RAJKUMARI AMRIT KAUR COLLEGE OF NURSING LAJPAT NAGAR TOPIC: MANAGEMENT OF FIRST STAGE OF LABOR

Management of first stage of labour: The first stage of labour extends from the first signs of labour to full dilation of the cervix. There is usually wide

variation between the duration in primi and multipara. To avoid/prevent the complications during the labour to the mother there should be active management which include the monitoring of mother as well as fetus.

PRINCIPLE: 1) Non-interference with watchful expectancy so to prepare the patient for natural birth. 2) To monitor carefully the progress the labour, maternal conditions and fetal behavior so as to detect any

intrapartum complication early.

PRELIMINARIES: This consists of basic evaluation of the current clinical condition. Enquiry is to be made about the onset of labor pains or leakage of l iquor, if any. Thorough general and obstetrical examination including vaginal examination are to be carried out and recorded. Records of antenatal visits, investigation reports and any specific

treatment given, if available, are to be reviewed. ACTUAL MANAGEMENT: Objectives:

-PREPARE MOTHER FOR smooth delivery in 2nd stage -Monitor progress, maternal and foetal condition. CARE:

PREPARATION OF THE LABOR ROOM: -Preparation of the labor room starting from admission room to examination room, baby room and delivery room with all instruments, l inens and drugs.

- Follow all universal precautions. ADMISSION: -Admission of the mother

-Take consent -Provide nursing support -Collect detailed history

EXAMINATION OF MOTHER: -Examination of mother which covers vital signs, general examination, abdominal examination every 4 hr. Type of blood group Hb, blood glucose.

-Urine analysis is also undertaken for protein and glucose. 4 hrly OBSERVATIONS: MOTHER: Reaction to labour: some mother may view the contractions experienced as positive, motivating, l ife giving force.

Others may feel them as pain and resist them. One woma n may welcome the event with excitement because soon she will see her baby, another may be glad the pregnancy is over. If the midwife concentrates her attention on the woman, she can help to absorb and deflect some of her anxieties.

ASSESSMENT BY PARTOGRAPH: Vital signs:

Pulse rate: pulse is recorded every 30 minutes and marked with a (.) in the partograph. If the rate increases to more than 100 beats/min it may be indicative of infection, ketosis or haemorrhage. Or it may

be a sign of ruptured membrane. Temperature: it is recorded every 2 hourly. If hyperpyrexia is there it is the indication of infection or

ketosis.

Blood pressure: it is measured every 4 hourly and marked with an (↕). The B.P must be monitored very closely following the instil lation of local anaesthetic into the epidural space.

Urinalysis: all urine passed during labour must be tested for glucose, ketones and proteins. Ketones may occur as a result of starvation or maternal distress. A trace of protein may be present following rupture of the membranes but more significant proteinuria may indicate worsening pre-eclampsia.

Fluid balance: a record should be kept of all urine passed to ensure that the bladder is being emptied. If IV

infusion is in progress, the fluid administered must be recoded accurately. Observe the tongue periodically for hydration.

EVIDENCE OF MATERNAL DISTRESS ARE: Anxious look with sunken eyes

Dehydration, dry tongue

Acetone smell in breath

Rising pulse rate of 100/min or more

Hot, dry vagina often with offensive discharge

Scanty high coloured urine with presence of acetone

PROGRESS OF LABOUR: ABDOMINAL EXAMINATION: this should be repeated at intervals throughout labour in order to assess the length, strength and frequency of contractions and descent of the presenting part.

Contractions: the length, strength and frequency of contractions should be noted. The strength of contractions are judged by laying a hand on the uterus and noting the degree of hardness during a contraction & by timing its length. Contractions which are unduly long or very strong and in quick succession give cause for concern as fetal hypoxia may develop.

The number of contractions in 10 min and duration of each contraction in sec are recorded in partograph. Partograph is charted every half an hour. Contraction duration <20seconds ░ ; between 20 and 40 secs ▓ ; and >40 secs ▐. Pelvic grip: gradual disappearance of poles of the head( sinciput and occiput) which were felt.

Descent of the presenting part: during 1st stage, descent can be followed almost entirely by abdominal

palpation. It is usual to describe the level in terms of the fifths of the head which can stil l be felt above the

brim. In the primigravida the fetal head is usually engaged before labour begins. If this is not the case, the level of the head must be estimated frequently by abdominal palpation in order to observe whether the head will pass through the brim with the aid of good contractions.

VAGINAL EXAMINATION: It is useful to do when progress is in doubt or another indication a rises. (a) Dilatation of the cervix in centimeters in relation to hours of labor is a reliable index to note the progress of labor. (b) To note the position of the head and degree of flexion.

(c) To note the station of the head in relation to the ischial spines. (d) Color of the liquor (clear or meconium stained) if the membranes are ruptured

(e) Degree of moulding of the head—Moulding occurs first at the junction of occipitoparietal bones and then between the parietal bones. (f) Caput formation—Progressive increase is more important than its mere presence

Effacement or dilatation of the cervix: In normal labour the primigravid cervix effaces before dilating, whereas in multigravida these two events occur simultaneously. Progressive dilatation is monitored as labour continues and charted on the partograph. This will allow for early detection of abnormal progress

and indicates when intervevtion is l ikely. Descent: when assessed vaginally, the level or station of the presenting part is estimated in relation to the

ischial spines which are fixed points at the outlet of the bony pelvis. To note the station of the head in relation to the ischial spine.

Flexion: in vertex presentation the progress depends on increased flexion. The flexion is assessed by position of the sutures and fontanelles. If the head is fully flexed, the posterior fontanelle becomes almost

central; if the head is deflexed, both anterior and posterior fontanelles are palpable. Rotation: it is assessed by noting changes in the position of the fetus between one examination and the

next. Degree of moulding of the head: moulding occurs first at the junction of the occipito-parietal bones and

then between the parietal bones.

MONITORING OF THE FETUS: THE FETAL HEART:

Rate: This should be counted over a minute in order to allow for variations. The rate should be between 120-160 beats/min.

Rhythm: the normal fetal heart has a coupled beat which should remain steady. Any noticeable

irregularity in the rhythm may give cause for concern. FHR alongwith its rhythm and intensity should be noted every half hour in 1 st stage and every 15 min in 2nd stage or following rupture of membranes. The observation should be made immediately following uterine contraction. The count should be made for 60 sec. for routine clinical observation, ordinary stethoscope is quite suitable. Doppler

ultrasonic cardiography, however, is useful in the case of obesity and polyhydramnios. To avoid confusion of maternal and fetal heart rate, maternal pulse should be counted. Otherwise maternal tachycardia may be wrongly treated as fetal heart rate.

Continuous recording: it usually combines a fetal cardiograph and a maternal tocograph in a cardiograph apparatus. This presents a graphic record of the response of the fetal heart to uterine activity as well as information about its rate and rhythm.

The cardiotocograph provides information on:

1. Baseline fetal heart rate: this is the fetal heart rate between uterine contractions. A rate more rapid than 160 bpm. A rate more rapid than 160 bpm is termed baseline tachycardia & a rate slower than 120 bpm is baseline bradycardia.

2. Baseline variability: electrical activity in the fetal heart results in minute variations in the length of each

beat. This causes the tracing jagged, rather than a smooth line. The baseline rate should vary by atleast 5 beats over a period of 1 minute. Loss of this variability may indicate fetal hypoxia but may also be noted for a short period after the administration of maternal pethidine which depr esses the cardiac reflex

centre in the fetal brain 3. Baseline tachycardia: detection of fetal heart rate oin between contractions in excess of 160beats/min.

this step of finding is always required for the impending effects of fetal hypoxia, maternal pyrexia or dehydration and anxiety.

4. Baseline bradycardia: slowing of the fetal heart rate to below 120 beats/min. the congenital fetal heart lesions could be the probable reason preceds fetal death.

5. Beat to beat variations: the ECG of the fetus depicts smooth recorded pattern uninfluenced by uterine contractions. Loss of beat to beat variations is usually present in the fetal hypoxia and in the mothers

under the effect of sedation. 6. Acceleration pattern: it is short l ived quickening of the fetal heart rate with uterus contractions. It is due

to changes in the baseline.

7. Deceleration pattern: transient slowing of fetal heart rate causing a depression or ‘dip’ to appear on the fetal heart rate graph is reffered as deceleration pattern.

Normal fetal heart pattern has the following features: Baseline rate between 120 to 160 beats/min

Normal beat to beat variability

no deceleration.

Acceleration of more than 15beats/min with fetal movements and uterine contractions.

RESPONSE OF FETAL HEART TO UTERINE CONTRACTIONS:

The fetal heart rate will normally remain steady or accelerate during uterine contractions. A late decelaration begins during or after a contraction, reaches its nadir after the peak of the contraction and has not recovered by

the time that the contractions has ended. FETAL BLOOD SAMPLING: The fetus who has become hypoxic will also become acidotic as the pH of its blood is lowered. The normal pH of fetal blood is 7.33 or above. If it falls below 7.25 in the 1 st stage, careful surveillance is required. Acidosis can only

be confirmed by the amniocentesis. AMNIOTIC FLUID STATUS: following rupture of the membranes amniotic fluid escapes from the uterus continuosly and may provide information about the condition of the fetus.

Color: If the fetus becomes hypoxic, meconium may be passed as hypoxia causes relaxation of the anal sphincter.the amniotic fluid becomes green as a result of meconium staining. Amniotic fluid which is a muddy yellow colour or which is only slightly green may signify previous distress from which the fetus has

recovered. In the case of a fetus who is severely affected by rhesus iso-immunisation the amniotic fluid may be golden yellow owing to an excess of bil irubin.

Viscosity and odor of amniotic fluid: it is watery and lacks a strong odor. Infection is suspected if the fluid is thick, cloudy or foul smelling.

Amount od the amniotic fluid: expected amount is 500-1200ml. hydramnios if >2000ml of fluid and oligohydramnios if <500ml.

Fetal distress: it occurs when the fetus suffers oxygen deprivation and becomes hypoxic.

SIGNS OF FETAL DISTRESS: 1. Fetal tachycardia which is an early sign of oxygen deprivation. 2. Fetal bradycardia or fetal heart rate decelerations related to uterine contractions. 3. Passage of meconium-stained amniotic fluid.

MANAGEMENT OF FETAL DISTRESS: When signs of fetal distress occur the midwife must call a doctor. If syntocinon is being administered, it must be stopped and the woman placed in a favourable position, usually on her left side. If fetal distress is more than

transient, delivery will be expedited. In the 1st stage of labor this will necessitate caesarean section. PSYCHOLOGICAL CARE;

Providing home like atmosphere and privacy, involving family, providing companionship caring attitude and emotional support by touching and assuring words. 1. Environment: anxiety will affect the mother’s perception and understanding therefore laboring woman

should be welcomed and encouraged to feel at ease. A trusting atmosphere between a woman and her care

giver , a feeling of being among friends and a knowledge of the skil ls required to cope wi th the stresses of labor set the scene for a positive childbirth experience.

2. Emotional support: it is provided by exercising skill in imparting confidence, expressing caring and dependability and being an advocate for the child bearing woman. The caregiver should display a tolerant non

judgemental attitude, ensuring that the woman is accepted whatever her reactions and behavior may be. ASEPSIS AND ANTISEPSIS;

On part of mother attendant and delivery process toileting vagina with antiseptic lotion . PREVENTION OF INFECTION:

Universal precautions to be kept in mind. The skin and membranes: an intact skin provides an excellent barrier to organisms and it is important to

protect its integrity. This involves the avoidance of surgical wounds whenever possible, i ncluding perineal lacerations and episiotomy. The fetal membranes should be preserved intact unless there is positive indication for their rupture which would outweigh the advantage of their protective functions.

Hygiene: a clean body and environment will reduce the organisms which have access to the mother. This implies the need for barrier methods to be used when caring for woman with any transmissible infection such as gastroenteritis, hepatitis or HIV infection. Pay attention to keep the perineum clean and dry. Also encourage the woman to wash her hands before or after taking something orally.

Restriction of invasive techniques: performance of vaginal examination, are necessary during labour but the midwife should aim to reduce these to a minimum and ens ure that she has a sound reason before

embarking on a procedure. MAINTAIN GENERAL HYGIENE; -Comb hair, cut nails, wash mouth, shower bath if provision is there and give hospital clothing. - Pay attention to keep the perineum clean and dry. Also encourage the woman to wash her hands before or after

taking something orally. CARE OF BLADDER The gradual descent of presenting part into the true pelvis compresses the urinary bladder. It is most l ikely that

even with 100ml of the urine, distension occurs. DISTENDED BLADDER IS A PRECURSOR TO THE FOLLOWING COMPLICATIONS:

i) Obstructed/prolonged labour: a full bladder prevents descent of presenting part. ii) Atonicity of uterine walls: distended bladder reduces uterine capacity to contract, so increase the

risk of post partum haemorrhage. iii) Difficulty in delivering the shoulders: full bladder interfere in descent/rotation of shoulder.

iv) The midwife should inspect the abdomen for presence of distension: patient is encouraged to pass urine by herself as full bladder often inhibits uterine contractions and may lead to infection. If woman cannot go to the toilet she is given a bedpan. Privacy should be maintained and ensure maximum

comfort by placing the bedpan on a stool or chair or letting the woman adopt a squatting position on the bed. The sound or feel of water can also help to trigger the micturition reflex.

If the patient fails to pass urine specially in late first stage of labour catheterization is to be done with strict aseptic precautions.drain out the urine. Observe the urine for colour, amount and any abnormalities. Remove the catheter

and make the woman comfortable. Bowel: An enema with soap and water or glycerine suppository tradi tionally given in early stage. This may be given if the rectum feels loaded on vaginal examination. But enema neither shortens the duration of labor nor reduces the infection rate.

Perineal shave: perineal hair harbor organisms and may infect the woman’s vulva during labor. Prepare and shave the perineal area including mons pubis, vulva and anal region to facil itate germ free process of delivery.

REST AND SLEEP 1). Rest and ambulation: if the membranes are intact , the patient is allowed to walk about. Thi s attitude prevents

venacaval compression and encourages descent of the head. Ambulation can reduce the duration of labour, need of analgesia and improves maternal comfort. If, however, labour is monitored electronically or analgesic drug(epidural analgesia) is given, she should be in bed.

2). Positions for lobor and birth:

Position Advantages Disadvantages

Standing

Takes advantage of gravity during and between

contractions. Contractions are less painful and more productive. May speed labor.

May increase urge to push in 2nd stage.

Poor control at birth.

Hard for health care provider to see the baby.

Standing and leaning forward

In addition to above also relieves backache. May be more restful than standing.

May be tiring for mother as well as the care provider

Walking

Fetus is well aligned with angle of pelvis. Encourages descent through pelvic mobility.

Not recommended if you have high B.P. Cannot be used with continuous electronic

fetal monitoring.

Sitting upright

Good resting position. Can be used with electronic fetal monitoring.

May not be possible in high B.P.

Semisitting

Vaginal exam possible.

Easy position to get into on bed or delivery table.

Access to perineum can be poor.

Mobility of coccyx is impaired. Put some stress on perineum but less than when lying on back.

Hands and knees,

Helps relieve backache Assist rotation baby in occiput postier position

Allows for vaginal exam Takes pressure off hemorrhoids

Hard for supporter to maintain the eye contact.

Hard for mother to see what’s going on.

Kneeling, leaning forward with

support

Helps relieve bachache. Allows for pelvic rocking. Less strain on wrists and hands than hands and

knees position.

Hard for health care provider to help in birth.

Side-lying

Very good resting position.

Convenient for many intervention. Helps lower elevated b.p. Safe if pain medication is used.

May promote progress of labor when alternated with walking gravity neutral. Takes pressure off hemorrhoids. Facil itates relaxation between pushing efforts.

Allows posterior sacral movement in 2nd stage. Widens pelvic outlet to its maximum. Requires less bearing down efforts. May enhance rotation and descent in a difficult

birth. Helpful if mother does not feel an urge to push. Allows freedom to shift weight for comfort.

Hard for health care provider to access fetal

heart tones. No help from gravity. If no one can hold mother’s legs then she

will support on her own. Mother will feel too passive in this situation

Squatting

May help perineum for effective bearing down.

Often trying sometimes hard for health care provider to hear fetal heart tones.

May be hard for supporter to assist in birth.

Sitting on toilet Supported

squat

Maximizes diameters of bony pelvis. Permits relaxation while avoiding stretching of the muscles connected to the pelvis.

Pressure from toilet seat may be un comfortable.

A water birth means at least part of labor, delivery, or both happen while mother in a birth pool fi l led with warm water. It can take place in a hospital, a birthing center, or at home. A doctor, nurse-midwife, or midwife helps mother through it.

The use of a birthing pool during the first stage of labor might: Help ease pain

Keep mother from needing anesthesia

Speed up labor

A warm bath might help mother to relax and help mother to feel more in control. Floating in water helps

mother move around more easily than in bed, too. Some science suggests that the water may lower chances of severe vaginal tearing. And it may

improve blood flow to the uterus. But study results about these points aren’t clear.

WATER BIRTH RISKS

Baby could get an infection.

The umbilical cord could snap before baby comes out of the water. baby’s body temperature could be too high or too low.

baby could breathe in bath water. Baby could have seizures or not be able to breathe.

CONTRAINDICATIONS Mother younger than 17 or older than 35.

Complications l ike preeclampsia or diabetes.

Twins or multiple pregnancy

The baby is in the breech position.

The baby is premature.

Big baby.

Mother need to be constantly monitored and it can’t be done in the tub.

Mother have an infection

BENEFITS OF WATER BIRTH: RELAXATION. . Labour stops and starts without progressing s teadily. The relaxing effect of water will help to keep the contractions in rhythm so that they are less stressful for you and your baby.

SHORTER LABOUR. The water helps muscles relax, so you don't waste any energy being tense. All energy can be used to focus contractions. This

wi l l help make labour quicker.

PRIVACY AND CONTROL. When you are in the pool, you are in your own world and may feel much more in control. You can labour undisturbed in the privacy of the pool.

BUOYANCY. The water makes it easy to move about, so can make yourself comfortable. The best position for you is likely to be the one that helps baby move most easily through your pelvis.

COPING WITH PAIN. Being immersed in warm water may make contractions more bearable, just as having a bath helps ease tummy ache or

backache. Therefore, you are less likely to need pain relief drugs such as pethidine or an epidural to help you cope. If you do need pain relief during labour, you may need to leave the birthing pool for certain types of pain relief.

CONSTANT PRESENCE OF A DOCTOR. Hospital protocols state that a doctor must be with you all the time you are in the birthing pool. If you are labouring on dry land, i t is quite common for your doctor to leave you for periods while she attends to other women in labour.

NATURAL LABOUR. LESS RISK OF A TEAR.

perineum may be less likely to tear because the water softens your tissues so that they can s tretch easily around your baby's head as he i s being born. Some people think that the perineum may be additionally protected because the pressure in the

womb is similar to the pressure in the birthing pool, making the birth of your baby's head more gentle, and possibly reducing postnatal perineal pain.

BETTER USE OF GRAVITY.

Mother i s more likely to give birth in an upright position if mother is using the birthing pool than on dry land. Being upright gives the advantage of working with gravity and may lead to a quicker, easier delivery.

PEACEFUL BIRTH FOR BABY. It's l ikely that your baby will find birth less traumatic i f he is born into an environment similar to the one he enjoyed in the

womb. Emerging from the waters of the womb into the water of th e birthing pool may make the transition to the outside world easier for him .

POSSIBLE HAZARDS OF LABOURING IN WATER? INFECTION.

There may be a ri sk of infection from the birthing pool itself, the outlet or inlet pipes, or i f your bowels open in the pool. However, the research to date doesn't support this.

UNPLEASANT ENVIRONMENT.

You may not l ike the idea of the hospital staff or nurse having to sieve any debris (blood clots, faeces) out of the water in order to keep it clean.

LACK OF PAIN RELIEF. You may find that being in the birthing pool does not make your contractions any less painful. If your plan was to spend most of

your labour in water, i t could be very demoralising to have to get out so that you can have drugs, such as an epidural, for pain rel ief.

EMERGENCY SITUATIONS.

BABY STARTING TO BREATHE UNDERWATER.

GREATER RISK OF TEARING.

SNAPPED UMBILICAL CORD. It's s lightly more common for the umbilical cord to snap following a waterbirth than a land birth. A snapped cord should not be

an emergency s ituation for a properly tra ined doctor. Doctors are now advised to avoid pulling on the cord as they l ift the b aby from the water into his mother's arms.

.

DIET/NUTRITION: Mother require adequate nutrition and hydration, give salty lemon water, soups and fruit juices and plenty of fluids. Nausea, breathlessness and pain due to progressive labour interfere in normal eating and drinking.There is delayed emptying of the stomach in labour. Eating a nd drinking during labour will put woman at an increased risk

of regurgitation and aspiration of gastric contents. Low pH of the gastric content is a real danger if aspirated following general anesthesia when needed unexpectedly. So food is withheld during active labour. Fluids in the form of plain water, ice chips or fruit juice may be given in early labour. If woman has been fasting at

the time of labour, strong acidic gastric juice, if aspirated can cause chemical pneumonitis. Infusion: observe for the signs of dehydration like cracked lips, dry mouth or a parched tongue. Intravenous fluid with ringer solution is started where any intervention is anticipated or the patient is under general anesthesia.

Relief of pain:

Relief of pain and promotion comfort by anaesthesia, sacral massage, acupressure and drugs (pethidine 100mg 1/m, when pain is established and cervix is 3 cm dilated. PHARMACOLOGICAL METHOD:

The common analgesic drug used is pethidine 50-100mg IM when the pains are well established in the active stage of labour. If necessary, it is repeated after 4 hours. Pethidine is an effective analgesic as well as sedative. Metoclopramide 10mg I.M is commonly given to combat vomiting due to pethidine. Pethidine crosses the

placenta & is a respiratory depressant to the neonate. The drug should not be given if delivery is anticipated within 2 hours. NON PHARMACOLOGICAL METHODS OF PAIN CONTROL:

Homeopathy: aconitum solution relieves anxiety and fear arising out of pain during labour.kalicarbonicum is used to alleviate back pain. Gelsium solutions regulate uterine actions and ensure normal labor.

Hydrotherapy: it reduces the length of labour by relieving the muscular spasm and pain. The process of ‘hydrokinesis’ is a major diluting force in relieving discomfort and strain on the pelvic area of the

mother/woman. Main advantage is that there is less need of analgesics, opiates and oxytoxins during labor. Other benefits include considerable reduction in incidences of genital tract trauma and less requir ement of internal examination in labor.

Comfort measures: The back rub, besides promoting muscle relaxation counteract the internal pressure on the spine of the woman. During contractions, lower backache or localized pain occurs as a result of the pressure exerted by the fetal head. The pain increases beyond the tolerance power of the mother if the fetus is in the posterior position. So, apply external pressure on the spine with equal force, so as to counteract the

internal pressure of the spine. This is helpful in reducing the pain. Enquire from the woman, frequently about the proper location of the pressure being applied by you, as the pain site changes with the descent of the fetal head in the pelvis. Massage the spot and the adjacent areas at the same ti me by moving the palm in a circular

way without l ifting up at the proper or identified spot.

Ask the woman to l ie down in a lateral position, so that maximum amount of pressure could be exerted over the back. Use of powder or lotion is beneficial in back rub.

1).Abdominal rub: It is a l ight circular massage using palm and fingers over the entire abdominal area either by the attendant or by significant others. This is done using one hand for feeling contractions and other hand for holding woman’s hand. Abdominal rub gives the feeling of comfort to the woman. It improves the blood circulation by dilating the compressed blood vessels, which have caused tissue anoxia. The increased blood flow combats the

tissue hypoxia and provides a psychological basis for decrease in pain. 2).Efflurage: it is a method of applying pressure over the abdomen by laboring woman,, using both of her hands in a definite pattern. It is done mainly over the lower abdomen (symphasis pubis to just above her umbilicus). The woman uses all fingers of her both hands loosely separated, covers the entire abdominal area in two circular

patterns up and outwards from the umbilicus, down and around or in a reverse pattern. The circular movements of the fingers improve the circulation over the area, thereby reducing tissue hypoxia as well as decreasing the pain. 3).Relief from the leg cramps: leg cramps during labor result by pressure of the presenting part on the nerves of

the extremities. The nerves passing through the obturator foramen get compres sed between the pelvic bone and the fetal head. The leg cramps usually severe in nature, can be relieved by straightening the legs and dorsiflexing the feet alternatively. Avoid the massaging the legs, as there is a risk of dislodging unknown thrombi devel oped during months of trouble with venous return and possible varicosities.

RESEARCH DONE ON THE PAIN RELIEVING METHODS: PROBLEM STATEMENT:

A study to evaluate the effectiveness of back massage and breathing exercises on pain relief on primi mothers during 1st stage of labor in a selected govt. hospital of delhi was undertaken by ROSAMMA BASIL, IN 2001. OBJECTIVES OF THE STUDY:

1).To assess the intensity of pain in primi mothers during the 1 st stage of labor before and after back massage and deep breathing exercises. 2).To evaluate the effectiveness of back massage and deep breathing exercises in reducing the intensity of pain, as evident from the pain scores.

The conceptual framework adopted for study was based on nursing process. The resea rch approach was experimental research with pre test, post test control group design. Purposive random sampling technique was

used to obtain adequate size of sample. Sample comprised of 26 experimental and 26 control group primi mothers during 1st stage of labor. A standard pain assessment tool (0-10 numerical pain intensity scale) was used to collect data. Data were analysed using descriptive and inferential statistics. Sample characteristics were collected using intervention technique and

physical examination. Following conclusion were made on the basis of findings: -Back massage and breathing exercises were found to be an effective non pharmacological measure for significantly reducing the intensity of labor pains in primi mothers.

SIGNS OF POTENTIAL COMPLICATIONS: 1.Contractions consistently lasting >90sec

2.Contractions consistently occurring <2min apart 3.fetal bradycardia, tachycardia, decreased variability not associated with fetal sleep cycle or temporary effects of CNS depressant drugs given to the woman, or late or severe deceleration. 4.Irregular fetal heart rate, suspected fetal dysrhythmias

5.Appearance of meconiumstained or bloody fluid from the vagina. 6.Arrest in progress of cervical dilation or effacement, descent of the fetus, or both. 7.Maternal temperature of >380 C

8.Foul smelling vaginal discharge 9.Continuous bright or dark red vaginal bleeding.

NURSING CARE PLAN NURSING DIAGNOSIS: Anxiety related to labor and the birthing process NURSING INTERVENTION:

-orient woman and significant others to labor and birth unit and explain admission protocol to allay initial feelings of anxiety. Assess woman’s knowledge, experience and expectation of labor; note any signs or expressions of anxiety,

nervousness or fear to establish a baseline for intervention. -discuss the expected progression of labor and describe what to expect during the process to allay anxiety associated with the unknown. Actively involve woman in care decisions during labor, interpret sights and sounds of environment and share

information on progress of labor to increase the sense of control and allay fears. NURSING DIAGNOSIS Acute pain related to increasing frequency and intensity of contractions. NURSING INTERVENTIONS:

-Assesss woman’s level of pain and strategies that she has used to cope with pain to establish a baseline for intervention. -encourage significant others to to remain as support person during labor process to assist with support and

comfort measures, because measures are often more effective when delivered by a familiar person. -instruct mother to use specific techniques such as conscious relaxation, focused breathing, effleurage, massage and application of sacral pressure to increase relaxation. -provide comfort measures such as frequent mouth care to prevent dry mouth, changing of gown or bed covers to

relieve discomfort associated with diaphoresis. -help woman change position to reduce stiffness. -explain what analgesics and anesthesia are available for use during labor and birth to provide knowledge to help

woman make decisions about pain control. NURSING DIAGNOSIS: Risk for impaired urinary elimination related to sensory impairment secondry to labor.

NURSING INTERVENTION: -palpate the bladder superior to symphysis on a frequent basis to detect a full bladder that occurs from increased fluid intake and inability to feel urge to void. -encourage frequent voiding and catheterize if necessary to avoid bladder distension because it impedes progress

of fetus down birth canal and may result in trauma to the bladder. -assist to bathroom to void if appropriate, provide privacy, and use techniques to stimulate voiding such as running water

NURSING DIAGNOSIS: Risk for ineffective individual coping related to birth process. NURSING INTERVENTION:

-constantly monitor events of second stage of labor and birth, including physiologic responses of woman and partner, to ensure maternal, partner and fetal well being. -provide ongoing feedback to mother to allay anxiety and enhance participation. -encourage woman to experiment with various positions to assist downward movement of fetus.

-continue to provide comfort measures and minimize distraction to decrease discomfort and aid in focus on the birth process. -ensure that woman takes deep cleansing breaths before and after each contraction to enhance gas exchange and

oxygen transport to the fetus. -encourage woman to push spontaneously when urge to bear down is perceived during a contraction to aid descent and rotation f fetus. -encourageWoman to exhale, holding breath for short periods of while bearing down.

-have woman take deep breaths and relax between contractions to reduce fatigue and increase effectiveness of pushing efforts.

-have mother pant as fetal head crowns to control birth of head. -explain to woman what is expected in the 3rd stage of labor to enlist cooperation. -have woman maintain her position to facil itate delivery of the placenta.

NURSING DIAGNOSIS: Fatigue related to energy expenditure during labor and birth NURSING INTERVENTIONS: -educate woman about need for rest and help her to plan strategies (e.g. restricting visitors, increasing role of

support systems performing functions associated with daily routines) that allow specific time for rest and sleep to ensure that woman can restore depleted energy levels i n preparation for caring for a new infant. -monitor woman’s fatigue level and the amount of rest received to ensure restoration of energy.

NURSING DIAGNOSIS: Risk for deficient fluid volume related to decreased fluid intke and increased fluid loss during labor and birth. NURSING INTERVENTIONS:

-monitor fluid loss (i.e. blood, urine, perspiration) and vital signs, inspect skin tugor and mucous membranes for dryness to evaluate hydration status. -administer parentral fluid per physician or nurse orders to maintain hydration.

-monitor the fundus for firmness after placental separation to ensure adequate contraction and prevent further blood loss. -offer oral fluids following orders of physician or nurse and desire of laboring woman to provide hydration.

RECORDS AND REPORTS: Throughout the 1st stage of labour the midwife must keep meticulous records of all events and of the woman’s physical and psychological condition and condition of her fetus. While observing the progress of labour she should be alert for signs of the 2nd stage of labour.

BIBLIOGRAPHY: 1) D.C.Dutta;“Textbook of Obstetrics”; HiralalKonar; 7 th Edition; P 134-136. 2) Myles ; Text Book for Midwives; Churchill Livingston; 15 th Edition; P 411-477

3) Dr. G.K. Sandhu, “Obstetric and midwifery” ,lotus; page no 133-147 4) Cathyrene, ‘comprehensive maternity nursing’, Lippincott, 2nd edition, page no.601-639 5) Anamma Jacob,”maternity nursing”, Lippincott, 5 th edition, page no.490-530 6) Basvanthappa,”midwifery and reproductive health nursing”, Elsevier, page no.350 -390

7) Margrat Duncan Jensen,”maternity and gynecological care”,1284 il lustration, page no. 387 -420 8) http//www.Google.com

Management of the first stage of labour

(HAND OUT)

Advisor: Madam Dr. Mrs. Molly babu

Speaker: SAVITA

M.N (PREV)