A Midwifery Perspective Ann Rath

Home of Active Management Total No of Deliveries 2012 =8978 Total No of Babies =9142

Birth of a 1 st Baby A PROFOUND EMOTIONAL EXPERIENCE Moulds attitude to all subsequent births If happy unlikely to have any apprehension Unhappy –Requesting LSCS

1973 Although childbirth has long ceased to present a serious physical challenge to healthy to women in western society –the emotional impact of labour remains a matter of common concern O’Driscoll K BMJ 1973 ;

Diagnosis of Labour The diagnosis of labour is the single most important item in the conduct of labour. If the initial diagnosis is wrong, all subsequent management is likely to be wrong too. Midwife is the only person who makes this important diagnosis in our hospital

Preparation for Labour Preparation takes away the fear of the unknown. Women are familiar with terminology and labour records.

Diagnosis in Practice Painful Uterine Contractions 1 : 10 Show Spontaneous Rupture of Membranes

On arrival to the Labour Ward

The Midwife learns this important skill while working as a Junior Midwife under the close supervision of the Midwife in charge or her deputy.

Findings on Vaginal Examination Cervix uneffaced and undilated 37 weeks Gestation Contractions 1 : 20 Given an adequate explanation and allowed home

Vaginal Examination Cervix Partially effaced 39 weeks gestation Contractions 1 : 20 Home or retain in antenatal ward 40 / 41 weeks Gestation Contractions 1 : 10/8 +/ - Show Retain and reassess in 1 hour

Vaginal Examination Cervix fully effaced Painful Uterine Contractions + / - Show or + / - SROM In Labour and will deliver within 12 hours

Vaginal Examination Cervix 2cms dilated In Labour 80% of women admitted to the labour ward have a cervical dilatation of < 3cms

Diagnosis of Labour A woman who is admitted with painful uterine contractions supported by either a show or spontaneous rupture of the membranes, and on vaginal examination her cervix is fully effaced is deemed in labour, and retained in the labour ward and therefore committed to delivery which is anticipated within 12 hours.

Effaced cervix is confirmation of diagnosis of labour irrespective of dilatation

Diagnosis of Labour Dilatation of the cervix represents the sole conclusive evidence of labour. Effacement is the feature which serves to distinguish between the cervix which passively admits a finger tip and the cervix which is actively dilated to the extent of 1cm in labour.

gl Clear Distinction between Nullips and Multips

Amniotomy is performed at the diagnosis of labour  To assess the fetal condition at the start of labour  Determine which fetuses need continuous electronic monitoring  Other beneficial effects  Shortens the labour  Decreases need for oxytocin

Management of Labour Latent phase Is not useful in the diagnosis and the management of labour Effacement of the cervix is the key to the diagnosis of labour and it’s graphic analysis and that is when the partogram is started Dilatation on diagnosis 80% < 3cm Latent phase Acceleration phase Active phase Deceleration phase yes

Spontaneously labouring nulliparous women with a single cephalic pregnancy at 37 weeks or greater Philosophy A clear pattern of dilation should emerge and determined clinically within the first 3-4 hours of labour 1 cm an hour is taken as normal progress

4 hours is too long to wait between examinations to make the diagnosis of inefficient uterine action Efficient uterine action and normal progress only be confirmed by doing vaginal examinations 2 hourly before oxytocin is started. Average number of vaginal examinations in total is 3.7 Epidural rate 50%. 90% of epidurals given within 4 hrs CS rate 7% and not increased significantly over the last 25 years Spontaneously labouring nulliparous single cephalic women at term

Level of mutual confidence must be present between midwives and doctors Clear chain of command Mutual Respect Co-ordinator/Midwife in charge has a vital role to play

Evaluate Outcomes Patient Satisfaction Peer Review Clinical Outcomes

Feedback ImprovementSuggestions Satisfaction

Labour Feedback Form

Following Delivery Positive Points One to one care Communication Pain relief Antenatal classes Breastfeeding Friendly Staff Negative Points Communication –Medical terms used –Lack of information Pain relief issues –Waiting time for epidural –Ineffective pain relief Facilities –Car parking –Overcrowding

No blame culture Continuous communication Clinical governance Risk management Quality improvement Continual Audit

Management of labour An active interest in labour