NORMAL LABOUR

BY: RENARD KABWE

RN

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 INTRODUCTION

 The processes that occur are both physiological and

psychological and women anticipate labour differently and so
behave differently during labour
 Labour is an event with great psychological, social and emotional
meaning for the mother and her family. In addition, many women
experience stress and physical pain.
 The midwife and all other supporters should display tact and
sensitivity to respect the needs and choices of the individual
woman and provide an environment which enables her to labour
and give birth with dignity.
GENERAL OBJECTIVES

 Bythe end of the discussion you should be

able to identify, describe and manage normal
labour.
 Specific objectives

 Define normal labour

 Outline the premonitory signs of labour
 State the true signs of normal labour
 Differentiate true from false labour
 Describe the physiology and mechanism of labour
 Discuss the management of a woman in first, second
and third stages of labour
 Outline the complication of labour
DEFINATIONS

 Labour (parturition): this is the process whereby a

viable foetus and the placenta and membranes are
expelled from the uterus into the pelvic or birth canal
and through the vaginal orifice (Sellers 1, 1994).
 Normal labour;
It is labour in which the foetus is born at term (between
36 and 42 weeks’ gestation), presents by vertex, the
process is completed spontaneously and does not
exceed 18hours, with no complications to both the
mother and the baby.
PREMONITORY SIGNS OF LABOUR

 These signs occur 2-3 weeks before labour starts and

include the following:
Lightening
 This is the sinking of the uterus 2-3 weeks before
term.
 The fundus no longer clouds to the lungs and
breathing is easier.
PREMONITORY SIGNS OF LABOUR

2. Frequency of Micturition
 Mild incontinence of urine occurs due to weakened
bladder control because of pelvic floor muscle
relaxation.
 This reduces sphincter function (these are pelvic
muscles)
 Pressure of the fetal head on the bladder limits its
capacity requiring to be emptied at all times.
PREMONITORY SIGNS OF LABOUR

3. False Pains/Braxton Hicks

 Braxton Hicks contractions are more intense but are
erratic and irregular, these contractions that have been
occurring throughout pregnancy – may become
uncomfortable.
 When these contractions are strong enough for the
woman to believe she is in labour, she is said to be in
false labour.
PREMONITORY SIGNS OF LABOUR

4. Taking up of the cervix to be part of the lower

uterine segment
 The cervix is drawn up and emerges into the lower
uterine segment and becomes part of the uterus, this
is possible because of the softened pelvic floor.
 In primi gravida, taking up of the cervix occurs before
dilation of external OS (before labour) while in multi
gravida it occurs in labour as dilation of the cervix
begins.
 This is due to the differences in muscle tonicity.
PREMONITORY SIGNS OF LABOUR

5. Sudden Burst of Energy

 Some women report a sudden burst of energy
approximately 24 – 48 hours before labour.
 The cause of the energy spurt is not known.
 In prenatal teaching the nurse should warn
prospective mothers not to over exert themselves
during this energy burst so they will not be
excessively tired when labour begins.
PREMONITORY SIGNS OF LABOUR

6. Other Signs
 Other premonitory signs include the following;
 Weight loss of 2.2 – 6.6 kg resulting from fluid loss
and electrolyte shifts due to changes in oestrogen
and progesterone levels.
 Increased backache, sacro-iliac pressure from the
influence of relaxin hormone on the pelvic joints
 Diarrhoea, indigestion, nausea and vomiting just prior
to the onset of labour
TRUE SIGNS OF LABOUR

a) Presence of show
 This is due to the plugging-off of the operculum; it will
be with blood and appears as blood stained mucus.
b) Dilation of the cervix
 This is due to upward retraction exerted by muscle
fibres in the upper uterine segment pulling on the
cervix making it to enlarge.
 Dilation is further aided by a well-fitting presenting
part.
TRUE SIGNS OF LABOUR

c). Painful rhythmic uterine contractions

 These are felt by the woman as tightening discomfort
or actual pain and they increase in intensity until they
reach the climax after which they diminish gradually.
 They have a pattern of being mild, moderate and
strong.
DIFFERENCES BETWEEN FALSE
AND TRUE LABOUR
True labour
 In true labour the uterine contractions are regular,
rhythmic and painful and increase in intensity
 As contractions increase in intensity the intervals
between contractions shorten gradually
 Contractions intensify when the woman is up and
about
DIFFERENCES BETWEEN FALSE
AND TRUE LABOUR

 Effacement of the cervix takes place, accompanied

by progressive dilation of the cervix and the
membranes feel tense during a contraction.
 Show is present as the operculum is shed

False labour
 Uterine contractions may be painful but not regular
and do not increase in intensity.
DIFFERENCES BETWEEN FALSE
AND TRUE LABOUR
 The interval between contractions varies
 Pain from uterine contractions is relieved by walking
 Show is absent
 Effacement of the cervix takes place but there is no
accompanying dilation of the cervix.
 The membranes do not become tense
STAGES OF LABOUR
1. First stage of labour
First stage of labour (the stage of dilation)
 This stage starts with the initiation of painful, regular
and rhythmic uterine contractions to full dilation of the
cervix (0-10 cm).
 This is the longest stage of labour and lasts about 11
to 16 hours in a prime gravida and should not exceed
18 hours and lasts about 6 to 8 hours in a multi gravid
woman and should not exceed 12 hours.
STAGES OF LABOUR

1. Latent phase which is 0 to 4 cm

dilatation
 This begins with the onset of regular contractions up
to 3cm dilation.
 As the cervix begins to dilate it also effaces, although
little or no foetal decent is evident.
 This phase may last 8 hours.
STAGES OF LABOUR

2. Active phase which is 4cm to 10 (full

dilatation of the cervix)
 This is the stage of when the cervix undergoes rapid
dilation.
 This begins when the cervix is 4cm, and in the presence
of rhythmic contractions, is complete when the cervix is
10cm dilated.
 The cervical dilation should at least be 1cm/hour in
primi-gravida and 1.5cm /hour in a multi-gravida.
PHYSIOLOGY OF FIRST STAGE OF LABOUR

 The length of labour varies in individuals and is

affected by both maternal and foetal factors.
 Generally the duration of labour is affected by parity,
birth interval, psychological state of the mother, and
the type of pelvis, the type of contractions, the
presentation and position of the foetus.
PHYSIOLOGY OF FIRST STAGE OF LABOUR

UTERINE ACTIONS
1. Fundal dominance
 Each contraction starts in the pacemakers, which are
situated on either side of the uterus near the cornua
and spreads across and down the uterus; they last
longer in the fundus.
 The peak is reached simultaneously in the whole
uterus and contractions fade from all parts together.
 This pattern allows the cervix to dilate and the fundus
which is contracting strongly to expel the foetus.
PHYSIOLOGY OF FIRST STAGE OF LABOUR

UTERINE ACTIONS
2. Polarity
 This is the neuromuscular harmony that occurs between
the two segments of the uterus throughout labour.
 The upper segment contracts and retracts strongly but
the lower segment contracts slightly and dilates slowly
(relaxes) to allow expulsion of the foetus to take place.
 If polarity is disorganised there is no noticeable
progress of labour and such labour is said to be
inhibited.
PHYSIOLOGY OF FIRST STAGE OF LABOUR

UTERINE ACTIONS
3. Contraction and retraction
 During labour the uterine muscles do not relax
completely following contraction.
 They retain some form of shortening called retraction;
hence do not completely return to their original length
after contraction.
 This assists in expulsion of the foetus because the
cavity of the uterus is reduced as the upper uterine
segment becomes shorter and thicker.
PHYSIOLOGY OF FIRST STAGE OF LABOUR

 Contractions are regular, rhythmic and occur over a

specified period of time. Initially they are weak, then
moderate and eventually become strong and
expulsive during the second stage of labour.
 In early labour uterine contractions may last less than
20 seconds (weak or mild) and occur after every 15 -
20 minutes.
 As labour progresses contractions increase in
intensity, duration and frequency.
PHYSIOLOGY OF FIRST STAGE OF LABOUR

 Moderate contractions last up to 20 to 40 seconds and

strong ones last more than 40 to 60 seconds
 By the end of the first stage of labour contractions
may occur at 2- 3 minute intervals lasting 50 -60
seconds.
PHYSIOLOGY OF FIRST STAGE OF LABOUR

4. Formation of upper and lower uterine segments

 At the end of pregnancy the uterus is divided into the
upper and lower uterine segments.
 The lower uterine segment has developed from the
isthmus.
 The upper uterine segment is thick and muscular to
enable it to contract and expel the foetus during
labour while the lower uterine segment is thinner to
allow for distension and dilatation during labour and
child birth.
PHYSIOLOGY OF FIRST STAGE OF LABOUR

 The longitudinal muscle fibres are responsible for

contraction and retraction while the circular muscle
fibres are responsible for distension and dilatation.
PHYSIOLOGY OF FIRST STAGE OF LABOUR

5. Formation of a retraction ring

 This refers to the physiological ridge/dermacation
which develops as a result of retraction of the upper
uterine segment, producing progressive thickening of
the walls of the upper segment at the same time
progressive thinning of the walls of the lower segment.
 NB: Bandl’s ring A.K.A Pathological retraction ring
where there is abnormal juctions between the two
segments of the uterus mostly associated with
obstructed labour.
PHYSIOLOGY OF FIRST STAGE OF LABOUR

 In normal labour it is not visible, but when it becomes

exaggerated and visible above the symphysis pubis it
is referred to as the bandl’s ring.
 This may be mistaken for a full bladder and it may be
an indication of obstructed labour pending uterine
rupture.
PHYSIOLOGY OF FIRST STAGE OF LABOUR

 The physiological ring rises gradually as the upper

uterine segment contracts and retracts and the lower
uterine segment thins out to accommodate the
descending foetus.
 Once the cervix is fully dilated and the foetus is
expelled through the birth canal, the retraction ring
rises no further.
PHYSIOLOGY OF FIRST STAGE OF LABOUR

6. Cervical effacement
 Effacement of the cervix may occur later in
pregnancy in primi gravida and in multigravida the
external os may begin to dilate before effacement.
 That is, effacement and dilatation of the cervix occur
simultaneously in multipara women.
 The muscle fibres surrounding the internal os are
drawn upwards and merge into the lower uterine
segment.
PHYSIOLOGY OF FIRST STAGE OF LABOUR

 The cervical canal widens at the level of the

internal os.
 The external os which is now called the os
uteri is dilated by the continuing traction
exerted by the retracting upper segment.
PHYSIOLOGY OF FIRST STAGE OF LABOUR

7. Dilation of the Cervix

 Dilatation of the cervix is a process of enlargement of
the external os from a tightly closed aperture to an
opening larger enough to allow for passage of the
foetal head.
 Dilatation occurs as a result of uterine action and
counter pressure applied by the bag of membranes
and the presenting part on the cervix.
PHYSIOLOGY OF FIRST STAGE OF LABOUR

 Pressure applied evenly to the cervix stimulates the

uterine fundus to respond by contracting e.g a well-
flexed foetal head closely applied to the cervix favours
efficient cervical dilatation.
 Cervical dilatation is assessed on vaginal examination
and is measured in centimetres from 0 to 10 (full
dilatation).
PHYSIOLOGY OF FIRST STAGE OF LABOUR

8. Show
 When effacement and dilatation of the cervix takes
place, the operculum which formed the cervical plug
during pregnancy is displaced or lost from the cervical
canal and is shade through the vagina as show.
 The blood comes from rupture of capillaries in the
decidua vera where the chorion has become
detached.
PHYSIOLOGY OF FIRST STAGE OF LABOUR

 The woman sees blood stained mucoid discharge

within a few hours after labour starts.
 Frank bleeding is considered abnormal while red blood
may herald the second stage of labour.
Mechanical factors

Formation of fore waters

 As the lower uterine segment stretches, the chorion is
detached from it and it becomes loose.
 The intra-uterine pressure causes the loosened part
of the sac to bulge downwards into the internal os.
 The well-flexed foetal head fits well into the cervix
and cuts off the fluid in front of the head from that
which surrounds the body.
Mechanical factors

 The fluid in front of the head is called the fore-

waters while that which surrounds the rest of the
body are called hind waters.
 The effect of separation of the fore waters prevents
the pressure that is applied to the hind waters during
uterine contractions from being applied to the fore
waters.
 This helps to keep the membranes intact in the first
stage of labour and be a natural defence against
ascending infection.
Mechanical factors

10. The general fluid pressure

 This the term used to describe the pressure that is
exerted by the uterine contractions on the amniotic
fluid during labour.
 As the pressure is applied, the fluid cannot be
compressed; hence this pressure is equalised
throughout the uterus and over the foetal body.
Mechanical factors

 When the membranes rupture and a significant

amount of fluid is lost during uterine contractions the
placenta and umbilical cord are compressed between
the uterine wall and the foetus causing diminished
blood supply to the foetus.
 Intact membranes during labour improve oxygen
supply to the foetus and also assist to prevent intra-
uterine infection if prolonged labour occurred.
PHYSIOLOGY OF FIRST STAGE OF LABOUR

11. Rupture of Membranes

 The best time for membranes to rupture is at the end
of the first stage of labour when the cervix is fully
dilated and delivery of the baby is imminent.
 This helps to minimize intra-uterine and foetal
infection especially in HIV and gonococcal infection.
Mechanical factors

 During labour membranes may rupture early if the

presenting part is poorly applied to the cervix resulting
in fore waters not being properly cut-off from the hind
waters.
 In certain incidences the membranes do not rupture
and appear at the vulva in the second stage of labour
as a sac covering the foetal head.
 Occasionally, membranes may rupture days before
labour begins for no reason.
 This is referred to as early rupture of membranes and
can predispose foetus to infection.
Mechanical factors

12. Fetal axis pressure

 This is the force of contraction that is transmitted to
the upper pole of the foetus, and down the long axis
of the foetus and applied to the cervix by the
presenting part.
 This occurs when the uterus rises forward during
each contraction and is more significant after rupture
of the membranes and during the second stage of
labour.
 MECHANISM OF LABOUR

Engagement

 This is when the largest diameter of the fetal head descends into the
maternal pelvis.

 The term engagement is referring to the widest part of the fetal head
successfully negotiating its way down deep into the maternal pelvis.
Engagement is identified by abdominal palpation, where the fetal head is
3/5th palpable or less.
.Descent

 The fetus descends into the pelvis.

 In the primigravida this is likely to occur from 38 weeks gestation
onwards, in a multigravida woman, this may not occur until labour is
established.
Descent is encouraged by:
 Increased abdominal muscle tone
 Braxton hicks in late stages of pregnancy
 Fundal dominance of the uterine contractions during labour
 Increased frequency and strength of contractions during labour
 As the head descends, it moves towards the pelvic brim in either the
left or right occipito-transverse position (this means the occiput can
be facing the left side or right side of the mother’s pelvis).
Flexion

 As the fetus descends through the pelvis, fundal

dominance of uterine contraction exerts pressure
down the fetal spine towards the occiput, forcing the
occiput to come into contact with the pelvic floor.
When this occurs the fetal neck flexes (chin to chest)
allowing the circumference of the fetal head to
reduce to sub-occipitobregmatic (9.5cm).
 In this position, the fetal skull has a smaller diameter
which assists passage through the pelvis
Internal rotation

 The pelvic floor has a gutter shape with a forward and downward
slope, encouraging the fetal head to rotate from the left or right
occipito-transverse position a total of 90-degrees, to an occipital-
anterior (occiput facing forward) position, to lie under the
subpubic arch.
 With each maternal contraction, the fetal head pushes down on
the pelvic floor. Following each contraction, a rebound effect
supports a small degree of rotation. Regular contractions
eventually lead to the fetal head completing the 90-degree turn.
 This rotation will occur during established labour and it is
commonly completed by the start of the second stage. Further
descent leads to the fetus moving into the vaginal canal and
eventually, with each contraction, the vertex becomes
increasingly visible at the vulva.
Crowning

 When the widest diameter of the fetal head

successfully negotiates through the narrowest part of
the maternal bony pelvis, the fetal head is considered
to be ‘crowning’.
 This is clinically evident when the head, visible at the
vulva, no longer retreats between contractions.
Complete delivery of the head is now imminent and
often the woman, who has been pushing, is
encouraged to pant so that the head is born with
control.
Extension of the presenting part

 The occiput slips beneath the suprapubic arch

allowing the head to extend. The fetal head is now
born and will be facing the maternal back with its
occiput anterior.
 Restitution

 Because the shoulders at the point of the head being

delivered are only just reaching the pelvic floor they
are often still negotiating the pelvic outlet and the
fetus may naturally align its head with the shoulders
 This is called restitution and visually you may see the
head externally rotate to face the right or left medial
thigh of the mother
Internal rotation

 During the next contraction, the shoulders, having

reached the pelvic floor, will complete their rotation
from a transverse position to an anterior-posterior
position.
 Evidence of this manoeuvre happening inside can be
visualised by seeing the head externally rotating as
the fetus keeps its spine aligned
Delivery of the shoulders and body

 Downward traction by the healthcare professional will

assist the delivery of the anterior shoulder below the
suprapubic arch.
 This is followed by upward traction assisting the
delivery of the posterior shoulder.
 The fetal body will be delivered by the contractions,
the health professional’s role is only to assist safe
negotiation of this last stage.
MANAGING A WONAN IN LABOUR

BY RENARD KABWE
RN
MANAGEMENT OF THE 1ST STAGE OF LABOUR

ADMISSION OF A CLIENT/PATIENT IN
LABOUR
Objectives
 To confirm if the patient is in labour
 To reassure the patient and allay anxiety
 To
detect any abnormality and take
appropriate action
 To prepare the woman for delivery
MANAGEMENT OF THE 1ST STAGE OF LABOUR

History and initial examination and

investigations
 Prepare
a clean and well dump dusted
room with all necessary equipment.
 Greet
the woman as she comes into the
admission room.
 Introduceyourself in a friendly and
reassuring manner in order to allay
anxiety and to give her confidence.
MANAGEMENT OF THE 1ST STAGE OF LABOUR
 Quickly assess the general condition of the
woman as she comes in by observing her
behaviour – gait, facial expressions and
appearance.
 Inquire about the labour and how she is feeling.
 Ask if she has a support person and whether she
wants the support person present during the
examination.
 Explain to the mother and the support person
what is going to happen
MANAGEMENT OF THE 1ST STAGE OF LABOUR
Review the antenatal card noting: -
 Age to confirm what is indicated on the
antenatal card
 Number of pregnancies
 Mode of delivery for previous pregnancies;
whether normal vaginal delivery, caesarian
section and what caused it
 Any problems during last deliveries
 Current HIV status
 If RPR and Hb were done and the results
 Urine analysis for protein ketones and sugar
MANAGEMENT OF THE 1ST
STAGE OF LABOUR
 Check the medical history, anything unusual
about the present pregnancy and relevant
data.
 (In an unbooked client/patient a full social,
medical/surgical obstetrical history must be
taken).
 Obtain details concerning the present labour:
 Time and onset of regular uterine contractions
 History of any show
MANAGEMENT OF THE 1ST
STAGE OF LABOUR
 Any vaginal bleeding observed, if so no
vaginal examination.
 Does she have any danger signs; -
severe headache, blurred vision,
dizziness, fever
 Ifthe membranes have ruptured and if so
at what time
 Colour of the liquor
MANAGEMENT OF THE 1ST
STAGE OF LABOUR
 Checkthe temperature, pulse and blood
pressure and record
 Obtaina clean specimen of urine and
test especially noting the presence of
albumin, sugar or acetone to rule out
pre-eclampsia, diabetes mellitus and
starvation.
 Measure the amount and record.
MANAGEMENT OF THE 1ST
STAGE OF LABOUR
 Askthe woman to lie on the couch, remove
her pants and adopt the supine position.
 Cover her with a bed sheet or gown.
 Sheshould not lie in this position for a long
time to prevent supine hypotension.
 Standon the woman’s right side; maintain
rapport with her by talking to her, at the same
time observe carefully her facial expression
during the procedures for any indication of
discomfort.
MANAGEMENT OF THE 1ST
STAGE OF LABOUR
 Carryout a head to toe examination taking
particular note of such abnormalities anaemia,
oedema, varicose veins, lymphadenopathy,
any abnomal vaginal discharge or vulva sores.
 Thephysical examination will help to find out
any problems that might have been missed
during antenatal care.
 Explain the procedure to the mother
 Ask her to empty the bladder if not yet done.
 Next carry out an abdominal examination
MANAGEMENT OF THE 1ST
STAGE OF LABOUR
ABDOMINAL EXAMINATION
 Inspection
 Size of the abdomen in relation to calculated
gestational age
 Shape and contour of the abdomen
 Any scars or skin changes
 Uterine contractions, type frequency and
duration
 Fetal movements and activity
MANAGEMENT OF THE 1ST
STAGE OF LABOUR
 Palpation
 Estimate the height of the uterine fundus
to confirm the gestational age
 Fundalpalpation for the part lying in the
upper pole
 Lateral palpation for the lie of the foetus
 Pelvic palpation to assess the presentation
and descent of the presenting part in
fifths.
MANAGEMENT OF THE 1ST
STAGE OF LABOUR
Auscultation of the foetal heart rate
is done noting the rate and rhythm
Record the findings of the abdominal
examination.
After the physical examination, if the
mother is in labour, perform a sterile
vaginal examination
MANAGEMENT OF THE 1ST
STAGE OF LABOUR
 If she is not in labour, then do a quick
inspection of the vulva to check on the
following:
 Cleanliness
 Presence of any sores, chancre or
condylomata lata, any warts
 Vaginal bleeding or abnormal discharge,
varicose, oedema
 If membranes are ruptured, note the type of
liquor – colour, odour any meconium staining
MANAGEMENT OF THE 1ST
STAGE OF LABOUR
 Any scar tissue which may indicate a previous
episiotomy, tears or female circumcision
 Inform the woman of the findings. If she is not
in labour, then a doctor or senior midwife
should now see her
 Strictprivacy should be maintained at all
times.
 Ifthe woman is in labour, then a vaginal
examination should be carried out under strict
aseptic technique as described below:
MANAGEMENT OF THE 1ST
STAGE OF LABOUR
VAGINAL EXAMINATION DURING LABOUR
 This is a sterile procedure.
Objectives
 To confirm that the woman is in labour
 To confirm the presentation
 To
establish a baseline data for subsequent
examinations
 To
determine the state of membranes,
whether ruptured or not
MANAGEMENT OF THE 1ST
STAGE OF LABOUR
 To exclude cord prolapse especially after
rupture of membranes if there is an ill-
fitting presenting part such as buttocks
or high head
 Toassess progress of labour before
giving any analgesia
 Toconfirm onset of 2nd stage of labour –
full dilatation of the cervix (10 cm)
MANAGEMENT OF THE 1ST
STAGE OF LABOUR
Indications for vaginal examination
 To make a diagnosis of labour
 To assess the progress of labour
 To confirm second stage of labour
 Torule out cord prolapse when membranes
rupture
 To confirm the presentation
 To assess labour before giving any analgesia
MANAGEMENT OF THE 1ST
STAGE OF LABOUR
Contra indications for vaginal
examination
 Where there is history of previous
vaginal bleeding during pregnancy or
where there is present vaginal bleeding
 In a patient with Shirodkor suture
 Wheremembranes have ruptured for
more than 24 hours and there is an
abnormal discharge
MANAGEMENT OF THE 1ST
STAGE OF LABOUR
 In cord prolapse as more fidgeting can
lead to spasms of the cord resulting in
hypoxia and fetal death.
 Ifthe cord presents; feel for pulsations
and put the mother in knee – chest
position and refer to the hospital.
 On vaginal examination, note the
following:
MANAGEMENT OF THE 1ST
STAGE OF LABOUR
Vulva
 Presence of blood, cleanliness, oedema, varicose
veins, ulcers, warts and any scars
Vagina
 Direct the fingers along the anterior wall and
note the degree of warmth and moisture and
vaginal texture.
 Itshould feel warm and moist, not dry (a sign of
obstructed labour), soft and distensible.
MANAGEMENT OF THE 1ST
STAGE OF LABOUR
Cervix
 When the examining fingers reach the end of
the vagina, palpate along the fornices and
proximity of the presenting part to examining
finger, feel the cervix and note the following:
 Degreeof effacement - how much has been
taken up
 Dilatationof the external cervical os, the
dilatation is by fingers, each finger is 2 cm
MANAGEMENT OF THE 1ST
STAGE OF LABOUR
 Application of the presenting part to the cervix -
whether ill or well-fitting
 Whether membranes are intact or not, if ruptured, feel
for the cord
 The presentation and feel for the land marks – sagittal
suture, lambda or bregma, when you go in and find
the sagittal suture, follow it with your finger until you
reach the posterior fontanelle
 Assess the location of the occiput in relation to the
maternal pelvis
MANAGEMENT OF THE 1ST
STAGE OF LABOUR
Assess the degree of moulding noting:
 0 – No moulding when bones are separated and
sutures could be easily felt and record on the
partogram as follows:
 + Bones are touching each other or are in apposition
 ++ Bones are overlapping but can be separated easily
with finger pressure
 +++ Bones are overlapping and cannot be separated
easily on finger pressure.
 This is a problem as the fetal head is under pressure
and may lead to injuries to the internal structures of
the skull.
MANAGEMENT OF THE 1ST
STAGE OF LABOUR
Assess the adequacy of the pelvis
 Feel for the sacro-promontory, which should not be
reached
 Feel the prominence of the ischial spines and they
should be smooth and not prominent
 Assess the sub pubic arch, which should accommodate
2 fingers comfortably/easily
 Assess the inter tuberous space by removing the
examining fingers and make a fist, then place the
knuckles between the ischial tuberosities.
 It should accommodate 4 knuckles
MANAGEMENT OF THE 1ST
STAGE OF LABOUR
 After
removal of fingers from the vagina
assess the degree of discharge – which
should be show- whether heavy show or
bleeding
 Remove gloves after rising them in jik
1 : 6 and dispose them in the
appropriate container
 Wash hands with soap and dry them
 Listen to the fetal heart.
MANAGEMENT OF THE 1ST
STAGE OF LABOUR
 Make the patient comfortable
 Auscultate the fetal heart, record the
findings and clear away the equipment.
 Inform the patient of the findings and
discuss her birth plan
 Ifthe woman is in the active phase (4, 5,
6, 7, 8) cm open the partograph
CARE OF THE WOMAN IN 1ST
STAGE OF LABOUR
Environment
 The
woman in the active phase will be
admitted to the labour ward.
 Theenvironment should be well
ventilated, clean, good lighting system,
able to provide privacy in a room or with
screens, warm with all emergency
equipment readily available and in
working condition.
CARE OF THE WOMAN IN 1ST
STAGE OF LABOUR
Emotional Support
 Thisis important as it determines the
progression of labour.
 Ifthe woman has fear, is worried or anxious
labour may be prolonged.
 Encourage the woman to have a support
person with her throughout e.g. her husband,
this will help to allay anxiety, give a sense of
security.
CARE OF THE WOMAN IN 1ST
STAGE OF LABOUR
 When one has a support person this will help to
promote a good relationship between the woman and
the support person.
 Make arrangements for the companion to sit in if the
environment allows.
 Facilitate good communication between the woman,
caregiver and support person.
 Give the woman as much information as she wishes.
 Encourage her to ask questions and allow her to
express her fears.
CARE OF THE WOMAN IN 1ST
STAGE OF LABOUR
 Explainall the procedures to be done on
the woman to allay anxiety and you need
to seek for permission.
 Berespectful to her wishes, i.e. her
choices.
 Ensure privacy and confidentiality.
 Provide
empathic support to the woman
throughout labour.
CARE OF THE WOMAN IN 1ST
STAGE OF LABOUR
Infection Prevention
 During delivery, the mother is at risk of
infection.
 The midwife has the responsibility to reduce the
risks of these infections through the following
ways:
 Useof disposable materials once and
decontaminate before you dispose.
 Useof sterile gloves during V.E, delivery of baby
and also when handling the placenta.
CARE OF THE WOMAN IN 1ST
STAGE OF LABOUR
Doing high level disinfection of
instruments CSSD/sterilize.
Reducing frequency of V.E
Avoiding routine rupture of
membranes
CARE OF THE WOMAN IN 1ST
STAGE OF LABOUR
Environmental Hygiene
 Ensure all the clothes are cleaned.
 Ensure cleanliness of your birthing or delivery
area.
 Use of clean linen when necessary
 Cleanthe beds with disinfectant after each
delivery.
 Clean all the spills immediately.
 Control traffic in the labour ward.
CARE OF THE WOMAN IN 1ST
STAGE OF LABOUR
Personal Hygiene
 Encourage the woman to bath depending on
cervical dilatation, can do mouth wash to
refresh mouth and wipe out sweat from face
and armpits.
 Clean or wash the vulva before V.E depending
on how dirty, and offer her a pad.
 Wash hands before and after examining the
woman.
CARE OF THE WOMAN IN 1ST
STAGE OF LABOUR
Position and Mobility
 Adoption of an upright position during labour will
facilitate uterine contractions and will help reduce the
use of analgesia.
 Allow her to adopt the most comfortable position.
 Encourage non-supine position, to prevent supine
hypotensive syndrome, if she chooses to lie in bed,
preferably lateral.
 Encourage her to move around her bed, it helps in
descent of the presenting part
CARE OF THE WOMAN IN 1ST
STAGE OF LABOUR
Diet and Fluid Intake
 The woman requires a lot of energy during
labour.
 The vigorous muscle contractions during
labour demand a continuous supply of
glucose.
 If this is not obtained in the diet, the body will
start metabolizing proteins and fats stored
resulting in ketoacidosis.
CARE OF THE WOMAN IN 1ST
STAGE OF LABOUR
 Inadequate glucose may lead to uterine inertia which
will prolong labour.
 Inadequate fluid intake will lead to dehydration, so the
women are encouraged to take a lot of sweet fluids
and easily digested food like porridge and biscuits.
 Encourage her to take a lot of nourishing fluids e.g.
fruit juice, if she can afford.
 Dehydration can exhaust the woman, slow down the
process of labour and make her contractions irregular.
Record whatever fluid and or food she is given
indicating time and amount.
CARE OF THE WOMAN IN 1ST
STAGE OF LABOUR
Bladder Care
 Encourage the woman to empty the bladder every two
hours.
 The need for micturition is usually diminished in
labour and so encourage the woman to pass urine
even if she does not feel the need.
 Do urinalysis and test for glucose, protein, acetone
and smell each time they pass urine.
 A full bladder prevents descent of the presenting part
from entering the brim and also inhibits uterine
contractions.
CARE OF THE WOMAN IN 1ST
STAGE OF LABOUR
 If the bladder remains full it is at risk of getting ripped
between the fetal head and pubic bone.
 This causes bruising which causes sloughing during
the puerperium causing vesical vaginal fistula.
 If the woman fails to empty the bladder, offer the bed
pan in a squatting position open nearby tap, pour
warm water on the vulva. Final step is to catheterize
the woman.
CARE OF THE WOMAN IN 1ST
STAGE OF LABOUR
Bowel Care
 The woman should be cleaned after opening the bowels;
if possible she can have a bath.
 The urge to pass stool may be an imminent indication of
the perineal phase of the 2nd stage.
 It occurs because the presenting part is pressing on the
rectum.
 The midwife should not allow the woman to use the
toilet when she is advanced in labour for fear of
delivering in the toilet.
 Avoid giving routine enemas to a woman in labour.
CARE OF THE WOMAN IN 1ST
STAGE OF LABOUR

Observations
 Observations are a vital component in the care of a
woman in labour.
 The midwife is required to be alert and very
observant to detect any complication early.
 Observe the reaction of the woman to labour.
 Women have different views of labour.
 Others with excitement while others with fear
CARE OF THE WOMAN IN 1ST
STAGE OF LABOUR
 Vital signs observation:
 Temperature - 2hourly, 4hourly
 Pulse and Respirations every ½ hour
 Blood pressure every 2hours
 The progress of labour is assessed 4hourly using a
partograph
CARE OF THE WOMAN IN 1ST
STAGE OF LABOUR
Active Phase of 1st Stage
 The woman in the active phase of labour will have the
findings recorded on the partograph.
 A partograph was developed by Dr. E.A Friedman
CARE OF THE WOMAN IN 1ST
STAGE OF LABOUR
THE USE OF A PARTOGRAPH
Definition of a Partograph
 A partograph is a tool used by the
midwife/obstetrician to monitor the progress of labour
and be able to detect any deviation from normal as
early as possible.
 The following information regarding labour is recorded
on the partograph
THE USE OF A PARTOGRAPH

PERSONAL PARTICULARS
 Name
 Gravid
 Parity
 Date of Admission
 Time of Admission
 Hospital Number
 Time membranes ruptured
THE USE OF A PARTOGRAPH

PROGRESS OF LABOUR
 A partograph is opened when cervical dilatation is 4cm or
more.
 It has 2 diagonal lines.
The alert line (alerts us)
 This is the 1st line.
 It represents the active phase of labour.
 It is drawn at 4cm dilatation to a point at the top of the
graph which will represent full dilatation.
THE USE OF A PARTOGRAPH

 The cervix dilates to a minimum of 1cm/hour in primi-

gravida and 1.5cm in multi-gravida
 This line alerts the midwife/Doctor to the fact that
progress of labour is abnormal when the readings
cross this line.
THE USE OF A PARTOGRAPH

Action line (action needs to be taken)

 This is the 2nd line, drawn parallel to and 4hours to the
right of the alert line.
 It indicates the need for something to be done about
poor progress of labour.

Cervical Dilation
 This is plotted as O with an upward arrow on top.
 The 1st V.E is recorded and then the subsequent will be
done every after 4hours and recorded.
THE USE OF A PARTOGRAPH

 On admission, cervical dilatation is recorded on the

alert line at the place equal to her dilatation and time
recorded at the space for time.
 If labour is progressing well, the plotting of cervical
dilatation will remain plotted on the left of the alert
line.
THE USE OF A PARTOGRAPH

Descent of the Head

 The cervix dilates as the foetal head descends into the
mother’s pelvis.
 Descent is determined abdominally as the midwife
places her hand over the foetal head. If all fingers
cover the head, it is said to be 5/5 above the pelvic
brim.
 Plot the descent of the head at every V.E conducted. It
is plotted using “Δ” “O”
THE USE OF A PARTOGRAPH

Uterine Contractions
 The midwife is required to note:
 The length
 The strength
 The frequency of uterine contractions
 The strength of the contractions is assessed from the
reactions of a woman and by laying your hand on the
fundus and noting the degree of hardness of the
contractions.
THE USE OF A PARTOGRAPH

 The following boxes show the type of contractions as

follows.
1. Fill in one horizontal square for each contraction felt
in a 10 – minute period
2. Use dots to fill in the squares for mild contractions
lasting less than 20 seconds.
3. Use diagonal lines to fill in the squares for moderate
contractions lasting 20 to 40 seconds.
4. Use solid color to fill in the squares for strong
contractions lasting 40 to 60 seconds
THE USE OF A PARTOGRAPH

 In the latent phase, contractions should be 1 or

more in 10 minutes, each lasting 20 seconds or more.
 In the active phase, contractions should be 2 or
more in 10 minutes, each lasting 20 seconds or more.
THE USE OF A PARTOGRAPH

FETAL WELLBEING
 Foetal Heart Rate
 Auscultate and listen to the foetal heart rate. It is a
safe and reliable way of knowing that the foetus is
well.
 This is done using a Pinards stethoscope or Doppler
Ultra Sound apparatus.
 Note the following:
THE USE OF A PARTOGRAPH

 Rate
 Count the fetal heart rate in a full complete
minute.
 Itshould be within the normal range 120-
160beats/min
 Below 120beats may indicate bradycardia and
above 160beats may indicate tachycardia, both
extremes would indicate fetal distress.
THE USE OF A PARTOGRAPH

 Rhythm
-The normal foetal heart has a coupled beat which
remains steady.
-The fetal heart rate is recorded on top of the graphs and
is plotted every 30minutes (1/2hourly)
THE USE OF A PARTOGRAPH

LIQUOR AND MEMBRANES

 The condition of liquor gives more information to the
midwife about the foetal condition especially after
they have ruptured.
 Normal liquor is clear.
 At each V.E, it is important to note the state of the
membranes or liquor and plot on the partograph as
follows:
THE USE OF A PARTOGRAPH

C- Clear liquor
B- Blood-stained liquor
M - Meconium stained liquor (fresh/old)
A - Absent liquor
I - Intact membranes
 Dark green meconium may indicate foetal distress
especially in non-breech presentation.
 Absent may indicate ruptured membrane or the baby is
post mature and hence reduced liquor volume.
 If the above are noted listen to the foetal heart every
15minutes (1/4hourly)
THE USE OF A PARTOGRAPH

MOULDING OF THE FETAL SKULL BONES

 Moulding allows for reduction of the foetal head
diameters and easy passage in the pelvic canal.
 The recording is as earlier discussed:
 0 No moulding
 + Bones in apposition
 ++ Bones overlapping but reducible on finger
pressure
 +++ Excessive moulding
THE USE OF A PARTOGRAPH

 In case of excessive moulding, the mother should be

referred to the next level of health service delivery.

MATERNAL WELLBEING
 All the recordings for the mother’s condition are
entered at the bottom of the partograph
 Vital Signs
 Pulse - recorded every 30minutes, mark with a dot.
THE USE OF A PARTOGRAPH

 Blood Pressure- recorded every 2-4 hours, it is marked

with fused arrows.
 Temperature- every 2hours
Urinalysis
 Each time the woman passes urine or micturites,
measure the amount and test for glucose, proteins and
acetone.
Drugs
 Record all drugs given to the mother during labour in
the space provided on the partograph
THE USE OF A PARTOGRAPH

Fluids
 Oral fluids or IV fluids should be recorded in the column
provided.
INTERPRETATION OF THE RESULTS
 1. The recording of the partograph should be done correctly
and adequately in order to have a precise interpretation.
 2. The recordings should be clear enough for everyone to
read and interpret.
 3. The symbols used should be familiar to everyone for
easy interpretation.
THE USE OF A PARTOGRAPH

RELIEF OF PAIN
 Labour is very painful.
 The pain threshold differs from one mother to another.
Some measures to relieve the pain are verbatim -
talking to the mother in order to divert her mind from
the pain, back rub or lower abdominal rubbing, luke-
warm bath and also walking around would be soothing
to a woman.
THE USE OF A PARTOGRAPH

 Administration of drugs Pethidine should not be done

4hours before delivery.
 It depresses the respiratory centre of the baby.
PREPARATION FOR SECOND STAGE OF
LABOUR

 Ensure that the delivery room is clean with the entire

necessary equipment ready, such as:
 Sterile delivery pack and a delivery trolley
 Working suction machine
 Oxygen cylinder is nearby and test for the flow of
oxygen
PREPARATION FOR SECOND STAGE OF
LABOUR

 The emergency tray has all the necessary and potent

drugs
 Prepare the baby layette in a cot
 Ensure that the wall clock is in good working order.
Observe for the signs of second stage – which are:
 Expulsive uterine contractions
 Spontaneous rupture of membranes
PREPARATION FOR SECOND STAGE OF
LABOUR

 The woman will become flushed, start sweating or

shivering
 Trickle of blood at the vaginal orifice
 Pouting and gapping of the anus
 Gapping of the vulva
 Bulging of the perineum
 Appearance of the presenting part on the vulva
SECOND STAGE OF LABOUR

 Second Stage of Labour- begins when the cervix is

fully dilated (10cm) to complete delivery the baby.
 Signs of Second stage of labour- 2nd Stage of labour
is characterised by:
 Expulsive uterine contractions
 Rupture of fore waters
 Dilatation and gaping of the anus
 Congestive of the vulva
 Appearance of the presenting part
The woman changes in behaviour, has an
involuntary urge to push, gives out soft
granting noises and has wild look.
 Trickle of blood at the vaginal orifice which
is due to lacerations of the vaginal mucosa
and the cervix.
 The confirmatory evidence of second stage
is available when no cervix rim is felt on
vaginal examination.
 Once the woman is in the second stage of labour,
do not leave her alone, and a constant and
careful supervision of her must be done.
 Management of Second Stage of
Labour
Aim- to ensure normal delivery of the baby.
 Requirements:
 Trolley and a resuscitaire in good working condition.
 Set a delivery Trolley:
 Environment- The room should
be clean and warm, and ensure
privacy.
Observations: Every 5 minutes, monitor fetal
wellbeing, progress of labour and maternal wellbeing.
 Fetal wellbeing-
 Do observation of Foetal heart rate, count and
record after every contraction to ascertain the foetal
wellbeing.
 If the membranes are ruptured, the liquor is
observed too if it is clear, meconium stained or
blood stained. Thick fresh meconium is a sign if fetal
distress or compromise.
Progress of Labour-
 Check uterine contractions every 30 minutes for
strength, length and frequency.
 The contractions are usually stronger and longer
than in the first stage, lasting up to one minute with
a longer resting phase.
 The descent of the presenting part should be
progressive.
 During a VE you also note the flexion of the head
and whether or not there is rotation of the head
which would indicate a well flexed head.
Maternal wellbeing-
 General psychological and physical condition-
should be observed closely as women usually are
anxious and afraid because the experience of the
descending foetal head and of fear of injuries and
the pain.
 Vital signs- do two hourly observations of
maternal Pulse and Blood Pressure and record.
 Note also the mother’s colour, whether she is
flushed or pale, note her skin temperature;
whether it’s hot to touch or not.
 Bladder care- a full bladder is very vulnerable to
damage from the pressure of the advancing head or
may delay the second stage of labour. Ask the
woman to pass urine or use a catheter to empty the
bladder
 Maternal comfort – as a result of her exertions,
the woman usually feels very hot and sticky and she
will find it soothing to have her face and neck
sponged with a cool flannel.
 Her mouth and lips may become very dry. Sips of
iced water are refreshing and moisturizing cream
can be applied to her lips.
 Hygiene The delivery procedure is an aseptic
technique.
 The midwife should take every precaution to ensure
that the woman suffers no infection or cross
infection during or after deliver.
 Clean the vulva and the surrounding parts with
sterile solutions whenever need arises.
 Actual management/procedure- Delivery of the
baby
 Procedure should be done by atleast 2 Midwives
 Ask the woman to pass urine or pass a catheter
if she fails to pass urine in order to prevent
delay in second stage or third stage.
 Place the woman in a position of choice (usually
dorsal is preferred) and cover her appropriately.
 Give her instructions on how to push.
 The midwife conducting the delivery now
washes her hands and dries them, and opens
the outer part of the delivery pack.
 S/he now puts on a gown if available, puts on
sterile gloves and complete the preparation of the
sterile part of the trolley.
 The second midwife is responsible for monitoring
fetal and maternal wellbeing, as well as the
efficiency of the uterine contractions.
 Observations are done after every 5 minutes.
 S/he is also responsible for seeing that the
mother maintains a good position and gives clear
helpful instructions.
 The attending midwife stands on the patient’s
right side.
 The perineum is swabbed with antiseptic solution.
 The advance of the fetal head should be carefully
watched and controlled in a downward direction
with the left hand.
 Meanwhile using the right hand the perineum and
anus are covered with a sterile pad.
 At this time, the decision as to whether or not to
perform an episiotomy is made.
Advise the mother to only push when she has a
contraction.
 The fetal head is delivered slowly to prevent trauma
of the head and perineal tears.
 Birth of the head
 Once the birth is eminent, the perineum should be
swabbed and a clean pad placed over the woman’s
anus on the perineum below the fourchette.
 The nurse conducting the delivery must watch for the
advance of the fetal head and can control it with light
support from her hand.
 The other hand with a swab should support the
perineum.
 But once the head has crowned, the mother can
control its birth by gently blowing or sighing out
each breath in order to reduce active pushing.
 When the head is born by extension, the nurse may
check the cord’s position, to see if it is not around
the neck of the baby.
 If the cord is very tight around the neck, two forceps
are used to clamp the cord in two places and it is
cut in the middle.
 Once the head is born, clean the baby’s eyes
with sterile swabs, and clear baby’s airway,
using a sucker.
 Birth of the shoulders
 Restitution and external rotation of the head
usually occurs, and this maximizes the smooth
birth of the shoulders and reduces the risk of
perineal lacerations.
 One shoulder should be released at a time to
avoid overstretching the perineum.
 Midwife places a hand on each side of the baby’s
head, over the ears, and gentle downward
traction is applied.
 This allows the anterior shoulder to slip beneath
the symphysis pubis while the posterior shoulder
remains in the vagina.
 The head and the trunk are guided in an upwards
curve to allow the posterior shoulder to escape
over the perineum.
 With the same movement, the rest of the baby’s
body is born by lateral flexion.
 When baby is born
 Dry the baby and put it on the mother’s abdomen.
 Clamp the cord by applying 2 artery forceps about
3cms apart, hold a swab over the cord, and cut the
cord.
 Note the time of the baby’s birth.
 Assess the baby’s condition especially his
respirations.
 Give an Apgar score at 1 and at 5minutes.
 Show the baby to the mother for identification
especially of the sex.
 Leave the baby skin to skin contact on the mother’s
abdomen
 Cover or wrap the baby in a dry towel or cloth to
prevent hypothermia.
 Palpate the mother’s abdomen to exclude a second
baby.
 The assistant midwife gives intramuscular 1ml or 10
units oxytocin within 1 minute of the delivery of the
baby.
 Place an identity band on the baby’s wrist.
 The following information should be put on the
identity band- name, date and time of the birth,
Apgar score and sex.
 Initiate breastfeeding as soon as possible (this
promotes mother/baby bonding and also stimulates
the production of oxytocin from the posterior
pituitary gland which in turn causes contraction of
the uterine muscles).
 Wrap the baby in a towel to reduce heat loss, then
give the baby to his mother.
THIRD STAGE OF LABOUR

 Definition: This is the stage of separation and

expulsion of the placenta and membranes and
control of bleeding.
 Its starts with complete birth of the baby to
complete expulsion of the placenta and membranes.
 The third stage lasts between 5-15 minutes but any
period up to 1 hour is normal the third stage lasts
between 5-15 minutes but any period up to 1 hour is
normal
 Management of 3rd Stage of
Labour

 The third stage management of labour is of two (2)

types:
 Active management and
 Passive management.
 The active management is recommended at
present time.
 Active management of the Third stage of
labour

Aims of mgt:

1. Complete delivery of placenta and membranes

2. Prevention of acute uterine inversion

3. Prevention of PPH
 After clumping and cutting the umbilical cord,
palpate the uterus to exclude presence of another
foetus.
 Give Injection Oxytocin 10 IU intramuscularly and
wait for a while for signs of placental separation to
appear, these include:
 A gash of fresh blood
 Lengthening of the cord
 Fundus become firm, rounder and smaller
 After confirming the signs of placental separation,
deliver the placenta and membranes by
Controlled Cord Traction (CCT).
 Thereafter inspect the placenta if it is healthy and
complete.
 Rub up the fundus to expel the clots and debris
that could have remained.
 Inspect the cervix and vagina and the perineum for
any tears that may need attention.
 If present suture/repair.
 Clean up the mother and make her comfortable.
 Clear equipment and clean up the delivery bed with
appropriate disinfectants.
 Remember to communicate with the woman
throughout the procedure.
 Give Information Education and Communication and
continue providing Psychological care.
COMPLICATION THAT OCCUR
DURING 2ND STAGE OF LABOUR
 1. ANTEPARTUM HAEMORRHAGE...This is caused
usually by Placental Previa or placental abruption.
 2. PERINEALTEARS...This is caused by pressure
exerted on the perineum by the presenting part.
 3. FOETAL DISTRESS...This may be due to Baby's mal-
presentations or malposition.
 4. TRAUMA....Trauma to the presenting part may be
that in Cephalopelvic disproportion were the Head is
bigger than the passage.
 5. PROLONGED 2ND STAGE OF LABOUR....This may be
due to a full bladder.
 EMPELA MUKWAI!!

BUSHE NAMUKWATA IFIPUSHO?

 ANY QUESTIONS ON NORMAL LABOUR?

BY RENARD KABWE
RN

For more infor: kabwerenard4@[Link] or 0972264474 or Nurse Renard on facebook page