Management of first stage of labour

General management

Upon the woman’s arrival at the hospital, she should be warmly greeted in a friendly manner and made to feel that she is expected. The midwife notes whether delivery is imminent and if so, makes immediate preparation to cope with it.

Incidence of normal labour

It varies from community to community. Generally proportion of normal labour is 85% and operative delivery is 15%.

Admission procedure

The admission process for a woman in true labour follows the same protocol as that for other hospitalized patients. The woman should receive a warm welcome, complete essential record collection and admission forms, be allocated a designated area, and receive a brief orientation regarding the hospital’s rules and regulations.

Woman in labour includes some other matter as:

i. General history taking and examination, inquiry about gravida and Last Menstrual Period.

ii. Prior to proceeding with full admission, it is crucial to determine if the woman is in true labor, achieved through a short labour history, thorough examination, observation and assessment by the midwife, who must also decide how far the labour has progression.

iii. Assessing the stage of labor involves evaluating specific indicators. If the woman experiences regular, painful uterine contractions accompanied by bearing down, she is likely in the last of the first stage of labor. Immediately observe the vaginal area for signs of bulging and the appearance of the presenting part. Should she be in the second stage of labour and the presenting part is crowning, immediate action is necessary. Immediately transferring her to the labour room for delivery or alternatively, preparing her for delivery while in bed.

iv. If woman is in first stage of labour follow the process of thorough admission procedure as name, address, age, guardian’s name etc.

v. Check vital sign and FHS to  identify women’s and fetal condition

vi. Perform vaginal examination

vii. Consent

viii. Reassure the relative by explaining condition of woman

ix. .Collect MCH record card with antenatal checkup record

x. Take detail history of labour

• Uterine contraction, rupture of the member, show, sleep, rest, food.

i. History taking

The history of previous labour and antenatal status provides clues to identifying whether a woman is in labour. Therefore, gathering detailed information about her personal, social, family, and obstetric history is crucial. The weight of previous spontaneous deliveries offers insights into pelvic capacity. Any history of previous instrumental deliveries, caesarean section or stillbirths should be reported to the doctors.

Any abnormal condition existing during pregnancy will also have been recorded as pre-eclampsia, anemia, diabetes, Rh factor negative so that obstetrician and pediatrician can arrange adequate management for possible problem.

In general women with normal and uncomplicated conditions can provide their obstetric history, but those experiencing eclampsia or severe toxemia might be unable to do so. In such cases, close relatives should be involved in acquiring this information. The process of history-taking encompasses the following:

1. Personal or individual  history: This include bio-demographic information about women. i.e. name, age, religion, address, husband/guardian’s name and age, occupation of woman/husband, age of marriage, duration of marriage etc.
2. Family medical history: Collecting and documenting family medical history can help identify patterns and potential risk factors for diseases such as: heart disease, diabetes, cancer, thyroid disorder etc.
3. Past medical history: The medical history provides an ideas of the women’s general health. i.e. anemia, hypertension, diabetes, renal and heart disease, STD, injuries to pelvis etc. because this disease condition may directly or indirectly effect the labour and new born baby.
4. Past obstetric history: Record in detail:

• All past pregnancies/abortion etc. any miscarriage
• All past labour, type, length of complication.
• All past babies, live or dead, sex, PPH or other problem.

5. Present obstetric history:

• Inquire about the date of the LMP.
• Determine the expected date of delivery (EDD).
• Collect information of gravida and para.
• Explore any implantation bleeding in this pregnancy.
• Investigate the presence of any minor or major disorders during the pregnancy.
• Ascertain the date of quickening and whether fetal movement has been felt. If not, inquire about when the mother anticipates fetal movements.
• If the woman expresses concerns about lack of fetal movement, promptly assess fetal heart sounds (FHS) and communicate with the obstetrician.

(ii). Assessment of maternal and fetal condition

Assessment  of uterine contraction in labour

Throughout pregnancy, there is rhythmic involuntary spasmodic  uterine contraction which are painless and have no effect on dilatation of the cervix. The character of contractions changes with the onset of labour. Assess the tonus, intensity, duration and frequency of contraction and retraction.

Method of recording contraction

Observing and recording contractions serves the primary purpose of tracking labour progress. To do this, place your palm on the abdomen. When a contraction initiates, the uterus becomes firm and maintains this state for a specific duration before gradually relaxing.

Pay attention to the timing and length of this firmness. Concurrently, women often experience pain. The duration of the uterus’ firmness constitutes the contraction duration. After a period, the firmness recurs, leading to a time interval between these two instances known as the contraction frequency.

The strength or degree of hardness is known as contraction’s strength divided into 3 categories.

1. Mild contraction: Pain is minimal and manageable for the woman. These contractions occur every 10-20 minutes and persist for 5-30 seconds.
2. Moderate contraction: The contraction is painful but within the woman’s tolerance level. It occurs more frequently and lasts longer compared to mild contractions. Typically observed towards the end of the first stage of labour.
3. Severe contraction: This is the sign of the second stage of labor, pain is intense and beyond the woman’s pain threshold. During contractions, there’s a bearing-down force exerted by the woman, and restlessness may arise. Reassurance between contractions becomes essential.

(iii) Examination of women in labour

(a) General examination of a women on labour

• -Before conducting any examination, it’s crucial to take into account the patient’s history, which includes reviewing past medical records, obstetric history, and the current pregnancy record.
• -Special emphasis should be placed on the woman’s build, stature, height, and any signs of limping or deformities.

Principles of general examination

1. Ensure to provide a comprehensive explanation to the woman regarding examination and procedures.
2. Kindly guide the woman to the restroom for urination and request her to collect 10-20 ml of urine in a specimen bottle. If there’s a history of antenatal urine tests showing positive results for albumin and sugar, it’s advisable to retest for both sugar and protein.
3. Weight the woman and document it.
4. .Inquire about the blood investigation report and note the blood group information on the woman’s chart.
5. Ensure women’s privacy is maintained by screening.
6. Request the woman to remove any extra clothing and shoes, assist her in positioning comfortably on the bed in a dorsal recumbent position. Instruct her to place both hands either above her head or below it.
7. .Advise her to relax her body during the examination to enhance comfort.
8. The nurse should have short nails and warm hands for optimal patient comfort.
9. When conducting the examination, utilize the palm of your hand instead of your fingers.
10. Always stand on the right side of the woman during the examination.
11. Perform the examination in a systematic manner.

Procedure of general examination of women  

1. If labour has not progressed, a brief general examination is performed. In this case, request the woman to empty her bladder and provide a urine specimen for protein, sugar, and ketone testing.
2. Give special attention to the woman’s build and stature, particularly focusing on short stature and any limb deformities or spinal issues.
3. Observe her overall appearance, including her general health and nutritional status, checking for signs of anemia, jaundice, and cleanliness.
4. Assess for the presence of edema in the legs, ankles, hands, or fingers. If the edema is related to pre-eclampsia, it may be accompanied by elevated blood pressure and proteinuria.
5. Evaluate for any signs of infection such as respiratory infections, gastroenteritis, or diarrhea, aiming to prevent the spread of infections among patients.
6. Measure weight and height.
7. .Examine the vulva for any gapping in the vaginal orifice or anus, perineal bulging, presence of discharge, bleeding, edema, and note any varicose veins.
8. Assess vital signs including temperature, pulse, respiration, blood pressure, and fetal heart sounds (FHS).

(b) Abdominal examination

Purposes

By abdominal examination it is possible to ascertain:

1. Determine the size of the uterus and establish if it aligns with the duration of amenorrhea.
2. Assess the size of the fetus.
3. Identify the lie, presentation, and attitude of the fetus.
4. Determine the presenting part.
5. Evaluate the abdominal size to detect anomalies such as excessive amniotic fluid (polyhydramnios), twin pregnancy, or abdominal tumors.

Steps of abdominal examination

1. Inspection

• Checking for linea nigra and striae gravidarum and observing their colour.,
• Monitoring fetal movement.
• Examining for previous Cesarean section scars.

2. Palpation

Palpation techniques such as measuring fundal height and comparing it with the week of gestation,

• Fundal palpation to identify the fetal head (hard, round, and ballotable, moving side to side) or the buttocks (wider, less hard, and less mobile)
• Lateral palpation to differentiate between irregular and smooth parts of the abdomen to determine fetal position (LOA, ROA, LSA, RSA)
• Pelvic palpation to identify the presenting part
• Powlik’s grip to assess engagement.

3. Auscultation

• FHS listen by fetal stethoscope, fetuscope, fetal phone, Doppler sonogram etc.
• FHS is double of woman’s pulse 130-140 beat/minute. carefully listen rate, regularity or any other abnormalities.

Vaginal examination

• This technique involves assessing the state of the vagina, uterus, and pelvis, as well as monitoring the advancement of labour through a vaginal examination.
• Its purpose is to ascertain whether the mother is experiencing true labour, evaluate the status of membrane rupture, and measure the degrees of cervical dilation.
• These assessments are typically carried out at intervals of every 4 hours. However, in the presence of risk factors, they might be conducted every 2 hours or as required.

Purposes of performing vaginal examinations

• To monitoring of cervical dilatation and effacement, particularly in high-risk cases.
• To determine the presence of labour or not.
• To assess the position and presentation of the fetus, ascertain the engagement of the fetal head, check for the integrity of the fetal membranes.
• To evaluate the degree of molding.

Indications

1. Monitoring cervical dilatation in high-risk cases
2. Diagnosing prolongation of latent phase
3. Doubt regarding presentation as may arise in a primi-gravida woman with rigid abdominal walls.
4. Assessing engagement in obese women.
5. When in doubt as to whether the second stage has begun e.g. Persistent pushing at end of first stage.
6. To determine the case of delay to report such facts as the level of the presenting part, size of the caput and the degree of moulding.
7. To identify the possibility of cord prolapsed in high risk condition as;

• After the membranes have ruptured in polyhydramnious.
• After the membranes have ruptured in a multiparous women when the head is not engaged.
• During labour induced by amniotomy.

8. When some abnormality of the fetus is suspected, e.g. Anencephaly or hydrocephaly

9. In multiple pregnancy, to find out  lie of second  twin.

Contraindications

1. Ante partum hemorrhage.
2. Amniotic fluid leaking.
3. Placenta Previa

Equipment required.

The following equipment is necessary for conducting a vaginal examination:

• Sterile solution bowl: used for holding antiseptic solution or other liquids
• Cotton balls: used for applying antiseptic solution or cleaning purposes.
• Sterile gloves (1 pair): essential to maintain aseptic conditions during the examination.
• Perineal pad: placed under the woman’s hips to protect the bed or surface from any fluids.
• Kidney tray: a sterile tray used for holding sterile instruments and materials.
• Sponge forceps: used to handle sterile items to clean perineal area.
• Screen: provides privacy for the woman during the examination.
• Perineal paper: placed under the woman to keep the examination area clean.
• Antiseptic solution (Betadine/dettol solution or boiled water): used for cleaning and disinfection.
• Bucket or polythene bag for soiled swabs: used to dispose of used swabs and other waste materials.
• Plastic apron: worn by the healthcare provider to protect clothing from contamination.

Procedure for vaginal examination

Introducing fingers into the vagina carries the potential risk of introducing exogenous infections. Therefore, careful hand and instrument sterilization is imperative, and the utilization of sterile gloves significantly reduces the likelihood of septic complications.

1. Preparing the woman, explaining the upcoming procedure and assuring her that it won’t be painful can promote relaxation, making the examination process smoother and the findings more comprehensive. Optimal positioning involves having the woman lie in a dorsal recumbent position for both comfort and improved visibility. Additionally, ensuring that the bladder is empty is essential to facilitate the examination process.

2. Preparation of the midwife or doctor includes the following steps:

• Wearing a face mask and gown for infection control measures.
• Toileting: Thoroughly washing the hands and forearms with soap and running water is essential. A scrubbing brush should be used for cleaning under the fingernails. This process should take a minimum of 3 minutes to ensure proper disinfection.

3. When preparing the solution, it should be poured over the vulva while gently separating the labia minora using the fingers of the left hand. This step ensures appropriate coverage and cleanliness during the examination.

4. The vulva should be prepared by swabbing with an antiseptic solution, such as Betadine or Dettol, in a motion from upward to downward and from inward to outward. This process helps ensure thorough disinfection.

5. During the examination, the midwife or doctor should wear sterile gloves. The middle and index fingers of the right hand should be gently introduced into the vagina after carefully separating the labia using the two fingers of the left hand. This approach facilitates a proper and controlled examination while maintaining aseptic conditions.

6. Great care should be taken to avoid touching the labia during the examination. When introducing the fingers, they should be held at a higher level than the vaginal orifice to prevent contact with the anus. The fingers should be guided along the anterior vaginal wall, and they should not be withdrawn until the necessary information has been gathered.

When maneuvering the hand to explore the vaginal canal, it’s crucial to ensure that the thumb does not come into contact with the anus or the vaginal orifice. This precaution helps maintain hygiene and prevents the potential transfer of bacteria during the examination.

Findings on vaginal examination

Degree of cervical dilation and effacement: the degress of cervical dilation, measured in centimeters, effacement of the cervix should be carefully noted and recorded.

Status of membrane and rupture of membranes: the condition of the amniotic membrane (bag of water) needs to be assessed. If the membranes have ruptured, the colour of the amniotic fluid should be noted.

Presenting part: determining the presenting part of the fetus is essential. This is often done by feeling for the position of the fontanelle and the sagittal suture in relation to the quadrants of the maternal pelvis.

These findings provide critical information about the progress of labour, fetal position, and overall maternal and fetal well-being. Careful and accurate documentation of these observations is crucial for effective patient care and clinical decision-making.

Method of interpreting vaginal findings

• Dilatation of the cervix
• Rim of cervix
• The bag of waters
• Level or station of the presenting part
• Diagnosis of presentation: In 96%  vertex  feeling hard skull bones, Fontanelles and sutures.
• Diagnosis of position: Posterior fontanelle in occipito-anterior position, the anterior fontanelle in Occipito posterior position and whether it is to the left or right side of the pelvis.
• The degree of moulding: judged by feeling the mount of overlapping of the skull bones, and when excessive, it suggest that intracranial injury is likely to have taken place.
• Abnormalities: prolapsed or presentation of cord, anencephaly, hydrocephaly and compound presentation can be diagnosed vaginally.

Cervical dilatation and measurement through finger

1. If the index finger can be inserted, the dilation is approximately 1.5 cm.
2. When one finger can be inserted with ease, the dilation is around 2 cm.
3. If two fingers can be inserted with slight resistance, the dilation is approximately 3 cm.
4. The dilation is around 4.5 cm when three fingers can be accommodated.
5. When four fingers can be inserted comfortably, the dilation is about 6 cm.
6. If there is no feel of the cervix, full dilation at 10 cm has been reached.

Physical care of women and physical comfort

1. A woman in labour often experiences increase in body temperature and profuse sweating, making her appreciate the opportunity to take a bath or shower, provided she feels physically able. Taking a warm bath can be comforting for women experiencing backache, and might enjoy immersing herself in deep, warm water.
2. As part of daily routine care, it’s important to assist the woman with tasks such as personal hygiene, toileting, and even helping her with tasks like dressing her hair. Regularly changing the pad when it becomes soiled is crucial to maintain cleanliness and comfort. Offering words of praise, encouragement, and reassurance throughout the labor process can greatly contribute to the woman’s emotional well-being.
3. Providing detailed information about the progress of labor is essential. Keeping the woman informed about her cervical dilatation, effacement, and the positioning of the baby helps her understand the ongoing process and feel more in control.
4. Leg cramps can be distressing during labor. A quick method to alleviate such cramps is to extend the leg and dorsiflex the foot, which often brings rapid relief.
5. In all aspects of care, ensuring the woman’s comfort, emotional support, and well-being are paramount, contributing to a positive labor experience.
6. Partograph monitoring:  this parameters including foetal heart rate, amniotic fluid clearness, cervical dilation, strength of uterine contractions, maternal pulse, and blood pressure, urine (acetone, protein) test.

Counseling the woman and her support person

It  is essential to prepare them for the various stages of labour:

1. Begin by explaining what to expect during the initial stages of labor, before contractions become intensely painful. Detail the natural progression of contractions, gradually increasing in strength and frequency as labour advances.
2. Clarify that as labour progresses, contractions will become stronger and occur closer together, signaling the approach of the delivery time.
3. Describe what the woman can anticipate during the actual delivery process. Reassure her that you will be present and supportive throughout the entire birth experience, offering comfort, guidance, and assistance as needed.

Emotional and psychological support

Emotional and psychological support for a woman in labour involves aiding her in maintaining self-control, fostering an environment of acceptance for her reactions and behaviors, and ensuring that she concludes her labour with a sense of accomplishment, even if the final outcome differs from her initial hopes. There are various ways through which you can assist her in attaining these objectives.

Position and mobility

1. Positon changes during labour can be used to promote comfort and prevent or correct problems in labour .
2. Frequent position changes to be effective in facilitating fetal rotation and decent. The potential advantages of mobility/ambulation include, enhance uterine cavity, distraction from labour discomforts, enhance maternal control and opportunity for close interaction with woman’s partner and care provider as they help her to walk.
3. Ambulance is associated with a reduced rate of operative e.g. Caesarean birth, forceps, vacuum) and less frequent use of narcotic analgesia.
4. Walking, sitting or standing during labour is more comfortable than lying down and facilitates the progress of labour.
5. Ambulation should be encouraged if membranes are intact, if the fetal presenting part is engaged after rupture of membranes, and if the woman has not received medication for pain.
6. When woman live in bed, she will usually change her position spontaneously as labour progresses. If she does not change positon every 30 to 60 minute, she should be assisted to do so.
7. Lateral position is preferred because it promote optimal utero-placental and renal blood flow and increases fetal oxygen saturation.
8. If the woman wants to lie supine, place the pillow under one hip to prevent the uterus from compressing the aorta and venacava.
9. If the fetus is in the occipito posterior position it may be helpful to encourage the woman to squat during contraction. The squat position increases the pelvic diameter that allows the head to rotate to be more anterior position.
10. A hand and knee position during contraction is also recommended to facilitate the rotation of the fetal occiput from the posterior to anterior position as gravity pulls the fetal back forward.

Nutrition and hydration

1. Nutritious fluid intake/ drink is important even in late labour. An adequate intake of fluids and calories is required to meet the energy demand and fluid losses associated with childbirth.
2. The progress of labour slows and ketosis develops if demands are not met and fat is metabolized. Reduced energy for bearing down efforts can increase the need for a forceps or vacuum assisted vaginal delivery When woman is permitted to continue fluids and food freely, they typically regulate their own oral intake in early labour, then tapering off to the intake of clear fluids and sips of water as labour intensifies and the second stage approaches.
3. Common practices is to allow clear fluids/liquids e.g. water, tea, apple juice during early labour, tapering off to sips of water as labour progress so becomes more active. Food and fluid consumed orally during labour can meet a laboring woman’s hydration and energy demands more effectively and satisfy than fluid administered I/V.

Bowel care

1. Most of the woman dosen’t have bowel movement during labour because of decreased intestinal mobility.
2. A stool that has formed in the large intestine is moved downward toward the anorectal area by the pressure exerted by the fetal presenting part as it descends. This stool is expelled during second  stage pushing.
3. The passes of stool with bearing down effort increases the risk of infection  may embarrass the woman thereby reducing the effectiveness of these efforts.
4. To prevent problems, the nurse should immediately clean the perineal area to remove any stool, while at the same time reassuring the woman that the passes of stool at this time is a normal and expected even because the same muscle used to expel the baby also expel stool.

Bladder care

1. The woman should be encouraged to empty her bladder every 1-2 hours during labour. A distended bladder may impose descent of presenting part; inhibit uterine contractions and leads to decreased bladder tone or atony of uterus after birth.
2. A careful record should be kept of the amount and time of each voiding. Women who receive epidural anesthesia/analgesia are especially at risk for the retention of urine and the need to void should be assessed more frequently.
3. It the woman cannot go to the toilet, she is given a bed pan. Privacy must be maintained and comfort must be ensured. If the woman fails to pass urine especially in late first stage, catherization is to be done with strict aseptic precautions.

Management of first stage of labour

Obstetrical management

Fetal monitoring: fetal heart rate, color of liquor

Fetal Heart Rate (FHR)

The FHS should be assessed by auscultation with a Doppler  or fetoscope.

1. If the women and fetus are determined to be low risk, the FHR is assessed and documented. A FHR outside the range of 120-160 beats/pm or a sudden change in FHR should be reported immediately.
2. FHR should be taken immediately after the rupture of membranes because this is most common time for the occurrence of prolapse of umbilical cord. FHR along with rhythm and intensity should be noted every 30 minute in first stage and every 15 minutes in second stage or following rupture of membrane.
3. Assessment should be done immediately following uterine contraction and count for one minute. Reassess the Fetal Heart Rate (FHR) after;

• Rupture of membranes
• Vaginal examination
• Ambulation (before and after)
• Change in infusion rate of oxytocin administration of drug (before and after)
• Urinary catheterization
• Expulsion of enema
• Recognition of abnormal uterine activity (close strong contraction)
• Decrease in fetal activity ( felt by mother).
• To avoid confusion, maternal and FHR, maternal pulse should be counted. Otherwise maternal tachycardia may be wrongly treated as FHR.

Colour of liquor (statues amniotic sac and fluid)

To determine whether amniotic membranes are intact ruptured.

• If membranes have ruptured note time of rupture,  color, amount and odor of the amniotic fluid.
• Normally amniotic fluid is clear, pale with little odour.
• Greenish fluid suggests fetal passage of meconium.
• Wine colored amniotic fluid indicate the presence of blood and indicates possible premature separation of the placenta.
• Foul or unpleasant odour of fluid suggests infection.

The nurse/midwife may perform a test to establish if the membranes have ruptured.

• Nitrazine paper which is sensitive to PH will turn deep blue if amniotic fluid is present. The deep blue indicates the slight alkalinity of the fluid.
• If leakage is due to urine, the color of the strip will remain yellow, which is slightly acidic.

 Ferning is characteristic pattern of crystallization in amniotic fluid when it dries. It may be observed by placing vaginal fluid on a slide, allowing it to dry, and then observed it under magnification. Urine and vaginal discharge will not show this pattern.

• Assess conditions associated with fetal compromise are as follows;
• Meconium – stained amniotic fluid
• FHR outside the normal range from 120 to 160 beats per minute.
• Yellowish, cloudy, foul odor to amniotic fluid (suggests infection)
• Slowing of FHR or persisting after contraction ends.
• Uterine contractions last longer than 90 second.
• Maternal fever (38⁰C or 100.4⁰F)
• Maternal hypotension (decreased utero-placental blood flow)
• Diminished uterine relaxation time between contractions.

Maternal Monitoring

Progress of labour

Assess uterine Contraction

Assess contraction by placing his/her fingertips on the women’s abdomen over uterine fundus for 10 minute in every 30 minute. A summary of frequency, duration and intensity of contractions should be recorded on the chart or in partograph.

The midwife should report when the contractions become weaker, shorter and less frequent, or when the contractions are almost continuous, with no relaxation between them.

Guidelines for assessment of contraction by palpation are;

• Assess contractions by palpation at least 3 consecutive contractions.

Guidelines for minimum interval between auscultation assessments;

• Hourly – latent phase.
• Every 30 minute-  during active and transition phase.
• Every 15 minute-during second stage.
• Assess more frequently if abnormal pattern exists.
• Place hand on uterine fundus. Use fingertips for more sensitivity.
• Determine the duration of the contraction; note time that elapses from beginning of the one until beginning of next.

Descent, Rotation and Flexion

• Initially decent often occurs slowly, especially in nulliparous, but it usually accelerates during active phase.
• It may occur very rapidly in multigravida. If descent is a delay in progress despite regular strong uterine contraction and maternal pushing, vaginal examination should be performed with maternal permission. The purpose is to confirm whether or not internal rotation of the head has taken place, to assess the station of the presenting part, and to determine whether caput succedaneum has formed.
• If the occiput has rotated anterior is well flexed and progress will continue, In the absence of good rotation and flexion, or a weakening of uterine contractions, or both, then a change of position, nutrition and hydration, or use of optimal fetal positioning technique may be considered.
• If there is evidence that either fetal or maternal conditions are compromised, an experienced obstetrician must be consulted.

Cervical Dilatation

• Assess dilatation at every vaginal examination and measured in cm. It is marked with crosses (X) on the parotograph at 4 cm dilatation.
• Alert Line starts at 4 cm of cervical dilatation and continue to point to the point of expected full dilatation  at the rate of 1 cm per hour.
• Action Line is drawn parallel and 4 hours to right of the alert line. This is the critical line at which specific management decisions must be made at the hospital, if a woman reaches the action line.

Descent of the Fetal Head

 Assessed by abdominal palpation before doing vaginal examination. Descent of the fetal head is measured in number of fingers when abdomen palpated. It refers to the part of the head palpable above the symphysis pubis.

• Head entirely above symphysis pubis is (5/5) palpable. Head is mobile
• Head two finger above the symphysis pubis is 2/5
• Head entirely below symphysis pubis or sinciput is at the level of symphysis pubis is 0/5 palpable.

Uterine Contraction

 Assess the frequency, duration and intensity of uterine contractions every 30 minute by direct palpation. Chart every half hour; count the number of contractions in a 10-minute time period and their duration in seconds. Shadow the duration of contraction as given below:

Duration of the Contraction

 From the time the contraction is first filled abdominally to the time when the contraction passes off, and measured in sec.

 Frequency of Contraction

 It is time of the interval from the beginning of one contraction to be beginning of the next contraction. The frequency usually recorded in minutes. Number assesses frequency of contraction in a 10-minute period.

 The frequency, duration and intensity of uterine contraction can be estimated by palpation. The fingers are placed lightly on the fundus of the uterus. The finger tips are more sensitive to the first tightening of the uterus. The tightening increases to a hard, board like consistency at the acme (peak) of the contraction and then gradually diminishes as the contraction goes down.

The tension in the uterine muscle between contraction and relaxation of the uterus felt on palpation.

Mild: Slightly tense fundus that is easy to indent with fingertips (feels like touching finger to tip of nose)

Moderate :Frim fundus that is difficult to incident with fingertips (feels like touching finger to chin)

Strong : Rigid, board like fundus that is almost impossible to incident with fingertips (feels like touching finger to forehead), and altered abdominal contour with contraction.

Station

Relationship of presenting part to an imaginary line drawn between the ischial spine of the maternal pelvis.

Spines are the most prominent bony projections felt on internal examination and a bispinous diameter is the shortest diameter of the pelvis in transverse plane being 10.5 cm.

• The station is ‘0’ if presenting part ( level of the spines).
• Station above spines (-1 cm, -2 cm, -3 cm, and floating)
• Station  below spines (+1cm, +2cm, +3cm and on the perineum).

The distance of the presenting part above and below the ischial spines is expressed in cm.

Active management of labour

1. Instruct and assist in provision of nutrition to laboring woman
2. Advice and help to maintain comfortable position and posture, however avoid prolonged supine position. Patient is allowed to walk during the early stage particularly with intact membranes. If rest is needed the patient lies on her left lateral position to prevent inferior vena cava compression and hence placental insufficiency and fetal distress.
3. Instruct and assist in evacuation of the rectum to avoid uterine inertia, help the descent of the presenting part, and avoid contamination by faces during delivery.
4. Instruct and assist in evacuation of the bladder. Ask women to micturate every 2-3 hour, if she cannot perform nursing measure or use a catheter. It prevents uterine inertia and helps descent of the presenting part.
5. Clean the vulva.
6. Support woman for non-pharmacological pain reliving measures.
7. Use and maintain partographic for labour management
8. Accurate diagnosis of labour singleton fetus, vertex presentation and no evidence of maternal and  fetal distress.

Complications

• Maternal distress
• Fetal distress
• Cephalo-pelvic disproportion
• Prolonged labour

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