NORMAL DELIVERY PROTOCOL

INTRODUCTION Labor is a physiologic process during which the products of conception (ie, the fetus, membranes, umbilical cord, and placenta) are expelled outside of the uterus. Labor is achieved with changes in the biochemical connective tissue and with gradual effacement and dilatation of the uterine cervix as a result of rhythmic uterine contractions of sufficient frequency, intensity, and duration. Labor is a clinical diagnosis. The onset of labor is defined as regular, painful uterine contractions resulting in progressive cervical effacement and dilatation. Cervical dilatation in the absence of uterine contraction suggests cervical insufficiency, whereas uterine contraction without cervical change does not meet the definition of labor. Obstetricians have divided labor into 3 stages that delineate milestones in a continuous process. The first stage begins with regular uterine contractions and ends with complete cervical dilatation at 10 cm. The second stage begins with complete cervical dilatation and ends with the delivery of the fetus. The third stage of labor is defined by the time period between the delivery of the fetus and the delivery of the placenta and fetal membranes. During this period, uterine contraction decreases basal blood flow, which results in thickening and reduction in the surface area of the myometrium underlying the placenta with subsequent detachment of the placenta. The fourth stage is concerned about the recovery from the physical process of birth and initiation of bonding. The duration of 2nd 3rd and 4th stages of labor are relatively short but it is of vital importance. During this period the mother and the fetus require unremitting supervision, for both are subject to trauma and other dangers, which do not occur during 1st stage of labor. The midwives knowledge, skill, and judgment are crucial factors in preventing complications, trauma and ensuring a safe delivery. Much has changed in antenatal, intra natal and postpartum care in recent decades, and many of the changes have arisen from a questioning and in some cases discarding of many of the interventions which had previously been considered appropriate or even essential. The protocol described in this manual is designed to encourage health professionals especially the trained midwives and policy-makers to join that questioning process. The specific goals of this protocol is to enhance the understanding, knowledge and skills of health professionals in maternity care and modern principles and practices of sound care in pregnancy, labour and birth and the postpartum period, through better case management and appropriate interventions, while maintaining safety. The protocol is designed to be evidence-based, family-centered and multidisciplinary in approach. It is also sensitive to a holistic approach to care, acknowledging the significance of caring for psychological and social as well as Biological concerns.

OBJECTIVES OF PROTOCOL

To increase knowledge and understanding: Midwives will: Develop their understanding of the role and responsibilities of the health care provider during pregnancy, birth and after. Develop an increased awareness of the psychological, biological, cultural and social aspects affecting the antenatal, intrapartum and postpartum periods. Understand the changing nature of maternity care and the ways these services focus on the needs of the users. Be encouraged to examine the scientific basis for their professional practice and to question and challenge their existing policies. Be encouraged to consider the appropriate design and philosophy underlying clinical practice in maternity and newborn care.

To Enhance diagnostic and clinical skills: Midwives will: Be able to know-how to manage the pregnancy and labour of low risk women and ensure that they are different from the management of women at higher risk. Develop an understanding of how to determine who is at risk. Be able to recognize the possibility that women may change from low to high risk and vice versa at different times before, during and after labour. Be able to define women for whom various interventions in labour, such as induction and Caesarean section, may be more appropriate.

To Enhance managerial skills: Midwives will: Understand the importance of a team approach to care in which all members of the perinatal care team are equally respected and valued. Use pre determined protocols for the management of certain categories of complicated labour. Appreciate the value of locally derived protocols for maternity practice as a means of improving the standards of practice and of increasing the morale and involvement of professionals in their service.

PRINCIPLES UNDERLYING THE COURSE:

Values and principles for care are: Care should be based on the use of appropriate technology. Care should be regionalized. Care should be evidence-based. Care should be multidisciplinary. Care should be holistic. Care should be family-centred. Care should be culturally appropriate. Care should involve women in decision-making.

NORMAL DELIVERY PROTOCOL

This protocol consists of three parts. Part 1 Part 2 Part 3 Personnel Out come Management measures for normal delivery

PART 1.

Personnel :delivery.

Refers to the qualified and experienced midwives who can conduct normal vaginal

What is expected out of the Personnel :The personnel should: Have an adequate knowledge of the anatomy and physiology related to pregnancy, birth and the postpartum period. Be fully familiar with obstetric techniques used in pregnancy and childbirth for both normal and complicated pregnancies and deliveries. Be familiar with various approaches to childbirth as practised at different birth centres. Be conversant with various methods of pain relief in labour, e.g. breathing techniques, relaxation, hypnosis, analgesia and anesthesia. Be familiar with the specialized care of the at risk mother and infant. Be able to use a variety of methods (including non-pharmacological means) of managing pain in labour. Know what observations to make to observe progress in labour;

Know how to manage a womans diet during labour; Be alert to the importance of making labour less medical; Recognize the importance of providing support for women in labour and birth.

PART- 2 Outcome:Outcome can be divided into 2 groups: Maternal outcome Fetal outcome

Maternal outcome: Safe vaginal delivery Less instrumentation Safe mother Minimize complications. Reduction in maternal mortality and morbidity rates. Early recovery Less postnatal complications Fetal outcome: Part 3 Management measures for normal delivery Management measures includes all those actions that a nurse midwife performs in order to end up into a healthy mother and healthy baby. The nurse midwife performs every action that is proved scientifically and uses an evidence based practice in managing the labour in progress. She uses every aspect of the nursing care plan in managing the labour process. The nurse midwife uses following steps in managing labour: Assessment Nursing Diagnosis Specific objective Planning Implementation Rationale Evaluation Reduction in mortality and morbidity rates Birth of healthy babies Less complications

Assesment: Assessing the start of labour is one of the most important aspects of the management of labour. Signs of the start of labour that a midwife should assess are: Uterine contractions Cervical dilatation and effacement Status of membranes Bloody discharge Bearing down efforts Progression of labour Any complications Fetal condition including heart rate

Nursing Diagnosis: Assessment helps a midwife in obtaining a baseline data about the mothers condition. It helps a midwife in making a nursing diagnosis. Specific objective: The specific objective or the ultimate goal of midwife is to bring about a healthy baby, without causing discomfort to the mother and also minimizing chances of complications. Some of the specific objectives that a midwife makes are: To reduce the length of labour To reduce the need for pain relief To reduce operative delivery To reduce poor neonatal outcome (poor Apgar score at five minutes) To reduce negative ratings of labour experiences To be probably more effective than the physical environment of the delivery area.

Planning: Includes the following: Interventions: Interventions include all those actions that are scientifically proved and are based on evidences in order to achieve the goals made. Interventions are classified into three phases viz, Assembling of necessary articles for delivery Arrangement of the delivery area Maintaining of all the aseptic precautions Assembling all the articles needed for neonate Being prepared to manage complications

Environment preparation Patient prepration: Before birth Maintaining sterile field

During birth Post birth ENVIRONMENT PREPARATION: It includes: Setting of the delivery zone Assembling all the necessary equipments

CRITERIA

ACTION

RATIONALE

Setting the delivery Maintaining a therapeutic environment for To maintain aseptic area. delivery: techniques and hence reducing the infection rates during and after Adequate light. delivery. Ventilation. Temperature of the room to be 21- 25 degree centigrade. Privacy Adequate equipments. Breakable or adjustable delivery bed. Kelly pad/ Rubber mackintosh Two pillows with cover Linen Leg stirrups if needed Check for facilities of running water. Keep scrub brush & soap. Keep cap ,mask& plastic/ rubber apron.

Assembling all the Sterile table should contain following necessary articles: articles.keeping in mind the three Cs 1. Articles needed for delivery:

Assembling necessary articles prior to delivery saves time and helps in maintaining asepsis.

Pair of gloves Gown

Towels Big sheet/ double draw sheet Leggings Baby towel. Bulb syringe/ Mucus extractor Gauze pieces Cotton pad/ Perineal pads Cleaning forceps) forceps (sponge holding

Small bowl with antiseptic solution & cotton balls.

Big bowl / Receiver Cord clamps 2( Long artery forceps) Cord cutting scissors Episiotomy scissors( if needed) 10 cc syringe& needle.

2. Keep ready the needed drugs & articles. Local anesthetics (Inj. Xylocaine 2% or 1%) Inj. Oxytocine-2 amps Inj. Methergin 1 amp I.V Fluids 5% D/W, R/L I.V set, Intracath Syringes & needles. Additional supplies & drugs for emergency Additional light source (Goose neck

lamp or flash light) Kidney tray, bucket etc

3. Prepare to receive the new born Pre warmed room. Radiant warmer/ room heater. Clean surface/ table. Suction apparatus Suction canula Oxygen & masks Bulb syringe / mucus extractor. Infant identification records, tape or bracelets. Cord clamps /cord tie Cord cutting scissors. Emergency equipments for resuscitation if needed. Inform concerned/ Doctor/NICU nurse etc.

PATIENT PREPRATION Before birth Maintaining sterile field

During birth Post birth

CRITERIA

ACTION

RATIONALE Assessing for the following signs help a midwife to act accordingly and also helps to monitor maternal and fetal condition.

Assess for: 1.Monitor maternal& fetal condition and a) Uterine contractions. labor progress Frequency Intensity Duration. b) FHR Accelerations & Decelerations.

c) Maternal vital signs. Blood pressure Pulse Temperature Respiration.

d) Inspect suprapubic area for distended bladder.

d) Vaginal discharge. Show Bleeding. Color of liquor.

e) Maternal energy level. Response to contractions. Bearing down efforts. General behavior and appearance

f) Descent of fetal head.

g) Monitor and maintain partograph To maintain a Maintaining sterile field: sterile field Asepsis is the utmost priority because it helps to prevent infections to mother and new born child.

Assisting midwife put on a cap, mask& apron. Removes the ornaments from fingers, wrist & hands. Scrub her hands for 3-4 mts. Put on sterile gown & gloves. Clean the perineum of the patient with swabs dipped in antiseptic solution.

Cleaning is done in an out ward direction from vagina-: Vulva Vagina Upper inner thighs Labia majora & minora Urethra &vagina Rectum

Drape the mother with sterile clothes. Cover birth area / bed with sterile sheet. Mothers legs are covered with leggings or a big sheet. Cover the abdomen with a towel. Pack the rectum with a sterile pad or cloth.

Prepare for episiotomy. (if needed) Infiltrate perineum with local anesthetics. Perform episiotomy on a thin bulging perineum just before crowing with uterine contractions.

During birth: Series of events that occur during 2nd stage of labour are: Delivery of head Delivery of shoulders Delivery of trunk and extremities

CRITERIA Delivery the head

ACTION of The principal followed are: To maintain flexion of the head To prevent its early extension To regulate its slow escape from the vulval outlet.

RATIONALE

1. The patient is encouraged for bearing down efforts This facilitates during uterine contractions. descent of head.

Helps to maintain flexion of head. 2. When the scalp is visible for 5cm in diameter, flexion of the head is maintained during contractions.

Helps to prevent infection.

The midwife pushes the occiput downwards and backwards by using thumb and index fingers of the left hand while pressing the perineum by the right palm with a sterile vulval pad. the 3. if the patient passes stool, it is cleaned and the When region is washed with antiseptic solution. perineum is fully

4. After repeated contractions the maximum diameter of the head streaches the vulval outlet without any recession of the head even after the contraction is over and it is termed as crowning of the head. It is important that the fetal head is only controlled not held back.

stretched and threatens to tear especially in primi.

5. Assist the mother with voluntary control of the bearing down efforts by coaching her to pant while letting uterine forces expel the fetus.The fore head, nose, mouth &the chin are delivered by extension.

6. Wait for restitution/ External rotation. Support the head with left hand. Wipe the mouth & nose with a moist gauze piece. Do gentle suction with a bulb syringe if mucus or meconium present. Gently palpate the fetal neck with two fingers to feel for the umbilical cord around the neck. If it is coiled around the neck tightly it must be clamped twice & cut in between clamps & unwound

before the birth proceeds. . Delivery of the shoulders 1. The head is grasped by both hands and is gently Being hasty in drawn posterior until the anterior shoulder is delivery of released from under the pubis. shoulders may lead to tear and lacerations.

Upward movement avoids excessive streaching of neck causing injury.

2. By drawing the head in upward direction posterior shoulder is delivered out of perineum.

Delivery trunk

of

1.

Control the expulsion of fetal body. Support the shoulders with the right hand & the buttocks with the left hand as the trunk is delivered by lateral flexion.

To prevent sudden slip of body & to avoid trauma to mother the body is

delivered following the curve of the birth canal.

2. Care of newborn Soon after the delivery cover the baby and place it slightly downward 15 degrees and suction the oro nasal secretions.

Facilitates drainage secetions.

of

Apgar score should be recorded in 1 and 5 minutes.

Helps to know about the general condition of thebaby.

Clamp the cord with kochers forceps and ligate the Prevents cord. Squeeze the cord with fingers prior to ligating accidental them. inclusion embryonic remenants.

of

Delay the cord clamping for about 2-3 minutes till Facilitataes transfer of 80cessation of cord pulsation. 100 ml of blood from placenta.

Post birth It includes entire third stage.

Seperation of placenta and membranes Expulsion of placenta and membranes Examination of placenta and membranes

CRITERIA Look for the separation of placenta and membranes.

ACTION

RATIONALE

Watch for signs and symptoms of placental These signs indicate that the placenta has separation. separated & passes Left hand is placed over the fundus of the to the vagina. uterus to recognize the signs of placental separation. A firm and contracted uterus. Sudden gush of dark blood from introitus. Lengthening of umbilical cord out side of vagina.

Shape of uterus from discoid to globular. Vaginal fullness.

Expulsion of Only when the features of placental separation and its Helps to strip out placenta and its decent into the lower segment are confirmed the the membranes membranes. patient is asked to bear down simultaneously with the intact. hardening of the uterus.

As soon as the placenta passes through the introitus, it is grasped by hands and twisted round and round with gentle traction.

Control bleeding

of Inj. Methergin 0.2mg IM can be given if there is a hospital policy. -OR Inj. Methergin 0.2mg IM after the expulsion of placenta & membranes. It should be given after checking the B.P.

Helps uterus to contract and thus helps to control bleeding.

Inj. Oxytocine 5 / 10 units in 500ml of D/W at a rate of 20-30 gtts/mt or as advised by doctor

Examination of Placenta is inspected for completeness or any placenta and anomalies. The membranes amnion and chroin are to membranes. be examined carefully for completeness and the cord is inspected for number of blood vessels.

Inspection is done to find out any cotyledon missing ot incompleteness of membranes.

Stabilization mother

of Pulse, blood pressure, behavior of the uterus any abnormal vaginal bleeding to be watched for atleast 1 hour after delivery. When fully satisfied that the general condition is good, pulse and blood pressure are steady, uterus is well contracted and there is no abnormal vaginal bleeding, the patient is shifted to ward.

To recognize any alarming symptoms and signs of impending complications.

Evaluation-: Evaluation is done in each step of management to assess the progress and to decide for the next step to be taken to prevent complication & to enhance a safe delivery.

Documentation-: Documentation of the labor process & birth is essential for good clinical care, prevention of overlapping of procedures & medications, communication& for medico legal concern. Documentation of labor progress with the use of a partograph provides for early identification of deviations from normal.

FLOW CHART FOR MANAGEMENT OF 2ND STAGE OF LABOR.

CERVIX FULLY DILATED.

Strong uterine contractions FHR normal and regular Good descent of fetal head. Good bearing down efforts.

If NO inform doctor & follow Management accordingly.

PREPARE FOR NORMAL DELIVERY. Unit Articles, supplies& Equipments Mother- Physically &Psychologically

MAINTAIN ASEPSIS Follow universal precautions Clean & drape the mother Handle & use of sterile articles.

WATCH FOR ADVANCEMENT OF FETAL HEAD. Infiltrate perineum & Perform episiotomy (if needed)

CONTROLLED DELIVERY OF FETAL HEAD. Flexion Extension

WAIT FOR RESTITUTION/ EXTERNAL ROTATION Wipe new borns face & mouth. Gentle suction (if needed) Check for cord around the neck.

DELIVERY OF SHOULDERS Gentle down ward & up ward traction

CONTROLLED DELIVERY Of BODY & EXTRIMITIES

ASSESS THE NEW BORN

FLOW CHART FOR MANAGEMENT OF 3RD AND 4TH STAGE OF LABOR.

Delivery of baby

Clamp & cut the cord

Watch for signs &symptoms placental separation Rise in uterine fundus Lengthening of umbilical cord Globular shape of uterine fundus Sudden gush of dark blood from vagina Vaginal fullness

Spontaneous delivery With contractions.

Delivery by controlled cord traction

Fails

Fails

Assisted expulsion

Manual removal.

Check vital signs.

Inj. Methergin 0.2mg im Inj. Oxytocine 10 units in iv drip.

Examine placenta & membranes

Inspect vulva, vagina, cervix &perineum & Repair if needed.

Monitor mother Vital signs, Contraction of uterus, bleeding and Voiding Shift to post natal ward when the mother is stable.

CONCLUTION

This protocol serves to establish guidelines and states what level of performance is required to obtain a specific desired out come. Protocol can help identify the actual competencies required by the midwifery-trained personnel in routine normal practice. Protocol guidelines will orient the new personnel to work efficiently. The quality of health service in terms of reduction in maternal and neonatal morbidity and mortality will be achieved through the right use of protocol.

References 1. Basvanthppa B.T, Text book of Midwifery and Reproductive Health nursing, 2006, 1st Edition, Jaypee brothers, New Delhi. Pp 326-340 2. Boback, M. Irene and Margaret Duncan Jensen, Maternity and Gynecologic care, 1993, 5 th Edition, Mosby,St. Louis London. Pp 470-519 3. Chakravarti Sudip and Daftry N Shirish, Manual of Obstetrics, 2005, 2nd Edition Elsevier India Pvt Ltd New Delhi. Pp 295-303. 4. Dawn C.S, Textbook of Obstetrics, Neonatology and Child Health Education, 2004,16th Edition, Dawn books Kolkata. Pp 249-255. 5. Diane M. Fraser Margaret A. Cooper, Myles text Book for Midwives, 2003, 14th Edition, Churchill Livingstone, London. Pp 487-520. 6. Dutta D.C Text Book of Obstetrics, 2004, 6th edition, New Central Book Agency, Calcutta. Pp 122- 144. 7. Jensen Lowdermilk, Boback, Maternity Nursing, 1994,4th Edition, Mosby London .Pp 247-314. 8. Lowdermilk Leonard Deitra, Perry .E Shannon, Boback M. Irene, Maternity And womens Health care, 1999,7th edition, Mosby London. Pp 554-578. 9. Perry E.Shannon and Wong L. Donnal , Maternal and Child Nursing Care ,1998, 1st Edition, Mosby U.S.A . Pp 424-441. 10. Pilliteri Adele , Maternal and Child Health Nursing Care of the Childbearing and Child rearing family, 1999, 3rd Edition,Lippincott New York. Pp 496-503. 11. Sherwen N Laurie, Mary Ann Scoloveno Carol Toussie Weingarten, Maternity Nursing, 1995, 3rd Edition, Appleton and lange, Stamford Connecticut. U.S.A. Pp 678-698. 12. Training Modules on Midwifery Practice for Safe motherhood, Intranatal care , 1996, UNICEF, Unicef Home Delhi, Module 2 Pp 26-31. 13. W.H.O., Standards of Midwifery Practice for Safe Motherhood, volume 1: Standards Document, 1999, Regional Publication,SEARO,No.38. 14. W.H.O., Standards of Midwifery Practice for Safe Motherhood, volume 3: Standards Document, 1999, Regional Publication,SEARO,No.38. 15. W.H.O., Standards of Midwifery Practice for Safe Motherhood, volume 4: Standards Document, 1999, Regional Publication,SEARO,No.38.

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