5.1.1 General recommendationsPersonnel should wear personal protective equipment (gloves, goggles, clothing and eye protection) to prevent infection from blood and other body fluids. Show
Ensure a calm reassuring environment and provide the woman as much privacy as possible during examinations and delivery. Encourage her to move about freely if desired and to have a person of her choice to accompany her. Anticipate the need for resuscitation at every birth. The necessary equipment should be ready at hand and ready for use. 5.1.2 Diagnosing the start of labour– Onset of uterine contractions: intermittent, rhythmic pains accompanied by a hardening of the uterus, progressively increasing in strength and frequency; Repeated contractions without cervical changes should not be considered as the start of labour. Repeated contractions that are ineffective (unaccompanied by cervical changes) and irregular, which spontaneously stop and then possibly start up again, represent false labour. In this case, do not rupture the membranes, do not administer oxytocin. Likewise,
cervical dilation with few or no contractions should not be considered the start of labour. Multiparous women in particular may have a dilated cervix (up to 5 cm) at term before the onset of labour. 5.1.3 Stages of labourFirst stage: dilation and foetal descent, divided into 2 phases1) Latent phase: from the start of labour to approximately 5 cm of dilation. Its duration varies depending on the number of prior deliveries. Figure 5.1 - Dilation curve
in the primipara (in a multipara, the curve is shifted to the left) Second stage: delivery of the infantBegins at full dilation. Third stage: delivery of the placentaSee Chapter 8. 5.1.4 First stage: dilation and descent of the foetusThe indicators being monitored are noted on the partograph (Section 5.2). Uterine contractions– Contractions progressively increase in strength and frequency: sometimes 30 minutes apart early in labour;
closer together (every 2 to 3 minutes) at the end of labour. General condition of the patient– Monitor the heart rate, blood pressure and temperature every 4 hours or more often in case of abnormality. Foetal heart rateFoetal heart rate monitoringUse a Pinard stethoscope or foetal Doppler, every 30 minutes during the active phase and every 5 minutes during active second stage, or as often as possible. Listen to and count for at least one whole minute immediately after the contraction. Normal foetal heart rate is 110 to 160 beats per minute. Management of abnormal foetal heart rate– In all cases: − If the foetal heart rate is less than 100 beats/minute: − If the foetal heart rate is more than 180 beats/minute: If the abnormal foetal heart rate persists or the amniotic fluid becomes stained with meconium, deliver quickly. If the cervix is fully dilated and the head engaged, perform instrumental delivery (vacuum extractor or forceps, depending on the operator’s skill and experience); otherwise consider caesarean section. Dilation during active phase– The cervix should remain soft, and dilate progressively. Dilation should be checked by vaginal examination every 4 hours if there are no particular problems (Figures 5.2). Figures 5.2 - Estimating cervical dilation Amniotic sac– The amniotic sac bulges during contractions and usually breaks spontaneously after 5 cm of dilation or at full dilation during delivery. Immediately after rupture, check the foetal heart rate and if necessary perform a vaginal examination in order to identify a potential prolapse of the umbilical cord
(Section 5.4). Once the membranes are ruptured, always use sterile gloves for vaginal examination. Foetal progress– Assess foetal descent by palpating the abdomen (portion of the foetal head felt above the symphysis pubis) before performing the vaginal examination.
– Use reference points on the foetal skull to determine the position of the head in the mother's pelvis. It is easier to determine the position of the head after the membranes have ruptured, and the cervix is more than 5 cm dilated. When the head is well flexed, the anterior (diamond-shaped) fontanelle is not palpable; only the sagittal suture and the posterior (triangular) fontanelle are. The posterior fontanelle is the landmark for the foetal occiput, and thus helps give the foetal position. In most cases, once the head is engaged, rotation of the head within the pelvis brings the foetal occiput under the mother's symphysis, with the posterior fontanelle along the anterior midline. 5.1.5 Second stage: delivery of the infantFundal pressure is always contra-indicated. This stage is often rapid in a multipara, and slower in a primipara. It should not, however, take longer than 2 hours in a multipara and 3 hours in a primipara If there is a traditional delivery position and no specific risk for the mother or child has been established, it is possible to assist a delivery in a woman on her back, on her left side, squatting or on all fours (Figures 5.4). Figures 5.4 - Delivery position – Rinse the vulva and perineum with clean water. Figures 5.5 - The different stages of occiput-anterior delivery Figures 5.6 - Progressive delivery of the head During this final phase—an active one for the birth attendant—the woman should stop all expulsive efforts and breathe deeply. With one hand, the birth attendant controls the extension of the head and moves it slightly side-to-side, in order to gradually free the parietal protuberances; if necessary (not routinely), the chin can be lifted with the other hand (Figure 5.7). Figure 5.7 - Bringing the perineum under the chin – At the moment of delivery, the perineum is extremely distended. Controlling the expulsion can help reduce the risk of a tear. Episiotomy (Section 5.8) is not routinely indicated. In an occiput-posterior delivery (Figure 5.8), where perineal distension is at a maximum, episiotomy may be helpful. Figure 5.8 - Occiput-posterior delivery – The head, once delivered, rotates spontaneously by at least 90°. The birth attendant helps this movement by grasping the head in both hands and exerting gentle downward traction to bring the anterior shoulder
under the symphysis and then deliver it then, smooth upward traction to deliver the posterior shoulder (Figures 5.9). Figures 5.9 - Delivery of
shoulders – Place the neonate on mother's chest. For neonatal care, see Chapter 10, Section 10.1. 5.1.6 Oxytocin administrationAdminister oxytocin to the mother immediately and then deliver the placenta (Chapter 8, Section 8.1.2). 5.1.7 Umbilical cord clampingSee Chapter 10, Section 10.1.1. What should the nurse do once there is prolapse of the umbilical cord?The immediate priority is to minimize pressure on the cord. Thus the nurse's initial action involves placing the client on bed rest and then placing the client in a knee-chest position or lowering the head of the bed, and elevating the maternal hips on a pillow to minimize the pressure on the cord.
What is the safest position for a woman in labor when the nurse notes a prolapsed cord?If the fetus is viable, place the mother in the knee-chest position (patient facing the bed, chest level to bed, knees tucked under chest, pelvis and buttocks elevated) or head-down tilt in the left lateral position and apply upward pressure against the presenting part to lift the fetus away from the prolapsed cord.
What is the first initial management of the nurse in case of prolapsed of the umbilical cord?Firstly, call for help - umbilical cord prolapse is an obstetric emergency. It should be managed as follows: Avoid handling the cord to reduce vasospasm. Manually elevate the presenting part by lifting the presenting part off the cord by vaginal digital examination.
How do you treat a prolapsed umbilical cord?Umbilical cord prolapse is an acute obstetric emergency that requires immediate delivery of the baby. The route of delivery is usually by cesarean section. The doctor will relieve cord compression by manually elevating the fetal presentation part until cesarean section is performed.
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