FIRST STAGE OF

LABOUR
Mrs. Triveni
Asst.lecturer
 DEFINITION
It starts from the onset of true labour
pain and ends up with full dilatation of cervix.

Also called as “cervical stage” of labour.

 DURATION
Average duration:

12 hours in primigravida
6 hours in multipara.
 PHASES

LATENT ACTIVE
PHASE PHASE
 LATENT PHASE
 It is defined as the period between the onset of
labor pains and completion of cervical
dilatation of 3-4cm.

Rate of cervical dilatation is about 0.35cm/hr.

 Duration: in primi 8 hrs. and in multipara it is 5
hours

 Frequency & interval: During this phase, initially

contractions comes at the interval of 15-30 mints.
With duration of about 30 seconds. But gradually
interval becomes shortened with increasing
intensity and duration and contraction comes at
interval of 5-7 mints and lasts for about 40 seconds.
 ACTIVE PHASE
 Begins when the cervix is 3-4cm and ends
with cervical dilatation of 8cm.

 During this phase, contraction occurs every 3-

5 minutes and lasts upto 60 seconds.

 Duration: primi= 6 hrs , multi= 4 hours

 Dilatation rate = 1.2-1.5cm/hr

 NORMAL SIGNS AND
SYMPTOMS OF ONSET
OF LABOUR
 Contraction and
retraction of uterine
muscles. Pain
Cervical dilatation and effacement
Formation of bag of water
 Maternal effect
The condition remain unaffected

Feeling of transient fatigue

Temperature remains unaffected.

Pulse rate is increased by 10-15 beats per
minute during contraction which settles down
to its previous rate in between contractions.

 Systolic blood pressure is raised by 10mm Hg

during contractions
 Fetal effect
There is no adverse effect on the fetus

 During contractions, Heart rate slows to 100-

120 beats/min. and soon returns to normal
about 140 beats/ min.
 During contraction, there is stagnation of
circulation through intervillous space resulting
in fetal sub-oxygenation with transient
hypoxia.

This stimulates the vagal Centre resulting in

bradycardia
ABNORMAL SIGNS
AND SYMPTOMS OF
ONSET OF LABOUR
 The signs which do not progress towards
normal labour in first stage are:
Uterine hypo contractility

Precipitous labour

Non- progress of labour

Long latent phase

Fetal distress
Uterine hypo contractility
This may happen in woman approaching
end of first stage of labor. Initially, labor begin
well but later on the uterus fails to contract
sufficiently. It usually occurs after medications
prescribed for decreasing the intensity or
frequency of contractions.
 Precipitous labour
In this, the woman’s uterus starts
contracting very strongly, in an effort to expel
the baby out more rapidly. This kind of labor
lasts only for 3 to 5 hours.
Precipitate labor can put the mother at risk of:

Heavy bleeding

Shock

Vaginal/ Cervical tear

 Non- progress of labour
This usually happens in the latent phase.
Slow effacement of the cervix can lead to non-
progressing labor.
Other factors which contribute to this are:

 Prolonged labor

 Psychological factors like fear, worry, stress

 Pain medications can also slow/ weaken the

contractions.
 Long latent phase
Normally the latent phase of labor in
primigravida (0-4cm) dilatation lasts from 6
hours whereas prolonged labor/ failure of
progression of labor lasts for nearly 20 hours
or more in primigravida and 14 hours or more
in multigravida.
 Fetal distress
This is also an abnormal sign which may occur
due to a number of factors written below:

 Induction/ augmentation of labor

 Maternal exhaustion

 Cephalopelvic disproportion (CPD)

High uncontrolled blood pressure

 EVENTS IN FIRST
STAGE OF LABOUR
Dilatation of cervix
Actual factors responsible are:
Uterine contraction and retraction
bag of membranes- hind water and fore water
Fetal axis pressure
Effacement or taking up of cervix
Lower uterine segment
PREPARATION OF LABOUR
ROOM
 A labor room is an area in the hospital that
is equipped for delivering babies. It is a room
or an area set aside for making or receiving
deliveries.

A labor room also known as birthing room

which is comfortable, furnished for the process
of labor and delivery to take place,
where in the baby is usually delivered and an
hour after delivery if everything is normal or
stable the mother is shifted to postnatal ward.

Delivery table setup

 Set-up of Radiant warmer

 Labor room set up

Prevent unrelated traffic

Visual observation
Emergency communication system
Resuscitation facilities
80sq.ft/ labour bed
Privacy
Equipped for obstretical and neonatal
emergencies
 Only 2 labor beds with adjacent toilet for each
delivery room.
Facilities for medications, charting, washing
and storage of supplies and equipment’s .
One shower with direct access from within
delivery room.
A toilet with hand washing area for staff
No more than 2 labour beds in one labour room.
 Recovery room
Separate recovery room with < 1500 births/yr.

Not < 2 beds with charting facilities with

visual observation of all beds.

 Provision of hand washing, medicine

dispensing, sink, storage of supplies and
equipments
 Pre-arrangement
 Anesthetist
Pediatrician
Obstetrician Nursing Officer
Non allowance of Visitors & unnecessary
people
Articles, drugs
 Labour room
Delivery room should be properly cleaned to
reduce the spread of infection and for keeping
it ready to use.

Use special lights with each labor table.

Delivery table, mattress, mackintosh on the
delivery table should be thoroughly cleaned
after each use.

 There should be good source of light in the

labor room
 ASSESSMENT &
OBSERVATION OF WOMEN
IN LABOR
Admit the mother in labor room and complete
procedures such as changing to hospital gown,
applying identification band and completing
chart forms.
 History Taking:- Onset of labor pains, Leakage
of liquor Vaginal examination ,Reviewing of
records or antenatal visits, investigation reports
or any other specific treatment given
Orient patient to labor & delivery room •

Explain admission protocol, labor process &

Management plans

Carry out perineal shave & administer enema

if not contraindicated

 Antiseptic dressing.
 Start IV line if indicated & administer fluids

 Provide physical & psychological care and

attend to comfort needs

 Monitor & evaluate maternal well-being, fetal

well-being and progress of labor by using
Partograph.
PARTOGRAPH
 DEFINITION
It is a composite graphical recording of
cervical dilatation and descent of head against
duration of labour in hours.

It also gives information about fetal and

maternal condition that are all recorded on
single sheet of paper.
 COMPONENTS
a) Patient information f ) Descend of fetal head

b) Fetal heart rate g ) Uterine contraction

c) Amniotic fluid

d) Moulding

e) Cervical dilatation
 Patient information

Fill out name, gravida, para, hospital

number, date and time of admission and time
of ruptured membranes.
 Fetal heart rate

The rate of the fetal heart rate indicates the

state of the fetus inside the uterus. Record
every half hour (.) .
 Amniotic fluid
Amniotic fluid: Record the colour of
amniotic fluid at every vaginal examination:
 I: membranes intact;
 C: membranes ruptured, clear fluid;
 M: meconium- stained fluid;
 B: blood-stained fluid.
 Moulding

Moulding is a state of reduction or loss of

space between skull bones.
Recording of degree of moulding

0: Bones are separated and sutures can be felt

easily

1: sutures apposed

2: sutures overlapped but reducible

 3: sutures overlapped and not reducible

 Cervical dilatation

Assessed at every vaginal examination and

marked with a cross (X).

 Begin plotting on the partograph at 4 cm.

 This graph consists of homogenous squares,

ten square vertically, each square indicate one
centimeter of cervical dilatation.
Cervical dilatation
The cross (X) in the graph are joined by a
continuous line begin plotting on the
partograph at 4 cm.

 The climbing tendency of this line normally

lies on the left of the middle of the graph.
 Alert line: A line starts at 4 cm of cervical
dilatation to the point of expected full
dilatation at the rate of 1 cm per hour.

 Action line: Parallel and 4 hours to the right

of the alert line
 Descent of the head

This is assessed by abdominal examination

before doing vaginal examination.

 Refers to the part of the head (divided into 5

parts) palpable above the symphysis pubis.

 Recorded as a circle (O) at every vaginal

examination.
 Uterine contraction
 Uterine contractions are recorded graphically on
the partograph according to their strength and
frequency.
 Observation of contraction is made half hourly in
the active phase.
 Palpate the number of contractions in 10 minutes
and their duration in seconds.
 Oxytocin drip

This consists of two lines, one for the record of

unit of oxytocin per liter of intravenous fluid
and other one is for drop of fluid per minute.

The recording can be made at the interval of

30 minutes as the uterine contraction.
 Drug and intravenous fluid

 Record any additional drug given and are

recorded at the particular point of time.

 This includes sedatives, antibiotics, IV fluids

etc. The name of the drugs and doses given
should be written clearly in the long box.
 Maternal condition

Pulse: Record every 30 minutes and mark with

a dot (.).

 Blood pressure: Record every 4 hours and

mark with arrows.

 Temperature: Record every 2 hours.

 ADVANTAGE

A single sheet of paper can provide details of

necessary information at a glance.

 No need to record labour events repeatedly

Gives clear picture of normality and

abnormality in labour.
It can predict deviation from duration of
labour. So that appropriate steps could be taken
in time.
 It facilitates handover procedure of staffs.
Save working time of staff against writing
labour notes in long hand.
Educational value for all staff.
 ACTIVE
MANAGEMENT
1. INDUCTION OF
LABOUR(IOL)
 DEFINITION
It means initiation of uterine contractions,
after the period of viability by any method that
is either medical, surgical or combined for the
purpose of vaginal delivery.
 PURPOSE
The induction is done when continuation of
pregnancy, may put to risk the health of the
mother or the fetus.

In such instances for the safety of both,

induction is indicated.
 INDICATION
 Hypertensive disorders of pregnancy (pre-eclampsia,
eclampsia)
 Post maturity
 APH especially Abruptio placenta
 IUGR
 Maternal medical conditions ( DM , chronic renal
disease)
 PROM
Fetus with a major congenital anomaly

 IUD

 Oligohydramnios

 Polyhydramnios

 Unstable lie- after correction into longitudinal

lie
 CONTRAINDICATION
CPD
 Contracted pelvis
 Malpresentation (transverse or oblique lie)
 High risk pregnancy with fetal compromise
 Utero placental factors ( Vasaprevia, placenta
previa, unexplained vaginal bleeding)
Previous classical cesarean section or hystrerotomy
Active genital herpes infection
 Heart disease
 Elderly primigravida with obstetric or medical
complications
 Pelvic tumor
 Cord presentation
 Cord prolapse
PRE-REQUISITED FOR IOL
The indication for the induct of labor is
confirmed

 All the contraindications of IOL are to be

excluded

 Fetal wellbeing is assessed

 Maturity of the fetus (pulmonary) is assessed

Fetal gestational age is ensured

Estimated weight is also compared

Before starting IOL, Bishop’s score is checked

and it should be >6 i.e a favorable score for
IOL .
 Bishop score
The Bishop score is a system used by
medical professionals to decide how likely it is
that you will go into labor soon.

Components:

Bishop includes dilation, effacement, station,

consistency and position
 INTERPRETATION
A Bishop score of 6-13 is considered to be
favorable for induction, or the chance of a
vaginal delivery with induction is similar to
spontaneous labor.
A score of 0-5 is considered to be unfavorable
if an induction is indicated cervical ripening
agents may be utilized.
METHODS OF IOL

Medical

combined Surgical
 Medical
 Oxytocin

Prostaglandins

Mifepristone
1. Oxytocin: is an endogenous uterotonic that
stimulates uterine contractions. Oxytocin
receptors present in the myometrium more in
the fundus than in the cervix & their
concentrations increase during pregnancy and
in labor . ( to 100-00 fold).
2. Prostaglandins:
 Dinoprostone (PGE2), dinoprost
 Misoprostol (PGE1)
 Carboprost (PGF2 alpha)
They act locally & cause myometrial contraction.
PGE2: 0.5 mg gel, applied intracervically for
cervical ripening & may be repeated after 6 hrs
for 3-4 doses if required.
PGE1: used either transvaginally or orally. A dose
of 25 micrograms transvaginally every 3 hrs to a
max. of 4 doses or orally 50 micrograms every 4
hrs. is found to be as effective as PGE2 for
cervical ripening and IOL.

PGF2alpha: acts locally, it is basically used for

myometrial contractions.
3. Mifepristone (ru486): Also known as steroid
receptor antagonist or Progesterone receptor
antagonist: Mifepristone blocks both
progesterone and glucocorticoid receptors. It
also helps in IOL and is useful in ripening of
cervix usually given Ru486, 200 mg vaginally
daily for 2 days.
 Surgical

Stripping of
ARM
membranes
1. Stripping of membranes

It is the digital separation of the

chorioamniotic membranes from the wall of
the cervix and lower uterine segment.

It is thought to work by release of

endogenous prostaglandins from the
membranes and decidua.
2. Artificial rupture of membranes
1. Low rupture of membrane
2. High rupture of membrane
Mechanism: It is related with stretching of
cervix, separation of membranes (liberation of
prostaglandins) and reduction of amniotic fluid
volume
 Combined
The combined medical and surgical
methods are commonly used to increase the
efficacy of IOL by reducing the induction
delivery interval.
 2. PAIN RELIEF
AND COMFORT IN
LABOR
 PAIN RELIEF

Analgesia should be used minimally in

pregnancy but in case if there is need of pain
killer then;

Inj. Pethidine 100 mg I/M (when pain is

well established with cervix 3cm dilated), if
necessary it is repeated after 4 hrs.
Transquilizers drugs may be given along with
pethidine;

 Promethazine = 25-30mg

 Triflupromazine = 5-10 mg

 Promazine = 25-50 mg
 COMFORT IN LABOUR
Non pharmacological techniques of pain relief
Birthing ball
Showering hydrotherapy immersion therapy
 ACTUAL
MANAGEMENT
Aseptic precautions should be followed
throughout the labor process
 Continuous emotional support,
encouragement and assurance is to be given to
boost the morale of the mother
Constant supervision is required. Careful
examination: Physical, pelvic and laboratory
tests should be performed
PRINCIPLES OF 1ST STAGE OF LABOR

Non- interference with watchful expectancy so

as to prepare the patient for smooth delivery in
the 2nd stage of labor

To monitor carefully the progress of labor,

maternal conditions and fetal behavior in order
to detect any deviation from normal.
 PRELIMINARIES
Enquiry is made about onset of labor pains

Enquiry is made about leakage of liquor

Thorough general examination is done

Thorough obstetrical examination is done

 Vaginal examination is done

 Antenatal records are checked

 If any investigation done then reports are

checked and note if there is any treatment
given
 MANAGEMENT
Prevention of Infection: asepsis maintenance;
before, during and after delivery
 General care of patient:
 Antiseptic dressing
Encouragement and assurance
Constant supervision
 Care of bowel: soap and water enema or
glycerine suppository is given

 Proper rest: in case when membranes are

ruptured

 Ambulation: when membranes are intact

Diet: Plain water, salty lemon water, soups and
fruit juice. Oral fluids and food should be
withheld as soon as active labor is established.
If there are chances of prolonged labor or
active management then IV infusion with 5%
dextrose is started.
Care of bladder: encouraged to empty her
bladder frequently or catheterization with soft
rubber catheter and maintaining strict aseptic
precautions.

 Relief of pain: Pethidine 100 mg I/M with

promethazine 25-30 mg ,I/M.

 Noting the progress of labor: Partograph

THANK YOU