A Midwifery Perspective

Ann Rath

Ann Rath Ann Rath

Home of Active Management

Total No of Deliveries 2012 =8978

Total No of Babies =9142

Birth of a 1st 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 ;3 135-137

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 ExaminationCervix

Partially effaced

39 weeks gestation

Contractions

1 : 20

Home or retain in antenatal

ward

40 / 41 weeksGestation

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 yes 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 SatisfactionPeer Review

Clinical Outcomes

FeedbackFeedback

ImprovementImprovementSuggestionsSuggestions

SatisfactionSatisfaction

EVALUATION FORM DELIVERY WARD DATE OF DELIVERY PARITY We would be grateful if you would spare the time to offer your views in response to the following questions. The information gained from these forms is analysed and used to improve our care. We value your comments and anything written will be treated seriously and in complete confidence. Thank you for taking the time to complete this form, if you feel you would like to discuss your labour further, please tick the box and we will contact you. As part of our wish to continually to improve the service we sometimes need to contact women after delivery. Please indicate if you would be prepared to be included in further questionnaires YES / NO

1.What do you think was good about your labour and the care you received?

2. What aspect of your care could have been improved?

3a Did you attend antenatal classes? Yes /No If Yes where did you attend classes 3b..How could you have been better prepared for your labour? 4.Any other comments.

PLEASE PLACE PATIENT STICKER HERE THANK YOU

Labour Feedback

Form

Following Delivery

Positive PointsPositive Points•One to one care•Communication•Pain relief•Antenatal classes•Breastfeeding•Friendly Staff

Negative PointsNegative 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