Oxford Handbook of Midwifery (57 page)

NUTRITION IN LABOUR

227

• Narcotics used for pain relief
  
• Suspicious CTG recording
  
• Trial of labour, breech, twins, etc.
  
• Severe pre-eclampsia
  
• Antepartum haemorrhage.
  

Recommended reading

Campion P, McCormick C (2002).
Eating and Drinking in Labour
. Cheshire: Books for Midwives Press.

Young D (2007). Eating in labour: The issue deserves revisiting….
Birth
34
(4), 279–81.

1. Sleutal M, Golden S (1999). Fasting in labour: relic or requirement.
   Journal of Obstetric, Gynaecology and Neonatal Nursing
   28
   (5), 507–12.
   
2. O’Sullivan G, Liu b, Hart D, Seed P, Shennan A (2009). Effect of food intake during labour on obstetric outcome: randomized controlled trail.
   British Medical Journal
   338,
   b784.
   
3. Odent M (1998). Labouring women are not marathon runners.
   Practising Midwife
   1
   (9), 16–18.
   
4. Ophir E, Solt I, Odeh M, Bornstein J (2007). Water intoxication—a dangerous condition in labour and delivery rooms.
   Obstetrical and Gynaecological Survey
   62
   (11), 731–8.
   

   CHAPTER 11
   Normal labour: first stage
   

   228‌‌
   

   Assessing progress of labour
   

   The means by which the midwife evaluates and assesses the progress being made, will influence the care and responses she gives based on the individual needs and choices of women in her care.
   

   Assessing progress during labour should not just involve monitoring the vital signs, assessing cervical dilatation, and intensity of uterine contractions.
   ¹
   The midwife should also use her hands on skills such as abdominal palpation, observation of the mother’s changing physical and emotional behaviour, vocalizations, and positioning.
   ²
   Assessment of progress does not rely on just one set of parameters, consideration of all of the previous pointers makes for holistic assessment.
   

   First stage
   

   • Verbal and observational history from the woman at onset and throughout labour.
     
   • General examination and vital signs.
     
   • Abdominal palpation and inspection (initially to give a baseline for future care), uterine activity, establish position and descent.
     
   • Vaginal examination: the midwife should ensure that sound clinical reasons are indicated prior to the procedure to safeguard against unnecessary intervention, exposure, and distress for the mother.
     
   • Psychological and emotional aspects, coping strategies, and support from birth attendants.
     
   • Loss per vagina: show, colour of amniotic fluid, rupture of membranes, meconium.
     
   • Record all ongoing assessments, examinations and overview of care on a partogram.
     

     Assessment in labour is based on a medical environment and perspective, therefore the commonly used baselines, such as length of labour/latent phase of first stage/action curves, etc., may not reflect the normal physiology of labour. Some would suggest that this has led to increased intervention and ultimately a rise in LSCS rates.
     

     Latent phase
     

   • Definition of onset of the first stage varies considerably; it is a dynamic process, therefore individualized care is important.
     

     •
     A prolonged latent phase may mean that the onset could be up to
     

     3/4/5cm dilatation.
     

   • There is evidence to support: minimizing early admission to a labour ward, maximizing assessment at home or in assessment areas, encouraging women to stay at home during the early stages.
     ^3,4
     

     Active phase
     

   • No differences in outcome or LSCS rate have been reported with an action line, this describes the timing of intervention/augmentation that is considered during labour of 2 or 4h. Reduced intervention has been reported with a 4h action line.
     ⁵
     
   • Assuming a baseline rate of 0.5cm/h as opposed to 1cm/h reduces unnecessary interventions and accounts for the slower labours of primigravidas.
     ⁶
     

ASSESSING PROGRESS OF LABOUR

229

Second stage

1. Warren C (1999). Why should I do vaginal examinations?
   Practising Midwife
   2
   (6), 12–13.
   
2. Baker A, Kenner A (1993). Communication of pain: vocalization as an indicator of the stages of labour.
   Australian and New Zealand Journal of Obstetrics and Gynaecology
   33
   (4), 384–5.
   
3. Holmes P, Lawrence W, Oppenheimer W, Wu Wen S (2001). The relationship between cervical dilatation at initial presentation in labour and subsequent intervention
   . British Journal of Obstetrics and Gynaecology
   108
   , 1120–4.
   
4. McNiven P, Williams J, Hodnett E, Kaufman K, Hannah M (1998). An early labour assessment program: A randomised controlled trial
   . Birth
   25
   (1), 5–10.
   
5. Lavender T, Wallymahmed A, Walkinshaw S (1999). Managing labour using partograms with dif- ferent action lines: a prospective study of women’s views.
   Birth
   26
   (2), 89–96.
   
6. Enkin M, Kierse M, Neilson J, Crowther C, Duley L, Hodnett E (2000).
   A Guide to Effective care in Pregnancy and Childbirth
   . Oxford: Oxford University Press.
   
7. Simkin P, Ancheta R (2000).
   The Labour Progress Handbook
   . Oxford: Blackwell Science.
   

   CHAPTER 11
   Normal labour: first stage
   

   230‌‌
   

   Abdominal examination
   

   Abdominal palpation in labour is one of the key clinical skills that the midwife uses to assess progress and determine the position of the fetus. At the first contact with the woman in labour the midwife will carry out a detailed abdominal examination to establish the progress and individual status of the woman’s labour so far. This information will enable the midwife to plan care, discuss care with the mother and her partner. The examination should be carried out between contractions avoiding any dis- comfort to the woman. The midwife will then need to palpate the fundus during a contraction if they are present to determine their strength and length.
   

   In normal labour the findings should be:
   

   • Lie: longitudinal, an oblique or transverse lie should be detected early and the woman referred.
     
   • Presentation: should be cephalic, any other presentation should be reported immediately.
     
   • Position should be established (Fig. 11.1).
     
   • Engagement of the fetal head should be determined in fifths above the brim of the pelvis. In primiparous women this is usually engaged prior to labour. When the head is engaged the occipital protuberance is barely felt from above.
     
   • Auscultation of the fetal heart should be between 110 and 160 beats per minute (bpm).
     
   • For information on how to perform an abdominal palpation, b see Abdominal examination, p. 74.
     

     During labour an abdominal palpation is repeated at regular intervals as above to assess position, lie, and descent of the fetal head. In addition palpation of uterine contractions throughout labour is important:
     

   • Palpation of the fundus of the uterus with the palm of the hand during contractions provides valuable information on the progress of labour.
     
   • The frequency of contractions—if they are occurring very close together and strong, this may indicate fetal hypoxia; therefore careful monitoring of the fetal heart is advised. Hyperstimulation with oxytocics may be one of the reasons for this, in which case the
     

     infusion should be stopped and a review of progress should be made.
     

     Contractions may be weaker and less often, which will indicate slow progress or fatigue of the mother. Encouraging ambulation and/or
     

     repositioning may re-establish uterine activity.
     

   • The strength and length of the contractions—assessing the strength of contractions may be subjective as the midwife cannot relate to the intensity of the pain the woman may be experiencing in relation to what is felt abdominally. This will depend on the individual’s pain threshold and perception.
     
   • Contractions are described and recorded in three ways:
     
     • Mild—the fundus feels tense throughout the contraction, but can be easily indented with the fingertips.
       
     • Moderate—the fundus feels more tense throughout the contraction and it is difficult to indent it with the fingertips.
       
     • Strong—the fundus feels tense, hard and rigid during the contraction.
       

ABDOMINAL EXAMINATION

231