1. Providing care during labor, childbirth and immediate postpartum

2. General Objective: To describe the best practices in caring for the woman during labor, delivery and immediate postpartum.

3. Specific Objectives To demonstrate the principles of good care in caring for the woman in labor, delivery and immediate postpartum To review the steps in providing intrapartal care To record and interpret observations accurately using the labor record and partograph To practice abdominal and internal examination during labor

4. Steps to follow in INTRAPARTAL CARE 1. Examine the woman for emergency signs. Unconscious, Convulsing Vomiting Severe headache with blurring of vision Vaginal bleeding Severe abdominal pain Looks very ill Fever Severe breathing difficulty Do NOT make a very sick woman wait, attend to her quickly!

5. 2. Greet the woman and make her comfortable. Ask for informed consent before examination or any procedure Respect privacy Communicate result of examination Steps to Follow in Intrapartal Care

6. 3. Assess the woman in labor.   Take the history of labor and record on the labor form.   Review Home Based Maternal Record (HBMR)/ Mother and Child Book When is delivery expected? Preterm or term? Prior pregnancies Birth plan   Assess uterine contractions: intensity, duration, and interval   Observe the woman’s response to contractions.   Perform abdominal exam: (Leopold’s maneuver, FHT) between contractions Steps to Follow in Intrapartal Care

7. 4) Determine the stage of labor. Explain to the woman that you will perform a vaginal examination and ask for her consent. Respect privacy Observe standard precautions Steps to Follow in Intrapartal Care

8. 4) Determine the stage of labor. Inspect the vulva for: o o Bulging perineum o o Any visible fetal parts o o Vaginal bleeding o o Leaking amniotic fluid; if yes, is it meconium stained, foul smelling? o o Warts, keloid tissue or scars that may interfere with delivery Steps to Follow in Intrapartal Care

9. 4) Determine the stage of labor. Perform gentle vaginal examination (do not start during contraction). Explain findings to the woman. Reassure her. RECORD findings in labor record or in partograph. Steps to Follow in Intrapartal Care

10. Determining Stage of Labor Not in Active Labor Early Active Labor Late Active Labor Imminent Delivery

11. Determining Stage of Labor SignsClassifyManage Bulging thin perineum Bulging thin perineum Vagina gaping and head visible Vagina gaping and head visible Full cervical dilation Full cervical dilation Imminent Delivery Manage 2 nd stage of labor Manage 2 nd stage of labor Record in partograph Record in partograph Cervical dilatation Cervical dilatation - Multigravida >5 cm - Primigravida >6 cm Late Active Labor Manage 1st stage of labor Manage 1st stage of labor Record in partograph Record in partograph Record in labor record Record in labor record Cervical dilatation at >4cm Cervical dilatation at >4cm Early Active Labor Manage 1st stage of labor Manage 1st stage of labor Record in partograph Record in partograph Record in labor record Record in labor record Cervical dilatation at 0-3 cm Cervical dilatation at 0-3 cm Contractions weak and <2 in 10 minutes Contractions weak and <2 in 10 minutes Not yet in Active Labor Record in labor record Record in labor record

12. 5. Decide if the woman can safely deliver. If there is indication for referral … in early labor and the referral hospital can be timely reached:   Refer urgently in late active labor:   Monitor progress of labor and deliver the baby   Prepare for immediate referral if still necessary If the woman or her family refuses referral   Explain the possible consequences   Continue to take care of her Steps to Follow in Intrapartal Care

13. 6. Give supportive care throughout labor. Activity #2: Identify which is correct and incorrect practice and explain why. Identify which is correct and incorrect practice and explain why.

14. A. Explain procedures, seek permission, respect privacy and discuss findings with the woman and her family.

15. B..

16. B. NEVER LEAVE a woman in labor alone.

17. C. Bathing before labor?

18. D. Bathing before labor Encourage woman to wash from her waist down or take a bath at the onset of labor.

19. E. Bladder emptying? Encourage her to: empty her bladder and bowels. Remind her to empty her bladder every 2 hours. (A full bladder may prolong the labor)

20. F. Position during Labor Respect and support her choice of a birthing position

21. G. Eating, Drinking???

22. 7. Eating, Drinking??? Encourage her to:  Eat and drink as she wishes.

23. Activity #3: Demo-role play of own practices 10 mins preparation 5 mins presentation 3 groups: 3 groups: 1 st stage 1 st stage 2 nd stage 2 nd stage 3 rd stage 3 rd stage

24. 7. Monitor and manage labor.   First stage: not yet in active labor, cervix is dilated 0-3 cm., contractions are weak, <2 in 10 minutes Every hour: Every hour: check for emergency signs, frequency, intensity & duration of contractions, FHR, mood and behavior. Every 4 hours: check vital signs and cervical dilatation. Record findings in Labor record REFER Assess progress of labor: After 8 hrs, if contractions are stronger & more frequent but no progress in cervical dilatation: REFER Steps to Follow in Intrapartal Care

25.   First stage: in active labor, cervix is dilated at 4 cm or more Check every 30 mins for emergency signs, frequency and duration of contractions, FHR, mood and behavior. Check every 4 hours: fever, PR, BP, cervical dilatation. Record time of rupture of membranes and color of the amniotic fluid. Record findings in partograph.

26. RELIEF of PAIN and DISCOMFORT  Suggest change of position  Encourage mobility as comfortable for her  Encourage proper breathing: breath more slowly, make a sighing noise, make 2 short breaths followed by a long breath out.  Massage her lower back if she finds it helpful

27. CAUTION  DO NOT do IE more frequently than every 4 hours unless necessary.  DO NOT allow the woman to push unless delivery is imminent →  DO NOT allow the woman to push unless delivery is imminent → pushing does not speed up labor, mother will become tired, cervix will swell.

28. DO NOT give medications to speed up labor → DANGEROUS: may cause trauma to the mother and baby (ex: Uterine rupture) DO NOT give medications to speed up labor → DANGEROUS: may cause trauma to the mother and baby (ex: Uterine rupture) DO NOT DO FUNDAL PRESSURE- DO NOT DO FUNDAL PRESSURE- may cause uterine rupture, fetal death

29. Second stage: from full dilatation (10cm) of the cervix until birth of baby. How to tell if a woman is in the 2 nd stage: On IE, cervix is fully dilated Woman wants to bear down Strong uterine contractions every 2-3 minutes Bulging thin perineum, fetal head visible during contractions. BOW will rupture

30. Monitoring the 2 nd stage Check uterine contractions, fetal heart rate, mood and behavior Continue recording in the partographREMINDER: 1. Massaging or stretching the perineum have not been shown to be beneficial. 2. DO NOT apply fundal pressure to help deliver the baby → may harm mother and baby.

31. 8. Deliver the Baby  Implement the 3 CLEANS 1. Clean hands 2. Clean delivery surface 3. Clean cutting and care of the cord WEAR DOUBLE GLOVES Steps to Follow in Intrapartal Care

32.  Stay with the woman and encourage her. Make her comfortable.  Check fetal heart tones every 15 minutes

33.  When the birth opening is stretching, support the perineum and anus with a clean swab to prevent lacerations  Ensure controlled delivery of the head Deliver the Baby

34. Controlled delivery of the head o Keep one hand on the head as it advances during contractions. Keep the head from coming out too quickly. o Support the perineum with other hand.

35. Controlled delivery of the head, cont’d.. o Discard pad and replace when soiled to prevent infection. o During delivery of the head, encourage woman to stop pushing and breathe rapidly with mouth open.

36.   Gently feel if the cord is around the neck   If it is loosely around the neck, slip it over the shoulders or head   If it is tight, place a finger under the cord, clamp and cut the cord, and unwind it from around the neck. Delivering the Baby

37.   Gently wipe the baby’s nose and mouth with a clean gauze or cloth.   Wait for external rotation (within 1-2 min), head will turn sideways bringing one shoulder just below the symphysis pubis and other facing the perineum  Apply gentle downward pressure to deliver top shoulder then lift baby up to deliver lower shoulder. Gently deliver the rest of the baby. Delivering the Baby

38. Delivering the baby 1. Put baby on mother’s abdomen in prone position. Cover with dry towel. 2. Thoroughly dry the baby immediately. Wipe eyes. 3. Discard wet cloth. 4. Put baby prone, in skin- to-skin contact on mother’s abdomen,. Keep the baby warm.

39. 5. Exclude 2 nd baby by palpating mother’s abdomen. 6. Give 10 IU oxytocin IM to the mother. (active management of the 3 rd stage of labor.)* the 3 rd stage of labor.)* * May be done by the midwife under * May be done by the midwife under supervision of doctor. supervision of doctor.

40. Delivering the baby 7. Watch for vaginal bleeding. 8. Remove first set of gloves. 9. When no more cord pulsation is felt on the cord (usually within 3 mins.) clamp the cord 2cm from the base using sterile plastic cord clamp 10. Sweep the cord and apply a second Kelly forceps 5cm from the base and then cut in-between.

41. Third Stage: Between birth of the baby and delivery of the placenta

42. 11. Deliver the placenta by controlled cord traction (with counter traction on the uterus above the symphysis pubis). 12. Massage uterus over the fundus.

43. 13. Inject oxytocin. (if not yet given as part of active management) (if not yet given as part of active management) 14. Encourage initiation of breastfeeding. Let baby stay on mother’s abdomen for 60-90 min mother’s abdomen for 60-90 min

44. Check that the placenta and membranes are complete. Put the placenta into a container for disposal.

45. Third stage: between birth of the baby and delivery of the placenta. ACTIVE MANAGEMENT* of the third stage of labor o o Cord is clamped o o Oxytocin is given within 2 min of delivery of the baby o o Placenta is delivered by controlled cord traction with countertraction above the symphysis pubis. o o Massage fundus. * May only be done by a midwife under supervision of doctor.

46. 9. Monitor closely within 1-hour after delivery (Immediate postpartum period) and give supportive care. Check for vaginal tears and bleeding. Clean the woman and make her comfortable. Check BP, PR, emergency signs & uterine contraction every 15 minutes. Initiate breastfeeding within 1-hour when the baby is ready.

47. Continue care after 1 hour postpartum. Keep watch closely for at least 2 hours. 10. Continue care after 1 hour postpartum. Keep watch closely for at least 2 hours. Temperature, BP and pulse every 30 minutes Check at 2, 3 and 4 hours, then every 4 hours:   emergency signs   uterine contraction Check for bladder distension if unable to void. Advise clean cloth/napkin to collect vaginal blood. Eat and drink high-energy food that are easily digestible. Companion: to watch her and to call you for bleeding or pain, dizzy or for any other problem Steps to Follow in Intrapartal Care

48. Keep the baby in the room with the mother, in her bed or within easy reach. Support exclusive breastfeeding on demand, day and night, as often and as long as the baby wants. Immunize according to the EPI schedule. Mother and companion to watch the baby:   breastfeeding difficulty   difficulty of breathing   cold feet   bleeding from the cord Check baby at around 4 and 8 hours and then daily:   cold feet, breastfeeding and breathing difficulty. FOR THE BABY

49. Advise postpartum care and hygiene.   Wash from waist down or have a sponge bath or a shower with warm water each morning or when she feels like it.   Use guava leaves decoction if woman prefers, for her wash or bath. 9. Continue care after 1 hour postpartum.

50. Medications   Iron 60 mg/ Folic acid 400ug 1 tablet daily… until 3 months postpartum   Vitamin A 200, 000 IU, 1 capsule after delivery or within 1 month postpartum 9. Continue care after 1 hour postpartum.

51. 11. Educate and counsel on family planning and provide the family planning method if available. Ask what are the couple’s plans regarding having more children. Give relevant information and advice. Advice that exclusive breastfeeding is the best contraceptive in the 1 st six months. Help her to choose the most appropriate method for her and her partner.

52. 12. Inform, teach and counsel the woman on important MCH messages. Talk to the woman when she is rested and comfortable. Also give important information and advice to her companion.

53. 13. Discharge the woman and her baby. The woman and her baby may be discharged 24 hours after delivery. Ensure that the woman is able to breastfeed successfully before discharge. Repeat important health information. Check understanding and arrange follow-up.

54. Providing care during labor, childbirth and immediate postpartum