Principles of intrapartum skills
First-stage issues
Learning outcomes
Having read this chapter, the reader should be able to:
The National Institute for Health and Care Excellence (NICE 2014) advise that the first stage of labour has two phases – latent and established (active). NICE (2014) suggest that the latent phase is from the onset of painful contractions (although they may be irregular) and a time during which there are cervical changes including effacement and dilatation up to 4 cm. Thus an established first stage of labour is from when the cervix is 4 cm dilated and there are regular painful contractions. This chapter focuses on a selection of the skills used by the midwife when caring for a woman during the first stage of labour (some of which may also be used at other times, e.g. second stage of labour). The chapter begins with a discussion of the definition of latent and active phases as progress is assessed on the basis of how these are defined. The use of different positions the woman can adopt follows and concludes with some of the skills used during the first stage of labour. The skills reviewed are examination per vaginam, often referred to as a vaginal examination (VE), amniotomy (artificial rupture of membranes, ARM), and application of a fetal scalp electrode (FSE) which may occur during a VE. It is recognized that the midwife uses other important skills during labour, in particular communication with and observation of the woman, as much information can be gleaned from this. However, this is not discussed within this text.
The latent and established phases of the first stage of labour and progress of labour
While the first stage of labour is classified as having latent and established phases, there is no universal agreement as to when one phase ends and the other begins, which makes assessing progress difficult. Women who present to hospital in the latent phase are often encouraged to go home and wait for labour to establish. NICE (2014) provide a very clear definition based around whether painful contractions are regular and whether the cervix is dilated from and beyond 4 cm. However, some multiparous women are assessed as being in the latent phase when they have painful contractions every 15 minutes and their cervix is 4 cm dilated as this may be considered a ‘multips os’. However, the woman herself may consider she is in labour and not wish to go home. Equally, some women will never have regular contractions yet still manage to birth their baby – are they in the established phase at any point? A medicalized definition of when the different phases of labour begin and end may be very different to the woman’s perception of her labour (RCM 2012a).
McDonald (2010) questions whether the latent phase actually exists or whether it is ‘pre-labour’ with the body undergoing the physical changes needed in preparation for birth, or is the latent phase the end of ‘pre-labour’. The RCM (2012a) suggest the latent phase and its duration and impact on labour is poorly understood. However, if the latent phase is taken into account when considering the overall length of the first stage, it can make the first stage appear longer and progress slower, leading to increased intervention (particularly if a partogram is used with alert and action lines).
NICE (2014) suggest the average length of time for the duration of labour for first labours is around 8 hours, and it is unusual for it to last longer than 18 hours, whereas for second and subsequent labours, the duration is around 5 hours and is unlikely to last over 12 hours. Thus they expect the duration of labour to vary between first and subsequent labours. However, they also state that delay in the established first stage is suspected when there is cervical dilatation of <2 cm in 4 hours for first and subsequent labours or there is slowing in the progress of labour for second and subsequent labours (NICE 2014). They also consider the amount of descent and rotation of the presenting part and any changes in the strength, duration, and frequency of uterine contractions should be considered (NICE 2014). However, a reduction in the frequency of contractions and slowing of cervical dilatation may be experienced as part of normal labour. Schmid & Downe (2010) suggest the woman will undergo a number of transition phases during labour which include a period when the cervix is dilated to 5–6 cm and again around 8–9 cm. During these transition periods, for some women, contractions slow and labour can slow down, perhaps even stop. Schmid & Downe (2010) suggest this is a time when the woman is able to restore her physical energy and as such should not be considered abnormal otherwise unnecessary intervention will occur. Zhang et al (2010) found it can take >6 hours for the cervix to dilate from 4 to 5 cm, and over 3 hours to move from 5–6 cm and suggest that with both first and subsequent labours the progress of cervical dilatation is the same up to 6 cm, after which the multiparous labour often progresses quicker than the first labour. They argue that, particularly for nulliparous women, labour does not progress in a consistent manner (Zhang et al 2010) yet women can birth their babies vaginally without adverse outcomes to mother or baby, a view supported by Incerti et al (2011). They also suggest that the established phase of labour should not be considered to begin until cervical dilatation is ≥6 cm, as before that no change in cervical dilatation is often normal (Zhang et al 2010).
Grasek et al (2014) studied the descent of the fetal head during term labour and calculated the median station for each centimetre of cervical dilatation for nulliparous and multiparous women. Nulliparous women had a median station of −3 at 0–1 cm, −2 at 2–3 cm, −1 at 4–5 cm, 0 at 6–8 cm, +1 at 9 cm, and +2 at 10 cm whereas multiparous had a slower descent of −3 at 0–3 cm, −2 at 4–5 cm, −1 at 6 cm, 0 at 7–9 cm, and +2 at 10 cm (Grasek et al 2014). Descent time between each of the stations was significantly quicker in multiparous women except for descent between +2 and +3.
When assessing progress, the midwife should take into account more than cervical dilatation but should also consider whether the position of the cervix has moved, whether it has ripened (softened), become effaced and whether the presenting part has rotated, flexed and descended (RCM 2012b). She should also consider where the woman is in her labour, what is happening with the contractions, whether the woman has entered a transition phase (as may be noted by her changing behaviours), and what definition of latent and established labour and ‘progress’ is being used. One advantage of assessing progress is that it allows time to transfer the woman to a facility with a higher level of care if delay is suspected (Downe et al 2013).
Maternal positioning
Women should be encouraged to adopt whichever positions they find comfortable during the first stage of labour (NICE 2014). Lawrence et al (2013) suggest that, given the freedom to do so, women will change position throughout labour and a change in positions should be encouraged to avoid the occurrence of pressure ulcer formation (see Chapter 53). For some women, changing position is more difficult due to constraints such as epidural anaesthesia or continuous fetal heart rate monitoring; however, the midwife can still enable the woman to make some positional changes, e.g. side-lying. The RCM (2012c) acknowledge that midwives should be proactive in demonstrating and encouraging different positions in labour, particularly for women with challenges such as continuous fetal heart rate monitoring and intravenous tubing. The environment is often the key to freedom of movement – one without a variety of furniture and props that encourage positional changes are more likely to have women who remain semi-reclined on the bed (Cutler 2012, RCM 2012c). When the bed is the dominant feature in the room women are likely to adopt this position; it is also a convenient position for the midwife when certain procedures are required (e.g. abdominal palpation, examination per vaginam). Lawrence et al (2013) suggest many women will be upright throughout labour but within the Western world, there is a preference for lying down when the cervix is around 5–6 cm. This would tie in with the transitional phase that occurs around this time in labour and the woman is in need of recharging her energy. Once this has happened the woman should be encouraged to be upright again. Cutler (2012) cautions midwives not to guide the woman onto the bed for their own convenience. Equally, after procedures such as abdominal palpation and VE undertaken with the woman on the bed, the midwife should encourage her to adopt her previous position.
Positions adopted can vary from upright (including walking, sitting, kneeling, squatting, all-fours) to recumbent (including supine, semi-recumbent, lateral, or side-lying); Chapman (2009) suggests that upright positions are more comfortable than sitting positions, with which the RCM (2012c) agrees. Upright positions encourage the fetus to descend into the pelvis (Lawrence et al 2013) and may also result in a shorter first stage, less severe pain, and less narcotic and epidural use (RCM 2012c). The National Childbirth Trust (NCT 2011) encourage women to keep moving in labour and also advocate rocking against the wall or holding on to an open door, swaying, walking around and up and down stairs, and the use of a birthing ball to remain upright. Simkin & Ancheta (2005) support the use of upright positions, suggesting moving around during labour can help the pelvic bones accommodate the fetus during its travels through the pelvis. Baker (2010) agrees, suggesting upright positions optimize the changes that occur within the pelvic joints during the end of pregnancy and labour (increasing pelvic diameters and causing slight changes in pelvic shape). Midwives advocate the use of stair walking or lifting one leg onto a surface so that the knee is higher than the other where labour appears to be slowing or asynclitism is present. The NCT (2011) suggest that if a woman has been mobilizing but is getting tired she could try kneeling or if she wants to sit, to ensure her feet are lower than her pelvis.
Squatting makes use of gravity and the pelvic changes (Sanderson 2012) but Cutler (2012) cautions that women in the Western world find it hard to maintain a squatting position as a result of shortening of the Achilles tendon from the use of chair sitting, wearing heeled shoes, and not using squatting for defaecation. For a woman to use squatting during labour, it is worth discussing this during pregnancy and encouraging her to practice, particularly if her partner is going to support her in the squat.
All-fours
Hunter et al (2007) found that women who were labouring with fetuses in an occipitoposterior position experienced less backache when adopting an all-fours position. This may also be achieved by leaning over a birthing ball to relieve pressure on the woman’s arms. It may be more comfortable for the woman if she has support/cushioning under her knees (e.g. pillow, padded mat). Hanson (2009) suggests an open knee–chest position (the buttocks are high, with the thighs at right angles to lower legs) can help to reduce the premature urge to push while a closed knee–chest position (the buttocks are lower to the ground, with knees and hips flexed and abducted beneath the abdomen) is useful if the cervix is oedematous.
Lateral (side-lying)
Ridley (2007) recommends women with an occipitoposterior position should lie on their side, ensuring it is the same side as the position of the fetal spine, to encourage fetal rotation to an occipitoanterior position (e.g. lie on right side for right occipitoposterior position), as this was found to increase the incidence of spontaneous vaginal delivery, decrease the length of labour, and reduce the risk of caesarean section compared with lying on the opposite side or any other position. This may be a way of alternating the position of a woman with restricted mobility, e.g. with epidural use, and relieving pressure from the buttocks, sacral area, and heels.
Supine
Women should be discouraged from lying supine. When the woman lies flat, the weight of the pregnant uterus can compress the major blood vessels (aortocaval compression) which can compromise maternal cardiac function and uterine blood flow. This reduces fetal oxygenation and causes alterations in the fetal acid–base status. If a woman wishes to lie supine, it is advisable to place a wedge under her right side to relieve the pressure off the major vessels. Contractions can appear to be less strong in the supine position compared to upright or lateral positions but if the woman becomes upright again, the contractions should return to their previous state (Lawrence et al 2013).
Semi-recumbent
Kerrigan (2006) suggests there is little evidence to support use of this position; however, some women may need to rest and adopt this position periodically during labour.
Examination per vaginam
A VE is an intimate, invasive procedure with the potential to cause distress and pain to the woman; thus it should only be undertaken when there is a clear clinical indication. Hassan et al (2012) remind us that for women, VE is a living experience that they may feel empowers them by increasing their self-confidence and belief in their childbearing ability or, equally, increase their feeling of vulnerability. While it is often undertaken to assess progress, it is imprecise when performed by different clinicians (RCM 2012b). There is also a risk of ascending infection with multiple examinations, particularly once the membranes have ruptured, although Cahill et al (2012) suggest the risk of maternal fever is not significantly increased by the number of VEs. While Lewin et al (2005) found women experience an average of three VEs during labour some women will have far more than this. Shepherd & Cheyne (2013) found the number of VEs undertaken increased as the length of time in labour in hospital increased, with 52% of women undergoing ≥3 VEs during labour with the most common rationale given by midwives was to assess labour progress.
Dixon & Foureur (2010) suggest that it is an intervention which disrupts the woman’s concentration and interferes with the labour rhythm, particularly as the woman may be required to change her position. There is no research-based information on which to make a recommendation for the timing and frequency of VEs during labour (RCM 2012b). Hassan et al (2012) caution that a VE should be done only when necessary and consideration should be given to the woman’s feelings and experiences during a VE. However, NICE (2014) recommend it should be undertaken 4-hourly, if there is concern about progress or in response to the woman’s wishes. An abdominal palpation should be undertaken prior to the VE so that the results of each can be correlated.
Indications
A VE may be undertaken prior to labour as part of an induction of labour procedure to insert a prostaglandin pessary or gel (Chapter 21) or to perform a membrane sweep (Chapter 29).
During labour, the midwife may undertake a VE to:
Contraindications
The midwife should not undertake a VE when there is:
This can be a very distressing procedure for some women and it is important the procedure is discussed with the woman before the VE is undertaken. Her informed consent should be obtained and the VE is not undertaken if the woman does not agree. The discussion should include the rationale for the procedure, what will happen, what is required of the woman, and confirmation that the VE will be stopped at any point if requested by the woman. The ideal time for much of this discussion is before the onset of labour but it should be repeated each time a VE is indicated. The discussion should also occur in a manner that allows the woman to ask questions and refuse the examination. Verbal and non-verbal communication should be continued during the procedure not only to provide the woman with information about what is happening but also so the midwife can recognize when the woman is experiencing discomfort/pain and requires the VE to end (Stewart 2005). Lewin et al (2005) found only 70% of women recalled a discussion of VE occurring prior the procedure, although 95% considered they were well informed of the findings. Only 40% felt they could refuse the examination and sadly, 22.2% felt their permission was not sought!
Information gained from undertaking an examination per vaginam
External genitalia
Prior to performing the VE the external genitalia should be observed for abnormalities such as varicosities, oedema, warts, signs of infection, and scarring, particularly if indicative of previous perineal or labial trauma or female genital mutilation. NICE (2014) advise that a VE may be very difficult in the presence of infibulated genital mutilation as may catheterization and applying a fetal scalp electrode. They further advise that if this is noted, a discussion should occur with the woman to inform her of the risks around delay in the second stage of labour and spontaneous ‘perineal’ trauma and the need for an anterior episiotomy and possibly defibulation in labour (NICE 2014), although this discussion should ideally take place during pregnancy.
If there is any discharge or bleeding from the vagina, the colour, consistency, amount and odour should be recorded. If the membranes have ruptured, amniotic fluid may be seen and the colour and odour should be noted. Clear liquor with a non-offensive odour is normal.
Vagina
The vagina should feel warm and moist, with soft distensible walls. A hot, dry vagina could be indicative of dehydration, infection or obstructed labour and a vagina that feels ‘tense’ may be associated with fear or previous scarring. The presence of varicosities, a cystocele, or a rectocele should be noted. A full rectum may be felt through the posterior vaginal wall which may lead the midwife to suggest the use of suppositories or an enema.
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