Providing care during labor, childbirth and immediate postpartum.

Providing care during labor, childbirth and

immediate postpartum

General Objective:General Objective:To describe the best practices in caring for To describe the best practices in caring for the woman during labor, delivery and the woman during labor, delivery and immediate postpartum. immediate postpartum.

Specific ObjectivesSpecific Objectives

To demonstrate the principles of good care in caring for the woman in labor, delivery and immediate postpartum

To review the steps in providing intrapartal care

To record and interpret observations accurately using the labor record and partograph

To practice abdominal and internal examination during labor

Steps to followin INTRAPARTAL CARE

1. Examine the woman for emergency signs.• Unconscious, Convulsing• Vomiting • Severe headache with blurring of vision • Vaginal bleeding• Severe abdominal pain• Looks very ill • Fever• Severe breathing difficulty

Do NOT make a very sick woman wait, attend to her quickly!

2. Greet the woman and make her comfortable. Ask for informed consent before

examination or any procedureRespect privacyCommunicate result of examination

Steps to Follow in Intrapartal Care

3. Assess the woman in labor. Take the history of labor and record on the labor form. Review Home Based Maternal Record (HBMR)/

Mother and Child Book When is delivery expected? Preterm or term? Prior pregnancies Birth plan

Assess uterine contractions: intensity, duration, and interval

Observe the woman’s response to contractions. Perform abdominal exam: (Leopold’s maneuver,

FHT) between contractions


4) Determine the stage of labor. Explain to the woman that you will perform a

vaginal examination and ask for her consent. Respect privacy Observe standard precautions


4) Determine the stage of labor.

Inspect the vulva for:o Bulging perineumo Any visible fetal partso Vaginal bleedingo Leaking amniotic fluid; if yes, is it

meconium stained, foul smelling?o Warts, keloid tissue or scars that may

interfere with delivery


4) Determine the stage of labor.

Perform gentle vaginal examination (do not start during contraction).

Explain findings to the woman. Reassure her.

RECORD findings in labor record or in partograph.


Determining Stage of LaborDetermining Stage of Labor

Not in Active Labor

Early Active Labor

Late Active Labor

Imminent Delivery

Determining Stage of LaborSignsSigns ClassifyClassify ManageManage

• Bulging thin perineum Bulging thin perineum • Vagina gaping and head Vagina gaping and head

visible visible • Full cervical dilation Full cervical dilation

Imminent Delivery Imminent Delivery • Manage 2Manage 2ndnd stage of stage of labor labor

• Record in partograph Record in partograph

Cervical dilatation Cervical dilatation - Multigravida - Multigravida >>5 cm5 cm- Primigravida - Primigravida >>6 cm6 cm

Late Active Labor Late Active Labor • Manage 1st stage of Manage 1st stage of labor labor

• Record in partograph Record in partograph • Record in labor record Record in labor record

Cervical dilatation at Cervical dilatation at >>4cm4cm

Early Active Labor Early Active Labor • Manage 1st stage of Manage 1st stage of labor labor

• Record in partograph Record in partograph • Record in labor recordRecord in labor record

Cervical dilatation at 0-3 Cervical dilatation at 0-3 cm cm

Contractions weak and Contractions weak and <2 in 10 minutes <2 in 10 minutes

Not yet in Active Not yet in Active Labor Labor

• Record in labor record Record in labor record

5. Decide if the woman can safely deliver. If there is indication for referral …

• in early labor and the referral hospital can be timely reached:

Refer urgently

• in late active labor: Monitor progress of labor and deliver the baby Prepare for immediate referral if still necessary

If the woman or her family refuses referral Explain the possible consequences Continue to take care of her


6. Give supportive care throughout labor.6. Give supportive care throughout labor.

Activity #2:Activity #2: Identify which is correct and incorrect Identify which is correct and incorrect

practice and explain why.practice and explain why.

A.A.

• Explain procedures, seek permission, respect privacy and discuss findings with the woman and her family.

B.B.

.

B.B.

NEVER LEAVE a woman in labor alone.

C. Bathing before labor?C. Bathing before labor?

D. Bathing before laborD. Bathing before labor

Encourage woman to wash from her waist down or take a bath at the onset of labor.

E. Bladder emptying?E. Bladder emptying?

Encourage her to:•empty her bladder and bowels. Remind her to empty her bladder every 2 hours. (A full bladder may prolong the labor)

F. Position during LaborF. Position during Labor

Respect and support her choice of a birthing position

G. Eating, Drinking???G. Eating, Drinking???

7. Eating, Drinking???7. Eating, Drinking???

Encourage her to:Eat and drink as she wishes.

Activity #3: Demo-role play of own Activity #3: Demo-role play of own practicespractices

10 mins preparation10 mins preparation

5 mins presentation 5 mins presentation 3 groups:3 groups:

11stst stage stage22ndnd stage stage33rdrd stage stage

7. Monitor and manage labor. First stage: not yet in active labor, cervix is dilated

0-3 cm., contractions are weak, <2 in 10 minutes

Every hourEvery hour: : check for emergency signs, frequency, intensity & duration of contractions, FHR, mood and behavior.

Every 4 hours: check vital signs and cervical dilatation.

Record findings in Labor record Assess progress of labor: After 8 hrs, if

contractions are stronger & more frequent but no progress in cervical dilatation: REFERREFER


First stage: in active labor, cervix is dilated at 4 cm or more Check every 30 mins for emergency signs,

frequency and duration of contractions, FHR, mood and behavior.

Check every 4 hours: fever, PR, BP, cervical dilatation.

Record time of rupture of membranes and color of the amniotic fluid.

Record findings in partograph.

RELIEF of PAIN and DISCOMFORTRELIEF of PAIN and DISCOMFORT

Suggest change of positionSuggest change of position Encourage mobility as comfortable for herEncourage mobility as comfortable for her Encourage proper breathing: breath more Encourage proper breathing: breath more

slowly, make a sighing noise, make 2 short slowly, make a sighing noise, make 2 short breaths followed by a long breath out.breaths followed by a long breath out.

Massage her lower back if she finds it helpfulMassage her lower back if she finds it helpful

CAUTIONCAUTION DO NOT do IE more frequently than every DO NOT do IE more frequently than every

4 hours unless necessary.4 hours unless necessary. DO NOT allow the woman to push unless DO NOT allow the woman to push unless

delivery is imminent delivery is imminent → → pushing does not speed up labor, mother will become tired, cervix will swell.

DO NOTDO NOT give medications to speed up give medications to speed up labor labor → → DANGEROUS:DANGEROUS: may cause may cause trauma to the mother and baby trauma to the mother and baby (ex: (ex: Uterine rupture)Uterine rupture)

DO NOT DO FUNDAL PRESSURE- DO NOT DO FUNDAL PRESSURE-

may cause may cause uterine rupture, fetal deathuterine rupture, fetal death

Second stage: from full dilatation (10cm) of the cervix until birth of baby.

How to tell if a woman is in the 2nd stage: On IE, cervix is fully dilated Woman wants to bear down Strong uterine contractions every 2-3 minutes Bulging thin perineum,

fetal head visible during contractions.

BOW will rupture

Monitoring the 2Monitoring the 2ndnd stage stage Check uterine contractions, fetal

heart rate, mood and behavior Continue recording in the

partograph

REMINDER:REMINDER:

1.1. Massaging or stretching the perineum Massaging or stretching the perineum have not been shown to be beneficial.have not been shown to be beneficial.

2.2. DO NOT apply fundal pressure to help DO NOT apply fundal pressure to help deliver the baby deliver the baby → → may harm mother and may harm mother and babybaby. .

8. Deliver the Baby8. Deliver the Baby

Implement the Implement the 3 CLEANS3 CLEANS1.1. Clean handsClean hands

2.2. Clean delivery surfaceClean delivery surface

3.3. Clean cutting and care of the cordClean cutting and care of the cord

WEAR DOUBLE GLOVESWEAR DOUBLE GLOVES


Stay with the woman Stay with the woman and encourage her. and encourage her. Make her Make her comfortable. comfortable.

Check fetal heart Check fetal heart tones every 15 tones every 15 minutesminutes

When the birth opening is When the birth opening is stretching, support the stretching, support the perineum and anus with perineum and anus with a clean swab to prevent a clean swab to prevent lacerationslacerations

Ensure controlled Ensure controlled delivery of the headdelivery of the head

Deliver the BabyDeliver the Baby

Controlled delivery of the headControlled delivery of the head

o Keep one hand on the Keep one hand on the head as it advances head as it advances during contractions. during contractions. Keep the head from Keep the head from coming out too coming out too quickly.quickly.

o Support the perineum Support the perineum with other hand. with other hand.

Controlled delivery of the head, cont’d . .Controlled delivery of the head, cont’d . .

o Discard pad and Discard pad and replace when soiled replace when soiled to prevent infection.to prevent infection.

o During delivery of During delivery of the head, the head, encourage woman encourage woman to stop pushing and to stop pushing and breathe rapidly with breathe rapidly with mouth open. mouth open.

Gently feel if the cord is around the neck If it is loosely around

the neck, slip it over the shoulders or head

If it is tight, place a finger under the cord, clamp and cut the cord, and unwind it from around the neck.

Delivering the BabyDelivering the Baby

Gently wipe the baby’s nose and mouth with a clean gauze or cloth.

Wait for external rotation (within 1-2 min), head will turn sideways bringing one shoulder just below the symphysis pubis and other facing the perineum

Apply gentle downward pressure to deliver top shoulder then lift baby up to deliver lower shoulder. Gently deliver the rest of the baby.

Delivering the BabyDelivering the Baby

Delivering the baby Delivering the baby

1.1. Put baby on mother’s Put baby on mother’s abdomen in prone abdomen in prone position. Cover with dry position. Cover with dry towel.towel.

2.2. Thoroughly dry the baby Thoroughly dry the baby immediately. Wipe immediately. Wipe eyes.eyes.

3.3. Discard wet cloth.Discard wet cloth.

4.4. Put baby prone, in skin-Put baby prone, in skin-to-skin contact on to-skin contact on mother’s abdomen,. mother’s abdomen,. Keep the baby warm.Keep the baby warm.

5. Exclude 25. Exclude 2ndnd baby by palpating mother’s baby by palpating mother’s abdomen. abdomen.

6.6. Give 10 IU oxytocin IM to the mother. Give 10 IU oxytocin IM to the mother. (active management of (active management of

the 3the 3rdrd stage of labor.)* stage of labor.)*

**May be done by the May be done by the midwife under midwife under

supervision of doctor.supervision of doctor.

Delivering the baby Delivering the baby

7.7. Watch for vaginal bleeding.Watch for vaginal bleeding.

8.8. Remove first set of gloves.Remove first set of gloves.

9.9. When no more cord pulsation is When no more cord pulsation is felt on the cord (usually within felt on the cord (usually within 3 mins.)3 mins.)

clamp the cord 2cm from the base clamp the cord 2cm from the base using sterile plastic cord clampusing sterile plastic cord clamp

10.10. Sweep the cord and apply a second Sweep the cord and apply a second Kelly forceps 5cm from the base Kelly forceps 5cm from the base and then cut in-between.and then cut in-between.

Third Stage: Between birth of the baby and delivery of the placenta

11. Deliver the placenta by controlled cord 11. Deliver the placenta by controlled cord traction (with counter traction on the uterus traction (with counter traction on the uterus above the symphysis pubis).above the symphysis pubis).

12. Massage uterus over the fundus.12. Massage uterus over the fundus.

13. Inject oxytocin. 13. Inject oxytocin.

(if not yet given as (if not yet given as part of active part of active management)management)

14. Encourage 14. Encourage initiation of initiation of breastfeeding. breastfeeding. Let baby stay on Let baby stay on

mother’s abdomen mother’s abdomen for 60-90 minfor 60-90 min

Check that the placenta and

membranes are complete. Put

the placenta into a container for

disposal.

Third stage: between birth of the baby and delivery of the placenta.

ACTIVE MANAGEMENT*

of the third stage of laboro Cord is clampedo Oxytocin is given within 2 min of delivery of the

babyo Placenta is delivered by controlled cord traction

with countertraction above the symphysis pubis.o Massage fundus.

* May only be done by a midwife under supervision of doctor.

9. 9. Monitor closely within 1-hour after delivery Monitor closely within 1-hour after delivery ((Immediate postpartum periodImmediate postpartum period) and give ) and give supportive care. supportive care.

Check for vaginal tears and bleeding.

Clean the woman and make her comfortable.

Check BP, PR, emergency signs & uterine contraction every 15 minutes.

Initiate breastfeeding within 1-hour when the baby is ready.

10. Continue care after 1 hour postpartum. Continue care after 1 hour postpartum. Keep watch closely for at least 2 hours.Keep watch closely for at least 2 hours. Temperature, BP and pulse every 30 minutes Check at 2, 3 and 4 hours, then every 4 hours:

emergency signs uterine contraction

Check for bladder distension if unable to void. Advise clean cloth/napkin to collect vaginal blood. Eat and drink high-energy food that are easily

digestible.

Companion: to watch her and to call you for bleeding or pain, dizzy or for any other problem


Keep the baby in the room with the mother, in her bed or within easy reach.

Support exclusive breastfeeding on demand, day and night, as often and as long as the baby wants.

Immunize according to the EPI schedule. Mother and companion to watch the baby:

breastfeeding difficulty difficulty of breathing cold feet bleeding from the cord

Check baby at around 4 and 8 hours and then daily: cold feet, breastfeeding and breathing difficulty.

FOR THE BABYFOR THE BABY

Advise postpartum care and hygiene. Wash from waist down or have a sponge

bath or a shower with warm water each morning or when she feels like it.

Use guava leaves decoction if woman prefers, for her wash or bath.

9. Continue care after 1 hour postpartum. 9. Continue care after 1 hour postpartum.

Medications Iron 60 mg/ Folic acid 400ug 1 tablet

daily… until 3 months postpartum Vitamin A 200, 000 IU, 1 capsule after

delivery or within 1 month postpartum

9. Continue care after 1 hour postpartum.9. Continue care after 1 hour postpartum.

11. Educate and counsel on family planning and provide the family planning method if available.

Ask what are the couple’s plans regarding having more children.

Give relevant information and advice. Advice that exclusive breastfeeding is the best

contraceptive in the 1st six months. Help her to choose the most appropriate

method for her and her partner.

12. Inform, teach and counsel the woman on important MCH messages.

Talk to the woman when she is rested

and comfortable.

Also give important information and

advice to her companion.

13. Discharge the woman and her baby. The woman and her baby may be discharged 24

hours after delivery.

Ensure that the woman is able to breastfeed successfully before discharge.

Repeat important health information.

Check understanding and arrange follow-up.

Providing care during labor, childbirth and immediate postpartum

Providing care during labor, childbirth and immediate postpartum.

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Transcript of Providing care during labor, childbirth and immediate postpartum.