Dr. Areefa Al Bahri Assistance professor

1. Dr. Areefa Al Bahri Assistance professor Nursing college- midwifery department-Islamic university of Gaza

12. Quality in Labour Room Privacy Infection Control Partograph Trained Staff Management of Complications Referral Protocols Drugs Availability Behavior of Staff Labor room register Availability of Doctors Resource: Dr Sandeep Mahatme

13. Assessment : Labour Room Labour Room • Labour table with Mcintosh sheet • Suction machine • Oxygen cylinder with face mask • Attached toilet in the labor room • Designated Newborn Corner (Radiant warmer, separate drug tray for the baby, suction canula, Pedal suction machine /mucus extractor, Ambu bag) • Privacy in the labor room • Flooring, Walls, Ceiling and Lighting adequate • Emergency Drug tray with: • Oxytocin injection • Diazepam Injection • Magnesium Sulphate Injection • Lignocaine Hydrochloride Injection • Nifedipine Tablet • Normal Delivery Kits availability • Equipment for assisted vacuum delivery • Equipment for forceps delivery (outlet forceps) • Surgical set for Episiotomy and minor procedures available • Availabilty of Gloves, Sterilized cotton gauze, Sterile syringes and needles, drip sets and IV infusions • Protocols displayed Resource: Dr Sandeep Mahatme

14. Labor room Protocol Delivery tray Availabilty of Gloves, Sterilized cotton gauze,. Spot light Curtain Oxygen Cylinder Labour table Attached toilet Monitor Infection control Drugs New born corner Trained staffs Trained midwives & Dr. Partographs Watch

15. delivery trolley Speculum Artery Forceps Needle holder Sponge holder Thumb Forceps Scissors- Straight & curved Cord Tie Gloves size 6, 6.5, 7,8 Xylocaine loaded Syringe Urinary Catheter Guaze, Pad * Retractor

18. Newborn Care Corner Radiant warmer Neonatal Ambu Bag with face mask Mucous Extractor Infant tray with clean cloth for draping the baby Oxygen cylinder with flow meter Nasal catheter Laryngoscope and Endotracheal intubation tube Paediatric Stethoscope Baby scale

19. Surgical set for Episiotomy and minor procedures available Caesarean Section Set

20. First stage midwifery care • Welcoming the woman & introduce your self • Review the referral note or pregnancy card to review history. • Ask to woman to empty bladder • Explain every procedure before do it • Check and record the vital sign: BP-RR-Temp • Do abdominal examination • Auscultate fetal heart sound. • Assess uterine contraction. • Maternal VS- IV fluid if needed • Oral intake • Assess bladder for fullness • Amniotomy if needed • Subsequent VE

21. Midwifery care in first stage • Nutrition and fluid : 1- encourage intake of oral fluid and come candies. 2- Encourage voiding every 2 hr. • Ambulation and position: 1- encourage ambulation if continues monitoring is not required. 2- encourage woman to avoid lying on her back. 3- if lying back encourage to be on left lateral position. • Hygiene: 1- offer to woman have a shower upon admission if she desire. 2-encourage and assess having warm shower if woman is not active phase. 3- assist woman to keep Perineal clean after vaginal examination. 4-change wet linen whatever possible .

23. When to do artificial rupture of membrane: 1- perform artificial rupture of membrane if woman is more than 4cm. 2- head is well applied. 3- Head is engaged The AROM is don by physician at MOH hospital and it can be don my midwife under doctor supervision or if the woman is 6 cm or more and its better not to do keep your delivery as much as without intervention. • If you perform AROM Follow-up 1- follow the progress of labour utilizing the partogram. 2- conduct vaginal examination After AROM & Q 2-4 hr 3. cervical examination should be kept to a minimum to avoid promoting intraamniotic infection. Document all of procedure, assessment finding on partogram.

25. Cervical examination steps

27. How to help the mother to relieve her Pain • Changing of body positions: lying down, walking, sitting etc. • Vocalization: reading Quran and chanting. • Breathing exercise • Touch and massage. • Hot/cold packs. • Warm shower: if possible may relieve her pain & increase her labour contraction. • Relaxation techniques. • Document alternative measures & any medication given.

28. Application of partogram • Under supervision of physician: • Undersupervioin of doctor: • Perform Aminotomy if the membrane is intact • Augment uterine contraction by oxytocin in absence of contraction • Perform vaginal examinationQ2 hr • If no progress after 6 hr of augmentation , SC is indicated

30. Partogram in first stage of labour • Star partogram for every woman in active phase of labour. • Record fetal condition include: Assess fetal heart Q 30 mint. • Use the following keys in documentation: I= intact membrane. C= clear B= blood staining M= meconium • Moulding: 0= bon are normally separated. + = bon touching each other. ++ = bone overlapping but easily separated. +++ = bone overlapping but can not separated.

31. 0= bon are normally separated

33. Use of oxytocin: • The midwife will obtain the physician order before initiating and oxytocin infusion: 1- perform vaginal examination. 2- commence oxytocin via dropper machine 3- follow the following standard of oxytocin initiation. 6- add 5 unit to 500 ml R/l 7- increase the drip rate according to protocol at 30 minutes interval until contraction lasting for 40- 45 sec. and occurring 3-4/10 minute.

34. Use of oxytocin Keep woman under continues fetal monitoring. Reduce oxytocin if good contractions have been established to prevent hyper stimulation Reassess progress by vaginal examination q/2 hr • Discontinue oxytocin in case of: 1- hypertonic uterine contraction. 2- Prolong fetal deceleration 3- Persistent fetal bradycardia. 4- Document .