UNIT 3

Admission Procedure of Women in Labour:

When the patient arrives in the hospital she
should be welcome in friendly manner and
make feel that she is expected, colllect all
necessary record and fill all forms of
admission and assign the seat for woman and
short orientation about hospital rule and
regulation.
Purposes
-

To closely observe, monitor a woman

with a history of complication.
To manage and prevent complications.
To observe and report signs, symptoms
and general condition of patient.
To assist in a safe delivery of the baby.
To provide immediate care, safety and
comfort of the mother and the baby.
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Equipments
BP instrument/vital sign tray
Weighing machine
Vaginal examination tray
Measuring tape
Fetuscope
Enema set (if needed)
Sterile cotton swab (wet and dry).
Admission form / investigation forms
Light source
Procedure
1. Welcome in a family manner.
2. Observe her gait, posture and general
condition.
3. If the woman is in the end of 1st stage of
labour or in second stage, complete the
admission procedure quickly and prepare
for the delivery.
4. The procedure of admission is same as of
general patient.
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5.

6.
7.

8.

9.

Receptioning care should be done

according to the condition of labour and
admission procedure should be finished
accordingly.
Check the antenatal card if she attended
antenatal clinic.
Obtain immediately history on following:
Name, age, last menstrual period,
gravida, parity etc.
Time of onset of labour, its length,
strength and freuqncy of contraction.
Rupture of membranes, ie yes or not, if
yes, record the time and note the colour
of the draining amniotic fluid.
Perform rapid evaluation of the general
condition of the women including vital
signs.
Assess the woman whether she is in true
labor or not by taking a short history and by
examination and observation.

10. Assess the stages of labor if she is in true

labor by monitoring number, frequency and
duration of uterine contraction.
11. Assess fetal condition. Listen to the fetal
heart rate immediately after a contraction.
Count the fetal heart rate for a full minute
at least once every 30 minutes during the
active phase and every five-minute during
the second stage.
12. If the woman is on end of first stage of
labor, observe the vulva for appearance of
presenting part or prolapse of cord, hand
etc.
If presents with any abnormal presenting
part on admission:
-Shout for help
-Provide psychological support
-Assess the nature of uterine action, show,
presentation, cervical dilatation.
13. If the woman is in second stage of labor
and has crowning of presenting part
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immediately transfer her to labor room for

delivery.
14. It is an important to ensure that the woman
is in true labour before completing the
thorough admission procedures. If mother
is not in true labour; keep her couple of
hours for observation and send her home if
labour does not progress to true labour.
15. If mother is in fairly first stage of labour
then follow the thorough admission
procedure.
16. Ask women to empty bladder and ask to
collect urine sample for glucose, protein
test.
17. Measure height and weight and check vital
signs of woman and keep record clearly.
18. Help the women at the examination table
or bed.
19. Perform head to toe examination,
abdominal & vaginal examination. Keep
record clearly.
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20. Check for urine albumin if possible, check

for presence of edema.
21. Obtain consent for normal delivery or
operative delivery and treatment
22. Collect MCH/ANC record, all reports
(HB, Blood group, HBsag etc), pregnancy
history, problems, plan for delivery etc.
23. Obtain the family history, which includes
medical and obstetrical problems.
24. Obtain the detail history of woman e.g.
medical history, surgical history, previous
pregnancy and labour history.
25. Obtain detail history of present labor about
uterine contraction, rupture of membrane,
show, sleep, rest and food.
26. If mother is not attended antenatal clinic,
send the blood sample for routine
investigation e.g. HB blood group RH
factors etc.
27. Assign the bed for patient; orientate the
patient about hospital rules, and regulation
as well as ward.
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28. Explain her and her family about condition

of mother, baby & labour.
29. Keep all events recorded with full
signature, complete the admission form and
record on census and send the required
copy to the administrative office.
Assess state of woman in labour if woman has
regular painful uterine contraction with
bearing down and she is on end of 1 st stage of
labour immediately observe the vulva for
bulging and appearance of presenting part.
History taking of mother in labour
The history of previous labor and antenatal
status provide clue to know the women in
labour so detail personal, social, family and
obstetric history should be taken.
The history taking include:
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1. Personal or individual history

This includes bio-demographic information
about woman i.e. name, age, religion,
address, occupation, age of Marriage,
duration of Marriage etc.
2. Family History
a.
Medical History Any medical
disease e.g. diabetes and hypertensions
in the family members.
b.
Obstetrical history Such as past
pregnancies and delivery in family
member, e.g. twins, any congenital
malformation.
3. Past History
a.

Medical history The medical

history provides an ideas of the women's
eneral health i.e. anemia, hypertension,
diabetes, renal and heart disease, STD,
injuries to the pelvis etc.
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b.
-

Obstetric history
Number of pregnancies/abortion/still
birth
Birth weight, sex and condition of the
baby during delivery
Type of delivery/course of labour
Length of pregnancies, labour and
complication of mother and baby.
History of PPH, neonatal asphyxia,
Neonatal death and history of twin
pregnancy etc.

4. Present obstetric history

Date of the last menstrual period
Calculation of EDD and gestational age
Gravida and para.
Disorders of pregnancy
Date of quickening, fetal movement
Any significant treatment, antenatal care
received or not, number of ANC visit and
number of injection TT taken.
Plan for delivery
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Uterine contraction
Rupture of membranes
Presentation of show
Sleep, rest and food taken
5. Other Psychosocial condition
Physical preparation for child birth
Previous child birth experiences
Support from significant others
Emotional integrity
II. Assssment of Maternal and Fetal
Condition
Assessment of uterine contraction in Labor:
Tonus:
Intensity:
Duration:
Frequency:
Retraction
Examination of Woman in Labour

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Physical
examination
should
include
documentation of the patient's vital signs, the
fetus' presentation, and assessment of the fetal
well-being. The frequency, duration, and
intensity of uterine contractions should be
assessed, particularly the abdominal and
pelvic examinations in patients who present in
possible labor.
Prior to touching the woman a sound
explanation of the proposed examination and
their significance should be given. Verbal
consent should be obtained and recorded in the
notes.
a. General Examination of a woman in
labour
- The woman is asked to empty her
bladder and a specimen of urine is tested
for protein, glucose and ketones.
- Observe general appearance, stature and
any abnormalities.
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Measure height and weight

The woman's hands and feet are usually
examined for signs of edema. Slight
swelling of the feet and ankles is normal,
but preorbital edema or puffiness of the
fingers or face is not.
Assess general status of health and
nutrition, anemia, jaundice, cleanliness
etc.
Assess any signs of infection as
respiratory infection, gastroenteritis etc.
Assess vital sign and FHS, although not
during a uterine contraction that
increases the heart rate slightly.
Observe vulva for gapping of the vaginal
orifice or anus gapping, bulging of
perineum, show discharge, bleeding,
smell of discharge and swelling.

b. Abdominal Examination

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It is important to detect any abnormalities

early in labour to avoid serious maternal and
fetal complication. The first abdominal
examination is carried out when the midwife
first examines the mother on admission and
this may be repeated at intervals throughout
the labour in order to assess the descent of the
head, length, strength, duration and frequency
of contraction. This is measured by the
number of fifths palpable above the pelvic
brim and should be recorded on the
partograph.
Method
Inspection The size of the uterus is assessed
by approximately by observation. A full
bladder, distended colon or obesity may give a
false impression of fetal size. Inspect the
pregnant uterus for: Size and shape of uterus
Linea nigra, striae gravidarum
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Fetal movement
Any incisional scar mark on the
abdomen
Cleanliness or skin condition of
abdomen for evidence of Scabies or ring
worm.
Palpation
An abdominal palpation is done to identify the
fetal position, presentation, gestational age etc.
The midwifes age hands should be clean and
warm. Arms and hands should be relaxed and
the pads, not the tips of the fingers used with
delicate precision.
The abdomen is palpated by using lateral grip,
fundal grip, pelvic grip and pawlik's grip.
(Hands are moved smoothly over the abdomen
in a stroking motion in order to avoid causing
contractions).
Fundal Palpation

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Fundal Palpation or The initial maneuver

involves the examiner placing both of his/her
hands on each upper quadrant of the patient's
abdomen and gently palpating the fundus with
the tips of the fingers to define which fetal
pole is present in the fundus. The palpation is
done facing the patient's face watching the
womens reaction to the procedure. If it is the
fetus' head, it should feel hard and round. In a
breech presentation, a large, nodular body is
felt. Interpretation of the findings
-

Smooth hard and globular mass suggest

head
Broad, soft and irregular mass suggests
breech
In transverse lie higher of the fetal poles
are palpated in the fundal area.

Lateral Palpation

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Thus is used to locate the fetal back in order to

determine position. The position is done
facing the patient's face the hands are to be
placed flat on either side of the umbilicus to
palpate one after the other, the sides and front
of the uterus to find out the position of the
back limbs and the anterior shoulder. The back
is suggested by smooth curved and resistant
feel. The limb side is comparatively empty
and there are small knobs like irregular pats.
Walking the fingertips of both hands over the
abdomen from one side to the other is an
excellent method of locating the back. The
fingers should be dipped into the abdominal
wall deeply. The firm back can be
distinguished from the fluctuating amniotic
fluid and the receding unobbly small parts.
To make the back more prominent, fundal
pressure can be applied with one hand and the
other used to 'walk' over the abdomen.
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 Pelvic Palpation (First Pelvic grip)

Pelvic palpation will identify the pole of the
fetus in the pelvis. The midwife should ask the
woman the bend her knees slightly in order to
relax the abdominal muscles and also suggest
that she breath steadily; relaxation may be
helped if she signs out slowly.The examination
is done facing the patient's feet. Foru gingers
of both the hands are placed on either side of
the midline in the lower pole of the uterus and
parallel to the inguinal ligament. The fingers
are pressed downwards and backwards in a
manner of approximation of fingertips to
palpate the part occupying the lower pole of
the uterus.
If the head is presenting a hard mass with a
distinctive round, smooth surface will be felt,
the midwife should also estimate how much of
the head is palpable above the pelvic brim to
determine engagement.
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 Pawlik's grip (Second pelvic grip)

The midwife should ask the woman to bend
her knees slightly in order to relax the
abdominal muscles. The examination is done
facing towards the patient's face. The over
stretched thumb and four fingers of the right
hand are placed over the lower pole of the
uterus keeping the ulnar border of the palm on
the upper border of the symphysis pubis.
When the fingers and the thumb are
approximated, the presenting part is grasped
distinctly if not engaged, and also the mobility
from side to side is tested. In transverse lie,
Paulik's grip is empty.

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AuscultationListening to the fetal heart is an important part

of the process. The presence of fetal heart
sound indicates that the baby is alive. The
general health of the fetus can be estimated by
observing the rate and rhythm of FHS per
minutes. Generally FHS is double of mother's
pulse i.e. 130-140 beats per minutes. FHS can
be listen by Fetus cope stethoscope, Doppler
sonogram etc.
The fetuscope/Stethoscope is placed on the
mother abdomen, at right angles to the fetal
back.
The ear must be in close, firm contact with the
stethescope/Fetuscope but the hand should not
touch it while listening because then
extraneous sounds are produced.
The stethescope should be move about until
the point of maximum intensity is located
where the fetal heart is heard most clearly.
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In different positions of the vertex, the

location of the FHS depends on the position of
the back and the degree of descent of the head.
In occipito anterior position, The FHS is
located in the middle of the Spino Umbilical
line of the same side. In ocipito-lateral
position, it is heard more laterally and same
side. In left occipito posterior position, it is
most difficult to locate the FHS
Vaginal examination
Vaginal examination is method to assist the
condition of vagina, uterus, pelvis and
progress of labour. The examination is done
with the patient lying in dorsal position. The
woman's bladder should be empty as the head
may be displaced by a full bladder as well as
being very uncomfortable for the woman.
Purpose
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To assess the adequacy of the birth canal

in relation to the fetus.
To make a positive diagnosis of labour
To determine the presentation and
position of fetus
To monitor cervical dilatation and
effacement
To ascertain whether fore water have
ruptured or to rupture them artificially.
To assess the progress or delay in labour
To assess status of head and degree of
moulding.
To determine if cord prolapse is likely to
occur.
To find out the lie of 2nd twin in multiple
pregnancy
When some abnormalities of the fetus is
suspected e.g. anencephaly, hydrocephaly.
To apply fetal scalp electrode.
Contraindication

Antepartum haemorhage
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Amniotic fluid leaking

Placenta previa
Articles
Sterile gloves 1 pair
Sterile water
Sterile cotton balls to give perineal care
Bowl
Kidney tray
Perineal towel
Mackintosh
Light
Screen
Soap and running water for hand washing
Sim's vaginal spaculum if needed
Artery clamp
General instruction
The bladder should be empty
The fingers should not be withdrawn until
the required information has been obtained.
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Perineal care should be given before

performing vaginal examination
It should be restricted or limited after
membranes have raptures.
It should be avoided in case of ante partum
haemorrhage
Read the pervious findings, which serve as
a base line data.
Indication
1.
At the onset of labour, it is
done to conform the onset of labour, to
detect the position and presenting part.
2.
It also done for pelvic
assessment specially in primigravida during
the initial examination
3.
Assessments of progress of
labour e.g. dilation of cervix, effecement of
cervi and descent of head.
4.
Following the rapture of the
membrane.

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5.
6.

When there is doubt, regarding

the presenting
When there is doubt where the
2nd stage has began e.g persistent pushing at
the end of first stage
To determine the causes of
delay in labour
When some abnormalities of
the fetus is suspected eg. Anencephaly or
hydrocephaly.
To find out the lie, presentation
and membrane of 2nd twin in multiple
pregnancies.

7.
8.

9.

Procedure

Explain the procedure the

mother what you are going to do

Ask the woman to empty the

bladder

Maintain privacy

Position the women.

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Position the women in dorsal

recumbent position with knees flexed.

Drape the patient.

Wash hands and apply gloves

using sterile technique.

Observe the external genitalia

for the following.
a.
Sign of varicosities, edema, vulval
warts or sores.
b.
Scar from previous episiotomy, tear.
c.
Discharge or bleeding from vaginal
orifice.
d.
Colour and odour of amniotic fluid, if
membranes have ruptured.
Cleanse the vulva and perineal area.
Instruct the women to relax and begin
slow, rhythmic breathing.
Apply sterile antiseptic cream or
lubricant to index and middle fingers of
gloved hand.

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 Holding the labia apart with thumb and

index fingers of left hand, insert the
lubricated fingers into vagina, palm side
down, pressing down wards.
With the fingers inside, explore the
vagina for required information taking
care not to touch clitoris or anus. Note
the following:
a.
The feel on touch of vaginal wall.
Normally vagina is warm and moist. Hot
dry vagina is a sign of obstructed labour
and hot vagina is seen in maternal fever.
b.
Consistency of vaginal walls. Firm
and rigid walls suggest long labour. A
normal finding is soft vaginal walls.
Examine the cervix with the fingers in
the vagina turned upwards. Locate the
cervical os by sweeping the fingers from
side to side. Assess the cervix for
Effacement, dilatation, consistency Fore
waters and position and presenting part.
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a. Cervical dilatation is determined by the

circumference with the fingers and forming
mental image of the size.
If tight index finger about 1 cm
A loose index finger about 2 cm
2 fingers tight about 3-4 cm
2 fingers loose about 4-5 cm
3 fingers about 5-6 cm
4 fingers about 7-9 cm
b. To identify the cervical effacement, we
have to measure length/depth of cervix.
If more than 2 cm 0%
If 1.5 cm 25%
If 1cm 50%
If 0.5cm 70% to 100%
c. Consistency Normal cervix is soft,
elastic and well applied to the presenting
part in normal labour.

Identify the position by feeling the

features of the presenting part. To determine
the position of the foetal head, proceed as
follows:
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a.

Locate the posterior fontanel by

gently palpating the foetal head.
Distinguish the posterior fontanel, which is
triangle shaped, from the anterior fontanel,
which diamond is shaped.
b.
Determine the relationship of
posterior fontanel to the maternal pubic
bone. If the posterior fontanel is located just
under the maternal pubic bone, the foetal
position is anterior. If the posterior fontanel
is located toward the back of the maternal
pelvis, the foetal position is posterior.
Note: With the fingers follow the sagital suture
to feel the fontanel. Posterior fontanel will
be felt in a well-flexed head.

Identify the presentation by feeling the

hard bones of the vault of the skull, the
fontanel and sutures.
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Assess the level of presenting part in

relation to maternal ischial spines. The
distance of the presenting part above and
below the ischial spines is expressed as
and + station respectively.
Assess the moulding by felling the
amount of overlapping of skull bones. The
parietal bones override the occipital bone in
case of moulding.
At the completion of the examination,
withdraw fingers from vagina; take care to
note the presence of any blood or amniotic
fluid.
After the examination, explain the
examination results to the women and her
partner, place clean pad under the womens
buttocks if needed, and help her to a
position of comfort.
Remove gloves and wash your hands.

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Record vaginal examination findings on

the foetal monitor tracing and on the labour
flow record as follows:Cervix:
Position Posterior or anterior
Consistency Firm pr soft
Effacement 0-100%
Dilatation 0-10cm.
Presenting part: Cephalic, Breech,
Shoulder, Compound
Foetal position: Left, Right, Anterior,
or posterior.
Station:
-5/5(floating) to
+5/5(crowning)
Membranes:
Intact, bulging, or
ruptured spontaneously or
artificially

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