Maternal Care addresses all the common and important problems that occur during pregnancy, labour, delivery and the puerperium. It covers: the antenatal and postnatal care of healthy women with normal pregnancies, monitoring and managing the progress of labour, specific medical problems during pregnancy, labour and the puerperium, family planning, regionalised perinatal care

1. 6
Monitoring the
condition of the
mother during
the first stage
of labour
Before you begin this unit, please take the MONITORING LABOUR
corresponding test at the end of the book to
assess your knowledge of the subject matter. You
should redo the test after you’ve worked through 6-1 What is labour?
the unit, to evaluate what you have learned.
Labour is the process whereby the fetus
and the placenta are delivered. The uterine
Objectives contractions cause the cervix to dilate and
eventually push the fetus and placenta through
and out of the vagina.
When you have completed this unit you
should be able to: 6-2 What are the stages of labour?
• Monitor the condition of the mother Labour is divided into three stages:
during the first stage of labour.
1. The first stage of labour.
• Record the clinical observations on the
2. The second stage of labour.
partogram. 3. The third stage of labour.
• Explain the clinical significance of the
Each stage of labour is important as it must
observations.
be correctly diagnosed and managed. There
• Manage any abnormalities which are are dangers to the mother in each of the three
detected. stages of labour.
Labour is divided into three stages.

2. MONITORING THE CONDITION OF THE MOTHER DURING THE FIRST STAGE OF LABOUR 133
6-3 What is the first stage of labour? •What is not normal and why is it not
normal?
The first stage of labour starts with the onset
2. Finally you must ask the question: What
of regular uterine contractions and ends when
must I do about the problem?
the cervix is fully dilated.
6-9 How is the condition of the
6-4 What must be monitored in
patient monitored?
the first stage of labour?
By regular observations of the following:
1. The condition of the mother.
2. The condition of the fetus. 1. The general condition of the patient.
3. The progress of labour. 2. Temperature.
3. Pulse rate.
6-5 What four questions should be asked 4. Blood pressure.
about each of these observations? 5. Urine output and urinalysis for protein and
ketones.
1. How often must the observations be done?
2. How are the findings recorded?
3. What is the clinical significance of the ASSESSING THE
findings?
4. What should be done if an observation is
GENERAL CONDITION
abnormal? OF THE PATIENT
6-6 What is the partogram?
6-10 Why is it important to observe
The partogram is a chart which shows the the general condition of the patient
progress of labour over time. It also displays during the first stage of labour?
observations reflecting the maternal and fetal
condition. The observations of every patient in If the general condition of the patient is not
the first stage of labour must be charted on a normal, there will usually be further abnormal
partogram. findings when the other observations are made.
6-11 When can the general condition of
All the observations of every patient in the first the patient be regarded as normal?
stage of labour must be recorded on a partogram.
A patient in the first stage of labour will
normally appear calm and relaxed between
6-7 What maternal observations contractions and does not look pale. During
are recorded on the partogram? contractions, her respiratory rate will increase
Notes on the general condition of the patient, and she will experience pain. However, she
as well as observations of the temperature, should not have pain between contractions.
pulse rate, blood pressure, urine volume and When a patient’s cervix is fully dilated, or
chemistry are recorded on the partogram. almost fully dilated, she becomes restless, may
vomit, and has an uncontrollable urge to bear
6-8 How should each observation down with contractions.
be assessed?
6-12 How often should the general
At the completion of any set of observations, condition of the patient be observed?
you must ask yourself the following questions:
The general condition of the patient should
1. Is everything normal? If the answer is no, be observed continuously, but noted specially
then you must ask: when other observations are made.

3. 134 MATERNAL CARE
6-13 When is the general condition 6-18 What may cause a pale face
of the patient abnormal? and mucous membranes?
When any of the following are present: This is usually due to either of the following:
1. Excessive anxiety. 1. Chronic anaemia, e.g. iron deficiency,
2. Severe, continuous pain. malaria, etc.
3. Severe exhaustion. 2. Blood loss, e.g. placenta praevia, abruptio
4. Dehydration. placentae or rupture of the uterus.
5. Marked pallor of the face and mucous
membranes. 6-19 Where must abnormalities in the
patient’s general condition be recorded?
6-14 What causes severe anxiety?
If the general condition of the patient
Anxiety is usually seen in primigravidas who: becomes abnormal, this must be noted in
the appropriate space at the bottom of the
1. Are not prepared for the process of labour
partogram as shown in figure 6-1.
and the labour ward.
2. Are not accompanied by a friend or family
member in the labour ward.
3. Cannot communicate due to language ASSESSING THE
differences. TEMPERATURE
6-15 What should you do if the patient
is very anxious and is experiencing 6-20 What is a normal temperature?
very painful contractions? The normal range of oral temperature is 36.0 to
1. The patient must be comforted and 37.0 °C. Therefore, a temperature higher than
reassured. If possible, someone she knows 37.0 °C is abnormal and is regarded as pyrexia.
should stay with her.
2. The patient must be offered appropriate 6-21 How often should you
pain relief. monitor the temperature?
Four-hourly, unless there is a particular reason
6-16 What causes severe, continuous to do so more frequently.
pain in the first stage of labour?
Severe, continuous pain always indicates that a 6-22 How is the temperature recorded?
complication is present, such as:
The temperature is recorded in the appropriate
1. Abruptio placentae. space on the partogram as shown in figure 6-1.
2. Rupture of the uterus.
3. An infection, such as acute pyelonephritis 6-23 What are the causes of
and chorioamnionitis. pyrexia during labour?
There are two main causes of a high maternal
6-17 When may severe exhaustion
temperature:
or dehydration occur?
1. Infection: This will most probably be in the
With a prolonged labour, e.g. with
urogenital tract, e.g. acute pyelonephritis
cephalopelvic disproportion.
or chorioamnionitis. However, it must be
remembered that any other infection may
be present during labour.

4. MONITORING THE CONDITION OF THE MOTHER DURING THE FIRST STAGE OF LABOUR 135
Figure 6-1: Recording maternal observations on the partogram
2. Maternal exhaustion: Dehydration causes with complications of immaturity in the
pyrexia. newborn infant may also result. If the
pyrexia is due to chorioamnionitis, the fetus
6-24 How should you manage is at high risk of becoming infected and may
a patient with pyrexia? present with pneumonia or septicaemia.
1. The cause of the high temperature must
be found and treated. It is particularly ASSESSING THE
important to look for acute pyelonephritis,
chorioamnionitis, and evidence of
PULSE RATE
maternal exhaustion. A high temperature
may also be due to an infection unrelated
6-26 What is the normal
to the pregnancy, e.g. pneumonia, viral
maternal pulse rate?
infections, malaria, etc.
2. The temperature may be brought down The normal range of the maternal pulse rate is
with paracetamol (e.g. Panado). 80 to 100 beats per minute.
6-25 What are the dangers of pyrexia? 6-27 How often should you
monitor the pulse rate?
1. To the mother: The temperature on its
own does not constitute a risk. However, if The pulse rate is monitored two-hourly during
the pyrexia is caused by an infection, the the latent phase of labour, and hourly during
infection may be dangerous to the mother. the active phase of the first stage of labour.
Fever may cause a patient to go into labour.
2. To the fetus: A high temperature can
cause fetal tachycardia. Preterm delivery

5. 136 MATERNAL CARE
6-28 How is the pulse rate recorded? 3. Any one of the hypertensive disorders of
pregnancy.
The pulse rate is recorded in the appropriate
space on the partogram as shown in figure 6-1.
6-35 What are the causes of
hypotension (low blood pressure)?
6-29 What are the causes of
a rapid pulse rate? 1. Some patients may normally have a low
blood pressure. Therefore, the blood
The commonest causes of a rapid pulse rate
pressure during labour must be compared
(tachycardia) are:
with that recorded during the antenatal
1. Anxiety. visits.
2. Pain. 2. Pressure of the uterus on the inferior vena
3. Pyrexia. cava when the patient lies on her back may
4. Exhaustion. decrease the venous return to the heart
5. Shock. and, thereby, cause the blood pressure to
fall. This is called supine hypotension.
6-30 What action should be taken 3. Shock. This is usually due to blood loss.
if the patient has tachycardia?
6-36 What are the risks of hypotension?
The cause of the tachycardia should be
determined and treated. 1. To the mother: If hypotension is due to
shock, the mother may suffer kidney
damage. Severe and uncorrected
ASSESSING THE hypotension may result in maternal death.
2. To the fetus: A fall in blood pressure results
BLOOD PRESSURE in decreased blood flow to the placenta,
reducing the supply of oxygen to the fetus.
This may cause fetal distress.
6-31 What is a normal blood pressure?
The normal range of blood pressure during the 6-37 What should you do for a
first stage of labour is 100/60 mm Hg or above, patient with hypotension?
but less than 140/90 mm Hg.
1. Establish the cause of the hypotension.
2. If the hypotension is due to the patient
6-32 How often should you
lying on her back, she should be turned
monitor the blood pressure?
onto her side. The blood pressure usually
Blood pressure should be monitored two- returns to normal within one or two
hourly during the latent phase of labour, and minutes. The fetal heart rate should then
hourly during the active phase of labour. be checked again.
3. If the hypotension is due to haemorrhage,
6-33 How is the blood pressure recorded? the patient must be resuscitated urgently
and be managed according to the cause of
The blood pressure is recorded in the the bleeding.
appropriate space on the partogram as shown
in figure 6-1.
6-38 How do you recognise shock?
6-34 What are the causes of Shock presents with one or more of the
hypertension (high blood pressure)? following features:
1. Anxiety. 1. Tachycardia.
2. Pain. 2. Hypotension.

6. MONITORING THE CONDITION OF THE MOTHER DURING THE FIRST STAGE OF LABOUR 137
3. Cold, sweaty skin. 6-43 What volume of urine passed indicates
oliguria (decreased urine output)?
6-39 What are the common causes of An amount of less than 20 ml per hour.
shock in the first stage of labour?
1. Shock during the first stage of labour is 6-44 What are the causes of oliguria?
almost always due to haemorrhage, for
1. Dehydration.
example:
2. Severe pre-eclampsia.
• Abruptio placentae.
3. Shock.
• Placenta praevia.
• A ruptured uterus. Patients suffering from any of these conditions
2. Infection as a cause of shock must always must have their urinary output accurately
be considered. monitored. An indwelling urinary catheter
must, therefore, be passed.
ASSESSING THE URINE NOTE The antidiuretic effect of
oxytocin may also cause oliguria.
6-40 What urine tests should The cause of the oliguria must be diagnosed
be done during labour? and treated.
1. Volume. 6-45 How can normal hydration
2. Protein. during labour be ensured?
3. Ketones.
1. If a vaginal delivery is expected, the patient
The presence and degree of proteinuria and should be encouraged to eat and drink
ketonuria is measured and graded with a during the latent phase of the first stage of
reagent strip, such as Dipstix. labour.
2. If a Caesarean section is expected, the
6-41 How often should you test the urine? patient must be kept nil per mouth while
1. Every four hours during the latent phase of in labour in preparation for surgery.
labour. 3. Low-risk patients must continue taking
2. Every two hours during the active phase of fluids, while patients with risk factors
labour. should be kept nil per mouth, during the
3. Each time the patient passes urine, if more active phase of the first stage of labour.
frequently than above. Intravenous fluids must be given to
patients with risk factors as well as to
patients with long labours.
6-42 How are the urinary
observations recorded?
The observations are recorded on the
Always ensure that a patient in labour has an
partogram: adequate fluid intake. Fluids should be given
intravenously if necessary.
1. Volume in ml.
2. Protein and ketones are recorded as 0 if
absent and 1+ to 4+ if present. 6-46 What is the significance of proteinuria?
The urinary observations should be recorded Proteinuria of more than a trace is never
on the partogram as shown in figure 6-1. normal. It is an important sign of:
1. Pre-eclampsia.
2. Urinary tract infection.

7. 138 MATERNAL CARE
3. Renal disease. 6-51 What are the effects of
maternal exhaustion?
When there is proteinuria, the urine must
always be examined for evidence of infection. 1. On the mother: Inadequate progress of
However, infection alone will not cause more labour due to poor uterine action in the first
than 1+ proteinuria. Proteinuria of 2+ or more stage, and poor maternal effort in bearing
should always be regarded as indicating pre- down during the second stage of labour.
eclampsia or chronic renal disease. 2. On the fetus: Fetal distress due to hypoxia.
This often results from incorrectly
6-47 What is the management of managed cephalopelvic disproportion.
a patient with proteinuria?
6-52 How can you prevent
The cause of the proteinuria must be deter-
maternal exhaustion?
mined, and the appropriate management given.
1. Make sure that the patient gets an
6-48 What is the clinical adequate intake of fluid and energy during
significance of ketonuria? labour. It may be necessary to give fluid
intravenously. Ringer’s lactate with 5%
Ketonuria is common in labour and may be dextrose will also ensure an adequate
normal. However, if a woman has ketonuria, energy supply to the patient.
it is important to look for signs of maternal 2. Ensure that the patient gets adequate
exhaustion. analgesia during labour.
3. Ensure that labour does not become
prolonged.
MATERNAL EXHAUSTION
6-53 How do you treat a patient
Maternal exhaustion is a term used to with maternal exhaustion?
describe a clinical condition consisting of
dehydration and exhaustion during prolonged If a patient has signs of maternal exhaustion
labour. It should not be confused with pain, then she should receive:
anxiety or shock. 1. An intravenous infusion, giving two litres
of Ringer’s lactate with 5% dextrose. The
6-49 How do you recognise first litre must be given quickly and the
maternal exhaustion? second litre given over two hours. It is
contra-indicated to give a patient in labour
The following physical signs may be present:
50 ml of 50% dextrose intravenously as this
1. Tachycardia. may be harmful to the fetus.
2. Pyrexia. 2. Adequate analgesia.
3. A dry mouth.
4. Oliguria.
5. Ketonuria. Maternal exhaustion may result in poor progress
of labour, while poor progress of labour may
6-50 What causes maternal exhaustion? result in maternal exhaustion.
A long labour with an insufficient supply of
6-54 Is it necessary for every patient to
fluid and energy to the patient.
receive intravenous fluid during labour?
No. Low-risk patients who are progressing
well in labour do not need intravenous fluid,
even if 1+ or 2+ ketonuria is present. If there

8. MONITORING THE CONDITION OF THE MOTHER DURING THE FIRST STAGE OF LABOUR 139
are no contraindications, patients should be appears anxious, has a dry mouth and a pulse
encouraged to take oral fluids during labour. rate of 120 beats per minute. She is able to pass
only 30 ml of urine which is dark in colour.
She has not passed any urine for the previous
CASE STUDY 1 few hours.
A patient is admitted at 32 weeks gestation. 1. What is the probable diagnosis?
She complains of lower abdominal pain and Maternal exhaustion due to a long labour
fever. On general examination her temperature with an inadequate fluid and energy intake.
is 38 °C. The diagnosis is confirmed by the presence of
maternal tachycardia and a dry mouth.
1. Does this patient have a
normal temperature? 2. What other findings would
No. She is pyrexial as her temperature is help confirm this diagnosis?
higher than 37 °C. Pyrexia and ketonuria.
2. Where should her 3. Does this patient have oliguria?
temperature be recorded?
Yes, as she obviously has passed less than 20 ml
In the appropriate space on the partogram. per hour during the past number of hours.
3. What are the most likely 4. Is ketonuria always abnormal?
causes of her pyrexia?
No, ketonuria on its own may be normal.
An acute pyelonephritis or chorioamnionitis
as she has pyrexia with lower abdominal pain.
5. How could maternal
exhaustion be avoided?
4. How should you manage
this patient’s pyrexia? By making sure that every patient receives an
adequate intake of fluid and energy during
Diagnose and treat the cause of the high labour. If a vaginal delivery is expected and no
temperature. The temperature should be high-risk factors are present, a patient should
brought down with paracetamol. continue to take fluids orally during the active
phase of the first stage of labour. Any patient
5. What are the dangers of with prolonged labour should receive fluids
maternal pyrexia to the fetus? intravenously.
Pyrexia may cause preterm labour, resulting
in the delivery of a preterm infant with all the 6. How should the patient’s
complications of immaturity. If the pyrexia exhaustion be treated?
is due to chorioamnionitis a preterm infant She should be given two litres of Ringer’s
will be born with a high risk of congenital lactate with 5% dextrose intravenously. The
pneumonia. first litre must be given quickly and the second
litre over two hours. In addition, adequate
analgesia should be given if needed.
CASE STUDY 2
A patient is admitted to hospital with a history
of labour for 24 hours. On admission she