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4. Labour - 1st Stage - Management-1.pptx
1. Labor – First Stage
Management
Dr. S. Kalavathi
Professor
RMCON, AU.
2. Introduction
Labor is a unique experience in women’s life.
Labor events have got great psychological, emotional and social
impact to the woman and her family.
The knowledge of physiological changes during labor, ensures
appropriate care to the mothers.
Labor pain is real and the mothers are sensitive.
Mother experiences pain, stress and fear of unknown/danger.
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3. Introduction
The main aim of MCH is reduction of Maternal &
Perinatal morbidity and mortality
The function of midwifery is preventive
Every mother would like to deliver a healthy baby
Every midwife should aim to fulfil her wish
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5. General Considerations
Caregivers need to be tactful, sensitive & respect mother’s feelings.
Privacy, and explanation is to be given.
Mother can choose her birth companion.
Continuous emotional support reduces the need for analgesia &
operative delivery.
Keep her informed her about the progress of labour.
Environment should be so, that she can birth with dignity.
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6. Aims of management in Normal Labor
Maximal observation with minimal active intervention.
Maintain normalcy.
Detect deviation from normal at the earliest possible moment.
Take necessary action like informing seniors or referring, etc.
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7. Admission of the Mother
Quick history collection, assessment need to be done.
Refer medical records, & learn the condition of the mother.
Care according to the stage of labour.
Make her feel comfortable by showing a welcome attitude &
by giving reassurance.
Admission bath may be given & dress, jewels, artificial
dentures, lenses, need to be taken care.
Consent form… 7
8. Antisepsis & Asepsis
Strict asepsis and antisepsis should be maintained.
Shaving/hair clipping of the vulva or perineal care as per policy.
Shower or bath & wear laundered gown.
Strict aseptic technique to be followed during vaginal examinations
& during conduction of delivery.
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9.
10. Vaginal examinations in labor
Vaginal examination findings serve as a baseline data.
Frequent PV exam should be avoided.
PV exams can be done every 4 hourly in normal labor to assess the
progress of labor.
Even if the proper aseptic techniques are followed there is chance of
introducing infection, specially after rupture of membranes.
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11. Vaginal examinations in labor [Cont..]
Indications
Vaginal examination is done on admission by a senior doctor:
to confirm the onset of labor & the onset of II stage of labor,
to confirm the presenting part & station,
to confirm the position,
to assess pelvic adequacy (Primi),
Following rupture of membranes, to exclude cord prolapse.
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12. Management of First Stage
Principles
Non interference with watchful expectancy so as to
prepare the patient for natural birth.
To monitor carefully the progress of labor, maternal
conditions and fetal behavior, so as to detect any
intra partum complications early.
Maintain privacy.
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13. Management of First Stage
General Care
Admission of the mother.
Confirm the stage in which she is & care accordingly.
Constant supervision.
Avoid supine position in bed to avoid vena caval congestion.
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14. Management of First Stage
Bowel Care
Traditionally an enema with soap and water or glycerine
suppository is given early in labor.
Enema reduce the load in the rectum & contamination in second
stage.
Studies have proved that enema does not shortens the 2nd stage
or the rate of infection.
Giving enema – Follow the Institution Policy
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15. Management of First Stage [Cont..]
Rest and Ambulation
Mother can be ambulated in first stage if,
The membranes are intact.
Not given any analgesia.
Ambulation may reduce the duration of labor and the
need of analgesics & improve the maternal comfort.
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16. Management of First Stage [Cont..]
Diet
Emptying of the stomach is delayed in labor.
Gastric content pH is low.
Fluids (Juices, water) may be given in early labor.
Intravenous infusion may be started where any intervention is
anticipated or patient is under regional anesthesia.
Food is withheld in active labor.
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17. Management of First Stage [Cont..]
Bladder Care
Encourage mother to empty the bladder by herself frequently [Full
bladder inhibits contractions and may cause infection].
If fails to urinate on her own, catheterize following aseptic
precautions.
If women can not go to the toilet, bedpan is to be provided.
Maintain privacy.
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18. Management of First Stage [Cont..]
Relief of Pain
Pain relief is an important aspect in care of mother in labour.
Pain relief is achieved by Pharmacological or Non Pharmacological methods.
Explanation, reassurance, relaxation, back massage, etc. are useful pain relief.
Common analgesic drug used is Pethidine, 50 to 100mg IM given in well
established labour, and can be repeated after 4 hours.
Pethidine crosses the placenta, causes respiratory depression to the neonate.
Pethidine should not be given if delivery is anticipated within 2 hours.
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19.
20. Management of First Stage – Observation
Maintain partograph
Maternal Vitals – Pulse, Respiration, BP, Temperature
Observe the tongue periodically for hydration
Uterine contractions – duration & interval
Urine output
21.
22. Partograph
Partograph is a paper-based tool developed by the W.H.O.. According to
standard W.H.O. protocol, different labour vitals need to be monitored at
a different intervals based on the stage of labour.
The partograph or partogram has been established as the “gold standard”
labor monitoring tool universally.
A partogram or partograph is a composite graphical record of key data
(maternal and fetal) during labour entered against time on a single sheet
of paper.
It includes, relevant measurements such as cervical dilation, fetal heart
rate, duration of labour and vital signs.
It is intended to provide an accurate record of progress in labour, & to
detect quickly, deviation from normal & to treat it accordingly.
23. Components of Partograph
Patient identification data.
Time: It is recorded at an interval of one hour.
Zero time (for spontaneous labour) is time of admission in the
labour ward.
For induced labour is time of induction.
Fetal heart rate is recorded every thirty minutes.
State of membranes and colour of liquor:
"I" designates intact membranes,
"C" designates clear and
"M" designates mecconium stained liquor.
24. Components of Partograph
Cervical dilatation and descent of head.
Uterine contractions: Squares in vertical columns are shaded
according to duration and intensity.
Drugs and fluids
Blood pressure: is recorded in vertical lines at an interval of 2
hours.
Pulse rate: is also recorded in vertical lines at an interval of 30
minutes.
Oxytocin: Concentration is noted down in upper box; while
dose is noted in lower box.
Urine analysis
Temperature recordings
25. Advantages of using Partograph
The use of the partograph is recommended as an important indicator for monitoring
intrapartum care.
Partograph includes several labour vitals including cervix dilatation of the mother.
Plotting the cervix dilatation against time can help in predicting early, deviation
from the normal progress of labour.
Provides information on single sheet of paper at a glance.
Improvement in maternal morbidity, perinatal morbidity and mortality.
A partograph is contained in the Perinatal Institute's "Birth notes’’.
Use of a partograph in established labour is recommended by the National Institute
for Clinical Excellence (NICE) in the "Intrapartum Care" guidelines.
26. Limitations of Partograph
Partograph requires a skilled healthcare worker to fill and
interpret the findings.
Often paper - partograph and the equipment required to
complete it are unavailable in low resource settings.
Despite decades of training and investment, implementation
rates and capacity to correctly use the partograph are very low.
According to some recent literature, cervical dilatation over
time is a poor predictor of severe adverse birth outcomes. This
raises questions around the validity of a partograph alert line.
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28. ADVANTAGES OF PARTOGRAPH
Provides information on single sheet of paper at a glance
Early prediction of deviation from normal progress of labour
Improvement in maternal morbidity, perinatal morbidity and
mortality.
Usage
A partograph is contained in the Perinatal Institute's "Birth notes“.
Use of partograph in labour is recommended by the National Institute
for Clinical Excellence (NICE) in the "Intrapartum Care" guidelines.
29. Limitations
It requires a skilled healthcare worker who can fill and interpret the
partograph.
Recent studies have shown there is no evidence that partograph use
is detrimental to outcomes.
Often paper-partograph and the equipment required to complete it
are unavailable in low resource settings.
Despite decades of training and investment, implementation rates
and capacity to correctly use the partograph are very low.
Some recent literature found that, cervical dilatation over time is a
poor predictor of adverse birth outcomes. This raises questions
around the validity of a partograph alert line.
30. Digital Partograph
A digital partograph is an electronic implementation of the standard
paper-based partograph/partogram that can work on a mobile or
tablet PC. Partograph is a paper-based tool developed by the W.H.O.
to monitor labour during pregnancy.
The use of the partograph is recommended as an important indicator
for monitoring intrapartum care. Partograph includes several labour
vitals including cervix dilatation of the mother. Plotting the cervix
dilatation against time can help in predicting deviation from the
normal progress of labour.
In order to overcome the limitations of paper-based partograph,
various researchers have suggested the use of digital partograph.
Much literature is available regarding the feasibility of a digital
partograph.
31. Digital Partograph
A digital
partograph is an
electronic
implementation
of the standard
paper-based
partograph that
can work on a
mobile or tablet
PC.
33. Advantages of Digital Partograph
Allows easy data analysis
Data is essential in healthcare & electronic partograph makes a digital copy of the
data.
Partograph itself is a very basic form of A I & with more data, we can improve the
underlying algorithm to predict complications, adverse outcomes during labour.
Availability
A common reason for low partograph use is non-availability of paper-based
partograph. The limitations, can be overcome by use of digital partograph.
The feasibility of digital partograph is high, provided an adequate power supply.
Ease of use
Plotting paper partograph requires training.
Digital photographs are made highly simple to use by taking advantage of advances
in human-computer interaction except that Non-tech savvy users might find it
overwhelming.
34. Advantages of Digital Partograph
Mitigating human errors
Electronic partograph remind the midwives to enter labour vitals in
case they forget the standard protocol.
In some cases, such small aid can be life-saving by decreasing the delay
in decision making.
Increased accountability & preventing false data entry.
Often the partograph is filled after delivery only for record keeping
purpose.
With electronic records, it is impossible to temper the data. Actual
time of data entry can be logged easily. This allows obtaining a correct
metric of protocol adherence for the labour monitoring process.
35. Management of First Stage – Observation
Descend of presenting part – by
Abdominal palpation,
Pelvic grip,
PV examination &
Shifting of maximal intensity of FHS
36. Management of I Stage-Assessment of Fetal Wellbeing
Check the FHR – Rate, rhythm, and intensity
Counted every half an hour in early labour; Every 15 minutes in late labour;
and every 5 minutes in second stage of labour
Count FHR for full 1 minute; The count immediately following uterine
contractions is valuable.
Normal FRH – 110 to 160 beats per minute
Continuous Electronic Fetal Monitoring – is done in high risk pregnancies
40. Management of First Stage [Cont..]
Assessment of Progress of Labor
Pain – duration and interval. As the labour advances, the duration
increases and the interval decreases.
Station of the head – can be assessed by abdominal palpation & PV
examination.
Cervical dilatation & effacement. After latent phase, in Primi – 1
cm/hour & in Multi – 1.5 cm/hour is the rate of dilatation.
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41.
42. Management of First Stage [Cont..]
Preparation for Second Stage of Labor
The mother may be anxious of labour, because of pain and
fear of unknown, Fear of outcome of labour etc.
Physical Preparation of the mother.
Psychological preparation of the mother.
Preparation of delivery tray, resuscitation tray etc.
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43. Evidence of Maternal Distress
Anxious look with sunken eyes,
Rising pulse rate of 100 per minute or more,
Dehydration, dry tongue,
Hot, dry vagina often with offensive discharge,
Acetone smell in breath,
Scanty high colour urine with presence of acetone.
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44. Management of First Stage – Observation
Descend of presenting part – by
Abdominal palpation,
Pelvic grip,
PV examination &
Shifting of maximal intensity of FHS
45. Management of I Stage-Assessment of Fetal Wellbeing
Check the FHR – Rate, rhythm, and intensity
Counted every half an hour in early labour; Every 15 minutes in late labour;
and every 5 minutes in second stage of labour
Count FHR for full 1 minute; The count immediately following uterine
contractions is valuable.
Normal FRH – 110 to 160 beats per minute
Continuous Electronic Fetal Monitoring – is done in high risk pregnancies
49. Management of First Stage [Cont..]
Assessment of Progress of Labor
Pain – duration and interval. As the labour advances,
the duration increases and the interval decreases.
Station of the head – can be assessed by abdominal
palpation & PV examination.
Cervical dilatation & effacement. After latent phase, in
Primi – 1 cm/hour & in Multi – 1.5 cm/hour is the rate
of dilatation. 49
50. Management of First Stage [Cont..]
Preparation for Second Stage of Labor
The mother may be anxious of labour, because of pain and
fear of unknown, Fear of outcome of labour etc.
Physical Preparation of the mother.
Psychological preparation of the mother.
Preparation of delivery tray, resuscitation tray etc.
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51. Evidence of Maternal Distress
Anxious look with sunken eyes,
Rising pulse rate of 100 per minute or more,
Dehydration, dry tongue,
Hot, dry vagina often with offensive discharge,
Acetone smell in breath,
Scanty high colour urine with presence of acetone.
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