A Midwifery Perspective
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Transcript of A Midwifery Perspective
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A Midwifery Perspective
Ann Rath
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Ann Rath Ann Rath
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Home of Active Management
Total No of Deliveries 2012 =8978
Total No of Babies =9142
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Birth of a 1st Baby
• A PROFOUND EMOTIONAL EXPERIENCE
• Moulds attitude to all subsequent births
• If happy unlikely to have any apprehension
• Unhappy –Requesting LSCS
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1973
Although childbirth has long ceased to present a serious physical challenge to healthy to women in western society –the emotional impact of labour
remains a matter of common concern
O’Driscoll K BMJ 1973 ;3 135-137
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Diagnosis of Labour
The diagnosis of labour is the single most important item in the conduct of labour.
If the initial diagnosis is wrong, all subsequent management is likely to be wrong too.
Midwife is the only person who makes this important diagnosis in our hospital
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Preparation for Labour
Preparation takes away the fear of the unknown.
Women are familiar with terminology and labour records.
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Diagnosis in Practice
Painful Uterine Contractions 1 : 10
Show
Spontaneous Rupture of Membranes
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On arrival to the Labour Ward
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The Midwife learns this important skill while working as a Junior Midwife under the close
supervision of the Midwife in charge or her deputy.
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Findings on Vaginal Examination
Cervix uneffaced
and undilated
37 weeks Gestation
Contractions
1 : 20
Given an adequate explanation and allowed home
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Vaginal ExaminationCervix
Partially effaced
39 weeks gestation
Contractions
1 : 20
Home or retain in antenatal
ward
40 / 41 weeksGestation
Contractions 1 : 10/8
+/ - Show
Retain and reassess in 1 hour
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Vaginal Examination
Cervix fully effaced
Painful Uterine Contractions
+ / - Show or
+ / - SROM
In Labour and will deliver within 12 hours
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Vaginal Examination
Cervix 2cms dilated
In Labour
80% of women admitted to the labour ward have a cervical dilatation of < 3cms
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Diagnosis of Labour
A woman who is admitted with painful uterine contractions supported by either a show or spontaneous rupture of the membranes, and on vaginal examination her cervix is fully effaced is deemed in labour, and retained in the labour ward and therefore committed to delivery which is anticipated within 12 hours.
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Effaced cervix is confirmation of
diagnosis of labour irrespective of
dilatation
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Diagnosis of Labour
Dilatation of the cervix represents the sole conclusive evidence of labour.
Effacement is the feature which serves to distinguish between the cervix which passively admits a finger tip and the cervix which is actively dilated to the extent of 1cm in labour.
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gl
Clear Distinction between Nullips and Multips
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Amniotomy is performed at the diagnosis of labour
To assess the fetal condition at the start of labour
Determine which fetuses need continuous electronic monitoring
Other beneficial effects Shortens the labour Decreases need for oxytocin
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Management of Labour
Latent phase
Is not useful in the diagnosis and the
management of labour
Effacement
of the cervix is the key to the diagnosis of labour
and it’s graphic analysis and that is when the partogram is started
Dilatation on diagnosis
80% < 3cm
Latent phase Acceleration phase
Active phase
Deceleration phase
yes yes yes
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Spontaneously labouring nulliparous women with a single cephalic pregnancy
at 37 weeks or greater
Philosophy
A clear pattern of dilation should emerge and determined clinically within the first 3-4 hours of labour
1 cm an hour is taken as normal progress
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4 hours is too long to wait between examinations to make the diagnosis
of inefficient uterine action
Efficient uterine action and normal progress only be confirmed by
doing vaginal examinations 2 hourly before oxytocin is started.
Average number of vaginal examinations in total is 3.7
Epidural rate 50%. 90% of epidurals given within 4 hrs
CS rate 7% and not increased significantly over the last 25 years
Spontaneously labouring nulliparous single cephalic
women at term
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• Level of mutual confidence must be present between midwives and doctors
• Clear chain of command
• Mutual Respect
• Co-ordinator/Midwife in charge has a vital role to play
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Evaluate Outcomes
Patient SatisfactionPeer Review
Clinical Outcomes
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FeedbackFeedback
ImprovementImprovementSuggestionsSuggestions
SatisfactionSatisfaction
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EVALUATION FORM DELIVERY WARD DATE OF DELIVERY PARITY We would be grateful if you would spare the time to offer your views in response to the following questions. The information gained from these forms is analysed and used to improve our care. We value your comments and anything written will be treated seriously and in complete confidence. Thank you for taking the time to complete this form, if you feel you would like to discuss your labour further, please tick the box and we will contact you. As part of our wish to continually to improve the service we sometimes need to contact women after delivery. Please indicate if you would be prepared to be included in further questionnaires YES / NO
1.What do you think was good about your labour and the care you received?
2. What aspect of your care could have been improved?
3a Did you attend antenatal classes? Yes /No If Yes where did you attend classes 3b..How could you have been better prepared for your labour? 4.Any other comments.
PLEASE PLACE PATIENT STICKER HERE THANK YOU
Labour Feedback
Form
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Following Delivery
Positive PointsPositive Points•One to one care•Communication•Pain relief•Antenatal classes•Breastfeeding•Friendly Staff
Negative PointsNegative Points•Communication
– Medical terms used – Lack of information
•Pain relief issues– Waiting time for epidural– Ineffective pain relief
•Facilities – Car parking– Overcrowding
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No blame culture
Continuous communication
Clinical governance
Risk management
Quality improvement
Continual Audit
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Management of labour
An active interest in
labour
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