First Stage of Labour

  • Assess general condition and ensure that client is in labour
  • Review notes to identify any significant points in the history
  • Conduct a routine examination
    • Do a general examination and assess the emotional status of the client.
    • Test urine
    • Take temperature, pulse, respiration and blood pressure
    • Palpate the abdomen to assess fundal height, lie and presentation of fetus.
    • Monitor contractions
    • Do a vaginal examination and make an assessment of the pelvis.
  • Administer enema except where contraindicated e.g. P.V. bleeding, meconium stained liquor.
  • Keep accurate and up to date records.

Progress Charting (Use Partogram)

  • Palpate uterine contractions noting their strength, frequency and duration.
  • Auscultate and document the fetal heart every 30 minutes.
  • Check and record temperature, pulse, respiration and blood pressure hourly.
  • Test urine for acetone, sugar and albumin.
  • Do vaginal examination every 3-4 hours, or more often, if the clinical situation warrants it to assess descent of presenting part.
  • Observe any discharge from the vagina, colour of liquor and type of discharge e.g. mucopurulent.
  • Observe for signs of fetal and/or maternal distress e.g. meconium stained liquor, maternal fever, tachycardia, dehydration.

Additional Care During First Stage of Labour

  • Relieve pain and discomfort
  • Provide emotional support
  • Assist client to control pain through non-drug approaches.
  • Encourage ambulation until the later stages of labour.
  • Maintain adequate nutrition, especially hydration and energy level.

Signs of Fetal Distress

  • Fetal heart rate- Slow (less than 110 beats per minute (bpm)) or rapid (more than 160 bpm).
  • Meconium stained liquor in a cephalic presentation.
  • Excessive fetal movements.

Signs of Maternal Distress

  • Rising pulse rate ≥100 bpm
  • Vomiting
  • Scanty, concentrated urine, acetone in urine
  • Ketone smell of breath
  • Increase in temperature >37.4º C or 99.4ºF
  • Marked restlessness or anxiety
  • Dry lips and tongue- dehydration

Indications for Referral to Medical Officer during First Stage of Labour

  • Maternal distress
  • Fetal distress
  • Very strong uterine contractions with no progress
  • Malpresentation
  • Prolapse of umbilical cord
  • Prolonged first stage
    • 10 hours or more in multipara
    • 12 hours or more in primigravida
  • Prolonged rupture of membranes (over 24hrs)
  • Vaginal bleeding

Second Stage of Labour

The attendant should do the following:

  • Ensure that the delivery room is readied.
  • Check the contents of the delivery pack.
    Delivery Pack
    • 1 Large bowl
    • 1 Kidney dish
    • 2 Gallipots
    • 1 Placenta dish
    • 2 Swab holders
    • 2 Spencer Wells forceps
    • Cord scissors
    • Episiotomy scissors
    • 3 Dressing towels
    • 1 Gown
    • Gloves
  • Prepare for episiotomy if indicated
  • Prepare to receive baby
  • Maintain clear airway by suction if necessary as soon as head is delivered
  • Have oxygen ready for use
  • Prepare drugs - syntometrine 1 ampoule (or syntocinon 5-10 units for clients with elevated blood pressure); lignocaine 1 % and 2%
  • Conduct delivery in approved manner, giving oxytocic drug I.M. upon delivery of anterior shoulder.
  • Keep alert for obstetric emergencies such as post partum haemorrhage
  • Ensure that mother sees and holds the infant, identifies the gender of the infant; then place an identification tag on the infant’s limb.
  • Put infant to breast with skin to skin contact; allow to suckle as long as the infant wants.

Indications for Referral to Medical Officer during 2nd State of Labour

  • Abnormal bleeding
  • Loss of / irregularity of fetal heart beat
  • Abnormal contractile pattern of uterus
  • Lack of progress or descent of presenting part
  • Prolapse of the cord
  • Fresh meconium-stained liquor
  • Shoulder dystocia
  • Any condition which may arise suddenly and which the nurse or midwife is unable to manage

Third Stage of Labour

  • Watch for signs of placental separation
  • Assist mother to expel placenta. Exert gentle traction on the cord as the placenta is delivered.
  • Inspect placenta and membranes for completeness.
  • Measure or estimate and record blood loss.
  • Inspect vagina and cervix for lacerations.
  • Repair episiotomy or lacerations.
  • Clean perineum

Indication for Referral to Medical Officer during 3rd Stage of Labour

  • Retained or incomplete placenta or membranes
  • Haemorrhage from uterus or lacerations
  • Maternal shock
  • Severe lacerations or extended episiotomy
  • Elevated blood pressure (over 130 /90 mm of Hg)
  • Temperature above 37°C or 99.4°F
  • Respiratory distress in the newborn

Post-Partum Observation and Care

Observe and record for one hour after delivery the following:

  • Client’s general condition
  • Vital signs temperature, pulse, respiration and blood pressure
  • Amount and colour of vaginal blood loss
  • Height of fundus, state of contraction

Indications for Referral to Medical Officer

Any abnormality detected during the puerperium should be reported to the Medical Officer. These include:

  • Pyrexia 99.4°F or 38°C and over after the first 24 hours.
  • Offensive lochia.
  • Persistent red lochia.
  • Subinvolution of the uterus and tenderness.
  • Pain developing in pre-existing varicose veins.
  • Increase in blood pressure
  • Behavioral changes in the mother.
  • Mastitis
  • Urinary problems - incontinence.

Empty Bladder

If bladder is distended and the woman is unable to pass urine:

  • Encourage the woman to urinate
  • If she is unable to urinate, catheterize the bladder:
    • Wash hands
    • Clean urethral area with antiseptic o Put on clean gloves o Spread labia, clean area again o Insert urinary catheter o Measure urine and record amount o Remove catheter

Caribbean Public Health Agency © 2014