Management of first stage of labor Purposes:

1. 2. 3. 4. 5. 6. 7. To conduct safe and clean delivery To provide necessary and adequate help to mother in labor To prevent the mother from maternal distress To delivered normal, healthy and alive baby To maintain normal delivery within normal time period To identify danger signs during labor and to take corrective action To avoid and difficulties during labor

Principles:
1. Noninterference with watchful expectancy so as to prepare the mother for a smooth delivery in the second stage 2. To monitor carefully the progress of labor, maternal conditions and fetal behavior so as to detect deviation from the normal at the earliest possible moment 3. Care of Mother During Labor 1. Positon and posture: There is no such hard and fast rule for positioning in labor.If the mother is tired then she can take rest.In the upright position, the anterior posterior diameter of the brim enlarges slightly.Bending the back and drawing in the abdominal muscles will facilitate engagement of the head;this can also be helped by sitting in a low chair or in the bed leaning forwards during uterine contractions. 2. Cleaniness and comfort: Perineal Shave: Routine perineal shaving has not been carried out now a day but in some hospital it is also practicing. Research has shown that perineal shaving is unnecessary and does not improve infection rate. Dislike of the procedure and abrasions sustained cause discomfort many women and distract from the positive experience of labour.Trimming of vaginal hair for clear vision during labor. Bowel preparation: This is not a routine procedure but if there has been no bowel action for 24 hours or the rectum feels loaded on vaginal examination,the women should be consulted ans asked if she would like an enema or suppositories.There is no evidence to suggest a ful rectum causes delay in the progress of labour(Drayton 1990),but the women may be embarrashed if she fells she is likely to pass faeces during labour. Bath or shower:If a women has had no access to a bath or shower at home she may wish to use these facilities on admission to the hospital. For women in normal labour a warm bath (birthing pool) can be an effective form of pain relief that allows increased mobility with no increased incidence of adverse out come for mother or baby.The women may choose to rest in the bath for a long time.The midwife should invite the mother who is mobile to have a bath or shower whenever she wishes during normal labour.

Clothing:It is entirely depend upon the individual women what she wears in labour.If in hospital she may prefer to wear the loose gown offered or she may feel more comfortable wearing her own choice of clothing.There is no reason to restrict her choice. 3. Communication and environment:Prior to the admission to the hospital the women should have been given good information about the physical process of labour and should have considered what stratigies she may used to cope during the birth.It is essential that the labouring women is welcomed and encouraged to feel at ease,and most of all that the midwife spends time actively listening as the women recounts the details of the onset of labour. 4. Emotional support:The midwife should display a tolerant nonjudgemental attitude,ensuring that the women is accepted whatever her reaction to labour may be.Women who feels in control of their own bodies who retain control of their behaviour and who fee they have an active part in decision making have a more satisfactory birth experiences. 5. Infection prevention: Reduce the transfer of airborne organism Visitors control Personal hygiene of mother and her attendant Invasive procedure can be kept to a minimum as an intact skin provides an excellent barrier to organisms and it is important to protect its integrity,(eg I/V, fetal blood sampling etc) The fetal membranes should also be preserved intact unless there is a positive indication for ARM Minimize P/V examination 4 hours apart after active phase of labor 6. Nutrition: The women need in labor is for energy and it is carbohydrate that will provide it. Low fat foods such as toast, biscuit, cereals, yoghurt, fruits juice, tea, lemon sugar water milk, soup are easily digestible foods. Fluid should be encourage according to mother's interest and availability of fruits during labor. 7. Bladder care: The women should be encouraged to empty her bladde4r every 1-2 hourly during labor. A full bladder may also initially prevent the fetal head from entering the pelvic brim. In all cases of delay in labor the midwife should ascertain whether the bladder is ful and encourage the women to void regularly. If it is not possible for the women to use the toilet the midwife should provide privacy and ensure maximum comfort by placing the bedpan on a stool or chair or encouraging the women adopt a squatting position on the bed.

8. Observation: Mothers' reactions to labor: Accurate and easy to understand information to the women about the progress of labor will provide encouragement. Pulse rate: The pulse rate is a positive indicator of the general physical condition of the women. If rate is increase to more than 100 beats per minute it may be indicative of anxiety, pain, infection, ketoacidosis or haemorrhage. It usual record the pulse rate every 1-2 hours during early or latent phase of labour and every 30 minutes when labour is in advance or active phase of labour. Temperature: Pyrexia is indicative of infection or ketosis or may be associated with epidural analgesia. In normal labour the maternal temperature should be recorded at least every 4 hours. Blood pressure: Blood pressure is measure every 2-4 hours unless it is abnormal, in which case more frequent recording will be necessary depending on the individual situation. The blood pressure must also be monitored very closely following epidural or spinal anesthetics. Urinanalysis: Urine passed during labour should be tested for glucose, ketones may occur as a result of starvation or maternal distress when all available energy has been utilized. A low level of ketones is very common during labour and thought not t be significant. unless the non-diabetic mother has recently eaten a large quantity of carbohydrate or sugar, glucose is found in the urine only following intravenous administration of glucose. A trace of protein may be a contaminant following rupture of the membranes or a sign of a urinary infection, but more significant proteinuria may indicate preeclampsia. Fluid balance: A record should be kept be of all urine passed to ensure that the bladder is being emptied. If an intravenous infusion is in progress, the fluids administered must be recorded accurately .It is particularly important to note how much fluid remains if a bag is changed when only partially used. Abdominal examination and contractions: An initial abdominal examination is carried out when the midwife first examines the mother. This should be repeated at intervals throughout labour in order to assess the length, strength and frequency of contractions and the descent of the presenting part. Vaginal examination and progress of labour: Vaginal examination during labour should not be done frequently. it may be useful to do so when progress in doubt or another indication arise. usually after active phase it is done 4 hourly to assess progress of labour ie dilatation, effacement, station, moulding and liquor can be observe. Fetal heart rate: fetal heart rate is good indication of fetus in utero. It is observed an hourly in active phase of labour. It is maintain between 110-160 beat per minute. Obsreve signs of maternal distress: e.g. dry mouth, acetone urine , low BP, and fast and irregular pulse

9. pain management: Nonpharmacological pain management Pharmacological Nonpharmacological pain management:

Homeopathy: Homeopathic remedies are prepared form plant extracts and from minerals.Castro (1992) recommend that such solutions as aconitum to relieve anxiety and kali carbonicum to alleviate back pain during labour. Hydrotheraphy:Immersion in water during labour as a means of analgesia has been used for years(Forde etal 1999).Forde etal (1999) maintain that hydrotherapy has other benefits such as reduction in the length of labour and a lower incidence of genital tract trauma. Research by Moore (1997) has revealed that hydrotherapy during child birth has the flowing outcomes: Mother require less augmentation of labor The mother's experience was positively affected by hydrotherapy The use of analgesia was consistently lower in this group The need of pethidine and Entonox was significantly reduced Music therapy: There is little mention of this potentiality to reduce pain. TENS (Transcutaneous electrical nerve stimulation: It is a widely used, well appreciated and an effective method of pain relief. This effectiveness is related to the action of TENS, which stimulates the production of natural endorphins and enkephalins and also ability to impede incoming pain stimuli. Change position encourage mobility Encourage breathing technique back rub, massage, holding her hand sponging over the forehead Showing concerns with mother and relatives. Explain every thing what is going on. Pharmacological : Opiate drugs Inhalation analgesia Regional analgesia (Epidural) 10. Teaching about bearing down or pushing effort: Bearing should be prohibited during first stage of labor because the cervix is not fully dilated, the women pushes her uterus downwards and puts such great strain on the transverse cervical ligament, which may cause uterine prolapsed.

Summary of Supportive Care During Labour and Child Birth: Encourage the women to have personal support from a person of her choice through out labour and birth encourage good communication and support by staff: Explain procedures seek permission and discuss findings with the women Provide supportive, encouraging atmosphere for birth, respectful of the women's wishes Ensure privacy and confidentiality Maintain cleanliness of the women and her environment: -Encourage the women to wash herself or bath shower at the onset of labour -wash the vulval and perineal areas before each examination -Wash your hands with soap before and after each examination -Ensure cleanliness of laboring and birthing areas -Cleans up spills immediately Help the women in labour who is anxious, fearful or in pain -Give her praise, encouragement and reassurance -Give her information on the process and progress of her labour -Listen to the women and be sensitive to her feelings.

References: WHO, UNFPA, UNICEF, World Bank, Managing complications in pregnancy and child birth. WHO 2000 Fraser DM and Cooper MA. Myle's textbook for Midwives.14 th edition 2003. Tuitui,R.Mannual of midwifery intranatal2nd edition 2004 .Vidyarthi pustak bhandar, bhotahity kathmandu Subedi D.Hand book of nursing midwifery manual, Makalu book and ststionary, Putali sadak Kathmandu