominal examination vaginal examination.followed by a vaginal examination. On vaginal examination the following problemsOn abdominal examination the following causing poor progress may be identified.problems causing poor progress may beidentified. 1. The presenting part is abnormal. Vertex (i.e. occipital) presentation of the fetal head1. The lie of the fetus is abnormal. If the lie of is the most favourable presentation for the fetus is transverse the patient will need the normal progress of labour. With any a Caesarean section.
  9. 9. 158 MATERNAL CARE other presentation of the fetal head in early Improvement in the station of the presenting labour (e.g. brow), there is no urgency part of the fetal head, in relation to the ischial to interfere, as the presentation may become more favourable when the patient spines, is not a reliable method of assessing is in established labour. However, in progress in the first stage of labour. established labour, if moulding is present in any presentation other than a vertex, a 8-28 How may problems with the passage Caesarean section will have to be done. cause poor progress in labour and how2. The position of the fetal head in relation to should these problems be managed? the pelvis is abnormal. An occipito-anterior (right or left) is the most favourable position The following problems with the passage may for normal progress of labour. Positions cause poor progress in labour: other than this (i.e. left or right occipito- 1. The membranes are still intact. Should the posterior) will progress more slowly. Labour membranes still be intact, they must be can be allowed to continue provided there ruptured and the patient reassessed after is progress, and no progressive evidence of four hours before poor progress can be disproportion. The patient will also need diagnosed. adequate pain relief and an intravenous 2. The pelvis is small. A pelvic assessment infusion to prevent dehydration. which shows a small pelvis, together with3. Cephalopelvic disproportion is present. 2+ or 3+ moulding of the fetal skull means • The head is examined for the amount that there is cephalopelvic disproportion, of caput succedaneum present. and is an indication for Caesarean section. Caput is not an accurate indicator of disproportion as it can also be present 8-29 What are the two important in the absence of disproportion, for causes of poor progress of labour? example, in a patient who bears down before the cervix is fully dilated. 1. Cephalopelvic disproportion. This is a • The sutures are examined for dangerous condition if it is not recognised moulding, which is the best indication early and not correctly managed. of the presence of disproportion. 2. Inadequate uterine action. This is a 3+ of moulding is a definite sign of common cause of poor progress in disproportion. In a vertex presentation, primigravidas. It can be easily corrected the sagittal and lambdoid (occipito- with an oxytocin infusion. parietal) sutures are examined. The worst degree of moulding noted in any 8-30 What must be done after the of the sutures is that which is recorded patient has been systematically on the partogram as the amount of evaluated to determine the cause moulding present. of the poor progress of labour? • Improvement in the station of the 1. The nurse attending to the patient must presenting part (i.e. the level of the inform the doctor about the clinical presenting part relative to the ischial findings. Together they must decide on the spines) is not a reliable method of cause of the slow progress and what action assessing progress in labour, compared must be taken to correct this problem. to descent and engagement of the fetal 2. A decision must also be made as to when head as determined on abdominal the next complete examination of the examination. patient will be done. Usually this will be in two hours, but sometimes in four hours. This consultation may be done by
  10. 10. THE FIRST STAGE OF LABOUR : MONITORING AND MANAGEMENT 159 telephone and it is not necessary for the Cephalopelvic disproportion may already be doctor to see the patient at this stage. present when the patient is admitted.3. If labour progresses satisfactorily following the action taken, labour is allowed to continue. However, if poor progress A high fetal head (3/5 or more above the brim) continues, or if the action line has been on abdominal examination, with 3+ moulding reached or crossed, the patient must be on vaginal examination, indicates cephalopelvic examined by the responsible doctor who disproportion. must then decide on further management.The following are examples of causes of 8-32 Does a patient’s cervix always dilatepoor progress in labour together with their at a rate slower than 1 cm per hour ifmanagement: cephalopelvic disproportion is present? When there is cephalopelvic disproportion, the Cause Action cervix usually dilates at a rate slower than 1 cm Cephalopelvic Caesarean section per hour, but the cervix may dilate normally, disproportion even though the fetal head remains high An anxious patient Reassurance and due to cephalopelvic disproportion. This is a unable to cope analgesia dangerous situation as it may be incorrectly with painful concluded that labour is progressing normally. contractions Inadequate uterine An oxytocin infusion 8-33 What features would make contractions you diagnose cephalopelvic disproportion when the fetal head Occipito-posterior Analgesia and an is not descending into the pelvis? position intravenous infusion Ineffective uterine Analgesia followed Often, especially in multiparous patients, the contractions by an oxytocin head does not descend into the pelvis until late infusion in the active phase of the first stage of labour. However, when the head does not descend into the pelvis, you should look for possible causes:CEPHALOPELVIC 1. A malpresentation, e.g. a face or a brow presentation.DISPROPORTION 2. Moulding (i.e. 2+ or 3+). If either of these are present, there is8-31 How will you know when poor progress cephalopelvic disproportion, and a Caesareanis due to cephalopelvic disproportion? section should be done.This can be recognised by the following On the other hand, labour can be allowed tofindings: continue if:1. On abdominal examination, the fetal head • There is no malpresentation. is not engaged in the pelvis. Remember, this • There is no more than 1+ moulding. is diagnosed by finding 3/5 or more of the • The maternal and fetal conditions are head palpable above the brim of the pelvis. good.2. On vaginal examination, there is severe The next complete physical examination must moulding (i.e. 3+) of the fetal skull. Severe be repeated within two hours. moulding must always be regarded as serious, as it confirms that cephalopelvic disproportion is present.
  11. 11. 160 MATERNAL CARE8-34 What should you do if you time to refer her to hospital before thedecide that the poor progress is due action line is cephalopelvic disproportion? 6. Patients who complain of painful contractions need analgesia before1. Once the diagnosis of cephalopelvic oxytocin is started. disproportion has been made, the infant must be delivered as soon as possible. This means that a Caesarean section will have 8-36 What are the contraindications to to be done. the use of oxytocin in order to strengthen2. While the preparations for Caesarean contractions in the first stage of labour? section are being made, it is of value to 1. Evidence of cephalopelvic disproportion. both the mother and fetus to suppress Oxytocin must, therefore, not be given if uterine contractions. This is done by there is already moulding (i.e. 2+ or 3+) giving three nifedipine (Adalat) 10 mg present. capsules by mouth (a total of 30 mg) 2. Any patient with a scar of the uterus, e.g. or give 250 μg (0.5 ml) salbutamol from a previous Caesarean section. (Ventolin) slowly intravenously, the 0.5 ml 3. Any patient with a fetus in whom the salbutamol is diluted with 9.5 ml sterile presenting part is not a vertex. water and given slowly intravenously over 4. Multiparas with poor progress during the five minutes, provided that there are no active phase of labour of the first stage of contraindications. labour. 5. Grande multiparity during the latent or active phase of the first stage of labour.INADEQUATE 6. When there is fetal distress.UTERINE ACTION 7. Patients with poor kidney function or heart valve disease.8-35 What should you do if you decide that NOTE Oxytocin has an antidiuretic effect, sothe poor progress is due to inadequate there is a danger of the patient developingor ineffective uterine contractions? pulmonary oedema. Hyperstimulation must be avoided if an oxytocin infusion1. Provided there are no contraindications, is used. Five or more contractions in ten the patient must be given an oxytocin minutes, or contractions lasting longer than infusion in order to strengthen the 60 seconds, indicate hyperstimulation. contractions.2. The patient’s progress must be reassessed 8-37 How must oxytocin be after two hours. administered when it is used3. If cervical dilatation has proceeded at the during the first stage of labour? rate of 1 cm per hour or more, progress The following is a good method: has been satisfactory and labour is allowed to continue. 1. Begin with one unit of oxytocin in one4. If cervical dilatation has been slower litre of Plasmolyte B, Ringer’s lactate or than 1 cm per hour once the patient has rehydration fluid. adequate uterine contractions, the patient 2. Use a giving set which delivers 20 drops must be reassessed by the responsible per ml. doctor. Cephalopelvic disproportion may 3. Start with 15 drops per minute and be present. increase the rate at intervals of 30 minutes5. If at this stage the patient is still in a to 30 drops, and then to 60 drops per peripheral clinic, there should be enough minute, until the patient gets at least three
  12. 12. THE FIRST STAGE OF LABOUR : MONITORING AND MANAGEMENT 161 contractions lasting at least 40 seconds and the availability of transport. In general, every ten minutes. arrangements must be made so that the patient4. If there are still inadequate contractions will be under the care of the responsible with one unit of oxytocin per litre at doctor by the time the graph depicting cervical 60 drops per minute, a new litre of dilatation crosses the action line. intravenous fluid containing eight units per litre is started at a rate of 15 drops per 8-39 What arrangements should minute. The rate is increased in the same you make to ensure the patient’s way as above until 30 drops per minute safety during transfer to hospital, if are being given. This is the maximum there is poor progress of labour? amount of oxytocin which should be used during the first stage of labour. 1. An intravenous infusion must be started. 2. The patient must lie on her side while NOTE The starting dose of oxytocin is ONE being transferred to hospital. milliunit (mUnit) per minute and the maximum 3. A nurse should accompany the patient, dose 12 mU per minute which is line with unless there is a trained ambulance crew. international dose recommendations. 4. If cephalopelvic disproportion is the cause of the poor progress of labour, the3-38 What are the effects of a long labour? contractions must be stopped. To stop contractions, three nifedipine (Adalat)Both the mother and fetus may be affected. 10 mg capsules (total of 30 mg) can be1. The mother. A patient in whom the taken orally or 250 μg (0.5 ml) salbutamol progress of labour is slow is more likely to (Ventolin) slowly intravenously, the 0.5 ml become anxious and to be dehydrated. If salbutamol is diluted with 9.5 ml sterile the poor progress is due to cephalopelvic water and given slowly intravenously over disproportion (i.e. obstructed labour), and five minutes. If indicated, the same dose labour is allowed to continue, then there is of salbutamol may be repeated after 30 the danger of the mother developing any or minutes. Both drugs should only be used if all of the following: there are no contraindications. • A ruptured uterus. • A vesicovaginal fistula. • A rectovaginal fistula. PROLAPSE OF THE2. The fetus. The stress of a long labour UMBILICAL CORD results in progressive fetal hypoxia, which causes fetal distress and eventually in intra- uterine death. 8-40 Why is prolapse of the umbilical cord a serious complication?THE REFERRAL OF Because the flow of blood between the fetus and placenta is severely reduced and mayPATIENTS WITH POOR stop completely, causing fetal distress andPROGRESS DURING THE possibly fetal death.ACTIVE PHASE OF THE 8-41 What is the difference between aFIRST STAGE OF LABOUR cord presentation and a cord prolapse? 1. With a cord presentation, the umbilicalThe guidelines for referral will vary cord lies in front of the presenting partfrom region to region, depending on the with the membranes still intact.distances between clinics and hospitals,
  13. 13. 162 MATERNAL CARE2. With a cord prolapse, the cord lies in front 1. If the cervix is 9 cm or more dilated and of the presenting part and the membranes the fetal head is on the perineum, the have ruptured. The loose cord may lie patient must bear down and the infant between the presenting part of the fetus must be delivered as soon as possible. and the cervix, in the vagina or outside 2. Otherwise the patient must be managed as the vagina. follows: • Replace the cord carefully into the8-42 How should a cord vagina.presentation be managed? • Give the patient mask oxygen and give 250 μg (0.5 ml) salbutamol (Ventolin)If the cord is felt between the membranes and slowly intravenously, the 0.5 mlthe presenting part of the fetus, if the fetus salbutamol is diluted with 9.5 ml sterileis alive and is viable and if the patient is in water and given slowly intravenouslylabour, a Caesarean section must be done. over five minutes to stop labour.This will prevent a cord prolapse when the • Put a Foley catheter into the patient’smembranes rupture. bladder and fill the bladder with 500 ml saline.8-43 Which patients are at risk • If the full bladder does not lift theof a prolapsed cord? presenting part off the prolapsed cord,1. Patients in labour with an abnormal the presenting part must be pushed up lie (e.g. transverse lie) or an abnormal by an assistant’s hand in the vagina, and presentation (e.g. breech presentation). by turning the patient into the knee-2. Patients who rupture their membranes chest position. when the fetal head is still not engaged (i.e. 4/5 or more above the pelvic brim, e.g. in a 8-46 Why should the cord carefully grande multipara). be replaced in the vagina?3. Patients with polyhydramnios where the The cord must not be allowed to become increased volume of liquor may wash the cold or dry as this will produce vasospasm cord out of the uterus. and, thereby, further reduce the blood flow4. Patients in preterm labour where the through the cord. presenting part is small relative to the pelvis when the membranes rupture. 8-47 Why are oxygen and salbutamol5. Patients with a multiple pregnancy, given to a patient with a prolapsed cord? where preterm labour, abnormal lie and polyhydramnios are common. 1. Giving oxygen to the patient may improve the oxygen supply to the fetus.8-44 What should be done when a 2. Stopping uterine contractions will reducepatient, who is at high risk of prolapse the pressure of the presenting part on theof the cord, ruptures her membranes? prolapsed cord.A sterile vaginal examination must 8-48 Should a Caesarean section be doneimmediately be done to determine whether on all women with a prolapsed cord if thethe cord has prolapsed. infant cannot be rapidly delivered vaginally?8-45 What is the management No. A Caesarean section is only done if theof a prolapsed cord? infant is potentially viable (28 weeks or more) and the cord is still pulsating. Otherwise theA vaginal examination must be done infant should be delivered vaginally as theimmediately. chances of survival are then extremely small.
  14. 14. THE FIRST STAGE OF LABOUR : MONITORING AND MANAGEMENT 163CASE STUDY 1 CASE STUDY 2A primigravida patient at term, who is HIV A patient at term is admitted in labour with anegative, is admitted to the labour ward. She has vertex presentation. The cervix is already 4 cmone contraction, lasting 30 seconds, every ten dilated. The cervical dilatation is recorded onminutes. The cervix is 1 cm dilated and 1.5 cm the alert line. At the next vaginal examinationlong. The maternal and fetal observations are the cervix has dilated to 8 cm. Caput can benormal. After four hours she is having two palpated over the fetal skull. It is decided thatcontractions, each lasting 40 seconds, every ten the progress is favourable and that the nextminutes. On vaginal examination the cervix is vaginal examination should be done after anow 2 cm dilated and 0.5 cm long with bulging further four hours.membranes. The diagnosis of poor progress oflabour due to poor uterine contractions is made 1. On admission, should theand an oxytocin infusion is started to improve woman’s cervical dilatation havecontractions. been entered on the alert line? Yes. The patient is in the active phase of the1. Do you agree with the diagnosis first stage of labour as her cervix is 4 cmof poor progress of labour? dilated. Therefore, the cervical dilatationThe diagnosis is incorrect as the patient is still must be plotted on the alert line. The futurein the latent phase of the first stage of labour. observations should fall on or to the left ofPoor progress of labour can only be diagnosed the alert the active phase of labour. 2. Do the findings of the second2. Why can it be said with certainty that the examination indicate normalpatient is in the latent phase of labour? progress of labour? • The cervix is still less than 3 cm dilated. Not necessarily, as no information is given • The cervix is dilating slowly. about the amount of fetal head palpable above • The cervix is effacing. the pelvic brim. Cervical dilatation without • The frequency of the uterine descent of the head does not always indicate contractions is increasing. normal progress of labour.3. What is your assessment of 3. Is normal cervical dilatation withthe patient’s management? improvement in the station of the presenting part possible if cephalopelvicApart from the wrong diagnosis, oxytocin disproportion is present?should not be given before the membraneshave been ruptured. Yes. The uterine contractions cause an increasing amount of caput and moulding,4. Should the patient’s membranes have which is incorrectly interpreted as normalbeen artificially ruptured when the progress of labour. In this case, caput wassecond vaginal examination was done? noted during the second examination. However, further information about anyNo. If the maternal and fetal condition are moulding and the amount of fetal headgood, you should wait until the cervix is 3 cm palpable above the pelvic brim are essentialor more dilated. The membranes may also be before it can be decided whether normalruptured if the patient has been in the latent progress is present or not.phase of labour for eight hours without anyprogress.
  15. 15. 164 MATERNAL CARE4. Was the correct decision made at the 3. What should be the management oftime of the second examination to repeat the patient’s poor progress of labour?the vaginal examination after four hours? Firstly, the patient should be reassuredNo. If the cervix is 8 cm dilated, the next and given analgesia with pethidine andexamination must be done two hours later, promethazine (Phenegan) or hydroxyzineor even sooner if there are indications that (Aterax). Then an oxytocin infusion should bethe woman’s cervix is fully dilated. If it is started to make the contractions more effective.uncertain whether the progress of labour isnormal then the examination should also be 4. Why is reassuring therepeated in two hours. patient so important? Anxious patients often progress slowlyCASE STUDY 3 in labour and have painful contractions. Emotional support during labour is a very important part of patient care.A primigravida patient at term is admitted inlabour. At the first examination the fetal head 5. When must the next vaginalis 2/5 above the pelvic brim and the cervix examination be done?is 6 cm dilated. Three contractions in tenminutes, each lasting 45 seconds, are palpated. The next vaginal examination should beAt the next examination four hours later, the done two hours later to determine whetherhead is still 2/5 above the brim and the cervix the treatment has been effective. During theis still 6 cm dilated. No moulding can be felt. examination it is very important to excludeThe patient is still having three contractions cephalopelvic ten minutes, each lasting 45 seconds andcomplains that the contractions are painful.Because there has been no progress in spite CASE STUDY 4of painful contractions of adequate frequencyand duration, it is decided that cephalopelvic A patient who is in labour at term hasdisproportion is present and that, therefore, a progressed slowly and the alert line has beenCaesarean section must be done. crossed. During a systematic evaluation of the patient by the midwife for poor progress1. Do you agree that the poor of labour, a diagnosis of an occipito-posteriorprogress of labour is due to position is made. As the patient is makingcephalopelvic disproportion? some progress, she decides to allow labourNo. To diagnose poor progress due to to continue. After four hours, the cervicalcephalopelvic disproportion, severe moulding dilatation falls on the action line. Although(3+) must be present. there is still slow progress, she again decides to allow labour to continue and to repeat the vaginal examination in a further two hours.2. What is most probably the reasonfor the poor progress of labour? 1. Was the patient managed correctlyThe patient is a primigravida with strong, when she crossed the alert line?painful contractions and no signs ofcephalopelvic disproportion. A diagnosis of Yes. She was systematically examined and aineffective uterine contractions (dysfunctional diagnosis of slow progress of labour due to anuterine contractions) can, therefore, be made occipito-posterior position was made.with confidence.
  16. 16. THE FIRST STAGE OF LABOUR : MONITORING AND MANAGEMENT 1652. What should be done if a long first 4. Under what conditions should thestage of labour is expected due to doctor allow labour to progress further?an occipito-posterior position?An intravenous infusion must be started If there is steady progress of labour, the maternalto ensure that the patient does not become and fetal conditions are good, and there is less thandehydrated. In addition, adequate analgesia 3+ moulding.must be given.3. Was the patient correctly managedwhen she reached the action line?No. A doctor should have evaluated thepatient. Further management should havebeen under his/her direction.