Assessing progress in the first stage of labour

*Written before an exam as revision where I believed this type of question would come up and completed after the exam for here. The question that I answered was “How does the midwife assess progress in the first and second stages of labour?” I’ve only answered the first part of the question here.*

I will discuss the role of the midwife, and what the student midwife must learn, in assessing progress in the first stage of labour.

The first stage of labour can be defined as ‘from the onset of regular contractions to the full dilation of the cervix’. It can further be divided into latent phase-up to 4cm dilation, active phase-from 4cm to 10cm dilatation and the transitional phase-from about 8cm to fully dilated. [On a side note, I read an interesting article about the misleading guide of stages in labour-Winter and Cameron, 2006. ‘The 'stages' model of labour: Deconstructing the myth’. British Journal of Midwifery, 14, 8. If anyone would like to read it, message me through Facebook].

The midwife records labour progress on a partogram, including the cm’s dilated, engagement, foetal heart rate and amniotic fluid draining. The partogram contains a graph with an action line by which the midwife assesses and compares the woman’s labour to the recommended guidelines. It is considered ‘normal’ for the active phase to last 12 hours; NICE guidelines recommend that progress should be 2cm per 4 hours.

Of course, not all women and their bodies are the same, these are just common signs. We must always make our observations and conclusions specific to each woman we care for in labour. 

There are a number of external signs of progress the midwife can observe, these include the strength, length and frequency of contractions, the mother’s behaviour, her breathing, her ability to cope, her voice, the presence of a bloody show,  the ‘purple line’ and the Rhombus of Michaelis.

During the latent phase of labour when contractions start they are usually short, far apart and not very strong. The woman can cope with them well and is able more or less to continue with her day. The latent stage in the primiparous woman usually lasts 3-4 hours, shorter in the multiparous, however this is can vary greatly.

 As labour continues into the active phase once the contractions increase in length, get closer together and stronger. She will now require more support and coping mechanisms to manage with the contractions. Contractions should build up to three every ten minutes and be approximately 45 seconds or longer in length, they should continue this way throughout the active stage of labour. The mother will not be able to talk through these contractions and her breathing may be deeper and heavier through them to cope. Bloody show is mucous from the vagina and blood from the cervix combined and indicates cervical dilation, as the cervix dilates there is usually more bloody show present. The purple line may become noticeable now, this is a purple line that appears from the anus up the buttock cleft. As the second stage progresses it will become longer towards the top of the buttock cleft and many midwives have noticed that once it reaches the top the woman in fully dilated. Another sign that midwives have found over the years that indicates nearing full dilation is the presence of the rhombus of Michaelis. The rhombus of Michaelis is a diamond shape protrusion (for want of a better word!) on the woman’s lower back that becomes visible as the bones adjust to allow the baby’s further descent into the pelvis. It is most visible when the mother leans forward and reaches her arms out, apparently also a sign of transition.

It has often been noted that once the woman meets the transitional stage her contractions may ease off a little but her urge to push will begin taking place. It is well known to hear a woman claim she cannot do this anymore, demanding pain relief and asking for the care providers to ‘end it all’ once she reaches transition stage (Fraser and Cooper, 2009). During transition if the membranes have not ruptured yet this is often when it occurs. This allows for the presenting part to descent further into the pelvis and apply itself well to the cervix. A sign from the baby that full dilation is nearing are decelerations during the peak of a contraction, this can indicate ‘foetal head or cord compression’ meaning the head is descending well. 

The first stage ends and the second stage of labour begins once pushing commences.

As mentioned before, every woman and her body is different and it is only by observing and working with each individual that we can care for her and assess her progress accurately. All of the above signs can be observed by interacting with the woman, asking her questions and simply becoming aware of her behaviour.

Feel free to ask me any questions about anything I’ve said here. Sorry if I’ve got something wrong, do correct me! Also, I happy to try find articles for people on any of the above :-)

Fantastic related listen: The second recording on the list, ‘Ungloved and Observing’ by Gloria Lemay http://internationaldayofthemidwife.wikispaces.com/International+Day+of+the+Midwife+2011