Oxford Handbook of Midwifery (72 page)

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Authors: Janet Medforth,Sue Battersby,Maggie Evans,Beverley Marsh,Angela Walker

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- Capillary naevi: small, pink marks may be observed on the upper eyelids, midline of the forehead, the upper lip, and the nape of the neck. These are common and fade over a period of months. Capillary naevi found elsewhere may be extensive, such as port wine stain.
- Neck: observation and inspection of the neck area is important to exclude webbing, a short neck, a large fold of skin at the back of the neck, and any swellings.
Chest: observe breathing and symmetry of the chest wall. Spacing and positioning of the nipples and any accessory nipples present.
Abdomen: the shape of the abdomen should be rounded, any obvious variations should be noted such as: a scaphoid or boat-shaped abdomen or swelling. The state of the cord should be observed, ensuring that it securely clamped. The cord should have three vessels and there should be no swelling or protrusions at the base. Absence of a vessel should be brought to the paediatrician’s notice immediately, as this may indicate cardiac or renal abnormalities.
Limbs and digits: count carefully and open the hands fully to expose any accessory digits, webbing, or trauma. The axillae, elbows, groins, and popliteal spaces also need to be inspected. The limbs should be inspected for equal length and observed for normal movement. The feet and ankles should be inspected for talipes.
External genitalia: in boys, observe the position of the urethral orifice, both testes should be situated in the scrotum. The foreskin should not be retracted as this is still adherent to the glans. Any obvious swelling in the inguinal area should be noted. In girls, gently inspect the labia— the urethral and vaginal orifices should be evident and a thick, white discharge may be present. Refer any discrepancy about the sex of the baby to the paediatrician promptly.
Back and spine: turning the baby over into the prone position, palpate and observe the back for any unevenness, swellings, dimples, or hairy patches that may be associated with an occult spinal abnormality. A baby from Asian or African ancestry may have a bruised appearance over the sacral area, this is normal and is referred to as the Mongolian blue spot. The presence and position of the anus can be observed.
It is also important to record in the notes whether the baby passes meconium at birth or shortly after, to confirm patency of the anus.
Hips: Ortolani or Barlow’s test, or possibly a modification of the two, is performed routinely to check for dysplasia of the hips. Depending on local policy, this will be carried out by the midwife or the paediatrician. Reference to local guidelines and any additional training required should be done prior to undertaking this procedure. If the paediatrician
performs the test within the first day of birth, there is no reason to do
it at the initial examination.
Measurements: the head circumference and length may be recorded. However, different units may have differing policies. Unless calibrated equipment is available, measuring the crown to heel length is grossly
CHAPTER 16
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inaccurate. If a calibrated device is used, it is essential that the baby’s legs are fully extended; this may require two people to assist to ensure accuracy. Measurement of the head circumference may be deferred to the third day, by which time any swelling will have
subsided. A measuring tape is used to encircle the head at the occipital protuberance and the supra-orbital ridges.
- Record the baby’s temperature.
- Record your findings in the baby’s notes. Communicate any abnormalities to the paediatrician or GP, and pass the information on to the midwife taking over the mother’s care on the postnatal ward. Inform the parents if a paediatrician needs to be notified and give the reasons why.
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  CHAPTER 16
  Immediate care of the newborn
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  Immediate care of the newborn
  The midwife should be familiar with the transitional requirements of adap- tation to external uterine life, so that she can make appropriate prepara- tions for the newborn’s arrival.
- The birthing room, whether at home or hospital, should be warm, ideally 21–25°C. Switch off fans and draw curtains to reduce heat loss within the environment.
- As the baby’s head is born, wipe excess mucus from his/her mouth.
- Touching the nasal nares may stimulate reflex inhalation of mucus and debris into the trachea and is not recommended.
- Following the birth of the trunk, lift the baby on to the mother’s abdomen or chest, unless this has been declined by the mother.
- Most babies will start to breathe and maintain a clear airway without intervention.
- Aggressive and deep suction is not recommended. When suction is required, use a mucus extractor or a soft suction catheter. It is important to aspirate the oropharynx first before aspirating the
  nasopharynx, to prevent mucus being drawn down the trachea when the baby gasps due to suction stimulation of the nasal passages.
- Cut the cord approximately 2–8cm from the baby’s umbilicus, between two cord clamps. Once the cord is clamped securely to prevent blood loss, cut the cord between the two clamps. Placing a gauze swab over the cord while cutting it will prevent blood spray over the delivery area.
  Identification of the newborn is important if the baby is born within a maternity unit; however, a home birth does not require labelling, unless the baby is a twin. Individual units will have their own policy on this; however, basic principles apply:
- Apply name bands immediately following birth, in some units this may be before the cord is cut
- Usually two bands are applied—most commonly to both ankles
- Write the name bands legibly, clearly identifying the family surname, the time and date of birth, and the baby’s gender. If gender is in any doubt, explain to the parents that you need to seek further help on this matter
- The mother or father should confirm that the information is correct before applying the name bands
- Ensure that both bands are not too tight nor too loose, but fixed securely and not causing trauma to the baby’s skin
- Check the bands daily and replace them if they become loose or fall off while the baby is in the hospital.
  Preventing heat loss in the time immediately following birth is crucial. The baby has an immature heat regulatory system, therefore provide a warm environment, as above.
  •
  Reduce heat loss by drying the baby at delivery. Wet towels need to be
  replaced with warm, pre-heated towels to prevent further heat loss.
- Skin-to-skin contact with the mother helps to reduce heat loss if the remaining exposed skin of the baby is covered.
- Cover the baby’s head, as substantial heat is lost through the head.
  IMMEDIATE CARE OF THE NEWBORN
  309
Loose clothing and comfortable swaddling with blankets will help to conserve body heat.
Some units may be provided with overhead heaters in the labour rooms. Care with overheating should be acknowledged. Hot water bottles used to pre-warm the cot at a home birth should be used with caution.
Routine bathing of the baby following birth is not necessary unless the baby is overly soiled from the birth process or there is risk of
contamination. Deferring non-urgent procedures such as bathing helps to maintain thermoregulation.
Observe the baby regularly for colour and skin temperature, to ensure that hypothermia is not present. Record the body temperature following birth.
The baby may require a dose of vitamin K, given as prophylaxis against bleeding disorders. This should have been discussed thoroughly with the woman prior to birth, so that she could make an informed choice regarding the risks/benefits. Depending on local policy, this may be given orally or by intramuscular injection.
The period immediately following birth should allow some time for the parents and the baby to communicate and develop the important relationship and rapport necessary for the baby’s well-being. Very often the baby is very alert following birth (unless drugs used in labour have blurred this response), resulting in an active three-way process of communication between the mother, father, and baby.
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Skin-to-skin
All mothers should be encouraged to hold their naked baby against their skin in a calm and unhurried environment immediately following birth, regardless of their feeding intention. Mothers should be given the opportunity prior to birth to discuss how this can be acceptably achieved. Cultural influences need to be considered within this discussion, as they may make implementation of skin-to-skin unacceptable.
Newborn babies find their mother’s breast partly by smell, and this instinctive process can be interfered with by clothing, wrapping in hospital towels, and separation, therefore these should be avoided whenever possible, b see Management of breastfeeding, p 662.
Benefits of skin-to-skin contact
- Babies gradually become more active, begin to root, and are at least three times more likely to suckle successfully.
- Babies demonstrate less distressed behaviour and cry less than those separated from their mothers, for example during suturing.
- Increased nurturing behaviour has been seen in mothers whose babies have touched their nipples and areolae within the first half hour of birth. Mothers planning to bottle feed could still enjoy and benefit from this instinctive interaction.
- The likelihood of PPH could be reduced as early contact and suckling stimulates the uterus to contract.
- Babies are much more likely to be breastfed for longer when uninterrupted skin-to-skin contact has occurred at birth.
- Mothers will feel higher levels of satisfaction with motherhood and have more positive feelings overall if they have been able to enjoy the first hour after birth without interruption.
  Physiological effects on the baby
- Skin-to-skin contact is an effective measure against hypothermia and hypoglycaemia.
- The blood chemistry of babies who have been acidotic or had a period of ‘fetal distress’ rectifies itself more quickly when skin-to-skin contact has occurred.
- Skin-to-skin contact is particularly important for babies who have had a traumatic birth, required resuscitation, and who need to be warmed. It should be initiated as soon as possible.
  Routine care practices which interfere with this process should be reconsidered and abandoned unless proven to be of benefit to the infant or mother in the circumstances in which they are initiated.
  0 Hospital routine should not take priority over the needs of the mother and child.
  Part 3
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  Complicated labour
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  Management of malpositions and malpresentations
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  Chapter 17
  313
  Occipito-posterior position
  314
  Face presentation
  316
  Brow presentation
  318
  Shoulder presentation
  319
  CHAPTER 17
  Management of malpositions
  314‌‌
  Occipito-posterior position
  These are cephalic presentations where the occiput is directed towards the right or left sacro-iliac joint—right occipito-posterior (ROP) and left occipito-posterior (LOP). These positions are the most common of all
  causes of mechanical difficulty in labour.
  Causes
- No definite cause has been established but on occasion it may be linked to abnormal shape of the maternal pelvis.
- There is a belief that maternal posture and lack of physical activity during pregnancy may be a predisposing factor, but this is not evidence based.
- Frequently the fetus has an attitude of deficient flexion of the head and spine.
- The occipito-posterior positions are the most common reason for non- engagement of the fetal head at term in the primigravida.
- Ultrasound scan may reveal an anteriorly placed placenta.
  Diagnosis
  Abdominal examination
- On inspection the abdomen is flattened below the level of the umbilicus.
- On palpation of the abdomen, the head is high and deflexed, limbs are felt on both sides of the midline. The back may be felt with difficulty laterally or may not be palpable.
- On auscultation of the fetal heart sounds are audible in the flank, over the fetal back; they are also easily heard in the midline because of the proximity of the fetal chest to the maternal abdominal wall.
  Clinical features during labour
- Continuous backache.
- Slow progress.
- Irregularly spaced contractions which tend to couple together.
- More frequent incidence of non-reassuring FHR patterns in labour.
- Early spontaneous rupture of the membranes.
- Slow descent of the fetal head.
- Increased rectal pressure towards the end of the first stage of labour resulting in an urge to push prior to full dilatation of the os uteri.
  Vaginal examination
- The degree of flexion of the head can be assessed during labour.
- The anterior fontanelle lies centrally or anteriorly.
- The posterior fontanelle may be out of reach.
- Caput and moulding are common
- When the head is deflexed the occipito-frontal diameter of 11.5cm presents.
- The presenting part is poorly applied to the cervix.
- The cervix may become oedematous as labour progresses.
- The head does not engage or descend easily, with risk of the following consequences.
  Consequences
- Prolonged labour
- Delay in the second stage of labour
  OCCIPITO-POSTERIOR POSITION
  315