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Intrapartum Care: Introduction
 

Intrapartum Care: Introduction

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Intrapartum Care was developed for doctors and advanced midwives who care for women who deliver in district hospitals. It contains theory chapters and skills workshops adapted from the labour chapters ...

Intrapartum Care was developed for doctors and advanced midwives who care for women who deliver in district hospitals. It contains theory chapters and skills workshops adapted from the labour chapters of Maternal Care. Monitoring the mother, fetus, and progress of labour, the second and third stages of labour, managing pain, the puerperium and family planning

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    Intrapartum Care: Introduction Intrapartum Care: Introduction Document Transcript

    • IntrapartumCareA learning programmefor professionalsDeveloped by thePerinatal Education Programme
    • Intrapartum CareA learning programmefor professionalsDeveloped by thePerinatal Education Programmewww.ebwhealthcare.com
    • VERY IMPORTANTWe have taken every care to ensure that drugdosages and related medical advice in this bookare accurate. However, drug dosages can changeand are updated often, so always double-checkdosages and procedures against a reliable,up-to-date formulary and the given drug‘sdocumentation before administering it.Intrapartum Care:A learning programme for professionalsUpdated 18 May 2010First published by EBW Healthcare in 2009Text © Perinatal Education Programme 2009Illustrations by Anne WestobyGetup © Electric Book Works 2009ISBN (print edition): 978-1-920218-38-6ISBN (PDF ebook edition): 978-1-920218-39-3All text in this book excluding the tests andanswers is published under the Creative CommonsAttribution Non-Commercial No DerivativesLicense. You can read up about this license at http://creativecommons.org/licenses/by-nc-nd/3.0/.The multiple-choice tests and answers in thispublication may not be reproduced, stored in aretrieval system, or transmitted in any form or byany means without the prior permission of ElectricBook Works, 87 Station Road, Observatory, CapeTown, 7925.Visit our websites at www.electricbookworks.comand www.ebwhealthcare.com
    • ContentsContents 3 Case study 2 32 Case study 3 33Acknowledgements 7 3 Monitoring and management of theIntroduction 9 first stage of labour 34 About the EBW Healthcare series 9 The diagnosis of labour 34 Why decentralised learning? 9 The two phases of the first stage of labour 34 Books in the EBW Healthcare series 9 Monitoring of the first stage of labour 35 Format of the courses 11 Management of a patient in the latent Contributors 12 phase of the first stage of labour 36 Updating the course material 13 Management of a patient in the active Contact information 13 phase of the first stage of labour 38 Poor progress in the active phase of the1 Monitoring the condition of the mother first stage of labour 40during the first stage of labour 15 Cephalopelvic disproportion 43 Monitoring labour 15 Inadequate uterine action 44 Assessing the general condition of the The referral of women with poor mother 16 progress during the active phase of Assessing the temperature 17 the first stage of labour 45 Assessing the pulse rate 19 Prolapse of the umbilical cord 46 Assessing the blood pressure 19 Case study 1 47 Assessing the urine 20 Case study 2 47 Maternal exhaustion 21 Case study 3 48 Case study 1 22 Case study 4 49 Case study 2 22 3A Skills workshop: Examination of the2 Monitoring the condition of the fetus abdomen in labour 50during the first stage of labour 24 Abdominal palpitation 50 Monitoring the fetus 24 Assessing contractions 53 Fetal heart rate patterns 26 Assessing the fetal heart rate 53 Managing a woman with an abnormal fetal heart rate pattern 30 The liquor 31 Case study 1 32
    • 4 INTRAPAR TUM CARE3B Skills workshop: Vaginal examination Case study 3 103in labour 54 Case study 4 104 Preparation for a vaginal examination in labour 54 6 Managing pain during labour 105 Procedure of examination 55 Pain relief in labour 105 The vulva and vagina 55 Use of analgesics in labour 106 The cervix 55 Naloxone 108 The membranes and liquor 56 Sedatation in labour 109 The presenting part 56 Inhalational analgesia 109 Moulding 60 Local anaesthesia 110 Epidural anaesthesia 1103C Skills workshop: Recording General anaesthesia 111observations on the partogram 62 Case study 1 111 The partogram 62 Case study 2 112 Recording the condition of the mother 62 Case study 3 113 Recording the condition of the fetus 62 Case study 4 113 Recording the progress of labour 64 Exercises on the correct use of the 7 The puerperium 115 partogram 66 The normal puerperium 115 Case study 1 66 Management of the puerperium 117 Case study 2 69 Puerperal pyrexia 120 Case study 3 70 Thromboembolism 123 Puerperal psychiatric disorders 1244 The second stage of labour 73 Secondary postpartum haemorrhage 125 The normal second stage of labour 73 Self-monitoring 125 Managing the second stage of labour 74 Case study 1 126 Episiotomy 77 Case study 2 126 Prolonged second stage of labour 78 Case study 3 127 Management of impacted shoulders 79 Case study 4 127 Managing the newborn infant 80 Case study 1 80 8 Family planning after pregnancy 130 Case study 2 81 Contraceptive counselling 130 Case study 3 82 Contraception after delivery 132 Case study 4 82 Case study 1 136 Case study 2 1364A Skills workshop: Performing and Case study 3 137repairing an episiotomy 84 Case study 4 137 Performing an episiotomy 84 Repairing an episiotomy 85 Tests 139 Test 1: Monitoring the condition of the5 The third stage of labour 90 mother during the first stage of labour 139 The normal third stage of labour 90 Test 2: Monitoring the condition of the Managing the third stage of labour 91 fetus during the first stage of labour 141 Examination of the placenta after birth 94 Test 3: Monitoring and management The abnormal third stage of labour 94 of the first stage of labour 143 Managing a postpartum haemorrhage 95 Test 4: The second stage of labour 146 Protecting the staff from HIV infection Test 5: The third stage of labour 149 during labour 102 Test 6: Managing pain during labour 152 Case study 1 102 Test 7: The puerperium 155 Case study 2 103 Test 8: Family planning after pregnancy 157
    • AcknowledgementsIntrapartum Care has been edited from Editor-in-Chief of the Perinatal Educationselected units of the Maternal Care manual Programme: Prof D L Woodsof the Perinatal Education Programme. This Editors of Intrapartum Care: Prof G B Theronlearning programme for professionals is and Prof R C Pattinsondeveloped by the Perinatal Education Trustand funded by Eduhealthcare. Contributors to Intrapartum Care: Prof H van C de Groot, Dr D H Greenfield, Ms H Louw,We acknowledge all the participants of the Prof G B Theron, Prof D L WoodsPerinatal Education Programme who havemade suggestions and offered constructivecriticism. It is only through constant feedbackfrom colleagues and participants that thecontent of the Perinatal Education Programmecourses can be improved.
    • IntroductionABOUT THE EBW WHY DECENTRALISEDHEALTHCARE SERIES LEARNING?EBW Healthcare publishes an innovative Continuing education for healthcare workersseries of distance-learning books for traditionally consists of courses and workshopshealthcare professionals, developed by the run by formal trainers at large central hospitals.Perinatal Education Trust, Eduhealthcare, These teaching courses are expensive to attend,the Desmond Tutu HIV Foundation and the often far away from the healthcare workers’Desmond Tutu TB Centre, with contributions family and places of work, and the contentfrom numerous experts. frequently fails to address the real healthcare requirements of the poor, rural communitiesOur aim is to provide appropriate, affordable who face the biggest healthcare challenges.and up-to-date learning material forhealthcare workers in under-resourced areas, To help solve these many problems, a self-so that they can manage their own continuing help decentralised learning method has beeneducation courses which will enable them to developed which addresses the needs oflearn, practise and deliver skillful, efficient professional healthcare workers, especiallypatient care. those in poor, rural communities.The EBW Healthcare series is built onthe experience of the Perinatal EducationProgramme (PEP), which has provided BOOKS IN THE EBWlearning opportunities to over 60 000 nurses HEALTHCARE SERIESand doctors in South Africa since 1992. Manyof the educational methods developed by PEPare now being adopted by the World Health Maternal Care addresses all the commonOrganisation (WHO). and important problems that occur during pregnancy, labour, delivery and the puerperium. It covers the antenatal and postnatal care of healthy women with normal pregnancies, monitoring and managing
    • 10 INTRAPAR TUM CAREthe progress of labour, specific medical glucose concentration, insertion of an umbilicalproblems during pregnancy, labour and the vein catheter, phototherapy, apnoea monitorspuerperium, family planning and regionalised and oxygen therapy.perinatal care. Skills workshops teach clinicalexamination in pregnancy and labour, routine Primary Newborn Care was writtenscreening tests, use of an antenatal card specifically for nurses and doctors whoand partogram, measuring blood pressure, provide primary care for newborn infants indetecting proteinuria and performing and level 1 clinics and hospitals. Primary Newbornrepairing an episiotomy. Care addresses the care of infants at birth, care of normal infants, care of low-birth-weightMaternal Care is aimed at healthcare workers infants, neonatal emergencies, and commonin level 1 hospitals or clinics. minor problems in newborn infants.Primary Maternal Care addresses the Mother and Baby Friendly Care describesneeds of healthcare workers who provide gentler, kinder, evidence-based ways of caringantenatal and postnatal care, but do not for women during pregnancy, labour andconduct deliveries. It is adapted from theory delivery. It also presents improved methodschapters and skills workshops from Maternal of providing infant care with an emphasisCare. This book is ideal for midwives and on kangaroo mother care and exclusivedoctors providing primary maternal care breastfeeding.in level 1 district hospitals and clinics,and complements the national protocol of Saving Mothers and Babies was developed inantenatal care in South Africa. response to the high maternal and perinatal mortality rates found in most developingIntrapartum Care was developed for doctors countries. Learning material used in the book isand advanced midwives who care for women based on the results of the annual confidentialwho deliver in district hospitals. It contains enquiries into maternal deaths and the Savingtheory chapters and skills workshops adapted Mothers and Saving Babies reports published infrom the labour chapters of Maternal Care. South Africa. It addresses the basic principlesParticular attention is given to the care of mortality audit, maternal mortality,of the mother, the management of labour perinatal mortality, managing mortalityand monitoring the wellbeing of the fetus. meetings and ways of reducing maternal andIntrapartum Care was written to support perinatal mortality rates. This book shouldand complement the national protocol of be used together with the Perinatal Problemintrapartum care in South Africa. Identification Programme (PPIP).Newborn Care was written for healthcare Birth Defects was written for healthcareworkers providing special care for newborn workers who look after individuals with birthinfants in regional hospitals. It covers defects, their families, and women who are atresuscitation at birth, assessing infant size and increased risk of giving birth to an infant with agestational age, routine care and feeding of both birth defect. Special attention is given to modesnormal and high-risk infants, the prevention, of inheritance, medical genetic counselling,diagnosis and management of hypothermia, and birth defects due to chromosomalhypoglycaemia, jaundice, respiratory distress, abnormalities, single gene defects, teratogensinfection, trauma, bleeding and congenital and multifactorial inheritance. This bookabnormalities, as well as communication with is being used in the Genetics Educationparents. Skills workshops address resuscitation, Programme which trains healthcare workers insize measurement, history, examination and genetic counselling in South Africa.clinical notes, nasogastric feeds, intravenousinfusions, use of incubators, measuring blood
    • INTRODUCTION 11Perinatal HIV enables midwives, nurses and nurses with wide experience in the careand doctors to care for pregnant women and of adults with HIV, through the auspices oftheir infants in communities where HIV the Desmond Tutu HIV Foundation at theinfection is common. Special emphasis has University of Cape Town.been placed on the prevention of mother-to-infant transmission of HIV. It covers the basicsof HIV infection and screening, antenatal FORMAT OF THE COURSESand intrapartum care of women with HIVinfection, care of HIV-exposed newborninfants, and parent counselling. 1. Objectives The learning objectives are clearly stated at theChildhood HIV enables nurses and doctors start of each chapter. They help the participantto care for children with HIV infection. It to identify and understand the importantaddresses an introduction to HIV in children, lessons to be learned.the clinical and immunological diagnosisof HIV infection, management of childrenwith and without antiretroviral treatment, 2. Pre- and post-testsantiretroviral drugs, opportunistic infections There is a multiple-choice test of 20 questionsand end-of-life care. for each chapter at the end of the book. Participants are encouraged to take a pre-testChildhood TB was written to enable before starting each chapter, to benchmarkhealthcare workers to learn about the primary their current knowledge, and a post-test aftercare of children with tuberculosis. The book each chapter, to assess what they have learned.covers an introduction to TB infection,and the clinical presentation, diagnosis, Self-assessment allows participants to monitormanagement and prevention of tuberculosis in their own progress through the course.children and HIV/TB co-infection. ChildhoodTB was developed by paediatricians with 3. Question-and-answer formatwide experience in the care of children with Theoretical knowledge is presented in atuberculosis, through the auspices of the question-and-answer format, which encouragesDesmond Tutu Tuberculosis Centre at the the learner to actively participate in theUniversity of Stellenbosch. learning process. In this way, the participant is led step by step through the definitions,Child Healthcare addresses all the common causes, diagnosis, prevention, dangers andand important clinical problems in children, management of a particular problem.including immunisation, history andexamination, growth and nutrition, acute Participants should cover the answer for a fewand chronic infections, parasites, and skin minutes with a piece of paper while thinkingconditions, as well as difficulties in the home about the correct reply to each question. Thisand society. Child Healthcare was developed method helps learning.for use in primary care settings. Simplified flow diagrams are also used, where necessary, to indicate the correct approach toAdult HIV covers an introduction to HIV diagnosing or managing a particular problem.infection, management of HIV-infected adultsat primary-care clinics, preparing patients forantiretroviral (ARV) treatment, ARV drugs, Each question is written in bold,starting and maintaining patients on ARV like this, and is identified with thetreatment and an approach to opportunistic number of the chapter, followed by theinfections. Adult HIV was developed by doctors number of the question, e.g. 5-23.
    • 12 INTRAPAR TUM CARE4. Important lessons Participants need to achieve at least 80% in the examination in order to successfully complete the course. Successful candidates Important practical lessons are emphasised by will be emailed a certificate which states placing them in a box like this. that they have successfully completed that course. EBW Healthcare courses are5. Notes not yet accredited for nurses, but South African doctors can earn CPD points on the NOTE Additional, non-essential information is successful completion of an examination. provided for interest and given in notes like this. These facts are not used in the case studies or Please contact info@ebwhealthcare.com or included in the multiple-choice questions. +27 021 44 88 336 when you are ready to take the exam.6. Case studiesEach chapter closes with a few case CONTRIBUTORSstudies which encourage the participantto consolidate and apply what was learned The developers of our learning materials are aearlier in the chapter. These studies give the multi-disciplinary team of nurses, midwives,participant an opportunity to see the problem obstetricians, neonatologists, and generalas it usually presents itself in the clinic or paediatricians. The development and review ofhospital. The participant should attempt to all course material is overseen by the Editor-answer each question in the case study before in-Chief, emeritus Professor Dave Woods,reading the correct answer. a previous head of neonatal medicine at the University of Cape Town who now consults to7. Practical training UNICEF and the WHO.Certain chapters contain skills workshops,which need to be practised by the participants Perinatal Education Trust(preferably in groups). The skills workshops, Books developed by the Perinatal Educationwhich are often illustrated with line drawings, Programme are provided as cheaply as possible.list essential equipment and present step-by- Writing and updating the programme is bothstep instructions on how to perform each funded and managed on a non-profit basis bytask. If participants aren’t familiar with a the Perinatal Education Trust.practical skill, they are encouraged to ask anappropriate medical or nursing colleague todemonstrate the clinical skill to them. In this Eduhealthcareway, senior personnel are encouraged to share Eduhealthcare is a non-profit organisationtheir skills with their colleagues. based in South Africa. It aims to improve health and wellbeing, especially in poor communities,8. Final examination through affordable education for healthcare workers. To this end it provides financialOn completion of each course, participants support for the development and publishing ofcan take a 75-question multiple-choice the EBW Healthcare series.examination on the EBW Healthcare website,when they are ready to. The Desmond Tutu HIV FoundationAll the exam questions will be taken fromthe multiple-choice tests from the book. The The Desmond Tutu HIV Foundation at thecontent of the skills workshops will not be University of Cape Town, South Africa, is aincluded in the examination. centre of excellence in HIV medicine, building
    • INTRODUCTION 13capacity through training and enhancing CONTACT INFORMATIONknowledge through research.The Desmond Tutu Tuberculosis Centre EBW HealthcareThe Desmond Tutu Tuberculosis Centre at Website: www.ebwhealthcare.comStellenbosch University, South Africa, strives Email: info@ebwhealthcare.comto improve the health of vulnerable groupsthrough the education of healthcare workers Telephone: +27 021 44 88 336and community members, and by influencing Fax: +27 088 021 44 88 336policy based on research into the epidemiologyof childhood tuberculosis, multi-drug- Post: 87 Station Road, Observatory, 7925,resistant tuberculosis, HIV/TB co-infection Cape Town, South Africaand preventing the spread of TB and HIV insouthern African. Editor-in-Chief: Professor Dave Woods Website: www.pepcourse.co.zaUPDATING THE Email: pepcourse@mweb.co.zaCOURSE MATERIAL Telephone: +27 021 786 5369 Fax: +27 021 671 8030EBW Healthcare learning materials Post: Perinatal Education Programme, PO Boxare regularly updated to keep up with 34502, Groote Schuur, Observatory, 7937,developments and changes in healthcare South Africaprotocols. Course participants can makeimportant contributions to the continualimprovement of EBW Healthcare booksby reporting factual or language errors,by identifying sections that are difficult tounderstand, and by suggesting additions orimprovements to the contents. Details ofalternative or better forms of managementwould be particularly appreciated. Please sendany comments or suggestions to the Editor-in-Chief, Professor Dave Woods.
    • 1 Monitoring the condition of the mother during the first stage of labourBefore you begin this unit, please take the MONITORING LABOURcorresponding test at the end of the book toassess your knowledge of the subject matter. Youshould redo the test after you’ve worked through 1-1 What is labour?the unit, to evaluate what you have learned Labour is the process whereby the fetus and the placenta are delivered. The uterine Objectives contractions cause the cervix to dilate and eventually push the fetus and placenta through the cervix and out of the vagina. Traditionally When you have completed this unit you labour is divided into different stages. should be able to: • Monitor the condition of the mother 1-2 What are the stages of labour? during the first stage of labour. Labour is divided into three stages: • Record the clinical observations on the 1. The first stage of labour. partogram. 2. The second stage of labour. • Explain the clinical significance of these 3. The third stage of labour. observations. Each stage of labour is important as it must • Manage any problems which are be correctly diagnosed and managed. There detected. are dangers to the mother in each of the three stages of labour. Labour is divided into three stages.
    • 16 INTRAPAR TUM CARE1-3 What is the first stage of labour? 3. Finally you must ask the question: ‘What must I do about the problem?’.The first stage of labour starts with the onsetof regular uterine contractions and ends whenthe cervix is fully dilated. 1-9 How is the condition of the mother monitored?1-4 What must be monitored in By regular observations of the following:the first stage of labour? 1. The general condition of the mother.1. The condition of the mother. 2. Temperature.2. The condition of the fetus. 3. Pulse rate.3. The progress of labour. 4. Blood pressure. 5. Urine output and urinalysis for protein and1-5 What four questions should be asked ketones.about each of these observations? Therefore, the general condition of the mother,1. How often must the observations be done? as well as observations of her temperature,2. How are the findings recorded? pulse rate, blood pressure, urine volume and3. What is the clinical significance of the chemistry must be recorded on the partogram. findings?4. What should be done if an observation is abnormal? ASSESSING THE GENERAL CONDITION1-6 What is the partogram? OF THE MOTHERThe partogram is a chart which shows theprogress of labour over time. It also displaysobservations reflecting the maternal and fetal 1-10 Why is it important to observecondition as well as the progress of labour. The the general condition of the motherobservations of every woman in the first stage during the first stage of labour?of labour must be charted on a partogram. If the general condition of the mother is not normal, there will usually be further abnormal1-7 What maternal observations findings when the other observations are made.are recorded on the partogram?All the maternal observations must be 1-11 When can the general condition ofcarefully recorded on the partogram. the mother be regarded as normal? A woman in the first stage of labour will All the observations of every mother in the first normally appear calm and relaxed between stage of labour must be recorded on a partogram. contractions and does not look pale. During contractions, her respiratory rate will increase and she will experience pain. However, she1-8 How should each should not have pain between contractions.observation be assessed? When a woman’s cervix is fully dilated, orAt the completion of any set of observations, almost fully dilated, she becomes restless, mayyou must ask yourself the following questions: vomit, and has an uncontrollable urge to bear down with contractions.1. Is everything normal? If the answer is no, then you must ask:2. What is not normal and why is it not normal?
    • MONITORING THE CONDITION OF THE MOTHER DURING THE FIRST STAGE OF LABOUR 171-12 How often should the general 1-17 When may severe exhaustioncondition of the mother be observed? or dehydration occur?The general condition of the mother should With a prolonged labour, e.g. withbe observed continuously, but noted specially cephalopelvic disproportion.when other observations are made. 1-18 What may cause a pale face1-13 When is the general condition and mucous membranes?of the mother abnormal? This is usually due to either of the following:When any of the following are present: 1. Chronic anaemia, e.g. iron deficiency,1. Excessive anxiety. malaria, etc.2. Severe, continuous pain. 2. Blood loss, e.g. placenta praevia, abruptio3. Severe exhaustion. placentae or rupture of the uterus.4. Dehydration.5. Marked pallor of the face and mucous 1-19 Where must abnormalities in the membranes. mother’s general condition be recorded? If the general condition of the woman1-14 What causes severe anxiety? becomes abnormal, this must be noted inAnxiety is usually seen in primigravidas who: the appropriate space at the bottom of the partogram as shown in figure 1-1.1. Are not prepared for the process of labour and the labour ward.2. Are not accompanied by a friend or family member in the labour ward. ASSESSING THE3. Cannot communicate due to language TEMPERATURE differences.1-15 What should you do if the mother 1-20 What is a normal temperature?is very anxious and is experiencing The normal range of oral temperature is 36.0 tovery painful contractions? 37.0 °C. Therefore, a temperature higher than1. She must be comforted and reassured. If 37.0 °C is abnormal and is regarded as pyrexia. possible, someone she knows should stay with her. 1-21 How often should you2. She must be offered appropriate pain relief. monitor the temperature? Four hourly, unless there is a particular reason1-16 What causes severe, continuous to do so more frequently.pain in the first stage of labour?Severe, continuous pain always indicates that a 1-22 How is the temperature recorded?complication is present, such as: The temperature is recorded in the appropriate1. Abruptio placentae. space on the partogram as shown in figure 1-1.2. Rupture of the uterus.3. An infection, such as acute pyelonephritis 1-23 What are the causes of and chorioamnionitis. pyrexia during labour? There are two main causes of a high maternal temperature:
    • 18 INTRAPAR TUM CAREFigure 1-1: Recording maternal observations on the partogram1. Infection: This will most probably be in the 1-25 What are the dangers of pyrexia? urogenital tract, e.g. acute pyelonephritis 1. To the mother: The temperature, on its or chorioamnionitis. However, it must own, does not constitute a risk. However, be remembered that any other infection, if the pyrexia is caused by an infection, the unrelated to the pregnancy, may be present infection may be dangerous to the mother. during labour, e.g. pneumonia, viral Fever may cause a woman to go into labour. infections or malaria. 2. To the fetus: A high temperature can cause2. Maternal exhaustion: Dehydration causes fetal tachycardia (fast heart rate). Preterm pyrexia. delivery with complications of immaturity in the newborn infant may also result. If1-24 How should you manage the pyrexia is due to chorioamnionitis, thematernal pyrexia? fetus is at high risk of becoming infected1. The cause of the high temperature must and may present with pneumonia. be found and treated. It is particularly important to look for acute pyelonephritis, chorioamnionitis and evidence of maternal exhaustion.2. The temperature may be brought down with paracetamol (e.g. Panado).
    • MONITORING THE CONDITION OF THE MOTHER DURING THE FIRST STAGE OF LABOUR 19ASSESSING THE 1-32 How often should you monitor the blood pressure?PULSE RATE Blood pressure is monitored two-hourly during the latent phase of labour and hourly1-26 What is the normal during the active phase of labour.maternal pulse rate? 1-33 How is the blood pressure recorded?The normal range of the maternal pulse rate is80 to 100 beats per minute. The blood pressure is recorded in the appropriate space on the partogram as shown1-27 How often should you in figure 1-1.monitor the pulse rate? 1-34 What are the causes ofThe pulse rate is monitored two-hourly during hypertension (high blood pressure)?the latent phase of labour, and hourly duringthe active phase of the first stage of labour. 1. Anxiety. 2. Pain.1-28 How is the pulse rate recorded? 3. Any one of the hypertensive disorders of pregnancy.The pulse rate is recorded in the appropriatespace on the partogram as shown in figure 1-1. 1-35 What are the causes of hypotension (low blood pressure)?1-29 What are the causes ofa rapid pulse rate? 1. Some women may normally have a low blood pressure. Therefore, the bloodThe commonest causes of a rapid pulse rate pressure during labour must be compared(tachycardia) are: with that recorded during the antenatal1. Anxiety. visits.2. Pain 2. Pressure of the uterus on the inferior vena3. Pyrexia. cava when the woman lies on her back may4. Exhaustion. decrease the venous return to the heart5. Shock. and, thereby, cause the blood pressure to fall. This is called supine hypotension.1-30 What action should be taken if 3. Shock. This is usually due to blood loss.the mother has a fast heart rate? 1-36 What are the risks of hypotension?The cause of the tachycardia should bedetermined and treated. 1. To the mother: If hypotension is due to shock, the mother may suffer kidney damage. Severe and uncorrectedASSESSING THE hypotension may result in maternal death. 2. To the fetus: A fall in blood pressure resultsBLOOD PRESSURE in decreased blood flow to the placenta, reducing the supply of oxygen to the fetus. This may cause fetal distress due to hypoxia.1-31 What is a normal blood pressure?The normal range of blood pressure during thefirst stage of labour is 100/60 mm Hg or above,but less than 140/90 mm Hg.
    • 20 INTRAPAR TUM CARE1-37 What should you do for a 1-41 How often should you test the urine?mother with hypotension? 1. Every four hours during the latent phase of1. Establish the cause of the hypotension. labour.2. If the hypotension is due to the woman 2. Every two hours during the active phase of lying on her back, she should be turned labour. onto her side. The blood pressure usually 3. Each time the woman passes urine, if more returns to normal within one to two frequently than above. minutes. The fetal heart rate should then be checked again. 1-42 How are the urinary3. If the hypotension is due to haemorrhage, observations recorded? the woman must be resuscitated urgently and be managed according to the cause of The observations are recorded on the the bleeding. partogram: 1. Volume in ml.1-38 How do you recognise shock? 2. Protein and ketones are recorded as 0 if absent and 1+ to 4+ if present.Shock presents with one or more of thefollowing features: The urinary observations should be recorded on the partogram as shown in figure 1-1.1. Tachycardia.2. Hypotension. NOTE If the reagent strip also tests for blood and3. The skin feels cold and sweaty. glucose, this information should be recorded on the partogram. However, microscopic1-39 What are the common causes of hematuria is often present during labour andshock in the first stage of labour? most women with an infusion containing 5% dextrose will have glucosuria present.1. Shock during the first stage of labour is almost always due to haemorrhage, for 1-43 What volume of urine passed indicates example: oliguria (decreased urine output)? • Abruptio placentae. • Placenta praevia. An amount of less than 20 ml per hour. • A ruptured uterus.2. Infection as a cause of shock must always 1-44 What are the causes of oliguria? be considered. 1. Dehydration. 2. Severe pre-eclampsia.ASSESSING THE URINE 3. Shock. Women suffering from any of these conditions must have their urinary output accurately1-40 What urine tests should monitored. An indwelling urinary catheterbe done during labour? must, therefore, be passed.1. Volume. The cause of the oliguria must be diagnosed2. Protein. and treated.3. Ketones.The presence and degree of proteinuria and 1-45 How can normal hydrationketonuria is measured and graded with a during labour be ensured?reagent strip, e.g. Dipstix. 1. If a vaginal delivery is expected, the woman should be encouraged to eat and
    • MONITORING THE CONDITION OF THE MOTHER DURING THE FIRST STAGE OF LABOUR 21 drink during the latent phase of the first 1-48 How do you recognise stage of labour. maternal exhaustion?2. If a Caesarean section is expected during The following physical signs of maternal labour, the woman must be kept nil per exhaustion may be present: mouth while being prepared for surgery.3. Women who are at low risk of problems 1. Tachycardia. must continue taking fluids, while women 2. Pyrexia. with risk factors should be kept nil per 3. A dry mouth. mouth, during the active phase of the first 4. Oliguria. stage of labour. Intravenous fluids must be 5. Ketonuria. given to women with risk factors as well as to women with long labours. 1-49 What causes maternal exhaustion? A long labour with an insufficient supply of Always ensure that a mother in labour has an fluid and energy to the woman. adequate fluid intake. Fluids should be given intravenously if necessary. 1-50 What are the effects of maternal exhaustion?1-46 What is the significance of proteinuria? 1. On the mother: Inadequate progress of labour due to poor uterine action in the firstProteinuria of more than a trace is never stage, and poor maternal effort in bearingnormal. It is an important sign of: down during the second stage of labour.1. Pre-eclampsia. 2. On the fetus: Fetal distress due to hypoxia.2. Urinary tract infection. This often results from incorrectly3. Renal disease. managed cephalopelvic disproportion.When there is proteinuria, the urine mustalways be examined for evidence of infection. 1-51 How can you preventHowever, infection alone will not cause more maternal exhaustion?than 1+ proteinuria. Proteinuria of 2+ or more 1. Make sure that the woman gets anshould always be regarded as indicating pre- adequate intake of fluid and energy duringeclampsia or chronic renal disease. labour. It may be necessary to give fluid intravenously. Ringer’s lactate with 5%1-47 What is the clinical dextrose will also ensure an adequatesignificance of ketonuria? energy supply to the woman.Ketonuria is common in labour and may be 2. Ensure that the woman gets adequatenormal. However, if a woman has ketonuria, analgesia during labour.it is important to look for signs of maternal 3. Ensure that labour does not becomeexhaustion. prolonged. 1-52 How do you treat a motherMATERNAL EXHAUSTION with maternal exhaustion? If a woman has signs of maternal exhaustionMaternal exhaustion is a term used to then she should receive:describe a clinical condition, consisting of 1. An intravenous infusion, giving two litresdehydration and exhaustion during prolonged of Ringer’s lactate with 5% dextrose. Thelabour. It should not be confused with pain, first litre must be given quickly and theanxiety or shock. second litre given over two hours. It is
    • 22 INTRAPAR TUM CARE contraindicated to give a woman in labour 5. What are the dangers of 50 ml of 50% dextrose intravenously as this maternal pyrexia to the fetus? may be harmful to the fetus. Pyrexia may cause preterm labour, resulting2. Adequate analgesia. in the delivery of a preterm infant with all the complications of immaturity. If the pyrexia Maternal exhaustion may result in poor progress is due to chorioamnionitis a preterm infant of labour, while poor progress of labour may will be born with a high risk of congenital result in maternal exhaustion. pneumonia.1-53 Is it necessary for every mother to CASE STUDY 2receive intravenous fluid during labour?No. Low risk women who are progressing A woman is admitted to hospital with a historywell in labour do not need intravenous fluid, of labour for 24 hours. On admission sheeven if 1+ or 2+ ketonuria is present. If there appears anxious, has a dry mouth and a pulseare no contraindications, women should be rate of 120 beats per minute. She is able to passencouraged to take oral fluids during labour. only 30 ml of urine which is dark in colour. She had not passed any urine for the previous few hours.CASE STUDY 1 1. What is the probable diagnosis?A woman is admitted at 32 weeks gestation. Maternal exhaustion due to a long labourShe complains of lower abdominal pain and with an inadequate fluid and energy intake.fever. On general examination her temperature The diagnosis is confirmed by the presence ofis 38 °C. maternal tachycardia and a dry mouth.1. Does this woman have a 2. What other findings wouldnormal temperature? help confirm this diagnosis?No. She is pyrexial as her temperature is Pyrexia and ketonuria.higher than 37 °C. 3. Does this woman have oliguria?2. Where should hertemperature be recorded? Yes, as she obviously has passed less than 20 ml per hour during the past number of hours.In the appropriate space on the partogram. 4. Is ketonuria always abnormal?3. What are the most likelycauses of her pyrexia? No, ketonuria on its own may be normal.Acute pyelonephritis or chorioamnionitis asshe has pyrexia with lower abdominal pain. 5. How could maternal exhaustion be avoided?4. How should you manage By making sure that every woman receivesthis woman’s pyrexia? an adequate intake of fluid and energy during labour. If a vaginal delivery is expected and noDiagnose and treat the cause of the high high risk factors are present, a woman shouldtemperature. The temperature should be continue to take fluids orally during the activebrought down with paracetamol. phase of the first stage of labour. Any woman
    • MONITORING THE CONDITION OF THE MOTHER DURING THE FIRST STAGE OF LABOUR 23with prolonged labour should receive fluidsintravenously.6. How should the woman’sexhaustion be treated?She should be given two litres of Ringer’slactate with 5% dextrose intravenously. Thefirst litre must be given quickly and the secondlitre over two hours. In addition, adequateanalgesia should be given if needed.
    • 2 Monitoring the condition of the fetus during the first stage of labourBefore you begin this unit, please take the MONITORING THE FETUScorresponding test at the end of the book toassess your knowledge of the subject matter. Youshould redo the test after you’ve worked through 2-1 Why should you monitorthe unit, to evaluate what you have learned the fetus during labour? It is essential to monitor the fetus during Objectives labour in order to assess the response to the stresses of labour. The stress of a normal labour usually has no effect on a healthy fetus. When you have completed this unit you should be able to: 2-2 What may stress the • Monitor the condition of the fetus fetus during labour? during labour. 1. Compression of the fetal head during • Record the findings on the partogram. contractions. • Understand the significance of the 2. A decrease in the supply of oxygen to the findings. fetus. • Understand the causes and signs of fetal 2-3 How does head compression distress. stress the fetus? • Interpret the significance of different fetal heart rate patterns and meconium- Uterine contractions may compress the fetal head and cause slowing of the fetal heart rate. stained liquor. Head compression usually does not harm the • Manage any abnormalities which are fetus. detected. NOTE Slowing of the fetal heart is due to vagal stimulation. With a long labour due to cephalopelvic disproportion, compression
    • MONITORING THE CONDITION OF THE FETUS DURING THE FIRST STAGE OF LABOUR 25 of the fetal head can be severe and 2-6 When do uterine contractions reduce repeated. This may result in fetal distress. the supply of oxygen to the fetus? Usually uterine contractions do not reduce2-4 What may reduce the supply the supply of oxygen to the fetus, as there is anof oxygen to the fetus? adequate store of oxygen in the placental blood1. Uterine contractions: Uterine contractions to meet the fetal needs during the contraction. are the commonest cause of a decrease Normal contractions in labour do not affect in the oxygen supply to the fetus during the healthy fetus with a normally functioning labour. placenta, and, therefore, are not dangerous.2. Abnormal uterine blood vessels: The However, contractions may reduce the oxygen placenta may fail to provide the fetus with supply to the fetus when: enough oxygen and nutrition due to a decrease in the blood flow through the 1. There is placental insufficiency. uterine blood vessels to the placenta, i.e. 2. The contractions are prolonged or very placental insufficiency. Women with pre- frequent. eclampsia have poorly formed, narrow 3. There is compression of the umbilical cord. spiral arteries that provide inadequate amounts of maternal blood to the 2-7 How does the fetus respond placenta. Maternal smoking can also cause to a lack of oxygen? narrowing of the uterine blood vessels. A reduction in the normal supply of oxygen to3. Abruptio placentae: Part or all of the the fetus causes fetal hypoxia. This is a lack of placenta stops functioning because it oxygen in the cells of the fetus. If the hypoxia is separated from the uterine wall by a is mild the fetus will be able to compensate retroplacental haemorrhage. There is also and, therefore, show no response. However, spasm of the uterus which reduces the severe fetal hypoxia will result in fetal distress. amount of maternal blood reaching the Severe, prolonged hypoxia will eventually placenta. As a result the fetus does not result in fetal death. receive enough oxygen.4. Cord prolapse or compression: This stops the fetal blood flow and transport of 2-8 How is fetal distress oxygen from the placenta to the fetus. recognised during labour? Fetal distress caused by a lack of oxygen results Uterine contractions are the commonest cause in a decrease in the fetal heart rate. The fetus responds to hypoxia with a bradycardia to of a decreased oxygen supply to the fetus conserve oxygen. during labour. 2-9 How do you assess the condition2-5 How do contractions reduce the of the fetus during labour?supply of oxygen to the fetus? Two observations are used:Uterine contractions may: 1. The fetal heart rate pattern.1. Reduce the maternal blood flow to the 2. The presence or absence of meconium in placenta due to the increase in intra- the liquor. uterine pressure.2. Compress the umbilical cord.
    • 26 INTRAPAR TUM CAREFETAL HEART RATE 2-12 How often should you monitor the fetal heart rate?PATTERNS Low risk patients who have had normal observations on admission:2-10 What devices can be used to 1. Two hourly during the latent phase ofmonitor the fetal heart rate? labour.Any one of the following three pieces of 2. Half hourly during the active phase ofequipment: labour.1. A fetal stethoscope. Women with a high risk of fetal distress should2. A ‘doptone’ (Doppler ultrasound fetal heart have their observations done more frequently. rate monitor). The following women would be regarded as at3. A cardiotocograph (CTG machine). higher risk:In most low risk labours the fetal heart rate is 1. Intermediate risk patients.determined using a fetal stethoscope. However, 2. High risk patients.a doptone is helpful if there is difficulty 3. Patients with abnormal observations onhearing the fetal heart, especially if distress or admission.intra-uterine death is suspected. If available, 4. Patients with meconium-stained liquor.a doptone is the preferred method in primary These women need more frequent recording ofcare clinics and hospitals. Cardiotocograph the fetal heart rate:is not needed in most labours but is animportant and accurate method of monitoring 1. Hourly during the latent phase of labour.the fetal heart in high risk pregnancies. 2. Half hourly during the active phase of labour. 3. At least every 15 minutes if fetal distress is A doptone is the preferred method of assessing suspected. the fetal heart rate in primary care clinics and hospitals. 2-13 What features of the fetal heart rate pattern should you2-11 How should you monitor always assess during labour?the fetal heart rate? There are two features that should always beBecause uterine contractions may decrease assessed:the maternal blood flow to the placenta, and 1. The baseline fetal heart rate: This is thethereby cause a reduced supply of oxygen to heart rate between contractions.the fetus, it is essential that the fetal heart rate 2. The presence or absence of decelerations: Ifshould be monitored during a contraction. In present, the relation of the deceleration topractice, this means that the fetal heart pattern the contraction must be determined:must be checked before, during and after the • Decelerations that occur only during acontraction. A comment on the fetal heart contraction (i.e. early decelerations).rate, without knowing what happens during • Decelerations that occur duringand after a contraction, is almost valueless. and after a deceleration (i.e. late decelerations) The fetal heart rate must be assessed before, • Decelerations that have no fixed relation to contractions (i.e. variable during, and after a contraction. decelerations).
    • MONITORING THE CONDITION OF THE FETUS DURING THE FIRST STAGE OF LABOUR 27 NOTE In addition, the variability of the fetal heart 2-16 What are early decelerations? rate can also be evaluated if a cardiotocograph is available. Good variability gives a spiky trace Early decelerations are characterised by a while poor variability gives a flat trace. slowing of the fetal heart rate starting at the beginning of the contraction, and returning2-14 What fetal heart rate patterns to normal by the end of the contraction. Earlycan be recognised with a fetal decelerations are usually due to compressionstethoscope or doptone? of the fetal head which causes the heart rate to slow during the contraction.1. Normal.2. Early deceleration. 2-17 What is the significance3. Late deceleration. of early decelerations?4. Variable deceleration.5. Baseline tachycardia. Early decelerations do not indicate the6. Baseline bradycardia. presence of fetal distress. However, these fetuses must be carefully monitored as they areThese fetal heart rate patterns (with the at an increased risk of fetal distress.exception of variable decelerations) canbe easily recognised with a stethoscope NOTE When early decelerations are seen on aor doptone. However, cardiotocograph CTG trace, normal variability of the fetal heartrecordings (figures 2-1, 2-2 and 2-3) are rate is reassuring that the fetus is not hypoxic.useful in learning to recognise the differencesbetween the three types of deceleration. 2-18 What are late decelerations?It is common to get a combination of A late deceleration is a slowing of the fetalpatterns, e.g. a baseline bradycardia with late heart rate during a contraction, with the ratedecelerations. It is also common to get one only returning to the baseline 30 seconds orpattern changing to another pattern with more after the contraction has ended.time, e.g. early decelerations becoming latedecelerations. With a late deceleration the fetal heart rate only NOTE The variation in fetal heart rate normally returns to the baseline 30 seconds or more after exceeds five beats or more per minute, giving the contraction has ended. the baseline a spiky appearance on a CTG trace. A loss or reduction in beat-to-beat variation to below five beats per minute gives NOTE When using a cardiotocograph, a late a flat baseline (a ‘flat trace’) which suggests deceleration is diagnosed when the lowest fetal distress. However a flat baseline may also point of the deceleration occurs 30 seconds occur if the fetus is asleep or as the result of or more after the peak of the contraction. the administration of analgesics (pethidine, morphine) or sedatives (phenobarbitone). 2-19 What is the significance of late decelerations?2-15 What is a normal fetal Late decelerations are a sign of fetal distressheart rate pattern? and are caused by fetal hypoxia. The degree to1. No decelerations during or after which the heart rate slows is not important. It is contractions. the timing of the deceleration that is important.2. A baseline rate of 100 – 160 beats per minute. Late decelerations indicate fetal distress.
    • 28 INTRAPAR TUM CAREFigure 2-1: An early deceleration Figure 2-2: A late deceleration2-20 What are variable decelerations? 2-22 What are the causes of aVariable decelerations have no fixed baseline tachycardia?relationship to uterine contractions. Therefore, 1. Maternal pyrexia.the pattern of decelerations changes from one 2. Maternal exhaustion.contraction to another. Variable decelerations 3. Hexoprenaline (Ipradol) administration.are usually caused by compression of the 4. Chorioamnionitis (infection of theumbilical cord and do not indicate the placenta and membranes).presence of fetal distress. However, these 5. Fetal haemorrhage or anaemia.fetuses must be carefully monitored as they areat an increased risk of fetal distress. There is an increased risk of fetal distress if a fetal tachycardia is present.Variable decelerations are not easy torecognise with a fetal stethoscope or doptone. 2-23 What is a baseline bradycardia?They are best detected with a cardiotocograph. A baseline fetal heart rate of less than 100 NOTE Variable decelerations accompanied by beats per minute. loss of variability of the fetal heart rate may indicate fetal distress. Variable decelerations 2-24 What is the cause of a with good variability is reassuring. baseline bradycardia?2-21 What is a baseline tachycardia? A baseline bradycardia of less than 100 beats per minute usually indicates fetal distressA baseline fetal heart rate of more than 160 which is caused by severe fetal hypoxia. Ifbeats per minute. decelerations are also present, a baseline bradycardia indicates that the fetus is at great risk of dying.
    • MONITORING THE CONDITION OF THE FETUS DURING THE FIRST STAGE OF LABOUR 29 These fetal heart rate patterns do not indicate fetal distress but warn that the fetal heart rate must be closely observed as fetal distress may develop. If electronic monitoring (a cardiotocograph) is available, the fetal heart rate pattern must be monitored. 2-28 What fetal heart rate patterns indicate fetal distress during labour? 1. Late decelerations. 2. A baseline bradycardia. NOTE On cardiotocography loss of variability of the fetal heart rate lasting more than 60 minutes also suggests fetal distress. 2-29 How should the fetal heart rate pattern be observed during labour?Figure 2-3: Variable decelerations The fetal heart rate must be observed before, during and after a contraction. The following questions must be answered and recorded on2-25 How should you assess the the partogram:condition of the fetus on the basisof the fetal heart rate pattern? 1. What is the baseline fetal heart rate? 2. Are there any decelerations?1. The fetal condition is normal if a normal 3. If decelerations are observed, what is their fetal heart rate pattern is present. relation to the uterine contractions?2. The fetal condition is uncertain if the fetal 4. If the fetal heart rate pattern is abnormal, heart rate pattern indicates that there is an how must the patient be managed? increased risk of fetal distress.3. The fetal condition is abnormal if the fetal 2-30 Which fetal heart rate pattern heart rate pattern indicates fetal distress. indicates that the fetal condition is good?2-26 What is a normal fetal heart 1. The baseline fetal heart rate is normal.rate pattern during labour? 2. There are no decelerations.A normal baseline fetal heart rate without anydecelerations.2-27 Which fetal heart rate patternsindicate an increased risk of fetaldistress during labour?1. Early decelerations.2. Variable decelerations.3. A baseline tachycardia.
    • 30 INTRAPAR TUM CAREFigure 2-4: Recording fetal observations on the partogramMANAGING A WOMAN and stop the oxytocin infusion to prevent uterine overstimulation.WITH AN ABNORMAL 2. If the fetal bradycardia persists, intra-FETAL HEART uterine resuscitation of the fetus must be given and the fetus delivered as quick asRATE PATTERN possible. 2-33 How is fetal resuscitation given?2-31 What must be done ifdecelerations are observed? 1. Turn the woman onto her side. 2. Give her 40% oxygen through a face mask.First the relation of the decelerations to the 3. Start an intravenous infusion of Ringer’suterine contractions must be observed to lactate and give 250 μg (0.5 ml) salbutamoldetermine the type of deceleration. Then (Ventolin) slowly intravenously, aftermanage the patient as follows: ensuring that there is no contraindication1. If the decelerations are early or variable, to its use. (Contraindications to salbutamol the fetal heart rate pattern warns that are heart valve disease, a shocked patient there is an increased risk of fetal distress or patient with tachycardia). The 0.5 ml and, therefore, the fetal heart rate must be salbutamol is diluted with 9.5 ml sterile checked every 15 minutes. water and given slowly intravenously over2. If late decelerations are present, the five minutes. management will be the same as the 4. Deliver the infant by the quickest possible management of fetal bradycardia. route. If the woman’s cervix is 9 cm or more dilated and the head is on the pelvicThe observations of the fetal heart rate must floor, proceed with an assisted deliverybe recorded on the partogram as shown in (forceps or vacuum). Otherwise, perform afigure 2-4. A note of what management is Caesarean section.decided upon must also be made under the 5. If the patient cannot be deliveredheading ‘Management’ at the bottom of the immediately (i.e. there is another patientpartogram. in theatre) the dose of salbutamol can be repeated if contractions start again, but not2-32 What must be done if a fetal within 30 minutes of the first dose or if thebradycardia is observed? maternal pulse is 120 or more beats perFetal distress due to severe hypoxia is present! minutes.Therefore, you should immediately do the It is important that you know how to give fetalfollowing: resuscitation, as it is a life-saving procedure when fetal distress is present, both during the1. Exclude other possible causes of antepartum period and in labour. bradycardia, e.g. turn the woman onto her side to correct supine hypotension,
    • MONITORING THE CONDITION OF THE FETUS DURING THE FIRST STAGE OF LABOUR 31Always prepare to resuscitate the infant after distress may be present. If not, the fetus isbirth if fetal distress is diagnosed during labour. at high risk of distress. 2. There is a danger of meconium aspiration NOTE Salbutamol (a beta2 stimulant) can also at delivery. be given from an inhaler but this method is less effective than the parenteral administration. Give four puffs from a salbutamol inhale. This Meconium-stained liquor warns that either fetal can be repeated every 10 minutes until the distress is present or that there is a high risk of uterine contractions are reduced in frequency fetal distress. and duration, or the maternal pulse reaches 120 beats per minute. Uterine contractions can also be suppressed with nifedipine (Adalat). Nifedipine 2-37 How should you monitor the 30 mg is given by mouth (one capsule = 10 mg). fetus during the first stage of labour The three capsules must be swallowed and not if the liquor is meconium stained? used sublingually. This method is slower than using intravenous salbutamol and the uterine 1. Observe carefully for late decelerations. contractions will only be reduced after 20 minutes. If present, then fetal distress must be diagnosed. 2. If late decelerations are absent, thenTHE LIQUOR observe the fetal heart rate pattern carefully during labour as about a third of fetuses with meconium-stained liquor will2-34 Is the liquor commonly develop fetal distress.meconium-stained? 3. If electronic monitoring (CTG) is available,Yes, in 10–20% of patients the liquor is yellow the fetal heart rate pattern must beor green due to meconium staining. The carefully monitored.incidence of meconium-stained liquor isincreased in the group of women that go into 2-38 How must the delivery be managedlabour after 42 weeks gestation. if there is meconium in the liquor? 1. The infant’s mouth and pharynx must2-35 Is it important to distinguish be thoroughly suctioned after deliverybetween thick and thin, or yellow of the head but before the shouldersand green meconium? and chest are delivered, i.e. before theAlthough fetal and neonatal complications infant breathes. This must be doneare more common which thick meconium, irrespective of whether a vaginal deliveryall cases of meconium-stained liquor should or Caesarean section is done.be managed the same during the first stage 2. Anticipate that the infant may need to beof labour. The presence of meconium is resuscitated at delivery. If the infant criesimportant and the management does not or breathes well no further suctioning isdepend on the consistency of the meconium. needed. However if the infant does not cry well, suction the infant again before starting mask ventilation. If intubation is2-36 What is the importance of needed, suction via the endotracheal tubemeconium in the liquor? before starting ventilation.1. Meconium-stained liquor usually indicates the presence of fetal hypoxia or an episode 2-39 How and when are the of fetal hypoxia in the past. Therefore, fetal liquor findings recorded? Three symbols are used to record the liquor findings on the partogram:
    • 32 INTRAPAR TUM CAREI = Intact membranes (i.e. no liquor draining). late decelerations, labour may be allowed to continue. However, very careful observationC = Clear liquor draining. of the fetal heart rate pattern is essential,M = Meconium-stained liquor draining. especially if oxytocin is to be restarted. The fetal heart should be listened to every 15The findings are recorded in the appropriate minutes or fetal heart rate monitoring with aspace on the partogram as shown in figure 2-4. cardiotocograph should be started.The liquor findings should be recorded when:1. The membranes rupture.2. A vaginal examination is done. CASE STUDY 23. A change in the liquor findings is noticed, e.g. if the liquor becomes meconium A woman who is 38 weeks pregnant presents stained. with an antepartum haemorrhage in labour. On examination, her temperature is 36.8 °C, her pulse rate 116 beats per minute, herCASE STUDY 1 blood pressure 120/80 mm Hg, and there is tenderness over the uterus. The baselineA primigravida with inadequate uterine fetal heart rate is 166 beats per minute. Thecontractions during labour is being treated fetal heart rate drops to 130 beats per minutewith an oxytocin infusion. She now has during contractions and then only returns tofrequent contractions, each lasting more than the baseline 35 seconds after the contraction40 seconds. With the woman in the lateral has ended.position, listening to the fetal heart rate revealslate decelerations. 1. Which of the maternal observations are abnormal and what is the probable1. What worries you most cause of these abnormal findings?about this woman? A maternal tachycardia is present and there isThe late decelerations indicate that fetal uterine tenderness. These findings suggest andistress is present. abruptio placentae.2. Should the fetus be 2. Which fetal observations are abnormal?delivered immediately? Both the baseline tachycardia and the lateNo. Correctable causes of poor oxygenation of decelerations.the fetus must first be ruled out, e.g. posturalhypotension and overstimulation of the uterus 3. How can you be certain thatwith oxytocin. The oxytocin infusion must these are late decelerations?be stopped and oxygen administered to thewoman. Then the fetal heart rate should be Because the deceleration continues forchecked again. more than 30 seconds after the end of the contraction. This observation indicates fetal distress. The number of beats by which the3. After stopping the oxytocin the fetal heart slows during a deceleration is notuterine contractions are less frequent. important.No further decelerations of the fetalheart rate are observed. What furthermanagement does this patient need?As overstimulation of the uterus withoxytocin was the most likely cause of the
    • MONITORING THE CONDITION OF THE FETUS DURING THE FIRST STAGE OF LABOUR 334. Why should an abruptio 3. How would you decide whetherplacentae cause fetal distress? this fetus is distressed?Part of the placenta has been separated from By listening to the fetal heart rate. Latethe wall of the uterus by a retroplacental clot. decelerations or a baseline bradycardia willAs a result, the fetus has become hypoxic. indicate fetal distress. 4. How should the fetus be monitoredCASE STUDY 3 during the remainder of the labour? The fetal heart rate pattern must beDuring the first stage of labour a woman’s liquor determined carefully every 15 minutes in orderis noticed to have become stained with thin to diagnose fetal distress should this occur.green meconium. The fetal heart rate pattern isnormal and labour is progressing well. 5. What preparations should be made for the infant at delivery?1. What is the importance of thechange in the colour of the liquor? The infant’s mouth and pharynx must be well suctioned immediately after the head has beenMeconium in the liquor indicates an episode delivered. No further suctioning is neededof fetal hypoxia and suggests that there may be if the infant cries or breathes well. However,fetal distress or that the fetus is at high risk of if the infant does not breathe well directlyfetal distress. after delivery, suctioning should be repeated before mask ventilation is started. If the infant2. Can thin meconium be a is intubated, further suctioning of the largersign of fetal distress? airways via the endotracheal tube should beYes. All meconium in the liquor indicates either done before ventilation is started.fetal distress or that the fetus is at high risk offetal distress. The management does not dependon whether the meconium is thick or thin.
    • 3 Monitoring and management of the first stage of labourBefore you begin this unit, please take the THE DIAGNOSIScorresponding test at the end of the book toassess your knowledge of the subject matter. You OF LABOURshould redo the test after you’ve worked throughthe unit, to evaluate what you have learned 3-1 When is a woman in labour? A woman is in labour when she has both of the Objectives following: 1. Regular uterine contractions with at least When you have completed this unit you one contraction every 10 minutes. should be able to: 2. Cervical changes (i.e. cervical effacement • Monitor and manage the first stage of and/or dilatation) or rupture of the membranes. labour. • Evaluate accurately the progress of labour. THE TWO PHASES OF THE • Know the importance of the alert and FIRST STAGE OF LABOUR action lines on the partogram. • Recognise poor progress during the first The first stage of labour can be divided into stage of labour. two phases: • Systematically evaluate a woman 1. The latent phase. to determine the cause of the poor 2. The active phase. progress in labour. • Manage a woman with poor progress in The first stage of labour is divided into the latent labour. phase and the active phase. • Recognise women at increased risk of prolapse of the umbilical cord. • Manage a woman with cord prolapse.
    • MONITORING AND MANAGEMENT OF THE FIRST STAGE OF LABOUR 353-2 What do you understand by the latent MONITORING OF THEphase of the first stage of labour? FIRST STAGE OF LABOUR1. The latent phase starts with the onset of labour and ends when the patient’s cervix is 3 cm dilated. With primigravidas the 3-4 What do you understand by a complete cervix should also be fully effaced to physical examination during labour? indicate that the latent phase has ended. However, in a multigravida the cervix need 1. The routine observations (usually done not be fully effaced. hourly or half hourly) of the condition of2. During the latent phase, the cervix dilates the mother, the condition of the fetus, and slowly. Although no time limit need be set the contractions. for cervical dilatation, this phase does not 2. A careful abdominal examination. normally last longer than eight hours. The 3. A careful vaginal examination. time taken may vary widely. This examination is only complete when the3. During the latent phase there is a findings have been charted on the partogram. progressive increase in the duration and If the findings are abnormal, a plan must be the frequency of uterine contractions. made regarding the further management of the patient.3-3 What do you understand by theactive phase of the first stage of labour? 3-5 When should you do a complete physical1. This phase starts when the cervix is 3 cm examination on a woman in labour? dilated and ends when the cervix is fully 1. On admission. dilated. 2. During the latent phase: Four hours after2. During the active phase, more rapid admission or when the woman starts dilatation of the cervix occurs. to experience more painful, regular3. The cervix should dilate at a rate of at least contractions. 1 cm per hour. 3. During the active phase: Four hourly, provided all observations indicate that NOTE Cervical dilatation of 4 cm rather than 3 progress is normal. If there is poor cm is sometimes used to indicate progression progress, the next complete examination to the active phase of the first stage of labour. will usually have to be done after two hours.The average rate of dilatation of the cervixduring the active phase is at least 1.5 cm After the complete examination has been doneper hour in multigravidas and 1.2 cm in and an assessment made about the progressprimigravidas. However, the lower limit of of labour, a decision must be taken on whenthe normal rate of cervical dilatation is 1 cm the next complete examination should beper hour. done. The time of the next examination is marked on the partogram with an arrow. The next complete examination may, if the The cervix should dilate at a rate of at least 1 cm circumstances demand it, be done sooner, but per hour in the active phase of labour. not later than the time indicated. 3-6 How should progress during the first stage of labour be monitored? A partogram is used to monitor and record the progress of labour.
    • 36 INTRAPAR TUM CARE3-7 What is a partogram? for instrumental delivery and Caesarean section.A partogram is a chart on which the progress 2. The progress of labour is very slow whenof labour over time can be presented. You will the graph of cervical dilatation crossesnotice that provision has been made on the or falls on this line. When this occurs,chart to record all the important observations action must be taken in order to hasten theregarding the condition of the mother, the delivery of the infant.condition of the fetus, and the progress oflabour.An example of a partogram is shown in If the cervical dilatation falls on, or crosses, thefigure 3-1. action line of the partogram, a doctor must be called to assess the patient.3-8 What is the first oblique lineon the partogram called?The alert line. It represents a rate of cervical MANAGEMENT OF Adilatation of 1 cm per hour. PATIENT IN THE LATENT PHASE OF THE FIRST3-9 What is the importance of the alert line?The alert line represents the minimum progress STAGE OF LABOURin cervical dilatation which is acceptable duringthe active phase of the first stage of labour. 3-12 What is the initial management of a patient in the latent phase of labour?3-10 What is the second obliqueline on the partogram called? When a woman is admitted in early labour, and on examination everything is foundThis line is called the action line. This line to be normal, only routine observationsfollows the same slope as the alert line. The are done. The next complete examinationtwo lines are spaced four hours apart. is done four hours later, or sooner if the woman starts to experience more regular NOTE If the travelling time between a clinic or and painful contractions. She should eat and district hospital without Caesarean section drink normally, and should be encouraged to facilities and the next level of care is one hour or more, a transfer line can be drawn walk around. She need not be admitted to the two hours after the alert line. This measure labour ward. will allow for earlier transfer of patients and The latent phase of labour should not last provide one to two hours for travelling time. longer than eight hours.3-11 What is the importanceof the action line? The latent phase of labour should not last longer than eight hours.1. Any woman whose graph of the cervical dilatation falls on or crosses the action line, must have a complete examination 3-13 What should you do at the by the doctor. Her further management second complete examination? must be under the doctor’s supervision At this time, the following must be assessed. and direction. If a woman is not already in hospital, she will need to be transferred 1. The contractions: If the contractions have into a hospital where there are facilities stopped the woman is no longer in labour, and if the maternal and fetal conditions are
    • MONITORING AND MANAGEMENT OF THE FIRST STAGE OF LABOUR 37Figure 3-1: An example of a partogram
    • 38 INTRAPAR TUM CARE normal, she may be discharged. However, has been slow during the latent if the contractions have remained regular, phase, it may be necessary to rupture then you must assess the cervix. the membranes or to commence an2. The cervix: oxytocin infusion if she is HIV positive. • If the effacement and dilatation of the cervix have remained unchanged, the woman is probably not in true MANAGEMENT OF A labour. If she is experiencing painful PATIENT IN THE ACTIVE contractions, she should be given an analgesic, e.g. pethidine 100 mg and PHASE OF THE FIRST promethazine (Phenegan) 25 mg STAGE OF LABOUR or hydroxyzine (Aterax) 100 mg by intramuscular injection. Provided that When a woman is admitted in the active all other observations are normal, the phase of labour, she will probably be in next complete physical examination is normal labour. However, the possibility planned for four hours later. of cephalopelvic disproportion must be • If there has been progress in effacement considered, especially if she is unbooked. and/or dilatation of the cervix, the woman is in labour and, provided that 3-15 How do you manage a woman all other observations are normal, the who is in normal labour? next complete examination is planned for four hours later. If the cervix is 3 cm When the condition of the mother and the or more dilated, the patient has now condition of the fetus are normal, and there progressed to the active phase of the are no signs of cephalopelvic disproportion, first stage of labour. the next complete examination must be done four hours later. The cervical dilatation, in3-14 What should you do if a woman has centimetres, is recorded on the alert line ofnot progressed to the active phase of the partogram.labour within eight hours after admission? 3-16 What represents normal progress1. The contractions may have stopped, in during the active phase of the first which case the woman is not in labour. If stage of labour on the partogram? the membranes have not ruptured and if there is no indication to induce labour, the 1. The recording of cervical dilatation at the woman should be discharged. She should various vaginal examinations lie on or to return when labour starts again. the left of the alert line. In other words2. The woman may still be having regular cervical dilatation is at least 1 cm per hour. contractions. In this case, further 2. There also is progressive descent of the management depends upon the state of fetal head into the pelvis. This is detected the cervix: by assessing the amount of the fetal head • If there has been no progress in above the brim of the pelvis on abdominal effacement and/or dilatation of the examination. Descent of the head during cervix, the woman is probably not in the active phase of the first stage of labour labour. The responsible doctor should may, however, occur late, especially in see and assess her, in order to decide multigravidas. whether labour should be induced. • If there has been progressive effacement and/or dilatation of the cervix, the woman is in labour. If the progress
    • MONITORING AND MANAGEMENT OF THE FIRST STAGE OF LABOUR 39 the effectiveness of the measures taken to With normal progress during the active phase the correct the poor progress. recordings of cervical dilatation lie on or to the 3. If a woman’s cervix is more than 6 cm left of the alert line and there will be progressive dilated, the next complete examination descent of the fetal head. would normally be done when the cervix is expected to be fully dilated. However,3-17 Why is it necessary to evaluate both the examination may need to be donecervical dilatation and the descent of earlier if there are signs that the cervix isthe head in order to determine whether already fully dilated.there has been progress in the activephase of the first stage of labour? 3-19 When should you rupture the woman’s membranes?1. Cervical dilatation without associated descent of the head does not necessarily 1. It is possible to reduce the risk of indicate progress in labour. transferring HIV from a mother to her2. Cervical dilatation may occur when there infant by keeping the duration of ruptured are good contractions, in association with membranes as short as possible. Therefore increasing caput succedaneum formation do not rupture the membranes of women and moulding of the fetal skull, while whose HIV status is positive or unknown the amount of fetal head palpable above if the membranes are still intact at the start the brim of the pelvis remains the same. of the active phase of labour. The following In these circumstances no real progress vaginal examination will not increase the has occurred, because the head is not risk of infection if the membranes are descending into the pelvis. intact. The next complete examination3. The station of the presenting part of the should be done after two hours when the head in relation to the ischial spines, as felt management should be as follows: on vaginal examination, can also improve • With normal progress do not rupture without further descent of the head and the membranes. without real progress having occurred. • With poor progress the membranes This is because of increasing caput should be ruptured and the next succedaneum and moulding. examination performed four hours later. 2. A woman who is HIV negative and in Descent of the head is assessed on abdominal labour with a vertex presentation may have and not on vaginal examination. her membranes ruptured with safety if: • She is in the active phase of labour.3-18 What circumstances will make it • The fetal head is 3/5 or less palpablenecessary to do vaginal examinations above the brim of the pelvis.more frequently than four-hourly in the 3. After rupturing the membranes, carefullyactive phase of the first stage of labour? feel around the fetal head to rule out the possibility of a cord prolapse.1. If cephalopelvic disproportion is suspected, the next vaginal examination If the fetal head is 4/5 or more above the must be done two hours later. pelvic brim (the pelvic inlet), and the cervix2. If a complete examination has revealed is 6 cm or more dilated, it is safer to carefully poor progress of labour, without the rupture the membranes than to allow them presence of cephalopelvic disproportion, to rupture spontaneously. This will reduce the the next complete examination should risk of cord prolapse. also be done two hours later, to assess
    • 40 INTRAPAR TUM CARE3-20 What should you do if a 3-23 What should you do if the graph showswoman ruptures her membranes cervical dilatation crossing the alert line?spontaneously during labour? A systematic assessment of the patient must1. If the fetal head is 4/5 or more palpable be made in order to determine the cause of the above the pelvic brim, or if there is a poor progress in labour. breech presentation, the woman is at high risk for a cord prolapse. A sterile vaginal 3-24 How should you systematically examination must, therefore, be done to examine a woman with poor progress in rule out this possibility. the active phase of the first stage of labour?2. If the fetal head is 3/5 or less palpable above the pelvic brim, it is highly Step 1 unlikely that a cord prolapse might Firstly two questions must be asked: happen. However, the fetal heart must be auscultated to rule out the possibility of 1. Is the woman in the active phase of the first fetal distress due to cord compression. stage of labour? 2. Are the membranes ruptured?3-21 What are the advantages of If the answer to both questions is ‘yes’, proceedrupturing a woman’s membranes? to step 2.1. Rupture of the membranes acts as a When patients are HIV negative with stimulus to labour, so that there is often intact membranes, artificial rupture of the better progress. membranes should be done and a systematic2. Meconium staining of the liquor will be assessment again made after two hours. detected. When patients are HIV positive with3. If the cord prolapses when the membranes intact membranes and with at least three are ruptured, this can be detected contractions of 40 seconds (strong) or immediately, and the appropriate more per 10 minutes present, a systematic management can therefore be started assessment is again made after two hours. without delay. Without contractions oxytocin can be usedIt is important to make sure that the woman is carefully to augment the contractions and ain the active phase of the first stage of labour systematic assessment again made two hoursbefore rupturing the membranes. after strong contractions have been achieved. NOTE An alternative method with HIV positive patients would be to rupture membranes andPOOR PROGRESS IN THE assess after two hours. With normal progress aACTIVE PHASE OF THE delivery would be achieved within four hours of rupture of membranes. With no progressFIRST STAGE OF LABOUR present a Caesarean section could be done within four hours of rupture of membranes. The transmission rate of HIV is significantly lower3-22 How would you recognise poor if babies are born within four hours of ruptureprogress in the active phase of labour? of membranes compared to longer periods of labour with rupture of the membranes.Poor progress is present when the graph showscervical dilatation crossing the alert line. In Step 2other words, cervical dilatation in the active The cause of the poor progress of labour mustphase of the first stage of labour is less than be determined by examining the woman using1 cm per hour. the ‘Rule of the four Ps’. The four Ps are:
    • MONITORING AND MANAGEMENT OF THE FIRST STAGE OF LABOUR 411. The patient. 3-26 How may problems with the2. The powers. ‘powers’ cause poor progress of labour?3. The passenger. The ‘powers’ (i.e. the uterine contractions)4. The passage. may either be inadequate or ineffective. Any patient in whom labour progresses normally The cause of poor progress of the active phase has both adequate and effective contractions, of the first stage of labour is determined by irrespective of the duration and frequency of assessing the four Ps. contractions. 1. Inadequate uterine contractions: Inadequate3-25 How may problems with the ‘patient’ uterine contractions can be the cause ofcause poor progress of labour and how poor progress of labour. Such contractions:should these problems be managed? • Last less than 40 seconds, and/or • There are fewer than two contractionsAny of the following factors may interfere with per 10 minutes.the normal progress of labour. 2. Ineffective uterine contractions: The uterine1. The patient needs pain relief: Women who contractions may be adequate but not experience very painful contractions, effective, as poor progress can occur even especially if associated with excessive in the presence of apparently good, painful anxiety, may have poor progress of labour contractions (i.e. two or more in 10 minutes as a result. Pain relief, emotional support with each contraction lasting 40 seconds and reassurance can be of great value in or longer), without disproportion being speeding up the progress of labour. present (i.e. no moulding of the fetal skull).2. The patient has a full bladder: A full The problem of ineffective contractions bladder not only causes mechanical occurs only in primigravidas. Any woman obstruction, but also depresses uterine whose labour progresses normally must muscle activity. A woman must be have effective uterine contractions. encouraged to pass urine frequently but Dysfunctional uterine contractions are may need catheterisation, and sometimes diagnosed when the uterine contractions an indwelling catheter until after delivery. appear to be ineffective.3. The patient is dehydrated: Dehydration is recognised by the fact that the woman 3-27 How may problems with the is thirsty, has a dry mouth, passes small ‘passenger’ cause poor progress amounts of concentrated urine and may of labour and how should these have ketonuria. Dehydration must be problems be managed? corrected as it may be the cause of the poor progress. With good care during The cause of poor progress of labour may be labour the woman will not become due to a problem with the ‘passenger’ (i.e. dehydrated, because she can eat and drink the fetus). These problems can be identified during the latent phase of labour and by performing an abdominal examination take oral fluids during the active phase of followed by a vaginal examination. labour. If there is poor progress during On abdominal examination the following the active phase of labour, an intravenous problems causing poor progress may be infusion must be started. identified.
    • 42 INTRAPAR TUM CARE1. The lie of the fetus is abnormal: If the lie of 1. The presenting part is abnormal: Vertex (i.e. the fetus is transverse the woman will need occipital) presentation of the fetal head a Caesarean section. is the most favourable presentation for2. The presenting part of the fetus is abnormal: the normal progress of labour. With any With a breech presentation, the woman other presentation of the fetal head in early must be assessed by a doctor to decide labour (e.g. brow), there is no urgency whether a vaginal delivery will be possible to interfere, as the presentation may or whether a Caesarean section is required. become more favourable when the patient If the presentation is cephalic, the part is in established labour. However, in of the head which is presenting must established labour, if moulding is present be determined on vaginal examination. in any presentation other than a vertex, a Fetuses who present by the breech and Caesarean section will have to be done. who comply with the criteria for vaginal 2. The position of the fetal head in relation to delivery, are only delivered vaginally if the pelvis is abnormal: An occipito-anterior there is normal progress during the first (right or left) is the most favourable stage of labour. position for normal progress of labour.3. Size of the fetus: A large fetus (i.e. estimated Positions other than this (i.e. left or as 4 kg or more), with signs of cephalopelvic right occipito-posterior) will progress disproportion (i.e. 2+ or 3+ moulding) must more slowly. Labour can be allowed to be delivered by Caesarean section. continue provided there is progress, and4. There are two or more fetuses: Poor progress no progressive evidence of cephalopelvic may also occur in a woman with a multiple disproportion. The patient will also need pregnancy, usually due to inadequate adequate pain relief and an intravenous uterine contractions. infusion to prevent dehydration.5. The fetal head has not engaged: The number 3. Cephalopelvic disproportion is present: of fifths of the head palpable above the • The fetal head is examined for the pelvic brim must always be assessed: amount of caput succedaneum present. • Engagement has occurred only when Caput is not an accurate indicator of 2/5 or less of the head is palpable above disproportion as it can also be present the brim of the pelvis. In this case the in the absence of disproportion, for problem of cephalopelvic disproportion example, in a woman who bears down at the pelvic inlet is excluded. before the cervix is fully dilated. • With 3/5 or more of the head above the • The sutures are examined for pelvic brim, plus 2+ or 3+ moulding, moulding, which is the best indication a Caesarean section is indicated for of the presence of cephalopelvic cephalopelvic disproportion at the disproportion. 3+ of moulding is a pelvic inlet. definite sign of disproportion. In a vertex presentation, the sagittal suture is examined for moulding. The degree An abdominal examination, to assess the lie and of moulding of the sagittal suture is the presenting part of the fetus, as well as the recorded on the partogram. amount of fetal head palpable above the pelvic • Improvement in the station of the brim, must always be done before performing a presenting part (i.e. the level of the vaginal examination. presenting part relative to the ischial spines) is not a reliable method ofOn vaginal examination the following problems assessing progress in labour. Rather,causing poor progress may be identified. the descent and engagement of the fetal head must be determined on abdominal examination.
    • MONITORING AND MANAGEMENT OF THE FIRST STAGE OF LABOUR 43 3. If labour progresses satisfactorily following Improvement in the station of the presenting the action taken, labour is allowed to part of the fetal head, in relation to the ischial continue. However, if poor progress spines, is not a reliable method of assessing continues, or if the action line has been progress in the first stage of labour. reached or crossed, the woman must be examined by the responsible doctor who3-28 How may problems with the ‘passage’ must then decide on further management.cause poor progress in labour and how The following are examples of causes ofshould these problems be managed? poor progress in labour together with theirThe following problems with the ‘passage’ may management:cause poor progress in labour:1. The membranes are still intact: Should the Cause Action membranes still be intact, they must be Cephalopelvic Caesarean section ruptured and the patient reassessed after disproportion four hours before poor progress can be An anxious woman Reassurance and diagnosed. unable to cope analgesia2. The pelvis is small: A pelvic assessment with painful which shows a small pelvis, together with contractions 2+ or 3+ moulding of the fetal skull means Inadequate uterine An oxytocin infusion that there is cephalopelvic disproportion, contractions and is an indication for Caesarean section. Occipito-posterior Analgesia and an3-29 What are the two important position intravenous infusioncauses of poor progress of labour? Ineffective uterine Analgesia followed contractions by an oxytocin1. Cephalopelvic disproportion: This is a infusion dangerous condition if it is not recognised early and not correctly managed.2. Inadequate uterine action: This is a common cause of poor progress in CEPHALOPELVIC primigravidas. It can be easily corrected DISPROPORTION with an oxytocin infusion.3-30 What must be done after a woman has 3-31 How will you know when poor progressbeen systematically evaluated to determine is due to cephalopelvic disproportion?the cause of the poor progress of labour? This can be recognised by the following1. The nurse attending to the woman must findings: inform the doctor about the clinical 1. On abdominal examination, the fetal head findings. Together they must decide on the is not engaged in the pelvis. Remember, this cause of the slow progress and what action is diagnosed by finding 3/5 or more of the must be taken to correct this problem. head palpable above the brim of the pelvis.2. A decision must also be made as to when 2. On vaginal examination, there is severe the next complete examination of the moulding (i.e. 3+) of the fetal skull. Severe woman should be done. Usually this will moulding must always be regarded as be in two hours, but sometimes in four serious, as it confirms that cephalopelvic hours. This consultation may be done by disproportion is present. telephone and it is not necessary for the doctor to see the woman at this stage.
    • 44 INTRAPAR TUM CARECephalopelvic disproportion may already be 3-34 What should you do if youpresent when the patient is admitted. decide that the poor progress is due to cephalopelvic disproportion? A high fetal head (3/5 or more above the brim) 1. Once the diagnosis of cephalopelvic on abdominal examination, with 3+ moulding disproportion has been made, the infant on vaginal examination, indicates cephalopelvic must be delivered as soon as possible. This, disproportion. therefore, means that a Caesarean section will have to be done. 2. While the preparations for Caesarean3-32 Does a woman’s cervix always dilate section are being made, it is of value toat a rate slower than 1 cm per hour if both the mother and fetus to suppresscephalopelvic disproportion is present? uterine contractions. This is done by givingWhen there is cephalopelvic disproportion, the three nifedipine (Adalat) 10 mg capsulescervix usually dilates at a rate slower than 1 cm by mouth (a total of 30 mg) provided thatper hour, but the cervix may dilate normally, there are no contraindications.even though the fetal head remains highdue to cephalopelvic disproportion. This is a INADEQUATEdangerous situation as it may be incorrectlyconcluded that labour is progressing normally. UTERINE ACTION3-33 What features would make 3-35 What should you do if you decide thatyou diagnose cephalopelvic the poor progress is due to inadequatedisproportion when the fetal head or ineffective uterine contractions?is not descending into the pelvis? 1. Provided there are no contraindications,Often, especially in multiparous patients, the the woman must be given an oxytocinhead does not descend into the pelvis until late infusion in order to strengthen thein the active phase of the first stage of labour. contractions.However, when the head does not descend into 2. The woman’s progress is reassessed afterthe pelvis, you should look for possible causes: two hours.1. A malpresentation, e.g. a face or a brow 3. If cervical dilatation has proceeded at the presentation. rate of 1 cm per hour or more, progress2. Moulding (i.e. 2+ or 3+). has been satisfactory and labour isIf either of these are present, there is allowed to continue.cephalopelvic disproportion, and a Caesarean 4. If cervical dilatation has been slowersection should be done. than 1 cm per hour once the woman has adequate uterine contractions she mustOn the other hand, labour can be allowed to be reassessed by the responsible doctor.continue if: Cephalopelvic disproportion may be • There is no malpresentation. present. • There is no more than 1+ moulding. 5. If at this stage the woman is still in a • The maternal and fetal conditions are peripheral clinic, there should be enough good. time to refer her to hospital before the action line is crossed.The next complete physical examination must 6. Patients who complain of painfulbe repeated within two hours. contractions need analgesia before oxytocin is started.
    • MONITORING AND MANAGEMENT OF THE FIRST STAGE OF LABOUR 453-36 What are the contraindications to minute. The rate is increased in the samethe use of oxytocin in order to strengthen way as above until 30 drops per minutecontractions in the first stage of labour? are being given. This is the maximum amount of oxytocin which should be used1. Evidence of cephalopelvic disproportion. during the first stage of labour. Oxytocin must, therefore, not be given if there is already moulding (i.e. 2+ or 3+) NOTE The starting dose of oxytocin is ONE present. milliunit (mUnit) per minute and the maximum2. Any patient with a scar of the uterus, e.g. dose 12 mU per minute which is line with from a previous Caesarean section. international dose recommendations.3. Any patient with a fetus in whom the presenting part is not a vertex. 3-38 What are the effects of a long labour?4. Multiparas with poor progress during the active phase of labour of the first stage of Both the mother and fetus may be affected: labour. 1. The mother: A woman in whom the5. Grande multiparity during the latent or progress of labour is slow, is more likely to active phase of the first stage of labour. become anxious and to be dehydrated. If6. When there is fetal distress. the poor progress is due to cephalopelvic7. Patients with poor kidney function or disproportion (i.e. obstructed labour), and heart valve disease. labour is allowed to continue, then there isOxytocin has an antidiuretic effect, so that the danger that she may develop any or allthere is a danger of the patient developing of the following:pulmonary oedema. Hyperstimulation must • A ruptured uterus.be avoided if an oxytocin infusion is used. • A vesicovaginal fistula.Five or more contractions in 10 minutes or • A rectovaginal fistula.contractions lasting longer than 60 seconds 2. The fetus: A long labour can result inindicate hyperstimulation. progressive fetal hypoxia, resulting in fetal distress and eventually in intra-uterine death.3-37 How must oxytocin beadministered when it is usedduring the first stage of labour? THE REFERRAL OF WOMENThe following is a good method: WITH POOR PROGRESS1. Begin with one unit of oxytocin in one DURING THE ACTIVE litre of Plasmolyte B, Ringer’s lactate or rehydration fluid. PHASE OF THE FIRST2. Use a giving set which delivers 20 drops STAGE OF LABOUR per ml.3. Start with 15 drops per minute and The guidelines for referral will vary increase the rate at intervals of 30 minutes from region to region, depending on the to 30 drops, and then to 60 drops per distances between clinics and hospitals, minute, until the patient gets at least three and the availability of transport. In general, contractions lasting at least 40 seconds arrangements must be made so that the every 10 minutes. woman will be under the care of the4. If there are still inadequate contractions responsible doctor by the time the graph shows with one unit of oxytocin per litre at cervical dilatation crossing the action line. 60 drops per minute, a new litre of intravenous fluid containing eight units per litre is started at a rate of 15 drops per
    • 46 INTRAPAR TUM CARE3-39 What arrangements should This will prevent a cord prolapse when theyou make to ensure the woman’s membranes rupture.safety during transfer to hospital, ifthere is poor progress of labour? 3-43 Which women are at risk1. An intravenous infusion must be started. of a prolapsed cord?2. The woman must lie on her side while 1. Women in labour with an abnormal being transferred to hospital. lie (e.g. transverse lie) or an abnormal3. A nurse should accompany the woman, presentation (e.g. breech presentation). unless there is a trained ambulance crew. 2. Women who rupture their membranes4. If cephalopelvic disproportion is the when the fetal head is still not engaged (i.e. cause of the poor progress of labour, the 4/5 or more above the pelvic brim, e.g. in a contractions must be stopped. To stop grande multipara). contractions, three nifedipine (Adalat) 10 3. Women with polyhydramnios where the mg capsules per mouth (total of 30 mg) increased volume of liquor may wash the can be taken. cord out of the uterus. 4. Women in preterm labour where the presenting part is small relative to thePROLAPSE OF THE pelvis when the membranes rupture.UMBILICAL CORD 5. Women with a multiple pregnancy, where preterm labour, abnormal lie and polyhydramnios are common.3-40 Why is prolapse of the umbilicalcord a serious complication? 3-44 What should be done when aBecause the flow of blood between the fetus woman, who is at high risk of prolapseand placenta is severely reduced and may of the cord, ruptures her membranes?stop completely, causing fetal distress and A sterile vaginal examination mustpossibly fetal death. immediately be done to determine whether the cord has prolapsed.3-41 What is the difference between acord presentation and a cord prolapse? 3-45 What is the management1. With a cord presentation, the umbilical of a prolapsed cord? cord lies in front of the presenting part A vaginal examination must be done with the membranes still intact. immediately:2. With a cord prolapse, the cord lies in front of the presenting part and the membranes 1. If the cervix is 9 cm or more dilated and have ruptured. The loose cord may lie the fetal head is on the perineum, the between the presenting part of the fetus woman must bear down and the infant and the cervix, in the vagina or outside must be delivered as soon as possible. the vagina. 2. Otherwise the woman must be managed as follows: • Replace the cord into the vagina or3-42 How should a cord cover it with a warm, wet towel.presentation be managed? • Give the woman mask oxygen andIf the cord is felt between the membranes and three nifedipine (Adalat) 10 mgthe presenting part of the fetus, if the fetus capsules per mouth (total of 30 mg) tois alive and is viable and if the woman is in stop labour.labour, a Caesarean section must be done.
    • MONITORING AND MANAGEMENT OF THE FIRST STAGE OF LABOUR 47 • Put a Foley catheter into the woman’s of labour, due to poor uterine contractions, is bladder and fill the bladder with made and an oxytocin infusion is started to 500 ml saline. improve contractions. • If the full bladder does not lift the presenting part off the prolapsed cord, 1. Do you agree with the diagnosis the presenting part must be pushed up of poor progress of labour? by an assistant’s hand in the vagina, and by turning the patient into the The diagnosis is incorrect as the woman is still knee-chest position in the latent phase of the first stage of labour. Poor progress of labour can only be diagnosed in the active phase of labour.3-46 Why should the cord be replaced inthe vagina or be covered by a warm towel? 2. Why can it be said with certainty that theThe cord must not be allowed to become woman is in the latent phase of labour?cold or dry as this will produce vasospasmand, thereby, further reduce the blood flow • The cervix is still less than 3 cm dilated.through the cord. • The cervix is dilating slowly. • The cervix is effacing. • The frequency of the uterine3-47 Why are oxygen and nifedipine given contractions is increasing.to a patient with a prolapsed cord?1. Giving oxygen to the woman may improve 3. What is your assessment of the oxygen supply to the fetus. the woman’s management?2. Stopping uterine contractions will reduce the pressure of the presenting part on the Apart from the wrong diagnosis, oxytocin prolapsed cord. should not be given before the membranes have been ruptured.3-48 Should a Caesarean section be doneon all women with a prolapsed cord if the 4. Should the woman’s membranesinfant cannot be rapidly delivered vaginally? have been artificially ruptured when the second vaginal examination was done?No. A Caesarean section is only done if theinfant is potentially viable (28 weeks or more) No. If the maternal and fetal condition areand the cord is still pulsating. Otherwise the good, you should wait until the cervix is 3 cminfant should be delivered vaginally as the or more dilated. The membranes may also bechances of survival are then extremely small. ruptured if the woman has been in the latent phase of labour for eight hours without any progress.CASE STUDY 1A primigravida woman at term, who is HIV CASE STUDY 2negative, is admitted to the labour ward. She hasone contraction, lasting 30 seconds, every 10 A woman at term is admitted in labour with aminutes. Her cervix is 1 cm dilated and 1.5 cm vertex presentation. The cervix is already 4 cmlong. The maternal and fetal observations are dilated. The cervical dilatation is recorded onnormal. After four hours she is having two the alert line. At the next vaginal examinationcontractions, each lasting 40 seconds, every 10 the cervix has dilated to 8 cm. Caput can beminutes. On vaginal examination her cervix is palpated over the fetal skull. It is decided thatnow 2 cm dilated and 0.5 cm long with bulging the progress is favourable and that the nextmembranes. The diagnosis of poor progress
    • 48 INTRAPAR TUM CAREvaginal examination should be done after a normal then the examination should also befurther four hours. repeated in two hours.1. On admission, should thewoman’s cervical dilatation have CASE STUDY 3been entered on the alert line?Yes. The patient is in the active phase of the A primigravida woman at term is admitted infirst stage of labour as her cervix is 4 cm labour. At the first examination the fetal headdilated. Therefore, the cervical dilatation was is 2/5 above the pelvic brim and the cervix iscorrectly plotted on the alert line. The future 6 cm dilated. Three contractions in 10 minutes,observations should fall on or to the left of each lasting 45 seconds, are palpated. At thethe alert line. next examination four hours later, the head is still 2/5 above the brim and the cervix is still 6 cm dilated. No moulding can be felt.2. Do the findings of the second The woman is still having three contractionsexamination indicate normal in 10 minutes, each lasting 45 seconds andprogress of labour? complains that the contractions are painful.Not necessarily, as no information is given Because there has been no progress in spiteabout the amount of fetal head palpable above of painful contractions of adequate frequencythe pelvic brim. Cervical dilatation without and duration, it is decided that cephalopelvicdescent of the head does not always indicate disproportion is present and that, therefore, anormal progress of labour. Caesarean section must be done.3. Is normal cervical dilatation with 1. Do you agree that the poorimprovement in the station of the progress of labour is due topresenting part possible if cephalopelvic cephalopelvic disproportion?disproportion is present? No. To diagnose poor progress due toYes. The uterine contractions cause an cephalopelvic disproportion, severe mouldingincreasing amount of caput and moulding, (3+) must be present.which is incorrectly interpreted as normalprogress of labour. In this case, caput was 2. What is most probably the reasonnoted during the second examination. for the poor progress of labour?However, further information about anymoulding and the amount of fetal head The patient is a primigravida with strong,palpable above the pelvic brim are essential painful contractions and no signs ofbefore it can be decided whether normal cephalopelvic disproportion. A diagnosis ofprogress is present or not. ineffective uterine contractions (dysfunctional uterine contractions) can, therefore, be made with confidence.4. Was the correct decision made at thetime of the second examination to repeatthe vaginal examination after four hours? 3. What should be the management of the woman’s poor progress of labour?No. If the cervix is 8 cm dilated, the nextexamination must be done two hours later, Firstly, the woman should be reassuredor even sooner if there are indications that and given analgesia with pethidine andthe woman’s cervix is fully dilated. If it is promethazine (Phenegan) or hydroxyzineuncertain whether the progress of labour is (Aterax). Then an oxytocin infusion should be started to make the contractions more effective.
    • MONITORING AND MANAGEMENT OF THE FIRST STAGE OF LABOUR 494. Why is reassuring the 1. Was the woman managed correctlywoman so important? when she crossed the alert line?Anxious patients often progress slowly Yes. She was systematically examined and ain labour and have painful contractions. diagnosis of slow progress of labour due to anEmotional support during labour is a very occipito-posterior position was made.important part of patient care. 2. What should be done if a long first5. When must the next vaginal stage of labour is expected due toexamination be done? an occipito-posterior position?The next vaginal examination should be An intravenous infusion must be started todone two hours later to determine whether ensure that the woman does not becomethe treatment has been effective. During the dehydrated. In addition, adequate analgesiaexamination it is very important to exclude must be given.cephalopelvic disproportion. 3. Was the woman correctly managed when she reached the action line?CASE STUDY 4 No. A doctor should have evaluated the woman. Further management should haveA woman who is in labour at term has been under his/her direction.progressed slowly and the alert line has beencrossed. During a systematic evaluation by 4. Under what conditions should thethe midwife for poor progress of labour, a doctor allow labour to progress further?diagnosis of an occipito-posterior positionis made. As the woman is making some If there is steady progress of labour, if theprogress, she decides to allow labour to maternal and fetal conditions are good, andcontinue. After four hours the cervical there is less than 3+ moulding.dilatation falls on the action line. Althoughthere is still slow progress, she again decidesto allow labour to continue and to repeat thevaginal examination in a further two hours.
    • 3A Skills workshop: Examination of the abdomen in labour B. What should be assessed on Objectives examination of the abdomen of a woman who is in labour? When you have completed this skills 1. The shape of the abdomen. 2. The height of the fundus. workshop you should be able to: 3. The size of the fetus. • Assess the size of the fetus. 4. The lie of the fetus. • Determine the fetal lie and presentation. 5. The presentation of the fetus • Determine the descent of the head. 6. The descent and engagement of the head. • Grade the uterine contractions. 7. The presence or absence of hardness and tenderness of the uterus. 8. The contractions. 9. Fetal heart rate pattern.ABDOMINAL PALPITATION C. Shape of the abdomenA. When should you examine the It is helpful to look at the shape and contour ofabdomen of a woman who is in labour? the abdomen.The abdominal examination forms an 1. The shape of the uterus will be oval with aimportant part of every complete physical singleton pregnancy and a longitudinal lie.examination in labour. The examination is 2. The shape of the uterus will be round withdone: a multiple pregnancy or polyhydramnios.1. On admission. 3. A ‘flattened’ lower abdomen suggests2. Before every vaginal examination. a vertex presentation with an occipito-3. At any other time when it is considered posterior position (ROP or LOP). necessary. 4. A suprapubic bulge suggests a full bladder.
    • SK ILLS WORKSHOP : EXAMINATION OF THE ABDOMEN IN LABOUR 51Figure 3A-1: Vertex, face and brow presentationsD. Height of the fundus whether a vaginal delivery is possible. With breech presentation, there is an increased riskIt is important to ask yourself whether the of cord prolapse or a placenta praevia.height of the fundus is in keeping with thewoman’s dates and the findings at previousantenatal attendances. G. Cephalic presentation of the fetus If the presentation is cephalic, it is sometimesE. Size of the fetus possible when palpating the abdomen to determine the presenting part of the fetalIt is important, on palpation, to assess the size head (vertex, face or brow). Figure 3A-1of the fetus. This is best done by feeling the indicates some features that can assist you insize of the fetal head. Is the size of the fetus in determining the presentation.keeping with the woman’s dates and the sizeof the uterus? A fetus which feels smaller thanexpected is likely to be associated with: H. Descent and engagement of the head1. Incorrect dates. This assessment is an essential part of every2. Intra-uterine growth restriction. examination of a woman in labour. The3. Multiple pregnancy. descent and engagement of the head is an important part of assessing the progress of labour and must be assessed before eachF. Lie and presentation of the fetus vaginal examination.It is important to know whether the lie is The amount of descent and engagement oflongitudinal (cephalic or breech presentation), the head is assessed by feeling how manyoblique, or transverse. The normal lie is fifths of the head are palpable above the brimlongitudinal. With an abnormal lie, there is of the pelvis:an increased risk of umbilical cord prolapse.An abnormal lie may suggest that there is a 1. 5/5 of the head palpable mean that themultiple pregnancy or a placenta praevia. whole head is above the brim of the pelvis. 2. 4/5 of the head palpable means that a smallIt is also important to know the presentation part of the head is below the brim of theof the fetus. The normal presentation is pelvis and can be lifted out of the pelviscephalic (fetal head presentation). If a breech with the deep pelvic grip.presentation is present, it must be decided
    • 52 INTRAPAR TUM CAREFigure 3A-2: An accurate method of determining the amount of head palpable above the brim of the pelvis3. 3/5 of the head palpable means that the NOTE Another method that could be used to head cannot be lifted out of the pelvis. On determine the amount of fetal head above the doing the deep pelvic grip, your fingers pelvis is to assess the number of fingers that will move outwards from the neck of the could be placed on the remaining fetal head above the pelvic brim, i.e. three fingers indicate fetus, then inwards before reaching the that the fetal head is 3/5 above pelvic brim. pelvic brim.4. 2/5 of the head palpable means that most of the head is below the pelvic brim, and Descent and engagement of the head are assessed on doing the deep pelvic grip, your fingers on abdominal and not on vaginal examination. only splay outwards from the fetal neck to the pelvic brim.5. 1/5 of the head palpable means that only I. Hardness and tenderness of the uterus the tip of the fetal head can be felt above A uterus may be regarded as abnormally hard: the pelvic brim. 1. When it is difficult to palpate fetal parts.It is very important to be able to distinguish 2. When the uterus feels harder than usual.between 3/5 and 2/5 head palpable above the This may occur:pelvic brim. If only 2/5 of the head is palpable,then engagement has taken place and the 1. In some primigravidas.possibility of disproportion at the pelvic inlet 2. During a contraction.can be ruled out. The head is still unengaged if 3. When there has been an abruptio placentae.3/5 head is palpable above the pelvic brim. 4. When the uterus has ruptured.
    • SK ILLS WORKSHOP : EXAMINATION OF THE ABDOMEN IN LABOUR 53Figure 3A-3: Method of grading the duration of uterine contractions for recording on the partogramWhen there is both hardness and tenderness of K. Grading the duration of contractionsthe uterus, without period of relaxation during 1. Contractions lasting less than 20 secondswhich the uterus is not tender, the commonest (‘weak contractions’).causes are: 2. Contractions lasting 20–40 seconds1. An abruptio placentae. (‘moderate contractions’)2. A ruptured uterus. 3. Contractions lasting more than 40 seconds (‘strong contractions’).Therefore, there is likely to be a serious problemif the uterus is harder than normal and there isalso tenderness without periods of relaxation. L. Grading the frequencyHardness or tenderness of the uterus must duration of contractionsbe recorded on the partogram and the most The frequency of contractions is assessed byexperienced person called to assess the woman. counting the number of contractions that occur in a period of 10 minutesASSESSINGCONTRACTIONS ASSESSING THE FETAL HEART RATEJ. ContractionsContractions can be felt by placing a hand M. Fetal heart rate patternon the abdomen and feeling when the uterus The fetal heart must be detected and the fetalbecomes hard, and when it relaxes. It is, heart rate pattern assessed and recorded everytherefore, possible to assess the length of time the abdomen is examined in labour.the contractions by taking the time at thebeginning and end of the contraction. Thestrength of each contraction is assessed bymeasuring the duration of the contraction.
    • 3B Skills workshop: Vaginal examination in labour 4. A suitable instrument for rupturing the Objectives membranes. 5. An antiseptic vaginal cream or sterile lubricant. When you have completed this skills An ordinary surgical glove can be used and workshop you should be able to: the woman does not need to be swabbed if the • Perform a complete vaginal examination membranes have not ruptured yet and are not during labour. going to be ruptured during the examination. • Assess the state of the cervix. • Assess the presenting part. B. Preparation of the woman for • Assess the size of the pelvis. a sterile vaginal examination 1. Explain to the woman what examination is to be done, and why it is going to be done.PREPARATION FOR A 2. The woman needs to know that it will be an uncomfortable examination, andVAGINAL EXAMINATION sometimes even a little painful.IN LABOUR 3. The woman should lie on her back, with her legs flexed and knees apart. Do not expose the woman until you are ready to examineA. Equipment that should be available her. It is sometimes necessary to examinefor a sterile vaginal examination the woman in the lithotomy position. 4. The woman’s vulva and perineum areA vaginal examination in labour is a sterile swabbed with tap water. This is done byprocedure if the membranes have ruptured first swabbing the labia majora and groinor are going to be ruptured during the on both sides and then swabbing theexamination. Therefore, a sterile tray is introitus while keeping the labia majoraneeded. The basic necessities are: apart with your thumb and forefinger.1. Swabs.2. Tap water for swabbing.3. Sterile gloves.
    • SK ILLS WORKSHOP : VAGINAL EXAMINATION IN LABOUR 55C. Preparation needed by the examiner • Presentation or prolapse of the umbilical cord.1. The person to do the vaginal examination 3. A speculum examination, NOT a digital must have either scrubbed or thoroughly examination, must be done if it is thought washed his/her hands. that the woman has preterm or prelabour2. Sterile gloves must be worn. rupture of the membranes.3. The examiner must think about the findings, and their significance for the woman and the management of her labour. THE CERVIXPROCEDURE OF When you examine the cervix you should observe:EXAMINATION 1. Length. 2. Dilatation.A vaginal examination in labour is asystematic examination, and the followingshould be assessed: E. Measuring cervical length1. Vulva and vagina. The cervix becomes progressively shorter2. Cervix. in early labour. The length of the cervix is3. Membranes. measured by assessing the length of the4. Liquor. endocervical canal. This is the distance5. Presenting part. between the internal os and the external os6. Pelvis. on digital examination. The endocervical canal of an uneffaced cervix is approximatelyAlways examine the abdominal before 3 cm long, but when the cervix is fully effacedperforming a vaginal examination in labour. there will be no endocervical canal, only a ring of thin cervix. The length of the cervix is An abdominal examination should always be measured in centimetres. In the past the term ‘cervical effacement’ was used and this was done before a vaginal examination. measured as a percentage. F. DilatationTHE VULVA AND VAGINA Dilatation must be assessed in centimetres, and is best measured by comparing theD. Important aspects of the degree of separation of the fingers on vaginalexamination of the vulva and vagina examination, with the set of circles in the labour ward. In assessing the dilatation of theThis examination is particularly important cervix, it is easy to make two mistakes:when the woman is first admitted: 1. If the cervix is very thin, it may be difficult1. When you examine the vulva you should to feel, and the woman may be said to be look for ulceration, condylomata, varices fully dilated, when in fact she is not. and any perineal scarring or rigidity. 2. When feeling the rim of the cervix, it2. When you examine the vagina, the is easy to stretch it, or pass the fingers presence or absence of the following through the cervix and feel the rim with features should be noted: the side of the fingers. Both of these • A vaginal discharge. methods cause the recording of dilatation • A full rectum. to be more than it really is. The correct • A vaginal stricture or septum.
    • 56 INTRAPAR TUM CARE Correct IncorrectFigure 3B-1: The correct method of measuring cervical dilatation method is to place the tips of the fingers on cord may prolapse. However, it is better the edges of the cervix. for the cord to prolapse while the hand of the examiner is in the vagina, when it can be detected immediately,THE MEMBRANES than to have the cord prolapse withAND LIQUOR spontaneous rupture of the membranes while the woman is unattended. • HIV positive patients should not haveG. Assessment of the membranes their membranes ruptured unless there is poor progress of labour.Rupture of the membranes may be obvious if 2. What is the condition of the liquor whenthere is liquor draining. However, one should the membranes rupture?always feel for the presence of membranesoverlying the presenting part. If the presenting The presence of meconium may change thepart is high, it is usually quite easy to feel management of the patient as it indicates thatintact membranes. It may be difficult to feel fetal distress has been and may still be present.them if the presenting part is well applied tothe cervix. In this case, one should wait for acontraction, when some liquor often comes THE PRESENTING PARTin front of the presenting part, allowing themembranes to be felt. Sometimes the umbilical An abdominal examination must havecord can be felt in front of the presenting part been done before the vaginal examination(a cord presentation). to determine the lie of the fetus and theIf the membranes are intact, the following two presenting part. If the presenting part is thequestions should be asked: fetal head, the number of fifths palpable above the pelvic brim must first be determined.1. Should the membranes be ruptured? • In most instances, if the woman is When palpating the presenting part on in the active phase of labour, the vaginal examination, there are four important membranes should be ruptured. questions that you must ask yourself: • When the presenting part is high, there is always the danger that the umbilical
    • SK ILLS WORKSHOP : VAGINAL EXAMINATION IN LABOUR 571. What is the presenting part, e.g. head, part is the head. However, on vaginal breech or shoulder? examination:2. If the head is presenting, what is the • Instead of a firm skull, something soft presentation, e.g. vertex, brow or face is felt. presentation? • The gum margins distinguish the3. What is the position of the presenting part mouth from the anus. in relation to the mother’s pelvis? • The cheek bones and the mouth form a4. If the presentation is vertex, is moulding triangle. present? • The orbital ridges above the eyes can be felt.H. Assessing the presenting part • The ears may be felt. 3. Features of a brow presentation. TheThe presenting part is usually the head but presenting part is high. The anteriormay be the breech, the arm, or the shoulder. fontanelle felt is on one side of the pelvis,1. Features of an occiput presentation. The the root of the nose on the other side, andFigure 3B-2: Features of an occiput presentation Figure 3B-4: Features of a brow presentation posterior fontanelle is normally felt. It is the orbital ridges may be felt laterally. a small triangular space. In contrast, the If the presenting part is not the head, it could anterior fontanelle is diamond shaped. If the be either a breech or a shoulder. head is well flexed, the anterior fontanelle will not be felt. If the anterior fontanelle can 4. Features of a breech presentation. On be easily felt, the head is deflexed. abdominal examination the presenting2. Features of a face presentation. On part is the breech (soft and triangular). On abdominal examination the presenting vaginal examination:Figure 3B-3: Features of a face presentation Figure 3B-5: Features of a breech presentation
    • 58 INTRAPAR TUM CARE Left occipito-anterior (LOA) Right occipito-posterior (ROP) Left mento-anterior (LMA) Left sacro-posterior (LSP)Figure 3B-6: Examples of the position of the presenting part with the patient lying on her back • Instead of a firm skull, something soft I. Determining the position is felt. of the presenting part • The anus does not have gum margins. Position means the relationship of a fixed • The anus and the ischial tuberosities point on the presenting part (i.e. the point of form a straight line. reference or the denominator) to the mother’s5. Features of a shoulder presentation. On pelvis. The position is determined on vaginal abdominal examination the lie will examination. be transverse or oblique. Features of a shoulder presentation on vaginal The point of reference (or denominator) is: examination will be quite easy if the arm 1. In a vertex presentation the point of has prolapsed. The shoulder is not always reference is the posterior fontanelle (i.e. the that easy to identify, unless the arm can be occiput). felt. The presenting part is usually high. 2. In a face presentation the point of reference is the chin (i.e. the mentum).
    • SK ILLS WORKSHOP : VAGINAL EXAMINATION IN LABOUR 59Figure 3B-7: Lateral view of the pelvis, showing the examining fingers just reaching the sacral promontory Normal pelvis Abnormal pelvisFigure 3B-8: The brim of the pelvis.3. In a breech presentation the point of J. Determining the descent and reference is the sacrum of the fetus. engagement of the headFor example, if the posterior fontanelle (i.e. the Descent and engagement of the head isfetal occiput) in a vertex presentation points assessed on abdominal and not on vaginalupwards (anterior) and towards the mother’s examination.left side the position of the presenting part iscalled a left occipito-anterior position.
    • 60 INTRAPAR TUM CARE Symphysis pubis Sacrum Ischeal tuberosity Coccyx – not palpableFigure 3B-9: The pelvic outletMOULDING L. Grading the degree of moulding The sagittal suture is palpated and theMoulding is the overlapping of the fetal skull relationship or closeness of the two adjacentbones at a suture which may occur during patietal bones assessed. The amount oflabour due to the head being compressed as it moulding recorded on the partogram shouldpasses through the pelvis of the mother. be the most severe degree found in any of the sutures palpated.K. The diagnosis of moulding The degree of moulding is assessed accordingIn a cephalic (head) presentation, moulding is to the following scale:diagnosed by feeling overlapping of the sagittal 0 = Normal separation of the bones with opensuture of the skull on vaginal examination, sutures.and assessing whether or not the overlap canbe reduced (corrected) by pressing gently with 1+ = Bones touching each other.the examining finger. 2+ = Bones overlapping, but can be separatedThe presence of caput succedaneum can also with gentle digital pressure.be felt as a soft, boggy swelling, which may 3+ = Bones overlapping, but cannot bemake it difficult to identify the presenting part separated with gentle digital pressure.of the fetal head clearly. With severe caput thesutures may be impossible to feel. 3+ is regarded as severe moulding. M. Assessing the pelvis When assessing the pelvis on vaginal examination, the size and shape of the pelvic
    • SK ILLS WORKSHOP : VAGINAL EXAMINATION IN LABOUR 61inlet, the mid-pelvis and the pelvic outlet must they are 3 cm or longer) and the spines arebe determined. small and round. 2. A small pelvis: The ligaments allow less1. To assess the size of the pelvic inlet, the than two fingers long and the spines are sacral promontory and the retropubic area prominent and sharp. are palpated.2. To assess the size of the mid-pelvis, the Step 3. Retropubic area curve of the sacrum, the sacrospinous Put two examining fingers, with the palm ligaments and the ischial spines are of the hand facing upwards, behind the palpated. symphysis pubis and then move them laterally3. To assess the size of the pelvic outlet, the to both sides: subpubic angle, intertuberous diameter and mobility of the coccyx are determined. 1. An adequate pelvis: The retropubic area is flat.It is important to use a step-by-step method to 2. A small pelvis: The retropubic area isassess the pelvis. angulated.Step 1. The sacrum Step 4. The subpubic angle and intertuberousStart with the sacral promontory and follow diameterthe curve of the sacrum down the midline. To measure the subpubic angle, the examining1. An adequate pelvis: The promontory fingers are turned so that the palm of the cannot be easily palpated, the sacrum is hand faces upward, a third finger is held at the well curved and the coccyx cannot be felt. entrance of the vagina (introitus) and the angle2. A small pelvis: The promontory is easily under the pubis felt. The intertuberous diameter palpated and prominent, the sacrum is is measured with the knuckles of a closed fist straight and the coccyx is prominent and/ placed between the ischial tuberosities. or fixed. 1. An adequate pelvis: The subpubic angleStep 2. The ischial spines and sacrospinous allows three fingers (i.e. an angle of aboutligaments 90 degrees) and the intertuberous diameter allows four knuckles.Lateral to the midsacrum, the sacrospinous 2. A small pelvis: The subpubic angle allowsligaments can be felt. If these ligaments are only two fingers (i.e. an angle of aboutfollowed laterally, the ischial spines can be 60 degrees) and the intertuberous diameterpalpated. allows only three knuckles.1. An adequate pelvis: Two fingers can be placed on the sacrospinous ligaments (i.e.
    • 3C Skills workshop: Recording observations on the partogram RECORDING THE Objectives CONDITION OF When you have completed this skills THE MOTHER workshop you should be able to: • Record and assess the condition of the A. Recording the blood pressure, mother. pulse and temperature • Record and assess the condition of the The maternal blood pressure, pulse and fetus. temperature should be recorded on the • Record and assess the progress of labour. partogram. B. Recording the urinary dataTHE PARTOGRAM 1. Volume is recorded in ml. 2. Protein is recorded as 0 to 4+.The condition of the mother, the condition 3. Ketones are recorded as 0 to 4+.of the fetus, and the progress of labour arerecorded on the partogram. RECORDING THE CONDITION OF THE FETUS C. Recording the fetal heart rate pattern The following two observations must be recorded on the partogram:
    • SK ILLS WORKSHOP : RECORDING OBSER VATIONS ON THE PAR TOGRAM 63Figure 3C-1: An example of a partogram
    • 64 INTRAPAR TUM CARE Time 06:00 10:00 Blood pressure 110/70 130/80 Pulse 70/min 90/min Temp 37 °C 37.1 °C Volume 175 ml 150 ml Protein None None Ketones None + Glucose None None Blood None ++Figure 3C-2: Recording maternal blood pressure, pulse, temperature and urine results on the partogram LIQUOR: C = Clear liquor M = Meconium-stained liqourFigure 3C-3: Recording the fetal heart rate pattern and the liquor findings on the partogram1. The baseline heart rate. RECORDING THE2. The presence or absence of decelerations. If decelerations are present, you must record PROGRESS OF LABOUR whether they are early or late decelerations. F. Recording the cervical dilatationD. Recording the liquor findings Cervical dilatation is measured in cm and thenThree symbols are used: recorded by marking an ‘X’ on the partogram.I = Intact membranes.C = Clear liquor draining. G. Recording the length of the cervixM = Meconium-stained liquor draining. The length of the cervix (effacement) is recorded by drawing a thick, vertical line on the same part of the chart that is used for theE. How often should you record cervical dilatation. The length of the line drawnthe liquor findings? indicates the length of the endocervical canalThe recordings should be made: in cm. It is drawn on the chart whenever the1. At the time of each vaginal examination. cervical dilatation is recorded. Alternatively, the2. Whenever a change in the liquor is noted, length of the endocervical canal, measured in e.g. when the membranes rupture or if the cm or mm, can be noted in the space provided. woman starts to drain meconium-stained liquor after having had clear liquor before.
    • SK ILLS WORKSHOP : RECORDING OBSER VATIONS ON THE PAR TOGRAM 65 Time 06:00 10:00 14:00 Dilatation 2 cm 4 cm 6 cm Length 2 cm 5 mm 2 mm Head above brim 4/5 3/5 2/5 Position ROP ROP ROP Moulding no no + Note: Transfer of recordings on chart from latent to active phase at 10:00.Figure 3C-4: Recording the cervical dilatation, cervical length, the amount of fetal head above the brim,position of the head and moulding on the partogram 06:00 1 weak contractions in 10 minutes 08:00 2 moderate contractions in 10 minutes 10:00 3 strong contractions in 10 minutes An infusion of one unit of oxytocin in one litre at 15 drops per minute is being administered from nine hours and at 30 drops per minute from 10 hours.Figure 3C-5: Recording the duration and frequency of contractions on the partogramH. Recording the amount of the contractions last less than 20 seconds (i.e.head palpable above the brim of the weak contractions), the block is striped if thepelvis (descent and engagement) contractions last between 20 and 40 seconds (i.e. moderate contractions) and the block isThe findings are recorded by marking an ‘O’ coloured-in completely if the contractionson the partogram. last more than 40 seconds each (i.e. strong contractions).I. Recording the position of the fetal headThe position of the fetal head is recorded L. Recording the frequency of contractionsby marking the ‘O’ with fontanelles and the The number of contractions occurring in 10sagittal suture. Alternatively, the position can minutes is recorded by marking off one blockbe noted (e.g. ROA) in the space provided. for each contraction, e.g. two blocks markedThis is recorded at every vaginal examination. off equals two contractions in 10 minutes, four blocks marked off equals four contractionsJ. Recording moulding of the fetal head in 10 minutes, and five blocks if five or moreThe degree of sagittal moulding (i.e. 0 to 3+) is contractions in 10 minutes.also recorded on the partogram. M. Recording drugs and intravenousK. Recording the duration of contractions fluid given during labourThe duration of contractions is also recorded In the space provided on the partogram youon the partogram. The block is stippled if the should record:
    • 66 INTRAPAR TUM CAREFigure 3C-6: Documenting medication, assessment, management and time on the partogram1. The name of the drug. observation is recorded, medication is given, an2. The dose of the drug given. assessment is made or management is altered.3. The time the drug was given.4. The type of intravenous fluid.5. The time the intravenous fluid was started. EXERCISES ON THE6. The rate of intravenous fluid administration. CORRECT USE OF7. The amount of intravenous fluid given THE PARTOGRAM (after completion). Only the information given in the cases willN. Assessment and management be shown on the partogram. In practice, allAfter each examination an assessment must the appropriate spaces on the partogrambe made and recorded on the partogram. All must be filled in.management in labour must also be recordedon the partogram. CASE STUDY 1O. Recording the time on the partogram A primigravida at term is admitted to aThe time, to the nearest half hour, should also primary care perinatal clinic at 06:00 withbe entered on the partogram whenever an a history of painful contractions for several hours. The maternal and fetal conditions are
    • SK ILLS WORKSHOP : RECORDING OBSER VATIONS ON THE PAR TOGRAM 67satisfactory. On abdominal examination a between 30 seconds each, are noted. Onsingle fetus with a longitudinal lie is found. vaginal examination the cervix is 2 mm longThe presenting part is the fetal head, and 4/5 and 5 cm dilated. The head is in the rightis palpable above the brim of the pelvis. Two occipito-anterior position. The membranescontractions in 10 minutes, each lasting 15 are artificially ruptured and the liquor isseconds are noted. On vaginal examination the found to be clear.cervix is 1 cm long and 2 cm dilated. The fetalhead is in the right occipito-lateral position. 4. Is the woman still in the latent phase of labour?1. Is the woman in active labour? No. The cervix is more than 3 cm dilated.No. The cervix is less than 3 cm dilated. Therefore she in the active phase of labour.Thefore the woman is still in the latent phaseof labour. 5. Where should you enter the findings obtained at 10:00?2. How should you enter your The findings must be entered on the latentfindings on the partogram? phase part of the partogram, four hours toAs the woman is still in the latent phase of the right of the findings at 06:00. However,labour, the descent and amount of fetal head as the woman is now in active labour, thispalpable above the brim, the presenting part information must then be transferred to theand the position of the head, the length and active phase part of the partogram. This mustdilatation of the cervix must be recorded on be indicated with an arrow.the vertical line forming the left hand marginof the latent phase part of the partogram. The 6. How should you transfer the findingscorrect way of entering the above data on the at 10:00 from the latent to the activepartogram is shown below in figure 3C-7. phase part of the partogram? The X (cervical dilatation) must be moved3. How should you manage horizontally to the right until it lies on thethis woman further? alert line. This will again be at 5 cm dilatation.The woman must have the routine observations The O (number of fifths of the head above theperformed at the usual intervals, e.g. pulse pelvic brim) is similarly transferred to lie onrate, blood pressure and fetal heart. She the same vertical line opposite the two lines onmust be offered analgesia and sedation. the vertical axis. The new position of the headAdequate analgesia, e.g. pethidine 100 mg and (ROA) must be indicated on the O. The lengthhydroxyzine 100 mg or promethazine 25 mg, of the cervix is recorded by a 5 mm thick blackshould be given by intramuscular injection column on the base line vertically below theas soon as she asks for pain relief. A second X and O. The fact that the membranes havecomplete examination should be done at been ruptured is entered in the block provided10:00, i.e. four hours after the first complete for medication/ I.V. fluids/management. Aexamination. The woman must be encouraged ‘C’ in the block provided for liquor indicatesto walk about as this will help the progress that the liquor is clear. The correct method oftowards the active phase of the first stage of transferring the above findings from the latentlabour. to the active part of the partogram is shown in figure 3C-7. (The length of the cervix and theAt the second complete examination the position of the fetal head may also be enteredmaternal and fetal conditions are satisfactory. in the appropriate blocks provided elsewhereOn abdominal examination 2/5 of the fetal on the partogram.)head is palpable above the brim of the pelvis.Three contractions in 10 minutes, lasting
    • 68 INTRAPAR TUM CAREFigure 3C-7: Information from case sudy 1 correctly entered onto the partogram
    • SK ILLS WORKSHOP : RECORDING OBSER VATIONS ON THE PAR TOGRAM 69CASE STUDY 2 On abdominal examination the head is 3/5 palpable above the brim of the pelvis. Three contractions in 10 minutes, each lasting 25A multigravida is admitted to the labour ward seconds, are noted. On vaginal examinationat 08:00 in labour at term. The maternal and the cervix is 5 mm long and 5 cm dilated withfetal conditions are satisfactory. On abdominal bulging membranes.examination the head is 5/5 palpable abovethe brim of the pelvis. Three contractions in The presenting part is in the left occipito-10 minutes, each lasting 25 seconds are noted. transverse position. Poor progress isOn vaginal examination the cervix is 1 mm diagnosed and a systemic assessment of thelong (i.e. fully effaced) and 4 cm dilated. The woman is made in order to determine thepresenting part is in the left occipito-posterior cause. Intact membranes and inadequateposition. The woman complains that her uterine contraction are diagnosed as thecontractions are painful. causes of the poor progress.1. Is the woman in the active 4. How should you record thesephase of labour? findings on the partogram?Yes, as the cervix is more than 3 cm dilated. The X must be recorded on the horizontal line corresponding to 5 cm cervical dilatation, four2. How should you record your findings? hours to the right of the record at 08:00. The O, the position of the fetal head and length ofAs the woman is in the active phase of labour, the cervix, are recorded on the same verticalthe findings must be entered on the active line as the X. The correct way of recordingphase part of the partogram. The X (cervical these observations is shown in figure 3C-8.dilatation) is recorded on the alert line,opposite 4 on the vertical axis indicating 4 cm 5. Is the progress of labour satisfactory?dilatation. The O (number of fifths palpableabove the pelvic brim) is recorded above the X No. This is immediately apparent byopposite the 5 on the vertical line. The length observing that the second X has crossedof the cervix is recorded by a 1 mm column on the alert line. For labour to have progressedthe base line, vertically below the X and O. The satisfactorily, the cervix should have been atcorrect way of recording the above findings is least 8 cm dilated (4 cm initially plus 1 cmin figure 3C-8. per hour over the past four hours).3. How should you manage 6. How should you managethe woman further? this woman further?She must have the routine observations The membranes must be ruptured. Ruptureperformed at the usual intervals, e.g. pulse of the membranes will result in strongerrate, blood pressure, fetal heart, and urine uterine contractions. Because there has beenoutput. She must be offered analgesia. inadequate progress of labour, a third completePethidine 100 mg and hydroxyzine 100 mg examination should be performed at 14:00,or promethazine 25 mg should be given by i.e. two hours after the second completeintramuscular injection as soon as she requests examination.pain relief. A second complete examination At the third complete examination the maternalshould be done at 12:00, i.e. four hours after and fetal conditions are satisfactory. Onthe first complete examination. abdominal examination the head is 1/5 palpableAt the second complete examination the above the pelvic brim. Four contractions in 10maternal and fetal conditions are satisfactory. minutes, each lasting 50 seconds are observed.
    • 70 INTRAPAR TUM CAREOn vaginal examination the cervix is 1 mm 1. How should you recordlong and 9 cm dilated. The presenting part is in the above findings?the left occipito-anterior position. The findings As the woman is in the active phase of labour,are recorded as shown in figure 3C-8. the findings must be entered on the active phase part of the partogram. The X (cervical7. What is your assessment of the dilatation) is recorded on the alert lineprogress of labour at 14:00? opposite the 5 on the vertical line. The otherLabour is progressing satisfactorily. This is findings are entered in their appropriate placesshown by the third X having moved closer as shown in figure 3C-9.to the alert line. Also the head, which hasrotated from the left occipito-posterior to the 2. Is the decision to schedule the nextleft occipito-anterior position, is engaged. A complete examination at 13:00 correct?spontaneous vertex delivery may be expected Yes. There are no signs of cephalopelvicwithin an hour. disproportion (e.g. 3+ moulding) on admission, and the maternal and fetal conditions are satisfactory.CASE STUDY 3 3. What observations must be doneA gravida 2 para 1 is admitted to the labour carefully during the next four hours?ward at 09:00 in labour at term. She has alreadyhad painful contractions for the past two hours. Meconium in the liquor indicates that theTwo years before she had a difficult forceps fetus is at an increased risk for fetal distress.delivery for a prolonged second stage of labour. Therefore, the fetal heart rate pattern must beThe infant’s birth weight was 3000 g. The observed carefully for signs of fetal distressmaternal and fetal conditions are satisfactory. (e.g. late decelerations).On abdominal examination the head is 4/5palpable above the brim of the pelvis. The 4. What is likely to happen to thiscervix is 2 mm long and 5 cm dilated. There woman’s progress of labour?is 1+ of moulding present and the presenting The most likely outcome is the developmentpart is in the right occipito-posterior position. of cephalopelvic disproportion. On abdominalThe woman is HIV negative and an artificial examination the head will remain 3/5 orrupture of the membranes is performed and a more palpable above the pelvic brim (i.e.small amount of meconium-stained liquor is unengaged) and on vaginal examination theredrained. The woman is given pethidine 100 mg will be 3+ moulding. An urgent Caesareanand hydroxyzine 100 mg. A second complete section should then be performed.examination is scheduled for 13:00.
    • SK ILLS WORKSHOP : RECORDING OBSER VATIONS ON THE PAR TOGRAM 71Figure 3C-8: Information from case study 2 correctly entered onto the partogram
    • 72 INTRAPAR TUM CAREFigure 3C-9: Information from case study 3 correctly entered onto the partogram
    • 4 The second stage of labourBefore you begin this unit, please take the THE NORMAL SECONDcorresponding test at the end of the book toassess your knowledge of the subject matter. You STAGE OF LABOURshould redo the test after you’ve worked throughthe unit, to evaluate what you have learned 4-1 What is the second stage of labour? The second stage of labour starts when the Objectives patient’s cervix is fully dilated and ends when the infant is completely delivered. When you have completed this unit you should be able to: The second stage of labour starts when the cervix • Identify the onset of the second stage of is fully dilated. labour. • Decide when the patient should start to 4-2 What symptoms and signs suggest that bear down. the second stage of labour has begun? • Communicate effectively with a patient One or more of the following may occur: during labour. 1. Uterine contractions increase in both • Use the maternal effort to the best frequency and duration, i.e. they are more advantage when the patient bears down. frequent and last longer. • Make careful observations during the 2. The patient becomes restless. second stage of labour. 3. Nausea and vomiting often occur. 4. The patient has an uncontrollable urge to • Accurately evaluate progress in the bear down (push). second stage of labour. 5. The perineum bulges during a contraction • Manage a patient with a prolonged as it is stretched by the fetal head. second stage of labour. If the symptoms and signs suggest that • Diagnose and manage impacted the second stage of labour has begun, an shoulders. abdominal examination must be done to assess the amount of head palpable above the
    • 74 INTRAPAR TUM CAREpelvic brim, followed by a vaginal examination 4-6 If the cervix is fully dilated butto assess whether the cervix is fully dilated. the head not yet engaged, when is it safe to wait for engagement before4-3 Is there a difference between allowing the patient to bear down?primigravidas and multigravidas at the 1. If there are no signs of fetal distress.start of the second stage of labour? 2. If there are no signs of cephalopelvicYes. In primigravidas the head is usually disproportion.engaged when the cervix reaches fulldilatation. In contrast, multigravidas often Waiting for engagement of the head in areach full cervical dilatation when the fetal patient with a fully dilated cervix should only behead is still not engaged. allowed if there are no signs of fetal distress or cephalopelvic disproportion.4-4 What is the definition ofengagement of the fetal head? Usually primigravidas only reach full cervicalThe fetal head is engaged when the largest dilatation after the fetal head has engaged.transverse diameter of the head (the biparietal However the fetal head may only engage afterdiameter) has passed through the pelvic inlet. the cervix is fully dilated in a multigravida.When the fetal head is engaged, 2/5 or less of Therefore, there is a greater chance ofthe head is palpable above the pelvic brim. cephalopelvic disproportion in a primigravida who reaches full cervical dilatation with an The fetal head is engaged when only 2/5 or less of unengaged fetal head. the head is palpable above the brim of the pelvis 4-7 How long should you wait before asking the patient to bear down if the cervix is fullyEngagement usually starts before the onset dilated but the head is not yet engaged?of labour. Initially 5/5 of the head is palpableabove the pelvic brim. Engagement of the head 1. The patient should be assessed after ancannot be determined on vaginal examination. hour if there are no signs of fetal distress and the maternal observations are normal. 2. Usually engagement of the head will occurMANAGING THE SECOND during this time and the patient will feel a strong urge to bear down within an hour.STAGE OF LABOUR 3. If the head has still not engaged after an hour, you can wait a further hour provided that all other observations are normal4-5 Should the patient start bearing down and there are no signs of cephalopelvicas soon as the cervix is fully dilated? disproportion.No. The patient should wait until the fetal head 4. If the head has not engaged after waitingstarts to distend the perineum, when she will two hours, delivery by Caesareanexperience a strong urge to bear down. Only section is most likely indicated A carefulone fifth or less of the fetal head or no fetal examination of the patient must be donehead will be palpable above the brim of the for cephalopelvic disproportion which maypelvis at this time be present as a result of a big fetus or an abnormal presentation of the fetal head. A patient should only start bearing down when the fetal head distends the perineum and she has a strong urge to bear down.
    • THE SECOND STAGE OF LABOUR 754-8 In what position should 4-9 How would you get the bestthe patient be delivered? maternal co-operation during the second stage of labour?1. The patient is usually delivered on her back (i.e. the dorsal position) because it is 1. Good communication between the easier for the person managing the delivery. patient and the midwife or doctor is However, this position has the disadvantage very important. A relationship of trust that it may cause postural hypotension developed during the first stage of labour which may result in fetal distress. This will encourage good communication and problem can be avoided if a firm pillow is co-operation during the second stage. placed under one of the patient’s hips so 2. The patient must know what is expected that she is turned 15 degrees onto her side of her during the second stage. The person and does not lie flat on her back. conducting the delivery should encourage2. The lateral position (i.e. on her side) and support the patient and inform her prevents the problem of postural about the progress. Good co-operation and hypotension. In addition, the person attempts at bearing down should be praised. conducting the delivery has a good view of the vulva and perineum, the pelvic 4-10 How should you ensure that a patient muscles are relaxed, and the delivery can bears down as effectively as possible? be better controlled. The lateral position is particularly useful when the patient will 1. While the patient is passive in the first not give her full co-operation. stage, she must actively use her strength3. The upright position (i.e. vertical or during the second stage of labour to squatting position) is becoming more assist the uterine contractions. The more frequently used. The patient sits on her heels effectively she uses her strength, the and supports herself on outstretched arms. shorter the second stage will be. This position has the following advantages: 2. The midwife or doctor must make sure • The maternal effort becomes more that the patient knows when and how to effective. bear down. • The duration of the second stage is 3. It is important that she rests between shortened. contractions and bears down during • Fewer patients need an assisted contractions. delivery. 4. At the height of the contraction, the4. The semi-Fowler’s position, where the patient is asked to take a deep breath, to patient’s back is lifted to 45 degrees from put her chin on her chest, and to bear the horizontal, may be used instead of down as if she were going to empty her the upright position. This partial sitting rectum. This action is most effective and position is comfortable both for the patient easiest if the patient holds onto her legs or and the person conducting the delivery. some other firm object. 5. Each bearing down effort should lastThe position used during the second stage of as long as possible. This is better than alabour depends on the patient’s choice and number of short efforts.the circumstances under which the delivery is 6. When the patient needs to breathe whileconducted. The position chosen should allow pushing, she must quickly breathe out, takefor the best maternal effort at bearing down. a deep breath and bear down again. 7. With multigravidas, it is sometimes necessary for the patient to breathe rather than push during a contraction to prevent the fetal head from delivering too quickly.
    • 76 INTRAPAR TUM CARE bearing down, a doctor must assess the Good communication between the patient patient for a possible assisted delivery. and the person conducting the delivery is very 2. If a primigravida has inadequate important during labour. uterine contractions and there are no signs of cephalopelvic disproportion4-11 What observations must be made (i.e. 2+ moulding or less), an oxytocinduring the second stage of labour? infusion should be started. When strong contractions are obtained the patient mustIf the head is still not engaged and it is decided start bearing down.to wait for engagement, the same observations 3. If there is no progress in the descentusually made during the first stage of labour of the head and signs of cephalopelvicshould be continued. disproportion are present (i.e. 3+If the head is engaged and the patient is asked moulding), the patient should not bearto bear down, the following observations down. Instead she should concentratemust be done: on her breathing during contractions. A Caesarean section is indicated.1. Listen to the fetal heart between contractions to determine the baseline fetal heart rate. With strong contractions and good bearing down2. Listen to the fetal heart immediately after there should be progress in the descent of the each contraction. If the fetal heart rate presenting part onto the perineum. remains the same as that of the baseline rate, you are reassured that the fetus is in good condition. However, if the fetal heart 4-14 How should you manage fetal is slower at the end of the contraction, distress in the second stage of labour? and the slow heart rate takes more than 1. An episiotomy should be done, if the fetal 30 seconds to return to the baseline rate head distends the perineum when the (i.e. a late deceleration), the fetus must be patient bears down, so that the fetus can be delivered as rapidly as possible because delivered with the next contraction. fetal distress has developed. 2. If the perineum does not bulge with3. Observe the frequency and duration of the contractions and it appears as if the fetus uterine contractions. will not be delivered after the next two4. Look for any vaginal bleeding. efforts at bearing down, then:5. Record the progress of labour. • Assess and proceed with an assisted delivery if there are no4-12 How is progress monitored contraindications.in the second stage of labour? • Otherwise an emergency Caesarean section must be performed. WhileWith every uterine contraction and bearing preparing the patient, intra-uterinedown effort there should be some progress in resuscitation must be done.the descent of the fetal head onto the perineum. 4-15 How should a normal vaginal4-13 What should be done if there delivery be managed?is no progress in the descent ofthe head onto the perineum? The midwife or doctor managing the delivery must always be prepared for possible1. If the patient has at least two contractions complications. Equipment which may be in 10 minutes, each lasting 40 seconds required must be at hand and in good working or more and there is no progress in the order. Drugs which may be needed must be descent of the head after four attempts at easily available.
    • THE SECOND STAGE OF LABOUR 771. Emptying the bladder: Any factor, such EPISIOTOMY as a full bladder, that prevents descent of the fetal head or decreases the strength of uterine contractions should be corrected. 4-16 What is the place of an Therefore, it is very important for the episiotomy in modern midwifery? patient to empty her bladder before starting to bear down. An episiotomy is not done routinely but only if2. Supporting the perineum: A swab should be there is a good indication, such as: placed over the patient’s anus to prevent the 1. When the infant needs to be delivered vulva, and later the fetal head, being soiled without delay: with stool (i.e. faeces). It is important to • Fetal distress during the second stage support the perineum in order to: of labour. • Increase flexion of the fetal head so that • Maternal exhaustion. the smallest possible diameter passes • A prolonged second stage of labour through the vagina. This can be done by when the fetal head bulges the pressing immediately above the anus. perineum and it is obvious that an • Relieve the pressure on the perineum. episiotomy will hasten the delivery. Remember that the perineum must be • When a quick and easy second stage in view all the time. is needed, e.g. in a patient with heart3. Crowning of the head: When the head is valve disease. crowning the vaginal outlet is stretched 2. When there is a high risk of a third degree and an episiotomy may be indicated. The tear: midwife or doctor should place one hand • A thick, tight perineum. on the vertex to prevent sudden delivery of • A previous third degree tear. the head. The other hand, supporting the • A repaired rectocoele. perineum, is now moved upwards to help 3. When a breech or forceps delivery is done. extend the head. It is important that the fetal head is only controlled and not held back. 4-17 Does a second degree4. Feeling for a cord: Check that the umbilical tear heal faster and with fewer cord is not wrapped tightly around the complications than an episiotomy? infant’s neck. A loose cord can be slipped over the head but a tight cord should be Yes. A second degree tear is easier to clamped and cut. repair and heals quicker with less pain and5. Delivering of the shoulders and body: With discomfort than an episiotomy. Therefore, gentle continuous posterior traction on a second degree tear is preferable to an the head and lateral flexion, the anterior episiotomy. A episiotomy should not be done shoulder is delivered from under the routinely in primigravidas. symphysis pubis. The posterior shoulder is then lifted over the perineum. The rest of An episiotomy should only be done if there is a the infant’s body is now delivered, following definite indication. the curve of the birth canal and not by simply pulling it straight out of the vagina. 4-18 Which type of episiotomy should be done? Usually a mediolateral episiotomy is done. However, if the midwife or doctor has experience with the technique, a median episiotomy can be done.
    • 78 INTRAPAR TUM CAREPROLONGED SECOND 4-21 How should a patient with prolonged second stage of labourSTAGE OF LABOUR be managed during transfer to a hospital for Caesarean section?4-19 What is the definition of a 1. The patient should lie on her side and notprolonged second stage of labour? bear down with contractions. Instead, she should concentrate on her breathing.1. When diagnosing a prolonged second stage 2. An intravenous infusion should be the time is usually measured from the start started and two ampoules (5 μg each) of bearing down. of hexoprenaline (Ipradol) given slowly2. If a primigravida bears down for more than intravenously or three nifedipine 45 minutes, or a multigravida for more (Adalat) 10 mg capsules (30 mg in total) than 30 minutes, without the infant being given by mouth, provided there are no delivered, a prolonged second stage of contraindications. labour is diagnosed. 3. If there are any signs of fetal distress the3. The most senior clinician available should patient should be given oxygen by face be notified and called to help. mask. The second stage of labour is prolonged if it lasts 4-22 What factors indicate that a longer than 45 minutes in a primigravida or 30 patient is at an increased risk of a minutes in a multigravida. prolonged second stage of labour? 1. Factors during the antenatal period which4-20 How should you manage a patient suggest that the patient will deliver a largewith a prolonged second stage of labour? infant: • A patient with a symphysis-fundus1. Usually an assisted delivery is done height measurement above the 90th once cephalopelvic disproportion has centile, when multiple pregnancy and been excluded and 1/5 or no fetal head polyhydramnios have been excluded, remains palpable above the pelvic brim. i.e. there appears to be a large fetus. A Caesarean section should be done if • Any patient with a symphysis-fundus cephalopelvic disproportion is present. height of 40 cm or more may have a2. If a doctor is not available, the patient fetus of 4 kg or more. Very few with a should be referred to a level 1 or 2 symphysis fundus measurement of less hospital with facilities to perform a than 40 cm will have a term infant of Caesarean section. 4 kg or more. • A patient with diabetes mellitus. Prolonged second stage of labour is a dangerous • A patient who weighs more than 85 kg. complication which requires immediate and • A patient with a previous infant weighing 4 kg or more at birth. appropriate management. 2. Factors during the first stage of labour: • An estimated fetal weight, assessed on abdominal examination, of 4 kg or more. • A patient with poor progress in the first stage of labour before eventually reaching full cervical dilatation. • A patient who progressed normally during the active phase of the first stage
    • THE SECOND STAGE OF LABOUR 79 of labour, but whose progress was slower must give the midwife or doctor her full from 7 or 8 cm until full dilatation. co-operation. 2. The patient should be moved so that her buttocks are over the edge of the bed to Slow progress in the first stage of labour may be allow good downward traction on the followed by a prolonged second stage of labour. fetal head. This can be done rapidly by removing the end of the bed or by turning the patient across the bed.MANAGEMENT OF 3. The patient’s hips and knees must be fully flexed so that her knees almost touchIMPACTED SHOULDERS her shoulders. The midwife or doctor must hold the infant’s head between both hands and firmly pull the head down4-23 Which patients are at high risk of (posteriorly) while an assistant must atdeveloping impacted shoulders? the same time press firmly just above theThe same patients who are at high risk of a patient’s symphysis pubis. The amountprolonged second stage of labour are also at of downward traction applied should behigh risk for impacted shoulders (shoulder gradually increased until a reasonabledystocia), i.e. women who probably have a amount of traction is used. This reduces thelarge infant. risk of a brachial plexus injury as opposed to traction applied as a jerk. The suprapubic4-24 What signs during the second pressure must be firm enough to allowstage of labour indicate that the the assistant’s hand to pass behind theshoulders are impacted? symphysis pubis. This procedure helps to get the infant’s anterior shoulder to pass under1. Normally the infant’s head is delivered the symphysis pubis. The patient must bear by extension. However, with impacted down as strongly as possible during these shoulders the head is held back, does attempts to deliver the shoulders. not distend the perineum and does not This procedure to deliver impacted undergo the normal rotation. shoulders is called the MacRobert’s method.2. The size of the infant’s head and cheeks at 1. If the infant is not delivered after two delivery indicate that the infant is big and attempts, you should deliver the posterior fat. Usually the patient is also fat. shoulder:3. Attempts at external rotation, lateral • The midwife or doctor should place a flexion and traction fail to deliver the right hand (if right-handed) or a left shoulders. hand (if left-handed) posterior to theThe earlier these signs of impacted shoulders fetus in the vagina to reach the infant’sare recognised, the better is the chance that shoulder. The cavity of the sacrum isthis complication will be successfully managed. the only area which provides space for manipulation.4-25 How should a patient with • The posterior arm of the infant shouldimpacted shoulders be managed? be followed until the elbow is reached. The arm must be flexed at the elbowThe following management should be carefully and then pulled anteriorly over thefollowed in a step-by-step manner: chest and out of the vagina. Delivery1. The patient must be told that a serious of the posterior arm also delivers the complication has developed and that she posterior shoulder.
    • 80 INTRAPAR TUM CARE • The anterior shoulder can now be suctioned. If necessary hold the shoulders freed by pulling the infant’s head down back until the airways have been cleared. (posteriorly). Always suction the mouth first before • If the anterior shoulder cannot be clearing the nose. released, the infant must be rotated 2. With clear liquor: Suctioning the infant’s through 180 degrees. During the airways is not necessary before delivering rotation the infant’s head and freed the shoulders. After delivery suctioning is arm should be firmly held. The freed only needed if the infant does not breathe arm will indicate the direction of the well. rotation, i.e. turn the infant so that the shoulder follows the freed arm. Once 4-27 What is the immediate management the anterior shoulder has been rotated of the infant after a vaginal delivery? into the hollow of the sacrum, the trapped shoulder can be released by Dry the infant very well and assess whether inserting a hand posteriorly, flexing the the infant cries or breathes well. If the arm at the elbow and pulling the arm infant breathes well, leave the infant on the out of the vagina. mother’s abdomen and only clamp and cut the umbilical cord after two to three minutes. IfThe rules of delivering impacted shoulders the infant does not breathe well, clamp and cutmust be followed carefully without panicking. the cord immediately and move the infant to aIf the infant is delivered within five minutes of convenient place for resuscitation.detecting the complication, no brain damageshould occur. While the above managementhelps to reduce the risk of birth injury, fracture CASE STUDY 1of the clavicle or humerus may occur withdelivery of the posterior shoulder. This is A multiparous patient presents in labour atpreferable to an Erb’s palsy (brachial plexus 18:00. The fetal head is palpable 3/5 aboveinjury). Time should not be wasted trying the pelvic brim and the cervix is found toother methods which are not effective. The be 7 cm dilated. The vaginal examination ismanagement of impacted shoulders should repeated at 21:00 when the alert line indicatesregularly be practised on mannequins. that the cervix should be fully dilated. The examination confirms that the cervix is Impaction of the shoulders is a serious fully dilated. However, the fetal head is still complication and requires fast and effective not engaged. Preparations are made for the management according to a clear plan. patient to start bearing down. 1. Do you agree that the patient should start bearing down now that she hasMANAGING THE reached full dilatation of the cervix?NEWBORN INFANT No. She should not start bearing down until the fetal head is engaged and has reached the perineum.4-26 Should you suction theinfant’s airways at delivery? 2. What symptoms and signs would1. With meconium-stained liquor: Once indicate to you that the patient the infant’s head has been delivered, do should start bearing down? not carry on with the delivery until the infant’s mouth and throat have been well The patient will have an uncontrollable urge to bear down. In addition the fetal head will be
    • THE SECOND STAGE OF LABOUR 81engaged on abdominal examination and the palpable above the pelvic brim while 3+fetal head will distend the perineum when the moulding is found on vaginal examination.patient bears down. The patient wants to bear down with contractions.3. If the abdominal examinationshows that the fetal head is not 1. What complications would you expectengaged what conditions must be when you consider the patient’s progressmet when deciding to wait before during the first stage of labour?allowing the patient to bear down? A prolonged second stage of labour as theFetal distress must be excluded by making patient’s progress in labour was slower thansure that there are no late fetal heart rate expected between 7 cm and full dilatation.decelerations. Cephalopelvic disproportionmust also be excluded by finding 2+ moulding 2. What would be the most likely cause ofor less on vaginal examination. a prolonged second stage in this patient? Cephalopelvic disproportion as indicated by4. How long is it safe to wait for an unengaged fetal head and 3+ moulding.the fetal head to engage?The patient should be examined again after 3. Do you agree with the decisionan hour. If the head is still not engaged, you to allow the patient to bear downcan wait for a further hour provided that because she is fully dilated?there are still no signs of either cephalopelvicdisproportion or fetal distress. Thereafter, No. As the patient has cephalopelvicthe patient must be evaluated for an assisted disproportion, a Caesarean section must bedelivery. If the conditions for an assisted performed.delivery cannot be met, a Caesarean sectionmust be done. 4. How should this patient be managed further if she is at a clinic?5. Would you manage a primigravid She must be referred to a hospital withpatient in the same way as a muligravida facilities to perform a Caesarean section.if she reached full cervical dilatationwithout engagement of the fetal head? 5. What arrangements must beUsually primigravidas only reach full made to make the transfer of thiscervical dilatation after the fetal head patient as safe as possible?has engaged. Therefore, there is a greater The patient must lie on her side and anchance of cephalopelvic disproportion in intravenous infusion must be started. If therea primigravida than in a multigravida who are no contraindications, the contractionsmay reach full cervical dilatation with an must be stopped with intravenousunengaged fetal head. hexoprenaline (Ipradol) or oral nifedipine (Adalat). If there is any concern about the condition of the fetus, the patient must beCASE STUDY 2 given face mask oxygen.A patient who progressed normally duringthe first stage of labour until a cervicaldilatation of 7 cm reaches full dilatation ofthe cervix after a further five hours. At thelast examination 3/5 of the fetal head is still
    • 82 INTRAPAR TUM CARECASE STUDY 3 5. How would you have managed this patient if the prolonged labour was due to poor co-operation and ineffectiveA primigravida patient has still not delivered attempts at bearing down by the patient?after her cervix has been fully dilated for45 minutes. The fetal head is not palpable Good communication between the staffabdominally and bulges the perineum when and the patient during the first stage ofthe patient bears down with contractions. A labour should have established a trustingprolonged second stage is diagnosed and a relationship. The patient should have beendecision made to proceed with an assisted told exactly what she should do during thedelivery. second stage. She should also have beeen supported, encouraged and praised.1. Do you agree with the diagnosisof prolonged second stage?This will depend on when the patient started CASE STUDY 4to bear down and whether her attempts atbearing down were effective. The diagnosis is A multigravid patient weighing 110 kgcorrect if she has been bearing down well for progresses to full cervical dilatation. After45 minutes. 30 minutes in the second stage of labour, the infant’s head is delivered with difficulty. The head is held back and does not distend the2. What should your management perineum while rotation of the head does notbe if the patient has been bearing occur.down well for 45 minutes?As the head is not palpable abdominally and 1. What complication has occurredis distending the perineum, an episiotomy during the second stage of labour?should be done. Thereafter, if the infant hasnot been delivered after a few contractions Impaction of the shoulders (i.e. shoulderwith the patient bearing down well, the patient dystocia).must be evaluated for an assisted delivery. 2. How could this complication3. Should an episiotomy be done at have been predicted?the delivery of all primigravidas? An overweight patient is at risk for developingNo. Only if there is a definite indication for impacted shoulders as infants born to thesean episiotomy. In this case an episiotomy is patients are often very big.indicated as the second stage is prolonged anddelivery would probably be rapidly achieved 3. How should this patientwith an episiotomy. be further managed? The patient’s buttocks must be moved to the4. The infant is delivered just before an edge of the bed so that good posterior tractionepisiotomy is done and after the birth it can be applied to the infant’s head. This canis noticed that the patient has a second be done quickly if the end of the bed candegree perineal tear. Would it have been be removed or if the patient can be swungpreferable to have done an episiotomy? around across the bed. The patient’s hipsNo. A second degree tear is preferable to an and knees should be flexed so that her kneesepisiotomy. A second degree tear is easier to almost reach her shoulders. The infant’s headrepair, heals faster and causes less pain and should be firmly held between both handsdiscomfort than an episiotomy. and pulled downwards (posteriorly) while an
    • THE SECOND STAGE OF LABOUR 83assistant, at the same time, presses down overthe suprapubic area. The amount of downwardtraction applied should be gradually increaseduntil a reasonable amount of traction is used.4. What should the further managementbe if these attempts to deliver theshoulders are not successful?An immediate attempt must be made todeliver the infant’s posterior arm. The personconducting the delivery must place a handposterior to the fetus in the vagina, flex theinfant’s posterior arm at the elbow and pullit out anteriorly over the chest. When thearm is pulled out the posterior shoulder willautomatically be delivered as well. The anteriorshoulder can now be released by pulling theinfant’s head downwards.
    • 4A Skills workshop: Performing and repairing an episiotomy done without adequate analgesia. Usually 10–15 Objectives ml 1% lignocaine (Xylotox) supplies adequate analgesia for performing an episiotomy. Be very careful that the local anaesthetic is not injected When you have completed this skills into the presenting part of the fetus. workshop you should be able to: • Perform a mediolateral episiotomy. C. Types of episiotomy • Repair an episiotomy. There are two methods of performing an episiotomy:PERFORMING AN 1. Mediolateral or oblique. 2. Midline.EPISIOTOMY The midline episiotomy has the danger that it can extend into the rectum to become a thirdA. The purpose of an episiotomy degree tear while the mediolateral episiotomy often results in more bleeding. This skills1. To aid the delivery of the presenting part workshop will only deal with the mediolateral when the perineum is tight and causing episiotomy because it is used most frequently, poor progress in the second stage of labour. is safe and requires the least experience.2. To prevent third degree perineal tears.3. To allow more space for operative or D. Performing a mediolateral episiotomy manipulative deliveries, e.g. forceps or breech deliveries. The incision should only be started during4. To shorten the second stage of labour, e.g. a contraction when the presenting part is with fetal distress. stretching the perineum. Doing the episiotomy too early may cause severe bleeding andB. Preparation for an episiotomy will not immediately assist the delivery. The incision is started in the midline with theIf you anticipate that an episiotomy may be scissors pointed 45 degrees away from theneeded, you should inject local anaesthetic into anus. It is usually directed to the patient’s leftthe perineum. An episiotomy should not be
    • THE SECOND STAGE OF LABOUR 85Figure 4A-1: The method of performing a left mediolateral episiotomybut can also be to the right. Two fingers of the Suturing the episiotomy usually stops theleft hand are slipped between the perineum venous bleeding but arterial bleeders need toand the presenting part when performing a be tied off.mediolateral episiotomy.E. Problems with episiotomies REPAIRING AN1. The episiotomy is done too soon: This EPISIOTOMY can result in excessive bleeding as the presenting part is not pressing on the perineum. An episiotomy will not help the F. Preparations for repairing an episiotomy descent of a high head. 1. This is an uncomfortable procedure for the2. Extension of the episiotomy by tearing: patient. Therefore, it is essential to explain This is not only a problem in a midline to her what is going to be done. episiotomy. Mediolateral episiotomies 2. The patient should be put into the may also tear through the anal sphincter lithotomy position if possible. into the rectum. However, extension of 3. It is essential to have a good light that must mediolateral episiotomies is less likely to be able to shine into the vagina. A normal occur than a midline episiotomy. ceiling light usually is not adequate.3. Excessive bleeding may occur: 4. Good analgesia is essential and is usually • When the episiotomy is done too early. provided by local anaesthesia which is • From a mediolateral episiotomy. given before the episiotomy is performed. • After the delivery. As 20 ml of 1% lignocaine may be safelyArterial bleeders may have to be temporarily infiltrated, 5–10 ml usually remains to beclamped, while venous bleeding is easily given in sensitive areas. An episiotomystopped by packing a swab into the wound. should not be sutured until there is good analgesia of the site.
    • 86 INTRAPAR TUM CAREFigure 4A-2: The method of safely handling a needleFigure 4A-3: An episiotomy wound5. In order to prevent blood which drains needle for the vaginal epithelium and out of the uterus from obscuring the muscles, and one on a cutting needle for episiotomy site, a rolled pad or tampon the skin. With smaller episiotomies one should be carefully inserted into the vagina packet on a round needle and one on a above the episiotomy wound. As this is cutting needle will be sufficient. Non- uncomfortable for the patient, she should absorbable suture material such as nylon be reassured while this is being done. and dermalon are very uncomfortable and6. Absorbable suture material should be used should not be used. Remember that the for the repair. Three packets of chromic patient has to sit on her wound. 0 are required. Two on a round (taper)
    • THE SECOND STAGE OF LABOUR 87Figure 4A-4: Suturing the vaginal epitheliumG.. The following important principles There are four important steps in the repair ofapply to the suturing of an episiotomy an episiotomy wound.1. The apex of the episiotomy must be Step 1 visualised and a suture put in at the apex. Place a suture (stitch) at the apex (the highest2. Dead space must be closed. point) of the incision in the vaginal epithelium.3. The same opposing tissue must be brought Then insert one or two more continuous together using the skin vaginal epithelium sutures in the vaginal epithelium. Do not juncture as an anatomical landmark. complete suturing the vaginal epithelium when4. Tissues must be brought together but not the episiotomy is large or deeply cut but leave strangulated by excessive tension on the this suture and do not cut it. When placing the sutures. suture at the apex, be very careful not to prick5. Haemostasis must be obtained. your finger with the needle.6. The needles must be handled with a pair of forceps and not by hand, and should be Step 2 removed from the operating field as soon Insert interrupted sutures in the muscles. Start as possible. at the apex of the wound. The aim is to bring the muscles together firmly and to eliminateH. The method of suturing an episiotomy any ‘dead space’, i.e. any spaces between theThree layers have to be repaired: muscles where blood can collect. Remember that the sutures must be inserted at 90 degrees1. The vaginal epithelium. to the line of the wound.2. The muscles.3. The perineal skin. When suturing the muscles, be careful not to put the suture through the rectum. If you
    • 88 INTRAPAR TUM CAREFigure 4A-5: Suturing the musclesFigure 4A-6: The correct position of the skin and vaginal epithelium
    • THE SECOND STAGE OF LABOUR 89Figure 4A-7: The repair of the skinmake sure that the point of the needle is seen Step 4when crossing from the one side to the other Use interrupted sutures with an absorbableof the deepest part of the wound, the stitch suture material to repair the perineal skin.will not be too deep. ‘Figure 8’ stitches (double Mattress sutures may be used. Do not pull thestitches) are used to suture the muscle layer. sutures tight as they only need to bring theWhen the muscles have been correctly sutured edges of the skin together. Sutures that are toothe cut edges of the vaginal epithelium and tight become uncomfortable for the patient.the skin should be lying close together. Themarkers for correct alignment are: When the suturing is complete:1. The remains of the hymen. 1. Remove the pad from the vagina. Be gentle2. The junction of the skin and the vaginal as this will be uncomfortable for the patient. epithelium. The skin is recognised by the 2. Put a finger into the rectum and feel if a darker pigmentation. suture has been placed through the rectal wall by mistake.Step 3 3. Make sure that the uterus is wellReturn to the vaginal epithelium and complete contracted.the continuous catgut suture, ending at the 4. Get the patient out of the lithotomyjunction with the skin. Do not pull the sutures position and make sure that she istight as they only need to bring the edges of comfortable.the vaginal epithelium together.
    • 5 The third stage of labourBefore you begin this unit, please take the THE NORMAL THIRDcorresponding test at the end of the book toassess your knowledge of the subject matter. You STAGE OF LABOURshould redo the test after you’ve worked throughthe unit, to evaluate what you have learned 5-1 What is the third stage of labour? The third stage of labour starts immediately Objectives after the delivery of the infant and ends with the delivery of the placenta and membranes. When you have completed this unit you 5-2 How long does the normal should be able to: third stage of labour last? • Define the third stage of labour. • Manage the third stage of labour. The normal duration of the third stage of labour lasts less than 30 minutes, and mostly • List the observations needed during the only two to five minutes. third stage of labour. • Examine a placenta after delivery. 5-3 What happens during the • Manage a patient with prolonged third third stage of labour? stage of labour. 1. Uterine contractions continue, although • Manage a patient with retained less frequently than in the second stage. placenta. 2. The uterus contracts and becomes smaller • List the causes of postpartum and, as a result, the placenta separates. haemorrhage. 3. The placenta is squeezed out of the upper • Manage a patient with postpartum uterine segment into the lower uterine segment and vagina. The placenta is then haemorrhage. delivered. • Prevent infection of the staff with HIV at 4. The contraction of the uterine muscle delivery. compresses the uterine blood vessels and this prevents bleeding. Thereafter, clotting (coagulation) takes place in the uterine blood vessels due to the normal clotting mechanism.
    • THE THIRD STAGE OF LABOUR 915-4 Why is the third stage 1. Blood loss is less than when the activeof labour important? method is used. Therefore the active method reduces the incidence ofExcessive bleeding is a common complication postpartum haemorrhage.during the third stage of labour. Therefore, 2. There is less possibility that oxytocin willthe third stage, if not correctly managed, be needed to contract the uterus followingcan be an extremely dangerous time for the the third stage of labour.patient. Postpartum haemorrhage is thecommonest cause of maternal death in some Disadvantages:developing countries. 1. The person actively managing the third stage of labour must not leave the patient. The third stage of labour can be a very dangerous Therefore, an assistant is needed to give the time and, therefore, must be correctly managed. oxytocic drug and examine the newborn infant, while the person conducting the delivery continues with the management of the third stage of labour.MANAGING THE THIRD 2. The risk of a retained placenta is increasedSTAGE OF LABOUR if the active method is not carried out correctly, especially if the first two contractions after the delivery of the infant5-5 How should the third stage are not used to deliver the placenta.of labour be managed? 3. Excessive traction on the umbilical cord can result in inversion of the uterus,There are two ways of managing the third especially if the fundus of the uterus is notstage of labour: supported by placing a hand above the1. The active method. bladder on the abdomen.2. The passive method.Whenever possible, the active method should Blood loss during the third stage of labour is lessbe used. However, midwives conducting when the active management is used.deliveries alone, without an assistant, in amidwife obstetric unit or level 1 hospitalmay use the passive method. Midwives who 5-6 What is the active managementchoose to use the passive method of managing of the third stage of labour?the third stage of labour MUST also be able 1. Immediately after the delivery of theto confidently use the active method, as this infant, an abdominal examination is donemethod may have to be used in some patients. to exclude a second twin. 2. An oxytocic drug is given if no second twin is present. Everybody conducting a delivery must be able 3. When the uterus contracts controlled cord to use the active method of managing the third traction must be applied: stage of labour. • Keep steady tension on the umbilical cord with one hand.5-6 What are the advantages and • Place the other hand just above thedisadvantages of the active method of symphysis pubis and push the uterusmanaging the third stage of labour? upwards. Controlled cord traction is also called theAdvantages: Brandt–Andrews method (manoeuvre).
    • 92 INTRAPAR TUM CARE4. Placental separation will take place when Oxytocin is the drug of choice in the the uterus contracts. When controlled cord traction is applied the placenta will be management of the third stage of labour. moved down from the upper segment to the lower segment of the uterus. 5-9 What are the actions of the two5. Once this occurs, continuous light components of syntometrine? traction on the umbilical cord will now 1. Oxytocin causes physiological uterine deliver the placenta from the lower contractions which start two to three uterine segment or vagina. minutes after an intramuscular injection6. If placental separation does not take place and continue for approximately one to during the first uterine contraction after three hours. giving the oxytocic drug, wait until the 2. Ergometrine causes a tonic contraction of next contraction occurs and then repeat the uterus which starts five to six minutes the manoeuvre. after an intramuscular injection andWith the passive method of managing the continues for about three hours.third stage of labour, the patient is askedto bear down only after there are signs of 5-10 What are the contraindicationsplacental separation. An oxytocic drug is only to the use of syntometrine?given after the placenta has been delivered. Syntometrine contains ergometrine and, therefore, should not be used if:5-8 Which oxytocic drug is usually givenduring the third stage of labour? 1. The patient is hypertensive. Ergometrine causes vasospasm which may result in aOne of the following two drugs is generally severe increase in the blood pressure.given: 2. The patient has heart valve disease.1. Oxytocin (Syntocinon ) 10 units. This is Tonic contraction of the uterus pushes a given intramuscularly. It is not necessary large volume of blood into the patient’s to protect this drug against direct light. circulation, which may cause heart failure Although the drug must also be kept in a with pulmonary oedema. refrigerator, it has a shelf life of one month at room temperature.2. Syntometrine. This is given by Make sure that there are no contraindications intramuscular injection. Syntometrine is before using syntometrine. supplied in a 1 ml ampoule which contains a mixture of five units oxytocin and 0.5 5-11 What oxytocic drug should be mg ergometrine maleate. The drug must used if there is a contraindication be protected from direct light at all times to the use of syntometrine? and must be kept in a refrigerator. The ampoules must, therefore, be kept in an Oxytocin (Syntocinon) should be used. An opaque container in the refrigerator. intravenous infusion of 10 units oxytocin in 200 ml normal saline is given at a rate of 30Oxytocin (Syntocinon) is the drug of choice. drops per minute or 10 units oxytocin areHowever, as Syntometrine is still widely given by intramuscular injection.prescribed, the correct use of this drug willalso be explained. 5-12 Should the umbilical cord be allowedThe latest information in the Cochrane Review to bleed before the placenta is delivered?indicates that the best drug and dosage to use 1. The umbilical cord must not be allowed tois oxytocin 10 units. bleed after the delivery of the first infant
    • THE THIRD STAGE OF LABOUR 93 in a multiple pregnancy. In identical twins • A short note on the suturing of an with a single placenta (monochorionic episiotomy or perineal tear. placenta), the undelivered second twin • The patient’s pulse rate, blood pressure may bleed to death if the umbilical cord and temperature. of the first born infant is allowed to bleed. • The completeness of the placenta Therefore, the forceps should be left in and membranes, and any placental place on the umbilical cord after the abnormality. delivery of the first twin. 3. Recordings made during the first hour2. The umbilical cord should be allowed after the delivery of the placenta: to bleed if the patient’s blood group is • During this time (sometimes called the Rhesus negative (Rh negative) with a fourth stage of labour) it is important single fetus. This will reduce the risk to record whether the uterus is well of fetal blood crossing the placenta to contracted and whether there is any the mother’s circulation and, thereby, excessive bleeding. During the first sensitizing the patient. Nevertheless, anti- hour after the completion of the third D immunoglobulin must always be given stage of labour, there is a high risk of to these patients. postpartum haemorrhage.3. Allowing the umbilical cord to bleed • If the third stage of labour and the during the third stage of labour, reduces observations were normal, the patient’s the placental volume and, thereby, speeds pulse rate and blood pressure should be up the separation of the placenta. As a measured again an hour later. general rule, the umbilical cord should • If the third stage of labour was not be allowed to bleed once a multiple normal, the observations must be pregnancy has been excluded. Recent repeated every 15 minutes, until the research suggest that the umbilical cord is patient’s condition is normal. Thereafter, best clamped and cut three minutes after the observations should be repeated delivery to allow the infant to receive extra every hour for further four hours. blood from the placenta. During the first hour after the delivery it is Allowing the umbilical cord to bleed after essential to ensure that the uterus is well delivering the infant speeds up the separation contracted and that there is no excessive bleeding. of the placenta. 5-14 When should the infant be given to5-13 What recordings must always be made the mother to hold and put to the breast?during and after the third stage of labour? As soon as possible after delivery. Usually1. Recordings made about the third stage of the infant is well dried and then placed labour: on the mother’s abdomen if the infant is • Duration of the third stage. crying or breathing well. Wait three minutes • The amount of blood lost. before clamping the umbilical cord and then • Medication given. give the infant to the mother to hold and • The condition of the perineum and the place to the breast. The nipple stimulation presence of any tears. causes uterine contractions which may help2. Recordings made immediately after the placental separation. delivery of the placenta: • Whether the uterus is well contracted or not. • Any excessive vaginal bleeding.
    • 94 INTRAPAR TUM CAREEXAMINATION OF THE 4. Size: Finally the placenta must be weighed.PLACENTA AFTER BIRTH The weight of the placenta increases with gestational age and is usually 1/6 the weight of the infant, i.e. 450–650 g at term.5-15 How should you examine If the placenta is abnormally large andthe placenta after delivery? heavy, the following possibilities must beEvery placenta must be examined for: considered: • A heavy, oedematous placenta is1. Completeness: suggestive of congenital syphilis. Make sure that both the placenta and the • A heavy, pale placenta is suggestive of membranes are complete after the delivery Rhesus haemolytic disease. of the placenta: • A placenta which is heavier than would • The membranes are examined for be expected for the weight of the completeness by holding the placenta infant, but with a normal appearance, is up by the umbilical cord so that the suggestive of maternal diabetes. membranes hang down. You will see A placenta which weighs less than would the round hole through which the be expected for the weight of the infant, infant was delivered. Examine the is suggestive of fetal intra-uterine growth membranes carefully to determine restriction (IUGR). whether they are complete. • The placenta is now held in both hands All placentas must be carefully examined for and the maternal surface is inspected after the membranes are folded away. completeness and abnormalities after delivery. A missing part of the placenta, or cotyledon, is thus easily noticed.2. Abnormalities: THE ABNORMAL THIRD • Cloudy membranes, or a placenta that smells offensive, suggest the STAGE OF LABOUR presence of chorioamnionitis. Peeling the amnion off the chorion is the best 5-16 What is a prolonged way of examining the amnion over third stage of labour? the placenta for cloudiness caused by chorioamnionitis. If the placenta has still not been delivered • Clots of blood which stick to the after 30 minutes, the third stage is said to be maternal surface suggest that abruptio prolonged. placentae has occurred. • Infarcts can be recognised as firm, pale The third stage is prolonged when the placenta areas on the maternal surface of the placenta. Calcification on the maternal still has not been delivered after 30 minutes. surface is normal.3. Umbilical cord: 5-17 How should a prolonged third Two arteries and a vein should be seen on stage of labour be managed? the cut end of the umbilical cord. If only 1. If the active method has been applied and one umbilical artery is present, the infant failed: must be carefully examined for other • An infusion with 20 units of oxytocin congenital abnormalities. in 1000 ml Basol or normal saline must be started and run in rapidly.
    • THE THIRD STAGE OF LABOUR 95 • Once the uterus is well contracted, MANAGING A try again to deliver the placenta by controlled cord traction. POSTPARTUM HAEMORRHAGE5-18 What should be done if theplacenta is still not delivered, afterthe routine management of a 5-20 What is a postpartum haemorrhage?prolonged third stage of labour? 1. Blood loss of more than 500 ml within theA vaginal examination must be done: first 24 hours after delivery of the infant. 2. Any bleeding after delivery, which appears1. If the placenta or part of the placenta is excessive. palpable in the vagina or lower segment of the uterus, this confirms that the placenta has separated. By pulling on the umbilical Any excessive bleeding after delivery should be cord with one hand, while pushing the considered to be a postpartum haemorrhage and fundus of the uterus upwards with the managed as such. other hand (i.e. controlled cord traction), the placenta can be delivered.2. If the placenta or part of the placenta is not 5-21 What should be done if a patient palpable in the vagina or lower segment of has a postpartum haemorrhage? the uterus and only the umbilical cord is The management will depend on whether the felt, then the placenta is still in the upper placenta has been delivered or not. segment of the uterus and a diagnosis of retained placenta must be made. 5-22 What is the management of a postpartum haemorrhage, if the A retained placenta is diagnosed if the placenta has not been delivered? management of prolonged labour has failed. 1. If the active method has been used to manage the third stage of labour, a rapid5-19 What is the management intravenous infusion of 20 units oxytocinof a retained placenta? in 1000 ml Basol or normal saline must be started, to ensure that the uterus is1. Continue with the intravenous infusion of well contracted. A further attempt should oxytocin and make sure that the uterus is now be made to deliver the placenta. well contracted. This will reduce the risk of Immediately after the delivery of the postpartum haemorrhage. placenta, make sure that the uterus is well2. While waiting for the theatre to be ready or contracted, by rubbing up the fundus. transfer of the patient, check continuously 2. If the attempt to deliver the placenta fails, whether the uterus remains well contracted the patient has a retained placenta and and for excessive vaginal bleeding. should be managed for a retained placenta. The blood pressure and pulse must be measured and recorded every 30 minutes. The management of a patient with a3. If the patient is at a clinic or a level 1 postpartum haemorrhage before the delivery of hospital without an operating theatre, the placenta is summarised in flow diagram 5-I. she must be transferred to a level 2 or 3 hospital, for manual removal of the placenta under general anaesthesia.4. Keep the patient ‘nil per mouth’.
    • 96 INTRAPAR TUM CAREFlow diagram 5-1: The management of a patient with a postpartum haemorrhage before the delivery of theplacenta5-23 What is the management of a patient If the bleeding persists following rubbing upwith a postpartum haemorrhage, if the the uterus, bleeding must be controlled byplacenta has already been delivered? bi-manual compression of the uterus. A fist is inserted in the vagina or four fingers with theThis is a dangerous complication, which must palm upwards in the posterior fornix of thebe rapidly and correctly managed, according vagina, with the other hand pushing down onto a clear plan: the fundus of the uterus abdominally.Step 1 Step 3Call for help. One cannot manage a A rapid intravenous infusion of 20 unitspostpartum haemorrhage alone. Someone oxytocin in 1000 ml Plasmalyte B or normalneeds to get the oxytocin, cannulas, infusion saline must be started. Once again, makesets and intravenous fluids while the other sure that the uterus is well contracted, byperson is controlling the bleeding. massaging it.Step 2 Step 4The uterus must immediately be rubbed up, The patient’s bladder must be emptied. Ai.e. massaged. This will cause the uterus to full bladder can cause the uterus to contractcontract and stop bleeding in most cases. poorly, with resultant haemorrhage.
    • THE THIRD STAGE OF LABOUR 97These four steps must always be carried out, Bleeding from an atonic uterus occurs in episodesirrespective of the cause of the postpartumhaemorrhage. The cause of the haemorrhage and consists of dark red blood clots.must now be diagnosed. 5-26 What are the possible NOTE Bleeding can also be controlled by causes of an atonic uterus? aortic compression. The aorta can be compressed abdominally by pressing down 1. A uterus full of blood clots is the at the level of the umbilicus. Compression commonest cause. of the aorta is particularly useful during a 2. A full bladder. laparotomy for postpartum haemorrhage. 3. Retained placental cotyledons. 4. Factors during the pregnancy, which resulted in an abnormally large uterus: A postpartum haemorrhage is a dangerous • A large infant. complication and must be managed according to • A multiple pregnancy. a definite plan. • Polyhydramnios. 5. A prolonged first stage of labour.5-24 What are the main causes of 6. The intravenous infusion of oxytocinpostpartum haemorrhage? during the first stage of labour. 7. General anaesthesia.The two main causes of postpartum 8. Grande multiparity.haemorrhage are: 9. Abruptio placentae.1. Haemorrhage due to an atonic (poorly contracted) uterus. The commonest causes of an atonic uterus are a2. Haemorrhage due to trauma, usually in the form of tears (lacerations). uterus full of blood clots and a full bladder.It is very important that they are differentiatedfrom one another as this will determine the 5-27 What is the correct managementcorrect management. of postpartum haemorrhage, if the clinical signs indicate bleeding from an atonic uterus? The two main causes of postpartum 1. Rub up the uterus, empty the patient’s haemorrhage are an atonic uterus and trauma. bladder and start a fast intravenous infusion of 20 units oxytocin in 1000 mlThe management of a patient with a postpartum Basol or normal saline.haemorrhage after the delivery of the placenta 2. If the uterus still tends to relax, examineis summarised in flow diagram 5-II. the placenta again, to check whether it is complete.5-25 What clinical signs indicate that the 3. If the placenta is not complete, manage thebleeding is caused by an atonic uterus? patient as detailed in section 5-28. 4. If the placenta is complete and the uterus1. The uterus is atonic (feels soft and spongy), remains poorly contracted, the patient or tends to become atonic after it is rubbed must be referred to a hospital with theatre up or after an oxytocin infusion is given. facilities. This is an extremely serious2. The bleeding is intermittent and consists complication, which could result in the mainly of dark red clots. patient’s death. While waiting for the3. If the uterus is rubbed up and becomes theatre or arranging transfer, the following well contracted, a large amount of dark red management must be followed: blood clots escapes from the vagina.
    • 98 INTRAPAR TUM CAREFlow diagram 5-2: The management of a patient with a postpartum haemorrhage after the delivery of theplacenta • Start a second, rapidly running, bleeding, until the patient is in theatre intravenous infusion and take a sample or until she reaches a level 2 hospital. of blood for urgent cross-matching. A • Lie the patient flat, or in the head- blood transfusion must be started as down position and give oxygen by soon as possible. means of a face mask. • The uterus must be bi-manually 5. Place three misoprostol (Cytotec) tablets compressed as explained in Step 2 of (one tablet = 200 μg) in the patient’s rectum. section 5-23. This should control the
    • THE THIRD STAGE OF LABOUR 995-28 What is the further management of is clamped. The balloon catheter is used inpostpartum haemorrhage due to an atonic conjunction with oxytocics or misoprostol.uterus if the initial management fails? It is important to note that the clinician mustAll patients that did not respond to the initial progress to the next step without delay until itemergency management should be transferred is certain that the bleeding has stopped.as acute emergencies to an appropriate level of If the bleeding persists a laparotomy (midlinecare, which will be at least level 1 hospitals with incision) is required:theatre facilities and emergency blood available. 1. If the patient has completed her family orProstaglandin F2-alpha is a potent uterotonics is of high parity, proceed directly with aagent. The drug may be injected into the total abdominal hysterectomy.myometrium. 5 mg is added to 20 ml saline 2. If the patient is primiparous or of low parity,and 2 ml injected into various sites in the the following steps could be followed:myometrium being careful not to inject • The patient is draped in the lithotomyintravascularly. Alternatively 5 mg may be position with the legs angled slightlyadded to a litre of the crystalloid infusion. downwards at about 30 degrees.If the uterus continues to relax, the patient This allows the surgeon more roomneeds to be taken to theatre in a level 2 hospital. during the operation. This will allowFour units of blood and a person with the skills immediate inspection to assess theto do an emergency hysterectomy need to be result of intra-abdominal measures toavailable if required. While waiting for theatre reduce blood loss.bi-manual compression of the uterus should be • Compression sutures are insertedapplied to reduce further blood loss. (B-Lynch sutures). The bladder peritoneum is opened. A Vicryl 1 sutureIn theatre an examination under general is passed through the lower segmentanaesthetic (EUA) is done: 2–3 cm from the lateral border of the1. Inspect the vagina and cervix for tears. uterus. These sutures are tied as tight as2. A bi-manual examination and exploration possible on top for the uterus 3–4 cm of the uterine cavity with two fingers for medial to the uterine cornu. retained placental tissue and a possible 3. If the bleeding persists systematic laceration. devascularisation of the uterus is required.3. The uterus is further emptied with a large Number one absorbable suturing material is ovum forceps and then firmly curetted used on a large round bodied (taper) needle. with a Baum’s curette. • First, ligate the uterine artery. A suture is inserted through full thicknessTrans-abdominal ultrasound in theatre is of myometrium just above the deflectionvalue to confirm that the uterus is empty. of the broad ligament on the pelvicInserting a balloon cather could be valuable to floor. This will be at the level of thereduce the bleeding while waiting for theatre internal os of the cervix. The anterioror if the patient is primiparous or of low entry and posterior exit point of theparity, where a hysterectomy after evacuation needle will be 2 cm medial to thewould be a last option. The balloon cather lateral insertion of the broad ligament.is made by using a large Foley’s catheter and Pass the needle back from posterior tosurgical latex glove. The glove is tied around anterior through an avacular portion ofthe Foley’s catheter above the bulb. Any suture the broad ligament and tie a tight knot.material can be used. Saline is infused under If bleeding persists a similar suture ispressure into the glove either by injecting with inserted on the other side of the uterus.a syringe or by squeezing a vacolitre. Once • If bleeding persists the anastomosis of500 ml of saline has been infused the catheter the ovarian and uterine artery is ligated
    • 100 INTRAPAR TUM CARE with a similar suture inserted above 5-30 What can be done to reduce the the level of the insertion of the ovarian risk of postpartum haemorrhage? ligament to the uterus and below the In patients who are at high risk of postpartum uterine tube. Both anastomoses need to haemorrhage (e.g. multiple pregnancy, be ligated with persistent bleeding. polyhydramnios or grande multiparity) the • If bleeding persists proceed with following should be done: a hysterectomy as a life saving procedure. A less experienced 1. An intravenous infusion should be started surgeon should perform a subtotal during the active phase of the first stage hysterectomy, by amputating the uterus of labour. above the cervix following the ligation 2. Twenty units of oxytocin in 1000 ml of the uterine arteries. Basol or normal saline should be given by rapid infusion after the placenta has beenAs a general principle the decision to do a delivered.hysterectomy must not be postponed too 3. Make sure that the uterus is welllong. Continued blood loss requiring the contracted during the first hour after thetransfusion of five or more units of blood delivery of the placenta and make sure thatcompromise blood clotting and increase the the patient empties her bladder frequently.risk of a maternal death. 5-31 What clinical signs indicate5-29 What should be done if the that the bleeding is from a tear?membranes or placenta are notcomplete after delivery and the 1. The uterus is well contracted.patient is not bleeding? 2. A continuous trickle of bright red blood comes from the uterus in spite of a well1. Incomplete membranes usually do not contracted uterus. cause any complications.2. An incomplete placenta with one or more cotyledons missing can cause a postpartum Bleeding from a tear causes a continuous trickle haemorrhage due to an atonic uterus. of bright red blood in spite of a well contracted Therefore, manage as follows: uterus. • An intravenous infusion of 20 units oxytocin in 1000 ml Basol or normal saline must be started to make sure that 5-32 What is the correct management the uterus is well contracted. if the clinical signs indicate that • Arrange for an evacuation of the uterus the bleeding is from a tear? or transfer the patient to a hospital with The patient should be placed in the lithotomy theatre facilities to evacuate the uterus. position and examined as follows: • Keep the patient ‘nil per mouth’ as a general anaesthetic will be necessary. 1. First the perineum must be examined for bleeding from a a tear or episiotomy. Repair any tear or episiotomy. An evacuation of the uterus under general 2. Thereafter, the vagina must be examined anaesthesia is required if placental cotyledons for a tear using the index finger of each are retained in the uterus. hand to hold the vagina open. If available, a retractor (a Werdheim’s retractor) is helpful in examining the vagina. If a tear is found it must be sutured.
    • THE THIRD STAGE OF LABOUR 1013. If a perineal or vaginal tear cannot be require a laparotomy and in most cases a found, a cervical tear or even a ruptured hysterectomy. uterus may be present. 5-34 What is the correct management5-33 What will the further management for bleeding from an episiotomy?be once a perineal and vaginal tear has 1. If the episiotomy has not yet been stitched,been excluded and the bleeding persists? it should be repaired. Make sure that allThe patient is put into the Lithotomy position. bleeding stops.A good light and a cervical suturing pack must 2. If the episiotomy has already been repaired,be available. The cervical suturing pack contains the stitches must be removed and thethree swab holders, a Sims speculum (or bleeding vessels must be identified and tiedAuvard’s speculum) and a Werdheim retractor. off. Then the episiotomy must be resutured.The postpartum cervix is very floppy and it canbe difficult to orientate oneself. Also there is 5-35 Which patients are at highoften a lot of blood making vision difficult. risk of a cervical tear?1. The vagina is held open with a posterior 1. Patients who bear down and deliver an inserted Sims speculum (or Auvard’s infant before the cervix is fully dilated. speculum) and an anterior inserted 2. Patients with a rapid labour when the cervix Werdheim retractor. A swab holder is dilates very quickly (a precipitous delivery). placed on the cervix at 12 o’clock to serve 3. Patients who have an instrument delivery. as a marker. A second swab holder is placed next to it. The part of the cervix 5-36 How can you recognise between the swab holders is inspected for an inverted uterus? a tear. A third swab holder is placed next to the second swab holder and the part 1. The diagnosis must be considered if a of the cervix between the swab holders patient suddenly becomes shocked during is inspected for a tear. The second swab the third stage of labour without excessive holder is then placed next to the third vaginal bleeding. swab holder and the cervix between them 2. No uterus is palpable on abdominal examined. The process of alternating examination. the second and third swab holders and 3. The uterus lies in the vagina or may even examining the cervix in between is repeated hang out of the vagina. around the cervix until one reaches the first ‘marker’ swab holder. The entire cervix will 5-37 What is the management of a then have been thoroughly examined. patient with an inverted uterus?2. If a cervical tear is found, two swab holders 1. Two fast running intravenous infusions are placed on both sides of the tear and if must be started to treat the shock. downward traction allows the full length 2. The patient must be transferred to a level 2 of the tear to be seen, the tear is sutured. or 3 hospital as an emergency. If the apex of the tear cannot be seen the patient needs to be taken to theatre and Bleeding disorders can also result in consent signed and preparations made for postpartum haemorrhage. Placental abruption a possible hysterectomy. is the commonest cause of a bleeding disorder3. In theatre a bi-manual examination and in the third stage of labour. In this situation exploration of the uterine cavity with two it is extremely important to ensure that the fingers for retained placental tissue is done. uterus is well contracted after the delivery of If the apex of the cervical laceration is the placenta. The powerful contraction of the seen, the tear is sutured. Larger tears will
    • 102 INTRAPAR TUM CAREuterus plays a greater role than blood clotting Procedures aimed at preventing the infection ofin the prevention of bleeding. staff with HIV must be strictly enforced.PROTECTING THE STAFF CASE STUDY 1FROM HIV INFECTIONDURING LABOUR Following normal first and second stages of labour, the third stage of labour is actively managed. The patient was not hypertensive5-38 What should be done during during her pregnancy and does not have alabour to prevent the staff from history of heart valve disease. Syntometrine isbecoming infected with the human given by intramuscular injection and the patientimmunodeficiency virus (HIV)? is observed for signs of placental separation.All patients should be regarded as beingpotentially infected with HIV, the virus which 1. Were the necessary precautions takencauses AIDS (acquired immunodeficiency before giving the Syntometrine ?syndrome). The virus is present in blood, No. A second twin must be excluded beforeliquor and placental tissue. Contamination giving the Syntometrine.of the eyes or cuts on the hands or arms, andpricks by contaminated needles carry a small 2. Is the third stage of labour beingrisk of causing infection. correctly managed by the active method?Therefore, the following precautions should be No. The placenta must be delivered whentaken for all deliveries: the uterus contracts. If the active method of1. The person conducting the delivery must managing the third stage is used, it is incorrect wear gloves and a plastic apron. A face to wait for signs of placental separation. mask and goggles are recommended. People wearing glasses need only a mask to 3. How soon after giving the Syntometrine protect their face. does the uterus contract?2. Any person who resuscitates the infant or cleans the labour ward after the delivery Syntometrine includes oxytocin which causes must wear gloves. uterine contractions two to three minutes after3. The umbilical cord must be squeezed intramuscular administration. to empty it of blood before applying the second clamp. This will prevent blood 4. What should have been done as spurting out when the cord is cut. soon as the uterus contracted?4. Injection needles must be placed in a The umbilical cord should have been steadily sharps container immediately after being pulled with one hand while the other hand was used. Needles must not be replaced into pushing upwards on the uterus, i.e. controlled their sheaths. cord traction. Placental separation and then5. When an episiotomy is repaired, the needle placental delivery occur with the uterine must only be held with needle holder and contraction. the tissues with forceps.6. The needle should be cut loose from the suture material and replaced in the dish as soon as possible. When the needle is to be used again, it must be held in a safe manner with forceps.
    • THE THIRD STAGE OF LABOUR 1035. What should be done if placental 3. What should be done in a peripheralseparation does not take place with clinic if the placenta is retained?the first uterine contraction? The patient should be transferred to a hospitalA second uterine contraction will occur five with theatre facilities for a manual removal ofto six minutes after giving Syntometrine by the placenta under general anaesthesia.intramuscular injection due to the action ofthe ergometrine. A second attempt must now 4. What complication is this patientbe made to deliver the placenta by controlled at high risk of developing?cord traction. Most placentas which are notdelivered with the first contraction will be A postpartum haemorrhage due to an atonicdelivered with the second contraction. uterus. 5. What should have been doneCASE STUDY 2 in this case to make the patient’s transfer to hospital safer?A patient with normal first and second stages An intravenous infusion of 20 units oxytocinof labour has been delivered by a midwife in 1000 ml Basol or normal saline shouldworking alone at a peripheral clinic. A second have been started. She should also have beentwin is excluded on abdominal examination carefully observed to make sure that the uterusand the passive method is used to manage the was well contracted. Make sure that the uterusthird stage of labour. After 30 minutes there remains well contracted, and measure thehas been no sign of placental separation. A blood pressure and pulse rate every 15 minutesdiagnosis of retained placenta is made and the until the patient is transferred.doctor in the nearest district hospital phoned.The doctor agrees to accept the patient andarranges ambulance transfer to the hospital. CASE STUDY 31. Is the diagnosis of a retained After normal first and second stages of labourplacenta correct? in a grande multipara, the placenta is deliveredNo. The diagnosis of retained placenta can by the active management of the third stageonly be made if the placenta is not delivered of labour. There are no complications. Halfafter the active method of managing the third an hour later you are called to see the patientstage of labour has been used. The correct as she is bleeding vaginally. You immediatelydiagnosis is a prolonged third stage of labour. measure her blood pressure which indicates that she is shocked.2. What should have been done in thiscase of a prolonged third stage of labour? 1. Was the patient’s third stage of labour correctly managed?The placenta should have been delivered bythe active method of managing the third No. As the patient falls into a high risk groupstage of labour, i.e. by giving oxytocin 10 for postpartum haemorrhage, an intravenousunits intramuscular and using controlled infusion should have been started during thecord traction. first stage of labour. Twenty units of oxytocin should have been added to the infusion after the placenta was delivered. The patient should also have been carefully observed to make sure that the uterus remained well contracted.
    • 104 INTRAPAR TUM CARE2. Do you agree that the first step in the examination the cervix was found to be 7 cmmanagement of postpartum haemorrhage dilated and paper thin. When observationsis to measure the blood pressure? were made an hour after delivery of the placenta, the patient was found lying in a poolNo. The first step should be to rub up the of blood. Her uterus was well contracted anduterus in order to stop the bleeding. her bladder was empty.3. What should be the further 1. What should be the next step inmanagement of this patient? the management of this patient?A rapid intravenous infusion of 20 units A rapid intravenous infusion of 20 unitsoxytocin in 1000 ml Basol or normal saline oxytocin in 1000 ml Plasmalyte B or normalshould be started. Make sure that the uterus is saline should be started and you should makewell contracted. Then check that the patient’s sure that the uterus is well contracted.bladder is empty as a full bladder can causerelaxation of the uterus. 2. In spite of this management a continuous trickle of bright red4. What additional management blood is observed. What is the mostis needed for this patient? likely cause of the bleeding?The cause of the bleeding must now be found. A tear.The two important causes of postpartumhaemorrhage are an atonic uterus or a tear. 3. Why is this patient at high risk of a cervical tear?5. What is the most probable cause of thispatient’s postpartum haemorrhage? Because the infant was delivered through an incompletely dilated cervix.As she is a grande multipara the most likelycause is an atonic uterus. 4. What should be the next step in the management of this patient?6. What are the clinical signs ofbleeding due to an atonic uterus? The patient must be placed in the lithotomy position and be examined for a vaginal orThe uterus will not be well contracted and perineal tear. Any tear must be sutured.will tend to relax after it is rubbed up. Inaddition, the bleeding is not continuous butoccurs in episodes, and the blood consists of 5. The midwife who is managing thisdark red clots. patient does not find either a vaginal or perineal tear. What should be the next step in the management of this patient?CASE STUDY 4 A doctor should examine the patient for a cervical tear. The most likely site of a tear is theA primigravid patient who did not co-operate cervix as this patient probably delivered beforewell during the first stage of labour delivers full cervical dilatation.soon after a vaginal examination. At the
    • 6 Managing pain during labourBefore you begin this unit, please take the Analgesics must not be confused withcorresponding test at the end of the book to sedatives which do not relieve pain but onlyassess your knowledge of the subject matter. You make the patient drowsy.should redo the test after you’ve worked throughthe unit, to evaluate what you have learned 6-2 What is anaesthesia? Anaesthesia means the loss of all sensation, Objectives including pain. Local anaesthesia causes the loss of all sensation in that region of the body. With general anaesthesia the patient loses When you have completed this unit you consciousness. should be able to: • Explain the differences between 6-3 What causes pain during labour? analgesia, anaesthesia and sedation. Pain in labour is caused by: • List the causes of pain in labour. 1. Contractions: They progressively increase • List which drugs can be given during in duration and frequency during the first labour for analgesia. stage of labour and, therefore, become • Ensure that a patient has adequate pain more painful. Contractions are most relief during labour. painful when the cervix is fully dilated and • List the dangers of the drugs which can the patient has an urge to bear down. At first the pain is felt over the abdomen but be used for pain relief. later, when the cervix is nearly fully dilated, • Prepare a patient for general pain is felt in the lower back. anaesthesia. 2. Cervical dilatation: This is due to uterine contractions and pressure of the presenting part on the cervix.PAIN RELIEF IN LABOUR 3. Vaginal examinations and procedures: Any vaginal examination is uncomfortable and for many patients is6-1 What is analgesia? also painful. This is particularly so when a forceps delivery, a vacuum extraction orAnalgesia means the relief of pain. Drugs an episiotomy is performed.used to relieve pain are called analgesics.
    • 106 INTRAPAR TUM CAREThe amount of pain experienced by patients A calm, considerate and caring attitude fromin labour is very variable. Some patients have those who are attending the patient in labourlittle pain, while others have severe pain, even is important. Thorough but gentle clinicalduring early labour. examinations, rubbing the patient’s back and talking to her all do much to relieve the stress6-4 What will make the pain worse? of labour and to some extent the pain.Anxiety, fear and uncertainty lower the pain Most patients find it helpful to have someonethreshold. This is particularly noticeable with them during labour. A lay person or doulain primigravid patients, especially if they can fulfill this role perfectly well. A patientare very young. Pain increases the patient’s should be encouraged to have her husband,anxiety, which in turn reduces her ability to a family member or someone else that shetolerate pain. knows well to stay with her during labour.6-5 What general or non pharmacological Antenatal preparation and emotional supportmeasures will contribute to are important in reducing anxiety and painreduce pain during labour? during labour.1. Knowledge of what to expect during labour. This important information should NOTE Rubbing a patient’s lower back is of great be provided during antenatal visits to help as the nerve impulses that come from patients that will be experiencing labour the skin over the lower back travel to the same for the first time. spinal segments as the nerve impulses from2. A pleasant environment and the support the cervix and uterus. The nerve impulses from the lower back, therefore, partially block those and encouragement of those who are from the uterus and cervix. As a result, the pain attending to the patient. of contractions is experienced as less painful3. The help and support of a family member, by the patient if the lower back is rubbed. partner, friend or doula is of great value.4. Allowing patients to walk around during labour. USE OF ANALGESICS6-6 Why are the environment and IN LABOURemotional support importantto a patient in labour? 6-7 Why do you need to give aA patient should be prepared for her labour patient analgesia during labour?during the antenatal period. Primigravidasmust be told in simple terms what is going to 1. As health workers, one of our primaryhappen during labour. Relaxation exercises responsibilities is to relieve pain andand breathing methods can help patients suffering. All too often pain duringprepare for labour, and should be taught as labour is regarded as part of a normalpart of antenatal care. process. Therefore, during labour patients should frequently be asked whether theyDuring labour, particularly during the latent need pain relief. If required, the mostphase and early in the active phase of the first appropriate and effective form of analgesiastage, patients may be encouraged to walk available must be given.around and not spend all the time in bed in 2. The relief of pain often allows labour tothe labour ward. This reduces the amount progress more rapidly by reducing theof pain experienced during contractions. In anxiety which is caused by pain. It isaddition contractions will be more effectiveresulting in labour progressing faster.
    • MANAGING PAIN DURING LABOUR 107 well known that anxiety may cause poor • Opiates, e.g. pethidine. progress during labour. • Inhalational analgesia, i.e. nitrous oxide with oxygen. • Local anaesthesia. The relief of pain is very important and must • Epidural anaesthesia. receive careful attention when a patient is cared • General anaesthesia. for during labour. 6-11 Which analgesic drug is commonly6-8 Should all patients in used in the first stage of labour?labour receive analgesia? Pethidine. This drug is a powerful analgesic butNo. Some patients have little pain in labour commonly causes nausea and vomiting as a sideand, therefore, may not need an analgesic. effect. Pethidine also produces some sedation.Other patients feel that they are able totolerate the pain of uterine contractions, e.g. 6-12 What drug is often givenby concentrating on their breathing, and together with pethidine?choose not to have analgesia. It is importantto consider the patient’s wishes when deciding Promethazine (Phenegan) or hydroxyzinewhether or not to give analgesia. However, (Aterax). They combine well with pethidinemost patients do need analgesia during labour. for three reasons: 1. They have a tranquillising effect which6-9 When do you give analgesia makes the patient feel more relaxed.to a patient in labour? 2. They have an anti-emetic effect, reducing the nausea and vomiting due to pethidine.1. In the first stage of labour: 3. They increase the analgesic effect of • When patients ask for pain relief. pethidine. • When patients experience painful uterine contractions during a normal The dose of promethazine is 25 mg and labour. hydroxyzine is 100 mg, irrespective of the • When patients have painful amount of pethidine given. contractions and in addition require oxytocin stimulation of labour. 6-13 What are the actions of pethidine? • When patients have painful It is a powerful analgesic but causes depression contractions with slow progress during of the central nervous system. Large doses can, the active phase of the first stage of therefore, cause respiratory depression. A drop labour, e.g. with an occipito-posterior in blood pressure may also occur. Pethidine position. crosses the placenta and can cause respiratory2. In the second stage of labour: depression in the newborn infant who may, • When an episiotomy is done. therefore, need resuscitation at birth. • When an instrumental delivery is done.3. In the third stage of labour: Morphine, which is less commonly used, has • When an episiotomy or perineal tear is similar actions and side effects to pethidine. repaired. Pethidine and morphine may temporarily affect the cardiotocogram with the fetal heart rate6-10 What methods of providing tracing showing loss of beat-to-beat variation.analgesia can you use?1. General measures as mentioned in sections An overdose of pethidine may cause respiratory 6-5 and 6-6 above. depression in both the mother and her infant.2. Specific methods:
    • 108 INTRAPAR TUM CARE6-14 How is pethidine usually given and 6-17 How often may pethidinehow long is its duration of action? be given in labour?1. The intramuscular route: If an adequate dose of intramuscular pethidine • This is the commonest method of is given, it is usually not necessary to repeat giving pethidine, especially with a the drug within four hours. (In South Africa cervical dilatation of less than 7 cm. registered nurses are allowed by law to give • Pain relief will be experienced about 30 100 mg pethidine by intramuscular injection minutes after administration and the during labour, without a doctor’s prescription, duration of action will be about four and to repeat the injection after an interval of hours, although this varies from patient four hours or more.) to patient.2. The intravenous route: • This method may be used if the patient NALOXONE requires analgesia urgently and the cervix is already 7 cm or more dilated. • Pain relief is experienced within five 6-18 How should you treat minutes and the duration of action will respiratory depression due to be about two hours. pethidine in a newborn infant? Naloxone (Narcan) is a specific antidote to6-15 What dose of pethidine pethidine (and morphine) and will reverse theshould be given? effects of the drug.1. The intramuscular route: Two mg per kg If a patient was given pethidine during body weight. Therefore, 100 to 150 mg is labour, and delivers an infant who does not usually given. Patients weighing less than breathe well after birth, the infant should be 50 kg must receive 75 mg. given naloxone (Narcan). The correct dose of2. The intravenous route: One mg per kg Narcan is 0.1 mg/kg (i.e. 0.25ml/kg). A 1 ml body weight. Therefore, 50 to 75 mg is ampoule contains 0.4 mg naloxone. Therefore, usually given. Obese patients weighing an average sized infant requires 0.75 ml while more than 75 kg must not receive more a large infant up to 1 ml naloxone. Do not than 75 mg. An intravenous infusion must give naloxone to asphyxiated infants whose first be started before the drug is given. mothers have not received pethidine (or morphine). Naloxone will not reverse the6-16 How close to full dilatation respiratory depression caused by barbituratesmay pethidine be given? (e.g. phenobarbitone), benzodiazepines (e.g.There is no limit to how late in labour Valium) or a general anaesthetic.pethidine can be given. If the patient needs Research has shown that the previouslyanalgesia she should be given the appropriate recommended dose (0.01 mg/kg) of Neonataldose. However, if she receives pethidine within Narcan is tenfold too low. The use of Neonatalsix hours of delivery, the infant may have Narcan must, therefore, be stopped andrespiratory depression at birth. replaced with adult Narcan. Pethidine may be given late in labour if needed. Infants who do not breathe well after delivery should only receive naloxone if their mothers were given pethidine or morphine during labour.
    • MANAGING PAIN DURING LABOUR 1096-19 How should naloxone be given? INHALATIONALUsually naloxone is given to a newborn ANALGESIAinfant by intramuscular injection into theanterolateral aspect of the thigh. The drug willreverse the effects of pethidine. Meanwhile, it 6-22 What inhalationalis important to continue ventilating the infant. analgesia is available?Naloxone can also be given intravenously.The drug acts more rapidly when given The most commonly used inhalationalintravenously, e.g. into the umbilical vein. analgesic is Entonox. This is a mixture of 50% nitrous oxide and 50% oxygen. It is usually supplied in cylinders and is breathed in by6-20 Is a single dose of naloxone adequate? the patient through a mask when she needsYes. A single dose of naloxone is almost always pain relief.adequate to reverse the respiratory depression The advantages of Entonox are:caused by pethidine. The action lasts about30 minutes. Some infants may become 1. It is safe for mother and fetus.lethargic after 30 minutes and may then 2. It is short acting.require a second dose of naloxone. 3. It acts quickly. The disadvantages of Entonox are:SEDATION IN LABOUR 1. It is expensive. 2. It requires special apparatus for administration.6-21 Are sedatives useful in labour? 3. It is not always effective because the patient needs to start inhaling the gas as soon asIn practice there are very few indications the contraction starts for the analgesicfor the use of sedatives in labour. If a effect to be present during the peak ofpatient is restless or distressed, it is almost the contraction. Many patients start thealways because of pain and she, therefore, inhalation too late.needs analgesia. The tranquillising effect of 4. Patients often hyperventilate and get ‘pinspromethazine (Phenegan) or hydroxyzine and needles’ in their face and hands.(Aterax) together with pethidine will providesufficient sedation for a restless patient. The 6-23 Which patients shoulddose is 25 mg promethazine (Phenegan) and preferably use entonox?100 mg hydroxyzine (Aterax). A patient requiring analgesia for the first timeThere is no role for sedation with diazepam in advanced labour, where the delivery is(Valium) and barbiturates. Sedatives may expected within an hour.also cross the placenta and sedate theinfant. Diazepam (Valium) can cause severerespiratory depression in the infant and this 6-24 Does entonox have anyeffect is not reversed by naloxone. serious side effects? No. Entonox is completely safe and cannot be used in excessive doses. Entonox is a completely safe analgesic.
    • 110 INTRAPAR TUM CARELOCAL ANAESTHESIA 6-28 What is the duration of action of lignocaine? Lignocaine results in loss of sensation in the6-25 What is a local anaesthetic? infiltrated area for 45 minutes. If the maximumLocal anaesthetics are drugs which are injected dose has already been given but more localinto the tissues and which result in a loss anaesthetic is required, a further 10 ml of 1%of all sensation in the injected area. Local lignocaine may be given after 30 minutes.anaesthetics often give a burning sensationwhich lasts one to two minutes while they arebeing injected. The patient should be warned EPIDURAL ANAESTHESIAabout this before starting the injection.Lignocaine (Xylocaine) is the local anaesthetic 6-29 What are the indicationsused most commonly. Although available in for epidural anaesthesia?different concentrations it is best to only usethe 1% solution. The possibility of giving an 1. When there is poor progress during theoverdose will then be reduced. active phase of the first stage of labour, e.g. due to an occipito-posterior position.6-26 When should you use 2. When ineffective uterine contractions area local anaesthetic? present, prior to starting oxytocin. 3. When it is important to prevent bearingThere are two main indications for local down before a patient’s cervix is fullyanaesthesia in labour: dilated, e.g. with a preterm infant or a1. When performing an episiotomy, or when breech presentation. repairing an episiotomy or perineal tear. 4. Caesarean sections may also be done under2. When performing a pudendal block. The epidural anaesthesia. local anaesthetic acts on the pudendal This is the ideal form of local anaesthesia nerves, and is usually given before an as it offers the patient complete pain relief. instrumental delivery. Unfortunately special training and equipment are necessary for giving epidural anaesthesia6-27 What are the risks of and, therefore, it is only available in most levellocal anaesthesia? 2 and 3 hospitals.1. Too much local anaesthetic is dangerous and may cause convulsions. The 6-30 What special nursing care is required maximum dose of a 1% solution of following an epidural anaesthetic? lignocaine (Xylocaine) for a patient of 1. There is a danger of hypotension following average size is 20 ml. the administration of the first and each2. A local anaesthetic can cause convulsions if further dose of the local anaesthetic. The it is injected into a vein in error. blood pressure must be taken every fiveThe maximum safe dose of lignocaine minutes for 30 minutes following eachis 3 mg/kg body weight. One ml of a 1% dose of the local anaesthetic.lignocaine solution contains 10 mg lignocaine. 2. Depending on the amount of anaesthesia achieved, patients often cannot pass urine. A Foley’s catheter is, therefore, often An overdose, or intravenous injection, of a local required until the effect of the anaesthesia anaesthetic may cause convulsions. wears off.
    • MANAGING PAIN DURING LABOUR 111GENERAL ANAESTHESIA which contain particles that can cause a chemical pneumonitis if the drug is aspirated.6-31 What are the dangers for apregnant or postpartum patient when CASE STUDY 1receiving a general anaesthetic?Any pregnant or postpartum patient who A patient and her husband present at thereceives a general anaesthetic has a very high maternity hospital. She is 26 years old, gravidarisk of vomiting and aspirating stomach 2 para 1 and at term. Her antenatal course hascontents because: been normal and her routine observations on admission are also normal. The fetal1. Stomach emptying is delayed. presentation is cephalic with 2/5 of the fetal2. The tone of the sphincter in the lower head palpable above the pelvic brim. The oesophagus is reduced. membranes rupture spontaneously and her3. The intra-abdominal pressure is increased. cervix is found to be 5 cm dilated on vaginalPatients who have been starved must be examination. The patient is relaxed and doesmanaged in the same way as patients who have not find her contractions painful. She isrecently eaten. During a general anaesthesic, admitted to the labour ward and given 100 mgthe risk of the patient vomiting is particularly pethidine and 100 mg hydroxyzine (Aterax)high during intubation and extubation. by intramuscular injection as she is already in the active phase of the first stage of labour. Her husband is asked to wait outside the6-32 What precautions must be labour ward. It is suggested that he go hometaken preoperatively that will for a while as the infant is unlikely to be bornreduce the dangers of vomiting? during the next five or six hours.1. A patient who may require a general anaesthetic should be kept nil per mouth 1. Has the patient been correctly managed? (i.e. she should be starved).2. Metoclopramide (Maxalon) 20 mg (two No. She did not require analgesia. Not all ampoules) should be given intravenously patients need analgesia during labour. Some 15 minutes before the induction of general patients experience little pain during labour anaesthesia. Metoclopramide is an anti- while others handle the pain of contractions emetic (prevents vomiting), it speeds up with no difficulty. emptying of the stomach and it increases the tone of the lower oesophagus. The drug 2. What would have been the correct acts for about two hours. management of this patient?3. The gastric acid must be neutralised by The patient should have been reassured that an antacid before the induction of general her labour was progressing normally. She anaesthesia. Usually 30 ml of a 0.3 molar should have been encouraged to walk about solution of sodium citrate is given. If and not spend all the time in bed. Analgesia induction of anaesthesia is not started need not be given routinely to all patients in within 30 minutes of the sodium citrate active labour. being given, the 30 ml dose should be repeated. 3. Do you agree with the handlingSodium citrate is cheap and can be made up of the patient’s husband?by any pharmacist. It is an electrolyte solutionand, therefore, preferable to other antacids No. Most patients prefer to have someone they know well remain with them during labour. Her
    • 112 INTRAPAR TUM CAREhusband should have been encouraged to stay very painful while the pain in turn makes herwith her if that was what the patient wanted. even more anxious.4. What should the husband do if he 2. What should have been donestays with his wife during labour? during the antenatal period to avoid the present situation?Simply being there is reassuring to thepatient. He can help to keep her relaxed and Receiving good information about thecomfortable. Furthermore, he can be shown process of labour at antenatal visits, attendinghow to rub her back during contractions. antenatal exercise classes and visiting the labour ward during the last weeks of5. Is it of any value to rub a patient’s pregnancy would have resulted in a far moreback during contractions, or is it relaxed patient in labour.only an ‘old wife’s tale’ that has noplace in modern midwifery? 3. What should have been done in the labour ward to reduce her anxiety?Rubbing a patient’s lower back is of great helpas the nerve impulses that come from the skin She should have experienced a pleasantover the lower back travel to the same spinal atmosphere in the labour ward withsegments as the nerve impulses from the cervix understanding and encouragement from theand uterus. The nerve impulses from the lower staff. They should have reassured her thatback, therefore, partially block those from everything was under control and that therethe uterus and cervix. As a result, the pain of was no reason for her to be frightened. Thecontractions is experienced as less painful by staff themselves should appear confident,the patient if the lower back is rubbed. relaxed and caring. It is important that a family member or friend of the patient’s remain with her.CASE STUDY 2 4. Should the doctor prescribe 10 mgA 16-year-old patient presents in labour at of intravenous diazepam (Valium)term after a normal pregnancy. She is very because the patient is unmanageable?anxious, does not co-operate with the labour No. Sedatives, especially diazepam, should beward staff and complains of unbearable pain used very rarely because they may result induring contractions. She bears down with severe respiratory depression in the infant atevery contraction even though the cervix is birth. This complication is not reversed by theonly 4 cm dilated. The patient is told to behave commonly available drugs at delivery.herself. She is informed that the worst partof labour is still to come and is scolded for 5. What would have been the correctbecoming pregnant. As she is a primigravida, management of labour for thisshe is promised analgesia when her cervix patient, beside reassurance?reaches 6 cm dilatation. She should have been encouraged to1. Why is the patient frightened? concentrate on her breathing during contractions. In addition she should have beenBecause she is unprepared for labour and given adequate analgesia as soon as possible.does not know what to expect. In addition,she is in a strange environment and the staffare unfriendly and aggressive. Being anxiousresults in her experiencing her contractions as
    • MANAGING PAIN DURING LABOUR 1136. What form of analgesia should 4. What would be the best route ofhave been given to this patient? administering the pethidine to this patient?The ideal form of analgesia for this patient The pethidine should preferably be givenwould have been an epidural anaesthetic as intravenously. Pain relief will then be obtainedit provides complete pain relief. Alternatively in five minutes and the effect of the drugshe should have been given pethidine and should last two hours.promethazine (Phenegan) or hydroxyzine(Aterax) by intramuscular injection. The 5. The infant is delivered 45 minutestranquillising effect of promethazine or after the pethidine is given. Whathydroxyzine would have helped to lessen her complication of the drug may beanxiety. present in the infant at delivery? The infant may have respiratory depression and as a result may not breathe adequately at birth.CASE STUDY 3 6. How should the infant be managedCervical dilatation in a multigravid patient if the breathing is inadequatein labour at term progresses from 3 cm to (i.e. the infant has asphyxia)?8 cm in four hours. Now for the first timeshe complains that her contractions are very The infant must be resuscitated with artificialpainful. The doctor informs the midwife that respiration provided via a face mask orshe is progressing fast and that her cervix will endotracheal tube. Naloxone (Narcan) cansoon be fully dilated. He adds that the patient be given to the infant to reverse the effect ofmust just continue without analgesia for the the pethidine. Naloxone is usually given bylast two hours as the delivery will soon be over. intramuscular injection. However, it acts more rapidly if it is given into the umbilical vein.1. Do you agree with thepatient’s management?No. The patient needs analgesia and the most CASE STUDY 4appropriate form of analgesia should beoffered to her. A multigravid patient, who has had two previous Caesarean sections, is booked for an elective Caesarean section under2. What would be the best form of general anaesthesia at 39 weeks gestation.analgesia to offer this patient? The patient is admitted to hospital at 07:00,Entonox (nitrous oxide with oxygen) as it having had nothing to eat since midnight.works rapidly and is completely safe. She also She is prepared for surgery at 08:00. As theonly needs analgesia for a short time as her patient has been kept ‘nil by mouth’ no drugcervix will soon be fully dilated. to prevent vomiting during intubation and extubation is given. Only an intravenous3. If Entonox is not available or if infusion is started and a Foley’s catheterthe patient is unable to use Entonox passed before she is moved to theatre.correctly, what other form ofanalgesia should be considered? 1. Do you agree that a drug to prevent vomiting is not needed as the patient hasPethidine and promethazine (Phenegan) or had nothing to eat or drink for eight hours?hydroxyzine (Aterax). No. All pregnant patients are at risk of vomiting during general anaesthesia even if
    • 114 INTRAPAR TUM CAREthey have taken nothing by mouth during the anaesthesia. It is an anti-emetic, it increasespast few hours. the stomach emptying time and raises the sphincter tone of the lower oesophagus. These2. Why should a pregnant patient who effects will reduce the danger of vomiting. Anhas not eaten overnight still be at risk of antacid should also be given before the generalvomiting during a general anaesthetic? anaesthetic. The drug of choice is 30 ml of a 0.3 molar solution of sodium citrate.Because her stomach has a delayed emptyingtime, the lower oesophageal tone is reduced 4. Both these drugs are given at 07:45.and she has a raised intra-abdominal pressure. However, due to a delay, the patient is only taken to theatre at 08:30. Is it3. What preventative measures should have necessary to repeat either of these drugs?been carried out during the pre-operativepreparation of the patient for theatre? The metoclopramide (Maxalon) acts for two hours so need not be repeated. However, theMetoclopramide (Maxalon) 20 mg (two sodium citrate acts for only 30 minutes and,ampoules) must be given intravenously therefore, must be repeated before the start of15 minutes before the induction of the anaesthetic.
    • 7 The puerperiumBefore you begin this unit, please take the THE NORMALcorresponding test at the end of the book toassess your knowledge of the subject matter. You PUERPERIUMshould redo the test after you’ve worked throughthe unit, to evaluate what you have learned. 7-1 What is the puerperium? The puerperium is the period from the end Objectives of the third stage of labour until most of the patient’s organs have returned to their pre- pregnant state. When you have completed this unit you should be able to: 7-2 How long does the puerperium last? • Define the puerperium. • List the physical changes which occur The puerperium starts when the placenta is delivered and lasts for six weeks (42 days). during the puerperium. However, some organs may only return to • Manage the normal puerperium. their pre-pregnant state weeks or even months • Diagnose and manage the various after the six weeks have elapsed (e.g. the causes of puerperal pyrexia. ureters). Other organs never regain their pre- • Recognise the puerperal psychiatric pregnant state (e.g. the perineum). disorders. It is important for the midwife or doctor • Diagnose and manage secondary to assess whether the puerperal patient has postpartum haemorrhage. returned, as closely as possible, to normal • Teach the patient the concept of ‘the health and activity. mother as a monitor’. The puerperium starts when the placenta is delivered and lasts for six weeks. 7-3 Why is the puerperium important? 1. The patient recovers from her labour, which often leaves her tired and even
    • 116 INTRAPAR TUM CARE exhausted. There is, nevertheless, a feeling 3. Abdominal wall: of great relief and happiness. • The abdominal wall is flaccid (loose2. The patient undergoes what is probably the and wrinkled) and some separation most important psychological experience of (divarication) of the abdominal her life, as she realises that she is responsible muscles occurs. for another human being, her infant. • Pregnancy marks (striae gravidarum),3. Breastfeeding should be established. where present, do not disappear but do4. The patient should decide, with the tend to become less red in time. guidance of a midwife or doctor, on an 4. Gastrointestinal tract: appropriate contraceptive method. • Thirst is common. • The appetite varies from anorexia to7-4 What physical changes ravenous hunger.occur in the puerperium? • There may be flatulence (excess wind). • Many patients are constipated as aAlmost every organ undergoes change in the result of decreased tone of the bowelpuerperium. These adjustments range from during pregnancy, decreased foodmild to marked. Only those changes which are intake during labour and passingimportant in the management of the normal stool during the late first stage andpuerperium will be described here. second stage of labour. Constipation1. General condition: is common in the presence of an • Some women experience shivering episiotomy or painful haemorrhoids. soon after delivery, without a change in The routine administration of enemas body temperature. when patients are admitted in labour • The pulse rate may be slow, normal or is unnecessary and is not beneficial to fast, but should not be above 100 beats patients. It also causes constipation during per minute. the puerperium. • The blood pressure may also vary and 5. Urinary tract: may be slightly elevated in an otherwise • Retention of urine is common and healthy patient. It should, however, be may result from decreased tone of the less than 140/90 mm Hg. bladder in pregnancy and oedema of • There is an immediate drop in weight the urethra following delivery. Dysuria of about 8 kg after delivery. Further and difficulty in passing urine may weight loss follows involution of lead to complete urinary retention, or the uterus and the normal diuresis retention with overflow incontinence. (increased amount of urine passed), but A full bladder will interfere with also depends on whether the patient uterine contraction. breastfeeds her infant. • A diuresis usually occurs on the2. Skin: second or third day of the puerperium. • The increased pigmentation of the face, In oedematous patients it may start abdominal wall and vulva lightens but immediately after delivery. the areolae may remain darker than • Stress incontinence (a leak of urine) they were before pregnancy. is common when the patient laughs • With the onset of diuresis the general or coughs. It may first be noted in puffiness and any oedema disappear in the puerperium or follow stress a few days. incontinence which was present during • Marked sweating may occur for some pregnancy. Often stress incontinence days. becomes worse initially but tends to improve with time and with pelvic floor exercises.
    • THE PUERPERIUM 117 Pelvic floor exercises are also known as fingers. By the 7th day postpartum the pinch or ‘knyp’ exercises. The muscles that cervical os will have closed. are exercised are those used to suddenly • Uterus: The most important change stop a stream of urine midway through occurring in the uterus is involution. micturition. These muscles should be After delivery the uterus is about the tightened, as strongly as possible, 10 times in size of a 20 week pregnancy. By the end succession on at least four occasions a day. of the first week it is about 12 weeks Normal bladder function is likely to be in size. At 14 days the fundus of the temporarily impaired when a patient has uterus should no longer be palpable been given epidural analgesia. Complete above the symphysis pubis. After six retention of urine or retention with weeks it has decreased to the size of a overflow may occur. normal multiparous uterus, which is6. Blood: slightly larger than a nulliparous one. • The haemoglobin concentration This remarkable decrease in size is the becomes stable around the 4th day of result of contraction and retraction the puerperium. of the uterine muscle. The normally • The platelet count is raised and the involuting uterus should be firm and platelets become more sticky from the non tender. The decidua of the uterus 4th to 10th day after delivery. These necroses (dies), due to ischaemia, and is and other changes in the clotting shed as the lochia. The average duration (coagulation) factors may cause of red lochia is 24 days. Thereafter, the thrombo-embolism in the puerperium. lochia becomes straw coloured. Normal7. Breasts: lochia has a typical, non-offensive smell. Marked changes occur during the Offensive lochia is always abnormal. puerperium with the production of milk.8. Genital tract: Very marked changes occur in the genital MANAGEMENT OF tract during the puerperium: THE PUERPERIUM • Vulva: The vulva is swollen and congested after delivery, but these The management of the puerperium may be features rapidly disappear. Tears or an divided into three stages: episiotomy usually heal easily. • Vagina: Immediately after delivery 1. The management of the first hour after the vagina is large, smooth walled, delivery of the placenta (sometimes called oedematous and congested. It rapidly the fourth stage of labour). shrinks in size and rugae return by the 2. The management of the rest of the third week. The vaginal walls remain puerperium. laxer than before and some degree of 3. The six week postnatal visit. vaginal prolapse (cystocoele and/or rectocoele) is common after a vaginal 7-5 How should you manage the delivery. Small vaginal tears, which are patient during the first hour after very common, usually heal in seven to the delivery of the placenta? 10 days. The two main objectives of managing the first • Cervix: After the first vaginal delivery hour of the puerperium are: the circular external os of the nullipara becomes slit-like. For the first few 1. To ensure that the patient is, and remains, days after delivery the cervix remains in a good condition. partially open, admitting one or two 2. The prevention of a postpartum haemorrhage (PPH).
    • 118 INTRAPAR TUM CARETo achieve these, you should: 3. Allowed to bond with her infant. 4. Allowed to rest for as long as she needs to.1. Perform certain routine observations.2. Care for the needs of the patient.3. Get the patient’s co-operation in ensuring 7-8 How can the patient help to prevent that her uterus remains well contracted postpartum haemorrhage during and that she reports any vaginal bleeding. the first hour of the puerperium?The correct management of the first hour of 1. The patient should be shown how tothe puerperium is most important as the risk observe:of postpartum haemorrhage is greatest at this • The height of the uterine fundus intime. relation to the umbilicus. • The feel of a well-contracted uterus. • The amount of vaginal bleeding.7-6 Which routine observations 2. She should be shown how to ‘rub up’ theshould you perform in the first hour uterus.after delivery of the placenta? 3. She should be told that if the uterine1. Immediately after the delivery of the fundus rises or the uterus relaxes or if placenta you should: vaginal bleeding increases, she must: • Assess whether the uterus is well • Immediately call the midwife. contracted. • In the meantime rub up the uterus. • Assess whether vaginal bleeding These two important steps may help prevent a appears more than normal. postpartum haemorrhage. • Record the patient’s pulse rate, blood pressure and temperature.2. During the first hour after the delivery The patient can play a very important role in the of the placenta, provided that the above prevention of postpartum haemorrhage. observations are normal, you should: • Continuously assess whether the uterus is well contracted and that no excessive 7-9 When should a postpartum vaginal bleeding is present. patient be allowed to go home? • Repeat the measurement of the pulse This will depend on: rate and blood pressure after one hour. • If the patient’s condition changes, 1. Whether the patient had a normal observations must be done more pregnancy and delivery. frequently until the patient’s condition 2. The circumstances of the hospital or clinic returns to normal. where the patient was delivered. 7-10 When should a patient be Observations during the first hour of the allowed to go home following a puerperium are extremely important. normal pregnancy and delivery? A patient who has had a normal pregnancy7-7 How should you care for the and delivery may be allowed to go homeneeds of the patient during the about six hours after the birth of her infant,first hour of the puerperium? provided:After the placenta has been delivered the 1. The observations done on the mother andpatient needs to be: infant since delivery have been normal.1. Washed. 2. The mother and infant are normal on2. Given something to drink and maybe to eat. examination, and the infant is sucking well.
    • THE PUERPERIUM 1193. The patient is able to attend her nearest 2. A patient who has had a Caesarean section clinic on the day after delivery (day one) will usually stay in hospital for three days and then again on days three and five or longer. after delivery for postnatal care, or be 3. A patient who has had a postpartum visited at home by a midwife on those haemorrhage must be kept in hospital for days. Primigravidas should be seen again at least 24 hours to ensure that her uterus on day seven, especially to ensure that is well contracted and that there is no breastfeeding is well established. further bleeding.4. Patients who received no antenatal care and are delivered without having had any 7-12 How will the circumstances at a clinic screening tests must have a rapid syphilis test or hospital influence the time of discharge? and a rapid Rhesus grouping. Counselling for HIV testing must also be done. 1. Some clinics have no space to5. A postnatal card needs to be completed accommodate patients for longer than six for the mother on discharge as this is the hours after delivery. Therefore, patients who only means of communication between the cannot be discharged safely at six hours will delivery site and the clinic where she will have to be transferred to a hospital. receive postnatal care (figure 7-1). 2. Some hospitals manage patients who live in remote areas where follow up is notA patient should only be discharged home after possible. These patients will have to be keptdelivery if no abnormalities are found when in hospital longer before discharge.the following examinations are performed:1. A general examination, paying particular 7-13 What postnatal care should be attention to the: given during the puerperium after the • Pulse rate. patient has left the hospital or clinic? • Blood pressure. The following observations must be done on • Temperature. the mother: • Haemoglobin concentration.2. An abdominal examination, paying 1. Assess the patient’s general condition. particular attention to the state of 2. Observe the pulse rate, blood pressure and contraction and tenderness of the uterus. temperature.3. An inspection of the episiotomy site. 3. Determine the height of the uterine fundus4. The amount, colour and odour of the lochia. and assess whether any uterine tenderness5. A postnatal was completed for the mother is present. and infant. 4. Assess the amount, colour and odour of the lochia.7-11 When should a patient be 5. Check whether the episiotomy is healingdischarged from hospital following a satisfactorily.complicated pregnancy and delivery? 6. Ask if the patient passes urine normally and enquire about any urinary symptoms.This will depend on the nature of the Reassure the patient if she has not passed acomplication and the method of delivery. For stool by day 5.example: 7. Measure the haemoglobin concentration if1. A patient with pre-eclampsia should the patient appears pale. be kept in hospital until her blood 8. Assess the condition of the patient’s breasts pressure has returned to normal or is well and nipples. Determine whether successful controlled with oral drugs. breastfeeding has been established. The following observations must be done on the infant:
    • 120 INTRAPAR TUM CARE1. Assess whether the infant appears well. 7-15 Which topics should you2. Check whether the infant is jaundiced. include under patient education3. Examine the umbilical stump for signs of in the puerperium? infection. Patient education regarding herself, her4. Examine the eyes for conjunctivitis. infant and her family should not start during5. Ask whether the infant has passed urine the puerperium, but should be part of any and stool. woman’s general education, starting at school.6. Assess whether the infant is feeding well Topics which should be emphasised in patient and is satisfied after a feed. education in the puerperium include: 1. Personal and infant care. The successful establishment of breastfeeding is 2. Offensive lochia must be reported one of the most important goals of patient care immediately. during the puerperium. 3. The ‘puerperal blues’. 4. Family planning.7-14 How often should a patient be 5. Any special arrangements for the nextseen at the nearest clinic to her home pregnancy and delivery.following discharge from the hosital 6. When to start coitus again. Usuallyor clinic where she was delivered? coitus can be started three to four weeks postpartum when the episiotomy or tearsThis will depend on the availability of clinics have healed.and the distance the patient stays from aclinics. Ideally she must be seen on day one,three and five. However, if this is not feasible Patient education is an important and oftena single visit on day three is most valuable to neglected part of postnatal care.identify complications that may occur duringthe puerperium and to provide treatment that 7-16 When should a patient be seen againwill prevent severe complications. A system after postnatal care has been completed?by which clinics are informed about patientsin their drainage area that were discharged The postnatal visit is usually held six weeksfrom hospital following a delivery will be of after delivery. By this time almost all the organgreat value. changes which occurred during pregnancy should have disappeared.7-14 How can you help to establishsuccessful breastfeeding? A patient and her infant should only be dischargedBy providing patient education and motivation. if they are both well and have been referred toThis should preferably start before pregnancy the local maternal and child health clinic, and theand continue throughout the antenatal period patient has received contraceptive counselling.and after pregnancy. Encouragement andsupport are very important during the firstweeks after delivery. The important role ofbreastfeeding in lowering infant mortality in PUERPERAL PYREXIApoor communities must be remembered. 7-20 When is puerperal pyrexia present? A patient has puerperal pyrexia if her oral temperature rises to 38 °C or higher during the puerperium.
    • THE PUERPERIUM 1217-21 Why is puerperal pyrexia important? • Lower abdominal tenderness. • Offensive lochia.Because it may be caused by serious • The episiotomy wound or perineal orcomplications of the puerperium. vaginal tears may be infected.Breastfeeding may be interfered with. Thepatient may become very ill or even die. If possible, an endocervical swab should be taken for microscopy, culture and sensitivity tests. Puerperal pyrexia may be caused by a serious complication of the puerperium. 7-25 How should you manage genital tract infection?7-22 What are the causes of 1. Prevention:puerperal pyrexia? • Strict asepsis during delivery.1. Genital tract infection. • Reduction in the number of vaginal2. Urinary tract infection. examinations during labour to a3. Mastitis or breast abscess. minimum.4. Thrombophlebitis (superficial vein • Prevention of unnecessary trauma thrombosis). during labour.5. Respiratory tract infection. • Isolation of infected patients.6. Other infections. 2. Treatment: • Admit the patient to hospital.7-23 What is the cause of • Measures to bring down thegenital tract infection? temperature, e.g. tepid sponging. • Analgesia, e.g. paracetamol (Panado)Genital tract infection (or puerperal sepsis) 1 g (two adult tablets) orally six-hourly.is caused by bacterial infection of the raw • Intravenous fluids with strict intakeplacental site or lacerations of the cervix, and output measurement.vagina or perineum. • Broad-spectrum antibiotics, e.g.Genital tract infection is usually caused intravenous ampicillin and oralby the group A or group B Streptococcus, metronidazole (Flagyl). If the patientStaphylococcus aureus or anaerobic bacteria. is to be referred, antibiotic treatment must be started before transfer.7-24 How should you diagnose • The haemoglobin concentration mustgenital tract infection? be measured. A blood transfusion must be given if the haemoglobin1. History: concentration is below 8 g/dl. If one or more of the following is present: • Removal of all stitches if the wound is • Preterm or prelabour rupture of the infected. membranes, a long labour, operative • Drainage of any abscess. delivery or incomplete delivery of • If there is subinvolution of the the placenta or membranes may have uterus, an evacuation under general occurred. anaesthetic must be done. • The patient will feel generally unwell. • Lower abdominal pain. 24 hours after starting this treatment the2. Examination: patient’s condition should have improved • Pyrexia, usually developing within the considerably and the temperature should first 24 hours after delivery. Rigors may by then be normal. If this is not the case, occur. evacuation of the uterus is required and • Marked tachycardia. gentamicin must be added to the antibiotics.
    • 122 INTRAPAR TUM CAREA laporotomy and possibly a hysterectomy 3. Side room and special investigations:are indicated, if peritonitis and subinvolution • Microscopy of a midstream or catheterof the uterus are present, and there is no specimen of urine usually shows largeresponse to the measures detailed above. numbers of pus cells and bacteria.Transfer the patient to the appropriate level • Culture and sensitivity tests of theof care for this purpose. urine must be done if the facilities are available.7-26 How must a patient with The presence of pyrexia and punch tendernessoffensive lochia be managed? in the renal angles indicate an upper renal1. If the patient has pyrexia she must be tract infection and a diagnosis of acute admitted to hospital and be treated as pyelonephritis must be made. explained in section 7-25.2. If the involution of the patient’s uterus is 7-28 How should you manage a patient slower than expected and the cervical os with a urinary tract infection? remains open, retained placental products 1. Prevention: are present. An evacuation of the uterus • Avoid catheterisation whenever under general anaesthesia must be done. possible. If catheterisation is essential, Further treatment is as explained in it must be done with strict aseptic section 7-25. precautions.3. If the patient has a normal temperature 2. Treatment: and normal involution of her uterus, she • Admit the patient to hospital. can be managed as an out patient with oral • Measures to bring down the ampicillin and metronidazole (Flagyl). temperature. • Analgesia, e.g. paracetamol (Panado) Offensive lochia is an important sign of genital 1 g orally six-hourly. tract infection. • Intravenous fluids. • Intravenous ampicillin 1 g and clavulanic acid 200 mg (Augmentin)7-27 How should you diagnose immediately and eight-hourly ora upper urinary tract infection cefuroxime (Zinacef) 750 mg eight-(acute pyelonephritis)? hourly.1. History: Organisms causing acute pyelonephritis are • The patient may have been catheterised often resistant to ampicillin, either intravenous during labour or in the puerperium. ampicillin and clavulanic acid (Augmentin) or • The patient complains of rigors cefuroxime (Zinacef) must be used. (shivering) and lower abdominal pain and/or pain in the lower back over one or both the kidneys (the loins). Antibiotics should not be given to a patient • Dysuria and frequency. However, these with puerperal pyrexia until she has been fully are not reliable symptoms of urinary investigated. tract infection.2. Examination: • Pyrexia, often with rigors (shivering). • Tachycardia. • Suprapubic tenderness and/or tenderness, especially to percussion, over the kidneys (punch tenderness in the renal angles).
    • THE PUERPERIUM 123THROMBOEMBOLISM 1. History: • The patient may have had general anaesthesia with endotracheal7-29 What is superficial vein intubation, e.g. for a Caesarean section.thrombophlebitis? • Cough, which may be productive. • Pain in the chest.This is a non-infective inflammation and • A recent upper respiratory tractthrombosis of the forearm where an infusion infection.was given or superficial veins of the leg. 2. Examination:Thrombophlebitis commonly occurs during • Pyrexia.the puerperium, especially in varicose veins. • Tachypnoea (breathing rapidly). • Tachycardia.7-30 How should you diagnose 3. Special investigations:superficial leg vein thrombophlebitis? • A chest X-ray is useful in diagnosing1. History: pneumonia. • Painful swelling of the leg or forearm. Examination of the chest may reveal basal • Presence of varicose veins. dullness due to collapse, increased breath2. Examination: sounds or crepitations due to pneumonia, or • Pyrexia. bilateral rhonchi due to bronchitis. • Tachycardia. • Presence of a localised area of the leg 7-33 How should you manage a patient or forearm which is swollen, red and with a lower respiratory tract infection. tender. 1. Prevention:7-31 How should you manage a patient • Skilled anaesthesia.with superficial vein thrombophlebitis? • Proper care of the patient during induction and recovery from1. Give analgesia, e.g. aspirin 300 mg (one anaesthesia. adult tablet) six-hourly. • Encourage deep breathing and coughing2. Support the leg with an elastic bandage. following a general anaesthetic to3. Encourage the patient to walk around. prevent lower lobe collapse.There is no indication for anticoagulant 2. Treatment:therapy unless there is deep vein thrombosis. • Admit the patient to hospital unless theHowever, if there are signs of infection of infection is very mild.the drip site a course of antibiotics should • Oxygen if required.be prescribed. The skin around the drip site • Ampicillin orally or intravenouslywould be swollen (indurated), tender, warm depending on the severity of theand red. Prescribe a course of oral amoxacillin. infection. • Analgesia, e.g. paracetamol (Panado) 1g six-hourly.7-32 How should you diagnose a • Physiotherapy.lower respiratory tract infection? 3. Special investigations:A lower respiratory tract infection, such as • Send a sample of sputum foracute bronchitis or pneumonia, is diagnosed microscopy, culture and sensitivityas follows: testing if possible.
    • 124 INTRAPAR TUM CARE7-34 Which other infections may PUERPERAL PSYCHIATRICcause puerperal pyrexia? DISORDERSTonsillitis, influenza and any other acuteinfection, e.g. acute appendicitis. 7-36 Which are the puerperal7-35 What should you do if a patient psychiatric disorders?presents with puerperal pyrexia? 1. The ‘puerperal blues’.1. Ask the patient what she thinks is wrong 2. Temporary postnatal depression. with her. 3. Puerperal psychosis.2. Specifically ask for symptoms which point to: 7-37 Why is it important to recognise the • An infection of the throat or ears. various puerperal psychiatric disorders? • Mastitis or breast abscess. • A chest infection. 1. The ‘puerperal blues’ are very common • A urinary tract infection. in the first week after delivery, especially • An infected abdominal wound if the on day 3. The patient feels miserable and patient had a Caesarean section or a cries easily. Although the patient may be puerperal sterilisation. very distressed, all that is required is an • Genital tract infection. explanation, reassurance, and a caring, • Superficial leg vein thrombophlebitis. sympathetic attitude and emotional support.3. Examine the patient systematically, The condition improves within a few days. including the: 2. Postnatal depression is much commoner • Throat and ears. than is generally realised. It may last for • Breasts. months or even years and patients may • Chest. need to be referred to a psychiatrist. • Abdominal wound, if present. Patients with postnatal depression usually • Urinary tract. present with a depressed mood that • Genital tract. cannot be relieved, a lack of interest in • Legs, especially the calves. their surroundings, a poor or excessive4. Perform the necessary special appetite, sleeping difficulties, feelings of investigations, but always send off a: inadequacy, guilt and helplessness, and • Endocervical swab. sometimes suicidal thoughts. • Midstream or catheter specimen of 3. Puerperal psychosis is an uncommon but urine. very important condition. The onset is5. Start the appropriate treatment. usually acute and an observant attendant will notice the sudden and marked change in the patient’s behaviour. She may rapidly If a patient presents with puerperal pyrexia pose a threat to her infant, the staff and the cause of the pyrexia must be found and herself. Such a patient must be referred appropriately treated. urgently to a psychiatrist and will usually need admission to a psychiatric unit. Patients with puerperal psychosis are unable to care for themselves or their infants. They are often disorientated and paranoid and may have hallucinations. They may also be severely depressed or manic.
    • THE PUERPERIUM 125SECONDARY POSTPARTUM 7-42 How should you manage a patient with secondary postpartum haemorrhage?HAEMORRHAGE 1. Prevention: • Aseptic technique throughout labour,7-38 What is secondary the delivery and the puerperium.postpartum haemorrhage? • Careful examination after delivery to determine whether the placenta andThis is any amount of vaginal bleeding, other membranes are complete.than the normal amount of lochia, occurring • Proper repair of vaginal and perinealafter the first 24 hours postpartum until the lacerations.end of the puerperium. It commonly occurs 2. Treatment:between the fifth and fifteenth days after • Admission of the patient to hospital isdelivery. indicated, except in very mild cases of secondary postpartum haemorrhage.7-39 Why is secondary postpartum • Review of the clinical notes with regardhaemorrhage important? to completeness of the placenta and1. A secondary postpartum haemorrhage membranes. may be so severe that it causes shock. • Obtain an endocervical swab for2. Unless the cause of the secondary bacteriology. postpartum haemorrhage is treated, the • Give ampicillin and metronidazole vaginal bleeding will continue. (Flagyl) orally. • Give Syntometrine 1 ml intramuscularly or 20 units oxytocin in7-40 What are the causes of secondary an intravenous infusion.postpartum haemorrhage? • Blood transfusion, if the haemoglobin1. Genital tract infection with or without concentration drops below 8 g/dl. retention of a piece of placenta or part of the • Removal of retained placental products membranes. This is the commonest cause. under general anaesthesia.2. Separation of an infected slough in a cervical or vaginal laceration. 7-43 What may you find on physical3. Breakdown (dehiscence) of a Caesarean examination to suggest that retained section wound of the uterus. pieces of placenta or membranesHowever, the cause is unknown in up to half of are the cause of a secondarythese patients. postpartum haemorrhage?Gestational trophoblastic disease 1. The uterus will be involuting slower than(hydatidiform mole or choriocarcinoma) and usual.a disorder of blood coagulation may also cause 2. Even though the patient may be more thansecondary postpartum haemorrhage. seven days postpartum, the cervical os will have remained open.7-41 What clinical features should alert youto the possibility of the patient developing SELF-MONITORINGsecondary postpartum haemorrhage?1. A history of incomplete delivery of the placenta and/or membranes. 7-44 What is meant by the concept2. Unexplained puerperal pyrexia. of ‘the mother as a monitor’?3. Delayed involution of the uterus. This is a concept where the patient is made4. Offensive and/or persistently red lochia. aware of the many ways in which she can
    • 126 INTRAPAR TUM CAREmonitor her own, as well as her fetus’ or infant’s 1. How can you get the patient’s help inwellbeing, during pregnancy, in labour and in preventing a postpartum haemorrhage?the puerperium. This has two major advantages: The patient should be shown how to observe:1. The patient becomes much more involved 1. The height of the uterine fundus. in her own perinatal care. 2. Whether the uterus is well-contracted.2. Possible complications will be reported by 3. The amount of vaginal bleeding. the patient at the earliest opportunity. 4. She should also be asked to empty her bladder frequently.7-45 How can the patient act as amonitor in the puerperium? 2. What should the patient do ifThe patient must be encouraged to report she notices that her uterus relaxesthe following complications as soon as she and/or there is vaginal bleeding?becomes aware of them: She should rub up the uterus and call you1. Maternal complications: immediately. • Symptoms of puerperal pyrexia. • Breakdown of an episiotomy. 3. What should you check on • Breastfeeding problems. before leaving the patient? • Excessive or offensive lochia. • Recurrence of vaginal bleeding, i.e. You should make sure that: secondary postpartum haemorrhage. 1. The patient and her infant’s observations are • Prolonged postnatal depression. normal and both their conditions are stable.2. Complications in the infant: 2. The patient understands what she has to do. • Poor feeding or other feeding 3. You will be able to hear the patient, if she problems. calls you. • Lethargy. • Jaundice. • Conjunctivitis. CASE STUDY 2 • Infection of the umbilical cord stump. A patient is day three following an uncomplicated Caesarean section for Each patient must be taught to monitor her own cephalopelvic disproportion. She complains wellbeing, as well as that of her fetus or infant. of leaking urine when coughing or laughing, and she is also worried that she has not passed a stool since the delivery. She starts to cry andCASE STUDY 1 says that she should not have fallen pregnant. Her infant takes the breast well and sleeps wellFollowing a spontaneous vertex delivery in after each feed. On examination the patienta district hospital, you have delivered the appears well, her observations are normal, theplacenta and membranes completely. The uterus is the size of a 16-week pregnant uterus,maternal and fetal conditions are good and the abdominal wound appears normal and thethere is no abnormal vaginal bleeding. You lochia is red and not offensive.are also responsible for the casualty unit andare called. You will have to leave the patient 1. Is her puerperium progressing normally?alone for a while. Yes. The patient appears healthy with normal observations, and the involution of her uterus is satisfactory.
    • THE PUERPERIUM 1272. What should be done about 39 °C, a pulse rate of 110 beats per minute andthe patient’s complaints? complains of a headache and lower abdominal pain. The uterus is tender to palpation.Stress incontinence is common duringthe puerperium. Therefore, the patientmust be reassured that it will improve over 1. What does the patient present with?time. However, pelvic floor exercises must Puerperal pyrexia.be explained to her as they will hastenimprovement of her incontinence. She need 2. What is the most likely causenot be worried about not having passed a stool of the puerperal pyrexia?as this is normal during the first few days ofthe puerperium. Genital tract infection, i.e. puerperal sepsis. This diagnosis is suggested by the general signs3. Why is the patient regretting of infection and the uterine tenderness. Theher pregnancy and crying for patient had a prolonged first stage of labour,no apparent reason? which is usually accompanied by a greater than usual number of vaginal examinations and,She probably has the ‘puerperal blues’ which therefore, predisposes to genital tract infection.are common in the puerperium. Listensympathetically to the patient’s complaints 3. Was the early postnatal managementand reassure her that she is managing well as of this patient correct?a mother. Also explain that her feelings arenormal and are experienced by most mothers. No. The patient should not have been discharged home so early as she had a4. What educational topics must prolonged first stage of labour which placesbe discussed with the patient her at a higher risk of infection. She shouldbefore discharging her home? have been observed for at least 24 hours.1. Family size and when she plans to have her 4. How should you manage this next infant. patient further in the clinic?2. Which contraceptive method she should use and how to use it correctly. She must be admitted. Paracetamol (Panado)3. The care and feeding of her infant, 1 g orally may be given for the headache. If stressing the importance of breastfeeding. necessary she should be given a tepid sponging.4. The time that coitus can be resumed. An intravenous infusion should be started and she must receive intravenous ampicillinAlso ask about, and discuss, any other and oral metronidazole (Flagyl). Twenty fouruncertainties which the patient may have. hours later the patient’s condition should have improved considerably and the temperature should by then be normal. If this is not theCASE STUDY 3 case, evacuation of the uterus is required and gentamicin must be added to the antibiotics..Following a prolonged first stage of labour dueto an occipito-posterior position, a patient hasa spontaneous vertex delivery. The placenta and CASE STUDY 4membranes are complete. There is no excessivepostpartum blood loss and the patient is A patient is seen at a district hospital on daydischarged home after six hours. Within 24 five following a normal pregnancy, labour andhours of delivery the patient is brought back to delivery. She complains of rigors and lowerthe district hospital. She has a temperature of abdominal pain. She has a temperature of
    • 128 INTRAPAR TUM CARE38.5 °C, tenderness over both kidneys (loins) 3. Do you agree with the managementand tenderness to percussion over both renal given to the patient?angles. A diagnosis of puerperal pyrexia is made No. A urinary tract infection that causesand the patient is given oral ampicillin. She is puerperal pyrexia is an indication forasked to come back to the clinic on day seven. admitting the patient to hospital. Intravenous ampicillin plus clavulanic acid (Augmentum)1. Are you satisfied with the must be given as this will lead to a rapiddiagnosis of puerperal pyrexia? recovery and prevent serious complications.No. Puerperal pyrexia is a clinical sign andnot a diagnosis. The cause of the pyrexia must 4. Why is a puerperal patient atbe found by taking a history, doing a physical risk of a urinary tract infection andexamination and, if indicated, completing how may this be prevented?special investigations. Catheterisation is often required and this increases the risk of a urinary tract infection.2. What is the most likely cause Catheterisation must only be carried outof the patient’s pyrexia? when necessary and must always be done asAn upper urinary tract infection (acute an aseptic procedure. Screening and treatingpyelonephritis) as suggested by the pyrexia, asymptomatic bacteriuria at the antenatalrigors, lower abdominal pain and tenderness clinic will reduce acute pyelonephritis duringover the kidneys. the puerperium.
    • THE PUERPERIUM 129Figure 7-1: A postnatal card for assessing a woman within the first week and again at 6 weeks after delivery
    • 8 Family planning after pregnancyBefore you begin this unit, please take the for everybody. Family planning is an importantcorresponding test at the end of the book to part of primary health care and includes:assess your knowledge of the subject matter. You 1. Promoting a caring and responsibleshould redo the test after you’ve worked through attitude to sexual behaviour.the unit, to evaluate what you have learned 2. Ensuring that every child is wanted. 3. Encouraging the planning and spacing of the number of children according to Objectives a family’s home conditions and financial income. When you have completed this unit you 4. Providing the highest quality of maternal should be able to: and child care. 5. Educating the community with regard • Give contraceptive counselling. to the disastrous effects of unchecked • List the efficiency, contraindications and population growth on the environment. side effects of the various contraceptive methods. 8-2 Who needs contraceptive counselling? • List the important health benefits of While the best time to advise a woman on contraception. contraception is before the first coitus, the • Advise a postpartum patient on antenatal and postdelivery periods provide an the most appropriate method of excellent opportunity to provide contraceptive contraception. counselling. Some patients will ask you for contraceptive advice. However, you will often have to first motivate a patient to accept contraception before you can advise her aboutCONTRACEPTIVE an appropriate method of contraception.COUNSELLING All women should be offered contraceptive counselling after delivery.8-1 What is family planning?Family planning is far more than simply birthcontrol, and aims at improving the quality of life
    • FAMILY PLANNING AFTER PREGNANC Y 1318-3 How should you motivate a patient with her husband and, where appropriate,to accept contraception after delivery? other members of her family or friends.A good way to motivate a patient to accept Step 2: The patient’s choice of a contraceptivecontraception is to discuss with her, or methodpreferably with both her and her partner, thehealth and socio-economic effects further The patient should always be asked whichchildren could have on her and the rest of the contraceptive method she would prefer as thisfamily. Explain the immediate benefits of a will obviously be the method with which she issmaller, well spaced family. most likely to continue.It is generally hopeless to try and promote Step 3: Consideration of contraindications to thecontraception by itself. To gain individual and patient’s preferred methodcommunity support, family planning mustbe seen as part of total primary health care. You must decide whether the patient’s choiceA high perinatal or infant mortality rate in a of a contraceptive method is suitable, takingcommunity is likely to result in a rejection of into consideration:contraception. 1. The effectiveness of each contraceptive method.8-4 How should you give contraceptive 2. The contraindications to eachadvice after delivery? contraceptive method.There are five important steps which should be 3. The side effects of each contraceptivefollowed: method. 4. The general health benefits of eachStep 1: Discussion of the patient’s future contraceptive method.reproductive career If the contraceptive efficiency of the preferredIdeally a woman should consider and plan method is appropriate, if there are noher family before her first pregnancy, just as contraindications to it, and if the patient isshe would have considered her professional prepared to accept the possible side effects,career. Unfortunately in practice this hardly then the method chosen by the patient shouldever happens and many women only discuss be used. Otherwise help her to choose thetheir reproductive careers for the first time most appropriate alternative method.when they are already pregnant or after thebirth of the infant. When planning her family Step 4: Selection of the most appropriatethe woman (or preferably the couple) should alternative method of contraceptiondecide on: The selection of the most suitable alternative1. The number of children wanted. method of contraception after delivery will2. The time intervals between pregnancies depend on a number of factors including the as this will influence the method of patient’s wishes, her age, the risk of side effects contraception used. and whether or not a very effective method of3. The contraceptive method of choice when contraception is required. the family is complete. Step 5: Counselling the patient once theVery often the patient will be unable or contraceptive method has been chosenunwilling to make these decisions immediatelyafter delivery. However, it is essential to discuss Virtually every contraceptive method has itscontraception with the patient so that she can own side effects. It is a most important partplan her family. This should be done together of contraceptive counselling to explain the possible side effects to the patient. Expert
    • 132 INTRAPAR TUM CAREfamily planning advice must be sought if the Breastfeeding, spermicides alone, coitusdistrict hospital is unable to deal satisfactorily interruptus and the ‘safe period’ are all verywith the patient’s problem. If family planning unreliable. All women should know aboutmethod problems are not satisfactorily solved, postcoital contraception.the patient will probably stop using any formof contraception. Breastfeeding cannot be relied upon to provide postpartum contraception. After delivery the reproductive career of each patient must be discussed with her in order to 8-6 How effective are the various decide on the most appropriate method of family contraceptive methods? planning to be used. Contraceptive methods for use after delivery may be divided into very effective and less effective ones. Sterilisation, injectables, oralCONTRACEPTION contraceptives and intra-uterine contraceptiveAFTER DELIVERY devices are very effective. Condoms are less effective contraceptives. The effectiveness of a contraceptive method8-5 What contraceptive methods is given as an index which indicates thecan be offered after delivery? number of women who would be expected to1. Sterilisation. Either tubal ligation (tubal fall pregnant if 100 women used that method occlusion) or vasectomy. for one year. The ideal efficacy index is 0.2. Injectables (i.e. an intramuscular injection The higher the index, the less effective is the of depot progestogen). method of contraception. The efficacy of the3. Oral contraceptives. Either the combined various contraceptive methods for use after pill (containing both oestrogen and delivery is shown in table 8-1. progestogen) or a progestogen-only pill (the ‘minipill’). 8-7 How effective is postcoital4. An intra-uterine contraceptive device contraception? (IUCD). 1. Norlevo, E Gen-C or Ovral are effective5. The condom. within five days of unprotected sexualTable 8-1: The efficacy of the various contraceptive methods for use after delivery Contraceptive method Efficacy index Sterilisation: Vasectomy 0.05 Tubal ligation 0.5 Injectables: Depo-Provera/Petogen 0.2 Nur-Isterate 0.6 Oral contraceptives: Combined pill 0.3 Minipill 1.2 IUCD: Copper 0.5 Condom* Male 2-15 Female (Reality female condom) 5-15*The safety of condoms depends on the reliability with which they are used.
    • FAMILY PLANNING AFTER PREGNANC Y 133 intercourse, but are more reliable the • Oestrogen dependent malignancies earlier they are used. such as breast or uterine cancer.2. A copper intra-uterine contraceptive 4. Progestogen-only pill (minipill): device can be inserted within six days of • None. unprotected intercourse. 5. Intra-uterine contraceptive device:3. Postcoital methods should only be used in • A history of excessive menstruation. an emergency and not as a regular method • Anaemia. of contraception. • Multiple sex partners when the risk of4. If Norlevo is used, one tablet should be genital infection is high. taken as soon as possible after intercourse, • Pelvic inflammatory disease. followed by another one tablet after A menstrual abnormality is a contraindication exactly 12 hours. to any of the hormonal contraceptive methods5. If Ovral or E-Gen-C is used, two tablets (injectables, combined pill or progestogen-only are taken as soon as possible after pill) until the cause of the menstrual irregularity intercourse, followed by another two has been diagnosed. Thereafter, hormonal tablets exactly 12 hours later. contraception may often be used to correct theThe tablets for postcoital contraception menstrual irregularity. However, during theoften cause nausea and vomiting reduce puerperium a previous history of menstrualtheir effectiveness. These side effects are less irregularity before the pregnancy is not awith Norlevo which contains no oestrogen. contraindication to hormonal contraception.Therefore Norlevo is a more reliable method If a woman has a medical complication, thenand should be used if available. Norlevo as a a more detailed list of contraindications maysingle dose method will soon be available in be obtained from the standard reference booksSouth Africa. such as J Guillebaud, Contraception: Your questions answered. Fourth edition. London:8-8 What are the contraindications to Churchill Livingstone 2004 (a new edition isthe various contraceptive methods? expected soon).The following are the common or important The World Health Orgainsation (WHO)conditions where the various contraceptive medical eligibility criteria for contraceptive usemethods should not be used: is also available on a WHO website (www.who.1. Sterilisation: int/reproductive-health/publications/mec/). • Marital disharmony. • Psychological problems. 8-9 What are the major side effects of • Forced or hasty decision. the various contraceptive methods? • Gynaecological problem requiring Most contraceptive methods have side hysterectomy. effects. Some side effects are unacceptable to2. Injectables: a patient and will cause her to discontinue • Depression. the particular method. However, in many • Pregnancy planned within one year. instances side effects are mild or disappear3. Combined pills: with time. It is, therefore, very important • A history of venous thrombo- to counsel a patient carefully about the side embolism. effects of the various contraceptive methods, • Age 35 years or more with risk factors and to determine whether she would find any for cardiovascular disease such as of them unacceptable. At the same time the smoking. patient may be reassured that some side effects • Anyone of 50 or more years. will most likely become less or disappear after a few months’ use of the method.
    • 134 INTRAPAR TUM CAREThe major side effects of the various • Perforation of the uterus is uncommon.contraceptive methods used after delivery are: • Ectopic pregnancy is not prevented. Progesterone containing intra-uterine1. Sterilisation: contraceptive devices (Mirena) have lesser Tubal ligation and vasectomy have no side effects and reduce menstrual blood medical side effects and, therefore, loss. These devices are expensive and not should be highly recommended during generally available in the public health counselling of patients who have completed sector. their families. Menstrual irregularities 6. Condom: are not a problem. However, about 5% of • Decreased sensation for both partners. women later regret sterilisation. • Not socially acceptable to everyone.2. Injectables: • Menstrual abnormalities, e.g. amenorrhoea, irregular menstruation If a couple have completed their family the or spotting. contraceptive method of choice is tubal ligation • Weight gain. or vasectomy. • Headaches. • Delayed return to fertility within a Additional contraceptive precautions must be year of stopping the method. There is taken when the contraceptive effectiveness of no evidence that fertility is reduced an oral contraceptive may be impaired, e.g. thereafter. diarrhoea or when taking antibiotics. There With Nur-Isterate there is a quicker is no medical reason for stopping a hormonal return to fertility, slightly less weight gain method periodically to ‘give the body a rest’. and a lower incidence of headaches and amenorrhoea than with Depo-Provera or Petogen. 8-10 What are the important health3. Combined pill: benefits of contraceptives? • Reduction of lactation. The main objective of all contraceptive • Menstrual abnormalities, e.g. spotting methods is to prevent pregnancy. In developing between periods. countries pregnancy is a major cause of • Nausea and vomiting. mortality and morbidity in women. Therefore, • Depression. the prevention of pregnancy is a very important • Fluid retention and breast tenderness. general health benefit of all contraceptives. • Chloasma (a brown mark on the face). • Headaches and migraine. Various methods of contraception have4. Progestogen-only pill: a number of additional health benefits. • Menstrual abnormalities, e.g. irregular Although these benefits are often important, menstruation. they are not generally appreciated by many • Headaches. patients and health-care workers: • Weight gain. 1. Injectables:5. Copper containing intra-uterine • Decrease in dysmenorrhoea. contraceptive device. • Less premenstrual tension. • Expulsion in 3–15 cases per 100 • Less iron deficiency anaemia due to women who use the device for one year. decreased menstrual flow. • Pain at insertion. • No effect on lactation. • Dysmenorrhoea. 2. Combined pill: • Menorrhagia (excessive and/or • Decrease in dysmenorrhoea. prolonged bleeding). • Decrease in menorrhagia (heavy and/or • Increase in pelvic inflammatory prolonged menstruation). disease.
    • FAMILY PLANNING AFTER PREGNANC Y 135 • Less iron-deficiency anaemia. • A combined pill until 35 years of age if • Less premenstrual tension. there are risk factors for cardiovascular • Fewer ovarian cysts. disease, or until 50 years of age if these • Less benign breast disease. risk factors are absent. • Less endometrial and ovarian 4. Patients of 35 years or over without risk carcinoma. factors for cardiovascular disease:3. Progestogen-only pill: • Tubal ligation or vasectomy is the • No effect on lactation. logical method.4. Condom: • A combined pill until 50 years of age. • Less risk of HIV infection and other • An injectable until 50 years of age. sexually transmitted diseases. • A progestogen-only pill until 50 years • Less pelvic inflammatory disease. of age. • Less cervical intra-epithelial neoplasia. • An intra-uterine contraceptive device until one year after the periods have stopped, i.e. when there is no further The condom is the only contraceptive method risk of pregnancy. that provides protection against HIV infection. 5. Patients of 35 years or over with risk factors for cardiovascular disease:8-11 What is the most appropriate • as above but no combination pill.method of contraception fora woman after delivery? The puerperium is the most convenient timeThe most suitable methods for the following for the patient to have a bilateral tubal ligationgroups of women are: performed.1. Lactating patients: • An injectable, but not if a further Every effort should be made to provide pregnancy is planned within the next facilities for tubal ligation during the year. puerperium for all patients who request • A progestogen-only pill (minipill) for sterilisation after delivery. three months, then the combined pill. Remember that sperms may be present • An intra-uterine contraceptive device. in the ejaculate for up to three months2. Teenagers and patients with multiple following vasectomy. Therefore, an additional sexual partners. contraceptive method must be used during • An injectable, as this is a reliable method this time. even with unreliable patients who might forget to use another method. 8-12 What are the risk factors for • Additional protection against HIV cardiovascular disease in women infection by using a condom is taking the combined pill? essential. It is important to stress that the patient should only have The risk of cardiovascular disease increases intercourse with a partner who is markedly in women of 35 or more years of age willing to use a condom. who have one or more of the following risk3. Patients whose families are complete: factors: • Tubal ligation or vasectomy is the 1. Smoking logical choice. 2. Hypertension • An injectable, e.g. Depo-Provera or 3. Diabetes Petogen (12 weekly) or Nur-Isterate 4. Hypercholesterolaemia (eight-weekly). 5. A personal history of cardiovascular disease
    • 136 INTRAPAR TUM CARE contraceptive or an intra-uterine contraceptive Smoking is a risk factor for cardiovascular disease. device would be the next best choice.8-13 When should an intra- 3. If the patient accepts tubal ligation,uterine contraceptive device when should this be done?be inserted after delivery? The most convenient time for the patientIt should not be inserted before six weeks as and her family is the day after deliverythe uterine cavity would not yet have returned (postpartum sterilisation). Every effort shouldto its normal size. At six weeks or more after be made to provide facilities for postpartumdelivery there is the lowest risk of: sterilisation for all patients who request it.1. Pregnancy2. Expulsion 4. If the couple decides not to have a tubal ligation or vasectomy, how willPostpartum patients choosing this method must you determine whether an injectablebe discharged on an injectable contraceptive or an intra-uterine contraceptiveor progestogen-only pill until an intra-uterine device would be the best choice?contraceptive device has been inserted. Assessing the risk for pelvic inflammatoryInsertion of an intra-uterine contraceptive disease will determine which of the twodevice immediately after delivery may be methods to use. If the patient has a stableconsidered if it is thought likely that a patient relationship, an intra-uterine contraceptivewill not use another contraceptive methods and device may be more appropriate. However, ifwhere sterilisation is not appropriate. However, she or her husband (or boyfriend) has otherthe expulsion rate will be as high as 20%. sexual partners, an injectable contraceptive would be indicated.CASE STUDY 1 5. What other advice must be given to a patient at risk of sexuallyA 36-year-old patient has delivered her fourth transmitted infections?child in a district hospital. All her children arealive and well. She is a smoker but is otherwise The patient must insist that her partner wearshealthy. She has never used contraception. a condom during sexual intercourse. This will reduce the risk of HIV infection.1. Should you counsel this patientabout contraception? CASE STUDY 2Yes. Every sexually active person needscontraceptive counselling. This patient in A 15-year-old primigravida had a normalparticular needs counselling as she is at an delivery the previous day in a district hospital.increased risk of maternal and perinatal She has never used contraception. Her mothercomplications, should she fall pregnant again, asks you for contraceptive advice for herbecause of her age and parity. daughter after delivery. The patient’s boyfriend has deserted her.2. Which contraceptive methods wouldbe appropriate for this patient? 1. Does this young teenager requireTubal ligation or vasectomy would be the contraceptive advice after delivery?most appropriate method of contraception if Yes, she will certainly need contraceptiveshe does not want further children. Should counselling and should start on a contraceptiveshe not want sterilisation, either an injectable
    • FAMILY PLANNING AFTER PREGNANC Y 137method before discharge from hospital. She 1. The patient says that she has usedneeds to learn sexual responsibility and must an injectable contraceptive for fivebe told where the nearest clinic to her home years before this pregnancy and wouldis for follow-up. She also needs to know about like to continue with this method.postcoital contraception. What would your advice be? Injectable contraception would not be2. Which contraceptive method would be appropriate as she plans her next pregnancymost the appropriate for this patient? within a year, and there may be a delayedAn injectable contraceptive would probably be return to fertility.the best method for her as she needs reliablecontraception for a long time. 2. If the patient insists on using an injectable contraceptive, which drug3. Why would she need a long would you advise her to use?term contraceptive? Any of the injectables can be used (DepoBecause she should only have her next child Provera/Petogen or Nur-Isterate) as there is nowhen she is much older and has a stable proven advantage of the one above the others.relationship. 3. Following further counselling, the4. If the patient prefers to use an oral patient decides on oral contraceptioncontraceptive, would you regard and is given a combined pill. Do youthis as an appropriate method agree with this management?of contraception for her? No. As she plans to breastfeed, she shouldNo. A method which she is more likely to be given a progestogen-only pill. Combineduse correctly and reliably would be more oral contraceptive pills may reduce milkappropriate. Oral contraceptives are only production while breastfeeding is beingreliable if taken every day. established. Progestogen-only pills have no effect on breastfeeding.5. The patient and her mother are worriedthat the long term effect of injectablecontraception could be harmful to a girl CASE STUDY 4of 15 years. What would be your advice? A married primipara from a rural area has justInjectable contraception is extremely safe and, been delivered in a district hospital. She has atherefore, is an appropriate method for long stable relationship with her husband and theyterm use. This method will not reduce her decide to have their next infant in five yearsfuture fertility. time. The patient would like to have an intra- uterine contraceptive device inserted.CASE STUDY 3 1. Is this an appropriate method for this patient?You have just delivered the first infant of ahealthy 32-year-old patient. In discussing Yes, as the risk of developing pelviccontraception with her, she mentions that she inflammatory disease is low.is planning to fall pregnant again within a yearafter she stops breastfeeding. She is a schoolteacher and would like to continue her careerafter having two children.
    • 138 INTRAPAR TUM CARE2. When should the device be inserted? 4. The patient asks if the intra-uterine contraceptive device could be insertedSix weeks or more after delivery as there is before she is discharged from hospital.an increased risk of expulsion if the device is Would this be appropriate management?inserted earlier. The expulsion rate and, therefore, the risk of3. Could the patient, in the contraceptive failure is much higher if themeantime, rely on breastfeeding device is inserted soon after delivery. Therefore,as a contraceptive method? it would be far better if she were to return six weeks later for insertion of the device.No. The risk of pregnancy is too high. Sheshould use reliable contraception, such asinjectable contraception or the progestogen-only pill, until the device is inserted.
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