Labour Vital signs & Abdominal check Visual Aid

Introduction

For this assignment, I have created visual aids to be used to inform Crystal on the importance of monitoring maternal vital signs and abdominal examination in labour. Crystal is hoping for a spontaneous labour and birth with no pharmaceutical pain relief so it is key she sees these comprehensive assessments as guarding, promoting and facilitating her normal physiological process while ensuring safety by identifying complications for her and her baby 1,2.
For the visual aids, I have created some affirmation displays with associated information about routine maternal checks that may be offered to Crystal during labour.
 
These designs can be used in several ways:

• a three-fold, double sided flyer with the other side being upside down so image/affirmation section can be cut out separately.
• 6 separate cards on thicker board to be cut or folded for display in the birth setting.
• Poster size prints of the affirmation sections that can be framed in the birth space to remind Crystal of the importance of the checks by association.

 
I have used some of my own feminine and nature-based images that will aim to increase her sense of comfort, relaxation, and well-being. Feminine and nature images have also been shown to lower maternal heart rates, shorten labours, reduce epidural use and increase Apgar scores 3,4 that will support Crystal’s aspirations. I have used a consumer-friendly font and use non-medical language. I have used affirmations taken from the website ‘Healthline’ 5.
 
I see the aid being used as a handout in an antenatal session with some more detailed discussion had with each page/card. The discussion can then be sustained with Crystal using the affirmations within her own home and labour setting. The maternity setting can enhance this association and the environment by using the framed versions in the labour room.

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Temperature

What:
a body temperature measurement usually around 37°C 6,7.
 
Why:
to check for signs of fever that can indicate infection or dehydration 6.
 
When:
with initial labour assessment 7,8.
4 hourly in active labour 7,8.
every hour with pushing 8.
immediately after birth of placenta 7,8.
1hr after birth 8.
if clinically indicated 7.
 
How:
midwife using a thermometer on forehead or under tongue 6.
 
Further Discussion Information:

• Both fetal and maternal temperatures increased significantly by progression of labour, and significantly more in the presence of epidural 9.
• In the normal labour temperatures remain stable, while with abnormal labour there may be a slow increase of temperature 10.
• Maternal hyperthermia is associated with worse outcomes for baby 6.
• Refer for two consecutive temperature readings of 38°C or above at least an hour apart 11.

 

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Heart/Pulse Rate

What: 
the rhythm of a beating heart 12.
 
Why:
to separate from the baby's heart rate & check for signs of anxiety, pain, infection, ketosis or haemorrhage 13. 
 
When:
with initial labour assessment 7,8.
every 30 min in active labour 8,14.
every 15 min with pushing 7,8,14.
immediately after birth of placenta 7,8.
15 minutely until 1hr after birth 8.
if clinically indicated 7.
 
How:
compressing an artery close to the surface of the skin with fingertips, usually in the wrist 12.

Further Discussion Information

• Late pregnancy average 64–104 bpm with an average of 84 bpm 12.
• First stage of labour the average is around 88 bpm, increasing to 96 bpm during contractions 12.
• The average mean heart rate in second stage was 93.8 14.
• Refer for a pulse over 120 beats/minute on 2 occasions 30 minutes apart 7.

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Respiration Rate

What:
the depth & regularity of breathing 15.
 
Why:
to monitor oxygen inhalation & carbon dioxide exhalation for working muscles & pain reduction. Watching for hyperventilation 15.
 
When:
with initial labour assessment, every 4 hours in active labour, every hour with pushing, immediately after birth of placenta, 15 minutely until 1hr after birth & if clinically indicated 8.
 
How:
visually observed 15.
 
Further Discussion Information

• increased 40-60% in labour 15.
• Breath-holding should be discouraged 15.
• Maternal hyperventilation can also lead to dizziness, tingling and decreased fetal oxygenation 16.
• Encourage deep, slow breathing between contractions to maintain oxygenation 15.

 

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Blood Pressure

What:
the force the blood places on vessels 17.
 
Why:
to monitor for high pressure 13 & ensure adequate oxygen to vital organs 17.
 
When: 
with initial labour assessment 7,8.
4 hourly in active labour 7,8.
hourly with pushing 7,8.
immediately after birth of placenta 7,8.
1hr after birth & if clinically indicated 7.
 
How: 
with an inflatable cuff & measurement gauge around upper arm, either electronically or with a midwife listening with stethoscope in elbow bend 17.

Further Discussion Information

• Average ~ 90/60 - 140/90 mmHg 17.

• Can be caused by supine position or shock 13.
• Refer for a single raised diastolic blood pressure of 90 mmHg or more or raised systolic blood pressure of 140 mmHg or more on 2 consecutive readings taken 30 minutes apart 7.
• Performed 5-min intervals for 20 min following the administration of epidural medication 13.

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Abdominal Palpation ​

​What: 
finding position of baby 13,18.
 
Why:
to access position, descent & progress & deviation from normal 7,8,18 & find best position to hear baby's heart 8.
 
When: 
with initial labour assessment 7,8,13.
2 hourly in active labour 8.
hourly with pushing 8.
immediately after birth of placenta for height & tone 8.
15 minutely until 1hr after birth 8.
prior to vaginal exam 8.
if clinically indicated 7.
 
How: 
midwife uses hands on belly while you are partially reclining on back 8.
 
Further Discussion Information

• Explanation of deep pelvic palpation as it is only used in labour to measure the number of fifths of the baby’s head that is palpable above the pelvic brim 13.
• As woman is semi recumbent, a position not ideal for labour proficiency, it is important to encourage her to be upright as soon as possible so not to disturb her rhythm of labour or extend the compression on the inferior vena cava and abdominal aorta 8.

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Contraction Palpation

What:
feeling for uterine activity and relaxation 8.
 
Why:
to access length, strength & frequency of contractions 7,18.
Checking for hypertonicity 7.
 
When:
with initial labour assessment 7,8.
10 min every 30min for active labour, pushing & birthing placenta, & if clinically indicated 7,8.
 
How:
midwife uses fingers on belly near sternum and counts how many contractions in 10min 18.
 
Discussion Information

• Midwife could mention that physiological plateaus or pauses may occur and can be important mechanisms for self-regulation of the mother-infant dyad and preventing maternal and fetal distress and not a sign of pathological dystocia which then could result in unnecessary medical interventions 19.
• Stay with the woman as this is an opportunity for physical connection and to offer reassurance to her and her support team 8.

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Concluding remarks

It is important when talking to a woman about these clinical checks that often care settings impose time constraints which do not allow for their individual variation of spontaneous labour, but that informed consent will be acknowledged and her autonomy supported 20.
 
To support her autonomy, midwives are required to be with the woman rather than only doing things to her to then become better attuned to her evolving situation and safety. Midwives can integrate these clinical checks into the whole dynamic of care, rather than having them be the central concern 21.

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References

(1)       International Confederation of Midwives [ICM]. Essential Competencies for Midwifery Practice, 2019.
(2)       Nursing and Midwifery Board of Australia [NMBA]. Midwife Standards for Practice, 2018.
(3)       Aburas, R.; Pati, D.; Casanova, R.; Adams, N. G. The Influence of Nature Stimulus in Enhancing the Birth Experience. HERD Health Environ. Res. Des. J. 2017, 10 (2), 81–100. https://doi.org/10.1177/1937586716665581.
(4)       Setola, N.; Naldi, E.; Cocina, G. G.; Eide, L. B.; Iannuzzi, L.; Daly, D. The Impact of the Physical Environment on Intrapartum Maternity Care: Identification of Eight Crucial Building Spaces. HERD Health Environ. Res. Des. J. 2019, 12(4), 67–98. https://doi.org/10.1177/1937586719826058.
(5)       Zapata, K. 20 Powerful Birth Affirmations to Encourage and Inspire You. Healthline. https://www.healthline.com/health/pregnancy/birth-affirmations#example-birth-affirmations.
(6)       Johnson, R.; Taylor, W.; Smith, S. de-Vitry; Bayes, S. Temperature. In Skills for Midwifery Practice Australian & New Zealand Edition; Elsevier Australia, 2022; pp 41–50.
(7)       National Institute for Health and Care Excellence [NICE]. Intrapartum Care for Healthy Women and Babies. 2017.
(8)       Safer Care Victoria [SCV]. Care during labour and birth. Safer Care Victoria. https://www.bettersafercare.vic.gov.au/clinical-guidance/maternity/care-during-labour-and-birth (accessed 2022-05-11).
(9)       Lavesson, T.; Källén, K.; Olofsson, P. Fetal and Maternal Temperatures during Labor and Delivery: A Prospective Descriptive Study. J. Matern. Fetal Neonatal Med. 2018, 31 (12), 1533–1541. https://doi.org/10.1080/14767058.2017.1319928.
(10)     Schouten, F.; Wolf, H.; Smit, B.; Bekedam, D.; de Vos, R.; Wahlen, I. Maternal Temperature during Labour. BJOG Int. J. Obstet. Gynaecol. 2008, 115 (9), 1131–1137. https://doi.org/10.1111/j.1471-0528.2008.01781.x.
(11)     Australian College of Midwives. National Midwifery Guidelines for Consultation and Referral, 4th ed.; ACM: Canberra, 2021.
(12)     Johnson, R.; Taylor, W.; Smith, S. de-Vitry; Bayes, S. Pulse. In Skills for Midwifery Practice Australian & New Zealand Edition; Elsevier Australia, 2022; pp 51–58.
(13)     Jackson, K.; Anderson, M.; Marshall, J. E. Physiology and Care During the First Stage of Labour. In Myles Textbook for Midwives; Elsevier Limited, 2020; pp 447–499.
(14)     Towers, C. V.; Trussell, J.; Heidel, R. E.; Chernicky, L.; Howard, B. C. Incidence of Maternal Tachycardia during the Second Stage of Labor: A Prospective Observational Cohort Study. J. Matern. Fetal Neonatal Med. 2019, 32 (10), 1615–1619. https://doi.org/10.1080/14767058.2017.1411476.
(15)     Johnson, R.; Taylor, W.; Smith, S. de-Vitry; Bayes, S. Respiration. In Skills for Midwifery Practice Australian & New Zealand Edition; Elsevier Australia, 2022; pp 59–68.
(16)     Blackburn, S. Maternal, Fetal, & Neonatal Physiology: A Clinical Perspective, 5th Edition.; Elsevier Saunders: Maryland Heights, 2016.
(17)     Johnson, R.; Taylor, W.; Smith, S. de-Vitry; Bayes, S. Blood Pressure. In Skills for Midwifery Practice Australian & New Zealand Edition; Elsevier Australia, 2022; pp 69–90.
(18)     Johnson, R.; Taylor, W.; Smith, S. de-Vitry; Bayes, S. Abdominal Examination during Labour. In Skills for Midwifery Practice Australian & New Zealand Edition; Elsevier Australia, 2022; pp 309–312.
(19)     Weckend, M.; Davison, C.; Bayes, S. Physiological Plateaus during Normal Labor and Birth: A Scoping Review of Contemporary Concepts and Definitions. Birth 2022, birt.12607. https://doi.org/10.1111/birt.12607.
(20)     de Jonge, A.; Dahlen, H.; Downe, S. ‘Watchful Attendance’ during Labour and Birth. Sex. Reprod. Healthc. 2021, 28, 100617. https://doi.org/10.1016/j.srhc.2021.100617.
(21)     Bradfield, Z.; Hauck, Y.; Duggan, R.; Kelly, M. Midwives’ Perceptions of Being ‘with Woman’: A Phenomenological Study. BMC Pregnancy Childbirth 2019, 19 (1), 363. https://doi.org/10.1186/s12884-019-2548-4.