The Management of Normal Labour

The objective of intrapartum care is to deliver a healthy baby to a healthy mother. The preparation of the mother for the process of parturition begins well before the onset of labour. This includes antenatal care and antenatal classes to educate the parents-to-be. It is important for the mother and her partner to understand what actually happens during the various stages of labour.

The mother should be advised to come into hospital, or to call the midwife in the event of a home birth, when contractions are at regular 10?15 minute intervals, when there is a show or if and when the membranes rupture. If the mother is in early labour, she should be encouraged to take a shower and to empty her bowels and bladder. Shaving of the pubic hair is no longer considered necessary unless there is a likelihood of delivery by caesarean section, in which case the abdomen should be shaved down to the pubic hairline. It is common practice in the United Kingdom to organize ?domino? (dom iciliary in and out) deliveries, whereby the mother is discharged home 6 hours after delivery, provided that the delivery is uncomplicated.

   

Assessment On Admission

The Management of Normal Labour

When a woman is admitted in labour, a history is taken and an examination undertaken. The examination includes:

  • temperature,
  • pulse,
  • respiration,
  • blood pressure
  • and state of hydration;
  • the urine should be tested for glucose, ketone bodies and protein
  • examination of the abdomen: inspection, palpation and auscultation to determine the fetal lie, presentation and position, and the station of the presenting part, as well as to determine the presence of a fetal heartbeat
  • vaginal examination in labour should be performed only after cleansing of the vulva and introitus and using an aseptic technique with sterile gloves and an antiseptic cream. The following factors should be noted:

    • the consistency, effacement and dilatation of the cervix
    • whether the membranes are intact or ruptured and,
    • if ruptured, the colour of the amniotic fluid
    • nature and presentation of the presenting part
    • its relationship to the level of the ischial spines
    • assessment of the bony pelvis and in particular of the pelvic outlet.

First Stage Of Labour

The Management of Normal Labour

The principles are:
  • Observation and intervention if the labour becomes abnormal
  • Pain relief during labour and emotional support for the mother
  • Adequate hydration throughout labour.

The introduction of graphic records (partograms) has proved to be a major advance in the management of labour because it enables the early recognition of a labour that is becoming dysfunctional. The value of this type of record system is that it draws attention visually to any aberration from normal progress in labour.

The fetal heart rate is charted as beats/minute and decelerations of heart rate that occur during contractions are recorded by an arrow down to the lowest heart rate recorded on the partogram. These records are an adjunct to the actual recording of fetal heart rate.

The time of rupture of the membranes and the nature of the amniotic fluid (i.e. whether it is clear or meconium-stained) are also recorded. Moulding of the fetal head and the presence of caput are also noted they provide an indicator of obstructed labour.

Progress Of Labour

The Management of Normal Labour

Progress in labour is measured by assessing the rate of cervical dilatation and descent of the presenting part. To assess the rate of progress, vaginal examination should be performed on admission to hospital and every 4 hours during the first stage of labour. Cervical dilatation is recorded in centimetres along the scale of 0?10 of the cervicograph and a plot of the cervical dilatation is recorded. The graph for progress in a normal labour is recorded on the chart. Dilatation of the cervix occurs in two well-defined phases. The latent phase starts at the onset of labour and ends at 3 cm dilatation. This takes up some two thirds of the whole time of labour. This is followed by the active phase that extends from the end of the latent phase until the onset of the second stage when full cervical dilatation has been reached.

If the dilatation of the cervix lags more than two hours behind the expected rate of dilatation, the labour is considered to be abnormal. The rate of dilatation increases rapidly during the active phase of labour although it slows again near the phase of full cervical dilatation. The station of the head is also charted on the partogram using the following definitions

  • If the head is high, the level is five-fifths above the pelvic brim
  • If the head is just descending into the pelvic brim, it is four-fifths above the brim
  • If less than half the head is through the brim, it is three fifths above the brim
  • If more than half the head is through the brim it is two-fifths above the brim
  • If just the base of the skull is palpable abdominally, it is one-fifth above the brim.

The station of the head is plotted on the 0?5 gradation of the partogram.

Descent is also recorded by assessing the level of the presenting part above or below the level of the ischial spines at vaginal examination. The nature and frequency of the uterine contractions are recorded on the chart by shading in the number of contractions per 10 minutes. Dotted squares indicate contractions of less than 20 seconds duration, crosshatched squares are contractions between 20 and 40 seconds duration, while contractions lasting longer than 40 seconds are shown by complete shading of the squares.

 

Nutrition and Fluids

The Management of Normal Labour

If there is a likelihood that the mother will need operative delivery under general anaesthesia, then it is clearly important to avoid oral intake at any significant level during the first stage of labour. Delayed gastric emptying may result in vomiting and inhalation of vomitus if general anaesthesia for operative delivery is needed. On the other hand, most operative deliveries are now achieved under epidural anaesthesia and therefore there is a case for giving some fluids and light nutrition orally if labour is progressing normally and a vaginal delivery can be anticipated. Intravenous fluid replacement should be considered after 6 hours in labour if delivery is not imminent. Dehydration is the major cause of acidosis and ketosis.The classic signs of dehydration in labour include tachycardia, mild pyrexia and loss of tissue turgor. Remember that labour can be hard physical work and that the environmental temperature of delivery rooms is often raised to meet the needs of the baby rather than the mother, leading to considerable insensible fluid loss.If delivery is not imminent at the end of 6 hours, an intravenous infusion should be commenced.

Women's Health


The aim of this web site is to provide a general guide and it is not intended as a substitute for a consultation with an appropriate specialist in respect of individual care and treatment.

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