Intrapartum/labour Flashcards
First stage in the low risk at term
Regular painful contractions AND some cervical effacement and dilatation of at least 4-6cm?
No.
Latent first stage [Irregular, less than 4-6cm]
- Initial assessment
- reassure latent stage is normal
- individualized support: rest, hydration, nutrition
- Advise mobilization may establish contractions
- Discuss comfort strategies and risks and benefits.
- Involve support people/partner
- Offer admission or return/remain at home according to individual need/circumstances
- Provide information on when to return to hospital and/or notify healthcare profession:
- Increasing strength, frequency, duration of contractions
- requiring pain management
- vaginal bleeding, rupture of membranes
- reduced fetal movement
- any concerns - Plan an agreed time for reassessment
First stage in the low risk at term
Regular painful contractions AND some cervical effacement and dilatation of at least 4-6cm?
Yes.
Active first stage. Supportive care: - Consider one-to-one midwifery support - review birth plan - environment (privacy, calmness, setting) - mobilization and positioning - involve support people/partner - comfort and pain management strategies
Ongoing (following initial) assessment
- maternal and fetal condition
- progress and descent of the fetal head
- FHR: every 15-30 minutes intermittent auscultation (differentiate maternal pulse)
- Temperature and BP: 4 hourly
- Maternal pulse: every 30 minutes
- Abdominal palpation: 4 hourly, prior to vaginal examination and as required to monitor progress.
- Contractions: every 30 minutes for 10 minutes
- Vaginal loss: hourly
- Offer VE: 4 hourly and if indicated
- Nutrition as desired and encourage hydration
- Bladder: monitor/encourage 2 hourly voiding
- Emotional coping, discomfort and pain.
First stage in the low risk at term
Regular painful contractions AND some cervical effacement and dilatation of at least 4-6cm?
Yes, but delayed.
Protracted labour - cervical dilatation of:
- nulliparous: < 2 cm in 4 hours
- multiparous: < 2 cm in 4 hours or a slowing of progress
Arrest in labour: cervical dilatation >6cm and ruptured membranes - there is no or limited cervical change after 4 hours of adequate contractions.
First stage in the low risk at term Regular painful contractions AND some cervical effacement and dilatation of at least 4-6cm? Yes. Risk factors or diagnosis of delay? Yes.
Discuss, consult, refer and manage.
Refer to Queensland guidelines.
First stage in the low risk at term Regular painful contractions AND some cervical effacement and dilatation of at least 4-6cm? Yes. Risk factors or diagnosis of delay? No.
Continue care as per active first stage.
Anticipate vaginal birth.
Identify commencement of second stage.
Second stage (full dilatation) in the low risk, term woman.
Baby visible or urge to push?
No.
Passive second stage - full cervical dilatation without the urge to push.
Care and assessment:
- FHR: every 15 minutes. Differentiate from maternal pulse.
- Delay pushing if no urge to push.
- Other care and assessment as per active second stage.
Second stage (full dilatation) in the low risk, term woman.
Baby visible or urge to push?
No.
Delay in passive second stage.
In hour (multiparous and nulliparous) if: no urge to push or no evidence of flexion/rotation/descent.
Second stage (full dilatation) in the low risk, term woman.
Baby visible or urge to push?
Yes.
Active second stage - full cervical dilatation or baby visible with involuntary expulsive contractions.
Supportive care-consider:
- Measures to promote, protect, support normal birth.
- Maternal/fetal wellbeing and expected progress
- Provide emotional support
Assessment:
- Maternal and fetal condition
- progress and descent of presenting part
- FHR: toward end and after each contraction or at least every 5 minutes. Differentiate from maternal pulse
- temperature, BP: 4 hourly
- Maternal pulse: every 15 minutes and if indicated to differentiate from FHR.
- Contractions: continuous assessment
- Abdominal palpation: prior to VE and as required to monitor progress.
- Offer VE only if indicated
- Nutrition and hydration: offer oral fluids between contractions.
- Bladder: monitor and encourage voiding.
- Discomfort and pain: warm perineal compress may aid comfort.
Second stage (full dilatation) in the low risk, term woman. Baby visible or urge to push? No. Delay in passive second stage. Risk factors or diagnosis of delay? Yes.
Discuss, consult, refer, manage as per Queensland guidelines.
Second stage (full dilatation) in the low risk, term woman.
Baby visible or urge to push?
Yes.
Delay in active second stage.
Birth not imminent and:
1) nulliparous woman
- insufficient flexion/rotation/descent within 1 hour
- active phase > 2 hours
- active and passive phase > 3 hours
2) multiparous woman
- insufficient flexion/rotation/descent within 30 minutes
- active phase > 1 hour
- active and passive phase > 2 hours
Longer durations may be appropriate where:
- maternal and fetal condition is optimal
- appropriate consultation and referral has occurred.
Third and fourth stage (full dilatation) in the low risk mother and baby.
Encourage, maintain and practice what?
- Environment that promotes newborn physiological
adaptation - Uninterrupted skin to skin contact for at least 1 hour or after first feed
- Woman and baby are not separated or left alone
- Minimal interference in maternal/baby bonding
- Support to breastfeed (if method of choice)
Third stage (full dilatation) in the low risk mother and baby. From birth of baby to birth of placenta/membranes
Management:
Modified active: recommend for all births
o Oxytocin 10 IU IM after birth of baby
o Wait at least 1–3 minutes after birth or for cord
pulsation to cease and then clamp and cut cord
o Controlled cord traction and uterine guarding
after signs of separation
o Prolonged after 30 minutes
Physiological: o Suitable for well women without risk factors o Placenta birthed by maternal effort/gravity o Oxytocin not administered o Clamp cord after pulsation ceased o No controlled cord traction o Prolonged after 60 minutes · If concern with cord integrity or FHR: o Clamp and cut the cord
Ongoing care:
· Encourage upright position
· Ensure bladder empty
· Maintain calm, warm and relaxed environment
· Support privacy and reduce interruptions
· Encourage to focus on physiological process
· Observe general physical condition
Fourth stage (full dilatation) in the low risk mother and baby. First 6 hours after birth of placenta/membranes
Supportive care:
· Encourage mother to eat, drink and rest
· Discuss and offer pain relief (if indicated)
· Consider personal hygiene needs
· Assess emotional and psychological wellbeing
· If RhD negative blood group, review indications
for RhD immunoglobulin
Assessment (for the first two hours)
Alter frequency of observations/assessment as
indicated.
· Temperature: within the first hour
· Pulse, RR, BP: after birth of the placenta
· Fundus and lochia: after birth of the placenta, then
every 15‒30 minutes
· Perineum: with first maternal observations
· Pain and discomfort
· Urine output: monitor voiding postpartum
· Examine placenta, membranes and cord
Third and fourth stage. Low risk mother and baby.
Baby’s cares.
Initial assessment
· Breathing, HR, colour, reflex irritability, tone.
Apgar score at 1 and 5 minutes
· Initial brief newborn examination
Supportive care
· Maintain warmth with:
Clear visibility and optimal airway position
Adequate lighting for observation of colour
Ongoing assessment
· Respiratory rate, colour, positioning for patent
airway every 15 minutes for first 2 hours
· Temperature and HR within 1 hour of birth
Non-urgent care (after first feed) · Weight, length and head circumference · Recommend phytomenadione (vitamin K/ Konakion® ) 1 mg IM · Offer Hepatitis B vaccine (as per local policy)
Definition of normal birth
Spontaneous onset
Low risk at start of labour
Remains low risk throughout
Baby is born: spontaneously, vertex position, 37-42 weeks gestation (term).
Two factors: risk status of pregnancy and course of labour and birth.
Intermittent fetal auscultation.
Nitrous oxide and oxygen.
Third stage: physiological, modified active third stage (delayed cord clamping).
No maternal or fetal complications or risk factors.
Normal birth excludes
Induction of labour Augmentation: ARM, oxytocin infusion Continuous fetal monitoring Pharmacological pain relief: opioids, epidural or spinal, general anaesthetic. Instrumental birth (forceps or vacuum). CS Episiotomy Early cord clamping Complications: - risk factors at commencement of labour - intrapartum - immediate postnatal (2hours of birth).
Indication for consultation or referral
Deviations from normal, when indicated:
- Increase the frequency of recommended observations as required
- Modify care as relevant to individual circumstances while maintaining a focus on
supporting the principles of normal birth
- Discuss, consult, refer and manage as indicated according to professional 2,20-23 and
Queensland guidelines
Woman centered care
Holistic care taking account of the woman’s physical, psychosocial, cultural, emotional
and spiritual needs
- Focusing on the woman’s expectations, aspirations and needs, rather than the
institutional or professional needs
- Recognising the woman’s right to self-determination through choice, control and
continuity of care from a known or known caregivers
- Acknowledging a woman’s right to privacy and to make her own informed, autonomous
health care decisions
- Recognising the needs of the baby, the woman’s family and significant others while acknowledging that the woman remains the decision maker in her care
Present information in a manner that promotes physiological birth
- Share and discuss information with the woman to enable informed choice and consent
- Respect the woman’s right to decline recommended care
- Provide a pathway for women declining recommended care
- Provide emotional and physical support to the woman
- Use supportive language to build confidence in the woman
- Respect and implement birth plan [refer to Table 4. Birth preparation]
- Involve the woman in clinical handover
Birth preparation
- Normal birth
- Psychoeducation
- Options for model of care
- Birth plan and preferences
Normal birth:
- Provide pregnancy care as per the Queensland PHR27
- Inform the woman that giving birth is a normal physiological event
- Offer information and discussion about:
- Benefits of physiological birth
- Signs of labour
- What to expect in the latent stage of labour
- How to differentiate between Braxton Hicks and active labour contractions
- Normal vaginal loss: how to recognise amniotic fluid
- Pain and support strategies [refer to Section 3 Comfort and coping strategies]
- Informed consent including for vaginal examination
Psychoeducation
- Provide an opportunity to discuss previous birth experience
- Reduces fear of birth in women who report high childbirth fear
· Associated with:
o Increased spontaneous vaginal birth
o Reduced caesarean section
o Increased positive birth experience
Respect and support a woman’s choice of model of care and caregiver
- Aim to provide continuity of carer close to the woman’s home
- Offer information about model of care options and their risks and benefits
to facilitate informed decision making including about:
o Place of birth
o Pharmacological and non-pharmacological pain management
o Duration of second stage
- Third stage management: Offer information about ongoing care options if deviations from normal
Birth plan and preferences
Provide opportunities to develop a birth plan and discuss birth preferences including:
o Cultural requirements for birth
o Support person(s)
- Supports:
o Involvement of women in their care
o Information sharing
o Effective communication
o The woman be central to decision-making
- The values and beliefs of caregivers can influence the success of a plan
- Avoid unidirectional/checklist birth plans
Comfort and coping strategies
- Consider the woman’s coping ability, mobility, weight, and stage of labour and support her choices
- Utilise the woman’s birth plan if provided
