MANAGEMENT OF

FIRST STAGE OF
LABOUR
BY:
P.RANJANI
Manipal College of Nursing
MAHE, Manipal
Central Objective:

Behavioral objectives:
INTRODUCTION
 Care of the women during the first stage of
labor is directed toward safe delivery of a live
healthy baby to a couple who have had a
happy and fulfilling child birth experience.
ADMISSION PROCEDURES
1.Admission consent.
2.Pre admission records:
- Pre register.
3.Prenatal record:
Age, Height and Weight, General health,
Medical conditions, History of surgical
interventions, Parity and Gravity.
Previous obstetrics history is reviewed for the
following problems like ,type of labor ,type of
delivery, condition of baby at birth.

Present pregnancy information's such as LMP,

height of the fundus, estimated weight of the
fetus ,Fetal heart rate, gestational week of
initial visit, diagnostic studies, medications
used during pregnancy, laboratory studies.
4.Interview:
The woman's chief complaints ,Frequency and
duration of contractions, Character of discomfort,
presence of vaginal discharge or show, status of
amniotic membrane.
5.Psychologic responses:
General appearance, behaviour, verbal interaction,
body posture and set, perceptual acuity, energy level,
discomfort or pain and cultural background.
PHYSICAL EXAMINATION
1.Vital signs
2.Urine specimen: Blood sugar and albumin
3.Timing of uterine contractions:
a) Increment
b)Acme
c)Decrement
Average contraction lasts 40 to 60 seconds.
4.Abdominal palpation- Leopolds
maneuvers

First maneuver
Second maneuver
Third maneuver
Fourth maneuver
5. Fetal heart rate assessment:

Normal fetal heart rate is 120 to 160

beats per minute.
Abnormalities in FHR irregular rhythm,
Rate above 160 or below 120 .
Two techniques :
a) Auscultation: Delee or leffs fetoscope
b) Electronic fetal heart monitoring:
Ultrasound fetoscope or Doppler
instrument
Continuous electronic fetal monitor:
Internal fetal monitoring
External fetal monitoring
Delee
 Allen
 Leff
6.Fetal blood sampling:

Normal fetal scalp PH level would be more

than7.25.
Fetal scalp PH levels of less than 7.20indicate
acidosis and the need for immediate delivery.
7.Vaginal and rectal examination

It is performed to assess the

dilatation, station, effacement, presenting part,
Position of the presenting part, presence of
molding or caput, and status of fetal
membranes.
8.Assessment in case of rupture
membranes:

Amnionitis- yellowish foul smelling fluid

indicate infection.
Thick greenish or brownish fluid- fetus has
passed meconium and may be in distress.
 Nitrazine paper test

 Ferning test
PARTOGRAM
 Partogram is a structured graphical
representation of progress of labor.it is a
graphical record of cervical dilatation in
centimeters against duration of labor in hour
 Indications:
All primigravidas, high risk pregnancies,
malpositions, malpresentations,trial of labor
in boderline contracted pelvis, previous LSCS
cases
Components:

1. Progress of labor
2. Fetal condition
3. Maternal condition
 Advantages:
a) All necessary information is on a single page
b) Objective record
c) Facilitates hand over formalities
d) Predictive value
E) Medico legal
Dysfunctional labor diagnosis

1.Prolonged latent phase

2.Protracted active phase
3.Secondary arrest of cervical dilatation
4.Failure of decent
5.Precipitous labor
PERINEAL PREPARATION

-Provide clean field for delivery

- For episiotomy repair
ENEMA
Purposes:
1.To prevent contamination of the perineum by
feces
2.To provide more room in the pelvis
3.To help stimulate uterine contractions
An enema is not given if the women has an
unusual amount of vaginal bleeding or is
rapidly approaching the second stage of labor.
BLADDER
It is important to keep the laboring woman's
bladder as empty as possible because a full
bladder mechanically impedes the descent of
the fetal head.
ACTIVITY
Labor woman should able to assume a
position of comfort even if that means getting
on all fours and rocking her pelvis up and
down.
Never should the woman flat on her back
because the pressure of the full uterus on the
vena cava and other major vessels can slow
down the venous return blood flow to her
brain causing supine hypotensive syndrome.
 If the women membranes have ruptured early
in labor and the presenting part is not yet
engaged, she should remain in bed because of
the possibility of an umbilical cord prolapse.

 If the membranes are intact or if the

presenting part is tight against the cervix she
may be more comfortable walking around,
taking warm shower ,sitting, or rocking.
 Up right maternal posture and ambulation
during labor are not only more comfortable
for the woman but also can facilitate labor.
When the women assumes the upright
position during labor, gravity enhances fetal
descent and rotation. Thus sitting position and
ambulation can shorten the duration of labor.
FOOD
Because gastric motility decreases during
labor and digestion slows. Water and ice chips
are usually recommended. Fruit juices, or teas
with added sugar or honey can help to
maintain the women's level of hydration as
well as blood sugar level. A record of fluid
intake and output must be kept during labor.
Intravenous therapy may be necessary for
hydration and / or medication.
COMFORT MEASURES
1.Replacing the solid bed linen and napkin.
2.Privacy and comfort of the women should be
considered during procedure or examination
3.Encourage the use of lip balm to keep the lips
hydrated
4.Explaining all procedures to woman and
obtaining her permission
PAIN MANAGEMENT

DURING LABOUR
PAIN MANAGEMENT
1.Non pharmacologic interventions
2.Pharmacologic interventions
NON PHARMACOLOGIC
INTERVENTIONS
1.Continuous labor support:
with trained nurse
Advantages:
a. It increases the coping ability of the women
b. Decrease the use of pain medications
c. Fewer obstetric interventions
d. Lower cesarean delivery
2.Trans cutaneous electrical nerve
stimulation

 Two pairs of electrodes are taped on either

side of the thoracic and sacral spine.
continuous mild electrical currents are applied
from a battery operated device. during the
contraction the woman increases the
stimulation by turning the control knobs on
the device.
Advantage:
a. pain relief
b. reducing or eliminating the need for analgesia
c. non invasive
d. easy to learn simple to perform
3.Relaxation techniques:
-music and effleurage

Patterned breathing techniques for labor:

a. Slow paced breathing:

Slow deliberate breath, 6 to 10 breaths per
minute
b. Modified paced breathing:
begins with slow deep breaths at the beginning of the
contraction then increases the rate and depth of the
respirations as she reaches the peak of contraction.

c. Pattern paced breathing or the pant blow technique:

Similar to modified paced breathing with the
additional of rhythmic pattern. women takes 4 light
breaths and then blows out through her lips.
 Advantage:
-does not require any special tools
- promotes relaxation
 Disadvantage:
- requires training and practice before labor
to be most effective.
4.Attention focusing:
a. Internal focus or Imagery-(positive thought):
The women is encouraged to visualize a positive,
healing situation during contraction.
Advantage:
-non invasive, requires no special tools
-involves spirituality with the birthing process
Disadvantage:
- requires discipline and practice, may not be
effective in individual with mental illness
 b. External focus:
The woman who focuses externally opens her eyes
and focuses on a picture, person or object that is
helpful to her (ex) grand mother photo-remembering
that her grand mother had birthed 11 babies all at
homes with out drugs.
Focusing on sounds, music, voices, relaxation
and breathing may also benefit the laboring women.
5.Movement and positioning:

- changing the positions frequently.

- if the women wants to be on her back place
a pillow under one hip to prevent
supine hypotension.
- birthing ball allows her to rock and move to
a position of comfort.
6.Touch and Massage, Effleurage:
-light circular finger tip movements on the
abdomen.
- direct deeper pressure may be applied with
the hands over the area of greatest pain
intensity, often above the pubic bone or on the
upper thighs.
-back massage with fists or palms of the
hand or with the tennis ball.
Advantage:
- easy to learn and simple to perform
- does not require any special tools
Disadvantage:
-it is less effective during active labor as the
contractions become more intense
7.Water therapy
Exposure to warm water either by showering or
bathing in a tub or whirlpool can significantly
increase the ability of the laboring woman to cope
with uterine contractions.
-the bath be limited to 1 to 2 hours in length
- water temperature be maintained at or lower than
body temperature
Advantage:
- promote relaxation
- decrease the sensation of pain
Disadvantage:
-require availability of a tub
-may slow labor if used too early
-the woman may notice decrease effectiveness
over time
8.Hypnosis:
The woman attends several sessions with
trained therapist. At each session she learns
how to induce a trance like state that she can
use during labor.
Advantage:
- require no special tool
- promotes sense of comfort
- involves holistic approach
Disadvantage;
- special training by therapist is needed
- expensive
-does not work for all women
-severe anxiety and psychosis is possible side
effect
9.Intradermal water injections:

Four injections of 0.1 ml sterile water are

given in to the intra dermal space in the lower
Back. The injection significantly reduces back
pain for 45 to 90 minutes after they are given.
Disadvantage:
- invasive
- not effective for abdominal discomfort
associated with contractions.
10.Acupressure and Acupuncture:

- traditional Chinese medicine

-acupuncture involves the use of needles
-acupressure is a noninvasive form
of massage
-stimulating the energy points
Advantage:
-Address the holistic nature of labor and
incorporates spiritual and emotional aspects
-acupressure is noninvasive
Disadvantage:
-requires trained practitioner to perform
-acupuncture is invasive and requires
special needle
PHARMACOLOGIC
INTERVENTIONS
1. Analgesia and sedation:

A.Barbiturates such as sacobarbital (seconal) and

pentobarbital (nembutal)
Advantage:
-Promote sleep in the early stage of labor
-decrease the anxiety
Disadvantage:
- reduce but does not eliminate pain sensation
- neonatal respiratory depression

Associated side effects:

-central nervous system depression
-decreased FHR variability
B. Opioids(narcotic analgesics):
such as meperidine (demerol) and fentanyl
(sublimaze)
Advantage:
-increase the women ability to cope with
uterine contractions.
Disadvantage:
-reduce but does not eliminate pain sensation
-neonatal central nervous system and respiratory
depression
-inhibits neonatal sucking and delays effective
feeding
-may decrease neonatal alertness
Side effects:
-nausea and vomiting, drowsiness, FHR
variability, hypo ventilation.
2.Anesthesia:
local, regional and general.
A. Para cervical block:
Injection of local anesthetic in the area close to
the cervix.
Advantage:
-excellent pain relief
Disadvantage:
-duration of pain relief is short
-central nervous system depression
-constriction of uterine artery
Side effects:
-fetal bradycardia, fainting, neuropathy, abscess,
toxicity and laceration of the vaginal mucous
membrane.
B. Epidural:
Advantage:
-relives pain better than opioids
-completely eliminates pain sensation
Disadvantage:
- impairs motor function
-require frequent urinary catheterization
-need for labor augmentation when administered
before 5 cm of dilatation
-increase the duration of second stage of labor
-vacuum assistance and forceps are more
frequently required.
Side effects:
-hypotension, fever, shivering,itching,head ache
and fetal distress
SOCIOCULTURAL ASPECTS OF
PAIN MANAGEMENT
General Nursing action:
1.Encourage relaxation
2.Provide company and privacy when they need
3.Minimise adverse environmental stimuli
4.Provide adequate room temperature and
ventilation
5.Provide comfortable position
6.Reassurance
7.Keep the couple informed of what is happening
8.Encourage them to talk about their
disappointment
9.Make sound judgments
10.Share in the couples joy if their expectations
have been met or their grief if they have not.
 Father during labor
 Father in labor suite
 Grandparents during labor
 Siblings during labor
EMERGENCY CARE
Prolapsed umbilical cord
Interventions:
-Relieve compression of the cord
Place woman in to extreme trendelenburgs or
modified sims position
-Administer oxygen,
-Increasing the patternal fluid infusion rate
-Deliver fetus immediately
Inadequate uterine relaxation:
Interventions:
-Change maternal position-Left lateral,
Modified Sims position
-Discontinuing the oxytocin,
-Administer oxygen,
-Increasing the paternal fluid infusion rate
Fetal distress:
Intervention:
-Change the maternal position,
-Discontinuing the oxytocin,
-Administer oxygen,
-Increasing the paternal fluid infusion rate.
CARE OF HIV INFECTED WOMEN
 Zidovudine loading dose
 No elective amniotomy
 Routine episiotomy is not recommended
 Attachment of scalp electrode
 Universal precautions
 SUMMARY
 EVALUATION QUESTIONS:

 ASSIGNMENT:
 Reference :
 Dutta, D. C. (2011). Textbook of Obstetrics (7th
edition ed.). (H. Konar, Ed.) Kolkata, West
Bengal, India: New Central Book Agency (P) Ltd.
 Lisa K Mandeville, Nan H Troiano. High Risk
Intrapartum Nursing. J.B Lippincott Company.
 Myles(20040. Texbook od Midwives(15th
Edition). ( Diane M. Fraser, Margaret A Cooper)
Elsevier Publication.
 https://en.wikipedia.org/wiki/Eclampsia
 http://www.healthline.com/health/eclampsia
THANK YOU