NCM 109 Finals PDF

NCM 109 FINALS CARE OF MOTHER AND CHILD AT RISK OR WITH PROBLEMS (RLE) ○ SURGICAL TECHNIQUE Introduction to Sterile Technique: - Proper aseptic techniques is one of the most fundamental and essential principles of infection control in the Clinical and Surgical setting. Aseptic Techniques are those w...

NCM 109 FINALS CARE OF MOTHER AND CHILD AT RISK OR WITH PROBLEMS (RLE) ○ SURGICAL TECHNIQUE Introduction to Sterile Technique: - Proper aseptic techniques is one of the most fundamental and essential principles of infection control in the Clinical and Surgical setting. Aseptic Techniques are those which: - Remove/reduce or kill microorganisms from hands and objects - Employ sterile instruments - Reduce patient risk of exposure to microorganisms that cannot be removed Aseptic Technique - Immediately before and during surgical procedures to reduce post-operative infection: a. Hand washing b. Surgical Attire c. Surgical scrub, sterile gowning & gloving d. Patients surgical skin preparation e. Using surgical barriers (surgical drapes and PPE) f. Using safe operative technique Asepsis Absence of microorganism that cause disease Freedom from infection Aseptic Technique = methods by which contamination with microorganisms is prevented Principles of Aseptic Technique Only sterile items are used within the sterile field Sterile persons are gowned and gloved ○ Gowns are only sterile from waist to shoulder Gloved hand must be kept in sight at all times Only the top of a draped table is considered sterile Sterile persons touch only sterile items or areas Unsterile persons avoid reaching over the sterile field The edges of anything that encloses sterile contents are considered unsterile Sterile field is created as close as possible to the time of use Sterile areas are continuously kept in view Sterile persons keep well within the sterile area Sterile persons keep contact with sterile areas to a minimum Unsterile persons avoid sterile areas Destruction of the integrity of microbial barriers results in contamination SURGICAL HAND ANTISEPSIS Process of removing as many microorganisms as possible from the hands and arms by mechanical washing and chemical antisepsis before participating in a surgical procedure Despite the mechanical action and the chemical antimicrobial component of the scrub process, skin is never sterile. 4 factors affecting the effectiveness of surgical hand antisepsis: 1. The preparation before cleansing 2. The choice of antiseptic solution 3. The cleansing method 4. The duration of hand cleansing CHARACTERISTICS OF SURGICAL SCRUB NCM 109 (RLE) | MUNSAYAC 1 Performance characteristics for a surgical scrub agent generally fall into four categories: 1. Antimicrobial Action- an ideal agent would have a broad spectrum of antimicrobial activity against pathogenic organisms. This agent would have to work rapidly. An agent that does not work rapidly may not provide adequate bacterial reduction before being rinsed off. 2. Persistent Activity- an agent offering persistent activity keeps the bacterial count low under the gloves, It is not unusual for a surgery to last in excess of two hours. Studies have shown the rate of glove failures (non-visible holes) increases with the duration of surgery. In addition, studies show bacteria grow faster under gloves than ungloved hands. 3. Safety- the ideal agent would be non-irritating and non-sensitizing. It must have no appreciable ocular or ototoxicity, be safe for use on the body, and not be damaging to the skin or environment. 4. Acceptanceprobably most important to achieving compliance in using a new product is its acceptance by the healthcare worker. A product that has ideal antimicrobial action and an excellent safety profile is of little value to good infection control if the user population fails to support its use. Although each is important in its own right, all four characteristics should be present for a complete package. SURGICAL SKIN ANTISEPSIS AND WOUND CLASSIFICATION - According to the Centers for Disease Control and Prevention (CDC, 2017) surgical skin preparations should have an alcohol based antiseptic unless contraindicated. AORN recommends dual agent preps containing alcohol. - - Surgical site preparation solutions include the following: - Betadine scrub & paint (iodophor), CHG, Prevail (iodophor & alcohol), Chloraprep (CHG & alcohol) Dual agents such as Chloraprep and Prevail have ideal antimicrobial properties and prevention of SSI: - Broad spectrum - Rapid bactericidal activity - Persistence or residual properties on the skin - Effective in the presence of blood - Non-irritating or have low allergic and/or toxic responses - No or minimal systemic absorption - Contraindicated for neonates and if used incorrectly can be a fire risk Choice of Antiseptic Solution Antimicrobial soaps, aqueous scrubs (ex. biguanides), alcohol rubs used as antiseptic solutions Alcoholic chlorhexidine was found to have greater residual antimicrobial activity ○ Review by Tanner et al, reported that biguanides (ex. Chlorhexidine gluconate is more effective in removing microorganism on hands than Iodophors (ex. Povidone iodine) The Methodology of the Scrub The time method: All surgical scrubs are 3-5 minutes in length All are performed using a surgical scrub brush and an antimicrobial soap solution Preparation Before Surgical Scrub Removal of finger rings/ jewelry, nail polish and artificial nails NCM 109 (RLE) | MUNSAYAC 2 ○ Finger rings and jewelry can harbor microorganism and dead skin Dark nail polish obscures the subungual space and likelihood of careful cleansing is reduced ○ Artificial nail increases the microbial load on hands Perform a preliminary hand washing with antimicrobial soap Wash both of your hands and arms, lathering up well ○ Rinse and dry Clean underneath your fingernails with a nail file Surgical Scrub Procedure 1. Remove sterile disposable brush-sponge from its wrapper and moisten the sponge 2. Lather fingertips with sponge side of brush, then using brush side of brush scrub the spaces under the fingernails of the right or left hand with 30 circular strokes 3. Lather digits; scrub 20 circular strokes on all four sides of each finger 4. Lather palm, back of hand, heel of hand and space between thumb and index finger (scrub 20 circular strokes) on each 5. Forearm scrub - divide the forearm into 3 inch increments (the brush is 3 inches lengthwise) Use the sponge side of the brush lengthwise to apply soap around the wrist Scrub 20 circular strokes on all four sides of wrist Then move up the forearm - lather, then scrub ending 2 inches above the elbow 6. Repeat the previous steps for the other arm 7. Discard the brush 8. Rinse hands and arms without retracing or contaminating allow the water to drip from the elbows 9. After final rinse, turn water off and keep scrubbed hands and arms in view to avoid contamination and back into operating room 10. In the operating room, dry hands and arms with a sterile towel before donning a sterile surgical gown and gloves Drying the Hands Step 1: Reach down to the opened sterile package containing the gown, and pick up the towel. Be careful not to drip water onto the pack. Step 2: Open the towel full-length, holding one end away from the non-sterile scrub attire. Bend slightly forward. Step 3: Dry both hands thoroughly but independently. To dry one arm, hold the towel in the opposite hand and, using the oscillating motion of the arm, draw the towel up to the elbow. Step 4: Carefully reverse the towel, still holding it away from the body. Dry the opposite arm on the unused end of the towel. Gowning Technique Step 1: Reach down to the sterile package and lift the folded gown directly upward Step 2: Step back away from the table into an unobstructed area to provide a wide margin of safety while gowning Step 3: Holding the folded gown, carefully locate the neckline Step 4: Holding the inside front of the gown just below the neckline with both hands, let the gown unfold, keeping the inside of the gown toward the body. Do not touch the outside of the gown with bare hands - the gown is considered contaminated. Step 5: Holding the hands at shoulder level, slip both arms into the armholes simultaneously The circulator brings the gown over the shoulders by reaching inside to the shoulder and arm seams – The gown is pulled on, leaving the cuffs of the sleeves extended over the hands – The back of the gown is securely tied or fastened at the neck and waist, touch the outside of the gown at the line of ties or fasteners in the back only NCM 109 (RLE) | MUNSAYAC 3 Summary Principles: Touch only the inside of the gown while donning it If touch the outside, the gown is considered contaminated Scrubbed hands and arms are considered contaminated if they fall below the waist level or touch the body After donning the gown, the only parts of the gown that are considered sterile are the sleeves and front from waist level to a few inches below neck opening Gloving by the Closed Glove Technique Preferred method over open-gloving technique Provides a bacterial barrier between patient and surgeon Step1: Using the right hand and keeping it within the cuff of the sleeve, pick up the left glove from the inner wrap of the glove package by grasping the folded cuff Step 2: Extend the left forearm with the palm upward. Place the palm of the glove against the palm of the left hand, grasping in the left hand the top edge of the cuff, above the palm. In correct position, glove fingers are pointing toward you and the thumb of the glove is down Step 3: Grasp the back of the cuff in the left hand and turn it over the end of the left sleeve and hand The cuff of the glove is now over the stockinette cuff of the gown, with the hand still inside the sleeve Step 4: Grasp the top of the left glove and underlying gown sleeve with the covered right hand Pull the glove on over the extended right fingers until it completely covers the stockinette cuff Step 5: Glove the right hand in the same manner Use the gloved left hand to pull on the right glove DISINFECTION AND STERILIZATION Cleaning- the physical removal of organic material or soil from objects, is usually done by using water with or without detergents. Sterilization- is the destruction of all forms of microbial life; it is carried out in the hospital with steam under pressure, liquid or gaseous chemicals, or dry heat. Disinfection- defined as the intermediate measures between physical cleaning and sterilization, is carried out with pasteurization or chemical germicides. The level of disinfection achieved depends on several factors: contact time temperature type and concentration of the active ingredients of the chemical germicide the nature of microbial contamination. TYPES OF DISINFECTION High-level disinfection: can be expected to destroy all microorganisms, with the exception of large numbers of bacterial spores. Intermediate disinfection: inactivates Mycobacterium tuberculosis, vegetative bacteria, most viruses, and most fungi; does not necessarily kill bacterial spores. Low-level disinfection: can kill most bacteria, some viruses, and some fungi; cannot be relied on to kill resistant microorganisms such as tubercle bacilli or bacterial spores. Medical devices, equipment, and surgical materials are divided into three general categories based on the potential risk of infection involved in their use: 1. critical items 2. semicritical items 3. noncritical item Critical items Critical items are instruments or objects that are introduced directly NCM 109 (RLE) | MUNSAYAC 4 into the bloodstream or into other normally sterile areas of the body. Examples are surgical instruments, cardiac catheters, implants, pertinent components of the heart-lung oxygenator, and the blood compartment of a hemodialyzer. Sterility at the time of use is required for these items; consequently, one of several accepted sterilization procedures is generally recommended. Semicritical items These items come in contact with intact mucous membranes, but they do not ordinarily penetrate body surfaces. Examples are noninvasive flexible and rigid fiberoptic endoscopes, endotracheal tubes, anesthesia breathing circuits, and cystoscopes. Sterilization is not absolutely essential; at a minimum, a high-level disinfection procedure that can be expected to destroy vegetative microorganisms, most fungal spores, tubercle bacilli, and small nonlipid viruses are recommended. In most cases, meticulous physical cleaning followed by an appropriate high-level disinfection treatment gives the user a reasonable degree of assurance that the items are free of pathogens. Noncritical items Noncritical items are those that either do not ordinarily touch the patient or touch only intact skin. Such items include crutches, headboards, blood pressure cuffs, and a variety of other medical accessories. These items rarely, if ever, transmit disease. Consequently, washing with a detergent may be sufficient. Items must be thoroughly cleaned before processing, because organic material (e.g blood and proteins) may contain high concentrations of microorganisms. Also, such organic material may inactivate chemical germicides and protect microorganisms from the disinfection or sterilization process. For noncritical items- cleaning can consist only of: 1) washing with a detergent or a disinfectant-detergent, 2) rinsing, 3) thorough drying. Steam sterilization Steam sterilization is the most inexpensive and an effective method for sterilization. Steam sterilization is unsuitable for processing plastics with low melting points, powders, or anhydrous oils. Items that are to be sterilized but not used immediately need to be wrapped for storage. Sterility can be maintained in storage for various lengths of time, depending on the type of wrapping material, the conditions of storage, and the integrity of the package. Monitoring of steam sterilization processes to check the highest temperature that is reached during sterilization and the length of time that this temperature is maintained heat- and steam-sensitive chemical indicators can be used on the outside of each pack a large pack might have a chemical indicator both on the outside and the inside to verify that steam has penetrated the pack Microbiological monitoring Microbiological monitoring of steam sterilizers is recommended at least once a week with commercial preparations of spores of Bacillus stearothermophilus (a microorganism having spores that are particularly resistant to moist heat, thus assuring a wide margin of safety). NCM 109 (RLE) | MUNSAYAC 5 One positive spore test (spores not killed) does not necessarily indicate that items were processed. The sterilizer is not sterile, but it does suggest that the sterilizer should be rechecked for proper temperature, length of cycle, loading, and use and that the test be repeated. Sterilization of implantable items implantable items, such as orthopedic devices, require special handling before and during sterilization; thus, packs containing implantable objects need to be clearly labeled so they will be appropriately processed. To guarantee a wide margin of safety, it is recommended that each load of such items be tested with a spore test and that the sterilized item not be released for use until the spore test is negative at 48 hours. If it is not possible to process an implantable object with a confirmed 48-hour spore test before use, it is recommended that the unwrapped object receive the equivalent of full-cycle steam sterilization and not flash sterilization. Ethylene oxide gas sterilization It is a more complex and expensive process than steam sterilization It is usually restricted to objects that might be damaged by heat or excessive moisture. Before sterilization, objects also need to be cleaned thoroughly and wrapped in a material that allows the gas to penetrate. Because ethylene oxide gas is toxic, precautions (e.g., local exhaust ventilation) should be taken to protect personnel. All objects processed by gas sterilization also need special aeration according to manufacturer's recommendations before use to remove toxic residues of ethylene oxide. Chemical indicators need to be used with each package to show that it has been exposed to the gas sterilization process. Moreover, it is recommended that gas sterilizers be checked at least once a week with commercial preparations of spores, usually Bacillus subtilis. Powders and anhydrous oils can be sterilized by dry heat. Microbiological monitoring of dry heat sterilizers usually provides a wide margin of safety for dry heat sterilization. Liquid chemicals can be used for sterilization and disinfection when steam, gas, or dry heat sterilization is not indicated or available The most appropriate chemical germicide for a particular situation can be selected by responsible personnel in each hospital based on: 1. the object to be disinfected, 2. the level of disinfection needed, and the scope of services, physical facilities, 3. and personnel available in the hospital. Gloves may be indicated to prevent skin reactions when some chemical disinfectants are used. Items subjected to high-level disinfection with liquid chemicals need to be rinsed in sterile water to remove toxic or irritating residues and then thoroughly dried. Subsequently, the objects need to be handled aseptically with sterile gloves and towels and stored in protective wrappers to prevent recontamination. Recommendations Cleaning- All objects to be disinfected or sterilized should first be thoroughly cleaned to remove all organic matter (blood and tissue) and other residue. Indications for Sterilization and High-Level Disinfection Critical medical devices or patient-care equipment that enter normally sterile tissue or the NCM 109 (RLE) | MUNSAYAC 6 vascular system or through which blood flows should be subjected to a sterilization procedure before each use. Laparoscopes, arthroscopes, and other scopes that enter normally sterile tissue should be subjected to a sterilization procedure before each use; if this is not feasible, they should receive at least high-level disinfection. Equipment that touches mucous membranes, e.g., endoscopes, endotracheal tubes, anesthesia breathing circuits, and respiratory therapy equipment, should receive high-level disinfection. Methods of Sterilization Whenever sterilization is indicated, a steam sterilizer should be used unless the object to be sterilized will be damaged by heat, pressure, or moisture or is otherwise inappropriate for steam sterilization. In this case, another acceptable method of sterilization should be used. Flash sterilization [270°F (132°C) for 3 minutes in a gravity displacement steam sterilizer] is not recommended for implantable items. Biological Monitoring of Sterilizers All sterilizers should be monitored at least once a week with commercial preparations of spores intended specifically for that type of sterilizer (i.e., Bacillus stearothermophilus for steam sterilizers and Bacillus subtilis for ethylene oxide and dry heat sterilizers). Every load that contains implantable objects should be monitored. These implantable objects should not be used until the spore test is found to be negative at 48 hours. If spores are not killed in routine spore tests, the sterilizer should immediately be checked for proper use and function and the spore test repeated. Objects, other than implantable objects, do not need to be recalled because of a single positive spore test unless the sterilizer or the sterilization procedure is defective. If spore tests remain positive, use of the sterilizer should be discontinued until it is serviced. Use and Preventive Maintenance Manufacturers' instructions should be followed for use and maintenance of sterilizers. Chemical Indicators Chemical indicators that will show a package has been through a sterilization cycle should be visible on the outside of each package sterilized. Use of Sterile Items An item should not be used if its sterility is questionable, e.g., its package is punctured, torn, or wet. Reprocessing Single-Use or Disposable Items Items or devices that cannot be cleaned and sterilized or disinfected without altering their physical integrity and function should not be reprocessed. Reprocessing procedures that result in residual toxicity or compromise the overall safety or effectiveness of the items or devices should be avoided. Role of Central Sterile Department (CSSD) Rinsing Cleaning Drying Inspection and assembly Packaging Labeling Sterilization Storage Distribution NCM 109 (RLE) | MUNSAYAC Supply 7 Summary 1. Proper aseptic technique is one of the fundamental and essential principles of infection control 2. This stepwise process of proper aseptic technique should be performed every single time in the OR - LABOR is the series of events by which uterine contractions and abdominal pressure expel a fetus and placenta from the uterus. Regular contractions cause progressive dilatation of the cervix and create sufficient muscular uterine force to allow a baby to be pushed out into the extrauterine world. Labor represents a time of change as it is both an ending and a beginning for the woman, her fetus, and her family (Archie & Roman, 2013). Labor and birth are unique events, requiring a woman to employ all the psychological and physical coping methods she has available. Regardless of the amount of childbirth preparation or the number of times a woman has been through the birth experience, family centered nursing care is the approach that best supports the woman as she focuses on the beginning of her new family. This goal for nursing is further emphasized by 2020 National Health Goals ASSESSING AND ADMITTING PREGNANT WOMAN ASSESSMENT FOR A WOMAN IN LABOR - A woman in labor is keenly aware of both nonverbal and verbal expressions around her (i.e., not only words spoken but gestures such as eye rolling or sighing). - Because of this sensitivity, an assessment must be done - - quickly yet thoroughly and gently because she may have difficulty being patient, for example, while admission information is obtained or relaxing for a vaginal examination. Remember that pain is a subjective symptom. Only the woman can evaluate how much she is experiencing or how much she wants to endure. Assess how much discomfort she is experiencing and how she feels about her labor not only by what she scores on a pain scale but also by subtle signs of pain such as facial tenseness, flushing or paleness of the face, hands clenched in a fist, rapid breathing. or rapid pulse rate. Appreciate that the fetus as well as the mother is under stress from the process of labor, so both need vital sign assessments. DIAGNOSIS Nursing diagnosis in labor generally relates to a woman's reaction to labor. Common nursing diagnosis include: Pain related to labor contractions Anxiety related to process of labor and birth Health-seeking behaviors related to management of discomfort of labor Situational low self-esteem related to inability to use planned childbirth method Although the discomfort of labor contractions is commonly referred to as "contractions" rather than "pain", do not omit the word "pain" from a nursing diagnosis because the term strengthens an understanding of the problem as well as alerts a woman she should feel free to ask for something for pain as the point she feels she needs additional help OUTCOME IDENTIFICATION AND PLANNING - When establishing expected outcomes for a woman in labor and NCM 109 (RLE) | MUNSAYAC 8 - her partner, be certain they are realistic and that they can be met. Although labor usually takes place over a relatively short time frame (average, 12 hours), it is important not to project a definite time limit for labor to be completed because the length of labor can vary greatly from woman to woman and still be within normal limits. It is necessary also to appreciate the magnitude of labor. It is unlikely all the fear or anxiety experienced during a woman's labor can be completely alleviated. Often, because it is such an unusual and significant experience, the average couple may need guidance in order to be able to employ additional coping measures. Be certain to incorporate a support person as well as the woman in planning so the experience is a shared one. Although a couple may have learned about the stages of labor and what to expect at each stage during pregnancy, the reality of labor may seem very different from what they imagined. Be certain also that planning is flexible and individualized, allowing the woman to experience the full significance of the event. MEASURING FUNDAL HEIGHT - At 12 weeks gestation (near the end of the first trimester, three-month period), The fundus (upper margin of the body of the uterus) may be palpated (firm globular mass) through the abdomen above the pubic bone (symphysis pubis). The size of the uterus usually reaches its peak at about 36 weeks' gestation PROCEDURE: Ensure hands are clean and warm. Place the zero mark of the tape measure at the uppermost order of the uterine fundus. 1. Run the tape measure along the midline of the woman's abdomen to the uppermost border of the symphysis pubis. 2. To locate the fundus the hand is moved down the abdomen below the xiphisternum until the curved upper border of the fundus is felt. 3. Position the woman in a supine position with her legs extended. 4. Ensure hands are clean and warm. 5. Place the zero mark of the tape measure at the uppermost border of the uterine fundus. 6. Document the distance in centimeters and compare with the calculated gestation. NOTE It has been demonstrated the fundal height can be 3 cm higher at 17-20 weeks gestation if the woman has a full bladder. An enlarged uterus can compress the inferior vena cava and the lower aorta leading maternal supine hypotension and reduced utero- placental blood flow which can cause fetal compromise Warm hands minimize maternal discomfort and potential for inducing contraction of the uterus. SUPINE HYPOSENSITIVE SYNDROME - When a pregnant woman is lying flat on her back, the weight of her uterus and its contents compresses the large blood vessel (vena cava) leading from her lower body to the heart. - When this blood vessel is squashed, the blood flow back to NCM 109 (RLE) | MUNSAYAC 9 - the heart is reduced, which in turn leads to a reduction in the blood flow out of the heart to the rest of the body. common after 24 weeks of pregnancy to twin pregnancies increase the volume of amniotic fluid (waters surrounding the fetus). The decrease amount going back to the heart result in decreased cardiac output that leads to: Decreased blood pressure Decreased blood supply to the brain causing dizziness, faintness and lightheadedness ASSESSMENT OF FUNDAL HEIGHT - Fundal height increases as the fetus inside the uterus grows, thus it should be measured every clinic visit to help determine fetal growth. - Fundal height measurements will also help estimate AOG and EDC. - The landmarks to be used in measuring the FH (fundal height) are top of symphysis pubis, the umbilicus and xiphoid. - Fundal height below the umbilicus is less than 20 weeks gestation. - Fundal height above the umbilicus is more than 20 weeks gestation. Points to remember: - To ensure accuracy the woman should empty her bladder and the examiner should perform the measurement at every examination. MCDONALD RULE: is used to determine the age of gestation by measuring from the fundus (obtaining the fundal height) to the symphysis pubis. Month: Fundal Height in cmx2/7 Week: Fundal Height in cmx8/7 BARTHOLOMEW RULE: Fundal height is determined by relating to the different landmarks in the abdomen are: - Symphysis pubis Umbilicus Xiphoid process CHECKING FHT Fetal Heart Rate (FHR) Monitoring is the measuring of the fetus heart rate during labor by using a special instrument. Types and methods of fetal heart monitoring: 1. Intermittent Auscultation 2. Electronic Fetal Monitoring (EFM) Although fairly passive in labor, a fetus is subjected to extreme pressure by uterine contractions and passage through the birth canal, so it is important to ascertain that the FHR remains within normal limits despite these pressures. Auscultation of Fetal Heart Sounds - Fetal heart sounds are transmitted best through the convex portion of a fetus because that is the part that lies in closest contact with the uterine wall. - In breech presentation, fetal heart sounds are usually best heard through the fetal back. (woman's umbilicus or above) - In a face presentation, the back becomes concave so the sounds are best heard through the more convex. - In cephalic presentations, they are heard loudest low in a woman's abdomen. FHR patterns Normal Pattern: Baseline FHR = 120 - 160 bpm (Beat/min.) Tachycardia: Baseline FHR above 160 bpm NCM 109 (RLE) | MUNSAYAC 10 Bradycardia: Baseline FHR less than 120 bpm The Baseline Fetal Heart Rate A baseline FHR is determined by analyzing the pace of fetal heartbeats recorded in a minimum of 2 minutes obtained between contractions. A normal rate is 110 to 160 beats/min. Intermittent Auscultation Technique: Auscultation is a method of listening to the fetal heartbeat for about 60 seconds by using a fetal stethoscope (Fetoscope or Pinard), or a hand held Doppler ultrasound device. Advisable for normal pregnancies INTERMITTENT AUSCULTATION TECHNIQUE heart rate and using a pressure sensor to monitor the mother's contractions at the same time. There are 2 types of EFM: 1. External monitoring 2. Internal monitoring Indications of EFM Pregnancy complications (Diabetes, preeclampsia...) Preterm labor. Previous cesarean. The baby is smaller than expected. Multiple fetuses. Overweight mother. Prolonged 1st stage of labor. The amniotic fluid contains significant amounts of meconium (The baby's first poo). Induction of labor. A high temperature mother. EXTERNAL MONITORING ADVANTAGES DISADVANTAGES Woman has more freedom to move about because no electrodes are attached to her The RN/RM must spend more time in monitoring. The RN/RM, can provide more attention to the woman and her partner - There is a possibility of missing an abnormal FHT. While listening to the heartbeat, the doctor also palpates the mother's uterus by placing a hand on the abdomen to measure the contractions. Intermittent auscultation should be done: Every 15-30 minutes during the active phase of 1st stage Every 5-15 minutes during the pushing phase of the 2nd stage. Electronic Fetal Monitoring (EFM) EFM is an electronic monitor used to continuously measure the fetus's ADVANTAGES DISADVANTAGES Noninvasive and does not pose risk of infection may not be able to detect short term variability. Provides continuous tracing of FHT Fetal movement and maternal movement may interfere with continuous monitoring so woman is instructed to limit changing positions Enable the nurse / midwife to detect signs of fetal compromise early Internal monitoring: Measure the heart rate through a wire called (electrode) contains a needle, inserted through the vagina and cervix, and placed under the baby's scalp. And measuring the contractions with a thin tube inserted into the uterus can be done only after the NCM 109 (RLE) | MUNSAYAC 11 cervix has dilated to at least 2cm and the amniotic sac has ruptured. INTERNAL MONITORING ADVANTAGES DISADVANTAGES Not affected by fetal movement The primary risk of invasive monitoring is infection (chorioamnionitis, osteomyelitis or fetal scalp cellulitis) It provides continuous and accurate recording even if the woman moves and changes position. Trained practitioner must insert the electrode It provides accurate information regarding variability. beats/min or more above baseline, with a duration of 10 seconds or more but less than 2 minutes from onset to return. when the fetus moves, it is expected that the FHT will increase A least 15 bpm for 15 seconds is considered normal. DECELERATIONS Rate of FHT decreases at the onset of uterine contraction but return to normal before the end of contraction this is normal response of the fetus to head compression caused by umbilical LATE DECELERATIONS BASELINE VARIABILITY Refer to fluctuation caused by balancing acts of sympathetic (increase FHT) and parasympathetic branches (decreases FHT) of the autonomic nervous system. The presence of normal variability is a reassuring sign that the fetus's nervous system is intact ACCELERATIONS Non Periodic accelerations are temporary normal increases in FHR caused by fetal movement, a change in maternal position, or administration of an analgesic. An acceleration is a visually apparent abrupt increase (onset to peak in less than 30 seconds) in the FHR. At 32 weeks of gestation and beyond, an acceleration has a peak of 15 beats/ min or more above baseline with a duration of 15 seconds or more but less than 2 minutes from onset to return. Before 32 weeks of gestation, an acceleration has a peak of 10 CAUSES MANAGEMENT Indicative of uteroplacental insufficiency which can be due to uterine tetany from oxytocin administration, maternal supine hypotension, hypertensive disorders DM and other chronic disorder of the mother Position of the left side Discontinue oxytocin Give mask oxygen at 8 10L/min Notify physician Prepare for birth if no improvement Tocolytics may be ordered by the physician to relax the uterus and allow more blood flow to the placenta PROLONGED DECELERATIONS are decelerations that decrease from the FHR baseline of 15 beats/min or more and last longer than 2 to 3 minutes but les than 10 minutes. They generally reflect an isolated occurrence, but they may signify a significant rent, such as cord compression or maternal hypotension. For this reason they must be reported and documented Variable Decelerations NCM 109 (RLE) | MUNSAYAC 12 The pattern of variable decelerations refers to decelerations that occur at unpredictable times in relation to contractions. They may indicate compression of the cord, which can be an ominous development in terms of fetal well-being (Fig. 15.20). Cord compression may be occurring because of a prolapsed cord, but it most often occurs because the fetus is simply lying on the cord. It tends to occur more frequently after rupture of the membranes than when membranes are intact, or with oligohydramnios (the presence of less than a normal amount of amniotic fluid), such as occurs in postterm pregnancy or with intrauterine growth restriction. As a first step, change the woman's position from supine to lateral if she is not already lying on her side. If a prolapsed cord is diagnosed as the cause of the variable decelerations, oxygen will be prescribed as well as changing her position to a knee-to-chest one to help relieve pressure on the cord. Because a prolapsed cord is a potential serious complication of labor, nursing care and outcomes are further discussed in Chapter 23. VARIABLE PATTERN DECELERATIONS CAUSES MANAGEMENT Most often due to cord compression. Note here that the deceleration is often not continuous, occurring only as long as the cord is compressed and FHT normalizes when the compression is relieved after Relieve pressure on the cord by changing maternal position to lateral or knee chest. The compression is relieved when the variability disappears and FHT tracing is normal. uterine contraction Oligohydramios Perform IE to check for cord prolapse. Give oxygen by face mask if it persist after changing position Stop infusion oxygen Notify physician Amnioinfusion (infusion of saline into the uterus ) may be performed by the physician to relieve compression The Sinusoidal Pattern In a fetus who is severely anemic or hypoxic, central nervous system control of heart pacing may be so impaired that the FHR pattern resembles a smooth, frequently undulating wave with a cycle frequency of 3 to 5 per minute and persisting 20 minutes or more. Although the cause of this pattern is poorly understood, it is recognized to be as ominous as a late deceleration or variable deceleration pattern and so needs to be reported. For unknown reasons, on occasion, especially after administration of a narcotic to the mother, a pseudo sinusoidal or false sinusoidal pattern may appear. These are usually transient, resolve spontaneously without intervention, and are associated with a good fetal outcome. The pattern may show some variability and perhaps an FHR acceleration. Identifying these is equally important so they can be differentiated from a true sinusoidal pattern. NCM 109 (RLE) | MUNSAYAC 13 FHR baseline, variability, and patterns are categorized from 1 to 3 to help establish if a deviation is serious. Knowing these helps you to understand why interventions are initiated at certain points (Table 15.6). CAUSES Fetal hypoxemia Fetal anemia Fetal sleep (normal sleep cycle is 20minutes) Prematurity Medication taken by the mother : magnesium sulfate, narcotics tocolytics CAUSES - Fetus hypoxia as a result of analgesia & Maternal hypotension Prolonged umbilical cord compression fetal decompensation from prolonged hypoxia Vagal stimulation caused by compression of head during contraction. MANAGEMENT- Place mother on the left side. Assess for cord prolapse. Administer oxygen AT RISK Latent Phase Take FHT every 30 min Active Phase Take FHT every 15 minutes Second Phase Take FHT every 5 minutes 1. Assess FHT immediately after the rupture of the bag of water, whether artificially or spontaneously. 2. Assess FHT before and after: a. administration of drugs that affect maternal vital signs and FHT such as analgesic and at the peak action time of the drugs. b. Performing invasive procedure : IE, enema, amnioinfusion, catheterization c. Ambulation of laboring women. d. After any significant change in the uterine contraction is noted MONITORING UTERINE CONTRACTIONS PURPOSE OF MONITORING UTERINE CONTRACTION to assess the ability of the uterus to dilate the cervix to determine the progress of labor to detect abnormalities of uterine contractions to evaluate any signs of fetal distress. FREQUENCY IN MONITORING FHT LOW RISK Latent Phase Take FHT every hour Active Phase Take FHT every 15-30 mins Second Phase Take FHT every 5-15 mins NCM 109 (RLE) | MUNSAYAC 14 around 10 centimeters, which is about equal to the diameter of a softball. DURATION INTENSITY is the time from the beginning of one contraction to the end of that same contraction. During labor, the duration of the contractions will start out short (25 to 35 seconds long) and ultimately get to 70 90 seconds long. The intensity of the contractions also changes as labor progresses and this is a good sign that labor is progressing well. What is the level of pain? Describe the nature & location of the pain? FREQUENCY is measured from the beginning of one contraction to the beginning of the very next contraction. INTERVAL Refers to the time that lapse between two uterine contractions. It is measured from the end of a contraction to the beginning of the next contraction. DILATION The cervix will dilate to EFFACEMENT (thinning and shortening) that the cervix stretches and gets thinner. PRESENTING PART Is a part of the fetal body that enters theThe presentation of the fetus is determined by fetal lie and attitude STATION is the relationship of the presenting part of the fetus to an imaginary line drawn at the level of the ischial spines of the mother. 2. Station describes the degree of advancement or descent of the presenting part through the pelvis. METHODS OF MONITORING UTERINE CONTRACTION MANUAL: assessment by palpation using fingers placed over the fundus. external pressure monitor: uses a tocodynamometer, a transducer that converts pressure to electrical signals. a flat disk with flush plunger is secured over the abdomen with an elastic belt. as the uterus contracts, the abdominal wall rises and presses against the transducer. This movement is converted to an electrical signal and is recorded on paper. The external pressure monitor may not be as accurate when monitoring NCM 109 (RLE) | MUNSAYAC 15 intensity of uterine contractions as palpation by a skilled nurse. INTERNAL PRESSURE MONITOR: uses a catheter with sterile water. The catheter tip is inserted inside the uterus, just above the presenting part. When a client has an internal pressure monitor, assess regularly for signs of infection. TECHNIQUES: 1. When timing the contraction place warm hands with palms facing down over the fundus where the strongest uterine contractions can be felt. 2. use fingertips to feel for the uterine contraction as they are the most sensitive area of the palms. 3. check contractions every 15 to 30 minutes during the first stage. 4. the nurse palpating the fundus can feel uterine contraction approximately 5 seconds before the client feels it and the client usually feels contraction pain when the strength reaches beyond 25 mm 5. measure duration by timing from the moment the uterus first tense until it relaxes. 6. measure frequency from the beginning of one contraction to the beginning of the next contraction. 7. time 3-4 contractions to have a good picture of frequency. 8. a new nurse may have difficulty assessing intensity of uterine contraction, a practical guide is to compare it with consistency of the following parts of the face: Mild Uterine Contraction Can be inserted as far as the tip of the nose Moderate UC As firm as the chin Strong UC As firm as the forehead Assess and report the following abnormal findings Intensity If uterus does not relax completely in between UC Duration More than 70 seconds Interval Less than 20 seconds Frequency Exceed 3 times every 10 minutes PERFORMING LEOPOLD’S MANEUVER - - Leopold maneuvers are used to help midwives and nurses determine fetal presentation and position. The maneuvers have 4 specific actions that the midwife must perform. The nurse uses this process along with the assessment of the maternal pelvis' shape to determine if complications will occur during the delivery and if the patient will require a cesarean section. Difficult to perform on Obese woman Women with polyhydramnios Primigravida with a very anterior wall uncooperative women tight Timing: 24-26 weeks Tips for Performing Leopold Maneuvers 1. Instruct the female to empty her bladder before performing the maneuver so that she will be comfortable and the contour of the fetus is not obscured. 2. Put the woman in a comfortable position with her knees flexed. 3. Drape the patient and place a pillow under her head. 4. Explain the procedure to the patient and answer any questions that she may have. NCM 109 (RLE) | MUNSAYAC 16 5. Make sure that the hands are warm before coming in contact with the patient's abdomen. 6. Rub the hands together vigorously to prevent uterine contractions and use the palm of the hand instead of the fingers. 7. The midwife should stand with the body facing the patient during the first three maneuvers and facing the feet of the patient during the final maneuver. - left hand to explore the woman's uterus on the right side. Repeat this step on the opposite side using the opposite hand. The nurse should observe that the fetal back is smooth and firm. The extremities of the fetus should feel like protrusions and small irregularities. The back should connect with the form felt in the lower (maternal inlet) and upper abdomen. FIRST MANEUVER THIRD MANEUVER 1. FUNDAL GRIP: Palpate the upper abdomen of women in a lie down position. - During palpation, the both hands should be in cupping position and able to grip and palpate the upper part of the abdomen in order to know which fetal part. - Generally you will be going to find the buttocks, which feel soft but sometimes you may feel hard & if it feels hard then think of the head of the fetus. Because head feels firm round and hard 1. PAWLICK'S GRIP: Palpate the lower part of the abdomen which is just above the symphysis portion. SECOND MANEUVER 1. LATERAL GRIP: This process is done to identify the location of a fetal back. - Palpate on the lateral side of the abdomen using the palm of hands. - Generally the fetal back will feel firm and smooth while fetal extremities like arms & legs will feel like nodules and small irregularities. - This will help in finding the position PERFORMING SECOND MANEUVER - After the nurse identifies the form and palpates the upper abdomen, the location of the fetus' and back must be identified. - While still facing the patient, the nurse should apply deep pressure with the palm of his or her hands to palpate the abdomen gently. - Perform this maneuver by placing the right hand on one side of the patient's abdomen while using the - Hold the lower part of the abdomen between the index finger and thumb. Press inward and feel the movement If head of a fetus is in presentation, then feel the determination of heads attitude PERFORMING THIRD MANEUVER - This step should be done while facing the patient's feet and involves locating the fetus' brow. - The nurse should gently move the fingers on both hands toward the pubis by sliding the hands over the sides of the patient's uterus, and the side where the greatest resistance to the descending fingers is the location of the brow. - A well-flexed fetal head is located on the opposite side of the fetal back and if the head is extended, the back of the head is felt on the side that the back is located. - a head that cannot be felt has likely descended. - In this step the nurses must identify the part of the fetus that is above the inlet. - The nurse must use the fingers and thumb on the right hand to grasp the lower abdomen area located above the pubic symphysis. NCM 109 (RLE) | MUNSAYAC 17 - The findings should be determined in the first maneuver. The two- hand approach is an alternative that is more comfortable for the patient. Nurse can perform this approach by positioning the fingers of both hands in a lateral position on one side of the presented part. FOURTH MANEUVER PELVIC GRIP: This procedure is also known as a pelvic grip. - Palpation of the pelvis is performed. - The examiner should stand and face towards women's feet - Palpate both sides of the pelvic region to determine head prominence. - If the head of a fetus is flexed and extended it means that the opposite side is the fetal back. PRECAUTIONS: 1. During this process take care of the pressure you put on mothers abdomen. 2. Your palpation pressure should not disturb the fetus. 3. It may be difficult to determined in fatty women 4. It should be done under train examiner 5. It may require ultrasonography to understand the subtle details of the fetus. COMPONENTS OF LABOR A successful labor depends on four integrated concepts, often referred to as the four Ps: 1. The passage (a woman's pelvis) is of adequate size and contour. 2. The passenger (the fetus) is of appropriate size and in an advantageous position and presentation. 3. The powers of labor (uterine factors) are adequate. 4. The psyche, or a woman's psychological state which may either encourage or inhibit labor. This can be based on her past life experiences as well as her present psychological state. 1. THE PASSENGERS OF LABOR THE FETUS IS THE MAIN CHARACTER The main passenger is the fetus and the head is the most important part of its body because of the following reasons: 1. Being the largest part of the Fetal body, the head is the part that would most likely encounter difficulty during delivery. 2. It is always the presenting part so its measurements, position and presentation are important factors that affect labor outcome. 3. It is the least compressible of all fetal parts so it has to assume different positions, called mechanisms of labor, as it passes through the birth canal in order to present its smallest diameter and encounter the least resistance. 1.1 Structure of the Fetal Skull The cranium, the uppermost portion of the skull, is composed of eight bones. a, one frontal bone a. one frontal bone b. two parietal bones c. two temporal bones d. one occipital bone e. one sphenoid f. one ethmoid Note: the frontal, parietal and occipital bones are the most important fetal skull bones because they form the presenting bart when the fetus is in cephalic presentation. Suture Lines The fetal skull is not yet completely ossified at birth and its bones are joined only by membranes so that spaces actually exist between them. These spaces are called suture lines or sutures: NCM 109 (RLE) | MUNSAYAC 18 Presenting Part Is a part of the fetal body that enters the true pelvis first and which is also the first part to come out during delivery. The presentation of the fetus is determined by fetal lie and attitude a. Sagittal suture is located the 2 parietal bones b. Frontal suture is located the two frontal bones c. Coronal suture is located frontal and parietal bones d. Lambdoidal suture is between parietal and bones between between between located occipital The suture lines are important because they allow the skull bones to overlap, called molding, during delivery in order to reduce the size of the fetal head. Sutures also provide allowance for further brain development. Fontanels are membrane covered spaces located between the intersections of suture lines: a. Anterior Fontanel or Bregma is formed by the intersection of the sagittal, frontal and coronal sutures. b. It is diamond shaped and closes between 12 to 18 months of age. c. Posterior Fontanel or Lambda is formed by the intersection of sagittal and lambdoid sutures. d. It is triangular in shape and closes by 2 to 3 months of age. 2. The area between the two fontanelles is called the vertex. The area over the frontal bone is called the sinciput and the area over the occipital bone is called the occiput. 3. The location of fontanels (assessed by internal examination) can help to determine the position and presentation of the fetus. 1.2 Structure of the Fetal Skull Cephalic Presentation: The head comes out first during delivery. 1. Vertex Presentation: Occurs when the head is completely flexed so that the chin touches the chest. It is the most ideal type of presentation because the smallest diameter of the fetal head, occipito bregmatic (9.5 cm), is presented with the posterior fontanel as the presenting part. 2. Sinciput Presentation: Occurs when the head is partially flexed and the anterior fontanel is the presenting part. The occipitofrontal diameter (12.5 cm) is presented for delivery Also called military position because it gives the appearance of a military person at attention. 3. Brow Presentation: Occurs when the head is extended or bent backward causing the occipitomental diameter (13.5 cm) to be presented for delivery 4. Face Presentation: Occurs when the head is sharply extended causing the occiput to come in contact with the back of the fetus. During the course of labor, resistance by the pelvic floor can cause the head to extend further causing neck fracture and damage to the cervical cord. Chin Presentation: Occurs when the head is hyperextended with the chin as the presenting part. 1. Vertex 2. Brow 3. Sinciput 4. Mentum NCM 109 (RLE) | MUNSAYAC 19 Breech Presentation: The feet or buttocks come out first during delivery: 1. Frank Breech 2. Complete Breech 3. Footling Breech 1. Cephalic Presentation Vertex - Complete flexion Brow Partial - flexion/Moderate Flexion Sinciput - Moderate flexion Face Extension - Poor Flexion Chin Hyperextension - Very Poor Flexion Shoulder Presentation: In a transverse lie, a fetus lies horizontally in the pelvis so the longest fetal axis is perpendicular to that of the mother. The presenting part is usually one of the shoulders (acromion process), an iliac crest, a hand, or an elbow (Fig. 15.5). The usual contour of the mother's abdomen at term may appear fuller side to side rather than top to bottom. 2. TRANSVERSE LIE: The long axis of the fetus forms a right angle with the long axis of the mother, which means that the fetus is lying crosswise in the mother's abdomen. Causes of shoulder presentation a. Relaxed abdominal walls due to grand multiparity b. Pelvic contraction c. Placenta previa Compound presentation: This presentation occurs when there is prolapsed of the fetal hand alongside the vertex, breech or shoulder 1.3 Fetal Lie Lie is the relationship between the long (cephalocaudal) axis of the fetal body and the long (cephalocaudal) axis of a woman's body ( the fetus is lying in a horizontal (transverse) or a vertical (longitudinal) position. Approximately 96% of fetuses assume a longitudinal lie (with their long axis parallel to the long axis of the woman) (Ferreira, Borowski, Czuba, et al., 2015). Longitudinal lies are further classified as cephalic, which means the fetal head will be the first part to contact the cervix, or breech, with a foot or the buttocks as the first portion to contact the cervix. 1. LONGITUDINAL LIE: The long axis of the fetus is parallel to the long axis of the mother, meaning, the fetus is lying lengthwise in the mother's abdomen 3. OBLIQUE LIE: This lie is the most unstable. The fetus assuming this lie usually rotates to transverse or longitudinal lie in the course of labor. Fetal Attitude or Habitus 1. Attitude refers to the degree of flexion of the fetal body, head and extremities, or the relationship of fetal parts to each other. 2. In an effort to accommodate itself in the limited space and the shape of the uterus, the fetus usually assumes an attitude of complete flexion. The spinal column is bent; head is flexed forward with the chin touching the chest, legs bent at the knees and the calves pressing against the thighs. This is the ideal attitude of the fetus that is known as the fetal position. 3. Attitude of general flexion occurs when all parts of the fetus mentioned below are flexed. Areas to look at for flexion a. Head-discussed in the previous paragraph. b. Thighs-flexed on the abdomen. c. Knees-flexed at the knee joints. d. Arches of the feet-rest on the anterior surface of the legs. e. Arms-crossed over the chest. 1.4 Fetal Position refers to the relationship of the presenting part to one of the quadrant of the mother's pelvis POSITION NCM 109 (RLE) | MUNSAYAC 20 - - is important because it can influence both the process and efficiency of labor. Typically, a fetus is born fastest from an ROA or LOA position. Labor can be considerably extended if the position is posterior (ROP or LOP) and may be more painful for a woman because the rotation of the fetal head puts pressure on sacral nerves. Encouraging a woman to rest in a Sims position on the same side as the fetal spine or use a hands and knees position (Simkin,2010) may encourage rotation from an occipito posterior to an occipito anterior position prior to and during labor Presentation Fetal Points of direction or Denominator 1. Vertex / Occiput 2. Face and chin / Mentum 3. Breech / Sacrum 4. Shoulder / Scapula Pelvic Landmarks: The pelvis is divided into several areas in order to locate accurately the position of the presenting part. These areas are known as the four quadrants of the maternal pelvis. a. Left Anterior Quadrant: When fetal denominator faces the anterior left side of the mother's pelvis b. Left Posterior Quadrant: When the fetal denominator faces the left posterior side of the mother's pelvis. c. Right Anterior Quadrant: When the fetal denominator faces the right anterior side of the mother's pelvis. d. Right Posterior Quadrant : When the fetal denominator faces the right posterior side of the mother's pelvis. e. Left Transverse: When fetal denominator faces the left side of the mother's pelvis f. Right Transverse: When fetal denominator faces the right side of the mother's pelvis Knowing positions will help the nurse- midwife to identify where to look for FHT. This is the reason why abdominal palpation is performed before taking FHT. In breach, the FHT will be upper Ror L quadrant, above the umbilicus. In vertex, FHT will be lower R or L quadrant, below the umbilicus. MATERNAL, NEWBORN, CHILD HEALTH AND NURSING (MNCHN) STRATEGY ESSENTIAL MATERNAL CARE Preparing for a Birth 1. Provide essential care within facility 2. Introduce yourself to woman 3. Obtain pregnancy history and birth plan 4. Check laboratory results including RPR, HIV 5. Identify companion of choice 6. Perform handwashing 7. Examine the woman and take her BP, HR, RR and temperature 8. Assess fetal heart rate 9. Assess presence of labor and stage 10. Fill out WHO Partograph if cervix >4cm 11. Call for help, Stabilize, 12. Refer if equipment and skilled manpower are NOT available Recommended Practices During Labor 1. Admission to labor when the parturient is already in the active phase - Less need for CS - No difference in need for labor augmentation 2. Allow a companion of choice to provide continuous support during labor 3. Position of choice during 1st stage of labor/Upright position/Mobility 4. Routine use of WHO partograph to monitor progress of labor 5. Limit the total number of lE to 5 or less. NCM 109 (RLE) | MUNSAYAC 21 PRACTICES RECOMMENDED DURING LABOR 1. Admission to labor when the parturient is already in the active phase - Less need for CS - No difference in need for labor augmentation 2. Allow a companion of choice to provide continuous support during labor Continuous Maternal Support One-to-one intrapartum support - Companion of choice (husband, partner, friend, relative) - Health provider Good communication Respect for privacy Non Supine position/Position of choice/Mobility Allowing food and drink during labor/No routine IVF Adequate and timely pain relief Spontaneous vaginal delivery by 8% Instrumental vaginal delivery 10% Duration of labor- SHORTER by 1/2 hour Need for pain relief by 10% Occurrence of 5 minute Apgar < 7 by 30% Freedom of movement: distract mothers from the discomfort of labor, release muscle tension, and give a mother the sense of control PRACTICES NOT RECOMMENDED DURING LABOR 1. Routine NPO No evidence of improved outcomes for mother nor newborn if on NPO Very small probable risk of maternal aspiration mortality - 7/10 M births For normal, low risk birth, no need for NPO except when intervention is anticipated 2. Routine amniotomy to shorten spontaneous labor Risk of dysfunctional labor by 25% No difference in duration of 1st & 2nd stage of labor, CS rate, cord prolapse, maternal infection and Apgar score < 7 at 5 mins among women w/ or w/o amniotomy (Smyth, R.M.D., et.al., 2007 updated 2010) Significant risk of cord prolapse, abruptio placenta, intrauterine infection 3. Routine oxytocin augmentation Should be used by doctors only when indicated and in facilities where there is immediate access to CS NEVER use IM oxytocin before birth of the infant because its dosage cannot be adapted to the level of uterine activity 1. Routine perineal shaving on admission for labor and delivery. 2. Routine enema during the first stage of labor. 3. Routine amniotomy 4. Routine oxytocin augmentation 5. Routine NPO 6. Routine IVF Advantage is to have ready access for emergency meds Disadvantages: - Interferes with the natural birthing process - restricts women's freedom to move - Not as effective as food and fluids in labor to treat/prevent dehydration, ketosis or electrolyte imbalance Encourage BIRTH COMPANION Encourage women to: MOVE AROUND and assume POSITION she is comfortable in Take in in light snacks and oral fluids Empty her bladder - Every 30 min: plot HR, contractions and FHB - Every 2 hours: plot temperature NCM 109 (RLE) | MUNSAYAC 22 - Every 4 hours: plot BP PRACTICES RECOMMENDED DURING DELIVERY PREPARE FOR THE BIRTH Ensure delivery room T° is between 25-28 Ensure that there are no air drafts Discuss maternal and NB care in the immediate postpartum period Perform HANDWASHING Arrange instrument and other needs + 0.5 chlorine solution for decontamination Prepare equipment and NB resuscitation PRIOR TO DELIVERY Perform proper handwashing Don sterile double gloves Allow the mother to push as she wishes with contractions Do not perform routine episiotomy HAND HYGIENE Hand hygiene single most important method of controlling spread of infection Very crucial that this is carried out correctly at appropriate times by all health workers Methods: handwashing, antiseptic handwash, antiseptic hand rub or surgical hand antisepsis HANDWASHING Visibly dirty or visibly soiled with blood or fluids 40 – 60 seconds HAND RUB Hands are not visibly soiled Access to handwashing facilities is not available 20 – 30 seconds BEFORE HANDWASHING Remove all hand (and wrist) jewelry: Rings on nurses’ hands resulted in an increased frequency of hand carriage of S. aureus, gram-negative bacilli, or Candida species 10-fold higher skin organism counts Larger increase when several rings present REMINDERS NO artificial fingernails or extenders NO long fingernails Gloving DOES NOT replace the need for hand hygiene. WHY USE GLOVES To reduce the risk of contamination of hands with blood and other body fluids To reduce the risk of spreading germs to the environment and of transmission from: ○ health-care worker to the patient ○ patient to health worker ○ from one patient to another WHEN TO USE GLOVE Before a sterile procedure Anticipation of contact with blood or another body fluid Contact with patient (and his immediate surroundings) during contact precautions GLOVE REMOVAL As soon as gloves are damaged After contact with blood, other body fluid, broken skin & mucous membrane After contact with patient (& his/her surroundings) WHAT GLOVES TO USE? Sterile gloves – in surgical procedures, vaginal delivery Non-sterile/clean gloves – potential for touching blood, body fluids, secretions, stool/urine and items visibly soiled by above: NCM 109 (RLE) | MUNSAYAC 23 ○ Direct patient exposure – examination, handling of patients ○ Indirect patient exposure – emptying basins, handling instruments, handling waste, cleaning up spills of body fluids Not indicated - no potential for exposure to blood or body fluids, or contaminated environment (doing PE, giving injections and oral meds, writing on chart, etc) REMINDERS Gloves must be worn according to STANDARD and CONTACT PRECAUTIONS Hand hygiene should be performed when appropriate regardless of indications for glove use SKIN PREPARATION AND DISINFECTION Practical guidance on skin disinfection To disinfect skin, use the following steps: 1. Apply a 70% alcohol (isopropyl or ethanol) on a single-use swab or cotton ball. - DO NOT use methanol or methyl alcohol as these are not safe for human use. 2. Wipe the area from the center of the injection site working outwards, without going over the same area. 3. Apply the solution for 30 seconds then allow it to dry completely. - DO NOT pre-soak cotton balls in a container – these become highly contaminated with hand and environmental bacteria. - DO NOT use alcohol skin disinfection for administration of vaccinations. Best Practices in Infection Prevention and Control Cell Phones carry organisms! One of every 5 cellphones found to carry infection-causing microorganisms Microorganisms from mobile phones and hands were similar - some known to cause hospital-acquired infections RECOMMENDED POSITION DURING DELIVERY 1. Upright position during delivery - Anterior-posterior and transverse diameters of pelvic outlet BE enhances fetal movement through the maternal pelvis in descent for birth - Efficiency of uterine contractions - Improved fetal alignment 2. Encourage pushing only when the mother has the urge to push Diagnosis of the 2nd Stage of Labor Traditional Defined by a "fully dilated cervix" Coached to push though out-of-phase with her own sensation Non-Traditional Redefined as “complete cervical dilatation” + “spontaneous expulsive efforts" (Simian, 1991) Pelvic phase of passive descent Perineal phase of active pushing 3. Selective (non-routine) episiotomy - Posterior perineal trauma by 12% NCM 109 (RLE) | MUNSAYAC 24 Perineal Support and Controlled Delivery of the Head During delivery of the head, encourage women to stop pushing and breathe rapidly with their mouths open. Keep one hand on the head as it advances during contractions while the other hand supports the perineum. 4. Use of prophylactic oxytocin for management of third stage of labor after palpating the abdomen to rule out a 2nd baby (AMTSL 1) 5. Properly- timed cord clamping 1-3 mins after birth or when cord pulsations stop 6. Controlled cord traction and counter-traction (AMTSL 2) - No difference in rates of maternal mortality or serious morbidity and need for additional uterotonics. 7. Uterine massage after delivery of placenta (AMTSL 3) PRACTICES NOT RECOMMENDED DURING DELIVERY 1. Perineal massage in the 2nd stage of labor Compared to hand off technique, perineal massage: 3rd-4th degree tears, no difference in 1st and 2nd degree tears, vaginal pain, nor blood loss NOT recommended because commonly noted complications in practice (perineal edema, perineal wound infection and perineal wound dehiscence) not evaluated and need further studies 2. Fundal pressure during the 2nd stage of labor 2nd stage duration by 29 mins 3rd & 4th degree perineal tears No difference in rates of PPH, instrumental vaginal delivery, Apgar score < 7 at 5 mins, and NICU admission Uterine rupture not evaluated CARE AFTER DELIVERY RECOMMENDED Routine inspection of birth canal for lacerations Inspection of placenta & membranes for completeness Uterine massage Early resumption of feeding Prophylactic antibiotics only for 3rd/4th degree tears Keep mother and newborn together NOT RECOMMENDED Manual exploration of the uterus Routine use of ice packs over the hypogastrium. IMMEDIATE POSTPARTUM CARE Monitor mother at 2, 3 and 4 hours then every 4 hours Advise on postpartum care and hygiene Encourage mother to eat and rest Encourage mother to empty bladder and ensure that she has passed urine POSTPARTUM FAMILY PLANNING Summary- Key Points ESSENTIAL MATERNAL CARE Maternal and neonatal mortality in the Philippines is still unacceptably high NCM 109 (RLE) | MUNSAYAC 25 Prevention of postpartum hemorrhage through interventions like the use AMTSL will address the #1 cause of maternal mortality The evidence-based practices in the EINC Protocol are lifesaving for mother and baby NCM 109 (RLE) | MUNSAYAC 26