MATERNAL AT RISK LAB

• 2nd stage

  Needs assessment if expulsive phase is more than 30 mins (Max 1 hr in primigravida and 30 minutes in multipara) - total of 2 hr in primigravida and 1 hr in multi
• Active Phase

  On or at the left of the alert line
• 3rd stage

  Retained placenta if not delivered by 30 minutes
• Main components of Partograph

  • Progress of labor
  • Maternal condition
  • Fetal condition
  • Drugs/Medications given
• If plotting passes ALERT line

  • Reassess woman and consider referral if facilities are not available to deal with obstetric emergencies, unless delivery is imminent
  • Alert transport services
  • Monitor intensively
• If plotting reaches the ACTION line

  The patient must be already in EmOC facility
• Normal labor is the sequence of uterine contractions that results in effacement and dilatation of the cervix and voluntary bearing-down efforts to the expulsion per vagina of the products of conception
• Abnormal labor is labor that deviates from the course of normal labor
• Maternal and neonatal complication are increased with increasing duration of labor
• Several labor abnormalities that may interfere with the orderly progression to spontaneous delivery = DYSTOCIA
• Core Steps

  • Dry the baby immediately after birth
  • Properly timed cord clamping
  • Early skin-to-skin contact
  • Continued non-separation of the baby and the mother
• Continued non-separation of Mother and baby

  1. Within 90 minutes of age - Provide breastfeeding support for the initiation of breastfeeding

  2. Leave the newborn on mother’s chest in skin-to-skin contact

  3. Observe the newborn

  4. Monitor the mother and baby during the first hour after complete delivery of the placenta
• Properly-timed Cord Clamping

  1. Time band: 1 - 3 minutes

  2. Remove the first set of gloves immediately prior to cord clamping

  3. Palpate the umbilical cord

  4. Wait until the pulsations stopped then clamp the cord using sterile plastic clamp 2 cm from the base of the umbilical cord

  5. Then clamp again using sterile clamp at 5cm from the base of the umbilical cord and cut in between of the clamps using the sterile scissor
• 2nd stage of labor (Intrapartal stage)

  Perineal bulging, with presenting part visible
• Immediate and thorough drying of the newborn

  1. Within the first 30 seconds - Dry and Provide warmth

  2. Immediate and thorough drying for 30 seconds to one minute warms the newborn and stimulates breathing. Do a quick check on newborn’s breathing while drying

  3. Using a clean, dry cloth, thoroughly dry the baby, wiping the face, eyes, head, front and back, arms and legs

  4. Remove wet cloth and replace it with dry cloth

  5. NOTE – Do not suction unless your mouth/nose are obstructed with secretions or other material
• Initiation of breastfeeding

  1. Do not give sugar water, formula or other prelacteals

  2. Do not give bottles or pacifiers

  3. Do not throw away colostrum

  4. If the mother is HIV-positive, counsel the mother on breastfeeding

  5. If the mother has HIV/AIDS: Universal precautions must be followed as with any other delivery and after care

  6. Her baby can have immediate skin-to-skin contact

  7. Breastfeeding can begin when the baby is ready after delivery

  8. Do not give the baby any other food or drink

  9. Good attachment and positioning are vital

  10. If replacement feeding, prepare formula for the mother for the first few feeds
• Early skin-to-skin contact

  1. After 30 seconds - Place the newborn prone on the mother’s abdomen or chest skin-to-skin

  2. Cover the newborn's back with a blanket and head with a bonnet

  3. Place identification band on ankle
• BALLARD SCORE
• It is a quick test performed on a baby at 1 and 5 minutes after birth
• Essential Intrapartum and Newborn Care

  1. It aims in the early initiation of breastfeeding

  2. Provide quality maternal and newborn care

  3. To address neonatal deaths in the country

  4. Enhances bonds between mother and newborn
• The 5-minute score tells the health care provider how well the baby is doing outside the mother's womb
• The 1-minute score determines how well the baby tolerated the birthing process
• APGAR score
• Causes of Low Apgar Scores

  • Premature babies
  • Babies born via CS
  • Babies who have complicated deliveries
  • Infections
  • Placental Abruption
  • Prolonged and arrested labor
  • Umbilical cord problems
  • Uterine hyper
• Apgar testing is typically done at one and five minutes after a baby is born, and it may be repeated at 10, 15, and 20 minutes if the score is low
• Early Deceleration

  • Gradual decrease in the FHR in which the nadir occurs at the peak of the contraction. Rarely decreases more than 30 to 40 bpm below the baseline
  • Cause: Head compression
• Cardiotocography (CTG)

  1. Records changes in the fetal heart rate and their temporal relationship to uterine contractions

  2. External fetal heart rate monitoring
• Causes of Low Apgar Scores

  • Premature babies
  • Babies born via CS
  • Babies who have complicated deliveries
  • Infections
  • Placental Abruption
  • Prolonged and arrested labor
  • Umbilical cord problems
  • Uterine hyperstimulation/tachysystole
  • Uterine rupture
  • Fetal monitoring errors
• Essential Procedures in High-risk Labor and Delivery

  1. Contributing factors affecting labor and delivery

  2. Complication with power (force of labor)

  3. Precipitous labor and birth

  4. Postterm pregnancy

  5. Fetal malposition

  6. Fetal malpresentation

  7. Macrosomia

  8. Umbilical cord problems

  9. Prolapsed umbilical cord

  10. Amniotic fluid embolism

  11. Uterine rupture

  12. Cephalopelvic disproportion (CPD)

  13. Complications of 3rd and 4th stages of labor
• FHR Variabilities

  • Abrupt decreases in FHR below baseline and have an unpredictable shape on the FHR baseline, possibly demonstrating no consistent relationship to uterine contractions
  • Causes: Cord compression, Cord prolapse
• Apgar scoring

  Performed after a baby is born, and may be repeated at 10, 15, and 20 minutes if the score is low
• Acceleration

  • Transitory increases in the FHR above the baseline associated with sympathetic nervous stimulation. Visually apparent, with elevations of FHR of more than 15 bpm above the baseline, lasting 15 seconds. Reassuring. Oxygen is good
• Late Deceleration

  • Transitory decreases in FHR that occur after a contraction begins. FHR does not return to baseline levels until well after the contraction has ended
  • Cause: Placental insufficiency
• Biophysical Profile

  1. Observes the fetus’s heart rate, breathing, movement, muscle tone, and the amount of amniotic fluid surrounding the fetus in the uterus

  2. Biophysical Profile Scoring

  3. What to expect During a Biophysical Profile
• Biophysical Profile Scoring

  • Results are added for a score between zero and 10. A score between eight and 10 is considered normal. A lower score may suggest a possible problem that could call for more evaluation. A score of four or less may call for pregnancy monitoring or inducement of labor
• Modified Biophysical Profile

  Combination of a nonstress test and an amniotic fluid index
• Management of Mothers who are at High-risk or harmful conditions before, during and after pregnancy

  1. Preterm labor

  2. Therapeutic management in Preterm labor: Drug - MAGNESIUM SULFATE
• MAGNESIUM SULFATE

  • Relaxes uterine muscles to stop irritability and contractions, to arrest uterine contractions for preterm labor
  • Used in seizure prophylaxis and treatment of seizures in preeclamptic and eclamptic patients for almost 100 years
• Terbutaline sulfate (Brethine)

  • Relaxes smooth muscles to calm uterus, inhibits uterine activity to arrest preterm labor
  • Usually effective in delaying birth for up to 48 hours
• Administering MAGNESIUM SULFATE

  IV with a loading dose of 4–6 g over 15–30 minutes initially, and then maintain infusion at 1–4 g per hour