ASSESMENT OF WOMEN IN

LABOUR

PROF. ROSALINE RACHEL. P

PRINCIPAL
MMM COLLEGE OF NURSING,
CHENNAI.
A mother's joy 2
begins when new
life is stirring
inside... when a
tiny heartbeat is
heard for the very
first time, and a
playful kick
reminds her that
she is never alone.
 Healthy Mothers and Healthy
Newborn:The Vital Link
Global Scenario
3

Every minute around the world

380 women become pregnant

190 women face unplanned and unwanted pregnancy

110 women experience pregnancy related

complications (25%)

40 women have unsafe abortions

1 women dies
Source: White Ribbon Alliance
 Preconception Counseling 4

 High risk factor(s) and its possible effects on the

mother, fetus, and the newborn.

 Proper monitoring during pregnancy and labor.

 Possibility of early intervention with resulting

preterm labour.

 Antenatal care in a well equipped clinic.

 Institutional delivery
 Identification of high risk
pregnancy during antenatal care
5

Conditions detected during history taking:

 Age; whether young (> 18) or elderly (< 35)
Primigravida.
 Parity; whether nullipara (primigravida), or grand
multipara (< 4)
 Previous obstetric difficulties, fetal loss or
abnormalities
 Medical disorders as; Diabetes mellitus, cardiac or
renal disease
 Conditions observed 6 during general
examination
 Extreme obesity (maternal weight > 120 kg).
 Short stature (less than 150 cm)
 Hypertension (>140/90)
 Severe anemia (Hb <8.0 gm %)
 Cardiac or renal disease.
 Poor weight gain during pregnancy
 Conditions diagnosed
7
during obstetric
examination
 Pre- eclampsia

 Multiple pregnancy

 Antepartum hemorrhage

 Malpresentations, and
Feto-pelvic disproportion
 Conditions detected during investigations
8
 Severe anemia, thrombocytopenia, hyperglycemia,
Glycosuria & Albuminuria.

 Rh negative blood typing

 Any infections

 Hepatitis B & C and HIV.

 Screening for fetal
9

anomalies
 Congenital anomalies

 Chromosomal abnormalities
 A few primary steps:

 Ensure early registration: first check-up to be

conducted within 12 weeks (first three months of
pregnancy).
 Track every pregnancy for conducting at least four
antenatal check-ups (including the first visit for
registration).
 Administer two doses of TT injection.
 Provide at least 100 tablets of IFA.
 Suggested schedule for antenatal visits

 1st visit: Within 12 weeks—preferably as soon

as pregnancy is suspected—for
 registration of pregnancy and first antenatal check-
up
 2nd visit: Between 14 and 26 weeks
 3rd visit: Between 28 and 34 weeks
 4th visit: Between 36 weeks and term
 Components of Antenatal Check-up

 I. History-taking
 During the first visit, a detailed history of the woman
needs to be taken to:
 (i) Confirm the pregnancy (first visit only).
 (ii) Identify whether there were complications during
any previous pregnancy/confinement that may have
a bearing on the present one.
 (iii) Identify any current medical/surgical or
obstetric condition(s) that may complicate the
present pregnancy.
 An admission assessment includes

 maternal health history,

 physical assessment,
 fetal assessment,
 laboratory studies, and
 assessment of psychological status.
 Maternal Health History

 MEDICAL HISTORY
 Surgical, including gynaecological procedures
 Anaesthetic difficulties, difficult intubation in
particular
 Blood transfusion, where, when and why?
 Allergies
 Medical disorders
 Prescribed medications and drug allergies
 Thrombo-embolism
 Mental illness
 FAMILY HISTORY

 Hypertension
 Diabetes in 1 st degree relative
 Congenital/hereditary disorders
 Multiple pregnancy
 Thrombo-embolism
 SOCIAL HISTORY

 Home and family situation

 Marital status
 Employment status
 Alcohol
 Smoking
 Illicit drug use/substance abuse
 Obstetric history/history of previous
pregnancies

 Recurrent early abortion

 Post-abortion complications
 Hypertension, pre-eclampsia or eclampsia
 Ante-Partum Haemorrhage (APH)
 Breech or transverse presentation
 Obstructed labour, including dystocia
 Perineal injuries/tears
 Excessive bleeding after delivery
 Puerperal sepsis
BOOKING VISIT
 previous bad obstetric history(needs
referral)

 Stillbirth or neonatal loss

 Th ree or more spontaneous consecutive abortions
 Obstructed labour
 Premature births, twins or multiple pregnancies
 Weight of the previous baby <2500 g or >4500 g
 Admission for hypertension or pre-eclampsia/eclampsia in
the previous pregnancy
 Surgery on the reproductive tract
 Congenital anomaly
 Treatment for infertility
 Spinal deformities, such as scoliosis/kyphosis/polio
 Rh negative in the previous pregnancy
 History of any current systemic
illness(es)/past history of illness

 High blood pressure (hypertension)

 Diabetes
 Breathlessness on exertion, palpitations (heart disease)
 Chronic cough, blood in the sputum, prolonged fever
(tuberculosis)
 Renal disease
 Convulsions (epilepsy)
 Attacks of breathlessness or asthma
 Jaundice
 Malaria
 Other illnesses, e.g. Reproductive Tract Infection (RTI),
Sexually Transmitted Infection
 (STI) and HIV/AIDS.
 CONTRACEPTIVE HISTORY
 Details of method used.
 If hormonal, when was 'pill' discontinued?
 Was the pregnancy planned?
 Length of time trying to conceive?
 Symptoms indicating discomfort

 Nausea and vomiting

 Heartburn
 Constipation
 Increased frequency of urination
 Fever
 Persistent vomiting
 Abnormal vaginal discharge/itching
 Palpitations, easy fatigability
 Breathlessness at rest/on mild exertion
 Generalised swelling of the body, puffi ness of the face
 Severe headache and blurring of vision
 Passing smaller amounts of urine and burning sensation during micturition
 Vaginal bleeding
 Decreased or absent foetal movement
 Leaking of watery fl uid per vaginum (P/V)
II. Physical examination
 Physical Examination of the Laboring Woman

Steps you should take to prepare for the

examination:
 Ask woman to empty bladder (collect urine for
testing).
 Prepare to follow a logical order.
 Prepare to chart logically immediately after exam
(make notes).
 Remember to use all your senses during
assessment
 Remember to explain everything you are doing.
 Exam should be carried out immediately and as
quickly as possible.
 Urine tests used during intrapartum
 Ph: Measures acidity/alkalinity of the urine.below normal
indicate high fluid intake, levels above the norm indicate
inadequate fluids & dehydration.
 Protein: Normal = Negative, Small amounts may be in
urine from vaginal secretions & dehydration, Amounts of
2+ to 4+ may indicate be one indicator of possible UTI,
Kidney Infection or PIH.
 Glucose Normal = Negative or + I. High levels of glucose
may be one indicator of high blood sugar, gestational
diabetes or diabetes mellitus. Always ask what woman has
recently eaten if her BS is high.
 Ketones
 Normal = Negative. Ketones are products of the breakdown
of fatty acids caused by fasting.
 The body breaks down fats because there are not enough
carbohydrates and proteins available.
 Ketones may be deleterious to fetus.
 Perform Physical Exam
 General appearance:
Edema, skin color, hygiene, pain, distress, mood
 Measure vital signs:
Blood pressure, pulse, respiration, temperature
 Blood pressure
Take blood pressure with woman in sitting or side lying
position
Compare blood pressure with prenatal blood pressure
 At what point would you determine if the patient were
hypertensive?
 What additional assessments and interventions would you
take if patient were hypertensive?
 Test for proteinuria.
Assess for facial and general edema.
Test for hyperreflexia.
Ask if patient is having headaches, blurred vision, spots in
vision.
Notify provider of any pathologic results
 Physical Exam
 Pulse
Rate: 60 - 90
Increased pulse can be dehydration, anxiety.
Always question possibility of cardiac problems.
What is the most common cardiac problem in a
young female?
 Respiration
Don’t count during a contraction
 Temperature
Think about infection and dehydration
 Continuous Maternal
Assessment
 Weight
 Blood pressure
 Blood sugar levels
 Hemoglobin
 DTR
 Breast examination

 Observe the size and shape of the nipples for the

presence of inverted or fl at nipples.
 Try and pull out the nipples to see if they can be
pulled out easily. Flat nipples that can
 be pulled out do not interfere with breastfeeding.
Truly inverted nipples might create a
 problem in breastfeeding. If the nipples are inverted,
the woman must be advised to pull
 on them and roll them between the thumb and index
fi nger.
 A 10 cc or 20 cc disposable plastic syringe can also be
used for correcting inverted
 nipples. Cut the barrel of the syringe from the end where
the needle is attached. Take out
 the plunger and put it in from the opposite end, which is
the cut end of the syringe. Push
 the piston forward fully, and gently place the open end of
the barrel in such a way that
 it encircles the nipple and areola. Pull back the plunger,
thus creating negative pressure.
 Th e nipple will be sucked into the barrel and pulled out
in the process.
 Cut the end of a
plastic syringe

Insert piston from

cut end

Mother gently pulls

the piston
 Abdominal Exam
 An abdominal examination should include a
measurement of fundal height as well as an
assessment of fetal size (estimated fetal weight),
 Presentation and position using Leopold's
maneuvers.
 Inspect: Scars, linea, striae, symmetry
 Palpate: fundal height, fetal position
 Auscultate: fetal heart tones
 Determine and palpate contractions
Inspect and palpate lower extremities
 Press firmly with thumbs about 5 seconds over
shin
 If any signs of elevated blood pressure, elicit DTR
 If reflexes are hyperactive, check for clonus
 Measuring Fundal Height
 Place the zero line of the tape
measure on the anterior
border of the symphysis
pubis and stretch tape over
midline of abdomen to top of
fundus.
 The tape should be brought
over the curve of the fundus.
 The height of the fundus in
centimeters equals the
number of weeks gestation
plus or minus 2.
 After 32 weeks the
relationship is less accurate.
 Leopold’s Maneuver
Abdominal Examination for
Position and Presentation and
Size
 Are used to determine the
orientation of the fetus through
abdominal palpation.
 Hands have an acute sense of
touch especially when attached
to a well-trained mind.
 You should always assess for
position, presentation,
engagement and size by
abdominal examination.
 With warm hands and gentle
pressure palpate the abdomen
for soft consistency, fluctuating
amniotic fluid, indefinite
outlines and baby’s small
knobby parts.
 Monitoring the Mother and Fetus During Labor
 A 20 minute fetal monitor strip is done for all
patients on admission.
 As long as the patient is healthy, the
presentation normal, the presenting part well
engaged, and the fetus in good condition, the
woman may walk about or be in bed as she
wishes.
 The patient's condition and progress is
checked periodically.
 FHT's are checked q 30 min in latent phase, q
15min. in active phase, and q 5min. in second
stage.
 The maternal temp is taken q 4 hrs., q 2 hours if
ROM. Variations to this timing depend on the
maternal-fetal situation.
 labor

 The progress of labor is followed by abdominal

or vaginal examination to note the position of the
baby, the station of the presenting part, and the
dilatation of the cervix.
 These examinations should be done only often
enough to ensure the safe conduct of labor, i.e.,
to determine that the rate of dilatation is within
the normal range or to evaluate the patient if she
is requesting medication.
 labor

 Over distension of the bladder is obviated by

urging the patient to void every few hours.
 If she is not able to do so, catheterization may be
necessary, since a full bladder impedes progress.
 Adequate amounts of fluids and nourishment
are essential.
 If the patient is unable to take enough orally, a
intravenous of Lactated Ringers solution may be
given.
 Labor
 During the first stage, the patient should be
impressed with the important of relaxing with the
contractions.
 Help the couple as much as possible to work with
the contractions and compliment them for a good
job.
 The passage of meconium stained fluid in a
cephalic presentation is a possible sign of fetal
distress and if present, the patient should be
continually monitored during active labor.
 Abdominal examination for contractions
 An initial abdominal
examination is carried out on
admission by laying a hand on
the uterus and palpating,
noting the degree of hardness
during a contraction and
timing its length.
 This should be repeated at
intervals throughout labor in
order to assess the length,  The monitor should never be
strength and frequency of relied on; the mother’s
abdomen should be regularly
contractions and the descent palpated by hand
of the presenting part.
 The uterus should always feel
softer between contractions.
 Abdominal exam for contractions
 Uterine contractility can be quantified subjectively
by palpation or objectively by the use of an external
tocodynamometer or an intrauterine pressure
catheter (IUPC).
 The external tocodynamometer can generally
provide reliable information about the frequency of
uterine contractions and their approximate
duration
 Uterine contractions
 The actual amount of intrauterine pressure
generated with each contraction must be
measured by internal devices, such as the
intrauterine pressure catheter.
 The traditionally used measure of uterine work is
called the Montevideo method.
 Montevideo units are calculated by totaling the
peak uterine pressures (in mm/Hg) minus the
baseline pressures over a ten minute period.
 At least 200 Montevideo units are required before
the forces of labor can be considered adequate
(i.e., when a protraction or arrest disorder is
noted measures should be taken to ensure that
contractions at least 200 Montevideo units exist
before a cesarean delivery is undertaken).
Uterine Contractions
 Fetal heart checks

 A fetal heart check and an abdominal palpation

for fetal position and presentation should always
precede initial vaginal examination.
 The vulva should be carefully inspected for
lesions (e.g., herpes, etc), some assessment of the
superpubic angle, prominence of the iliac spine
and size of the pelvis in relation to the fetal head
should be made.
 Purpose of exam is to assess the status of
membranes, fetal presentation and position,
engagement, effacement, cervical dilatation and
station.
 Status of Membrane

 Lie and Presentation  Engagement

 Status of membrane
 Effacement  Station
 Procedure

 Prepare client the same way as for a speculum

examination.
 Lubricate index and middle finger of examining
hand generously.
Separate the labia with gloved fingers.
 Inspect vaginal opening (introitus). Observe for:
 Amount of bloody show: advanced labor
Ruptured membranes
Discharge that is malodorous
Discharge that is deep yellow or greenish brown:
Meconium
Ulcerated areas on perineum: Herpes, Syphilis
 Examinations

 Examinations are done

with aseptic technique
(sterile gloves and antiseptic
solution).
 You insert two fingers into the
vagina and feel the cervix and
the top of the baby’s head to
gather information about the
dilation and the presentation of
the baby.
 This may be uncomfortable,
especially during a contraction.
 Cervical dilation: 1 finger represents
aprox 1.5 cm
 Vaginal Exams
 There is no place for routine vaginal
examinations in any labor.
 Vaginal examination should only be done when
there is doubt about the clinical situation or
symptoms, and the information gathered is
necessary or likely to be of use in making a
clinical decision.
 Excessive vaginal examinations carry with it
the risk of increased infection.
 You should rely on behavior and emotional
responses and physical sensations rather than
vaginal exams.
 Reasons to defer or avoid digital
vaginal examination
 The vaginal examination should be avoided or
deferred in certain circumstances.
 In most of these situations a careful speculum
examination is acceptable:
 (1) Significant vaginal bleeding of unknown
etiology (delay examination until placenta previa
has been ruled out by ultrasonography),
 (2) Presence of placenta previa,
 (3) Ruptured membranes in patients who are not
in labor and for whom immediate induction of
labor is not anticipated,
 (4) Presence of active HSV lesions in a patient
with ruptured membranes.
 Questions to ask yourself as you perform a Vaginal
Examination

 Status of amniotic membranes:

 Are they intact. Bulging through the cervix?
 Status of cervix:
 Is it soft or firm (the cervix must be soft before it
can efface and dilate), anterior or posterior? (the
cervix must be anterior before it can really start to
dilate)
 How much effacement?
 0%/long and thin to 100%/completely thinned out.
 How much dilation?
 0 (closed) to 10 cm. (dilation complete).
 Questions: continued
 Fetal presentation:
 What is the presenting part? (head, breech, other
fetal part)
 What is the fetal position? (left/right,
anterior/posterior/transverse)
 Fetal station:
 What is the presenting part in relation to the
ischial spines?
 Engagement:
 Is the presenting part engaged and well applied
to the cervix? stabilized in the middle of the
pelvis below the level of the ischial spine [zero
station].
 To confirm that membranes have ruptured, a sample
 of fluid is taken from the vagina and tested with
Nitrazine paper to determine the fluid’s pH. Vaginal
fluid is acidic, whereas amniotic fluid is alkaline and
turns Nitrazine paper blue.
 If the Nitrazine test is inconclusive, an additional
test, called the fern test, can be used to confirm
rupture of membranes. With this test, a sample of
fluid is obtained, applied to a microscope slide, and
allowed to dry. Using a microscope, the slide is
examined for a characteristic fern pattern that
indicates the presence of amniotic fluid.
 Assessing Cervical effacement
Cervical effacement: Palpate degree of thickness; normal
cervix about 1 inch thick
 How to determine station
 Station is the relationship of the
presenting part to the ischial  Levels of progress
spines. through the
 Locate the lowest portion of pelvis using -5 to
+5
presenting part, then sweep the
fingers deeply to one side of
pelvis to feel for ischial spines.
 To determine station estimate
in centimeters, the tip of
presenting part is above the
ischial spine.
 Tell the mother your findings.
 Mechanism of labor

 The following definitions must be mastered

to be able to discuss and understand the
mechanism of labor:
 Attitude. This refers to the posturing of the joints
and relation of fetal parts to one another.
 The normal fetal attitude when labor begins is with
all joints in flexion.
 Mechanism of Labor
 Lie. This refers to the longitudinal axis of the
fetus in relation to the mother's longitudinal axis;
i.e., transverse, oblique, or longitudinal
(parallel).
 Presentation. This describes that part on the
fetus lying over the inlet of the pelvis or at the
cervical os.
 Point of Reference or Direction.
 This is an arbitrary point on the presenting part
used to orient it to the maternal pelvis [usually
occiput, mentum (chin) or sacrum].
 Mechanism of labor

 Position. This describes the relation of the point

of reference to one of the eight octanes of the pelvic
inlet (e.g., LOT: the occiput is transverse and to the
left).
 Engagement. This occurs when the biparietal
diameter is at or below the inlet of the true pelvis.
 Station. This references the presenting part to
the level of the ischial spines measured in plus or
minus centimeters.
 Normal mechanisms of labor/Cardinal
Movements - Occiput anterior positions

 Definition: A mechanism of labor is a series of

passive, adaptive movements of the fetal head
and shoulders through the birth canal.
 Related factors
 Passage: Size and morphology of the pelvis
 Passenger: Size of the baby and moldability of the
fetal skull
 Powers: Quality (efficiency) of uterine contractions
and voluntary expulsive forces and quality and
direction of soft tissue resistance, especially of the
levator ani muscles
 Psyche: Mom’s attitude
 Cardinal movements of labor
 1. Engagement: Mechanism by which the
greatest transverse diameter of the head in vertex
(biparietal diameter) passes through the
pelvic inlet (usually 0 station).
 The head usually enters the pelvis in the transverse
or oblique - the inlet is a transverse oval.
 Cardinal movements of labor

 2. Descent: This occurs intermittently with

contractions and is brought about by one or more
forces:
 Pressure of the amniotic fluid, direct pressure of the
fundus upon the breech, contractions of abdominal
muscles (2nd stage) and extension and straightening
of the fetal body.
 Cardinal movements of labor

 3. Flexion: As soon as the vertex meets resistance

from the cervix, walls of the pelvis or the pelvic
floor, flexion results.
 The chin is brought into contact with the fetal
thorax and the resenting diameter is changed from
occipitofrontal to suboccipitobregmatic (9.5 cms.)
 Cardinal movements of labor

 4. Internal Rotation: After engagement, as

the head descends, the lowermost portion of
the head (usually the occiput) meets resistance
from one side or the other of the pelvic floor and is
rotated about 45 degrees anteriorly to the midline
under the symphysis.
 Internal rotation brings the AP diameter of the
head in line with the AP diameter of the pelvic
outlet.
 Cardinal movements of labor

 5. Extension: With further descent and full flexion

of the head, the nucha (the base of the occiput)
becomes impinged under the symphysis.
 Upward resistance from the pelvic floor causes the
head to extend, with the bregma, brow, nose, mouth
and chin being born successively.
 6. Restitution

 When the head is free of resistance, it untwists,

causing the occiput to move about 45 degrees back to
its original left or right position.
 The sagittal suture has now resumed its normal right
angeled relationship to the transverse (bisacromial)
diameter of the shoulders.
 7. External Rotation
 The shoulders have entered the pelvis and engaged
with the bisacromial diameter in the transverse or
in an oblique diameter.
 The leading (anterior) shoulder meets the
resistance of the side of the pelvic floor and is
rotated anteriorly toward the midline under the
symphysis.
 This movement brings the long axis of the
shoulders in line with the long axis of the pelvic
outlet.
 The movement of the shoulders causes the occiput
to rotate another 45 degrees, to the transverse
position.
 8. Expulsion: Delivery of the anterior
shoulder, posterior shoulder, and the rest of the
body
 The 6 steps of labor progression

 Labor can be defined as regular, painful uterine

contractions that result in progressive cervical
change.
 The diagnosis of labor progression may be
dependent upon the patient's history of uterine
contractions as well as information gathered from
abdominal palpation and vaginal examination.
 Evidence of progressive cervical effacement and/or
dilation is necessary in order to distinguish true
labor from false labor.
 NOTE:

 Labor progresses in six ways and all are

equally important.
 Frequency, duration and intensity of contractions
cannot be relied upon as measures of progression in
labor.
 Cervical dilatation and fetal descent are the
only indicators that labor is progressing.
 1. Cervical Ripening

 The cervix ripens or softens. As a woman’s body

gets ready to labor it produces prostaglandin.
 This causes the cervix to soften from the consistency
of rubber to something that feels like a
marshmallow.
 2. Cervical Position
 The cervix moves from a posterior to an
anterior position.
 During most of the pregnancy, the cervix points
toward the back (posterior), but during the last
few weeks of pregnancy or in early labor, it
moves forward (anterior).
 The uterus may contract for several days
intermittently before true labor begins to
accomplish these first two things, softening the
cervix and bringing the cervix from the back of
the vagina to the front of the vagina.
 3. Cervical Effacement
 The cervix effaces About two inches in length is
average size, but in early labor, the cervix begins
to get shorter and thinner (effacement).
 By the active part of labor the cervix will be
completely effaced and be paper-thin.
 It is vital to understand that when the cervix has
not undergone the first three steps (ripening,
effacement, and anterior movement of the
cervix), significant dilation (beyond 3-4 cm in the
nullipara, more in the multipara) rarely occurs),
but that pre-labor contractions are
accomplishing the important job of pre-paring
the cervix to dilate.
 4. Cervical Dilatation

 The cervix dilates and active labor begins.

 Not much dilatation can occur until the
cervix has completed the above three
processes.
 Remember the cervix needs to get very soft, move to
an anterior position and get paper-thin before it will
dilate much past 3-4 centimeters.
 5. Fetal Head rotation, flexion and
molding

 The head begins to change shape to fit through the

pelvis.
 Remember, this is called molding.
 Rotation, flexion, molding, and descent of the fetal
head take place in active labor and second stage
 6. Fetal Descent and
Birth

 The fetus descends and is born.

 Descent occurs as the baby lowers itself into your
pelvis.
 Remember, descent is measured in terms of
"stations."
 Stages of Labor
 The first stage of labor begins when uterine
contractions of sufficient frequency, intensity and
duration result in effacement and dilation of the
cervix.
 The first stage is completed when the cervix
reaches 10 cm.
 The second stage involves descent of the fetus and
its eventual expulsion from the vagina.
 It begins with complete cervical dilation (10 cm)
and ends with delivery of the infant.
 The third stage of labor involves delivery of the
placenta.
 It begins with the completion of the infants'
delivery and ends with delivery of the placenta
and membranes.
 1st Stage of Labor

 FIRST STAGE LABOR

 LATENT
 Pre-labor
 Ripening and effacement of the cervix
 LATENT-EARLY LABOR
(0-3 cm.)

 Contractions:
 5-20 minutes apart
  30-45 seconds long
  Mild, feel like cramps, back pain,
pressure
 ACTIVE LABOR
(4-8 cm.)

 Contractions:
 2-5 minutes apart
  45-60 seconds long
  Stronger and more intense
 TRANSITION LABOR
(8-10 cm)

 Contractions:
 1 -2 minutes apart
  45-90 seconds long
  The strongest they will get
 SECOND STAGE LABOR
(10 cm. -Birth)

 Contractions:
 3-5 minutes apart
  60-120 seconds long
  Less aware of contractions,
 more aware of urge to push and fullness in
vagina as baby moves down
 THIRD STAGE Delivery of the
Placenta

 Contractions:
 Irregular
  A feeling of fullness and cramping as
placenta separates
  A time for mom to hold and enjoy baby.
 Prolonged Latent Phase
 A prolonged latent phase is present when the active
phase of labor is not achieved after 14 hours in
multiparous patients and 20 hours in nulliparous
patients.
 There are two basic methods for prolonged latent
phase, narcotic analgesia or oxytocin augmentation
of labor.
 Prolonged or Protracted Active Phase
 A protracted active phase is defined as
progression at less than 1.2 cm an hour in
nulliparous patients and less than 1.5 cm and
hour in parous patients during the active phase.
 This disorder is associated with a higher
incidence of occiput posterior and occiput
transverse fetal positions.
 It may also be indicative of true cephalopelvic
disproportion or it may result from inhibitory
effects of narcotics analgesia.
 Condition is treated by first assessing the
adequacy of labor (i.e., placing an intrauterine
pressure catheter and determining the number of
Montevideo units).
 Prolonged or Protracted Active Phase

 The size of the fetus in relation to the pelvis must

also be determined.
 The 3 P’s when addressing active phase labor
abnormalities:
 The power refers to the adequacy of labor
 The passenger refers to the size and attitude of
the fetus
 The pelvis refers to the size and shape of the
maternal boney pelvis.
 In these cases labor augmentation with oxytocin is
indicated if uterine contractile forces are found to
be inadequate.
 Active Phase Arrest
 This is the most common abnormality of labor in
women who are ultimately delivered by cesarean
section.
 It is defined as a lack of cervical progress over 2 or
more hours, despite adequate uterine contractions
(> 200 Montevideo units).
 As with Protracted Active Phase, the three P's must
be assessed and in most cases a trial of oxytocin
augmentation given.
 Second Stage Disorders:
 The average primigravida can expect to spend
one to two hours in the second stage of labor
while the multiparous women will typically have
a second stage of 30 minutes duration or less.
 These times may be significantly increased in
patients who have epidural anesthesia.
 In the presence of an epidural anesthetic the
second stage may last as long as three hours in a
nulliparous patient and as long as 1-1/2 hours in
a parous patient.
 Protracted Descent:
 Common causes of protracted descent include
poor maternal expulsive effort and excessive fetal
size relative to the maternal pelvis.
 A common management approach to protracted
descent is to simply allow a longer period of time
for the patient to push.
 In a patient with epidural anesthesia who has
poor effort initially, expectant management can
be undertaken while the patient is allowed to
relax for the first 1 to 1-1/2 hours after becoming
completely dilated (laboring down).
 When the fetal vertex reaches a +2 station or
more a forceps or vacuum delivery may be used.
 Arrested Descent

 Arrested Descent occurs when there is no

advancement of the presenting part for more
than an hour.
 The criteria are the same in both the nulliparous
and multiparous patients.
 The reasons for this disorder are the same as
Protracted Descent.
 Reducing the level of maternal epidural
anesthesia may be helpful in some cases.
 Additionally, changes in maternal position such
as having the mother assume the "squatting"
position may be helpful.
 Fluids
 IV fluids (usually dextrose and water or lactated
Ringer's solution) are indicated when the mother
is NPO status and should be run at a rate of 125
mL per hour, which ensures that the mother
receives 1,000 mL of fluid every 8 hours.
 A normal healthy woman, who already has
approximately 2 L of stored body water in
extravascular spaces.
 Routine IV fluid administration can induce fluid
overload, hyperglycemia in the fetus, and
hypoglycemia in the newborn, and can alter
plasma sodium levels.
 Comfort Measures for the Laboring
Woman
 Do not leave alone in active labor.
 Change soiled and damp linen promptly.
Provide mouth care.
 Ice chips, lubricate lips.
 Keep room cool, uncluttered, quiet and privacy.
 Promote participation of coach.
 The use of a specific breathing pattern during
labor contractions has two objectives:
 Helping the woman relax by distracting her from
the intense contraction sensations.
 Ensuring a steady, adequate intake of oxygen
 Breathing techniques
 This technique is done only during contractions.
Rest and sleep between contractions is important.
 Instruct the laboring woman to do the following:
 Assume a comfortable position.
 Try to maintain a relaxed state throughout the con-
traction.
 Close her eyes or concentrate on a focal point while
doing the breathing (e.g., a pretty picture, a button
on someone's shirt).
Cleansing Breath
 Begin and end each breathing technique with a
cleansing breath.
 This is simply a deep quick breath, like a big sigh.
 Inhalation is through the nose; exhalation is
through slightly pursed lips.
 Slow paced breathing
 This technique can be used in early labor and for
as long as the mother is comfortable with it.
 For some women, this may last throughout the
entire first stage of labor.
 1. Take a cleansing breath as soon the contraction
begins.
 2. Breathe slowly and deeply in through the nose
and out through slightly pursed lips or the nose
over the duration of the contraction.
 3. Maintain a steady rate of approximately 6 to 9
breaths during a 60-second contraction (the
cleansing breaths do not count).
 Anesthesia
 Neuraxial and regional
techniques, with minimal
motor blockade are now
popular.
 Neuraxial analgesia is
defined as intrathecal or
epidural administration of
opioids and/or local
anesthetics for treatment
of postoperative pain or
other acute pain
problems.
 Neuraxial analgesia
includes epidural, spinal
and combined spinal-
epidural techniques.
 Procedure Description
 Patients receive a 1 liter LR IV bolus and an oral
antacid (Bicitra) prior to the placement of the
epidural.
 The fluid bolus potentially alleviates any
precipitous drops in the patient’s blood pressure.
 B/P are recorded prior to the start of the epidural,
when a test dose is administered, when a bolus dose
is administered, and q 5-15 minutes until stable.
 After one hour of stable BP's, BP's can be recorded
q 30 min until delivery. FHR and contractions are
recorded at these intervals also.
 Patients are kept NPO or ice chips only after
placement.
 Anesthesia

 1st stage of labor, anesthetic dosages are given to

limit the block to the (T10) and upper lumbar.
 This allows perineal tone to be maintained to avoid
interfering with internal rotation of the fetal hd to
the occiput anterior position.
 2nd Stage of labor, the block can be extended to the
sacral area to promote perineal relaxation, delivery,
and episiotomy repair.
 Pt-controlled epidural anesthesia: allows the pt to
self-titrate periodic amounts of anesthetic
 Nursing personnel should understand

 The risk of respiratory depression, including

delayed respiratory depression when hydrophilic
opioids are used
 Assessment and management of respiratory
depression
 Assessment of motor and sensory blockade
 Assessment and management of hypotension in
patients receiving neuraxial analgesia
 Signs and symptoms of the rare, but catastrophic,
complications of neuraxial analgesia.
 Intrauterine Resuscitation

 What is intrauterine resuscitation?

Interventions undertaken to attempt to change the
relationship of the uterus, placenta, cord, and fetus
to improve placental and fetal oxygenation.
 These are empirically designed to overcome
uteroplacental insufficiency or to decrease cord
compromise.
 These include the following
 Positioning the mother to right/left side lying
recumbent or knee-chest to improve blood flow to
the uterus
 Repositioning the mother to alleviate cord
compression
 Discontinuing oxytocin -Tocolysis with
subcutaneous Terbutaline to decrease/moderate
uterine activity and improve blood flow
 Increasing IV fluids to enhance maternal blood
flow volume
 Administering oxygen to the mother in an effort to
promote oxygen flow across the placental
membrane
 Amniotomy
 Artificial rupture of membranes performed at or
beyond 3 cm dilation.
 The technique involves perforation of the fetal
membranes with a sterile plastic instrument
(amnihook) or by applying a fetal scalp electrode
through the membranes onto the fetal scalp.
 The procedure may be associated with changes in
the fetal heart rate (e.g., accelerations or
bradycardia) secondary to prolonged uterine
contraction, secondary to release of a large
quantity of fluid or in some cases prolapse of the
umbilical cord.
 These include the following
 Positioning the mother to right/left side lying
recumbent or knee-chest to improve blood flow to
the uterus
 Repositioning the mother to alleviate cord
compression
 Discontinuing oxytocin -Tocolysis with
subcutaneous Terbutaline to decrease/moderate
uterine activity and improve blood flow
 Increasing IV fluids to enhance maternal blood
flow volume
 Administering oxygen to the mother in an effort to
promote oxygen flow across the placental
membrane
 Amniotomy
 Artificial rupture of membranes performed at or
beyond 3 cm dilation.
 The technique involves perforation of the fetal
membranes with a sterile plastic instrument
(amnihook) or by applying a fetal scalp electrode
through the membranes onto the fetal scalp.
 The procedure may be associated with changes in
the fetal heart rate (e.g., accelerations or
bradycardia) secondary to prolonged uterine
contraction, secondary to release of a large
quantity of fluid or in some cases prolapse of the
umbilical cord.
 KEY MESSAGES

 • Register every pregnancy within 12 weeks.

 • Track every pregnancy by name for provision of quality ANC, skilled
 birth attendance and postnatal services.
 • Ensure four antenatal visits to monitor the progress of pregnancy.
 This includes the registration and 1st ANC in the fi rst trimester.
 • Give every pregnant woman Tetanus Toxoid (TT) injections and
 Iron Folic Acid (IFA) supplementation.
 • Test the blood for haemoglobin, urine for sugar and protein at
 EVERY VISIT.
 • Record blood pressure and weight at EVERY VISIT.
 • Advise and encourage the woman to opt for institutional delivery.
 • Maintain proper records for better case management and follow up.
 • Do not give a pregnant woman any medication during the fi rst
 trimester unless advised by a physician