Management of Normal Labour and Postnatal Care

NORMAL LABOUR

Labour is the physiological termination of pregnancy. Approximately 280 days from the last menstrual period. It is the process by which the products of gestation are expelled through the birth canal after the 28^th week.

Normal labour occurs at term and is spontaneous in onset with the fetus presenting by the vertex. The process should be completed with acceptable time i.e. within 24 hours vaginally with no complications arising.

Causes of the Onset of Labour

Hormonal, Biochemical and mechanical changes that occur around term may trigger labour.

Hormonal changes include release of oxytocin and altered Oestrogen and Progesterone ratio.

Biochemical includes prostaglandin while Mechanical includes pressure from the presenting part and over stretched uterus.

Premonitory Signs of Labour

Lightening: 2-3 weeks before term. The lower uterine segment softens and stretches causing the sinking of the uterus in the lower birth canal.
Frequency of micturition: this is the pressure of the presenting part on the bladder.
False labour pain occurs; irregular contractions occurs in the abdomen and are due to contraction and relaxation of the uterus, it does not increase in intensity whereas with the true labour pains the contraction progress in intensity.
Taking up of cervix: the cervix being drawn up and merged into the lower uterine segment. Or shortening of the cervix.

SIGNS OF TRUE LABOUR

There is a painful uterine contraction: the patient is aware of the contractions as it gives her pain and headache. The pain occurs in regular intervals and rarely exceeds 3 seconds.
The show: this is plug mucus which has occupied the cervical canal during pregnancy. It escapes from the vagina as the OS dilates.
Dilatation of the OS: this is felt on vagina examination.
The cervix is said to be shorter and taken up.

STAGES OF LABOUR

FIRST STAGE: this begins with the regular and rhythmic uterine contraction resulting in the full dilatation of the cervical OS. In primipara it is between 12-18 hours but in multiparous women it is between 6-12hours

SECOND STAGE: this commence with full dilatation of the cervix until complete expulsion of the foetus. In the primiparous women it is up 1 hour.

THIRD STAGE: this is the separation and expulsion of the placenta, the membranes and the subsequent control of bleeding. Last for ½ to 1 hour in both categories.

FOURTH STAGE: this is the period of observation of the mother after the placenta is delivered.

Signs and symptoms of placental descend and separation;

Elongation of the cord
Gush of blood and liquor
The uterus feels harder, smaller and mobile
The uterus rises in the abdomen and is felt palpable above or at the level of the umbilicus
The placenta is seen at the vulva. The method by which the placenta uses to separate is shultze and ducan method.

MANAGEMENT OF NORMAL LABOUR

Procedure of admission; the patient should be welcomed and reassured in a friendly atmosphere.
Her condition as she enters labour ward should be noted at the same time.
Her ANC record should be secured as it gives the full history and any important instruction that have been written down by the doctor about the patient.
If the patient is not attending ANC, a full medical history and obstetric history must be taken.

MANAGEMENT OF ADMISSION

If a patient is admitted for delivery, the following information or history should be obtained as it gives an idea whether the patient is in labour or not;

The uterine contraction: careful note should be observed about the time of onset of contraction, frequency and severity.
The show: whether she has had the show and the time noticed
Rupture of membranes
Find out if she had sufficient food
Her sleeping pattern.

GENERAL EXAMINATION

A The patient‘s appearance and general condition should be noted.

B Look out for any rush and oedema

C Her temperature, pulse, respiration should be taken as well as her blood pressure

D A specimen of urine should be obtained and tested for albumen, sugar acetone and protein.

ABDOMINAL EXAMINATION

On the abdomen, you inspect, palpate and auscultate to ascertain;

The present lie
The presentation
The position
The engagement
The foetal heart sound should be check to know the condition of the foetus at the beginning of labour.

GENERAL PREPARATION

Shaving: the patient vulva and perineal area should be shaved for hygienic purpose as hair harbor organisms.
Enema should be given in routine cases because a loaded rectum will block labour.
The patient should take a bath, wear a clean gown and sterile pad given.

PHYSICAL CARE OF THE PATIENT

POSITION: the patient should be allowed to get up and walk about during the first stage of labour. She can adopt any position she like to comfort her.
COMFORT AND PERSONAL TOILETING: Act gentle to the patient by attending to her problems and changing of her draw sheet when wet.
ASEPSIS: Labour should be conducted with the same aseptic and antiseptic precaution.
CARE OF THE BLADDER: encourage her to empty her bladder throughout labour.
FLUIDS AND FOODS: dehydration must be avoided and the patient’s health maintained to enable her to bear down during the second stage of labour. A light nourishing diet and glucose drink should be served to the patient.
MONITORING OF VITAL SIGNS: monitor the vital signs of the mother such as temperature, pulse, blood pressure and respiration. The foetal heart sound should be taken and recorded hourly.Monitor input and output chart and recorded.
OBSERVE THE MEMBRANE: to see whether they are ruptured or not through vagina examination.

MANAGEMENT OF SECOND STAGE OF LABOUR

Preparations;

A trolley must be ready for the delivery containing bowls, gauze, swabs, lotions, and instruments, a gown, a pair of gloves, sterile towels and dressing.
The resuscitation tray should contain 2 mucus extractors, gauze, swabs hypodermic syringe and cord ligatures and also drugs like vitamin k.
The cot should be readily tilted with head lower than the feet

OBSERVATION DURING THE SECOND STAGE OF LABOUR

Observe the foetal heart sound frequently after every contraction or every 5 minutes.
Observe the mother’s condition every 10 minute or more often if the second stage is prolonged
Observe the bladder if it is full a catheter should be passed to prevent obstructed labour.

CARE DURING THE SECOND STAGE OF LABOUR

Any sweat on the woman’s forehead should be dried
Sips of water can be given to moisture the lips, tongue and throat at regular intervals.
Reassurance and encouragement should be freely given to make her feel that she is being taken care of by an experienced and competent nurse.
She should be reminded of when to push and relax

TECHNIQUES OF DELIVERY

Should the membrane be intact at this stage it should be seen at the vulva and ruptured artificially with a artery forceps.
The vulva should be swabbed.
She should be encouraged to rest between contractions i.e. when the painful contractions are off.
The nurse should now swab the vulva with a mild antiseptic such as dettol.
Perineal pads should be placed over the anus with each successful contractions and expulsive action of the mother.
When the head is crowned, the fingers are placed at the occiput to control the head but no force should be keep the head back.
The head can be delivered between contractions and as the head crowns, instructs the woman to pant.
As soon as the fore head has passed over the perineum, do not turn back to the patient as she may push the child out on to the floor.
The baby’s eyes should be swabbed from within outwards before it opens the eyes to prevent them from being contaminated causing ophthalmic neonatorium.
Two fingers should be used to feel round the neck or cord if any it is lifted over the head gently.
The cord must be clamped in two places with two forceps and cut in between them with a sharp pointed scissors, fixing a finger under the cord to prevent nipping the baby’s neck.
When external rotation of the head bends, the head is grasped by the biparietal eminence and gently brought downwards towards the anus in order to free and deliver the anterior shoulder.
1 ml syntometrine is given.
The head is drawn up wards towards the abdomen to deliver the posterior shoulder.
Inj. Ergometrine 0.5 Maybe given I.M. when the head crowns or when the anterior shoulder is delivered or after complete separation of the placenta and membrane.
After the delivery a sucker, is used to drain mucus and liquor from the throat and mouth.
The baby is then wrapped-up and laid on its side in prepared cot with the feet tilted or raised to assist drainage of the mucus
Apply a wrist band show the baby to its mother.

MANAGEMENT OF 3RD STAGE OF LABOUR

All soiled linen should be removed and the woman must be cleaned up whilst a fresh clothing is provided.
All the vital signs should be taken and recorded especially the blood pressure and pulse rates.
The fundus should be observed to ensure that the uterus is well contracted.
The bladder should be emptied and the blood clots should be removed before she is sent to the lying in ward.
Give her something to sip.
Observe the size and consistency of the uterus after the delivery.
Observe the amount of blood loss during and immediately after the birth of the baby and report if necessary.
Examine the placenta to ensure that no part is retained.

POSTNATAL CARE

This is the care rendered to women after delivery. Puerperium which will be discussed under this topic is part of the postnatal care.

Puerperium; is the period immediately after the end of labour until the reproductive organs return to their normal pregravid state. During this time, the breast secretes milk for feeding the baby and this begins immediately after the placenta is expelled. Normal puerperium is a period of 6weeks immediately after childbirth or abortion.

THE LYING-IN PERIOD: this is the time during which the mother rests and is attended to by the nurse, who attends to the baby as well. In Ghana, the lying in period is 7 days.

THE PHYSIOLOGY OF PUERPERIUM

The physiological changes include;

Involution of the uterus and other generative organs.
Discharge of Lochia.
Establishment of lactation.

INVOLUTION: is the processes by which all reproductive organs which are affected by pregnancy return to their pregravid state. This is by a mechanism called autolysis or self digestion.

Factors that cause involution are;

Gross retraction of the uterine muscle fibres
Ischaemia
By autolysis

LOCHIA: this is discharge from the genital tract after delivery or abortion. The scent is unpleasant but not offensive and alkaline in reaction. They occur in stages:

A Lochia rubra (red): it takes 1-4 days to complete.

B Lochia serosa (pink): it takes 5-9 days

C Lochia alba (white): it takes 10-15 days

ESTABLISHMENT OF LACTATION

While the uterus and other structure are returning to their pre-pregnant state, anatomically and physiologically the breast become fully matured. They secrete colostrium for the first day. From the 2nd - 3rd day, when prolactin is circulating in sufficient large quantities, the glandular cells begin to secrete large quantities of milk. This may give rise to physiological engorgement of the breast and the milk begins to flow freely from the 4th - 5th day onwards. By the 6th day, the breasts are soft and active with the flowing out easily.

MANAGEMENT OF PUERPERIUM

AIMS;

To promote maternal and infant health
To promote breast feeding
To establish emotional well being
To promote involution
To prevent infection and other complications

PRINCIPLES IN THE MANAGEMENT OF PUERPERIUM

The total hygiene of the mother and the child should be taken care of.
There should be special care for the perineum especially where there are stitches.
There should be vulva swabbing at least 2 times a day for the 1st 3 days and the patient should be encouraged to have a hot sitz bath for the rest of the days.
Care should be taken of the bladder and bowels to promote involution.
Special observation should be made on the TPR to detect infections.
Adequate rest and sleep should be ensured.
The diet should be balanced and copious fluid intake should be encouraged.
Routine medication such as iron, multivite should be given to supplement the diet.
The haemoglobin should be checked on the 4th and 5th day to see if there is anaemia and this should be corrected by good diet and iron supplement.
Breastfeeding should be encouraged to promote involution and special care should be taken of the nipple.
The fundal height should be read.

POST NATAL VISITS

During such visits, the nurse ensures that the mother has fully recovered from the stress and strain of child birth and that lactation is fully established. She is at this time advised on family planning if necessary. She should be examined for signs of cancer of cervix and breast.

POSTNATAL EXERCISE: these are exercises which are taught to the puerperal woman to help her regain her shape after child birth. They are exercise that strengthen the abdominal muscles, correct lordosis and tighten the pelvic floor muscles.

MINOR DISORDERS OF PUERPERIUM

THE AFTER PAINS: painful uterine contractions after delivery.

Management; serving of mild analgesic like paracetamol and tablet Ergometrine 0.5mg daily x 2days should be given if there is a piece of membrane retained.

HAEMORRHOIDS: the straining during the second stage of labour may make the varicose veins around the rectum collapse.

Management; analgesic suppository (senekot xylocainy) may be applied, anusol suppository may also be inserted, mild laxative may be given to soften the stool and avoid constipation, ice compresses maybe given to reduce the pain, magnesium sulphate dressing may be applied to reduce the oedema etc.

RETENTION OF URINE: bruising of the urethra and vagina during labour may give the patient pain on micturition and she may intentionally stop herself from passing urine.

Management; encourage the patient to urinate and catheter should be the last measure.

BACKACHE: it may be due to sacro-iliac straining which is probably due to stretching of the sacro-iliac ligament, may be due to retroverted uterus, prolapse of the uterus, low grade pelvic infection etc.

Management: analgesics are given to relieve pain, refer the patient to a doctor for necessary examination and treatment

CRAMPS: Is a painful contraction especially of the calf muscles after the completion of labour.

Management: the foot should be flexed several times and the calf massaged for a temporal relief.

SORE PERINEUM: if it is due to episiotomy, she may need analgesics.

PUERPERAL PYREXIA: is any fibril condition which occurs in women after childbirth or abortion where a temperature of 40^oc is recorded for a period of 24 hours or has recurred during that period. It may be due to infection of the respiratory system, urinary tract, breast etc.

Management: antibiotics and antipyretic.

ENLARGED BREAST: pain in the breast, slight temperature and the breast appear oedematous and not to be touched.

Management: very gentle expression of the milk, the breast should be massaged gently using a little olive oil or water; the mother should be given a firm breast support such as supporting brassier etc.

POSTNATAL EXAMINATION OF THE MOTHER

Monitory of vital signs (T, P, R, B/P)
Urine analysis
Haemoglobin estimation
Breast inspection to make sure that lactation is normal and the baby is breast feeding properly
The Pelvis is examined for any infection, sores, discharges from the vagina etc.
The tone of the abdominal muscles is examined to see whether the muscles are going to normal length and tone.

POSTNATAL EXAMINATION OF THE BABY

Weight of the baby should be checked
The mouth should be examined for thrush
The skin and mucosa should be examined for jaundice as well as anaemia and rashes
Problems of feeding should be checked and advised
The stool and urine should be also be examined.
Look out for the baby’s general appearance and any problem should be solved.