INTRAPARTUM CARE ZWE.pptx myanmar slide

intrapartum care 2023

1. INTRAPARTUM CARE NICE GUIDELINE PUBLISHED 29 th SEPTEMBER 2023

2. CONTENTS Antenatal education about labour Placed of birth Pain relief during labour PROM First stage of labour Second stage of labour Third stage of labour Care of new born baby Care of women after birth

3. Antenatal education Information about latent first stage of labour Experiencing pain Contact to midwife or emergency Braxton hicks or active labour pain Waterbreak & if any vaginal loss (2014, amended 2023)

4. Placed of birth Low risk multiparous women – home, midwifery led, obstetric unit Low risk nulliparous - midwifery led

5. Obstetric unit Current pregnancy- APH, BMI, BP >140/90 mmHg or more, grandmultiparity >4, age >40, fibroid, fetal abnormality, macrosomia, under psychiatric care

6. Pain relief during labour Don’t Aroma therapy, yoga or acupuncture, Acupressure, hypnosis Do not use high concentration of LA

7. CARE OF WOMEN WITH PROM (>37 +0 ) RISK ASSEEEMENT Meconium stained liquor, vaginal bleeding,blood -stained liquor, reduced fetal movement, continuous abdominal pain, foul smell or changes in liquor color, feeling unwell, GBS, FGR, low lying placenta 60% of PROM will go into labour within 24hr If labour is not started after 24hr, induction of labour as soon as possible Intrapartum antibiotic are recommended in some situation

8. First stage of labour Latent first stage – period of time not necessarily continuous, there are contraction, some cervical change, position, consisitency , effacement and dilation up to 4cm Established first stage- regular contraction, progressive dilatation from 4cm

9. Assessment of women in first stage oF labour AN record ( including screening) Personalized care plan Antenatal or intrapartum risk factors Ask her length, strength and frequency of contraction Any pain and explain pain relief options Record any vaginal loss BP, PR, Temp, RR, urinalysis Check if she need intraartum antibiotic

10. Vaginal examination If the women appear to be in established labour , offer vaginal examination (2014 amended 2023) Be sure it is necessary and will add important imformation for decision making Very distressing, highly anxious, unfamiliar e nvironment cause she already in pain So should explain the reason, get the consent , ensure privacy, dignity and confort Advice she can decline the examination

11. F indings from ve Station of presenting parts Position of presenting part Present oor abscent of caput or moulding Cervical effacement Cervical dilation Present or abscent of membrane

12. Ongoing assessment during first stage Uterine contraction – ½ hrly Pulse- hrly Temp, BP, PP – 4hrly VE- 4hrly Bladder care- 4hrly Do not routinely perform amniotomy (2007) Do not routinely used combined amniotomy and use of oxytocin(2007)

13. Delay in first stage Suspected delay — cervical dilatation <2cm in next 4hr assess( both primi & multip ) Change in strength, duration and frequency of uterine contraction Descent and rotation of baby head Wait 2hr and VE again to diagnose confirm delay if <1cm dilatation After diagnosing delay, Amniotomy to shorten labour , then wait 2hr for VE If no progress after amniotomy , consider oxytocin (obstetrician) VE again 4hr after oxytocin, if <2cm , needed to assess whether caesarean birth If >2cm, 4hrly VE

14. SECOND STAGE OF LABOUR Onset is when the baby is visible, or involuntary or active pushing with full dilatation of cervix May be upto 2hr with epidural VE hrly ( position of head, descent, caput and moulding ) Women lying her side increase chance of spontaneous vaginal birth After 1hr of full dilatation of cervix(no epidural), carry out further assessment if she does not get urge to push

15. Not routinely , but if episiotomy is performed, Right mediolateral 45-60 degrees Provide effective analgesia before episiotomy

16. Delay second stage Confirmed delay in second stage- assessment and confirm fetal well being Differentiation fetal and maternal HR Confirm that there are no sign of obstructed labour Confirm that contraction are infrequent or ineffective

17. Expediting birth Birth with forceps or ventouse – if concern about the well being, prolonged second stage, women requests assistance If she declines instrumental, discuss options vaginal, caesarean birth or reconsider forceps , ventouse IV Coamoxiclav or alternative single dose within 6hr after cord clamping (if instrumental)2023 Caesaarean birth if vaginal birth is not possible (2007)

18. Third stage of labour The time from the birth of baby to expulsion of placenta and membranes Active management of third stage— utero-tonic drugs(IV 5unit , or IM 10 unit oxytocin) + cord clamping and cutting of cord + controlled cord traction after signs of separation of placenta Oxytocin + ergometrine if risk of PPH, but contraindicated in severe hypertension, PE, eclampsia, severe cardiac, hepatic or renal disease For caesarean section, sloe IV injection Carbetocin to prevent PPH( 2023) Cord clamp( 1-5 min)

19. Prolonged third stage Prolonged third stage Diagnose a prolonged third stage of labour if it is not completed within 30 minutes of the birth with active management or within 60 minutes of the birth with physiological management

20. Retained placenta Secure intravenous access if the placenta is retained, and explain to the woman why this is needed. [2014 ] Do not use umbilical vein agents if the placenta is retained. [2014] Do not use intravenous oxytocic agents routinely to deliver a retained placenta. [2014] Give intravenous oxytocic agents if the placenta is retained and the woman is bleeding excessively. [2014] If the placenta is retained and there is concern about the woman's condition: offer a vaginal examination to assess the need to undertake manual removal of the placenta Do not carry out uterine exploration or manual removal of the placenta without an anaesthetic . [2014]

21. Postpartum hemorrhage Risk factors previous postpartum haemorrhage over 1,000 mL or requiring blood transfusion placenta accreta spectrum pre-eclampsia maternal haemoglobin level below 85 g/ litre at onset of labour BMI greater than 35 kg/m2 grand multiparity (parity 4 or more) antepartum haemorrhage or placental abruption overdistention of the uterus (for example, multiple pregnancy, polyhydramnios) existing uterine abnormalities (for example, fibroids ) low-lying placenta. [2007, amended 2023]

22. Antenatal & intrapartum risk induction or augmentation of labour with oxytocin or prostaglandins prolonged first or second stage of labour sepsis oxytocin use during labour precipitate labour birth with forceps or ventouse caesarean birth shoulder dystocia delay in delivery of the placenta. [2007, amended 2023]

23. Management of pph

24. Care of the women after birth INITIAL ASSESSMENT Record temperature, BP, PR ,RR Check uterine contraction and lochia Examine placenta, membranes, completeness Check for voiding, catheterization for >6hr of distension PERINEAL CARE 1st DEGREE- skin only 2 nd DEGREE – perineal muscle, no sphincter 3 rd DEGREE (3a) <50% ,(3b) >50% of external anal sphincter, (3c) internal anal sphincter 4 th DEGREE – Perineum, anal sphincter complex + anal epithelium Rectal examination to assess anal sphincter injury(2007)

25. Perineal repair PRINCIPLES Repair with aseptic technique Check equipment and count swabs and needles before and after procedure Good lighting Good anatomical alignment is given to cosmetic result documentation Test effective analgesia 20ml of 1% lignocaine or equivalent Skin – continuous subcuticular(2007) Vaginal wall & muscle layer – continuous non locking suture

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