What is the initial management for a patient in labour?

Initial Management for a Patient in Labour

The initial management for a patient in labour should include placing the woman in a lateral decubitus position, establishing continuous electronic fetal heart rate monitoring, providing appropriate analgesia if desired, monitoring maternal vital signs, and administering IV fluids at 125-250 mL/hour of isotonic crystalloid solution. 1, 2

Initial Assessment and Positioning

• Place the woman in a lateral decubitus position to attenuate the hemodynamic impact of uterine contractions 1
• This position helps optimize uteroplacental perfusion and reduces compression of the inferior vena cava
• Continuous electronic fetal heart rate monitoring should be established to detect early signs of fetal distress 1, 3
• Maternal vital signs should be monitored, particularly blood pressure and heart rate

Fluid Management

• Administer IV fluids at a rate of 125-250 mL/hour of isotonic crystalloid solution (0.9% NaCl or Ringer's lactate) 2
• For women with cardiovascular disease, careful monitoring of IV perfusion is essential 1, 2
• For women with smaller stature, fluid volume should be adjusted downward proportionally 2
• Avoid hypotonic solutions, particularly in patients with brain injury 2

Pain Management

• If epidural analgesia is requested:
  • Lumbar epidural analgesia is recommended as it reduces pain-related elevations of sympathetic activity and reduces the urge to push 1
  • Monitor blood pressure every 5 minutes for at least 15 minutes following administration of neuraxial analgesia 1
  • The attending midwife should remain with the patient during this time 1
  • Check sensory and motor block hourly during neuraxial analgesia 1

Monitoring During Labour

Maternal Monitoring

• Monitor systemic arterial pressure and maternal heart rate regularly 1
• Check for motor block by asking the woman to straight-leg raise hourly 1
• If dense motor block is present, assist with regular position changes to avoid skin pressure damage 1

Fetal Monitoring

• Continuous electronic fetal heart rate monitoring is recommended 1, 3
• Be aware that maternal heart rate can sometimes be misidentified as fetal heart rate 4
• Distinguish between maternal and fetal heart rate patterns by noting that:
  • Baseline maternal heart rates are typically lower than fetal heart rates
  • Maternal heart rates show higher variability
  • Maternal heart rates typically show accelerations with contractions but no decelerations 4

Labour Progress Monitoring

• The active phase of labour is characterized by regular, painful contractions with cervical change
• In the active phase, cervical dilation typically progresses at a minimum rate of 1.2 cm/hour in nulliparas and 1.5 cm/hour in multiparas 1
• Slower rates (as low as 0.6 cm/hour) may occur but warrant closer monitoring for potential labour disorders 1

Special Considerations

Anticoagulated Women with Prosthetic Valves

• Switch from oral anticoagulants to LMWH or unfractionated heparin (UFH) from the 36th week 1
• Women on LMWH should be switched to IV UFH at least 36 hours before induction or cesarean delivery 1
• UFH should be discontinued 4-6 hours before planned delivery and restarted 4-6 hours after delivery if there are no bleeding complications 1

Post-Delivery Management

• After placental delivery, administer a slow IV infusion of oxytocin (<2 U/min) to prevent maternal hemorrhage 1, 2, 5
• Avoid methylergonovine due to risk of vasoconstriction and hypertension 1
• Continue hemodynamic monitoring for at least 24 hours after delivery, particularly in women with structural heart disease 1, 2

Common Pitfalls to Avoid

• Misidentification of maternal heart rate as fetal heart rate can lead to unnecessary interventions 4
• Failure to monitor for motor block can miss early signs of complications 1
• Excessive fluid administration can lead to fluid overload, particularly in women with cardiovascular disease 2
• Rapid administration of oxytocin can cause systemic hypotension 1, 5
• Inadequate fetal monitoring during labour increases the risk of undetected fetal distress 3, 6

By following these guidelines, healthcare providers can optimize outcomes for both mother and baby during the labour process.