FIRST STAGE OF LABOUR.

Presentation on theme: "FIRST STAGE OF LABOUR."— Presentation transcript:

1 FIRST STAGE OF LABOUR

2 LABOUR Labour is described as a process by which the fetus placenta and membranes are expelled through the birth canal

3 NORMAL LABOUR Occurs at term Spontaneous in onset
Fetus presenting by the vertex Process completed within 18 hours No complications arise

4 STAGES OF LABOUR FIRST STAGE ( 12hr primi,6hr multi)
SECONT STAGE (2hr primi,30 mins multi) THIRD STAGE (15 mins in both primi and multi) FOURTH STAGE ( 1 hour)

5

6 FIRST STAGE OF LABOUR Latent phase Mild, short contractions
Cervix 0-3cms 6 – 8 hrs Active phase Moderate to strong contraction Cervix 4-7 cms 4.6 h for nullipara and 2.4 h for multipara Transition Strong contraction Cervix 7-10cms

7 FIRST STAGE

8 SIGNS AND SYMPTOMS OF IMPENTING LABOUR
Lightening Frequency of micturition Spurious labour Cervical changes Premature rupture of membrane Bloody show Energy spurt Gastrointestinal upset

9 LIGHTENING

10 EFFACEMENT

11 SHOW

12 PREMATURE RUPTURE OF MEMBRANE

13 CAUSES OF ONSET OF LABOUR
Uterine distension theory Oxytocin stimulation theory Prostaglandin stimulation theory Progesterone withdrawal theory Estrogen stimulation theory Fetal cortisol theory

14 CAUSES OF ONSET OF LABOUR
Uterine distension (Optimal distension theory) Overstretching promotes muscle excitability Oxytocin stimulation theory Oxytocin inhibit calcium binding to sacroplasmic reticulum Increasing the intracellular calcium level Promotes myometrial contraction Sensitivity of oxytocin to myometrium increases in the late pregnancy due to increase in the number of oxytocin receptors Oxytocin promotes release of prostaglandins from the decidua

15 Contd…. Prostaglandin stimulation theory Prostaglandin may diffuse to myometrium and initiate labour Progesterone withdrawal theory Progesterone binds Calcium to the sacroplasmic reticulum Decrease intracellular calcium level Estrogen stimulation theory Increases the release of oxytocin from the maternal pituitary Promotes synthesis of receptors for oxytocin

16 Feto placental contribution Activation of hypothalamo pituitary axis
Contd…. Feto placental contribution Activation of hypothalamo pituitary axis CRH Increase release of ACTH Fetal adrenals Increased cortisol secretion Accelerated production oestrogen and prostaglandins from the placenta Contractile system of myometrium

17 PHYSIOLOGICAL PROCESS IN THE FIRST STAGE OF LABOUR
UTERINE ACTION Fundal Dominance Polarity Contraction and Retraction Formation of Upper and Lower Uterine Segment Retraction Ring Cervical Effacement Cervical Dialation Ripening of the cervix

18 FUNDAL DOMINENCE

19 CONTRACTION AND RETRACTION

20 RETRACTION RING

21 CERVICAL EFFACEMENT

22

23 MECHANICAL FACTORS Formation of the forewaters General fluid pressure Rupture of the membranes Fetal axis pressure Descend of presenting part

24 GENERAL FLUID PRESSURE

25 FETAL AXIS PRESSURE

26 DESCENT OF THE PRESENTING PART

27 FACTORS INFLUENCING LABOUR
PASSAGE WAY PASSENGER(FOETUS AND PLACENTA) POWERS POSITION OF MOTHER PSYCHOLOGIC RESPONCE

28 INITIAL ASSESSMENT AND DIAGNOSIS
Age Gravida and para Time of onset of uterine contractions Duration of contractions Intensity of contraction (when lying down contrasted to when walking around) Location of discomfort or pain Length of labour Number of years since the last baby

29 Contd…. Method of previous delivery
Size of largest and smallest previous babies Expected date of delivery and present weeks of gestation Absence, presence or increase in bloody show Presence of vaginal bleeding Membranes ruptured or not Any prenatal problem

30 PHYSICAL EXAMINATION VITAL SIGNS
Elevated temperature – Infectious process Elevated pulse – Infection, Shock or Anxiety Elevated respiration – Shock and anxiety Elevated or lowered Bp – Hypertensive disorders or shock Elevated systolic or normal diastolic Bp - Anxiety

31 PHYSICAL EXAMINATION – CONTD….
PHYSICAL MEASUREMENTS Height and weight Fetal heart tone Normal – beats per minute Heart rate below 120 or above 160 – Fetal distress

32 PHYSICAL EXAMINATION – CONTD….
Contraction pattern Frequency Duration Intensity Engagement Unengaged or unfixed head in primigravid in labour indicate CPD

33 PHYSICAL EXAMINATION – CONTD….
Estimated fetal weight and fundal height Smaller than expected fundal height and fetal weight – incorrect date or small for date baby Larger than EFW and fundal height - incorrect date or large baby Large baby – uterine atony,shoulder dystocia

34 PHYSICAL EXAMINATION – CONTD….
Lie, Presentation, Position and Variety Abnormal lie , presentation, or position Edema of extremities One of the classical sign of preeclampsia Physiological edema is normal Pelvic examination and vaginal examination Effacement Confirm abdominal diagnosis

35 PHYSICAL EXAMINATION – CONTD….
Position of the cervix Anterior cervix indicates readiness for labour Station To determine station of the fetal head Whether or not the membranes have ruptured Amniotic fluid escaping from the cervical os Amniotic fluid pooled in the vagina Membranes are not felt over the presenting part

36 NURSING MANAGEMENT ENVIORMENT
Feel comfortable in their own surroundings Facilities for prompt and efficient action Reduce anxiety Labour women should be welcomed and encouraged in their own surrounding

37 Contd…. EMOTIONAL SUPPORT
Should display a tolerant and non judgemental attitude Companion in labour Explanation Privacy

38 Contd…. PREVENTION OF INFECTION Mothers wellbeing during pregnancy
Factors affecting resistance The blood Nutritional status The skin and the membranes Hygiene Rest General hygiene and care of the environment Asepsis and antisepsis Restriction of invasive techniques

39 Contd…. POSITION AND MOBILITY
Upright position – facilitate efficient contraction - shorten latent phase - reduce the need for analgesia She may rock,walk,kneel or squat (effective in OP position) Recumbent position can cause compression of the inferior vena cava and supine hypotension Lateral position is preferable if wishes to lie down

40 OTHER FACTORS GOVERNING CHOICE OF POSITION
Analgesia Unable to walk if narcotic analgesia is requested Lateral position or supported sitting is suitable Epidural analgesia demands women should be in bed either sitting up or lying on her side Monitoring Cardiotocograph limit the choice of position Fetal condition Supine hypotension reduces fetal oxygenation Intravenous infusion Complication APH,ROM When the head is high

41 NUTRITION Advice prior to admission Women need energy – CHO Foods – Toast,breakfast cereal,yogurt,fruit juice,tea,plain biscuit,clear broth Fluids taken freely Intake in early labour Depending upon hospital policy Glycogenic and fluid requirement Comfort Drink,brushing,mouth wash.

42 BLADDER CARE Empty bladder every 1.5 to 2 hours Full bladder inhibit descend of the fetal head and effective uterine contraction Uterine retension can cause hypotonic uterine action

43 BOWEL Soap and water enema or glycerine suppository Emptying the bowel prevents the soiling of the rectum in the second stage of labour

44 OBSERVATIONS MOTHER REACTION TO LABOUR VITAL SIGNS URINALYSIS
FLUID BALANCE PROGRESS Abdominal Examination Vaginal Examination

45 REACTION TO LABOUR Some women experience contractions as positive, motivating, life giving force Others feel them as pain and resist them As labour progress she may feel less confident

46 VITAL SIGNS TEMPERATURE Pulse rate should be steady
More than 100 – infection,ketosis,haemorrhage Rising pulse rate – rupture of uterus Record 1-2 hr in early labour Record every minutes when labour is more advanced PULSE Pyrexia – infection, ketosis Record every 4 hours BLOOD PRESSURE Every 4 hours unless it is abnormal Hypotension – supine position,shock,epidural anaesthesia

47 URINALYSIS Test urine for glucose,ketones and protein Ketones – starvation or maternal distress Trace of protein – Rupture of membrane Significant proteinuria – Worsening pre eclampsia FLUID BALANCE Record of intake and output must be recorded

48 PROGRESS ABDOMINAL EXAMINATION
Regular abdominal examination throughout labour Nature of contractions like intensity, frequency and duration are assessed clinically No of contractions should be assessed in 10 minutes Duration of contraction should be assessed in seconds Pelvic grip – gradual disappearance of the poles of the head Shifting the maximal impulse of the FHS downward and medially

49 OBSERVATIONS THE FETUS THE FETAL HEART FETAL BLOOD SAMPLING
AMNIOTIC FLUID FETAL DISTRESS

50 The fetal heart TYPES INTERMITTENT RECORDING CONTINUOUS RECORDING

51 INTERMITTENT FETAL HEART RATE MONITORING
This term is used when the fetal heart rate is auscultated at interval using a Pinard’s fetoscope or a Doppler ultrasound apparatus Rate should be counted over a minute Normal rate is between 120 and 160 beats per minute Rhythm should remain steady FHR should be monitored immediately following uterine contraction

52 CONTINUOUS FETAL HEART RATE MONITORING
Continuous recording usually involves fetal cardiograph and maternal tocograph in a cardiotocograph apparutus Observes the response of the fetal heart to uterine activity as well as rate and rhythm Usually applied for 20min or be used for whole labour

53 Fetal blood sampling Normal pH of fetal blood is 7.33or above
Fetus who become hypoxic will also become acidotic

54 Amniotic fluid Amniotic fluid normally clear
Amniotic fluid provides information about the condition of the fetus Green – Meconium staining Muddy yellow colour or slightly green – Previous distress Golden yellow – Rhesus iso-immunisation Bleeding – May be rupture of vasa previa

55 Fetal Distress Signs of fetal distress
Fetal tachycardia R/T oxygen deprivation Fetal bradycardia R/T uterine contraction Passage of meconium stained amniotic fluid Management Call a doctor Syntocin must be stopped Place mother in left lateral position Administer oxygen First stage prepare for LSCS Second stage liberal episiotomy fails ventouse or forceps

56 ACTIVE MANAGEMENT OF FIRST STAGE OF LABOUR
Definition Describe a range of policies which helps to achieve efficient uterine action, thereby preventing prolonged labour in primigravidae Aim Not to expose anyone with the stress of labour for more than 12 hours

57 Components of active management of labour
Accurate diagnosis of labour Regular rhythmic contraction Accompanied by show,ROM or complete effacement Early rupture of the membrane 1hr after labour is diagnosed Not the colour of the liquor Monitoring cervical dialation PV hourly for the first 3hrs then at 2hrs interval Chart observations in a partogram Cervical dialation 1cm per hour is acceptable Continuous professional support for the mother

58 NOW THE ACTIVE MANAGEMENT OF LABOUR INCLUDE
Rupture of membrane Followed by oxytocin infusion