SECTION III: INTRANATAL CARE
MANAGEMENT OF NORMAL LABOUR
First Stage of Labour
- Assess general condition and ensure that client is in labour
- Review notes to identify any significant points in the history
Conduct a routine examination
- Do a general examination and assess the emotional status of the client.
- Test urine
- Take temperature, pulse, respiration and blood pressure
- Palpate the abdomen to assess fundal height, lie and presentation of fetus.
- Monitor contractions
- Do a vaginal examination and make an assessment of the pelvis.
- Administer enema except where contraindicated e.g. P.V. bleeding, meconium stained liquor.
- Keep accurate and up to date records.
Progress Charting (Use Partogram)
- Palpate uterine contractions noting their strength, frequency and duration.
- Auscultate and document the fetal heart every 30 minutes.
- Check and record temperature, pulse, respiration and blood pressure hourly.
- Test urine for acetone, sugar and albumin.
- Do vaginal examination every 3-4 hours, or more often, if the clinical situation warrants it to assess descent of presenting part.
- Observe any discharge from the vagina, colour of liquor and type of discharge e.g. mucopurulent.
- Observe for signs of fetal and/or maternal distress e.g. meconium stained liquor, maternal fever, tachycardia, dehydration.
Additional Care During First Stage of Labour
- Relieve pain and discomfort
- Provide emotional support
- Assist client to control pain through non-drug approaches.
- Encourage ambulation until the later stages of labour.
- Maintain adequate nutrition, especially hydration and energy level.
Signs of Fetal Distress
- Fetal heart rate- Slow (less than 110 beats per minute (bpm)) or rapid (more than 160 bpm).
- Meconium stained liquor in a cephalic presentation.
- Excessive fetal movements.
Signs of Maternal Distress
- Rising pulse rate ≥100 bpm
- Scanty, concentrated urine, acetone in urine
- Ketone smell of breath
- Increase in temperature >37.4º C or 99.4ºF
- Marked restlessness or anxiety
- Dry lips and tongue- dehydration
Indications for Referral to Medical Officer during First Stage of Labour
- Maternal distress
- Fetal distress
- Very strong uterine contractions with no progress
- Prolapse of umbilical cord
Prolonged first stage
- 10 hours or more in multipara
- 12 hours or more in primigravida
- Prolonged rupture of membranes (over 24hrs)
- Vaginal bleeding
Second Stage of Labour
The attendant should do the following:
- Ensure that the delivery room is readied.
Check the contents of the delivery pack.
- 1 Large bowl
- 1 Kidney dish
- 2 Gallipots
- 1 Placenta dish
- 2 Swab holders
- 2 Spencer Wells forceps
- Cord scissors
- Episiotomy scissors
- 3 Dressing towels
- 1 Gown
- Prepare for episiotomy if indicated
- Prepare to receive baby
- Maintain clear airway by suction if necessary as soon as head is delivered
- Have oxygen ready for use
- Prepare drugs - syntometrine 1 ampoule (or syntocinon 5-10 units for clients with elevated blood pressure); lignocaine 1 % and 2%
- Conduct delivery in approved manner, giving oxytocic drug I.M. upon delivery of anterior shoulder.
- Keep alert for obstetric emergencies such as post partum haemorrhage
- Ensure that mother sees and holds the infant, identifies the gender of the infant; then place an identification tag on the infant’s limb.
- Put infant to breast with skin to skin contact; allow to suckle as long as the infant wants.
Indications for Referral to Medical Officer during 2nd State of Labour
- Abnormal bleeding
- Loss of / irregularity of fetal heart beat
- Abnormal contractile pattern of uterus
- Lack of progress or descent of presenting part
- Prolapse of the cord
- Fresh meconium-stained liquor
- Shoulder dystocia
- Any condition which may arise suddenly and which the nurse or midwife is unable to manage
Third Stage of Labour
- Watch for signs of placental separation
- Assist mother to expel placenta. Exert gentle traction on the cord as the placenta is delivered.
- Inspect placenta and membranes for completeness.
- Measure or estimate and record blood loss.
- Inspect vagina and cervix for lacerations.
- Repair episiotomy or lacerations.
- Clean perineum
Indication for Referral to Medical Officer during 3rd Stage of Labour
- Retained or incomplete placenta or membranes
- Haemorrhage from uterus or lacerations
- Maternal shock
- Severe lacerations or extended episiotomy
- Elevated blood pressure (over 130 /90 mm of Hg)
- Temperature above 37°C or 99.4°F
- Respiratory distress in the newborn
Post-Partum Observation and Care
Observe and record for one hour after delivery the following:
- Client’s general condition
- Vital signs temperature, pulse, respiration and blood pressure
- Amount and colour of vaginal blood loss
- Height of fundus, state of contraction
Indications for Referral to Medical Officer
Any abnormality detected during the puerperium should be reported to the Medical Officer. These include:
- Pyrexia 99.4°F or 38°C and over after the first 24 hours.
- Offensive lochia.
- Persistent red lochia.
- Subinvolution of the uterus and tenderness.
- Pain developing in pre-existing varicose veins.
- Increase in blood pressure
- Behavioral changes in the mother.
- Urinary problems - incontinence.
If bladder is distended and the woman is unable to pass urine:
- Encourage the woman to urinate
If she is unable to urinate, catheterize the bladder:
- Wash hands
- Clean urethral area with antiseptic o Put on clean gloves o Spread labia, clean area again o Insert urinary catheter o Measure urine and record amount o Remove catheter