It entails the stages of labour.What actually happens before, during and after childbirth. Either to talk of terms like Braxton Hicks contractions,the Main stages in labor as well and other things being equal
It entails the stages of labour.What actually happens before, during and after childbirth. Either to talk of terms like Braxton Hicks contractions,the Main stages in labor as well and other things being equal
It entails the stages of labour.What actually happens before, during and after childbirth. Either to talk of terms like Braxton Hicks contractions,the Main stages in labor as well and other things being equal
It entails the stages of labour.What actually happens before, during and after childbirth. Either to talk of terms like Braxton Hicks contractions,the Main stages in labor as well and other things being equal
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LABOUR
LABOUR
It is the process by which the foetus,
placenta and membrane are expelled through the birth canal after the 28th week of pregnancy. Labour begins when there are regular, painful contraction lasting at least 20sec (timed by a trained observer), occurring at a frequency of at least two contractions in every 10min and with a cervical dilation of at least 3cm. NORMAL LABOUR Labour is said to be normal when the process begins spontaneously at term with fetus presenting by the vertex and is completed within 18hrs with no complications. Signs and symptoms of true Labour 1. Premonitory signs of labour These are signs which are to announce that labour is approaching. They are very useful where the gestational age of pregnancy is not definite. They are Lightening Frequent micturation False pain or spurious labour Taking up of cervix Lightening This is sinking of the uterus into the pelvic. The head of the fetus descend into the pelvic brim. Frequency of micturation Due the fetal head pressing on the bladder and limiting its capacity. False pain or spurious labour Erratic and irregular pain confined chiefly to the lower part of the abdomen. These type of pain do not cause dilatation of the cervix. Taking up of the cervix This is shortening of the cervical canal because it is drawn to emerge into the lower uterine segment 2. True labour Contractions Show Dilatation of the cervix STAGES OF LABOUR First stage Second stage Third stage Fourth stage First stage This stage starts from the onset of regular uterine contractions to the full dilation of the cervical os. It lasts 12hrs in primip and 6-12hrs in multips. The first stages of labour consist of Latent Active phase • Latent phase Here, the contraction occurs less than 3 in 10mins and lasts less than 20sec • Active phase This stage lasts 6hrs with contractions occurring 3 to 4 times in 10mins, each lasting 40-60sec. The cervix dilate from 4cm to 10cm at an average rate of 1cm in 1hr. Second stage Starts from full cervical dilatation to the complete expulsion of the baby. It normally lasts 1-2hrs in primip and 30min in multipara. Third stage Starts from birth of the baby to the expulsion of the placenta and membranes. Fourth stage This is a period of six hours following the expulsion of the placenta.
MANAGEMENT OF FIRST STAGE OF LABOUR
Objectives: The goal of care during labour and delivery is to ensure the most positive outcome, namely a healthy mother and healthy baby • Welcome and reassure her in a friendly manner • Show concern and eagerness to help • Explain procedures to her • Observe condition of the client as you welcome her into the clinic. Collect and analyse antenatal record The following routine care should be given during the first stages; A)Take history; I. Onset and symptoms of labour II. Danger symptoms- bleeding, foetal movement, fever, offensive liquor III. Review maternal health record if available if not, ask about obstetric, medical/surgical history B) Perform physical examination/assessment (observe stringent aseptic procedures) I. Thorough general physical examination II. Abnormal examination III. Vaginal examination check for; -show -cervical dilation -presentation C. Look for any abnormalities such as offensive meconium-stained liquor
D. Record findings E. Monitor labour
in the latent phase, monitor;
Contractions -1/2 hourly Descent four hourly Feotal heart -1/2 hourly Cervical dilatation –four hourly F) Record all findings on observation chart I. Use partograph for client in active phase, there are no contra-indication. II. Monitor progress as plotted on partograph. III. Identify any problems and take appropriate action.
perform vaginal examinations every
four hours unless otherwise indicated. If dilatation on admission is 4cm or above, 2 to 3 hourly vaginal examination may be necessary. Avoid too frequent vaginal examinations to prevent infections. . G. Explain to mother and/or accompanying person(s) -progress of labour -reasons for ; any intervention Referral
H. Give emotional support and reassurance
GENERAL EXAMINATION PHYSICAL EXAMINATION • INSPECTION - Appearance of the client like being pallor, rashes on the skin or oedema - Vulva examination- check on the anatomy of the vulva and the presence of the following; warts, varicose veins, oedema. - Check the temperature, pulse, respiration, BP, FH - Urine R/E( routine examination ) • Palpation- abdominal examination • Auscultation of foetal HR(pinard horn, doppler foetal monitor) All these are done to check on the lie, presentation, position engagement and foetal condition.
PHYSICAL CARE OF THE PATIENT
Position A woman in labour should be allowed to assume any position confortable to her. She should not be confined to bed especially in first stage of labour Personal hygiene help her bath, mouth and teeth cleaned, bed linen straightening and changed as and when necessary. Observe aseptic techniques in your care by washing hands before and after care. Eg. After touching each patient . Wear gowns and gloves, use sterile instrument for procedure. Care of the bladder Encourage frequent emptying of the bladder through out labour. Catheterization should be a last resort. Empty the bladder every 3 to 4 hours. Nutrition Light nourishing diet in every first stage. Give drinks. Please follow hospital protocol for nutrition guideline Rest and sleep Encourage rest by making the environment quite and with a conducive temperature. Alleviate pain by sacral massages, some analgesics like pethidine and sedatives like phenergan 12.5- 25mg are allowed in the early first stage of labour. NB, these drugs are not given when cervical dilatation is beyond 6cm. Observation of the progress of labour Timing of contraction Observe vulva pads for show and greenish colour. Observe for decent Elimination Encourage emptying of the bowel. A full bladder and bowel impedes uterine contractions. Vaginal examination; Indications; • To decide whether she is in true labour • To ascertain cervical dilation • Confirm the lie of a second twin • Confirm presentation and also after rapture of membranes to ascertain the course of delay and prolonged labour CONTRAINDICATIONS OF V/E Antepartum haemorrhage In trial labour so as not to introduce infection INTERPRETATION OF V/E • 1c…………..a tip of finger • 2cm………..a large finger • 3cm………..2 fingers • 4cm…………3 fingers • 5cm………..1/2 dilatation dilated • 6cm……….1/2 dilated • 7cm……….3/4 dilated • 8cm………..rim of cervix • 9cm…………almost fully dilated • 10cm………. Fully dilated CERVICAL DILATION BOARD . . NB. Always conduct vaginal examination to confirm full dilation before allowing and encouraging patient to bear.
SECOND STAGE OF LABOUR
This stage of labour start from full cervical dilatation to
the complete expulsion of the baby Signs and symptoms of the 2nd stage of labour • Change in the characteristics of uterine contractions ie they become regular and have a bearing down effect or feeling on the woman • Bulging of the perineum • Anus dilate and has the appearance of capital letter D • Gapping of the vulva and the vertex is seen peeping • Pelvic floor is displaced On V/E, cervix is not felt Position in labour Squatting, kneeling, standing Left lateral position Upright position Lithotomy; this is the preferred one in Ghana MANAGEMENT OF SECOND STAGE OF LABOUR The second stage start from full dilation of the cervix to the birth of the baby.It usually lasts up to 30min in multipara, and 60min in nullipara respectively. The clinical signs/symptoms indicating that the second stage has started include the following; contraction become stronger and are of longer durations, lasting 40-60sec and occur at shorter intervals (3 contraction in ten minute) The woman feels pressure in the rectum accompanied by the urge to defecate The perineum bulges and the anus dilate Nausea and retching may occur as the cervix reaches full dilation . Delivery steps Explain to patient what to expect during labour Position patient according to her preference Wear protective clothing( plastic apron, boot, goggles and mask) Wash hands with soap and water and dry with sterile towel Put on sterile gloves on both hands Clean vulva/perineum with antiseptic solution eg. Chlorhexidine/savlon. Drape the woman appropriately for delivery Check delivery trolley and instruments Infiltrate the perineum with anaesthetics, if indicated Maintain flexion of the head as it comes out of the vagina Observe perineum for impending tear Prepare and perform episiotomy when indicated Prevent soiling of the perineum using a sanitary pad to cover the anus Observation during the second stage of labor
1.Fetal condition : listening to fetal heart rate after every two
contractions or 15 minute. the normal FHR is 120 to 160 beat per minute. 2. Maternal condition ; temperature, pulse , respiration , Bp. Contraction for strength, frequency and duration of vagina examination. 3. Bladder; the woman should not be allow to enter the second stage with a full bladder because full bladder can rupture bladder and can prevent decent of the head. It can also cause poor uterine contraction and cause postpartum haemorrhage. OTHER CARE STILL UNDER SECOND STAGE • Reassurance • Mop around the forehead • Give sips of water to moisten the lips, tongue and throat • Continue with education as to when to push, relax and about the right way of bending down Third stage of labour This start with the delivery of the infant and ends with the delivery of the placenta and it membranes. physiology of the third stage of labour • Separation of the placenta from the upper uterine segment . • Descent and expulsion of the placenta • Control of bleeding Mode of placenta delivery After separation of placenta had been seen, one hand is placed above the symphysis pubis with the palms facing the umbilicus exerting pressure in and upward direction. the outer hands grasp the cord winding it around the hand. When the placenta is visible at the vulva, it is cupped in the hands to ease pressure on the fragile membrane. It is delivered gently into a receiver Care of the patient after expulsion of the placenta The patient is cleaned up after the delivery of the placenta and the perineum posterior vaginal wall and vulva are inspected for laceration. If the laceration needs suturing, arrange and suture them immediately, tidy up the woman and put a sterile pad in her vulva. IM Ergometrine 0-5mg could be given to maintain good uterine contraction. Collect all blood clot around, any clot in the uterus expelled. Provide warmth by changing any wet cloth and make her comfortable to rest. Congratulate her and serve her with a warm drink after placenta have been examined and found to be complete. observe TPR and BP. EXAMINATION OF THE PLACENTA AND MEMBRANES. The 3rd stage of labour is never said to be completed until the placenta and membranes are examined and found to be complete. Method Collect all blood and clot into a measuring jug and measure. Please add and estimate the amount of blood that wet the bed linen. Hold the by the cord like an inverted umbrella and membranes inspected to see if any are torned or restrained. This can be detected by inserting the second hand into the holes and sweep around and when no whole is found, except from where the baby, then it is passed and it is complete. In the case of ragged membranes make attempt to look for them and put pieces together to give an overall picture of completeness. CONT Now lay the placenta on a flat surface and examine minutely both placenta and membranes kill the amnion from the chorion right up to the umbilica cord so as to view fully the chorion. The presence of the blood vessels and the hole other than one large through which the baby came is suggestive of succenturiate lobe. Note the insertion of the cord. Fit all the cotyledon together. If there is any suspicion that the placenta and membranes are incomplete keep them and inform doctor immediately. Weigh placenta and record. RECORD THE BLOOD LOSS Document in the folder also the state of the placenta and its membrane. Consider the woman out of danger after the above. Please continue observing. FOURTH STAGE OF LABOUR; this is the first hour after delivery. Observe mother and baby closely for any deviation from normal, attention should be paid to blood loss by recording after approximation. MANAGEMENT OF THE FOURTH STAGE OF LABOUR The fourth stage is the first six hours following the birth of the placenta. FIRST HOUR; Put the baby to mother’s breast within half hour of delivery. Do the following; • Monitor mother BP and pulse every 15 minutes • Palpate and massage the uterus every 15minutes for 1hour to ensure it remains firmly contracted • Inspect the introitus every 15minutes for any active bleeding. • Check T.P.R., B.P, and record • Palpate the fungus to see if uterus has contracted well. CONT” EXAMINE THE BABY; • Breathing • Colour • Muscle tone • palate(cleft palate) • Anus(inperforate anus) • Continue to keep baby warm, especially the head 2-6hours
Do the following;
• Take the blood pressure and pulse every 2hours
• Take temperature at least once • Encourage the woman to pass urine frequently • Palpate the uterus. Palpate bladder and check vagina for bleeding for every hourly. • Support mother to continue breast feeding. If mother is HIV positive and chooses not to breastfeed support mother’s choice. • Administer 1.0mg of vitamin K to the baby to prevent haemorrhagic disease for babies weighing less than2.5kg give 0.5mg. • Instil antibiotic drops-chloramphenical or tetracycline 0.5% into baby’s eyes. cont • Carry out a detail examination of baby from head to toe to exclude abnormalities • Dry or wipe the baby ( do not bath the baby within the first 24hours). • Offer supportive care • Talk to mother and encourage her ask questions to express her feelings • Advise birth companion to remain with the woman during the period • Ensure woman has a clean bed • Replace soiled and wet clothing and bedding • Encourage the mother to pass urine when she feels the urge or if bladder palpable. • Encourage adequate fluid intake and appropriate food and sufficient rest. • Maintain a calm environment conducive to mother • Provide continuous support to parent or relative about the well-being of the baby and the mother. Group 6 members • ISAIAH KWOFIE …….. RGN/18/060 • AWINBUGRI STEVEN….. RGN/18/039 • APPIAH BABA ABEL…….. RGN/18/026 • KYEI PRISCILLA…….RGN/18/061 • OSEI KISSIWAA ABIGAIL…… RGN/18/084 • ADUSEI GLORIA……. RGN/18/008 • OBENEWAH STELLA….. RGN/18/076 • AMOAH DEDE HENRIETTA…..RGN/18/018 • ASUBOAH KWAME KODUAH….. RGN/18/037 • AWINI JOSEPH……. RGN/18/040 • ACHEAMPONG SAMUEL……..RGN/18/002