Normal Labour, DeliveryNormal Labour, Delivery

andand

Postnatal CarePostnatal Care

AIMS

• Understand the process of normal labour

• Understand what Active Management of the Third Stage of Labour (AMTSL) is and it’s importance

• Knowledge of evidence based practices

When is a Woman in Labour? • Diagnosis of Labour

2-3 uterine contractions in 10mins Progressive shortening and thinning of the

cervix during labour and Cervical dilatation 4cm or more dilated

Normal Labour• Stages of Labour First Stage: onset of labour pains to full dilatation

of the cervix Second Stage: full dilatation of the cervix to the

delivery of the baby Third Stage: starts after the delivery of the baby

ending with the delivery of the placenta Immediate postpartum (‘Fourth Stage’): frequent

monitoring in the one hour following delivery

Supportive Care

• Many providers continue to use, untimely, inappropriate and/or unnecessary interventions, leading to complications

• Example: immobilising women, not allowing eating and drinking

Supportive Care

• Supportive care during labour is the most important thing to help the woman tolerate labour pains and facilitate the progress of labour

Supportive Care

• Support from a birth partner or companion.

• Good communication and building trust with staff.

• Encourage walking around and changing positions frequently.

• Encourage adequate intake of food and drinks

• Monitor maternal and fetal wellbeing using the partograph

Care that is of no proven benefit

• Routine shaving of the pudendal area.• Giving an enema.• Routinely cutting episiotomy for delivery.• Application of fundal pressure

Management of Labour

• Not in active labour (cx 0-3cm, contraction <2/10)

- Monitor every hour: contractions, FHR- Monitor every 4 hours: HR, BP, temp

• In active labour (cx 4cm or more)

- START partograph- Monitor every 30 min: contractions, FHR,

presence of any danger signs- Monitor every 4 hours: cervical dilatation, HR,

BP, temp

Assessing Progress in Labour

- Assessing changes in cervical dilatation and effacement (PV examination)

- Foetal descent (PV and Abdominally)

5ths of Head palpable above symphysis pubis

Second Stage• Once the cervix is fully dilated, encourage the

woman to assume the position she prefers to push only with a contraction.

Squatting, sitting and standing positions may make pushing easier

Avoid routine catheterization which may lead to infections.

When delivery is imminent the women may be put in dorsal lithotomy position for the actual conduct of delivery

Second Stage

Delivery of the head: Control birth of the head to keep it flexed. Gently support the perineum as the baby’s

head delivers. Feel around the baby’s neck for the umbilical

cord: - if the cord is loose, slip it over the baby’s head- if the cord is tight clamp and cut it.

[!] NO routine episiotomy

Second Stage

Completion of delivery :• Allow the baby’s head to turn spontaneously.• Deliver one shoulder at a time - anterior then

posterior.• Support the rest of the baby’s body as it slides out.• Dry and wrap baby, assess breathing• Ensure the baby is kept warm and in skin-to-skin

contact on the mother’s chest/abdomen.

Third stage of labor

The classical expectant management

• Wait for the natural forces of labor to bring about 3rd stage contraction and placental separation

• Look for the signs of placental separation• Controlled cord traction to expel the placenta

and membranes• Optional administration of Oxytocics

Active management of 3rd stage

• Oxytocic administration immediately after delivery of the baby so that the uterine contractions and placental separation is not left to the natural uncertain forces of labor

• Controlled cord traction on perception of a strong uterine contraction with out waiting for the actual signs of placental separation

• Uterine massage to maintain the contraction

Active Management of the Third Stage

As practiced• Palpate the abdomen to rule out the presence of an additional baby(s)• Give Oxytocin: 10 units • Clamp and cut the umbilical cord • Controlled cord traction on perception of a strong uterine contraction

with out waiting for the actual signs of placental separation• Uterine massage to maintain the contraction

Controlled Cord Traction• Should be done only when the uterus is

felt to have contracted strongly• Make sure the bladder is empty• Hold the clamped cord in one hand and

with the other hand apply counter traction on the uterus. Keep slight tension on the cord and await a contraction.

Controlled Cord TractionCont

• Pull downward on the cord to deliver the placenta, applying counter traction to the uterus with the other hand

• If it does not succeed at first attempt wait for some more time for a stronger uterine contraction

• Stress on a complete examination of the placenta for any retained placental fragments

Third Stage• As the placenta delivers, gently turn it until

the membranes are twisted and slowly pull to complete the delivery.

• Check the placenta to be sure none of it is missing.

• Examine the woman carefully and repair any tears to the cervix or vagina or repair the episiotomy.

[ ! ] NO routine packing of vagina while attempting a repair.

Immediate PNC - Mother

• Routine observations• Regular checks for vaginal bleeding and contraction of

uterus. • Examine perineum for tears. • Pain relief• Encourage the mother to eat, drink and rest• Consider IUD insertion• Identify any signs of complications, stabilise and REFER

Observations

• 1-2 hours: every 15 minutes• 3-5 hours: every 30 minutes• >5 hours: every 4 hours

• Length of stay in health facility: Advise observation for 24hours

Immediate PNC - Newborn

• Encourage early breastfeeding• Keep warm, check temp every 15min by feeling the feet• Examine for any malformation or abnormality > REFER• Care of the cord, check for bleeding• Give VIT K 1mg IM.• Delay baby’s first bath to beyond 24 hours of birth

[!] Avoid separating mother from baby whenever possible. Do not leave mother and baby unattended at any time.

[!] NO routine suction of throat and nose