Midwifery Management First Stage of Labor

Midwifery Management During the First Stage of Labor

• Midwifery management during the first stage of labor focuses on the initial evaluation of the woman and the fetus.
• Initial evaluation includes review of medical history, physical assessment, laboratory investigations, current physical well-being of the woman and fetus, woman's medical and obstetric history, social situation, and expectations.
• A comprehensive approach is necessary to identify actual and potential problems and create a mutually agreeable and appropriate plan of care. This approach must include history, physical examination, and laboratory investigation.
• Women who haven't received adequate prenatal care are at increased risk of adverse obstetric complications like preterm birth, stillbirth, and infants who are too large or small for their gestational age.
• Critical history items should be double-checked with the woman to confirm the existence of drug allergies, blood transfusions or reactions, and major obstetric or medical complications during the pregnancy.
• The prenatal record reviewed should be included in the intrapartum medical record.
• An interim history includes any change in health status since the last documented visit, chief complaint, history of present illness, and a brief review of relevant systems. This completes the history database and guides the physical examination.

History

• History includes elements like the woman's age and parity (number of pregnancies)
• Estimated date of delivery and weeks of gestational age
• Complications of the current pregnancy (e.g., Group B Streptococcus status)
• Major complications of previous pregnancies (prenatal, intrapartum, and postpartum periods)
• Previous labor experience (including duration and mode of delivery)
• Size of previous babies
• Fetal movement pattern
• Vaginal bleeding
• Status of membranes
• Time of onset of contractions (character, frequency, duration, intensity)
• Aggravating and relieving factors of contractions
• Last oral intake

Physical Examination

• A comprehensive physical examination is indicated when a woman has no prenatal records available or has received inadequate prenatal care.
• Components include vital signs (blood pressure, temperature, pulse, respirations), auscultation of heart and lungs, abdominal palpation (to determine contraction pattern, fetal lie, presentation, position, and engagement), abdominal palpation (to determine estimated fetal weight and fundal height), visual inspection of abdominal scars, assessment of peripheral or facial edema, pelvic and cervical exam.
• Cervical effacement and dilation, cervix position, station of presenting part, fetal lie, presentation, position, tone and elasticity of the vagina and perineum, and confirmation of membrane status.
• Visual inspection of the perineum and assessment of fetal heart rate.

Pelvic and Cervical Examination

• Progressive cervical effacement and dilatation is a sign of true labor.
• Cervical position (anterior or posterior) affects labor readiness.
• Fetal station indicates fetal descent and pelvic adequacy.
• Molding or caput succedaneum indicates fetal adaptation to the pelvis.
• Digital examination findings enhance abdominal assessments of fetal lie, presentation, and position.
• Palpation of the vagina and perineum can help assess risk of perineal lacerations.
• Membrane status and examination of the perineum for lesions or discharge are considered.
• Assessment of fetal heart rate is important to assess fetal well-being.

Optional or Supplemental Examinations

• Measurement of maternal weight is relevant when compared to pre-pregnancy weight or previous prenatal visits.
• Clinical pelvimetry supports clinical judgment when estimating pelvic adequacy.
• Evaluation of reflexes (Hyperreflexia and clonus) and determination of clonus presence are signs of severe preeclampsia/eclampsia.
• Speculum examination facilitates visualization of the cervix and vaginal vault, confirmation of membrane rupture, collection of specimens, and estimate of cervical dilation and effacement.

Laboratory Investigation

• Identification of the woman's blood type, Rh status, and presence of anemias.
• Glucose tolerance testing
• Perinatal infections (e.g., hepatitis B infection or carrier status, HIV status).

Confirmation of Labor Status

• Active labor begins when cervical dilatation reaches 6 cm or more.
• Labor status is determined based on at least two adequately spaced cervical examinations (e.g., 2-4 hours apart.)
• Regular, painful contractions and complete or near-complete effacement can indicate active labor, even if dilation is only 4 cm or 5 cm if immediately preceded by cervical change.

Components of Midwifery Care for Laboring Women

• Labor support and pain management.
• Maternal position and level of activity.
• Hydration and nutrition.
• Intravenous access.
• Membrane management
• Fetal Heart Rate Monitoring
• Uterine Contraction Monitoring

Continuing Evaluation During Labor

• Continuing evaluation focuses on maternal well-being, fetal well-being, and labor progress.

Maternal Well-being

• General maternal condition includes fatigue, physical depletion, behavior, pain perception, and ability to cope.
• Maternal vital signs (blood pressure, pulse, respirations, temperature) are monitored for specific schedules related to labor and membrane rupture.

Urinary Output

• Women in labor should empty their bladder every two hours during the active phase.
• Methods to encourage voiding are spontaneous voiding, ambulation to toilet, or common methods (listening to water, warm water on perineum, light suprapubic pressure).
• Catheterization might be considered if above methods are unsuccessful.

Bladder Distension

• Bladder distension can occur, especially with epidurals.
• Receiving a fluid bolus prior to an epidural increases the likelihood of bladder distension.
• Once the epidural is active women are unable to sense the urge to urinate and have reduced muscle control to void.
• An intermittent or indwelling catheter may be required to drain the bladder to minimize risk of infection or retention.