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FIRST STAGE OF LABOUR

FIRST STAGE OF LABOUR. LABOUR. Labour is described as a process by which the fetus placenta and membranes are expelled through the birth canal. NORMAL LABOUR. Occurs at term Spontaneous in onset Fetus presenting by the vertex Process completed within 18 hours No complications arise.

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FIRST STAGE OF LABOUR

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  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. 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

  6. FIRST STAGE

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

  8. LIGHTENING

  9. EFFACEMENT

  10. SHOW

  11. PREMATURE RUPTURE OF MEMBRANE

  12. CAUSES OF ONSET OF LABOUR • Uterine distension theory • Oxytocin stimulation theory • Prostaglandin stimulation theory • Progesterone withdrawal theory • Estrogen stimulation theory • Fetal cortisol theory

  13. 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

  14. 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

  15. 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

  16. 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

  17. FUNDAL DOMINENCE

  18. CONTRACTION AND RETRACTION

  19. RETRACTION RING

  20. CERVICAL EFFACEMENT

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

  22. GENERAL FLUID PRESSURE

  23. FETAL AXIS PRESSURE

  24. DESCENT OF THE PRESENTING PART

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

  26. 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

  27. 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

  28. 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

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

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

  31. 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

  32. 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

  33. 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

  34. 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

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

  36. 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

  37. 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

  38. 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

  39. NUTRITION • Advice prior to admission • Women need energy – CHO • Foods – Toast,breakfastcereal,yogurt,fruitjuice,tea,plainbiscuit,clear broth • Fluids taken freely • Intake in early labour • Depending upon hospital policy • Glycogenic and fluid requirement • Comfort • Drink,brushing,mouth wash.

  40. 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

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

  42. OBSERVATIONS MOTHER • REACTION TO LABOUR • VITAL SIGNS • URINALYSIS • FLUID BALANCE • PROGRESS • Abdominal Examination • Vaginal Examination

  43. 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

  44. 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 15-30 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

  45. 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

  46. 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

  47. OBSERVATIONS THE FETUS • THE FETAL HEART • FETAL BLOOD SAMPLING • AMNIOTIC FLUID • FETAL DISTRESS

  48. The fetal heart TYPES • INTERMITTENT RECORDING • CONTINUOUS RECORDING

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