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First Stage of Labor

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By: Dr. Ayman Bukhari House officer Obstetrics & Gynaecology Partogram: Maternal status Fetal heart rate Dilatation & descent Uterine contractions Partogram: a ... – PowerPoint PPT presentation

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Title: First Stage of Labor


1
First Stage of Labor

  • By Dr. Ayman Bukhari

  • House officer
  • Obstetrics Gynaecology

2
Contents
  • Introduction
  • Stages of labor
  • Diagnosis
  • Management on admission
  • Active management of labor
  • 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 and active phases.
  • active phase subdivided into three additional
    phases
  • acceleration phase
  • phase of maximum slope
  • deceleration phase

6
Recommendations on definitions of the first stage
of labor
  • Latent phase  The existence of a latent phase
    and subphases of active labor are somewhat
    controversial.
  • Latent phase is typically characterized by mild,
    infrequent, irregular contractions with gradual
    change in cervical dilation (usually lt1 cm / h)
    and effacement.

Nulliparous Multiparous
Latent phase 6.4 h 4.8 h
Abnormal 20 h 14 h
  • Not influenced by maternal age, birth weight, or
    obstetric abnormalities

7
Recommendations on definitions of the first stage
of labor
  • Active phase   begins at 3 to 4 centimeters when
    cervical dilatation is plotted against time this
    is the beginning of the active phase.
  • characterized by painful contractions of
    increasing frequency, intensity, and duration
    accompanied by more rapid (usually gt1 cm /h)
    cervical change.

8
Recommendations on definitions of the first stage
of labor
9
Recommendations on definitions of the first stage
of labor
10
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

Labor unit
Meet the criteria
Discharge if labor hasnt begun
Rest observation Until next day
Antinatal ward
Didnt meet the criteria
11
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.

12
Management on admission
  • Patient preparation  There is no evidence that
    routine enemas or perineal shaving is beneficial
    .
  • A urinary catheter is not necessary unless the
    woman is unable to void, but she should be
    encouraged to empty her bladder regularly as a
    full bladder can impede fetal descent.
  • Fluids and oral intake  There is no consensus on
    acceptable maternal oral intake during
    uncomplicated labor

13
Management on admission
  • Placement of an intravenous line or a hep-lock
    at the time admission is recommended.
  • Interestingly, one randomized trial found that
    women who received intravenous hydration at 250
    mL/h had fewer labors persisting for over 12
    hours and less need for oxytocin augmentation
    than those who received 125 mL/h

14
Management on admission
  • Antibiotic prophylaxis   (in some centers)
  • to prevent early-onset neonatal infection is
    appropriate patients
  • the agent of choice is intravenous penicillin.
    A minimum of four hours of intrapartum therapy
    has been recommended prior to delivery
  • Although normal labor and vaginal delivery is not
    an indication for prophylaxis against infective
    endocarditis, some centers generally administer
    antibiotic prophylaxis during labor to pregnant
    women with underlying valvular heart disease.

15
Management on admission
  • Monitoring  All pregnant women require
    surveillance (eg, monitoring of vital signs and
    FHR) since 20 to 25 of all perinatal morbidity
    and mortality occurs in pregnancies with no
    underlying risk factors for adverse outcome .
  • Assessment of the quality of the uterine
    contractions and cervical examinations are
    repeated at appropriate intervals to follow the
    progress of labor.

16
Management on admission
17
Management on admission
18
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
  • Careful diagnosis of labor by strict criteria
  • Constant monitoring of labor with specific
    standards for normal progression
  • Prompt intervention (eg, amniotomy, high dose
    oxytocin) according to established guidelines if
    progress is unsatisfactory .

19
Active management of labor
  • The active management of labor is generally
    limited to women who meet the following criteria
  • Nulliparous
  • Term pregnancy
  • Singleton infant in cephalic presentation
  • No pregnancy complications
  • Experiencing spontaneous onset of labor.

20
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)

21
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.

22
Active management of labor
  •   Interventions with amniotomy and/or high
    dose oxytocin are initiated if progress does not
    proceed according to the defined standards.
  • Rutpure of the fetal membranes provides
    information about fetal status, but does not
    appear to significantly accelerate labor . In
    the Dublin protocol, rupture must be performed
    before treatment with oxytocin, which is
    administered only in the presence of clear
    amniotic fluid .

23
Active management of labor
  • If membranes are ruptured when there is
    polyhydramnios or an unengaged fetal presenting
    part, it is prudent to use a small gauge 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 C or HIV in
    order to minimize exposure of the fetus to
    ascending infection.

24
Active management of labor
  • So usually, Amniotomy is indicated to further
    evaluate fetal status (eg, placement of a fetal
    scalp electrode) or uterine contractions (eg,
    placement of an intrauterine pressure catheter).

25
Active management of labor
  • Slower progress in the nulliparous patient is
    most often the result of inefficient uterine
    action .
  • In the absence of medical contraindications,
    labor that fails to progress is treated with
    oxytocin

26
Monitoring
  • It is desirable that all examinations be
    performed by a single individual to minimize
    interobserver variations
  • A vaginal examination during labor often raises
    anxiety and interrupts the womans focus if
    there is (PRoM), increasing numbers of VEs have
    been found to be associated with neonatal
    sepsis .

27
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.

28
Monitoring
  • Recommendations on initial monitoring
  • Psychological Emotional
  • Vitals Urinalysis
  • Uterine contractions
  • Abdominal examination_Leopold manouvers
  • Vaginal loss show, liquor, blood
  • Vaginal examination....when necessary
  • Pain control
  • FHR

29
Monitoring
  • Explain

30
Monitoring
  • Fetal heart rate  
  • fetal heart rate assessment has become a
    standard of care for all women in the United
    States because patients and clinicians are
    reassured by normal results and believe there is
    some value in detecting abnormal patterns.

31
Monitoring
  • The American College of Obstetricians and
    Gynecologists suggests that electronic fetal
    monitoring tracings to be reviewed
  • In general, continuous intrapartum FHR monitoring
    is suggested for high-risk patients and when FHR
    below 110 or over 160 BPM

First stage Second stage
Low risky 30 min 15 min
High risky 15 min 5 min
32
Monitoring
  • Intermittent auscultation of the F.H is
    recommended
  • Once a woman is in established active labor,
    intermittent auscultation of the fetal heart
    after a contraction should be continued
  • Intermittent auscultation can be undertaken by
    either Doppler ultrasound or Pinard stethoscope.

33
Monitoring
  • Uterine contractions 
  • simple observation of the mother
  • palpation of the fundus
  • CTG
  • direct measurement of intrauterine pressure via
    internal manometry or pressure transducers
  • 95 of women in active labor will have
  • 3-5 contractions per 10 minutes.

34
Partogram
  • Maternal status
  • Fetal heart rate 
  • Dilatation descent
  • Uterine contractions

35
Partogram
  • a graphical representation that clearly shows the
    patient's labor compared to the expected lower
    limit of "normal progress 
  • Some clinicians employ a partogram with alert and
    action lines. The alert line represents the rate
    of dilatation of the slowest 10 of labors in
    primigravidae. Crossing the alert line suggests
    that the patient should be transferred to a
    hospital if she is laboring in a rural setting.
    The action line is parallel and four hours to the
    right of the alert line crossing the action line
    suggests the need for intervention (eg,
    artificial rupture of the membranes,
    administration of oxytocics).

36
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37
Abnormalities
  • Cervix
  • Uterus
  • Maternal pelvis
  • Fetus
  • i.e ( power, passenger, or pelvis).
  • Hypocontractile uterine activity   is the most
    common cause of protraction or arrest disorders
    in the first stage of labor. This entity refers
    to uterine activity that is either not
    sufficiently strong or not appropriately
    coordinated to dilate the cervix and expel the
    fetus. It occurs in 3-8 of parturients and can
    be quantified as uterine contraction pressures
    less than 200 Montevideo units.

38
Abnormalities
  • Augmentation  Hypocontractile uterine activity
    is treated with oxytocin in the United States.
    Oxytocin is the only medication approved by the
    US Food and Drug Administration (FDA) for labor
    stimulation in the active phase

39
Abnormalities
  • Active phase arrest is diagnosed when a
    protraction disorder persists despite oxytocin
    therapy to achieve 200 Montevideo units for
    greater than two hours cesarean delivery is
    typically performed at this point.
  • The National Institute for Health and Clinical
    Excellence (NICE) also recommended starting
    oxytocin and monitoring the progress of labor
    over the next four hours. If less than 2 cm of
    cervical dilatation occurred, they recommended
    consideration of cesarean delivery

40
Abnormalities
  • Cephalopelvic disproportion  A disproportion
    between the size of the fetus relative to the
    mother can lead to a diagnosis of dystocia . This
    diagnosis is based upon observation of slow or
    arrested labor during the active phase. However,
    it is usually duo to fetal malposition (eg,
    extended or asynclitic fetal head) or
    malpresentation (mento- posterior, brow), rather
    than a true disparity between fetal and maternal
    pelvic dimensions

41
Abnormalities
  • Diagnosis of POSITION can generally be
    made by digital examination, but if there is
    uncertainty, ultrasound examination is useful and
    accurate
  • (OA) (left 2/3)
  • (Transverse positions are unstable)
  • (OP) mostly spontaneously rotate to (OA) during
    the course of labor.
  • However, approximately 5 experience malposition
    with persistent OP position or transverse arrest.

42
Pain Control
  • The pain of childbirth is likely to be the most
    severe pain that a woman experiences during her
    lifetime.

43
Pain Control
  • women should be involved in the decision of pain
    relief, to increase maternal satisfaction.
  • This can be accomplished by educating women about
    pain relief techniques during pregnancy, prior to
    the onset of labor, as rational decision-making
    is difficult during times of emotional physical
    stress .
  • Furthermore, using patient-controlled epidural
    analgesia (PCEA) empowers the parturient by
    giving her direct control of her pain relief, and
    this may increase maternal satisfaction .

44
Pain Control
  • First stage of
    labor  
  • Visceral or cramp-like
  • source
  • uterus and cervix, produced by distention of
    uterine and cervical mechanoreceptors and by
    ischemia of uterine and cervical tissues///. The
    pain signal enters the spinal cord after
    traversing the T10, T11, T12, and L1 .
  • abdominal wall, lumbosacral region, iliac
    crests, gluteal areas, and thighs.///
  • Transition refers to the shift from the late
    first stage (7 to 10 cm cervical dilation) to the
    second stage of labor. Transition is associated
    with greater nociceptive input as the parturient
    begins to experience somatic pain from vaginal
    distention.

45
Pain Control
  • Hyperventilation   consistently accompanies
    labor pain. Arterial CO2 partial pressures less
    than 20 mmHg are not uncommon, and profound
    hypocarbia may inhibit ventilatory drive between
    contractions and result in maternal hypoxemia,
    lightheadedness, and loss of consciousness .
    respiratory alkalosis, which impairs oxygen
    transfer from the maternal to fetal circulation,
    may occur.

46
Pain Control
  • Psychological effects  unrelieved pain may also
    be a factor that contributes to the development
    of postpartum psychological trauma. This may
    negatively influence the mother's postpartum
    adjustment, and in its most severe form, result
    in post-traumatic stress disorder (PTSD) which
    shouldnt be underestemated.

47
ANALGESIA FOR THE FIRST STAGE OF LABOR 
  • classified as either
  • systemic
  • locoregional

48
Systemic
  • Intravenous
  • Intramuscular
  • inhalation routes
  • most popular agents are opioids (eg, morphine,
    fentanyl, meperidine)

49
Systemic
  • Newer opioid analgesics  Fentanyl, a synthetic
    opioid, and its congeners (eg, sufentanil,
    alfentanil, and remifentanil) have also been used
    to provide labor pain relief. These drugs have a
    short duration of action, so they are best
    administered using the intravenous, rather than
    the intramuscular route.

50
Systemic
  • Inhalation agents  Nitrous oxide . The
    parturient self-administers the anesthetic gas
    using a hand-held face mask. The safety of this
    technique is that the parturient will be unable
    to hold the mask if she becomes too drowsy. A
    systematic review on nitric oxide for relief of
    labor pain concluded it was inexpensive, easy to
    administer, and safe for both mother and fetus.
    The analgesic effect was better than that
    produced by opioids, but less than with epidural
    analgesia

51
Regional techniques
  • Epidurals and Spinals are the most popular
    modalities
  • Regional techniques are widely acknowledged to be
    the only consistently effective means of
    relieving the pain of labor and delivery. Local
    injection may also be administered to achieve
    paracervical or pudendal nerve block.

52
Pain control
  • Epidural analgesia provided better pain relief
    than parenteral opioids. However, opioids were
    associated with a shorter duration of labor, less
    oxytocin augmentation, and fewer instrumental
    deliveries compared to epidural analgesia.
  • Side effects- epidural Nausea, vomiting, and
    sedation Respiratory depression which was the
    major neonatal concern

53
References
  • Up-to-Date
  • Clinical Guideline, September 2007,Funded to
    produce guidelines for the NHS by NICE
  • Royal College of Obstetricians and
    Gynaecologists Clinical Effectiveness Support
    Unit. The Care of Women Requesting Induced
  • Abortion. Evidence-based guideline No. 7.
    London RCOG
  • Government Statistical Service and Department of
    Health. NHS Maternity Statistics, England
    200203. Statistical Bulletin 2004/10.
  • London Department of Health 2004.
  • National Assembly for Wales. Maternity
    Statistics, Wales Methods of Delivery, No. SDR
    40/2004. Cardiff National
  • Assembly for Wales
  • National Collaborating Centre for Womens and
    Childrens Health, Intrapartum care of healthy
    women and their babies dur ing childbirth

54
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