Labor Room Protocols

1. Dr.Vijayalakshmi.G.Pillai.
DGO,MRCOG.
VIJAYALAKSHMI MEDICAL
CENTRE,
CHAKKARAPARAMBU,VENNALA
ERNAKULAM

3.  "The delivery of the infant into the arms of a
conscious and pain-free mother is one of the
most exciting and rewarding moments in
medicine" said Donald Moir, founder
President of the Obstetric Anesthetist's
Association.
 He had worked hand in hand with Sir Ian Donald.
They were together instrumental in shaping present
day “attitudes”of care towards a pregnant and
parturient mother.
 I feel strongly for this.

4. Goal?

5.  I feel, Obstetrics is to be practiced with the
conviction and courage of a well disciplined
Army.
 Routine work requires just periodic drills.
 But Emergencies have to be handled and led
with the fitness and courage of a winning
Army’s General.

8.  It is a myth that Cesarean Section mitigates most vows
of untoward complications to the mother or the fetus.
 FIGO, WHO and various Governments have tried to
stipulate certain acceptable percentage of
complications and hence CS rate.
 Kerala Gov. has introduced a GO in the form of
“guidelines” to reduce Cesarean rate.
 If followed well, definitely it stands testimony to the
acceptable “good practice Obstetric judgments”of all
developed countries.

9. G.O for Caesarean section rate - Arogyakeralam.gov.in

13.  At around 16 weeks onwards we encourage
patients to visit our Antenatal Physiotherapy
sessions, at least twice in pregnancy.
 We make sure that they practice these things.
 Many buy theraband and exercise ball and
bring even to labour room to practice while in
labour.
A short video taken at our physiotherapy
premises.

16.  Play an important role.
 All are well trained and disciplined to have
good presence of mind.
 They have kept their “check-lists” in the form of
documents which hang in each Labour room.
 From patient comfort, to positioning during
labour, dose adjustments of drugs as per
schedule are done by them.

22.  Emergency admission is the usual norm to all low
risk patients.
 Elective labour Induction is opted only for
Obstetric indications.
 We have private Labour-delivery-postpartum
rooms for every patient.
 A birth attendant, preferably husband is expected
to be with the patient throughout her stay in the
labour room.
 Baby resuscitation room is adjacent.

24.  Not all patients have active managementof labour, including
“must do amniotomy”at or above 4cm.
 Social convenience of the doctors, priorities for other cases,
patient fixation etc. modify our actions.
 Patients who do not want to “modify”their natural labour are left
to their wishes,except that they are asked to undergo
intermittentCTG monitoring.
 Patients even refuse PV at first stage of labour after the initial
assessment at admission, and may get on to the Labour cot only
at second stage, without further PV assessment and , having
refused all pharmacological agents.
 Labour help classes galore in a society like Kochi,and they
advocate“natural” child birth.

26.  The Bishop score system to assess methods of Induction of
Labour.
 PGE2 gel (Dinoprostone)intracervically is the favoured
method of choice in the low score patients, where a cervical
“ripening”is what is intended.
 All women who are induced,stay under continuous CTG in
the labour room.
 For the ones having cervical ripening,monitoringis for 1-2
hrs in the labour room.
 In a patient with score =/> 7, Amniotomyfollowedby
Oxytocin Infusion of the low dose protocol is followed.
 All infusions are given by Infusion pump in well titrated
doses.

28.  GDM on Insulin in well controlledmothers with average size
babies have IOL at 39/+ weeks.
 Post datism is waiting up to 41 weeks for spontaneous onset of
labour.
 PROM at term with clear liquor and no clinical evidence of
chorioamnonitis,waits up to 24 hrs before an IOL is planned.
 PGE2 gel is not denied if the Bishop score is poor for PROM.
 Twice weekly BPP scoring is done for every woman at or near
40 weeks.
 For a 40+ weeker woman,the vigilance is further strict with
daily NST as well.

30.  A case is called failed Induction after a liberal trial,
especially in a primigravida.
 For cervical ripening, intracervical Dinoprostone gel,
0.5mg every 6 hrs to a maximum of 3 doses each day,
starting at 6.00 am and lasting a maximum of 9 doses,
spread over 3 to 7 days.
 A patient has the right to stop further trials of IOL, if she
finds it mentally not acceptable.
 Most women consent to maximum try.
 Routine sweeping/stripping of membranes is attempted
to almost all low risk women around 38 weeks unless
they decline.

31.  All though we have a recordedPartogram, it is hardly followed.
 A dated, timed sequence of events in the IP record sheets with
explicit orders make up for the cramped Partogram.
 All patients are monitored by a multipara monitor (usually only SPO2
& NIBP).
 ECG leads are connected only in cases of : all Epidurals,
unexplained maternal tachycardia, known Cardiac conditions,
severe PIH on Labetalol Infusion and MgSulf infusion etc.
 All fetuses are continuously monitored by external CTG, unless
specifically told to be ambulant.
 Preload of crystalloids given to all mothers who opt for epidurals.
 Patients in active labour are restricted from eating solid food and
only clear fluid is recommended, except citric juices, caffeine
containing drinks etc.

33.  Many first timers are apprehensive about Epidural analgesia.
 Many would like to opt out of this choice,imagining that the
“pain would be bearable”.
 Many, who later choose Epidural analgesia in labour,are the
ones who had thought of opting out in the initial stages.
 N2O2 and O2 inhalation anesthesia (CSDS) is also offered in
our hospital and patient is not asked to give special consent .
 CSDS (Conscious Sedation Delivery System) is found to be
very useful and convenient to the ones who think Epidurals
may cause long term complications.
 It has liberal takers.

34.  In many countries today, the availability of regional
analgesia for labour is considered a reflection of standard
obstetric care.
 According to the 2001 survey, the epidural acceptance is
up to 60% in the major maternity centers of the US.
 The NHS Maternity Statistics of 2005-2006 in the UK
reported that one-third of the parturient chose epidural
analgesia.
 In our country,the awareness is still lacking.

35.  The concentration of local anesthetic used to
maintain labour epidural analgesia is (0.0625-
0.125%).
 The use of a low concentration of local anesthetic has
reduced the total dose of local anesthetic used as
well as the side-effects,such as motor blockade.
 Continuous dilute low-dose mixtures has major
advantage over intermittent bolus dose.
 The dosage recommended for labour analgesia is
0.0625% bupivacaine with 2 mcg/ml of fentanyl,
infusing at 10-12 ml/h.

39.  It is an apparatus which is used to deliver a mixture of
N2O2 and O2 through a nasal mask (gas & mask).
 The one in our Labour room is designed to draw each of
these gases from the central gas pipeline valve, do the
mixing at the ratio of N2O2 and O2 as per our settings and
to a volume determined by us.
 For margin of safety,O2 can be given up to the maximum
100% and N2O2 cannot go beyond 70%
 A maximum ratio is of 70:30 of N2O2 to O2 and the
minimum is 0:100 of N2O2 to O2.

40.  The usual pre-set volume of the mixed gas flow rate is
6 to 8 litres per minute.
 The usual settings will be of the ratio 50:50 of both gases.
The ratio is adjusted according to patient pain and need for
Oxygen.
 It is self administered and has high level of safety at the
settings mentioned above.
 The system has an on-demand valve in the mask, which
opens to let in gas only if the woman inhales deeply.
 The gas is odorless.
 The patient is conscious throughout the inhalation and
obeys to command.

41.  The time spent in laboring and the sense of pain seems to
be detached from her memory.
 Labour progresses very fast because of absence of anxiety.
 Many patients do not recall the labour experience the next
day.
 It is a good agent in a well conditioned mind.
 It is cheap and effective and much superior to IV Opioids.
 There is no Fetal respiratory depression as it is flushed
from our systems in less than 30 seconds.

46.  Each per-vaginal examination is done with utmost aseptic
precautions.
 For each PV, a separate sterile bowl,gauze/cotton and gloves
are used (PV set) after proper aseptic hand washing.
 After documenting in the Indoor case file, a check book of
records kept by the nurses is initialed,to ensure limited
numbers of PV exams as well as to clearly note the name and
time of the person who has done that.
 This cross check has clearly reduced the rate of Infections,and
we have a minimum antibiotic use protocol (single use
Cefuroxime1.5 gm IV).
 For each patient, Amniotomy is done by sterile plastic single
use “Amnihook”.

52. Encouraged in our hospital, especially in
woman known to have emotionally taken the
decision for CS at the first time around.
Offered only to a woman who has been
following up with us .
Should be well motivated.
Stripping of membranes done at 38 weeks.
No attempt at IOL is done.
Amniotomy at 4cm is done for
augmentation of labour.
No augmentation Oxytocin drip is
recommended.
Monitored by CTG all through labour
.
Epidurals are not denied as also CSDS.
Has to sign the informed consent form .
The chance of success ofVBAC in well
chosen women equals International
standards or more.

53.  Outlet Forceps or vacuum delivery is safely applied to
many women although it isn’t a routine.
 Maternal exhaustion, prolongation of second stage and
fetal distress are the indications.
 If under epidural analgesia,the patient is made to sit up
and a bolus dose of 3-4 ml is pushed, and the instrument
delivery is attempted only after 10-15 minutes.
 This is to give good perineal infiltration effect for a
painless forceps and vacuum.

54.  For women on CSDS, liberal perineal infiltration
Anesthesia is used.
 We use only the silastic cup for vacuum.
 All primigravidas have mandatory episiotomy.
 Closure is done in layers using 2 0’Vicryl
Rapide (polyglactin suture).