Labour can be very challenging for pregnant women especially those pregnant for the first time and great care is to be given during this period because of the perinatal mortality that can occur if proper care is neglected. The aim of ensuring special care or management during this period of labour is to provide the mother with a relaxed, friendly atmosphere within which her well-being and that of her baby can be closely monitored and supervised. The presence of her husband, mother or friend is required to ensure the best seamless care possible.
Management of labour involves monitoring of mother and monitoring of the fetus to assess any possible difficulties in delivery and strategize on measures to take to ensure successful delivery and post delivery condition. It takes the combined effort of the healthcare team and relatives of the woman to make this work. Pregnant women who are in labour and cooperate with their care givers can be rest assured with a successful labour process.
Care of the mother
- General care measures need to be addressed. The mother should not be left alone at any point of time. Fears and anxieties can be allayed and confidence encouraged by a supportive midwife. Minimal perineal shaving may be done in case episiotomy may be required. If the rectum is full, a suppository can be given to reduce the risk of fetal soiling in late labour. Access to bath or shower should be available.
- Diet needs to be withheld during labour to avoid delayed gastric emptying which leads to danger of inhalation of stomach content should a general anaesthetic be required for delivery.
- Pulse rate, blood pressure and urinary output are measured regularly and if ketosis or dehydration occurs, they should be treated with intravenous fluids.
- Continuous assessment of labour is necessary especially contractions, cervical dilatation and fetal descent in preparation for delivery.
- If required, analgesia can be given to the woman. The method of analgesia given will be dependent on the mother’s preference, her reaction to her contractions and the likely length of labour.
- The mother should not be allowed to make repulsive efforts until full dilatation of cervix has been confirmed. Premature pushing can make the cervix oedematous and delay progress. Organised pushing should also not be initiated until the baby’s head is visible.
- Monitoring of the fetus including fetal heart rate and presence of meconium in liquor should continually be carried out. If hypoxia is suspected from increased heart rate, fetal blood sampling can be taken for further assessment.
High risk pregnancies will demand extra care measures in addition to the above mentioned. A high risk pregnancy refers to one which predisposes or increases the risk of morbidities and/or mortality during pregnancy in mother and child.
Major High risk pregnancies to consider
- Bleeding from vagina before labour.
- Woman’s age < 18 years or > 35 years and having the first pregnancy.
- Underlying medical conditions such as severe anaemia, sickle cell disease, hypertension, diabetes, heart disease, asthma, tuberculosis, thyroid disorders, and HIV infection.
- Grand multiparity (woman who has had more than 5 children already).
- History of Postpartum haemorrhage or retained placenta.
- Fetal malpresentation at term.
- Multiple gestation (twins or more).
- Post date pregnancy ( gestational age > 42 weeks).
- Cephalopelvic disproportion with mother’s height < 154cm.
- Macrosomal babies who are large for date at term (fundal height > 40cm or fetal weight > 4kg).
- Past history of still births or death of baby after 1 week of delivery.
- Past history of miscarriage (spontaneous abortion) during the same time of gestation.
- Intrauterine Growth Retardation with uterine size smaller than gestational age.
- Previous instrumental delivery (vacuum extraction or forceps delivery).
- Previous surgical operation on uterus or cesarean section.
- Preterm labour at < 37 weeks gestation.
K. P. Hanretty, “Management of labour” Obstetrics illustrated (6th edition).