![DIAGNOSIS OF POOR
PROGNOSIS OF LABOUR
Prolonged bradycardia and meconium stained liquor
Possibility of foetal distress
Prolonged latent phase when more than eight hours
in primigrvida and more than six hours in
multigravida
Prolonged latent phase may be due to fault in power,
passage or passenger
Passage is small due to contracted pelvis
Passenger, hydrocephalous, brow [occiput not felt]
Large baby, shoulder presentation](https://image.slidesharecdn.com/finalfirststageoflabour-150711214209-lva1-app6891/85/Final-first-stage-of-labour-48-320.jpg)
Final first stage of labour
- 1. BALKEEJ KAUR M.SC(N) 2ND YEAR AIMS,CON SRI MUKTSAR SAHIB PUNJAB
- 2. Contents: Introduction Stages of labour Diagnosis Management on admission Active management of labour Monitoring Partogram Abnormalities Pain control
- 3. Introduction Labor : Uterine contractions resulting in progressive dilation and effacement of the cervix and accompanied by descent and expulsion of the fetus. Abnormal labor, dystocia, and failure to progress are terms used to describe a difficult labor pattern Approximately 20 % of labors involve dystocia
- 4. Stages of labor NORMAL LABOR — divided into Four stages First stage: time from the onset of labor until complete cervical dilatation Second stage: time from complete cervical dilatation to expulsion of the fetus Third stage: time from expulsion of the fetus to expulsion of the placenta Fourth stage: the 1st post partum hour..
- 5. Recommendations on definitions of the first stage of labor: The first stage is further subdivided into the latent active ,and transition phase latent phase- onset of regularly perceieved contractions and ends when rapid cervical dilatation begins Contractions are mild Lasting 20-40 seconds Cervical effacement occurs,cervix dilate 0-3 cm 6 hours in nullipara and 4.5 hours in multipara.
- 6. .ACTIVE PHASE Cervical dilatation increasing from 4-7 cm Contractions last 40-60 seconds and occur every 3-5 minutes 3 hours in nullipara and 2 hours in multipara Show and spontaneous ruptures of membranes may occur
- 7. ACTIVE PHASE DIVIDED INTO THREE ADDITIONAL PHASES: -Acceleration phase -phase of maximum slope -deceleration phase
- 8. TRANSITION PHASE CONTRACTIONS REACH THEIR PEAK OF INTENSITY CERVICAL DILATATION INCREASE FROM 8- 10CM CONTRACTIONS LASTS FOR 60- 90 SECONDS OCCUR EVERY 2-3 MINUTES IF THE MEMBRANES ARE NOT RUPTURED PREVIOUSLY THEY WILL RUPTURE AT 10 CM
- 9. CERVICAL EFFACEMENT AND DILATATION DURING LABOUR
- 10. ….
- 11. Recommendations on definitions of the first stage of labor:
- 12. FACTORS AFFECTING FIRST STAGE OF LABOUR: 1.UTERINE FACTORS: FUNDAL DOMINENCE POLLARITY
- 13. CONTD…… CONTRACTION AND RETRACTION FORMATION OF UPPER AND LOWER UTERINE SEGMENT RETRACTION RING
- 15. CONTD… PRESENCE OF SHOW 2.MECHANICAL ACTORS- FORMATION OF FOREWATERS
- 18. CONTD….. GENERAL FLUID PRESSURE FETAL AXIS PRESSURE
- 19. Diagnosis of labor The determination of whether a woman is in labor is made within one hour of admission . Diagnosis of labor is made only when painfull contractions are accompanied by any one of the following : Bloody show Rupture of the membranes Full cervical effacement. Cervical dilatation is not part of the criteria Meet the criteria Didn’t meet the criteria Rest & observation Until next day Antinatal ward
- 20. Diagnosis of labor The correct diagnosis of labor is considered to be the single most important determination in the management of labor because an incorrect diagnosis of active labor will lead to inappropriate interventions and an increased likelihood of cesarean delivery.
- 21. MANAGEMENT OF FIRST STAGE OF LABOUR OBJECTIVE-TO HAVE A WATCHFUL EXPECTANCY AND TO MONITOR THE PROGRESS OF LABOUR AND TO PREVENT COMPLICATIONS INITIAL ASSESSMENT- Onset of contraction Frequency Duration Memebrane Liquor Present and previous obstetric history,drug history
- 22. Contd…… CLINICAL EXAMINATION Pallor Jaundice Hydration Pulse/bp/temp,/resp. rate chest,/cvs oedema
- 23. Contd……oOEDEMA
- 24. PER ABDOMEN EXAMINATION Uterine contraction Frequency and duration in 10 min Fundal hieght
- 25. Contd…..
- 26. LIE/PRESENTATION
- 27. Contd…. FHR to be noted every 15 minutes with fetal doppler
- 28. PER VAGINAL EXAMINATION Discharge show Absence or presence of membranes Station of head
- 32. MANAGEMENT GENERAL-emotional support and assurance are given BOWEL-encourage women for warm bath,soap enema REST AND AMBULATION-when membranes are intact women is encouraged for ambulation,when ruptured women advised for rest. DIET-fruit juice ,soup,salt lemon juice is recommended.NPO 6-8 hours prior to surgery BLADDER CARE-encourage the women to empty the bladder,if failed catheterization with aseptic tecniques
- 33. Contd….. PARTOGRAPH-monitor the progress of the labour by plotting the partograph
- 34. Partogram: Maternal status Fetal heart rate Dilatation & descent Uterine contractions
- 35. Contd….
- 36. Cont….. Watch for maternal and fetal well being. Psychological preparation of the mother P/V examination should be done : 1 to 4 hours in the first stage and at 1 hour intervel at the second stage At rupture of membranes to evaluate for cord prolapse Prior to intrapartum administration of analgesia When the parturient feels the urge to push When the FHR falls,to evaluate the conditions like uterine rupture or cord prolapse
- 37. Contd…. Placement of intravenous line at the time of admission is recommended.-it is found that women who received Intravenous hydration at 250ml/hr had fewer labors persisting for over 12 hours and less need for oxytocin augmentation than those who received 120ml/hr. ANTIBIOTIC PROPHYLAXIS –in some centers to prevent early onset neonatal infection intravenous penicillin is given
- 38. Active management of labor It refers to active control, rather than passive observation, over the course of labor by the obstetrical provider. It includes three essential elements I. Careful diagnosis of labor by strict criteria II.Constant monitoring of labor with specific standards for normal progression III.Prompt intervention (eg, amniotomy, high dose oxytocin) according to established guidelines if progress is unsatisfactory .
- 39. Active management of labor The active management of labor is generally limited to women who meet the following criteria: 1) Nulliparous 2)Term pregnancy 3)Singleton infant in cephalic presentation 4)No pregnancy complications 5)Experiencing spontaneous onset of labor.
- 40. Active management of labor Nulliparous labor tends to be more subject to failure to progress . administration of oxytocin, sometimes at high dosages, is one of the interventions involved in active management. This is safer in nulligravid women since the nulligravid uterus is virtually immune to rupture (except as a result of manipulation or previous surgery)
- 41. Active management of labor Recommendation on routine amniotomy Limited evidence showed no substantial benefit for early amniotomy and routine use of oxytocin compared with conservative management of labor. In normally progressing labor, amniotomy should not be performed routinely. Combined early amniotomy with use of oxytocin should not be used routinely.
- 42. ACTIVE MANAGEMENT OF LABOUR Interventions with amniotomy,and/or high dose oxytocin are initiated if progress does not succeed according to the defined standards. Rupture of the fetal membranes provides information About fetal status,but does not appear to significantly accelerate labour.In the dublin protocol,rupture must be performed before treatment with oxytocin which is administered only in the presence of clear amniotic fluid.
- 43. ACTIVE MANAGEMENT OF LABOUR If membranes are ruptured when there is polyhydramnios or an inengaged fetal presenting part,it is prudent to use a small gauze needle,rather than a hook,to puncture the fetal membranes in one or more places,and to perform the procedure in the operating room.This controlled amniotomy permits emergency cesarean delivery in the event of an umbilical cord prolapse. Routine amniotomy should not be performed in women with active hepatitis B and C or HIV inoreder to minimize exposure of the fetus to ascending infection.
- 44. ACTIVE MANAGEMENT OF LABOUR Slower progress in the nulliparous patient is most often the result of inefficient uterine action. In the absence of medical contraindications,labour that falls to progress is treated with oxytocin.
- 45. MONITORING It is desirable that all examinations should be done by single individual to minimize interobservor variations. A vaginal examination during labour often raises anxiety and interrupts the women focus Increased number of vaginal examination is associated with neonatal sepsis
- 46. Monitoring: Recommendations on monitoring during the established first stage of labor A pictorial record of labor (partogram) should be used once labor is established. 4 hourly temperature and blood pressure hourly pulse half-hourly documentation of frequency of contractions frequency of emptying the bladder vaginal examination offered 4 hourly, or when there is concern about progress Intermittent auscultation of the fetal heart after a contraction should occur for at least 1 minute, at least every 15 minutes, and the rate should be recorded as an average.
- 47. Monitoring: Recommendations on initial monitoring: 1) Psychological & Emotional 2)Vitals & Urinalysis 3)Uterine contractions 4)Abdominal examination_Leopold manouvers 5)Vaginal loss – show, liquor, blood 6)Vaginal examination....when necessary 7) Pain control 8)FHR
- 48. DIAGNOSIS OF POOR PROGNOSIS OF LABOUR Prolonged bradycardia and meconium stained liquor Possibility of foetal distress Prolonged latent phase when more than eight hours in primigrvida and more than six hours in multigravida Prolonged latent phase may be due to fault in power, passage or passenger Passage is small due to contracted pelvis Passenger, hydrocephalous, brow [occiput not felt] Large baby, shoulder presentation
- 49. ROLE OF NURSE IN CARING OF THE WOMAN IN THE FIRST STAGE OF LABOUR Admitting client to birthing area after determining that client is in labor Determining if client's membranes have ruptured Encouraging family participation as appropriate with the labor process Performing Leopold maneuver and vaginal exams as appropriate Monitoring maternal vital signs and fetal heart rate and patterns, reporting any deviations or abnormalities
- 50. CONTD….. Applying electronic fetal monitor as appropriate Assessing pain level, instituting positioning, breathing, relaxation, and other methods for pain control; administering analgesics as ordered Providing ice chips, wet washcloth, or hard candy Encouraging voiding at least every 2 hours Assisting with anesthetic administration Assisting with amniotomy with assessment of fetal heart rate, fetal positioning, and fetal cord after amniotomy
- 51. CONTD…. Assisting with amniotomy with assessment of fetal heart rate, fetal positioning, and fetal cord after amniotomy Cleansing perineum and assisting with pad changes regularly Monitoring progress including vaginal discharge, cervical dilation and effacement, position, and fetal descent Performing vaginal examinations as necessary Assisting coach and supporting client and partner
- 52. CONTD….. Palpating to determine contraction intensity Reassuring client about normal fetal heart rates Adjusting monitor to achieve and maintain clear tracing Interpreting rhythm strips when at least a 10-minute tracing has been obtained
- 53. CONTD….. Preparing supplies and equipment for delivery Notifying primary health care provider at appropriate time to scrub for attending delivery Verifying maternal and fetal heart rate response to uterine contractions during intrapartal care Instructing client and partner about reasons for electronic monitoring Applying tocotransducer snugly after determining fetal position via Leopold maneuver