MANAGEMENT OF THE FIRST STAGE OF LABOUR

FNP LECTURE THEME 4 Lecturer : Ms Aliti Qarikau

Objectives
At the end of this theme students would be able to : Discuss normal labour Define terminologies Describe the management of first stage of labour describe events/ care of the first stage of labour Discuss promotion and maintenance of aseptic technique

Introduction
Care during labour should be aimed towards achieving the best possible physical, emotional and psychological outcome for the woman and baby. The onset of labour is a complex physiological process and therefore it cannot be easily defined by a single event. Although labour is a continuous process, it is convenient to divide it into stages. Definitions of the stages of labour need to be clear in order to ensure that women and the staff providing their care have an accurate and shared understanding of the concepts involved, enabling them to communicate effectively.

1- Latent Phase of Labor:

Uterine contraction may be very mild, irregular not forceful enough to cause much pressure on the cervix. the cervix slowly becomes shorter and softer. This is known as 'Effacement'. Dilation of the cervix occurs from 0 cm to 4 cm. frequency at this stage is from 1-3 per 10 minutes and each contraction lasts for less than a minute. The uterus may become firm and more prominent with every contraction.

 In some women, the labor pains start at the back. This is more likely if the head of the fetus is more posteriorly placed and presses on the mother's spine or ligaments.

2.Active Phase of Labor:

uterus contracts more frequently and the pain is maximum. Uterine contraction occurs after every 3-5 minutes and lasts for more than a minute. The uterus becomes hard and more prominent as the pain increases and softer as the uterus relaxes

 The pains sometimes start at the back and radiates down to the thighs. Later on, at the end of this stage, the pains come even more frequently and appear to run into each other in quick succession. The cervix dilates from 4 cm to 8 cm. Women whose waters have not ruptured at the onset of labour, can experience a gush of water flowing out of the vagina at this stage.

3.Transitional Phase of Labor:

marks the transition from the first stage of labour to the second stage of labour. The cervix dilates from 8 cm to 10 cm At full dilatation at the end of the first stage of labour, the cervix is about 10 cm in diameter ( the maximum diameter of the fetal head is also 10 cm when it is in a normal position, the baby can be born easily through the cervix)

Characteristics of T/phase
Restlessness Hyperventilation Bewilderment and sometimes anger Difficulty following directions Focus on self Irritability Statements like dont touch me Nausea, occasionally vomiting Very warm feeling Perspiration on upper lips Increasing rectal pressure

ADMISSION OF CLIENT IN LABOUR

May be different for each person Each client must be cared for individually based on her particular situation Assessing the condition of mother and fetus may be undertaken in a

sequential order or may need to be performed simultaneously. It is important to determine which stage of labour the woman may be in at the time of admission

When a woman is admitted in early labour, time can be taken to establish the nurse client relationship by: Making the woman and her partner or family feel welcome Determining their expectations about the birth (did they attend childbirth classes/) Identifying cultural values and preferences related to the birth process

Initial assessment
A copy of the prenatal record is added to the clients admission record Clients who have not received prenatal care will need more extensive assessment.

When a woman is admitted in active labour, a history is taken and an examination undertaken. The examination includes: temperature pulse Respiration blood pressure Auscultation of heart and lungs Fetal heart rate (FHR), continuous fetal monitoringCTG

 Contractions monitored for frequency, duration and intensity state of hydration the urine should be tested for glucose, ketone bodies and protein Inspection for signs of edema of face, hands, legs and sacrum

Examination of the abdomen:

inspection, palpation and auscultation to determine: the fetal lie, presentation and position, and the station of the presenting part, as well as to determine the presence of a fetal heartbeat (The FH beat may be heard in various places on the mothers abdomen depending on the position of the fetus)

VAGINAL EXAMINATION : should be performed only after cleansing of the vulva and introitus and using an aseptic technique with sterile gloves and an antiseptic cream.

The following factors should be noted: the consistency, effacement and dilatation of the cervix whether the membranes are intact or ruptured and, if ruptured, the colour of the amniotic fluid presence of bloody show nature and presentation of the presenting part its relationship to the level of the ischial spines assessment of the bony pelvis and in particular of the pelvic outlet

CONTRACTIONS:
are assessed by placing the fingers of one hand on the fundus of the uterus, and using a light pressure to keep the fingers still begin in the fundus and spreads down the uterus Person assessing the uterine contractions can feel the tightening of the uterus before the woman is aware of it

 At least 3 contractions in a row should be assessed The time each contraction begins and ends (duration) and the time lapse between contractions (frequency), should be noted. The intensity can be estimated by how easily the uterus can be indented during a contraction.

Mild contraction

moderate contraction Strong contraction

Uterus is easily indented with the fingertips; feels like the tip of the nose Uterus is more difficult to indent with the fingertips; feels similar to the chin Uterus unable to be indented with fingertips; feels like the forehead

 Station is a term used to describe the descent of the baby into the pelvis. An imaginary line is drawn between the ischial spines. This is the "zero" line, and when the baby reaches this line it is considered to be in "zero station." When the baby is above this imaginary line it is in a minus station. When the baby is below, it is in a "plus" station. Stations are measured from -5 at the pelvic inlet to +4 at the pelvic outlet

Nursing interventions
Focuses on continuous assessment of : labour progress and fetal well-being providing maternal physical care Assisting the client and her support person Providing and assisting with pharmacological comfort measures

1) Continuous assessment of labour and fetal well-being

The nurse personally assess labour progress, times the contractions and listens to the FHR at regular intervals Records findings on the partogram One to one continuous support

Electronic fetal monitoring

2 Types- 1) intermittent auscultation (sonicaid/doppler) 2) continuous EFM (CTG) EFM provides a visual record of the FHR in relation to the uterine contractions It allows early detection of fetal distress and abnormal uterine activity

Changing from intermittent auscultation to continuous EFM Significant meconium stained liquor (also considered for light meconium stained Abnormal FHR detected by intermittent auscultation-less than 110bpm greater than 160bpm, any decelerations after contractions Maternal pyrexia defined > 38C/once or 37.5C on 2 occasions 2 hrs apart. Fresh bleeding developing in labour

 External indirect monitoring (CTG cardiotocograph procedure: A tocodynamometer (for uterine activity) is placed on the mothers abdomen near the fundus A strap around the mother holds it in place

A doppler transducer( ultrasonic device) is placed on the mothers abdomen and moved around until the fetal heart is heard the bestthis is also strapped in place Sound waves are bounced off the fetal heart and picked up and displayed by the monitor

2- Providing maternal physical care Includes: comfort measures hygiene measures ambulation and position food and fluid intake elimination

a) Comfort measures
Offering the client fluids Providing oral care Assisting the client with frequent position changes- (encourage side-lying or upright positions) Providing encouragement and praise

 Suggesting the use of cold wash cloth on the forehead or nape of the neck Keeping client informed of the progress Giving back rub Assist client in walking to showers Offering analgesics as ordered

b) Hygiene measures
Offer showers if not contraindicated for the client Bed linens should be clean and dry Change mackintosh frequently if needed Perineal care/changing of sanitary pads when soaked Oral care

c) Ambulation and position

May increase uterine activity, provide distraction from the discomforts of labour, enhance maternal control of the situation Encourage client to walk only if: the membranes are still intact Presenting part is engaged after ROM If she has not had pain medication. Side- lying position promotes uteroplacental blood flow Upright positionplace pillow under one hip to keep uterus from compressing the aorta and vena cava

d) Food and fluid intake

Clear fluids are all that is offered Sometimes I.V fluids are started on clients Keep an accurate I&O record if I.V fluid s are infusing (danger of hypervolemia)

Elimination
Encourage client to void every 2 hours Allow to walk to bathroom if not contraindicated Catheterize if client cannot void and bladder is distended Monitor input & output

Assisting client and support persons S/P can be : the babys father or may be
another man or woman Should be treated with respect regardless of relationship to the mother or fetus Breathing techniques 3 types:Slow deep breathing Shallow breathing Pant- blow breathing

Providing pharmacological comfort measures

Non- pharmacological (as discussed earlier) Pharmacological- systemic medications, regional blocks, general anesthesia Systemic medications should be administered only if: The client is willing to receive them and vital signs are stable

 The fetus is : term exhibits normal movement, FHR is 120-160bpm with no late or variable decelerations Amniotic fluid is not meconium stained

Contractions: - Are well established - Cervix dilated at least 4-5cm in a nullipara, 3-4cm in a multipara, presenting part is engaged - No complications are identified

 Effects on the fetus depends on: The dosage given, timing and route of administration and the pharmacokinetics of the drug (best avoided if there is less than 3 hours before delivery).

Suggested time frame for selected assessments

Assessment BP,P, R temperature Latent phase q1h q4h Active phase q1h q4h Transition 2nd stage phase q30min q4h q5min

(if ROM)

q2h

q2h

q2h

FHR contractions

q1h q1h

q3omin q30min

q15min q15min

q5min
continuously

Promotion and maintenance of aseptic technique

Wear disposal gloves anytime hands might come in contact with amniotic fluid, bloody show, urine or feces Wear splash aprons and eye-covering (goggles or face masks) when the splashing of body fluids is possible Wash hands before putting on gloves and immediately after removing them Before catheterizationcleanse vulva and perineum thoroughly to remove any amniotic fluid and bloody show Avoid unnecessary V.E Use of sterile trays/ instruments

Referencing
White. L, (2005). Foundations of Maternal & pediatric nursing.(2nd ed.). Thomson, Delmar learning Fraser, D. M, Cooper, A. (2003). Myles text book for Midwives (14th ed.).Churchill Livingston, Elsevier. Olds, London, Ladewig.(1992).MaternalNewborn Nursing A family- centered approach.(4th ed.).Addison Wesley. Redwood City.