Download - Normal labor amtsl
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Normal Labour, DeliveryNormal Labour, Delivery
andand
Postnatal CarePostnatal Care
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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
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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
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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
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Supportive Care
• Many providers continue to use, untimely, inappropriate and/or unnecessary interventions, leading to complications
• Example: immobilising women, not allowing eating and drinking
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Supportive Care
• Supportive care during labour is the most important thing to help the woman tolerate labour pains and facilitate the progress of labour
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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
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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
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Management of Labour
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• Not in active labour (cx 0-3cm, contraction <2/10)
- Monitor every hour: contractions, FHR- Monitor every 4 hours: HR, BP, temp
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• 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
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Assessing Progress in Labour
- Assessing changes in cervical dilatation and effacement (PV examination)
- Foetal descent (PV and Abdominally)
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5ths of Head palpable above symphysis pubis
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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
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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
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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.
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Third stage of labor
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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
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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
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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
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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.
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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
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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.
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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
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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
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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