MANAGEMENT OF FIRST STAGE OF LABOR

•	Duration.
•	Principles of Management. 
•	Maternal monitoring.
•	Fetal monitoring.

Duration

1.	The first stage of labor is timed from the diagnosis of onset of labor to full dilatation of the cervix.

2.	Dilatation of the cervix occurs in two phases:

a.	Latent phase: 

i.	begins with the onset of labor and ends when the cervix is 3cm dilated.

ii.	this phase is variable in duration depending on the effacement of the cervix at the onset of labor and could be the longest phase if the Bishop score is initially low.

b.	Active phase: occurs from 3cm to full dilatation.

Principles of Management

1.	Provision of continuity of care and emotional support to the mother.

2.	Observation of the progress of labor with timely intervention if it becomes abnormal.

3.	Monitoring of fetal well-being.

4.	Adequate and appropriate pain relief consistent with the woman’s needs.

5.	Adequate hydration to prevent ketosis. 

Maternal monitoring

1.	General:

a.	Admit to labor ward with onset of labor.

b.	Set up I/V line for hydration.

c.	Avoid food consumption.

d.	Encourage ambulation. 

2.	Vital signs:

a.	½ hourly heart rate.

b.	4 hourly BP, temperature and urine output.

3.	Pain relief:

a.	TENS: transcutaneous electrical nerve stimulation.

b.	Entonox.

c.	Pethidine.

d.	Epidural analgesia.

4.	Vaginal examination:

a.	Palpate abdomen first to reassess presentation and engagement.

b.	4 hourly if adequate contractions are present.

c.	3 hourly when:

i.	on oxytocin for induction / augmentation.

ii.	evidence of fetal compromise.

iii.	weak contractions, when augmentation may be necessary. 

5.	A partogram is a graphical record of labor and it monitors the following:

a.	Instant visual assessment of the rate of cervical dilatation against an expected norm, according to the parity of the woman.

b.	Frequency and strength of contractions.

c.	Descent of the head in 5th palpable.

d.	Amount and color of the amniotic fluid draining.

e.	Basic parameters: blood pressure, pulse rate and temperature.

Fetal monitoring

1.	Intrapartum risk factors:

a.	Oligohydramnios.

b.	Meconium.

c.	Labor of more than eight hours.

d.	The use of epidurals and oxytocin.

e.	Induced labor.

2.	Ultrasound

a.	Confirmation of fetal viability if the fetal heart is difficult to auscultate. 

b.	Estimation of fetal size if the fetus is thought to be large or small for gestational age.

c.	Determination of presenting part when palpation is difficult.

d.	Position of fetal head when high in early labor.

e.	Location of placental edge if there is brisk bleeding in early labor to exclude placenta praevia.

f.	Determination of the amount of amniotic fluid if there is suspected rupture of membranes.

3.	Cardiotocography:

a.	Records the fetal heart rate on a paper strip.

b.	This is carried out either by an external abdominal transducer or a fetal scalp attachment inserted through the vagina. 

c.	The uterine contractions are also recorded on the same strip of paper by either external or internal monitoring.

4.	Fetal blood sampling:

a.	Capillary blood from scalp skin.

b.	Analyser: pH, BE, pO2, pCO2.

c.	Proven to reduce unnecessary LSCS in labor.