Intrapartum Care Flashcards
Stages of Labour
- The onset of regular contractions (increasing in length and frequency) to full dilation of the cervix (10cm); process of cervix softening, opening and thinning out.
- Full dilation of the cervix to delivery of the neonate; process of pushing the foetus out of the birth canal.
- Birth of infant to delivery of placenta; process of gentle uterine contractions to loosen and push out placenta and to stop bleeding.
- Delivery of placenta and control of bleeding until 1hour post-birth.
Stage 1
Signs & Symptoms (6)
- Discomfort progressing to pain (incl. lower-back pain)
- Lightening – movement of infant in maternal pelvis
- Braxton Hicks contractions – intermittent period-like cramps
- Bloody show – blood-stained discharge of mucous (operculum)
- Waters breaking – spontaneous rupture of amniotic membrane; clear-pink water.
- GIT discomfort - nausea/vomiting and/or diarrhoea
Stage 1
Duration & Factors
Approx. 12-14 hours (primigravida) or 6-10 hours (multigravida).
Factors:
1. Passenger – foetal size, position and HR pattern.
2. Power – strength, frequency and duration of contractions,
3. Passage – pelvic anatomy and measurements.
Stage 1
Stages
- Latent - cervix dilates to 3cm; contractions are mild and irregular.
- Active (est. labour) - cervix dilates 7-8 cm; contractions become stronger, more regular and more painful (approx. 30-60sec/3-4min)
- Transition - cervix dilates to 10cm; continuous painful contractions and rectal pressure.
Stage 1
Speeding-up Labour
A. Artificial rupture of membranes
B. Oxytocin infusion
Stage 1
When to transfer to hospital?
- Contractions <3-5min apart
- Waters break
- Bright red bloody discharge
- Spontaneous labour if planned c-section
- Changes in foetal movement pattern
Stage 1
Midwifery Care (9)
- Maternal observations
- Foetal observations
- Encourage upright/active movement
- Pain-relief
- Psychosocial support
- Nutrition and hydration
- Education
- Involve support person
- Review birth plan
- Encourage 2-3hrly voiding
Non-Pharmacologic Pain Relief
Pharmacologic Pain Relief
Stage 1
Initial Assessment (10)
- Emotional/psychological state
- Foetal movements in past 24hrs
- Vaginal losses - colour, volume, odour, blood.
- Contractions - time of onset, frequency, strength, duration, resting tone.
- Pregnancy care record - parity/gestation, antenatal events/complications, PMHx.
- Maternal vital signs
- Urinalysis - ketones, flucose, protein.
- Palpate abdomen - foetal size, foetal presentation/position, symphyseal-fundal height.
- Foetal heart rate
- Vaginal examination - cervical dilation.
Stage 1
Signs of Progress
- Cervical dilatation
- Cervical effacement
- Descent of the presenting part (confirmed by abdominal or vaginal examination)
- Increasing strength and duration of contractions.
Stage 1
Maternal Observations
Every 30min:
1. Palpate uterine activity and contractions
2. HR
3. Vaginal losses
Every 4hours (or as indicated)
1. Vital signs
2. Vaginal examination
Stage 1
Foetal Observations
A) CTG only if indicated - e.g. prolonged labour, maternal fever, abnormal foetal HR, bleeding; OR
B) Intermittent auscultation toward end of contraction
Stage 2
Foetal Observations
A) CTG ; OR
B) Not actively pushing - 15min; OR
C) Active pushing - 5min or post-contraction
Stage 2
Maternal Observations
- HR - 15min
- Palpate uterine activity and contractions - 30min
- Vital signs - 60min
Urinary Catheterisation (in/out)
Indications
Pregnant woman:
1. Has not passed urine for 2-3 hours
2. Has difficulty passing urine
3. Has a palpable bladder
Stage 2
Perineal Care
Stage 2
Directed Pushing
Stage 2
Self-directed Pushing
Stage 2
Birth & Hands-on Technique
- Call for second-clinician
- Support perineum
- Apply gentle counter-pressure on foetal head
- Apply gentle traction to release anterior shoulder (if required) and allow posterior shoulder to be released
- Place baby skin-to-skin with mother immediately post-birth
- Delayed cord clamping (>1min)
Stage 2
Episiotomy - Indications
- First vaginal birth requiring forceps/ventouse
- Suspected or confirmed fetal compromise
- Delayed second stage
- A severe perineal tear is judged to be imminent (‘button-holing’, significant blanching).
Assisted Birth
Definition & Indications
The use of instruments to assist in delivery of foetus.
Indications:
- failure to progress
- maternal exhaustion in 2nd stage,
- foetal distress
- awkward positioning of infant
- vaginal delivery of premature infant.
Assisted Birth
Methods
A. Ventouse – vacuum cap attached to infant’s head by suction; clinician assists to deliver infant during maternal contraction/pushing.
B. Forceps – positioning of forceps around infant’s head; clinician gently pulls to assist delivery; may be specially designed to turn the infant to particular sides.
*Administration of local anaesthetic to perineum/vagina +/- episiotomy
Induction
Definition & Indications
Assisting commencement of labour using artificial methods.
Indications
- Maternal hypertension
- Pre-eclampsia
- Miscarriage
- Enlarged foetus
- Cephalon-pelvic disproportion
- Diabetes.
- Intra-uterine growth restriction
- Mild foetal distress
- Foetal post-maturity.
Induction
Methods
- Prostin E2 (prostaglandin) – administered as pessary or gel to ripen cervix; requires careful monitoring of mother and infant.
- Balloon catheter – inserted into cervix and inflated with water to apply pressure; left in situ for approx. 12hours.
- Artificial rupture of membranes – use of amnihook/amnicot to break membranes per vagina.
- Synoticinon IV infusion – stimulates uterine contractions; requires careful dosing and monitoring; midwife increases dose every 30min until labour commenced; foetal heart rate monitored via CTG.
Stage 3
Active Management
Complete within 30min of birth:
1. Administer uterotonic agent - 10iu IM/IV oxytocin
2. Cut umbilical cord once pulsations cease
3. Perform controlled cord traction WITH conter-pressure to uterus (guarding)
4. Post-delivery check fundus for uterine tone and perform fundal massage if active bleeding
5. Monitor blood loss
*Recommended method
Stage 3
Physiological Management
Completed within 60min of birth:
1. Leave cord intact until pulsation ceased and/or placenta birthed
2. Encourage skin-to-skin and breast-feeding
3. Encourage upright maternal position
4. Monitor signs of separation
Stage 4
Placental Examination
- Completeness and deviation from normal
Stage 4
Maternal Care (9)
- Uninterrupted skin-to-skin contact for min 1hr
- Encourage breast-feeding and educate about secure attachment
- Ensure warmth and comfort
- Encourage food, fluids and rest
- Assess emotional/psychological response to labour/birth
- Encourage presence of support person
- Regular maternal observations
- Perineal care
- Bladder care
Stage 4
Postpartum Maternal Observations
Immediately post-birth and 15min for 1hour:
1. Vital signs
2. Uterus tone and height (firm and central
3. Blood loss
Immediately post-birth and 1hr
1. Perineum
2. Pain/discomfort
Stage 4
Neonatal Care
- Clean and dry infant
- APGAR score - 1 and 5min.
- Uninterrupted skin-to-skin contact for first hour (thermoregulation)
- Explain importance of positioning for patent airway
- Observe and support initial feed
- Weight, height and head circumference
- Administer Vitamin K (Konakion)
- Administer HepB vaccine
Stage 3
Signs of Separation
- Uterus rises in the abdomen
- Uterus becomes firmer.
- A trickle or gush of blood from the vagina
- Lengthening of the cord
- Cord does not retract with supra-pubic pressure.
