Intrapartum/labour Flashcards

Question

Vaginal Examination

Answer 1

Indication · Aim to keep the number of VE to a minimum19 · To assist in decision making, recommend VE: o Within four hours of presentation o Offer every four hours in active labour40 o If clinical concerns identified ``` Contraindication Maternal consent not obtained · Antepartum haemorrhage · Ruptured membranes and not in labour · Placenta praevia · Placental position unknown · Suspected preterm labour ``` Prior to vaginal examination Consider: o Is a VE necessary? o Will a VE aid clinical decision making? · Review history and most recent ultrasound scan result · Explain procedure and gain consent · Acknowledge VE can be distressing to some women · Ensure the woman’s bladder is empty · Perform abdominal examination and FHR auscultation ``` During vaginal examination Maintain privacy, dignity and respect · Consider the woman’s comfort · Perform VE between contractions · Assessment: o Observe general appearance of perineal and vulval area o Position of cervix—posterior, mid, anterior o Dilatation o Effacement o Consistency—soft, medium, firm o Application of presenting part o Membranes intact/no membranes felt o Liquor—note colour, volume, odour o Level of presenting part in relation to ischial spines (-3 to +3) o Presence of caput and moulding o Fetal position and attitude ``` Following vaginal examination · Explain findings and any potential impact on the birth plan · Auscultate FHR · Document findings

Answer 2

Onset A period of time, possibly intermittent periods, associated with: o Irregular painful contractions and o Some cervical effacement and dilatation less than 4 cm to 6 cm Duration The duration of latent phase is difficult to measure · From 4–6 cm the rate of cervical dilatation is the same for both nulliparous and multiparous women o May take six hours to progress from 4–5 cm o May take three hours to progress from 5–6 cm Prolonged latent phase Limited high quality evidence to provide a contemporary definition · Suggested to be: o More than 20 hours in nulliparous women o More than 14 hours in multiparous women Assessment Complete an initial assessment [refer to Table 12. Clinical assessment] Offer individualised support: o Offer simple analgesia as required Low level evidence suggests associations between paracetamol in pregnancy and later asthma in childhood and hyperkinesic disorders; but relevance when use is limited to an acute situation is unclear Information and resources o Encourage ongoing resilience and positive self-belief o Rest, hydration, nutrition, mobilisation, support o Reassurance and coping strategies [refer to Section 3 Comfort and coping strategies] Ongoing support Offer choices for ongoing care, consider: o Individual clinical circumstances o Distance and travel time to facility · Latent first stage: o If not requiring one to one care, recommend return home o If one-to-one support needed, recommend hospital admission Nulliparous women admitted prior to active labour are more likely to experience oxytocin augmentation and CS · Active first stage: admit for one-to-one labour and birth support o Requesting the woman to return home may contribute to a negative experience · Reiterate the actions of hormones that support physiological birth Return/remain at home If the woman decides to return or remain at home, provide information on: o Coping strategies o When to return/make contact, including if: Any concerns. Increased frequency, strength and duration of contractions. Increased pain or discomfort requiring additional support or analgesia. Vaginal bleeding. Membrane rupture. Reduced or concern about fetal movements. Plan an agreed time for reassessment at each contact

Answer 3

Context Traditionally defined as commencing between 4 cm and 5 cm of cervical dilatation, although increasing evidence that some women may not be in active labour before 6 cm dilatation · Nulliparous women have longer active labours and slower dilatation than traditionally defined o May be related to increasing maternal age and maternal and fetal body sizes o Refer to Appendix A: Comparisons of labour definitions · Women may self-report active labour commenced when uterine activity becomes stronger and more regular · A substantial number of women may not have a consistent or linear pattern of active phase of labour Onset Defined in this guideline as when there is: o Regular painful contractions40 and o Progressive cervical dilatation of at least 4 cm to 6 cm · If cervical dilatation unknown, use maternal account of regular and painful contractions Progress In active labour, cervical dilatation of two cm in four hours is considered normal o Dilatation of 0.5 cm per hour is generally accepted · At the transitional phase of 8–10 cm cervical dilatation, supportive needs increase—may exhibit shakiness, irritability, nausea and vomiting · Consider all aspects of progress including: o Maternal and fetal condition o Cervical dilatation and rate of change o Descent and rotation of the fetal head o Strength, duration and frequency of contractions o Parity o Previous labour history o Slowing of progress in the multiparous woman

Answer 4

Partogram Commence when active labour is confirmed131 · Although quality of evidence for clinical benefit is low o Provides a pictorial overview of progress o Facilitates timely transfer of care o May assist in the detection of prolonged labour · If alert lines are used, a four hour action line is recommended Assessment and support Continuous one-to-one support required [refer to Section 2.4 Continuity of care] · Routine use of CTG for low risk women is not recommended o Refer to Queensland Clinical Guideline: Intrapartum fetal surveillance · Provide ongoing support for coping strategies · Refer to Section 3 Comfort and coping strategies Facilitate involvement of support persons as per woman’s wishes Position and mobilisation There is little evidence that any one position is optimal in labour · Avoid supine position as it is associated with adverse effects including: o Supine hypotension o Abnormal FHR · Promote and support adoption of upright (kneeling, squatting or standing) and mobile positions o Compared to recumbent, lateral or supine positions during first stage of labour, upright positions are associated with a reduction in duration of first stage · Birth ball may be an effective tool to reduce labour pain and optimise fetal position Nutrition and hydration For low risk women, restricting oral intake has shown no improvement on maternal or fetal birth outcomes and may be distressing for some women o Support woman to eat and drink as desired o Offer frequent sips of water · Intrapartum isotonic and carbohydrate drinks are no any more beneficial than drinking water · Oral carbohydrate supplements do not alter labour outcomes

Answer 5

Diagnosis of delay Categorised as either: o Protracted labour (slower progress than is usual) Nulliparous— cervical dilatation of less than 2 cm in 4 hours Multiparous— cervical dilatation of less than 2 cm in 4 hours or a slowing in the progress of labour40 o Arrest in labour (complete cessation of progress)12 Diagnosed at cervical dilatation of 6 cm or more with ruptured membranes and no or limited cervical change for four hours of adequate contractions Consultation and referral Consultation and/or referral with midwifery team leader/obstetrician · Consider if clinical intervention is required · Assess: o All aspects of progress o Maternal and fetal condition o Refer to Queensland Clinical Guideline: Intrapartum fetal surveillance Supporting progress towards normal birth · Refer to: o Section 2 Supporting normal birth and o Section 3 Comfort and coping strategies · For multiparous women, review previous labour patterns · There is no robust evidence to support or reject ARM for women in prolonged labour

Answer 6

Onset Full cervical dilatation before or in the absence of involuntary expulsive contractions Progress/delay · Delay pushing (in the absence of clinical concern) if there is no urge to push · There is no consensus for a defined duration for passive second stage · Reassess and consult with obstetrician if in one hour (multiparous or nulliparous) there is: o No urge to push or o No evidence of progress

Answer 7

Onset The baby is visible or full cervical dilatation and expulsive contractions Progress/delay · Consult and refer with obstetrician if progress is slow in: o Nulliparous woman after one hour of active second stage o Multiparous woman after 30 minutes of active second stage · There is no robust evidence to support or reject ARM for women in prolonged second stage Diagnose delay · If birth is not imminent in: o Nulliparous woman after two hours of active second stage o Multiparous woman after one hour of active second stage · Refer to Queensland Clinical Guideline: Intrapartum fetal surveillance

Answer 8

``` Supportive care · Continue ongoing assessments · Refer to: o Section 2 Supporting normal birth and o Section 3 Comfort and coping strategies ``` Duration of second stage A specific absolute maximum length of second stage (passive plus active) has not been identified · Rather than rigid time limits, base decision-making on continuing assessment of: o Maternal physical and emotional condition o Fetal condition o Progress of labour o Maternal preferences · Offer information about risks and benefits of longer and shorter duration relevant to individual circumstances · Longer durations may be appropriate in individual women where: o Maternal and fetal condition is optimal o Appropriate consultation and referral has occurred · Refer to: o Appendix A: Comparisons of labour definitions o Appendix B: Summary position statements on length of labour Duration and urogynaecological outcomes for nulliparous women: · There is a paucity of robust evidence regarding uro gynaecological outcomes associated with prolonged second stage · Increased length of second stage is associated with increased risk of primary postpartum haemorrhage (PPH) · If spontaneous vaginal birth: o Duration of second stage is not associated with obstetric anal sphincter injury o Prolonged second stage is not associated with persistent urinary incontinence

Answer 9

``` FHR - four hourly. Maternal temperature - four hourly Pulse/RR - four hourly. BP - four hourly. Abdominal palpation: if indicated, prior to VE. Contractions - four hourly VE - if clinical concerns. No contraindications. Vaginal loss - hourly Urinary - encourage voiding two hourly. ```

Answer 10

FHR - intermittent auscultation. 15-30 minutely. Maternal temperature - four hourly. [water immersion - hourly] Pulse/RR - 30 minutely BP - four hourly Abdominal palpation: as required to monitor progress, prior to VE. Contractions - 30 minutes (10 minutes), expect 3-5 in 10 minutes, lasting 60 seconds, 60 seconds resting tone. VE - offer four hourly. If clinically indicated Vaginal loss - hourly Urinary - encourage and monitoring voiding two hourly.

Answer 11

FHR - Passive: 15 minutely. Active: auscultate FHR immediately after a contraction for at least one minute at least every 5 minutes. Maternal temperature - four hourly. [water immersion - 30 minutely] Pulse/RR - differentiate from FHR, passive: 30 minutely. Active: 15 minutely. More frequently if indicated. BP - four hourly Abdominal palpation: as required to monitor progress, prior to VE. Contractions - Continuous assessment. VE - as clinically indicated to aid decision making. Vaginal loss - observe continuously Urinary - monitor frequency and encourage voiding.

Answer 12

Kneeling and all fours position are associated with increased incidence of intact perineum · Sitting, squatting and birth stool are associated with increased incidence of perineal trauma · Upright position in second stage is associated with (quality of evidence generally low) o A significant reduction in assisted birth o A reduced incidence of episiotomy o An increased incidence of second degree tears o An increased incidence of blood loss 500 mL or more · Upright position in second stage may reduce the duration of second stage for nulliparous women

Answer 13

Encourage the woman to push to her own bodily instincts which will usually support pushing with an open glottis · Avoid coaching women to push in a prolonged closed glottis effort (Valsalva manoeuvre) · Do not check for nuchal cord

Answer 14

· Refer to Queensland Clinical Guideline: Perineal care · Perineal warm compresses (heat therapy) during second stage may be associated with: o Decreased incidence of third and fourth degree tears o Reduced pain scores o Increased satisfaction and comfort · Insufficient evidence to support guidance or flexion of the head to reduce perineal trauma · Insufficient evidence to preferentially recommend either ‘hands on’ or ‘hands poised’ techniques to avoid perineal trauma—either can be used to facilitate spontaneous birth.

Answer 15

Birth of the baby to the birth of the placenta and membranes. Modified active (delayed cord clamping) Recommended for all births while initiating essential neonatal care o Administer uterotonic immediately after the birth of the baby and before the cord is clamped and cut o Wait at least one to three minutes after birth of baby or for cord pulsation to cease and then clamp and cut the cord o Use controlled cord traction (CCT) after signs of separation · Prolonged when not completed within 30 minutes of the birth of the baby Physiological Suitable for women who: o Have a healthy pregnancy o Have had a normal first and second stage of labour o Have no risk factors for excessive bleeding o Make an informed decision after discussion of the risks and benefits · Routinely includes: o No uterotonic o No clamping of the cord until pulsation has ceased or following birth of the placenta o Leave cord unclamped (or if cut, leave the maternal end unclamped) o Placenta births spontaneously by maternal effort o Healthcare provider unobtrusively waits and observes for signs of separation and remains ‘hands off’ · Prolonged when not completed within 60 minutes of the birth of the baby · Recommend intervention with oxytocin if bleeding needs to be controlled

Answer 16

· If physiological management, recommend oxytocin where: o Placenta not birthed within 60 minutes of the birth of the baby o The woman wishes to shorten the length of third stage o Increasing blood loss

Answer 17

``` Concerns regarding heavy bleeding o Refer to Queensland Clinical Guideline: Primary postpartum haemorrhage · Maternal pyrexia · Retained placenta · Maternal collapse · Uterine inversion ```

Answer 18

``` Placenta General shape and appearance · Calcification or infarctions · Evidence of abruption · Absence of cotyledons · Succenturiate lobe ``` Membranes 1 amnion and 1 chorion · Complete or ragged · Presence of vessels ``` Cord · Cord insertion site · 2 arteries and 1 vein · Velamentous insertion o Vessels noted in membranes ```

Answer 19

· Placenta suspected or diagnosed as incomplete40 · Offensive odour—collect culture swab from maternal and fetal surface · If abnormality detected consider request for histopathology · Advise women: o About normal vaginal blood loss o To seek assistance if passing clots, increase in loss, offensive loss, or pain

Answer 20

Context · Respect cultural and personal perspectives · The woman has the right to take her placenta home · Provide information relevant to the circumstances Transport, storage and disposal Recommend transport in cooled, sealed, leak-proof container o Short term storage in fridge o Longer term storage in freezer · Follow local protocols regarding storage and transport · Refer woman to local council guidance regarding burial or disposal of the placenta on private or public property Ingestion Ingestion of the placenta is not recommended167 due to limited research, particularly: o If it is not their own placenta (due to the risk of blood borne infections) o If the placenta has not been stored in a fridge or freezer o If the placenta has been sent for pathology examination (likely to have been immersed in formaldehyde solution)

Answer 21

Environment Maintain intimate environment for woman and preferred support person · Ensure does not interfere with mother baby bonding/skin to skin care · Recommend no food or drink until after assessment and decision regarding anaesthetic requirement · Discuss and offer adequate pain relief prior to assessment · Facilitate comfortable position in which the genital structures can be clearly observed · Ensure adequate lighting · Ensure woman is comfortable and warm · If water birth, delay suturing for one hour after leaving the water to enable perineal tissue to revitalise ``` Assessment Perform a systematic perineal assessment · Following assessment, explain: o Findings o Recommended plan for repair (if required) o Ongoing self-care ``` Indications for consultation and referral Repair outside of the clinician’s level of competency and credentialling · Inadequate pain relief reported · Adequate visualisation and assessment is not possible

Answer 22

· Ensure adequate lighting for observation of colour · Perform and record unobtrusive regular newborn observations · Provide close continuous care · Record the time from birth to the onset of regular respirations ``` First two hours: Position, patency airway - 15 minutely Respiratory rate and effort - 15 minutely Colour - 15 minutely Heart rate - within one hour of birth Temperature - within one hour of birth ```

Answer 23

Place the baby skin to skin with mother immediately following birth · Maintain warmth by drying baby and with pre-warmed towels or blankets · Assess and record Apgar score at 1 and 5 minutes o Assess tone, breathing, heart rate, colour and reflex irritability · Refer to Queensland Clinical Guidelines: o Routine newborn assessment o Neonatal resuscitation

Answer 24

· Encourage and support uninterrupted skin to skin contact: o For a minimum of one hour or o Until after the first breastfeed (if feeding choice) · Explain the importance of positioning the baby to maintain a patent airway o Support baby’s head and neck in a neutral position o Cover baby’s back with a warm towel or blanket o Continued vigilant baby observations · Observe initial breastfeed and offer help if needed · Refer to Queensland Clinical Guideline: Establishing breastfeeding Avoid separation within the first hour of birth including for: o Weight, length and head circumference o Bathing o Administration of phytomenadione (vitamin K) or newborn immunisations

Answer 25

· Neonatal resuscitation required · Any deviations from normal · Identification of a physical abnormality

Answer 26

Temperature - within 1st hour Pulse, RR, BP - once after birth of the placenta Blood loss - after birth of the placenta - 15-30 minutely Perineum - after first observations, reassess if indicated Pain - initial assessment, review if indicated Urine output - within the first two hours

Answer 27

· Provide an environment that promotes physiological adaptation · Respond to requests for pain management · Nutrition and hydration—offer food and drink · Consider personal hygiene needs · Observe emotional and psychological response to labour and birth · Observe response towards her baby · Assess the mother-infant interaction · Vigilant unobtrusive observations of the baby [refer to Table 29. Newborn care and assessment] · Venous thromboembolism (VTE) risk assessment o Refer to Queensland Clinical Guideline: Venous thromboembolism (VTE) prophylaxis in pregnancy and the puerperium

Answer 28

· Review cord blood result · If indicated: o Obtain maternal Kleihauer or flow cytometry o Recommend RhD immunoglobulin Quantification of the presence of positive fetal cells will guide dose

Intrapartum/labour Flashcards

(52 cards)