Midwifery Management During First Stage of Labor - Al-Balqa Applied University 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.