ADMISSION OF A WOMAN IN LABOUR

BY C. PHIRI

ADMISSION OF A WOMAN IN LABOUR

OBJECTIVES Collect relevant history from a woman in labour during admission. Perform a complete physical examination of a woman in labour. Interpret the gathered information. Develop a plan of care for a woman in labour. Implement the developed plan of care. Evaluate the care given to the woman.

ADMISSION OF A WOMAN IN LABOUR

HISTORY TAKING (see learning guide) PHYSICAL EXAMINATION (see learning guide) LABORATORY INVESTIGATIONS (depending on findings) INTERPRETATION OF FINDINGS / DIAGNOSIS. DEVELOP PLAN OF CARE -Individualized to meet clients needs, preferences, life style, cultural beliefs, socio economic status etc.

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EVALUATE PLAN OF CARE

-evaluate improvement, change in position. Repeat lab tests.

ADMISSION OF A WOMAN IN LABOUR VAGINAL EXAMINATION OBJECTIVES Explain the indications for performing a vaginal examination in pregnancy, labour and puerperium. Explain contraindications to vaginal examination. Explain the prerequisites for performing a vaginal examination. Perform a vaginal examination. Explain the expected findings during a vaginal examination. Interpret the information obtained on vaginal examination. Document the findings obtained on vaginal examination.

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INDICATIONS: IN PREGNANCY Diagnose pregnancy in 1st trimester. Check cervix Pelvic assessment in 3rd trimester. Assess favourability of cervix before induction.

VAGINAL EXAMINATION contd

IN LABOUR To assess if the woman is in labour To have baseline information of the progress of labour To assess state of the membranes, presenting part and dilatation of cervix,. To assess relationship of presenting part to cervix and pelvis. To assess engagement of presenting part and the station of the presenting part.

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To assess the state of the presenting part-moulding, caput,and position of fetus. Confirm findings obtained on abdominal palpation. To assess progress of labour. To rule out cord prolapse after rupture of membranes if head is not engaged, or if fetal distress develops. To induce labour through ARM. Before inserting prostaglandins or administration of oxytocin infusion to ascertain dilatation of the cervix. After birth of 2nd twin to confirm presentation of subsequent babies. To confirm full dilatation of the cervix and onset of 2nd stage. For manual removal of the placenta. After suturing the perineumto ascertain size of perineum and to ensure no swab has been left insie the vagina. Before giving analgesia.

VAGINAL EXAMINATION contd PUERPERIUM To ensure complete involution of the uterus. To check the cervix. and to carry out any treatment for cervical erosion. To take a Pap smear. To insert an IUCD.

VAGINAL EXAMINATION contd CONTRAINDICATIONS History of PV bleeding in pregnancy, or PV bleeding present before or during labour. Placenta preavia or abruptio. Preterm labour, unstable lie, high presenting part, malpresentation, polyhydramnious, multiple pregnancy until lie of 1st twin is established for fear of rupturing membranes. If VE will cause spread of infection e.g. presence of Bartholin gland abscess, abnormal vaginal discharge, herpes infection. History of abortion in pregnancy, or previous preterm labours. Presence of Shirodkars suture in pregnancy.

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PROCEDURE Explain to the client. Position the woman in dorsal position, legs abducted knees flexed. Wash hands with soap and water and put sterile gloves. INSPECTION Perineal scars. Oedema Vaginal discharge-colour, odour, consistency and amount. Varicosities. Redness. warts, heamorrhoids.feaces,3rd degree tears scar. Sores Liqour- amount,colour,odour, consistency. Mucus and blood SHOW amount of bleeding any clots.

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Do a 6 swab technique using Chlorhexidine solution. Drape legs and vulva area using sterile towels. Pour Chlorhexidine on vulval area. Open labia with fingers of left hand. Dip index and middle finger in cream for gentle insertion into vagina. After examination remove fingers, clean the woman and give a sterile pad. Let the woman lie on her side and reassure her. Record findings and explain to the woman.

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FINDINGS

Warm and moist. Hot and dry. Firm,Rigid,septum. Discharge colour, amount, odour. Liqour

PELVIC ASSESSMENT

OBJECTIVES Stat the aims for performing a pelvic assessment. Explain the prerequisites for performing a pelvic assessment. Perform a pelvic assessment. Interpret information gathered on pelvic assessment. Describe the normal findings of a pelvic assessment. Document findings obtained on pelvic assessment.

ADMISSION OF A WOMAN IN LABOUR contd

PELVIC ASSESSMENT AIMS To detect abnormalities of the bony pelvis. To measure diameters of the pelvis, inlet, cavity, and outlet. To predict mode of delivery.

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PREREQUISITES Aseptic technique. Explain to the client. Collect necessary equipment. Ensure empty bladder. Do abdominal palpation. Provide maximum privacy. Dorsal position legs abducted, knees flexed. Examine vulva for abnormalities. Know the measurement of the hand.

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METHOD DIAGONAL CONJUGATE OR INTERNAL CONJUGATE Extends from the inferior margin of the symphysis pubis to the center of the sacral promontory and should measure 12.5cm. The tip of the middle finger feels for the center of the sacral promontory. The site where the bottom of the pubic arch meets the hand is marked or noted. If the hand measures less tan 12.5cm, the sacral promontory should not be reached in the average sized pelvis. Try to follow the brim. In an average sized pelvis the brim cannot be followed.

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CURVE OF SACRUM The middle finger runs gently down the curve of the sacrum. COCCYX The end of the coccyx is pressed gently. GREATER SCIATIC NOTCHES The middle and fore finger are inserted in the sciatic notches on either side. ISCHIAL SPINES Ischial spines are gently palpated with the tips of the fingers. SUBPUBIC ARCH Turn the fingers horizontally and press them gently upwards against the lower border of the arch.

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BITUBEROUS OR INTERTUBEROUS DIAMETER Remove the fingers from the vaginal orifice. Make the hand into a fist and place the knuckles between the ischial tuberosities . NORMAL FINDINGS DIAGONAL CONJUGATE Measurement 12.5cm measured from the tip of the middle finger to the point where the thumb meets the hand. CURVE OF SACRUM Smooth and broad Rounded concave curve. Narrow sacrum indicates narrow pelvic cavity or canal.

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COCCYX Slightly movable Fixed and projecting coccyx indicates narrow antero posterior diameter of outlet. GREATER SCIATIC NOTCHES Should admit more than 2 fingers If 2 fingers or less pelvic cavity and outlet are narrow. ISCHIAL SPINES Not easily palpable, not prominent. If prominent cause delay in second stage of labour or obstruction in second stage of labour.

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SUB-PUBIC ARCH Should accommodate 2 fingers with an angle of about 90 degrees. Less than 80 indicates reduced transverse diameter of the outlet leading to difficulty of delivery of the head through the pelvic outlet leading to trauma. BITUBEROUS OR INTERTUBEROUS DIAMETER Width of the knuckles should fit comfortably between the ischial tuberosities. This indicates an adequate transverse diameter of the outlet. Measures about 10.5cm.

THE END THAN K Y O