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PREPARATION FOR LABOURby MONIA ZITOUNI ABDI SENIOR STAFF MIDWIFE

LABOUR & DELIVERY

What is Normal Labour?DEFINITIONS:LABOUR IS DESCRIBED AS THE PROCESS BY WHICH THE FETUS, THE PLACENTA AND THE MEMBRANES ARE EXPELLED THROUGH THE BIRTH CANAL. IT INVOLVES MORE THAN EXPULSIVE MUSCULAR EFFORT OF THE UTERUS.THE TERM LABOUR IS USED AFTER 28 WEEKS OF GESTATION BEFORE THEN IT IS CALLED ABORTION.

NORMAL LABOUR – is known as “eutocia”.

IT is DESCRIBED AS ONE IN WHICH:1. THE FETUS IS BORN AT TERM AND

PRESENTS BY VERTEX.2. THE PROCESS IS COMPLETED

SPONTENOUSLY (BY THE NATURAL UNAIDED EFFORTS OF THE MOTHER)

3.THE TIME DOES NOT EXCEED 24 HOURS

4.NO COMPLICATIONS SHOULD ARISE

5.DIFFICULT OR ABNORMAL LABOUR IS

KNOWN AS DYSTOCIA.

Causes Of The Onset Of Labour

THE ONSET OF LABOUR APPEARS TO BE THE RESULT OF A COMBINATION OF FACTORS : HORMONAL, NERVOUS AND CIRCULATORY.HORMONAL:OXYTOCIN FROM THE POSTERIOR PITUITARY GLANDPLACENTA HAS STIMULATING ACTION

ON THE PREGNANT UTERUS WHICH HAS BEEN SENSITIZED BY SOME HORMONAL FACTORS.

2. INCREASED CONTRACTILITY AS PREGNANCY ADVANCES .

3. THE PRESSURE OF THE PRENSENTING PART

ON THE NERVE ENDINGS IN THE CERVIX

STIMULATES THE CERVICAL GANGLION AND THE WOMAN EXPERIENCES A SHOW LABOUR IS MORE LIKELY TO START ON TIME WHEN THE HEAD IS ENGAGED THAN WHEN IT IS HIGH.

THE PREMONITORY SIGNS OF LABOUR

DURING THE 3 WEEKS PRIOR TO THE ONSET OF LABOR, CERTAIN CHANGES TAKES PLACE, WHICH ARE USEFUL TO DETERMINE THE APPROACH OF LABOUR: 1. LIGHTENING 2. FREQUENCY OF MICTURATION 3. FALSE PAINS 4. SLIGHT TAKING UP OF THE CERVIX

1. Lightening:

TAKES PLACE ABOUT 2 WEEKS OR 3 WEEKS BEFORE TERM BECAUSE THE FUNDUS NO LONGER CROWDS THE LUNGS, BREATHING IS EASIER,THE HEART AND STOMACH CAN FUNCTION BETTER AND THE RELIEF OF THE PRESSURE EXPERIENCED BY THE WOMAN IS DESCRIBED AS LIGHTENING. IT OCCURS BECAUSE THE SYMPHISIS PUBIS WIDENS. THE SOFTENED RELAXED PELVIC FLOOR SAGS BY 3.8CM ALLOWING THE UTERUS TO DESCEND FURTHER INTO THE PELVIS.

THE LOWER SEGMENT STRETCHES AND THE FETUS SINKS FURTHER DOWN INSIDE THE UTERUS

THE FUNDUS IS THEN AT A LOWER LEVEL.

2.Frequency of Micturation: this may be due to pressure of the fetal head on the bladder limiting its capacity and requiring to be empty more frequently.

3.False pain: these are irregular, causing the uterus to contract and relax whereas in true labor the uterus contract and retracts.

4.Taking up of the cervix:

the cervix is shorter because it is been drawn up and melted in the lower uterine segment.

Signs of True Labour:

1. Painful rhythmic uterine contractions.2. These are now felt by the woman as tightening,

discomfort or actual pain. 3. During contraction the uterus feel hard to the

touch, slight back pain may also be present.4. Dilatation of the cervical os.5. Show – is a blood stained mucoid discharge seen

few hours before or within the labor period, the mucous is the thick substance which formed the cervical plug during pregnancy.

Stages of Labour1.First Stage of Labour – the

latent phase is prior to the active one, and it may last 6-8 hrs in primi. When the cervix dilates from 0 to 3-4cm and the cervical canal shorten from 3cm long to 0.5cm.The active first stage of labor is the time when the cervix undergo more rapid dilation from 3-4 cm and in the presence of rhythmic contractions is completed when the cervix is fully dilated.

2. Second stage of labour -

the second stage is that of expulsion of the fetus it begins when the cervix is fully dilated and the woman feels the urge to expel the baby it is completed when the baby is born.

3. Third stage of labour – is that of separation and expulsion of placenta and membranes, it also involves the control of bleeding.

Positions in Labor• There is no laid down rule regarding the position to be adopted by the patient in labour.

• If a multi gravida woman goes into labor during the evening, being busy all day with house hold chores and children she is tired and should be advised to lie down and sleep if she can while there is reasonable interval between contractions.

The up

The up-right position:There is an advantage in the assumption of the up right position as the fetus sinks into the lower pole of the uterus, and by pressing on the cervical nerve endings stimulates good uterine action.

It also facilitates dilatation of the os.

In the erect position the anteroposterior diameter of the pelvic brim is enlarged because of certain degree of movement s which takes place at the sacro illiac joints

RECUMBENT POSITION – When the intensity of the contraction is higher. The woman should be in the bed so than she relaxes and conserves her energy and analgesics can be given to her to relieve the pain.

DIET DURING LABOUR.

THIS SUBJECT PRESENTS GREAT DIFFICULTIES, BOTH THE NUTRITIONAL REQUIREMENT OF THE WOMAN IN LABOUR AND THE GRAVE RISK OF ANAETHESIA MUST BE GIVEN DUE CONCIDERATION. THE MODERN TENDENCY IS TO WITHOLD FOOD WHEN LABOUR IS ESTABLISHED AND TO GIVE IVFLUID INSTEAD.DURING EARLY LABOUR, SMALL LIGHT MEALS SHOULD BE GIVEN SUCH AS TEA, BREAD TOAST, FRUIT JELLY, SOUP, ICE CREAM…..

PAIN RELIEF IN LABOUR

DEFINITION:PAIN IS SAID TO BE A FEELING OF DISTRESS CAUSED BY STIMULATION OF NERVE ENDINGS .PAIN IS A COMPLEX PERSONAL, SUBJECTIVE, MULTIFACTORIAL PHENOMENON WICH IS INFLUENCED BY PSYCHOLOGICAL, BIOLOGICAL, SOCIOCULTURAL AND ECONOMIC FACTORS.

A VARIETY OF FACTOR MAY AFFECT THE INTENSITY AND AMOUNT OF PAIN EXPERIENCED BY THE WOMAN IN LABOUR :•PERCEPTION OF PAIN.•TOLERANCE OF PAIN .•COPING WITH PAIN.•EXPERIENCE OF PAIN : (SILENT OR SHOUTING)•ENVIRONMENT OF PAIN: (HOSPITAL)

OPIATE DRUGS OPIATES DRUGS ARE FREQUENTLY USED DURING LABOUR BECAUSE OF THEIR POWERFUL ANALGESIC PROPERTIES THE COMMONLY USED OPIATE DURING LABOUR IS: •PETHIDINE100mg IS GIVEN WITH 10mg OF PLASIL TO AVOID THE SIDE EFFECTS OF OPIATES; NAUSIA,VOMITING AND DROWSINESS IN THE MOTHER . AND DEPRESSION OF THE BABYS RESPIRATORY CENTER AT BIRTH-(NARCAN 0.4 IS ALWAYS READY TO BE GIVEN TO THESE BABIES.

INHALATION ANALGESIAENTONOX IS THE MOST COMMONLY USED INHALATION ANALGESIC IN LABOUR. IT IS A PRE MIXED GAS OF 50% NITROUS OXIDE AND 50% OXYGEN. IN OUR DEPARTMENT THIS GAS IS PIPED. MOTHERS ARE INFORMED OF THE FUNCTION OF THE APPARATUS BEING ADVISE THAT THE OPTIMAL ANALGESIA IS OBTAINED BY CLOSELY APPLYING THE MASK TO THE FACE.

THE ENTONOX TAKES EFFECT WITHIN 20 SECONDS .SO ITS IMPORTANT THAT THE WOMAN USES IT AT THE HEIGHT OF THECONTRACTION. THIS METHOD OF PAIN RELIEF IS SIMPLE, USEFUL AND THE PATIENT IS ABLE TO ADMINISTER IT HERSELF.

REGIONAL ANALGESIA –EPIDURAL

MORE WOMEN ARE NOW REQUESTING A PAIN FREE LABOUR AND ASK FOR EPIDURAL (ibrat adhaher) AS SOON AS THE LABOUR IS ESTABLISHED WHEN ADVICING A WOMAN ABOUT ADVANTAGES AND DISADVANTAGES OF EPIDURAL ANALGESIA IT IS IMPORTANT TO USE LOCAL EVIDENCE ABOUT AVAILABILITY AND THE PROCEDURE USED THAT WOMAN CAN MAKE REALISTIC CHOICE FOR HER LABOUR

THE WOMAN (AND THE HUSBAND IF AROUND) MUST BE GIVEN A CLEAR EXPLANATION ABOUT THE PROCEDURE AND SECURE HER CONSENT ON THE EPIDURAL ANESTHESIA FORMBLOOD RESULTS FOR CBC, APTT, PT SHOULD BE READYSTART IV RINGERS/LACTATE AT LEAST ONE UNITPREPARE THE EPIDURAL TROLEY AND DRUGSAND ALL NECESSARY DOCUMENTS.

EPIDURAL ANALGESIAADVANTAGES: DISADVANTAGES:

EFFECTIVE PAIN RELEIFTENDENCY TO LOWER BLOOD PRESSUREUSED IN CASES OF PIHDOES NOT DEPRESS RESPIRATORY CENTER OF THE FETUS IF LABOUR IS PROLONGED IT ALLOWS PATIENT TO REST

INEFFECTIVE BLOCKMORE FREQUENT MONITORING OF VITAL SIGNESLENGTHENS FIRST STAGE OF LABOUR LESS SENSATION OF EXPULSIVE EFFORTS AND LENGTHENS SECOND STAGE OF LABOUR INCREASES INSTRUMENTAL DELIVERIES

EMOTIONAL SUPPORTTHIS TERM IS USED TO EMBRACE THE CONCEPT OF MEETING THE EMOTIONAL NEEDS OF THE WOMAN IN LABOUR AS A FEELING, SUFFERING AND PROBABLY APPREHENSIVE BUILDING UP THE WOMANs CONFIDENCE. NOT ONLY MUST THE MIDWIFE GIVE EMOTIONAL SUPPORT, SHE MUST ALL TIMES DEMONSTRATE THIS BY HER WORDS AND HER ACTIONS.

ISOLATED FROM HER LOVED ONES, - THE COMFORTING COMPANIONSHIP OF THE MIDWIFE WHO WILL LISTEN, EXPLAIN, ENCOURAGE AND ASSURE THE WOMAN OR KEEP SILENT AS REQUIRED IS OF GREAT VALUE TO THE WOMAN AT THIS TIMETO ADVOCATE COMMUNICATION FOR THE PEACE OF MIND OF MOST WOMEN IT IS ESSENTIAL THAT THEY ARE KEPT INFORMED REGARDING THE PROGRESS THEY ARE MAKING.

THE WOMAN RESPONSE S MAGNIFICENTLY TO A WORD OF A PRAISE, EXPLANATION AND REASON (EXAMPLE: PRIOR TO V/E) THE WOMAN IS TOLD WHY THIS IS BEING DONE, THAT THE WOMAN WILL RELAX. THE FINDINGS WILL BE ACCURATE AFTERWARDS SHE IS ASSURED THAT ALL IS WELL AND SHE IS DOING FINE.A WOMAN WHO SCREAMS IN LABOUR DO SO FROM FEAR THAN FROM PAIN. THE MW SHOULD COMMUNICATE CONFIDENCE BY HER CALM, COMPETENT BEARING AND KINDLY ACTIONS, TELLING THE WOMAN NOT TO BE FRIGHTENED AND NOT TO WORRY.

THE RESPONSIBILITY OF THE MIDWIFE

•THE MW HAS AN IMPORTANT ENABLING AND FACILITATING ROLE TO HELP THE WOMAN MAINTAIN CONTROL OF PAIN DURING LABOUR.• CAREFUL ADMINISTRATION OF DRUGS AND MONITORING THE EFFECTS OF THESE IS ESSENTIAL TO THE PROVISION OF QUALITY CARE. ACCURATE AND DETAILED RECORDS OF ALL CARE GIVEN WILL PROVIDE A GOOD BASIS FROM WHICH PROPER DECISION MAY BE MADE CONCERNING THE PROGRESS AND THE NEEDS OF THE WOMAN .

WHAT TO TAKE TO HOSPITAL?WHEN TO PACK?

Ideally you should get your hospital bag ready with all your essentials about two weeks before your due date. It can be to have two bags for labour and for hospital stay afterwards.LABOUR KIT CONTAINING

Massage oil and (shampoo, lotion, lip balm, comb)towelsrobewarm socks (to wear in the delivery room)maternity underwear

SlippersNight gown (one that opens in front if planning for breastfeeding)Nursing braClothing for the trip home after deliveryBaby’s bag(newborn clothes, blanket, diaper, gentle baby wipes, baby shampoo, lotion, oil, soap.Mittens , (most babies are born with long finger nails and can scratch their faces just to protect them)

THANK YOU