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Cmre Developmennt Life Saving Skills for Nurses and Midwivw.

LABOR – MONITOR PROGRESS AND GIVE CARE.

HISTORY AND PHYSICAL EXAMINATION.

Take History. Welcome the woman and others coming with her Show her a comfortable place to sit or lie depending on her presentation Responsible Atenatal Care Have a Wholistic Approach ASK and LISTEN Guide the conversation.

QUESTIONS TO ASK. When did your labor pains begin? How often do they come? How long do they last? Where do you feel the pain? Is the baby moving? Have you received antenatal care? With whom? How many visits? Have you had any problems? How many weeks pregnant are you? If the woman in labor is not at term, REFER . Has your bag of waters (membranes) broken? When? What color ?.

QUESTIONS TO ASK( cont ). Have you had any bloody mucus (show) or bleeding? Have you had any headaches, spots in front of your eyes, blurry vision, abdominal or epigastric pain, severe heart burn? When did you last eat or drink? When did you last pass stool or urine? Medications. Have you taken any medicine or treatment to increase or decrease your labor pains? Are you taking other medicines? Are you allergic to any medicines?.

QUESTIONS TO ASK( cont ). Did a traditional birth attendant or family member come with you? What is her name? According to policy in your facility, ask: Did you have an HIV test during your pregnancy or other time? What was the result?.

DISCUSSIONS.

PHYSICAL EXAMINATION LOOK AND FEEL.

When you see a woman in labor , you must do physical examinations of the woman and her unborn baby to find out how things are going for them. Before you start, explain to the woman and her family what you are going to do. Give them time to ask questions and help them understand why you are doing the exam. A physical examination on admission will help you find any new problems or any problems that might have been missed in antenatal clinic. This exam is even more important for a woman who has not attended antenatal clinic. Examinations during labor will help you identify any problems early ..

When you first see a woman in labor , you must make a quick decision. Is she about to deliver? If you think the delivery will happen soon, you need to know:.

General Physical Examination. Explain what you are going to do. During the examination tell the woman what you are doing and why. If there is time, offer the woman time to bathe (basin and water or shower). This may be done when the woman first arrives. Ask the woman to empty her bladder and collect a urine sample . If there are signs of pre-eclampsia, test her urine for protein. See Testing Urine for Protein in Guide for Caregivers – Procedures and Tests ..

General Physical Examination(CONT.). Wash your hands before you begin and help the woman get comfortable. Take her temperature, pulse and blood pressure LOOK at her general condition . If she has no antenatal card, see if the woman is shorter than other women from her area. Too short (stunting) from malnutrition may cause a small pelvis. This can alert you to think about CPD if there are any problems with descent. Is she dehydrated? Is she ill or tired or in pain? Is she worried? Is she malnourished? LOOK at the eyes, ears, nose, mouth, throat, neck, and skin for signs of infection or anemia . LOOK at the hands and face for edema ..

Abdominal Examination , a n abdominal examination helps you find the progress of labor and the condition of the baby.

Abdominal Examination(cont.). LOOK for the shape of the uterus , for any cesarean section scar, and for the way the baby is lying. LOOK for any movement of the baby. LOOK for contractions, unusual shapes or swelling. The normal uterus is longer than wide (ovoid). Jerky movements in one area are usually the baby's arms and legs moving. FEEL the abdomen using the 4 steps to check for height of uterus, lie, presentation, position and engagement of the presenting part of the baby. Make sure your hands are warm and dry after washing them. Use the flat surface of your fingers for palpating. Keep your fingers together. Press evenly and firmly to feel the fundal height and the parts of the baby. Refer to Module 2: Antenatal Care , for fundal height measurements. Try to estimate the size of the baby and whether there is more than one baby..

Abdominal Examination(cont.). Step 1: What is in the top of the uterus? HOW: Stand beside the woman looking at her face. Put your hands on both sides of the top of the uterus and curve your fingers around, see Figure 4, Step 1. Palpate for shape, size, firmness, and how easily the baby moves. Ask yourself, "What is in the top of the uterus?" FINDINGS: If the fetal head is in the top of the uterus, you will feel a round and hard part which is movable. If the buttocks are felt, they will be irregular, bulky, and softer than the head, and the top of the uterus will feel full and not easily moved. If there is a transverse lie, the fundus will feel empty..

Abdominal Examination(cont.). Step 2: Where are the baby’s back, arms, legs? HOW: Continue to stand at the side of the woman. Place both hands further down on the abdomen and push down with one hand, pushing the fetus to the other side of the abdomen, see Figure 4, Step 2. Feel the fetus so that you can tell the parts. Gently move the baby from side to side to find out which side has the back and which side has the arms and legs. FINDINGS: A firm, continuous, smooth part will be the back of the fetus . If you feel small, bumpy, irregular parts, which may move or hit your hand, these will be the fetal feet or knees. If you can not feel the back on either side, this will tell you the back is towards the back of the woman, a posterior position. A transverse lie is when the baby = s body is felt across the abdomen..

Abdominal Examination(cont.).

Abdominal Examination(cont.). Step 3: What is in the lower part of the uterus and how easily does it move? HOW: Turn your back toward the woman’s feet as you stand to one side. Have the woman bend her knees. With one hand, feel the part of the baby in the lower part of the abdomen between your thumb and your fingers, see Figure 5, Step 3. Ask yourself, "What is in the lower part of the uterus?" Compare to your findings of the first palpation. FINDINGS: If the mass moves up, the presenting part is not engaged. Most often, the head is the presenting part. This is a cephalic presentation. If the head is the presenting part, try to move it from side to side. If the head can not be moved, the head is engaged (usually after 36 weeks but sometimes not until labor starts). If neither the head nor the buttocks can be felt in the lower abdomen, the baby is lying sideways, a transverse presentation..

Abdominal Examination(cont.). Step 4: What is the lie, presentation, position, engagement and attitude? HOW: Turn your back toward the woman's head as you stand to one side. Make sure that the woman's knees are bent. Place both hands on the sides of the abdomen and press them down and towards the pelvis. (See Figure 5, Step 4.) FINDINGS: Compare the findings to the other palpations and decide on the lie, presentation, position and engagement..

Abdominal Examination(cont.). step 3 Step 4.

Abdominal Examination(cont.). FEEL the abdomen for descent of the head.

Abdominal Examination(cont.). 5/5 = 4/5 = The head is just entering the brim. The sinciput and occiput are easily felt 3/5 =.

LISTEN for and count the baby’s heart rate. Listening to the fetal heart rate is a safe and reliable way of knowing how the baby is doing during labor . On the partograph there are darker lines at 120 – 160. These are the limits for a normal fetal heart rate . A normal fetal heart rate varies with each baby. Monitoring and listening for changes are the most important part of listening to the fetal heart rate. LISTEN for a full minute just as a contraction is ending to decide how well the baby is doing with the stress of labor . Count the number of beats..

LISTEN for and count the baby’s heart rate. A very slow fetal heart rate (less than 120) without contractions or staying very slow or a drop of even 20 beats per minute during a contraction that continues for 15 – 20 seconds after a contraction ends before returning to normal (late deceleration) is a sign of fetal distress. A very fast fetal heart rate (more than 160) may be a response of the baby to maternal fever, drugs, hypertension, dehydration, antepartum hemorrhage or infection and may indicate fetal distress. A very fast fetal heart rate when the woman’s pulse is within normal limits is a sign of fetal distress..

FEEL for the frequency, duration, strength, and relaxation of the contractions.

FEEL for the frequency, duration, strength, and relaxation of the contractions.

Vaginal Examination. Explain to the woman what you are going to do . Reassure her and explain each step during the examination. Provide privacy. Gather your equipment. Position. Ask the woman to lie on her back with her knees bent and her legs spread apart. Cover her as much as possible. Wash your hands with soap and water . Put on clean, sterile or high-level disinfected gloves. LOOK for discharge (blood, liquor, meconium) on her clothing and genitals. A whitish, clear, watery, or blood tinged discharge may be the mucous plug or liquor (amniotic fluid). A yellow or green stained liquor may be a warning sign of fetal distress. The meconium (baby=s stool) discharge may be a breech presentation. Clean the genital area Place 6 cotton balls or cloth squares or gauze in antiseptic or soapy solution. LOOK for any drainage at the vulva. If you see blood that is more than bloody show, do not continue with the vaginal examination. Wipe the woman's genital area from front to back using one cotton ball, cloth square or gauze for each wipe. Wipe each labia major (outer lips), each labia minora (inner lips), the clitoris and vulva..

The Partograph. The partograph 1 is a clear way to record the history and physical examination information on one chart. It helps you see and show the progress of a woman’s labor . It is a useful tool to manage the labor of women with and without complications. This graph can be used in hospitals, maternities, and homes to help identify women whose labors are not progressing normally The partograph is not a replacement for labor care . The Ministry of Health may provide all labor forms to government health facilities. Midwives in private practice can have copies made for their own use. The midwife, doctor, and other healthcare workers caring for a woman in labor are responsible for recording and using the information..

The Partograph. Progress of Labor Cervical dilatation Descent of fetal head Molding of fetal skull Fetal Condition Fetal heart rate Membranes and liquor Maternal Condition Pulse Blood Pressure Uterine contractions Urine tests and volume Medications given Fluid intake.

The Partograph. When a woman is admitted in labor , you do a complete evaluation of her condition and the condition of her baby. This includes a history and physical examination, with both abdominal and vaginal examinations. The following information helps you learn how to record and interpret your findings on the partograph..

The Partograph. Cervical Dilatation Record dilatation of the cervix. Look at the partograph, Figure 14. Find the area along the left side, labeled : CX (cm) [Plot X]. Along the left side are the numbers 0 – 10. Each number and square represents 1 cm dilatation and represents the number of cm the cervix is dilated. Record time. 2 Find the bottom of the graph for numbers 0 – 24 for the Hours and Time in labor . Each number and square represents one hour. The time of admission is written below, and to the left of the first square, next to “Time”. Record labor progress Alert line begins at 4 cm dilation and goes to 10 cm. This line increases 1 cm per hour. Progress is satisfactory if the cervix dilates at least 1 cm per hour and remains on or to the left of the alert line. Action line is drawn 4 hours to the right of the Alert line for 4 cm to 10 cm dilatation . Progress is not satisfactory if the cervix dilates less than 1 cm per hour and moves to the right of the alert line or on the action line. Descent of the Fetal Head Measure descent of the fetal head every four hours in latent phase , every one hour in active phase and immediately before doing a vaginal examination. Vaginal exams are usually done every four hours. As discussed in LOOK and FEEL, descent is measured abdominally in "fifths" of the head palpable above the pelvic brim. Descent is recorded using an ‘ O ’ on the graph. This is shown in Figure 14. Progress is satisfactory if the fetal head descends. Uterine Contractions Normally, contractions come more often and last longer as labor progresses. A woman must be in labor for the partograph to be useful in monitoring labor progress. FEEL contractions for 10 minutes at a time to know how often they come and how many seconds they last. In latent phase feel every hour. In active phase feel every 30 minutes..

Module 3: Labor. 3.39. LSS 4 th Edition 2008. Figure 17. Partograph – front page..

Module 3: Labor. 3.40. LSS 4 th Edition 2008. Back of Partograph.

Module 3: Labor. 3.41. LSS 4 th Edition 2008. Recording on the Partograph - Back Page On the back of the partograph form, are labor notes and delivery outcome, Figure 18. This part of the form can be modified for your needs. You may use your form or this one if you do not have one. You may choose to have one page for labor notes and a separate page for the outcome of the delivery. All of this information makes a complete labor record form. Labor notes Write additional labor care that you do not write on the front of the partograph. For example, each time you give the woman fluids to drink or food to eat, record it here. When the woman is walking around, has a bad backache, or takes a bath, record her activities. Delivery Delivery date, time, method. Record the method as spontaneous, vacuum extraction, cesarean section, forceps, or destructive operation. Perineum and anesthesia. Record whether perineum is intact, any laceration (tear) or episiotomy and repair. Record any anesthesia given, such as local. Third stage If active management of third stage labor was done: Record the time, type of medication and dose given. Placenta and membranes: Record time of placental delivery, and if complete or incomplete. Blood loss: Record the estimated amount; small (less than 250 cc), moderate (250 to 499 cc), large (more than 500 cc). Baby APGAR of newborn: Record the baby’s APGAR at 1 and 5 minutes after birth. (Refer to Guide for Caregivers – Procedures for information on APGAR). Newborn baby details: Record weight, length, sex, delivery presentation. Complications of woman or baby Use this section to write any problems for the woman or baby. Details of management are written on a postpartum or newborn record. Fourth stage The woman and baby are monitored every 15 minutes for 2 hours, then every 30 minutes for an hour, then every hour for 3 hours. Check woman: BP, pulse, fundus, bleeding and bladder. Check baby: breathe, suck, warm and cord for any bleeding. See back of partograph . Midwife or person delivering and date: Filled in at the end of recording the information..

Care and Management of Second Stage. When the cervix is fully dilated, the uterus contracts and the woman bears down, pushing the baby out of the uterus. The baby is pushed down through the birth canal (vagina) to be born (second stage of labor ). You will care for the woman during second and third stage labor to make the birth as safe as possible. It is important to continue to ASK and LISTEN and to LOOK and FEEL so you give the best care for the woman and baby as the woman’s labor continues..

Cont.. Giving birth is a natural part of life and most women can give birth without any help. It does involve powerful, sometimes painful, uterine contractions and much stretching of the woman's soft tissues. Birth can be frightening to some women. Prepare the woman, equipment and the room Make sure everything is clean and ready for the birth Use a regular bed, table, or clean pad on the floor for normal deliveries for a clean space that is comfortable for the delivering woman Explain to the woman what will happen during the second stage of labor ..

Cont.. Check the woman and baby and record findings on the partograph Pushing. Confirm full dilatation of the cervix. When the cervix is fully dilated and the baby’s head begins to move into the birth canal, the woman usually feels like pushing. Help the woman get in a good pushing position. Most women, if given the choice, choose to give birth in “upright” positions. Allowing the woman to choose what is comfortable for her is an important part of caring behavior . If possible, let the woman decide which position she would like, including traditional positions. These positions have special benefits: . A LONGER SECOND STAGE (WITHOUT PUSHING) CAUSES NO RISK TO THE WOMAN OR HER BABY. When the woman feels the urge to push, help her push correctly.

Cont.. When the baby’s head is about to crown, help the woman get in a good birthing position. Help prevent tears around the vaginal opening. As the baby's head crowns try to prevent the woman’s tissues from tearing.

Cont.. Check for the cord around the baby's neck when the head is delivered. Again ask the woman to blow so she does not push Wipe the baby's face. Deliver the baby's shoulders. After wiping the baby’s face, ask the woman to give a gentle push. Cup your hands parallel around the sides of the baby’s head. Do not hold the neck. To prevent tearing of the birth canal, it is best to deliver one shoulder at a time. Deliver the upper (anterior) shoulder. Gently move the baby's head toward the woman's coccyx. Deliver the lower (posterior) shoulder. Gently move the baby's head toward the woman's abdomen. Do not bend the baby's neck or pull on the baby’s head too much or too hard. Do not pull with your fingers around the baby’s neck or under the baby’s arm pits. Deliver the baby's body. After the shoulders are born, the rest of the body usually slides out easily. Remember that new babies are wet and slippery..

Active Management of Third Stage Care. Give oxytocin for placenta separation Give newborn care. Feel the uterus to make sure there is no other baby. Give 10 units oxytocin IM, within 1 minute after the birth for placental separation, if no other baby is felt..

Cont.. Clamp and cut the cord 2-3 minutes after birth. “Blood volume is increased when cord clamping is delayed 3 or more minutes, even when the baby is placed on the mother’s abdomen,” (Mercer, 2001). Prevent blood splashing when cutting the cord: Clamp or tie cord on baby’s side Milk cord to drain blood toward the placenta Clamp or tie cord on placental side Cut the cord between the 2 clamps (ties).

Cont. Keep mother and baby together. Let the mother hold her baby close, skin to skin, close to the breast. Cover mother and baby to keep them warm. Give the baby an Apgar score. “The Apgar score, at 1 minute of age, focuses attention on the condition of the infant immediately after birth. At 5 minutes, it is a rapid method for assessing effectiveness of newborn care and the condition of the infant,” ( Papile , 2001). Give the baby an Apgar score at 1 and 5 minutes after birth by giving points for the following criteria..

Module 3: Labor. 3.58. LSS 4 th Edition 2008. Criteria 2 Points 1 Point 0 Points A ppearance (color) Comp l e tel y pink body and face Pink body, blue arms and legs Pale or blue body and face P ulse (heart beat) More than 100 beats per minute 100 or less beats per minute No heart beat G rimace (reflex to stimulation) Crying , cou g hing, or sneezing Grimace or puckering of face No response A ctivity (muscle tone) A c tiv e movement, waving arms and legs, flexion Som e movement, some flexion Limp arms and legs, no flexion, no movement R espiratio n s (breathing) Strong cry, regular breathing Slow, irregular breathing, retracting of chest wall, grunting or weak cry N o breathi n g, no cry.

Deliver the placenta and membranes. Controll cord traction.

Fourth Stage Care. Check the genitals for tears and any problems, see Module 4: Episiotomy. Monitor the woman and baby closely the first 6 hours postpartum. Immediately after delivery, the mother is tired. Her cervix is still dilated. It is easy for her to get an infected uterus. Very heavy bleeding ( hemorrhage ) is also dangerous. It is the single largest cause of maternal deaths the first 4 hours after delivery, even in normal births. Prevent and manage signs of hemorrhage , infection, anemia and high blood pressure. The baby is just learning how to breathe and suck. Staying warm is critical. It is easy for a newborn to get an infection. Everything touching the baby must be as clean as possible. Give active fourth stage care to the woman and baby to prevent and recognize problems early. Close monitoring, support and counseling are part of active fourth stage care. If at all possible, the woman and baby should remain in, or close to, the birthing area for the first 3 hours of active care, see Module 10: Postpartum. Check the woman and baby every 15 minutes for 2 hours, every 30 minutes for 1 hour, and every hour for 3 hours..

Cont.. Breathing. Check the baby for breathing. Sometimes new babies forget to breathe and need a little stimulation like rubbing the back. Warmth. Encourage skin to skin contact to keep the baby warm and to encourage breast feeding as soon as the mother and baby are ready. Keep the baby with the mother, covering both. Delay first bath for 24 hours. Sucking. Check the baby for sucking. Blood pressure and pulse. Important signs for shock, hemorrhage and pre- eclampsia. Uterine firmness. FEEL the uterus to be sure it is firm and rub the uterus. Teach the woman what her firm uterus should feel like. She can rub it to keep it firm. Vaginal bleeding. LOOK at the amount of bleeding to make sure that the woman is not bleeding too much ( hemorrhage ). It is normal for the woman to bleed after the birth. The blood looks like the monthly menses. The blood comes out in little amounts when the uterus contracts and when the woman coughs, moves or stands. Bladder. Encourage the woman to empty her bladder every 2 hours. Bonding. The first hour after birth is the most important time for bonding. Do not hurry the newborn to the breast. Give healthy newborns uninterrupted full skin to skin contact with the mother. Attaching to the breast begins the bonding between mother and baby. Other care. Help the woman clean herself after birth. Wash your hands and put on gloves. Remove any soiled cloths. Wash blood and fluids off the woman’s body. Wash the woman’s genitals downward, away from the vagina using clean soapy water solution and a clean cloth. Be careful not to bring the cloth from the anus towards the vagina. Teach the woman about perineal care, see Module 10: Postpartum. Help the woman eat and drink. Most women are ready to eat soon after birth. If she is not hungry, she should take something to drink to get her strength back. Give the new family some time alone if the woman and baby are healthy..

Episiotomy – Prevent and Repair.

Cont.. Episiotomy – a cut made in the perineum at the end of the second stage of labor to let the baby out when the baby or woman is in distress. An episiotomy is not a normal procedure. Episiotomy increases the woman’s risk of too much bleeding, infection, and painful healing. There is no information that an episiotomy lessens the risk of severe perineal trauma or helps perineal healing. There is no information that an episiotomy prevents fetal trauma, or reduces the risk of urinary stress incontinence after delivery, see Module 10: Postpartum Care. It is very important that midwives know how to prevent an episiotomy and protect the perineum from lacerations. Genital trauma after spontaneous vaginal birth is common. Lacerations and episiotomies cause more trauma including scarring, unsatisfactory sexual intercourse, heavy blood loss, infection, and even death. A small laceration of the cervix, not repaired, can cause death. It is important that midwives know how to repair both lacerations and episiotomies, to reduce both sickness (morbidity) and death (mortality). Look in the Guide for Caregivers for the skill checklist..