Federal Democratic Republic of Ethiopia Ministry of Health

Labour and Delivery Care Blended Learning Module for the Health Extension Programme

HEAT Health Education and Training HEAT in Africa

Federal Democratic Republic of Ethiopia Ministry of Health

The Ethiopian Federal Ministry of Health (FMOH) and the Regional Health Bureaus (RHBs) have developed this innovative Blended Learning Programme in partnership with the HEAT Team from The Open University UK and a range of medical experts and health science specialists within Ethiopia. Together, we are producing 13 Modules to upgrade the theoretical knowledge of the country’s 33,000 rural Health Extension Workers to that of Health Extension Practitioners, and to train new entrants to the service. Every student learning from these Modules is supported by a Tutor and a series of Practical Training Mentors who deliver the parallel Practical Skills Training Programme. This blended approach to workplace learning ensures that students achieve all the required theoretical and practical competencies while they continue to provide health services for their communities. These Blended Learning Modules cover the full range of health promotion, disease prevention, basic management and essential treatment protocols to improve and protect the health of rural communities in Ethiopia. A strong focus is on enabling Ethiopia to meet the Millennium Development Goals to reduce maternal mortality by three-quarters and under-5 child mortality by two-thirds by the year 2015. The Modules cover antenatal care, labour and delivery, postnatal care, the integrated management of newborn and childhood illness, communicable diseases (including HIV/AIDS, malaria, TB, leprosy and other common infectious diseases), family planning, adolescent and youth reproductive health, nutrition and food safety, hygiene and environmental health, non-communicable diseases, health education and community mobilisation, and health planning and professional ethics. In time, all the Modules will be accessible from the Ethiopian Federal Ministry of Health website at www.moh.gov.et; online versions will also be available to download from the HEAT (Health Education and Training) website at www.open.ac.uk/africa/heat as open educational resources, free to other countries across Africa and anywhere in the world to download and adapt for their own training programmes.

Dr Kesetebirhan Admasu State Minister of Health Ethiopian Federal Ministry of Health

i Acknowledgements Labour and Delivery Care is one of 13 Blended Learning Modules for the Ethiopian Health Extension Programme. Together with the practical skills training sessions that accompany each of the supported self-study texts, this programme will upgrade the Health Extension Workers who complete the curriculum to Health Extension Practitioners at Level-IV of the Ethiopian Occupational Standards. The upgrading programme is sponsored by the Ethiopian Federal Ministry of Health (FMOH) and the Regional Health Bureaus (RHBs). The FMOH gratefully acknowledges the receipt of funding for this programme from the Ethiopian Office of UNICEF (the United Nations Children’s Emergency Fund), The Open University UK, the Alan and Nesta Ferguson Foundation Trust UK, and AMREF (the African Medical and Research Foundation). We are also thankful for the support of the Ethiopian Office of Jhpiego for freely enabling their expert to participate in the development of this Module. This Labour and Delivery Care Module was produced by a team of Ethiopian experts, who were trained and supported by experts in blended learning pedagogy from the HEAT (Health Education and Training) Team for Africa at The Open University UK. The contributors of original material are: Dr Yifru Berhan, Hawassa University, College of Medicine and Health Sciences Dr Basiro Davey, HEAT Team, The Open University UK Dr Yirgu Gebrehiwot, Addis Ababa University, Faculty of Medicine Dr Mulualem Gessese, Yekatit 12 Hospital, Addis Ababa Fekadu Mazengia, Gondar University Sr Alemnesh Tekleberhan, Jhpiego Ethiopia The Academic Editors of Labour and Delivery Care are Dr Basiro Davey, Deputy Director (Ethiopia), HEAT Team, and Peggotty Graham, both at The Open University UK. Basiro Davey also produced the anatomical diagrams; the other illustrations in colour were drawn by Dr Radmilla Mileusnic at The Open University. The other members of the HEAT Team are: Lesley-Anne Long, HEAT Programme Director Alison Robinson, HEAT Programme Coordinator Dawn Partner, HEAT Senior Production Assistant Jessica Aumann, HEAT Programme Assistant We acknowledge the vital contributions of the Programme Coordinators within Ethiopia: Ato Mohammed Hussein Abeseko, UNICEF Ethiopia and the Federal Ministry of Health Ato Tedla Mulatu, AMREF Ethiopia The cover design for Labour and Delivery Care is by Chris Hough, Learning and Teaching Solutions, The Open University UK. The cover photographs are reproduced with the permission of Nancy Durrell McKenna, Founder Director of SafeHands for Mothers. We particularly wish to acknowledge our use in this Module of adapted extracts and illustrations from Safe and Clean Birth and Newborn Care: A Reference for Health Extension Workers in Ethiopia (2008), which was based on A Book for Midwives: Care for Pregnancy, Birth and Women’s Health by Susan Klein, Suellen Miller and Fiona Thompson (2004), published by the Hesperian Foundation, Berkeley, California, USA. The Book for Midwives was created with the

ii collaboration of hundreds of advisors, reviewers, writers, artists and others, whose expertise is gratefully acknowledged. It is through the generous permission and encouragement of the Hesperian Foundation for others to copy, reproduce, or adapt the original book, including its illustrations, to meet local needs — provided that reproductions are provided free or at cost and not for profit — that the production of parts of thisLabour and Delivery Care Module was made possible. Safe and Clean Birth and Newborn Care was adapted from the original book by the Ethiopian Federal Ministry of Health (FMOH) Safe Motherhood Technical Working Group, with P. Annie Clark, MPH, CNM, Midwifery Advisor, ACCESS Program/American College of Nurse Midwives, with the generous support of the US Agency for International Development under the terms of the ACCESS Cooperative Agreement GHS-A-00-04-00002-00. The author of Study Session 7, Dr Mulualem Gessese, wishes to acknowledge the following sources: Perinatal Education Program: Newborn Care, Unit 20, 2005; Textbook of Neonatal Resuscitation, 5th Edition, American Heart Association, American Academy of Pediatrics, 2007; Protocol of Common Newborn Problems, Yekatit 12 Hospital, 2008; Community Based Postnatal Care: A Practical Guide for Community Health Workers, 2009. The opinions expressed in this Module are those of the authors and do not necessarily reflect the views of any of the donor organisations whose generous support made the production of Labour and Delivery Care possible.

iii Contents

Study Session

1 Recognition of the Normal Labour

2 Assessing the Woman in Labour

3 Care of the Woman in Labour

4 Using the Partograph

5 Conducting the Normal Delivery

6 Active Management of the Third Stage of Labour

7 Neonatal Resuscitation

8 Malpresentations and Multiple Pregnancies

9 Obstructed and Prolonged Labour

10 Ruptured Uterus

11 Postpartum Haemorrhage

Notes on the Self-Assessment Questions (SAQs)

iv Introduction to the Labour and Delivery Care Module The World Health Organization (WHO) states that every year more than 133 million babies are born globally, of which 90% are in low- and middle-income countries. Every year, almost 8 million children die before their fifth birthday, but the great majority of these deaths occur in the perinatal period (i.e. around the time of birth). Global perinatal mortality is estimated to be about 7 million deaths every year (3.5 million stillbirths and 3.5 million deaths in the first 7 days). This death toll is more than the combined annual deaths globally due to HIV/AIDS (2.1 million), tuberculosis (1.6 million) and malaria (1.3 million), which together add up to 5 million lives lost. Almost one quarter of the 7 million perinatal deaths occur during labour and delivery. The causes of perinatal and maternal deaths in developing countries are almost similar (haemorrhage, hypertensive disorders of pregnancy, eclampsia, infection and obstructed labour). The lives of many women in labour and delivery and their babies could be saved in less developed countries if births were attended by well-trained health professionals. Globally, the proportion of births attended by a skilled birth attendant in less developed countries increased from about 50% in 1990 to 60% in 2006. The global targets set at a special session of the United Nations General Assembly in 1999 were 80% by 2005, 85% by 2010 and 90% by 2015. This shows that the achievement was far below the target and there is a great need for further endeavour. To be specific, regions with the lowest proportions of skilled-birth-attended deliveries were eastern Africa (34%), western Africa (41%) and south-central Asia (47%). It is also in these regions where the highest numbers of maternal and perinatal deaths occur. In Ethiopia there is some progress in antenatal care coverage, but the labour and delivery service may be the lowest in the world: more than 94% of pregnant women labour and deliver at home, unattended by skilled healthcare personnel. Probably that is why more than 10,000 Ethiopian women are suffering at home from one of the morbid complications of obstructed labour (fistula, an opening between the birth canal and other internal organs), and the maternity wing of almost all public hospitals outside Addis Ababa are filled by women with complications due to obstructed labour. An estimated 22,000 women die in Ethiopia every year from a cause associated with their pregnancy or childbirth. Many of the common causes of maternal and perinatal mortality, including obstructed labour, eclampsia and postpartum haemorrhage, are of an unpredictable nature. Therefore it is the presence of skilled personnel intervening during an emergency in labour and delivery that brings significant change in maternal and child health outcomes. Taking this into account, the current recommendation is that every labouring mother should be attended by a skilled person either at a health facility or at home. The aim is to conduct a normal delivery for the majority, and early detection and referral for those women and babies who develop complications. This Labour and Delivery Care Module is formulated to equip you with the basic principles and practice of skilled birth attendance at Health Post and home level. It has 11 study sessions. You will first learn in detail how to identify true labour, the different stages of labour, the preparations and skills for conducting a normal delivery and supporting the mother through the four stages, and techniques for monitoring the progress of labour using a chart called the partograph. The second half of the Module introduces you to the basic techniques of newborn resuscitation, identifying and managing malpresentations and twin births during labour, and the diagnosis and emergency interventions in obstructed labour, uterine rupture and postpartum haemorrhage. All of the principles and techniques taught in this Module will be reinforced and expanded in your practical skills training. Blending the theory and practice of labour and delivery care will enable you to support the health and the survival of labouring women and newborns in your community.

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StudySession 1Recognition of Normal Labour

Study Session 1RecognitionofNormal Labour Introduction Ideally thesamehealth professional will look afterthe pregnant woman and herbabyfromthe firstantenatal visituntil theend of thepostnatal period. This is knownasthe continuum of care.You have alreadystudied the ModuleonAntenatal Care. Now youare moving on to learnabout Labour and Delivery Care. Labour is thetermfor thechangesinanatomy and physiology in thefemalereproductivetract that preparethe fetusand the placenta fordelivery. In themajorityofcases, this happens when thebabyis fully developedatfullterm, between 37-40 weeks gestation. Labour heralds theend of thebaby’stimeinthe uterus andthe beginningofadaptationtolife outside themother. This firststudy sessionservesasanintroductiontothe Labourand Delivery Care Module. The emphasisisonhelping you make thediagnosis of true labour anddistinguishingitfromfalse labour,and recognising thesigns of the four stages of labour. Thissession will help you to understand thelabour and deliveryprocess, so that you can make accurate decisions andfeel confident when you attend births. Youwill also learnhow to preparethe pregnant womantobecome awareofthe changesinher bodythatindicatelabour will start soon, andhow to recognise theonset of true labour,soshe can send for you to come in good time. Learning Outcomesfor StudySession1 When you have studied this session, youshouldbeableto: 1.1Define anduse correctly allofthe keyterms printedinbold. (SAQ 1.1, 1.2, 1.3and 1.4) 1.2Describethe signs of truelabour anddistinguish between true and false labour.(SAQs1.2 and1.3) 1.3Explaintothe mother how to recognise theonset of truelabour. (SAQ 1.2) 1.4Describethe characteristic features andmechanisms of thefour stages of labour.(SAQ1.4) 1.5Describethe seven cardinalmovementsmadebythe baby as it descends thebirthcanal in anormallabour.(SAQ1.4)

1.1The indefinite nature of labour Youneed to be awarethatlabour maystart at anytime. Thisisone of its ‘indefinite’ features, so you shouldalwaysbereadytotakeappropriate action. Despitemuchadvancementofmaternaland fetalhealth sciences, so far nobody knowsexactly:

. When is labour going to start?

That is whyeventhe normal onset of labour is anticipatedinawide range of weeks(at Health Postlevel 37–40 weeks is considered thenormal ‘window’; at hospitallevel,itcan be at 37–42 weeks with closefollowupusing ultrasound scanning).Although it is good to calculate the expected dateof delivery as 40 weeks fromthe mother’slast normalmenstrual period

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(LNMP),ifshe knows thedate(many mothersdonot), tell herthatshe is probably not going to deliveronthe expected date.Onlyabout 2% of deliveriesoccuronthe expected date even among women who know their LNMPdateexactly.The othermajor indefinite features of labour are:

. What initiates/stimulates labour to begin? Is it factorsinthe fetus, the mother or both? . Whydosomewomen developpreterm labour? . Whydounpredictedlabour abnormalitiesoccur?

We have to leavethese questions unanswered,and focusonthe normallabour occurringatterm.

1.1.1Normallabour A normallabour hasthe following characteristics:

. Spontaneous onset (it begins on its own, without medical intervention) . Rhythmic andregular uterinecontractions . Vertexpresentation (the ‘crown’ of thebaby’shead is presented to the opening cervix,asyou learnedinStudy Session 6ofthe Antenatal Care Module) . Vaginaldeliveryoccurs without activeinterventioninlessthan12hours foramultigravida mother andless than 18 hoursfor aprimigravida (first birth) . No maternal or fetalcomplications.

Any type of labourthatdeviatesfromthese conditions is considered abnormal, andusually requiresreferralfor specialistcare. Youwill learnhow to deal with differenttypesofabnormallabour laterinthisModuleinStudy Sessions 8-11.Next, we describe thesigns that tell you andthe mother that true labour hasbegun. 1.2How do youknowthattruelabourhas begun? True labour is characterized by regular,rhythmic andstrong uterine contractions that will increase progressively andcannot be abolishedbyanti- pain medication. Painsymptomsmay be relieved alittle if thewoman takes painkillingdrugs,but truelabour will stillprogress.

1.2.1Whatisadequate uterine contraction? If truelabour is progressing, therewill be adequateuterine contraction, evaluatedonthe basisofthree features — thefrequency,the durationand the intensity of thecontractions:

. The frequency of uterinecontractions will be 3-5times in every10 minuteperiod. . Eachcontractionlasts40–60 seconds;thisisknownasthe duration of contractions. . The woman tellsyou that hercontractions feel strong; this is the intensity of contractions.

Youcan assess thestrengthofuterinecontractions foryourselfbypalpating thewoman’sabdomen in theareaofthe fundus (top) of theuterus. In between

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contractions,whenthe uterus is relaxedand themuscularwallissoft, you will be able to palpatethe fetalparts.But when astrong contractioncomes,you will not be able to feel thefetal parts, becausethe abdominal wall overthe uterus is very tenseand very painfulifyou applydeep pressure with your fingers. In Study Session4,you will learnhow to record thefrequency, durationand intensity of contractions on achart calledthe partograph.

1.2.2Showand leakage of amniotic fluid During most of thepregnancy, thetinyopening in thecervixispluggedwith mucus. In thelast fewdaysofpregnancy, thecervixmay begintoopen. Sometimesthe mucusand alittle bitofblood drip out of thevagina. Thisis called show.Itmay come out allatonce, likeaplug, or it mayleak slowly forseveral days.Whenyou see theshow,you know that thecervixis softening, thinning andbeginning to efface (open).Becareful nottoconfuse theshow with thenormaldischarge (wetness fromthe vagina)thatmany womenhaveinthe twoweeksbeforelabour begins.Thatdischarge is mostly clear mucusand is not coloured alittle bitred with blood. True labour maybespontaneously established with or without show and with or without leakageofamniotic fluid (the watersinthe fetalmembranes surrounding thebaby).Inmanyparts of Ethiopia, peoplethink that labour is not progressing if they don’t see leakageofamniotic fluideitherbeforeor afterlabour begins.Thisisnot true.You should be clear that showand leakageofamniotic fluidare not requiredfor labour to beginorprogress. When thebag of waters breaks(fetalmembranes rupture),there can be abig gushofamniotic fluidfromthe vagina,oraslow leak.Inmostwomen,the bagofwatersnormally breaksduringearly labour.Ifthe fetalmembranes rupture before labour begins,there shouldonlybeafewhoursdelay before If labourhas notstartedornot progressedmuch within6hours labour starts.Iflabour doesnot start within 6hoursafterthe bagofwaters afterthe waters break,refer the breaks, thereisariskofinfectionenteringthe uterus,which gets strongerthe womantoahigher health facility more timethatgoesbyafterthe membranesrupture. Youlearnedabout as soon as possible. prematureruptureofmembranes (orPROM) in Study Session 17 of the Antenatal Care Module. Remember that ‘premature’ refers to thefetal membranesrupturing ‘early’ (beforelabour starts) – not to thegestationalage of thebaby, which maybepreterm,termorpost-term whenthe waters break. However, even if thefetal membranesbreak after labour begins,asis normallythe case, thereare some risksassociated with theleakageof amniotic fluidthatyou shouldbeaware of. ■ Think back to whatyou alreadylearned about PROM. Canyou suggest whatrisks might occurifthe watersbreak while thewoman is already in labour? □ Potentialcomplications of ruptureoffetal membranes during labour are:

. Infection: Sincethe ‘door’ to theuterusisopenand you aregoing to do pelvic examinations with your gloved fingerstoassess theprogress of labour,there is ariskoftransferring infectionintothe uterus unless you areverycareful about hygiene(as you will learninlater study sessions of this Module).Thisriskgetsbiggerifthe labour is prolonged. . Theumbilical cord may prolapse (bepushedout ahead of thebabyas thewatersgushout through thecervix),orthe cord maybecome trappedagainst theendometrialwallbythe baby which is no longer

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kept ‘floating’ by theamniotic fluid. If thecordiscompressed, the baby can develophypoxia(lowoxygenlevels) becausethe blood flow is restrictedinthe cord,and it maydie or be braindamaged.

1.2.3Distinguishingtruelabourfromfalse labour There is aconditiontermed falselabour,which maybefeltone or twoweeks ahead of true labour.Itischaracterised by irregular contractions which are less painfulthanintruelabour andtheydon’tprogress. Table1.1 contrasts thecharacteristicsoftrueand falselabour.Whenawoman hasafalse labour, sheshouldnot be discouraged.Tellher that although sheisnot yetintrue labour,the signs sheisexperiencingmean that herlabour will start soon. Advise heronthe signs of true labour (Table 1.1and thenextsection) and tell hertocallyou or to come to theHealth Postwhenthe signs of true labour appear.

Table1.1 Characteristicsoftrueand false labour

CharacteristicsTruelabourFalse labour Uterine Contractions occur at regular Contractions occuratirregular contractions intervals, butthe interval intervals between eachcontraction gradually becomes shorter Duration of each contraction Durationremains unchanged — gradually increases either long or short Intensityofcontractions Intensityremains unchanged becomes stronger andstronger Cervical Cervix progressivelydilatesCervixdoes notdilate, remains dilation less than 2cm Pain Discomfortatthe back in the Discomfort is non-specific(has abdomen,cannot be stopped by no particularlocation) and is stronganti-painmedication usually relieved by strong anti- pain medicationorbywalking

1.2.4 Helpingthe mother recognize atrue labour There is no waytobesurewhenawoman’slabour will begin, but thereare some signs that it will start soon. Babies oftendroplower in themother’s bellyabout 2weeksbeforebirth,which is knownaslightening;commonly, mothersfeel that thebabyisnolongerlying ‘high’ in theabdomen,and not pushing herstomach upwards.Ifshe hashad babies before,thisbabymay not drop until labour begins. Othersigns mayhappenonlyadayortwo before labour starts. The mother’s stool maychange,oralittleshow (bloody mucus) maycomeout of the vagina.Sometimes, thebag of watersleaksorbreaks(prematureruptureof fetalmembranes — PROM)beforelabour begins. Recognizing true labour isn’taneasy task forthe mother,particularly if this is her firstbaby. She may come repeatedly to theHealth Postorcallfor you, assumingthatminor complaints arethe start of truelabour.Counsellingthe mother andher family on birth preparedness is part of focused antenatalcare (asyou learnedinStudy Session 13 of the Antenatal Care Module).When you counsel heronhow to recognize true labour andwhatactions to take, make sure you usesimpleand easily understandablelanguage andclearly

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demonstratewhatshe will feel on herabdomen.Your role is very important, firsttominimizethe mother’sanxietyabout thelabour,and second to reduce herunnecessarycosts andtimespent visiting thehealth facility forfalse labour or minorcomplaints. Tell herthattruelabour is:

. Regularlyand progressively increasing pushing-downpain, which happens about 3-5times in every10minutes. (Check whethershe knowsorcan estimatehow long 10 minutes is). . Characterized by apushing down pain,which is usually felt firstinher lowerback andmoving around to thefront in thelower abdomen below herbelly button.

Demonstrate on herabdomen:

. What will happendue to lightening . Whereshe will feel theabdomen is hard duringcontractions . Whereshe will feel themaximum pushing-down pain.

1.3Stagesoflabour In this section, you will learnsomebasicintroductory informationabout the stages of labour andbirth.Each stagewillbediscussed in more detail in subsequent study sessions in this Module. Labour is traditionally dividedinto four stages:

. The firststage of labour (thecervical opening stage) . The second stageoflabour (thepushing stage, ending in thebirthofthe baby) . The third stageoflabour (thebirth of theplacenta) . The fourth stageoflabour(the first4hoursafter birth).

1.3.1First stageoflabour The first stageoflabour is characterized by progressive opening of the cervix, which dilatesenough to letthe baby out of theuterus. Formostofthe pregnancy, nothing can getinorout of thecervix, because thetinyopening in it is pluggedwithmucus. During pregnancythe cervixislong and firm,likeabig toe(see Figure1.1a), but theimmediate effect of uterinecontractionistodilatethe cervixand shortenthe lowersegment of theuterus, so theedges of thecervixare gradually drawnback andare takenup. Thisprocessiscalled effacement (Figure1.1band c).

Figure 1.1Effacementofthe cervix. (a)Beforelabourbegins, thecervixisnot effaced.(b) Cervixis60% effaced.(c) Cervix is fully effaced.

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The cervixthendilates(thediametergraduallyincreases) – this is known as cervicaldilatation.Each timethe uterus contracts, it pulls alittlebit of the cervixupand open. Between contractions,the cervixrelaxes. The firststage is dividedintotwo phases: thelatentand theactivephase, based on how much thecervixhas dilated.

Latent phase The latent phase is theperiodbetween thestart of regular rhythmic contractions up to cervical dilatationof4cm.Duringthisphase, contractions mayormay not be very painful, andthe cervixdilatesveryslowly. The latent phase ends when therateatwhich thecervixisdilatingspeedsup(it dilates more quickly).Thissignals thestart of theactivephase.

Active phase The activephase is saidtobewhenthe cervixisgreater than 4cmdilated. Contractions become regular,frequent andusually painful. The rate of cervical dilationbecomes faster anditmay increase in diameter by as much as 1.2to 1.5cmper hour,but theminimum dilation rate shouldbeatleast 1cmper hour.You shouldstart to plot data on the partograph at this stage, as you will learntodoinStudy Session 4ofthisModule. Cervical dilatation continuesuntil thecervixiscompletelyopen: adiameterof 10 cm is called fullydilated.Thisiswideenough forthe baby to pass through (Figure1.2). At this diameter,you wouldnot feel thecervixoverthe fetalhead when you make avaginal examinationwithyour gloved fingers. (Wewilldescribehow to do this laterinthisModuleand you will be shown how to do it in your practical trainingsessions.)

Figure1.2 Afully dilatedcervixis10cmindiameter.

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1.3.2Second stageoflabour The second stage begins when thecervixisfully dilated(10 cm)and is completedwhenthe baby is completely born. Afterthe cervixisfully dilated, themothertypically hasthe urge to push.Her efforts in ‘bearingdown’ with thecontractions of theuterusmove thebabyout through thecervixand down thevagina. Thisisknown as fetaldescent.The rate of fetaldescent is an important indicator of theprogress of labour,which will be describedinmore detail later. The averagedurationofsecond stageis1hour andusually not longerthan2hours. Table1.2 summarises thesymptomsand signs during the firstand second stages of normallabour.

Table1.2 Characteristicsofthe firstand secondstagesofnormallabour.

Symptoms and signsStage Phase Cervix notdilated Falselabour/Notin Uterinecontractions notregular or labour strong Regular uterinecontractionbut not First Latent verystrong Cervix dilatedless than 4cm Regular andstrong uterine First Active contractions Cervix dilated4–9cm Rate of dilatationtypically 1cmper hourorfaster Fetaldescent begins Cervix fullydilated(10 cm) Second Early (non- Fetaldescent continues expulsive) Mother has no urge to push Cervix fullydilated(10 cm) Second Late (expulsive) Thedelivery of thebaby marks Presenting partoffetus reaches pelvic theend of thesecondstage. floor Mother has theurgetopush

1.3.3Third stageoflabour The thirdstage of labour is thedeliveryofthe placenta andmembranes after thebabyhas been born. The durationisusually amaximum of 30 minutes. (You will learnmoreabout this stageinStudy Session 6ofthisModule.)

1.3.4Fourthstageoflabour The firstfour hoursimmediately followingplacentaldeliveryare critical,and have been designated by some expertsasthe fourth stage of labour.Thisis because afterthe deliveryofthe placenta,the woman can have torrential vaginalbleedingdue to failure of uterinecontractions to closeoff thetorn blood vesselswhere theplacenta detached fromthe uterinewall. Therefore, you shouldbevigilant to detect revealed or concealed postpartum haemorrhageand manage it accordingly. (You will learnabout this in detail in Study Session 11 of this Module).

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The placenta,membranes andumbilical cord shouldbeexaminedfor completeness andfor abnormalities (Study Session 6covers this). Maternal bloodpressure andpulse should be recorded immediatelyafterdeliveryand every15minutes forthe firstfour hours. Normally,after thedeliveryofthe placenta,the uterus will become firm duetosustained contraction, so the womanmight feel strong contractions afterthe birth.Reassure herthatthese contractions arehealthy, andhelptostopthe bleeding. 1.4Mechanisms of normallabour The seven cardinal movements arethe seriesofpositionalchangesmadeby thebabywhich assist itspassage through thebirth canal.(Cardinal means ‘fundamentally important’.) The positionbeforethe movementsbegin is shown in Figure1.3 (diagram 1) andthe seven movementsare in diagrams 2 to 8. As you read thedescriptions that follow, keep looking at Figure1.3.

Figure1.3 Thestartingpositionand theseven cardinalmovements of thebabyas it descends throughthe birthcanal.The smallpicturesshowthe positionofthe baby’shead,asifyou were lookingupthe birthcanal.(Source: WHO, 2008, Midwifery EducationModule:ManagingProlonged andObstructedLabour,2nd edn.,Figure 1.5, page 23)

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Thepositionalchangesmadebythe baby arespecific, deliberateand precise. They allowthe smallest diameter of thebabytopass through themother's pelvic cavity. Neitheryou nor themotherisresponsible forthese positional changes. The baby hasthe responsibility forthe seven cardinalmovements.

1.4.1Engagement Engagement is whenthe fetalhead enters into thepelvicinlet (Figure1.3, diagram2). Thehead is saidtobeengaged when the biparietaldiameter (measuringear tip to ear tipacrossthe topofthe babys head,see Figure1.4 below) descends into thepelvicinlet,and the occiput is at thelevel of the ischialspinesinthe mother’spelvis(see Figure 1.5).

Figure 1.4Mouldingofthe fetalskull mayoccurduring descent; in this example, one parietal bone is overlappingthe otheratthe sagittalsuture.The occiputand thedistanceknown as thebi-parietal diameter have been labelled.

Figure 1.5The pelvic inlet, viewed from above. Note theposition of theischial spines.

1.4.2Descent Thetermfetal descent is used to describe theprogressive downward movement of thefetal presenting part (commonlythe head)through the pelvis.Whenthere is regular andstrong uterinecontraction, andthe size of thebabys’ head andthe size of themother’spelviccavity areinproportionso thebabycan pass through, therewillbecontinuous fetaldescent deep into the

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pelvic cavity. Sincethe pelvic cavity is enclosed with pelvic bones, when the uterus is stronglypushing down, occasionally thefetal scalpbonesundergo overlapping at thesuturelines in ordertoallowthe head to pass through the narrow space. Thisoverlapping is called moulding.The commonest typesof moulding include one parietalbone overlapping overthe otherparietalbone along thesagittalsuture(Figure1.4), theoccipitalbone overlapping the temporal bone,and thefrontal bone overlapping theparietalbones.

1.4.3Flexion The movement known as flexion occurs duringdescent andisbrought about by theresistance felt by thebaby’shead againstthe soft tissues andbonesof themother’spelvis. Theresistance brings about a flexioninthe baby’shead so that thechinmeetsthe chest (Figure1.3,diagram 2).The smallest diameter of thebaby’shead presents into thepelvis.

1.4.4Internal rotation Youcan seethe diametersofthe As thehead reaches thepelvic floor,ittypically rotatestoaccommodate the pelvic inletand outlet if youlook change in diametersofthe pelvis (Figure1.3,diagram 3).Atthe pelvic inlet, back to Figures6.3 and6.4 in the thediameterofthe pelvis is widest fromright to left.Atthe pelvic outlet,the AntenatalCare Module, Part 1. diameter is widest from front to back.Sothe baby must rotate fromlying sideways to turningits face towardsthe mother’sbackbone (Figure1.3, diagram4). When therotationiscomplete, theback of thebaby’shead is againstthe front of themother’spelvis).The sagittalsutureinthe fetalskull is no longeratanangle, but pointsstraight down towardsthe mother’s backbone.Thismovement is called internal rotation because it occurs while thebabyisstillcompletelyinsidethe mother.

1.4.5Extension Afterinternalrotationiscomplete, thebaby’shead passes through thepelvis andashortrest occurs whenthe baby’sneck is underthe mother’spubicarch. Then extension of thebaby’shead andneck occur – theneck extends,sothe chin is no longerpressed againstthe baby’schest,and thetop of thehead, face andchinare born(Figure1.3,diagrams4and5).

1.4.6Externalrotation (restitution) Afterthe head of thebabyisborn, thereisaslight pauseinthe actionof labour.Duringthispause,the baby must rotate so that his/herface moves from facing themother’sbackbone to facing either of herinnerthighs (Figure1.3,diagram 6).Thismovement is called external rotation because part of thebabyisalreadyoutside themother(it is also called restitution). The rotationisnecessary as thebaby’sshoulders must fitaround andunder themother’spubicbone.

1.4.7Expulsion Almostimmediately afterexternalrotation, theanterior(foremost)shoulder movesout fromunderthe pubicbone (Figure1.3,diagram 7).The mother’s perineum becomesdistendedbythe posterior(second) shoulder, which is then also born(Figure1.3,diagram 8).The rest of thebaby’sbody is then born (expulsion), with an upwardmotionofthe baby’sbody assisted by thecare provider.

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Study Session 1Recognition of Normal Labour

1.4.8Inconclusion Note that at everystage of labour thereisdescent. To be specific, after the fetalhead undergoes flexion, thereisdescent;after internal rotation, thereis descent; afterextension, thereisdescent andsoon. In thenextstudy session, we will describethe progress of anormallabour in more detail. Summary of StudySession1 In Study Session1you have learnedthat: 1Truelabour is anatural process characterized by regular,rhythmic and strong uterinecontractions that will increase progressively andproduce cervical effacementand dilatation. 2Truelabour can beginwithout ashow andwithout thewatersbreaking (ruptureoffetal membranes). 3Awomaninastateoffalse labour hasuterine contractionofirregular intervalsand intensitythatcan be relieved by anti-painmedication. 4The woman herselfcan recognize true labour if you lether know that it is manifested by pushing downpains occurring 3-5times in every10 minutes, each contractionlasting40-60 seconds. 5There arefour stages of labour: ◦ The firststage starts with truelabourand ends with full cervical dilatation (10cm);itisdivided into latent andactivephases. ◦ Thesecond stageisfromfullcervical dilatation to delivery of the baby. ◦ Thethird stageisfromthe deliveryofthe baby to delivery of the placenta. ◦ Thefourth stageisthe first4hoursafterplacentaldeliverywhen youneed to followthe mother as closelyasduringlabour and delivery. 6Inanormally progressing labour,the baby performsseven cardinal movementsasitpasses down thebirth canal:engagement ® descent ® flexion ® internal rotation ® extension ® external rotation/restitution ® expulsion. 7There is fetaldescent duringevery cardinalmovement. 8Moulding of thebaby’sskullmay occurasitpasses through themother’s pelvis,underpressure from thecontractions pushing it through thenarrow space.

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Self-Assessment Questions (SAQs) forStudy Session1 Now that you have completedthisstudy session, youcan assess how well you have achievedits Learning Outcomes by answeringthe questions below. Write your answersinyour Study Diaryand discuss them with your Tutoratthe next Study SupportMeeting. Youcan check your answerswith theNotes on theSelf-AssessmentQuestions at theend of this Module. SAQ1.1 (testsLearning Outcome 1.1) Attempt Activity 1.1below.

Activity 1.1Grabexercise on thekey definitions Write each of theboldterms listed belowonasmallpiece of paper. Roll up each piece andput them in asmall basket or bowl. Pick one at atimeand try to define theterm. Writeyour answersinyour StudyDiary.Finally,compare your answerswiththe definitions in this study session. Youcan repeat theexerciseuntil you arefamiliarwithall of the words. true labour,effacement,dilatation,presenting part, show,ruptureoffetal membranes, engagement,descent, first stage,second stage,third stage, fourth stage

SAQ1.2 (testsLearning Outcomes1.2 and1.3) Read Case Study 1.1and then answer thequestions that follow it.

Case Study1.1 MrsAbeba Mrs.Abeba is 30 yearsofage andishavingher firstbaby. She hascome to theHealth Postbecause she begantoget regular pushing-down pains about3hoursago. She saysthatthe painsstart in herback andmove forwardtothe front of herabdomen,each pain lastsabout 40 seconds, andtheyoccur2-3times in every8minutes. When you examineher, you find that hercervixisfully effaced andthe diameter is 4cm. Mrs Abeba’smother-in-lawhas told hershe isn’tinlabour because shehasn’t hada‘show’.

(a)Whatare thesigns suggestingtruelabour from MrsAbeba’sdescription andthe physical examination? (b)Whatstage of labour hasshe reached andhow do you know this? (c)Whatwill you say to MrsAbeba to help herrecognise that she is really in labour?

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Study Session1 Recognition of Normal Labour

SAQ1.3 (tests Learning Outcomes 1.2) Table1.3 summarises thedifferencebetween trueand false labour.Fillin theempty boxeswith appropriate descriptions.

Table1.3 True andfalse labour.

True labour Falselabour Contractions occur at regular intervals Duration of each contractiongradually increases Intensity of contractions is unchanged cervix progressively dilates Discomfort usually relieved by anti-pain medicationorwith walking

SAQ1.4 (tests Learning Outcomes 1.1, 1.4and 1.5) Whichofthe following statements is false?Ineach case, explainwhatis incorrect. ALighteningiswhenthe baby floatshigherinthe abdomen shortly before labour begins. BThe second stageoflabour ends with theexpulsion of thebabyfrom thebirth canal. CThe fourth stageoflabour lastsfor 4hoursand begins when the placenta andfetal membraneshavebeenexpelled. DThe overlapping of fetalskullbonesduringthe descentthrough the mother’spelvisiscalled flexion. EThe fetalhead is engagedwhenthe occiput of thefetal skull reaches thelevel of theischialspinesinthe mother’spelvis. FDuringanormalbirth,boththe baby’sshoulders arebornatthe same time.

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StudySession 2Assessing theWoman in Labour

Study Session 2Assessing theWoman in Labour Introduction In the firststudy session in this Module, you learnedhow to tell if true labour hasbegun, about thefour stages of labour,and themovementsthe baby makesasitdescendsthrough thebirth canal.Inthisstudy session, you will learnhow to assess thecondition of awoman who is already in labour,the conditionofthe fetus, andhow it is positionedinher uterus.Wealsowant you to payattentiontogiving ‘woman-friendlycare’ which respects her beliefs andrights. Labour will alreadyhavebegun in almost allcases whenyou arecalledtoa woman’shomeorwhenshe arrives at your HealthPost. Oneofthe most critical assessmentsyou have to make in Labourand Delivery Care is at the timewhenyou firstattend alabour.Rapid early assessment is required so that you can decide on thecareneeded forthe labouringmother, in case immediatereferraloremergency measures arerequired. If alliswell, you need to take thewoman’shistory in detail andconductaphysical examination in orderidentify thestage of labour that she hasreached,and discoverany informationfromher historythatmay affect theprogress or outcomeofher labour.Thisstudy session buildsonthe assessment andhistory-takingskills you developedduringyour studyofthe Antenatal Care Module. Learning Outcomesfor StudySession2 When you have studied this session, youshouldbeableto: 2.1Define anduse correctly allofthe keywords printedinbold. (SAQ 2.5) 2.2Describehow you wouldconductarapidassessmentofawomanin labour.(SAQ 2.1) 2.3Describethe features of woman — friendlycareduringlabour and delivery. (SAQ 2.3) 2.4Describethe stepsinhistory taking of awoman in the firststage of a normallabour. (SAQ 2.3) 2.5Explainhow you wouldpalpate theabdomen of awoman in labour to assess thesize, lieand presentationofthe baby.(SAQ 2.2) 2.6Explainhow you wouldconductavaginalexaminationofawomanin labour to assess theprogress of labour.(SAQ2.4) 2.7Differentiate between normaland abnormal findings duringthe assessment of awoman in labour.(SAQ2.4)

2.1Rapid evaluation of awomaninlabour On firstseeing awoman who is alreadyinlabour,your immediatetask is to make arapid assessment of whetherthere is anycause forconcern. Does she need an urgent referral foremergency care, or is herlabourprogressing normallyatthisstage?

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2.1.1Whatyou must do forarapid assessment

Thingsyou need to have . HerAntenatal Care Card (if shehas been in your carepreviously);ifshe hascometoyou forthe firsttimeand sheisalreadyinlabour,start anew health record forher Youwill learnhow to usethe . Partographfor recordingthe progress of labour partographinStudy Session4. . Sterilegloves . Fetoscope to listen to thebaby’sheartbeat . Thermometer to take themother’stemperature . Watchorother timertohelpyou measure thefetal heartrateand the mother’spulse rate . Bloodpressuremeasuring cuff with stethoscope . Swabs(3-4balls of gauzesoakedwithantisepticsolutionsuchassavlon (chlorhexidene 2-4%) to clean theperineumbeforedoing avaginal examination. Youcan preparewarmwater andsoapifyou have no Never usealcohol to swab the genitalarea! antiseptic solution. Sometimes awoman maycometoyou at theHealth Postalreadyinthe second stageoflabour.Inthiscase, take hertothe deliverycouch immediatelyand make herascomfortableaspossible. If you areseeing herat home, select an appropriate place andmakeitasclean andsafeasyou can in Theequipment forattendinga theavailabletime. It is important to prepare in advance theequipmentyou normaldeliveryisdescribed in will need forattending adeliveryand keep it packed andreadyatall times in StudySession 3. caseyou arecalledtoawomanwho is closetogivingbirth.

Check hervital signs . Bloodpressure: normalvaluesrange between 90/60 mmHg to below 140/90 mmHg. . Maternal pulse rate:normalrange is 80-100 beats/minute, but shouldnot be greater than 110beats/minute in awoman in labour. . Temperature: average37oC; if it is between 37.5-38.4oCthe womanhas a lowgrade fever;ifitis38.5oCorabove,she hasahigh grade fever.

Youlearned howtostart IV If one or more of these vitals signs is outside of thenormalrange,you should fluidsinStudy Session22ofthe referher immediately(Figure 2.1).Ifthe values deviatealong way outside AntenatalCare Module andyour thenormalrange (and you have been trained to do so), referher afteryou practicalskills training. have begun an infusion of intravenous (IV) fluids.

Look at andlistentothe woman . Didsomeone carry herintothe Health Post? . Is thereblood on herclothingoronthe floor beneathher (Figure2.2)? . Is shegrunting, moaning, or bearingdown?

Ask her, or someone whoiswithher,whether she hasnow or hasrecently had: Figure 2.1Don’tdelay in . Vaginalbleeding referring awoman with . Severe headache/blurredvision abnormal vitalsigns. . Convulsions or loss of consciousness . Difficulty breathing . Fever

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StudySession 2Assessing theWoman in Labour

. Severe abdominal pain . Prematureleakageofamniotic fluid(waters breakingearly).

If thewoman currently hasany of these symptoms, immediately:

. Shout forhelp . Stay calmand focusonthe woman . Stay with her — do not leaveher alone . Take immediateactiontogivethe necessary pre-referraltreatmentsand referher urgently to thenearest hospitalorhealth centre. Figure 2.2Ifthe womanis losing alot of blood, sheneeds Managementofcomplicated laboursiscoveredindetailinStudy Sessions urgenthelp. 8-11 of this Module,including referral procedures andwhattodoonthe journeytothe health facility. 2.2History-takinginlabour Thebest waytolearnabout awoman’shistory is to ask her, but you must do History-takingwas coveredin this sensitively. At first,she maynot be comfortabletalking with you. If she Study Session8of the Antenatal feelsshy about herbody or about sex,itmay be difficult forher to tell you Care Module. things that you need to know about herhealth.Try to help herfeel comfortablebylistening carefully,answeringher questions,keepingwhatshe tells you private, andtreatingher with respect.

2.2.1The importanceofwoman-friendly care Theprinciples of woman-friendlycare areshown in Box 2.1.

Box2.1 Woman-friendlycareinlabour and delivery

1Itprovidesaservice that is acceptabletothe woman,which: ◦ Respectsher beliefs,traditions andculture ◦ Considersthe emotional, psychological,and social well-being of thewoman ◦ Providesrelevantand feasibleadvice. 2Itempowersthe woman, andwhoever she wantstobewithher duringthe labour,sothattheycan become activeparticipantsinher care. Your role is then to teach them how to carefor herand keep them allinformedabout what is happening. 3Itconsidersand respectsthe rightsofthe woman: ◦ Herright to informationabout herhealth andthatofher baby ◦ Herright to be informed about theprocess of labour and deliver andwhattoexpectasitprogresses ◦ Herright to give or withholdher permission/consentfor all examinations andprocedures. 4Itrequiresall healthcarestaff to usegood interpersonal skills and communicateclearly in language thewoman can understand.

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2.2.2Recordingsocio-demographicdata If you have lookedafterthe mother duringher antenatalcarecheck-ups,you will alreadyknow this information. If this is the firsttimeyou have seen her, record hernameand herage:thisisparticularly important if sheisavery young first-timemother, below18yearsofage,which is commoninEthiopia. Youwill learnmoreabout Also record herheight if possible, or estimateit; this will help you to evaluate ‘cephalopelvic disproportion’in whether she is ‘small’ forthe size of thebaby, which maymean that she Study Session9of this Module. couldhaveproblemsgivingbirth if thebaby’shead cannot fitthrough her smallpelvis. Next ask heraddress, religion(if shechooses to share this informationwith you) andoccupation(if sheisinemployment),and record it in theappropriate space in thechart. Write down what is hermainpresentingsymptom (her complaint), which in this case is usuallylabour pain (contractions), andabearing-down sensationif sheisalreadyinsecond stageoflabour.

2.2.3Historyofpastand present pregnancy Askabout thenumberofprevious pregnanciesand births(if any) thewoman hashad,and about thecurrent pregnancy. Box 2.2shows you how to record thenumberofpregnanciesand/or thenumberofbirths,using thetraditional terminology. Gestationalage is thenumberofweeksthe fetushas been in the uterus;the averagenumberofweeksatfulltermis40, calculatedfromthe date whenthe woman’s last normalmenstrual period (LNMP) began.

Box2.2 Gravidityand paritystatus

Gravidity is thetotal numberofprevious pregnancies, regardless of the outcome, including spontaneous miscarriage or abortionbefore28weeks of gestation.

. Gravida1or primigravida: firstpregnancy . Gravida2:second pregnancy, etc. . Multigravida:pregnant twoormoretimes (numbernot specified)

Forwomen whocan’t tell you Parity is thenumberofbabiesdelivered either aliveordead after 28 theexact number of gestational weeksofgestation. weeks,any delivery they think wasafter about7months (30 . Nullipara or Para 0: no pregnancyreached 28 weeks weeks)countsinthe parity . PrimiparaorPara1:one birth after28weeks number. . Para 2: twobirthsafter 28 weeks . Multipara: twoormorebirthsafter28weeks(numbernot specified) . Grandmultipara: five or more births after28weeks.

■ Awoman comestoyour Health Postinlabour at full term.She tellsyou that she haspreviously givenbirth to twolivebabies(bothatthe gestationalage of 40 weeks), andone dead baby (stillbirth)at32weeks. She also hadaspontaneous miscarriage at 26 weeks.Record thegravidity andparityofthiswoman.

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Study Session2 Assessing theWoman in Labour

□ She will be Gravida5:she hashad 2livebabies+1dead baby at 32 weeks +1miscarriage at 26 weeks +1current pregnancy. She will be Para3:she hasgiven birth to 2livebabies+1dead baby after28weeks.

Estimating theexpected date of delivery Youshouldalsoask whenwas the firstday of herlast normalmenstrual period(LNMP).Thiswillhelpyou to calculate the expected date of delivery (EDD)and thegestationalage of thefetus.Calculating theEDD and gestationalage will help you to identifywhether thelabour is preterm, term or post-term.Often women do not recalltheir LNMP; in such cases it is useful to ask herwhenshe firstfelther baby’smovement inside her(quickeningor fetalkick).Thisoccurs at approximately 18-20 weeks in primigravida mothersand 16-18 weeks in multigravidas.

2.2.4Dangersigns andsymptoms Askher about any dangersymptoms that she hasnoticed.(Asymptom is somethingthataperson experiences andcan tell you about;asign is somethingthatonlyatrained health workerwillnotice, or can discoverfrom an examinationortest.) ■ Canyou recallthe dangersymptomsinpregnancyfromStudy Session 17 of the Antenatal Care Module? □ Danger symptomsinclude vaginalbleeding(heavierthanshow), persistentheadache, blurringofvision, convulsions,lossof consciousness, epigastricorsevereabdominal pain,fever,leakageof amniotic fluidbeforethe onset of labour,and abnormalvaginal discharge. If shereports anyofthe above dangersymptoms, referthe mother to the nearest health facility as soonaspossible.

2.3Physical examinationinlabour When you physically examineawomaninlabour,your focuswill be on her abdomen,vaginaand cervix, so remember to:

. Maintain herprivacy . Followthe principles of woman-friendlycare(see Box 2.1) . Examine hercomprehensively (head to toe) . Lookfor signs of anaemia (paleness inside theeyelids, pale fingernails and gums) . Lookfor yellowish discoloration of theeyes(jaundice),which indicates liverdisease.

2.3.1Inspection of theabdomen In ordertomemorizewhataspects to inspect on theabdomen of awoman in labour,you can take theinitial ‘S’ lettersofthe threepointstolookout for: size, shapeand scars.

. Size:Isthe abdomen toobig or toosmall forthe gestationalage of the fetus? If it is toosmall,the baby maynot have developedproperly;ifitis toobig,the woman mayhavetwins,oraconditioncalled polyhydramnios (too much amniotic fluid).Ifthe abdomen is either too bigortoo small, referthe mother to ahealth facility.

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. Shape:Doesthe abdomen have an ovalshape (likeanegg — alittle bit wideratthe topofthe uterus andnarroweratthe lowersegment)? At near to full term,orinlabour,thisshape usuallyindicates that thebabyis presenting ‘head-down’.Ifitisround likeaball,itmay indicatean abnormalpresentation(as you will learnbelow,and in Study Session8). . Scar:Observe if shehas ascar from an operation in thelower abdomen, fromaprevious caesarean delivery (Figure2.3); thescar will usually be just above herpubicbone;ifshe hashad surgeryonher uterus previously, referher to thenearest health facility.Scarring of theuterusputsher at riskofuterineruptureduringthe current delivery(as you will learnin Study Session10).

Figure2.3 Previous caesarean surgeryincreases theriskduring thenextlabour.

2.3.2Palpation of theabdomen Palpation meansfeelingthe abdomen with your hands in specificpositions, or moving them in particularways, usingcertain levels of pressure. Askthe mother to liedown on herback andbendher legs at theknees, with herfeet flat on thebed.You need to be able to move around her: sometimesyou will be palpatingher abdomen while standing at herfeetand lookingupher body towardsher head;sometimes you will be standing behind herand facing her feet;and sometimesyou will standbesideher. ■ Canyou recallthe purposes of abdominal palpationinawomanin labour?(Theyare thesameasduringthe pregnancy; see Antenatal Care Module, Study Session 11.) □ Palpationhelps you to assess the size of thefetus,its presentation (which part of thebabywill ‘present’ at thecervixduringdelivery),and its position relativetothe mother’sbody (e.g.isitfacing towardsher front or herback).

There arefour palpations of theabdomen,which arecommonlyreferredtoby midwivesand doctors as Leopold’smanoeuvres.You need to do them in the correct sequence.

First Leopold’smanoeuvre:fundalpalpation Fundalpalpitation meanspalpatingthe dome-shaped upperpartofthe uterus,calledthe fundus.Duringantenatal care, you shouldhavebeen measuring thelengthofthe uterus fromthe mother’spubicbone to the

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Study Session2 Assessing theWoman in Labour

fundus,and comparingthiswiththe baby’sgestationalage to see if it was growingnormally.The purposeofpalpatingthe fundus in awoman in labour is to discoverhow thebabyislying in theuterus. Usethe palmsofbothhands to palpateoneither side of thefundus,withyour fingers quite closetogether (see Figure2.4). Feel whether thetop part of the uterus is hard androundedorsoftand irregular.Ifthe shapes feel soft and irregular andtheydon’teasily move undergentlepressurefromyour hands, then thebaby’sbuttocksare occupying thefundus (asinFigure2.4)and it is ‘head-down’.Thisiscephalicpresentation (cephalicmeanshead). There are several differentcephalic presentations,which you will learnabout in Study Session 8. The most common, andthe easiest forthe baby to be born, is calledthe vertex presentation.

Figure 2.4Fundal palpation — the firstmanoeuvre.Thisbabyisinacephalic (head-down)presentation. (Source: WHO, 2008, Managing Prolongedand Obstructed Labour, Figure7.4,page115) If you canfeel ahard, round shapeinthe fundus, this is thebaby’shead.Ina womanwho is alreadyinlabour,thismeansthe baby is in the breech presentation (the buttocksare thepresentingpart). It is safest to refera womanwhosebabyisinthe breech position because thebirth is likely to be more difficult andthe risk of complications is higher. If thefundus feels ‘empty’,the baby maybelying diagonallyortransverselyacrossthe uterus. Thesecond manoeuvrewill help to clarifythis.

Second Leopold’smanoeuvre:lateral palpation Thesecond manoeuvrehelps you to discoverthe fetallie:isthe baby lying longitudinally (straight), obliquely (diagonally across theuterus),or transversely (horizontally)? The longitudinallie is normal(see Figures 2.4 above,and 2.5onthe next page). Atransverselie in labour shouldbereferred urgently;the baby cannot be bornthrough thevaginainthispositionand may need caesarean surgery to deliver it.

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Figure2.5 Lateralpalpation–thesecond manoeuvre. (a)The back of thefetus is towards thefrontofthe mother’sabdomen;(b) Theback of thefetus is towards themother’sback.(Source: WHO, 2008, Managing Prolongedand Obstructed Labour, Figures7.4 and7.5,pages 115and 116) Place your hands on either side of themiddleofher abdomen.Pushgently with one hand while holding theother hand firm to steadythe uterus;alternate thepressure between your twohands.Ifyou feel theround, hard shapeofthe baby’shead at one side,and thefundus feelsempty,itmay be atransverselie andyou shouldrefer themotherurgently. The second manoeuvrealsohelps to determinewhether thebabyisfacing inwardsoroutwards.Notethe regularityofthe shapes youcan feel under your hands.Ifyou can feel alarge smoothshape underone hand, this is probably thebaby’sback,which meansitisfacing inwards(Figure2.5a).In this startingpositionitiseasier forthe baby to beginthe seven cardinal movements youlearnedabout in Study Session 1(look back at Figure1.3). If you can feel smallirregular ‘lumps’ underyour hands,these are probablythe baby’sfeet,knees andelbows anditisfacing outwards (Figure2.5b).Itisnot so easy forittorotateasitpasses down thebirth canal fromthisstarting position.

Third Leopold’smanoeuvre:deep pelvic palpation The third manoeuvrehelps to confirm your earlier findings about thefetal presentation—is it cephalic or breech? ■ What is cephalicpresentation? □ Thefetus is head downwith its buttocksoccupying thefundus (theupper part of theuterus).

Face thewoman’sfeet andplace your hands on thelower part of her abdomen,withyour fingersgently pressing inwardsjustabove herpubicbone (see Figure2.6). Youare feelingfor thepresenting part of thefetus as it engageswith thecervix. If it is hard andround, thepresentationiscephalic; if it is softerand irregular,suspect abreech presentation.

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Study Session2 Assessing theWoman in Labour

Figure 2.6Deep pelvic palpation–thethird manoeuvre helpstodetermine the presentingpart. Both thesebabiesare in cephalicpresentation, but(a) is in the occipito-anteriorposition,whereas (b) is occipito-posterior. (Source: WHO, 2008, as in Figure2.5) Youmay also be able to confirm your findings fromthe second manoeuvre Youlearned directionalterms in about whetherthe baby hasits back towardsyou or not.Ifitdoes, this is anatomy, like anterior and calledthe occipito-anterior position:the occiput is thepoint at theback of posterior, in StudySession 3of thefetal skull,which is lyinginthe anterior position(Figure2.6a), that is, the AntenatalCare Module,Part1. towardsthe front of themother. Ababythatpresents in the occipito-posterior position(Figure2.6b) mayencounter more difficultiesduringdelivery.

Fourth Leopold’smanoeuvre:Pawlick’sgrip Thepurposeofthe fourth manoeuvre(also known as Pawlick’sgrip)isto help determinewhether thefetal head (in acephalic presentation) has descendedintothe mother’spelvisand engaged in thecervix. (Engagement wasexplainedinStudy Session 1.)The extent of engagement is estimated by how many fingers you can grip thefetal head with (Figure2.7). If all five fingers can grip thefetal head just above themother’spubicbone, thehead is not yetengaged. When you can only grip it with thewidth of two fingers,the head is engaged.

Figure 2.7Pawlick’sgrip — thefourthmanoeuvre helps to determinewhether thepresentingparthas engaged. (Source: WHO, 2008,asinFigure2.4)

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2.3.3Measuringfetalheart rate Useafetoscope or stethoscope to listentothe fetalheartrate immediately after acontraction. Listeningtosounds inside theabdomen is called Auscultation is pronounced ‘oss- auscultation. Countthe numberoffetal heartbeats forafull minuteatleast kool-tay-shun’. onceevery 30 minutes duringthe activephase firststage of labour andevery 5minutes duringthe second stage. If thereare fetalheartrateabnormalities (less than 120 or more than 160 beatsper minute, sustainedfor 10 minutes), suspect fetaldistress andrefer urgently to ahealth facility,unless thelabour is progressing fast andthe baby is about to be born. (You will learnabout fetal distress in Study Session4.)

2.3.4Measuringcontractions To assess thefrequencyand durationofcontractions,put your hand overthe mother’sabdomen,around thefundus.You will sense theabdomen startingto tighten andbecome hard.The mother maymake ‘pain’ sounds with the contraction. Count the frequency,i.e.numberofcontractions in 10 minutes, andthe duration (thetimeelapsed duringeach contractioninseconds). You will learnhow to record these measurements,the mother’svital signsand your measurements of thefetal heartrateonachartcalledapartograph in StudySession 4.

2.3.5Vaginalexamination The functions of avaginal examinationare to:

. Determineiftruelabour hasbegun andthe stageithas reached,based on measuring thedilatationofthe cervix . Assess theprogress of labour in termsofthe rate of increase in cervical dilatationand thedescent of thefetus downthe birthcanal . Identify thefetal presentationand position . Detect any moulding of thefetal skull bones(theextenttowhich they overlapunderpressure fromthe birth canal) . Assess thesizeofthe mother’spelvisand itsadequacy forthe passageof thefetus . Checkthe colour of theamniotic fluid.

In this study session, we will onlyfocus on the firstofthese reasonsfor conducting avaginal examination: assessingthe stageoflabour by measuring thedilatationofthe cervix. Allofthe otherfunctions of vaginalexamination will be coveredinlater study sessions.

Assessing cervical dilatation Wash your hands thoroughlywith soap andclean waterfor twofullminutes. Thenput on newsterile gloves. Tell themotherwhatyou aregoing to do. Vaginal examination is done usingtwo gloved fingers. Trytocollect allthe informationyou need before withdrawingfromthe vagina,becauseonceyou have withdrawnyour fingersyou shouldnot put them back in again.

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Study Session 2Assessing theWoman in Labour

■ Canyou explainwhy not? □ Puttingyour examining fingers back into thevaginacouldintroduce infection.

In particularrepeatedvaginal examinationcausesinfection: it shouldnot be donemoreoftenthanevery 4hours, unless thereisajustifiable need (e.g.to confirm second stageoflabour). Thewoman should lie downonher back,bendher legs andopenher knees. Gently swab theexternalgenitalia with sterile gauzedippedinantiseptic solution. Separate thelabia with two fingers on your non-dominanthand(the dominanthandisthe one you write with). Dipyour examining fingers (index andmiddle fingers) into an antisepticlubricatingcream andinsertthemvery gently into thevagina, followingthe directionofthe vagina,upwards and backwards. Askthe womantotakedeep breaths andtry to relax, as this will help to decrease thediscomfortofthe procedure. Cervical dilatation is theincrease in diameter of thecervical opening, estimated in centimeters. Dilatation happens afterthe cervixhas effaced (the 3cmlengthofthe cervixhas been drawnupintothe uterus,asyou sawin Figure1.1 in theprevious study session.)Estimatingthe diameter of the cervical openingtakes practice. Activity 2.1will help you.

Activity 2.1Practice measuringcervical dilatation Allowabout 20 minutes forthisactivity.You will need apiece of hard paper or thin card, aruler,compass (fordrawing circles),penciland scissors. 1Make10circles on thehardpaper,withincreasing diameters: 1cm, 2cm, 3cm, etc. up to 10 cm. 2Leaveawide margin around each circle andcut thecardinto10squares of thesame size. 3Remove theinsideofeach circle with scissors. 4Write thediameterofeach circle on thecard. 5Chooseacircle andplace one or bothyour examining fingers into the hole. Canyou getboth fingers into thehole? Thencoveryour eyes andtry to estimatethe diameter of theholeincentimetres. 6Try to estimatethe diameter of each holewithyour eyes closed.Then check to see if you arecorrect.Try this repeatedly.

■ From Study Session 1, what diameter will thecervixhavereached when thelabour progresses from(a) latent to active firststage?(b) active first stagetosecond stage? □ (a)4cm;(b) 10 cm (fullydilated).

2.3.6Assess theexternal genitaliaand vagina The finalassessmentwewill describe in this study session is to check the mother’sexternalgenitaliaand theinnersurface of hervaginafor warning signs.Look carefully to see if thereis:

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In the Postnatal Care Module you . Any abnormaldischarge (thick yellowish or white andfoul smelling) from willlearn how to put ointment thevagina, or inflamed sores on theexternalgenitalia,which maybedue (tetracycline) in thenewborn’s to aurinarytract infectionorsexuallytransmitted infection. eyes to protectthemfrom infectionacquiredfromthe . Vaginalscarringdue to injury duringaprevious birth,orfromfemale mother’s birth canal. genitalmutilation (circumcision).Thisincreases theriskofafistula occurring duringlabour (a torn opening between thevaginaand other organs). . Is thereswellinginthe vagina,and if thereis, coulditobstruct thepassage of thebaby?

If you see anyofthe signs above,you should referthe mother to ahealth facility,unless thelabour is advanced andthe baby is about to be born. In thenextstudy session, we describe how to carefor thewoman in labour. Summary of StudySession2 In Study Session 2you have learnedthat: 1Prepare your equipmentfor attending alabour anddeliveryinadvance,so you arereadytogoimmediatelyifcalled. 2Makearapid evaluation of thelabouringwoman’svitalsigns (blood pressure, pulse rate andtemperature). 3Followthe principles of woman-friendlycarebyrespecting herbeliefs, wishes andrights, andempoweringher andher chosen caregiversto supportthe labour anddelivery. 4Ask about andrecord thewoman’sname, age, address, gravidityand parity, last menstrual period, when she firstfeltthe fetusmove,and how long sincethe firstcontraction. 5Ask about dangersymptoms: vaginalbleeding, headache, convulsions, breathing difficulties, fever, severeabdominal pain or prematureleakageof amniotic fluid(waters breaking). 6Use abdominal palpationusing thefour Leopold’smanoeuvres to determinethe fetalpresentationand position, andthe extent of engagement of thepresenting part. 7Doyour vaginalexaminationofthe womaninlabour to assess cervical dilatation, fetalpresentationand descent, theconditionofthe fetalskull, andsigns of vaginalinfection, scarringorswelling.

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Study Session2 Assessing theWoman in Labour

Self-Assessment Questions (SAQs)for Study Session 2 Nowthatyou have completedthisstudy session, you can assess how well you have achievedits Learning Outcomesbyansweringthe followingquestions. Writeyour answersinyour Study Diaryand discuss them with your Tutorat thenextStudy SupportMeeting. Youcan checkyour answerswiththe Notes on theSelf-AssessmentQuestions at theend of this Module. SAQ2.1 (tests Learning Outcome2.2) Imaginethatyou arecalledtothe homeofayoung woman.She is in labour.Whatdoyou immediatelydo?

SAQ2.2 (tests Learning Outcome2.5) Youare usingabdominal palpationaspartofyour physical assessment of labour foramother in your care. Fill in theempty boxesinTable 2.1 below.

Table2.1 Leopold’smanoeuvres.

Name of Area of theabdomen to be What youare checking palpation palpated Fundal palpation Hands placed flat on either side of themiddleofthe abdomen; first one andthen theother pushes inwards Facing thefeet, with hands on thelower partofher abdomen, pressinwards with your fingers just aboveher pubic bone Whether thefetal head has engaged in thecervix-if you can only grip it with two finger — widthabovethe mother’s pubic bone,the head is engaged

SAQ2.3 (tests Learning Outcomes 2.3and 2.4) Makeda hascometoyour Health Post.You have done your initialrapid assessment,and thereisnoneedfor instantreferral. Youare now taking herhistory.How do you go about doing this andwhatinformation do you need to check with her?

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SAQ2.4 (testsLearning Outcomes2.6 and2.7) Younow have Makeda’shistory andare carryingout aphysical examination. What do you do firstand what areyou looking for?

SAQ2.5 (tests Learning Outcome2.1) Whichofthe following statements is false?Ineach case, say what is incorrect. (a)Atemperatureof39°Cindicates a high grade fever. (b)The gestational age is how oldthe mother is whenshe becomes pregnant. (c) Parity is thenumberofbabiesdelivered aliveafter28weeksof gestation. (d) Gravidity is thetotal numberofprevious pregnanciesregardlessofthe outcome. (e)The threepointstolook out forwheninspectingawomen’sabdomen in labour are size, shape and scars. (f) Fundalpalpation is thedrum-like beat you sometimeshear when listeningtothe baby’sheartwith afetoscope. (g) Breech presentation indicates potential complications duringdelivery. (h) Ausculation is thesound mothersinlabour sometimes make.

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StudySession 3Careofthe WomaninLabour

Study Session 3 Careofthe WomaninLabour Introduction In theprevious sessionofthisModuleyou were introduced to thedefinitions, signs andsymptoms, andstagesofnormallabour.Labour andbirthofthe baby is aunique experience in thelifeofany family andone of special personalsignificance forthe mother.Your constant companionshipand skilful management of thebirth can contributemuchtothe harmonious atmosphere andfeelingoftrust duringlabour anddelivery, which favoursagood outcome.Caringfor thewoman in labour demands sensitivityfromyou as the birth attendant,and awareness of themother’sperception of herlabour andof herneeds, as they relate to herexperience. In this session you will learnabout ways that you can supportawomanall through thebirth of thebaby. Youwill also be introduced to thebasic principles of maternal andfetal monitoringduringlabour,and learnabout standard hygienefor infectionpreventionand theequipmentyou need to preparefor adeliveryathomeorinahealth facility. Learning Outcomesfor StudySession3 When you have studied this session, youshouldbeableto: 3.1Define anduse correctly allofthe keyterms printedinbold. (SAQ 3.7) 3.2Assess theindividualneedsofthe woman in labour andprovide care accordingly. (SAQs 3.1and 3.7) 3.3Provide emotionaland psychological supportfor thewoman in labour. (SAQ 3.1) 3.4Perform propermaternaland fetalmonitoringand recordinginthe first andsecond stages of labour.(SAQs3.2,3.3,3.5 and3.6) 3.5Prepare delivery equipmentfor anormalbirth. (SAQ 3.4) 3.6Adopt standard hygieneprecautions andinfectionpreventionin deliverycare. (SAQs3.4 and3.7)

3.1Assessingthe needsofthe womaninlabour Everywoman needsadifferent kind of support.But allwomen need kindness, respect andattention. Watchand listentoher to see how sheisfeeling. Encourageher,soshe canfeel strong andconfident in labour.Helpher relax andwelcome herlabour.

3.1.1Support thelabour When you supportthe mother’slabour,you help herrelax instead of fighting againstit(Figure3.1). Although labour supportwill not make labour painless, it can make labour easier, shorterand safer.You will learnmanywaysto supportthe labour in this study session, including by physical actions (touch, sounds,etc.) andgivingpsychological andemotionalsupport. Figure 3.1Helpthe womanin labour to relax.

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3.1.2Guard the labour When you guard thelabour,you protect it frominterference. Keep rude andunkind peopleaway. Themothershouldnot have to worry about family problems.Sometimes even supportiveand loving friends can interfere with thelabour.Atsomebirths, thebest waytohelpistoask everyone to leavethe room so that themothercan labour without being distracted. Some peoplebelieve that more drugs,toolsand examinationofthe mother Do not useunnecessary drugs or will make thebirth safer.But that is usuallynot true — they can make the procedures!Donot give the birth harder or cause problems. Injections or pillsthatare supposed to hurry mother drugstohurry thelabour thebirth can make labour more painful, andcan kill boththe mother andthe —theyadd uselessrisks. baby.

3.1.3Position andmobility Severalconsiderations govern thechoice of positionduringthe firststage of labour.Ofthese themostimportant is that of maternal preference — how sheprefers to give birth.But some womenneed your encouragementtotry differentpositions. Helpthe woman move duringlabour.She can squat,sit, kneel or take other positions (Figure3.2). Allofthese positions aregood. Changing positions helpsthe cervixopenmoreevenly.

Figure3.2 Changing positioninthe firststage helpsthe mother to cope better with herlabour.

3.1.4Helping themother to manage her contractions In early labour shemay be able to sleep.Manywomen feel very tired when theircontractions arestrong. They mayfear they will not have thestrengthto pushthe baby out. But feelingtiredisthe body’sway of making themother rest andrelax.Ifeverythingisall right,she will have thestrengthtogive birth whenthe timecomes.

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StudySession 3Careofthe WomaninLabour

To saveher strength, themothershouldrestbetween contractions,evenwhen labour firstbegins. Thismeansthatwhenshe is not having acontraction, she shouldlet herbody relax, take deep breaths,and sometimessit or liedown.

3.1.5Touch Labour can be more difficult when thewoman is afraid or tense. Reassuring thewoman that thepainshe hasisnormalcan help lessen that fear.Touchcan help awoman in labour,but find out what kind of touchshe wants. Here are Do not massagethe belly.Itwill someexamplesoftouchthatwomen oftenlike: notspeed labour andcan cause . A firm,still hand pressingonthe lowerback duringcontractions theplacentatoseparatetoo soon.(Youalready learned about . Massagebetween contractions,especially on thefeet or back prematureseparation of the . Hot or cold cloths on thelower back or belly(Figure3.3). If themotheris placenta andlatepregnancy sweating, acool wet clothonthe forehead usuallyfeelsgood. bleedinginStudy Session21of the AntenatalCare Module,Part2. It canalsohappentoo soon duringlabour.)

Figure 3.3Awarm wet clothoragentle massageonthe lower back can relieve labour pain.

3.1.6Sounds Making sounds in labour can help women to allowthe birthcanal to open. Notall womenwanttomakenoise, but encouragewomen to try.Low sounds, likegrowlinganimalnoisesorhumming, can be very helpful. Somewomen chantorsing. The womancan be as loud as she wantstobe. Some noises can make womenfeelmoretense.High-pitchedsounds and screamsusually do not help.Ifshe startstomakehigh, tensesounds,ask her to make lowsounds (Figure3.4). Figure 3.4You canmakelow sounds yourselftoguide her. 3.1.7Breathing Theway awoman breathescan have astrong effect on how herlabour will feel.Inthe firststage of labour,there aremanykinds of breathing that may make labour easier.Try these ways of breathing yourselfand show themother how to do it.Helpher to choosewhich one worksbest to minimize thepain. Encouragemothers to try differentwaysofbreathing throughout labour:

. Slow blowing.Ask thewoman to take along, slow breath. To breathe out sheshouldmakeakiss with herlipsand slowly blow.Breathing in throughthe nosecan help herbreathe slowly. . Heebreathing.The womantakes aslowdeep breathand then blowsout short, quick breaths while shemakes soft ‘hee, hee’ sounds. . Panting.The woman takesquick,shallow breaths. . Strong blowing.The womanblows hard andfast.

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3.1.8Drinkingfluids during labour Awoman in labour uses up thewater in herbody quickly andshe also uses up alot of energy.Duringthe firststage of labour,she shoulddrink at least 1 cupevery hour of ahighcalorie fluidsuchastea, soft drinks,soup, or fruit juice. If shedoesnot drinkenough, shemay getdehydrated (not enough water in thebody).Thiscan make herlabour much longerand harder. Dehydrationcan also make awoman feel exhausted. Signsofdehydrationinclude:

. Drylips . Sunkeneyes . Loss of stretchiness of skin . Mild fever(up to 38°C) . Fast, deep breathing (morethan20breaths aminute) . Fast,weak pulse (morethan100 beatsaminute) . Baby’sheartbeat faster than 160 beatsaminute.

3.1.9Bladder care Encourage thewoman to urinateatleast onceevery 2hours(Figure3.5a).If herbladderisfull, hercontractions mayget weaker andher labour longer. A full bladdercan also cause pain,problemswithpushing out theplacenta,and bleedingafterchildbirth.Remindthe mother to urinate – she maynot remember.

Figure3.5 (a)Encourage hertourinate at leastevery 2hours. (b)Afullbladder can prolonglabourand cause pain.

To check if thebladderisfull, feel themother’slower belly.Afull bladder feelslikeaplastic bagfullofwater.Whenthe bladderisveryfull, you can seethe shapeofitunderthe mother’sskin(Figure3.5b).Donot waituntil herbladdergetsthisbig.

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StudySession 3Careofthe WomaninLabour

If themother’sbladder is full, shemusturinate.Ifshe cannot walk, try puttingapanorextra padding underher bottomand lether urinatewhere she is.Itmay help hertobegin to urinateifyou dipher hand in warm water. ■ Whydoyou thinkafull bladdercan interfere with thenormalprogress of labour?(Thinkback to whatyou know from theprevious twostudy sessions.) □ Duringthe firstand second stageoflabour,afullbladder interferes with thenormaluterinecontractionand inhibits thebaby’shead fromentering thepelvicbrim.

As you will see in Study Session 6, duringthe third stageoflabour it can also delaydeliveryofthe placenta,which increases theriskofpost-partum haemorrhage(Study Session 11).

3.1.10 Emotionaland psychological support forthe woman in labour Emotionaland psychological supportfor thewoman in labour consists of helpingthe mother to feel in controlofherself, to feel acceptedwhateverher reactions andbehaviour maybeand to complete herlabour feelingthatshe is asuccess, even if theoutcome wasnot what shehopedfor.There areseveral ways you can help hertoachieve this.

Companion in labour Youdonot have to workalone to give supporttothe mother duringlabour. Thereisevidencethatthe presence of constant supportfromthe woman’s husband, closerelatives or friends in labour favoursgood progress. There is no rule aboutwho shouldsupport heriftheycareabout herand arewillingto help her. Most important,theyshouldbepeoplethe mother wantstohaveat thebirth.

Good communication Keep thewoman informed about theprogress of labour.The womanhas the right to know about theprogress of labour andthe conditionofherselfand thebaby. Counsel thewoman andher supportperson about ongoing caresuch as physical care, comfortand emotionalsupport. Counsel thewoman (and hersupportperson)whattoexpect early in labour, before contractions become toopainful,and laterwhencontractions become stronger(wherefeasible).Explainabout thecontractions getting strongerand closer together as she gets closer to thetimetodeliver baby.Explainwhatto expect duringthe delivery.Reassurethe woman that you will be with her throughout theprocess of giving birth. 3.2Maternal andfetal monitoring duringlabour Propermaternaland fetalmonitoringduringlabour is very important as this is theonlyway to assess theprogress of labour andtoidentifydeviations from normal.

3.2.1Assessingthe progress of labour Laboursare alldifferent. Someare fast,someare slow.Thisisnormal. But in ahealthylabour,there shouldbeprogress. Progress meansthatlabourshould

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be gettingstrongerand thecervixshouldbeopening. Box 3.1(on thenext page)summarizes themainfeatures of alabour that is progressing normally.

Box3.1 Gradualprogress of normal labour

. Contractions getlonger, strongerand closer together. . The uterus feelsharderwhenyou touchitduringacontraction (Figure3.6). . Amount of ‘show’ increases. Figure 3.6Reassure themother . The bagofwatersbreaks. that contractions getstronger . The motherburps,sweatsand vomits,orher legs shake. because thelabourisgoing well. . The motherfeelsshe wantstopushdown through herlower abdomen.

In Study Session 4you will learnhow to useachartcalledapartograph to assess theprogress of labour andrecord your observations andmeasurements accurately.But firstweare going to describewhathappens in thewoman’s body to introduceyou to theimportant features that need to be assessed duringlabour.

3.2.2Uterinecontractions The frequency, lengthand strengthofthe contractions should be monitored andrecorded everyhalfhour. Frequency indicates thenumberofcontractions thewoman hasinten minutes. Countthem. Length refers to theamount of time each contractionlasts. Measure thetimeonyour watch (if youhave one). Strength indicates theseverityofpainexperienced duringeach contraction; ask themothertotellyou about this. In normallabour,asthe labour progresses thecontractions become more frequent,theylast longer, andtheyfeel strongertothe mother (morepainful).

3.2.3Dilatation of the cervix The progress of labour is usually assessed by thedegreeofdilatationofthe cervix. Cervicaldilatationisassessed by doing avaginal examinationevery four hours andusing your fingerstoestimatehow wide thecervixhas opened. (Wedescribed how to do this in Study Session 2).Innormallabour the averageratefor cervical dilatationisone centimetre everyhour (1 cm per hour).

3.2.4Descent of thepresenting part Youmeasure descentofthe presenting part of thefetus by abdominal palpationinrelationtothe pelvic brim.The descentofthe presenting part can also be detected by vaginalexamination. Thisshouldbeassessed and recorded everytwo hoursduringthe labour.

3.2.5Dischargesfromthe vagina Show is thenamegiven to theblood-stainedmucus seen in early labour. Towardsthe endofthe firststage atrickle of blood mayappear.Amniotic Mechonium is pronounced ‘mee- fluidmay be seen tricklingfromthe vagina afterthe membraneshave koh-nee-um’. ruptured.The presence of mechonium (dark-green coloured discharge,which

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StudySession 3Careofthe WomaninLabour

is the firststool of thebaby) in theamniotic fluidsuggestsfetal distress as it doesnot normallypass stool until afterthe birth.Later in this Module, you will learnwhatactions to take if thefetus or themotherisendangered.

3.2.6Fetalcondition Thefetal conditionduringlabour can be assessed by obtaining information about thefetal heartrate(thenumberofbeatsper minute) andits patternin relationtothe mother’scontractions.Check thefetal heartrateevery 30 minutes by listening(auscultation),which you learnedtodoinStudy Session 11 of the Antenatal Care Moduleusing afetoscope or stethoscope. ■ Do you remember whatisthe normalrange of thefetal heartrate? □ Normalfetal heartraterangesfrom100–180 beatsper minute.

3.2.7Maternalcondition Count thewoman’spulse rate every30minutes andmeasure herblood pressure andtemperature everyfour hours, as you learnedhow to do in Study Session 9ofthe Antenatal Care Module. Additionally,documentonyour labour monitoring charthow oftenthe mother eats, drinks andurinates.

Blood pressure goes down If herdiastolic blood pressure (the bottomnumber) suddenlydrops 15 points or more,thisisadangerous warningsign. Thisusually meansthatthe mother If thewoman’s bloodpressure is bleedingheavily.Ifyou do not see anybleedingfromher vagina,her suddenlydrops,she needstogo placenta mayhavedetached andshe might have bleedinginside(intrapartum to thehospitalimmediately! haemorrhage).

Blood pressure goes up Blood pressure of 140/90 mmHgorhigherisawarningsign. Thewoman may have pre-eclampsia,which can cause convulsions(eclampsia), detached placenta,bleedinginthe brain, or aseverehaemorrhage. The baby maydie andthe mother maydie as well. Youlearnedall about eclampsia andpre- eclampsia in Study Session 19 of the Antenatal Care Module, Part 2. Blood pressure andall theother measurements outlinedabove arerecorded on the partograph, as you will learninthe next studysession. Next we turn to theequipmentyou will need to preparefor thedelivery. 3.3Preparingtoconduct adelivery When thewoman is approachingthe second stageoflabour youshould preparefor thedeliveryofthe baby.

3.3.1Signs of secondstagelabour . Contractions becomesstrongerand more expulsive. . Dilation and ‘gapping’ of theanus (theanalsphincteropens duringthe contraction). . Appearanceofthe presenting part of thefetus underthe vulva. . Fulldilation of thecervixtoadiameter of 10 cm.

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3.3.2Preparingthe birthing place Oncethe onset of thesecond stagehas been confirmed you shouldmake preliminarypreparations forthe delivery. Theroom shouldbewarmand well litsothatthe perineumand vulva can be easily observed. Aclean surface shouldbepreparedtoreceive thebaby(Figure3.7)using theinfectioncontrol procedures describedinSection3.5.Spread waterproof covers to protect the bedand the floor.Makesurethere is awarmcoatand clothesfor thebaby.

Figure3.7 Supplies to conductthe deliveryinclude making asafeand clean placefor themothertogivebirth.

3.3.3Equipment and suppliesneeded to conductdelivery Youshould always have allthe suppliesand toolsyou will need forthe birth (Box 3.2and Figure 3.8) readyatthe Health Postand youshouldtakethem to thewoman’shomeifthe deliveryisgoing to happenthere.She maybe able to provide some of thesimplest things,likesoapand clean cloths,but you shouldalwaysbefully prepared.Use Box3.2 as achecklist — tickeach item as you pack it to go to abirth.

Box3.2 Checklistofbirthing equipment

. Clean water, soap andhandtowel. . Apron,goggle, face mask andgown. . Sterile gloves. . Sterile or very cleannew string to tiethe cord. . Newrazorblade or sterilized scissors. . Twosterileclamp forceps, forclampingthe umbilical cord before you cutit. . Mucustraporsuctionbulbtosuckmucus from thebaby’sairways(if needed). . Sterile gauze, cottonswaband sanitarypad forthe mother. . Twodry,clean baby towels andtwo drapes. . Bloodpressure cuff andstethoscope. . Antisepticsolutionfor cleaningthe mother’sperineumand genital area.

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StudySession 3Careofthe WomaninLabour

. 10 IU (internationalunits)ofthe injectable drug calledoxytocin,or 600 mg(microgram)tablets of misoprostol. These drugs areused for thepreventionofpost-partumhaemorrhage. Oxytocinisthe preferred drug forthispurpose, but if you don’thaveitthenmisoprostol can be used.(Youwilllearnall about this in Study Session 6.) . Tetracyclineeye ointment (antibioticeye ointment used forthe preventionofeye infectioninthe newborn; you will learnabout this in thenextModule, on Postnatal Care). . Three buckets or smallbowlseach with 0.5% chlorinesolution, or soap solution andclean water. (Toprepare 0.5% chlorinesolutionyou can usethe locally availableBerekina. Read theconcentrationfrom thebottle — if it is 5% you can make asolutionof0.5%strengthby mixing one cupofBerekinawith nine cups of clean water.) . Plastic bowl to receive theplacenta.

Figure 3.8Equipment needed for attendinganormal birth.

3.4Preventing infectionduringdelivery Infectionmakes peoplesickand can even kill them.Itisone of themost common causes of deathafterchildbirth. Most of your actions duringlabour anddeliverycan be safe onlyifyou areabletofollowthe basicrules to preventinfection, as outlined in this section. Youcan summarise these rulesas the ‘threecleans’:clean hands,clean surface (for thedelivery) andclean

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equipment. Youalreadyknow you must thoroughlyclean theplace wherethe baby will be born. In addition, you shouldfollowother standard hygiene measures as described below.

3.4.1Handwashing ■ Howcan you preventinfectionbywashing your hands? □ Washingyour hands is one of themostimportant things you candoto preventinfection. It prevents you from spreadinggerms to another person, andithelps protect you fromgerms,too.

If you can do nothing else to preventinfection, you must wash your hands (see Figure3.9 andBox 3.3).

Figure3.9 Howtodoa2-minutehandwash.

Box3.3 Always do a2-minutehandwash

Before you Afteryou Touchthe mother’svaginaClean up afterthe birth Do avaginalorpelvicexaminationTouch any bloodorother body fluids Deliver thebaby Urinateorpass stool Checkthe newborn

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StudySession 3Careofthe WomaninLabour

Alcohol andglycerine hand cleaner Youcan make asimplehandcleaner (rub) to useifyou do not have waterto wash your hands.Whenused correctly,thiscleaner will kill most of thegerms on your hands. Mix 2ml(millilitres) of glycerinewith100 ml of ethyl or isopropyl alcohol (strength60% to 90%)orany alcohol used forskincleaningbeforean injection. To clean your hands,rub about 5ml(1teaspoon)ofthe hand cleanerinto yourhands,rub them together thoroughlyand make sure to clean between your fingersand underyour nails.Keep rubbing until your hands aredry.Do not rinse your hands or wipe them with acloth. Wash yourhands with soap andwater afterevery 5–10 uses of thehand cleaner solutiontoreducethe build-upofhandsofteners. Do not useahand rubifyour hands arecontaminated with body fluids or are visiblydirty;instead wash your hands with soap andwater.

3.4.2Wearprotective clothing

Gloves Thereare differentkinds of glovesfor differentpurposes. Utilityorheavy dutyglovesare used fortouching dirty instruments, linensand waste; doing housekeeping; andcleaningcontaminated surfaces. Sterile,single- useclean examinationglovesare used when you will come into contact with unbrokenmucus membranes(when youare doing avaginal examination),orwhenyou areatriskofexposuretoblood or otherbody fluids.Sterile (germ-free) surgical glovesare used forall procedures having contact with tissues underthe skin or with thebloodstream. Wear gloveswheneveryou touchthe mother’sgenitals, or anyblood or body fluid. Afteruse, discard theglovessafely.

Face mask,eye protection andapron or gown Aface mask,eye protectionand averyclean apronorgownare wornfor sortingand cleaninginstrumentsand linens, attending avaginal delivery, and cuttingthe umbilical cord.Eye protectioncan includegoggles, face shields or plainglasses.

Feet protection Feet protectionshouldbeaclosed shoe or boot made from rubberorleather. If leather, coverthe shoeswith plastic bags.Shoesorbootsprotect the wearer frominjurybysharp or heavyitems,and theplastic bags protect you fromblood or otherbody fluids on the floor.

3.4.3Clean and high-level disinfect your tools Before andafterthe baby hasbeen born, decontaminate (remove germs) from allinstrumentswith a0.5%chlorinesolution. First, soak them for10minutes, then wash with asoapy solutionand lastly with clean water. Youcan usea smallbrush to scrub them clean.After decontaminationmakethe instruments sterile (germ-free) by usingasterilizer machine, or boil them for20minutes. (If you have access to asterilizer machine, followthe instructions carefully.)

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3.4.4Clean surfacefor delivery and safe disposalofbirth wastes Make sure theareawhere themotherwill give birth is scrubbedclean,and that allcloths, towels or drapes areclean anddry — particularly thosethe mother liesonand theclothsyou wrap around thenewbornbabytoclean it. Put allwastes afterthe birth (blood, contaminated cloths,membranes andthe placenta)inaleak-proof containersuchasatinwith atight-fittinglid,and disposeofitsafelyinaproperplace where it is unlikelytobefound.Itis usuallyrecommendedtoburywastes in thegroundorburnthem. It is very important to preventother peopleinthe community fromgetting sick fromthe germsleftonthese wastes. Be careful with needles. When you have finished usingadisposable syringe, put theneedle into thesafetybox. Do notleaveneedleslying around. 3.5Inconclusion Now that you know how to supportthe woman in labour,whatequipmentis needed andhow to disposeofwastes, we can progress to teachingyou about thedeliveryitself. In thenextstudy sessionyou will learnhow to usethe partograph. Summary of StudySession3 In Study Session 3you have learnedthat: 1All womenduringlabour anddeliveryneed individualized care. Pregnant women shouldbeencouraged to seek supportfromaskilledbirth attendant. 2Provide physical andpsychological supporttothe woman in labour and thetrusted supportperson whoiswith her. 3Assist hertoadopt differentpositions,try differentbreathing patterns,be massaged on herback andmakelow sounds duringlabour,asthishelps hertorelieve pain andmanagethe contractions. 4Encourageher to take one cupoffluidatleast everyhour andassist herto emptyher bladderatleast onceevery twohours. 5Keep herinformedabout theprogress of herlabour,soshe remains relaxedand confident. 6Monitor fetalcondition by checkingthe fetalheartbeat every30minutes; it shouldbewithinthe normalrange. 7Monitor maternal condition by measuring herblood pressure and temperatureevery 4hours,and herpulse rate every30minutes. 8Assess theprogress of labour by checkinguterinecontractions (length, strengthand frequency) every30minutes, descentofthe head everytwo hoursand cervical dilatation everyfour hours. 9Prepare theequipmentyou will need forthe birth,including protective clothing foryourself; scrub or sterilise everything that will come into contact with tissueorbody fluids. 10 Hand washing with soap andclean wateristhe most important way to reducethe riskofinfectionbeing passed to themotherand baby during labour anddelivery.

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StudySession 3Careofthe WomaninLabour

Self-Assessment Questions (SAQs)for Study Session 3 Nowthatyou have completedthisstudy session, you can assess how well you have achievedits Learning Outcomesbyansweringthe questions belowCase Study 3.1. Writeyour answersinyour Study Diaryand discuss them with yourTutor at thenextStudy SupportMeeting. Youcan check your answers with theNotes on theSelf-AssessmentQuestions at theend of this Module. Firstread Case Study 3.1and then answer thequestions that followit.

Case Study3.1 WoizeroAlmaz WoizeroAlmaz is afulltermpregnant woman whocametothe Health Postwith pushing down pain andblood stainedvaginal discharge which began five hoursearlier. Thisisher firstpregnancyand sheisvery anxious about it. On examinationyou found sheisinfirststage of labour.

SAQ3.1 (tests Learning Outcomes 3.2and 3.3) What supportcan you give hertoalleviateWoizeroAlmaz’sfear about hercondition?

SAQ3.2 (tests Learning Outcome3.4) What assessment toolsand meanswillyou usetoassess theprogress of Almaz’slabour?How will these assessmentshelpyou?

SAQ3.3 (tests Learning Outcomes 3.5and 3.6) During the firststage of labour,whattype of food will you recommend to her? Andhow oftenwillyou trytoget hertoeat something?

SAQ3.4 (tests Learning Outcomes 3.5and 3.6) When youare providing caretoAlmaz duringher labour,how do you preventinfectionbeing transmitted to herand herbaby?

SAQ3.5 (tests LearningOutcome3.4) What will you assess (and how often) to check whetherAlmaz’slabour is progressing normally?

SAQ3.6 (tests Learning Outcome3.4) What wouldindicatethatAlmaz’sbabyisshowing signs of fetal distress?

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SAQ3.7 (testsLearning Outcomes3.1,3.2 and3.6) Whichofthe following statements is false?Ineach case explainwhatis incorrect. AMaternalpreferencemeansrespecting how themotherwants to give birth. BInthe firststage of labour themothershouldnot drinkanything in case shevomits. CThe frequencyofcontractions refers to how painfulthe contractions become. DMeconium discharging fromthe vagina is asignoffetal distress. EThe ‘threecleans’ areclean hands, clean surface forthe deliveryand clean equipment.

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Study Session4 Usingthe Partograph

Study Session 4Using thePartograph Introduction Among the five majorcausesofmaternalmortality in developing countries likeEthiopia(hypertension, haemorrhage, infection, obstructed labour and unsafeabortion),the middlethree (haemorrhage, infection, obstructed labour) arehighlycorrelatedwith prolonged labour.Tobespecific, postpartum haemorrhageand postpartumsepsis(infection) areverycommonwhenthe labour gets prolongedbeyond 18-24 hours. Obstructedlabour is thedirect outcome of abnormally prolongedlabour;you will learnabout this in detail in Study Session 9ofthisModule. To avoidsuchcomplications,achartcalleda partograph will help you to identify theabnormalprogress of alabour that is prolongedand which maybeobstructed.Itwill also alertyou to signs of fetal distress. In this study session, you will learnabout theprinciples of usingthe partograph, theinterpretationofwhatittells you aboutthe labour you are supervising, andwhatactions you shouldtakewhenthe recordings you make on thepartographdeviate fromthe normalrange.Whenthe labour is progressing well, therecord on thepartographreassures you andthe mother that she andher baby areingood health. Learning Outcomesfor StudySession4 When you have studied this session, youshouldbeableto: 4.1Define anduse correctly allofthe keyterms printedinbold.(SAQs 4.1and 4.3) 4.2Describethe significance andthe applications of thepartographin labour progress monitoring. (SAQs 4.1and 4.2) 4.3Describethe componentsofapartographand statethe correct time intervalsfor recordingyourobservationsand measurements.(SAQs4.1 and4.3) 4.4Describethe indicatorsinapartographthatshowgoodprogress of labour,and signs of fetaland maternal wellbeing. (SAQ 4.3) 4.5Identify theindicatorsinapartographfor immediatereferraltoa hospitalduringthe labour.(SAQ 4.3)

4.1The valueofusingthe partograph The partograph is agraphical presentationofthe progress of labour,and of fetaland maternal conditionduringlabour.Itisthe best tool to help you detect whether labour is progressing normally or abnormally,and to warn you as soonaspossibleifthere aresigns of fetaldistress or if themother’svital signs deviatefromthe normalrange.Research studies have shownthat maternal andfetal complications due to prolongedlabour wereless common when theprogress of labourwas monitoredbythe birth attendant usinga partograph. Forthisreason,you should always useapartographwhile attending awoman in labour,either at herhomeorinthe HealthPost.

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In thestudy sessions in this Module, you have learned(or will learn) the majorreasonswhy you need to monitoralabouringmothersocarefully. Rememberthatalabour that is progressing well requiresyourhelp less than a labour that is progressing abnormally.Documenting your findings on the partographduringthe labour enablesyou to know quickly if somethingis going wrong, andwhether you shouldrefer themothertothe nearest health centreorhospitalfor furtherevaluationand intervention. 4.2Finding your wayaround of the partograph The partographisactuallyyour record chartfor thelabouringmother (Figure4.1). It hasanidentificationsectionatthe topwhere you write the name andage of themother, her ‘gravida’ and ‘para’ status,her Health Post or hospitalregistrationnumber, thedateand time when you firstattendedher forthe delivery, andthe timethe fetalmembranes ruptured (her ‘waters broke’). ■ What is thedifferencebetween awoman who is amultigravidaand one whoisamultipara? □ A multigravida is awoman who hasbeen pregnant at least oncebefore thecurrent pregnancy. A multipara is awoman who haspreviously givenbirthtolivebabiesatleast twicebeforenow.

On theback of thepartograph(if you arenot usinganotherchart), you can also record some significantfacts, such as thewoman’spast obstetrichistory, past andpresent medical history, any findings from aphysical examination andany interventions you initiate (including medications,deliverynotes and referral).

4.2.1The graph sectionsofthe partograph The graphsections of thepartographare where you record keyfeatures of the fetusorthe mother in differentareas of thechart. We will describe each feature, startingfromthe topofFigure4.1 andtravellingdown the partograph.

. Immediatelybelow thepatient’sidentificationdetails,you record the Fetal HeartRate initiallyand then every30minutes. The scale forfetal heart rate covers therange from 80 to 200beatsper minute. . Belowthe fetalheartrate, thereare tworows closetogether.The firstof these is labelled Liquor – whichisthe medical term forthe amniotic fluid; if thefetal membraneshaveruptured,you shouldrecordthe colour of the fluidinitiallyand every4hours. . The rowbelow ‘Liquor’ is labelled Moulding;thisisthe extent to which thebonesofthe fetalskullare overlapping each otherasthe baby’shead is forced down thebirth canal;you shouldassessthe degree of moulding initially andevery 4hours

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Study Session4 Usingthe Partograph

Figure 4.1The partograph showingwhere to enterthe patient’sidentification detailsatthe topand thegraphic componentbelow.

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. Below ‘Moulding’ thereisanareaofthe partographlabelled Cervix (cm) (PlotX)forrecording cervical dilatation,i.e.the diameter of themother’s cervixincentimetres. Thisareaofthe partographisalsowhere you record DescentofHead(Plot O),which is how fardown thebirth canal the baby’shead hasprogressed. Yourecord these measurements as either Xor O, initiallyand every4hours. There aretwo rows at thebottomofthis section of thepartographtowrite thenumberofhourssince you began monitoringthe labour andthe timeonthe clock. . The next section of thepartographisfor recording Contractionsper 10 mins (minutes)initially andevery 30 minutes. . Belowthatare tworows forrecordingadministrationofOxytocin during labour andthe amount given. (You areNOT supposed to do this – it is for adoctortodecide!However, youwill be trained to give oxytocin after the baby hasbeen bornifthere is ariskofpostpartumhaemorrhage.) Youlearned about giving IV . The next area is labelled Drugsgiven and IV fluids giventothe mother. (intravenous) fluidtherapy to . Near thebottomofthe partographiswhere you record themother’s vital womenwho arehaemorrhaging in StudySession 22 of the signs;the chartislabelled Pulse and BP (blood pressure) with apossible ° AntenatalCare Module. range from60to180. Below that you record themother’s Temp C (temperature). . At theverybottomyou record thecharacteristicsofthe mother’s Urine: protein,acetone, volume.You learnedhow to useurinedipsticks to test forthe presenceofaprotein(albumin)duringantenatal care.

■ What can you tell from thecolour of theamniotic fluid? □ If it hasfresh bright redblood in it,thisisawarningsignthatthe mother maybehaemorrhaginginternally;ifithas dark green meconium (the baby’s firststool)init, this is asignoffetal distress.

4.2.2The Alertand Action lines In thesectionfor cervical dilatation andfetal head descent, thereare two diagonal lines labelled Alert and Action.The Alertlinestartsat4cm of cervical dilatationand it travels diagonally upwards to thepoint of expected full dilatation(10 cm)atthe rate of 1cmper hour.The Actionlineisparallel to theAlert line, and4hourstothe right of theAlert line. These twolines are designedtowarnyou to take actionquickly if thelabour is not progressing normally.

Youshouldrefer thewoman to ahealth centre or hospitalifthe marks recordingcervical dilatation crossover theAlert line, i.e. indicatingthat cervical dilationisproceedingtoo slowly.(The Action lineisfor making decisions at health-facilitylevel.)

4.3Recording andinterpretingthe progress of labour As youlearnedinStudy Session 1ofthisModule, anormally progressing labour is characterized by at least 1cmper hour cervical dilatation, oncethe labour hasentered the active firststage of labour.

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StudySession 4Using thePartograph

Anotherimportant point is that (unless youdetect anymaternalorfetal problems),every 30 minutes you will be countingfetal heartbeatsfor one full minute, anduterinecontractions for10minutes. Youshoulddoadigitalvaginal examinationinitially to assess:

. The extent of cervical effacement (look back at Figure1.1)and cervical dilatation . The presenting part of thefetus . The status of thefetal membranes(intact or ruptured)and amniotic fluid . The relativesizeofthe mother’spelvistocheck if thebrim is wide enough forthe baby to pass through.

Thereafter, in every4hoursyou shouldcheck thechange in:

. Cervical dilatation . Developmentofcervical oedema (aninitiallythincervixmay become thickerifthe woman starts to pushtoo early,orifthe labour is too prolongedwith minimalchange in cervical dilatation) . Position(of thefetus,ifyou areabletoidentifyit) . Fetalhead descent . Developmentofmouldingand caput (Study Session 2inthisModule) . Amniotic fluidcolour (if thefetal membraneshavealreadyruptured).

Youshouldrecord each of your findings on thepartographatthe stated time intervalsaslabour,progresses. The graphs you plot will show you whether everything is going wellorone or more of themeasurements is acause for concern. When you record the findingsonthe partograph, make sure that:

. Youuse one partographformper each labouringmother. (Occasionally, you maymakeadiagnosis of true labour andstart recordingonthe partograph, but then you realiselater that it wasactuallyafalse labour. Youmay decide to send thewoman homeoradvise hertocontinue her normaldaily activities. When truelabour is finally established, useanew partographand not thepreviously startedone). . Youstart recordingonthe partographwhenthe labour is in active first stage(cervicaldilation of 4cmand above). . Your recordings shouldbeclearly visiblesothatanybody whoknows about thepartographcan understand andinterpret themarks you have made.

If you have to referthe mother to ahigherlevel health facility,you should sendthe partographwith your referral noteand record your interpretation of thepartographinthe note. ■ Without looking back overthe previous sections,quickly write down the partographmeasurements that you must make in ordertomonitorthe progress of labour. □ Compare your list with thepartographinFigure4.1.Ifyou areatall uncertain about anyofthe measurements,thenre-read Sections 4.2and 4.3.

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4.4Cervical dilatation As youlearnedinStudy Session 1ofthisModule, the firststage of labour is dividedintothe latent andthe activephases. The latent phase at theonset of labour lastsuntil cervical dilatation is 4cmand is accompaniedbyeffacement of thecervix(as shown in Figure1.1 previously). Thelatentphase maylast up to 8hours, althoughitisusually completedmorequickly than this. Although regular assessmentsofmaternaland fetalwellbeing andarecord of all findings shouldbemade, these are not plottedonthe partograph until labour enters theactivephase. Vaginalexaminations arecarried out approximately every4hoursfromthis point until thebabyisborn. The active phase of the firststage of labour startswhenthe cervixis4cm dilatedand it is completedatfulldilatation, i.e. 10 cm.Progress in cervical dilatationduringthe activephase is at least 1cmper hour (oftenquicker in multigravida mothers). In thecervical dilatationsectionofthe partograph, down theleftside, arethe numbers 0–10.Each number/square represents 1cmdilatation. Along the bottomofthissectionare 24 squares, each representing1hour.The dilatation of thecervixisestimated by vaginalexamination andrecorded on the partographwith an Xmarkevery 4hours. Cervical dilatationinmultipara womenmay need to be checked more frequently than every4hoursin advanced labour,because theirprogress is likely to be faster than that of women who aregivingbirth forthe firsttime. ■ In theexample in Figure 4.2, what change in cervical dilatation hasbeen recorded overwhattimeperiod?

Figure4.2 An exampleofhow to record cervical dilatation (markedbyXs) and fetalhead descent(marked by 0s)using apartograph. □ Thecervical dilatation was about 5cmat1hour afterthe monitoringof this labour began; afteranother four hours, themother’scervixwas fully dilatedat10cm.

If progress of labourissatisfactory, therecordingofcervical dilatation will remain on, or to theleft, of thealert line.

If themembranes have ruptured andthe woman hasnocontractions,donot performadigitalvaginal examination, as it doesnot help to establish the diagnosisand thereisarisk of introducinginfection. (PROM, premature ruptureofmembranes, wasthe subject of Study Session 17 of the Antenatal Care Module.)

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Study Session 4Using thePartograph

4.5Descentofthe fetalhead Forlabour to progress well, dilatation of thecervixshouldbeaccompaniedby descentofthe fetalhead,which is plottedonthe samesectionofthe partograph, butusing Oasthe symbol.But before you can do that,you must learntoestimatethe progress of fetaldescent by measuring the station of the fetalhead,asshowninFigure4.3.The stationcan onlybedeterminedby examinationofthe woman’svaginawith your gloved fingers, andbyreference to thepositionofthe presenting part of thefetal skull relative to theischial spines in themother’spelvicbrim.

Figure 4.3Assessing thestation (descent)ofthe fetalhead by vaginal examination, relativetothe ischialspinesinthe mother’spelvicbrim. (Source: WHO, 2008, MidwiferyEducation Module:ManagingProlonged and Obstructed Labour, Figure 7.28,page132) As you can see fromFigure4.3,whenthe fetalhead is at the same level as theischialspines, this is calledstation0.Ifthe head is higherupthebirth canal than theischialspines, thestationisgiven a negative number.Atstation -4or-3the fetalhead is still ‘floating’ andnot yetengaged; at station -2or -1itisdescendingcloser to theischialspines. If thefetal head is lowerdown thebirth canal than theischial spines, the stationisgiven a positive number. At station+1and even more at station+2, you will be able to see thepresenting part of baby’shead bulging forward duringlabour contractions.Atstation+3the baby’shead is crowning, i.e. visibleatthe vaginalopening even between contractions.The cervix shouldbefully dilatedatthispoint. Nowthatyou have learnedabout thedifferent stations of fetaldescent, there is acomplicationabout recordingthese positions on thepartograph. In the section of thepartographwhere cervical dilatationand descentofhead are recorded,the scale to thelefthas thevaluesfrom0to 10. By tradition, the values 0to5are used to record thelevel of fetaldescent.Table 4.1shows you how to convert thestationofthe fetalhead(as showninFigure4.3)to thecorresponding mark you placeonthe partographbywritingO. (Remember, you mark fetaldescent with Os andcervical dilatation with Xs, so thetwo arenot confused.)

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Table4.1 Correspondingpositions of thestationofthe fetalhead(determined by vaginal examination) and therecordoffetal descentonthe partograph.

When thebaby’sheadstarts Station of fetalhead (Figure4.3) Correspondingmarkonthe partograph crowning (station +3), youmay nothavetime to record the O -4or-35 mark on thepartograph! -2or-14 03 +1 2 +2 1 +3 0

■ What doescrowning mean andwhatdoesittellyou? □ Crowning means that thepresenting part of thebaby’shead remains visiblebetween contractions;thisindicatesthatthe cervix is fully dilated.

4.6Assessing moulding andcaput formation The five separatebonesofthe fetalskullare joined together by sutures, which arequite flexible duringthe birth,and thereare also twolargersoftareas calledfontanels(Figure4.4). Movement in thesutures andfontanelsallows theskullbonestooverlapeach othertosomeextentasthe head is forced down thebirth canal by thecontractions of theuterus. The extent of overlapping of fetalskullbonesiscalled moulding,and it canproducea pointed or flattenedshape to thebaby’shead when it is born(Figure4.5).

Figure 4.4Suturesand fontanels in the newborn’sskull.

Figure4.5 Normal variations in moulding of thenewborn skull, whichusually disappearswithin1-3daysafter thebirth. Some baby’sskulls have aswellingcalledacaput in theareathatwas pressed againstthe cervixduringlabour anddelivery(Figure4.6); this is commoneveninalabour that is progressing normally.Wheneveryou detect Aswelling on onesideofthe moulding or caputformation in thefetal skull as thebabyismoving down the newborn’s head is adangersign birth canal,you have to be more careful in evaluating themotherfor possible andshouldbereferredurgently; disproportionbetween herpelvicopening andthe size of thebaby’shead. bloodorother fluidmay be building up in thebaby’sskull. Make sure that thepelvicopening is largeenough forthe baby to pass through. Asmall pelvis is commoninwomen who were malnourishedas children,and is afrequent cause of prolongedand obstructedlabour.

Figure4.6 Acaput (swelling) of thefetal skullisnormal if it develops centrally, butnot if it is displaced to oneside.

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Study Session 4Using thePartograph

4.6.1Recordingmoulding on thepartograph To identifymoulding, firstpalpate thesuturelines on thefetal head (look back at Figure1.4 in the first study session of this Module) andappreciate whetherthe following conditions apply. The skullbonesthatare most likely to overlapare theparietalbones, whichare joined by thesagittal suture, and have theanteriorand posteriorfontanelstothe front andback.

. Sutures apposed: Thisiswhenadjacentskullbonesare touching each other, but arenot overlapping. Thisiscalleddegree1moulding (+1). . Sutures overlapped but reducible: Thisiswhenyou feel that one skull bone is overlapping another, but when you gently pushthe overlapped bone it goesback easily.Thisiscalleddegree2moulding (+2). . Sutures overlapped and not reducible:Thisiswhenyou feel that one skullbone is overlapping another, but when you trytopushthe overlapped bone,itdoesnot go back.Thisiscalleddegree3moulding (+3).Ifyou find +3 moulding with poor progress of labour,thismay indicatethatthe Youneedtorefer themother urgently to ahealthfacilityifyou labour is at increased risk of becoming obstructed. identify signsofanobstructed labour. Youwilllearn more When you documentthe degree of moulding on thepartograph, useascale aboutthisinStudy Session9 from0(nomoulding) to +3,and writetheminthe rowofboxesprovided: 0Bonesare separated andthe suturescan be felt easily. +1 Bonesare just touching each other. +2 Bonesare overlapping but can be separatedeasily with pressure by your finger. +3 Bonesare overlapping but cannotbeseparated easily with pressure by your finger.

In thepartograph, thereisnospecificspace to documentcaput formation. However, caput detectionshouldbepartofyour assessment duringeach vaginalexamination. Like moulding, you gradethe degree of caput as 0, +1, +2 or +3. Because of itssubjectivenature, gradingthe caput as +1 or +3 simply indicates a ‘small’ anda‘large’ caput respectively.You can document thedegreeofcaput either on theback of thepartograph, or on themother’s health record (if you have it). ■ Imaginethatyou areassessing thedegreeofmoulding of afetal skull. What finding wouldmakeyou referthe woman in labour most urgently, andwhy? □ If you found +3 moulding andthe labour was progressing poorly,itmay mean thereisuterine obstruction.

4.7Uterinecontractions Youalreadyknow that good uterinecontractions arenecessaryfor good progress of labour (Study Session 2).Normally,contractions become more frequent andlast longeraslabour progresses. Contractions arerecorded every 30 minutes on thepartographintheir own section, which is belowthe hour/ timerows. At thelefthandsideiswritten ‘Contractions per10mins’ andthe scale is numberedfrom1–5. Eachsquare represents one contraction, so that if twocontractions arefeltin10minutes, you shouldshade twosquares.

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On each shaded square, youwillalsoindicatethe duration of each contraction by usingthe symbolsshown in Figure4.7.

Figure4.7 Differentshading on thesquares youdrawonthe partograph indicates thestrengthand duration of contractions.

4.8Assessmentand recordingoffetal wellbeing How do youknow that thefetus is in good health duringlabour anddelivery? The methods opentoyou arelimited,but you can assess fetalcondition:

. By countingthe fetalheartbeat every30minutes; . If thefetal membraneshaveruptured,bycheckingthe colour of the amniotic fluid.

4.8.1Fetalheart rate as an indicatoroffetal distress The normal fetalheartrateatterm(37 weeksand more)isinthe range of 120-160 beats/minute. If thefetal heartratecounted at anytimeinlabour is either below 120 beats/minuteorabove 160beats/minute, it is awarning for you to count it more frequently untilithas stabilized within thenormalrange. It is common forthe fetalheartratetobeabitout of thenormalrange fora shortwhile andthenreturntonormal. However, fetaldistress duringlabour anddeliverycan be expressed as:

. Fetalheartbeat persistently (for10minutes or more)remains below 120 beats/minute(doctors callthis persistent fetalbradycardia). . Fetalheartbeat persistently (for10minutes or more)remains above 160 beats/minute(doctors callthis persistent fetaltachycardia).

4.8.2Causes of fetal distress There aremanyfactors that can affect fetalwellbeing duringlabour and delivery.You learnedinthe AntenatalCare Module(Study Session 5) that the fetusisdependent on good functioning of theplacenta andgood supplyof nutrientsand oxygenfromthe maternal blood circulation. Whenever thereis inadequacy in maternal supplyorplacentalfunction,the fetuswill be at risk of asphyxia, whichisgoing to be manifested by thefetal heartbeat deviating from thenormalrange.Other factorsthatwillaffectfetal wellbeing, which maybeindicated by abnormalfetal heartrate, areshowninBox 4.1.

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Study Session 4Using thePartograph

Box4.1 Reasons forfetal heartratedeviatingfromthe normal range

Placentalblood flow to thefetus is compromised,which commonly Youlearned abouthypertensive occurs whenthere is: disordersofpregnancy,maternal anaemia andplacental abruption . Hypertensivedisorderofpregnancy in StudySessions18, 19 and21 . Maternal anaemia of the AntenatalCare Module, Part 2. . Decreasedmaternalblood volume(hypovolemia)due to blood loss, or body fluidlossthrough vomitingand diarrhoea . Maternal hypoxia(shortage of oxygen) due to maternal heartorlung disease, or livinginavery high altitude . Aplacenta which is ‘aged’

. Amniotic fluidbecomesscanty,which prevents thefetus frommoving easily;the umbilical cord maybecome compressed againstthe uterine wall by thebaby’sbody . Umbilical cord is compressed becauseofprolapsed (comingdown the birth canal ahead of thefetus), or is entangled around thebaby’sneck . Placenta prematurelyseparates fromthe uterinewall(placental abruption).

With that background in mind, countingthe fetalheartbeat every30minutes andrecordingitonthe partograph, mayhelpyou to detect the firstsignof anydeviationfor thenormalrange.Onceyou detect anyfetal heartrate abnormality,you shouldn’twaitfor another30minutes; count it as frequently as possibleand arrangereferralquickly if persists formorethan10minutes.

4.8.3Recordingfetalheart rate on the partograph Thefetal heartrateisrecorded at thetop of thepartographevery half hour in the firststage of labour (if everycount is within thenormalrange), andevery 5minutes in thesecond stage. Count thefetal heartrate:

. As frequently as possiblefor about 10 minutes anddecide what to do thereafter. . Count every five minutes if theamniotic fluid(called liquor on the partograph) contains thickgreen or black meconium. . Whenever thefetal membranesrupture, because occasionally theremay be cord prolapse andcompression, or placental abruptionasthe amniotic fluid gushesout.

Each squarefor thefetal heartonthe partographrepresents 30 minutes. When thefetal heartrateisinthe normalrange andthe amniotic fluidisclear or onlylightly blood-stained, you can record theresults on thepartograph, as in theexample in Figure4.8 (onthe next page). When you count thefetal heart rate at less than 30 minuteintervals,use theback of thepartographtorecord each measurement. Prepareacolumnfor thetimeand fetalheartrate.

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Figure4.8 Exampleofnormal fetalheartraterecorded on thepartograph at 30 minuteintervals.

4.8.4Amniotic fluid as an indicatoroffetaldistress Another indicator of fetaldistress which hasalreadybeen mentionedis meconium-stained amniotic fluid(greenishorblackishliquor). Lightlystained amniotic fluidmay not necessarilyindicatefetal distress, unlessitis accompaniedbypersistentfetal heartratedeviations outside thenormalrange. The following observations aremadeateachvaginal examinationand recorded on thepartograph, immediatelybelow thefetal heartraterecordings. If thefetal membranesare intact,writethe letter ‘I’ (for ‘intact’). If themembranes areruptured and:

. liquor is absent, write ‘A’ (for ‘absent’) . liquor is clear,write ‘C’ (for ‘clear’) . liquor is blood-stained, record ‘B’

. liquor is meconium-stained,record ‘M1’ forlightly stained, ‘M2’ fora little bitthick and ‘M3’ forverythick liquorwhich is likesoup (see Box 4.2).

Box4.2 Extentofmeconium staining

Referthe womaninlabour to ahigherhealth facilityasearly as possible if you see:

. M1 liquor in latent firststage of labour,evenwithnormalfetal heart rate.

. M2 liquor in early active firststage of labour,evenwith normalfetal heartrate.

. M3 liquor in anystage of labour,unless progressing fast.

4.9Assessment of maternal wellbeing Duringlabour anddelivery, afteryour thorough initialevaluation, maternal wellbeingisfollowedbymeasuring themother’svitalsigns:blood pressure, pulse, temperature, andurine output. Blood pressure is measured everyfour hours. Pulse is recorded every30minutes. Temperature is recorded every2 hours. Urineoutput is recorded everytimeurine is passed.Ifyou identify persistent deviations fromthe normalrange of anyofthese measurements, referthe mother to ahigherhealth facility.

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Study Session 4Using thePartograph

Summary of StudySession4 In Study Session4,you have learnedthat: 1The partographisavaluable tool to help you detect abnormalprogress of labour,fetal distress andsigns that themotherisindifficulty. 2The partographisdesignedfor recordingmaternalidentification, fetalheart rate,colour of theamniotic fluid, moulding of thefetal skull,cervical dilatation, fetaldescent, uterinecontractions,whether oxytocin was administered or intravenous fluids weregiven,maternalvital signs and urineoutput. 3Start recordingonthe partographwhenthe labour is in active firststage (4 cm or above). 4Cervical dilatation, descentofthe fetalhead anduterinecontractions are used in assessingthe progress of labour.About 1cm/hour cervical dilatationand 1cmdescent in four hoursindicategood progress in the active firststage. 5Fetal heartrateand uterinecontractions arerecordedevery 30 minutes if they areinthe normalrange.Assess cervical dilatation, fetaldescent,the colour of amniotic fluid(if fetalmembranes have ruptured), andthe degree of moulding or caput everyfourhours. 6Doadigitalvaginal examinationimmediatelyifthe membranesrupture andagushofamniotic fluidcomes out whilethe woman is in anystage of labour. 7Refer thewoman to health centreorhospitalifthe cervical dilatation mark crossesthe Alertlineonthe partograph. 8Whenyou identify +3 moulding of thefetal skull with poor progress of labour,thisindicates labour obstruction, so referthe mother urgently. 9Fetal heartratebelow 120/minorabove 160/minfor more than 10 minutes is an urgent indicationtorefer themother, unless thelabour is progressing toofast. 10 Even with anormalfetal heartrate, referifyou see amniotic fluid(liquor) lightly stainedwith meconium in latent firststage of labour,ormoderately stainedinearly active firststage of labour,orthick amniotic fluidinall stages of labour,unlessthe labour is progressing toofast.

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Self-Assessment Questions (SAQs) forStudy Session4 Now that you have completedthisstudy session, youcan assess how well you have achievedits Learning Outcomes by answeringthe following questions. Write your answersinyour Study Diaryand discuss them with your Tutorat thenextStudy Support Meeting. Youcan check your answerswiththe Notes on theSelf-AssessmentQuestions at theend of this Module. SAQ4.1 (testsLearning Outcomes4.1,4.2 and4.3) Read Case Study 4.1and then answer thequestions that follow it.

Case Study4.1 Bekelech’sstory Bekelech is agravida 5, para 4mother, whosecurrent pregnancyhas reached thegestationalage of 40 weeks and4days.Whenyou arriveat herhouse, she is alreadyinlabour.Duringyour firstassessment, shehad four contractions in 10 minutes, each lasting35-40 seconds.Onvaginal examination, thefetal head wasat-3station andBekelech’scervixwas dilatedto5cm. Thefetal heartrateatthe firstcount was144 beats/min.

(a)Whatdoesitmean to say that Bekelech is a ‘gravida5,para4 mother’? (b)How wouldyou describe thegestationalage of Bekelech’sbaby? (c)Which stageoflabour hasshe reached andisthe baby’shead engaged yet? (d)Isthe fetalheart rate normalorabnormal? (e)Whatwouldyou do to monitorthe progress of Bekelech’slabour? (f) How oftenwouldyou do avaginal examinationinBekelech’scaseand why?

SAQ4.2 (testsLearning Outcome 4.2) Givetwo reasonsfor usingapartograph.

SAQ4.3 (testsLearning Outcomes4.1,4.3,4.4 and4.5) (a)Whatindicatorsofgood progressoflabour wouldyou record on the partograph? (b)Whatindicatorsoffetal wellbeing wouldyou record on thepartograph? (c)How oftenshouldyou measurethe vitalsigns of themotherand record them on thepartographinanormally progressing labour? (d)Whatare thekey indicatorsfor immediatereferral?

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Study Session5 Conducting aNormalDelivery

Study Session 5ConductingaNormal Delivery Introduction In theprevious studysessions of this Module, you wereintroduced to the definition, signs,symptomsand stages of labour andthe useofthe partograph. Youalsolearned about care of thewoman in labour.Inthis session, youwill learnhow to assist thewoman in thesecond stageofa normallabour andhow to deliverthe baby.The second stageisthe part of labour when themotherpushesthe baby out of theuterusand down the vagina,and thebabyisborn. Second stage begins when thecervixis completely dilatedand ends when thebabyisdelivered. During thesecondstage,the mother’spassive controlduringthe long hoursof the firststage of labour is replaced by intensephysical effort andexertionfor acomparativelyshortperiod. The mother andher supportperson require stamina, courageand confidencefromthe birthattendant. Ahealthyoutcome forthe mother andher baby depends upon your competence in providing quality care andthe successfulpartnershipbetween you andthe mother. Learning Outcomesfor StudySession5 When you have studied this session you shouldbeableto: 5.1Define anduse correctly allofthe keywords printedinbold.(SAQs 5.1, 5.2and 5.3) 5.2Describethe signs of second stagelabour andexplainwhatis happening to themotherand thebabyasitmovesdown thebirth canal. (SAQs 5.1and 5.2) 5.3Describehow you wouldassess if thesecond stageisprogressing normally andidentifythe warning signs that sufficient progress is not beingmade. (SAQs5.1 and5.2) 5.4Describehow you wouldconductthe normaldeliveryofahealthy baby andgiveitimmediate newborncare. (SAQs 5.3and 5.4) 5.5Explainhow you wouldsupportbonding between mother and newbornafterthe delivery. (SAQ 5.5)

5.1Recognisingthe signs of second stagelabour Theonlypositivesignindiagnosingsecond stageoflabour is full dilatation of thecervix. The onlyway you canbecertain thecervixisdilatedall the wayistodoavaginalexamination. But remember:repeated vaginalexams can cause infection. It is betternot to do avaginal exam frequently (less than 4hoursinterval) unless:

. When you count thefetal heartbeat it is outside thenormalrange (outside 120-160 beatsper minute). . There is asuddengushofamniotic fluid, which mayindicatethatthere is ariskfor cord prolapse or placentalabruption. . Youdetect signs of second stageoflabour beginning before thenext scheduled vaginalexamination. (See Box 5.1for signs of second stage.)

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With experience, you can usuallytellwhenthe mother is readytopush without doing avaginal exam.

Box5.1 Signsofsecond stage

If themotherhas twoormoreofthese signs,she is probably in second stageoflabour:

. She feelsanuncontrollable urge to push(shemay say she needsto pass stool) . She mayholdher breathorgrunt duringcontractions . She starts to sweat . Hermood changes — shemay become sleepyormorefocused . Herexternalgenitalsoranus begintobulge out duringcontractions . She feelsthe baby’shead begintomove into thevagina . Apurplelineappearsbetween themother’sbuttocksastheyspread apartfromthe pressure of thebaby’shead.

5.1.1Whathappens during secondstageoflabour? Duringsecond stage, whenthe baby is high in thevagina, you can see the mother’sgenitals bulge duringcontractions.Her anus mayopenalittle. Between contractions,her genitals relax(Figure5.1).

Figure5.1 Genitals relaxbetween contractions. Each contraction(andeach push fromthe mother)movesthe baby further down. Between contractions,the mother’suterusrelaxes andpulls thebaby back up alittle (but not as farasitwas before thecontraction). Afterawhile,you can see alittleofthe baby’sheadcomingdown thevagina duringcontractions.The baby moveslikeanocean tide:inand out,inand out,but each timecloser to birth (Figures 5.2a-d).

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Study Session5 Conducting aNormalDelivery

When thebaby’sheadstretchesthe vaginalopening to about thesizeofthe palm of your hand (Figure5.3), thehead will stay at theopening -even between contractions.Thisiscalled crowning.Oncethe head is born, therest of thebodyusually slipsout easily with one or twopushes.

5.1.2How does thebaby move through thebirth canal? Figure5.4 showsthe movement of thebabythrough thebirth canal.Babies move this wayiftheyare positionedhead-first, with theirbacks toward their Figure 5.3The fetalhead mother’sbellies. But many babies do not face this way. Ababywho faces the stretchesthe vaginalopening to mother’sfront,orwho is breech,movesinadifferentway.Watch each birth thesizeofthe palm of your hand. closelytosee how babies in differentpositions move.

Figure 5.4The sevencardinalmovements of thebabyduring labour anddelivery.

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5.2Helpthe motherand baby have asafebirth Continuetocheck themother’svitalsigns as you have been doing duringthe firststage of labour.

5.2.1Checkthe baby’s heartbeat The baby’sheartbeatishardertohear in second stagebecause theheartis usuallylower in themother’sbelly.Ifyou areexperienced,you maybeable to hear thebaby’sheartbetween contractions.You can hear it best very lowin themother’sbelly,near thepubicbone (Figure5.5). It is OK forthe heartbeat to be as slow as 100 beatsaminuteduringapushing contraction. But it shouldcomeright back up to thenormalrateassoon as thecontractionis Figure 5.5Checkingthe over. fetalheartbeat during the ■ What is thenormalfetal heatbeat? second stageoflabour. □ Between 120 and160 beatsper minute.

If thebaby’sheartbeatdoesnot come back up within 1minute, or stays slower than 100 beatsaminutefor more than afew minutes, thebabymay be in trouble. Askthe mother to change position(to lieonher side), andcheck thebaby’sheartbeat again. If it is still slow,ask themothertostoppushing forafewcontractions.Makesureshe takesdeep,long breaths so that the baby will getadequate oxygen.

5.2.2Supportthe mother’s pushing When thecervixisfully dilated, themother’sbody will pushthe baby out. Somehealthcareproviders getveryexcited duringthe pushing stage. They yell at mothers, ‘Push!Push!’ butmothers do not usuallyneed much help to push. Theirbodies pushnaturally,and when they areencouraged and supported, women will usually find theway to pushthatfeelsright andgets thebabyout. If amotherhas difficultypushing, do not scold or threaten her. And never insult or hitawoman to make herpush. Upsetting or frighteningher can slow thebirth.Instead,explainhow to pushwell(Figure5.6). Each contractionisa newchance. Praise herfor trying. Figure 5.6Gently Tell themotherwhenyou see herouter genitals bulge.Explainthatthismeans encourage themotherto thebabyiscomingdown. When you see thehead,let themothertouchit. push when shefeelsthe Thismay also help hertopushbetter. urge. Letthe mother choosethe positionthatfeels good to her. Youalreadylearned about differentpositions in firststage in StudySession 3. But notethatitis not good forthe mother to lie flat on herback duringanormalbirth.Lying flat can squeeze theblood vesselsthatbringblood to thebabyand themother, andcan make thebirth slower.

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StudySession 5ConductingaNormalDelivery

Figure 5.7Different positions duringsecond stageoflabour.

5.2.3Watch forwarning signs Watchthe speed of each birth.Ifthe birth is taking toolong, take thewoman to ahospital. This is one of themostimportant things you can do to prevent Do not applyfundalpressureto serious problems or even deathofwomen in labour. help pushthe baby out. Fundal pressure cancause the placenta Firstbabiesmay take afull2hoursofstrong contractions andgood pushing to detach or theuterusto to be born. Second andlater babies usuallytakeless than 1hour of pushing. rupture. Watchhow fast thebaby’shead is moving downthrough thebirth canal.As long as thebabycontinuestomove down (evenveryslowly),and thebaby’s heartbeat is normal, andthe mother hasstrength, then thebirth is normaland healthy. Themothershouldcontinue to pushuntil thehead crowns. Butpushing foralong timewith no progress can cause serious problems, including fistula, uterinerupture (you will learnabout this in Study Session10 of this Module),orevendeathofthe baby or mother.Ifyou do not see the mother’sgenitalsbulging after30minutes of strong pushing, or if themild bulging doesnot increase, thehead maynot be coming down. If thebabyis not moving down at allafter1hour of pushing, themotherneedshelp. Therefore, referimmediately if thewoman stayed (couldn’tdeliver)inthe second stagefor more than:

. 1hourwith no good progress (multigravida woman) . 2hours with no good progress (primigravida).

Good progress in thesecond stageischaracterized by amarkedchange in levelofstation of thebaby’shead.Ifyou have awoman in thesecond stage with little or no fetaldescent, or you seeany signs that thebabyisdeveloping

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caput or excessive moulding of its skull, referthe woman to hospitalora health centreimmediately. 5.3Conductingdelivery of thebaby Your skill andjudgmentare crucialfactorsinminimizingtraumafor the mother andensuringasafe deliveryfor thebaby. These qualitiesare acquired through experiencebut certain basicprinciples must be appliedwhateverthe expertiseyou have.These are:

. Observationofprogressofthe labour . Prevention of infection . Emotionaland physical comfortofthe mother . Anticipationofnormalevents . Recognitionofabnormallabour or fetaldistress.

5.3.1Prevent tearsinthe vaginal opening The birth of thebaby’shead maytear themother’svaginal opening. Butyou can preventtearsbysupportingthe vagina duringthe birth.Insome communities, circumcision of girls(also calledfemalegenital cutting) is common. Thisharmful traditionalpracticecauses scarsthatmay not stretch enough to letthe baby out or thescar maytear as thebabyisborn.

5.3.2Deliveryofthe head Wash your hands welland putonsterile glovesand otherprotectivematerials. Clean theperineal area usingantispetic and(if you have them)put clean drapes (cloths) overthe mother’sthighs. Pressone hand firmly on theperineum(theskinbetween theopening of the vagina andthe anus). Thishandwillkeep thebaby’schinclose to its chest — making it easier forthe head to come out (Figure5.8). Useapiece of clothor gauzetocoverthe mother’sanus;somefaeces (stool)may be pushedout with thebaby’shead. Figure 5.8Assistingthe deliveryofthe baby’shead. Useyourother hand to applygentle downwardpressure on thetop of the baby’shead to keep thebaby’shead flexed (bentdownwards). Oncethe head hascrowned, thehead is bornbythe extensionofthe face, which appearsatthe perineum. Clear thebaby’snoseand mouth. When thehead is born, andbeforethe rest of thebody comesout,you mayneed to help thebabybreathe by clearingits mouthand nose. If thebabyhas somemucus or water in its noseormouth, wipe it gently with aclean clothwrappedaround your finger.

5.3.3Checkifthe cord is around the baby’s neck If thereisarest between thebirth of thehead andthe birth of theshoulders, feel forthe cord around thebaby’sneck.

. If thecordiswrappedlooselyaround theneck,loosen it so it can slip overthe baby’shead or shoulders. . If thecordisverytight,orifitiswrappedaround theneck more than once, try to loosen it andslip it overthe head.

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. If you cannot loosen thecord, andifthe cord is preventing thebabyfrom coming out,you mayhavetoclamp andcut it.

If you can, usemedical hemostats(clamps)and blunt-tippedscissors for clamping andcutting thecordinthissituation. If youdonot have them,use clean string andanewrazor. Clamportie in twoplaces andcut in between (Figure5.9). Be very careful not to cutthe mother or thebaby’sneck.

Figure 5.9Cutting thecord when it is wrappedaround thebaby’sneck.

5.3.4Deliveryofthe shoulders If youcut thecordbefore the Afterthe baby’shead is bornand he or sheturns to face themother’sleg, birth of thebaby, themother wait forthe next contraction. Askthe mother to give agentlepushassoon as must push hard andget thebaby outfast. Withoutthe cord,the she feelsthe contraction. Usually, thebaby’sshoulders will slip right out.To baby cannot getany oxygenuntil preventtearing, trytobring out one shoulderatatime(Figure5.10). he or shebeginstobreathe.

Figure 5.10 Deliveryofthe shoulderswhenthe mother is in differentbirthing positions.

Do not bend thebaby’s head far. Guidethe head —donot pull it.!

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5.3.5Deliveryofthe baby’s body Afterthe shoulders areborn, therest of thebody usuallyslides out without anytrouble. Rememberthatnew babies arewet andslippery.Becareful not to drop thebaby! Put thebabyonthe mother’sabdomen,dry thebabywithaclean clothand then put anew,clean blanketoverhim or hertokeep thebabywarm. Be sure thetop of thebaby’shead is coveredwithahatorblanket. If everything seemsOK, give thebabythe chance to breastfeed right away.You do not have to wait until theplacenta comesout or thecordiscut.

5.3.6Cutting the cord Most of thetime, thereisnoneed to hurry to cutthe cord right away.Leaving thecordattached will help thebabytohaveenough iron in hisorher blood, because someofthe blood in theplacenta drains along thecordand into the baby.Itwillalsokeep thebabyonthe mother’sbelly which is thebest place to be right now.Waituntil thecordstops pulsing andlooks likeitismostly emptyofblood. BUTifthe mother is known to be HIV-infected or herHIV status is not known, it is bettertocut thecordsoon afteryou have driedthe baby and made sure that he or sheiswarm.

Figure5.11Cutting theumbilical cord. Useasterile stringorsterile clamptotightly tie or clampthe cord about two fingerwidthsfromthe baby’sbelly.(The baby’sriskofgettingtetanus is greater whenthe cord is cutfar fromthe body.) Tieasquare knot (Figure5.11). Put anothersterile stringorclamp one finger fromthe firstknot. And,ifyou do not have aclamp on thecordonthe mother’sside, addathird knot two fingers fromthe second knot.Puttingadoubleknot on thecordreduces the risk of bleeding. Cut after thesecond tie(e.g. the firsttie is approximately 3cmfromthe baby’sabdomen andthe second is approximately 5cm).Cut afterthe 5cmtie with asterile razorblade or sterile scissors.

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5.4Immediate care of thenewborn baby Essentialnewborncare includesthe following actions.But notethatyou will learnabout resuscitationofthe newbornwho is not breathing adequately in Study Session 6.

5.4.1Clean childbirth andcordcare Principles of cleanliness are essentialinbothhomeand health postchildbirth to preventinfectiontothe mother andbaby. These are:

. Clean your hands . Clean themother’sperineum . Nothing unclean introduced vaginally . Clean deliverysurface . Cleanliness in cord clamping andcutting.

Thestump of theumbilical cord must be kept clean anddry to prevent infection. Wash it with soap andclean wateronlyifitissoiled. Remember:

. Do not applydressings or substances of anykind . If thecordbleeds, re-tieit.

It usuallyfalls off4-7daysafter birth, but until this happens,place thecord Do not putdirt or dung on the cord stump! Dirt and dung do outside thenappy to preventcontaminationwith urine/faeces. notprotectthe stump —they causeserious infections. 5.4.2Check the newborn Most babies arealert andstrong when they areborn. Otherbabiesstart slow, but as the firstfew minutes pass,theybreathe andmove better, getstronger, andbecome less blue.Immediately afterdelivery, clear airwaysand stimulate thebabywhile drying. To see how healthythe baby is,watch for:

. Breathing: babies shouldstart to breathe normally within seconds after birth. Babies whocry afterbirth areusually breathingwell. But many babies breathe well anddonot cryatall. . Colour: thebaby’sskinshouldbeanormalcolour – not pale or bluish. . Muscletone:the baby shouldmove hisorher arms andlegsvigorously.

Allofthese things shouldbechecked simultaneously within the firstminute afterbirth.You will learnabout this in detail in Study Session 6ofthis Module.

5.4.3Warmthand bonding Newborn babies areatincreased riskofgetting extremelycold. The mother andthe baby shouldbekeptskin-to-skincontact, coveredwith aclean,dry blanket. This shouldbedone immediatelyafterthe birth, even before you cut thecord. Themother’sbody will keep thebabywarm, andthe smellofthe mother’s milk will encouragehim or hertosuck. Be gentle with anew baby.The first houristhe best timefor themotherand baby to be together,and they should not be separated. Thistimetogether will also help to start breastfeedingas early as possible.

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5.4.4Early breastfeeding If everything is normalafterthe birth, themothershouldbreastfeed herbaby right away (Figure5.12).She mayneed some help gettingstarted.The first milk to come from thebreast is yellowish andiscalled colostrum.Some womenthink that colostrumisbad forthe baby anddonot breastfeed in the firstday afterthe birth.But colostrumisveryimportant!Itisfullofprotein andhelps to protect thebabyfrominfections.

. Breastfeedingmakes theuteruscontract.Thishelps theplacenta come out, anditmay help preventheavybleeding. . Breastfeedinghelps thebabytoclear fluidfromhis noseand mouthand breathe more easily. Figure 5.12 Breastfeedingis . Breastfeedingisagood way forthe mother andbabytobegin to know good for themotherand baby. each other. . Breastfeedingcomforts thebaby. . Breastfeedingcan help themotherrelax andfeel good about hernew baby.

If thebabydoesnot seem able to breastfeed,see if it hasalot of mucusinhis or hernose. To help themucus drain, laythe baby acrossthe mother’schest with its head lowerthanits body.Strokethe baby’sback from thewaist up to theshoulders.Afterdrainingthe mucus, help themothertoput thebabyto thebreast again. Youwilllearnalotmoreabout breastfeedinginthe next Moduleinthiscurriculum on Postnatal Care. Summary of StudySession5 In Study Session 5you learnedthat: 1The second stageoflabour begins when thecervixiscompletelydilated andends when thebabyisdelivered.Close attention, skilledcareand prompt actionare needed fromyou forasafe clean birth. 2The signs of second stageare whenthe mother feelsanuncontrollable urge to push, sheholds herbreathorgruntsduringcontractions,she starts to sweat,her mood changes, herexternalgenitals or anus begintobulge out duringcontractions,she feelsthe baby’shead begintomove into the vagina,apurplelineappears between herbuttocks. 3Check themother’svital signs, thefetal heartbeat andthe descentofthe baby’shead at intervalstoensurethatlabour is progressing normally. 4Watch forwarning signs that labour is not progressing sufficientlyduring thesecond stageand take appropriate actiontorefer themother. 5Supportthe mother’spushing duringthe time of actualdelivery. 6Ifthe cord is trappedaround thebaby’sneck,cut it before thebody is delivered — but make sure themotherpusheshardtoget thebabyout fast. 7Maintaincleanliness throughout theentire process of labour anddelivery to preventinfectiontothe mother andbaby. 8Keep thenewbornbabywarmand make sure it is breathing well. 9Initiateearly breast feeding.

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Self-Assessment Questions (SAQs)for Study Session 5 Nowthatyou have completedthisstudy session, you can assess how well you have achievedits Learning Outcomesbyansweringthe questions belowCase Study 3.1. Writeyour answersinyour Study Diaryand discuss them with yourTutor at thenextStudy SupportMeeting. Youcan check your answers with theNotes on theSelf-AssessmentQuestions at theend of this Module. SAQ5.1 (tests LearningOutcomes 5.1, 5.2and 5.3) Whichofthe following statements is false?Ineach case, explainwhatis incorrect. AFulldilatationofthe cervix to 10 cm is themostimportant sign that thesecond stageoflabour is beginning. BInsecond stage, themother’sgenitalstendtobulge during contractions andrelax between contractions. CCrowning is thenamegiven to themomentwhenthe baby’shead is completely born. DInanormaldelivery, thebabymovesdownthe birth canal facing the front of themother’sbody,with itsback towardsher backbone. EWhile it is still in thebirth canal, thebaby’sheartbeat tendstoget faster duringacontraction. FLet themotherchoosethe position that she feelsmostcomfortablein whenshe gets theurgetopushinthe second stageoflabour.

SAQ5.2 (tests LearningOutcome5.3) List four warningsigns that secondstage labour maynot be progressing normally.

SAQ5.3 (tests LearningOutcome5.4) Imaginethatthe baby’shead hasbeen bornand you arewaiting forthe next contractiontodeliver thebaby’sshoulders.Whatshouldyou do if you find that theumbilical cord is wrappedaround thebaby’sneck?

SAQ5.4 (tests LearningOutcomes 5.4and 5.5) Rearrange thefollowing actions into thecorrect orderduringdeliveryof thebabyand immediatelyafterwards. (J andKare on thenextpage.) AOncethe baby’shead is born, help it to breathe by clearingits nose andmouth. BWash yourhands welland put on sterile glovesand otherprotective clothing. CToprevent tearingofthe mother’sbirth vagina or perineum, deliver thebaby’sshoulders one at atime. DPress one hand firmly overthe mother’sperineum. EWhenthe baby hasbeen completely delivered,put it on themother’s abdomen anddry it with aclean cloth. FClean themother’sperineal area with antiseptic. GClamp or tie thecordintwo places andcut it in between theclamps. HUse your otherhandtoapplygentle downwardpressure on thetop of thebaby’shead to keep it flexed (bentdownwards). ICoverthe baby to keep it warm andgiveitachance to breastfeed straight away.

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JUse apiece of clothorgauze to coverthe mother’sanus in case any faeces come out with thebaby. KCheck that thecordisnot around thebaby’sneck.

SAQ5.5 (tests LearningOutcome5.5) What do you do to help bonding between themotherand hernewborn baby?

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Study Session6 Active Management of theThird Stage of Labour

Study Session 6ActiveManagementof theThird StageofLabour Introduction In the finalstudy session of this Module, you will learnabout postpartum haemorrhage(PPH),which is aleadingcause of maternal mortality, responsible forabout aquarterofall maternal deaths.Worldwide,around 127,000 women everyyear dieofpostpartumhaemorrhage. The majority of these fatalcases of excessive bleedingoccurinthe first24hoursafter deliveryofthe baby,asaresult of complications arisingduringthe thirdstage of labour.Tominimizethe risks of PPH in this critical stageoflabour,aset of procedures have been developedthatall birth attendantsshouldfollow, calledactivemanagementofthird stageoflabour (AMTSL).Correctly applied, AMSTL can reducethe riskofpostpartumhaemorrhagebymorethan 60%. In this study session, you will learnwhatismeantbyAMTSL andthe procedures you will conductduringeach of its sixsteps.Thisknowledge will help you to identifythe complications that mayariseduringthe thirdstage of labour andmanagethemmoreeffectively. Learning Outcomesfor StudySession6 When you have studied this session, youshouldbeableto: 6.1Define anduse correctly allofthe keywords printedinbold. (SAQ 6.1) 6.2Explainthe naturalphysiological process of placentaldelivery. (SAQ 6.1) 6.3Describethe sixsteps of activemanagementofthird stageoflabour (AMTSL).(SAQ 6.2) 6.4Summarisethe regimens foreach of theuterotonicdrugs used in AMTSL. (SAQs6.2 and6.3) 6.5Explainhow you wouldexamine theplacenta andmembranes for completeness. (SAQ 6.3) 6.6Describethe warningsigns forcomplications that mayariseduringthe thirdstage of labour.(SAQ 6.4)

6.1The third stageoflabour The thirdstage of labour begins with thebirth of thebabyand ends with the deliveryofthe placenta andfetal membranes. Normally,itshouldlast less than 30 minutes.

6.1.1Naturalprocesses during thethird stage In acomplication-freelabour,the thirdstage is whennatural physiological processes spontaneously deliver theplacenta andfetal membranes. For this to happenunproblematically,the cervixmustremainopenand thereneedstobe gooduterinecontraction. In themajority of cases, theprocesses occurinthe following order:

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1 Separationofthe placenta: Theplacenta separates fromthe wallofuterus (see Figure6.1aand b).Asitdetaches, blood fromthe tinyvesselsinthe placentalbed begins to clot between theplacenta andthe muscularwallof theuterus(the myometrium). 2 Descentofthe placenta: Afterseparation, theplacenta movesdownthe birthcanal andthrough thedilatedcervix(see Figure6.1c). 3 Expulsionofthe placenta: The placenta is completely expelledfromthe birthcanal (see Figure6.1d).

Thisexpulsion marksthe endofthe third stageoflabour.Thereafter, the muscles of theuteruscontinue to contract powerfully andthus compress the torn blood vessels. This, (togetherwith blood clotting) quickly reduces and stops thepostpartumbleeding.

Figure6.1 (a)Placenta notseparated at thebeginning of thirdstage.(b) Placenta begins separatingand ablood clot formsbehindit. (c)Placenta descending through thecervix. (d) Placenta completely expelled marks theend of thirdstage; theuteruscontractspowerfully.(Source:WHO,2008, MidwiferyEducation Manual:ManagingPostpartumHaemorrhage,Figures 1.5to1.7,pages 22-23)

Study Session 11 of this Module 6.1.2Complicationsoccurring during the thirdstage of will tell youindetailabout postpartumhaemorrhageand labour atonicuterus; theother termsin Womenwho give birth unattendedbyaskilledhealthcareprovider(likeyou) Box6.1 arecovered in this study aremorelikelytoexperiencecomplications at allstagesoflabour,including session. thethird stage. Thesecomplications arelistedinBox 6.1below.Theycan

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ariseeveninadeliverywhere theplacenta wasimplanted in agood position in thetop two-thirdsofthe uterus,labour was not prolongedand thebirth was normal.Insuchcases, while anormaland spontaneous deliveryofthe placenta duringthe third stagemight be expected,complications can still arise unpredictably.You shouldalwaysbepreparedfor theunexpected emergency.

Box6.1 Common complicationsofthird stageoflabour

Allthese complications aremuchmorelikelytooccurifthe third stage is not properly managed, usingthe AMTSL approach. Retained placenta The placenta remainsinsidethe uterus forlongerthan30minutes after deliveryofthe baby,usually due to one or more of thefollowing:

. Uterinecontractions maybeinadequate to expelthe placenta . The cervixmight have retracted toofast andpartially closed,trapping theplacenta in theuterus . The bladdermay be full andobstructingplacentaldelivery.

Excessive bleeding(PPH) PPH is thelossofmorethan500 ml of blood following deliveryofthe baby.Mostbleedingcomes from wherethe placenta wasattached to the uterus,and is bright or dark blood andusually thick. PPH occurs when theuterusfails to contract well,usually due to:

. Partially separated placenta (itremains partly attached to theuterine wall . Completelyseparated placenta,but retained inside theuterus . Atonic uterus;the muscularwallofthe uterus couldnot contract powerfullyenough to arrest thenatural bleedingwhich occurs when theplacenta separates.

Uterine inversion The uterus is pulled ‘inside out’ as thebabyorthe placenta is delivered, andpartlyemerges through thevagina.

6.2Activemanagementofthird stageoflabour (AMTSL) Abirth attendant applying activemanagement of thirdstage of labour (AMTSL) is thekey to reducingthe riskofthe complications set out in Box6.1.The term ‘activemanagement’ indicates that you arenot waitingfor spontaneous placentaldelivery. Rather,you will interveneinacarefully programmedsequentialmanner, as follows:

. As soon as thebabyisdelivered,put it on themother’sabdomen in skin- to-skincontact with her. Cover them with ablanket. . Clampthe baby’sumbilical cord at twositesand cutitinbetween,asyou learnedtodoinStudy Session 5.

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. Thenfollowthe stepsinBox 6.2. We describeeach of them in detail in thenextsection.

Box6.2 Thesix stepsofAMTSL in sequence

1Check theuterusfor thepresence of asecond baby. 2Inless than one minute, administer a uterotonicdrug (a hormone- like chemical that makesthe uterus contract more powerfully). 3Applycontrolledcordtraction. 4Afterdeliveryofthe placenta,immediately start massagingthe uterus. 5Examine theplacenta to make sure it is complete andnone of it has been retained in theuterus. 6Examine thewoman’svagina, perineum andexternalgenitaliafor lacerations andactivebleeding.

Step 1Checkthe uterus –isthereasecondbaby? Immediatelyafterthe birth of thebaby, check forthe presenceofasecond baby by palpatingthe uterus through themother’sabdomen.Whenyou feel certain that theuterusdoesnot containasecond baby,and you can feel that it hasreduced in size to no larger than at 24 weeksofgestation, go to step 2. The reason forcheckingsocarefully is because thedrugyou will administer to themotherinstep2will make theuteruscontract so powerfully that it will damage ababythatremains inside it.Ifyou find that thereisatwin,givethe theuterotonicdrug after thebirth of thesecond baby.

Step 2Administer auterotonicdrugtohelpthe uterus contract The commonlyused uterotonicdrugs in obstetricpracticeare:

. misoprostol(tablets) . oxytocin (injectable) . ergometrine(injectable).

These drugs help theuterustocontinue contractingstronglyand rhythmically afterthe baby is born: they facilitate placentaldeliveryand help to prevent excessive bleedingfromarelaxed(atonic) uterus.Although thereare three possibledrugs,for deliveriesinlow-resource settings,suchashomes in rural areas of Ethiopia, on many occasions misoprostolmay be theonlyone of these drugs that you will be able to use. Oxytocinisthe drug recommended by theWorld Health Organization(WHO),but it maynot be practical forthe following reason:

HealthPosts aresupplied with a Oxytocin andergometrine always have to be kept refrigerated at 2–8°C, refrigeratorand mobile icebox so they arenot suitablefor ahomedeliveryunlessthe householdhas a fortransport of vaccinesto refrigerator,oryou have amobile icebox. They also have to be protected outreachevents, as described in fromexposuretolight. the Immunization Module.

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Dosagesofuterotonicdrugs In less than one minuteafterthe delivery of thebaby, andafter clamping and cuttingthe umbilical cord,givethe mother one of thefollowing:

. misoprostol 600 micrograms(mg),i.e.three 200 mgtablets by mouthwith adrinkofwater. OR (if you carry this in an icebox) . oxytocin 10 internationalunits (IU)injecteddeep into thewoman’sthigh muscles (intramuscularinjection, IM). OR Note that ergometrine is not recommended foruse by rural . ergometrine 0.4–0.5milligrams (mg) injected deep into thewoman’sthigh HealthExtension Practitioners. muscles (intramuscularinjection, IM).

When theuterusiswellcontracted it will feel very hard.Thisshouldoccur between 2-7minutes afterthe administration of thedrug, depending on which one is given.

Advantages anddisadvantagesofthe uterotonicdrugs Misoprostolisless effectivethanoxytocin andhas more side-effects. However, in many ruralsituations you will have no otheroptionbut to useit because of theneed to storeoxytocin in arefrigerator or icebox. It will be important thereforetoadvise themotherthatwhile it will be effectivein preventingbleeding, shemay also experience someside-effects. Thisapplies whicheveruterotonicdrugyou aregiving, but especially in thecase of misoprostol, whichcauses side-effectsinasignificantproportionofwomen. They are:

. Shivering: this maystart 1hour aftertakingmisoprostoland will subside after2–6hours. Askthe family to offerthe mother warm teaor‘atmit’,as well as blankets. . Fever: this is rarer, but maystart afterthe shivering. It is not necessarily a sign of infectionand it will disappear within 2–8hoursafter taking the drug. . Diarrhoea: mayalsooccurand normally lastsless than aday. . Nausea andvomiting: can also occur, but will subside2–6hours afterwards.

■ What is thegreat advantagethatmisoprotol hascomparedtothe other uterotonicdrugs? □ It comesintabletform, so injectionequipment(syringes, needles) are not required, anditdoesnot need to be stored in arefrigerator so it can be used where thereisnoway of keepingdrugs very cold.

Oxytocin is therecommended uterotonicdruginall situations whereitis feasibletouse it, because it is more effectivethanthe otherdrugs andhas fewerside-effects. Oxytocin is anaturally occurring hormone in thewoman’s It is not plannedtouse body, which is involvedinthe onset andprogression of uterinecontractions ergometrineinthe ruralHealth duringlabour.Manufactured oxytocin is givenafterthe deliverytoensure ExtensionService.Itmust never that theuterusgoesoncontractingrhythmically,likenatural uterine be giventoawoman withpre- contractions.However,itdoesnot have asustained action(theeffect subsides eclampsia, eclampsia or high bloodpressure,because it causes quite quickly)and it must be stored in arefrigerator andprotected fromlight. theblood vesselstoconstrict, Ergometrineisless widely used because it is such astrong uterotonicdrug forcingher bloodpressure even higher. that it mayhasten theclosure of thecervixbeforethe deliveryofthe placenta.

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It takeslongertoact than oxytocin (6-7minutes whengiven intramuscularly) anditcausesmarkedspasm of theuterusbyaseries of rapidsustained contractions,which areunlikethe naturaluterinecontractions.However,itis long-lasting, with an effect overapproximately 2–4hours.

Step 3Apply controlledcordtractionwithcounter- pressure When theuterusiswellcontracted it will feel very hard.Thisshouldoccur2– 3minutes afterthe administration of one of theuterotonicdrugs.Then controlled cord tractionwith counterpressure is used to help to expelthe placenta (see Figure6.2 andBox 6.3).

Figure6.2 Controlledcord traction. Theright hand is pullingthe clamped umbilical cord (making traction)while thelefthandisexerting counter-pressure on thelower abdomen, just abovethe pubicbone. (Source: WHO, 2008, To avoid inversion of theuterus Midwifery EducationManual:ManagingPostpartumHaemorrhage,Figure 1.18, (turninginsideout and coming page 33) outofthe vagina), controlled cord tractionshould NEVERbe applied withoutcounter-pressure to theabdomen. Box6.3 Howtodocontrolled cordtraction with counter- pressure

1Clamp theumbilical cord closetothe perineum(oncepulsationofthe blood vesselsstops in thecordofahealthynewborn) andholdthe cord in one hand. 2Place theother hand just above thewoman’spubicbone andstabilize theuterusbyapplying counter-pressure to theabdomen during controlled cord traction. 3Keep slight tensiononthe cord andawait astrong uterinecontraction (usually every2-3minutes). 4With thestrong uterinecontraction, encouragethe mother to pushand very gently pulldownwardonthe cord to deliver theplacenta. Continue to applycounter-pressure to theuterus. 5Between contractions,gently holdthe cord andwaituntil theuterus is well contracted again. 6With thenextcontraction, repeat controlled cord tractionwith counter-pressure. 7Ifthe placenta doesnot descendduring30-40 seconds of controlled cord traction do not continue to pullonthe cord.

The following actions complete therest of thedeliveryofthe placenta. As theplacenta is delivered,itshouldbecaught in bothhands at thevulva to preventthe membranestearingand some beingleftbehind. Holdthe placenta

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Study Session 6ActiveManagementofthe Third Stage of Labour

in twohands andgently turn it until themembranes aretwisted (see Figure6.3). Slowlypulltocompletethe deliveryofthe placenta.

Figure 6.3Deliveryofthe placenta. Delivery of theplacenta marksthe endofthe thirdstage of labour.Atthis timethe uterus shouldbehard, round andmovablewhenyou palpatethe abdomen.You shouldbeabletofeel it midway between themother’s umbilicus(bellybutton) andher pubicbone.There shouldbenobleeding fromthe vagina.The bladdershouldbeempty.

Step 4Massage theuterus Right afterthe placenta is delivered,rubbing theuterusisagood way to contract it andstopthe bleeding. Many women need theiruterusrubbedto help it to contract (Figure6.4).

Figure 6.4Rub theuterusimmediately afterthe birth, then every15minutes for 2hours, then every30minutes.Showthe womanhow to rub herown uterus,ora relativemay help.

Step 5Examine the placenta and fetal membranes Youmustlook carefully at theplacenta to be sure that noneofitismissing. ■ From your knowledge of theanatomy of theplacenta (Antenatal Care Module, Study Session5), whichisthe ‘maternal’ surface — thetop side wherethe umbilical cord emerges, or theunderside(bottom) of the pelvis? □ The maternal surface of theplacenta is theunderside, opposite to theside where theumbilical cord emerges.

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If aportion of thematernalsurface (bottomofthe placenta,see Figure6.5)is missing, or thereare torn membraneswithblood vessels, suspectthatretained placenta fragments remain in theuterusand referthe mother quickly.

Figure6.5 Checkingthe underside (maternalsurface) of theplacenta to seeifit is intact. ■ Canyou explainwhy? □ She is more at risk of postpartumhaemorrhageifapiece of theplacenta is retained in theuterus.

The irregular roundedshapesonthe undersideofthe placenta arecalled lobes (sometextbooks callthem cotyledons). By contrast thetop of theplacenta (the side that wasfacing thebaby) is smoothand shiny. Thecordattaches on this side,and then spreads out into many deep-blueblood vesselsthatlook like tree roots(Figure6.6).

Checking theplacenta forcompleteness Figure 6.6The topofthe placenta. 1Holdthe placenta in thepalms of your hands,withthe maternal side facing upward. Make sure that allthe lobules arepresentand fittogether. 2Thenholdthe cord with one hand, allowing theplacenta andmembranes to hang down. 3Place theother hand inside themembranes, spreading the fingers out,to make sure that themembranes arecomplete(Figure6.7).

Figure6.7 Hold themembranes open like this to check they arecomplete. 4Ensurethatthe positionofcordattachment to theplacentaisnormal, and inspect thecut endofthe cord forthe presence of twoarteriesand one vein (Figure6.8). 5Safelydisposeofthe placenta by either burying it whereitwillnot be dug up by animals, or incinerate it if you have thefacilitiestodosoinyour Figure 6.8The cutend of the community. cord hastwo arteries and one vein.

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StudySession 6ActiveManagementofthe Third Stage of Labour

6Ifthe membranestear,gentlyexamine theuppervaginaand cervixofthe woman.You must wear sterile/disinfected glovesand useasponge forceps to remove anypieces of membrane that arepresent.

It is dangerous forthe mother if anyparts of theplacenta or membranesare left behind in theuterus.

Figure 6.9Placentalexamination (usingadummyplacenta)demonstratingcorrect inspectionofthe maternal surface (underside). Thelobes should complete:notear or sign of breakage when theplacenta is stretched flat over thehealth worker’s hand.

Step 6Examining forcuts,tears and bleeding Theanatomical termsinthissectionwereall explainedand illustratedin Study Session 3ofthe Antenatal Care Module, Part 1(see Figure3.2). To complete themanagementofthe third stageoflabour,dothe following: 1Gently separatethe labiaand inspect thelower vagina andperineumfor lacerations that mayneed to be repairedtoprevent further blood loss (Figure6.10). 2Gently cleanse thevulva andperineumwith boiled(then cooled)warm wateroraweak antisepticsolution. 3Applyaclean padorcloth with firm pressure to theareathatisbleeding forabout 10 minutes. If bleedingcontinuesafter this time, referthe woman immediately, keepingthe pressure appliedtothe wound. 4Monitorthe woman every15minutes -thismeansmeasuring hervital Figure 6.10 Adeep tear in the signs,massaging heruterustoensurethatitiscontracted andcheckingfor vagina can lead to postpartum excessive vaginalbleeding. haemorrhage. ■ Whyisitimportant to complete thesix stepsofAMTSL in aparticular orderand what is that order? □ Keepingtothe exact orderofactions is important,because theevidence on which AMTSLisbased shows that if it is correctly applied(including in theright order) it can reducethe risk of PPH by 60%.Refer back to Box 6.2ifyou can’trememberthe orderofthe sixsteps.

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6.3Intervention in complicationsafter applying AMTSL 6.3.1Excessive bleeding(postpartumhaemorrhage or PPH) Youwilllearnthe definitionofexcessive bleedingand theactions to take if thewoman haspostpartumhaemorrhage(PPH) in Study Session 11 of this Module; it also describesthe interventions you can take duringand afterthe third stageoflabourtoreducethe risk of PPH.The main pointsare summarized brieflyhere.

. Rubbing theuterusand (if you have been trained to do it)using thetwo- handed pressure method (Study Session 11). Do not give additional . Giving asecond doseofoxytocin 10 IU by intramuscularinjection, or a misoprostol if oxytocin wasthe second doseofmisoprostol400 µg rectally (bypushing thetablets gently drug used originally. into therectumthrough thewoman's anus), or by puttingthe tabletsunder hertongue wheretheycan slowlydissolve. . Initiatingbreastfeedingimmediately afterdelivery: thecontractions that expelthe milk will also make theuteruscontract.

Remembernot to exceed 1,000 mgofmisoprostol (5 tablets).Ifthe woman hasalreadytaken 600 mg(3tablets)after thebirth of thebaby, andshe needs asecond dosebecause of excessive bleeding, it shouldbenomorethan400 mg(2tablets)via therectum.Thisway,the woman will have fewerside- effects. If shedid not take 600 mgoforalmisoprostolafterthe birthofthe baby andhas signs of excessive bleeding, give her1,000 mgofmisoprostol viathe rectum in one dose. If thebleedingdoesnot stop quickly afterthe second doseofmisoprostol, then referthe woman to thenearest health facilityurgently.Sometimes, bleedingcomes fromatorn vagina,atorn cervix, or atornuterus. Usually If excessivebleeding occurs,the this bleedingcomes in aconstant,slowtrickle. The bloodisusually bright red mother shouldbetaken to the health facilityimmediately.You andthin. Actions to take while waitingfor transport: will learnwhattodoonthe . Liethe mother down with herfeethigherthanher head andher head journeyinStudy Session11. turned sideways;keep herwarmwith blankets. . Secure an intravenous (IV)lineand begin fluidinfusionwith Normal SalineorRinger’sLactatesolution. (You learnedhow to do this in Study Session 22 of the Antenatal Care Moduleand your practical skills training.)You maybetrained to addafurtherdoseofoxytocin to the fluids in theIVbag,but this is onlypossibleifyou can keep thedrug refrigerated until needed. . Keep theareaofthe vulva andperineumclean. . Arrange to accompanythe mother to thehospitalifatall possible. . Also askfamily membersorfriends to go with themotherand look after thebaby(andtobepossibleblood donors).

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Study Session6 Active Management of theThird Stage of Labour

6.3.2Retained placenta Retained placenta is whenthe placenta remainsinthe uterus beyond 30 minutes afterthe birth of thebaby. If this happens:

. Do not attemptfurther controlled cord tractiontoseparatethe placenta. . Followthe instructions forpre-referraltreatment as givenabove forPPH andget thewoman to ahealth facility foremergency careasquickly as possible.

Summary of StudySession6 In Study Session6you have learnedthat: 1Activemanagementofthird stageoflabour (AMTSL) is thebest interventiontoreducethe risk of PPH by more than 60%.Therefore, AMTSL hastobeappliedroutinely(to alldeliveringmothers). 2The sequential physiological changesinthe thirdstage of labour are: separationofthe placenta,descent of theplacenta,expulsion of the placenta andcontrolofbleeding. 3Commoncomplications that can occurduringthird stageoflabour include retained placenta,postpartumhaemorrhageand uterineinversion. 4The componentsofAMTSL in sequentialorder arecheckingfor asecond baby,administration of uterotonicdrugs,controlled cord traction, uterine massageafter delivery of theplacenta,placental examinationfor completeness, andexamining thegenital area forlacerations andactive bleeding. 5Oxytocin,ergometrineand misoprostolare commonlyused uterotonic drugs.Because ergometrineisavery strong drug,itisnot recommended foruse in Ethiopia’srural Health Extension Service. Oxytocin and ergometrine must always be kept in arefrigerator until needed;misoprostol comesintabletform. 6Administermisoprostoloroxytocin within one minuteofthe deliveryof thebaby. 7Awell-contracted uterus is felt as firm to hard,welldelineated andwithno activevaginal bleeding, unless thesource of bleedingisdue to tear or lacerations of thelower genitalarea. 8Missed placentallobe,retainedplacenta,relaxed enlarged soft uterus, bleedingcontinuing despite therepeat administration of uterotonicdrugs anduterinemassage areall indications forsettingupanintravenous line forpre-referral IV fluidinfusionand immediatereferraltoahealth facility.

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Self-Assessment Questions (SAQs) forStudy Session6 Now that you have completedthisstudy session, youcan assess how well you have achievedits Learning Outcomes by answeringthe following questions. Write your answersinyour Study Diaryand discuss them with your Tutorat thenextStudy Support Meeting. Youcan check your answerswiththe Notes on theSelf-AssessmentQuestions at theend of this Module. SAQ6.1 (testsLearning Outcomes6.1 and6.2) (a)How do you define thethird stageoflabour? (b)Whatphysiological changeshappenduringthe third stageofanormal uncomplicated labour?

SAQ6.2 (testsLearning Outcomes6.1 and6.3) AlemituisaHealth Extension Practitioner(HEP) in avillage Health Post.She hasjustdelivered ababyather Health Postand themotheris in thethird stageoflabour,and hasbegun breastfeeding. Alemituhas been trained to useAMTSL. What,indetail, arethe sixsteps that she must followinorder to do this?

SAQ6.3 (testsLearning Outcome 6.3) Imaginethatyou have managedthe third stageoflabour forawomanin your community by correctly usingAMTSL, but shehas developed continuous bleeding. (a)Doyou provide additionalmisoprostol? If yes, what doseshouldyou give herand in whatform? (b)Whatelsecouldyou do? (c)Whatshouldyou do if thewoman continuestobleed?

SAQ6.4 (testsLearning Outcome 6.6) What arethe warningsigns forthe complications that mayarise during thethird stageoflabour?

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StudySession 7NeonatalResuscitation

Study Session 7Neonatal Resuscitation Introduction Themomentwhenababy is bornisalsothe time when thebirth attendant has to make averyrapid assessment of thecondition of thenewborntodecide whetheritneedshelping to breathe.Within afew seconds you have to be able to identify thegeneral dangersigns in anewbornthattellyou to intervene quickly to protect it from developing serious complications,orevendying, because it is not able to getenough oxygenintoits body.Ofcourse, most babies breathe spontaneously as soonastheyare bornand allyou need to do is follow thesteps of basicnewborncare, which were brieflyoutlinedin Study Session 5ofthisModule. Youwill learntheminmuchgreater detail in theModuleonPostnatal Care andthe stepswillbecoveredagain in the ModuleonIntegrated Management of Newbornand Childhood Illness. However, in this study session our focusisonnewborns who are not breathing well, andwhatyou need to do in ordertoresuscitate them andget them breathing normally. Youwilllearnhow to distinguish between ahealthy baby andone that is moderately or severely asphyxiated (i.e. shortofoxygen due to breathing problems),and thecorrect actionthatyou should take.This study session is unusualinthatmuchofitistaught through diagrams. Learning Outcomesfor StudySession7 When you have studied this session you shouldbeableto: 7.1Define anduse correctly allofthe keywords printedinbold. (SAQ 7.2) 7.2Summarisethe most important signs of neonatal asphyxiathatmean you shouldbegin neonatalresuscitation. (SAQ 7.1) 7.3Explainhow newborns can be helped to breathe by applying standard resuscitationtechniques. (SAQs7.1 and7.2) 7.4Identify theequipmentyou will need to give newbornresuscitation andhow it shouldbeused correctly.(SAQ7.3) 7.5Describethe things you should not do when assessing anewbornfor possiblebreathing difficulties. (SAQ 7.4) 7.6Summarisethe main health riskstonewbornsand theactivitiesthat form thebasisofessential newborncare. (SAQ 7.5)

7.1Newborn respiration andresuscitation We beginbybrieflysummarizing what usuallyhappens when anewborn makesthe transitionfromlife in itsmother’suterus, to life in theoutside world, whereitmustbreathe foritself.

7.1.1Breathing in ahealthy newborn Normally,ahealthybabystarts to breathspontaneously immediatelyafter delivery(Figure7.1). If thebreathing startedspontaneously andissustained by thebabywithout assistance, it indicates that:

. The fetuswas not asphyxiated whileinthe uterus . The respiratory system is functioning well . The cardiovascularsystem(heartand blood vessels) is functioning well

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. There is coordinationbythe brainofthe movementsrequiredfor sustained rhythmical breathing (brain is functioning well).

Figure7.1 Afull-term normal newbornwho is breathing well haspinkish skin colour andsemi-flexed arms andlegs; he hasmadeagoodtransitionfromthe mother’suterus to theoutside world. (Photo:DrMulualemGessese) ■ Howdoyou check fetalwellbeing duringlabour anddelivery? □ Ahealthyfetus hasaheartratebetween 120–160 beats/minute. When the fetalmembranes rupture, theamniotic fluidthatleaksfromthe mother’s vagina is clear,not heavilyblood-stainedorcoloured greenish-black by meconium — thebaby’s firststool.

If you checked thefetal heartrateatregular intervalsall through themother’s labour,and recorded theresult on thepartograph(as you learnedinStudy Session 4),you shouldhavereferredany mother whose unbornbabyshowed signs of fetaldistress. Therefore, it shouldberelativelyuncommonfor you to deliveranasphyxiated baby.However, complications in childbirth can develop unpredictably, or you maybecalledtoawomanwho is alreadyfar advanced in thesecond stageoflabour when you reach her. Therefore,you need to know howtoprovide neonatalresuscitationincase you deliver an asphyxiated baby.

7.1.2Newbornasphyxia As youlearnedinStudy Session 4ofthisModule, asphyxia (shortage of oxygen) in theuterusisdue to an inadequate supplyofoxygenfromthe mother’sblood or aproblem in theplacenta.Thismay result in:

. Asphyxia at birth (mild,moderate or severe) . Learning difficultiesorcognitive impairment, which become apparent duringchildhood development; they aredue to braincells beingdestroyed by lack of oxygenduringlabour anddelivery. . Deathofthe newborn.

However,neonatalasphyxia is mainly due to failure of thenewborntobreathe afterbirth,orits heartfails to pumpenough blood to thelungs for gas Gasexchangeiswhenoxygen exchange,orithas lowhaemoglobinlevels(anaemia)soitcannot deliver from theinhaledair is absorbed enough oxygenaround thebody.The baby whocannot breathe cannot into theblood as it passes establishindependent life outside themother. Therefore,the purpose of throughthe lungs, andwaste carbon dioxide is releasedfrom neonatalresuscitationistohelpthe newborntoestablishspontaneous theblood into theair that is breathing andfacilitateoxygendeliverytoits organs andtissues – particularly breathed out thebrain,which is very quickly damagedbyoxygenshortage.You mayalso

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need to resuscitate anybabythatisseverelyanaemic due to blood loss during labour anddelivery, or that continuestobecyanotic despiteestablished breathing. Cyanosis is abluishdiscolourationofthe lipsand skin,which occurs whenthere is insufficientoxygen in theblood (Figure7.2).

Figure 7.2Apretermnewbornwithproblems:she lookscyanotic(bluish), her limbsare floppy because hermuscletoneisnot strong,and shehas breathing problems. (Photo:DrMulualemGessese) To avoidthe immediateand long-term complications of asphyxia,inaddition to thelabour anddeliverycarethatyou provide to themother, andthe routine newborncareofthe baby (e.g.cuttingthe cord,keepingthe baby warm),you also have to provide life-savinginterventions forany newbornwho cannot breathe properly. 7.2Types of neonatal resuscitation Thereare threetechniquesthatyou will learnabout in this studysession and in your practical skills training. They are:

. Ventilation:using ahand-operatedpumpcalledanambu-bag (Figure7.3), which pumpsair into thebaby’slungs through amask fitted overits nose andmouth. (You mayhear health professionals referring to ventilationas ‘ambu-bagging’.)

Figure 7.3Resuscitationtechniquepracticed withaventilator(ambu-bag) on a training doll. (Photo:DrYifrewBerhan)

. Suctioning:using adevicecalledabulbsyringe to extract mucusand fluid from thebaby’snoseand mouth.

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. Heartmassage:pressing on thebaby’schest in arhythmic wayto stimulatethe heartbeat (Figure7.4).

Figure7.4 Cardiacmassage techniquepracticed on atrainingdoll. Youcan seea ventilator at thetop rightofthe picture. (Photo:DrYifrewBerhan)

7.2.1Basic equipment neededfor newborn resuscitation . Twoclean linen/cottoncloths: one to drythe newbornand one to wrap himorher afterwards . Plastic bulbsyringe to remove secretions fromthe mouthand nose, especially whenmeconium is present . Ambu-bagand mask to give oxygendirectly into thebaby’slungs . Aperson trained in neonatalresuscitation(like you) . Heatsource(lamp)toprovide warmth,ifpossible.

7.2.2Beforeyou start resuscitation Before you applyany form of resuscitation, make sure that:

. The baby is alive:Ifthe newborndoesn’tappear to be alive, FIRSTlisten to its chestwith astethoscope.Ifthere is no heartbeat,the baby is already dead (see Table7.1 below). . Yougradedthe extentofasphyxia:Ifyou can hear aheartbeat,but you estimateittobeless than 60 beats/minute, applyheartmassage first,then ventilatealternately on andoff,tillthe heartbeat is above 60 beats/minute (see Table7.1 below). . Thebaby is not deeply meconium stained:Ifthe baby’sskinisstained with meconium,orthe oral andnasal cavitiesare filledwithmeconium- stained fluid(Figure7.5 on thenextpage),you should not resuscitate before suctioning theoral, nasal andpharyngeal areas. Ventilationwill aggravatethe baby’sbreathing problem because it will forcethe meconium-stained fluiddeep into thebaby’slungs,where it will blockthe gasexchange.

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Figure 7.5Ababy whoisnot breathing (no signsofchest or nose movement) andwithmeconium stainedall overits body.(Photo: Dr Mulualem Gessese) 7.3Assessingthe degree of asphyxia Moderate to severelyasphyxiated babies usually requireintensive resuscitation, so thenextthing you have to learnishow to gradeasphyxiain anewborn. Within no more than 5seconds afterthe birth,you shouldmakea very rapidassessmenttofind out whetherthe baby is aliveordead,and (ifit is alive) to assess whether it hasany degree of asphyxia. Aseverely asphyxiated baby maynot breathe at all, theremay be no movement of its limbs (armsand legs), andthe skin colour maybedeeply blue or deeply white. Ababywho is not breathing at allafterbirth,orwho is onlygasping forbreath, or whoisbreathing less than 30 breaths perminuteneedshelp immediately. If ababydoesnot breathe soon afterbirth,itmay getbrain damage or die. Most babies who arenot breathing can be saved if resuscitated correctly andquickly. From Table7.1,you can learnhow to assess anewborn’sdegreeofasphyxia. Also look againatthe threephotos of newborns with differentlevel of asphyxia(Figures 7.1, 7.2and 7.5).

Table7.1 Assessingthe degree of asphyxia.

SignsNoasphyxiaMild Moderate Severe asphyxia asphyxia asphyxia HeartrateAbove 100 Above 100 Above60 Below60beats/ beats/minute beats/minute beats/minute minute Skin colour Pink Mild blue Moderately Deeplyblue blue Breathing Crying Crying Breathing but Notbreathing, or Gaspingiswhenthe newborn can pattern notstrong gasping type take only afew breaths with difficulty andwithwidegapsin Limb Moving well Weakly Floppy Floppy between; it is usuallyasign that movement moving thebabyisclose to death. Meconium- No No Maybe Usually stained ResuscitationNoneedFastresponse Good response Takes along time to respond

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Assessmentofthe degree of asphyxiashouldnot take you more than 5 seconds.Doitfast but don’tpanic.

Sinceneonatalresuscitation is an actionthatyou need to perform rapidly (withinone minuteafterdelivery),itisbettertoestimate than to count the heartrate, andtoobserve thepattern of breathing rather than to count the respiratory rate.Table 7.2gives you asimplified descriptionofthe signs that indicatewhatisnormaland abnormalimmediatelyafterbirth.

Table7.2 Normal andabnormal physical findings in thenewborn immediatelyafter birth.

SignsNormal findings Abnormal findings Colour ShouldbepinkBlueorcyanosed (shortage of oxygen) White,pallor(anaemia) Yellowish (jaundice) Breathing40-60 breaths/minuteNobreathing ‘Lessthan’ canbereplacedbythe Breathingratelessthan30/minute Gasping(very fewbreaths with symbol,asin>30/min. difficulty breathing) Heartrate120-160beats/minuteNoheartbeat at all Heartbeatlessthan100/minute Muscle Fulltermnewborn has semi-flexed Poor flexionofthe limbs; arms tone arms and legs (Figure 7.1) andlegs floppy (Figure 7.2), indicates moderatetosevere asphyxiaaffectingthe brain Reflexes Baby respondstoafinger put into No responsetotouching theroof theroof of its mouth of thebaby’smouth

7.4Neonatalresuscitationprocedures Before you go to attend anydelivery, you shouldmakecertain that you have prepared theequipmentnecessarytoapplyneonatalresuscitation andgive immediatecaretothe newbornifrequired. In this section we move on to the actions that you shouldtakeonceyou have assessed thedegreeofasphyxia.

7.4.1The first fiveseconds Table7.3 (onthe next page)summariseswhatyou shoulddointhe first5 seconds afterthe baby is bornifthe signs of asphyxiaare present.Afteryou have seen this overview, we will look at thespecificactions in detail.

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Table7.3 Actions in responsetosigns of neonatal asphyxia.

What is thenewborn Assessment Action doing? Crying and moving limbsProbablyahealthy Resuscitationnot needed baby Weak breathing, notmoving Probably moderately Assist breathing by on and limbs, moderate cyanosis asphyxiated offventilation(as described in Section7.4.8) Notcrying, breathing or Probably severely Estimate heartrate gasping; not moving limbs/ asphyxiated Call an assistant (family floppy; maybecyanosed or member or other) meconiumstained Suctionthe oral,nasal and As above Heartrateabove 60 pharyngeal area in less than beats/minute 5seconds using abulb syringe On andoff ventilation As above Heartratebelow 60 As above,but with the beats/minute additionofcardiac massage (seeFigure7.4)

7.4.2Checkingthe newborn’sheart rate The apicalheartbeat (orAHB) is just anothernamefor theheartbeat heard through astethoscope overthe area of theheartonthe left side of thechest, as shown in Figure7.6.Itiscalled ‘apical’ because theheartbeat is heard directly fromthe surface of theheart. ■ What is thenamegiven to thenumberofheartbeatsper minutemeasured away fromthe theheart? □ It is calledthe pulserate.

Thenewborn’sheartbeatscan also be countedbyfeelingthe pulse at thebase of theumbilical cord,asshowninFigure7.6.

Figure 7.7Checkingand counting theapical heartbeat (AHB)and feelingfor the pulse at thebaseofthe umbilical cord.

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7.4.3The initialactions The listbelow setsout theactions you shouldtakefor all newborns in the sequence shown, irrespective of thedegreeofasphyxia: 1Fast drying as shown in Figure7.8 2Keepingthe baby warm. 3Clearingthe mouthand noseasshowninFigure7.9 4Applygentletactilestimulationtoinitiateorenhancebreathing as shown in Figure7.10 5Simultaneously assessingthe degree of asphyxiaasshown earlier in Tables 7.1to7.3 6Positioning thebabyfor resuscitation if thereare signs of asphyxia, as shown in Figure7.11

Now study each of these figures in turn.Look at them carefully andmake surethatyou read thecaptions andother notes associatedwith them.

7.4.4Dry thebaby quicklyand keepitwarm Laythe baby on awarmsurface away fromdrafts. Useaheat lamp or other overheadwarmer, if available. Thendry thebabyasshown in Figure7.8.

Figure7.8 Howtodry thebaby: (top)lay thebabyonits back anddry it thoroughly;(bottom left)removethe wet cloth; (bottom right) tiltthe baby’schin to reposition thebaby’shead andkeep itsairway open. Placethe baby in skin-to-skin contact with themother, coveredbyawarm blanket. Place awarmcap or shawltocoverthe baby’shead.

7.4.5Clearing the mouth and nose If abulbsyringe is available: Suction themouth first, then thebaby’snose(‘m’before ‘n’) — see Figure 7.9.

No deep suctioningwithabulb If no bulbsyringe: syringe! It cancause slowingof theheart rate (bradycardia). Clear secretions fromthe mouthand nosewithaclean,dry cloth.

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Figure 7.9Suctioningthe newborn with abulbsyringetoclear mucusfromits upper airway: (top)suction themouth first; (bottom) then suctionthe baby’snose (‘m’ before ‘n’).

7.4.6Apply gentletactile stimulation to initiate or enhance breathing

Figure 7.10 Howtogivegentletactilestimulation:(left)rub thebaby’sabdomen up anddown; (centreand right) flick theunderside of thebaby’sfootwith your fingers. DO NOT stimulateby:

. Slapping theback . Squeezing therib cage Thesetypes of stimulation are dangerousand candamagethe . Forcing thebaby’sthighs into itsabdomen newborn. . Dilating theanalsphincter(theringofmusclethatcloses theanus) . Hot or cold compressesorbaths . Shaking theumbilical cord.

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7.4.7Ifyou diagnose asphyxia,startresuscitation! Positionthe newbornonhis or herback with theneck slightly extendedas shown in thetop pictureinFigure7.11. Open theairwaybyclearingthe mouthand nosewith suctionusing thebulbsyringe as you saw previously in Figure 7.9.

Figure7.11How to position thenewborn’shead to keep its airway open:(top) correct,the baby’schinistilted theright amount;(middle)the baby’shead is tiltedtoo farback,placing pressure on thewindpipeinits neck;(bottom) the baby’shead is nottilted enough — itschinistoo closetoits chestand theairway is compressed. . Position yourselfatthe head of thebaby(see Figure7.12).

Figure7.12The correct position fornewborn resuscitation usinganambu-bag.

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If theapicalheartbeat is >(morethan)60beats/minute:

. Ventilatewith theappropriate size of mask andaself-inflatingambu-bag. The mask shouldbefitted as shown in Figure7.13. Make a firm seal between themask andthe baby’sface, so aircannotescapefromunderthe edgesofthe mask.But don’tforce themask down ontothe baby’sface, because this couldpushits chin down towardsits chest (bottomdiagram in Figure7.11) andcompress itsairway.

If theapicalheart beat is <(less than) 60 beats/minute:

. Apply heartmassage(look back at Figure7.4)and ventilatealternately(on andoff ventilation) with theambu-bag.

Figure 7.13 Correctand incorrectsizeofmask: (top)correct:Coversmouth, nose, andchin; (bottom left)incorrect:too large — covers eyes andextends over chin;(bottomright)incorrect: toosmall — does notcovernoseand mouth.

7.4.8Ventilate at 40 breaths perminute Count out loud: ‘Breathe — two — three’ as you ventilatethe baby (see Figure7.14onthe next page). Squeeze thebag as you say ‘Breathe’ and release thepressure on thebag as you say ‘two — three’.Thishelps you to ventilate with an even rhythm,atarate that thenewborn’slungs arenaturally adaptedto. Theamount of airyou aremoving into andout of thelungs is theequivalent of about 40 breaths perminute. Applyenough pressure to createanoticeable, gentle rise andfallinthe baby’schest.The firstfew breaths mayrequire higherpressures, but if thebabyappearstobetakingavery deep breath, you areusing toomuchpressure.

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Figure7.14Timingthe rate of ventilation as yousay ‘Breathe — two — three’.

7.4.9Evaluate the baby during ventilation The best sign of good ventilationand improvement in thebaby’sconditionis an increase in heartratetomorethan100 beats/minute. ■ What otherchange wouldyou expect to see in thebabywhile youare ventilating it, if theresuscitationisgoing well? □ Youwould expect to see thebaby’sskincolour change frombluishor very pale,toahealthierpinkish colour.You mayalsosee thebabybegin to move alittlebit, beginning to flex itslimbs andlook less floppy.

When you stop ventilatingfor amoment, is thebabycapable of spontaneous breathing or crying? Theseare good signs.Manybabiesrecoververyquickly afterashortperiodofventilation, but keep closelymonitoringthe baby until you aresureitisbreathing wellonits own. If thebabyremains weakorishavingirregularbreathing after30minutes of resuscitation, referthe mother andbabyurgentlytoahealth centre or hospital where they have facilitiestohelpbabieswho arehavingdifficulty breathing. Go with them andkeep ventilating thebabyall theway.Makesureitiskept warm at alltimes. Newbornseasily lose heat andthiscouldbefatal in ababy that can’tbreathe adequately on its own.

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Figure7.15summarisesthe stepsinnewbornresuscitationwhich youhave learnedinSection7.4.

Figure 7.15 Asummary of thesteps in newbornresuscitation in theformofa flow chart. 7.5Immediate essentialnewborn care We endthisstudy session with areminderabout essentialnewborncare, whichyou shouldconductwith allbabies, regardless of whethertheyhave anysigns of asphyxiation. When thebaby’sumbilical cord is cut, thereare many physiological changesinsidethe baby’sbody to allowittomakethe necessaryadaptationtolife outside itsmother. It is generallytougherto surviveinthe outside world than in therelativesafetyofthe uterus,sowe need to providebasiccaretothe newborntohelpitresist somepotential health riskslistedinBox 7.1.

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Box7.1 Health riskstonewborns

Newbornsneedadditionalcaretoprevent:

. Spontaneous bleeding, usually from thegastrointestinal tract,due to VitaminKdeficiency . Bleedingdue to birth trauma (usually manifested late afterdelivery with swellingoverscalpthatrequiresimmediatereferral) . Eye infections duetoChlamydiatrachomatis and Neisseria gonorrhea (bacteria which arecommoncauses of sexuallytransmitted infections;the baby can acquire these infections as it passes through thebirth canal) Vaccinepreventable diseases are . Some vaccine preventablediseases such as poliomyelitis and discussedindetailinthe tuberculosis CommunicableDiseases Module, StudySessions3and4. . Hypothermia (becoming toocold) . Hypoglycaemia (low blood glucoselevel)

Prevention of mother-to-child . Mother-to-child transmission of HIV, if themotherisHIV-positive. transmission (PMTCT)ofHIV is coveredinthe AntenatalCare Module,Study Session17; the drugs andprocedures for PMTCT With thehealth risks in Box 7.1inmind, make sure that you give allnewborn aregiven in the Communicable babies thefollowing essentialcare: Diseases Module,Study Session27. . Tiethe umbilical cord two finger-widthsfromthe baby’sabdomen and place asecond tietwo finger-widths away from the firstone.Cut thecord between the firstand second ties. Check that theumbilical cord stumpis not bleedingand is not cuttoo short . Applytetracyclineeye ointment onceonly, to preventeye infections. . Inject vitaminK(1 mg,intramuscularly)intothe front of thebaby’smid- thightoprevent spontaneous bleeding. Thevaccination schedule forall . Give the firstdoseoforalpolio vaccine andBCG vaccine (against thevaccinesinthe EPIare tuberculosis)according to theguidelinesinthe Ethiopian Expanded described in full in the Programme of Immunization(EPI). Immunization Module. . The body temperatureofthe newbornmustremainabove 36oC. Place the baby on themother’sabdomen in skin-to-skin contact with her, where it can breastfeed.Coverthembothwithablanketand put awarmhat or shawloverthe baby’shead. Youwill learnall about . Ensurethatthe baby is sucklingwelland themother’sbreast is producing breastfeedinginthe Postnatal Care adequate milk.Ifbreastmilk is not preferred, make sure that adequate Module.Breastfeeding andHIV replacementfeedingisready. Initiateearly andexclusive breastfeeding arecovered in the Communicable unless thereare good reasonstoavoidit, e.g. in an HIV-positivemother. Diseases Module,Study Session27. . The baby shouldget preventivetreatment to protect it from HIVifits mother is HIV-positive.

Summary of StudySession7 In Study Session 7, you have learnedthat: 1The most important signs of asphyxiationinnewborns at delivery are: difficultybreathing,gasping or no breathing; abnormalheartbeat;poor muscletone(floppy limbs);lack of movement;bluishskincolour (cyanosis), andbeing stainedwith meconium.

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2Assessmentofthe degree of asphyxiashouldbedone in the first5seconds afterthe birth,atthe sametimeascommencingbasicnewborncare (e.g.dryingthe baby,keepingitwarm, tyingand cuttingthe cord,etc). 3Swift actionisnecessarytobegin resuscitating ababywho is not breathing well, afteryou have suctionedits mouthand then its nose. 4Check that thebabyisalive(listen foranapical heartbeat); that theheart rate is above 60 beats/minute(beginheartmassage before resuscitation if theheartrateisless than 60 beats/minute);and that thebabyisnot stained with meconium,which must be suctionedout before resuscitation can begin. 5Positionthe baby with itsneck extendedtoopenthe airways; place a correctly fittingventilationmask overthe baby’smouthand nose, and beginventilating at arateofabout 40 breaths perminute. 6Watch forsigns of improvement:e.g.pinkish colour,movement, ability to breathe unaided,etc.Refer urgently if this hasnot been achieved after30 minutes of ventilation. 7Remembertoconductall theactivitiesofessentialnewborncare, including cord care, giving avitamin Kinjectionand tetracyclineeye ointment, establishing early andexclusive breastfeeding, andensuringthatanti-HIV medicationisgiven to preventmother-to-child-transmission.

Self-Assessment Questions (SAQs)for Study Session 7 Nowthatyou have completedthisstudy session, you can assess how well you have achievedits Learning Outcomesbyansweringthe followingquestions. Writeyour answersinyour Study Diaryand discuss them with your Tutorat thenextStudy SupportMeeting. Youcan checkyour answerswiththe Notes on theSelf-AssessmentQuestions at theend of this Module. SAQ7.1 (tests Learning Outcomes 7.2and 7.3) Firstread Case Study7.1 andthenanswer thequestions that followit.

Case Study7.1 Atsede’sbaby can’tbreathe A25year-old woman calledAtsedewas brought to your HealthPost afterbeing in labour for38hoursathome. Soon aftershe reached you, shegavebirth to afulltermbabyboy.You assessed thebabyand found he was not making anybreathing effort,hehad no movement of his limbs andhis whole body wascoveredwith meconium-stained amniotic fluid. When you driedhim andapplied tactile stimulation, thebabystill didn’tshow anyefforttobreathe.

(a)Isthisbabyasphyxiated?Ifyes, whatisthe degree of asphyxia? (b)Whatare your immediatenextsteps?Thenwhatdoyou do? (c)Couldthe birth complicationinthisnewbornhavebeen prevented, and if so,how?

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SAQ7.2 (testsLearning Outcomes7.4 List thebasicequipmentyou will need in ordertoresuscitate anewborn with breathing difficulties.

SAQ7.3 (testsLearning Outcomes7.1,7.2,7.4,7.5 and7.6) Whichofthe following statements is false? In each casesay whatis incorrect. AIfanewborncriessoon afterbirth,itisasignofasphyxiaoccurring before delivery. BCyanosis meansbeing coveredwith meconium alloverthe body. CThe apical heartbeat can be detected by listeningtothe baby’schest with astethoscope. DGas exchange in thelungs happens when carbon dioxide is breathed in andoxygenisbreathedout. EGivingthe newbornaVitaminKinjectionistoprevent eye infections. FThe recommendedventilation rate fornewborns is 40 breaths/minute.

SAQ7.4 (testsLearning Outcome 7.4) Whichofthe following ways of stimulatingthe newbornare recommended, andwhich aredangerous andnot allowed?

. Slapping theback . Rubbing theabdomen gently up anddown . Squeezing therib cage . Forcing thighs into theabdomen . Flicking theunderside of thebaby’sfoot with your fingers . Dilating theanalsphincter . Hot or cold compresses or baths . Shaking theumbilical cord.

SAQ7.5 Table7.1 summarises somecommonhealth riskstonewborns andthe immediateessentialcaretoprevent thosecomplications.Someofthe boxeshavebeen left blankfor youtocomplete.

Table7.1 foruse with SAQ 7.5

Newbornhealth risk Essential newborncare Eyeinfection Spontaneousbleeding Hypothermia Hypoglycaemia

96 StudySession 8AbnormalPresentations andMultiplePregnancies

Study Session 8AbnormalPresentations andMultiplePregnancies Introduction In previous study sessions of this module, you have been introduced to the definitions,signs,symptomsand stages of normallabour, andabout the ‘normal’ vertex presentationofthe fetusduringdelivery. In this study session, you will learnabout themostcommonabnormalpresentations (breech, shoulder, face or brow), theirdiagnosticcriteria andthe requiredactions you need to take to preventcomplications developing duringlabour.Taking prompt actionmay save thelife of themotherand herbabyifthe delivery becomesobstructed because thebabyisinanabnormalpresentation. We will also tell you about twin birthsand thecomplications that mayresultifthe two babies become ‘locked’ together,preventingeither of them frombeing born. Learning Outcomesfor StudySession8 Afterstudying this session, you shouldbeableto: 8.1Define anduse correctly allofthe keywords printedinbold.(SAQs 8.1and 8.2) 8.2Describehow you wouldidentifyafetusinthe vertexpresentation anddistinguish this from common malpresentations andmalpositions. (SAQs 8.1and 8.2) 8.3Describethe causes andcomplications forthe fetusand themotherof fetalmalpresentationduringfulltermlabour.(SAQ 8.3) 8.3Describehow you wouldidentifyamultiplepregnancyand the complications that mayarise.(SAQ8.4) 8.4Explainwhenand how you wouldrefer awoman in labour due to abnormalfetal presentationormultiple pregnancy. (SAQ 8.4)

8.1Normaland abnormalpresentations 8.1.1Vertexpresentation In about 95%ofdeliveries, thepartofthe fetuswhich arrives firstatthe mother’spelvicbrim is thehighest part of thefetal head,which is calledthe vertex (Figure8.1). Thispresentationiscalledthe vertex presentation. Notice that thebaby’schinistuckeddowntowards its chest,sothatthe vertexisthe leadingpartenteringthe mother’spelvis. The baby’shead is said to be ‘well-flexed’ in this position.

97 Figure8.1 Ababyinthe well-flexed vertex presentationbefore birth, relative to themother’spelvis. (Source: WHO, Managing ComplicationsinPregnancy and Childbirth.) Duringearly pregnancy, thebabyisthe otherway up — with itsbottom pointingdown towardsthe mother’scervix — which is calledthe breech presentation.Thisisbecause duringits early development, thehead of the fetusisbiggerthanits buttocks; so in themajority of cases, thehead occupies thewidest cavity,i.e.the fundus (roundedtop) of theuterus. As thefetus growslarger, thebuttocksbecome biggerthanthe head andthe baby spontaneously reverses its position, so itsbuttocksoccupy thefundus.In short, in early pregnancy, themajority of fetuses are in thebreech presentation andlater in pregnancymostofthemmakeaspontaneous transition to the vertex presentation.

8.1.2Malpresentations Youwill learnabout obstructed When thebabypresents itselfinthe mother’spelvisinany position otherthan labourinStudy Session9. thevertexpresentation, this is termed an abnormalpresentation, or malpresentation.The reason forreferringtothisas‘abnormal’ is because it is associated with amuchhigherriskofobstructionand otherbirth complications than thevertexpresentation. The most common typesof malpresentationare termed breech,shoulder, face or brow.Wewilldiscuss each of theseinturnlater.Noticethatthe baby can be ‘head-down’ butinan abnormalpresentation, as in face or brow presentations,whenthe baby’sface or forehead (brow) is thepresenting part.

8.1.3Malposition Although it maynot be so easy foryou to identify this,the baby can also be in an abnormal position even whenitisinthe vertexpresentation. In anormal delivery,whenthe baby’shead hasengagedinthe mother’spelvis, the back of thebaby’sskull(the occiput)pointstowards the front of themother’s pelvis (the pubicsymphysis), wherethe twopubicbonesare fused together. Youlearned thedirectional Thisorientationofthe fetalskulliscalledthe occipito-anterior position positions: anterior/infront of and (Figure8.2a). If theocciput (back)ofthe fetalskullistowards themother’s posterior/behindorinthe back back,this occipito-posterior position(Figure8.2b) is a vertex malposition, of,inthe Antenatal Care Module, because it is more difficult forthe baby to be borninthisorientation. The Part 1, Study Session3. good thingisthatmorethan90% of babies in vertexmalpositions undergo rotationtothe occipito-anteriorpositionand aredelivered normally.

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Figure 8.2Possiblepositions of thefetal skullwhenthe baby is in thevertex Note that thefetal skullcan also presentationand themotherislying on herback:(a) Thenormal ‘straight’ be tilted to theleftortothe occipito-anteriorposition in whichthe baby can be born most easily.(b) The right in either theoccipito- ‘straight’ occipito posteriormalposition makesbirth more difficult.(Source: anterior or occipito-posterior courtesy of Mikael Häggström,accessedfromhttp://commons.wikimedia.org/wiki/ positions. File:Cephalic_presentation_-_straight_occipito-anterior.png) 8.2Causes andconsequences of malpresentationsand malpositions In themajority of individualcases it maynot be possibletoidentify what caused thebabytobeinanabnormal presentationorpositionduringdelivery. However, thegeneral conditions that arethought to increase theriskof malpresentationormalposition arelistedbelow:

. Abnormally increased or decreased amount of amniotic fluid . Atumour (abnormaltissuegrowth) in theuteruspreventingthe spontaneous inversionofthe fetusfrombreech to vertexpresentation duringlatepregnancy . Abnormalshape of thepelvis . Laxity (slackness) of muscularlayer in thewalls of theuterus . Multiple pregnancy(more than one baby in theuterus) Multiple pregnancy is thesubject of Section8.7 of this study . Placenta previa (placenta partly or completely coveringthe cervical session.You learned about opening). placenta previa in the Antenatal Care Module, StudySession 21. If thebabypresents at thedilating cervixinanabnormalpresentation or malposition, it will more difficult (and maybeimpossible) forittocomplete the seven cardinal movements that you learnedabout in Study Sessions 3and 5. As aresult,birth is more difficult andthere is an increased risk of complications,including:

. Prematureruptureofthe fetalmembranes (PROM) Youlearned aboutPROMin Study Session17ofthe Antenatal . Prematurelabour Care Module, Part 2. . Slow,erratic, short-lived contractions . Uncoordinatedand extremely painfulcontractions,with slow or no progressoflabour . Prolongedand obstructed labour,leadingtoaruptured uterus (see Study Sessions 9and 10 of this Module) . Postpartumhaemorrhage(see Study Session 11)

99 . Fetaland maternal distress,which maylead to thedeathofthe baby and/ or themother.

With these complications in mind, we now turn your attentiontothe commonest typesofmalpresentationand how to recognise them. 8.3Breechpresentation In a breech presentation,the fetuslieswithits buttocksinthe lowerpartof theuterus, andits buttocksand/or thefeet arethe presenting parts during delivery.Breech presentationoccurs on averagein3-4% of deliveriesafter 34 weeksofpregnancy. ■ When is thebreech positionthe normal position forthe fetus? □ During early pregnancythe baby’sbottompointsdown towardsthe mother’scervix, andits head (thelargest part of thefetus at this stageof development) occupies thefundus (roundedtop) of theuterus, which is thewidest part of theuterinecavity.

8.3.1Causes of breechpresentation Youcan seeatransverselie in In themajorityofcases thereisnoobvious reason why thefetus should Figure8.7 laterinthisstudy present by thebreech at full term.Inpractice, whatiscommonlyobservedis session. theassociationofbreech presentationatdeliverywithatransverse lie earlier in thepregnancy, i.e. thefetus liessidewaysacrossthe mother’sabdomen, facing asidewaysimplanted placenta.Itisthought that whenthe placenta is in front of thebaby’sface, it mayobstruct thenormalprocess of inversion, when thebabyturns head-down as it gets biggerduringthe pregnancy. As a result, thefetus turnsinthe otherdirectionand ends in thebreech presentation. Someother circumstances that arethought to favour abreech presentationduringlabour include:

. Prematurelabour,beginning before thebabyundergoesspontanous inversionfrombreech to vertex presentation . Multiple pregnancy, preventingthe normalinversionofone or bothbabies Polyhydramnios is pronounced . Polyhydramnios: excessive amount of amniotic fluid, which makesitmore ‘poll-ee-hy-dram-nee-oss’. difficult forthe fetalhead to ‘engage’ with themother’scervix Hydrocephaly is pronounced‘hy- droh-keff-all-ee’ . Hydrocephaly (‘wateronthe brain’)i.e.anabnormally largefetal head due to excessive accumulation of fluidaround thebrain . Placenta praevia . Breech delivery in theprevious pregnancy . Abnormalformation of theuterus.

8.3.2Diagnosis of breech presentation On abdominal palpationthe fetalhead is found above themother’sumbilicus as ahard, smooth, roundedmass,which gently ‘ballots’ (can be rocked) between your hands.

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■ Whydoyou thinkamass that ‘ballots’ high up in theabdomen is asign of breechpresentation? (You learnedabout this in Study Session 11 of the Antenatal Care Module.) □ The baby’shead can ‘rock’ alittle bitbecause of the flexibility of the baby’sneck,soifthere is arounded, ballotable mass above themother’s umbilicus it is very likelytobethe baby’shead.Ifthe baby was ‘bottom- up’ (vertexpresentation) thewholeofits back will move of you tryto rock thefetal parts at thefundus (Figure8.3).

Figure 8.3(a) Thewhole back of ababyinthe vertex position will move if you rock it at thefundus; (b) Thehead can be ‘rocked’ andthe back staysstill in a breech presentation. Once thefetus hasengagedand labour hasbegun, thebreech baby’sbuttocks can be felt as soft andirregular on vaginalexamination. They feel very differenttothe relatively hard roundedmass of thefetal skull in avertex presentation. When thefetal membranesrupture, thebuttocksand/orfeet can be felt more clearly.The baby’sanus maybefeltand fresh thick, dark meconium maybeseen on your examining finger. If thebaby’slegsare extended, you maybeabletofeel theexternalgenitalia andeventellthe sex of thebabybeforeitisborn.

8.3.3Types of breechpresentation Thereare threetypesofbreech presentation, illustratedinFigure8.4 on the next page.Theyare:

. Completebreech is characterized by flexionofthe legs at bothhipsand kneejoints, so thelegsare bent underneath thebaby. . Frank breech is thecommonest type of breech presentation, andis characterized by flexionatthe hipjointsand extensionatthe kneejoints, so boththe baby’slegspoint straight upwards. . Footling breech is whenone or bothlegsare extendedatthe hipand knee jointand thebabypresents ‘foot first’.

101 Figure8.4 Differenttypes of breech presentation. (Source: WHO, as in Figure8.1)

8.3.4Risksofbreechpresentation Regardless of thetype of breech presentation, thereare significantassociated riskstothe baby.Theyinclude: Refer allcases of breech . The fetalhead gets stuck(arrested)beforedelivery presentation to thenearest . Labour becomesobstructed whenthe fetusisdisproportionately largefor higher-level health facility. thesizeofthe maternal pelvis . Cordprolapse mayoccur, i.e. theumbilical cord is pushedout ahead of Cord prolapse in anormal thebabyand mayget compressed againstthe wallofthe cervixorvagina (vertex) presentation was illustrated in Study Session17of . Prematureseparationofthe placenta (placentalabruption) the Antenatal Care Module,and . Birth injury to thebaby, e.g. fractureofthe arms or legs,nerve damage, placentalabruptionwas covered traumatothe internal organs,spinalcorddamage, etc. in Study Session 21. Abreech birthmay also result in traumatothe mother’sbirthcanal or external genitalia through beingoverstretchedbythe poorly fitting fetalparts. ■ What will be theeffect on thebabyifitgetsstuck,the labour is obstructed,the cord prolapses, or placentalabruptionoccurs?

Youlearned aboutthe causes and □ Theresult will be hypoxia,i.e.itwill be deprived of oxygen, andmay consequences of hypoxiainthe sufferpermanent braindamageordie. AntenatalCare Module. 8.4Face presentation Facepresentation occurs whenthe baby’sneck is so completely extended (bentbackwards) that theocciput at theback of thefetal skull touchesthe baby’sown spine(see Figure8.5). In this position,the baby’sface will present to you duringdelivery.

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Figure 8.5Facepresentation. (a)The baby’schinisfacingtowards thefrontof themother’spelvis; (b)the chin is facing towards themother’sbackbone. (Source: WHO, as in Figure8.1). Theincidence of face presentationisabout 1in500 pregnanciesinfullterm Refer themotherifababyinthe labours. In Figure8.5,you can see how flexed thehead is at theneck.Babies chin posteriorfacepresentation whopresentinthe ‘chin posterior’ position(on theright in Figure8.5) does notrotateand thelabouris prolonged. usually rotate spontaneously duringlabour,and assumethe ‘chin anterior’ position, whichmakes it easier forthemtobeborn. However,theyare unlikelytobedelivered vaginallyiftheyfailtoundergospontaneous rotation to thechinanteriorposition, because thebaby’schinusually gets stuck againstthe mother’ssacrum (thebony prominence at theback of herpelvis). Ababyinthispositionwill have to be delivered by caesarean surgery.

8.4.1Causes of face presentation Thecauses of face presentationare similartothosealreadydescribed for breech births:

. Laxity (slackness) of theuterusaftermanyprevious full-term pregnancies . Multiple pregnancy . Polyhydramnios (excessive amniotic fluid) . Congenitalabnormality of thefetus (e.g.anencephaly,which meansnoor incomplete skullbones) . Abnormalshape of themother’spelvis.

8.4.2Diagnosis of face presentation Face presentationmay not be easily detected by abdominal palpation, especially if thechinisinthe posterior position. On abdominal examination, you mayfeel irregular shapes, formed because thefetal spine is curved in an ‘S’ shape. However,onvaginal examination, you can detect face presentation because:

. The presenting part will be high, soft andirregular.

103 . When thecervixissufficientlydilated,you maybeabletofeel partsofthe face, such as theorbital ridgesabove theeyes, thenoseormouth, gums, or bony chin. . If themembranes areruptured,the baby maysuckyour examining finger!

But as labour progresses, thebaby’sface becomes oedematous (swollenwith fluid),makingitmoredifficult to distinguish fromthe soft shapeyou will feel in abreech presentation.

8.4.3Complicationsoffacepresentation Complications forthe fetusinclude:

. Obstructed labour andruptured uterus . Cordprolapse . Facialbruising . Cerebral haemorrhage(bleedinginsidethe fetalskull).

8.5Browpresentation In brow presentation,the baby’shead is onlypartially extendedatthe neck (compare this with face presentation),soits brow (forehead)isthe presenting part (Figure8.6). This presentationisrare, with an incidenceof1in 1000 deliveriesatfullterm.

8.5.1Possiblecauses of brow presentation Youhaveseen allofthese factorsbefore, as causes of othermalpresentations:

. Lax uterus due to repeated full term pregnancy . Multiple pregnancy Figure 8.6Brow presentation. (Source: WHO, as in . Polyhydramnios Figure 8.1) . Abnormalshape of themother’spelvis.

8.5.2Diagnosis of brow presentation Brow presentationisnot usually detected before theonset of labour,exceptby very experienced birth attendants. On abdominal examination, thehead is high in themother’sabdomen,appearsundulylarge anddoesnot descendintothe pelvis,despite good uterinecontractions.Onvaginal examination, the presenting part is high andmay be difficult to reach.You maybeabletofeel Recallthe appearance of a theroot of thenose, eyes, but not themouth, tip of thenoseorchin. Youmay normalcaput overthe posterior also feel the anterior fontanel,but alarge caput (swelling) towardsthe front fontanel shown in Figure4.4 of thefetal skull maymask this landmarkifthe woman hasbeen in labour for earlier in this Module. some hours.

8.5.3Complicationsofbrowpresentation The complications of brow presentationare much thesameasfor other malpresentations:

. Obstructed labour andruptured uterus . Cordprolapse . Facialbruising . Cerebral haemorrhage.

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■ Whichare you more likelytoencounter — face or brow presentations? □ Facepresentation, whichoccurs in 1in500 full term labours. Brow presentationismorerare, at 1in1,000 full term labours.

8.6Shoulderpresentation Shoulder presentation is rare at full term,but mayoccurwhenthe fetuslies transverselyacrossthe uterus (Figure8.7), if it stoppedpart-waythrough spontaneous inversionfrombreechtovertex, or it maylie transverselyfrom early pregnancy. If thebabyliesfacingupwards,its back maybethe presenting part;iffacing downwards its hand mayemergethrough thecervix. Ababyinthe transverseposition cannot be bornthrough thevaginaand the labour will be obstructed. Refer babies in shoulderpresentation urgently.

Figure 8.7Transverselie (shoulder presentation). This baby cannotdescend through thebirth canal.

Do not attempttoturna 8.6.1Causes of shoulder presentation sideways lyingbaby. Unless a Causes of shoulderpresentationcouldbematernalorfetal factors. trainedphysician or midwifecan turn thebaby‘head down’, it Maternal factorsinclude: mustbedelivered by caesarean surgery. . Lax abdominal anduterine muscles: most oftenafterseveral previous pregnancies . Uterineabnormality . Contracted (abnormally narrow) pelvis.

Fetalfactors include:

. Pretermlabour . Multiple pregnancy . Polyhydramnios . Placenta previa.

105 ■ What do ‘placenta previa’ and ‘polyhydramnios’ indicate? □ Placenta previa is when theplacenta is partly or completely coveringthe cervical opening. Polyhydramnios is an excess of amniotic fluid. They arebothpotentialcauses of malpresentation.

8.6.2Diagnosis of shoulder presentation On abdominal palpation, theuterusappearsbroader andthe height of the fundus is less than expected forthe period of gestation, because thefundus is not occupied by either thebaby’shead or buttocks. Youcan usually feel the head on one side of themother’sabdomen.Onvaginal examination, in early labour,the presenting part maynot be felt,but when thelabour is well progressed,you mayfeel thebaby’sribs. When theshoulderentersthe pelvic brim,the baby’sarm mayprolapseand become visibleoutside thevagina.

8.6.3Complicationsofshoulderpresentation Complications include:

. Cordprolapse . Trauma to aprolapsed arm . Obstructed labour andruptured uterus . Fetal hypoxiaand death.

Remember that ashoulderpresentation meansthe baby cannot be born through thevagina; if you detect it in awoman who is alreadyinlabour,refer herurgently to ahigherhealth facility.

In allcases of malpresentation or malposition, do not attempttoturnthe baby with your hands!Onlyaspecially trained doctorormidwife should attemptthis. Referthe mother so she andher baby canget emergency obstetric care.

8.7Multiplepregnancy In this section, we turn to thesubject of multiple pregnancy,whenthere is more than one fetusinthe uterus.Morethan95% of multiple pregnanciesare twins(twofetuses),but therecan also be triplets(threefetuses),quadruplets (four fetuses),quintuplets(five fetuses),and otherhigherorder multiples with adecliningchanceofoccurrence. The spontaneous occurrenceoftwins varies by country:itislowestinEast AsiancountrieslikeJapan andChina (1 out of 1000 pregnanciesare fraternal or non-identical twins),and highest in black Africans, particularly in Nigeria, where 1in20pregnanciesare fraternal twins. In general, compared to single babies, multiple pregnanciesare highly associated with early pregnancylossand high perinatalmortality,mainlydue to prematurity.

8.7.1Types of twinpregnancy Twinsmay be identical (monozygotic)ornon-identical andfraternal (dizigotic). Monozygotic twins developfromasinglefertilized ovum (the zygote),sotheyare always thesamesex andtheyshare thesameplacenta.By contrast, dizygotic twins developfromtwo differentzygotes, so they can have

106 Study Session8 AbnormalPresentations andMultiplePregnancies

thesameordifferent sex,and they have separateplacentas. Figure8.8 shows thetypesoftwinpregnancyand theprocesses by which they areformed.

Figure 8.8Types of twin pregnancy:(a) Fraternalornon-identical twinsusually eachhaveaplacenta of theirown,althoughtheycan fuse if thetwo placentaslie very closetogether. (b)Identical twinsalwaysshare thesameplacenta,but usuallytheyhavetheir ownfetal membranes.

107 8.7.2Diagnosis of twin pregnancy On abdominal examinationyou maynoticethat:

. The size of theuterusislargerthanthe expected forthe periodfor gestation. . The uterus looks round andbroad,and fetalmovement maybeseen overa largearea. (The shapeofthe uterus at term in asingleton pregnancyinthe vertexpresentation appearsheart-shaped rounderatthe topand narrower at thebottom.) . Twoheadscan be felt. . Twofetal heartbeatsmay be heardiftwo people listenatthe sametime, andtheycan detect at least 10 beatsdifferent (Figure8.9). . Ultrasound examinationcan make an absolute diagnosis of twin pregnancy.

8.7.3Consequencesoftwin pregnancy Womenwho arepregnant with twinsare more prone to suffer with theminor disordersofpregnancy, like morningsickness, nausea andheartburn. Twin pregnancyisone cause of hyperemesisgravidarum(persistent, severenausea andvomiting).Mothers of twinsare also more at risk of developing ironand folate-deficiency anaemia duringpregnancy. ■ Canyou suggest whyanaemia is agreater risk in multiple pregnancies? □ Themotherhas to supplythe nutrients to feed two(or more)babies; if sheisnot gettingenough iron andfolateinher diet,orthrough supplements,she will become anaemic.

Othercomplications include thefollowing:

. Pregnancy-relatedhypertensivedisorders likepre-eclampsia andeclampsia Figure 8.9Two people can aremorecommonintwinpregnancies. listen fortwins,bytapping in . Pressure symptomsmay occurinlatepregnancydue to theincreased rhythmwiththe twofetal heart weight andsizeofthe uterus. beats. . Labour oftenoccurs spontaneously before term,withpremature deliveryor prematureruptureofmembranes (PROM). . Respiratory deficit(shortness of breath, because of fast growing uterus)is anothercommonproblem.

Youwill learnabout lowbirth Twin babies maybesmall in comparison to theirgestationalage andmore weight babies in detail in the pronetothe complications associated with lowbirth weight (increased Postnatal Care Module. vulnerability to infection, losing heat,difficultybreastfeeding).

. Malpresentation is more common in twin pregnancies, andtheymay also be ‘locked’ at theneck with one twin in thevertexpresentation andthe otherinbreech.The risksassociatedwithmalpresentations already describedalsoapply:prolapsed cord,pooruterine contraction, prolonged or obstructed labour,postpartumhaemorrhage, andfetal hypoxiaand death. . Conjoinedtwins (fused twins, joined at thehead,chest,orabdomen,or through theback)may also rarely occur.

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8.8Managementofwomen with malpresentation or multiple pregnancy As you have seen in this study session, anypresentation otherthanvertexhas its own dangers forthe mother andbaby. For this reason,all women who developabnormalpresentationormultiple pregnancyshouldideally have skilledcarebyseniorhealth professionalsinahealth facility where thereisa comprehensiveemergency obstetric service. Earlydetectionand referralofa womaninany of these situations cansaveher life andthatofher baby. ■ What can you do to reducethe risksarising frommalpresentationor multiple pregnancyinwomen in your care? □ Duringfocused antenatalcareofthe pregnant women in your community, at everyvisit after36weeksofgestationyou shouldcheck forthe presence of abnormalfetal presentation. If you detect abnormal presentationormultiplepregnancy, you shouldrefer thewoman before theonset of labour.

Summary of StudySession8 In Study Session8,you learnedthat: 1Duringearly pregnancy, babies arenaturally in thebreech position, but in 95% of cases they spontaneously reverseintothe vertex presentation before labour begins. 2Malpresentationormalpositionofthe fetusatfulltermincreases therisk of obstructed labour andother birthcomplications. 3Commoncauses of malpresentations/malpositions include:excessamniotic fluid, abnormalshape andsizeofthe pelvis;uterinetumour;placenta praevia;slackness of uterinemuscles (aftermanyprevious pregnancies);or multiple pregnancy. 4Commoncomplications include:premature ruptureofmembranes, prematurelabour,prolonged/obstructed labour;ruptured uterus;postpartum haemorrhage; fetaland maternal distress whichmay lead to death. 5Vertexmalpositioniswhenthe fetalhead is in theoccipito-posterior position — i.e. theback of thefetal skull is towardsthe mother’sback instead of pointingtowards thefront of themother’spelvis. 90% of vertex malpositions rotate anddeliver normally. 6Breech presentation(complete,frank or footling) is whenthe baby’s buttockspresentduringlabour.Itoccurs in 3-4% of laboursafter34 weeksofpregnancyand maylead to obstructed labour,cordprolapse, hypoxia, prematureseparationofthe placenta,birth injury to thebabyor to thebirth canal. 7Face presentationiswhenthe fetalhead is bent so farbackwardsthatthe face presents duringlabour.Itoccurs in about 1in500 full term labours. ‘Chinposterior’ face presentations usually rotate spontaneously to the ‘chin anterior’ position anddeliver normally.Ifrotationdoesnot occur, a caesarean deliveryislikelytobenecessary. 8Browpresentationiswhenthe baby’sforehead is thepresenting part. It occurs in about 1in1000fulltermlaboursand is difficult to detect before theonset of labour.Caesarean delivery is likelytobenecessary. 9Shoulderpresentation occurs whenthe fetallie duringlabouristransverse. Oncelabouriswellprogressed, vaginalexaminationmay feel thebaby’s

109 ribs, andanarm maysometimes prolapse.Caesarean deliveryisalways requiredunless adoctorormidwife can turn thebabyhead-down. 10 Multiple pregnanciesare always at high risk of malpresentation. Mothers need greaterantenatal care, andtwins aremoreprone to complications associated with lowbirth weight andprematurity. 11 Any presentationother than vertex after34weeksofgestationis considered as high risk to themotherand to herbaby. Do notattempt to turn amalpresenting or malpositionedbaby! Refer themotherfor emergencyobstetric care.

Self-Assessment Questions (SAQs) forStudy Session8 Now that you have completedthisstudy session, youcan assess how well you have achievedits Learning Outcomes by answeringthe following questions. Write your answersinyour Study Diaryand discuss them with your Tutorat thenextStudy Support Meeting. Youcan check your answerswiththe Notes on theSelf-AssessmentQuestions at theend of this Module. SAQ8.1 (testsLearning Outcomes8.1,8.2 and8.4) Whichofthe following definitions aretrueand whichare false? Write down thecorrect definitionfor anywhich you thinkare false. AFundus — the ‘roundedtop’ andwidest cavity of theuterus. BCompletebreech — where thelegsare bent at bothhipsand knee joints andare folded underneaththe baby. CFrank breech — where thebreech is so difficult to treat that you have to be very frank andopenwiththe mother about thedifficulties shewill face in thebirth. DFootling breech — whenone or bothlegsare extendedsothatthe baby presents ‘foot first’. EHypoxia — thebabygetstoo much oxygen. FMultiplepregnancy — when amotherhas hadmanybabies previously. GMonozygotic twins — developfromasinglefertilized ovum (the zygote).Theycan be differentsexes but they sharethe sameplacenta. HDizygotic twins — developfromtwo zygotes.Theyhaveseparate placentas, andcan be of thesamesex or differentsexes.

SAQ8.2 (testsLearning Outcomes8.1 and8.2) What arethe main differences between normaland abnormalfetal presentations?Use thecorrect medical termsinbold in your explanation.

SAQ8.3 (testsLearning Outcomes8.3 and8.5) (a)Listthe common complications of malpresentations or malpositionof thefetus at full term. (b)Whatactionshouldyou take if you identify that thefetus is presenting abnormallyand labour hasnot yetbegun? (c)Whatshouldyou not attempttodo?

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SAQ8.4 (tests Learning Outcomes 8.4and 8.5) Apregnant woman movesintoyour villagewho is alreadyat37weeks gestation. Youhaven’tseen herbefore. Shetells you that she gave birth to twinsthree yearsago andwants to knowifshe is having twinsagain this time. (a)How wouldyou check this? (b)Ifyou diagnosetwins,whatwouldyou do to reducethe risksduring labour anddelivery?

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StudySession 9Obstructed Labour

Study Session 9ObstructedLabour Introduction Obstructed labour is atotally preventablelabour complication. Oneofyour majorroles as askilledbirth attendant is to preventthe occurrenceof obstructed labour in womeninyour community.Itishighlyprevalent in the ruralareas of Ethiopia, particularlyamong women whoare in labour at home foralong time. Obstructed labour is associated with ahigh perinatal mortalityand morbidity (fetaland newborndeaths,and disease anddisability occurring around thetimeofthe birth).Itcontributes to 22%ofthe maternal mortality in Ethiopia.Thisshocking figureiscertainly an underestimationofthe problem,because deaths due to obstructed labour areoftenclassified under othercomplications (suchassepsis, postpartumhaemorrhageorruptured uterus). In this session, you will learnhow to identify theclinical signs of prolonged andobstructed laboursand determinethe best management.Delayed management of obstructed labour oftencauses fistulainsurviving women, whichifnot treated,may make them outcastsfromtheir community forthe rest of theirlives. Learning Outcomesfor StudySession9 When you have studied this session, youshouldbeableto: 9.1Define anduse correctly allofthe keywords printedinbold.(SAQs 9.2and 9.3) 9.2Listthe main causes of obstructedlabour anddescribehow each factor contributes to thedevelopmentofthiscomplication. (SAQ 9.1) 9.3Describethe clinical signs of obstructedlabour andthe common maternal andfetal complications that result fromuterineobstruction. (SAQ 9.3) 9.4Describethe management of obstructedlabour andwaysofpreventing it through your actions.(SAQ 9.3) 9.5Explainhow social changesatcommunity levelcouldaffect therisk of obstructedlabouroccurring. (SAQ 9.4)

9.1Defining obstructed labour Obstructed labour is thefailure of thefetus to descendthrough thebirth canal,because thereisanimpossiblebarrier (obstruction) preventingits descentdespitestronguterinecontractions.The obstructionusually occurs at thepelvicbrim,but occasionallyitmay occurinthe pelvic cavity or at the outletofthe pelvis.Whenlabourisprolongedbecause of failuretoprogress, thereisahighriskthatthe descentofthe fetuswill become obstructed.There is no singledefinitionofprolongedlabour,because what countsas‘toolong’ varieswiththe stageoflabour (see Box 9.1).

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Box9.1 When is labour classed as prolongedinthe differentstages of labour?

. Prolongedlatentphaseoflabour:whentruelabour lastsfor more than about 8hours without enteringintothe active firststage. . Prolongedactivephaseoflabour:whentruelabour takesmorethan about 12 hours without entering into thesecond stage. . Prolongedsecondstage of labour: ◦ Multigravida mother:whenitlastsfor more than 1hour. ◦ Primigravida mother:whenitlastsfor more than 2hours. Although labour canbeclassed as ‘prolonged’ at anystage,you should note that obstructed labour most commonlydevelops afterthe labour has enteredintothe second stage.

9.2Causes of obstructed labour As indicated above,obstructed labour is generallyasecond stage phenomenon, in women whoselabour is prolonged. Whylabour becomes prolongedorobstructedmay be due to one of the ‘Ps’ (asmidwivesand obstetricians callthem): ‘powers’, ‘passenger’ and ‘passage’.

. Powers:Inadequate power,due to poor or uncoordinateduterine contractions,isamajorcause of prolongedlabour. Either theuterine contractions arenot strong enough to efface anddilate thecervixinthe firststage of labour,orthe muscular effort of theuterusisinsufficientto pushthe baby down thebirth canal duringthe second stage. . Passenger: Thefetus is the ‘passenger’ travelling down thebirth canal. Prolongedlabour mayoccurifthe fetalhead is toolarge to pass through themother’spelvis, or thefetal presentationisabnormal. . Passage: Thebirth canal is thepassage, so labour maybeprolongedifthe mother’spelvisistoo smallfor thebabytopass through or thepelvishas an abnormalshape,orifthere is atumour or otherphysical obstructionin thepelvis.

Table9.1 (onthe next page)summarizes themechanical causes of ‘passenger’ and ‘passage’ failure.

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Table9.1 Causes of passenger and passagefailuresthatleadtoprolongedand possiblyobstructed labours.

Passenger Passage Head: Bony pelvis: ● Largefetal head (big forthatpelvis) ● Contracted (due to malnutrition) ● Hydrocephalus(brainsurroundedby ● Deformed (due to trauma, polio) fluid, whichmakesthe skullswell) Softtissue: Presentationand position: ● Tumour in thepelvis ● Brow,face, shoulder ● Viralinfectioninthe uterus or ● Persistent malposition abdomen Twin pregnancy: ● Scars(from female circumcision) ● Locked twins(locked at theneck) ● Conjoined twins(fusedtogether with some shared organs)

Themechanical causes of prolongedand obstructed labour shown in Table9.1 canbegroupedintovarious categories: cephalopelvic disproportion; malpresentations andmalpositions;oranabnormality in thefetus or the mother which obstructs thebirth canal.Wewill look at each of these in turn in more detail.

9.2.1Cephalopelvic disproportion (CPD) Cephalic (pronounced‘seff-ah- Cephalopelvic disproportion(CPD) meansitisdifficult or impossiblefor the lik’)isfromaGreekword fetustopass safelythrough themother’spelvisdue either to amaternalpelvis meaning ‘the head’. Disproportiontellsyou that the that is toonarrowfor that fetalhead,oralargefetal head relativetothat sizeofthe fetalheadisdifferent mother’spelvis(see Figure9.1,and thinkback to theanatomy of thematernal from thesizeofthe mother’s pelvis andfetal skull which you learnedinStudy Session 6ofthe Antenatal pelvic brim. Care Module).The small(or contracted)pelvisindeveloping countrieslike Ethiopiaisgenerally due to malnutritioninchildhood persistingintoadult life.Cephalopelvic disproportioncannotusually be diagnosed before the37th week of pregnancybecause before then thebaby’shead hasnot reached birth size.

9.2.2Abnormalpresentationsand multiple pregnancies Persistent malpresentation or malposition areother majorcauses of obstructed labour. ■ Can you distinguish between these twoterms andrecallsomeabnormal fetalpresentations andmalpositions from Study Session 8? □ Malpresentation is anypresentationother than vertex (the topofthe baby’sskullisthe presentingpart).The most common malpresentations are breech (thebaby’sbuttocksand/or itsfeetpresent first), and shoulder when it engages ‘shoulder first’.Malpositioniswhenthe baby is ‘head down’ (cephalicpresentation),but thevertexisinthe wrongposition relative to themother’spelvis. Twoofthe most common malpositions result in face and brow presentations.

Youalsolearnedabout multiple pregnanciesinStudy Session 8. Labour can Figure 9.1Cephalopelvic be obstructed by locked twins (the twobabiesare ‘locked’ together at their disproportion: this woman’s neckswhenthe firsttwinisinbreech presentationand thesecondtwinisin pelvis is toosmall forher baby’shead.

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cephalicpresentation),orconjoinedtwins (twins fused at thechest,head or anyother site).

9.2.3Fetalabnormalities Some fetalabnormalitiesresultinafetuswith an abnormally largehead diameter,for example, hydrocephalus, which is due to excessive accumulation of fluidaround thebaby’sbrain.

9.2.4Abnormalitiesofthe reproductive tract Female genitalmutilation is the Apossiblecause of obstructed labour is if themotherhas atumour (growthor subjectofStudy Session5inthe swelling of tissue) in herpelviccavity,orascarred birthcanal due to asevere Module on Adolescent and Youth type of female genitalmutilation(‘female circumcision’). Or shemay have a Reproductive Health. tight perineum (theareabetween thevulva andthe anus), which doesnot stretchinorder to allowthe baby to pass through. 9.3Clinicalsigns of obstructed labour Akey sign of an obstructedlabour is if thewidestdiameterofthe fetalskull remains stationary above thepelvicbrimbecause it is unabletodescend.You shouldbeabletodetect this by careful palpationofthe mother’sabdomen as theuterusrelaxes andsoftens between contractions.However, if theuterushas gone into toniccontraction (it is continuously hard)and sits tightly moulded around thefetus,itwill be very difficult to feel whether thefetus is making anyprogress in thebirth canal.Palpation will also be very painfulfor the woman. In this case you will have to rely more on othersigns foryour diagnosis, listed below.

9.3.1Assessmentofclinicalsigns of obstruction Obstructedlabour is more likely to occurif:

. The labour hasbeen prolonged(lastingmorethan12hours) . The motherappearsexhausted, anxious andweak . Rupture of thefetal membranesand passing of amniotic fluidwas premature(several hoursbeforelabour began) . The mother hasabnormalvital signs:fast pulse rate,above 100 beats/ minute; lowblood pressure; respirationrateabove 30 breaths/minute; possiblyalsoaraisedtemperature.

Youshould assess awoman with this labour historybydoing avaginal examination. Any of thefollowing additionalsigns wouldsuggest the presence of obstruction:

. Foul-smelling meconium draining fromthe mother’svagina. . Concentratedurine, whichmay containmeconium or blood. . Oedema (swellingdue to collectionoffluidinthe tissues) of thevulva (female external genitalia,including thelabias),especially if thewoman hasbeenpushing foralong time. Vagina feelshot anddry to your gloved examining fingerbecause of dehydration. . Oedema of thecervix. . Alarge swellingoverthe fetalskullcan be felt (caput,Study Session 4). . Malpresentation or malpositionofthe fetus.

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. Poor cervical effacement (look back at Figure1.1 in the firststudy session);asthe result thecervixfeelslikean‘emptysleeve’. . Bandl’sringmay be seen (Figure9.2).

9.3.2Bandl’s ring Bandl’sring is thenamegiven to thedepressionbetween theupperand lower halves of theuterus, at about thelevel of theumbilicus.Itshouldnot be seen or felt on abdominal examinationduringanormallabour (Figure9.2a), but when it becomesvisible and/or palpable (Figure9.2b) Bandl’sringisalate sign of obstructed labour.Above this ring is thegrosslythickened,upper uterinesegment whichispulledupwards (retracted)towards themother’sribs. Belowthe Bandl’sringisthe distended(swollen),dangerously thinned, lower uterinesegment.The lowerabdomen can be furtherdistendedbyafull bladder andgas in theintestines.

Figure 9.2(a) Normal shapeofpregnantabdomen during labour,inawoman lyingonher back;(b) Bandl’sringinthe abdomenofawomanwithobstructed labour.

9.3.3Evidencefromthe partograph YouwillrememberfromStudy Session 4thatthe partographisakeytoolin detectinganabnormalorprolongedlabour.Obstructed labour is revealed by recordings on thepartographofthe rate of cervical dilatation(which, as you know, shouldprogress at arateofatleast 1cmper hour) andthe rate of fetal head descent. Figure9.3(a) showsapartographrecord of anormallabour with progressive cervical dilatation andfetal head descent. Howeverin Figure9.3(b)you can quickly see that thereisevidenceofaprolonged firstor second stageoflabour because:

. thecervical dilatation measurementhas crossed the ‘Alertline’ andifno actionistaken it will crossthe Actionline, despitestronguterine contractions;the fetalhead is not descending.

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Figure9.3 (a)Normalcervical dilatation andfetal head descentrecorded on a partograph. (b)Cervical dilatation hasstoppedand therecord linehas crossedthe Actionline.

Thecervical dilation record on thepartographshouldnot crossthe Alert and/or Actionline. If this occurs you shouldconsider this to be a prolongedand possiblyobstructed labour andmakeanurgentreferral.

■ In Figure9.3(b), how many hoursafter recordings beganonthe partographdid cervical dilation stop progressing? □ Thecervixstoppeddilating 4hoursafterthe partographrecord began.

■ In thepartographshown in Figure9.3(b), howmuchtimehas passed sincethere wasany sign of cervical dilatation? □ Thepartographshowsthatthere wasnoincrease in cervicaldiameterfor theprevioustwo andahalf hours.

9.4Managementofobstructed labour There areseveral things that you can do to try to relievethe obstructionifthe record of cervical dilatation reaches theAlert lineonthe partograph, and before it approaches theActionline. The details of these procedures were taught in the Antenatal Care Module(Study Session 22) andyour practical skills training, so we will onlyrefer brieflytothemhere.

. If thewoman hassigns of shock(fast pulse andlow blood pressure), preparetogiveher an intravenous infusion of Normal SalineorRinger’s Lactate to rehydrateher.Use alarge (No. 18 or 20) cannula. Infuse her with 1litreoffluids,with the flow rate running as quickly as possible, then repeat 1litre every20minutes until herpulse slows to less than 90

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beatsper minute, andher diastolic blood pressure (whenthe heartrelaxes afterabeat)is90mmHgorhigher. . If you thinkthe obstructionmay be due to averyfullbladder, prepareto drainitbyinserting acatheter. Clean theperineal area andcatheterizethe mother’sbladdertodrain theurine into aclosed container. Relieving this obstructionmay be enough to allowthe baby to be born.Notethat catheterizationofthe bladderinawomanwith obstructed labour is usually very difficult, because theurethra is also obstructed by thedeeply engaged baby’shead. . Referthe mother urgently to ahealth facility where asurgicalservice is available(Figure 9.4).She mayneed emergencydeliverybycaesarean section(cuttingopenher abdomen anduterus) to getthe baby out alive andalsotosaveher life.

Figure 9.4Don’tdelay in referringawomanwhose labourmay be obstructed. 9.5Complicationsresultingfromobstructed labour Thecomplications of uterineobstructionfor themotherand forthe fetusor newborncan be very serious.Rememberthatuterineobstructions happen mainly because of aprolonged labour at homethatwas not wellmanaged and whichwas not referredquickly enough. Thecommonest complication affectingthe mother is theformationofafistula.

9.5.1Fistula Fistula is an abnormalopening (usually as aresult of ruptured tissues) between the:

. Vagina andthe urinarybladder . Vagina andrectum . Vagina andurethra (thetube bringing urinefromthe bladdertothe opening in thevulva) . Vagina andureter(thetube bringing urinefromeach kidneytothe bladder).

As aresultofthe fistula, urineorfaeces getintothe vagina andexitinan uncontrolledway.Awoman with a fistualcan leak urineorfaeces while walking, or doing anydaily activities, andthe wastestainsher clothesand Figure 9.5Fistula is oneofthe creates abad smell(Figure9.5). Because of these effects, herhusband and most distressingcomplications family maystigmatizeher or make heranoutcast.You can also imaginewhat of obstructed labour.

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continuously leakingurineorfaeces meansatapersonallevel.Other consequences of fistulamay includeconstant depression, andmanyphysical illnesses andinfections of thereproductive tract,bladderand kidneys,which mayevenresult in thewoman taking herown life. Obstructedlabour is responsiblefor about 20% of allcases of fistula formation(see theresearch study reportedinFigure9.6).

Incidence=0.20 ×0.25×0.20 =0.001,or1per1,000 deliveries

Figure9.6 Clinical expert-based estimation of progressionofprolonged labour to stillbirth andobstetric fistuladevelopment in high-risk sub-Saharan African countries(Source: AmyTsuietal.,The Gates Institute,Johns HopkinsBloomberg School of Public Health,July30, 2005) Otherrarecauses of fistulaare congenitalmalformation(abnormal communication, usually between therectum andvagina, found at birth), infection(specifically tuberculosis), trauma,forceful sexualintercourse (rape), andearly agesexualintercourse.

9.5.2Other common complications of obstructed labour To summarisebriefly, unless it is well managed, obstructed labour can also lead to thefollowing complications in themother:

. Postpartumhaemorrhage(you will learnabout this in Study Session 11 in this Module) . Slow return of theuterustoits pre-pregnancysize . Shock(lowblood pressureand fast pulse rate) . The smallintestinebecomesparalyzed andstops movement (paralytic ileus) . Sepsis (widespread infectionthroughout thebody) . Death.

Youwill learnindetailabout Complications of obstructed labour forthe newborncan include: complications affectingthe newborn in theModules on . Neonatalsepsis Postnatal Care and Integrated . Convulsions (fits) ManagementofNewbornand . Facial injury Childhood Illness . Severe asphyxia(life-threateninglack of oxygen) . Death.

9.6Prevention of obstructed labour There areseveral things that askilled birthattendant can do to preventa prolongedlabour frombecoming obstructed.Additionally, certain cultural changeswould also make asignificantdifferencetothe circumstances that increase theriskofobstructed labour.Wenow look brieflyatthese factors.

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9.6.1Skilledbirth attendance As we saidatthe beginning, obstructedlabourisamajorcause of maternal deathworldwide,and especially in developing countries like Ethiopia.The most important interventionthatcould preventthistollofdeathand disability is having theservices of askilled attendant at thebirth. So areally important part of your role as arural health workeristoteach thepeopleinyour community (men as well as women) about theimportanceofgetting skilled careatevery delivery.Encouragethe women to come to you foradvice and maintain closelinks with thehealth centresorhospital(if thereisone)inyour area to facilitate quick andefficientreferralincases of emergency.

9.6.2Usingthe partograph Thebest diagnostic tool foridentifyingprolongedlabouristoplotthe stages of labour on thepartograph, at thesametimeasregularly assessingfetal and maternal condition(seealsoStudy Session 4).The partographrecord will give you an early warningiflabour maybeprolongedtothe pointwhere an obstructed uterus seemslikelyand referralisessential. So always remember to useitwhenattending anydelivery. ■ What arethe twothings you must do to minimise thechances of a woman whoisinlabour developing a fistula? □ The twothings you shoulddoare:

. Closelymonitorthe progressoflabour usingthe partograph to check that therecord of cervical dilatation staysonortothe left of theAlert line. . Urgently referthe mother to ahealth facilityifshe hasanobstruction (therecord of cervical dilatation is approachingthe Action lineonthe partograph),with pre-referralIVfluidinfusionorbladder catheterizationifappropriate.

9.6.3Birth preparedenessand complication readiness As you learnedinthe Antenatal Care Module(Study Session 13),birth preparedness andcomplicationreadiness arethe pillars of safer labour and delivery. So assist your community to organize themselves into birth preparedness teams, which have theleadership, knowledge,funding and transporttotransfermothers to thenearest health facility if thereisan emergencysuchasobstructed labour.

9.6.4Nutritional education It is also important to interveneinthe underlyingfactorsthatincrease therisk of obstructed labour.Aswesaidearlier, amajor cause of obstructed labour is asmall pelvis,which is mostly theresult of poor nutritionduringchildhood persisting into adultlife. Thusitisimportant to improve childhood nutrition through health education, especially forgirls,toreducethe risk of prolonged andobstructed labour in laterlife.

9.6.5Delayingearly marriage Anotherissueisearly marriage.Researches in Ethiopia have shown that 50% Early marriage is thesubject of a of women, especially ruralwomen,get marriedonaverage at around 16 years, study sessioninthe Module on andmostofthemrapidly become pregnant.Thisgroup of very young mothers Adolescent and YouthReproductive Health. is at especially high risk of obstructed labour because thepelvishas not

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grownsufficiently to accommodate thebaby’shead.Inyour discussions with women, theirpartnersand community leadersyou can point outthese risksof early marriage,and trytopersuadethemofthe importanceofdelayingthe firstbirthuntil afterthe woman is 18. As part of this,you will need to promotecontraception(family planning methods)asaway of delaying the firstpregnancyamong these very young women. If unwanted pregnancy occurs,itisalsoimportant to counsel about safe abortion services (as described in the Antenatal Care Module, Part 2, Study Session 20). Summary of StudySession9 In Study Session 9you have learnedthat: 1Obstructed labour is failureofdescentofthe fetusthrough thebirthcanal (pelvis) because thereisanimpossiblebarrier (obstruction) preventingits descentinspite of strong uterinecontractions. 2Causes of obstructed labour arecephalopelvic disproportion (CPD), abnormalpresentations,fetal abnormalitiesand abnormalitiesofthe maternal reproductivetract. 3Causes of prolongedlabourare abnormality in one or more of thethree ‘Ps’:power,passenger andpassage. 4The best diagnostic tool foryou to identifyprolongedlabour is the partograph. 5The clinical features of obstructed labour include mother stay in labour for more than 12 hours, exhaustedand unable to supportherself, deranged vitalsigns,dehydrated,Bandl’sringformationinthe abdomen,bladderfull above thesymphysispubis, bigcaput andbig moulding, maybe edematous vaginalopening. 6Commonmaternalcomplications of obstructedlabour include sepsis, paralyticileus,postpartumhaemorrhage, fistulaformation. 7Commonfetal complications of obstructed labour aresevereasphyxia, neonatalsepsisand death. 8Early referralcan save thelifeofthe woman andthe baby in case of obstructed labour.

Self-Assessment Questions (SAQs) forStudy Session9 Now that you have completedthisstudy session, youcan assess how well you have achievedits Learning Outcomes by answeringthe following questions. Write your answersinyour Study Diaryand discuss them with your Tutorat thenextStudy Support Meeting. Youcan check your answerswiththe Notes on theSelf-AssessmentQuestions at theend of this Module.

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StudySession 9Obstructed Labour

SAQ9.1 (tests Learning Outcome9.2) Writedown what you understand by thethree ‘Ps’ andhow they cause obstructed labour.

SAQ9.2 (tests Learning Outcome9.1) Writedown what you understand by thefollowing terms: (a)Perinatal mortality andmorbidity (b)Prolongedlatentphase of labour (c)Prolongedsecond stageoflabour (d)Malposition (e)Caput.

SAQ9.3 (tests Learning Outcomes 9.1, 9.3and 9.4) Read Case Study 9.3and then answer thequestions that follow it.

Case Study9.1 Tadelech’sstory Tadelech livesinMekit Woreda.The journeyfromvillage to city can take days,and shelives farfromevenahealth post. Tadelech is 25 years oldand hasalreadydelivered twochildrensafelyinthe village.Thisis herthird pregnancy. Contractions started at 40 weeksofgestation. After twodaysoflabour Tadelech is carriedonahome-made stretchertoyour health post. When you examineTadelech, findstwo swellings (masses) overthe abdomen,with adepression between them at about thelevel of thewoman’sumbilicus (belly button).You also find that thebaby’shead is not engaged(it is just above thepelvicbrim). On vaginalexamination, you estimatethatTadelech’scervixis8cm dilatedand thestation of the fetalhead is -3. Tadelech’svaginaishot anddry andshe hasoedemaof thevulva.

(a)Fromthe case study what signs do you find that indicateprolongedor obstructed labour? (b)How do you manage Tadelech’scondition?

SAQ9.4 (tests Learning Outcome9.5) Howcan you reducethe risksofaprolongedand obstructed labour for womengivingbirthathome?

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Study Session10RupturedUterus

Study Session 10 Ruptured Uterus Introduction Ruptured uterus is atearingorburstingofthe uterus due to thepressure exertedbyanobstructed labour.Uterinerupture is very prevalentin developing countries like Ethiopia, where around 94% of deliveriesoccurat homewithnoskilledhealth professionalattending thelabour.Whenlabour ends with aruptured uterus,the usualconsequences forthe woman (if she survives),are losing herbabyand losing heruterus. Almost allcases of uterineruptureoccuramong multiparous women,who have previously givenbirth at least once aftertheir baby reached 28 weeksof gestation. Youwill find out why this is so laterinthisstudy session. Uterine rupturecan also occuramong womenwithascarreduterus, if thescar tissue tearsopen. However,inEthiopiaand otherdevelopingcountries, almost all cases of uterineruptureoccurinwomen with an unscarreduteruswhose labour becameobstructedwhennoone was present to intervene. In this study session you will learnabout theriskfactorsand clinical features of ruptured uterus,its consequences forthe mother andthe baby,and how to institutelife- savinginterventions. Learning Outcomesfor StudySession10 When you have studied this session, youshouldbeableto: 10.1Define anduse correctly allofthe keywords printedinbold.(SAQs 10.1and 10.2) 10.2Describethe predisposingfactorsfor uterineruptureand explainwhy multiparous womenare at greater risk than first-time mothers. (SAQ 10.2) 10.3Describethe warning signsand clinical features of uterinerupture andthe common complications that result fromit. (SAQs 10.3 and10.4) 10.4Explainhow you wouldperform life-savinginterventions forwomen with aruptured uterus,and what actions you wouldtaketoreducethe risk of uterineruptureduringlabour.(SAQ10.4)

10.1 Predisposing factors foraruptured uterus Theuterusofawomaninlabour mayruptureifthe delivery is obstructed (for anyreason)while theuteruscontinuescontractinguntil it tearsorbursts. You alreadyknow alot about thecomplications of labour anddeliveryfromStudy Sessions 8and 9, so you shouldbewellpreparedtoanswerthe following question. ■ What factorscan you suggestthatwouldincreasethe risk of aruptured uterus occurring? □ Uterinerupturemay occurifthe labour is obstructeddue to:

. Cephalopelvic disproportion (thefetal head is toolarge or the mother’spelvisistoo smalltoallow thebabytodescend down the birth canal). . Persistent malpresentationormalposition of thefetus (e.g.breech, face, brow or shoulderpresentation, or thebabyishead down (vertex presentation) but in theoccipito-posterior position(with theback of its skulltowards themother’sback).

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. Multiple pregnancy (twinsormorebabies, especially if they are ‘locked’ at theneck or conjoined/fused together). . Physical obstruction preventingthe baby from descending (e.g.a tumour in theabdomen or uterus). . Scarring of theuterus(whichwereferredtointhe introduction to this study session).

The firstfour causes have alreadybeencoveredindetailinearlierstudy sessions,but thereismoretobesaidabout uterinescarringand some other reasonswhy uterinerupturemay occur.

10.1.1Uterinescarring Awoman who hashad previous surgeryonher uterus – forexample,to deliverababy by caesarean section, or to remove auterinetumour – will be left with scar tissuewhere thesevered uterinewallhas healed.Scar tissueis less flexible than theintact wall of theuterusand it cannot stretchevenly duringlabour contractions.Ifthe labour is obstructedfor along time, the powerfulcontractions of themusclelayer in theuterine wallmay cause the scar tissuetotear open. Anotherreason forscarringofthe uterus is if it was perforated duringanabortion foraprevious pregnancy.

10.1.2Scarred cervix The cervixmay also have been damagedduringaprevious delivery,for examplebyforcepsused to help deliver ababythatwas failingtomake progress after thehead hadcrowned. Or cervical damage mayhaveresultedif surgical instrumentswereinsertedintothe uterus viathe vagina,for example to controlpostpartumhaemorrhage, or to treat aproblem in theuterussuchas inflammationofthe uterinelining. In anyofthese cases theinjured cervixwill developscar tissueafter healingthatmay burst open duringanobstructed labour. ■ Do you recallfromthe Antenatal Care Module, whatnames aregiven to themusclelayer in theuterusand theinnerliningofthe uterus (where theplacenta forms)? □ Themusclelayer is calledthe myometrium,and theinnerliningisthe endometrium.

10.1.3Previouslyrepaired fistula Youlearnedabout fistulainStudy Session 9. It is one of themostserious complications of obstructedlabour andishighlyprevalent in therural areas of Ethiopia. If awoman developedafistuladuringaprevious labour,which was then surgically repaired,the scarringthatdeveloped as the fistulahealed may have been so extensivethatitobstructsthe delivery of thenextbaby. ■ Whichpartofthe birth canal will be scarred by arepaired fistula? □ Thevagina: a fistula is atornopening betweenthe vagina andeitherthe urinarybladder, therectum,the urethraorthe ureter.

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StudySession 10 Ruptured Uterus

Womenwho areknowntohaveascarred uterus,cervixorvaginashould be stronglyadvised to deliver theirnextbabyinahealth facility with a blood transfusion service andthe surgical equipmentand expertise to perform acaesarean delivery if theneed arises.

10.2 Whyare multiparouswomenmore at risk of uterine rupture? A multiparouswoman is one who haspreviously givenbirth to at least one baby after28weeksofgestation. The gestationalage is significant, because by 28 weeks thefetus will have reached asubstantialsizeand weight,sothe multiparous woman’suteruswill alreadyhavebeen stretched. One result of this stretching is that thedeliveryisexpected to be easierinsubsequent pregnancies – which is,indeed,usually thecase. Despitethisfact,multiparous womenare more likelythanprimiparous (first-time) motherstoexperience uterineruptureiftheir labour is obstructed. ■ Canyou suggest areason forthisunexpected finding? □ One reason is that first-timemothers do nothaveaprevious historyof complicated delivery,whereas awoman who hasgiven birthbeforemay have alreadyhad complications which caused scarringofthe uterus or otherparts of thebirth canal.Suchscarring is ariskfactor fora ruptured uterus.

10.2.1 Uterineinertia Anotherreason whymultiparous women with prolongedorobstructedlabours aremoreatriskofuterine rupturerelates to thefact that they continue experiencingpowerfullabour contractions formuchlongerthan first-time mothers. In primiparous women, theuterine contractions remain relatively strong only forabout the first24hoursoflabour,afterwhich thecontractions become weaker in intensity andshorterinduration. Afterabout 36 hours, in the majority of primiparous women,the uterus is exhaustedand they develop uterine inertia,which is whenthe contractions become very weak in intensity, with ashortdurationand long intervalsbetween them.For such first-time mothers, because uterinecontractions have almost ceased, uterineruptureisa rare phenomenon. By contrast,the risk to multiparous womenwhoselabour is obstructedisthatthe uterinecontractions remain forceful andfrequent for very much longer, andasaresult theuterusismorelikelytorupture. Primiparous women do face otherserious problems, however, because uterine inertia meansthatthe fetalhead will stay in thematernalpelvisfor along time. Thisincreases theriskoffetal hypoxia(oxygenshortage), and fistula formation, retentionofurineand infectioninthe obstructed bladderofthe mother.

10.2.2 Traditional abdominalmassage In some parts of Ethiopia, abdominal massage duringlabour is acommon culturalpractice, particularly whenlabour is prolonged. Traditionalbirth attendantsorvillagewomen usebutterand otherlubricants to rubthe

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abdomen andapplypressure on thefundus (roundedtop) of theuterustotry to pushthe baby downwards.Thisisanextremely harmfultraditionalpractice sinceitcan lead to aruptured uterus,especially in multiparous women(for thereasonsgiven above).

10.2.3Inappropriate use of uterotonicagents Whenever you useauterotonicdrug (drugs that cause uterinecontraction, e.g. misoprostol, oxytocin or ergometrine)for activemanagementofthe third stageoflabour (recall Study Session 6),you must firstcheck that thereisno otherfetus in theuterus. Thisisbecause if you mistakenly administer a uterotonicagent when thereisstill afetus in theuterus, it will contract so powerfullythatitcan easily rupture, especially in thecase of multiparous women.Alsoitislikelytoasphyxiate thebaby. ■ Whyare multiparous mothersatgreater risk of aruptured uterus than primiparous women? □ Scarringofthe uterus is amajor risk factor in uterinerupture, because scar tissueisless flexible andmay tear openduringcontractions.A multiparous woman mayhavescarsfromacaesarean,orfroma complicated earlierdeliverywhich damagedthe birthcanal.Also, her uterus will go on contractingfor along time without developing uterine inertia,evenifthe labour is obstructed.

10.3Clinicalfeatures andconsequencesof ruptured uterus Uterineruptureistotally preventableifall cases of prolongedlabour are managedeffectivelyand appropriate actionistaken before theuterus spontaneously ruptures.

10.3.1Warningsigns of imminent uterine rupture Box 10.1 shows thecommonwarning signs of imminent uterinerupture. These are thebest indicatorsthatthe labour is obstructedand that,unlessthe baby is quickly delivered by surgical operation, theuterusisverylikelyto rupturesoon.

Box10.1Warning signsofuterine rupture

. Frequent,strong uterinecontractions,occurringmorethan5times in every10minutes, and/or each contractionlasting60-90 seconds or longer. . Fetalheartrateabove 160 beats/minute, or below120 beats/minute, persistingfor more than 10 minutes – this is oftenthe earliest sign of obstructionaffectingthe fetus. . Bandl’sringformation (see Study Session 9and Figure10.1). . Tenderness in thelower segment of theuterus. . Possiblyalsovaginal bleeding.

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StudySession 10 Ruptured Uterus

Figure 10.1 Anormalabdominal contour(left)and an obstructed uterus with Bandl’sring(right),indicatingimminentriskofrupture. ■ Howcan thepartographaid you in spottingthe potential imminenceof uterinerupture? □ Sinceyou useittochart thefrequencyand durationofcontractions,as well as changestothe fetalheartrate, you will quicklysee if either of these is in thewarning zone indicated in Box 10.1 above.

10.3.2 Signs thatthe uterushas ruptured The firstsignthatthe uterus hasruptured is that thecontractions stop completely.Other signs rapidlyfollow.

Tender swollenabdomen Tenderness is pain elicitedwhenyou touchthe abdomen.The abdomen is tenderbecause of theruptureinthe uterus andirritationcaused by blood accumulatinginthe abdominal cavity.The abdomen appearsdistended (swollen) because theuterusisinitially totally wrappedaround thefetus and blood is escaping into theabdominal cavity.Bowel movement will be reduced or absent (paralytic ileus) so you will not be able to hear bowel sounds with your stethoscope.The bladdermay also be obstructed,which contributes to theswellingand tenderness. As timepasses, infectionmay developinthe abdomen,which will cause additionalswelling.

Easily palpable fetalparts,absentmovementand fetalheart sounds Thefetus cannot survivelong in aruptured uterus.Afterthe initialwrapping of theuterustightly around its body,parts of thefetus mayemergethrough therupture, or theentirefetus mayescapefromthe uterus into theabdominal cavity.Whenthishappens,ifyou palpatethe abdomen,onlythe abdominal wall will be between your hand andthe fetus, so you will be able to feel the fetalparts easily.Ifthe baby hasdied, themotherwill not feel it moving, and you will notbeabletohear afetal heartbeat.

10.3.3 Consequences forthe mother Theconsequences of therupturefor themotherdependonthe extent of the blood loss, how much time haspassed sincethe ruptureoccurred, andwhether herabdominal cavityand blood system are infected.

Extent of blood loss Uterinerupturebyits nature is atraumatothe uterinetissuewhere therewill be tearingofuterine muscles andblood vessels.Ifthe ruptureinvolvesmajor blood vessels, particularly uterinearteries, theblood loss will be massive. Unless rapidemergency intervention occurs,the blood loss will almost certainlycause thedeathofthe fetus, andthe mother will be in severe haemorrhagicshock (described below),which will be followed by herdeath.

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If theruptureoccurs in an area of theuteruswhere majorblood vesselsaren’t involved,the womanhas agreater chance of survival.

The durationofthe rupture It oftenhappens that ruralwomen,who arenot haemorrhagingexcessively andwhoseconditiondoesnot appear to them or theirfamilies to be immediatelylife-threatening, will remain at homefor hours, even days,after theuterushas ruptured.However,the longerthe woman remainsuntreated with aruptured uterus,the higherthe chance of greater blood loss, acute kidney failure andinfectionwhich hasdisseminated (spread)throughout her body.

Presence of establishedinfection Aruptured uterus meansthere is direct communicationbetween thebirth canal andthe abdominal cavity. Otherinternalorgans, including partsofthe intestines, rectum andbladdermay also have been damagedand be leaking theircontents into theabdomen.Asaresult,microorganismscan easily spread around thewholeofthe abdominalcavity,and enterthe blood circulation through theruptured blood vessels. Thedevelopmentofinfectioninthe abdominal cavity is called peritonitis;infectiondisseminated around thebody in theblood circulationiscalled septicaemia.Ifthe womansurvivesthe initialrupturebut remainsuntreated formorethanabout 6hours, theriskof one or bothofthese conditions occurringisveryhighindeed.Therefore,early recognitionthatarupturehas occurredand early referralare of paramount significance in savingthe life of themother. Dependingonthe extent of blood loss, durationoftimesince theruptureand status of anyinfection, thewoman with aruptured uterus maydevelop some or allofthe complications describedbelow.

Haemorrhagic shock The signs of this rapidlyfatal condition arethatthe mother hasorfeels:

. Faint, dizzy,weak or confused . Pale skin andcoldsweats . Fast pulse (above 100 beats/minute) or toofast to be recordable . Rapidlydropping or unrecordable blood pressure . Fast breathing (above 30 breaths/minute) . Sometimes loss of consciousness . Significantlyreduced or absent urineoutput.

Septic shock Thisoccurs if theruptureand haemorrhagehaveresulted in septicaemia.The signs arethe sameasfor haemorrhagic shock, but with theaddition of high grade fever (above 38oC).

Othercomplications . Peritonitis:infectioninthe abdominal cavity. . Acutekidneyfailure due to lowblood volume.

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. Almostall cases coming to hospitals will be managedbyremoving the uterus (a hysterectomy),sothe woman will be unabletohavemore children.

■ What happens to thefetus at thestage of an imminent ruptured uterus andimmediatelyafterwards? □ Beforethe ruptureits heartrateispersistentlyabove 160 beats/minute, or below120 beats/minute. Afterthe rupturethe uterus wrapsitselfaround thefetus,and with blood draining into theabdominal cavity,itquickly dies unless thereisimmediate surgerytoremove it.

10.4 Interventionsinruptured uterus Thefollowing guidelines will help you to preventorreducethe risk of ruptured uterus occurring in labouring women in your community:

. Usethe partographtofollowthe progress of awoman in labour,toensure you getearly warningifthe labour is not progressingnormally (you learnedhow to usethe partographinStudy Session 4ofthisModule). . Referwomen quickly if you suspect thelabourisprolongedorobstructed (see referral criteria below). . Adviseall multiparouswomen with apotentially scarred uterus (because of complications with an earlier birth) to deliver in ahealth facility with the capacity forblood transfusion andcaesarean delivery.Givethe same advice to anywoman who hashad auterinetumour removed. . Explaintocommunity memberswhy it is important not to massagethe uterus duringlabour,orapplypressure on theuterustotry to hasten delivery;ask them not to do this even thoughitisatraditional practice. . Useuterotonicdrugs to help deliver theplacenta,but only after checking that thelast fetushas been delivered.

10.4.1 Referral criteria forprolongedlabour Do not allowawoman to remain foralong timeinthe firstorsecond stages of labour without making an efficientreferral. ■ When shouldyou referamultiparous or primiparous womanwhose labour is prolonged? (Think back to Study Session 9.) □ Referralfor prolongedlabour should happenfor allwomen if:

. Thelatent firststage of labour lastsmorethan8hoursbeforeentering into theactive firststage . Theactive firststage lastsmorethan12hoursbeforeenteringintothe second stage . Thesecond stageoflabour lastsmorethanone hour in amultiparous woman, or more than twohoursinaprimiparous woman,unless the birth of thebabyseemstobeimminent.

Your majorroleisprimaryprevention – in this case, making sure that if thereisobstructed labour,you can getthe woman to ahealth facility for emergencycareintimetoprevent uterinerupture.However, thereare many reasonswhy you mayhavetogiveemergency careyourselftoawomanwith aruptured uterus,where your role will be secondaryprevention of the complications associated with uterinerupture.

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10.4.2Primary prevention:getting to ahealthfacilityfor emergencycarebeforeuterine rupture ■ Thinkback to whatyou learnedinthe Antenatal Care Module(Study Session 13) andthe discussion thereabout making areferral. What must you remember to do? □ Youshould:

. Writeareferralnotewith as much detail as possible. . Mobilise thecommunity’semergency transport plan forthe mother. Go with herifyou can. . If possible, warn thehealth facility to expect her. If thereisachoice of health facility at roughlyequaldistance, check which one has facilitiesfor emergencysurgery andblood transfusionand sendher there.

10.4.3Secondaryprevention: emergencycarefor awoman in shock Shockisaninevitableconsequenceofaruptured uterus.Soyou referher quickly to thenearest health facility with thenecessaryemergency care services. On theway,havethe woman liewith herfeet higherthanher head, Awoman in shockneedshelp fast. You musttreat herquickly andher head turned to one side (Figure10.2).Keep herwarmand calm. to save herlife.

Figure10.2Positionfor transporting awoman in shocktohospital. Coverher with blankets to keep herwarm. If you have been trained to do so,begin to give herintravenous fluids.You learnedhow to do this in the Antenatal Care Module, Study Session 22, and in your practical skills training. If sheisconscious,she can drinkwater or rehydration fluids (oralrehydrationsalts,ORS). If sheisnot conscious,donot give heranything by mouth-no medicines, drinkorfood. Otherimportant preparations that you shouldalreadyhaveput in place areto:

. Ensurethatyour antenataladvice explainedclearly to thewoman the importanceofhavingskilledhelpwhenshe goes into labour . Persuadethe woman’sfamily andher community to make aplanin advancefor possibleemergencies, including transportand financialsupport . Make sure that you arewellversed andskilledinmakinganearly diagnosis andconducting pre-referral emergencyprocedures . Make sure thewoman goestothe health facility accompaniedbyatleast two fitadultpersonswho can be potentialblood donors, andgowithher if you can.

Finally, try to reducethe possibility of anydelay,which can mean the difference between life anddeath. The reasonswhy so many Ethiopian women dieofaruptured uterus arereluctancetoseek skilledhelpatbirth andthen delayinseekingmedical help followingarupture; furtherdelay in getting

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Study Session 10 Ruptured Uterus

treatment because of distance to ahealth facility;orlack of equipmentand appropriately trained personnelwhenthe woman arrives foremergency care. If you remember allthese pointsyou will have thebestpossiblechanceof ensuring that thewoman is quickly referredtothe most appropriate facility for emergencyinterventionand care. Summary of StudySession10 In Study Session10you have learnedthat: 1InEthiopia, uterinerupturemostoftenoccurs because of neglected obstructedlabour.With early interventionand appropriate care, uterine ruptureisalmostentirelypreventable. 2Morecases of uterineruptureoccuramong multiparous women than among primiparous women.One reason is that in primiparous woman uterineintertia actstoprevent contractions remainingforceful andfrequent forsuchalong timethatuterine ruptureoccurs. 3Uterine inertiainprimiparous women hasother risks: because thefetal head staysinthe pelvis foralong timethere is increased risk of fetal hypoxia, fistulaformation, retentionofurineand infectionofthe bladder. 4The main predisposingfactor foruterine ruptureisanobstructed labour, which maybedue to cephalopelvic disproportion, malpresentation/ malpositionofthe fetus, multiple pregnancy, auterinetumour,orscarring. Otherfactorsincreasing theriskofruptureinclude apreviously repaired fistula, injudicious useofuterotonicdrugs,and abdominal massageduring labour by traditionalhealers. 5The clinical features of imminent uterineruptureare persistent uterine contractions of 60-90 seconds durationorlonger, occurringmorethan5 timesinevery 10 minutes, fetalheartbeat derangement (persistently above 160 beats/minuteorbelow 120 beats/minute),Bandl’sringformation, abdominal tenderness, andmaybe vaginalbleeding. 6The keysignthatauterus hasruptured is that contractions stop completely. 7Other signs of aruptured uterus mayinclude abdominal tenderness, easily palpable fetalparts,abdominal distension, absence of fetalkickand absence of fetalheartbeat. 8The clinical conditionofawomanwith aruptured uterus depends on the extent of blood loss, durationofruptureand presence of established infection. 9Commoncomplications of uterineruptureare fetaldeath, maternal death, infectionand haemorrhagic and/or septic shock, peritonitis,acute kidney failure, andsurgical removalofthe uterus 10 Somereasonswhy so many Ethiopian women dieofaruptured uterus are: reluctance to seek skilledhelpatbirth andthendelay in seekingmedical help following arupture; further delayingettingtreatment because of distance to ahealth facility;orlack of equipmentand appropriatelytrained personnelwhenthe woman arrivesfor emergencycare.

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Self-Assessment Questions (SAQs) forStudy Session10 Now that you have completedthisstudy session, youcan assess how well you have achievedits Learning Outcomes by answeringthe following questions. Write your answersinyour Study Diaryand discuss them with your Tutorat thenextStudy Support Meeting. Youcan check your answerswiththe Notes on theSelf-AssessmentQuestions at theend of this Module. SAQ10.1(tests Learning Outcomes10.1and 10.2) What arethe main factorsthatmay predisposeawomantodevelop a uterinerupture?

SAQ10.2(tests Learning Outcomes10.1and 10.2) Whyare multiparous womenatgreater risk of uterinerupturethan primiparous women?

SAQ10.3(tests Learning Outcome 10.3) Complete Table10.1below by adding details of thewarning signs of a possible uterinerupture.

Table10.1Warning signs of possibleuterine rupture.

ActionsWarning signs Timingthe stages of labour Timingthe uterinecontractions Checkingthe fetalheart rate Checkingthe abdomen

SAQ10.4(tests Learning Outcomes10.3and 10.4) (a)Whatcomplications mayfollowuterinerupture? (b)Whatactions shouldyou take if uterineruptureoccurs?

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Study Session 11 PostpartumHaemorrhage

Study Session 11 Postpartum Haemorrhage Introduction Worldwide,every year,anestimated 127,000 womendie as aresult of blood loss followinglabour anddelivery. It is theworld’sleadingcause of maternal mortality,accountingfor aquarter of allmaternaldeaths.Intotal thereare 14 millioncasesofhaemorrhageoccurringevery year in associationwith pregnancyand childbirth,the majority of which arebecause failure of the uterus to contract properly afterdeliveryofthe placenta resultsinheavy bleedingorpostpartumhaemorrhage.InStudy Session 6you learnedabout themanagementofthe thirdstage of labour,which begins with deliveryofthe baby andends with deliveryofthe placenta andfetal membranes. In this study session, you will learnabout postpartumhaemorrhage(PPH) and its management.PPH is one of themostalarmingand serious emergenciesin childbirth andyour rapidactions can save many lives. Do notforgetthat antepartumhaemorrhage (excessive bleeding before labour begins)can also threaten thelifeofthe mother andfetus.You learnedabout early andlate pregnancybleedinginStudy Sessions 20 and21ofthe Antenatal Care Module. ■ Canyou recallthe twomostcommoncauses of late pregnancybleeding? □ They are: placenta previa,whenthe placenta is closetoorcoveringthe cervixand it tearsawayasthe cervixbeginstoefface anddilateas labour begins;and placentalabruption,whenthe placenta is situated normally in thetop two-thirdsofthe uterus,but it detaches before the birth of thebaby.

Learning Outcomesfor StudySession11 When you have studied this session you shouldbeableto: 11.1 Define anduse correctly allofthe keywords printedinbold. (SAQ 11.1) 11.2 Describe thecauses andriskfactorsfor atonicand traumatic postpartumhaemorrhage. (SAQ 11.2) 11.3 Describe interventions that can help to preventpostpartum haemorrhage, including actions duringpregnancyand labour stages two andthree. (SAQ 11.3) 11.4 Explain how you wouldprovide emergencymanagementfor women who developpostpartumhaemorrhage. (SAQ 11.3)

11.1 What is postpartum haemorrhage? Postpartumhaemorrhage (or PPH)isdefinedasexcessive bleeding from the reproductivetract at anytimefollowing thebaby’sbirth anduptosix weeks afterdelivery. Some70-90% of PPH cases occurwithin the first24hours afterdeliveryand aredue to failureofthe uterus to contract properlyafterthe placenta detaches. Firm uterinecontractionisnecessarytoclose offthe torn blood vesselsinthe placentalbed.

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Riskfactors areexisting PPH is an unpredictable and rapid cause of maternal death. It is unpredictable underlying conditions whichmake in that two-thirdsofwomen who developPPH have none of theknown risk acondition more likely to happen factors (doctors refertoanadversecondition as idiopathic if thereisno or more dangerous. known reason why it occurred).Inother cases, awoman with PPH doeshave one or more of theknown risk factors(we review them laterinthisstudy session),orthe PPHisdue to mismanagementofthe third stageoflabour by thehealthcareprovider.

11.1.1How much bleedingis‘excessive’? Youlearned howtomeasure In normalbirths, themotherusually loses asmall amount of blood (about bloodpressure and pulsein 150 ml or acupful)asthe baby is bornand afterdeliveryofthe placenta. Session9ofthe Antenatal Care When theamount exceeds300 ml (2 cupfuls) it is considered as heavy Module;the causes and bleeding(Figure11.1). Excessive bleeding is oftendefinedasmorethan500 management of haemorrhagic shockwerecovered in Sessions ml of blood loss. However, forseverelyanaemic women, bloodlossofeven 20-22 of that Module. 200-250 ml can be fatal. Forthatreason,abetterdefinitionofpostpartum haemorrhagemight be ‘anyamount of bleedingthatcauses deteriorationinthe woman’sconditionand signs of haemorrhagic shock’,i.e.low blood pressure, fast pulse, pallor, weakness or confusion).

11.1.2Classification of postpartumhaemorrhage Postpartumhaemorrhagecan be classified based upon the timing of the bleedingfollowing deliveryofthe baby andthe cause of thebleeding. Classifications based on thetimingofbleedingare:

. Primarypostpartumhaemorrhage is excessive bleedingoccurring during thethird stageoflabour,orwithin 24 hoursofdelivery. . Secondarypostpartumhaemorrhage (also knownaslate postpartum Figure 11.1 Heavy bleedingis haemorrhage) includesexcessivebleedingoccurringbetween 24 hours more than 300ml; excessive afterdeliveryofthe baby and6weekspostpartum. bleedingismorethan500 ml. Classifications based on the cause of thebleedingare termed either atonic or traumatic PPH. We will discuss each of these andtheir management in the next twosections. 11.2Atonicpostpartum haemorrhage The word ‘atonic’ means ‘loss of musculartone or strengthtocontract’. Atonic postpartumhaemorrhage is characterized by excessive bleeding whenthe uterus is not wellcontracted afterthe delivery, andissoft, distended andlackingmusculartone. More precisely, in atonicPPH, the myometrium (themusclelayer in thewall of theuterus) failstocontract andcompress thematernalblood vesselsthat tear as theplacenta pulls away fromthe wall of theuterus. Most bleeding afterbirth comesfromthe place wherethe placenta waspreviously attached. If themyometriumfails to constrict strongly, it cannot compress theblood vesselstocontrolthe bleeding.

11.2.1Causes of atonicPPH Any conditionthatinterfereswith uterinecontraction, such as aretained placenta,remnantsofplacentaltissue, or retained amniotic membranesor bloodclots,increases theriskofexcessive bleeding. If theplacenta has separatedbut is still, even partially,inthe uterus,itcan preventthe uterus from contracting. Even asmall piece of placenta or ablood clot left inside the

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StudySession 11 PostpartumHaemorrhage

uterus can keep it in theatoniccondition. When theuterusisnot contracted, themother’sblood vesselscontinue to pumpblood out andthe woman will quickly lose blood. Thereal problem with atonic PPH is that you cannot predictwho will bleed excessively afterthe birth,and this is because two-thirds of womenwho developatonicPPH have no known risk factors. Thisiswhy it is important to remember that all women must be considered at risk andpreventionofPPH must be apartofevery birth. The most important known risk factorsare summarized below.

Interference with theabilityofthe uterus to contract Note that whileyou cannot prevent an atonicuterusfromoccurring(norcan you always predictit),knowing thefactorsthatmakeitmorelikelywillhelp you to be alerttothese possiblesigns of atonicPPH:

. Placenta previaorplacentalabruption:inbothconditions themuscle fibres in themyometriumare damagedatthe placentalsite. . Retained placenta:thisiswhenthe wholeorpartofthe placenta remains inside theuterus, interfering with thenormalmuscularcontractionatthe placentalsite. . Incomplete separationofthe placenta:thisiswhenpartofthe placenta hasseparated fromthe uterinewalland part of it remainsattached. . Fullbladder:the structural closeness of theuterusand thebladdermeans that afullbladdercan interfere with thenormaluterinecontractions throughout labour andafterdelivery. . High parity:thisreferstoawomanwho hashad more than five pregnancies; themuscles of themyometriumcan lose theirstrengthto contract firmly,due to repeated stretching. . Multiple pregnancy:causes theuterustoincrease its size to accommodate twoormorebabies(Study Session 10);following theirdelivery, the overstretched uterus maytakealong timetocontract firmly. . Polyhydramnios:anexcessive amount of amniotic fluidsurrounding the baby (morethan3litres) can overstretchthe uterus in thesameway as multiplepregnancy. . Large baby: (over4.0 kilograms) can also overstretchthe uterus. . Prolongedlabour:whenthe labour extends more than 12 hours(Study Session 9),the muscles of themyometriumcan become so exhaustedby repeated contractionthattheycan no longercontract properly (uterine inertia).

Anaemia in themother Anaemia (lack of redblood cells due to lowhaemoglobin)putsthe mother at greater risk of postpartumhaemorrhage, because herblood doesnot clot as easily as in anon-anaemic person. Blood loss is also more serious in someone with anaemia.(Youlearnedaboutthe diagnosis andmanagementofanaemia duringpregnancyinStudy Session 18 of the Antenatal Care Module.)

Mismanagementofthe thirdstage of labour Study Session 6described how activemanagementofdeliveryofthe placenta shouldbeconductedand what actions shouldbeavoided.

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■ What is thenamegiven to thecorrect method of activelyassisting deliveryofthe placenta? □ It is called controlledcordtraction.

■ What incorrect actions by thebirth attendant duringthe thirdstage could result in postpartumhaemorrhage? □ Trying to deliver theplacenta before it separates; pushing down on the fundus of theuteruswhile pulling on theumbilical cord;not waitingfor acontractionbeforeapplying controlled cord tractionand/or notapplying counter-pressure to themother’sabdomen.(Read Study Session 6again if you areunsureofthe stepsincontrolled cord traction.)

11.3Traumatic postpartum haemorrhage In traumatic postpartumhaemorrhage,excessivebleedingoccurs as aresult of trauma (injury)tothe reproductive tract following deliveryofthe baby. Trauma canoccurtothe cervix, vagina,perineumoranus.Itcouldalsobe from aruptured uterus (see Study Session10).Signs of traumatic postpartum haemorrhageare whenthere is bleedingfromthe vagina but theuterusiswell contracted (hard). Trauma to thereproductivetract is preventablethrough skilledand gentle management duringdelivery, andreferringthe mother in good timeifthe labour is prolonged, or if thefetus is in an abnormalpresentation or malposition(Study Session 8). 11.4Reducingthe risk of postpartum haemorrhage In this section we brieflyreviewthe actions you can take at differentstagesto reduce theriskofpostpartumhaemorrhageoccurring – beginning with a pregnant woman before labourstarts.

11.4.1Interventionsduringantenatalcare Youshould arrange forwomen with known risk factors(as describedabove foratonicPPH) to give birth in ahealth facility,where theriskofPPH can be more easily managedand urgent actiontaken if it occurs.Insomecases (e.g.ofplacenta previa,malpresentationortwins), thebabymay have to be deliveredbycaesarean surgery.There aremanyreasonswhy women maynot want to go to ahealth facility,and it is important that you explainclearly and sensitivelytomothers whoare at increased risk why it is not safe forthemto give birth at home. If they refuse, make sure that an emergencyreferralplan is in place andthatpotential blood donorsare readyincase thewoman needs ablood transfusion. The high risk of PPH associated with anaemia is onereason why youshould screen routinelyfor anaemia at everyantenatal (and postnatal)visit, andtake actiontoprevent it.

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Study Session 11 PostpartumHaemorrhage

■ What shouldyou do to preventanaemia in thepregnant women in your Youlearned howtodothisin care? the Antenatal Care Module as part of focused antenatalcare(Study □ Counsel them on good nutritionwith afocus on availableiron-rich and Session13),nutrition in folate-richfoods (e.g.darkgreen leafyvegetables, whole grains,red pregnancy (Study Session14),and meats, eggs)and provide iron/folate supplements. thepreventionand treatmentof anaemia (StudySession 18). ■ What actions shouldyou take to preventanaemia caused by malariaand hookworm?

□ Encourage theuse of insecticide-treated bednetsasprotectionagainst Malaria and hookworm are beingbittenbythe mosquitoes that transmit themalaria parasite.Provide coveredindetailinthe treatment (mebendazole)after the firsttrimester of pregnancyinareas of CommunicableDiseases Module. high hookwormprevalence.

11.4.2 Interventionsduringthe secondstage of labour . Useapartographtomonitorand manage labour andprevent prolonged labour (see Study Session 4ofthisModule). . Encourage thewoman to keep herbladderempty. . Do notencouragepushing before thecervixisfully dilated. . Do not applyfundalpressure (pressing on thetop of theuterus) to assist thebirth of thebaby. . Assist thewoman in thecontrolled delivery of thebaby’shead and shoulders to preventtears(see Study Session 3ofthisModule).Place the fingers of one hand againstthe baby’shead to keep it flexed (bent), supportthe perineum with theother hand, andteach thewoman breathing techniquestopushortostoppushing.

11.4.3 Interventionsduringand afterthe thirdstageof labour Forwomen with no known risk factors, you can reducethe risk of PPH by correct andcareful management of thethird stageoflabour,asdescribed in Study Session 6. In summary, themainpointstorememberare as follows:

. Afterdeliveringthe baby (and checkingthatthere is no otherbabyleft behind in theuterus),givethe woman misoprostol600 mg(micrograms) by mouth, or oxytocin 10 IU (internationalunits)byintramuscular injectiontohelpthe uterus to contract. . Do notapplyfundalpressure to assist thedeliveryofthe placenta. . Rub theuterusimmediately afterthe placenta is delivered,and at least every15minutes forthe first2hoursafter birthtokeep theuteruswell- contracted.Teach thewoman to massageand check herown uterus to keep it firm,and tell hertocallfor assistance if it is soft or if bleeding increases (Figure11.2, on thenextpage).

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Figure11.2Rubbing theuterushelps to stimulateuterine contractionafter placentaldelivery. . Do acareful inspection forlacerations of thevagina, perineumand anus. . Do acareful inspection of theplacenta to ensure that it is intact (Study Session 6showed how to do this). . Help themothertobreastfeed thebabyimmediately afteritisborn – even before theplacentahas delivered(Figure11.3).Whenthe baby sucks, the mother’sbody makesits own oxytocin,which stimulates theuterusto contract at thesametimeasitstimulates themilkducts to contract andlet down milk into thebaby’smouth. Breastfeedinghelps to deliver the placenta andreducepostpartumbleeding.

Figure8.3 Breastfeedingimmediately afterthe birthhelps to reduce postpartum bleeding, as well as bondingthe mother andbaby. Youlearned theprinciples of . Encourage thewoman to emptyher bladderimmediately afterthe birth. urinarycatheterization in Study The uterus maystaysoftbecause themother’sbladderisfull. If she Session22ofthe AntenatalCare cannot urinatehelpher by tricklingwarmwater overher abdomen.Ifthis Module andyourpractical skills doesnot work, shemay need to have acatheter(aplastic tube)put into training. herbladdertohelpher urinate.

■ Thereare interventionsyou can make before,duringand afterlabour whichmay help to reducethe risk of PPH.Quickly see how many of these you can list. □ To check how wellyou answered,re-read Sections 11.4.1,11.4.2and 11.4.3 of this study session.

However,rememberthatevenifyou make allthe interventions possible, postpartumhaemorrhagecan still occurunpredictablyafter any deliveryand you shouldalwaysbepreparedtotakeemergency action, as describednext.

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StudySession 11 PostpartumHaemorrhage

11.5 Emergency managementofpostpartum haemorrhage If themotherbeginstobleed excessively afterthe delivery,you must take actionquickly to transport hertothe nearest health facility.Postpartum haemorrhagecan kill herand many healthcareproviders underestimatehow much blood awoman loses. If you face such aproblem your firstaction shouldbetoshout forhelpsothe woman’sfamilyorneighbourscometohelp you take hertothe nearest health facility(Figure11.4).

Figure 11.4 Do notdelay in referringawomanwithpostpartumhaemorrhage.

11.5.1 Uterotonic drugs andIVfluids to manage atonicPPH If themotherisbleedingheavily, while you arewaitingfor theemergency transport, give herasecond doseofoxytocin 10 IU by intramuscular injection, or asecond doseofmisoprostol400 µg rectally (bypushing the tabletsgently into therectum through thewoman's anus), or by puttingthe tabletsunderher tongue wheretheycan slowlydissolve. Do not give additionalmisoprostolifoxytocin wasthe drug used originally.

Do not exceed 1,000 µg of misoprostol! If you gave 600 mgorally straight afterthe baby wasborn, thesecond doseshouldbenomorethan 400 mgrectally.

If you have been trained to do so,begin pre-referralinfusionofintravenous Youlearned theprinciplesofIV (IV) fluids to preventand treat shock.InfuseNormalSaline9%orRinger’s fluid infusion in Study Session22 Lactatesolution, setwith thefastest possible flow rate.Ensurethatthe bagof of the AntenatalCare Module and your practicalskillstraining. IV solutionisheldhigherthanthe woman’shead allthe time,including when she is beingtransported to thenearesthealth facility.

11.5.2 Usetwo-handed pressure on theuterus If bleedingisveryheavyand rubbing theuterusdoesnot stop thebleeding, try two-handedpressure on theuterus(see Figure11.5).Scoop up theuterus, fold it forward, andsqueeze it hard (you will be shown how to do this in your practical skills training).Cup one hand overthe topofthe uterus.Put your otherhandabove thepubicbone andpushthe uterus towardsyour cupped hand. Youshouldbesqueezing theuterusbetween your twohands.

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If you have been trained to do so,you canapplytwo-handeduterine compression by insertingone glovedhandinsidethe vagina andclenching your hand behind thecervix, while theother hand is pressing on theabdomen to compress theuterus.

Figure11.5Two-handed pressure over theuterus can help to stop postpartum bleeding. As soon as thebleedingslows down andthe uterus feels firm,slowlystopthe two-hand pressure. If bleedingcontinues, referthe woman to thenearest health centre facility.Try to keep two-handedpressure on theuteruswhile you aretransporting themother. Do notleavethe baby behind – have someone carry it. Make sure youtakepossibleblood donors fromher relativeswith you as thewoman mayneed ablood transfusion.

11.5.3Emergency managementfor traumaticPPH Trytoslowthe bleedingfromaninjury(e.g. atear in theperineumorvagina) by applying pressure overthe source of thehaemorrhage. Rollup10to15 pieces of sterile gauzeorasmall, sterile clothintoathickpad andpushit firmly againstthe bleedingpartofthe tear.Holditthere for10minutes. Carefully remove thegauze andcheck forbleeding. If thetear is still bleeding, pressthe gauzeagainst thesource of thehaemorrhageagain and take thewoman to thenearesthealth facility.Donot stop pressing on thetear until you gettothere.Ifthe womanhas along or deep tear,evenifitisnot bleedingmuch, take hertoahealth facility where it can be repaired. 11.6Achecklistfor emergency referral Finally, as we come to theend of this ModuleonLabourand Delivery Care, Table11.1summarisessomekey pointstorememberduringemergency referralfor postpartumhaemorrhage, or anyofthe otherlife-threatening emergenciesdescribed in earlier study sessions.Inthe next Module, the continuum of caremovesforwardtothe conductofPostnatal Care.

Table11.1 Important activitiesduringtransferofthe womantoahospital.

Aimtomaintain: Actions Contractionofthe uterus Applygentle uterinemassage,ortwo-handed compression of theuterus, andmaintainthis during referral Emptybladder If thewoman cannot urinate,insertaself- retainingcathetertodrain the bladderand leave it in place during referral

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StudySession 11 PostpartumHaemorrhage

Adequateblood volume If thewoman is haemorrhaging or in shock, administerintravenous fluids and maintain theinfusionduringreferral Vitalsigns Checkcolour, pulse, bloodpressure, temperature, bloodloss, levelof consciousness Warmth Coverthe womanwith blankets PositionThe womanshouldlie flat,but with herlegs raised above theheight of her head to help maintain herblood pressure ConfidenceGivethe womanyour emotionalsupportand reassurance; keep herascalmaspossible Accurate recordsand referralnoteWritedownall your findings andthe interventions youare making on thereferral note,with thewoman’shistory and identificationdetails

■ What arethe twomostimportant pointstorememberaboutPPH? □ Youshouldrememberthat:

. Although some riskfactorsare associatedwith PPH,two thirds of womenwho developPPH have no known riskfactors. Whichwomen will developPPH is thereforehighlyunpredictable. . Becauseofthisyou need to be alerttothe possibility of PPHfor everywoman in your carewho givesbirth. And because PPH is life- threateningyou must be readytotakeappropriate emergencyaction, including gettingher as quickly as possibletoahealth facility.

Summary of StudySession11 In Study Session11, youhavelearnedthat: 1Postpartumhaemorrhage(PPH) is one of theleadingcauses of maternal deathindeveloping countries. It is difficult to predictwhich women will developPPH,soyou shouldbepreparedtodeal with it at everybirth. 2PPH can be preventedtoagreatextentbyskilled careduringpregnancy, labour anddelivery, andthe immediatepostpartumperiod. 3Duringantenatal care, allpregnant women shouldreceive advice about diet andmalaria prevention, treatment forhookworm, andiron/folate supplements to preventanaemia,which is ariskfactor forPPH. 4Refer early if labour is prolongedand controlthe deliveryofthe baby’s head during second stagetoprevent traumaticPPH. 5Afterdeliveryofthe baby,givemisoprostoloroxytocin to preventatonic PPH,and massagethe uterus afterdeliveryofthe placenta. 6IfPPH develops,identify thecause of thebleeding. If due to atonicuterus (with or without with retained placenta), massagethe uterus usingtwo- handedpressure,empty thebladder(usingacatheterifnecessary),secure an IV fluidinfusion, andadministereitherasecond doseofoxytocin 10 IU by intramuscularinjection, or asecond dose of misoprostol400 µg rectally or by putting thetablets underher tongue. 7IfPPH is due to trauma,apply firm pressure to thesource of thebleeding with asterile padfor 10 minutes.Ifbleedingcontinues, reapplythe

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pressure andrefer thewoman to ahealth facility where thetear can be repaired. 8Whenyou need to arrange referraltoahealth facility,staywiththe mother,checkingher vitalsigns,maintaining uterinepressure andgiving herwarmthand emotionalsupport.

Self-Assessment Questions (SAQs) forStudy Session11 Now that you have completedthisstudy session, youcan assess how well you have achievedits Learning Outcomes by answeringthe following questions. Write your answersinyour Study Diaryand discuss them with your Tutorat thenextStudy Support Meeting. Youcan check your answerswiththe Notes on theSelf-AssessmentQuestions at theend of this Module. SAQ11.1(tests Learning Outcome 11.1) Youare drafting theinformationthatyou want to sendwiththe referral notice foramother with PPH andyou writeitout as below. Ayoung trainee colleague asks you to explainwhatyou have written.How would youexplainyour referral note, including allthe termsinbold,sothat your colleague can understand?

‘Iamreferring Mebrihit. Sheisahighparity mother with excessive bleeding andisconsideredtobeexperiencing primarypostpartum haemorrhage.Iwas carefultoavoid trauma when assistingher delivery. Palpationindicates atonic postpartum haemorrhage whichIsuspect is due to failure of the myometrium.’

SAQ11.2(tests Learning Outcomes11.2and 11.3) Youare assessingapregnant woman in your carefor potentialriskof PPH. (a)Whatquestions wouldyou ask herand what wouldyou remember to check as part of your antenatalcarevisit? (b)Whatchecksand interventions wouldyou make duringher labour and delivery?

SAQ11.3(tests Learning Outcome 11.4) Gelila deliveredababy 40 minutes ago. Yougaveher 600 mgof misoprostolorallyimmediatelyafterthe birth, but theplacentahas not come outyet.She hasemptied herbladder. After10minutes theplacenta comesout andyou check that it is intact,but Gelila startsbleeding heavily.Whatdoyou do?

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NotesonSelf-AssessmentQuestions(SAQs) for Labourand Delivery Care

NotesonSelf-AssessmentQuestions (SAQs) for Labour andDeliveryCare StudySession1 SAQ1.1 Checkyour definitions of theboldterms by finding each of them in Study Session 1and comparingwhatyou have writteninyour Study Diarywith our definitioninthissession. If anyofyour definitions were differentfromours, try Activity 1.1again until you getall of them right.

SAQ1.2 (a)Mrs Abebaisintruelabour because herpains aresigns of adequate uterinecontractions:theyare regular,frequent (2-3every 8minutes), andthe durationisabout 40 seconds,which is expected in true labour. Hercervixiseffaced anddilated to 4cmafter3hoursofcontractions. (b)She is in the firststage of labour, at thecross-overpoint between the latent phase andthe activephase, which occurs whenthe cervixis dilatedto4cm. (c)Reassure MrsAbeba that labour can beginnormallywithout a ‘show’. Hercontractions have been coming for3hourswithout stopping, and theirstrengthand regularityare as expecedtinanormallabour.

SAQ1.3 The completedversion of Table1.3 is shown below.

True labour Falselabour Contractions occur at regular intervalsContractions occur at irregularintervals. Duration of each contractiongradually Duration remainsunchanged – either increases long or short Intensity of contractions becomes Intensityremains unchanged stronger and stronger Cervix progressivelydilatesCervixdoesnot dilate Discomfort cannotbestoppedbystrong Discomfort usually relieved by anti-pain anti-painmedication medicationorbywalking

SAQ1.4 Aisfalse. Lightening is whenthe baby drops lower in theabdomen before labour begins. Bistrue. The second stageoflabour ends with theexpulsion of the baby from thebirth canal. Cistrue. The fourth stageoflabour lastsfor 4hoursand begins when theplacenta andfetal membraneshavebeen expelled. Disfalse. The overlapping of fetalskullbonesduringthe descent through themother’spelvisiscalled moulding (not flexion). Eistrue. The fetalhead is engagedwhenthe occiput of thefetal skull reaches thelevel of theischialspinesinthe mother’spelvis. Fisfalse. Duringanormalbirth, one of thebaby’sshoulders is born first, followed by theother shoulder.

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StudySession2 SAQ2.1 Youneed to immediatelyundertake arapid evaluationtodecide whether thereisany reason to referthe young woman foremergency careby:

. Checking thefetal heartbeat (is it within thenormalrange of 120-160 beats/minute); . Checkingher vitalsigns:blood pressure, pulse andtemperature,tosee if they arewithin thenormalranges(see Section2.1.1) . Looking to see if thereany signs of bleeding or leakingofamniotic fluid . Asking her(or someone with her) if shehas aheadache/blurredvision, difficultybreathing, convulsions,severeabdominal pain If thereare signs of fetaldistress (heartrateoutside thenormalrange), or anyofthe vitalsigns areoutside thenormalrange,orifany of the danger symptomsare present, you shouldrefer herimmediately.

SAQ2.2

Table2.1 Leopold’smanoeuvrescompleted.

Name of Area of theabdomen to be What youare checking palpation palpated Fundal With handsnear thetop of the Fetallie – whetheritislying palpation mother’sabdomen,press your longitudinally (normal), fingersaround thefundusofthe obliquely or transversely uterus Lateral Handsplaced flat on either side An initialdiagnosisofhow the palpation of themiddleofthe abdomen; baby is lyingand whetheritis firstone and then theother ‘head down’ or breech pushes inwards Deep pelvic Facing themother’sfeet,with Confirmationofwhether the palpation hands on thelower part of her presentationiscephalic (head abdomen,press inwardswith down)orbreech (bottomdown) your fingersjustabove her pubicbone Pawlick’sgrip Fingersgripthe fetalheadjust Whetherthe fetal head has above themother’spubicbone engaged in thecervix – if you canonlygrip it with two finger-widths abovethe mother’spubicbonethe head is engaged

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SAQ2.3 (a)TotakeMakeda’shistory you will need to make herfeel comfortable talkingtoyou. Youdothisbyfollowing theprinciplesofwoman- friendlycare in how you put your questions,and by listeningcarefully, answeringher questions andkeepingwhatshe tellsyou private(look againatBox 2.1for allthe details of woman-friendlycare). (b)Informationthatyou need fromMakeda:

. Hername, age, height,address, religion(if sheiswillingtotellyou) andoccupation(if sheisemployed). . What is her ‘presenting symptom’ (e.g.labour pains, feelings of bearing down?) . Whethershe hashad previous pregnanciesand births(how many and whether therewereany complications). . When wasthe firstday of herlast normalmenstrual period? . Whethershe hasnoticed any dangersymptoms (e.g.vaginal bleeding, headache, abnormalvaginal discharge).

SAQ2.4 Before startingthe vaginalexamination remember to followthe principles of woman-friendlycareand reassure Makeda about her privacy.Thenwash your hands thoroughlyand put on newsurgical gloves. Duringthe examinationyou check:

. The extent of cervical dilation . The size of Makeda’spelvisand theadequacy of thepassage forthe fetus . The extent of any moulding (overlapping) of thefetal skull bones because of pressure fromthe birthcanal . Any abnormal, foul smellingdischarge,any scarring, or swelling (all of these arewarning signs andifyou detect anyrefer Makeda to ahealth facility).

SAQ2.5 (a) A is True.Ahigh grade fever is atemperature above 38.5ºC(low gradefever is between 37.5-38.4ºC. (b) B is false.The gestational age is thenumberofweeksthe fetushas been in theuteralcalculatedfromthe date whenthe women’s last normal menstrual period (LNMP) began. (c) C is false.Parity is thenumberofbabiesdelivered either aliveor dead after28weeksofgestation. (d) D is true.Gravidity is thetotal numberofprevious pregnancies regardless of theoutcome. (e) E is true.Anabdominal scar indicates thepossibility of scarringof theuteruswhich increases theriskofuterinerupture. (f) F is false. Fundal palpation meanspalpatingthe dome-shaped upper part of theuteruscalledthe fundus to check theposition of thefetal head. (g) G is false. Breech presentation is whenthe buttocksare the presenting part indicatingpotential difficultiesatdeliveryand theneed forreferral. (h) H is false.Auscultation is listening to sounds inside theabdomen.

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StudySession3 SAQ3.1 To reassure Almaz, be kind andrespect herand herculture andnorms. Show interest in her. Explain whatishappening andhow thelabour will progress. Encourage hertoask questions andexpressher ideas and worries. Tell herabout theconditionofher baby.Allow atrusted support person to be with her. Explain each procedurebeforeyou do it.

SAQ3.2 Measuring Almaz’sblood pressure, temperatureand pulse helpsyou to know about hercondition. By checkingthe fetalheartbeat it is possible to identify thepresence of fetaldistress. Monitoringthe contractions, cervical dilatation anddescent of thebaby’shead allhelptoassess the progress of labour.(When you have learnedabout thepartographin Study Session 4, you will know that it is thebest tool to followthe progress of labour andtodetect anyabnormalityontime).

SAQ3.3 During the firststage of labour,ahighcalorie fluiddietisrecommended. Some examples aretea, soft drinks,soup, andfruit juice. Almazshould drinkatleast one cupevery hour.

SAQ3.4 Adopt standard precautions andinfectionpreventionprocedures during vaginalexaminationsand conducting thedelivery. Wash your hands before andafter each procedurefor at least 2minutes, usingsoapand clean wateroranalcohol hand cleaner.Wear clean protectiveclothing such as an apron, goggles,mask, glovesand shoes. Usesafewaste disposal methods (burying or burning).Scrub, decontaminateand sterilize metalorglass instrumentsusing a0.5%chlorinesolutionfor 10 minutes, then cleaningwithsoapy water andboiling or usinga sterilizationmachine.

SAQ3.5 Youwouldmeasure vitalsigns in themother: blood pressure and temperatureevery 4hours, pulse every30minutes. Youwouldmonitorthe frequency, lengthand strengthofher contractions every30minutes; in normallabour,asthe labour progresses, contractions become faster,strongerand more frequent. Cervicaldilatation is assessed by doing avaginal examinationevery 4 hours; in normallabour theaverage rate forcervical dilatationisatleast 1cmper hour. Youwouldmeasure the descentofthe presentingpart every2hoursby abdominalpalpationofthe fetalhead in relationtothe pelvic brim,orby vaginalexamination.

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SAQ3.6 The presence of dark-green meconium in theamniotic fluidleakingfrom Almaz’svaginaduringlabour suggestsfetal distress; meconium is the baby’s firststool anditdoesnot normallypass stool until afterthe birth. The fetalheartrateinadistressed baby duringlabour anddeliverycould either be significantlyabove or belowthe normal range of 100–180 beats perminute.

SAQ3.7 A is true. Respecting maternal preferencesincludeshow shewants to give birth. B is false. Duringthe firststage of labour themothershoulddrinkat least one cupoffluidevery hour to preventdehydration. C is false. The frequency of contractions refers to how often they come in every10minuteperiodduringthe labour;itdoesnot refertohow painfultheybecome,which is the strength of contractions. D is true. Meconium dischargedfromthe vagina is asignoffetal distress. E is true. The ‘threecleans’ areclean hands,clean surface fordelivery andclean equipment. Study Session 4 SAQ4.1 (a)Asagravida5,para4mother youknow that Bekelech hashad 5 pregnanciesofwhich 1has not resultedinalive birth. (b)At40weeksand 4daysthe gestationisterm(or full term). (c)Bekelch’scervixhas dilatedto5cmand sheishavingfour contractions in 10 minutes of 35-40 secondseach,soshe hasentered theactive phase of firststage labour.At-3station, thefetal head is not yet engaged. (d)The fetalheartrateiswithin thenormalrange of 120-160 beats/minute. (e)AsBekelech’slabour is in theactivephase andher cervixhas dilated to more than 4cm, you immediatelybegin regular monitoring of the progress of herlabour,her vitalsigns,and indicatorsoffetal wellbeing distress. Yourecord of allthese keymeasurements on thepartograph (referagain to Figure4.1 andSection4.2.1). (f) Youdecide to do vaginalexaminations more frequently than the advisory four hours, because Bekelech’slabour mayprogress quite quickly as she is amultigravida/multiparamother. And youkeep alert to thepossibility of somethinggoing wrong, because Bekelech has alreadylostone baby before it wasborn.

SAQ4.2 Twokey reasonsfor usingapartographare because: (a)Ifused correctly it is averyuseful tool fordetectingwhether or not labour is progressing normally,and thereforewhether areferralis needed.Whenthe labour is progressing well,the record on the partographreassuresyou andthe mother that sheand herbabyare in goodhealth. (b)Research hasshown that fetalcomplications of prolongedlabour are less commonwhenthe birth attendant uses apartographtomonitorthe progress of labour.

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SAQ4.3 (a)Good progress of labour is indicated by: arateofdilation of thecervix that keepsitonortothe left of thealert line; evidence of fetaldescent coinciding with cervical dilation;and contractions which showasteady increase in durationand thenumberin10minutes. (b)Fetal wellbeing is indicated by: afetal heartratebetween 120-160 beats/minute(except forslight changeslastingless than 10 minutes); moulding (overlapping of fetalskullbones) of not more than +2;and

clear or onlyslightly stainedliquor (C or M1). (c)Inanormally progressing labour,you wouldmeasure themother’s blood pressure (every 4hours), pulse (every 30 minutes),temperature (every 2hours) andurine (every timeitispassed), andrecord them on thepartograph. (d)Indicatorsfor immediatereferralinclude:slowrateofcervical dilation (tothe right of theAlert line on thepartograph);poor progress of labour,togetherwith +3 moulding of thefetal skull; fetalheartbeat persistently below120 or above 160 beats/minute; liquor (amniotic fluid) stainedwith meconium,depending on thestage of labour,even

with normalfetal heartrate: (referM1liquor in latent firststage;M2 liquor in early active firststage,and M3 liquor in anystage,unless labour is progressing fast. StudySession5 SAQ5.1 A is true. Full dilatationofthe cervixto10cmisthe most important sign that secondstage of labour is beginning. B is true. In second stage, themother’sgenitalstendtobulge during contractions andrelax between contractions. C is false. Crowning is whenthe topofthe baby’shead stretchesthe vaginalopening to thesizeofyour hand anditstays in theopening even between contractions. D is false. In anormaldelivery, thebabymoves down thebirth canal facing the back of themother’sbody,withits own back towardsher belly. E is false. Whileitisstill in thebirth canal,the baby’sheartbeat tends to get slower (not faster) duringacontraction. F is true. Youshouldlet themotherchoosethe position that she feels most comfortableinwhenshe gets theurgetopushinthe second stage of labour.

SAQ5.2 Warningsigns that secondstage maynot be progressing normally include:

. Fetal heartbeat staysabove or belowthe normalrange (120-160 beats perminute) even between contractions of themother’suterus. . Asuddengushofamniotic fluidleaves thevagina, which mayindicate acordprolapseorplacental abruption. . Amultigravidamotherhas been pushing for1hour without thebaby moving down thebirth canal,oraprimigravida mother hasbeen pushing for2hours with no good progress. . Baby is not descending andthere aresigns that it is developing caput or excessive moulding of thefetal skull.

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SAQ5.3 First, try to loosen thecordand slip it overthe baby’shead.Ifyou cannot loosen it anditispreventingthe baby frombeing delivered, clampthe cord in twoplaces (ortie it with very clean string) andcut it in between theclamps. Be careful not to cutthe mother or thebaby’s neck.

SAQ5.4 The correct sequence is as follows: BWash yourhands welland put on sterile glovesand otherprotective clothing. FClean themother’sperineal area with antiseptic. DPress one hand firmly overthe mother’sperineum. JUse apiece of clothorgauze to coverthe mother’sanus in case any faeces come out with thebaby. HUse your otherhandtoapplygentle downwardpressure on thetop of thebaby’shead to keep it flexed (bentdownwards). AOncethe baby’shead is born, help it to breathe by clearingits nose andmouth. KCheck that thecordisnot around thebaby’sneck. CToprevent tearingofthe mother’sbirth vagina or perineum, deliver thebaby’sshoulders one at atime. EWhenthe baby hasbeen completely delivered,put it on themother’s abdomen anddry it with aclean cloth. ICoverthe baby to keep it warm andgiveitachance to breastfeed straight away. GClamp or tie thecordintwo places andcut it in between theclamps.

SAQ5.5 To help bonding between themotherand hernewbornbabyyou place thebabyonthe mother’sabdomen as soonasitisborn, andgiveitan early opportunity to breastfeed.Donot separatethe mother andher baby duringatleast the firsthour afterthe birth. Study Session 6 SAQ6.1 (a)The thirdstage of labour begins with thebirth of thebabyand ends with thedeliveryofthe placenta andits attached membranes.

(b)The physiological changesare:

◦ As theplacentaseparates fromthe wall of uterus blood fromthe vesselsinthe placenta bedbegin to clot between theplacenta wall andthe myometrium(themuscularwallofthe uterus). ◦ Theplacenta movesdownthe birthcanal andthrough thedilated cervixbeforebeing expelled. ◦ Once expelled, themuscles of theuteruscontract andcompress the torn blood vesselssothatany postpartumbleedingisstopped, and theuterusbecomeshardand round.

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SAQ6.2 Sixsteps to follow: 1Check:isthere asecond baby? 2Giveauterotonicdrugtohelpthe uterus contract:

. Misoprostol600 mg(micrograms) tabletsgiven orally with water, or . Oxytocin 10 IU injected intramuscularly. . Do NOT give ergometrine. 3Deliver theplacenta by controlled cord tractionwith counter-pressure (see Box 6.3for details of how to do this). 4Massage theuterus. 5Examine theplacenta andfetal membranestocheck nothing is missing(i.e. check thematernalsurface andthe lobules, put your hand inside themembranes to make sure they arecomplete, andcheck that the positionofthe cord is normal). 6Examine thewomen’svaginaand external genitalia forsigns of tears andactivebleeding.

SAQ6.3 (a)Yes, so long as you do not exceed 1,000 mgofmisoprostolintotal,you can give up to afurther 400 mgifyou have alreadygiven 600 mg. You shouldgivethe second dosebyinserting thetablets into therectum. (b)Asthe mother hasalreadybegun breastfeeding, rubthe uterus usingthe two-handedpressure method to stimulatecontractions. (c)Ifthe bleedingdoesnot stop quickly afterthe second doseof misoprostol, you need to referthe woman to thenearest health facility as quickly as possible, startingher on IV fluids before you go.

SAQ6.4 Warningsigns of potentialcomplications duringthe third stageoflabour are:

. Aretainedplacenta or aplacenta that hasonlybeen partiallyexpelled . Acervixwhich hasclosed before thedeliveryofthe placenta . Weak uterinecontractions . Asoftuterusfeltonpalpation . Third stageoflabour lastingover30minutes . Perineal,vaginal or cervical tearing . Excessive bleeding(postpartumhaemorrhage). StudySession7 SAQ7.1 (a)Atsede’sbabyisseverelyasphyxiated.The dangersigns arethathewas not making anybreathing effort,ormovinghis limbs,hewas covered with meconium andtactile stimulationhad no effect. (b)Your next step is to dryhim quickly,wraphim warmly,and remove meconium from hismouthand nosewith thebulbsyringe andaclean cloth. Listen foranapical heartbeat andifitisbelow 60 beats/minute, beginheartmassage,alternatingwithventilating thebabyatabout 40 breaths perminute.

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NotesonSelf-AssessmentQuestions(SAQs) for Labourand Delivery Care

(c)The birth complicationinthisnewborncouldhavebeen preventedby Atsedereceiving skilled birth attendancemuchearlierinher labour fromsomeone who couldmonitorthe signs of fetaldistress andrefer herfor emergencycare; 38 hoursistoo long to wait.

SAQ7.2 The basicequipmentyou will need in ordertoresuscitate anewborn with breathing difficultiesare:

. Twoclean linen/cottoncloths: one to drythe newbornand one to wrap himorher afterwards . Plastic bulbsyringe to remove secretions from themouthand nose, especially when meconium is present . Ambu-bag andmask to give oxygendirectly into thebaby’slungs . Aperson trained in neonatalresuscitation(likeyou) . Heatsource (lamp) to provide warmth, if possible.

SAQ7.3 A is false. If anewborncries soonafterbirth,itisasign of asphyxia occurring before delivery. B is false. Cyanosismeanshavingabluish colour to theskinbecause of oxygenshortage (asphyxia). C is true. The apical heartbeat can be detected by listening to the baby’schest with astethoscope. D is false. Gasexchange in thelungs happens when carbon dioxide is breathed out andoxygenisbreathed in. E is false. Giving thenewbornavitaminKinjectionistoprevent spontaneous bleeding; tetracyclineointmentisgiven to preventeye infections. F is true.The recommendedventilationratefor newborns is 40 breaths/ minute.

SAQ7.4 Only twoofthe ways in thelistare recommended forgentletactile stimulationofthe baby:

. Rubbing theabdomen gently up anddown . Flicking theundersideofthe baby’sfoot with your fingers. Allthe otherwayslistedare dangerous andshouldnot happen.

SAQ7.5 The completedTable 7.1isbelow.

Table7.1 Completed

Newbornhealth risk Essential newborn care EyeinfectionApply tetracyclineeye ointment Spontaneous bleeding Inject1mg vitamin Kintramuscularly Skin-to-skincontactwith mother,blankets Hypothermia andcap Earlybreastfeedingoradequate Hypoglycaemia replacementfeeding

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StudySession8 SAQ8.1 A is true. The fundus is the ‘roundedtop’ andwidest cavity of the uterus. B is true. Completebreech is where thelegsare bent at bothhipsand kneejointsand arefoldedunderneaththe baby. C is false.Afrank breech is themostcommontype of breech presentationand is whenthe baby’slegspoint straight upwards (see Figure8.4). D is true. Afootlingbreech is whenone or bothlegsare extendedso that thebabypresents ‘foot first’. E is false.Hypoxiaiswhenthe baby is deprived of oxygenand risks permanentbrain damage or death. F is false. Multiple pregnancyiswhenthere is more than one fetusin theuterus. G is false. Monozygotic twinsdevelop fromasinglefertilized ovum (thezygote),and they arealwaysthe same sex,aswellassharing the sameplacenta. H is true. Dizygotic twinsdevelop fromtwo zygotes, have separate placentas, andcan be of thesameordifferent sexes.

SAQ8.2 In a normal presentation, the vertex (thehighest part of thefetal head) arrives firstatthe mother’spelvicbrim,with the occiput (theback of the baby’sskull) pointingtowards thefront of themother’spelvis(the pubic symphysis). Abnormal presentations arewhenthere is either a vertex malposition (theocciput of thefetal skull pointstowards themother’sback instead towardsofthe pubicsymphysis), or a malpresentation (whenanything otherthanthe vertex is presenting):e.g. breech presentation (buttocks first); face presentation (face first); brow presentation (forehead first); and shoulder presentation (transversefetal).

SAQ8.3 (a)The common complications of malpresentationormalposition of the fetusatfullterminclude:premature ruptureofmembranes, premature labour,prolonged/obstructed labour;ruptureduterus; postpartum haemorrhage; fetaland maternal distress which mayleadtodeath. (b)You shouldrefer themothertoahigherhealth facility – shemay need emergencyobstetric care. (c)You should not attempttoturnthe baby by hand. Thisshouldonlybe attemptedbyaspecially trained doctorormidwife andshouldonlybe done at ahealth facility.

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SAQ8.4 (a)How to check if this pregnancyistwins:

. Is theuteruslargerthanexpected forthe period of gestation? . What is itsshape – is it round (indicativeoftwins)orheart-shaped (as in asingleton pregnancy)? . Can youfeel more than one head? . Canyou hear twofetal heartbeats(twopeoplelistening at thesame time)with at least 10 beatsdifference? . If thereisaccess to ahigherhealth facility,and you arestill not sure, tryand getthe woman to it foranultrasound scan. (b)How do you reducethe risksduringdeliveryoftwins?

. Be extra careful to check that themotherisnot anaemic. . Encourage hertorest andput herfeet up to reduce theriskofincreased blood pressure or swelling in herlegsand feet. . Be alerttothe increased risk of pre-eclampsia. . Expect hertogointolabour before term,and be readytoget hertothe health facility before shegoesintolabour,going with herifatall possible. . Getinearly touchwiththathealth facility to warn them to expect a referralfromyou. . Make sure that transportisreadytotakeher to ahealth facility when needed. Study Session 9 SAQ9.1 The three ‘Ps’ (powers, passengerand passage) are ashorthand way of describing themaincausesofobstructedlabour. Afteryou have checked your answerswith ours(below),re-read Section9.2 formoredetailabout thecauses.

. Powers refers to thestrengthofthe uterinecontractions – tooweak or uncoordinatedand thebabyisnot pusheddownthe birthcanal. . Passengerreferstothe baby – if thehead is toobig or deformed,orif theposition or presentationiswrong, thebabywill not be able to pass down thebirth canal. . Passagereferstothe birth canal – if it is toosmall or deformed,orhas blockagesfromtumoursorscars, thebabywill notbeabletopass smoothly.

SAQ9.2 (a)Perinatal mortality andmorbidity -fetal andnewborndeaths,and disease anddisability occurring around thetimeofthe birth. (b)Prolongedlatentphase of labour -whentruelabour lastsfor more than about 8hourswithout enteringintothe active firststage. (c)Prolongedsecond stageoflabour -whenitlastsfor more than 1hour (formultigravidamothers)and more than 2hours(primigravida mothers). (d)Malposition-when thebabyis‘head down’ but thevertex(thetop of thebaby’sskull) is in thewrong positionrelativetothe mother’s pelvis. (e)Caput -alargecentralswellingonthe fetalskull.

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(f) Fistula — an abnormalopening (usually resultingfromatear)between thevaginaand theurinary bladder(or therectum or urethraorureter).

SAQ9.3 (a)The following signs in Tadelech’scasestudy suggestbothprolonged andobstructed labour:

. It is clear that while Tadelech hasbeen in theactive firststage of labour forsometime(dilatedcervixof8cm), but shemay actually be in a prolongedactivephaseoflabour (whentruelabour lastsfor more than about 8hourswithout finally enteringthe second stage).Since you have not been monitoringher labour up to this point,you cannot be absolutelysurewhether hercervixisdilating slowly, or if dilatationhas completely ceased andthe labour is not progressing at all. . The twoswellings (masses) above andbelow thedepression in her abdomen known as Bandl’sring indicateanobstructed labour. . Furthermore,at-3the baby’shead is not engaged, andremains above thepelvicbrim; this indicates that it is not descending as youwould expect it to do afterTadelech hasbeen in labour fortwo days. . The hotand dryvaginaand oedema (swellingdue to collectionoffluid in thetissues) of thevulva arefurther signs of apotentialobstruction. (b)Itisclear that Tadelech needsurgentreferraltoahealth facility. Your actions shouldbeto:

. Explainthiscalmlytoher andher family. . Activatethe birth preparedness plan to gether transferredtoahealth facility as quickly as possible, together with herbirthcompanion. . Tadelech’svitalsigns suggest sheisinshock: shehas afast pulse rate andlow blood pressure).Her hot anddry vagina indicates dehydration. Youbegin treatingher forshockand dehydrationbygivingher an intravenous infusion (see Section9.4)and keepingitworking duringthe trip to thehigherhealth facility. . If theobstructionappearspartlytobecaused by an overfull bladder which thewoman cannot emptyinthe normalway,you drainthisusing acatheter.

SAQ9.4 Youcan reducethe risksofobstructedlabour by:

. Teachingthe importanceofgood childhood nutritiontoensurethat girls’ pelvic boneshavethe best chance of developing to thenormal size forsafedelivery. . Promotingfamilyplanning anddiscouragingearly marriage and especially pregnancyatless than 18 yearsofage. . Explaining theimportancefor thesafetyofthe mother andbabyof having askilled careattendant at alldeliveries. . Assistingyour community in organizing birth preparedness teamsso that in an emergencytheycan getthe mother to thenearest health facility as quickly as possible. . Always usingapartographtomonitorthe progress of labour.

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NotesonSelf-AssessmentQuestions(SAQs) for Labourand Delivery Care

Study Session 10 SAQ10.1 Factorspredisposingawomantodevelop auterinerupture(keywords in bold)are:

. Obstructedlabour caused by: thefetal head beingtoo largeorthe mother’spelvisbeing toosmall forthe baby to descendthrough the birth canal (cephalopelvic disproportion); malpresentation and malposition of thefetus;ormultiple pregnancy (see Study Session 8 fordetails of allthese). . Otherphysical obstructions such as atumour,orscarring fromdamage at aprevious birth (e.g.afistula,atornopening between thevaginaand bladder, rectum,urethra or ureter). . Traditionalpractices, e.g. inappropriate abdominal massageorpushing down on thefundus duringlabour. . Inappropriate useofauterotonicdrug (used to cause contractions).

SAQ10.2 Primiparous women aregivingbirth forthe firsttime. In a firstbirth thereisthe likelihood of alongerlabour.However,inprimiparous women, uterine inertia (contractions become weaker andshorter, with longerintervals)occurs afterabout 36 hours, greatly reducingthe risk of uterinerupture. In contrast,inmultiparous womenhavehad at least one baby after28 weeks’ gestation, theuteruswillgooncontractingstronglyfor much longerthanthe primiparous uterus.Ifobstructionpreventsdeliveryfor a long time,particularly if thereisscarringfromacomplicated earlier birth,the uterus is much more likelytorupture.

SAQ10.3 The completedversion of Table10.1appearsbelow.

Table10.1Warning signsofpossibleuterinerupture(completed).

ActionsWarning signs Timingthe stages of labourLabour is prolonged:latent first stagelasts more than 8hours; active firststage lastsmore than 12 hours; secondstage lastsmorethan1 hour in amultipara, or more than2hours in a primipara Timingthe uterinecontractions Persistent uterinecontractions of 60-90 secondsdurationorlonger, occurring more than5timesinevery 10 minutes Checking thefetal heart rate Fetalheart rate persistently above 160 beats/ minuteorbelow 120 beats/minute Checking theabdomen Lowersegment of theuterusistender on palpation; Bandl’sringispresent Checking thevaginaVaginalbleedingmay be present

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SAQ10.4 (a)Complications of uterineruptureinclude:

. Death of thefetus unlessthere is immediatesurgery to remove it. . Severe haemorrhageand haemorrhagic shockfor themother(identified by faintness, pale skin,fast pulse, dropping blood pressure, fast breathing, lapses into unconsciousness, reduced urineoutput)leadingto deathofthe mother unless she gets immediatetreatment. . Infection: peritonitis (infectionofthe abdominal cavity) and/or septicaemia (bacterialinfectionofthe blood),leadingtopotentially fatal septicshock. . Acute kidneyfailure (because of loss of blood volume). . Hysterectomy. (b)The most important actionistoget thewoman to thenearest health facilitycapable of dealingwitharuptured uterus as quickly as possible; sheneedstobekeptwarmand calm, lyingdown with feet higherthan ‘her’ head andher head on one side.You shouldgiveher intravenous fluids.Ifshe is unconscious do not give anything by mouth. StudySession11 SAQ11.1 Here is how you couldhaveexplained to your trainee colleague what youhad written in your referralnote:

‘Iamreferring Mebrihit.She hashad more than 5pregnancies (highparity) anddeveloped bleedinginexcessof500 ml of blood(excessive bleeding) within 24 hoursofdelivery(primarypostpartumhaemorrhage). Iwas very careful to avoidany injury (trauma) during thedelivery. Feelingher abdomen(palpation) indicates that heruterus is soft andhas notcontracted properlyafter delivery(atonic postpartum haemorrhage). Isuspect this is because themuscularwallofher uterus (myometrium)isfailing to contract andclose theblood vesselswhere theplacenta pulledaway from theuterus’.

SAQ11.2 Here aresomeofthe questions to ask andthings to do. We expect you mayhavethought of even more. (a)Antenatal care-questions to ask andthings to check:

. Is sheafirst-time mother (primiparous)orhas she hadone or more deliveriesalready(multiparous), i.e. puttingher more at risk of atonic PPH? . If multiparous,was herearlierbabyverylarge (over4kg) or didshe have twins? (eitherofwhich mayhaveoverstretched heruterus). . Doesshe remember if shehad an excessive amount of amniotic fluidin aprevious pregnancy(polyhydramnios)? More than 3litrescan also overstretch theuterus. . Have youscreened foranaemia (which youshouldcontinue in your postnatal checks)?Ifshe hasanaemia have you advisedher about good nutrition? . Is thecommunity transport plan readyincase of emergencyreferral? (b)Duringand afterdelivery – interventions to make andthings to check:

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. Make sure sheregularly emptiesher bladdertoavoidinterferingwith normaluterinecontractions,including immediatelyafter birth. . Use thepartographtomonitorlabour progress so that you quickly noticeany signs that might potentially lead to PPH(e.g. obstruction leadingtopossibleuterinerupture). . Be careful not to encouragepushing before thecervixisfully dilated andhelptoensurecontrolleddeliveryofthe baby’shead andshoulders in ordertoprevent tears. . Encourage andhelpthe mother to breastfeed immediately(so shestarts to make herown oxytocin,which will stimulatethe uterus to contract). . Check that theplacenta hasfully separated andisintact,thenrub the uterus every15minutes forthe first2hourstohelpkeep theuteruswell contracted.

SAQ11.3 Here is what you shoulddo:

. Immediatelyshout forGelila’sfamily andneighbourstoget transport readyincase thebleedingbecomesexcessive andshe needstogotothe nearest health facility. . Check herrateofbleedingand unless it hasquickly reduced,assume this is acase of atonicpostpartumhaemorrhage. . If shehad 600 mgmisoprostolafterthe birth,giveher asecond doseof 400 mgmisoprostolrectally or underher tongue to help heruterusto contract.Ifshe hadoxytocin before,giveher another10IUby intramuscularinjection. . LieGelila on herback with herfeet higherthanthe head,coverher with blankets andmakesureshe is warm. . If you aretrained to do so,begin pre-referral infusion of IV fluids. . Tryrubbing theuterustoencourageittocontract.Ifthisfails then try two-handedcompression on theuterus. If thebleedingstops andthe uterus starts to feel firm,slowlyrelease thepressure.Ifbleedingdoesn’t stop, continue thereferralprocess andget hertothe health facility as quickly as possible. . AccompanyGelila to thefacility,checkingher vitalsigns,and continuing to administer intravenous fluids.Makesureher baby comes tooand that thereare appropriate peopletolook afteritand to act as possibleblood donors. . Writedown everything that you have done on thereferralnote, together with Gelila’shistory andidentificationdetails.

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