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1                                                   Monitoring the                                                   condi...
16    INTRAPAR TUM CARE1-3 What is the first stage of labour?               3. Finally you must ask the question: ‘What   ...
MONITORING THE CONDITION OF THE MOTHER DURING THE FIRST STAGE OF LABOUR           171-12 How often should the general     ...
18    INTRAPAR TUM CAREFigure 1-1: Recording maternal observations on the partogram1. Infection: This will most probably b...
MONITORING THE CONDITION OF THE MOTHER DURING THE FIRST STAGE OF LABOUR          19ASSESSING THE                          ...
20   INTRAPAR TUM CARE1-37 What should you do for a                  1-41 How often should you test the urine?mother with ...
MONITORING THE CONDITION OF THE MOTHER DURING THE FIRST STAGE OF LABOUR           21   drink during the latent phase of th...
22   INTRAPAR TUM CARE   contraindicated to give a woman in labour       5. What are the dangers of   50 ml of 50% dextros...
MONITORING THE CONDITION OF THE MOTHER DURING THE FIRST STAGE OF LABOUR   23with prolonged labour should receive fluidsint...
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Intrapartum Care: Monitoring the condition of the mother during the first stage of labour

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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

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Intrapartum Care: Monitoring the condition of the mother during the first stage of labour

  1. 1. 1 Monitoring the condition of the mother during the first stage of labourBefore you begin this unit, please take the MONITORING LABOURcorresponding test at the end of the book toassess your knowledge of the subject matter. Youshould redo the test after you’ve worked through 1-1 What is labour?the unit, to evaluate what you have learned Labour is the process whereby the fetus and the placenta are delivered. The uterine Objectives contractions cause the cervix to dilate and eventually push the fetus and placenta through the cervix and out of the vagina. Traditionally When you have completed this unit you labour is divided into different stages. should be able to: • Monitor the condition of the mother 1-2 What are the stages of labour? during the first stage of labour. Labour is divided into three stages: • Record the clinical observations on the 1. The first stage of labour. partogram. 2. The second stage of labour. • Explain the clinical significance of these 3. The third stage of labour. observations. Each stage of labour is important as it must • Manage any problems which are be correctly diagnosed and managed. There detected. are dangers to the mother in each of the three stages of labour. Labour is divided into three stages.
  2. 2. 16 INTRAPAR TUM CARE1-3 What is the first stage of labour? 3. Finally you must ask the question: ‘What must I do about the problem?’.The first stage of labour starts with the onsetof regular uterine contractions and ends whenthe cervix is fully dilated. 1-9 How is the condition of the mother monitored?1-4 What must be monitored in By regular observations of the following:the first stage of labour? 1. The general condition of the mother.1. The condition of the mother. 2. Temperature.2. The condition of the fetus. 3. Pulse rate.3. The progress of labour. 4. Blood pressure. 5. Urine output and urinalysis for protein and1-5 What four questions should be asked ketones.about each of these observations? Therefore, the general condition of the mother,1. How often must the observations be done? as well as observations of her temperature,2. How are the findings recorded? pulse rate, blood pressure, urine volume and3. What is the clinical significance of the chemistry must be recorded on the partogram. findings?4. What should be done if an observation is abnormal? ASSESSING THE GENERAL CONDITION1-6 What is the partogram? OF THE MOTHERThe partogram is a chart which shows theprogress of labour over time. It also displaysobservations reflecting the maternal and fetal 1-10 Why is it important to observecondition as well as the progress of labour. The the general condition of the motherobservations of every woman in the first stage during the first stage of labour?of labour must be charted on a partogram. If the general condition of the mother is not normal, there will usually be further abnormal1-7 What maternal observations findings when the other observations are made.are recorded on the partogram?All the maternal observations must be 1-11 When can the general condition ofcarefully recorded on the partogram. the mother be regarded as normal? A woman in the first stage of labour will All the observations of every mother in the first normally appear calm and relaxed between stage of labour must be recorded on a partogram. contractions and does not look pale. During contractions, her respiratory rate will increase and she will experience pain. However, she1-8 How should each should not have pain between contractions.observation be assessed? When a woman’s cervix is fully dilated, orAt the completion of any set of observations, almost fully dilated, she becomes restless, mayyou must ask yourself the following questions: vomit, and has an uncontrollable urge to bear down with contractions.1. Is everything normal? If the answer is no, then you must ask:2. What is not normal and why is it not normal?
  3. 3. MONITORING THE CONDITION OF THE MOTHER DURING THE FIRST STAGE OF LABOUR 171-12 How often should the general 1-17 When may severe exhaustioncondition of the mother be observed? or dehydration occur?The general condition of the mother should With a prolonged labour, e.g. withbe observed continuously, but noted specially cephalopelvic disproportion.when other observations are made. 1-18 What may cause a pale face1-13 When is the general condition and mucous membranes?of the mother abnormal? This is usually due to either of the following:When any of the following are present: 1. Chronic anaemia, e.g. iron deficiency,1. Excessive anxiety. malaria, etc.2. Severe, continuous pain. 2. Blood loss, e.g. placenta praevia, abruptio3. Severe exhaustion. placentae or rupture of the uterus.4. Dehydration.5. Marked pallor of the face and mucous 1-19 Where must abnormalities in the membranes. mother’s general condition be recorded? If the general condition of the woman1-14 What causes severe anxiety? becomes abnormal, this must be noted inAnxiety is usually seen in primigravidas who: the appropriate space at the bottom of the partogram as shown in figure 1-1.1. Are not prepared for the process of labour and the labour ward.2. Are not accompanied by a friend or family member in the labour ward. ASSESSING THE3. Cannot communicate due to language TEMPERATURE differences.1-15 What should you do if the mother 1-20 What is a normal temperature?is very anxious and is experiencing The normal range of oral temperature is 36.0 tovery painful contractions? 37.0 °C. Therefore, a temperature higher than1. She must be comforted and reassured. If 37.0 °C is abnormal and is regarded as pyrexia. possible, someone she knows should stay with her. 1-21 How often should you2. She must be offered appropriate pain relief. monitor the temperature? Four hourly, unless there is a particular reason1-16 What causes severe, continuous to do so more frequently.pain in the first stage of labour?Severe, continuous pain always indicates that a 1-22 How is the temperature recorded?complication is present, such as: The temperature is recorded in the appropriate1. Abruptio placentae. space on the partogram as shown in figure 1-1.2. Rupture of the uterus.3. An infection, such as acute pyelonephritis 1-23 What are the causes of and chorioamnionitis. pyrexia during labour? There are two main causes of a high maternal temperature:
  4. 4. 18 INTRAPAR TUM CAREFigure 1-1: Recording maternal observations on the partogram1. Infection: This will most probably be in the 1-25 What are the dangers of pyrexia? urogenital tract, e.g. acute pyelonephritis 1. To the mother: The temperature, on its or chorioamnionitis. However, it must own, does not constitute a risk. However, be remembered that any other infection, if the pyrexia is caused by an infection, the unrelated to the pregnancy, may be present infection may be dangerous to the mother. during labour, e.g. pneumonia, viral Fever may cause a woman to go into labour. infections or malaria. 2. To the fetus: A high temperature can cause2. Maternal exhaustion: Dehydration causes fetal tachycardia (fast heart rate). Preterm pyrexia. delivery with complications of immaturity in the newborn infant may also result. If1-24 How should you manage the pyrexia is due to chorioamnionitis, thematernal pyrexia? fetus is at high risk of becoming infected1. The cause of the high temperature must and may present with pneumonia. be found and treated. It is particularly important to look for acute pyelonephritis, chorioamnionitis and evidence of maternal exhaustion.2. The temperature may be brought down with paracetamol (e.g. Panado).
  5. 5. MONITORING THE CONDITION OF THE MOTHER DURING THE FIRST STAGE OF LABOUR 19ASSESSING THE 1-32 How often should you monitor the blood pressure?PULSE RATE Blood pressure is monitored two-hourly during the latent phase of labour and hourly1-26 What is the normal during the active phase of labour.maternal pulse rate? 1-33 How is the blood pressure recorded?The normal range of the maternal pulse rate is80 to 100 beats per minute. The blood pressure is recorded in the appropriate space on the partogram as shown1-27 How often should you in figure 1-1.monitor the pulse rate? 1-34 What are the causes ofThe pulse rate is monitored two-hourly during hypertension (high blood pressure)?the latent phase of labour, and hourly duringthe active phase of the first stage of labour. 1. Anxiety. 2. Pain.1-28 How is the pulse rate recorded? 3. Any one of the hypertensive disorders of pregnancy.The pulse rate is recorded in the appropriatespace on the partogram as shown in figure 1-1. 1-35 What are the causes of hypotension (low blood pressure)?1-29 What are the causes ofa rapid pulse rate? 1. Some women may normally have a low blood pressure. Therefore, the bloodThe commonest causes of a rapid pulse rate pressure during labour must be compared(tachycardia) are: with that recorded during the antenatal1. Anxiety. visits.2. Pain 2. Pressure of the uterus on the inferior vena3. Pyrexia. cava when the woman lies on her back may4. Exhaustion. decrease the venous return to the heart5. Shock. and, thereby, cause the blood pressure to fall. This is called supine hypotension.1-30 What action should be taken if 3. Shock. This is usually due to blood loss.the mother has a fast heart rate? 1-36 What are the risks of hypotension?The cause of the tachycardia should bedetermined and treated. 1. To the mother: If hypotension is due to shock, the mother may suffer kidney damage. Severe and uncorrectedASSESSING THE hypotension may result in maternal death. 2. To the fetus: A fall in blood pressure resultsBLOOD PRESSURE in decreased blood flow to the placenta, reducing the supply of oxygen to the fetus. This may cause fetal distress due to hypoxia.1-31 What is a normal blood pressure?The normal range of blood pressure during thefirst stage of labour is 100/60 mm Hg or above,but less than 140/90 mm Hg.
  6. 6. 20 INTRAPAR TUM CARE1-37 What should you do for a 1-41 How often should you test the urine?mother with hypotension? 1. Every four hours during the latent phase of1. Establish the cause of the hypotension. labour.2. If the hypotension is due to the woman 2. Every two hours during the active phase of lying on her back, she should be turned labour. onto her side. The blood pressure usually 3. Each time the woman passes urine, if more returns to normal within one to two frequently than above. minutes. The fetal heart rate should then be checked again. 1-42 How are the urinary3. If the hypotension is due to haemorrhage, observations recorded? the woman must be resuscitated urgently and be managed according to the cause of The observations are recorded on the the bleeding. partogram: 1. Volume in ml.1-38 How do you recognise shock? 2. Protein and ketones are recorded as 0 if absent and 1+ to 4+ if present.Shock presents with one or more of thefollowing features: The urinary observations should be recorded on the partogram as shown in figure 1-1.1. Tachycardia.2. Hypotension. NOTE If the reagent strip also tests for blood and3. The skin feels cold and sweaty. glucose, this information should be recorded on the partogram. However, microscopic1-39 What are the common causes of hematuria is often present during labour andshock in the first stage of labour? most women with an infusion containing 5% dextrose will have glucosuria present.1. Shock during the first stage of labour is almost always due to haemorrhage, for 1-43 What volume of urine passed indicates example: oliguria (decreased urine output)? • Abruptio placentae. • Placenta praevia. An amount of less than 20 ml per hour. • A ruptured uterus.2. Infection as a cause of shock must always 1-44 What are the causes of oliguria? be considered. 1. Dehydration. 2. Severe pre-eclampsia.ASSESSING THE URINE 3. Shock. Women suffering from any of these conditions must have their urinary output accurately1-40 What urine tests should monitored. An indwelling urinary catheterbe done during labour? must, therefore, be passed.1. Volume. The cause of the oliguria must be diagnosed2. Protein. and treated.3. Ketones.The presence and degree of proteinuria and 1-45 How can normal hydrationketonuria is measured and graded with a during labour be ensured?reagent strip, e.g. Dipstix. 1. If a vaginal delivery is expected, the woman should be encouraged to eat and
  7. 7. MONITORING THE CONDITION OF THE MOTHER DURING THE FIRST STAGE OF LABOUR 21 drink during the latent phase of the first 1-48 How do you recognise stage of labour. maternal exhaustion?2. If a Caesarean section is expected during The following physical signs of maternal labour, the woman must be kept nil per exhaustion may be present: mouth while being prepared for surgery.3. Women who are at low risk of problems 1. Tachycardia. must continue taking fluids, while women 2. Pyrexia. with risk factors should be kept nil per 3. A dry mouth. mouth, during the active phase of the first 4. Oliguria. stage of labour. Intravenous fluids must be 5. Ketonuria. given to women with risk factors as well as to women with long labours. 1-49 What causes maternal exhaustion? A long labour with an insufficient supply of Always ensure that a mother in labour has an fluid and energy to the woman. adequate fluid intake. Fluids should be given intravenously if necessary. 1-50 What are the effects of maternal exhaustion?1-46 What is the significance of proteinuria? 1. On the mother: Inadequate progress of labour due to poor uterine action in the firstProteinuria of more than a trace is never stage, and poor maternal effort in bearingnormal. It is an important sign of: down during the second stage of labour.1. Pre-eclampsia. 2. On the fetus: Fetal distress due to hypoxia.2. Urinary tract infection. This often results from incorrectly3. Renal disease. managed cephalopelvic disproportion.When there is proteinuria, the urine mustalways be examined for evidence of infection. 1-51 How can you preventHowever, infection alone will not cause more maternal exhaustion?than 1+ proteinuria. Proteinuria of 2+ or more 1. Make sure that the woman gets anshould always be regarded as indicating pre- adequate intake of fluid and energy duringeclampsia or chronic renal disease. labour. It may be necessary to give fluid intravenously. Ringer’s lactate with 5%1-47 What is the clinical dextrose will also ensure an adequatesignificance of ketonuria? energy supply to the woman.Ketonuria is common in labour and may be 2. Ensure that the woman gets adequatenormal. However, if a woman has ketonuria, analgesia during labour.it is important to look for signs of maternal 3. Ensure that labour does not becomeexhaustion. prolonged. 1-52 How do you treat a motherMATERNAL EXHAUSTION with maternal exhaustion? If a woman has signs of maternal exhaustionMaternal exhaustion is a term used to then she should receive:describe a clinical condition, consisting of 1. An intravenous infusion, giving two litresdehydration and exhaustion during prolonged of Ringer’s lactate with 5% dextrose. Thelabour. It should not be confused with pain, first litre must be given quickly and theanxiety or shock. second litre given over two hours. It is
  8. 8. 22 INTRAPAR TUM CARE contraindicated to give a woman in labour 5. What are the dangers of 50 ml of 50% dextrose intravenously as this maternal pyrexia to the fetus? may be harmful to the fetus. Pyrexia may cause preterm labour, resulting2. Adequate analgesia. in the delivery of a preterm infant with all the complications of immaturity. If the pyrexia Maternal exhaustion may result in poor progress is due to chorioamnionitis a preterm infant of labour, while poor progress of labour may will be born with a high risk of congenital result in maternal exhaustion. pneumonia.1-53 Is it necessary for every mother to CASE STUDY 2receive intravenous fluid during labour?No. Low risk women who are progressing A woman is admitted to hospital with a historywell in labour do not need intravenous fluid, of labour for 24 hours. On admission sheeven if 1+ or 2+ ketonuria is present. If there appears anxious, has a dry mouth and a pulseare no contraindications, women should be rate of 120 beats per minute. She is able to passencouraged to take oral fluids during labour. only 30 ml of urine which is dark in colour. She had not passed any urine for the previous few hours.CASE STUDY 1 1. What is the probable diagnosis?A woman is admitted at 32 weeks gestation. Maternal exhaustion due to a long labourShe complains of lower abdominal pain and with an inadequate fluid and energy intake.fever. On general examination her temperature The diagnosis is confirmed by the presence ofis 38 °C. maternal tachycardia and a dry mouth.1. Does this woman have a 2. What other findings wouldnormal temperature? help confirm this diagnosis?No. She is pyrexial as her temperature is Pyrexia and ketonuria.higher than 37 °C. 3. Does this woman have oliguria?2. Where should hertemperature be recorded? Yes, as she obviously has passed less than 20 ml per hour during the past number of hours.In the appropriate space on the partogram. 4. Is ketonuria always abnormal?3. What are the most likelycauses of her pyrexia? No, ketonuria on its own may be normal.Acute pyelonephritis or chorioamnionitis asshe has pyrexia with lower abdominal pain. 5. How could maternal exhaustion be avoided?4. How should you manage By making sure that every woman receivesthis woman’s pyrexia? an adequate intake of fluid and energy during labour. If a vaginal delivery is expected and noDiagnose and treat the cause of the high high risk factors are present, a woman shouldtemperature. The temperature should be continue to take fluids orally during the activebrought down with paracetamol. phase of the first stage of labour. Any woman
  9. 9. MONITORING THE CONDITION OF THE MOTHER DURING THE FIRST STAGE OF LABOUR 23with prolonged labour should receive fluidsintravenously.6. How should the woman’sexhaustion be treated?She should be given two litres of Ringer’slactate with 5% dextrose intravenously. Thefirst litre must be given quickly and the secondlitre over two hours. In addition, adequateanalgesia should be given if needed.

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