ManageMent of first stage of labour

by: savita

ManageMent of first stage of labor:

• The first stage of labor extends from the first signs of labor 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 labor to the mother there should be an active management which include the monitoring of mother as well as fetus.

objectives:

• Prepare mother for smooth delivery in 2nd stage

• Monitor progress, maternal and foetal condition.

care of MotHer• 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, linens 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 labor: some mother may view the contractions experienced as positive, motivating, life giving force. Others may feel them as pain and resist them. One woman 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.

cont…• Blood pressure: it is measured every 4 hourly

and marked with an (↕).

• Urinalysis: all urine passed during labor 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. 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

abDoMinal eXaMination:

• 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 still 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

• (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

CONT….• 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 likely.

• 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.

CONT….• 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: • FHR alongwith its rhythm and intensity should be noted

every half hour in 1st 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.

• 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.

CARDIOTOCOGRAPH• 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:

• 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.

CONT….• 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.

• Baseline tachycardia: Detection of fetal heart rate in 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.

CONT…• 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.

• 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.

• ACCELERATION PATTERN: it is short lived quickening of the fetal heart rate with uterus contractions. It is due to changes in the baseline.

• 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 variabilityno 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 deceleration 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 1st stage, careful surveillance is required. Acidosis can only be confirmed by the amniocentesis.

AMNIOTIC FlUID COlOR: meconium may be passed the

amniotic fluid becomes green as a result of meconium staining.

Muddy yellow colour or which is only slightly green may signify previous distress from which the fetus has recovered.

Rhesus iso-immunisation; golden yellow color shows an excess of bilirubin.

• VISCOSITy AND ODOR : it is watery and lacks a strong odor. Infection is suspected if the fluid is thick, cloudy or foul smelling.

• AMOUNT: expected amount is 500-1200ml. polyhydramnios if >2000ml of fluid oligohydramnios if <500ml.

FETAl DISTRESS

• It occurs when the fetus suffers oxygen deprivation and becomes hypoxic.

• SIGNS OF FETAl DISTRESS: • Fetal tachycardia which is an early sign of

oxygen deprivation.• Fetal bradycardia or fetal heart rate

decelerations related to uterine contractions.

• 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.

• 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 skills required to cope with the stresses of labor set the scene for a positive childbirth experience.

• 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;

.

• 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, including 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.

CoNT…

• RESTRICTION OF INVASIVE TECHNIQUES: performance of vaginal examination, are necessary during labour but the midwife should aim to reduce these to a minimum and ensure 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 likely that even with 100ml of the urine, distension occurs.

• DISTENDED BLADDER IS A PRECURSOR TO THE FOLLOWING COMPLICATIONS

• OBSTRUCTED/PROLONGED LABOUR: a full bladder prevents descent of presenting part.

• ATONICITY OF UTERINE WALLS: distended bladder reduces uterine capacity to contract, so increase the risk of post partum haemorrhage.

• DIFFICULTY IN DELIVERING THE SHOULDERS: full bladder interfere in descent/rotation of shoulder.

• 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.

CoNT…..

• Bowel: An enema with soap and water or glycerine suppository traditionally 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 facilitate germ free process of delivery.

REST AND SLEEP

• 1). Rest and ambulation: if the membranes are intact , the patient is allowed to walk about. This 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.

PoSITIoNS uSED FoR BIRTh AND LABoR

POSITION ADVANTAGESStanding

Standing and leaning forward Walking

Sitting upright

Semisitting

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. In addition to above also relieves backache.May be more restful than standing. Fetus is well aligned with angle of pelvis.Encourages descent through pelvic mobility.

Good resting position.Can be used with electronic fetal monitoring. Vaginal exam possible.Easy position to get into on bed or delivery table.

CoNT….POSITION ADVANTAGES

Sitting, leaning forward with support Hands and knees, Kneeling, laning forwardwith support

In addition to above it is a Good position with backrub. Helps relieve backacheAssist rotation baby in occiput postier positionAllows for vaginal exam Takes pressure off hemorrhoids Helps relieve bachache.Allows for pelvic rocking.Less strain on wrists and hands than hands and knees position.

CoNT….POSITION ADVANTAGES

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.-Facilitates 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.

CoNT….

POSITION ADVANTAGES

Squatting Sitting on toilet Supported squat

May help perineum for effective bearing down. Maximizes diameters of bony pelvis.Permits relaxation while avoiding stretching of the muscles connected to the pelvis

DIET/NuTRITIoN• 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 and 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. 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.

• 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

RELIEvE 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 METhoD• 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. 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 requirement 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.

• Ask the woman to lie 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.

Cont…• 1).Abdominal rub: It is a light 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

• 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 compressed 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.

ReseaRCh done on pain Relieve 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 1st 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.

•

Cont….• The conceptual framework adopted for study was based

on nursing process. The research 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.

nURsinG manaGement• 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.

•

Cont…• 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.

Cont….• 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

Cont…• 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 facilitate delivery of the placenta.•

Cont…• 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 in preparation for caring for a new infant.

• -monitor woman’s fatigue level and the amount of rest received to ensure restoration of energy.

Cont….

• 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.

Cont….

• 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.

•