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The diagnosis of labour8-1 When is a patient in labour?A patient is in labour when she has regular (at least 1 contraction every 10 minutes) painful uterine contractions with:
Management of suspected labourIf 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 2 hourly. The women can be discharged home if:
The two phases of the first stage of labourThe first stage of labour can be divided into two phases:
8-2 What do you understand by the latent phase of the first stage of labour?
8-3 What do you understand by the active phase of the first stage of labour?
Monitoring of the first stage of labour8-4 What do you understand by a complete physical examination during labour?
This examination is only complete when the findings have been charted on the partogram. If the findings are abnormal, a plan must be made regarding the further management of the patient. 8-5 When should you do a complete physical examination on a patient in labour?
After the complete examination has been done and an assessment made about the progress of labour, a decision is taken on when the next complete examination should be done. The time of the next examination is marked on the partogram with an arrow. The next complete examination may, if the circumstances demand it, be done sooner (but not later) than the time indicated. 8-6 How should progress during the first stage of labour be monitored?A partogram is used to monitor and record the progress of labour. 8-7 What is a partogram?A partogram is a chart on which the progress of labour over time is presented. You will notice that provision has been made on the chart to record all the important observations regarding the condition of the mother, the condition of the fetus, and the progress of labour. An example of a partogram is shown in figure 8-1.
8-8 What is the first oblique line on the partogram called?The alert line. It represents a rate of cervical dilatation of 1 cm per hour. 8-9 What is the importance of the alert line?The alert line represents normal progress in cervical dilatation which is acceptable during the active phase of the first stage of labour. 8-10 What is the second oblique line on the partogram called?This line is called the action line. 8-11 What is the importance of the action line?
Management of a patient in the latent phase of the first stage of labourThe latent phase of labour should not last longer than 8 hours. 8-12 What is the initial management of a patient in the latent phase of labour?When a patient is admitted in early labour, and on examination everything is found to be normal, the fetal heart rate and the duration and frequency of uterine contractions must be monitored 2 hourly. The next complete examination is done 6 hours later, or sooner if the patient starts to experience more regular and painful contractions. The patient should eat and drink normally, and should be encouraged to walk around. She need not be admitted to the labour ward. 8-13 What should you do at the second complete examination?At this time, the following must be assessed.
8-14 What should you do if a patient has not progressed to the active phase of labour within 12 hours after admission?
Management of a patient in the active phase of the first stage of labourWhen a patient is admitted in the active phase of labour, she will probably be in normal labour. However, the possibility of cephalopelvic disproportion must be considered, especially if the patient is unbooked. 8-15 How do you manage a patient who is in normal labour?When the condition of the mother and the condition of the fetus are normal, and there are no signs of cephalopelvic disproportion, the next complete examination must be done 4 hours later. The cervical dilatation, in centimetres, is recorded on the alert line of the partogram. 8-16 What represents normal progress during the active phase of the first stage of labour on the partogram?
8-17 Why is it necessary to evaluate both cervical dilatation and the descent of the head in order to determine whether there has been progress in the active phase of the first stage of labour?
8-18 What circumstances will make it necessary to do vaginal examinations more frequently than 4-hourly in the active phase of the first stage of labour?
8-19 When should you rupture the patient’s membranes?
If the fetal head is 4/5 or more above the pelvic brim, and the cervix is 6 cm or more dilated, it is safer to carefully rupture the membranes than to allow them to rupture spontaneously. This will reduce the risk of cord prolapse. 8-20 What should you do if a patient ruptures her membranes spontaneously during labour?
8-21 What are the advantages of rupturing a patient’s membranes?
It is important to make sure that the patient is in the active phase of the first stage of labour before rupturing the membranes. Poor progress in the active phase of the first stage of labour8-22 How would you recognise poor progress in the active phase of labour?Poor progress is present when the graph showing cervical dilatation crosses the alert line. In other words, cervical dilatation in the active phase of the first stage of labour is less than 1 cm per hour. 8-23 What should you do if the graph showing cervical dilatation crosses the alert line?A systematic assessment of the patient must be made in order to determine the cause of the poor progress in labour. 8-24 How should you systematically examine a patient with poor progress in the active phase of the first stage of labour?
If the answer to both questions is ‘yes’, proceed to step 2.
8-25 How may problems with the patient cause poor progress of labour and how should these problems be managed?Any of the following factors may interfere with the normal progress of labour.
8-26 How may problems with the powers cause poor progress of labour?The powers (i.e. the uterine contractions) may either be inadequate or ineffective. Any patient in whom labour progresses normally has both adequate and effective contractions, irrespective of the duration and frequency of contractions.
8-27 How may problems with the passenger cause poor progress of labour and how should these problems be managed?The cause of poor progress of labour may be due to a problem with the passenger (i.e. the fetus). These problems can be identified by performing an abdominal examination followed by a vaginal examination. On abdominal examination the following problems causing poor progress may be identified.
On vaginal examination the following problems causing poor progress may be identified.
8-28 How may problems with the passage cause poor progress in labour and how should these problems be managed?The following problems with the passage may cause poor progress in labour:
8-29 What are the two important causes of poor progress of labour?
8-30 What must be done after the patient has been systematically evaluated to determine the cause of the poor progress of labour?
The following are examples of causes of poor progress in labour together with their management:
Cephalopelvic disproportion8-31 How will you know when poor progress is due to cephalopelvic disproportion?This can be recognised by the following findings:
Cephalopelvic disproportion may already be present when the patient is admitted.
8-32 Does a patient’s cervix always dilate at a rate slower than 1 cm per hour if cephalopelvic disproportion is present?When there is cephalopelvic disproportion, the cervix usually dilates at a rate slower than 1 cm per hour, but the cervix may dilate normally, even though the fetal head remains high due to cephalopelvic disproportion. This is a dangerous situation as it may be incorrectly concluded that labour is progressing normally. 8-33 What features would make you diagnose cephalopelvic disproportion when the fetal head is not descending into the pelvis?Often, especially in multiparous patients, the head does not descend into the pelvis until late in the active phase of the first stage of labour. However, when the head does not descend into the pelvis, you should look for possible causes:
If either of these are present, there is cephalopelvic disproportion, and a Caesarean section should be done. On the other hand, labour can be allowed to continue if:
The next complete physical examination must be repeated within 2 hours. 8-34 What should you do if you decide that the poor progress is due to cephalopelvic disproportion?
Inadequate uterine action8-35 What should you do if you decide that the poor progress is due to inadequate or ineffective uterine contractions?
8-36 What are the contraindications to the use of oxytocin in order to strengthen contractions in the first stage of labour?
8-37 How must oxytocin be administered when it is used during the first stage of labour?The following is a good method:
8-38 What are the effects of a long labour?Both the mother and fetus may be affected.
The referral of patients with poor progress during the active phase of the first stage of labourThe guidelines for referral will vary from region to region, depending on the distances between clinics and hospitals, and the availability of transport. In general, arrangements must be made so that the patient will be under the care of the responsible doctor by the time the graph depicting cervical dilatation crosses the action line. 8-39 What arrangements should you make to ensure the patient’s safety during transfer to hospital, if there is poor progress of labour?
Prolapse of the umbilical cord8-40 Why is prolapse of the umbilical cord a serious complication?Because the flow of blood between the fetus and placenta is severely reduced and may stop completely, causing fetal distress and possibly fetal death. 8-41 What is the difference between a cord presentation and a cord prolapse?
8-42 How should a cord presentation be managed?If the cord is felt between the membranes and the presenting part of the fetus, if the fetus is alive and is viable and if the patient is in labour, a Caesarean section must be done. This will prevent a cord prolapse when the membranes rupture. 8-43 Which patients are at risk of a prolapsed cord?
8-44 What should be done when a patient, who is at high risk of prolapse of the cord, ruptures her membranes?A sterile vaginal examination must immediately be done to determine whether the cord has prolapsed. 8-45 What is the management of a prolapsed cord?A vaginal examination must be done immediately.
8-46 Why should the cord carefully be replaced in the vagina?The cord must not be allowed to become cold or dry as this will produce vasospasm and, thereby, further reduce the blood flow through the cord. 8-47 Why is salbutamol given to a patient with a prolapsed cord?Stopping uterine contractions will reduce the pressure of the presenting part on the prolapsed cord. 8-48 Should a Caesarean section be done on all women with a prolapsed cord if the infant cannot be rapidly delivered vaginally?No. A Caesarean section is only done if the infant is potentially viable (28 weeks or more) and the cord is still pulsating. Otherwise the infant should be delivered vaginally as the chances of survival are then extremely small. Women living with HIVOn admission to the labour ward the HIV status of all pregnant women must be established, documented and the correct antiretroviral (ARV) medication prescribed. Women with negative antenatal HIV screening tests need to be retested. 8-49 How should antiretroviral medication be administered to HIV positive women during labour?Women who have been on ARV prophylaxis or treatment during pregnancy should continue taking their daily dose of TLD or FDC throughout labour. They do not need any additional ARV drugs in labour. However women living with HIV who have defaulted their treatment and women diagnosed to be positive during labour should receive TLD and a single dose of 200 mg nevirapine (NVP). Case study 1A primigravida patient at term, who is HIV negative, is admitted to the labour ward. She has 1 contraction, 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 2 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 is made and an oxytocin infusion is started to improve contractions. 1. Do you agree with the 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. 2. Why can it be said with certainty that the patient is in the latent phase of labour?
3. 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. 4. Should the patient’s membranes have been artificially ruptured when the second vaginal examination was done?No. If the maternal and fetal condition are good, you should wait until the cervix is dilated 5 cm or more. The membranes may also be ruptured if the patient has been in the latent phase of labour for 12 hours without any progress. Case study 2A 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 a further 4 hours. 1. On admission, should the woman’s cervical dilatation have been entered on the alert line?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. The future observations should fall on or to the left of the alert line. 2. Do the findings of the second examination indicate normal progress of labour?Not necessarily, as no information is given about the amount of fetal head palpable above the pelvic brim. Cervical dilatation without 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. 3. Is normal cervical dilatation with improvement in the station of the presenting part possible if cephalopelvic disproportion is present?Yes. The uterine contractions cause an increasing amount of caput and moulding, which is incorrectly interpreted as normal progress of labour. In this case, caput was noted during the second examination. However, further information about any moulding and the amount of fetal head palpable above the pelvic brim are essential before it can be decided whether normal progress is present or not. 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. Case study 3A primigravida patient at term is admitted in labour. At the first examination the fetal head is 2/5 above the pelvic brim and the cervix is 6 cm dilated. 3 contractions in 10 minutes, each lasting 45 seconds, are palpated. At the next examination 4 hours later, the head is still 2/5 above the brim and the cervix is still 6 cm dilated. No moulding can be felt. The patient is still having 3 contractions in 10 minutes, each lasting 45 seconds and complains that the contractions are painful. Because there has been no progress in spite of painful contractions of adequate frequency and duration, it is decided that cephalopelvic disproportion is present and that, therefore, a Caesarean section must be done. 1. Do you agree that the poor progress of labour is due to cephalopelvic disproportion?No. To diagnose poor progress due to cephalopelvic disproportion, severe moulding (3+) must be present. 2. What is most probably the reason for the poor progress of labour?The patient is a primigravida with strong, painful contractions and no signs of cephalopelvic disproportion. A diagnosis of ineffective uterine contractions (dysfunctional uterine contractions) can, therefore, be made with confidence. 3. What should be the management of the patient’s poor progress of labour?Firstly, the patient should be reassured and given analgesia with pethidine and promethazine (Phenegan) or hydroxyzine (Aterax). Then an oxytocin infusion should be started to make the contractions more effective. 4. Why is reassuring the patient so important?Anxious patients often progress slowly in labour and have painful contractions. Emotional support during labour is a very important part of patient care. 5. When must the next vaginal examination be done?The next vaginal examination should be done 2 hours later to determine whether the treatment has been effective. During the examination it is very important to exclude cephalopelvic disproportion. Case study 4A patient who is in labour at term has progressed slowly and the alert line has been crossed. During a systematic evaluation of the patient by the midwife for poor progress of labour, a diagnosis of an occipito-posterior position is made. As the patient is making some progress, she decides to allow labour to continue. After 4 hours, the cervical dilatation falls on the action line. Although there is still slow progress, she again decides to allow labour to continue and to repeat the vaginal examination in a further 2 hours. 1. Was the patient managed correctly when she crossed the alert line?Yes. She was systematically examined and a diagnosis of slow progress of labour due to an occipito-posterior position was made. 2. What should be done if a long first stage of labour is expected due to an occipito-posterior position?An intravenous infusion must be started to ensure that the patient does not become dehydrated. In addition, adequate analgesia must be given. 3. Was the patient correctly managed when she reached the action line?No. A doctor should have evaluated the patient. Further management should have been under his/her direction. 4. Under what conditions should the doctor allow labour to progress further?If there is steady progress of labour, the maternal and fetal conditions are good, and there is less than 3+ moulding. Which nursing action should be initiated first when there is evidence of prolapse cord?The oxytocin infusion must be stopped to prevent uterine rupture and fetal compromise. Which of the following is the nurse's initial action when umbilical cord prolapse occurs? Question 5 Explanation: The immediate priority is to minimize pressure on the cord.
Which of the following should the nurse monitor to ensure the safety of a woman receiving magnesium sulfate Epsom salts to stop labor?The answer is E. The nurse should monitor for Magnesium Sulfate toxicity.
What are the factors that enable the baby to initiate respiration immediately postpartum?A number of factors have been implicated in the initiation of postnatal breathing: decreased oxygen concentration, increased carbon dioxide concentration and a decrease in pH, all of which may stimulate fetal aortic and carotid chemoreceptors, triggering the respiratory center in the medulla to initiate respiration.
Which drug is administered to treat chorioamnionitis in a client during labor?The standard drug treatment in the mother with chorioamnionitis includes ampicillin and an aminoglycoside (ie, usually gentamicin), although clindamycin may be added for anaerobic pathogens.
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