Slide 7
Detecting problems and managing them early is different from “risk assessment.” In risk assessment, most people who are classified as “high risk” do not ultimately have complications, and a significant proportion of women who have complications do not have any identifiable “risk factors.” For example, 20% of women with eclampsia have seizures that occur without any warning signs, such as hypertension.
Every patient, therefore, should be considered at risk for potential problems at labor and childbirth. They should be monitored closely regarding her emotional well-being, the progress of labor and the fetal status. With a heightened awareness, the provider is more likely to be ready for complications and to treat them without delay.
Slide 8
The partograph is a useful tool for monitoring the progress of labor. Use it to avoid unnecessary interventions so maternal and neonatal morbidity are not needlessly increased, to intervene in a timely manner to avoid maternal and neonatal morbidity or mortality and to ensure close monitoring of the woman in labor.
At the alert line, the onset of the active phase of labor (4 cm), the patient is expected to reach full dilation at the rate of 1 cm/hour. At the action line, which is 4 hours to the risk of the alert line, the practitioner is signaled to take action if the patient is not following the expected course of labor.
Slide 9
This WHO trial started in 1987.
Slide 10
In this WHO partograph study, after using the partograph, there were significantly fewer women who had labor longer than 18 hours, needed augmentation of labor or had postpartum infection.
Slide 11
A Cochrane Review also evaluated the usefulness of applying specific criteria to diagnose active labor, to see if it had any effect on the outcome of labor. Specific criteria were used.
Slide 12
Lauzon and Hodnett found that if strict criteria were used, there were fewer unnecessary interventions, such as the use of oxytocics or analgesia. This improves the labor process for the patient and facilitates a favorable outcome.
Slide 18
Also refer to the HIV set.
Slide 19
These principles apply to all levels of care.
Slide 21
Non-invasive, non-pharmacological pain relief reduces the need for
pharmacological/lower dose needed.
Slide 23
Dorsal lithotomy
-
Advantages: Ease for practitioners in assisting at the childbirth, dealing with complications, administering medications, and fetal monitoring
-
Disadvantages: Danger of supine hypotension and increased length of second stage
Side lying
-
Advantages: Fewer perineal lacerations because of greater control of the fetal head during childbirth, and greater relaxation and less tension of the perineal muscles
-
Disadvantage: Need a person to help hold up the leg of the woman
Squatting
-
Advantages: Both the transverse and anterior-posterior diameter of the pelvic outlet are bigger; Results in less oxytocin stimulation, fewer mechanically assisted
deliveries, fewer and less severe perineal lacerations (if the perineum was adequately supported), and fewer episiotomies
-
Disadvantage: If used before engagement of the caput, it may impede descent; if used without adequate perineal support, can result in increased maternal injuries
Hands and knees
-
Advantages: Less perineal trauma because gravity directs pressure away from the perineum and at the same time promotes fetal descent, and there is increased perineal elasticity in this position
-
Disadvantage: Wrist fatigue and tiring for the woman if used for long periods
Semi-sitting
-
Advantage: Maximizes thrust and direction of uterine contractions' force on fetus so as to enhance passage though the pelvic canal; Resulted in fewer late decelerations and increased Apgar scores
-
Disadvantage: May slow labor if not alternated with other positions because the contractions are of lower intensity and less efficient in dilating the cervix than standing/lateral positions
Sitting
Slide 25
Data show that emotional and physical support reduce the complications of labor, such as the need of analgesia and operative interventions.
Slide 27
Data show that non-supine positions result in many more favorable outcomes, such as a shorter second stage, less interventions, such as episiotomy or vacuum, and less pain for the woman. They contribute to her overall comfort.
Slide 28
Enemas are uncomfortable, can damage the bowel and do not expedite labor or decrease neonatal infection or perinatal wound infection.
Shaving does not reduce infection, and, in fact, may increase the risk of infection or transmission of HIV or hepatitis to the fetus if the mother has open cuts on the perineum. Lavage or revision of the uterus can cause infection, trauma and shock.
Slide 29
Rectal examinations are uncomfortable, inaccurate and do not reduce the incidence of puerperal infection. In some instances, this examination may be needed, such as when assessing progress of labor in a woman with female genital cutting. Ideally, however, she would get early analgesia and have the infibulations opened for proper vaginal examination during labor.
X-ray pelvimetry may increase the likelihood of leukemia in the child.
Slide 30
There is no evidence for or against perineal massage in the second stage of labor. There is, however, convincing evidence that antepartum perineal massage for up to 6 weeks before delivery may help stretch the perineum and reduce trauma at delivery.
Slide 31
Women self-regulate their food intake during labor, usually limiting it to fluids, therefore, restricting intake may be unnecessary. Routinely placing an IV may not be necessary and may increase the risk of infection.
