How to Manage the First Stage of Labour

When managing the first stage of labour, you should keep to the following procedure, making sure you record your findings in a partogram:

• Admit the patient to the waiting room, reassure her, and introduce her to other patients.
• Reassure her and explain what is being done at every stage.
• Give her an enema only if she is in early labour(this will reduce the risk of faecal soiling and infection at delivery).
• The patient may have a warm bath and change into a hospital gown.
• Encourage her to walk about and empty her bladder frequently.
• Give her plenty of fluids with sugar or glucose as she has to work hard and needs the energy.
• Do not allow any solid foods as the stomach takes a long time to empty in labour.
• Should she need an operation and anaesthesia, the emptying of the stomach will be difficult and she might vomit and inhale the vomit.
• If she is in much pain and the delivery is still far off, give her a sedative.

Check the following regularly:

• Check the foetal heart rate half hourly or more often if you suspect distress
• Check uterine contractions (strength, type, frequency and duration) as well as maternal pulse, BP and temperature.
• Check the urine output and check for albumin and acetone if indicated every two hours.
• Every four hours check the level of the presenting part and the degree of dilatation of the cervix.
• Constantly check the woman’s reaction to labour and be aware of her needs, especially for pain relief. You can repeat pethidine 50 mg IM if cervical dilatation is still 5 cm or less. Do not give more pethidine if delivery is imminent as it depresses the baby’s respiration
• Towards the end of the first stage, she can rest on her side, or in any position she finds comfortable, for example, squatting.
• Discourage pushing or bearing down before the cervix is fully dilated 
• Early pushing only exhausts the woman and will cause oedema of the cervix and interfere with normal dilatation
• If the bladder is full and she cannot empty it on her own, catheterize her using aseptic technique.
• When the membranes rupture, usually at the end of the first stage, check the colour of the liquor for meconium staining, the foetal heart rate and do a vaginal examination to exclude prolapse of the cord.

Observations to record in the partogram

➢Vital signs

➢Blood pressure

➢ Details of vaginal examination

➢ Contraction strength and number of contractions in ten minutes

➢Fluid balance

➢ Urinalysis

➢Drugs administered

When observing the contractions, you should note the following:

• Uterine contraction duration, strength and frequency.
• In early labour the contractions are mild, lasting 20 to 30 seconds and are infrequent.
• As labour progresses, the contractions become stronger, lasting 40 to 50 seconds and are about three contractions per ten minutes.
• The uterus should always relax between contractions.
• The cervix dilates progressively from 4cm at a rate of approximately 1cm and 1.5cm hourly in primigravida and multigravida respectively.
• The descent of the presenting part can be noted by abdominal palpation or vaginal examination.
• Avoid unnecessary vaginal examination.
• Remember to allay the mother’s fears and reassure her throughout your examination and indeed throughout labour. A mother in labour needs to feel loved, cared for and to be treated with dignity.

Prevention of Infection

To prepare for clean delivery you should:

• Give an enema or suppositories
• Avoid shaving the pubic hair, given current HIV/AIDS prevalence rates.
• Allow the mother to have bath whenever she wishes as it is soothing during labour.
• Practice aseptic techniques through labour.
• Ensure a clean environment within and around the ward.

After conducting a thorough examination of the mother and recording your observations in the partogram, there are a number of things you can do to make her feel comfortable during her labour i.e. allow her to change position and move around, use back massage, have a chosen companion with her during labour, allow her to take fluids as required and return the placenta to parents if so desired and directed by the culture. However, do not forget to check on the fetus especially if you suspect.

What Happens in the Second Stage of Labour

As mentioned earlier, the second stage of labour begins with full dilatation of the cervix. It is the stage of descent and expulsion of the baby.

It normally lasts from one to two hours on average in primigravida, and half an hour in multipara.

If this stage goes beyond two hours it is considered abnormal.

The contractions become stronger, lasting 40 to 60 seconds, with a one-minute recovery.

The retracted and contracting uterus pushes the foetus down into the pelvis.

During the relaxation phase the pelvic floor pushes the presenting part up again but the retracted uterus does not allow all the progress achieved to be lost.

Progressively the presenting part moves down until it reaches the pelvic floor.

The presence of a foreign body in the vagina makes the woman want to bear down even against her will. 

The voluntary muscles of her abdomen and diaphragm help the uterus in the pushing.

As a contraction comes the mother should be instructed to take in a deep breath, hold it and then bear down.

These expulsive efforts are partially voluntary. The vagina widens to accommodate the baby. It is now a continuous cavity with the uterus. The presenting part may push out feces from the rectum as it goes through the vagina.

When the presenting part reaches the pelvic floor it starts stretching the vulva, causing much pain, especially in the primigravida.

For some time it keeps popping out during a contraction and receding back.

After some time it can no longer slip back. This is known as ‘crowning’. The head will have passed through the bony outlet of the pelvis. The perineum becomes stretched and paper-thin and it is at this stage that an episiotomy should be performed if necessary. The next contraction normally expels the presenting part.

What Happens in the Mechanism of the Second Stage of Labour

The mechanism of labor refers to a series of movements the fetus has to make to pass through the birth canal.

Lie

Lie means the relation of the fetus to the long axis of the uterus. It may be longitudinal, oblique or transverse.

Presentation

The presenting part of the foetus is that part which is in or over the pelvic brim. Its position is examined in relation to the cervix. It could be vertex, face, or a breech. However, 95% of all presentations are cephalic, and the presenting part is usually the vertex.

Attitude

The pelvis is a curved passage with different diameters at the inlet, mid-cavity and outlet.

The foetus, therefore, has to adapt itself to the shape, size, and curve of the pelvis at different levels as it descends.

To be able to manage labour skilfully, you need to understand the natural movements made by the baby so that, when assisting in delivery, you can follow the movements rather than oppose them. The factors, that influence the mechanism of labor, are known as the three ‘Ps’: power, passage, and passenger.

Power

The stronger the contraction in a well prepared mother, the better the outcome of labour.

Passage

The size, shape and resistance of the birth canal including the bony pelvis, cervix, vagina and pelvic floor may speed up or slow down the process of delivery. A gynaecoid pelvis and a fully dilated cervix speed up the process.

Passenger

This refers to the size, lie and presentation of the foetus, as well as the placenta and membranes.

For the foetus, a vertex presentation makes labour shorter as the presenting part fits well on the cervical Os and stimulates the cervix to dilate faster.

It is important to remember that descent occurs throughout and as mentioned earlier, ninety five per cent of all presentations are cephalic, and the presenting part is usually the vertex. 

This areas boundaries include the bregma or the anterior fontanel, the perietal eminences and the posterior fontanel.

The presenting diameter is, therefore, the smallest – 9.5cm. In order to present with the smallest diameter, the head must be well flexed on the neck with the chin touching the chest. 

As the leading part meets the resistance of the pelvic floor it rotates 1/8th forwards until it comes under the symphysis pubis.

The mechanism of labour in a cephalic vertex presentation includes the following steps:

➢Engagement and descent

➢Internal rotation

➢Birth by extension of the head

➢Restitution and external rotation

What Engagement and Descent Mean During Labour

Engagement is the descent of the presenting diameter through the pelvic brim.

The head usually engages late in pregnancy in the primigravida while in the multipara it does not engage till labour starts.

The head enters the pelvic brim in oblique diameter with sub occipital frontal diameter (10.5cm). With good uterine contraction, there is more flexion of the head. The head engages with suboccipital bregmatic (9.5 cms) oblique diameter of the pelvis brim.

Internal Rotation

The head rotates 1/8th of a circle. Such a rotation is achieved by the action of the uterine muscle pushing downwards. The pointed vertex presents on the broad levator ani muscle. When the vertex reaches the perineum, the occiput turns from the posterior to the anterior position.

Anteriorly there is more room for further descent. When the occiput is below the symphysispubis, crowning takes place.

Birth By Extension of the Head

Once the occiput has escaped from under the symphysis pubis, the head extends forward. The nape of the neck is pressed firmly against the pubic arch. This extension of the head causes the anterior part to stretch the perineum gradually.

Further extension allows the sinciput, face and chin to escape the perineum and the head is born by extension. Extension is the result of action from two forces. The abdominal and thoracic muscles exert downward pressure. The pelvic floor and perineum resist this pressure and push the head forward and upward through the weak area, which is the vagina.

What Restitution Means During Labour

The head turns 1/8 of the circle to the left, back to where it was before. This rotation takes place to undo the twist, which occurred during the previous internal rotation.

This ‘undoing of the twist’ is known as restitution.

What Internal Rotation of the shoulder mean during Labour

When the head is passing through the level of the ischial spines and the outlet in anterior posterior position, the shoulders enter in the oblique diameter of the pelvis and rotate forward 1/8 of a circle. The shoulders are now in the anterior posterior diameter of the outlet. The anterior shoulder escapes the symphysis pubis while the posterior shoulder sweeps the perineum.

What External Rotation of the Head Means During Labour

As the internal rotation of the shoulders takes place, the head, which has already been born, rotates 1/8 of a circle as in restitution. The head now lies in the lateral position.

Meaning Of Lateral Flexion During Labour/Birth

Following these movements the body bends sideways to follow the curve of the birth canal.

The anterior shoulder escapes under the symphysis pubis and the posterior shoulder sweeps the perineum. The body of the baby is born by lateral flexion.

To recap, the cardinal movements of labour in a vertex presentation are:

1. Engagement

2. Descent

3. Flexion

4. Internal rotation

5. Extension

6. External restitution of the head

7. Expulsion

An easy way to remember these movements is by use of the mnemonic device -‘ Every descent Family In Europe Eats Eggs’

Management of the Second Stage of Normal Labour

The signs of the second stage of labour

• Expulsive uterine contraction. This may happen in occipital posterior or when the head is deeply engaged with fully loaded rectum (in a case where the mother is not in second stage)
• A trickle of blood
• There may be no bleeding while the cervix is fully dilated
• Pouting and gaping of the anus
• Gaping of the vulva in primigravida. The vulva of multiparous will gape even in premature pushing
• Tenseness between the anus and coccyx
• Bulging of the perineum usually means delivery is imminent

Equipment required
in second stage of labour

You will need a trolley with a top and bottom shelf.

On the top shelf make sure you have:

• Sterile delivery pack
• Small bucket with 0.5% jik for decontaminating instruments
• Bucket with 0.5% jik for decontaminating linen
• A bucket with plastic bag for used swabs and gloves

On the bottom shelf you should have the following:

• Suturing pack
• Antiseptic solution
• Draw sheet and mackintosh
• Syntocinon drawn, in a receiver
• Lignocaine
• 5% dextrose solution 500mls
• Needles
• Branulars

Steps for the management of the second stage of labour:

• Explain the procedure to the mother and reassure her
• Ask your assistant to open and arrange the delivery pack while you scrub up.
• Gown and glove yourself methodically.
• Instruct your assistant to put the patient in the dorsal position.
• Swab the mother methodically.
• Lubricate your two fingers and perform vaginal examination to confirm second stage.
• You should also instruct your assistant to check the foetal heart beat after every contraction, the mother’s pulse after every ten minutes and to administer syntometrin after the delivery of the anterior shoulder
• Tell the patient to wait for a contraction. When it comes, she should take in a full breath, close her mouth and bear down as strongly as she can, then quickly take in another breath and bear down again.
• She should be able to make at least two efforts during each contraction and relax between contractions. Encourage her all the time and explain the progress being made towards the birth of her baby.
• Place the baby towel on the bed, with the scissors and two forceps for clamping the cord. Prepare two pieces of cotton wool for wiping the newborn’s eyes, some gauze for cleaning the airway and for a covering when cutting the cord.
• At this stage the head might start distending the perineum. The anus starts dilating and the head is seen at the vulva. It keeps receding between contractions.
• When the head distends the perineum check if the perineum is stretching well.
• Place the left hand on the advancing head with fingers spread equally over the vertex towards the bregma to stop any sudden explosive effort during and after crowning of the head. With the right hand guard the perineum, holding it with the pad.
• Check if the perineum is stretching. If not, give an episiotomy at the height of a contraction if there is any indication that the head is about to crown.

Crowning of the Head

Next is the crowning of the head.

The parietal eminences pass through the bony outlet. At this stage the head no longer recedes between contractions.

Tell the mother to stop pushing as this might lead to a rapid delivery of the head and consequent brain damage. Ask her to pant. Research has shown that a series of short pushes are more effective than a long pus.

It is really hard work! So keep encouraging the mother with kind words and warmth.

Extension of the head

Assist the extension by grasping the parietal eminences with your left hand. Let the head come out slowly and naturally. Feel for the cord around the baby’s neck. If it is there, slip it from the baby’s neck over the head. If it is too tight, place two artery forceps on the cord and cut it between them. When the nose and mouth come out, wipe away the mucus with a sterile swab.

By this point the whole head should be out. The head will have restituted and rotated spontaneously to face the mother’s left or right thigh. 

This shows you that the shoulders have descended and rotated to the anterior posterior diameter.

Delivering the Shoulders by Lateral Flexion of the Body

Place one hand above and one below the fontal head. Depress the head gently toward the anus/neck, making sure it is neither twisted nor bent sideways till the anterior shoulder is free.

The delivering of anterior shoulder

Remind your assistant to give syntometrine intramuscularly (in a single dose). Guide the head upwards in the direction of the mother’s abdomen.

The delivering of posterior shoulder

The posterior shoulder will escape smoothly over the perineum. The rest of the body will be born by lateral flexion. Ask your assistant for the time and note the time of birth. Place the baby at a slight slant to drain the mucous. Put the baby on the baby towel, clamp and cut the cord. Give the APGAR score to the baby. Show the baby to the mother to identify the sex of the baby.

Ask your assistant to continue with the immediate care of the baby. Continue with the delivery of the placenta by using control cord traction. Check the placenta for completeness and/or malformation. Measure blood loss.

Do the first examination of the baby. Weigh the baby. Do a post natal examination and record all the findings. Give the mother a hot drink and transfer her to the postnatal ward.

Read More