Intrapartum 111

Providing Care During Labor, Childbirth and Immediate Postpartum|NRG 203| Jane Pathay

Steps to follow  Leaking amniotic fluid; if yes, is it meconium

in INTRAPARTAL CARE stained, foul smelling?
 Warts, keloid tissue or scars that may
1. Examine the woman for emergency signs. interfere with delivery
 Unconscious, Convulsing
 Vomiting
 Severe headache with blurring of vision  Perform gentle vaginal examination (do not start
 Vaginal bleeding during contraction).
 Severe abdominal pain  Explain findings to the woman. Reassure her.
 Looks very ill  RECORD findings in labor record or in partograph.
 Fever
 Severe breathing difficulty
Determining Stage of Labor
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 procedure
 Respect privacy
 Communicate result of examination

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 5. Decide if the woman can safely deliver. If there is
 Birth plan indication for referral …
 Assess uterine contractions: intensity, duration,
 in early labor and the referral hospital can be timely
and interval, freq
reached:
 Observe the woman’s response to contractions.
 Refer urgently
 Perform abdominal exam: (Leopold’s
maneuver, FHT) between contractions
 in late active labor:
 Steps to Follow in Intrapartal Care
 Monitor progress of labor and deliver the baby
4) Determine the stage of labor.  Prepare for immediate referral if still necessary

 Explain to the woman that you will perform a

vaginal examination and ask for her consent.
 If the woman or her family refuses referral
 Respect privacy
 Observe standard precautions  Explain the possible consequences
 Inspect the vulva for:  Continue to take care of her
 Bulging perineum
 Ask for examples of conditions that require
 Any visible fetal parts
referral.
 Vaginal bleeding
6. Give supportive care through out labor.
Activity #2:
Identify which is correct and incorrect practice and
explain why.
1. Explain procedures, seek permission, respect
privacy and discuss findings with the woman and her
family.
2. Bathing before labor
 Encourage woman to wash from her waist down
or take a bath at the onset of labor.
3. 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)
4. Position during Labor
 Respect and support her choice of a birthing
position
5. Eating, Drinking???
Encourage her to:
 Eat and drink as she wishes.
 Contractions will make her thirsty and the sugar
will give her energy for her labor. Do not give
solid foods – this may make her vomit.
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 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: REFER
A. 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 DISCOMFORT
 Suggest change of position
 Encourage mobility as comfortable for her
 Encourage proper breathing: breath more slowly,
make a sighing noise, make 2 short breaths followed
by a long breath out.
 Massage her lower back if she finds it helpful
CAUTION
 DO NOT do IE more frequently than every 4 hours
unless necessary.
 DO NOT allow the woman to push unless delivery is
imminent → pushing does not speed up labor,
mother will become tired, cervix will swell.
 DO NOT give medications to speed up labor →
DANGEROUS: may cause trauma to the mother and
baby (ex: Uterine rupture)
 DO NOT DO FUNDAL PRESSURE- may cause
uterine rupture, fetal death
B. 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
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 Monitoring the 2nd stage

 Check uterine contractions, fetal heart rate, mood

and behavior
 Continue recording in the partograph

REMINDER:

1. Massaging or stretching the perineum have not

been shown to be beneficial.
2. DO NOT apply fundal pressure to help deliver
the baby → may harm mother and baby.
8. Deliver the Baby
 Implement the 3 CLEANS
1. Clean hands
2. Clean delivery surface
3. Clean cutting and care of the cord
 Keep one hand on the head as it advances during
contractions. Keep the head from coming out too
quickly.
 Support the perineum with other hand.
 Controlled delivery of the head, cont’d . .
 Discard pad and replace when soiled to prevent
infection.
 During delivery of the head, encourage woman to
stop pushing and breathe rapidly with mouth open.

WEAR DOUBLE GLOVES

 Stay with the woman and encourage her. Make her

comfortable.
 Check fetal heart tones every 15 minutes
 When the birth opening is stretching, support the
perineum and anus with a clean swab to prevent
lacerations (Mod. Ritgen’s Manueuver)
 Ensure controlled delivery of the head

 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.

Controlled delivery of the head

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 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 Baby
*May be done by the midwife under supervision of
doctor.
7. Watch for vaginal bleeding.
8. Remove first set of gloves.
9. When no more cord pulsation is felt on the cord
(usually within 3 mins.)
 clamp the cord 2cm from the base using sterile
plastic cord clamp

Delivering the baby

1. Put baby on mother’s abdomen in prone position.

Cover with dry towel.
2. Thoroughly dry the baby immediately. Wipe eyes.
3. Discard wet cloth.
4. Put baby prone, in skin-to-skin contact on mother’s
abdomen,. Keep the baby warm.

10. Sweep the cord and apply a second Kelly forceps

5cm from the base and then cut in-between.

Third Stage: Between birth of the baby and delivery

5. Exclude 2nd baby by palpating mother’s abdomen. of the placenta
6. .Give 10 IU Oxytocin IM to the mother. (active
management of the 3rd stage of labor.)*
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11. Deliver the placenta by controlled cord traction
(with counter traction on the uterus above the symphysis
pubis).
12. Massage uterus over the fundus.
13. Inject oxytocin.
(if not yet given as part of active management)
14. Encourage initiation of breastfeeding. Let
baby stay on mother’s abdomen for 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 labor
 Cord is clamped
 Oxytocin is given within 2 min of delivery of the baby
 Placenta is delivered by controlled cord traction with
countertraction above the symphysis pubis.
 Massage fundus.
* May only be done by a midwife under supervision of
doctor.
9. Monitor closely within 1-hour after delivery
(Immediate postpartum period) and give 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.
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10. Continue care after 1 hour postpartum. 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
FOR THE BABY
 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.
9. Continue care after 1 hour postpartum.
 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.
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
 According to the CDC, if you've already had a
baby with a neural tube defect, getting enough
folic acid may reduce your risk of having another
child with a neural tube defect by as much as
70%.
 Oral iron supplementation, either alone or in
combination with folic acid supplementation,
may be provided to postpartum women for 6–12
weeks following delivery for reducing the risk of
anaemia
 Postpartum vitamin A supplementation of
lactating women will raise breastmilk vitamin A
content.
 The most common symptom of vitamin A
deficiency in young children and pregnant
women is an eye condition called xerophthalmia.
Xerophthalmia is the inability to see in low light,
and it can lead to blindness if it isn't treated -
making the cornea very dry, thus damaging the
retina and cornea.
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.
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 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.
 Take time to explain, use visual aids, and
demonstrate important lessons.
 Encourage them to participate actively in
discussions and to ask questions.

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.