The initial examination in the first stage of labor involves taking a medical history, performing a physical examination including vital signs and abdominal/pelvic exams, and monitoring the fetus. The midwife obtains consent for exams and procedures, provides emotional support, and observes the woman's progress through the stages of labor using a partograph to chart cervical dilation and other indicators. Proper nutrition, positioning, bladder care, and infection prevention protocols are followed during labor management.

1. 1st stage of labor
initial examination

7. Assessment
 History
 Examination
 General
 Abdominal
 P.V
 Investigation

8. . Taking a past history
 If the woman has booked in the hospital.
parity and age .
 Characteristic of previous labors , specially if
operative delivery was necessary .
 Weight of previous babies .
 Condition of previous babies .
 Evidence of CPD.
 Maternal disease, such as PET , anemia , DM
or HD .
 Rhesus iso- immunization .
 Checking for ante natal records

9.  Birth plan:-
 Most woman give birth at hospital .
 Welcome the woman and introduce your self
in order to establish trusting relation ship .
 Explore the following issue with mother.
A. chose birth companion.
B. chose of clothes.
c. Ambulation and pain relive .
d. position during delivery
e. procedure such as AROM ,exercise

10. Midwife's initial physical examination :-
on admission
 Welcoming
 Explanation should be given to the mother about any
procedure and purpose of examination.
 Verbal or written consent should be obtained and
recorded on the note .
 Ask the woman to empty her bladder and urine
specimen should be tested for protein and sugar .
 Take vital signs .
 Physical exam include hands and legs for edema,
general appearance.
 Detailed abdominal examination to assess position
and presentation and decent of presenting part .

16.  FHR monitor before P.V Exam
 Vaginal examination offered 4 hourly, or when
there is concern about progress
 You have to obtain verbal consent before doing
V.E
 she should empty her bladder before
examination .

23. P.V examination

24. Indication for vaginal examination
 To identify the presentation .
 Determine the head engagement
 To diagnose whether the fore water are ruptured
or not .
 To exclude cord prolapsed after SROM.
 Assess the progress of labour.
 To diagnose the entering of 2nd stage of labor
(urge to push).
 Prior to intrapartum administration of analgesia
 To do Artificial rupture of membranes
 In case of fetal distress

26. Cervical Examination: Component of
P.V
 Dilatation 0-10 cm
 1 cm: one finger fits tightly inside
 4 cm: two fingers fit loosely inside
 8 cm: only two cm remaining on each side around the
presenting part
 10 cm: no cervix is palpable around presenting part.
 Effacement: Thinning of the cervix caused by
pressure from the fetal head. It is expressed either as
a percent (0% = no effacement, 100% = complete
thinning) or by length (2cm, 1cm, 0cm).
 Station, zero at ischial spine ,
 Position of cx : anterior , posterior, central
 Consistency: softening of the cx. firm, moderate firm
soft
 Presenting part : ceph. breech
 Status of membranes: intact or rupture

30. Cervical effacement
Figure 1.1 Effacement of the cervix.
(a) Before labour begins, the cervix is not
effaced. (b) Cervix is 60% effaced.
(b) (c) Cervix is fully effaced.

33. Adequacy of the pelvis

34. Fetal heart monitoring
 Intermittent auscultation of the fetal heart after a
contraction should occur for at least 1 minute, at
least every 15 minutes, and the rate should be
recorded as an average.
 Finding of PV Exam:-
 The condition of the vulva and the perineum .
 Any vaginal discharge .
 Cystocele or rectocele .
 Cervical dilatation , consistency , effacement ,
bag of water , the presenting part its position,
engagement , and molding .

37.  Records :- ( on the partograph )
 Pantograph it is the chart on which recording the
progress of labor in graphic method in order to
identified early any deviation from normal , by
which a visual means of recording all observation
and include the following.
 F/H, temp, P, Bp , PV , cont , intake, out put , UA ,
medication ,

38. Partogram:
 a graphical representation that clearly shows the
patient's labor compared to the expected lower limit
of "normal progress
 Some clinicians employ a partogram with alert and
action lines. The alert line represents the rate of
dilatation of the slowest 10 % of labors in
primigravidae. Crossing the alert line suggests that
the patient should be transferred to a hospital if she
is laboring in a rural setting.
 The action line is parallel and four hours to the right
of the alert line; crossing the action line suggests the
need for intervention (eg, artificial rupture of the
membranes, administration of oxytocics agent).

47. The 1st stage of labor
management
 Communication and environment :-
 Labor word staff should have good
communication skills
 God communication on labor word between
women and midwife , midwife and Dr , and Dr
and women can have enormous impact .

48. Communication
 None verbal communication such as written
birth planes, and involvement of the whole
team in decision making .
 Woman should have been given good
information about the physiological process of
labor .
 She should have to know what strategies may
use in cope during birth.
 It is important to welcome woman and
encouraged to feel at ease.
 The midwife should spends time actively
listing

49. Emotional support
 Emotional support is provided by the
following:-
 A) exercising skill in imparting confidence ,
expiring caring and dependability as well as
being an supporter for the child bearing
woman if needed .
 B) The midwife should be none judgmental
attitude .
 C) The woman should be accepted
whatever her reaction to labor .
 D) woman who control her body, behavior
,has active part in decision making , have
more satisfactory birth experience

50. Companion in labor:-
 One to one support during labor ,creates strong
feeling of security and satisfaction as well as
having a positive effect on the out come .
 Reduction use of pain relief , in operative vaginal
delivery ,and cesarean section , length of labor ,
and no harmful effect demonstrated .
 She chosen her companion , whether her
husband , friend , or family member , or even the
student midwife
 Companion can help reduce anxiety , walk with
her, support her decision about pain relive
,provide encouragement , and reassurance ,
helping with physical comfort .

51. Consent and information giving
 consent :- woman should signs on special
form wither she accept or refuse any medical
treatment or procedure , may be done during
labor such as , taking blood sample , after
giving adequate information and
comprehension of that information .

52. Cleanliness and comfort
 Bowel preparation .
 Perineal shave if needed .
 Bath or shower .
 Clothing .

54. Prevention of infection
 Effective cleaning will reduce the transfer of
air borne organisms .
 Restriction of visitor in labor room is
necessary .
 Complete scrubbing for beds and rooms after
use .
 The high standard of cleanliness should be
maintained to the environment .
 Personal hygiene for the mother and her
attendance is important.

55.  Woman should encouraged to bath and wash
as she wishes .
 The midwife must wash her hand before and
after any procedure .
 She must wear gloves when handling any
solid or contaminated object .
 Woman with infection such as hepatitis or
having H I V they need very specialized care
for prevention of cross infection such as
isolation, special midwife care for her.

56.  Minimize staying in hospital is important by
encouraging woman to stay at home during
latent phase of labor and also reduce the
duration of labor .
 Invasive procedure should be kept to maintain
skin integrity to provide an excellent barrier to
infection .
 The fetal membrane should remain intact
unless there is indication for ruptured .
 After rupture of membrane restriction of
vaginal examination with strict sterile
technique is important

57. Pre labor rupture of fetal membranes
at term
 If woman present with pre labor rupture of
membrane , restriction of vaginal examination is
important in order to reduce in ascending
infection .
 Sterile speculum examination is done to confirm
the driftnet rupture .
 High vaginal swab taken .
 After 24 – 48 hours if labor dose not started ,
spontaneously induction of labor is performed .
 Observe signs of infection e.g. temp , FHR .
 Anti biotic may be used to reduce neonatal
infection .

58. Position and mobilizing
 Up right position during labor is more significant
to woman because it provide less pain and less
perennial trauma .
 Her position should be influenced with fetal
position e.g. o p position or lateral .
 Any position woman found is comfortable for her
she should adapted unless other indication such
as fetal condition or position of fetal head .

59. Analgesia
 Advantage and disadvantage of all method of
analgesia available should be discussed with
woman during ANC .
 Epidural give most effective pain relief but
increase incidence of instrumental delivery .

60. Nutrition
 woman's need in labor for CHO . So tots , cereal,
yoghurt, fruit, juice, tea, biscuits, ice cream, jelly,
and fluid can be given .
 Some hospitals may allow woman with free
problem .
 Some hospital keep woman NPO because may
need for urgent operation , or fear of regurgitation
because emptying time of stomach is delayed .
 NPO may cause accumulation of acid in the
stomach and this can lead to chemical
pnemoniaitis if inhaled

61. NUTRITION
 Uterine muscle are in need for glucose during
contraction .
 Without glucose supply body start to metabolism
storage of protein and fat .
 Without glucose uterine inertia will occur .
 high concentration of IV glucose may cause fetal
blood glucose increase and production of insulin
will be high and result in hypoglycemia of the new
born ..

62. Bladder care
 Woman should be encouraged to empty her
bladder every 1-2 hours .
 Midwife should not wait for mother request to void
because sensation of needing mecturation is
reduced (epidural )
 Full bladder may interfere with the decent of the
presenting part.
 Reduce the contractility of the uterus which
increase risk of PPH .
 In and out catheterization may done if woman
unable to void and after dewing your nursing
measure to void .

63. observation
 Maternal condition;-
 Mother's reaction to labor e.g. happiness ,
excitement motivating , apprehension , fear ,
worry anxious .
 Advice and assistance , encouragement, can help
her ,
 Accurate and easy to understand information
about the progress of labor .
 Pulse rate may increase because of pain , anxiety
, ketosis and bleeding , so every 1-2 hours should
be taken and recorded .
 Temperature , hyper pyrexia may indicate
infection or ketosis .

64.  The BP measured every 2-4 hours unless
indicated
 In active phase hourly .
 BP must be monitored every closely following
epidural or spinal anesthesia .
 PET , essential hypertension , measuring BP may
needed more frequently .
 Urine analysis should be tested for glucose ,
ketenes , and protein .
 Fluid balance , a record of intake and out put is
important .
 Abdominal examination to asses the length ,
strength , and frequency of uterine contraction ,
the decent of the presenting part .

65.  Vaginal examination for the progress of labor to
diagnose the progress of labor
 The fetus;- assessment of the fetal condition
during labor by fetal heart patterns , fetal PH ,
and the amniotic fluid .