Antenatal Care & Management Of Labour

Antenatal period :
Antenatal period is the interval from conception up to the delivery of the baby. It is usually associated with both physiological and psychological changes in the woman.


Antenatal Care :
Antenatal care is the process whereby both the mother and the growing fetus are systematically examined throughout the antenatal period. It is a form of preventive medicine in which the risk factors are recognized early in the antenatal period and specific interventional measures are instituted.


Aims Of Antenatal Care

• To ensure healthy mother and infants at the end of pregnancy. 
• To prevent and manage pregnancy related disorders and compliments. 
• To address the psychological and medical needs of the woman. 

Antenatal Clinic Visiting Schedule
Traditionally, antenatal clinic visits in normal pregnancy are structured depending on the gestational age. Antenatal visits are usually attended every 4 weeks until 28 weeks gestational age; then every 2 weeks until 36 weeks gestation; then attendance is weekly until delivery. The first antenatal visit is the booking visit and usually features the following :

• Detailed history 
• Physical examination 
• Laboratory investigations 
• Preventive drug therapy for both malaria depending on the gestational age and tetanus
• Health education. 

Antenatal clinic visit may be more frequent in high risk pregnancy such as in multiple pregnancy, hypertension in pregnancy, multiple pregnancy, sickle cell disease, heart diseases, kidney disease, etc.


Normal Labour
Labour is defined as the act of expulsion of the fetus and placenta to the outside world through the vagina with minimal risk to both the mother and the fetus. It is characterized by the onset of painful, palpable, regular uterine contractions of progressively increasing frequency and intensity. This process is accompanied by progressive opening of the cervix and descent of the fetus eventually leading to the delivery of both the baby and the placenta through the vagina.
The usual period of labour is about 8-12 hours.

Stages Of Labour
Labour is divided into 3 stages

• First stage
• Second stage
• Third stage. 

First stage:
First stage of labour is composed of 2 phases namely the LATENT and ACTIVE phase. At this stage, there is progressive dilatation of the cervix from 0 to 10 CM.

• Latent phase (first stage) : this phase represents the period during which the cervix opens (dilates) from 0 to 4cm. 
• Active phase (first stage) : this is the period during which the cervix dilates from 4 to 10cm (full dilatation) 

The active phase of the first stage usually lasts 12 hours. If this phase in more than 12 hours, it is said to be prolonged.

Second Stage Of Labour
This is the stage from full dilatation (ie 10cm) until the baby is delivered.

Third Stage Of Labour
This is the period between the delivery of the baby and delivery of the placenta.


Mechanism Of Labour
Mechanism of labour refers to the various changes in both position and attitude of the baby as it passes through the birth canal. It comprises of the following :

• Descent
• Flexion
• Internal rotation 
• Extension 
• Restitution 
• External rotation 
• Delivery of the shoulders
• Delivery of the baby. 

Management Of Labour
The management of labour involves history taking, examination and intervention.
1. History Taking : the following features are to be looked out in a pregnant woman who is in labour

• Is there regular, intermittent, painful uterine contraction
• Is there passage of bloody cervical mucus "plug" otherwise regarded to as SHOW. this may not been seen in some pregnant women  in labour 
• Is there amniotic membrane rupture and drainage of amniotic fluid (liquor) 
• Does she still feel fetal movement 
• What time did the labour symptoms start
• Is the pregnancy term
• Is there any vaginal bleeding before the onset of labour symptoms and signs.

2. Physical Examination
In obstetric examination, the following are to be felt for :

• Symphysiofundal height 
• Lie
• Presentation 
• Engagement 
• Fetal heart tone and rate. This is done using the fetal stethoscope or hand held Doppler ultrasound (sonic aid).

Vaginal examination : this should not be done too frequently. Four (4) hourly assessment is recommended unless otherwise indicated. Avoid too frequent digital vaginal examination as this could lead to infection.

Things To Look Out For During A Vaginal Examination

• Consistency of the cervix (that is how soft or firm the cervix is) 
• Position of the cervix (ie, is whether the cervix is anterior, middle or posterior) 
• Degree of opening (dilatation) of the cervix 
• Presentation of the baby (ie, the part of the baby which is felt eg, feet, head, buttocks, shoulder, etc) 
• Umbilical cord (in umbilical cord prolapsed). 

Never Do A Vaginal Examination In A Pregnant Woman Who Is At Least In Her Third Trimester Of Pregnancy And Who Has Vaginal Bleeding Until A Scan Is Done To Exclude Placenta Previae.

Some of the things you may be required to do during the process of labour

• Ensure that the pregnant woman who is in labour is comfortable 
• Never shout at, beat or scold a woman in labour. It is "criminal ". Show empathy; you are a nurse not a "slave driver ".
• Frequently listen to the fetal heart tone (at least 5 to 15 minutes) during labour. Call for help if you  hear abnormal fetal heart tones/rates. A rate of >180 or <100 abnormal="" and="" call="" for="" help.="" is="" li="" nbsp="" should="" you="">
• Encourage the woman in labor to push only when she has the irresistible urge to do so. This coincides with uterine contractions. At this time, the woman feels the urge to bear down. 
• Call for help if the labour progress halts or becomes abnormally slow. 
• Call for help in case of shoulder Dystocia. This occurs when the baby's head is delivered but the rest of the body fails to be delivered as well. At this stage, do not give Fundal Pressure more so if the woman has had a uterus operation in the past for eg, Cs, Myomectomy, etc. 
• Immediately clean the face of the baby upon delivery of the head. 
• Also quickly suck the mouth and both nostrils just before the deli of the rest of the body. 
• If the baby does not cry immediately after delivery, (ie, baby has possible birth asphyxia), call for help and meanwhile, stimulate the baby by tapping the soles of the feet as well as rubbing the back. Also continue clearing the airway by suctioning to remove secretions.

Management Of The Third Stage Of Labour
Third stage of labour is the stage when the placenta is delivered following the delivery of the baby. The placenta should be delivered within 1 to 10 minutes after the delivery of the baby. If the placenta is not delivered after 30 minutes of the delivery of the baby, it is  said to be retained. This is termed Retained Placenta. When this happens, immediately call for help.

Passive Management Of Third Stage :
Here, the placenta is left to separate on its own accord, probably with the aid of gravity and /or nipple stimulation. There is no immediate clamping and cutting of the umbilical cord.

Active Management Of The Third Stage
This involves the following :

• Administration of oxytocin's immediately following delivery of the baby. For example, ergometrin or oxytocin
• Immediate clamping and cutting of the umbilical cord 
• Delivery of the placenta using "controlled cord traction"
• Intermittent fundal massage.