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4.4.1 Managing the first stage of labour (shouldn’t exceed 12hrs)

In the latent phase the cervix is 0-4cm dilated and contractions are weak, less than 2 in 10minutes.

1. Monitor the following every 1 hour:

Contractions:

• Frequency (once in how many minutes)

• Intensity (how strong) 

• Duration (How long does it last in seconds) 

Fetal Heart Rate: The normal FHR is 120 – 160 beats per minutes.

Any Sign of Emergency: E.g. difficulty in breathing, vaginal bleeding, convulsions or unconsciousness (Refer)

2. Monitor the following every 4 hours:

• Cervical dilatation in cm: - Unless indicated, do not do a VE more than once every 4 hrs.

• Temperature

• Pulse

• Blood Pressure

3. Record the time of rupture of the membranes and the colour of the amniotic fluid.

4. If after 8 hours the contractions are stronger and more frequent, but there is no progress in cervical dilatation with or without rapture of the membranes, refer immediately to a General Hospital. It is a case of non – progressive labour.

5. On the other hand, if after 8 hours, there is no increase in the intensity/frequency/duration contractions, and the membranes have not ruptured and there is no progress in cervical dilatation, ask the woman to relax. Advise her to send for you again when the pain/discomfort increase and/or there is vaginal bleeding, and/or the membranes ruptur

In the active phase: when the cervix is 5cm or more dilated. Start plotting on the PARTOGRAPH

1. Monitor the following every 30min.

• Frequency, intensity and duration of the contractions

• FHR

• Presence of any emergency sign

2. Monitor the following every 4hrs

• Cervical dilatation 

• Temperature

• Pulse

• Blood Pressure

4.4.2 Managing the Second Stage of Labour (Shouldn’t exceed 1hrs)

The following are signs of second stage of labour:-

1. Full dilatation of cervix

2. Bulging of the perineum 

3. Gaping of the anus

4. Presenting part appears

5. Expulsive uterine contractions

6. Retching and vomiting 

1. Monitor the following every 5 minutes 

• Frequency, duration and intensity of contractions

• FHR

• Perineal thinning and bulging

• Visible descent of foetal head during contractions

2. The upright positions such as standing, sitting, squatting and being on all fours makes pushing easier, therefore, if the woman finds it difficult to push, or there is slow descent of the head, you should help her to change position.

3. During the 2nd stage, the woman should be allowed to push down with contractions if she has the urge.

4. Do not ask the woman to hold her breath and bear down as this can be harmful by reducing the blood flow through the uterus and placenta, hence reducing the oxygen supply to the fetus.

5. Bearing down efforts are not required until the head has descended into the perineum. Therefore, the woman should not be advised to push actively until the fetal head is distending the perineum. Occasionally, the woman feels the urge to push before the cervix is fully dilated. This should be discouraged as it can result in oedema of the cervix which may delay the progress of labour.

6. To prevent pushing at the end of the first stage of labour (before full dilation), teach the woman to pant, i.e. to breath with an open mouth, take in 2 short breaths followed by a long breath out

7. Teach the woman to be aware of her normal breathing encourage her to breath out more slowly, making a sighing noise, and to relax with each breath.

8. It is not advisable to give the woman oxytocics to shorten the second stage

9. Ensure a controlled delivery of the head by taking the following precautions:

• Keep one hand gently on the head as it advances with the contractions.

• Support the perineum with the other hand during delivery and cover the anus with a pad held in position by the side of the hand.

• Leave the perineum visible (between the thumb and the index finger)

• Ask the mother to breathe deeply and steadily with her mouth open, and not to push during delivery of the head. Wipe the mouth and nose with sterile swab.

10.  Feel gently around the baby’s neck for the presence of the umbilical cord around the neck. If cord is presence:

• If it is loose around the neck, deliver the baby through the loop of the cord, or slip the cord over the baby’s head.

• If tight, clamp it and cut the cord, and then unwind it from around the neck.

11. To deliver the shoulders and rest of the body:

• Wait for spontaneous rotation which usually happens within 1-2 minutes

• Apply a gentle pressure downwards to deliver the anterior shoulder.

• Then lift the baby up, towards the mother’s abdomen, to deliver the posterior shoulder. The rest of the baby’s body follows smoothly.

• Place the baby on the mother’s abdomen.

12.  Note the time of delivery

13.  Give immediate newborn care

14.  Rule out the presence of another baby by palpating the abdomen and trying to feel for fetal parts.

15.  Follow these steps to cut the cord:

• Tie and cut the cord after 2-3 minutes during which time the cord will normally stop pulsating. It results in an increased amount of blood being transfused into the foetalcirculation and this help in avoiding neonatal anaemia.

• Put ties tightly around the cord at 2cm and 5cm from the baby’s abdomen.

• Cut between the ties with a sterile blade

• Look for oozing of blood from the stump. If there is oozing, place a second tie between the baby’s skin and the first tie. Leave the stump dry.

16. Place the baby on the mother’s chest for skin-to-skin contact.

17. Cover the baby to prevent loss of body heat. If the room is cool, use additional blankets to cover the mother and the baby.

18. Encourage the mother to initiate breastfeeding.