3 Care and support during labour and immediately after delivery

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Contents

Objectives

When you have completed this chapter, you should be able to:

Decision making before delivery

3-1 What decisions need to be considered?

Any woman in labour needs to be assessed not only in terms of the medical care she and the baby require, but also based on whether there is an actively involved father or other close family members who need to be involved in the delivery and decision making. Hopefully full assessment has been made prior to labour to ascertain this, but it is important that no assumptions are made without sensitive history taking. All attempts should be made to include a significant other, even if this has to be done telephonically.

If a birth care plan is in place, try to accommodate the plan as far as medical interventions will allow. If no birth plan is available, the following will need to be considered:

  1. Method of delivery and interventions – spontaneous labour, induction of labour or Caesarean section
  2. Type of pain relief for the mother
  3. Place of delivery – depending on the goals of care (that is, active care or comfort care) for the baby may influence the place of delivery
  4. Delivery room – where possible, consider privacy and the emotional needs of the family and which family members should be present
  5. Staff at delivery – depending on the goals of care consider privacy and number of staff who need to be present during the labour and delivery. Keep the handover of staff to a minimum where possible. All staff attending to the mother must be made aware of the birth care plan and/or intervention levels that have been decided upon.
  6. Fetal monitoring during labour – the decision whether to monitor the fetal heart during labour should be made before the onset of labour after being discussed with the parents.
  7. Resuscitation interventions – all staff attending the delivery need to be informed in advance as to the level of interventions to be performed:
    • No resuscitation
    • Limited interventions
    • Full resuscitation
  8. Memory-making opportunities if it is thought that the baby may only live for a few minutes to hours after the delivery.

It is best if all decisions related to the care of the baby during labour and immediately after delivery are made in advance and are recorded in the birth plan.

Management during labour

3-2 What are the primary goals for management of labour if the baby is not expected to live long after delivery?

If a palliative care approach for the baby is anticipated or planned for antenatally, the goals for the labour should include both the following:

3-3 Should the baby’s heart rate be monitored during labour?

If a decision has been made not to resuscitate the baby then there is no indication to monitor the fetal heart rate during labour and to offer a Caesarean section if fetal distress develops. This plan should be discussed with the parents and the clinical staff. Management of labour should address the care of the mother.

Usually, the fetal heart rate is not monitored during labour if the baby has a life-limiting condition.

If the baby dies during labour the palliative care support is similar to that offered if the baby dies during the antenatal period.

Management of the baby and mother after delivery

3-4 What immediate post-delivery care of the baby is needed?

The following need to be addressed:

  1. An immediate assessment after the baby is born.
  2. Should the baby be resuscitated if needed?
  3. What delivery room care is needed?
  4. What holistic comfort care should be provided?
  5. What symptom management should be given?

3-5 What assessment should be made immediately after the baby is born?

The immediate assessment is important to determine if the options in the birth plan are still appropriate and if anything needs to be discussed or changed, as there may be fewer or more problems than anticipated. Be prepared for different outcomes, for example, the birth defects may be worse than previously thought or baby may live longer than anticipated after delivery.

3-6 Should the baby be resuscitated?

While the decision regarding resuscitation status should be made well before delivery, this decision may need to change once the baby is assessed:

This decision needs to be made within a minute of delivery and should be part of the immediate assessment.

A decision whether to offer resuscitation is best made before the baby is born.

3-7 What delivery room care is needed?

All babies should be dried and wrapped in warm blankets. Review the birth plan for wishes for routine newborn care and desired interventions such as whether an intramuscular injection of vitamin K should be given and the possibility of the transition to a neonatal intensive care ward or nursery if the baby lives longer than expected.

3-8 How should holistic comfort care be offered?

Holistic comfort care consists of non-pharmacological techniques and possible pharmacological interventions. This may include providing warmth, swaddling, enteral feeding, pain medication and oxygen if needed. Most significantly, comfort care comprises intimate contact with unrestricted physical contact and bonding between parents and their baby. Close contact is usually limited when baby is undergoing intensive care. If the baby is not for active resuscitation, then continue with comfort care allowing baby:

A decision not to actively resuscitate a baby must never be taken as a reason not to provide comfort care for the short period that the baby may live.

3-9 What symptom management may be needed?

Anticipate the kind of distressing symptoms the baby may experience such as dyspnoea (difficulty breathing) or pain. Follow the advance care plan if available. Otherwise discuss the options like oxygen or low dose morphine to keep the baby comfortable. If it looks like the baby may survive a while, consider providing symptom control via the least painful route – nasogastric tube or the buccal route (inside the cheek).

3-10 What support do you need to provide for the mother/parents at this time?

Support must be holistic, considering the physical, psychosocial and spiritual needs that the mother (and family) have. The aim is to help prevent and relieve suffering, while providing non-judgemental sensitive care and comfort to both the baby and the family. Be available to answer questions and assist when asked. Routine post-delivery care must be offered but, at the same time, if the baby’s death is imminent do not rush but allow the mother (and the family) to spend time with her (their) baby saying goodbye. If it appears that the baby may survive this immediate period, the mother may be transferred to a private ward, away from the normal routine of a labour and postnatal ward, without the sense she is being abandoned by the healthcare providers. Depending on the intervention level, the baby will either be admitted into the neonatal unit/nursery or stay with the mother for holistic comfort care.

Palliative care in the delivery room may require preparation for the ‘hello’ (birth) AND the possibility of ‘goodbye’ (death) at the same time.

3-11 What support do parents need during this stressful experience?

Literature and research have shown that most parents want the following from the experience:

3-12 Who else may need to be supported during this time?

  1. Siblings (often the ‘forgotten mourners’)
  2. Grandparents
  3. Extended family as some cultures and religions include family members in their rituals
  4. Other caregivers who may be supporting the family

3-13 What type of support can you provide for the siblings and extended family?

One of the most important factors to consider is allowing the family time with their baby if the intervention is to be comfort care, however long or short the time they choose. Parents should be encouraged to include the siblings in this special time. Simple and truthful answers and explanations of what to expect and what is happening need to be shared at the child’s level of development. If other family members are in the waiting room, feedback should be provided on an ongoing basis as to what is happening, or, if the parents wish, they should be allowed in with them.

3-14 What if death occurs in the delivery room?

It is important to be prepared that the baby may die in the delivery room. Where possible allow for the following interventions:

3-15 What memory-making activities can be considered?

Keeping the memory of the baby alive after death can be a helpful way to manage feelings of grief and bereavement. Ideas for memory-making include:

Even if the baby only lives for a few minutes these memories are very important to the parents. At least they had a brief opportunity to meet their child.

Do not forget memory-making activities if a baby dies soon after delivery.

3-16 What if the baby survives longer than expected?

If a baby does better than expected, parents have more time to make decisions about future care, including potential discharge home. Discharge planning may include a plan for ongoing palliative care support, advance care planning may include measures intended to improve the baby’s quality of life and end-of-life care.

Case study 1

A pregnant woman is seen at her local antenatal clinic for a routine check-up. Everything had been going well but the midwives are now concerned that the baby is small for gestational age. She is then referred to the regional hospital and an ultrasound scan reveals a serious cardiac abnormality. Further referrals and assessment result in the diagnosis of Trisomy 18 being made. She is offered a termination, but refuses. She carries on with the pregnancy and presents alone in early preterm labour to the hospital.

1. As she has arrived alone, can we safely assume that she is a single mother with no family support?

No. Any woman in labour needs to be assessed not only in terms of the medical care she and the baby require, but also whether there is an actively involved father or other important family member that needs to be involved in the delivery and decision making. Hopefully full assessment has been made prior to labour to ascertain this, but it is important that no assumptions are made without sensitive history taking.

2. She reports that the father of the child is very stressed as he is stuck in another city at work. He had planned to take leave closer to when the baby is due. How can you include this father in the care and management?

All attempts should be made to include a significant other, even if this has to be done telephonically. A cell phone is very helpful in providing palliative care support.

3. This mother did not speak with a palliative care team during the pregnancy and there is no birth plan in place. What are the most important things to discuss with the parents now?

The baby has a life-limiting condition, therefore, the overall prognosis is poor. Both the mother and father (even telephonically) should be involved in the decisions whether to monitor the fetal heart during labour and what resuscitation interventions they would choose:

Also discuss what memory-making activities they would like to consider.

4. The father manages to arrive at the hospital as the mother is in active labour. How can you support the father?

Check the father’s understanding and then allow him into the delivery room if that is in accordance with the mother’s wishes. The staff, where possible, should consider privacy and the emotional needs of the family.

5. After honest and open counselling, the parents accept that the prognosis is poor and decide on a palliative approach. After delivery, the baby is pink and cries well. The parents tell you they have named the baby Zoli. How do you support the parents at this time?

Respect their wishes as far as possible. Call the baby by its name. Allow them as much time with their baby as they need. If they choose not to see or spend time with their baby respect their wishes but make mementos for them which you can always share with them at a later stage if they so wish. Respect their religious or cultural beliefs and practices and be mindful that parents and family members may have differing spiritual preferences or needs. Ask them if there are any rituals they want to be performed, for example blessing the baby, a baptism or a naming ceremony.

6. Who else may need to be supported during this time?

Case study 2

You are part of the team at the delivery of a baby diagnosed antenatally with Potter sequence, a rare congenital disorder associated with a lack of amniotic fluid due to absent or poorly functioning kidneys during pregnancy. The baby is not expected to live long after delivery and the parents have asked that there be no active resuscitation or aggressive interventions.

1. What holistic comfort care interventions can be provided for the baby if the baby lives for a few minutes to hours?

This may include providing warmth, swaddling, enteral feeding, pain medication and oxygen if needed. Most significantly, comfort care comprises intimate and unrestricted physical contact and bonding between parents and their baby:

2. How can you prepare the family for the event that the baby dies in the delivery room?

It is important to explain to the parents the physical changes that are likely to occur as their baby dies, such as terminal gasping. Reassure them that if their baby appears to be in distress everything possible will be done to manage pain and distressing symptoms. Ensure explanations are given in simple non-medical terms that they will understand. Reassure them that you are available to support the family where and when necessary. Provide privacy for the baby and parents where possible, even if that means drawing curtains around an incubator or cot. If hospital protocol allows, find out if the parents would like the siblings and grandparents to spend time with them also saying goodbye to the baby.

3. What memory-making activities can be considered?

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