Woman presenting to birth suite at term Flashcards
First step
Initial assessment Indication for presentation: contractions, vaginal loss, spontaneous ROM, pain
Important history
Verbal Hand help record Model of care General health and well being Obstetric and gynaecological history Medical/surgical history Psychosocial, spiritual Investigations during pregnancy LMP, EDD by scan or period Presence of contractions Gush of fluid/blood Fetal movements
Investigations during pregnancy need to know
Blood and urine test results->blood group, resus, infection screens, Hb levels, urine, BP throughout pregnancy Measurements of fundus Results of CFTS, US morphology and growth scans Whooping cough vaccination
What examination is required
Vitals, BP, Temperature, General CTG for fetal monitoring Abdominal examination->privacy and consent. Fundal height, lie, presentation, position, engagement. Contractions, FHR, CTG, FM Vaginal Loss->nil. show, liquor, blood Vaginal examination->if indicated and no contraindications
What advice to give when baby is OP position and in established labour
OP presentations are common in primi, sometimes can make labour slower as baby has to rotate 135 degrees anterior.
Information recorded on partogram
Vagina Cervix–>effacement, consistency, dilitation, application of presenting part, membranes, liquor Presenting part–> Nature, level, sutures, fontanelles, position, caput, moulding Pelvic assessment Procedures and recommendations FHR Descent Oxytocin Contractions Drugs and fluids Temp BP Maternal HR Urine, bowels, vomit
When is a partogram started
When in established labour 4cm dilated
When are the warning and action lines drawn
2 hours for warning and 4 hours for action line to the right of the expected cervical dilation of 1cm per hour.
Expected cervical dilation rate/hour
1cm/hour
When to reassess uncomplicated established labour
4 hourly
Purpose of ARM
To bring the presenting part closer to the cervix, increase production of natural prostaglandins
Prior to administering an epidural, 3 things need to do
Consent and catheter, CTG
Indications for continuous CTG (10)
Preterm Prolonged Suspected fetal compromise Meconium stained liquor FHR abnormalities Oxitocin Epidural Previous CS Multiples Any condition that led to antenatal CTG monitoring
Risks of epidural (7)
Maternal motor blockade, reduced movement Xbladder sensation->need for catheter Hypotension Need for continous CTG Slight increase in overall length of labour Slight increase in operative vaginal delivery Small risk of postnatal headache
How to commence an oxytocin infusion
Establish indication Gain IV access Main-line infusion of Hartmanns/normal saline w/ T connector Oxytocin infusion in 500ml hartmanns containing 10IU hartmanns commenced via T piece
When to increase oxytocin infusion rate
Increased half hourly until desired labour pattern acheived
Oxytocin dose acheived with fluid load
ml/h, micro-units/min 10/3.25 20/6.5 40/13
10 units oxytocin in 500ml equals how many units of oxytocin/ml
0.02
Following intial VE on presentation what next?
Discomfort and pain-> assess response to contraction Review birth plan Discuss options Reassure, reinforce coping Note preference for pain relief
Documentation after presenting
Date time and reason Assessment Time regular contractions commences Time of SROM Communication, advice, management plan
Following initial assessment
Discuss/consult if risk factor identified Triage stage of labour and manage as indicated
Defining active first stage labour
Regular painful contractions Progressive dilation of cervix 4-5 cm
Overview of management in active first stage labour (5)
Supportive care Ongoing assessment Documentation Identify risks Diagnose delay in active first stage
Define delay in first stage
Cervical dilation
Supportive care in active first stage- aspects to consider (6)
Woman centred Review birth plan Environment Mobilisation and positioning One to one care Non-pharmacological comfort strategies
Ongoing assessment in active first stage labour (12)
Maternal and fetal condition Progress and descent of fetal head FHR- 1/4 to 1.2 hourly Temp and BP 4 hourly Maternal pulse 1/2 hourly Abdominal palpation 4 hourly Contractions 1/2 hourly for 10 minutes Vaginal loss hourly VE 4 hourly/indication Nutrition and hydration- offer fluids/food Bladder- monitor and encourage 2 hourly emptying Discomfort and pain
Documentation during first stage
Intrapartum record Date and time labour commenced Assessment Effectiveness of supportive care Time of SROM- color, odour, amount, consistency Communication, advice and management plan
Define latent first stage
Some cervical change with cervical dilation and effacement up to 4-5 cm 1 contraction/5 mins 30-60s regular
Management of latent first stage if not admitted/discharge
Encourage to remain at home Reassure normality Discuss comfort strategies Advise mobilisation may establish contractions Provide support information and instructions on when to return Document
Support strategies for latent stage labour
If tired- rest Hydration and nutrition Warm showers/baths Massage/back rubs TENS Paracetamol 1 g 6 hourly or 1 g hourly orally
What is the bishop score and measurements
Rates the readiness of the cervix for labour Dilation Effacement Station Consistency Position if cervix
What bishop score says cervix is favourable and unfavourable
Favourable when >6 Unfavourable when
What is the defining feature of second stage labour
Urge to push or active maternal effort of pushing
Overview of care in second stage
Onset when full cervical dilation, maternal pushing Supportive case–>environment, positioning, emotional support Assessment Documentation Identify delay in active second stage
Assessment requirements in second stage
Maternal and fetal condition FHR
Define delay in second stage
In nulliparous- after 2 hours or when total length of second stage >3 hours Multiparous > 1 hour
Management of passive second stage
Full dilation w/o involuntary expulsive contractions FHR 1/4 hourly Delay pushing if no urge Other care as per second stage
When is diagnosis of delay in passive second stage made
Nulliparous and multiparous- after 1 hour
Definition of third stage labour
From birth of baby to expulsion of placenta
Management overview of third stage
Supportive care: environment, skin to skin, minimal interruption of maternal/newborn bonding Physiological/Active or Modified active management Care and assessment Documentation
Physiological management of third stage
Birth of placenta by maternal effort only Clamp cord after cessation of pulsation No routine use of uterotonics
Active management of third stage labour
Routine administration of uterotonics CCT Uterine massage
Modified active management of third stage labour
Active management with uterotonics after cord pulsation has ceased
Care and assessment in third stage labour
Observe breastfeeding Encourage upright Ensure empty bladder Observe general physical condition- color, resp, vaginal losses, womans self report
Following birth of placenta, assess
Temperature, pulse, BP Blood loss Fundus Placenta and membranes Perineum
Documentation in third stage
Time of birth of placenta Management, care and assessment Estimated blood loss Communication, advice and management plan
Define prolonged third stage
Active >30 mins Physiological >60 mins
Fourth stage new born care- immediate
Initial assess- skin to skin Tone, breathing, HR, colour, reflex Apgar Newborn examination Ensure not separated from mother STS for minimum 1 hour Initiate breastfeeding Keep warm Ensure clear visibility of newborn and optimal airway positioning Lighting adequate to observe for colour
Care of newborn following breastfeeding
Weight, length, HC Administer Vitamin K and hepatitis V RR, colour, position 1/4 hourly for 2 hours Temp and HR 1 hour from brith Document- date, time, apgar, assessment, ID, commence neonatal clinical pathway and health record.
Care of mother in fourth stage
STS contact Keep with baby Allow bonding Eat, drink and rest Pain relief offer Personal hygeine needs If negative blood group- cord blood test to determine Anti-D requirements Temperature w/i first hour Pulse, respiration, lochia after birth of placenta and 1/4 and 1/2 hourly Perineum Pain Urine output Document
Mechanism of changes to cervix in first stage
- Uterus contracts and retracts->heaping of upper uterus, cervix thins and stretches.
Methods of induction of labour
- Artificial rupture of membrane +/ dinoprostone 2. Oxytocin infusion
Mechanism of labour
- Estrogen +myometrium activity, progesterone suppresses 2. Late pregnancy: fetal adrenals +DHEAS->Estrogen and contractions 3. Decidua produces PG->contractions->hypoxia->+PG 4. Final pathway in cytosol free calcium->actin + myosin
Process of CCT
- Uterotonic drugs given following delivery of anterior shoulder 2. Left hand above symphysis pubis guards front wall of uterus preventing inversion. Empty bladder, relax 3. Umbilical cord grasped in right hand, steady traction until delivered 4. Membrane follows placenta->may need gentle rotation of placenta to help peel off. Check for completeness
Pin relief options
- Non-drug Warm bath Relaxation Hypnosis TENS 2. Drug Nitrous oxide: inhale before each contraction Morphine: no antispasmodic, for OP, long labours. AVoid 2 hours before delivery, can cause depression to baby. Give metoclopramide. Pethidine Diamorphine 3. Anaesthesia Local Regional: epiD at T11-S4 General: when emergency C-section and need speed
Movements of fetus during labour
- Flexion Head engages when head through pelvic brim 2. Descent Brim to mid cavity 3. Internal rotation One parietal lower than the other 4. Further flexion Chin tightly up against fetal chest Occiput behind pubis 5. Extension’Head forward, gradual extension, distending perineum Widest part passes through introitus= crowning 6. Restitution and internal rotation Shoulders enter maximum diameter One shoulder leads->rotates and head rotates 90 degrees Shoulders in AO behind pubic symphysis 7. Delivery of the body Assist lateral flexion of fetal head, ant shoulder slips under Posterior shoulder follows
Potential changes in fetal heart
- Fetal tachyC 2. Baseline bradyC 3. Baseline variability Increased Loss of variability 4. Intermittent changes Deccelerations Accelerations
Normal fetal heart rate and baseline variability
- Normal FHR 110-160 2. Normal variability 6-25 beats/ minute
Define fetal tachyC and causes
- FHR >170 2. Maternal tachyC->pyrexia, pain, deH, blood loss 3. Fetal hypoxia->prolonged, intense contractions, por placental flow etc
Baseline bradyC significance
- If baseline 110-120 usually of no significance
- Mild bradycardia of between 100-120bpm is common in the following situations:
Post-date gestation
Occiput posterior or transverse presentations
- Severe prolonged bradycardia (< 80 bpm for > 3 minutes) indicates severe hypoxia
Prolonged cord compression
Cord prolapse
Epidural & Spinal Anaesthesia
Maternal seizures
Rapid foetal descent
Define increased variability and causes
- Increased = 25 variability
- Fetal hypoxia
- Fetal anemia
Define loss of variability and causes
- Reassuring – ≥ 5 bpm
- Non-reassuring – < 5bpm for between 40-90 minutes
- Abnormal – < 5bpm for >90 minutes
Causes
- Foetus sleeping – this should last no longer than 40 minutes – most common cause
- Foetal acidosis (due to hypoxia) – more likely if late decelerations also present
- Foetal tachycardia
- Drugs – opiates, benzodiazipine’s, methyldopa, magnesium sulphate
- Prematurity – variability is reduced at earlier gestation (<28 weeks)
- Congenital heart abnormalities
Early deccelerations
- Vagal response as head compression during descent
- Usually no significance- physiological
- Early decelerations start when uterine contraction begins & recover when uterine contraction stops.
- Quickly resolves once the uterine contraction ends & intracranial pressure reduces
Late decceleration
- U shaped, >30 s after contraction and continue following the contraction
- This type of deceleration indicates there is insufficient blood flow through the uterus & placenta
- As a result blood flow to the foetus is significantly reduced causing foetal hypoxia & acidosis
Reduced utero-placental blood flow can be caused by: ¹
- Maternal hypotension
- Pre-eclampsia
- Uterine hyper-stimulation
Needs to be taken seriously, fetal pH monitoring
Variable deccelerations
- Isolated variable, Common
Umbilical cord compressed
As long as returns to normal, baby no aphyxiated and fetal blood sampling not required
- Recurrent variable deccellerations
Vary in shape and relationship to contraction
Most commonly caused by cord compression between presenting part and pelvic side walls
Accelerations
- Intermittent FHR ++above baseline 2. Sign of fetal health
