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Course: Maternity Nursing�Topic: Nursing Care During First Stage of Labour

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Module Goals

The learner will be able to:

Describe the monitoring, management and evaluation of the first stage of labour
Describe the importance of using a partograph
Identify poor progress during the first stage of labour
Recognise risk factors and management of prolapsed umbilical cord

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Labour

The process where uterine contractions cause the cervix to dilate resulting in the delivery of fetus and the placenta.

Signs of true labour:

Cervical changes take place (effacement and dilation)
Rupture of the membranes
“Show” or bloody discharge from vagina

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Stages of Labour (Normal Vaginal Delivery)

4 stages of Labour:

First Stage (cervical dilatation from 0-10 cm)
Second Stage (full cervical dilatation and the birth of the infant)
Third Stage (delivery of infant to the delivery of placenta)
Fourth Stage (The first hour after delivery of the placenta)

Note: Each stage carries risks to the mother and fetus and must be managed appropriately

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First Stage of Labour

Management initiated during the admission process
Begins with regular uterine contraction and ends with the full dilation of the cervix
Monitoring and documentation includes assessment of mother, fetus and progress of labour
Accurate assessment is required to differentiate between normal and abnormal findings and to respond appropriately

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Admission of the mother
The first stage of labour starts with the contraction of the uterus. As soon as the contraction begins, the cervix thins and starts to open. A fully dilated cervix is 10 cm, and the baby gets delivered. Once the cervix fully opens, the first stage of labourcomes to an end. It is important to know that some women may be confused, and get anxious about the false labour pain (also called Braxton Hicks contractions). Knowing the difference between true and false labour helps the healthcare professional and act accordingly.

The difference between true and false labour is timing and changes with the movement:

i.e. True labour contractions come at a regular intervals, contractions continue and do not continue with the change of position and movement.

False Labour comes at irregular intervals, and contractions might stop or decrease with walking, taking rest, or changing position.

Note: If the diagnosis of labour is uncertain, the women should be observed for 4 hours. The fetal heart rate and duration and frequency of uterine contractions are observed every 2 hourly. The women can be discharged home if:

The maternal and fetal condition remains normal.
No increase in duration and frequency of uterine contractions occurred.
The membranes did not rupture.
No cervical changes occurred since admission.

While the labour starts as a healthcare provider, there should be careful assessment, monitoring of mother, fetus, and progress of labour and has to be carefully documented in a partograph.

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First Stage of Labour

During Admission Process :

Provide a professional, empathetic welcoming approach
Assess for admission criteria
Obtain history: Onset of contractions, ‘show’
Complete physical examination
Take vital signs
Perform abdominal and vaginal examination to determine dilation, effacement, fetal position and engagement
Obtain blood work and urine analysis

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During the admission process, a nurse should welcome the mother and her partner professionally: i.e. Greeting the mother and family, introducing self , and if there are other relatives or families present with the mother, ask them to wait in a designated area.

Admission criteria: In order to evaluate the presence of true labour , a nurse assesses the onset of contractions, presence of vaginal discharge (show), loss of fluids (rupture of membranes), pattern of uterine contraction (regular or irregular, frequency) and cervical dilation and effacement. If any of these criteria are met, she then moves to the history-taking segment.
History – Please refer to the “Maternal History” for more details. Information from the mother: onset of contractions, rupture of membranes, any bleeding, etc.

Physical examination – The physical examination takes place with privacy and confidentiality. A nurse-midwife has to assess the general condition of the mother: exhaustion, anemic, hydration, pain, marked pallor, and fetus: heart rate, decent e.t.c. It is very important to understand that a nurse should do a complete physical examination on admission, 6 hours after the admission (latent phase), and four hourly at the active phase of labour . If there is poor progress of labour, physical examination should be done every 2 hourly.

Vital sign: Vital signs are assessed i.e. Blood pressure, temperature, pulse, respiration

Abdominal examination: In an abdominal examination, a nurse inspects the mother, palpates the lie of the fetus, presentation, and engagement. The fundal height is measured, and the fetal heart and rhythm and rate are assessed.

Vaginal examination: Vaginal examination is done in order to ensure the true labour of the mother. Here cervical dilation and effacement are measured and determine if the membrane is intact. 5 Ps are assessed.

Laboratory: Hematology, Hematocrit, Hemoglobin, Blood Group, Rh factor, cross-match might be ordered. Urine analysis would be done in order to assess the presence of protein, sugar, ketone bodies (warning signs). After the assessment, all the findings are documented in the patient's chart and partograph.

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First Stage of Labour

Provide emotional support to the patient and her family

Offer comfort
Address concerns
Options for pain relief

Diet: Tea and light food, avoid dehydration
Bladder: every 2 hourly voiding
Documentation: Careful record of findings

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Emotional support:

Provides comfort: The nurse will always try to make her patient comfortable in a new environment. She will focus on the patient’s safety and address emotional and physical needs such as pain management and hygiene. The nurse should always adhere to aseptic procedures during labour and aware of the warning signs during the labour process so that complications can be prevented.

Every action of healthcare providers deeply affects the mother and her family. Pregnancy itself is a life-changing experience, and fear of labour pain is a normal among the woman. A nurse should address her fear, and encourage family members to provide her support and encouragement during the labour process. Excessive pain and discomfort can make a pregnant woman irritable, a nurse should be empathetic and demonstrate her compassion through verbal encouragement.. A pregnant woman needs a calm environment that is free from noises and conversation.

A pregnant woman might feel anxious about anticipating labour pain and feel helpless. In such cases, a nurse should educate the patient regarding pain management options. It might include pharmacological or non-pharmacological measures. Knowing the options will make the woman confident and hopeful.

Diet: Everyone might not be aware of the diet during labour . Thus, a nurse has to give information about what can be eaten during labour . During early labor, black tea and light digestive biscuits can be given. It is important to make sure that the woman is not dehydrated. Dehydration has many negative impacts, and prolonged labour may result in dehydration. If the signs of dehydration are present, she should be given an I.V infusion with 5% or 10% dextrose.

Bladder: A special consideration has to be given to the bladder. It is important to understand that a full bladder prevents the fetal head from engaging. Thus pregnant women should be encouraged to empty the bladder every two hourly.

Documentation- Everything obtained from the examination has to be recorded carefully in a chart or a partograph. Maternal pulse, contractions (onset, strength, and frequency) have to be monitored every half-hour. The bladder should be assessed every 1.5- 2 hours. Blood pressure, temperature, abdominal examination, vaginal examination, urine test (for acetone or albumin) has to be checked every four hours. Note: Vaginal examination should not be done in case the membranes rupture.

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What Would the Nurse Do?

You are an intern in a birthing centre. Mrs. XYZ is 35-weeks pregnant with her first child. After arriving at the birthing center, she states that she is in labour as she is experiencing diffuse mild contractions for the last few hours. On careful examination by a midwife, her cervix is closed and is not dilated. She is advised to return home.

Discuss the rationale for sending the client home.

What explanation would you give the client and what discharge instructions would you provide?

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Partograph

Managerial documentation tool to monitor duration of labour
Measures the progress of labour over time
Observation charted in partograph are

Progress of labour (dilatation and effacement)
The fetal condition (decent: station)
The maternal condition (vital signs)

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Partograph: Sample

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In the center of the partograph, there is a graph. Along with the left side number 0-10 against squares. Each square represents 1 cm dilatation. Along the bottom of the graph are numbered 0-24: each square represents 1 hour.

Dilatation of the cervix is measured in centimeter. The dilatation of the cervix is plotted with an "X". The 1st vaginal examination on admission includes a pelvic assessment and the findings are recorded. The vaginal examinations are performed every 4 hrs unless contraindicated. However, in the case of multipara, women may be assessed more often.

Note: The first oblique line of the partograph is called the Alert Line (represents the cervical dilation). It is important because the alert line represents normal progress in cervical dilatation which is acceptable during the active phase of the first stage of labour .

The second oblique line in the partograph is Action Line. If any patient whose alert line falls on or crosses the action line, the woman needs a complete examination. This requires immediate physician supervision for higher management. Sometimes it may indicate instrument delivery or cesarean section.

The progress of labour is very slow when the graph of cervical dilatation crosses or falls on the action line. When this occurs, action must be taken in order to hasten the delivery of the infant.

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Partograph: Progress of Labour

Cervical dilatation is marked with “X” in cm
Effacement is recorded by drawing a thick, vertical line on the same part of the cervical dilation chart
Record fetal head descent and engagement at every vaginal examination
Symbol ‘O’ with fontanelles and sagittal sutures marking inside

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Partograph: Progress of Labour

Record degree of moulding of the fetal head as 0 to 3+
Record duration of contraction:

Stippled block: Contractions lasts < 20 seconds
Striped block: Contractions lasts between 20 - 40 seconds
Completely colored block: Contractions lasts >40 seconds

Record frequency of contractions:

No. of contractions occurring within 10 minutes is recorded
One block equals one contraction. E.g., if two blocks are marked off = 2 contractions in 10 minutes.

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What Would the Nurse Do?

A patient is admitted to the hospital with a history of labour for 24 hours. On admission, she appears anxious, has a dry mouth, and a pulse rate of 120 beats per minute. She states that her urine is dark and that she has not passed any urine for the previous few hours.

Discuss the following:

Probable diagnosis
Hydration status
How exhaustion can be avoided
Treatment of maternal exhaustion

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What is the probable diagnosis?

Maternal exhaustion due to long labour with inadequate fluid and energy intake. The diagnosis is confirmed by the presence of maternal tachycardia and a dry mouth. Other findings like pyrexia and ketonuria may help confirm a diagnosis.

Does this patient have oliguria?

Yes, as she has passed less than 20 ml per hour over several hours

How could maternal exhaustion be avoided?

By making sure that every patient receives an adequate intake of fluid and calories during labour . If a vaginal delivery is expected and no high-risk factors are present, a patient should continue to take fluids orally during the active phase of the first stage of labor. Any patient with prolonged labour should receive fluids intravenously.

How should the patient’s exhaustion be treated?

The patient should be given 2 liters of Ringer’s lactate with 5% dextrose intravenously (routinely). The first liter must be given quickly and the second liter over 2 hours. Also, adequate analgesia should be given if needed.

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Partograph: Fetal Condition

Record condition of the fetus
The baseline heart rate
The presence or absence of decelerations and if present, if decelerations are early or late
Liquor/ amniotic fluid findings:

I = Intact membranes

C = Clear liquor, draining

M = Meconium-stained fluid

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Partograph: Condition of the Mother

Record the condition of the mother
Blood pressure, pulse, respirations and temperature.
Record the urine output

Volume recorded in ml
Protein recorded in 0 to 4+
Ketones recorded as 0 to 4+

Record IV fluids and medications given during labour

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Progress of labour : Three Phases of First Stage

First phase (latent): Cervical dilation of 0-3 centimeters

Second phase (active): Cervical dilation of 3-7 centimeters

Transition: 7-10 cm

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Management of Patient in Latent Phase of Labour

Complete physical examination
Careful monitoring: mother, fetus, and labour progress
Second complete physical examination after 6 hours
If labour does not progress:

Rule out false labour
Examination after another 6 hours to determine progress

What to do if there is no progress of labour after 12 hours of admission?

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The patient may come to the hospital/birthing center with some signs of labour . During the admission in early labour , there should be careful monitoring of mother, fetus, and progress of labour . If everything is found to be normal e.g. fetal heart rate, duration, and frequency of contraction then she must be monitored every 2 hours. The patient should be admitted to the labour ward. There will be a second complete examination after six hours of admission(if the patient starts experiencing more regular and painful contractions). At this point, the patient should be encouraged to take enough fluids and have something light to eat. Walking and exercise(duck walking, squatting) are found helpful to progress the labour .

The second Complete Examination:

During this examination, a nurse or midwife will assess the following:

Contractions: Monitor the frequency and duration of contraction. If contraction has stopped, it could indicate false labour and if maternal and fetal conditions are normal, she may be discharged. However, if the contractions have not progressed and the frequency and duration remain the same, the cervix has to be assessed.
The cervix: If the effacement and dilatation of the cervix have remained unchanged, the patient is probably not in true labour . She may be discharged if all the observations remained normal. If there is some progress in effacement and/or dilatation of the cervix, the patient is in labour and, provided that all other observations are normal, the next complete examination is planned for 6 hours later. She needs to be monitored frequently.

What to do if there is no progress in the latent phase of labour to the active phase of labour within 12 hours after admission?

If contractions stop: Indicates false labour , the patient may be discharged.
No rupture of membrane or no indication of inducing labour : Discharge the patient.
The patient still having regular contraction: Further management depends upon the state of the cervix:

If there has been no progress in effacement and/or dilatation of the cervix, the patient is probably not in labour . The responsible physician should see and assess this patient in order to decide whether the patient should be discharged or labour induced.
If there has been progressive effacement and/or dilatation of the cervix then the patient is in labour . The patient needs physician supervision and assessment. If the progress has been slow during the latent phase, it may be necessary to rupture the membranes or commence an oxytocin infusion( augmentation of labour ).

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Patient Management in Active Phase of Labour

Cervical dilation 5 cm or more
Complete physical examination is done every 4 hours
Cervical dilation is documented in partograph
Descent of head assessed
Avoid frequent vaginal examinations (less than 4 hours apart)

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When a patient is admitted with cervical dilation of 5 cm or above, she is in the active phase of labour .

However, the possibility of cephalopelvic disproportion must be considered.

Management of a patient who is in normal labour

If the condition of mother and fetus is normal, there are no signs of cephalopelvic disproportion. Then another complete examination should be done in the next 4 hours. Cervical dilation should be measured in partograph.

Normal progress during the active phase of the first stage of labour

There is progressive descent of the fetal head into the pelvis. It is assessed in an abdominal examination (fetal head above the brim of the pelvis). However, the descent of the head may occur late in the case of multigravida.

Note: Descent of the head is assessed externally (abdominal ) and internally (Station)

(Please refer to slide deck ‘Overview of Labour and Birth Process’ slide numbers 13 and 14)

Vaginal examinations should be done more frequently (in less than 4 hours ) if:

If cephalopelvic disproportion is suspected ( next vaginal examination should be done in 2 hrs).
If there is poor progress of labour (without the presence of cephalopelvic disproportion). The next complete examination should also be done 2 hours later, to assess the progress.
If dilation of the cervix is 8 cm dilated or more, the next complete examination would normally be done when the cervix is expected to be fully dilated. However, if the cervix is already fully dilated, the examination may need to be done earlier.

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Rupture of Membranes

Usually, rupture of membrane acts as stimuli for the progress of labour
Can detect cord prolapse and meconium staining
If membranes are ruptured spontaneously during labour

Assess the fetal head for risk of cord prolapse

Some patients need artificial rupture of membrane by healthcare professionals

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Advantages of rupturing a patient’s membranes

Acts as a stimulus for the better progress of labour . Once the water breaks, a healthcare professional can easily detect the chances of cord prolapse or find meconium-stained fluid. Immediate interventions can be taken in order to minimize complications.

Spontaneous rupture of membrane during labour:

In this case, the care provider should assess for the chances of cord prolapse: i.e.

If the fetal head is 4/5 or more palpable above the pelvic inlet, or if there is a breech presentation, the patient is at high risk for cord prolapse. A sterile vaginal examination must be done to rule out this possibility.
If the fetal head is 3/5 or less palpable above the pelvic inlet, it is highly unlikely that a cord prolapse might happen. However, the fetal heart must be monitored to rule out the possibility of fetal distress due to cord compression.

Need of Rupture of membrane:

It is important to make sure that the patient is in the active phase of the first stage of labour before rupturing the membranes.
To reduce the risk of transferring HIV from other to the fetus, the membrane is ruptured (keeping duration as short as possible).

The membranes of patients whose HIV status is positive or unknown, if they are still intact at the start of the active phase of labour must not be ruptured. With normal progress do not rupture the membranes but with poor progress, the membranes should be ruptured, and the next examination performed 4 hours later.

A patient who is HIV negative or living with HIV with an undetectable viral load and in labour with a vertex presentation may have her membranes ruptured with safety if the patient is in the active phase of labour and the fetal head is 3/5 or less palpable above the brim of the pelvis.

After rupturing the membranes, rule out the possibility of cord prolapse by feeling around the head of the fetus.
The chances of cord prolapse are reduced if the membrane is ruptured with aseptic technique (rather than allowing spontaneous rupture) if the fetal head is 4/5 or more above the pelvic brim, and the cervix is 6 cm or more dilated.

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Poor Progress in First Stage of labour

Cervical dilation less than 1 cm per hour
Identification: Cervical dilation cross the alert line
Cause: Cephalopelvic Disproportion, Ineffective uterine contraction
Need systemic evaluation and management

Immediate, supervision, and interventions required

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Poor progress is said when cervical dilatation in the active phase of the first stage of labour is less than 1 cm per hour. It can be identified via partograph; if the dilation line crosses the alert line. The causes of poor progress of labour are Cephalopelvic Disproportion, Ineffective uterine contraction.

A systemic examination is needed with such a patient. A nurse should follow the following steps:

Step 1: Ask two questions:

Is the patient in the active phase of the first stage of labour?
Are the membranes ruptured?

If the answer to both questions is ‘yes’, proceed to step 2.

Step 2: The cause of the poor progress of labour must be determined by examining the patient using the ‘Rule of the 4 Ps’. The 4 Ps are:

The patient.

The powers.

The passenger.

The passage.

What must be done after the patient has been systematically evaluated to determine the cause of the poor progress of labour ?

The nurse attending to the patient must inform the doctor about the clinical findings and together they can rule out the cause of the slow progress
A decision on immediate action
Schedule the next complete examination (2 hours or 4 hours)
If labour progresses satisfactorily following the action taken, labour is allowed to continue.
Need a doctor's presence in order to assess, supervise, and take effective interventions if the action line has been reached or crossed.

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What Would the Nurse Do?

A primigravida patient at term is admitted to the labour ward. She has had contractions, lasting 30 seconds, every 10 minutes. The cervix is 1 cm dilated and 1.5 cm long. The maternal and fetal observations are normal. After 4 hours, she is having two contractions, each lasting 40 seconds, every 10 minutes. On vaginal examination, the cervix is now 2 cm dilated and 0.5 cm long with bulging membranes. The diagnosis of poor progress of labour due to poor uterine contractions are made and an oxytocin infusion is started to improve contractions.

Discussion:

View on diagnosis of poor progress of labour
Assessment of patient's management
Thoughts on artificial rupture of membrane

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Diagnosis of poor progress of labour : The diagnosis is incorrect as the patient is still in the latent phase of the first stage of labour . Poor progress of labour can only be diagnosed in the active phase of labour .
Why can it be said with certainty that the patient is in the latent phase of labour ?

The cervix is still less than 3 cm dilated.
The cervix is dilating slowly.
The cervix is effacing.
The frequency of the uterine contractions is increasing.

What is your assessment of the patient’s management?

Apart from the wrong diagnosis, oxytocin should not be given before the membranes have been ruptured.

Should the patient’s membranes have been artificially ruptured when the second vaginal examination was done?

No. If the maternal and fetal conditions are good, a nurse should wait until the cervix is dilated 5 cm or more. If the patient has been in the latent phase of labour for 12 hours without any progress, membranes may also be ruptured, membranes.

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Poor Progress of Labour: Related to Patient

Need for pain relief: Excessive pain with strong contractions
Full bladder: Mechanical obstruction for engagement, depresses uterine contraction
Exhaustion: Lack of energy has an impact on mother and fetus
Dehydration: Contributes to exhaustion

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The patient may have painful and strong contractions requiring analgesia. Sometimes the pain may be associated with severe anxiety and causes slow progress of labour . Pain relief, emotional support, positive affirmation, and praise may be helpful to speed up the labour process.
If a patient has a full bladder, it prevents the fetal head from reaching engagement. A full bladder also depresses the strength of uterine muscle activity and results in slow progress. The patient must be encouraged to pass urine every 2 hourly. If urine is obstructed, catheterization should be done until delivery.
Exhaustion: State caused by an insufficient supply of fluid and energy to the patient. It causes inadequate progress of labour due to poor uterine action in the first stage, and poor maternal effort in bearing down during the second stage of labour .
Fetal distress due to hypoxia: This often results from prolonged labour due to cephalopelvic disproportion.
Dehydration makes the patient exhausted and delays the progress of labour . Signs of dehydration include: thirst, dry mouth, Oliguria, ketones in urine, Dehydration must be corrected immediately. The patient should be encouraged to eat and drink at the latent phase. And oral fluids can be taken at the active phase. In case of severe dehydration, or inability to take fluids orally, intravenous infusion (dextrose) must be started.

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Problems with Passenger and Passage: Management

Passenger: Fetus

Problems: Abnormal fetal lie, abnormal presenting parts, large fetus, more than one fetus, no engagement
Management:

C- Section

Passage: Refers to the bony pelvis, cervical dilation, and effacement

Management:

Intact membrane, membrane should be ruptured
C-section

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The cause of poor progress of labour may be due to a problem with the passenger (i.e. the fetus). It may be identified by abdominal assessment and by vaginal examination.

Problem with the passenger occurs when:

The fetal lie is abnormal: E.g. Transverse lie, oblique, longitudinal. It needs a c-section
Presenting part is Abnormal: If the baby is in a breech presentation: the doctor should decide vaginal or c-section.
Large Fetus: A large fetus (i.e. estimated as 4 kg or more), with signs of cephalopelvic disproportion (i.e. 2+ or 3+ molding), must be delivered by Caesarean section.
Two or more fetuses: Multiple pregnancies can also cause poor progression of labour . Poor progress may also occur in a patient with multiple pregnancies, usually due to inadequate uterine contractions.
No fetal engagement: If the head of the fetus does not get engaged in the pelvic area of the mother (35% or more of the head above the pelvic brim with 2+ or 3+ moulding) cephalopelvic disproportion is suspected. Requires C-section.

Passage:

The membranes are still intact. If the membrane is still intact, the membrane should be ruptured and the patient should be reassessed at 4 hours before the diagnosis of poor progress of labour .

A pelvic assessment that shows a small pelvis, together with 2+ or 3+ molding of the fetal skull means that there is cephalopelvic disproportion and is an indication for Caesarean section.

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Problems with 5 P’s and Management:

The following are examples of causes of poor progress in labour together with their management:

Please refer to the slide deck “Overview of Labour and Birth Process”

Cause	Action
Cephalopelvic disproportion	Caesarean section
An anxious patient unable to cope with painful contractions	Reassurance and analgesia
Inadequate uterine contractions	An oxytocin infusion
Occipito-posterior position	Analgesia and an intravenous infusion
Ineffective uterine contractions	Analgesia followed by an oxytocin infusion

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What Would the Nurse Do?

A patient at term is admitted in labour with a vertex presentation. The cervix is already 5 cm dilated. The cervical dilatation is recorded on the alert line. At the next vaginal examination, the cervix has dilated to 8 cm. Caput can be palpated over the fetal skull. It is decided that the progress is favourable and that the next vaginal examination should be done after 4 hours.

Was the entered cervical dilation on the alert line correct?

What does the second examination indicate?

Was the decision of reassessment after 4 hours correct?

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On admission, was the entered cervical dilation on the alert line correct?

Yes. The patient is in the active phase of the first stage of labour as her cervix is 5 cm dilated. Therefore, the cervical dilatation must be plotted on the alert line. Future observations should fall on or to the left of the alert line.

2. What does the second examination indicate?

It does not necessarily indicate the normal progress of labour . As no information is given about the amount of fetal head palpable above the pelvic brim. Cervical dilatation without the descent of the head does not always indicate normal progress of labour . Cervical dilatation was also slower than 1 cm per hour and the alert line was crossed.

4. Was the correct decision made at the time of the second examination to repeat the vaginal examination after 4 hours?

No. If the cervix is 8 cm dilated, the next examination must be done 2 hours later, or even sooner if there are indications that the woman’s cervix is fully dilated. If it is uncertain whether the progress of labour is normal then the examination should also be repeated in 2 hours.

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Effects of a Prolonged Labour:

Mother:

Anxiety and dehydration
Ruptured uterus
Vesicovaginal fistula
Rectovaginal fistula

Fetus:

Hypoxia
Fetal distress
Intrauterine death

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Prolapse Umbilical Cord:

Umbilical Cord presents in front of presenting part (after rupture of membranes)
Medical Urgency: Requires a C-Section
Risk factors: Abnormal lie or presentation, polyhydramnios, preterm labour , multiple pregnancy
Management:

Elevate fetal head to alleviate pressure on the umbilical cord
Oxygen
Catheterization
Salbutamol
C-section for viable fetus

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Glossary:

Polyhydramnios: Excessive amount of amniotic fluid around the baby inside the amniotic sac.
Viable: Capable of surviving or living

Prolapse of the umbilical cord: It is a condition where the umbilical cord lies in front of the presenting part of the fetus while the membrane ruptures. The cord may lie between the presenting part of the fetus or cervix, in the vagina, or outside the vagina. Prolapse cord is a medical emergency because the blood flow between the fetus and the placenta may decrease or stop causing fetal distress or even death. Cord presentation and cord prolapse are two different things (In cord presentation, the membrane remains intact, and if the fetus is alive, a c-section must be done).

Risk of a prolapsed cord

Patients in labour with an abnormal lie (e.g. transverse lie, oblique lie) or an abnormal presentation (e.g. breech presentation).
Rupture of membrane before the engagement of the fetal head.
Polyhydramnios where the increased volume of liquor may wash the cord out of the uterus.
Patients in preterm labour where the presenting part is small relative to the pelvis when the membranes rupture.
Patients with multiple pregnancies, where preterm labour , abnormal lie, and polyhydramnios are common.

Note: In order to determine the prolapsed cord, a sterile vaginal examination must immediately be done.

Management of a prolapsed cord:

A vaginal examination must be done immediately.
If the cervix is 9 cm or more dilated and the fetal head is on the perineum, the patient must bear down and the infant must be delivered as soon as possible.

Otherwise, the patient must be managed as follows:

The cord has to be replaced carefully in the vagina to prevent vasospasm (cold or heat cause vasospasm).
The patient has to be given oxygen and salbutamol has to be given IV slowly to stop the contraction of the uterus (0.5 ml salbutamol diluted with 9.5 ml of sterile water and given slowly IV over 5 minutes)
Foley catheter has to be inserted into the patient’s bladder and fill the bladder with 500mls saline. It is done to lift the presenting part off the cord. The presenting part must be pushed up in the vagina by turning the patient into a knee-chest position.
Cesarean section is an ultimate solution. However, not everyone with a prolapsed cord needs C-section. If the fetus is viable, a c-section is done. Otherwise, the fetus is delivered vaginally.

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Oxytocin Use

Inadequate contractions
Observation a key during the infusion
Some patients may need analgesic before oxytocin infusion
The maximum amount of oxytocin during the first stage of labour is two units
Contraindications: cephalopelvic disproportion, uterine scars, abnormal fetal presentation (breech)

Contact info: info@nursesinternational.org

Management of poor progress of labour due to inadequate uterine contraction:

Provided there are no contraindications, the patient must be given an oxytocin infusion in order to strengthen the contractions. During this process of infusion,

The patient’s progress must be reassessed after 2 hours.
If cervical dilatation is at the rate of 1 cm per hour or more ( progress has been satisfactory) and labour is allowed to continue.
If cervical dilatation is less than 1 cm per hour even the patient has adequate contractions, the patient has to be assessed by the doctor as there may be chances of cephalopelvic disproportion. A patient may need referrals in tertiary care.
The analgesic may be needed for some patients before infusing oxytocin.

Contraindications of Oxytocin use at the first stage of labour.

Evidence of cephalopelvic disproportion
Patient with uterine scar from previous c-section
Multiparas with poor progress
Fetal distress
Poor kidney function or heart valve disease

Note: Oxytocin has an antidiuretic effect, so there is a risk of the patient developing pulmonary edema. Hyperstimulation may result in induction with oxytocin. ( Hyperstimulation: 5 or more contractions in 10 minutes, or contractions lasting longer than 60 seconds).

8-37 How must oxytocin be administered when it is used during the first stage of labour?

The following is a good method:

Begin with 1 unit of oxytocin in 1 liter of Plasmalyte B, Ringer’s lactate, or rehydration fluid.
Use a giving set that delivers 20 drops per ml.
Start with 15 drops per minute and increase the rate at intervals of 30 minutes to 30 drops, and then to 60 drops per minute, until the patient gets at least three contractions lasting at least 40 seconds every 10 minutes.
If there are still inadequate contractions with 1 unit of oxytocin per liter at 60 drops per minute, a new liter of intravenous fluid containing 8 units per liter is started at a rate of 15 drops per minute. The rate is increased in the same way as above until 45 drops per minute are being given. This is the maximum amount of oxytocin which should be used during the first stage of labour .

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Red Flags

Pyrexia during labour: indicates infection
Fetal heart rate less than 100 beats per minutes: severe hypoxia
Presenting rope-like structure during vaginal examination: cord prolapse
Meconium stained amniotic fluid: fetal distress
Maternal tachycardia, hypotension, cold and clammy skin: signs of shock

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Cultural Considerations

In Southeast Asia, Bangladesh, Nepal and India, husbands are usually not present during the delivery process. They believe that women are considered “impure” and also men should not interfere in the labour process
Chinese are taught self-restraint and, oftentimes, may refuse pain medication offered for the first time; They may consider it is impolite to accept something the first time it is offered
Filipinos, Korean value stoicism. They believe that a woman must experience pain and discomfort as part of the childbirth process.
Women from Latin American and Black cultures may be verbally expressive in labor

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References:

Assegid. M. Obstetric and Gynecological Nursing. Ethiopia. Ethiopia Public, Health Training Initiative, The Carter Center, the Ethiopia Ministry of Health, and the Ethiopia Ministry of Education. 2003. Pp 79-93

BetterCare Learning programs (n.d). Maternal care: Monitoring and Managing the first stage of Labour. Retrieved on 30^th of September 2020 from https://bettercare.co.za/learn/maternal-care/text/08.html#8-monitoring-and-managing-the-first-stage-of-labour

Greene, M. J. (2007). Strategies for incorporating cultural competence into child education curriculum. The Journal of Perinatal education. Vol( 16 (2), Pp 33-37. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1905821/

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