A Midwifery Perspective

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A Midwifery Perspective

• Ann Rath

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Ann Rath
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Home of Active Management

• Total No of Deliveries 2012 8978
• Total No of Babies 9142

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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

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1973Although 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
concernODriscoll K BMJ 1973 3 135-137
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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
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Preparation for Labour
Preparation takes away the fear of the unknown.
Women are familiar with terminology and labour
records.
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Diagnosis in Practice
Painful Uterine Contractions 1 10
Show
Spontaneous Rupture of Membranes
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On arrival to the Labour Ward
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The Midwife learns this important skill while
working as a Junior Midwife under the close
supervision of the Midwife in charge or her
deputy.
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Findings on Vaginal Examination
Cervix uneffaced and undilated
37 weeks Gestation Contractions 1 20
Given an adequate explanation and allowed home
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Vaginal Examination
39 weeks gestation Contractions 1 20
Cervix Partially effaced
40 / 41 weeks Gestation Contractions 1 10/8 /
- Show
Home or retain in antenatal ward
Retain and reassess in 1 hour
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Vaginal Examination
Painful Uterine Contractions / - Show or / -
SROM
Cervix fully effaced
In Labour and will deliver within 12 hours
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Vaginal Examination
Cervix 2cms dilated
In Labour
80 of women admitted to the labour ward have a
cervical dilatation of lt 3cms
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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.
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Effaced cervix is confirmation of diagnosis of
labour irrespective of dilatation
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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.
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Clear Distinction between Nullips and Multips
gl
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• 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

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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 its graphic analysis
and that is when the partogram is
started Dilatation on diagnosis 80 lt 3cm
yes
yes
yes
Deceleration phase
Active phase
Latent phase
Acceleration phase
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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
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Spontaneously labouring nulliparous single
cephalic women at term
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
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• 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

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Evaluate OutcomesPatient SatisfactionPeer
Review Clinical Outcomes
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Labour Feedback Form
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Following Delivery

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

• Negative Points
• Communication
• Medical terms used
• Lack of information
• Pain relief issues
• Waiting time for epidural
• Ineffective pain relief
• Facilities
• Car parking
• Overcrowding

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Continual Audit

• No blame culture
• Continuous communication
• Clinical governance
• Risk management
• Quality improvement

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An active interest in labour
Management of labour
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