Normal First Stage of Labour

Overview: The First Stage of Labour is the period when the uterus starts regular, painful contractions that cause the cervix to open completely (fully dilate). This module explains exactly how the uterus works to push the baby down, how a midwife manages a mother when she arrives at the hospital, and the step-by-step rules for checking the mother safely.

1. Physiology of the First Stage of Labour

A. Uterine Action (How the Womb Works)

Fundal Dominance: Each contraction of the uterus starts from the very top (the fundus) near the corners (cornua) and spreads across and downwards. The contraction lasts longer at the top where it is strongest, but the peak of the pain is felt all over the uterus at the same time. This strong top action allows the cervix to open and pushes the baby down.
Polarity: This is a natural teamwork (neuromuscular harmony) between the top and bottom parts of the uterus during labor. During a contraction, the upper part contracts strongly and pulls back to expel the baby, while the lower part relaxes and opens up to let the baby pass. If this teamwork is disorganized, labor will stop progressing.
Contraction and Retraction: During labor, when a contraction ends, the muscle fibers do not relax completely. They keep some of their shortness. This is called retraction. Because of this special ability, the upper uterus becomes shorter and thicker, making the space inside smaller, which helps push the baby out.
Formation of Upper and Lower Uterine Segments: By the end of pregnancy, the uterus divides into two parts:
- Upper Segment: Mainly for strong contractions; it is thick and muscular.
- Lower Segment: Mainly for stretching and opening; it is thin and develops from the lower neck of the womb (the isthmus), becoming about 8-10cm long.
Retraction Ring: This is a small ridge formed between the thick upper segment and the thin lower segment. As labor goes on, this normal ridge rises higher. You cannot normally see it on the outside. However, in dangerous obstructed labor, it rises very high and becomes clearly visible above the pubic bone. This dangerous sign is called a Bandl’s Ring.

B. Cervical Action (How the Cervix Opens)

Cervical Effacement: This means the cervix gets pulled up and thins out. The muscle fibers around the inner opening (internal os) are pulled upwards by the upper uterus until the cervix merges completely into the lower uterine segment.
Cervical Dilatation: This is the process where the tight, closed opening of the cervix enlarges into a hole big enough for the baby's head to pass. It is measured in centimeters (cm). A fully open cervix at term equals 10cm. The pressure from the bag of waters and the baby's well-bent head pushing down helps the cervix open smoothly.
Show: This is the blood-stained thick mucus seen just before or at the start of labor. It is the mucus plug (operculum) that blocked the cervix during pregnancy. The blood comes from tiny broken blood vessels when the bag of waters separates from the opening cervix.

C. Mechanical Factors

Formation of Fore Waters: As the lower uterus stretches, the bag of waters (chorion) detaches from it. The baby's head drops down and blocks the fluid. The small amount of water trapped in front of the baby's head is called the fore waters, and the water behind the baby's body is called the hind waters.
General Fluid Pressure: When the water bag is still intact, the squeezing pressure of the contractions is spread evenly through the fluid over the baby's whole body. Since water cannot be compressed, this protects the baby. If the waters break early, the uterus squeezes directly on the baby and the umbilical cord, which can dangerously reduce the baby's oxygen supply.
Rupture of Membranes (Breaking the Waters): The normal time for the waters to break is at the end of the first stage of labor when the cervix is fully open (10cm). Sometimes they break days before labor, or early in labor if the baby is sitting in a bad position. Rarely, the bag never breaks, and the baby is born completely covered in the water sac. This is called being born in a Caul.
Fetal Axis Pressure: During a contraction, the force from the top of the uterus travels straight down the baby's spine, pushing the baby's presenting part hard against the cervix.
Descent of the Presenting Part: This is the downward movement of the baby through the mother's pelvis. The head twists, turns, bends, and stretches to fit through three main obstacles:
- Pelvic Inlet / Brim: When the widest part of the head passes the brim, it is called engaged. The baby is now at Station 0.
- Pelvic Cavity: When the head reaches deep down near the perineum, it is at Station +2.
- Pelvic Outlet: The head finally passes under the pubic arch and out of the body.

2. Management of the First Stage of Labour

🎯 Aims of Management

To strictly monitor the progress of labor.
To prevent the mother from becoming completely exhausted.
To prevent infections.
To give comfort to the mother and keep her morale and spirits high.
To relieve her pain.
To prevent and catch any complications early.

Admission of a Mother in Labour

When a mother arrives at the health facility, the midwife must systematically admit her to ensure total safety.

Welcome: Greet the mother and her relatives warmly to reduce their fear and anxiety. Build a good relationship (rapport).
History Taking: While she sits or lies down comfortably, review her antenatal card and ask:
- Demographic data (Name, age, etc.)
- Exact date and time of admission.
- Exactly when the contractions started.
- How often the contractions come (frequency) and how strong they are.
- Whether her waters (membranes) have broken.
Consent: Explain what you will do and get her permission (consent). Ensure she has enough clear information before deciding.
Vital Observations:
- Pulse: Check every 30 minutes. If it is over 100 beats/min, it indicates severe pain, anxiety, infection, lack of energy (ketosis), or bleeding.
- Blood Pressure (BP): Check every 2 hours.
- Temperature & Respiration: Check every 4 hours (normal breathing is 16-20 breaths/min).
Investigations: Test her urine for acetones (dehydration), glucose, and proteins. Draw blood for Hemoglobin (Hb) levels, grouping, and cross-matching just in case she needs a blood transfusion.

Examinations on Admission

General Examination: Check the mother from head to toe. Notice if she looks healthy or sick. Look for body deformities, pale eyes (anemia), yellow eyes (jaundice), swelling (oedema), dehydration, infections, swollen leg veins (varicose veins), and swollen neck veins. Examine her breasts to see if they are ready and suitable for breastfeeding.
Abdominal Examination: Ensure her bladder is totally empty first.
- Inspection: Look at the size, shape, scars, and signs of pregnancy.
- Palpation: Feel for pain (tenderness), measure the height of the fundus, find the presentation, lie, position, and how deep the baby is (descent). Feel the contractions (frequency, length, and strength).
- Auscultation: Listen to the fetal heart rate, checking if it is regular and strong.

3. Vaginal Examination (VE)

This is a strictly clean (sterile) procedure carried out by a midwife by inserting fingers into the mother's vagina to check the progress of labor and rule out any abnormalities.

Indications (Reasons to do a VE)

During Pregnancy: To confirm pregnancy, rule out tumors like fibroids, assess the size of the pelvis, check if the cervix is closed, confirm if a miscarriage is happening, and check abnormal discharges.
During the First Stage of Labour:
- To find out how many centimeters the cervix has opened (dilatation).
- To make sure the umbilical cord has not dropped down (cord prolapse) when the waters break.
- To confirm the cervix is fully open (10cm) when the mother feels the urge to push.
- To check if the cervix is soft before forcing labor to start (induction).
- To rule out a blocked delivery in cases of very long, prolonged labor.
- To positively identify what part of the baby is coming first (presentation) and if it is engaged.
During the Second Stage: To confirm full dilatation, check why the baby is not descending, and check the position of a second twin after the first is born.
During the Third Stage: If the placenta is delayed, to feel if it is stuck in the birth canal. To check for torn tissues (lacerations) or remove large blood clots. For manual removal of a trapped placenta.
During the Puerperium (After Birth): To check if stitches have healed after 6 weeks, ensure organs have returned to normal, take swabs for lab testing, or find the cause of a bad discharge.

Contraindications (When NEVER to do a VE)

Active Vaginal Bleeding (APH): If the mother is bleeding heavily, inserting fingers can tear the placenta and cause fatal bleeding.
Recent Pelvic Surgery or Trauma: The tissues are delicate and easily damaged.
Threatened Miscarriage or Ectopic Pregnancy: It may cause the water to break early or rupture an ectopic tube.
Cervical Incompetence: If the cervix is very weak, touching it can force it open and cause a premature birth.
Active Pelvic Infection (PID): It can push bad bacteria deeper into the womb.
Severe Pain: If the mother is in extreme pain, stop immediately.
Patient Refusal: The mother has the absolute right to refuse the procedure.
Elective Caesarean Section: If she is already planned for surgery, there is no need.

Complications of Vaginal Examination

Discomfort or Pain: Especially if the mother is frightened or anxious.
Vaginal Bleeding: A small amount of spotting is normal, but rough checking can cause cuts (lacerations).
Infection: It can accidentally push outside bacteria into the clean vaginal canal.
Premature Rupture of Membranes (PROM): Pushing too hard can pop the water bag by mistake, causing premature labor.

Requirements for a VE

On the Tray: A gallipot for swabs with antiseptic, 2 receivers, sterile gloves, vaginal speculum, sterile bowl for lotion, clean perineal pads, a sheet and a mackintosh (waterproof sheet), clean gloves, and lubricating gel.
At the Bedside: A privacy screen, hand washing water and soap, and a bedpan.

Procedure for Vaginal Examination

Welcome the mother and explain what you will do. Ask her to empty her bladder.
Screen the bed for privacy and assemble your tray. Encourage the mother to relax her body. Her arms should rest by her side so her stomach muscles stay soft.
Help her lie on her back with knees bent and wide apart (dorsal position). Cover her legs with a sheet (drape).
Place the waterproof mackintosh and draw sheet under her buttocks.
Put on clean gloves. Observe the outside (vulva) before cleaning. Check hygiene, swollen veins, warts, sores, old scars, or female circumcision. Check any fluids coming out. If the fluid smells bad, it means infection. If it is green (meconium), the baby is suffocating (fetal distress).
Clean (swab) the vulva using your left hand, wiping purely from front to back (towards the anus) to prevent transferring feces into the vagina.
Remove clean gloves, wash hands thoroughly, and put on highly sterile gloves.
Dip the two fingers of your right hand into the sterile lubricant. Use your left hand to hold the vaginal lips open. Gently insert the two fingers downwards and backwards. Point them along the front wall of the vagina.
Do not remove your fingers until you have felt everything you need to know. Note: Never touch the clitoris as it causes severe discomfort to the mother.

Findings During VE (What the Midwife Feels For)

Condition of the Vagina: It should feel warm and moist. A completely hot and dry vagina means the labor has been stuck for hours (obstructed labor) and the mother is in deep danger.
Condition of the Cervix: A normal cervix in labor is very thin and stretches like a rubber band tightly around the baby's head. If the cervix feels thick and spongy, it might be the placenta blocking the way (Placenta Previa). If the cervix is not tight against the baby's head, the baby is in a bad position. You must assess how much it has opened (dilatation) and how thin it is (effacement).
The Membranes (Water Bag): If the bag is not broken, it feels tight like a balloon during a contraction.
Level / Station: You feel exactly how deep the baby's head has dropped by comparing it to the mother's side bones (ischial spines).
Fetal Position: Feel the baby's skull bones. You will usually feel a straight line (the sagittal suture) and trace it to a soft spot (fontanel). If you feel the skull bones overlapping strongly, it tells you how the baby's head is squeezing to fit.
Pelvic Capacity: Feel the mother's inside bones again to be absolutely sure the birth canal is wide enough.

After finishing, gently remove your fingers, check them for fresh blood or colored fluid, clean the mother, remove your gloves, and record every single finding on the Partograph.

4. Nursing Care Plan & Sample Questions

📝 Practice Scenario & Nursing Diagnoses

Question 1: Formulate 3 actual and 2 potential nursing diagnoses for a mother in the first stage of labour.

Actual Nursing Diagnoses:

Pain related to strong uterine contractions and cervical dilation, as evidenced by the patient verbally complaining of pain and crying out.
Anxiety related to fear, uncertainty, and anticipation of labor, as evidenced by the mother asking many restless questions about whether she will deliver safely.
Fluid volume deficit related to increased fluid loss (sweating) and frequent urination during labor.

Potential Nursing Diagnoses:

Risk for fetal distress related to the strong physical changes and pressure on the baby during contractions.
Risk for ineffective coping related to severe labor pain and emotional stress.

Question 2: Outline 10 nursing interventions for this mother, giving the rationale (scientific reason) for each.

Assess the pain level (scale 0-10): Rationale: This helps the midwife know exactly how much pain the mother is feeling so they can give the right pain relief.
Teach deep breathing and relaxation: Rationale: Proper breathing keeps the mother calm, stops her muscles from going tight, and reduces her anxiety.
Educate her about the labor process: Rationale: Knowing what is happening removes the fear of the unknown and makes her feel in control.
Provide constant emotional support: Rationale: Having a caring midwife by her side provides a deep sense of security and safety.
Encourage frequent walking and changing positions: Rationale: Moving around helps blood flow, reduces pain, and uses gravity to pull the baby into a good position.
Give frequent sips of clear fluids/water: Rationale: Labor is heavy exercise. Drinking prevents dehydration and replaces water lost through sweating.
Monitor her vital signs (BP, Pulse, Temp) regularly: Rationale: Catching any sudden changes early stops small problems from becoming emergencies.
Listen to the Fetal Heart Rate regularly: Rationale: This is the only way to know if the baby is getting enough oxygen or is suffocating inside.
Provide pain relief (warm massages or safe drugs): Rationale: Reducing extreme pain prevents shock and keeps the mother comfortable.
Collaborate with doctors if labor stops: Rationale: Good teamwork ensures that if the mother needs surgery (C-Section), it is done quickly before the baby gets tired.