Wednesday 17th October 2018

Labour and Delivery

A Mother with her new born child

Breast Cancer Health Education at Bethesda

Labour; -Coordinated effective sequence of involuntary uterine contractions that result in:effacement and dilatation of the cervixvoluntary bearing down efforts leading to the expulsion per vagina of the products of conceptionDelivery

Is the mode of actual expulsion of the fetus and placenta. Abortion is delivery before 20 weeks of gestation.

Parturition is birth process

True Labour is characterised by; regular uterine contractions(pains).become more frequent, forceful and occurring over longer duration with passage of time.The main aspects of labour are;

  • Passage
  • Passenger
  • Power
  • Psyche

False labour Quite common in late pregnancy.regular brief uterine contractions evoking back and abdominal painContractions are inconsistent in interval, duration and strength and cause no change in cervix.

No significance except causing anxiety, premature hospital admission.

Interventions to improve maternal and newborn outcome

  • Begins early in the life of the girl child by feeding her on the right foods for proper bone development to reduce risk of obstructed labor
  • Immunization to remove polio which would complicate labour
  • Education of the girl child.
  • Before conception, mother should begin taking folate tablets.
  • The maternal HIV sero status should be known beforehand to ensure PMTCT if mother is HIV .

Course of Labour

First stage
Begins with the onset of contractions and ends with cervical effacement and full dilatation(10cm )
Longest stage of labour with an average duration of 8-12hrs in PGs,multipara 6-8hrs

Intervention in the first Stage

Monitor and Record the progress of labour on a partogragh( Report about both maternal and fetal condition )
Minimize stress on the mothers condition as much as possible and encourage to take tea with sugar to give energy for the second stage of labour

Preparation of Delivery

Adequate delivery room facilities including anesthesia, resuscitation equipment and drugs, sterile surgical instruments, drapes, sponges, sutures
Transport patient to delivery room, position the patient on the delivery table/bed
Clean the vulva
Apply drapes to the legs and abdomen
All the above ensure a surgically clean field for delivery
Physicians and assistants must scrub their hands and wear masks and sterile gowns and gloves as a major surgical procedure
Maintain proper perineal hygiene. Clean the vulva region b4 and after internal examination, after defecation and voiding or when soiling by vaginal secretions occurs
Encourage the patient to void as labour progresses(consider catheterization when necessary )

Second stage
From full dilatation of the cervix to complete birth of the baby
Mother feels a desire to bear down and push with each contraction
Progress measured by descent of the presenting part
Usually does not exist beyond 2hrs in normal labor
Spontaneous delivery of the presenting part by the vertex is divided into 3 phases

  • delivery of the head
  • delivery of the shoulders
  • delivery of the body and legs

Management

When presenting part distends the perineum, anesthesia may be administered. Pudendal nerve block may be performed
Episiotomy is carried out when tear is imminent especially in prime gravidas to prevent perineal body tears.
Distention of the perineum may be accentuated by the patient and vacuum extractors
applied from the coccygeal region upward will extend the head at the proper time and thereby protect the perineal musculature from tear.

Immediate Care Of The Infant

Once delivered infant should be held with the head lower than the body to facilitate drainage by gravity of accumulated mucus and bronchial secretions in the airways
Record apgar score at 1min and 5min
Clear air passage by means of a soft rubber bulb syringe
Some place the child on the mother to collect warmth as the cord is being cut.
Maintain body temp of the infant by radiant heat to avoid chilling, wrap the baby in dry warm clothing after drying and weighing to avoid heat loss.
Apply a sterile cord clamp, cord tie of umbilical tape, or rubber band
Wipe eyelids with cotton wool, drop of 1% silver nitrate or tetracycline
A physical examination is done in order to tell the sex of the baby, any life threatening abnormalities etc
When feasible, the mother should be given the infant to hold or even to nurse
Transfer the infant to the nurse for further observation and care

Third stage
Period from delivery of the baby to delivery of the placenta and the membranes.
Can last for 30mins before intervention is done
Signs of placental separation include; gush of the blood, lenghtening of the cord, uterus becomes globular /fundus raises
Critical monitoring of the mother 1 hr following delivery of the placenta is critical because of possible hemorrhage( often called 4th stage)

Management of Third Stage

Active management of third stage in involves;

  • IM oxytocin 10iu on anterior thigh within 1min of delivery
  • Deliver the placenta by CCT( controlled cord traction )
  • Massage uterus to expel clots

Immmediate Care of the Mother

Inspect the genital tract for any laceration ,extension of episiotomy incisions, hematomas in the perineum, vagina and cervix and if present repair should be done

Other Aids to Normal Labour

Episiotomies ;
Most important in PG but even in multigravida
Pudendal incision to widen vulvar orifice to permit easier passage of the fetus
Advantages;

  • Prevents perineal tear lacerations
  • Relieves compression of the fetal head
  • Shortens 2nd stage by removing resistance

Induction & augmentation of labour;
Prolonged labour
Diabetes mellitus
Rh isommunisation
Pre eclampia
Chronic hypertension

Traditional Birth Attendants

It is a reality that in Uganda more women deliver at home with the traditional birth attendant or in poorly equipped health centers where they are mismanaged hence the increased incidence of maternal mortality during labour in Uganda.
However there has been introduction of programs to improve their skills and safety

Post Natal Care

The postnatal period is the time from third stage of labour to six weeks post partum aka puerperium. This is a period of time during which the body physiology and anatomy returns to the pre-gravid state.

PNC involves both mother and the newborn.
PNC is divided into immediate, early and late.
Immediate PNC begins on the labour ward involves monitoring vitals every 15 minutes, asses pain, tears and laceration, bonding with the baby.
Continue to monitor vitals, complications of labour PPH,sepsis, pain relief,examine breasts,
Advise mother on diet, ambulation and physiotherapy, hygiene..breast feeding( teach mother how.
Ask about lochia, sleep, bowel (gas and stool), emotional support. discharge mother via family planning clinic.

Late Post Natal Care

She may resume sexual intercourse if perinium is intact at 4 weeks postpartum, if there was a tear then advise after 6-8 wks.
Encourage vaginal laxity exercises.
Talk about child immunization, feeding and encourage not to wean till 6 months age,

Post Natal Care for Caesarian Section

Immediate; vitals every 15 mins, monitor urine output hourly, vaginal bleeding, IV fluids in 1st 24 hours then resume oral feeding on day 2 post surgery.
Early PNC; remove the catheter within 24 hours post surgery, examine vitals, lochia, advise on hygiene.
Late PNC; remove sutures 7 days post surgery, discuss contraception, manage any complications that may arise, examine the mental status. mother returns at the end of puerperium to have a post natal examination which involves an assessment of her mental status and her physical wellbeing(ask about urination,), also assessing the child’s welfare.

Care of the New Born

Immediate; examine the newborn( apgar score, sex, weight, nevirapin syrup if mother is HIV +ve, give tetracycline on the conjunctiva, ensure that Baby Is warm)
Early; is baby feeding well, examine newborn( for congenital abnormalities eg,. Locked hip, clubbed foot etc), immunization,

Factors affecting choice of place of delivery

Social Factors

  • Behavior of the clinical personnel…unconcerned
  • Ignorance…husband, mother. It may be viewed as a shameful matter
  • Maternal level of education, unfounded fear for c/s
  • Family structure… she is the sole provider of the family
  • Inlaws.

Economic Factors

  • Teenage pregnancies that often get delivered in the villages
  • Poor road networks and lack of transport to the health center
  • Distance of nearest available health care center… the further away, the higher the possibility of the tba
  • Financial demands of the health care center…cost of stay in hospital, feeding, hospital charge for care given etc
  • Mother as bread earner of the home

Cultural Factors

  • Insisting on the TBA, keep the placenta, shower herbs to speed progress of labour
  • Family planning methods
  • Availability or absence of attendants during labour.
  • Religious beliefs
  • Birth position

Improvements on facility or skilled attendant delivery

  • Train more health workers
  • Provide quality health services eg.PMTCT, IPT
  • Policy on surveillance and supervision of health centers.
  • Media sensitization to educate mothers about ANC
  • Involvement of NGOs
  • Improve transportation facilities
  • Encourage women participation in decision making
  • Involve and train TBAs about delivery, advise them to refer any complicated deliveries.
  • Alleviate fears and myths on delivery in the hospital
  • Political will incentives for the health care providers.