Intrapartum Care was developed for doctors and advanced midwives who care for women who deliver in district hospitals. It contains theory chapters and skills workshops adapted from the labour chapters of Maternal Care. monitoring the mother, fetus, and progress of labour, the second and third stages of labour, managing pain, the puerperium and family planning

1. 3
Monitoring and
management
of the first
stage of labour
Before you begin this unit, please take the THE DIAGNOSIS
corresponding test at the end of the book to
assess your knowledge of the subject matter. You OF LABOUR
should redo the test after you’ve worked through
the unit, to evaluate what you have learned
3-1 When is a woman in labour?
A woman is in labour when she has both of the
Objectives following:
1. Regular uterine contractions with at least
When you have completed this unit you one contraction every 10 minutes.
should be able to: 2. Cervical changes (i.e. cervical effacement
• Monitor and manage the first stage of and/or dilatation) or rupture of the
membranes.
labour.
• Evaluate accurately the progress of
labour. THE TWO PHASES OF THE
• Know the importance of the alert and FIRST STAGE OF LABOUR
action lines on the partogram.
• Recognise poor progress during the first The first stage of labour can be divided into
stage of labour. two phases:
• Systematically evaluate a woman 1. The latent phase.
to determine the cause of the poor 2. The active phase.
progress in labour.
• Manage a woman with poor progress in The first stage of labour is divided into the latent
labour. phase and the active phase.
• Recognise women at increased risk of
prolapse of the umbilical cord.
• Manage a woman with cord prolapse.

2. MONITORING AND MANAGEMENT OF THE FIRST STAGE OF LABOUR 35
3-2 What do you understand by the latent MONITORING OF THE
phase of the first stage of labour?
FIRST STAGE OF LABOUR
1. The latent phase starts with the onset of
labour and ends when the patient’s cervix
is 3 cm dilated. With primigravidas the 3-4 What do you understand by a complete
cervix should also be fully effaced to physical examination during labour?
indicate that the latent phase has ended.
However, in a multigravida the cervix need 1. The routine observations (usually done
not be fully effaced. hourly or half hourly) of the condition of
2. During the latent phase, the cervix dilates the mother, the condition of the fetus, and
slowly. Although no time limit need be set the contractions.
for cervical dilatation, this phase does not 2. A careful abdominal examination.
normally last longer than eight hours. The 3. A careful vaginal examination.
time taken may vary widely. This examination is only complete when the
3. During the latent phase there is a findings have been charted on the partogram.
progressive increase in the duration and If the findings are abnormal, a plan must be
the frequency of uterine contractions. made regarding the further management of
the patient.
3-3 What do you understand by the
active phase of the first stage of labour? 3-5 When should you do a complete physical
1. This phase starts when the cervix is 3 cm examination on a woman in labour?
dilated and ends when the cervix is fully 1. On admission.
dilated. 2. During the latent phase: Four hours after
2. During the active phase, more rapid admission or when the woman starts
dilatation of the cervix occurs. to experience more painful, regular
3. The cervix should dilate at a rate of at least contractions.
1 cm per hour. 3. During the active phase: Four hourly,
provided all observations indicate that
NOTE Cervical dilatation of 4 cm rather than 3
progress is normal. If there is poor
cm is sometimes used to indicate progression progress, the next complete examination
to the active phase of the first stage of labour.
will usually have to be done after two
hours.
The average rate of dilatation of the cervix
during the active phase is at least 1.5 cm After the complete examination has been done
per hour in multigravidas and 1.2 cm in and an assessment made about the progress
primigravidas. However, the lower limit of of labour, a decision must be taken on when
the normal rate of cervical dilatation is 1 cm the next complete examination should be
per hour. done. The time of the next examination is
marked on the partogram with an arrow.
The next complete examination may, if the
The cervix should dilate at a rate of at least 1 cm circumstances demand it, be done sooner, but
per hour in the active phase of labour. not later than the time indicated.
3-6 How should progress during the
first stage of labour be monitored?
A partogram is used to monitor and record the
progress of labour.

3. 36 INTRAPAR TUM CARE
3-7 What is a partogram? for instrumental delivery and Caesarean
section.
A partogram is a chart on which the progress
2. The progress of labour is very slow when
of labour over time can be presented. You will
the graph of cervical dilatation crosses
notice that provision has been made on the
or falls on this line. When this occurs,
chart to record all the important observations
action must be taken in order to hasten the
regarding the condition of the mother, the
delivery of the infant.
condition of the fetus, and the progress of
labour.
An example of a partogram is shown in If the cervical dilatation falls on, or crosses, the
figure 3-1. action line of the partogram, a doctor must be
called to assess the patient.
3-8 What is the first oblique line
on the partogram called?
The alert line. It represents a rate of cervical MANAGEMENT OF A
dilatation of 1 cm per hour. PATIENT IN THE LATENT
PHASE OF THE FIRST
3-9 What is the importance of the alert line?
The alert line represents the minimum progress
STAGE OF LABOUR
in cervical dilatation which is acceptable during
the active phase of the first stage of labour. 3-12 What is the initial management of
a patient in the latent phase of labour?
3-10 What is the second oblique
line on the partogram called? When a woman is admitted in early labour,
and on examination everything is found
This line is called the action line. This line to be normal, only routine observations
follows the same slope as the alert line. The are done. The next complete examination
two lines are spaced four hours apart. is done four hours later, or sooner if the
woman starts to experience more regular
NOTE If the travelling time between a clinic or
and painful contractions. She should eat and
district hospital without Caesarean section
drink normally, and should be encouraged to
facilities and the next level of care is one
hour or more, a transfer line can be drawn
walk around. She need not be admitted to the
two hours after the alert line. This measure labour ward.
will allow for earlier transfer of patients and The latent phase of labour should not last
provide one to two hours for travelling time. longer than eight hours.
3-11 What is the importance
of the action line? The latent phase of labour should not last longer
than eight hours.
1. Any woman whose graph of the cervical
dilatation falls on or crosses the action
line, must have a complete examination 3-13 What should you do at the
by the doctor. Her further management second complete examination?
must be under the doctor’s supervision At this time, the following must be assessed.
and direction. If a woman is not already
in hospital, she will need to be transferred 1. The contractions: If the contractions have
into a hospital where there are facilities stopped the woman is no longer in labour,
and if the maternal and fetal conditions are

4. MONITORING AND MANAGEMENT OF THE FIRST STAGE OF LABOUR 37
Figure 3-1: An example of a partogram

5. 38 INTRAPAR TUM CARE
normal, she may be discharged. However, has been slow during the latent
if the contractions have remained regular, phase, it may be necessary to rupture
then you must assess the cervix. the membranes or to commence an
2. The cervix: oxytocin infusion if she is HIV positive.
• If the effacement and dilatation of
the cervix have remained unchanged,
the woman is probably not in true MANAGEMENT OF A
labour. If she is experiencing painful PATIENT IN THE ACTIVE
contractions, she should be given an
analgesic, e.g. pethidine 100 mg and PHASE OF THE FIRST
promethazine (Phenegan) 25 mg STAGE OF LABOUR
or hydroxyzine (Aterax) 100 mg by
intramuscular injection. Provided that When a woman is admitted in the active
all other observations are normal, the phase of labour, she will probably be in
next complete physical examination is normal labour. However, the possibility
planned for four hours later. of cephalopelvic disproportion must be
• If there has been progress in effacement considered, especially if she is unbooked.
and/or dilatation of the cervix, the
woman is in labour and, provided that
3-15 How do you manage a woman
all other observations are normal, the
who is in normal labour?
next complete examination is planned
for four hours later. If the cervix is 3 cm When the condition of the mother and the
or more dilated, the patient has now condition of the fetus are normal, and there
progressed to the active phase of the are no signs of cephalopelvic disproportion,
first stage of labour. the next complete examination must be done
four hours later. The cervical dilatation, in
3-14 What should you do if a woman has centimetres, is recorded on the alert line of
not progressed to the active phase of the partogram.
labour within eight hours after admission?
3-16 What represents normal progress
1. The contractions may have stopped, in
during the active phase of the first
which case the woman is not in labour. If
stage of labour on the partogram?
the membranes have not ruptured and if
there is no indication to induce labour, the 1. The recording of cervical dilatation at the
woman should be discharged. She should various vaginal examinations lie on or to
return when labour starts again. the left of the alert line. In other words
2. The woman may still be having regular cervical dilatation is at least 1 cm per hour.
contractions. In this case, further 2. There also is progressive descent of the
management depends upon the state of fetal head into the pelvis. This is detected
the cervix: by assessing the amount of the fetal head
• If there has been no progress in above the brim of the pelvis on abdominal
effacement and/or dilatation of the examination. Descent of the head during
cervix, the woman is probably not in the active phase of the first stage of labour
labour. The responsible doctor should may, however, occur late, especially in
see and assess her, in order to decide multigravidas.
whether labour should be induced.
• If there has been progressive effacement
and/or dilatation of the cervix, the
woman is in labour. If the progress

6. MONITORING AND MANAGEMENT OF THE FIRST STAGE OF LABOUR 39
the effectiveness of the measures taken to
With normal progress during the active phase the
correct the poor progress.
recordings of cervical dilatation lie on or to the 3. If a woman’s cervix is more than 6 cm
left of the alert line and there will be progressive dilated, the next complete examination
descent of the fetal head. would normally be done when the cervix
is expected to be fully dilated. However,
3-17 Why is it necessary to evaluate both the examination may need to be done
cervical dilatation and the descent of earlier if there are signs that the cervix is
the head in order to determine whether already fully dilated.
there has been progress in the active
phase of the first stage of labour? 3-19 When should you rupture
the woman’s membranes?
1. Cervical dilatation without associated
descent of the head does not necessarily 1. It is possible to reduce the risk of
indicate progress in labour. transferring HIV from a mother to her
2. Cervical dilatation may occur when there infant by keeping the duration of ruptured
are good contractions, in association with membranes as short as possible. Therefore
increasing caput succedaneum formation do not rupture the membranes of women
and moulding of the fetal skull, while whose HIV status is positive or unknown
the amount of fetal head palpable above if the membranes are still intact at the start
the brim of the pelvis remains the same. of the active phase of labour. The following
In these circumstances no real progress vaginal examination will not increase the
has occurred, because the head is not risk of infection if the membranes are
descending into the pelvis. intact. The next complete examination
3. The station of the presenting part of the should be done after two hours when the
head in relation to the ischial spines, as felt management should be as follows:
on vaginal examination, can also improve • With normal progress do not rupture
without further descent of the head and the membranes.
without real progress having occurred. • With poor progress the membranes
This is because of increasing caput should be ruptured and the next
succedaneum and moulding. examination performed four hours
later.
2. A woman who is HIV negative and in
Descent of the head is assessed on abdominal labour with a vertex presentation may have
and not on vaginal examination. her membranes ruptured with safety if:
• She is in the active phase of labour.
3-18 What circumstances will make it • The fetal head is 3/5 or less palpable
necessary to do vaginal examinations above the brim of the pelvis.
more frequently than four-hourly in the 3. After rupturing the membranes, carefully
active phase of the first stage of labour? feel around the fetal head to rule out the
possibility of a cord prolapse.
1. If cephalopelvic disproportion is
suspected, the next vaginal examination If the fetal head is 4/5 or more above the
must be done two hours later. pelvic brim (the pelvic inlet), and the cervix
2. If a complete examination has revealed is 6 cm or more dilated, it is safer to carefully
poor progress of labour, without the rupture the membranes than to allow them
presence of cephalopelvic disproportion, to rupture spontaneously. This will reduce the
the next complete examination should risk of cord prolapse.
also be done two hours later, to assess

7. 40 INTRAPAR TUM CARE
3-20 What should you do if a 3-23 What should you do if the graph shows
woman ruptures her membranes cervical dilatation crossing the alert line?
spontaneously during labour?
A systematic assessment of the patient must
1. If the fetal head is 4/5 or more palpable be made in order to determine the cause of the
above the pelvic brim, or if there is a poor progress in labour.
breech presentation, the woman is at high
risk for a cord prolapse. A sterile vaginal 3-24 How should you systematically
examination must, therefore, be done to examine a woman with poor progress in
rule out this possibility. the active phase of the first stage of labour?
2. If the fetal head is 3/5 or less palpable
above the pelvic brim, it is highly Step 1
unlikely that a cord prolapse might Firstly two questions must be asked:
happen. However, the fetal heart must be
auscultated to rule out the possibility of 1. Is the woman in the active phase of the first
fetal distress due to cord compression. stage of labour?
2. Are the membranes ruptured?
3-21 What are the advantages of If the answer to both questions is ‘yes’, proceed
rupturing a woman’s membranes? to step 2.
1. Rupture of the membranes acts as a When patients are HIV negative with
stimulus to labour, so that there is often intact membranes, artificial rupture of the
better progress. membranes should be done and a systematic
2. Meconium staining of the liquor will be assessment again made after two hours.
detected. When patients are HIV positive with
3. If the cord prolapses when the membranes intact membranes and with at least three
are ruptured, this can be detected contractions of 40 seconds (strong) or
immediately, and the appropriate more per 10 minutes present, a systematic
management can therefore be started assessment is again made after two hours.
without delay. Without contractions oxytocin can be used
It is important to make sure that the woman is carefully to augment the contractions and a
in the active phase of the first stage of labour systematic assessment again made two hours
before rupturing the membranes. after strong contractions have been achieved.
NOTE An alternative method with HIV positive
POOR PROGRESS IN THE patients would be to rupture membranes and
assess after two hours. With normal progress a
ACTIVE PHASE OF THE delivery would be achieved within four hours
of rupture of membranes. With no progress
FIRST STAGE OF LABOUR present a Caesarean section could be done
within four hours of rupture of membranes. The
transmission rate of HIV is significantly lower
3-22 How would you recognise poor if babies are born within four hours of rupture
progress in the active phase of labour? of membranes compared to longer periods
of labour with rupture of the membranes.
Poor progress is present when the graph shows
cervical dilatation crossing the alert line. In Step 2
other words, cervical dilatation in the active The cause of the poor progress of labour must
phase of the first stage of labour is less than be determined by examining the woman using
1 cm per hour. the ‘Rule of the four Ps’. The four Ps are:

8. MONITORING AND MANAGEMENT OF THE FIRST STAGE OF LABOUR 41
1. The patient. 3-26 How may problems with the
2. The powers. ‘powers’ cause poor progress of labour?
3. The passenger.
The ‘powers’ (i.e. the uterine contractions)
4. The passage.
may either be inadequate or ineffective. Any
patient in whom labour progresses normally
The cause of poor progress of the active phase has both adequate and effective contractions,
of the first stage of labour is determined by irrespective of the duration and frequency of
assessing the four Ps. contractions.
1. Inadequate uterine contractions: Inadequate
3-25 How may problems with the ‘patient’ uterine contractions can be the cause of
cause poor progress of labour and how poor progress of labour. Such contractions:
should these problems be managed? • Last less than 40 seconds, and/or
• There are fewer than two contractions
Any of the following factors may interfere with per 10 minutes.
the normal progress of labour. 2. Ineffective uterine contractions: The uterine
1. The patient needs pain relief: Women who contractions may be adequate but not
experience very painful contractions, effective, as poor progress can occur even
especially if associated with excessive in the presence of apparently good, painful
anxiety, may have poor progress of labour contractions (i.e. two or more in 10 minutes
as a result. Pain relief, emotional support with each contraction lasting 40 seconds
and reassurance can be of great value in or longer), without disproportion being
speeding up the progress of labour. present (i.e. no moulding of the fetal skull).
2. The patient has a full bladder: A full The problem of ineffective contractions
bladder not only causes mechanical occurs only in primigravidas. Any woman
obstruction, but also depresses uterine whose labour progresses normally must
muscle activity. A woman must be have effective uterine contractions.
encouraged to pass urine frequently but Dysfunctional uterine contractions are
may need catheterisation, and sometimes diagnosed when the uterine contractions
an indwelling catheter until after delivery. appear to be ineffective.
3. The patient is dehydrated: Dehydration
is recognised by the fact that the woman
3-27 How may problems with the
is thirsty, has a dry mouth, passes small
‘passenger’ cause poor progress
amounts of concentrated urine and may
of labour and how should these
have ketonuria. Dehydration must be
problems be managed?
corrected as it may be the cause of the
poor progress. With good care during The cause of poor progress of labour may be
labour the woman will not become due to a problem with the ‘passenger’ (i.e.
dehydrated, because she can eat and drink the fetus). These problems can be identified
during the latent phase of labour and by performing an abdominal examination
take oral fluids during the active phase of followed by a vaginal examination.
labour. If there is poor progress during On abdominal examination the following
the active phase of labour, an intravenous problems causing poor progress may be
infusion must be started. identified.

9. 42 INTRAPAR TUM CARE
1. The lie of the fetus is abnormal: If the lie of 1. The presenting part is abnormal: Vertex (i.e.
the fetus is transverse the woman will need occipital) presentation of the fetal head
a Caesarean section. is the most favourable presentation for
2. The presenting part of the fetus is abnormal: the normal progress of labour. With any
With a breech presentation, the woman other presentation of the fetal head in early
must be assessed by a doctor to decide labour (e.g. brow), there is no urgency
whether a vaginal delivery will be possible to interfere, as the presentation may
or whether a Caesarean section is required. become more favourable when the patient
If the presentation is cephalic, the part is in established labour. However, in
of the head which is presenting must established labour, if moulding is present
be determined on vaginal examination. in any presentation other than a vertex, a
Fetuses who present by the breech and Caesarean section will have to be done.
who comply with the criteria for vaginal 2. The position of the fetal head in relation to
delivery, are only delivered vaginally if the pelvis is abnormal: An occipito-anterior
there is normal progress during the first (right or left) is the most favourable
stage of labour. position for normal progress of labour.
3. Size of the fetus: A large fetus (i.e. estimated Positions other than this (i.e. left or
as 4 kg or more), with signs of cephalopelvic right occipito-posterior) will progress
disproportion (i.e. 2+ or 3+ moulding) must more slowly. Labour can be allowed to
be delivered by Caesarean section. continue provided there is progress, and
4. There are two or more fetuses: Poor progress no progressive evidence of cephalopelvic
may also occur in a woman with a multiple disproportion. The patient will also need
pregnancy, usually due to inadequate adequate pain relief and an intravenous
uterine contractions. infusion to prevent dehydration.
5. The fetal head has not engaged: The number 3. Cephalopelvic disproportion is present:
of fifths of the head palpable above the • The fetal head is examined for the
pelvic brim must always be assessed: amount of caput succedaneum present.
• Engagement has occurred only when Caput is not an accurate indicator of
2/5 or less of the head is palpable above disproportion as it can also be present
the brim of the pelvis. In this case the in the absence of disproportion, for
problem of cephalopelvic disproportion example, in a woman who bears down
at the pelvic inlet is excluded. before the cervix is fully dilated.
• With 3/5 or more of the head above the • The sutures are examined for
pelvic brim, plus 2+ or 3+ moulding, moulding, which is the best indication
a Caesarean section is indicated for of the presence of cephalopelvic
cephalopelvic disproportion at the disproportion. 3+ of moulding is a
pelvic inlet. definite sign of disproportion. In a
vertex presentation, the sagittal suture
is examined for moulding. The degree
An abdominal examination, to assess the lie and of moulding of the sagittal suture is
the presenting part of the fetus, as well as the recorded on the partogram.
amount of fetal head palpable above the pelvic • Improvement in the station of the
brim, must always be done before performing a presenting part (i.e. the level of the
vaginal examination. presenting part relative to the ischial
spines) is not a reliable method of
On vaginal examination the following problems assessing progress in labour. Rather,
causing poor progress may be identified. the descent and engagement of the
fetal head must be determined on
abdominal examination.

10. MONITORING AND MANAGEMENT OF THE FIRST STAGE OF LABOUR 43
3. If labour progresses satisfactorily following
Improvement in the station of the presenting
the action taken, labour is allowed to
part of the fetal head, in relation to the ischial continue. However, if poor progress
spines, is not a reliable method of assessing continues, or if the action line has been
progress in the first stage of labour. reached or crossed, the woman must be
examined by the responsible doctor who
3-28 How may problems with the ‘passage’ must then decide on further management.
cause poor progress in labour and how The following are examples of causes of
should these problems be managed? poor progress in labour together with their
The following problems with the ‘passage’ may management:
cause poor progress in labour:
1. The membranes are still intact: Should the Cause Action
membranes still be intact, they must be Cephalopelvic Caesarean section
ruptured and the patient reassessed after disproportion
four hours before poor progress can be An anxious woman Reassurance and
diagnosed. unable to cope analgesia
2. The pelvis is small: A pelvic assessment with painful
which shows a small pelvis, together with contractions
2+ or 3+ moulding of the fetal skull means
Inadequate uterine An oxytocin infusion
that there is cephalopelvic disproportion,
contractions
and is an indication for Caesarean section.
Occipito-posterior Analgesia and an
3-29 What are the two important position intravenous infusion
causes of poor progress of labour? Ineffective uterine Analgesia followed
contractions by an oxytocin
1. Cephalopelvic disproportion: This is a
infusion
dangerous condition if it is not recognised
early and not correctly managed.
2. Inadequate uterine action: This is a
common cause of poor progress in CEPHALOPELVIC
primigravidas. It can be easily corrected DISPROPORTION
with an oxytocin infusion.
3-30 What must be done after a woman has 3-31 How will you know when poor progress
been systematically evaluated to determine is due to cephalopelvic disproportion?
the cause of the poor progress of labour? This can be recognised by the following
1. The nurse attending to the woman must findings:
inform the doctor about the clinical 1. On abdominal examination, the fetal head
findings. Together they must decide on the is not engaged in the pelvis. Remember, this
cause of the slow progress and what action is diagnosed by finding 3/5 or more of the
must be taken to correct this problem. head palpable above the brim of the pelvis.
2. A decision must also be made as to when 2. On vaginal examination, there is severe
the next complete examination of the moulding (i.e. 3+) of the fetal skull. Severe
woman should be done. Usually this will moulding must always be regarded as
be in two hours, but sometimes in four serious, as it confirms that cephalopelvic
hours. This consultation may be done by disproportion is present.
telephone and it is not necessary for the
doctor to see the woman at this stage.

11. 44 INTRAPAR TUM CARE
Cephalopelvic disproportion may already be 3-34 What should you do if you
present when the patient is admitted. decide that the poor progress is due
to cephalopelvic disproportion?
A high fetal head (3/5 or more above the brim) 1. Once the diagnosis of cephalopelvic
on abdominal examination, with 3+ moulding disproportion has been made, the infant
on vaginal examination, indicates cephalopelvic must be delivered as soon as possible. This,
disproportion. therefore, means that a Caesarean section
will have to be done.
2. While the preparations for Caesarean
3-32 Does a woman’s cervix always dilate section are being made, it is of value to
at a rate slower than 1 cm per hour if both the mother and fetus to suppress
cephalopelvic disproportion is present? uterine contractions. This is done by giving
When there is cephalopelvic disproportion, the three nifedipine (Adalat) 10 mg capsules
cervix usually dilates at a rate slower than 1 cm by mouth (a total of 30 mg) provided that
per hour, but the cervix may dilate normally, there are no contraindications.
even though the fetal head remains high
due to cephalopelvic disproportion. This is a INADEQUATE
dangerous situation as it may be incorrectly
concluded that labour is progressing normally. UTERINE ACTION
3-33 What features would make
3-35 What should you do if you decide that
you diagnose cephalopelvic
the poor progress is due to inadequate
disproportion when the fetal head
or ineffective uterine contractions?
is not descending into the pelvis?
1. Provided there are no contraindications,
Often, especially in multiparous patients, the
the woman must be given an oxytocin
head does not descend into the pelvis until late
infusion in order to strengthen the
in the active phase of the first stage of labour.
contractions.
However, when the head does not descend into
2. The woman’s progress is reassessed after
the pelvis, you should look for possible causes:
two hours.
1. A malpresentation, e.g. a face or a brow 3. If cervical dilatation has proceeded at the
presentation. rate of 1 cm per hour or more, progress
2. Moulding (i.e. 2+ or 3+). has been satisfactory and labour is
If either of these are present, there is allowed to continue.
cephalopelvic disproportion, and a Caesarean 4. If cervical dilatation has been slower
section should be done. than 1 cm per hour once the woman has
adequate uterine contractions she must
On the other hand, labour can be allowed to be reassessed by the responsible doctor.
continue if: Cephalopelvic disproportion may be
• There is no malpresentation. present.
• There is no more than 1+ moulding. 5. If at this stage the woman is still in a
• The maternal and fetal conditions are peripheral clinic, there should be enough
good. time to refer her to hospital before the
action line is crossed.
The next complete physical examination must 6. Patients who complain of painful
be repeated within two hours. contractions need analgesia before
oxytocin is started.

12. MONITORING AND MANAGEMENT OF THE FIRST STAGE OF LABOUR 45
3-36 What are the contraindications to minute. The rate is increased in the same
the use of oxytocin in order to strengthen way as above until 30 drops per minute
contractions in the first stage of labour? are being given. This is the maximum
amount of oxytocin which should be used
1. Evidence of cephalopelvic disproportion.
during the first stage of labour.
Oxytocin must, therefore, not be given if
there is already moulding (i.e. 2+ or 3+) NOTE The starting dose of oxytocin is ONE
present. milliunit (mUnit) per minute and the maximum
2. Any patient with a scar of the uterus, e.g. dose 12 mU per minute which is line with
from a previous Caesarean section. international dose recommendations.
3. Any patient with a fetus in whom the
presenting part is not a vertex. 3-38 What are the effects of a long labour?
4. Multiparas with poor progress during the
active phase of labour of the first stage of Both the mother and fetus may be affected:
labour. 1. The mother: A woman in whom the
5. Grande multiparity during the latent or progress of labour is slow, is more likely to
active phase of the first stage of labour. become anxious and to be dehydrated. If
6. When there is fetal distress. the poor progress is due to cephalopelvic
7. Patients with poor kidney function or disproportion (i.e. obstructed labour), and
heart valve disease. labour is allowed to continue, then there is
Oxytocin has an antidiuretic effect, so that the danger that she may develop any or all
there is a danger of the patient developing of the following:
pulmonary oedema. Hyperstimulation must • A ruptured uterus.
be avoided if an oxytocin infusion is used. • A vesicovaginal fistula.
Five or more contractions in 10 minutes or • A rectovaginal fistula.
contractions lasting longer than 60 seconds 2. The fetus: A long labour can result in
indicate hyperstimulation. progressive fetal hypoxia, resulting in fetal
distress and eventually in intra-uterine
death.
3-37 How must oxytocin be
administered when it is used
during the first stage of labour? THE REFERRAL OF WOMEN
The following is a good method: WITH POOR PROGRESS
1. Begin with one unit of oxytocin in one DURING THE ACTIVE
litre of Plasmolyte B, Ringer’s lactate or
rehydration fluid. PHASE OF THE FIRST
2. Use a giving set which delivers 20 drops STAGE OF LABOUR
per ml.
3. Start with 15 drops per minute and
The guidelines for referral will vary
increase the rate at intervals of 30 minutes
from region to region, depending on the
to 30 drops, and then to 60 drops per
distances between clinics and hospitals,
minute, until the patient gets at least three
and the availability of transport. In general,
contractions lasting at least 40 seconds
arrangements must be made so that the
every 10 minutes.
woman will be under the care of the
4. If there are still inadequate contractions
responsible doctor by the time the graph shows
with one unit of oxytocin per litre at
cervical dilatation crossing the action line.
60 drops per minute, a new litre of
intravenous fluid containing eight units
per litre is started at a rate of 15 drops per

13. 46 INTRAPAR TUM CARE
3-39 What arrangements should This will prevent a cord prolapse when the
you make to ensure the woman’s membranes rupture.
safety during transfer to hospital, if
there is poor progress of labour? 3-43 Which women are at risk
1. An intravenous infusion must be started. of a prolapsed cord?
2. The woman must lie on her side while 1. Women in labour with an abnormal
being transferred to hospital. lie (e.g. transverse lie) or an abnormal
3. A nurse should accompany the woman, presentation (e.g. breech presentation).
unless there is a trained ambulance crew. 2. Women who rupture their membranes
4. If cephalopelvic disproportion is the when the fetal head is still not engaged (i.e.
cause of the poor progress of labour, the 4/5 or more above the pelvic brim, e.g. in a
contractions must be stopped. To stop grande multipara).
contractions, three nifedipine (Adalat) 10 3. Women with polyhydramnios where the
mg capsules per mouth (total of 30 mg) increased volume of liquor may wash the
can be taken. cord out of the uterus.
4. Women in preterm labour where the
presenting part is small relative to the
PROLAPSE OF THE pelvis when the membranes rupture.
UMBILICAL CORD 5. Women with a multiple pregnancy,
where preterm labour, abnormal lie and
polyhydramnios are common.
3-40 Why is prolapse of the umbilical
cord a serious complication? 3-44 What should be done when a
Because the flow of blood between the fetus woman, who is at high risk of prolapse
and placenta is severely reduced and may of the cord, ruptures her membranes?
stop completely, causing fetal distress and A sterile vaginal examination must
possibly fetal death. immediately be done to determine whether
the cord has prolapsed.
3-41 What is the difference between a
cord presentation and a cord prolapse? 3-45 What is the management
1. With a cord presentation, the umbilical of a prolapsed cord?
cord lies in front of the presenting part A vaginal examination must be done
with the membranes still intact. immediately:
2. With a cord prolapse, the cord lies in front
of the presenting part and the membranes 1. If the cervix is 9 cm or more dilated and
have ruptured. The loose cord may lie the fetal head is on the perineum, the
between the presenting part of the fetus woman must bear down and the infant
and the cervix, in the vagina or outside must be delivered as soon as possible.
the vagina. 2. Otherwise the woman must be managed as
follows:
• Replace the cord into the vagina or
3-42 How should a cord
cover it with a warm, wet towel.
presentation be managed?
• Give the woman mask oxygen and
If the cord is felt between the membranes and three nifedipine (Adalat) 10 mg
the presenting part of the fetus, if the fetus capsules per mouth (total of 30 mg) to
is alive and is viable and if the woman is in stop labour.
labour, a Caesarean section must be done.

14. MONITORING AND MANAGEMENT OF THE FIRST STAGE OF LABOUR 47
• Put a Foley catheter into the woman’s of labour, due to poor uterine contractions, is
bladder and fill the bladder with made and an oxytocin infusion is started to
500 ml saline. improve contractions.
• If the full bladder does not lift the
presenting part off the prolapsed cord, 1. Do you agree with the diagnosis
the presenting part must be pushed up of poor progress of labour?
by an assistant’s hand in the vagina,
and by turning the patient into the The diagnosis is incorrect as the woman is still
knee-chest position in the latent phase of the first stage of labour.
Poor progress of labour can only be diagnosed
in the active phase of labour.
3-46 Why should the cord be replaced in
the vagina or be covered by a warm towel?
2. Why can it be said with certainty that the
The cord must not be allowed to become woman is in the latent phase of labour?
cold or dry as this will produce vasospasm
and, thereby, further reduce the blood flow • The cervix is still less than 3 cm dilated.
through the cord. • The cervix is dilating slowly.
• The cervix is effacing.
• The frequency of the uterine
3-47 Why are oxygen and nifedipine given
contractions is increasing.
to a patient with a prolapsed cord?
1. Giving oxygen to the woman may improve 3. What is your assessment of
the oxygen supply to the fetus. the woman’s management?
2. Stopping uterine contractions will reduce
the pressure of the presenting part on the Apart from the wrong diagnosis, oxytocin
prolapsed cord. should not be given before the membranes
have been ruptured.
3-48 Should a Caesarean section be done
on all women with a prolapsed cord if the 4. Should the woman’s membranes
infant cannot be rapidly delivered vaginally? have been artificially ruptured when the
second vaginal examination was done?
No. A Caesarean section is only done if the
infant is potentially viable (28 weeks or more) No. If the maternal and fetal condition are
and the cord is still pulsating. Otherwise the good, you should wait until the cervix is 3 cm
infant should be delivered vaginally as the or more dilated. The membranes may also be
chances of survival are then extremely small. ruptured if the woman has been in the latent
phase of labour for eight hours without any
progress.
CASE STUDY 1
A primigravida woman at term, who is HIV
CASE STUDY 2
negative, is admitted to the labour ward. She has
one contraction, lasting 30 seconds, every 10 A woman at term is admitted in labour with a
minutes. Her cervix is 1 cm dilated and 1.5 cm vertex presentation. The cervix is already 4 cm
long. The maternal and fetal observations are dilated. The cervical dilatation is recorded on
normal. After four hours she is having two the alert line. At the next vaginal examination
contractions, each lasting 40 seconds, every 10 the cervix has dilated to 8 cm. Caput can be
minutes. On vaginal examination her cervix is palpated over the fetal skull. It is decided that
now 2 cm dilated and 0.5 cm long with bulging the progress is favourable and that the next
membranes. The diagnosis of poor progress

15. 48 INTRAPAR TUM CARE
vaginal examination should be done after a normal then the examination should also be
further four hours. repeated in two hours.
1. On admission, should the
woman’s cervical dilatation have CASE STUDY 3
been entered on the alert line?
Yes. The patient is in the active phase of the A primigravida woman at term is admitted in
first stage of labour as her cervix is 4 cm labour. At the first examination the fetal head
dilated. Therefore, the cervical dilatation was is 2/5 above the pelvic brim and the cervix is
correctly plotted on the alert line. The future 6 cm dilated. Three contractions in 10 minutes,
observations should fall on or to the left of each lasting 45 seconds, are palpated. At the
the alert line. next examination four hours later, the head
is still 2/5 above the brim and the cervix is
still 6 cm dilated. No moulding can be felt.
2. Do the findings of the second
The woman is still having three contractions
examination indicate normal
in 10 minutes, each lasting 45 seconds and
progress of labour?
complains that the contractions are painful.
Not necessarily, as no information is given Because there has been no progress in spite
about the amount of fetal head palpable above of painful contractions of adequate frequency
the pelvic brim. Cervical dilatation without and duration, it is decided that cephalopelvic
descent of the head does not always indicate disproportion is present and that, therefore, a
normal progress of labour. Caesarean section must be done.
3. Is normal cervical dilatation with 1. Do you agree that the poor
improvement in the station of the progress of labour is due to
presenting part possible if cephalopelvic cephalopelvic disproportion?
disproportion is present?
No. To diagnose poor progress due to
Yes. The uterine contractions cause an cephalopelvic disproportion, severe moulding
increasing amount of caput and moulding, (3+) must be present.
which is incorrectly interpreted as normal
progress of labour. In this case, caput was 2. What is most probably the reason
noted during the second examination. for the poor progress of labour?
However, further information about any
moulding and the amount of fetal head The patient is a primigravida with strong,
palpable above the pelvic brim are essential painful contractions and no signs of
before it can be decided whether normal cephalopelvic disproportion. A diagnosis of
progress is present or not. ineffective uterine contractions (dysfunctional
uterine contractions) can, therefore, be made
with confidence.
4. Was the correct decision made at the
time of the second examination to repeat
the vaginal examination after four hours? 3. What should be the management of
the woman’s poor progress of labour?
No. If the cervix is 8 cm dilated, the next
examination must be done two hours later, Firstly, the woman should be reassured
or even sooner if there are indications that and given analgesia with pethidine and
the woman’s cervix is fully dilated. If it is promethazine (Phenegan) or hydroxyzine
uncertain whether the progress of labour is (Aterax). Then an oxytocin infusion should be
started to make the contractions more effective.

16. MONITORING AND MANAGEMENT OF THE FIRST STAGE OF LABOUR 49
4. Why is reassuring the 1. Was the woman managed correctly
woman so important? when she crossed the alert line?
Anxious patients often progress slowly Yes. She was systematically examined and a
in labour and have painful contractions. diagnosis of slow progress of labour due to an
Emotional support during labour is a very occipito-posterior position was made.
important part of patient care.
2. What should be done if a long first
5. When must the next vaginal stage of labour is expected due to
examination be done? an occipito-posterior position?
The next vaginal examination should be An intravenous infusion must be started to
done two hours later to determine whether ensure that the woman does not become
the treatment has been effective. During the dehydrated. In addition, adequate analgesia
examination it is very important to exclude must be given.
cephalopelvic disproportion.
3. Was the woman correctly managed
when she reached the action line?
CASE STUDY 4 No. A doctor should have evaluated the
woman. Further management should have
A woman who is in labour at term has been under his/her direction.
progressed slowly and the alert line has been
crossed. During a systematic evaluation by
4. Under what conditions should the
the midwife for poor progress of labour, a
doctor allow labour to progress further?
diagnosis of an occipito-posterior position
is made. As the woman is making some If there is steady progress of labour, if the
progress, she decides to allow labour to maternal and fetal conditions are good, and
continue. After four hours the cervical there is less than 3+ moulding.
dilatation falls on the action line. Although
there is still slow progress, she again decides
to allow labour to continue and to repeat the
vaginal examination in a further two hours.