First Stage of Labor PDF

# Normal Labor ## Labor: It is the process by which the products of conception (a viable fetus, placenta and membrane) are expelled from the uterus via the vagina into the external environment. ## Normal labor:- Spontaneous expulsion, through the natural passages (birth canal) of a single, matur...

# Normal Labor ## Labor: It is the process by which the products of conception (a viable fetus, placenta and membrane) are expelled from the uterus via the vagina into the external environment. ## Normal labor:- Spontaneous expulsion, through the natural passages (birth canal) of a single, mature (37-42 completed weeks of pregnancy) viable fetus, presenting by vertex presentation, within a reasonable time, without fetal or maternal complications, without any intervention except episiotomy. ## Normal labor is that which:- 1. Spontaneous expulsion not induced. 2. Single (not twins or triple) 3. Mature = full term (37-42 weeks) gestation, not premature or post mature. * Preterm Labor: (≥28 week - (37) weeks gestation. * Post term labor: (≥42) weeks gestation. 4. Viable fetus (after 28 weeks) 5. Presenting by vertex (top of the head) the occiput in the anterior part of the pelvis (common presentation). 6. Within a reasonable time complete after 3hours and before 24 hours from time of its onset. * Prolonged labor: When duration of labor lasting >24 hours * Precipitate labor: When duration of labor lasting < 3 hours 7. Through the natural passages (birth canal) 8. Without complications to mother or fetus as hemorrhage. 9. Without any intervention except episiotomy (achieved without artificial aids such as ventose or forceps). ## Types of Labor: * Normal vaginal delivery (NVD) * Assisted delivery (by ventose or forceps) * cesarean section (CS) ## Factors affecting labor process: - (5 Ps) 1. **Passage**: Birth Passage: size and morphology of true pelvis, uterus, cervix, vagina, and perineum. Parity of woman. 2. **Passenger**: Presentation of the fetus "part of the fetus that enters the pelvis first" (breech, transverse). Size of the fetus, mold ability of the fetal skull. 3. **Powers**: * **Primary powers**: Quality, force and frequency of uterine contractions (frequency,duration & intensity) * **Secondary or auxiliary powers**: bearing down or straining. 4. **Psyche**: mother's attitude toward labor and her preparation for labor. Culture, Anxiety/Fear 5. **Position of the woman**: left lateral position to prevent pressure on inferior vena cava, increase cardiac output, increase placental perfusion & improve fetal heart rate ## Premonitory Signs of Labor: 1. weeks before real labor "False Labor" = Braxton Hicks contractions 2. Cervical changes: Effacement 3. Frequency of micturition (↑ urinage) 4. Sudden increase of energy (↑ epinephrine resulting from ↓ progesterone) 5. ↑ vaginal secretion 6. **Shelving**: In standing position the fundus of uterus descends slightly & falls forwards. 7. **Lightening**: It is the relief of upper abdominal pressure symptoms as dyspnea, dyspepsia and palpitation mother can breathe easily. 8. **Pelvic pressure symptoms (after engagement):** * Frequency of micturition * edema in extremities * lower back pain * difficulty in walking * Increased vaginal discharge. Due to :-Pelvic congestion, ↑ estrogen 9. N.B:-The fetal head descended in pelvis in primigravida. This is unlike multigravidas where the fetal head descended and the onset of labor coincides. ## Stages of labor: | Stage of labor | Another name | Beginning | Ending | Duration | |---|---|---|---|---| | 1st stage of labor | Stage of full cervical diltation & effacement | Begins with true labor pains | Ends with full cervical diltation 10 cm | Primi para: 10-16 hrs Or 12-18 hrs Multipara: 6-8 hrs | | Stage I latent phase (Slow cervical effacement) | Begins from the onset of regular contractions. Ends with acceleration of cervical dilatation. Prepares cervix for dilatation (0-3cm) | | <20 hours in Primi para <14 hours Multipara | | Stage 1 active phase (Rapid cervical dilatation) | Begins with acceleration of cervical dilatation. Ends at 10 cm dilatation. Rapid cervical dilatation (4-10 cm) | | <2/hours in Primi para <1.5/hrs in Multipara | | 2nd stage of labor | Stage of expulsion or delivery of fetus | Begins with10 cm dilatation | Ends with delivery of the baby | Primi para: 1 - 2 hrs Multipara: 1/2 - 1 hrs | | 3rd stage of labor | Stage of delivery or expulsion of the placenta | Begins with delivery of the baby. | Ends with delivery of the placenta | 10-15 minutes or <30 min in primipara & multi para >30minutes (retained placenta) | | 4th stage of labor | Stage of close observation | Begins with delivery of the placenta | Ends with 2 hrs after delivery | 2hrs in primipara & multi para | ## First stage of labor **Definition:** 1st stage of labor "stage of full cervical diltation": it starts with true labor pain & ends with full cervical diltation 10cm & effacement. **Duration:** * Primigravida = 10-16 or 16-18 hrs * Multigravida = 6-8 h ### Phases of the first stage: ***Latent phase*** * Started when the cervix dilated slowly and reached to about 3cm. * **Uterine contraction in latent phase:** * Frequency: 1 uterine contraction every 10 minute. * Duration: uterine contraction remains 20sec. * Intensity: uterus can be dented. ***Active phase*** * Rapid dilatation of the cervix to reach 10cm. * **Uterine contraction in active phase:** * Frequency: 3 uterine contractions every 10 minute. * Duration: uterine contraction remains 40-60 sec. * Intensity: uterus is felt hard. ### Signs & symptoms of 1st stage: * **Bloody show:** * It is an expelled cervical mucus plug pink stained with blood from * The mucous is the cervical mucus plug. * The blood arises from rupture of small vessels due to separation of the lower part of the bag of membrane from the lower uterine segment. * Labor is usually starts several hours to few days after show. * **True labor pain:** * **Physiological properties of uterine contractions:**- * **Contraction:** It is temporary shortening of muscle fibers (elasticity). * **Retraction:** It is permanent shortening of muscle fibers contributing to: * Taking up (effacement) of the cervix. * Reduction of uterine volume for expulsion of the fetus. ### 3 Phases of UC: The Contraction exhibits a wavelike pattern that begins slowly climbing (increment) to a peak (acme), and decreases (decrement) * a) increment ↑ * b) acme [peak] * c) decrement ↓ **Criteria or Parameters of UC:** * **Duration**- from beginning of one contraction to the end of the same contraction (How long) * **Frequency**- from beginning of one contraction to the beginning of another contraction (How often) * **Intensity**-mild or moderate or severe (How strong) * **Interval** - Resting time between contractions for placental perfusion ### Effects/functions of uterine contractions : * a) Descent of the fetus (1st stage) * b) Cervical effacement & dilatation(1st stage) * c) Expulsion of the fetus (2nd stage) * d) Control of bleeding from placental site (3rd stage) * e) prevent post-partum hemorrhage& help in uterine involution (4th stage & postpartum period) ## True & False labor pain : | Character | True labor pain | False labor pain | |---|---|---| | Contractions | Regular | Irregular | | Interval between contractions and intensity | Progressive (increase in frequency and intensity) | Short duration, not progressive | | Changes in the cervix | Associated with effacement and dilation of the cervix | Not associated with effacement and dilation of the cervix | | Membranes | Associated with bulging of membranes | Not associated with bulging of membranes | | Response to analgesia | Not relieved by sedation | Relieved by sedation | | Labor | Followed by labor | Not followed by labor | | Enema | Increased by enema | May increased or not | | Measures of relive | Not relived by eating, drinking, walking, sleeping or changing position | Relived by eating, drinking, walking, sleeping or changing position | ## Bearing down efforts: * **Starting:** At the end of first stage (onset of second stage) after full cervical-dilatation. It must be simultaneous with uterine contractions. * **Stopping:** With crowning of fetal head (Deliver the head with no bearing down). * **Contraindications:** Cardiac patient, hypertension with pregnancy & previous hernia repair. ## Importance of bearing down :- * a) First stage: it has no importance on cervical dilation. * b) Second stage: Expulsion of fetus. * c) Third stage: Expulsion of placenta. ## Cervical changes (cervical diltation & effacement): * **Cervical dilatation:** widening of cervix begins; cervix dilating and stretching and is measured in centimeters. (0-10cm). * In the Latent phase: cervical dilatation is less than 3 cm (slow cervical effacement). * In the Active phase: cervical dilatation is from 3-10 cm (progressive cervical dilatation). * Primigravida: cervix dilates about 1.2cm/hour. * Multigravida: cervix dilates about 1.5 cm/hour * **Cervical effacement:** softening, thinning, ripening, shortening and taking up of the cervix. It is expressed in percentage (0-100%) ## Formation of the bag of fore - waters: * The head fits in the LUS & the amniotic sac divided into: hind water (above the girdle of contact) and fore-water (below the girdle of contact) * The bag of fore-water bulges through the cervix and becomes tense during uterine contractions. * **Membranes:** ask the woman if she had a gush of fluid or not. If membranes are ruptured record the time of rupture. ## Management of 1st stage of labor ### Getting Ready: 1. Prepare the needed equipment 2. Welcome, greet the woman & Explain all procedures performed to her 3. Seek informed consent. 4. Ensure privacy and confidentiality. 5. Wash hands before each procedure ### Determine whether the woman is in labor or not through the presence of the following signs: 1. Uterine contractions (True labor pain) ask the woman when true contraction began. 2. Show: ask the woman if she had mucous discharge stained with blood. 3. Membranes: ask the woman if she had a gush of fluid or not. 4. Cervical changes: cervical effacement & dilatation 5. Formation of the bag of water ### Nursing assessment: | | History | Examination | Investigations | |---|---|---|---| | **I.** | Personal information * Medical and surgical history * Family history * Obstetrical history * Menstrual & contraceptive history * Present Pregnancy history | **II.** * General examination * Abdominal examination * Inspection * Palpation * Fundal height (level) * Leopold's maneuver * Fundal grip * Umbilical " lateral" grip * Suprapubic "Pelvic" grip * Pawlik grip * Auscultation: parameters of uterine contractions * Intermittent or Continuous FHR auscultation * Local (vaginal) examination | **III.** * CBC & Hemoglobin level * Blood group and Rh * Urine sample: Test urine for protein and sugar. * Human immunodeficiency virus(HIV) test * Hepatitis B & C virus test. * Kidney and liver function test | ### Active Management "Partograph": to record all important information about fetal condition, maternal condition and labor progress. ### Care of the woman during the first stage of labor: | | Maternal care | Fetal care | |---|---|---| | **I.** | 1. Assess progress of labor * 2. Monitor vital signs * 3. Nutrition and Hydration * 4. Rest and Sleep * 5. Comfort measures * 6. Ambulation * 7. Apply Measures of infection control * 8. Posture of woman in labor * 9. Care of bladder & bowel * 10. Observe signs of maternal distress * 11. Observe for complication | **II.** * 1. FHR auscultation * 2. Interval of FHR auscultation * 3. Observe and record signs of fetal distress |