Midwifery Management During First Stage of Labor PDF

Midwifery Management During the First Stage of Labor Labour & Delivery Course (MW321) Ghounan Samahan  Initial Evaluation of the Woman and Fetus Initial evaluation of a woman presenting with signs and symptoms of labor includes review of:  history, physical assessment...

Midwifery Management During the First Stage of Labor Labour & Delivery Course (MW321) Ghounan Samahan  Initial Evaluation of the Woman and Fetus Initial evaluation of a woman presenting with signs and symptoms of labor includes review of:  history, physical assessment & laboratory investigations.  the current physical well-being of the woman and fetus.  woman’s medical and obstetric history, social situation, and expectations. Initial Evaluation of the Woman and Fetus A comprehensive approach is necessary to:  identify actual and potential problems  create a mutually agreeable and appropriate plan of care. This approach should include: History Physical Examination Laboratory Investigation   History women who have not received adequate prenatal care are at increased risk of unexpected adverse obstetric complications including preterm birth and stillbirth, giving birth to infants who are large or small for gestational age Critical items of the history should be double-checked with the woman to verify the existence of: drug allergies blood transfusions and reactions major obstetric or medical complications during her pregnancy.   History oDocumentation the prenatal record that was reviewed should be included in her intrapartum medical record. o An interim history includes any change in health status from the time of the last documented visit to the present encounter, chief complaint, and history of present illness, coupled with a brief review of pertinent systems. This, will complete the history database and give direction to the physical examination. Physical Examination A comprehensive physical examination is indicated when a woman has no prenatal records available or has received inadequate prenatal care. Physical Examination  Laboratory Investigation  Identify the woman’s:  blood type  Rh status  Anemias  glucose tolerance testing  perinatal infections, hepatitis B infection or carrier status, and HIV status.  Confirmation of Labor Status active labor do not begin for many women until cervical dilatation reaches 6 cm or more labor status determinations must be based on at least two adequately spaced cervical examinations—for example, 2 to 4 hours apart. In the presence of regular, painful contractions and complete or near-complete effacement, it is reasonable to consider a woman to be in active labor at 4 cm or 5 cm dilation if that state of dilatation is immediately preceded by cervical change over time. Components of Midwifery Care for Laboring Women Labor Support and Pain Management Maternal Position and Level of Activity Hydration and Nutrition Intravenous Access Membrane Management Fetal Heart Rate Monitoring Uterine Contraction Monitoring Labor Support and Pain Management Women who receive continuous labor support are more likely to:  have a spontaneous vaginal birth use less pain medication have slightly shorter labors be more satisfied with their birth experiences than women who do not receive such support  Maternal Position and Level of Activity physical activity and positions used during labor are ideally those chosen by the laboring woman. many hospital labor settings have a culture of lying in bed during the first stage of labor while laboring in bed is considered to be convenient to some providers. Women assuming upright positions have shorter labor durations by approximately 1 hour and are less likely to have an epidural or cesarean birth, as compared to women who maintain recumbent positions. Creative use can be made of furniture, pillows, birthing balls, or an adjustable bed to support a laboring woman in a variety of upright positions, including hands and knees, sitting, standing, and squatting  Maternal Position and Level of Activity Lateral positions: they reduce the potential for aortic/vena cava compression with resulting maternal hypotension and potential fetal compromise. Lateral positions also facilitate kidney function and do not interfere with coordination and efficiency of uterine contractions. Ambulation or upright positions may be contraindicated upon rupture of membranes if the fetal head is unengaged or in the case of a malpresentation because of the heightened risk of umbilical cord prolapse.  Maternal Position and Level of Activity Women with medical or obstetric conditions such as severe preeclampsia, placental abruption, or acute infections will necessarily have their activity restricted due to their physiologic instability, the effect of medications, or increased fetal risk requiring continuous electronic fetal monitoring. Women who have physical mobility disabilities may require additional modifications to facilitate comfort and labor progression women who have a history of sexual or physical abuse may find any position such as lithotomy, or having providers stand over her, a trigger of previous trauma.  Hydration and Nutrition Given the current state of evidence, women should be free to drink and eat in labor as they wish and encouraged to maintain their fluid intake. The primary rationale cited for withholding food and fluid during labor is the decreased risk of gastric content aspiration during general anesthetic induction.  Hydration and Nutrition Effect of hydration: shorter first stage of labor duration. no significant differences in labor duration, oxytocin augmentation, or mode of delivery between women receiving oral fluids only or intravenous fluids at a rate of either 125 or 250 mL/hour. no significant differences in duration of labor, augmentation of labor, cesarean births, or Apgar scores between women with and without oral fluid and food restriction during labor.  Intravenous Access Intravenous access is also necessary for administration of some medications, such as antibiotic prophylaxis for women who are carriers of GBS, pain medications, or oxytocin augmentation. Prior to initiation of epidural anesthesia, establishing intravenous access allows for administration of isotonic fluid blood volume expanders to mitigate epidural-related hypotension.  Membrane Management AROM can be employed to induce labor either alone or with other agents, used routinely during labor in an effort to speed progress, or used selectively as a treatment for dystocia. Risks associated with AROM include: 1. umbilical cord compression with resultant fetal heart rate decelerations. 2. umbilical cord prolapse 3. maternal discomfort from the procedure. 4. increased risk of infection. 5. rarely, rupture of fetal vessels (vasa previa).  Amniotomy Current evidence suggests that when amniotomy is used in conjunction with oxytocin for induction or as a method of preventing dystocia in women who have mild labor delays, the decrease in labor duration associated with amniotomy may be statistically significant but not clinically relevant. The reduced risk of cesarean birth is significant but modest. In contrast, amniotomy alone does not appear to be a beneficial treatment for women with active-phase arrest  Amniotomy Cont” If there is a clinical rationale to perform an amniotomy, a cephalic presentation engagement in the pelvis should be confirmed. Before performing AROM, the midwife carefully reassesses the fetal station and ensures the fetal head is well applied to the cervix. Keeping the fingers in the cervix, the membranes can be gently disrupted with the amnihook. Care should be taken to avoid scratching the fetal head and the clinician’s fingers should be left in place during the initial gush of fluid to ensure a prolapsed cord does not occur. The fetal heart rate should be assessed during the procedure and monitored frequently for a short time afterward. Continuing Evaluation During Labor o Continuing evaluation during labor has three primary focuses: (1) maternal well-being (2) fetal well-being (3) labor progress.  Maternal Well-Being General Maternal Condition woman’s level of fatigue and physical depletion, her behavior and responses to labor, her perception of pain, and her ability to cope with labor. Maternal Vital Signs The following schedule for checking vital signs is frequently encountered as policy for a woman (without epidural anesthesia) during the first stage of labor who does not have a specific condition that would require more frequent monitoring: Blood pressure, pulse, and respirations: every hour Temperature: every 2 to 4 hours when the temperature is normal and the membranes are intact, and every 1 to 2 hours if the temperature is abnormal and/or after the membranes have ruptured.  Urinary Output A woman in labor should be encouraged to empty her bladder at least every 2 hours during the active phase of the first stage of labor. In the event of bladder distension, the first step is to facilitate spontaneous voiding. The best method is for the woman to walk to the toilet if there are no contraindications to ambulation! If she is unable to be out of bed and if the common methods (having her listen to the sound of running water; running warm water over her perineum; applying light suprapubic pressure; and having her practice perineal relaxation) do not initiate urination, then catheterization may be considered.  Bladder distension can occur in any laboring woman, but is especially likely in women with epidural anesthesia who receive a bolus of fluid prior to initiating the epidural. Once the epidural is active, the woman cannot feel the urge to urinate and may not have the muscle control needed to void. Intermittent or indwelling insertion of a urinary catheter to drain the bladder should be considered to minimize the risk of urinary retention or infection for these women.  Uterine Contraction Monitoring o Uterine activity can be evaluated by: correlating the woman’s perceptions of contractions with observation and abdominal palpation. Electronic monitoring methods: an external tocodynamometer or an intrauterine pressure catheter. accepted that three contractions within 10 minutes is the minimum frequency necessary to achieve progressive cervical change in active labor.  Fetal Well-Being Ongoing and standardized fetal heart rate assessment is essential to evaluating fetal well-being throughout labor regardless of the method chosen.  Fetal Heart Rate Monitoring The methods of Fetal Assessment During Labor: - intermittent auscultation of the fetal heart rate. - continuous external fetal heart rate assessment. - continuous internal fetal heart rate assessment. Indications for continuous FHR monitoring: high-risk pregnancy (diabetes, high blood pressure,...) high risk fetus (IUGR, LBW, …). to check how tocolytes or induction agents are affecting fetus.  External Fetal Heart Rate Monitoring With this method, a pair of belts is wrapped around abdomen. One belt uses Doppler to detect the fetal heart rate. The other belt measures the length of contractions and the time between them.  Internal Fetal Heart Rate Monitoring With this method, a wire called an electrode is placed on the part of the fetus closest to the cervix, usually the scalp. This device records the heart rate. Uterine contractions also may be monitored with a special tube called an intrauterine pressure catheter that is inserted through the vagina into uterus. Internal monitoring can be used only after the membranes of the amniotic sac have ruptured. Fetal Assessment During Labor  Labor Progress Digital Cervical Examinations cervical dilation can and should be obtained from each digital cervical examination that is performed during labor, in addition to: cervical effacement, position (posterior, mid- position, anterior), consistency (firm or soft), and fetal station and position. it is recommended that cervical examinations be performed by the same professional whenever possible. The traditional practice of conducting cervical examinations every 1 to 2 hours simply subjects the woman to unnecessary discomfort, intrusion, and increased risk of infection  During normal first-stage labor, a cervical examination may be indicated in the following situations: To establish an informational baseline that can be used for appropriately timing further examinations. to establish labor status prior to admission or labor interventions (prelabor, latent, or active labor). As an appropriately timed second examination to determine the woman’s labor progress. To inform management decisions related to management of labor pain. To verify complete dilation. To check for a prolapsed cord after spontaneous rupture of membranes if a prolapsed cord is a suspected risk (e.g., ballottable presenting part or fetal heart rate decelerations that do not resolve with usual maneuvers). Fetal Presentation, Position, and Station o Cervical examination provides information regarding: (1) fetal presentation; (2) fetal position; (3) fetal station; (4) the adaptation of the fetus to the pelvis (5) the presence or absence of molding; (6) the presence or absence of caput succedaneum Evaluation and Diagnosis of Ruptured Membranes Tests for and Classic Signs of Rupture of Membranes: 1. Observation of fluid coming from the cervical os. 2. The fern test is a classic method of assessing for ROM and is considered diagnostic in many settings when the classic pattern of ferning is clearly seen. 3. The nitrazine test uses limited-range pH paper or a commercially prepared swab to detect the rise in pH in vaginal discharge associated with the presence of amniotic fluid. The normal pH of the vagina of most women is acidic (approximately 4.5), whereas amniotic fluid is neutral to slightly alkaline (7.0–7.5). 4. Pooling of fluid in the posterior fornix of the vagina is a helpful sign, but it is not diagnostic for ROM without confirmation via ferning or nitrazine testing. 5. Ultrasound quantification may also be used.  Fern test During a sterile speculum examination, a sterile cotton swab is used to obtain a specimen of the fluid from the posterior vaginal fornix. Care must be taken not to touch the cervical os to avoid collecting cervical mucus. The specimen is spread thinly onto a microscope slide and allowed to dry thoroughly. The slide is then inspected without using a cover slip using a microscope at 10× power for a fern-like pattern (arborization) caused by crystallization due to the high sodium chloride and protein concentrations in amniotic fluid.  Diagnosis of Rupture of Membranes  The diagnosis of ruptured membranes is typically made via the constellation of history, physical examination, and positive testing Evaluation for Ruptured Membranes: History 1. Inquire about the time, amount, color, consistency, odor, and pattern of leaking (e.g., large gush, continued trickling). - These data are especially important for development of a management plan because the length of time from rupture of membranes to delivery is directly correlated with risk of maternal–fetal infection. - The characteristic of the fluid can reveal clues to fetal well-being. - ROM typically will cause a large gush of fluid, followed by a continuous watery discharge necessitating use of sanitary pads or even washcloths or towels. - In some instances of ruptured membranes, the only symptom the woman may notice is a feeling of moistness on her undergarments from a small, continuous discharge. - Assessing the woman’s ability to control the leakage with contraction of the pelvic floor muscles (Kegel) helps to differentiate PROM from urinary incontinence.  History Cont” 2. Inquire about any recent fever, abdominal pain, vaginal bleeding, abnormal discharge, urine symptoms, and last intercourse (Semen expelled from the vagina can sometimes be mistaken for amniotic fluid). 3. Inquire about signs of labor: contractions, bloody show, fetal movement, recent cervical assessments, or intercourse. 4. Confirm pregnancy dating (this is especially important if less than 37 weeks’ gestation). 5. Review the prenatal record for past obstetric history, prenatal issues, or current medical condition.  Physical Examination  When more than 6 to 12 hours passes, many of the diagnostic observations become unreliable because of lack of fluid. 1. Measure temperature, pulse, respirations, and blood pressure. 2. Perform heart and lung auscultation. 3. Palpate the abdomen for tenderness. 4. Perform Leopold’s maneuvers to assess fetal position, estimated fetal weight, and presenting part.  Ultrasound confirmation of the presenting part may be required. 5. Perform fetal assessment with Doppler or electronic FHR monitoring per institutional or practice guidelines.  Continuous electronic fetal heart rate monitoring is required for women who are between 24 to 37 weeks’ gestation.  Physical Examination Cont” 6. Perform a sterile speculum examination: Note the color, consistency, and amount of any fluid leaking from the vaginal introitus. As the speculum is carefully inserted, be alert for any evidence of prolapsed cord, bulging forebag, or protruding fetal parts. Visualize the cervical os and note any pooling of fluid in the vaginal vault or fluid leaking directly from the os.  Physical Examination Cont” Normal amniotic fluid can be clear, straw colored, or cloudy. - Flecks of white or creamy vernix may be noted in the amniotic fluid of preterm or near-term infants. - Dark yellow or green fluid indicates the presence of meconium in the amniotic fluid. - Meconium-stained fluid increases the risk for chorioamnionitis and can be an indication of fetal compromise. Amniotic fluid has a distinct musty odor, which differentiates it from urine, while foul-smelling fluid can be an indicator of infection.  Physical Examination Cont” If there is no visible fluid leaking from the os: 1. Have the woman perform a Valsalva maneuver or cough. 2. Alternatively, consider having an assistant apply gentle fundal pressure or gently elevate the presenting part abdominally to allow fluid to pass by the presenting part and flow through the cervical os. 3. Another option is to have the woman remain semi-reclining for 30 to 60 minutes and then repeat the sterile speculum examination. 4. Obtain sterile swab specimens of any fluid or discharge seen, avoiding the cervical mucus.  Physical Examination Cont” Using a sterile swab, collect a sample of fluid for 10–15 seconds from the vaginal pool at the posterior fornix or along the vaginal wall. Avoid the cervix. If a nitrazine swab is being used, the color change can be read directly from the swab. If nitrazine paper is being used, apply the swab to pH paper. A pH of 6.5 or higher is suggestive of amniotic fluid rupture. For fern test: - Immediately roll the swab across a dry, clean slide to create a thin film.Thick specimens may obscure ferning. - Set aside for 10 minutes. - Ferning is based on crystallization of the sodium chloride in amniotic fluid. This occurs as the liquid evaporates, so false-negative results are possible if the slide is examined before it is completely dry.  Physical Examination Cont” Obtain a wet mount of any discharge. Obtain a specimen for gonorrhea and chlamydia culture per protocols as required. Obtain GBS culture if the woman’s status is unknown or if it has been more than 5 weeks since the last GBS result. Visualize the cervix for dilation and length/effacement. Do not perform a digital vaginal/cervical examination unless signs of active labor are present. Microscopy Evaluation