Care during labor and delivery

1. SBA - Presentation 4 Care during labor and delivery Maternal Health Division Ministry of Health & Family Welfare Government of India

2. Session Objectives To learn about: • Difference between true and false labour • Stages of labour • Supplies required for normal delivery • Monitoring the first stage of labour using partograph • How to conduct and manage the second stage of labour Care during labor and delivery

3. True labour pains False labour pains Regular and predictable Irregular Felt first in lower back & sweeps towards lower abdomen Remains confined to lower abdomen Not relieved by rest Often relieved by rest Increase in duration, intensity and frequency with time Does not increase in duration, intensity or frequency “Show” blood stained mucus discharge present “Show” absent Accompanied by cervical changes Not accompanied by cervical changes Care during labor and delivery

4. Stages of labour First stage: From onset of labor till full dilatation of cervix • Latent Phase • Cervix < 4 cms • Contractions are weak • Less than 2 contractions per ten minutes • Active phase • Cervix > or = 4 cms • Contractions >3 per 10 min lasting 45 - 50 sec • Rate of dilatation 1cm / hour or more • Descent present Care during labor and delivery

5. Stages of labour Second stage: From full dilatation of cervix till delivery of baby • Full cervical dilatation • Bulging thinned out perineum • Gaping anus and vagina • Head visible at the perineum Care during labor and delivery

6. Stages of labour Third stage: From delivery of baby to delivery of placenta Fourth stage: For 2 hrs after delivery of the baby Care during labor and delivery

7. Monitoring of first stage of labour:Latent phase • Monitor every 1 hour • Contractions: • Frequency: How many contractions in 10 min • Duration: Each lasting for how many seconds • Fetal Heart Rate (FHR): • Monitor the following every 4 hours: • Temperature, pulse, blood pressure • Record time of rupture of membranes and color of amniotic fluid. • Look for presence of any emergency signs Difficulty in breathing, shock, vaginal bleeding, convulsions or unconsciousness Care during labor and delivery

8. Monitoring of first stage of labour:Latent phase In Latent Phase After 8 hours Contractions stronger, more frequent, no change in dilatation or effacement ROM +/- No increase in intensity / frequency / duration of contractions, membranes not ruptured and no progress in cervical dilatation Prolonged latent phase Ask woman to relax REFER to FRU Care during labor and delivery

9. Monitoring of first stage of labour: Active phase • Monitor the following every 30 minutes: • Maternal pulse, uterine contractions, FHR • Look for presence of - • Meconium or blood stained liquor or cord prolapse • Monitor the following every 4 hours: • Cervical dilatation (in cm) by P/V • Temperature • Blood pressure Care during labor and delivery

10. Monitoring of first stage of labour: Active phase In Active Phase • Never leave the woman alone • Start maintaining a partograph when the women reaches active labour • Ensure adequate hydration, avoid solid foods • Encourage upright position and walking • Monitor intensively using Partograph • Refer immediately if no progress Care during labor and delivery

11. Partograph What is a partograph? • Graphic recording of the progress of labor & condition of mother and fetus • Labor record , thus reduces paper work • Tool to identify complications of labor and make timely referrals Care during labor and delivery

12. Care during labor and delivery

13. Filling a Partograph Identification data • Name • Age, • Parity, • Date and time of admission • Registration number; • Time of rupture of membranes. Care during labor and delivery

14. Filling a Partograph Fetal Condition • Count fetal heart rate every half hour • Count for one full minute, immediately following a uterine contraction • Fetal distress:FHR <120 beats/minute or >160 beats/minute; Arrange for referral • Each of small boxes in the vertical column of partograph represents a half hour interval Care during labor and delivery

15. Filling a Partograph Record status of membranes and amniotic fluid in Partograph as follows: • Membranes intact (mark ‘I’) • Membranes ruptured (mark ‘R’) • Clear liquor (mark ‘C’) • Meconium stained liquor (mark ‘M’) Care during labor and delivery

16. Plotting a Partograph • Labor • Begin plotting in active labor • Cervical dilatation > 4 cms and > 2 contractions / 10 minutes • Plot the initial finding on alert line. Note the time. • Repeat P/V after 4 hours and plot the cervical dilatation Care during labor and delivery

17. Plotting a Partograph Chart the contractions every half an hour • Number of contractions in 10 mins • Duration in seconds. • Less than 20 seconds • Between 20 and 40 seconds • More than 40 seconds Care during labor and delivery

18. Plotting a Partograph • Interventions • Mention dose, route and time of administration of any drug • Mention the food items and liquids consumed Care during labor and delivery

19. Plotting a Partograph Maternal Condition • Record maternal pulse every half hour and mark with a dot ( . ) • Record maternal BP every 4 hours using a vertical arrow, with upper end signifying systolic BP and lower end diastolic BP • Record the temperature every 4 hours and note on temperature graph Care during labor and delivery

20. Plotting a Partograph • If Alert line is crossed (the plotting moves to the right of the alert line) it indicates abnormal labour : prolonged/ obstructed labour • Note the time • Refer to FRU • Ensure Provision of transport • Send partograph with patient Care during labor and delivery

21. Plotting a Partograph • Crossing of the Action line (the plotting moves to the right of the Action line) : indicates the need for intervention • By the time the action line is crossed the woman should ideally have reached the FRU for the appropriate intervention to take place Care during labor and delivery

22. What are the indications for referral to FRU – on the basis of partograph ? • FHR is <120 beats / min or > 160 beats / min • Meconium and /or blood stained amniotic fluid • When cervical dilatation plotting crosses the alert line (moves towards the right side of the alert line) • Contractions not increasing in duration, intensity and frequency (e.g. < 2 contractions lasting for < 20 sec in 10 min) Care during labor and delivery

23. Case studies Care during labor and delivery

24. Monitoring of second stage of labour • Monitor frequency and duration of contractions half hourly • Monitor fetal heart every 15 minutes • Watch for any emergency signs : excessive bleeding, convulsions Care during labor and delivery

25. Monitoring of second stage of labour • Watch for signs of imminent delivery • Gaping of vulva • Thinning and bulging of perineum • Pouting of anus • Head of the baby seen at vulva • Encourage the woman to push during contractions when she has an urge to do so while taking deep breaths Care during labor and delivery

26. Delivery of Head • Ensure a controlled delivery of the head by keeping one hand gently on the head and other supporting the perineum • Feel gently around the baby’s neck for presence of umbilical cord • If it is loose around the neck, deliver the baby through the loop of the cord, or slip the cord over the baby’s head • If it is tight around the neck, doubly clamp and cut in between Care during labor and delivery

27. Delivery of shoulders and rest of the body • Wait for the spontaneous rotation and delivery of the shoulders. This usually happens within 1-2 minutes • Apply gentle pressure downwards to deliver the top (anterior) shoulder • Then lift the baby up, towards the mother’s abdomen, to deliver the lower (posterior) shoulder • Rest of the baby’s body follows smoothly • Note the time of birth Care during labor and delivery

28. Key messages • Let the woman choose a comfortable position during labour and delivery • Maintain a partograph • Ensure timely referral Care during labor and delivery

29. Thank you Care during labor and delivery