1st stage of labour

& its management

by - Fanya Gomez
HS (2016 BATCH)
 Few definitions..
LABOUR : It is a series of events that takes place in an effort
to expel the viable products of conception after attaining
viability, are separated & expelled from uterus.
NORMAL LABOUR : Is the process by which fetus
presenting as vertex, expelled by natural efforts of the mother,
when reached term , with no complications & not more than
24hrs.
DYSTOCIA : Abnormal labour – ab. Pelvis , soft tissues,
expulsive forces or fetus.
Onset Of Labour

 1. PROSTAGLANDINS : increases during labour, further

inc. following mech. Stretching of cervix by stripping of
membranes.
- Acts synergistically with oxytocin – stimulating uterine
contractions.

 2. OXYTOCIN : produces rhythemic & regular

contractions.
- Inc. intracellular Ca, thereby stimulating uterine contractions.
- Widely used to induce & augment labour.
 3. oestrogen & progesterone
- Progesterone reduces muscle excitability , estrogen increases
myometrial excitability .
- Thus during pregnancy, high levels of progesterone & low
levels of oestrogen.
PRELABOUR
 Period begins few days before the onset of true labour.
Events :
1. Lightening & shelving of uterus – it is the decease in fundal height
seen at term. (d/t formation of lower segment of uterus- descends
into pelvis – falling forward of uterus = SHELVING SIGN.

2.Cervical ripening & softening

3. Increased uterine contractility - False labour pains (irregular

contractions, not accompanied by cervical dilatations, felt in lower abd
only)
-inc oxytocin
-inc prostaglandins
 TRUE LABOUR PAIN FALSE LABOUR
PAIN

1. UTERINE
CONTRCTION Regular & rhythmic (on & Irregular, continuous
a. Nature off pain)

inc intensity, frequency,

b. Progressive contraction
2. Cervical dilatation Progressive dilatations -

3. Site of pain Lower abd + radiating to Localized to abd

thigh & back

4.Show Blood + mucus -

discharge

5.Bag of membranes Felt -

Relieved by
Pain – not relieved sedation/enema
ASSESSMENT
 Onset of true labour pain marks onset of labour.
 At the time of admission :
1. Note the vitals of the patient
2. Perform leopold maneuvers
3. Auscultate for FHS – steth/doppler
4. Per vaginal examinations done to access
- Dilatation of cx
- Effacement of cx
- Position of cx
- Station of fetal head
- Status of membranes
Detailed assessment..
 A proper history to r/o any pregnancy complications.
 Cross matched blood kept ready
 Pulse/bp/temp – charting
 Abd ex – lie of fetus & presentation & 2nd pelvic grip – head
is engaged or not.
 Preparation of local parts
 Per vaginal examination
 Descent of head : By abd ex, to assess the no. fifths
palpable per abdomen – crichton method

 FHR – fetal doppler – monitored for at least 20

mins  admission test.
Stages of labour

 1st stage : onset of true labour pains to complete cervical

dilatations (10cm)

 2nd stage : complete cervical dilatation to delivery of fetus or

fetuses.

 3rd stage : separation & expulsion of the placenta & membranes.

 - 1st stage is divided into two phases :

a. LATENT PHASE
b. ACTIVE PHASE
 LATENT PHASE : Cervical effacement & dilatation up to 3-
4cm
- Lasts for 6-8hrs in a nullipara & 4-6hrs in multipara.

 ACTIVE PHASE : extends from 3-4cm dilatation to complete

cervical dilatation.
- Contractions get stronger & more frequent
- Takes about 5hrs in nullipara & 3hrs in multipara.

 Mean rate of cervical dilatation is 1.2cm/hr in nullipara & 1.5cm/hr

in a multipara.
 Active phase - 3 phases
- Acceleration phase (3-4cm dilatation)
- Phase of maximum slope (4-9cm)
- Deceleration Phase (9-10cm)
Events in first stage
 1. uterine contractions
 2. cervical changes
 3. show
 4. formation of lower uterine segment
 5. Descent of fetus
 6. formation of bag of membranes & rupture
1. Uterine contractions
 Regular, increase in duration & frequency – lasts for 30-
90secs, at least 3 in 10 mins
 Fundal dominance
 Synchronization of uterine activity
 Inc in intra-amniotic pressure
 Retractions of uterine muscle fibres.
 Inc in Pain
 Segments of uterus differentiate – upper seg  Contract &
retracts & lower seg  dilates .
2. Cervical changes
 Cervical effacement : shortening of cervical canal to a
circular opening , thus cervix incorporated into lower
segment.
 Cervical dilatation

3. SHOW – discharge of mucus mixed with blood.

4. FORMATION OF LOWER UTERINE SEGMENT –
during labour after effacement & dilatation , the upper segment
contracts & retracts to expel fetus  thicker, lower seg distends
& become thinner.

-clinical significance : junction btw two is seen as demarcation

 physiological retraction ring & area through which cs is
done.
 5. Fetal descent : begins in phase of maximum slope,
maximal in deceleration phase & 2ND Stage.
 6. Bag of membranes : detached easily from attachment to
the decidua, bulge into the cervical canal  tense & convex
 certain sign of labour.
- In the end of first stage, membranes rupture.
Management
 1.adequate fluid management
- Indications : use of regional anesthesia
- Maternal dehydration
- Poor progress in labour
- Post partum haemorrhage
 2. Monitoring
- Pulse 1/2hrly & bp – 2hrly, temp – 4th hrly.
- Signs of maternal distress – prolonged labour (tachycardia,
dehydration, dry tongue, sunken eyes, ketone bodies in urine).
- Continuous electronic fetal monitoring(EFM) / every 20mins – low
risk.
- Uterine contractions – palm of hands  intensity & frequency.
 3. PARTOGRAM - once the pt enters active phase.
 Graphical record of progress of labour.
 Progress of labour is noted  assessing cervical dilatation
 PV, descent of presenting part  abd ex.
 Once into active phase, vaginal ex. Done every 3-4hrs.
 Helps to detect prolonged / dysfunctional labour.
 4. analgesics – epidural analgesia, nitrous oxide,
transcutaneous electronic nerve stimulation
(TENS), intramuscular.
 5. maternal position – lateral recumbent position.
 6. bladder function – ensure pass urine regularly to
avoid bladder distension.
 7. ARM (artificial rupture of membranes)/
amniotomy
– kocher forceps , when presenting part is applied at cx.
Immediately, FHS is auscultated.
ADVANTAGES :
1. Promotes labour
2. Application of fetal head to cx
3. Color of liquor & meconium staining can be r/o.
Disadvantages :
- Cord prolapse, infection, abruption.

8. PROPHYLACTIC ANTIBIOTICS – ampicillin, cefotaxime,

ceftriaxone etc.