3_Intrapartum Care.pptx

8/19/2019 3_Intrapartum Care.pptx

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ONC MODULE FOR MIDWIVES

I n t rapar tum Care / Labor and De l i



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Mid$i%e mean& '$it($oman)


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UNI! *+ S!E#S !OFOLLOW IN IN!R"#"R!"LC"RE


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*, E-amine t(e $oman %oremer.en &i.n&

• nconsciousness! Convulsion• "o#itin$• Severe headache %ith &lurrin$ of vision• "a$inal &leedin$• Severe a&do#inal 'ain• (ooks very ill• Fever• Severe &reathin$ di)cult

Do NO! ma0e a ver &i0$oman $ait1 attend to (er

2ui0l3


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4, 5reet t(e $oman and ma0e (erom%ortable

• +sk for infor#ed consent &eforeexa#ination or any 'rocedure

• ,es'ect 'rivacy

• Co##unicate result of exa#ination

• ,eassure her and her fa#ily


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6, "&&e&& t(e $oman in labor

• Take the history of la&or and record on the la&orfor#

• -#'ortant .uestions to ask are

10 hen did contractions &e$an ho% fre.uentho% stron$

20 as the &a$ of %ater &roken -s the a#nioticuid clear or stained o% #any hours has it&een ru'tured

30 -s there is &leedin$ and if yes! %hen and ho%#uch

40 -s the &a&y is #ovin$ or not

*0 +re there any other concerns


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7, Revie$ Mot(er and C(ildBoo0 %or t(e urrent pre.nan

• -f no record! ask for

10 (ast #enstrual 'eriod (M7

20 hen is delivery ex'ected 9:C

30 :eter#ination %hether 'reter# or ter#-f in 'reter# la&or! notify assi$ned doctorand nurse for ad#inistration ofa''ro'riate #edicationso-f not in active la&or! 'ro'erly REFER!O !8E 8OS#I!"L

o-f in active la&or! deliver the &a&y and're'are for 'ossi&le resuscitation andreferral to the hos'ital


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40 istory of 'rior 're$nancies

-f any of the follo%in$ are 'resent!

REFER to the doctor for referral tothe hos'ital

• 7rior cesarean section! force's orvacuu# delivery

• 7ost'artu# he#orrha$e• +ny 'rior third de$ree tear

• ;ther co#'lications

7, Revie$ Mot(er and C(ildBoo0 %or t(e urrent pre.nan

9 R t


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I n t rapar tum Care / Labor and De l i9, Rev e$ re&u t& olaboratorie&1 dia.no&ti e-am&durin. previou& prenatal (e0+

up&• e#o$lo&in level

-f the e#o$lo&in =11 $/dl

continue routine la&or and delivery care

-f the e#o$lo&in >5 $/dl ? 11 $/dl and/orosevere 'al#ar and con@unctival 'alloro any 'allor %ith =3A &reaths/#in or tireseasily

o &reathless at rest or B/ diDDiness or heartrate =1AA/#in

9 R t


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-f the e#o$lo&in >5 $/dl ? 11 $/dl and/or

o ,9F9, to your doctor for referral to a

hos'italo 9sta&lish -" line &efore transfero Continue #onitorin$ vital si$ns and

'ro$ress of la&oro -f in late active la&or! deliver the &a&y

then CONDUC! UR5EN!L: !O "8OS#I!"L

9, Rev e$ re&u t& olaboratorie&1 dia.no&ti e-am&durin. previou& prenatal (e0+

up&

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• ,7, status -f ,7, test is 'ositive reactive

o,efer to the nurse and doctor for ad#inistrationof enDyl 'enicillin &y the nurse

o7lan to treat the ne%&orno9ncoura$e the %o#an to &rin$ her sexual'artner for treat#ent

o+dvice on correct and consistent use of

condo#s to 'revent ne% infection

-f ,7, test is ne$ative nonreactiveo+dvise on correct and consistent use ofcondo#s to 'revent infection


up&

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• -" status

-f 'ositive! follo% $eneralinfor#ation and counsellin$ on -"

• Tetanus i##uniDation status

-f not yet $iven! follo% thestandard reco##ended schedule


up&


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;, #er%orm an abdominal e-amination

• 7resence of 'revious cesarean sectionscar

-f not yet in late active la&or! UR5EN!L:

REFER !O " 8OS#I!"L

-f in late active la&or or i##inentdelivery deliver the &a&y %ith controlleddelivery of the head and 'ro#'t active#ana$e#ent of the third sta$e of la&or+MTS(


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• 7resence of a horiDontal rid$e acrossthe lo%er a&do#en

Si$n of i#'edin$ uterine ru'ture0

9#'ty the &ladder and o&serve a$aino -f still 'resent after catheteriDation!

do not 'rolon$ la&orG ur$ently notify

the doctor that you %ill refer the'atient to a hos'ital, CONDUC!UR5EN!L: !O !8E 8OS#I!"L


C b d l i


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• :eter#ine fetal lie

-f lon$itudinal! assess fetal'resentation

-f transverse lie! notify your doctorand UR5EN!L: REFER !O !8E8OS#I!"L and facilitate i##ediate

transfer0 9sta&lish an -" line%ith -"F :*(, 1 liter to run at 4Adro's 'er #inute


I C / L b d D l i

b d l i


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• :eter#ine fetal nu#&er hen there is #ore than 1 fetus

o -f the %o#an is in la&or! deter#ine the sta$e

of la&or 1st sta$e of la&or! facilitate ur$ent referral0

CONDUC! UR5EN!L: !O !8E8OS#I!"L

2nd

sta$e of la&or! deliver! 'roceed %ithadditional care 'rovisiono -f the %o#an is H;T in la&orFacilitate nonur$ent referral/transfer


I t t C / L b d D l i

I C / L b d D l i


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hen there is #ore than 1 fetusoCheck the 'resentation of the Irstfetus-f ce'halic 'resentation! allo% the la&o

to 'ro$ress as for a sin$le fetus! and#onitor 'ro$ress of la&or usin$ a

'arto$ra'h-f a &reech 'resentation! a''ly the sa#

$uidelines as for a sin$leton &reech

&irth if in i##inent delivery





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• (isten to fetal heart &eat0Count nu#&er of &eats in 1 full #inute0

-f fetal heart tones are a&sento+sk several other 'ersons to listen! usin$ fetal

:o''ler if availa&le0;, o&tain an ultrasound

if availa&le i##ediately0o -f FT are H;T detected on availa&le

ultrasound Fetus is dead! REFER to thedoctor or to the hos'ital

-f still una&le to hear FT other than ;ultrasound %ait for 1* #inutes and then re'eat0

7lace the %o#an on her left sideand ive her ox en at 4 6 ( er #inute0




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• (isten to fetal heart &eat0 Count nu#&erof &eats in 1 full #inute -f fetal heart rate F, is heard and is

nor#al 12A ? 16A &eats 'er full 1 #inute'roceed %ith &asic/routine care 'rovision

-f F, is a&nor#alSlo% >12A &eats 'er #inute in

the a&sence of contractions or 'ersistin$ aftercontractions ;, a ra'id FT =16Ain the a&sence of a ra'id #aternal heart ratedurin$ la&or FE!"LDIS!RESS,

I n t rapar t m Care / Labor and De l i



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o I% $it( FE!"L DIS!RESS< 7lace the %o#an on her left sideand $ive her oxy$en at 4 6 ( 'er#inute0

Hotify your doctor and facilitateUR5EN! REFERR"L/!R"NSFER

!O 8OS#I!"L Continue oxy$en 'er nasal canulaon the %ay to the hos'ital





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o I% $it( FE!"L DIS!RESS< -f the %o#an is in the 2nd sta$e of la&or

REFER to your doctor0

• :eliver as .uickly as 'ossi&le %ithE#ISIO!OM: !O BE DONE B: !8EDOC!OR

• 7re'are for resuscitation of thene%&orn if still necessary or have anassistant 're'are for resuscitation





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=, Determine t(e &ta.e o% labor

• 9x'lain to the %o#an that you %ill'erfor# a va$inal exa#ination andask for her consent

• ,es'ect 'rivacy

• ;&serve standard 'recautions




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• -ns'ect the vulva for

ul$in$ 'erineu#

+ny visi&le fetal 'arts

"a$inal &leedin$ (eakin$ a#niotic uidG if yes! is it

#econiu# stained! foul s#ellin$

arts! keloid tissue or scars that #ay

interfere %ith delivery

• 7erfor# $entle va$inal exa#ination:o not start durin$ contraction

=, Determine t(e &ta.e o% labor




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>, E-plain ?ndin.& to t(e $oman, Rea&&ure (er,

@, Reord ?ndin.& in labor

reord or in parto.rap(,

*A, DO NO! DO routine

perineal &(avin. or per%orma va.inal e-am i% t(ere i&bleedin. at = mont(& "O5




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Determinin. Sta.e o% LaborSIGNS CLASSIFY MANAGE

•

ul$in$ thin'erineu#• "a$ina $a'in$ and

head visi&le• Full cervical dilation

ImminentDeliver

•

Mana$e 2nd

sta$e ofla&or• ,ecord in

'arto$ra'h

Cervical dilatation

Multi$ravida =*c#

7ri#i$ravida =6c#

Late "tive

Labor

• Mana$e 1st sta$e

of la&or• ,ecord in

'arto$ra'h• ,ecord in la&or

record

Cervical dilatationat =4c#

Earl "tiveLabor

• Mana$e 1st sta$eof la&or

• ,ecord in'arto$ra'h

• ,ecord in la&orrecord

Cervical dilatationat A3 c# Not et in"tive

•

,ecord in la&orrecord




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**, Deide i% t(e $oman an&a%el deliver

• -f facility can #ana$e la&or and delivery! ad#it

• -f there is an indication for referral

– -n early la&or and the referral hos'ital can &e

ti#ely reached! REFER UR5EN!L:

• -f in late active la&or

– Monitor 'ro$ress of la&or an delivery

– 7re'are for i##ediate referral if needed

• -f the %o#an or her fa#ily refuses referral – 9x'lain the 'ossi&le conse.uences – Continue to take care of her




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• 9nsure 'ro'er co##unication %iththe %o#an and her relatives

•9x'lain all 'rocedures! seek'er#ission and discuss Indin$s %iththe %o#an and her fa#ily

• 9xa#ine the %o#an in a 'lace %hereshe is not ex'osed to 'eo'le otherthan the exa#inin$ 'erson and herchoice of co#'anion

*4, 5ive &upportive aret(rou.(out labor




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*4, 5ive &upportive aret(rou.(out labor

• 9nsure conIdentiality and res'ect'rivacy durin$ exa#inations anddiscussions

• -f kno%n -" 'ositive! Ind out %hat shehas told the co#'anion0 ,es'ect her%ishes0

– -f kno%n -" 'ositive! Ind out %hat she hastold her co#'anion0 ,es'ect her %ishes0

• H9"9, leave a %o#an in la&or alone




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*6, #rovide relie% %rom pain anddi&om%ort

• Su$$est chan$e of 'osition as she %ishes

• 9ncoura$e #o&ility and 'osition of choice

• 9ncoura$e co#'anion to #assa$e the%o#anJs &ack! hold the %o#anJs handand s'on$e her face &et%een

contractions• 9ncoura$e her to use the 'ro'er

&reathin$ techni.ue




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• 9ncoura$e %ar# &ath or sho%er! ifavaila&le

• 7ain #edications 'ossess risks0 se%ith caution

• -f %o#an is distressed or anxious!

investi$ate the cause

• -f 'ain is constant 'ersistin$&et%een contractions REFER to

doctor

*6, #rovide relie% %rom pain anddi&om%ort


I n t rapar tum Care / Labor and De l i*7 " i t t( t


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I n t rapar tum Care / Labor and De l i*7, "&&i&t t(e $oman to u&et(e proper breat(in.

te(ni2ue• Teach her to notice her nor#al &reathin$

• 9ncoura$e her to &reathe out #ore

slo%ly! #akin$ a si$hin$ noise! andrelax %ith each &reath

• -f she Ills diDDy! un%ell! is feelin$ 'ins

andneedles tin$lin$ in her face! handsand feet! encoura$e her to &reathe#ore slo%ly


I n t rapar tum Care / Labor and De l i*7 " i t t( t


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• To 'revent 'ushin$ at the end of theIrst sta$e of la&or! teach her to

7ant reathe %ith an o'en #outh

Take in 2 short &reaths follo%ed &y a lon$&reath out

• :urin$ delivery of the head! ask her notto 'ush &ut to &reathe steadily or to'ant

*7, "&&i&t t(e $oman to u&et(e proper breat(in.

te(ni2ue




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*9, En&ure leanline&&

• 9ncoura$e the %o#an to take a &ath or sho%eror %ash herself and $enitals at the onset of la&or

• ash the vulva and 'erineal areas &efore each

exa#ination

• ash your hands %ith soa' and %ater &eforeeach exa#ination0 se clean $loves for va$inalexa#ination0

• 9nsure the cleanliness of the la&or and &irthin$area

• Clean u' s'ills i##ediately




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Cleanline&& i& important, "llo$ t(e$oman to bat(e or $a&( (er&el%

durin. labor,


I n t rapar tum Care / Labor and De l i*; Eet& o% ontinuou&


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I n t rapar tum Care / Labor and De l i*;, Eet& o% ontinuou&maternal &upport durin.

labor• ,educe 'erce'tion of severe 'ain there&ylessenin$ the need for anesthesia – :uration of la&or shorter

– More s'ontaneous va$inal &irths – (ess instru#ental va$inal delivery/cesarean

section

– (ess 'ost'artu# 'ain

– 7rotects the #otherJs sense of safety andsecurity and #ake her less dissatisIed %ith&irth




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apa u Ca e / abo a d e

UNI! 4+ M"N"5EMEN! OF!8E FIRS! S!"5E OFL"BOR




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p /

De?nition o% t(e *&t Sta.e o%Labor

• 1st sta$e of la&or is the 'eriod fro# the onset ofre$ular contractions u' to full cervical dilatation The criteria for the dia$nosis of la&or include

oterine contraction of at least 4 in 2A #inuteso7ro$ressive chan$es in cervical dilatation andeKace#ent

oCervical eKace#ent or loss of the canal of thecervix of $reater than 5*L

• +ctive 'hase of la&or #eans cervical dilatationof at least 4 c#




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p /

Fir&t &ta.e latent p(a&e not etin ative labor

• CharacteriDed &y cervix dilated A3 c#!contractions are %eak! >2 in 1A#inutes

• Check for e#er$ency si$ns! fre.uency!intensity duration of contractions!F,! #ood and &ehavior every hour

• Check vital si$ns and cervical dilatationevery 4 hours

• ,ecord Indin$s in (a&or ,ecord




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p

• +ssess 'ro$ress of la&or

-f the %o#an is in early or latent 'hase

of la&or and >35 %eeks! REFERUR5EN!L: !O " 8OS#I!"L

-f contractions are stron$er and #ore

fre.uent for 8 hours &ut %ith no'ro$ress in cervical dilatation! REFERUR5EN!L: !O DOC!OR OR8OS#I!"L

Fir&t &ta.e latent p(a&e not etin ative labor




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Fir&t &ta.e in ative labor

• CharacteriDed as cervix dilated at 4c# or #ore! fre.uency of contractions3*/1A #inutes lastin$ = 4A seconds

• Check for e#er$ency si$ns! fre.uencyand duration of contractions! F,!#ood and &ehavior every 3A #inutes

• -f the %o#an is in active la&or and 35%eeks or #ore! 'roceed %ith &asiccare for nor#al la&or and &irth




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p

• Check te#'erature 'resence offever! &lood 'ressure 7! 'ulse

rate 7,! cervical dilatation every4 hours

• ,ecord ti#e of ru'ture of

#e#&ranes and color of thea#niotic uid





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• ,ecord Indin$s in the ; 'arto$ra'h -f the 'arto$ra'h 'asses to the ri$ht of the +(9,T

(-H9o ,eassess %o#an and consider criteria for referralo Call senior 'erson if availa&le0

+lert e#er$ency trans'ort serviceso 9ncoura$e %o#an to e#'ty &laddero 9nsure ade.uate hydration &ut o#it solid foodso 9ncoura$e u'ri$ht 'osition and %alkin$ if %o#an

%ishes0o Monitor intensively0o ,eassess in 2 hours and refer if no 'ro$ress0o -f referral takes a lon$ ti#e! refer i##ediatelyo :; H;T %ait to cross the action line0





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• ,ecord Indin$s in the ; 'arto$ra'h -f the 'arto$ra'h 'asses to the ri$ht of the +(9,T

(-H9o ,eassess %o#an and consider criteria for referralo Call senior 'erson if availa&le0

+lert e#er$ency trans'ort serviceso 9ncoura$e %o#an to e#'ty &laddero 9nsure ade.uate hydration &ut o#it solid foodso 9ncoura$e u'ri$ht 'osition and %alkin$ if %o#an

%ishes0o Monitor intensively0o ,eassess in 2 hours and refer if no 'ro$ress0o -f referral takes a lon$ ti#e! refer i##ediatelyo :; H;T %ait to cross the action line0





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• ,ecord Indin$s in the ; 'arto$ra'h

-f the 'arto$ra'h 'asses to the ri$ht of the+CT-;H (-H9! ,9F9, ,N9HT(O to doctorunless &irth is i##inent





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• ,elief of 'ain and disco#fortSu$$est chan$e of 'osition

9ncoura$e #o&ility as

co#forta&le for her9ncoura$e 'ro'er &reathin$&reath #ore slo%ly! #ake asi$hin$ noise!0 Make 2 short&reaths follo%ed &y a lon$&reath out0

Massa$e her lo%er &ack if

she Inds it hel'ful





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• :o H;T do routine ene#a Ho lon$er reco##ended as it is

unco#forta&le

Can da#a$e the &o%el

-ncreases the cost of delivery

:oes not shorten la&or or decrease

risk of infection of the ne%&orn or the'erineal %ound





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• :o H;T shave the 'erineal area,outine 'u&ic or 'erineal shavin$ of

no 'roven advanta$e or &eneIt

Can lead to side eKects like irritation!redness! #ulti'le su'erIcialscratches! &urnin$ and itchin$ of thevulva

-f need to re#ove the hair on the'erineu#! cli''in$ is a &etteralternative to shavin$0





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#reaution&

• :; H;T do -9 #ore fre.uently than every 4 hours

• :; H;T allo% the %o#an to 'ush unless deliveryis i##inent 0 7ushin$ at this sta$e does not

s'eed u' la&or0 -t %ill @ust #ake the cervix s%elland the #other tired0

• :; H;T $ive #edications to s'eed u' la&or 0 -tis dan$erous as it #ay cause trau#a to the#other and &a&y0

• :; H;T do fundal 'ressure as it #ay causeuterine ru'ture or fetal death




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UNI! 6+ !8E SECONDS!"5E OF L"BOR




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De?nition o% t(e 4nd Sta.e o%Labor

• 7eriod fro# full cervical dilatation 1Ac#to the &irth of the &a&y

• Criteria for dia$nosin$ a %o#anto &e in the 2nd sta$e of (a&or

Fully dilated cervix 1A c#0 oninternal exa#ination

o#an %ants to &ear do%n

Stron$ uterine contractions every

23 #inutes ul$in$ thin 'erineu# %ith the fetal head

visi&le durin$ contractions0

; %ill ru'ture if it has not ru'tured earlier


3I n t rapar tum Care / Labor and De l i


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#reparation o% t(e mot(er %ordeliver

• Continue close #onitorin$Check uterine contractions! fetal heart

rate! #ood and &ehaviour

Continue recordin$ in the 'arto$ra'h

• -#'le#ent the 3 C(9+HSClean hands0 ear dou&le $loves

Clean delivery surface

Clean cuttin$ and care of the cord




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• 9nsure all delivery e.ui'#ent andsu''lies! includin$ ne%&orn resuscitatione.ui'#ent are availa&le and 'lace ofdelivery is %ar# 2*PC 28°C)

• 9nsure &ladder is e#'ty09ncoura$e the %o#an to urinate0

-f una&le to 'ass urine! e#'ty &ladder

%ith catheter0

• Stay %ith the %o#an and encoura$e her0;Ker her e#otional and 'hysical su''ort

#reparation o% t(e mot(er %ordeliver




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Sta $it( t(e $oman in labor, Ma0e (er %eelom%ortable, Enoura.e (er, 5ive (erp(&ial and emotional &upport,




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Seond Sta.e o% Labor

• +ssist %o#an into a co#forta&le 'osition of herchoice! as u'ri$ht as 'ossi&le0:; H;T let her lie at horiDontally on her &ack0

• +llo% her to 'ush as she %ishes %ithcontractions0 DO NO! ur$e her to 'ush0 – -f after 3A #inutes of s'ontaneous ex'ulsive eKorts!

the 'erineu# does not &e$in to thin out and stretch%ith contractions! do a va$inal exa#ination to conIr#

full dilatation of cervix0 – -f cervix is not fully dilated! a%ait 2nd sta$e0 7lace

%o#an on her left side and discoura$e 'ushin$09ncoura$e &reathin$ techni.ue0




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• ait until head is visi&le and 'erineu#distendin$0 :; H;T #assa$e or stretchthe 'erineu#

• ash hands %ith clean %ater and soa'usin$ the 1234* #ethod

• 7ut on dou&le $loves @ust &efore

delivery if you are the sole &irthattendant0 Follo% universal 'recautionsdurin$ la&or and delivery0





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• -f second sta$e lasts for 2 hours or #ore%ithout visi&le steady descent of the head

REFER UR5EN!L: !O 8OS#I!"L

• -f %ith o&vious o&struction to 'ro$ress %arts!scarrin$/keloid tissue/'revious third de$reetear REFER to doctor to do a $enerouse'isioto#y0 :o not 'erfor# e'isioto#y

routinely0• -f &reech or other 'resentation

Mana$e a''ro'riately &ased on situation0





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• 9ncoura$e the #other to &ear do%n%hen the &a&yJs head is co#in$ do%n0

•hen the &irth o'enin$ is stretchin$!su''ort the 'erineu# and anus %ith aclean 'ad to 'revent lacerations0

•:; H;T a''ly fundal 'ressure to hel'deliver the &a&y as this #ay har# &oththe #other and the &a&y0




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En&ure ontrolled deliver o% t(e (ead

• :iscard 'ad and re'lace %hen soiled to'revent infection

• :urin$ delivery of the head! encoura$e

%o#an to sto' 'ushin$ and &reathera'idly %ith #outh o'en



5 l % l i% ( d i


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5entl %eel i% t(e ord i&around t(e ne0

• -f it is loosely around the neck! sli'it over the shoulders or head

• -f it is ti$ht! 'lace a In$er underthe cord! cla#' and cut the cord!and un%ind it fro# around theneck0

• ait for external rotation %ithin 12 #in! head %ill turn side%ays&rin$in$ one shoulder @ust &elo%



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• +''ly $entle do%n%ard 'ressure todeliver to' shoulder then lift &a&yu' to deliver lo%er shoulder0 Nently

deliver the rest of the &a&y0

• Call out the sex and ti#e ofdelivery of the &a&y0

5entl %eel i% t(e ord i&around t(e ne0




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4nd Sta.e o% Labor

Reommended #ratie

'ri$ht 'osition durin$

delivery

7erineal su''ort and

controlled delivery of the head

se of 'ro'hylactic oxytocin

for #$t of 3rd sta$e of la&or

7ro'erlyti#ed cord cla#'in$

Controlled cord traction %ith

countertraction delivery of

'lacenta

terine #assa$e

Not Reommended#ratie

Coachin$ the #other

to 'ush

7erineal #assa$e in

the 2nd sta$e of la&or

Fundal 'ressuredurin$ the second

sta$e of la&or




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UNI! 7+ !8E !8IRD "NDFOUR!8 S!"5ES OFL"BOR




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De?nition o% t(e 6rd and 7t( Sta.e& o% Labor

• 3rd Sta$e of (a&or

Covers the 'eriod fro# thedelivery of the &a&y to the deliveryof the 'lacenta

• 4th

Sta$e of (a&or The hour i##ediately after the

delivery of the 'lacenta




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6rd Sta.e o% Labor

• Call out the sex and the ti#e of &irth of the&a&y0 This #arks the end of the second sta$eand the start of the 3rd sta$e0

• 7lace the &a&y 'rone onthe #otherJs a&do#en0

• Thorou$hly and syste#atically

dry the &a&y! assess the &a&yJs &reathin$ and

'erfor# resuscitation

if needed0 :iscard the %et to%el0




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• 7lace the &a&y in skintoskin contact%ith the #other0 Cover %ith a freshdry linen and 'ut a &onnet on the

&a&yJs head0

6rd Sta.e o% Labor




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• 9xclude 2nd &a&y &y 'al'atin$#otherJs a&do#en0 +d#inister 1A -of oxytocin -M %ithin one #inute of

the &a&yJs &irth0

6rd Sta.e o% Labor




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• Cla#' the cord usin$a sterile 'lastic cla#'or tie at 2 c# fro#the u#&ilical &ase0

Cla#' a$ain at * c#fro# the &ase0 Cutthe cord close to the'lastic cla#'0

• ;&serve the stu#'for &lood ooDin$0 :onot &anda$e or &ind

the stu#'0 (eave it

6rd Sta.e o% Labor




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• 7lace the 'al# of theother hand on the(;9, a&do#en to

feel for the stron$uterine contraction0

• 7erfor# controlledcord traction CCT

%ith countertraction on the uterus

6rd Sta.e o% Labor




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• Su''ort the'lacenta %ith &othhands0

• Nently #ove#e#&ranes u' anddo%n until

delivered• Massa$e the uterus

6rd Sta.e o% Labor




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Component& o% "M!SL

10 +d#inistration of uterotonic oxytocin%ithin 1 #inute of the delivery of the &a&yafter excludin$ the 'resence of another&a&y

20 Controlled cord traction %ith countertraction on the uterus

30 terine #assa$e

POPPHI. Prevention of Postpartum Hemorrhage: Implementing Active Management of the hir! "tage of #a$or

%AM"#): A &eference Manual for Health Care Provi!ers. "eattle: PAH' (*.




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6rd Sta.e o% Labor

• 9xa#ine the 'lacenta and the#e#&ranes for co#'leteness

• 7ut the 'lacenta into a leak'roofcontainer for 'ro'er dis'osal0




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• Monitor &oth the #other and ne%&orn#aternalne%&orn dyad i##ediately afterthe delivery of the 'lacenta! %ithin 1 hourafter delivery -##ediate 'ost'artu# 'eriod0

9xa#ine the lo%er va$ina andthe 'erineu#0Check for tears and &leedin$0

Clean the %o#an and #akeher co#forta&le0

Check 7! 7,! e#er$ency si$nsand uterine contraction every 1* #inutes0

7t( Sta.e o% Labor




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7t( Sta.e o% Labor

• Qee' &a&y %ar#0 Maintain skintoskincontact &et%een #other and &a&y &ut&oth %ra''ed %ith linen0

• ait for &a&y to have &reastfeedin$ cues

• -nitiate &reastfeedin$ %ithin 1hour %henthe &a&y is ready0




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• +llo% &a&y to havea full &reastfeed&efore doin$ routine

ne%&orn care likeeye 'ro'hylaxis andvaccinations0

:; H;T interru't&reastfeedin$ forthese reasons0

7t( Sta.e o% Labor



6rd and 7t( Sta.e& o%


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6rd and 7t( Sta.e& o%Labor

Reommended#ratie

,outinely ins'ect the &irth

canal for lacerations

-ns'ect the 'lacenta

#e#&ranes for co#'leteness

9arly resu#'tion of feedin$

>6 hours after delivery

Massa$e the uterus ?ensure

uterus is %ell contracted

7ro'hylactic anti&iotics for

%o#en %ith a 3rd or 4th

de$ree 'erineal tear

9arly 'ost'artu# dischar$e

Not Reommended#ratie

Manual ex'loration of

the uterus,outine use of

ice'acks over the

hy'o$astriu#

,outine oral

#ethyler$o#etrine




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EINC #rotool

• + 'acka$e of evidence&ased 'ractices %hich isa series of ti#e &ound! chronolo$icallyordered!

standard 'rocedures that &irthin$ #others and

their ne%&orns receive durin$ la&or! delivery

and at &irth! res'ectively

• Mandated &y +d#inistrative ;rder 2AA


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Reommended OB#ratie&

• +ntenatal steroids for #others at risk for'reter# &irth

• +llo%in$ a co#'anion of choice

• Mo&ility and 'osition of choice durin$ la&or• se of 'arto$ra'h to #onitor the course of

la&or

• Honroutine 'ractice of 'erineal shavin$!

ene#a! H7;! -" uid ad#inistration!e'isioto#y

• +ctive Mana$e#ent of the 3rd Sta$e of (a&or

Cli k di M i l l


li k di i l l


8arm%ul/Unnee&&ar OB


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8arm%ul/Unnee&&ar OB#ratie&

• :oin$ early a#nioto#y to hasten la&or• ,outine ad#inistration of oxytocin to au$#ent la&or

• ,outine ad#inistration of anal$esia and/or

anesthesia

• Su'ine lithoto#y 'osition durin$ delivery• Fundal 'ressure to hasten the 2nd sta$e of la&or

• 7erineal #assa$e durin$ the 2nd sta$e of la&or

• ,outine #anual ex'loration of the uterine cavity

• ,outine #ethyler$o#etrine use even %ithout undueva$inal &leedin$

• -ce 'ack on the a&do#en in an atte#'t to control'ost'artu# he#orrha$e

Cli k di M i l l


Cli k di i l l


Reommended Maternal Care


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#ratie& to En&ure 5ood NeonatalOutome

• +ntenatal steroids $iven to the #other atrisk for 7T(

• Maintenance of roo# ther#ore$ulation at2*28PC

• 7erfor#ance of the 4 Core ste's of the9-HC 7rotocol -##ediate and thorou$h dryin$ at delivery

Skintoskin contact of #other and &a&y

7ro'erlyti#ed cord cla#'in$ %ithin 13 #inutes of &irthor %hen cord 'ulsations sto'

Honse'aration of #other and &a&y to encoura$e early&reastfeedin$ initiation0

• :ry cord care

Cli k t dit M t titl t l


Cli k di M i l l


Unnee&&ar and/or 8arm%ul


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Unnee&&ar and/or 8arm%ulNe$born #ratie&

• nnecessary suctionin$ of thene%&ornJs #outh and nose

• -##ediate cord cla#'in$• Foot'rintin$

• Cord care %ith antise'tics

• se of bigkis• 9arly &athin$ %ith re#oval of vernix

• +rtiIcial &reast#ilk su&stitutes






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Step+b+Step EINC





b


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Step+b+Step EINC






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#IC!URE UI





W(i( i& t(e reommended


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W(i( i& t(e reommendedpratie

"

B





W(i( i& t(e reommended


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3W(at i& t(e 7 Core Step

o% EINC

Documents

3_Intrapartum Care.pptx