Admission to labour ward

Chapter 5 Admission to labour ward



David T Y. Liu



CHAPTER CONTENTS


Admission for labour 23
Organisational requirements 24

Requirements for quality care 24

Assessment following admission 24
Presentation 24

Lie 24

Engagement 25

Auscultation 25

Examination of abdomen and pelvis 25

Cervical examination 27

Vaginal examination 27

Pelvic examination 28
Contracted pelvis 28

Routine for pelvic examination 30

Erect lateral pelvimetry (ELP) 31

Subsequent management 32


ADMISSION FOR LABOUR


The modern labour ward subserves many functions. It is a place where women can self-admit or are referred for assessment and reviewed by a well-equipped obstetric team when there are anxieties or complications associated with their pregnancy, for example suspected preterm labour, membrane rupture or abdominal pain.


Requirements for care are:


• Take a detailed history. Review the obstetric and gynaecological history.

• If appropriate, consult colleagues in other medical disciplines.

• Perform a thorough examination of the woman and fetus. This can include a cardiotocograph record and an ultrasound scan for reassurance.

• Reassure and allow home if there is no evidence of complication. Where necessary arrange follow-up appointments to ensure continuity of care.

• Admit to the antenatal ward for observation or treatment if there are medical or obstetric reasons. There is a place for admission to promote a caring attitude when a woman’s anxieties are not resolved.

The labour ward is also a place for emergency care of expectant mothers. Reasons for admission include medical emergencies, for example status asthmaticus or myocardial infarction, and obstetric complications, for example antepartum haemorrhage or eclampsia. When an emergency situation arises:


• Address the emergency. Stabilise the woman’s condition.

• Recruit support from appropriate colleagues such as anaesthetists, haematologists, physicians or surgeons. Where possible consult colleagues with particular interest in obstetrics.

• Address obstetric emergencies (see Chapter 6).

• Document clearly in detail all steps undertaken. This retrospective record is made as soon as possible when memories of events are still fresh in the mind.

• Keep partners and accompanying persons fully informed.

• Any emergency is a frightening situation. Efficient professionalism contributes much to a calm atmosphere and reduces anxiety.


Organisational requirements


The various functions of the labour ward demand a sound organisational structure to provide effective care. Requirements include:


• A lead clinician with particular interest in the labour ward and a lead midwife coordinator.

• A labour ward forum which meets on a regular basis (for example weekly) to encompass audit, teaching, health and safety and risk management issues.

• Close liaison with neonatologists.

• Frequent drills and regular updating to anticipate emergencies, for example shoulder dystocia or haemorrhage, to ensure provision of evidence-based care. Ability to interpret cardiotocograph traces is essential.

• Levels of staffing must be adequate. A robust process for induction of new staff of all levels, regular appraisal and continuing education programmes must be in place.

• A senior obstetrician supervises and must be readily available to advise and support. The ideal is a move towards consultant-based care for complicated pregnancies whereas midwives will attend to normal deliveries.


Requirements for quality care


Cultural changes prompted by better information, national (for example ‘Changing childbirth’ (Brown and Lumley 1998)) and international (for example National Health and Medical Research Council (NHMRC) 1996) directives, and surveys indicate women and their partners expect quality and satisfaction in addition to safe delivery. There is evidence to show the following contribute to perceived quality and satisfaction:


• Rapport and satisfaction during antenatal care.

• A welcoming attitude at the time of admission.

• Good communication. Women and partners kept well-informed at all stages and encouraged to participate in care decisions.

• Reassurance, encouragement and good pain relief. These steps are essential if active labour unexpectedly extends beyond 12 hours.

• Limiting the number of people in the delivery room at any one time. Respect the need for privacy.

• Ensuring continuity of care expectations even if the carer changes. Not all personal midwives can stay for the whole duration of labour.

• Being as helpful as possible.

• Taking note of the choice of language used for communication.

• Limiting use of episiotomy.

Labour is the most common reason for admission.


• Ascertain detailed history to determine diagnosis for onset of labour, the state of the fetal membranes and the presence of mucoid show.

• Consider the differential diagnosis for intermittent abdominal pain, vaginal bleeding and leakage of fluid from the vagina (e.g. urinary incontinence or infection).

• Review the antenatal history. Knowledge of antenatal history is particularly important when women ring in for advice. Document main points of conversation.

• Reassure once the correct diagnosis of labour has been established.


ASSESSMENT FOLLOWING ADMISSION



Presentation


This describes the fetal part presented or nearest to the cervix, e.g. cephalic presentation.



Lie


This defines the relation between the longitudinal axis of the fetus and that of the mother (Figure 5.1).


image

Figure 5.1 Longitudinal, oblique and transverse lie.



Engagement


This occurs when the biparietal (vertex) or bi-ischial (breech) diameters descend below the pelvic brim. Descent of the fetal head into the pelvis is usually described as if the head is divided into five segments. The head would be engaged if less than three-fifths were palpable above the pelvic brim (Figure 5.2).


image

Figure 5.2 Engagement described in fifths: left, non-engaged; right, engaged.



Auscultation


Auscultate with a Pinard stethoscope (Figure 5.3). The position of the anterior shoulder is further from the midline in the occipito-lateral and posterior positions.


image

Figure 5.3 Pinard stethoscope and Doppler fetal heart rate detector.



Examination of abdomen and pelvis



• Place the woman on her back, with her head on a single pillow, her hands by her side and both knees slightly bent. The bladder should be empty. Use the semi-recumbent position if supine hypotension troubles.

• Note the general health and clinical condition, for example generalised oedema. Record temperature, pulse, blood pressure, and examine urine for presence of protein, ketones, sugar and blood.

• Observe and note the shape and contour of the abdomen.

• Note the frequency, duration and intensity of uterine contractions.

• Stand on the woman’s right side, maintain rapport by conversation and watch her facial expression as a guide to inadvertent cause of discomfort during palpation.

• Warm hands and palpate the abdomen gently to estimate the gestational age by fundal height, approximate fetal size, lie, presentation, amount of liquor and engagement of the presenting part.

• Place hand on the fundus or measure to estimate fundal height. Percuss if there is difficulty locating upper limit of uterus. Fundal height is only a rough guide to gestational age (Figure 5.4).

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Related posts:

  1. Maternal and perinatal mortality
  2. Obstetric emergencies: training with skills drills
  3. Induction and augmentation of labour
  4. Normal labour and delivery

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Mar 16, 2017 | Posted by in NURSING | Comments Off on Admission to labour ward

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