Maximum observation with minimal active intervention.
Aim:
Non intereference with watchful expectancy so as to prepare the patient for natural birth.
To monitor carefully the progress of labour, maternal condition and fetal behaviour so as to detect any intrapartum complication early.
General Principle:
-Initial assessment
-Observation and intervention if labour becomes abnormal
-close monitoring of the fetal and maternal condition
-Adequate pain relief
-Emotional support
-Adequate hydration
Initial Assessment:
- Detailed History
- Clinical Examination
- Basic investigation
Aim:
- To identify as high risk before the onset of labour
O/E:
Vitals
General sign
Chest/CVS
P/A:
Fundal Height
Lie
Presentation
Engagement
Contraction
FHS
V/I:
P/V:- Dilatation,Effacement,Consistency,Position,Station,
Membrane Status ,CPD
Investigation:
Diagnosis and Confirmation of Labour:
Admission
1.Encouragement and Assurance
2.Maintain cleanliness of women and her enviroment
3.Rest and ambulation
4.Diet(Liquid and a few biscuits, I/V fluid)
5.Bladder(Encourage women to empty regularly)
6.Bowel(Donot give enema routinely)
7.Relief of pain:
- Suggest change of position
- Encourage mobility
- Massage her back
- Encourage breathing exercise
- If necessary pethidine 1 mg/kg body weight or morphine 0.1 mg/kg IM
- Epidural
8.Assessment of progression of labour by partograph
- Patient information
- FHR every 30 minutes
- Amniotic fluid:Record the color of amniotic fluid at every P/V.
I: Membrane intact
C: Clear fluid
M: Meconium stained fluid
B: Blood stained fluid
Moulding:
1.Sutures apposed
2.Sutures overlapped but reducible
3.Suture overlapped but not reducible
Cervix Dilatation:
-Assess at every vaginal examination and marked with a cross
-Begin plotting on the partograph at 4 cm
Alert line:
A line starts at 4 cm of cervical dilatation to the point of expected full dilatation at the rate of 1 cm/hr.
Action line: Parallel and 4 hrs to the right of the alert line.
Descent: Assessed by P/A. Head divided into five parts. Refers to the part of the head palpable above the s.pubis.
Hours: Refers to the time elapsed since onset of ASOL.
Time: Record actual time
Contraction: Chart every half and hourly.Palpate the no.of contraction in every 10 min.and duration in sec.
< 20 sec: mild
20-40 sec : moderate
>40 sec : Strong
Oxytocin: Amount ofoxytocin/ltr, Drops/min
- Drugs: Record if additional drugs given
- Pulse: Half hourly
- B.P: Every 4 hourly
- Temperature: 2 Hrly
- Protein,Acetone volume: Record every time urine is passed
Protraction - as a slow rate of cervical dilatation or descent
Primiparas - less than 1.2 cm dilatation per hour or less than 1 cm descent per hour.
multiparas - less than 1.5 cm dilatation per hour or less than 2 cm descent per hour.
Arrest disorders - as a complete cessation of dilatation or descent. Arrest of dilatation is defined as 2 hours with no cervical change, Arrest of descent as 1 hour without fetal descent.
SECOND STAGE OF LABOUR
Progress of second stage of labour:
1.Increasing intensity of uterine contraction
2.Appearance of bearing down effort
3.Urge to defecate with descent of presenting part
4.Complete dilatation of cervix as evidenced by P/V
AIM
1.To assist in the natural expulsion of the fetus slowly and steadily.
2.To prevent perineal injury
General measures:
Pt should be in bed
Constant supervision for progress of fetal & maternal condition.
Fetal condition:
If there is FHS less than 100 or more than 160 suspect fetal distress.
Position & presentation: other than occiput anterior with well flexed head are considered malposition.
Maternal conditions:
Evaluate the women for sign of distress:
Pulse: If the women’s pulse’s increased ,she
may be dehydrated or in pain.
BP: If BP decreased suspect APH.
Acetone: If acetone is present in the
urine,suspect poor hydration & nutrition and give dextrose IV.
Preperation for delivary:
once the cervix is fully
dilated & the women in expulsive
phase,encourage to assume position she
prefers & encourage to push.
- Clean hand:
- Clean surface:
- Clean cutting & ligating of the cord:
Delivery of Head
- Ask the women to pant or give only small pushes with contractions as the baby’s head delivers.
- To control birth of the head, place the fingers of one against the baby’s head to keep it flexed(bent).
- Continue to gently support the perineum as the baby’s head delivers.
- Once the baby’s head delivers, ask the women not to push.
- Suction the baby’s mouth and nose.
Feel around the baby’s neck for the umbilical cord:
- If the cord is around the neck but is loose,slip it over the baby’s head;
- If the cord is tight around the neck,doubly clamp and cut it before unwinding it from around the neck.
Hooking the fingers in the axillae should be avoided - injure the nerves of the upper extremity, producing a transient or possibly even a permanent paralysis.
Immediately after delivery of the newborn, there is usually a gush of amnionic fluid, often tinged with blood but not grossly bloody.
Delivery of shoulder
Completion of delivery
Clamping the Cord
The umbilical cord is cut between two umbilical cord clamps –
- one clamp at 4 to 5 cm from the fetal abdomen,
- other clamp at 2 to 3 cm from the fetal abdomen.
Timing of Cord Clamping
If after delivery, the newborn is placed at or below the level of the vaginal introitus for 3 minutes and the fetoplacental circulation is not immediately occluded by clamping the cord, an average of 80 mL of blood may be shifted from the placenta to the neonate.
This provides about 50 mg of iron, which reduces the frequency of iron deficiency anemia later in infancy.
The risk of circulatory overloading from gross hypervolemia is high, especially in preterm and growth-retarded neonates.
Management of the Third Stage of Labor
Immediately after delivery of the newborn, the size of the uterine fundus and its consistency are examined.
If the uterus remains firm and there is no unusual bleeding, watchful waiting until the placenta separates is the usual practice.
Massage is not employed, but the fundus is frequently palpated to make certain that the organ does not become atonic and filled with blood from placental separation.
When the placenta has separated, it should be determined that the uterus is firmly contracted.
The mother may be asked to bear down, and the intra-abdominal pressure may be adequate to expel the placenta.
If these efforts fail, or if spontaneous expulsion is not possible, then after pressure is exerted with the hand on the fundus to propel the detached placenta into the vagina
Vital signs
BP , Pulse
Full Bladder
Trauma
Uterine Relaxation / Atony
Sudden Collapse / Shock
VULVAL HAEMATOMA / RUPTURED UTERUS
pains - Analgesia if needed
Transfer to inpatient if all signs are normal
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