This presentation includes all the events , its sign and symptoms about IOL as well as management of women in the first stage of labor and how to assess the women in labor with the help of partograph.

1. FIRST STAGE OF
LABOR
Nikita Sharma
Nursing Tutor

2. FIRST STAGE OF LABOR
• It starts from the onset of true labor pains and ends till full dilatation of
cervix (10cm).
• Duration: approx. 12 hours in primigravida & 6 hours in multipara
• The first phase is divided into 3 phases:
1. Latent phase
2. Active phase
3. Transition phase

3. 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.

4. 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

5. TRANSITION PHASE
• The last and shortest part of 1st phase of labor.
• It is more intense phase of laboring women
• Contractions occur every 2-3 minutes lasting 60-90 seconds.
• Duration: primi= 2 hours, multi= 1 hour.

6. NORMAL SIGN & SYMPTOMS OF
ONST OF LABOR
Bloody Show
Contraction & retraction
of uterine muscles
Pains

7. Formation of upper & lower uterine segment
Development of retraction ring (Bandl’s ring)

8. Cervical dilatation & Effacement

9. Formation of bag of membranes
Rupture of membranes

10. MATERNAL SYSTEM
• The condition remain unaffected
• Feeling of transient fatigue
• 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
• Temperature remains unaffected.

11. 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.

12. ABNORMAL SIGNS
• The signs which do not progress towards normal labor in first stage are:
Abnormal
signs
Uterine
hypocontract
ility
Precipitous
labor
Non-
progress of
labor
Long latent
phase
Fetal
distress

13. • UTERINE HYPOCONTRACTILITY:
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.
ABNORMAL SIGNS

14. • 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:
1. Heavy bleeding
2. Shock
3. Vaginal/ Cervical tear
PRECIPITOUS LABOR

15. NON- PROGRESS OF LABOR
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:
1. Prolonged labor
2. Psychological factors like fear, worry, stress
3. Pain medications can also slow/ weaken the contractions.

16. LONG LATENT PHASE
• Normally the latent phase of labor in primigravida (0-4cm) dilatation lasts
from 6 hours to 2-3 days whereas prolonged labor/ failure of progression of
labor lasts for nearly 20 hours or more in primigravida and 14 hours or more
in multigravida.
• Apart from this, when a laboring mother is dilating less than 1-2cm/hr
during active labor which should normally be 3-7cm of dilatation.

17. FETAL DISTRESS
• This is also an abnormal sign which may occur due to a number of factors
written below:
1. Induction/ augmentation of labor
2. Maternal exhaustion
3. Cephalopelvic disproportion (CPD)
4. High uncontrolled blood pressure

18. DURATION
From onset of true labour pains till the full dilatation of cervix (10cm). It is
12 hrs in primigravida and 6 hrs in multiparae.
This stage is divided in to:
1. Latent Phase: also known as Prodromal stage or pre-labor. True labor
contractions to 3-4cm cervical dilatation or less than 4 cm dilatation.
2. Active Phase: also known as Dilatation phase. Begins with 4 cm of
dilataion to complete dilatation of cervix (10cm)

19. PHYSIOLOGY/EVENTS IN
FIRST STAGE OF LABOR

20. UTERINE CHANGES

21. UTERINE CHANGES
POLARITY
CONTRACTION & RETRACTION

22. UTERINE CHANGES
Formation of upper & lower uterine segment as well as bandl’s ring

23. CERVICAL CHANGES
Cervical ripening Cervical effacement

24. CERVICAL CHANGES
Cervical Dilatation Bloody show

25. MECHANICAL FACTORS
General fluid pressure Rupture of membranes
Fetal axis pressure &
descent of presenting part

26. PREPARATION OF LABOR 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.

27. • Delivery table setup
• Set-up of Radiant warmer
• Labor room set up
PREPARATION OF LABOR ROOM

28. Prevent unrelated
traffic
Visual observation Emergency
communication
system
Resuscitation
facilities
PREPARATION OF LABOR ROOM

29. 80 sq. ft./ labor
bed
Privacy Equipped for
obstetrical and
neonatal emergencies
2 labor beds with
adjacent toilet for
each delivery room
CRITERIA OF LABOR ROOM

30. PREPARATION OF LABOR ROOM
Facilities for
medications,
charting, hand
washing & storage of
supplies and
equipment's
One shower with
direct access
from within
delivery room
A toilet with hand
washing area for
staff
No > 2 labor beds
in one labor room

31. 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

32. PRE-ARRANGEMENT
Anesthetist
Pediatrician
Obstetrician
Nursing Officer
Non allowance of
Visitors &
unnecessary people
Articles,
drugs

33. LABOR ROOM
• Delivery room should be properly cleaned to reduce the spread of infection
and for keeping it ready to use.
• 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
• Use special lights with each labor table.

34. 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

35. • 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.
ASSESSMENT & OBSERVATION OF
WOMEN IN LABOR

36. PARTOGRAM

37. COMPONENTS OF PARTOGRAPH

38. A. Patient information: Fill out name, gravida, para, hospital number, date
and time of admission and time of ruptured membranes.
B. Fetal heart rate: The rate of the fetal heart rate indicates the state of the
fetus inside the uterus. Record every half hour (.)
C. 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.
COMPONENTS OF PARTOGRAPH

40. MOULDING

41. D. Moulding: is a state of reduction or loss of space between skull bones.
• Presence of increased moulding of the head high in the pelvis indicates CPD.
• 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
COMPONENTS OF PARTOGRAPH

42. E. Cervical dilatation :
• In Latent Phase: up to 4cm and rate = 0.35cm/hr
• In Active Phase: from 4cm to 8cm. Rate = 1.2-1.5cm/hr
• In Transition phase: from 8cm to 10cm. Rate = 1.5cm/hr
• In cervicograph: alert line starts at 4cm (WHO) and ends at 10cm
dilatation.
• The action line drawn 4 hrs to the right and parallel to the alert line.
COMPONENTS OF PARTOGRAPH

43. • 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
COMPONENTS OF PARTOGRAPH

44. F. 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.
• Hours: Refers to the time elapsed since onset of active phase of labour.
• Time: Record actual time.
• Descent of presenting part occurs at the rate of 1-2cm/hr.
COMPONENTS OF PARTOGRAPH

45. DESCENT

46. G. Uterine contractions : 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
COMPONENTS OF PARTOGRAPH

47. COMPONENTS OF PARTOGRAPH

48. • During Latent Phase: contractions come at interval of 15-30 minutes and
last up to 30 seconds
• During Active Phase: Contractions occur every 3-5 minutes & lasts for 60
seconds
• In Transition Phase: Contractions occur every 2-3 minutes & lasts for 60-
90 seconds
COMPONENTS OF PARTOGRAPH

49. H. 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
• 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.
COMPONENTS OF PARTOGRAPH

50. I. 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.
• Urine analysis: During the course of labour, the examination of urine is
important. In case of maternal distress the volume of urine may decrease
and it may contain ketone bodies.
COMPONENTS OF PARTOGRAPH

51. • The active phase of labour commence at 4 cm cervical dilatation.
• The latent phase of labour should not last longer than 8 hours
• During active labour, the rate of cervical dilatation should not be slower than
1cm/hours
• A lag time at 4 hours between a slowing of labour and the need for
intervention is unlikely to compromises the fetus or the woman and avoid
unnecessary intervention
PRINCIPLES OF PLOTTING
PARTOGRAPH

52. ADVANTAGES OF USING
PARTOGRAPH
1. A single sheet of paper can provide details of necessary information at a glance.
2. No need to record labour events repeatedly
3. Gives clear picture of normality and abnormality in labour.
4. It can predict deviation from duration of labour. So that appropriate steps could
be taken in time.
5. It facilitates handover procedure of staffs.
6. Save working time of staff against writing labour notes in long hand.
7. Educational value for all staff.

53. INDUCTION OF LABOR (IOL)
• 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.

54. INDICATION
• Hypertensive disorders of pregnancy (pre-eclampsia, eclampsia)#
• Post maturity#
• APH especially Abruptio placenta#
• IUGR
• Rh-Isoimmunization
• Maternal medical conditions ( DM , chronic renal disease)
• PROM#

55. • Fetus with a major congenital anomaly#
• IUD#
• Oligohydramnios
• Polyhydramnios#
• Unstable lie- after correction into longitudinal lie
(Note: # = Common indication of induction of labor)
INDICATION

56. CONTRAINDICATION OF IOL
• 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

57. CONTRAINDICATION OF IOL
• Active genital herpes infection
• Heart disease
• Elderly primigravida with obstetric or medical complications
• Pelvic tumor
• Cord presentation
• Cord prolapse

58. 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 .

59. BISHOP SCORE

61. METHODS OF CERVICAL RIPENING
• Prostaglandins
(PGs)
• Oxytocin
• Relaxin
• Steriod
receptor
anatgonist
Pharmacolog
-ical
method
• Stripping of
membranes
• Amniotomy
• Mechanical
dilators
Non-
pharmacolog
-ical
method

62. METHODS OF IOL
Medical
Surgical
combined

63. MEDICAL IOL
• 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)

64. PROSTAGLANDINS
1. Dinoprostone (PGE2), dinoprost
2. Misoprostol (PGE1)
3. 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.

65. 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.
PROSTAGLANDINS

66. 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.

67. SURGICAL INDUCTION OF LABOR
Stripping of
membranes
ARM

68. 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.
MECHANICAL METHOD OF INDUCTION (hygroscopic dilators)
1. Laminaria
2. Lamicel

70. 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

71. COMBINED METHODS
• The combined medical and surgical methods are commonly used to increase
the efficacy of IOL by reducing the induction delivery interval.

72. PAIN RELIEF AND COMFORT
IN LABOR

73. 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
These drugs potentiate the action of pethidine
so that total dose of pethidine required may be
reduced.

74. COMFORT IN LABOR
NON- PHARMACOLOGICAL TECHNIQUES OF PAIN RELIEF
MUSIC MASSAGE

75. COMFORT IN LABOR
ROCKING WALKING CHANGING
POSITIONS

76. • HYDROTHERAPY
COMFORT IN LABOR
SHOWERING
HYDROTHERAPY
IMMERSION
HYDROTHERAPY

77. APPLICATION OF HEAT AND COLD
HEAT APPLICATIONS
- Hot water bottle
- Hot moist towel
- Warm blankets
COLD APPLICATIONS
- Ice bags
- Wash cloths soaked in ice
water
- Bag of frozen peas
Both hot and
cold
applications
can also be
used on
separate parts
at the same
time

78. COMFORT IN LABOR
FOCUSED
BREATHING
RELAXATION
TECHNIQUES
BIRTHING BALL BEVERAGES

79. PHARMACOLOGICAL METHODS
1. Relaxants
2. Epidural anesthesia
3. Local anesthesia
4. Spinal block
5. CES block (combined spinal-epidural block)
6. General anesthesia

80. MANAGEMENT OF FIRST STAGE OF
LABOR
GENERAL:
• 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

81. PRINCIPLES OF 1ST STAGE OF LABOR
1. Non- interference with watchful expectancy so as to prepare the patient for
smooth delivery in the 2nd stage of labor
2. To monitor carefully the progress of labor, maternal conditions and fetal
behavior in order to detect any deviation from normal

82. PRELIMINARIES
1. Enquiry is made about onset of labor pains
2. Enquiry is made about leakage of liquor
3. Thorough general examination is done
4. Thorough obstetrical examination is done
5. Vaginal examination is done
6. Antenatal records are checked
7. If any investigation done then reports are checked and note if there is any
treatment given

83. • Prevention of Infection: asepsis maintenance; before, during and after
delivery
• General care of patient:
 Antiseptic dressing
Encouragement and assurance
Constant supervision
MANAGEMENT OF FIRST STAGE OF
LABOR

84. • 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.
MANAGEMENT OF FIRST STAGE OF
LABOR

85. • 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
MANAGEMENT OF FIRST STAGE OF
LABOR