North Cumbria Delivery
Suite Guidelines 2008
North Cumbria Acute Hospitals NHS Trust
North Cumbria Delivery Suite Guidelines 2008
Publication Date: 22/01/2008
Version 2.0
DOCUMENT CONTROL
Author/Contact
North Cumbria Obstetric Guideline Forum
Tel: 01228 814242
Email: xxxx.xxxxxx@xxxxxxxxxxxxxx.xxx.xx
Document Path & Filename
Y:\Trust Policy Group\Ratifed\January 2008\Del
Suite Guidelines\NC Del Suite Guidelines 2008 -
final version.doc
Document Reference
NCHE-OBS001
Version
2.0
Status
Approved
Publication Date
22/01/2008
Review Date
22/01/2011
Approved / Ratified / Notified Governance Committee Date: 15/01/2008
by
Trust Board Date: 22/01/2008
Distribution:
North Cumbria Acute Hospitals NHS Trust – Intranet
Please note that the Intranet version of this document is the only version that is
maintained. Any printed copies should therefore be viewed as “uncontrolled” and as
such, may not necessarily contain the latest updates and amendments.
Approval/Amendment Record
Version Date
Brief Summary of Change Author
0.1
25/05/2006
First meeting to overview R Lawley – CD / Obstetrics
Draft
J Eldred – Obstetrics
D Lightfoot (SOM) – Matron
S Forster (SOM) - Matron
0.15
19/07/2006
Reviewed by appropriate
Dr P Stride - Anaesthetics
specialties
Dr Q Kingsbury -
Anaesthetics
Dr M Ben-Hamida -
Paediatrics
Dr P Whitehead –
Paediatrics
Anne Musgrave (SOM) –
Head of Midwifery
S Whyte-Earl - Matron of
Neonatal Services
S Forster (SOM), Matron -
CIC Midwives
D Lightfoot (SOM), Matron –
WCH
Midwives
S Hall, Midwife -
PNH/Community Midwives
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North Cumbria Acute Hospitals NHS Trust
North Cumbria Delivery Suite Guidelines 2008
Publication Date: 22/01/2008
Version 2.0
L Musgrave (SOM), Matron -
Normal Birth Group
I Branch - Blood Transfusion
M Knowles - Microbiology
H Sawers – Diabetics
Mr Reid, Mr Wijesiriwardana
& Mr Bober – Obstetrics
L Hipple - Obstetrics
P Robson & B Bowness –
Bereavement Counsellor
G Butterworth – Document
Standards
1.1
28/09/2007
Updated following meeting North Cumbria Obstetric
Guideline Group
1.2
02/10/2007
Updated following meeting North Cumbria Obstetric
Guideline Group
1.3
30/11/2007
Updated following meeting North Cumbria Obstetric
Guideline Group
1.4
12/12/2007
Summary section updated North Cumbria Obstetric
to demonstrate agreed Guideline Group
changes to date as agreed
with Clinical effectiveness
Facilitator
Review Process Prior to Ratification:
Name Of Group/Department/Committee
Date
Governance Committee
14/09/2006
Trust Board
26/09/2006
North Cumbria Labour Ward Forum
20/07/2006
North Cumbria Obstetric Guideline Group
28/09/2007
North Cumbria Obstetric Guideline Group
02/10/2007
North Cumbria Obstetric Guideline Group
30/11/2007
Trust Policy Group
20/12/2007
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North Cumbria Acute Hospitals NHS Trust
North Cumbria Delivery Suite Guidelines 2008
Publication Date: 22/01/2008
Version 2.0
North Cumbria Delivery Suite Guidelines
CONTENTS
DOCUMENT CONTROL..................................................................................................2
SUMMARY ......................................................................................................................5
CHAPTER 1 - OVERVIEW ..............................................................................................8
CHAPTER 2 - MIDWIFERY CARE ON DELIVERY SUITE..............................................33
CHAPTER 3 - MATERNITY ASSESSMENT UNIT (MAU)...............................................47
CHAPTER 4 - INDUCTION OF LABOUR ........................................................................51
CHAPTER 5 - FIRST STAGE OF LABOUR ....................................................................59
CHAPTER 6 - SECOND STAGE OF LABOUR AND INSTRUMENTAL DELIVERY........74
CHAPTER 7 - THIRD STAGE OF LABOUR....................................................................84
CHAPTER 8 - PERINEAL REPAIR..................................................................................94
CHAPTER 9 - BREECH...................................................................................................100
CHAPTER 10 - MULTIPLE PREGNANCY ......................................................................106
CHAPTER 11 - SHOULDER DYSTOCIA ........................................................................111
CHAPTER 12 - PRE-TERM LABOUR .............................................................................117
CHAPTER 13 - FETAL HEART RATE MONITORING.....................................................128
CHAPTER 14 - ANTEPARTUM HAEMORRHAGE..........................................................139
CHAPTER 15 - POSTPARTUM HAEMORRHAGE .........................................................146
CHAPTER 16 - MANAGEMENT OF WOMEN REFUSING BLOOD TRANSFUSION .....160
CHAPTER 17 - THROMBOSIS AND THROMBOPROPHYLAXIS...................................164
CHAPTER 18 - CAESAREAN SECTION, VAGINAL BIRTH AFTER CAESAREAN SECTION
AND LAPAROTOMY.........................................................................................171
CHAPTER 19 - ANALGESIA AND ANAESTHESIA.........................................................189
CHAPTER 20 - INFECTION ............................................................................................203
CHAPTER 21 - ECLAMPSIA AND PRE-ECLAMPSIA.....................................................218
CHAPTER 22 - DIABETES..............................................................................................227
CHAPTER 23 - LATEX ALLERGY...................................................................................238
CHAPTER 24 - SUBSTANCE ABUSE.............................................................................244
CHAPTER 25 - MATERNAL COLLAPSE AND ACUTE MEDICAL PROBLEMS .............251
CHAPTER 26 - PREGNANCY LOSS AND MATERNAL DEATH ....................................260
CHAPTER 27 - CORD PROLAPSE.................................................................................281
CHAPTER 28 - PAEDIATRIC INVOLVMENT ON DELIVERY SUITE .............................287
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North Cumbria Acute Hospitals NHS Trust
North Cumbria Delivery Suite Guidelines 2008
Publication Date: 22/01/2008
Version 2.0
SUMMARY
These guidelines:
♦ have been produced by the multi-disciplinary groups for use by Health Care Professionals
working on Delivery Suites within North Cumbria, this includes the Cumberland Infirmary,
Whitehaven Hospital and Penrith Birthing Unit.
♦ are intended to guide practice but not to replace clinical judgement.
♦ are evidence-based where possible but otherwise reflect local practice.
♦ are published every two years.
Major changes in practice in the intervening period will be publicised and included at the rear
of the text. Please bring your own thoughts and recommendations to the attention of the
North Cumbria Labour Ward Forum.
The guidelines have been reviewed and amended to reflect the latest recommendations of
NICE Intrapartum Guidelines September 2007. These changes have been approved by the
North Cumbria Obstetric Guideline Group and are awaiting notification to the Trust Policy
Group, Governance Committee and Trust Board.
Additions / changes highlighted in
bold
Chapter Page Change
1.4
14
Women who have any of the following problems should be
referred directly from community midwife to the
obstetrician
(SpR or equivalent) and Lead Midwife at the acute unit.
1.4 15
No
5
♦ Documentation
♦ Call paramedic ambulance
♦ Inform LDRP/Delivery Suite
and Obstetrician
♦ Inform Supervisor of Midwives/Manager for support and
advice
1.5 15
First paragraph - Occasionally
an antenatal woman
Last paragraph, deleted ‘sick’
1.5
17/18
Added In-utero transfer form
1.6
19
Add in new information (highlighted green)
1.7
21
Added in new 1.7 – Arrangements for transfer of babies to other
units (alter following numbering).
1.8
22/23
Added in new 1.8
2.2 27
Added in bullet point -
no significant medical complication
(see NICE Intrapartum Care Guideline 2007 – Page 21-23)
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North Cumbria Delivery Suite Guidelines 2008
Publication Date: 22/01/2008
Version 2.0
2.4
27
If deviation from normality occurs, the midwife should discuss the
case with the
Obstetrician (See 1.4) and Lead Midwife co-
ordinating Delivery Suite
2.5 26
Dilatation of
4 cms (not 3)
2.7 28
Intermittent auscultation should be offered from the outset ‘
and
should occur for at least 1 minute’
2.8 28
Blood pressure measured every
4 hours (first paragraph)
2.14 32
Woman receiving opiates < 2 hours ago – changed on bulleted
list
2.14 33
Temperature
37.5
5.1
53
Added bullet points
Maternal
previous mysometry / hysterotomy
anaemia Hb <8.5 g/dl at onset of labour
substance abuse, including alcohol dependency
BMI > 35 kg /m2
Fetal
breech presentation
or other malpresentation
confirmed IUD
small for gestational age pregnancy
5.2 52
Observation list – ‘fetal heart every 15 minutes –
‘for at least 1
minute’
Plus sentence
‘Intermittent auscultation of the fetal heart after a
contraction should occur for at least 1 minute, at least every
15 minutes, and the rate should be recorded as an average.
The maternal pulse should be palpated if an FHR abnormality
is detected to differentiate the two heart rates’
5.2 54
Changed to BP every
4 hours (not 2)
5.4
60
Added flowchart at the end (Delay in first stage)
5.5
61/62 New info added / old info deleted – Spontaneous Pre-labour
Rupture of Membranes
5.5
66
Pre-labour Rupture of Membranes at term flowchart added
5.5 64
Under ‘Active Management’ – changed to
‘6 or under’
64
Under ‘Conservative Management’ deleted until ‘early ret’
6.3 68
Sentence added in –
Diagnosis of delay in the active second
stage of labour should be made with reference to the
algorithms on page 70-72
Added in -
The fetal heart should be monitored every 5 minutes
after a contraction
6
73
Delay of 2nd stage flowchart added
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North Cumbria Delivery Suite Guidelines 2008
Publication Date: 22/01/2008
Version 2.0
7.1 78/79 New information in 7.1 to replace old 7.1, 7.2, 7.3 and 7.4.
/
Also Definitions of third stage labour flowchart added
80
7.2
78
Old info on Management on Third Stage deleted, new info put in
7.3
82
Figure 1 – Delete ‘syntometrine’
7.3 83
Figure 2 – add in
‘do not clamp cord’ ‘until pulsations have
stopped’
7.4 80
Manual removal of placenta deleted
81
New information and flowchart added – Diagnosis of delay of Third
stage – old deleted
12.6 116
Steroids –addition to first paragraph –
The evidence for a course
of steroids, 34-36 weeks is therefore weaker but may be
appropriately given.
15.3 141/
Changes all cases of Tone, Trauma, Tissue and Thrombin to this
142/
order
143
Change ‘gauge’ to 16 (grey)
17.1 158/
Deleted old information (except for contra-indications to clexane)
159
and add new information
17.3
161
Deleted first 2 sentences
17.6
163
Thromboprophylaxis for labour assessment sheet deleted
18.2
167
Added ‘emergency’, ‘urgent’, ‘scheduled’, ‘elective’ on grading
19.1
183
List of women to be referred to cardiologist added
20.7
204
2 bullet lists added
21.1 212
Change loading dose initial treatment with -
in 50 ml syringe = 48
ml. Give as IV bolus dose over 5-10 minutes by doctor
21.5
214
Added BP info box at start
22.4
223
Deleted ‘1000 mls’
26.23 270/
Maternal death – new checklist added
271
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North Cumbria Acute Hospitals NHS Trust
North Cumbria Delivery Suite Guidelines 2008
Publication Date: 22/01/2008
Version 2.0
CHAPTER 1 - OVERVIEW
1.1
RESPONSIBILITIES OF STAFF ON DELIVERY SUITE ..................................16
1.2
HANDOVER OF CARE.....................................................................................20
1.3
TRANSFER OF MIDWIFERY CARE TO CONSULTANT RESPONSIBILITY ...21
1.4
TRANSFER INTO THE OBSTETRIC UNIT FROM HOME / PENRITH BIRTHING
CENTRE ...........................................................................................................21
1.5
TRANSFER OUT OF THE OBSTETRIC UNIT TO THE TERTIARY UNIT .......23
1.6
USING THE NEONATAL HOTLINES FOR IN UTERO TRANSFER REQUESTS
..........................................................................................................................26
1.7
ARRANGMENTS FOR THE TRANSFER OF BABIES TO OTHER UNITS ......28
1.8
TRANSFER OF POSTNATAL WOMEN TO TERTIARY UNITS .......................29
1.9
LABOUR WARD FORUM .................................................................................31
2.1
ADMISSION IN LABOUR..................................................................................34
2.2
LOW RISK WOMEN .........................................................................................34
2.3
HOME BIRTH ...................................................................................................34
2.4
TRANSFER TO MEDICAL CARE .....................................................................34
2.5
DIAGNOSIS OF LABOUR ................................................................................35
2.6
THE PROVISION OF ONE TO ONE CARE TO WOMEN IN ESTABLISHED LABOUR
..........................................................................................................................36
2.7
ADMISSION CTG .............................................................................................37
2.8
BLOOD PRESSURE.........................................................................................37
2.9
BLADDER CARE IN LABOUR ..........................................................................37
2.10
CORD GAS ANALYSIS ....................................................................................38
2.11
NUTRITION IN LABOUR ..................................................................................39
2.12
VENFLON SITING ............................................................................................39
2.13
CONCEALED PREGNANCY ............................................................................39
2.14
WATERBIRTH ..................................................................................................41
2.15
PREVENTING PRESSURE SORES.................................................................44
2.16
VIDEO AND SOUNDTAPE RECORDS AND PHOTOGRAPHS .......................44
3.1
INTRODUCTION...............................................................................................48
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North Cumbria Acute Hospitals NHS Trust
North Cumbria Delivery Suite Guidelines 2008
Publication Date: 22/01/2008
Version 2.0
3.1
INTRODUCTION...............................................................................................48
3.2
TRANSFER OF PATIENTS TO DELIVERY SUITE FROM ANTENATAL CLINIC OR
WARD ...............................................................................................................49
4.1
INDICATIONS FOR INDUCTION OF LABOUR ................................................52
4.2
41 WEEK ANTENATAL REVIEW .....................................................................52
4.3
ADMISSION FOR ASSESSMENT FOR INDUCTION.......................................52
4.4
OFFER OF INDUCTION FOR POST MATURITY DECLINED..........................53
4.5
INDUCTION REGIMEN ....................................................................................53
4.6
HYPERSTIMULATION......................................................................................54
4.7
AUGMENTATION FOR SPONTANEOUS RUPTURE OF THE MEMBRANES AT
TERM................................................................................................................54
4.8
RUPTURE OF THE MEMBRANES UNDER 37 WEEKS GESTATION ............54
4.9
INTRA-UTERINE DEATH .................................................................................56
5.1
RISK ASSESSMENT ........................................................................................60
5.2
PARTOGRAM ...................................................................................................61
5.3
BIRTH ENVIRONMENT....................................................................................63
5.4
DYSFUNCTIONAL LABOUR ............................................................................64
5.5
SPONTANEOUS RUPTURE OF MEMBRANES AT TERM..............................68
6.1
DEFINITION......................................................................................................75
6.1
DEFINITION......................................................................................................75
6.2
DIAGNOSIS ......................................................................................................75
6.3
MANAGEMENT ................................................................................................75
6.4
INSTRUMENTAL DELIVERY............................................................................75
6.5
MALPOSITION .................................................................................................78
6.6
PAEDIATRICIANS' ATTENDANCE AT INSTRUMENTAL DELIVERY .............78
6.7
PERINEAL REPAIR ..........................................................................................79
7.1
DEFINITIONS ...................................................................................................85
7.2
MANAGEMENT OF THIRD STAGE .................................................................85
7.3
PHYSIOLOGICAL THIRD STAGE OF LABOUR ..............................................86
7.4
TREATMENT OF WOMEN WITH A RETAINED PLACENTA...........................87
7.5
THE MORBIDLY ADHERENT PLACENTA.......................................................89
7.6
PLACENTAL HISTOLOGY ...............................................................................90
8.1
PERINEAL REPAIR ..........................................................................................95
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North Cumbria Delivery Suite Guidelines 2008
Publication Date: 22/01/2008
Version 2.0
8.2
CLASSIFICATION OF PERINEAL TRAUMA ....................................................95
8.3
ANALGESIA......................................................................................................95
8.4
SECOND DEGREE TEARS..............................................................................95
8.5
THIRD AND FOURTH DEGREE TEARS..........................................................96
9.1
ANTENATAL CONSIDERATIONS....................................................................101
9.2
ECV...................................................................................................................101
9.3
ELECTIVE CAESAREAN SECTION.................................................................101
9.4
PLANNED VAGINAL BREECH DELIVERY ......................................................101
9.5
TERM BREECH DIAGNOSED IN LABOUR .....................................................103
9.6
PRE-TERM BREECH .......................................................................................103
10.1
HIGH ORDER MULTIPLE PREGNANCY .........................................................107
10.2
INITIAL ASSESSMENT OF TWIN PREGNANCY.............................................107
10.3
FIRST STAGE OF LABOUR.............................................................................107
10.4
SECOND STAGE OF LABOUR ........................................................................108
10.5
THIRD STAGE OF LABOUR ............................................................................109
11.1
DEFINITION......................................................................................................112
11.2
ANTICIPATION .................................................................................................112
11.3
HELPERR .........................................................................................................112
11.4
SYMPHYSISIOTOMY .......................................................................................112
11.5
ZAVANELLI’S MANOEUVRE............................................................................113
11.6
HARD PULL......................................................................................................113
12.1
INITIAL ASSESSMENT ....................................................................................118
12.2
EXTREME PREMATURITY ..............................................................................118
12.3
FIBRONECTIN SWABS....................................................................................119
12.4
TOCOLYSIS .....................................................................................................120
12.5
ANTIBIOTICS ...................................................................................................122
12.6
STEROIDS........................................................................................................123
12.7
TEMPERATURE CONTROL AT BIRTH ...........................................................123
12.8
SURVIVAL AND MORBIDITY CHARTS ...........................................................124
13.1
FETAL HEART RATE MONITORING ...............................................................129
13.2
DEFINITIONS ...................................................................................................129
13.3
RISK ASSESSMENT ........................................................................................130
13.4
ANTENATAL FETAL HEART MONITORING....................................................131
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North Cumbria Acute Hospitals NHS Trust
North Cumbria Delivery Suite Guidelines 2008
Publication Date: 22/01/2008
Version 2.0
13.5
THE DAWES / REDMAN CRITERIA AS USED BY THE OXFORD SONICAID
SYSTEM ...........................................................................................................132
13.6
ADMISSION CTG .............................................................................................132
13.7
INTERMITTENT AUSCULTATION ...................................................................133
13.8
CONTINUOUS MONITORING..........................................................................133
13.9
CATEGORISATION OF FETAL HEART RATE FEATURES ............................134
13.10
CTG CLASSIFICATION ....................................................................................134
13.11 SUSPICIOUS CTG ...........................................................................................134
13.12
PATHOLOGICAL CTG......................................................................................135
13.13
FETAL SCALP BLOOD SAMPLING .................................................................135
13.14
DR C BRAVADO...............................................................................................136
14.1
INTRODUCTION...............................................................................................140
14.2
GENERAL MANAGEMENT ..............................................................................140
14.3
MANAGEMENT OF SEVERE HAEMORRHAGE IN THE COMMUNITY..........141
14.4
PLACENTA PRAEVIA.......................................................................................142
14.5
PLACENTAL ABRUPTION ...............................................................................143
15.1
BACKGROUND ................................................................................................147
15.2
MANAGEMENT OF SEVERE HAEMORRHAGE IN THE COMMUNITY..........147
15.3
MANAGEMENT OF MAJOR PPH.....................................................................148
15.4
THE ROLE OF STAFF DEALING WITH PPH...................................................151
15.5
SECONDARY PPH ...........................................................................................152
15.6
BLOOD TRANSFUSION...................................................................................153
15.7
RECOMBINANT FACTOR VIIA ........................................................................156
15.8
INITIAL MANAGEMENT OF MASSIVE HAEMORRHAGE – ORGANISING THE
TEAM ................................................................................................................158
16.1
BOOKING .........................................................................................................161
16.2
ANTENATAL CARE ..........................................................................................161
16.3
LABOUR ...........................................................................................................161
16.4
HAEMORRHAGE..............................................................................................161
16.5
POSTNATAL CARE..........................................................................................162
17.1
CHECKLIST FOR WOMEN NEEDING THROMBOPROPHYLAXIS.................165
17.2
CAESAREAN SECTION IN WOMEN TAKING THERAPEUTIC DOSES OF
CLEXANE .........................................................................................................167
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North Cumbria Delivery Suite Guidelines 2008
Publication Date: 22/01/2008
Version 2.0
17.3
THROMBOPROPHYLAXIS FOR LABOUR ......................................................168
17.4
LABOUR IN WOMEN TAKING THERAPEUTIC DOSES OF CLEXANE ..........168
17.5
WARFARIN.......................................................................................................169
18.1
ELECTIVE CAESAREAN SECTION.................................................................172
18.2
EMERGENCY CAESAREAN SECTION ...........................................................174
18.3
THE PROCEDURE ..........................................................................................176
18.4
ANALGESIA AFTER CAESAREAN SECTION .................................................179
18.5
CAESAREAN SECTION FOR PLACENTA PRAEVIA ACCRETA ....................180
18.6
CAESAREAN SECTION WITHOUT HEALTH INDICATIONS ..........................181
18.7
LAPAROTOMY .................................................................................................181
18.8
FEMALE STERILISATION................................................................................182
18.9
RECOVERY......................................................................................................182
18.10
VAGINAL BIRTH AFTER PREVIOUS CAESAREAN SECTION.......................183
18.11
PROPHYLACTIC ANTIBIOTICS FOR CAESAREAN SECTION ......................186
18.12
THROMBOPROPHYLAXIS IN PATIENTS RECEIVING SPINAL OR EPIDURAL
ANAESTHESIA .................................................................................................186
19.1
PRE DELIVERY ASSESSMENT OF ANALGESIC / ANAESTHETIC PROBLEMS
..........................................................................................................................190
19.2
PRESENCE AND ROLE OF ANAESTHETIST .................................................191
19.3
EPIDURAL ISSUES (WCH ONLY) ...................................................................191
19.4
URGENT ANAESTHESIA.................................................................................196
19.5
PHARMACOLOGICAL PAIN RELIEF IN LABOUR...........................................196
19.6
PREOPERATIVE FASTING GUIDELINES .......................................................197
19.7
FEEDING IN LABOUR......................................................................................197
19.8
ANTACID REGIMEN.........................................................................................197
19.9
WOMEN ON ANTITHROMBOTIC TREATMENT..............................................198
19.10
COMPLICATIONS OF THE THIRD STAGE .....................................................198
19.11
POST-OPERATIVE CARE................................................................................199
19.12
TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION (TENS) .............200
19.13
THE ADMINISTRATION OF HOMEOPATHIC OR HERBAL SUBSTANCES ...200
19.14
FAILED INTUBATION DRILL............................................................................200
20.1
INTRAPARTUM FEVER ...................................................................................204
20.2
GROUP B STREPTOCOCCAL INFECTION.....................................................204
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North Cumbria Delivery Suite Guidelines 2008
Publication Date: 22/01/2008
Version 2.0
20.3
HERPES SIMPLEX...........................................................................................207
20.4
HIV ....................................................................................................................208
20.5
HEPATITIS B AND HEPATITIS C.....................................................................210
20.6
ANTIBIOTIC PROPHYLAXIS FOR CAESAREAN SECTION ...........................211
20.7
ANTIBIOTIC PROPHYLAXIS FOR INFECTIVE ENDOCARDITIS....................211
20.8
MRSA................................................................................................................212
20.9
INFECTION CONTROL ....................................................................................212
20.10
INFECTION CONTROL FOR HIV/ HBV / HCV POSITIVE WOMEN ................213
21.1
CRITERIA FOR INCLUSION ............................................................................219
21.2
ANTICONVULSANT GUIDELINES...................................................................219
21.3
FURTHER NOTES ON THERAPY WITH MAGNESIUM ..................................220
21.4
ANAESTHETIC GUIDELINES ..........................................................................221
21.5
ANTIHYPERTENSIVE THERAPY GUIDELINES..............................................221
21.6
MAINTENANCE THERAPY FOR BLOOD PRESSURE CONTROL .................223
21.7
SIMPLIFIED FLUID GUIDELINES ....................................................................224
21.8
SUMMARY OF CARE......................................................................................225
22.1
GENERAL NOTES FOR OBSTETRIC STAFF ON THE MANAGEMENT OF WOMEN
WITH INSULIN-TREATED DIABETES .............................................................228
22.2
MANAGEMENT OF PREGNANT WOMEN WITH INSULIN-TREATED DIABETES
FOLLOWING EMERGENCY ADMISSION .......................................................229
22.3
MANAGEMENT OF STEROIDS IN PREGNANT WOMEN WITH DIABETES ..230
22.4
REGIMEN FOR ELECTIVE CAESAREAN SECTION, INDUCTION OF LABOUR OR
SPONTANEOUS DELIVERY............................................................................230
22.5
MANAGEMENT FOLLOWING DELIVERY .......................................................234
22.6
ADDITIONAL POINTS FOR THE CARE OF THE MOTHER WITH DIABETES
AFTER DELIVERY............................................................................................235
22.7
HYPOGLYCAEMIA IN MATERNITY PATIENTS ..............................................236
23.1
BACKGROUND ................................................................................................239
23.2
LATEX IN THE HOSPITAL ENVIRONMENT ....................................................239
23.3
IDENTIFICATION OF THE PROBLEM .............................................................240
23.4
PROVISION OF A LATEX-FREE ENVIRONMENT ..........................................240
23.5
TREATMENT OF ANAPHYLAXIS ....................................................................241
23.6
LATEX ALLERGY BOX.....................................................................................241
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Publication Date: 22/01/2008
Version 2.0
23.7
FURTHER INFORMATION...............................................................................242
24.1
AIMS .................................................................................................................245
24.2
INTRAPARTUM CARE .....................................................................................245
24.3
ANALGESIA IN LABOUR OR PRIOR TO CAESAREAN SECTION .................245
24.4
IMMEDIATE NEONATAL CARE .......................................................................246
24.5
NEONATAL WITHDRAWAL .............................................................................246
24.6
BREAST FEEDING...........................................................................................247
24.7
INFECTION ISSUES.........................................................................................247
24.8
THE IMPACT OF SUBSTANCE USE ON THE INFANT...................................248
24.9
USEFUL CONTACTS .......................................................................................249
25.1
MATERNAL COLLAPSE AND ACUTE MEDICAL PROBLEMS .......................252
25.2
TRANSFER TO THE INTENSIVE CARE UNIT.................................................254
25.3
UTERINE RUPTURE ........................................................................................256
25.4
MATERNAL STEROID COVER FOR DELIVERY.............................................256
25.5
MANAGEMENT OF HAEMOGLOBINOPATHIES.............................................256
25.6
SCREENING FOR HAEMOGLOBINPATHIES IN PREGNANCY .....................256
25.7
THALASSAEMIA SYNDROMES.......................................................................257
25.8
HAEMOGLOBIN VARIANTS – SICKLE CELL SYNDROMES ..........................257
26.1
BACKGROUND ................................................................................................261
26.2
THREATENED MISCARRIAGE........................................................................261
26.3
TERMINATION OF PREGNANCY FOR FETAL ABNORMALITY.....................261
26.4
INTRAUTERINE DEATH ..................................................................................262
26.5
SUPPORT NETWORK .....................................................................................262
26.6
TOPICS FOR DISCUSSION AND CONSIDERATION......................................263
26.7
MANAGEMENT OF PREGNANCY LOSS ........................................................264
26.8
FETUS OVER 24 WEEKS (NO POST MORTEM) ............................................266
26.9
FETUS OVER 24 WEEKS (FOR POST MORTEM)..........................................267
26.10
FETUS UNDER 24 WEEKS (NO POST MORTEM) .........................................269
26.11
FETUS UNDER 24 WEEKS (FOR POSTMORTEM) ........................................270
26.12
CYTOGENETIC SAMPLES TRANSPORT ARRANGEMENT...........................271
26.13
TWINS ..............................................................................................................272
26.14
CHAPLAINCY ...................................................................................................272
26.15
BAPTISM ..........................................................................................................272
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26.16
REGISTRATION OF DEATHS AND STILLBIRTH ............................................273
26.17
PROCEDURE FOR CARE OF THE PRE-VIABLE BORN INFANT ..................273
26.18
MANAGEMENT OF STILLBIRTH INCLUDING DELIVERY, POSTNATAL CARE AND
LAYING OUT ....................................................................................................273
26.19
PROCEDURE FOR USE OF THE CRADLE ROOM.........................................275
26.20
HAND AND FOOT PRINTS ..............................................................................276
26.21
BEREAVEMENT COUNSELLORS ...................................................................276
26.22
POSTNATAL REVIEW......................................................................................277
26.23
MATERNAL DEATH .........................................................................................277
27.1
CORD PROLAPSE ...........................................................................................282
27.1
CORD PROLAPSE ...........................................................................................282
28.1
CASES IN WHICH A PAEDIATRIC PROBLEM HAS BEEN IDENTIFIED
ANTENATALLY.................................................................................................289
28.2
URGENT INTRAUTERINE TRANSFER REQUESTS: THE HOT LINE PROCEDURE
..........................................................................................................................289
28.3
PAEDIATRIC ALERT DURING LABOUR .........................................................289
28.4
PAEDIATRIC PRESENCE AT DELIVERY (WCH ONLY) .................................289
28.5
RESUSCITATION OF NEONATES BY MIDWIVES (CIC ONLY) .....................290
28.6
URGENT CALL FOR PAEDIATRIC ASSISTANCE ..........................................290
28.7
MATERNAL ADVICE ........................................................................................291
28.8
ROUTINE MANAGEMENT OF THE BABY.......................................................291
28.9
DELIVERY IN THEATRE ..................................................................................291
28.10
MANAGEMENT OF BABY AT BIRTH WITH MECONIUM STAINED LIQUOR.291
28.11
SKIN-TO-SKIN & HYPOTHERMIA GUIDELINES.............................................292
28.12
HYPOGLYCAEMIA OF THE NEWBORN - ......................................................294
28.12
HYPOGLYCAEMIA OF THE NEWBORN - ......................................................295
28.13
UNEXPECTED ABNORMALITY OR DEATH....................................................299
28.14
HAEMOLYTIC DISEASE OF THE NEWBORN.................................................299
28.15
GROUP B STREPTOCOCCUS INFECTION ....................................................299
28.16
CHILD ABDUCTION – PROCEDURE FOR STAFF..........................................299
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1.1
RESPONSIBILITIES OF STAFF ON DELIVERY SUITE
Lead Midwife
To work in partnership with their professional colleagues in all disciplines within the
maternity unit
This important role is to co-ordinate all Delivery Suite activities at Consultant led units.
In order for this to be successful, the Lead Midwife needs:-
• Awareness of all expected admissions from the antenatal ward, maternity day unit and
antenatal clinic.
• Awareness of relevant community activity e.g. BBA, women labouring at home, Penrith
maternity unit.
• To ensure appropriate delegation of workload.
• To ensure appropriate levels and skill mix of staff present on Delivery Suite.
• Knowledge of all planned inductions of labour and elective LSCS.
• To ensure that all elective LSCS are present on the Delivery Suite and adequately
prepared so that the elective list can commence promptly.
• Knowledge of all pending assisted vaginal deliveries and emergency LSCS.
• Knowledge of all key personnel allocated to the labour ward from SHO to consultant. This
applies to anaesthetists and paediatricians. Contact information should be updated on the
white board.
• To provide first line neonatal resuscitation
• Regular updates from midwives as to the progress of their women in labour.
• To attend all delivery suite handovers.
• To co-ordinate when possible appropriate midwifery requests for medical staff attendance.
• To make an entry in the patient held records when a midwife seeks assistance/review.
• Ensure that the appropriate grade of medical staff attends or is requested as the condition
dictates. If the Lead Midwife has concerns with the obstetric SpR’s plan of care for the
woman then the consultant can be contacted. The SPR should be informed of the
concerns and proposed plan of action. If a junior midwife is not in agreement with the Lead
Midwife, then the SPR, consultant, manager and/or supervisor of midwives can be
contacted if deemed necessary. It is preferable that the midwife communicates her
concerns to the Lead Midwife.
• Expertise in co-ordinating personnel and communicating during obstetric emergencies.
• To provide support and advice for more junior midwives and medical staff.
• Ensure that all women and babies are transferred appropriately.
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Senior House Officer (SHO)
To work in partnership with their professional colleagues in all disciplines within the
maternity unit
• The SHO carries a baton bleep
• The bleep holder will hand this bleep over to the incoming SHO at the end of the shift
• The incoming SHO will check that the white board information is correct.
• The hand over should be accompanied by a formal handover of patient care to the
incoming team, by the Lead Midwife and the outgoing SpR of all the patients on labour
ward and relevant patients on the antenatal and postnatal wards
• Handover occurs at 0830 hours and 2030 hours
• The SHO’s may vary greatly with respect to the amount of previous medical and obstetric
experience. They will have differing career plans with some planning to become GP’s and
others career
• The SHO’s will take advice from and be guided, supported and directed by the Lead
Midwife, Obstetric Registrar and Consultant as to priority of labour ward duties
• The SHO should be bleeped when required after first ascertaining that s/he is not already
on the labour ward. The Lead Midwife should aim to be aware of ALL calls to the SHO
unless in emergencies or when s/he is busy
• The SHO should see women presenting to labour ward, Maternity Day Unit or the
antenatal postnatal ward when asked by a midwife and discuss ALL cases with a Registrar
or Consultant
• The SHO should write clear, legible entries in the hand held notes which should include
printed name, grade and signature along with the full date and time
• Prescribe drugs according to the agreed Guidelines and where in doubt seek the advice of
a senior colleague.
They should NOT prescribe syntocinon for the augmentation of
labour in multiparous women
• The SHO should be familiar with ALL Labour Ward Guidelines
Specialist Registrar (SpR) or 2nd on call
To work in partnership with their professional colleagues in all disciplines within the
maternity unit
• The registrar carries bleep 333 (CIC) or 5585 (WCH)
• The bleep holder will hand this bleep over to the incoming SpR at the end of the shift
• The incoming 2nd on call will check that the white board information is correct.
• The hand over should be accompanied by a formal handover of patient care to the
incoming team, by the Lead Midwife and the outgoing SpR of all the patients on labour
ward and relevant patients on the antenatal and postnatal wards
• Handover occurs at 0830 hours and 2030 hours
• The SpR should write clear, legible entries in the hand held notes which should include
printed name, grade and signature along with the full date and time
• The Obstetric SpR should have an awareness of ALL women on the labour ward and see
all women who are obstetric patients
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• A plan of action should be always documented each time a woman is reviewed throughout
the day or night
• Take opportunities to teach the SHO
• Delegate appropriate duties to the SHO
• The Obstetric SpR is the FIRST line of contact rather than the SHO for:
Acute Obstetric Emergencies
¾ CTG
abnormalities
• The SpR should ensure that s/he is constantly updated by the Lead Midwife of ALL
obstetric admissions to labour ward and of ALL potential antenatal or postnatal problems
• The SpR should ensure that s/he regularly updates the Lead Midwife of decisions made on
labour ward
• The SpR should inform the Consultant of ALL women going to theatre for a caesarean
section or trial of forceps
• The SpR should inform the Consultant of ALL women admitted to the High Dependency
Unit
• The SpR should inform the Consultant of ALL women in labour with a breech presentation
or twins
• The SpR should inform the Consultant of ALL women with a PPH or greater than 1 litre
• The SpR should inform the Consultant of any woman in labour at 23-32 weeks gestation
• The SpR should ask for senior support if labour ward is busy or s/he is unsure about a
clinical situation
• The SpR should be familiar with ALL Labour Ward Guidelines
Consultant or 3rd on call
To work in partnership with their professional colleagues in all disciplines within the
maternity unit
• The Consultant can provide senior input for labour ward in the following ways:
¾ During the weekday between 0830 hrs and 1700 hrs from dedicated labour ward
sessions
¾ After 1700 hrs and at the weekends by on-call cover which can be from home
The consultant can be contacted either directly from the ward – using the contact sheet
displayed in all ward areas or via switchboard.
It is the responsibility of the consultant on call to ensure that s/he is contactable at ALL times
whilst providing the senior medical cover for labour ward
• The consultant should write clear, legible entries in the hand held notes which should
include printed name, grade and signature along with the full date and time
• The consultant should be familiar with ALL Labour Ward Guidelines
• The consultant should consider being present on labour ward in the following situations
¾ Caesarean at full dilatation
¾ Trial of Forceps
¾ Admission to High Dependency Unit
¾ All vaginal breech deliveries
¾ All vaginal multiple birth deliveries
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¾ Massive obstetric haemorrhage
¾ Caesareans for placenta praevia
¾ Caesareans on gestations less than 28 weeks
• In the event that an in-utero transfer is required the consultant should liase directly with the
on-call consultant obstetrician, neonatal consultant/staff and midwifery staff in the
accepting unit to arrange the transfer
• In the event that further medical/surgical opinion is required from within the hospital
regarding a patient it is the responsibility of the Consultant to contact the relevant
consultant or delegate this to a junior as appropriate
Dedicated Session
• The consultant is onsite and always available during this session
• The session is normally dedicated to labour ward cover alone but occasionally may involve
covering from an antenatal clinic so long as a SpR is available to continue the clinic if
attendance on labour ward is required
• The Consultant will be available for advice by telephone or in person
• The consultant can by contacted by the SpR, SHO or a midwife as required
• The consultant will perform a ward round at 0830 hrs and 1700 hrs. This should be a full
board round with the obstetric team and Lead Midwife and then a room round of all
problem cases
• The consultant should liaise closely with the SpR to delegate duties and ensure that
elective work is carried out as soon as possible
• The consultant should ensure that cases are also correctly prioritised
On-call
• On a weekday evening the consultant should perform a ward round on labour ward prior to
going home. This should be a full board round with the obstetric team and Lead Midwife
and then consideration of the need for a room round of all problem cases
• The consultant should contact the Lead Midwife or the SpR for an update at some point
during the evening usually around 2200 hours
• The SpR and midwifery staff can contact the Consultant on call at any time for advice,
management decisions or to come into hospital
• At the weekend the Consultant should carry out a formal ward round on Saturday morning.
This should be a full board round with the obstetric team and Lead Midwife and then a
room round of all problem cases
• The round should include other relevant women on the antenatal/postnatal ward and
maternity day unit
• At the weekend the Consultant should undertake further ward rounds either directly or by
telephone during Sunday morning, the afternoons and evenings
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Locum Doctors
When a Locum Doctor is going to work on the Delivery Suite, his / her previous professional
experience must be checked in advance by a representative of the Consultant body. In
addition a formal introduction to the practices and guidelines of the North Cumbria Delivery
Suite is mandatory before he / she can commence work in the area. This introduction may be
given by the Lead Consultant for Delivery Suite or the Consultant on-call.
Wherever possible a Locum doctor should have the opportunity to work in other areas of the
Directorate before starting shift work on the Delivery Suite.
1.2
HANDOVER OF CARE
It is the responsibility of all practitioners involved in the delivery of Maternity and Obstetric
Care to provide a personal handover of all patients who have been under their care during the
preceding shift.
1. Details of the individual, e.g. name and parity
2. Date and time of admission
3. Details of progress since admission
4. Details of a plan of care
For SpR’s and SHO’s – A Baton Bleep should be personally transferred at the time of
handover.
Formal handover of medical care takes place at 0830 hrs – 0900 hrs and 2030 hrs – 2100 hrs
at CIC, at WCH 0900 hrs – 0930 hrs and 2030 hrs – 2100 hr each day.
Handover at 0830 hrs should be attended by the duty Consultant, Lead Midwife, Specialist
Registrar and SHO’s (oncoming and leaving).
Handover at 2030 hrs should be attended by the Lead Midwife, Specialist Registrar and
SHO’s (oncoming and leaving).
Midwifery Handover
Formal ‘group’ handover of midwifery care is lead by the Lead Midwife at 0730 hours and
2000 hours each day on Delivery Suite at CIC. At WCH handover times are at 0700 hrs, 1400
hrs and 2130 hrs each day on Delivery Suite.
In addition, the care of each woman on Delivery Suite is handed over from the ‘leaving’
midwife to the ‘oncoming’ midwife on a one-to-one basis at these times.
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1.3 TRANSFER OF MIDWIFERY CARE TO CONSULTANT
RESPONSIBILITY
When a patient under the care of midwives or a general practitioner is referred for an obstetric
opinion, responsibility for her obstetric care may pass on to the consultant concerned or
she/he may give an opinion and ask the midwives to continue her care. In either case this
should be made clear on the front of the patient’s notes.
When a patient under the care of midwives or GP is referred urgently for an obstetric opinion
or as an emergency for admission responsibility for her obstetric care is in the hands of the
consultant on-call for the time being.
When a patient in the labour ward under the care of the midwives develops an obstetric
abnormality the midwives must transfer her care to the consultant on-call. Often it may be
appropriate for an obstetric junior to give an opinion. Responsibility rests with the consultant
on-call.
When a patient whose care has been transferred to the consultant on-call requires further
follow-up it may be appropriate for that consultant to be further involved.
either
The case may be discussed with a consultant whose clinics are geographically more
convenient for the patient.
or
The consultant whose clinics are more convenient may be asked to see the patient
or
The consultant (or deputy) may transfer the patient’s care back to the community midwife.
In any of these situations the person responsible for the care should be clearly identifiable on
the front of the notes.
Obstetric responsibility remains with the consultant who first assumed care for the patient until
the case has been discussed – with another consultant or midwife and the care transferred.
The date and time of transfer of care should be recorded in the notes (unless the patient is
seen in an ante-natal clinic, in which case care is then assumed by the consultant in charge of
the ante-natal clinic).
Every antenatal in-patient needs a named consultant (unless she has been admitted under
midwifery care for observation and assessment of possible early labour)
1.4
TRANSFER INTO THE OBSTETRIC UNIT FROM HOME / PENRITH
BIRTHING CENTRE
1. Safety of mother and baby are paramount at all times
Transfer to hospital should be arranged at the earliest opportunity
Women who have any of the following problems should be referred directly from
community midwife to the obstetrician (SpR or equivalent) and Lead Midwife at the acute
unit.
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♦
Meconium stained liquor
♦
Slow progress in labour
♦
Whenever the fetal heart auscultation is no longer normal
♦ Malpresentation
♦ Premature
labour
♦
Premature spontaneous rupture of membranes
♦ Maternal
pyrexia
♦
High head in primip or parous women in advanced labour
♦ Intrauterine
death
♦ Retained
placenta
♦
Post partum haemorrhage
ANY OTHER SITUATION WHERE URGENT TRANSFER IS REQUIRED
Direct access is available to consultant on call via switchboard
2. Summoning an Ambulance in an Emergency
♦ Dial 999 ask for Paramedic Ambulance
♦ Give details of emergency as requested by operator
♦ Give specific details of location
3. Inform LDRP/Delivery Suite so that appropriate preparations can be made and relevant
medical staff can be alerted
4. Intrapartum women must always be accompanied by a midwife
NB: Ambulance services are not directly responsible for returning midwife to base. A
contract taxi can be provided via switchboard at acute units.
5. In the event of an emergency occurring, the midwives must deal with the emergency
situation working together in partnership
The midwives will identify a lead midwife to co-ordinate and facilitate the appropriate care
and initiate transfer
♦ Call 999 requesting paramedic ambulance
♦ If obstetric advice is required ask switchboard to urgently contact consultant on call to
discuss the situation
6. If the woman/mother does not consent to transfer:
♦ Documentation
♦ Call paramedic ambulance
♦ Inform LDRP/Delivery Suite and Obstetrician
♦ Inform Supervisor of Midwives/Manager for support and advice
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The midwife is responsible for all midwifery care and cannot arrange for anyone to act as a
substitute other than another practising midwife or a registered medical practitioner.
Good contemporaneous record keeping is essential to protect the welfare of patients and
clients.
1.5
TRANSFER OUT OF THE OBSTETRIC UNIT TO THE TERTIARY UNIT
Occasionally an antenatal woman may need to be transferred out of the CIC / WCH to a
tertiary unit. Only the duty consultant can sanction this move and he / she should do so after
liaising with the local SCBU and the woman who is to be transferred. A suitable destination
will be identified via the hotline (See over) and the Consultant Obstetrician will discuss with the
Consultant Obstetrician at the receiving hospital to confirm that the transfer can go ahead.
The following are situations where tertiary referral discussions should be considered:
♦ Cystic fibrosis or severe asthma
♦ Sickle cell anaemia, thalassaemia major
♦ Complex hypertension and renal disease
♦ Complex neurological conditions and complex unstable epilepsy
♦ Complex psychiatric disorders and substance abuse
♦ Cardiac
disease
♦ Complex diabetes mellitus
♦ SLE and other connective tissue disorders
♦ Thrombophilia and complex thrombo-embolic disease
♦ Recipients of solid organ transplant
♦ Severe
pre-eclampsia
♦ Pre-term labour and PPROM
♦ Complex
infections
♦ Acute
psychoses
Any woman transferring to a tertiary unit will be accompanied by a midwife. If accompanying
medical staff are required the grade of accompanying medical staff is the responsibility of the
consultant. Appendix 1 – Trust policy for the safe transfer of critically ill patients.
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INTER HOSPITAL/COMMUNITY TRANSFER FORM
To be used in all transfers- this is a legal record of transfer
PATIENT DETAILS
TRANSFER DETAILS
NAME……………………………………………… TRANSFER FROM……………………………..
ADDRESS……………………………………….
………………POSTCODE…………………....... RECIPIENT UNIT…………………………………
DOB…………………………………………........
HOSPITAL NUMBER……………………………. ……………………………………………………...
CONTACT NUMBER……………………….…... DATE OF
TRANSFER……………………………
REASON FOR TRANSFER
CLINICAL DETAILS ON TRANSFER
BP FH GESTATION ALLERGIES
AMBULANCE DETAILS
TIME OF DECISION…………………. ……TIME AMBULANCE
REQUESTED………………….
TIME READY TO TRANSFER……………………..CATEGORY………………………...............
TIME AMBULANCE ARRIVED…………………DEPARTURE TIME……………………………..
PREPARATION FOR TRANSFER YES NO
• TRANSPORT REQUESTED
• BED/COT ARRANGED
• MATERNAL NOTES
• FAMILY INFORMED
• DOCTORS LETTER
• CONTACT RECIPIENT HOSPITAL ON DEPARTURE WITH E.T.A.
EQUIPMENT/TRANSFER YES NO
• SONICAID
• OXYTOCIC DRUGS
• DELIVERY PACK/INSTRUMENTS
• TOWELS/ NEOWRAP
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STAFF ARRANGING TRANSFER ESCORTING PERSONAL
CONSULTANT……………………………………… MIDWIFE……………………………………………
MIDWIFE…………………………………………… DOCTOR…………………………………………………
AT RECIPIENT UNIT
CONSULTANT
……………………………………..
MONITORING REQUIRED DURING TRANSFER
TIME
MONITORING SaO2
RESPS
TEMP
BP/PULSE
160
150
140
130
120
110
100
90
80
70
60
50
40
DRUGS/FLUIDS ADMINISTERED DURING TRANSFER Time Sign
HANDOVER TO RECEIVING UNIT
DATE………………………………..
ARRIVAL TIME…………………….
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HANDOVER GIVEN TO……………………………………………………………………………………..
DOCTOR/MIDWIFE SIGNATURE…………………………………………………………………………..
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Publication Date: 22/01/2008
Version 2.0
1.6 USING THE NEONATAL HOTLINES FOR IN UTERO TRANSFER
REQUESTS
Background
The neonatal service for the former Northern Region covers a population of approximately 3.2
million, with 30,000 births annually. Four ‘provider’ units (based in Newcastle, Sunderland,
Stockton on Tees and Middlesbrough) perform approximately 85% of the neonatal intensive
care, with 11 ‘non-provider’ units performing mostly special care. The concentrating of
neonatal intensive care services into the provider units means that perinatal transfers are
inevitable.
Referrals
Requests for in-utero transfer are made via the neonatal hotlines. As a general rule the R.V.I.
(Newcastle – Hotline: 0191 230 3020) receives calls from Whitehaven, Carlisle, Hexham,
Wansbeck, North Tyneside, Gateshead, South Tyneside, Sunderland and Durham.
Hartlepool, North Tees, Darlington and Bishop Auckland refer to James Cook University
Hospital (Middlesbrough – Hotline: 01642 854727) in the first instance.
Procedure
In utero transfer requests should only be made if a consultant obstetrician intends to transfer a
patient, as locating a cot may take considerable time. Requests made via the hotlines will be
answered by neonatal staff who will ask for:
• Clinical details of the patient
• The name of the referring consultant and their contact details.
The neonatal staff will then:
• Identify an available neonatal cot
• Either pass the details to the on-call consultant obstetrician in that unit who will contact
the referring consultant
or
• Will ask the referring consultant to speak to the on-call consultant obstetrician at the
accepting unit.
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Any woman transferring to a tertiary unit will be accompanied by a midwife. If accompanying
medical staff are required the grade of accompanying medical staff is the responsibility of the
consultant.
Ambulance control should be contacted by the midwifery team leader or a delegated member
of staff. The nature of the transfer, destination, members of staff attending and the category
should be communicated to the ambulance control.
A time estimate of arrival of the ambulance should be obtained and documented on the
transfer form.
Records need not be photocopied and transferred with the patient.
An accompanying letter of explanation should be written to the accepting Consultant by either
the consultant or Registrar.
The midwife accompanying the woman should document the care given on route on the
transfer sheet.
The midwife should ensure relatives have directions / telephone numbers of the receiving
hospital.
The midwife should auscultate the fetal heart on departure and on arrival at the receiving unit.
She should take basic equipment to conduct a delivery and keep the baby warm.
If the baby delivers unexpectedly on route, the midwife’s role is to care for and comfort the
mother and care for the baby. Keeping the baby warm, ideally skin to skin, with the mother or
by the use of a neowrap if the baby is premature. The midwife should initiate basic life
support as necessary.
On arrival the midwife should inform the receiving midwife / doctor of the womans’ history on
transfer and complete the transfer form.
Transfer back to the base hospital is by ambulance. The midwife on return should ensure the
inutero transfer is recorded in the ‘In Utero Transfer’ book held on delivery suite.
Document: Name of Patient
Hospital to which patient is transferred
Reason for transfer
Mode of transfer
Name of Escort
Patient notes to be transferred with patients
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1.7
ARRANGMENTS FOR THE TRANSFER OF BABIES TO OTHER UNITS
There are two Neonatal Units in North Cumbria. The Cumberland Infirmary, Carlisle has
twelve special care cots and the West Cumberland Hospital, Whitehaven has ten special care
cots. They both provide high dependency care but any babies requiring intensive care are
transferred to the regional centre in the North East.
Intensive care equipment is available on both sites and this is used on a short-term basis until
the retrieval team from the regional centre arrives.
Babies requiring intensive care
• Baby is stabilised, intubated and ventilated by the Paediatric Consultant.
• It is Consultant Paediatricians responsibility to liaise with the Newcastle Neonatal
Service based on Ward 35 at The Royal Victoria Infirmary and they make
arrangements for the transfer of the baby – Hotline number 0191 230 3020
• Parents should be kept informed at all times
• Baptism should be offered prior to transfer
• Photographs should be taken and a cuddly toy and blanket given to the baby
• The retrieval team may consist of a Doctor, neonatal nurse or paramedics. They are
responsible for providing the necessary equipment for transfer.
• Care is transferred to the retrieval team and baby is prepared for transfer
• All notes should be copied and an x-ray disc prepared to accompany the baby
• The parents should be seen by the team and directions given so they can travel to the
receiving hospital
Babies requiring transfer for other reason
The Consultant Paediatrician makes the decision that the baby requires transfer for continuing
care and arranges for the baby to be admitted to the appropriate ward / hospital in the
Newcastle area.
This may be for surgery or appointments such as scans. Babies are also transferred back to
North Cumbria following intensive care when their condition has improved. They are escorted
by a qualified nurse in a portable incubator by ambulance. If the transfer is for an appointment
a hospital care may be used and the baby transferred in a car seat. The transport is booked
by the nurse in charge via ambulance control.
• The portable incubator is checked prior to use
• A saturation monitor is taken
• An intravenous infusion pump may be required
• Inform transferring hospital of time of departure so that they may feed baby earlier if
necessary
• Parents may be able to travel in the ambulance or car
• The babies should always be transferred in the portable incubator with the appropriate
restraints or a car seat properly fitted into the car
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1.8
TRANSFER OF POSTNATAL WOMEN TO TERTIARY UNITS
1. INTRODUCTION
During the immediate postnatal period to the time of transfer into the community complications
may arise that require women to be transferred to other departments or tertiary centres for
treatment. The transfer of these patients applies to both patients being moved between
departments but also being transferred to regional hospitals. There is no mental health
services locally that have mother and baby facilities therefore the on call consultant
psychiatrist needs to assess the patient and arrange the nearest bed available should this
situation arise.
2. OBJECTIVE
To use a systematic approach to ensure that patient is transferred in a safe and competent
manner by trained personnel. This is necessary when the capabilities of the obstetric team
are insufficient to meet the patient’s needs and therefore transfer to another speciality is
required.
3.
INDICATIONS FOR TRANSFER
• Severe
eclampsia
• Postpartum
haemorrhage
• Clotting
disorders
• Complications of underlying medical disorder, diabetes, asthma, thrombo-embolic
disease
• Mental disorders: puerperal psychosis, schizophrenia, postnatal depression
a) Assessment
The attending midwife is responsible for prompt referral to medical staff and inform lead
midwife for the unit
Medical staff have a responsibility to ensure consultant has been notified of deterioration in
patient’s condition that may necessitate transfer
b) Control
Identify the Consultant on call
Inform Consultant anaesthetist (as necessary)
c)
Communication The consultant on call is responsible for the decision to transfer the patients and has the
ultimate responsibility for the communication. Liaison should be directly with the on call
consultant and midwifery / nursing staff in the accepting department / unit
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In the event of further medical / surgical opinion being required from within the hospital it is
the responsibility of the consultant to contact the relevant consultant or delegate this to a
junior as appropriate.
Ensure patient remains fully informed of plan of care.
Where appropriate medical staff should discuss this with relatives.
The attending midwife should accompany the patient during the transfer process.
Written records are essential from both clinical and legal perspectives.
All documentation should be completed prior to transfer and notes must accompany
patient on transfer. Blood results should be recorded in notes.
Transferring midwife is responsible to providing handover to receiving midwife / nurse.
Ensure that the transfer form is complete
d)
Transport arrangements The midwife will identify a lead midwife to co-ordinate and facilitate the appropriate care
and initiate transfer.
Call ambulance control –01228 596365
Inform ambulance control that you have potential postnatal transfer. Provide as much
information as possible. State which transfer category is required Emergency or Urgent.
The consultant in charge of the patient will make the “transfer category” decision.
Preparation of the patient and transferring personnel.
When transferring a patient the same level of care should be maintained throughout.
Therefore prior to transfer the patient needs:-
• Stabilise the patient to reduce further physiological / psychological complications
• All necessary equipment must be checked prior to transfer
• Personnel undertaking transfer must be fully prepared, adequately trained and feel
competent to do so
Useful contact numbers;
Middlesbrough 01642
854
850850
(switchboard)
Sunderland
0191
565
6256
(switchboard)
Royal Victoria Infirmary
0191 233 6161
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1.9
LABOUR WARD FORUM
(Including North Cumbria Labour Ward Forum, Cumberland Infirmary and Whitehaven
Labour Ward Forum)
Local meetings are held monthly on each site (CIC forum includes Penrith). Please contact
Labour Ward Lead on either site for details.
North Cumbria meetings are held quarterly. Meetings are open to anyone who has an interest
in the running of the Delivery Suite. The permanent membership is as follows:
North Cumbria Labour Ward Forum
- Lead Consultant from both Obstetric Units
(Chair)
Lead Midwives (CIC, WCH, Penrith)
Risk Midwives
Heads of Midwifery
Supervisor of Midwives
Consultant Anaesthetist
Consultant Paediatrician
Lay Representative
Medical Director for Governance
Junior Midwife
Representative of Junior Medical Staff
SCBU Representative
The aim of the group is to ensure that the principles of Clinical Governance are met in the
delivery of intrapartum care.
To achieve this the group will:
♦ oversee all activity on Delivery Suite
♦ act as a point of liaison between professional and lay groups that hold an interest in the
functioning of Delivery Suite
♦ record policy in updated, multi-disciplinary Delivery Suite Guidelines
♦ verify and ratify such guidelines
♦ audit areas of clinical practice on Delivery Suite
♦ modify practice in the light of audit findings
♦ ensure that a programme of multi-disciplinary training is promoted, dealing with issues
related to the provision of intra-partum care
♦ ensure that mechanisms are in place to maintain the ongoing training of staff active in the
clinic area
♦ promote an active, inclusive risk management policy on Delivery Suite
♦ ensure that mechanisms are in place to respond to the issues raised at Risk Management
meetings on Delivery Suite
♦ monitor research activity on Delivery Suite
Local Labour Ward Forums have the same overall aim but a greater emphasis is placed on
the liaison between professional and lay members.
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Reference:
North Cumbria Acute Hospitals NHS Trust (2005) Policy for Transfer of Critically Ill Patients
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CHAPTER 2 - MIDWIFERY CARE ON DELIVERY SUITE
The guidelines presented in this section are compatible with the RCM Evidence Based
Guidelines for Midwifery Led Care in Labour (Midwifery Practice Guideline) published in 2005.
2.1
ADMISSION IN LABOUR..................................................................................34
2.2
LOW RISK WOMEN .........................................................................................34
2.3
HOME BIRTH ...................................................................................................34
2.4
TRANSFER TO MEDICAL CARE .....................................................................34
2.5
DIAGNOSIS OF LABOUR ................................................................................35
2.6
THE PROVISION OF ONE TO ONE CARE TO WOMEN IN ESTABLISHED LABOUR
..........................................................................................................................36
2.7
ADMISSION CTG .............................................................................................37
2.8
BLOOD PRESSURE.........................................................................................37
2.9
BLADDER CARE IN LABOUR ..........................................................................37
2.10
CORD GAS ANALYSIS ....................................................................................38
2.11
NUTRITION IN LABOUR ..................................................................................39
2.12
VENFLON SITING ............................................................................................39
2.13
CONCEALED PREGNANCY ............................................................................39
2.14
WATERBIRTH ..................................................................................................41
2.15
PREVENTING PRESSURE SORES.................................................................44
2.16
VIDEO AND SOUNDTAPE RECORDS AND PHOTOGRAPHS .......................44
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2.1 ADMISSION IN LABOUR
Women thought to be in labour and who arrive at Maternity Reception should be met by a
midwife and taken directly to a room on Delivery Suite for further assessment. If a woman is
found to be in established labour she should be admitted. The attending midwife should
welcome the woman and her birth partner(s), introduce herself and orientate the woman to the
department. Continuity of midwifery care is important so when possible, the midwife should
indicate how long she will be on duty and available to provide care for the woman.
2.2 LOW RISK WOMEN
Women who meet all of the following criteria will have midwifery led care in labour:
• 37+0 weeks gestation or greater
• singleton
pregnancy
• cephalic
presentation
• no obstetric complications
• no significant medical complication (see NICE Intrapartum Care Guideline 2007 – Page
21-23)
The following women may also be considered appropriate for midwifery led care:
• previous post partum haemorrhage < 1000 mls
• previous retained placenta
Midwifery led care will be depicted on the Delivery Suite board in orange ink at CIC or in the
Labour Ward book at WCH and these women will not normally be visited during medical ward
rounds.
2.3 HOME
BIRTH
There is no evidence that women at low risk of complications have a better outcome in labour
if booking for hospital rather than home birth or birth in a midwifery lead unit. Women should
receive unbiased information when making a choice about the place that they would like to
give birth.
Home birth is associated with the use of less analgesia, augmentation of labour and operative
delivery. Satisfaction with care also tends to be greater in women who give birth at home.
2.4
TRANSFER TO MEDICAL CARE
If deviation from normality occurs, the midwife should discuss the case with the Obstetrician
(See 1.4) and Lead Midwife co-ordinating Delivery Suite
. This transfer to high risk care should
be indicated on the board at CIC or in the book at WCH. The responsible consultant should
be entered on the front sheet of the patient notes. Staff must
be informed when maternal or
fetal complications arise. The following list is not exhaustive - common sense must be applied:
• need to discuss abnormality of the fetal heart
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• need to discuss the CTG or FBS
• significant fresh PV bleeding
• malpresentation
• slow progress in labour
• meconium stained liquor
• maternal pyrexia > 37.5 oC
In these circumstances, if the woman was previously booked under a community midwife, the
midwife looking after her on Delivery Suite must allocate a consultant to the case. The
nominated consultant will usually be the consultant on call that day. The woman’s notes
should also be altered accordingly.
A number of other indications may arise that necessitate the transfer of care from the
community midwife to the on call consultant after admission to Delivery Suite, including:
• under 37+0 or over 42+0 weeks gestation in labour
• induction or augmentation of labour
• use of regional anaesthesia
• use of antibiotics in labour
• instrumental birth or caesarean section
• retained
placenta
• PPH requiring blood transfusion
• third degree tear or other trauma repaired by a doctor
2.5
DIAGNOSIS OF LABOUR
The criteria for diagnosis of labour are change in cervical dilatation/effacement with regular
contractions. A combination of the criteria below may indicate labour:
(a)
History of regular contractions (at least 1:10)
(b)
Bulging membranes during contractions.
(c)
Spontaneous rupture of membranes.
(d)
History of a show.
(e)
Bishop score of 7 or more.
(f)
Cervical dilatation of 4 cm or more with full effacement.
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2.6 THE PROVISION OF ONE TO ONE CARE TO WOMEN IN
ESTABLISHED LABOUR
Lead Midwife needs to know the number
of midwives on duty and the number of
women in established labour
↓
If the number of women in established
labour exceed the number of midwives
the following plan is to be activated by
the Lead Midwife
↓
← Lead Midwife to discuss the elective →
During the Day
workload with Consultant Obstetrician
Out of Hours
and consider delay/cancellation
↓
↓
During the day contact a
Review of numbers of
Midwifery Manager to review
midwives on duty with the
staffing in all areas of
hospital
Directorate
↓
↓
Review numbers of
Consider moving HCA’s to
midwives on duty with the
the wards to support
hospital
Midwives
↓
Consider moving HCAs to
wards to support Midwives
If women on Delivery suite are not in
established labour transfer to MAU or
AN Ward
↓
Contact all community midwives
↓
Contact a Midwifery Manager at home
↓
Consider contacting Supervisor of
Midwives for support
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2.7 ADMISSION CTG
Intermittent auscultation should be offered from the outset and should occur for at least 1
minute. CTG should only be offered to women at high risk of fetal compromise (see Section
13) or to women specifically requesting the intervention.
2.8 BLOOD PRESSURE
First stage of labour
During the first stage of labour blood pressure should be measured and recorded once every
4 hours. If the systolic pressure reaches 160 mm/Hg or the diastolic reaches 100 mm/Hg it
should be rechecked at 15 minute intervals. If it remains elevated for 3 consecutive readings
over 45 minutes then review by medical staff is required.
Second stage of labour
During the second stage of labour, review by medical staff is required if the systolic blood
pressure reaches 170 mm/Hg or the diastolic reaches 110 mm/Hg for 3 consecutive readings
over 15 minutes.
2.9
BLADDER CARE IN LABOUR
The bladder is at particular risk in labour:
• with a prolonged second stage
• after regional anaesthesia
• after operative delivery, especially under regional anaesthesia
Encourage spontaneous voiding 4 hourly in labour and record this on the partogram. If a
woman cannot empty her bladder after 4 hours or passes small frequent amounts, an in-out
catheter should be considered to ensure the bladder is empty. This should coincide with a
vaginal assessment and the volume drained should be recorded. If over 500 ml then further
bladder care must be vigilant to avoid complications.
Women should be electively catheterised with a size 12 or 14 catheter after delivery if at
particularly high risk of postpartum retention:
• women with a residual of over 800 ml in labour
• women who have had a difficult instrumental delivery
• women who have sustained a severe perineal injury
In general, passage of urine should be achieved after delivery but before transfer to the
postnatal ward, or before transfer home if early discharge from hospital is planned. If a
postnatal woman is incontinent then in-out catheterisation is necessary to exclude retention
with overflow irrespective of whether she is voiding spontaneously.
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2.10 CORD GAS ANALYSIS
The normal Ph of fetal blood is 7.35 or above.
During labour there is a lowering of the Ph. This is caused by the gradual accumulation of
lactic acid (generated from anaerobic metabolism), which occurs during the transient hypoxia
the fetus experiences with each contraction.
Prolonged fetal hypoxia results in state of metabolic acidosis occurring.
The fetal Ph is a good indicator of fetal well-being or compromise.
A Ph reading of a specimen of cord blood taken at delivery can give valuable information
which can facilitate the management of the neonate.
It is recommended that a cord Ph should be taken from the following:-
• Non-elective Caesarean Section.
• Instrumental
deliveries.
• Deliveries which have had a FBS performed during labour.
• Babies requiring resuscitation at birth.
• Prolonged non-reassuring/abnormal CTG trace.
• Pre-term < 36 weeks
• Intrauterine
infection.
• Intra-uterine growth retardation
METHOD
♦ At delivery the cord should be double clamped with approximately four to six inches of
cord left between the clamps.
♦ Using a heparinised syringe and green needle. Separate samples should be obtained
from the umbilical vein and one of the umbilical arteries.
♦ Samples may be obtained for up to 40 minutes from a clamped section of cord.
The printed result slips should be filed into the mother’s notes. A written record of the results
should be recorded on the delivery section of the neonatal sheets. It is the responsibility for
the member of staff performing the delivery to document the results in the maternal notes.
If the arterial and venous pH values are similar (within 0.02), the paired samples should be
repeated within 30 minutes to ensure that they have been retrieved from different vessels.
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2.11 NUTRITION IN LABOUR
Fasting may result in dehydration and acidosis which can in turn increase the need for
medical intervention. Low risk women who wish to eat and drink in early labour should be
allowed to do so (see also the anaesthetic guidelines).
The following guidelines are suggested:
• diet offered should be light, nutritious and easily absorbed
• narcotics are a major factor in delaying stomach emptying. If these are used, then women
should stop eating and drinking should take only sips of water
• fluid may be taken throughout labour unless surgical intervention is anticipated. If there is
a high probability of intervention however, small sips of water only should be offered
• the volume of fluid taken should be recorded. Fizzy drinks should not be taken
• sips of water with oral medicines are always permitted if necessary
• ranitidine should be given according to the agreed protocol
2.12 VENFLON
SITING
If a venflon is needed, it should be sited by an appropriately trained midwife. If the midwife
caring for the woman is unable to do this then she should consult the Lead Midwife co-
ordinating the Delivery Suite in the first instance. IV access using a 18 (grey) IV catheter is
recommended for women in labour.
2.13 CONCEALED
PREGNANCY
A concealed pregnancy is where a woman, through fear, ignorance or denial does not accept,
or is unaware of the pregnancy in an appropriate way.
In a concealed pregnancy there is a higher risk of morbidity and mortality to both mother and
baby.
The mother has missed the opportunity for pre-natal diagnosis and genetic counselling. She is
more likely to be socially excluded with a greater risk of blood borne infections, drug misuse,
epilepsy and mental health problems compounded by poor social support.
It may be important to try and find out why the mother did not attend for antenatal care.
HISTORY
To include Medical, Surgical, Social, Menstrual, Obstetric, Drug History
.
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EXAMINATION
May include:- General
Abdominal
Vaginal : should not be performed until the placenta has been shown not to
be low
Ultrasound : The cerebellum is an accurate guide to gestational age <34
weeks.
Blood screening:-
Group + Rh factor
Full Blood Count
HIV
Hep
B
VDRL
Rubella
If delivers before the blood results are available, cord blood shall be taken for
Coomb’s testing and FBC.
? Toxicology screen if history or examination suggests a need.
AIM FOR DELIVERY IN A CONSULTANT UNIT IF TIME PERMITS
There may be circumstances where child protection procedures must be initiated: The
question of confidentiality will be overridden in these situations. Please refer to Child
Protection Procedures pp. 131. Should there be any doubt about whether a woman should be
referred, then consultations should take place with the Child Care Co-ordinator.
Post-natal Structure
− Discuss contraception before discharge.
− Consider referral to counsellor.
− Usual post-natal care with referral to Community Midwife and
Health Visitor.
− The General Practitioner should be informed of the delivery.
− Social Services should be informed as appropriate.
− The baby should have a full paediatric assessment if there is any
doubt surrounding his / her gestation.
Long Term
Following up with GP and Health Visitor with the GP offering contraceptive advice.
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2.14 WATERBIRTH
Inclusion criteria
• singleton, cephalic presentation low risk pregnancy
• between 37+0 and 42+0 weeks gestation
• spontaneous onset of labour
• informed choice of mother
Inclusion criteria with caution
(NB – these women should be delivered in an Obstetric Unit)
In the following situations, waterbirth is not absolutely contraindicated but the medical staff
should be involved in the decision making process before waterbirth is sanctioned:
• previous caesarean section but refer to VBAC (Chapter 18)
• previous shoulder dystocia
• previous third degree tear
Exclusion criteria
• induced labour when syntocinon is being used
• woman receiving opiates < 2 hours ago
• prolonged rupture of membranes > 48hrs
• any woman requiring IV fluids
• blood borne virus
• skin
infections
• BMI
>32
• a current history of epilepsy
• grand multiparity with previous third stage complications
Women carrying GBS and women with risk factors for the development of neonatal GBS
sepsis should not automatically be excluded from using the birthing pool.
Antenatal prerequisites
• discussion with named midwife to include benefits and risks
• agreed plan for pregnancy and birth to be documented in hand held records
Before entering the pool
• no electrical equipment near the pool
• pool temperature should be 35 – 37.50C, recorded on the partogram
• room temperature should be 21 - 220C, recorded on the partogram
• the mother should be encouraged to empty her bladder
• maternal and fetal observations should be recorded within normal range
• the mother should be made aware that she can leave the pool at any time if she wishes
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First stage of labour
On entering the pool, the woman must be made aware of the emergency exit procedure.
Document this discussion in hospital. The bed should be left at the correct height and stored
in the corner of the delivery room. Advise the woman not to get out of the pool unassisted.
The pool should be filled to the level of the mother’s breasts when she is in a sitting position
and the following should be recorded 4 hourly on the partogram:
• pool temperature, to be between 35 – 37.50C
• room temperature, to be between 21 - 220C
Maternal and fetal observations should be taken by the midwife and recorded as per Delivery
Suite Guidelines for labouring mothers who are low risk.
The mother should be encouraged to adopt any position she finds comfortable with the
support of her birth partner.
The following are good practice points:
• the mother may use entonox if required
• the midwife should encourage oral fluids to prevent dehydration
• faecal debris should be sieved out of the pool to minimise the risk of infection from E coli.
In the event of the pool becoming heavily contaminated, particularly in second stage,
consider asking the woman to leave the pool temporarily to empty and refill.
• the mother should be encouraged to leave the pool to void urine if possible
Reasons to leave pool in the first stage of labour
• any deviation from normality
• elevated maternal temperature – above 37.50C
• vaginal examination if the midwife feels this is necessary
• to have a systemic opiate analgesic
• if the mother feels faint or there are any concerns
Care of mother and baby during the second stage of labour
Two midwives, or one midwife plus one other member of staff, should be in attendance during
the birth.
Temperature of the pool should be maintained at 37 and 37.5 0C during the second stage.
The mother should only be encouraged to push when she has the urge - this should not be
hurried. Birth should be ‘hands off’ until baby is born, supported by verbal guidance alone. Do
not routinely feel for cord around the neck. The baby should be born completely underwater
with no air contact until he / she is raised to the surface gently afterwards. Ensure the head of
the baby emerges into air within a couple of minutes and given to the mother.
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Do not subject the cord to undue tension at birth, to minimize the possibility of snapping it.
Consider resting baby with head above the water, at the level of the mother’s uterus to
maintain warmth.
Reasons for the mother to leave the pool in the second stage
• to perform an episiotomy
• any fetal heart rate abnormality
• any other suspected abnormality
Care of mother and baby during the third stage of labour
The third stage should be managed as per the physiological third stage guidelines unless
maternal condition or choice necessitates active management. For a physiological third stage,
the cord should be left unclamped until the placenta and membranes have been expelled by
the mother, while she remains in the pool. Once the placenta has been expelled, the mother
should be encouraged to leave the pool.
If the third stage is to be managed actively, the cord should be clamped and cut and they baby
passed to the partner or staff member. Assist the woman out of the pool completely, or onto
the pool seat as soon as practically possible, then administer the oxytocic drug. Delivery by
CCT.
If perineal repair is required this should be delayed for one hour after birth as the tissues may
be waterlogged and friable.
Procedure for assisting women out of the birthing pool in an emergency
• Pull the emergency buzzer – call for help
• Place the red net underneath the woman and whilst supporting her head, lift her across
edge of pool and onto bed
• At least two members of staff should be either side of the woman
• Once on bed assist woman into appropriate position
• Complete emergency procedures as appropriate
Cleaning the pool
Following each use, the pool should be rinsed free of debris. The entire pool and surrounding
area should then be cleaned using a solution of a chlorine releasing agent (e.g. Haz-Tab
granules/tablets). Rinse and then dry the pool thoroughly. If a sieve has been used ensure this
is also cleaned as above.
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2.15 PREVENTING PRESSURE SORES
• Women in labour should be encouraged to be as mobile as possible.
• Correct moving and handling practices are essential in order to prevent shear and friction
forces during maternal repositioning.
• It is insufficient to relieve pressure for a matter of seconds. Women in labour require
effective pressure area management.
• Women who choose to have epidural anaesthesia during labour must be recognised as
being at high risk of developing pressure sores.
• Women undergoing elective or emergency caesarean section must be provided with
pressure relieving equipment while in theatre and following delivery.
• The sacral area must be kept clean and dry during labour. Any excess cleaning fluid
should be removed after epidural insertion.
• Correct positioning of sanitary towels and regular sanitary pad / linen changes will ensure
that the sacral area is kept clean and dry.
• An adequate level of hydration must be maintained.
• Women should be informed of the risk of developing pressure sores and encouraged to
participate in their own care.
• Mattresses should be checked regularly for signs of foam fatigue or damage.
• Obstetric mattresses should be at least 5 inches (preferably 6 inches) deep.
2.16 VIDEO AND SOUNDTAPE RECORDS AND PHOTOGRAPHS
The use of all video and sound tape recorders by non-hospital staff is prohibited in the
Delivery and Theatre suites of North Cumbria Acute Hospitals NHS Trust.
Video-photography in the delivery room is usually allowed once the baby is delivered,
provided it does not impinge upon the work of the staff.
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References
Alderdice F
et al (1995) Labour and birth in water in England and Wales: survey report
. Br J
Midwifery 3: 375-382.
ALSO (1996)
Advanced Life Support in Obstetrics: Course Syllabus ALSO (UK) Office,
Newcastle.
Austen T
et al (1997) Severe neonatal polycythaemia after third stage of labour underwater.
Lancet 350: 1445.
Baker C (1996) Nutrition and hydration in labour.
Br J Midwifery 4: 568-572.
Broach J, Newton N (1988) Food and bevereges in labour. Part II: the effects of cessation of
oral intake during labour.
Birth 15: 88-92.
Brown L (1998) The tide has turned: audit of water birth.
MIDIRS Midwifery Digest 6: 236-243.
Burns E, Kitzinger, S (2005) Midwifery guidelines for use of water in labour. Oxford Brookes
University Press.
Campbell R
et al (1999) Evaluation of midwife lead care provided at the Royal Bournmouth
Hospital.
Midwifery 15: 183-193.
Charles C (1998) Fetal hypothermia risk from warm water immersion.
Br J Midwifery 6: 152-
156.
Crawford JS (1986) Maternal mortality from Mendelson’s Syndrome
. Lancet 1: 920-921.
Department of Health Expert Maternity Group (1993)
Changing Childbirth London, HMSO.
Garland D, Jones K (1997) Waterbirth: updating the evidence.
Br J Midwifery 5: 368-373.
Garland D (2000) Waterbirth: an attitude to care (2nd Edition). Butterworth-Heinnmann, Oxford.
Geissbuehler V, Stein S, Eberhard J (2004) Waterbirths compared with landbirths: an
observational study of nine years.
J Perinat Med 32: 308-314.
Gilbert R, Tookey PA (1999) Perinatal mortality and morbidity among babies delivered in
water: surveillance study and postal survey.
BMJ 319: 483-487.
Hall SM, Holloway IM (1998) Staying in control: women’s experiences of labour in water.
Midwifery 14: 30-36.
Harper B (2001) Waterbirth Bibliography In:
http://www.waterbirth.org/index
Hundley V
et al (1994) Midwife managed delivery unit: a randomised controlled comparison
with consultant lead care.
BMJ 309: 1400-1404.
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Jessiman WC, Bryers H (2000) The Highland experience; immersion in water in labour.
MIDIRS Midwifery Digest 8: 357-361.
Johnston P (1996) Birth under water – to breathe or not to breathe.
BJOG 103: 202-208.
Malone C (2000) Pressure sores on the labour ward.
RCM Midwives J 3: Morrison B, Baker C (2001) How to raise awareness of pressure sore prevention.
Br J
Midwifery 9:
Nikoderm VC (2000) Immersion in water in pregnancy, labour and birth. In:
The Cochrane
Library of Systematic Reviews, Issue 4. Odent M (1983) Birth under water.
Lancet 147: 607.
RCOG (2001) Birth in Water. RCOG statement in the absence of a definitive guideline.
Rosser J (1994) Is waterbirth safe? The facts behind the controversy.
MIDIRS Midwifery
Digest 4: 4-6.
Shields N
et al (1998) Satisfaction with midwife managed care in different time periods: a
randomised trial of 1299 women.
Midwifery 14: 85-93.
Sweet BR (1997) Mayes Midwifery: a Textbook for Midwives (12th Edition). Bailliere Tindall,
London.
Turnbull D
et al (1996) Randomised, controlled trial of efficacy of midwife managed care.
Lancet 348: 213-218.
UKCC (1994) Position Statement on Waterbirths. United Kingdom Central Council for Nursing,
Midwifery and Health Visiting, London.
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CHAPTER 3 - MATERNITY ASSESSMENT UNIT (MAU)
3.1
INTRODUCTION...............................................................................................48
3.2
TRANSFER OF PATIENTS TO DELIVERY SUITE FROM ANTENATAL CLINIC OR
WARD ...............................................................................................................49
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3.1 INTRODUCTION
The maternity assessment unit (MAU) is open 0900 hrs – 1700 hrs week days, midwifery led,
telephone triage unit with subsequent care along side primary care and is designed to support
but not replace community / GP care.
Benefits:
• Midwifery-led
• Guideline
driven
• Consistency of approach and advice
• Telephone triage service
• 24 hour access to telephone advice and referral
• Sonography support including midwife sonographers
• Shorter waiting times for women
• A safe and relaxed environment
Referrals
Discussion of referrals with the MAU is encouraged after 16 weeks gestation. It is hoped to
avoid drop-in assessments that would be appropriately seen by the GP or community midwife.
Referrals are accepted from:
• Community
Midwives
• GP’s
• Patients
(Self-referral)
• Antenatal
Clinic
• Antenatal
Ward
• Delivery
Suite
Indications for referral include:
• Raised
BP
• Decreased fetal movements
• Fetal heart rate irregularities
• Post dates (>41 weeks) without a plan for induction of labour
• Pre-term pre-labour ruptured membranes
• Suspected obstetric cholestasis
• Abdominal pain in pregnancy unless severe
• Vaginal bleeding unless heavy
• Suspected urinary tract infection
• Suspected deep vein thrombosis
• Trauma / assault
• Other fetal concerns
• Postpartum
bleeding
• Wound dehiscence / breakdown
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Flexibility may be required between MAU, Maternity and Delivery Suite dependent upon
staffing and bed availability.
Examples of work not undertaken within the MAU
• Pregnancy
dating
• Viability at under 16 weeks (refer to Early Pregnancy Assessment Unit)
• Nuchal translucency / dating for Maternal Serum Screening
• Fetal anomaly screening
• Cervical length assessment
• Elective growth assessment
Medical Enquiries
GP’s and community midwives may still follow the previous system, contacting the on-call
Obstetric Registrar to discuss cases. Direct discussion with the MAU may, however, be more
appropriate in many cases.
The MAU and the role of the Early Pregnancy Assessment Unit (EPAU)
At CIC this remains unchanged. EPAU runs from Monday to Friday 0900 hrs – 1200 hrs.
Appointments are made by telephone (01228 814256).
At WCH EPAU runs from Monday to Friday 1200 hrs – 1400 hrs. Appointments are made by
telephone (Kirkstone Ward, 01946 693181 Ext 3257)
Women presenting out of hours are seen by the on call gynaecology team (up to 16 weeks),
though occasionally MAU assessment may be appropriate.
Postnatal review / admissions
Usually primary care review is appropriate. If this is not the case then obstetric complications
arising within 6 weeks of delivery should be first reviewed in the MAU.
Obstetric problems arising more than 6 weeks postnatal are referred for discussion to the on
call gynaecology SpR as subsequent admission would be to the gynaecology ward.
Non obstetric problems should not be seen in the MAU but referred to the appropriate medical
/ surgical / A & E Department.
3.2
TRANSFER OF PATIENTS TO DELIVERY SUITE FROM ANTENATAL
CLINIC OR WARD
From the antenatal clinic
The consultant or his / her deputy in antenatal clinic should be informed before the transfer of
any patient from antenatal clinic to Delivery Suite. Arrangements for elective admissions
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should be entered in the Delivery Suite diary after discussion with the senior midwife on the
Delivery Suite, so that the staffing provision can be adjusted.
From the antenatal ward
Emergency transfers
In an emergency, the Consultant Obstetrician or SpR will decide on the timing and the
appropriateness of transfer to Delivery Suite. The woman may not need to be examined
vaginally prior to transfer.
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CHAPTER 4 - INDUCTION OF LABOUR
The guidelines presented in this section are compatible with the RCOG / NICE Guidelines on
Induction of Labour published in 2001.
4.1
INDICATIONS FOR INDUCTION OF LABOUR ................................................52
4.2
41 WEEK ANTENATAL REVIEW .....................................................................52
4.3
ADMISSION FOR ASSESSMENT FOR INDUCTION.......................................52
4.4
OFFER OF INDUCTION FOR POST MATURITY DECLINED..........................53
4.5
INDUCTION REGIMEN ....................................................................................53
4.6
HYPERSTIMULATION......................................................................................54
4.7
AUGMENTATION FOR SPONTANEOUS RUPTURE OF THE MEMBRANES AT
TERM................................................................................................................54
4.8
RUPTURE OF THE MEMBRANES UNDER 37 WEEKS GESTATION ............54
4.9
INTRA-UTERINE DEATH .................................................................................56
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4.1
INDICATIONS FOR INDUCTION OF LABOUR
Most commonly, induction of labour (IOL) is carried out because of post-maturity. All
inductions must be discussed with the Consultant. The indication should be recorded in the
antenatal notes and on the front of the partogram:
• post
dates
• fetal indications (varied)
• maternal indications (varied)
The decision to induce labour before 41 weeks is a consultant decision. This decision may
include cervical assessment and membrane sweeps.
The decision to induce implies either that the mother or baby or both, will benefit and that if
induction fails, a caesarean section may be justifiable.
4.2
41 WEEK ANTENATAL REVIEW
At this visit review of the pregnancy should be offered together with a vaginal examination:
• to assess the cervix
• to sweep the membranes
This should be documented on the IOL sheet together with the indication for IOL.
• membrane sweep may cause discomfort and ‘show’
• membrane sweep increases the likelihood of spontaneous labour
The process of IOL should be explained to the woman and an appointment booked with
Delivery Suite for her to attend at term between term +10 and term + 14 days:
• earlier rather than later appointment if no ‘slots’ available
• earlier at the Consultant’s discretion, if the cervix is ‘favourable’
4.3
ADMISSION FOR ASSESSMENT FOR INDUCTION
When the woman is admitted, the attending midwife:
• completes the relevant part of the yellow notes
• makes an ‘induction of labour information leaflet’ available to the woman
Medical review should be sought if:
• indicated in antenatal clinic notes
• a medical problem is identified by the attending midwife
• requested by the woman
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4.4
OFFER OF INDUCTION FOR POST MATURITY DECLINED
When a woman declines induction she should be offered serial monitoring from 42 weeks.
This includes measurement of amniotic fluid index and twice weekly CTG. Induction should
be proposed if monitoring is abnormal.
4.5 INDUCTION
REGIMEN
This has been illustrated on the following pages.
Prostaglandins
These should usually be administered on Delivery Suite at CIC or Antenatal Ward at WCH.
Note that non-sterile gloves may be used when a pregnant woman who is not in labour and
who has intact membranes is being examined:
• 20 minute CTG prior to insertion of vaginal Prostin tablet
• 60 minute CTG following insertion of vaginal Prostin tablet. This should start 15 minutes
after insertion of the tablet.
• third dose only after discussion with the Consultant
• fourth dose rarely indicated and used only after discussion with the Consultant
Amniotomy
Amniotomy, or artificial rupture of the membranes (ARM) should be performed in a delivery
room using a sterile plastic amnihook. Check the tip of the hook afterwards to make sure that
it is intact. Sterile gloves should be worn when amniotomy is being performed.
Syntocinon (not to be given with intact membranes or within 6 hours of prostaglandins)
If the woman is experiencing contractions after her ARM:
• Advise her to mobilise for up to 4 hours then reassess her cervix
• Consider commencing syntocinon if no cervical change
If she is not contracting after her ARM:
• Advise her to mobilise for up to 4 hours then reassess her cervix
• Commence syntocinon if no cervical change
The fetal heart rate and contractions should be monitored continuously once syntocinon has
commenced. The syntocinon regimen has been included in the following pages.
For induction following previous caesarean section see Chapter 18.
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4.6 HYPERSTIMULATION
This is defined as the presence of more than 5 contractions in 10 minutes for more than 20
minutes, or the presence of a tonic uterine contraction i.e. a contraction lasting for longer than
2 minutes.
Hyperstimulation following the administration of Prostin or Rupture of Membranes:
• administer 0.25 to 0.5 mg terbutiline subcutaneously
• monitor carefully and continuously
• if the CTG remains normal or suspicious, adopt a ‘wait and see’ policy
• if the CTG is pathological, perform an FBS or deliver, referring to the CTG interpretation
guidelines (Section 13)
• Consider removing the prostin tablet.
Syntocinon hyperstimulation in the presence of a pathological CTG:
• turn off the syntocinon and turn the woman into the left lateral position
• consider giving 0.25 to 0.5 mg terbutaline subcutaneously
• wait, sample or deliver, referring to the CTG interpretation guidelines (Section 13)
Restarting syntocinon:
• recommence at half the previous dose, or…
• recommence at 0.6 ml/hr if the syntocinon has been off for more than 30 minutes
Syntocinon hyperstimulation in the presence of a normal or suspicious CTG:
•
half the syntocinon, then…
•
reduce the rate of infusion further every 30 minutes until contractions fall to 3-4:10
• monitor
carefully
4.7 AUGMENTATION FOR SPONTANEOUS RUPTURE OF THE
MEMBRANES AT TERM
See Chapter 5.5.
4.8
RUPTURE OF THE MEMBRANES UNDER 37 WEEKS GESTATION
This is dealt with in Chapter 12.
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Induction of Labour
Primigravidae
Multigravidae
↓
↓
↓
↓
Bishop’s Score
Bishop’s Score ≥ 6
↓
↓
↓
< 6
↓
↓
↓
↓
3mg prostin tablet posterior fornix
amniotomy
↓
↓
↓
↓
after 6 hours
after 6 hours
↓
↓
↓
↓
Re-assess Bishop’s
Bishop’s Score ≥ 6
Score < 6
↓
↓
↓
↓
↓
Amniotomy following
↓
morning
↓
↓
3mg prostin tablet posterior fornix
↓
↓
↓
↓
after 12 hours
after 12 hours
↓
↓
↓
↓
Bishop’s Score
Bishop’s Score ≥ 6
↓
< 6
↓
↓
↓
↓
amniotomy
↓
↓
↓
if amniotomy is not possible after two doses of prostin
discuss further management with the SpR or the Consultant
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4.9
INTRA-UTERINE DEATH
When the patient presents after, diagnosis and counselling, she should be encouraged /
advised to delay induction for 48 hours and offered
MIFEPRISTONE 200 mg orally to “prime” the uterus for the induction process.
Patient can be allowed home with open access to delivery suite for admission for induction.
Admission for induction should be arranged at a convenient time 48 hours after
MIFEPRISTONE has been given.
1.
Induction Regime - 13 – 22 weeks gestation
Mifepristone
200 mg orally
Misoprostol
800 micrograms vaginally followed 3 hours later
Misoprostol
400 micrograms vaginally followed 3 hours later
Misoprostol
400 micrograms vaginally followed 3 hours later
Misoprostol
400 micrograms vaginally
Induction Regime – 22-34 completed weeks gestation
MISOPROSTOL
200 micrograms intravaginal
MISOPROSTOL
200 micrograms orally after 3 hours
MISOPROSTOL
200 micrograms orally after 3 hours
MISOPROSTOL
200 micrograms orally after 3 hours
MISOPROSTOL
200 micrograms orally after 3 hours
Induction Regime – 34 weeks and above
MISOPROSTOL
100 micrograms intravaginal
MISOPROSTOL
100 micrograms orally after 3 hours
MISOPROSTOL
100 micrograms orally after 3 hours
MISOPROSTOL
100 micrograms orally after 3 hours
MISOPROSTOL
100 micrograms orally after 3 hours
Artificial rupture of membranes (ARM) must
NOT be carried out until labour is established.
98.9% of patients will deliver within 72 hours after first dose of Misoprostol.
Or
2. Prostoglandin
Induction
Use prostaglandin dosage with normal pregnancy but the membranes should not be ruptured
until delivery is imminent, see Chapter 26.7.
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Protocol for IV syntocinon
The dilution of Syntocinon used consists of 10 units in 50 ml normal saline, equivalent to 0.2
units in 1 ml. It should be prescribed by a doctor then checked by two qualified members of
staff. The midwives will also check that:
• the syringe is secured correctly in pump
• the correct pump setting initiated
• the infusion rate is checked, with initials from both members of staff at commencement
Syntocinon Regimen
Time (Mins)
Syntocinon Dose
Volume infused
(mu/min)
(mls/hour)
0 – 30
1
0.3
30 – 60
2
0.6
60 – 90
4
1.2
90 – 120
8
2.4
120 – 150
12
3.6
150 – 180
16
4.8
180 – 210
20
6.0
210 – 240
24
7.2
240 – 270
28
8.4
270 - 300
32
9.6
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References
Grant JM
et al (1992) Management of prelabour rupture of the membranes in term
primigravidae: report of a randomised prospective trial.
BJOG 99: 557-562.
Hannah ME
et al (1996) Induction of labour compared with expectant management for
prelabour rupture of the membranes at term.
NEJM 334: 1005-1100.
Hodnett E
et al (1997) Women’s evaluation of induction of labour versus expectant
management for prelabour rupture of the membranes at term.
Birth 24: 214-220.
Hughes RG, Brocklehurst P, Stenson B (2004) Prevention of early onset neonatal group B
streptococcal disease. RCOG Green Top Guideline Number 36, RCOG Press, London, UK.
Mozurkewich EL, Wolf PM (1997) Premature rupture of the membranes at term: a meta
analysis of three management schemes.
Am J Obstet Gynecol 171: 936-938.
NICE Induction of Labour Guidelines (2005)
Seaward PG
et al (1997) International multicentre term prelabour rupture of the membranes
study: evaluation of predictors of clinical chorioamnionitis and postpartum fever in patients
with prelabour rupture of the membranes at term.
Am J Obstet Gynecol 177: 1024-1029.
Shalev E
et al (1995) Comparison of 12 and 72 hours expectant management of premature
rupture of the membranes in term pregnancies.
Obstet Gynecol 85: 766-768.
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CHAPTER 5 - FIRST STAGE OF LABOUR
5.1
RISK ASSESSMENT ........................................................................................60
5.2
PARTOGRAM ...................................................................................................61
5.3
BIRTH ENVIRONMENT....................................................................................63
5.4
DYSFUNCTIONAL LABOUR ............................................................................64
5.5
SPONTANEOUS RUPTURE OF MEMBRANES AT TERM..............................68
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5.1 RISK
ASSESSMENT
On presentation to Delivery Suite, labouring women should be allocated to midwifery or
consultant led care by the midwife. Consultant care should be allocated to women with any
condition adversely affecting fetal or maternal wellbeing, such as:
Maternal
• previous myomectomy / hysterotomy
• placenta
praevia
• antepartum
haemorrhage
• previous postpartum haemorrhage > 1000 ml
• isoimmunisation - Rhesus or other antibodies
• previous caesarean section
• preeclampsia
• HIV / Hep B
• diabetes
• other maternal medical conditions
• anaemia Hb <8.5 g/dl at onset of labour
• substance abuse, including alcohol dependency
• BMI > 35 kg /m2
Fetal
• breech
presentation
or other malpresentation
• multiple
pregnancy
• thick
meconium
• polyhydramnios
• oligohydramnios
• congenital
abnormalities
• gestation under 37 weeks
• previous shoulder dystocia
• baby under 2.5 kg estimated weight
• confirmed
IUD
• small for gestational age pregnancy
Intrapartum
Transfer to high risk status should be precipitated by:
• use of syntocinon
• intrapartum
haemorrhage
• fetal heart rate abnormalities
• fetal capillary blood sampling
• prolonged rupture of the membranes
• any other concern about the woman’s wellbeing
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5.2 PARTOGRAM
A partogram should be kept for every woman in established labour. Entries should be
recorded legibly in black ink, timed and signed. Signatures should be accompanied by the
name and status of the attending obstetrician / midwife, printed in capitals. When retrospective
entries are made, they should be timed at the point of entry and approximate times of events
described in the text.
Observations
The following general observations should be recorded:
observation
interval
pulse
1 hour
blood pressure
4 hour
uterine
contractions
30
mins
(15 mins during syntocinon infusion)
fetal heart rate
15
mins (for at least 1 minute)
temperature
4 hour
liquor
colour
1
hour
Intermittent auscultation of the fetal heart after a contraction should occur for at least 1 minute,
at least every 15 minutes, and the rate should be recorded as an average. The maternal
pulse should be palpated if an FHR abnormality is detected to differentiate the two heart rates.
More frequent observations may be necessary for women who are hypertensive, pyrexial, or
have epidural analgesia.
Vaginal examination
In general, although there is no reliable research base upon which recommendations can be
made for the optimal frequency and timing of vaginal examination, this will normally be
undertaken 4 hourly. More frequent examinations may be considered:
• in dysfunctional labour
• in the late first stage of labour (7 to 9 cm cervical dilatation)
The examinations will usually be carried out by a midwife, but vaginal examination by medical
staff will be considered in the following circumstances:
• dysfunctional
labour
• established labour lasting more than 12 hours
• malpresentation
• malposition
• multiple
pregnancy
Sterile gloves should be worn but swabbing the vulva with an antiseptic solution is not
necessary. When the vulva is soiled, cleansing may be undertaken with tap water. At each
examination, the following information should be recorded:
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• amount of head palpable abdominally
• status of vulva / vagina
• effacement, consistency, dilatation and vaginal position of the cervix
• application of the presenting part to the cervix
• membrane status, and colour of liquor if applicable
• level and position of the presenting part in relation to the ischial spines
• presence and degree of caput and moulding
Fetal heart rate monitoring
This is dealt with in Section 13. In brief, low risk women should not routinely receive an
admission CTG. Intermittent monitoring should take place throughout the first stage of labour,
consisting of 1 minute of cardiac auscultation with Pinnard or Doppler every 15 minutes,
immediately following a contraction. A deceleration, baseline under 110 bpm or baseline over
160 bpm would precipitate continuous monitoring. High risk women are usually monitored
continuously once in established labour.
Saving serum and cross matching blood
Blood samples bottles should be labelled at the bedside then sent directly to the laboratory.
Retrieved blood should be group and saved as a precautionary measure in the face of:
• previous caesarean section
• suspected fetal distress
• breech
presentation
• multiple
pregnancy
• eclampsia / severe pre-eclampsia
• antenatal anaemia (Hb less than 9 gm/dl)
• recent antepartum haemorrhage
• previous third stage abnormality
• maternal red blood cell antibodies
Precautionary cross match of blood is not usually required in these circumstances, but should
be considered in the following situations:
• significant intrapartum haemorrhage
• labour in a woman with any grade of placenta praevia
• maternal red cell antibodies plus the presence of any other risk factor for haemorrhage
The amount of blood required for cross match will vary with the clinical circumstances and
should always be discussed with a senior clinician.
Fluid balance in labour
Labouring women are at risk of hyponatraemia, particularly when having a syntocinon infusion
under epidural blockade. To avoid this:
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• light breakfast may be given to women having Prostin for cervical ripening
• ketoneuria should be treated with intravenous Hartmann’s or normal saline
• intravenous dextrose should be avoided
5.3 BIRTH
ENVIRONMENT
The environment in which a woman labours influences the amount of fear and anxiety she
experiences. Labour in a high tech’ environment leads some women to feel loss of control,
increasing anxiety and interfering with the normal physiology of labour. In contrast, measures
taken to provide a homely environment may improve outcome for some women.
Supporting women in labour
One of the most important roles of the midwife / doctor is to provide the labouring woman with
support. Studies have highlighted four dimensions to this support:
• physical
support
• emotional
support
• information
• advocacy
Effective support is associated with shorter labour, less use of pharmacological analgesia and
less instrumental delivery.
Positions for labour
Adopting an upright position in the first stage of labour (sitting upright, walking, squatting,
kneeling, all fours) may be beneficial in encouraging strong uterine contractions with
concomitant shortening of the time taken to reach full dilatation. Upright stance may also help
to promote fetal cephalic rotation to an OA position, possibly contributing to a reduction in
pain. Finally, the complications of aorto caval compression are only encountered in women
opting for recumbent positions. While respecting women’s choice, midwives and doctors may
encourage mobilisation or rest in a non recumbent position during the first stage of labour.
Feeding in labour
Some women may wish to continue taking a light diet during labour, particularly during the first
stage. There is some equivocal evidence to suggest that in this population a permissive policy
may help to reduce instrumental and caesarean delivery by reducing ketosis and fatigue.
• light snacks such as ‘toast’ may be taken in early uncomplicated labour and…
• fluids may be taken throughout labour but..
• if surgical intervention is anticipated, fluid and snacks should be stopped…
• and substituted with small sips of water only
• the amount of fluid taken should be recorded and fizzy drinks should not be given
• oral medicines are always permitted if necessary
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The risk of acidic gastric aspiration (Mendelson’s syndrome) only appears to be increased in
women with additional risk factors for delayed gastric emptying. This includes women who
have received parenteral or epidural narcotic analgesia.
Consequently, although women should not be actively encouraged to eat during labour, a light
diet may be allowed early in the first stage on maternal request until such time as opiates
have been administered or an epidural sited.
Labouring in water - This issue is dealt with in Chapter 2.
Pain relief - This is dealt with in Chapter 19.
5.4 DYSFUNCTIONAL LABOUR
Progress of labour is defined by the rate of cervical dilatation and the speed of descent of the
presenting part into the pelvis. There is no universally accepted definition of dysfunctional
labour, but slower labours are associated with an increased rate of operative delivery.
Definition of dysfunctional labour
In the following circumstances the SpR must be involved in formulating a management plan:
• the rate of cervical dilatation is ≤ 0.5 cm / hr
• the presenting part is ≥ 1 cm above the ischial spines at the end of the first stage
• the presenting part is ≥ 2/5 palpable at the end of the first stage of labour
Aetiology
It is important to emphasise that dysfunctional labour is not a diagnosis. In planning
management, an attempt should be made to determine the aetiology. Causes include:
• inefficient uterine activity
• fetal malposition / malpresentation
• cephalopelvic disproportion (absolute or relative)
Note that genuine absolute CPD is unusual in the UK population.
Factors to be assessed
• past obstetric history
• nature of the contractions
• pattern of cervical dilatation
• cervical
oedema
• size of the baby
• fetal presentation and position
• caput / moulding
• pelvic
size
• pelvic masses (including bladder size)
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When present in conjunction with slow labour, the following factors must be regarded as
concerning, and an indication for careful assessment:
• multiparity
• secondary
arrest
• estimated fetal weight substantially increased compared to previous babies
• marked caput formation or moulding
Multiparity
Slow progress in labour may result from inadequate uterine activity in multiparous women and
will often respond to augmentation. Nonetheless, dysfunctional labour in a multiparous woman
in combination with other features such as secondary arrest, marked increase in fetal size
compared to past deliveries or the formation of caput or moulding is particularly concerning.
Management of such cases must be discussed with the SpR / consultant.
Secondary arrest
This is generally perceived to be indicative of cephalopelvic disproportion (CPD), particularly
when associated with marked cephalic moulding. Many women with secondary arrest will
nevertheless respond to syntocinon infusion. Before using syntocinon however, particular
attention must be directed towards assessment of the underlying cause of secondary arrest.
Discuss all such cases with the consultant.
Management of dysfunctional labour
Following assessment, the obstetrician will chose between expectant management,
augmentation of labour or caesarean section.
Expectant management
In the early stages of labour, progress of ≤ 0.5 cms / hr may be normal if accompanied by
cervical effacement and descent of the presenting part. Expectant management may then be
considered, particularly if contractions are increasing in frequency or intensity. If possible,
expectant management should be accompanied by mobilization.
ARM by Midwife
The following criteria must be met when performing amniotomy
• cervical os is 4 cm or more dilated
• presentation of fetus is cephalic
• caution should be taken if presenting part is above the ischial spines
• Amniotomy may be performed to attempt to accelerate labour if progress is slow.
• Fetal heart monitoring suggests fetal compromise
• Prior to application of FSE
• Fetal heart must be recorded prior to and following amniotomy.
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Augmentation
To augment contractions in the presence of intact membranes, amniotomy should first be
performed. Syntocinon may then be used following the infusion protocol shown overleaf. If the
attending midwife or doctor feels that contractions have improved significantly after
amniotomy alone, a delay of up to 2 hours may be employed before commencing the
syntocinon infusion. Vaginal examination should be repeated at this time however, to ensure
that the cervix has further dilated.
Protocol for IV syntocinon
The dilution of Syntocinon used consists of 10 units in 50 ml normal saline, equivalent to 0.2
units in 1 ml. It should be prescribed by a doctor then checked by two qualified members of
staff. The midwives will also check that:
• the syringe is secured correctly in pump
• the correct pump setting initiated
• the infusion rate is checked, with initials from both members of staff at commencement
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Delay in the first stage
Definition of delay in the first stage
Nuliparous:
Consider also:
Parous: < 2 cm
< 2 cm dilatation
• Descent and rotation of the fetal head
Dilatation in 4 hrs
in 4 hrs
• Changes in strength, duration and
or a slowing in
frequency of uterine contractions
progress
• Station and position of presenting part
• Woman’s emotional state
Delay suspected: consider amniotomy if membranes intact
Whether membranes ruptured or intact, advise vaginal exam 2 hours later
Amniotomy
Progress > 1 cm:
Explain procedure
Progress < 1 cm:
diagnose delay
return to 1st stage
and that it:
Offer support and effective pain relief
Offer continuous EFM
• Will shorten
labour by about
an hour
• May make
If membranes
If membranes intact: advise amniotomy.
contractions
ruptures
Advise repeat vaginal exam 2 hrs later
stronger and
more painful
Progress < 1 cm
Progress ? 1 cm: return
Oxytocin
to first stage
Explain that
oxytocin will bring
forward time of
Nulliparous:
Parous:
birth but not
Consider oxytocin following
•
influence mode of
Abdominal palpation
spontaneous or artificial
birth, will increase
• Vaginal exam
rupture of membranes. If
frequency and
before making decision about
oxytocin used advise
strength of
the use of oxytocin
continuous EFM.
contractions and
If oxytocin used advise
continuous EFM
continuous EFM
will be necessary.
Offer epidural
before starting
Vaginal exam 4 hours after starting oxytocin in established
oxytocin.
labour
Oxytocin
increments >
every 30 min;
increase until 4-5
Progress > 2 cm:
Progress < 2 cm:
contractions in
Vaginal exam 4 hourly
Consider CS
10 min
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5.5
SPONTANEOUS RUPTURE OF MEMBRANES AT TERM
Spontaneous pre-labour rupture of membranes at term
• There is no reason to carry out a speculum examination with a certain history of
rupture of the membranes at term.
• Women with an uncertain history of pre-labour rupture of the membranes should be
offered a speculum examination to determine whether their membranes have ruptured.
• Digital examination in the absence of contractions should be avoided.
• Women presenting with pre-labour rupture of membranes at term should be advised
that:
- The risk of serious neonatal infection is 1% rather than 0.5% for women with
intact membranes.
- 60% of women with pre-labour rupture of the membranes will go into labour
within 24 hours
-
induction of labour is appropriate approximately 24 hours after rupture of
the membranes
Planned early birth vs. Expectant management over 24 hours
Women in the planned early birth groups have a significantly shorter
period of time from rupture of membranes to birth and were less likely to
develop infection (chorioamnionitis and endometritis) compared with
women in the expectant management groups.
There was no difference between groups regarding mode of birth: no
significant increase in the caesarean or instrumental vaginal birth rates.
Babies born to women in the planned early birth groups were less likely to
be admitted to neonatal intensive care unit (NICU) or special care baby
unit (SCBU). Expectant management up to 24 hours shows no evidence
of a significant increase in neonatal infection rates. Longer period of time
from rupture of membranes to active labour were associated with a higher
incidence of neonatal infection.
• Until the induction is commenced or if expectant management beyond 24 hours is
chosen by the women:
- Lower vaginal swabs and maternal C-reactive protein should not be offered
- To detect any infection that may be developing women should be advised to
record their temperature every 4 hours during waking hours and to report
immediately any change in the colour or smell of their vaginal loss
- Women should be informed that bathing or showering are not associated with
an increase in infection, but that having sexual intercourse may be
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• Fetal movement and heart rate should be assessed at initial contact and then every 24
hours following rupture of the membranes while the woman is not in labour, and the
woman should be advised to report immediately any decrease in fetal movements.
• If labour has not started 24 hours after rupture of membranes, women should be
advised to give birth where there is access to neonatal services and advised to stay in
hospital for at least 12 hours following the birth.
• If there are no signs of infection in the woman, antibiotics should not be given to either
the woman or the baby, even if the membranes have been ruptured for over 24 hours.
• If there is evidence of infection in the woman, a full course of broad-spectrum
intravenous antibiotics should be prescribed.
• Women with pre-labour rupture of the membranes should be asked to inform their
healthcare professionals immediately of any concerns they may have about their
baby’s wellbeing in the first 5 days following birth, particularly in the first 12 hours when
the risk of infection is greatest.
• Blood, cerebrospinal fluid and / or surface culture tests should not be performed in an
asymptomatic baby.
• Asymptomatic term babies born to women with pre-labour rupture of the membranes
(more than 24 hours before labour) should be closely observed for the first 12 hours of
life (at 1 hour, 2 hours and then 2 hourly for 10 hrs). These observations should
include:
- General
wellbeing
- Chest movement and nasal flare
- Skin colour including perfusion, by testing capillary refill
- Feeding
- Muscle
tone
- Temperature
- Heart rate and respiration
A baby with any symptom of possible sepsis, or born to a women who has evidence of
chorioamnionitis should immediately be referred to a neonatal care specialist.
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Pre-labour rupture of the membranes (PROM) at term
Suspected PROM
PROM certain history
Normal progress
Offer speculum exam
If membranes intact advise
Avoid digital vaginal exam in
No speculum exam
women to return home
absence of contractions
PROM – Care of the woman
Advise woman that:
• Risk of serious neonatal infection is 1% rather than 0.5%
• 60% will go into labour within 24 hours
• induction of labour is appropriate after 24 hours
No antibiotics for woman or baby without signs of infection
If evidence of infection prescribe full course of broad-spectrum antibiotics
PROM >24 hrs
Until induction or if the woman chooses expectant management
Induction of labour
beyond 24 hours
Do not offer lower vaginal swabs and maternal C-reactive protein
Transfer/access to
Advise the woman to record her temperature every 4 hours during
neonatal care
waking hours and to report immediately any change in the colour or
smell of her vaginal loss
Stay in hospital at
least 12 hours after
Inform her that bathing or showering are not associated with an
birth so the baby can
increase in infection, but that having sexual intercourse may be
be observed
Assess fetal movement and heart rate at initial contact and then every
24 hours following membrane rupture while the woman is not in labour
Advise the woman to report immediately any decrease in fetal
movements
PROM – care of the baby
If no signs of infection do not give antibiotics to the baby
For baby with possible sepsis or born to a woman with evidence of chorioamnionitis: immediately refer to
neonatal care
Observe asymptomatic term babies (PROM >24 hrs) for the first 12 hours at 1 hour, 2 hours then 2-hourly for
10 hours:
• General
wellbeing
• Chest movements and nasal flare
• Skin colour (test capillary refill)
• Feeding
• Muscle
tone
• Temperature
• Heart rate and respiration
No blood, cerebrospinal fluid and/or surface culture tests for asymptomatic baby
Woman to inform immediately of any concerns about the baby in the first 5 days
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Active management
In both primips and multips, management depends upon cervical favourability.
Bishop’s score 6 or under : 3mg Prostin vaginal tablet then syntocinon 6 hours later as per
syntocinon regimen
Bishop’s score over 6:
no Prostin priming generally needed - syntocinon as per regimen
Active Management:
should be discussed with Obstetrician on call
Multiple Pregnancy:
should be discussed with the Consultant on call
Conservative management
Early return to hospital should be precipitated by:
• labour
• bleeding
• passage of meconium
• reduced fetal movements
• development of a temperature
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Syntocinon Regimen
Time (Mins)
Syntocinon Dose
Volume infused
(mu/min)
(mls/hour)
0 – 30
1
0.3
30 – 60
2
0.6
60 – 90
4
1.2
90 – 120
8
2.4
120 – 150
12
3.6
150 – 180
16
4.8
180 – 210
20
6.0
210 – 240
24
7.2
240 – 270
28
8.4
270 - 300
32
9.6
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References
Albers L, Schiff M, Gorwoda J (1996) The length of active labour in normal pregnancies.
Obstet Gynecol 87: 355-359.
Barrett JFR
et al (1992) Randomized trial of amniotomy in labour versus the intention to leave
membranes intact until the second stage.
BJOG 99: 5-9.
Goffnet F
et al (1997) Early amniotomy increases the frequency of fetal heart rate
abnormalities.
BJOG 104: 340-346.
Fraser WF
et al (1993) The Canadian early amniotomy group. Effect of early amniotomy on
the risk of dystocia in nulliparous women.
NEJM 328: 1145-1149.
NICE Intrapartum Guidelines
Tufnell D
et al (1989) Simulation of cervical changes in labour: reproducibility of expert
assessment.
Lancet 2: 1089-1090.
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CHAPTER 6 - SECOND STAGE OF LABOUR AND
INSTRUMENTAL DELIVERY
6.1
DEFINITION......................................................................................................75
6.2
DIAGNOSIS ......................................................................................................75
6.3
MANAGEMENT ................................................................................................75
6.4
INSTRUMENTAL DELIVERY............................................................................75
6.5
MALPOSITION .................................................................................................78
6.6
PAEDIATRICIANS' ATTENDANCE AT INSTRUMENTAL DELIVERY .............78
6.7
PERINEAL REPAIR ..........................................................................................79
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6.1 DEFINITION
The second stage extends from full cervical dilatation to birth. It may have two components:
Passive without
pushing
Active
with pushing
6.2 DIAGNOSIS
The second stage of labour is diagnosed:
• when the presenting part of the baby is visible
• on routine repeat vaginal examination, or…
• on vaginal examination performed when the woman feels an urge to push
6.3 MANAGEMENT
Flow charts for guidance can be found in the following pages. In general, adequate
contractions should be maintained. Diagnosis of delay in the active second stage of labour
should be made with reference to the algorithms on page 70-72. Maternal involvement in all
decision-making is of paramount importance in the second stage of labour.
• The fetal heart should be monitored every 5 minutes after a contraction.
• Every 30 minutes document frequency of contractions
• Every hour check BP, pulse, offer vaginal examination
• Every 4 hours check temperature
• Regularly check frequency of bladder emptying
• Assess progress, including fetal position and station
• If woman has full dilatation but no urge to push, assess after 1 hour
• Discourage the woman from lying supine / semi-supine
• Consider woman’s position, hydration and pain-relief needs
• Provide support and encouragement
6.4 INSTRUMENTAL
DELIVERY
Indications
• non progressive second stage (see the following flow charts)
• clear evidence of fetal compromise
9 hypoxic
9 infective
9 haemorrhagic
• maternal request, distress or inability to push
• maternal conditions in which active pushing is contraindicated
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Prerequisites for instrumental vaginal delivery
•
appropriately experienced operator
•
full cervical dilatation
• ruptured
membranes
• adequate
analgesia
• empty
bladder
•
cephalic 1/5 or less on abdominal palpation
•
cephalic zero station or lower on vaginal examination
•
no known cephalopelvic disproportion
• defined
position
Consent
Before delivering a baby with forceps or ventouse, an attempt must be made to obtain consent
from the labouring woman by making sure that the woman:
• is aware of your rationale for intervention
• has a basic understanding about the process of instrumental delivery
• understands the common risks of the procedure
• is given clinically reasonable alternatives
• agrees to the procedure
It is accepted that when a woman is in pain or has been given analgesics, it will be impossible
to guarantee that you have obtained valid, fully informed consent. This does not mean that
you should not try.
Make sure that the woman is aware of your rationale for intervention
Always tell the woman why you want to assist delivery and record this on the partogram or on
a consent form.
Make sure that the woman has a basic understanding about the process
As a minimum, the woman should be told that:
•
her legs will be placed in the lithotomy position
•
the bladder may need to be catheterised
•
an episiotomy is often required
•
sutures may be needed after the baby is born
It is important to try to discuss possible complications from an instrumental delivery:
e.g. for forceps delivery
•
baby - bruising to the face
•
baby - facial nerve palsy
•
baby - bony injury
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•
woman - genital tract laceration
•
woman - anal sphincter injury
•
woman - urinary incontinence
•
woman - post partum haemorrhage
e.g. for ventouse
•
baby - cephalhaematoma
•
baby - intracranial and retinal haemorrhage
•
woman - genital tract laceration
•
woman - anal sphincter injury
•
woman - post partum haemorrhage
Minor injuries to the baby are more common after ventouse and mothers tend to worry about
the baby’s appearance more after ventouse delivery. In contrast, forceps damage the
maternal anal sphincter more commonly.
Other rare complications may arise – the woman should be made aware of this but a fully
exhaustive discussion is not required in most cases.
An attempt at instrumental vaginal delivery does not always succeed, particularly if the
ventouse is being used. In these circumstances, a difficult caesarean section may be required.
Because of this and the known potential complications listed above, alternatives to
instrumental delivery should always be considered before the procedure starts.
The alternative to intervention with forceps or the ventouse will normally be for her to have no
intervention (ie) for her to carry on pushing. Occasionally however, the alternative of
caesarean section may be offered as first line management. This should usually be reserved
for cases in which there is clear concern that the instrumental delivery is likely to fail.
Make sure that the woman agrees to the procedure
In an acute situation in which the wellbeing of fetus is at risk, maternal consent may be
obtained orally or by some body movement or gesture. This consent should be recorded on
the partogram by the attending doctor at the earliest opportunity. Written consent should be
taken when practicable however, with one copy of the consent form filed in the notes and a
second copy given to the patient or her birth partner.
Procedure For Forceps Delivery
This is recorded in the following pages.
Procedure for ventouse delivery
This is recorded in the following pages.
Catheterisation
Foley's catheter should be considered for 24 hours after delivery whenever:
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• a dense epidural block has been used to facilitate instrumental vaginal delivery
• a spinal block has been used to facilitate instrumental vaginal delivery
• the vulva has been traumatised during instrumental vaginal delivery
Contraindications to ventouse delivery
• prematurity (below 34 weeks gestation)
• face, brow or breech presentation
• suspected fetal bleeding diathesis
• failure of the procedure may be more likely in the presence of excessive caput or poor
maternal effort.
Ventouse may be used if fetal scalp blood samples have been taken in labour, but the
operator must be confident that there has been minimal scalp trauma and that the fetus has
been left with no ongoing bleeding from the sample sites.
6.5 MALPOSITION
The indications for assisted delivery when the baby is in a malposition are the same as those
for babies presenting OA. No course of action is risk free: the operator must try to judge
whether an attempt at instrumental vaginal delivery is likely to be less traumatic for mother
and child than proceeding directly to caesarean section in each case.
Manual rotation of the fetal head
Manual rotation requires adequate analgesia and may be performed prior to applying
ventouse or forceps. The head should be flexed during a contraction while the mother is
encouraged to push. Rotation is achieved by applying pressure to the Lambdoid sutures.
Ventouse
The prerequisites, contraindications and risks are as recorded above for non rotational
ventouse. The ventouse is more likely to fail than forceps in the presence of significant caput
or moulding and with poor maternal effort, in which case the operator may be face with a
difficult caesarean section with an impacted fetal head.
Non-rotational forceps in malposition
The operator may opt to deliver the baby without rotation if the head is in a direct OP position,
3 cm below the ischial spines. A right medio lateral episiotomy should be employed.
6.6
PAEDIATRICIANS' ATTENDANCE AT INSTRUMENTAL DELIVERY
A paediatrician should only be asked to attend an instrumental delivery if it seems likely that
the baby will be in poor condition at birth.
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6.7 PERINEAL
REPAIR
This is dealt with in Chapter 8.
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Delay in the second stage
Nulliparous: delay suspected if inadequate
progress after 1 hour of active second stage
Offer vaginal exam; advise amniotomy if
membranes intact.
Offer support and encouragement and
consider analgesia / anaesthesia
Birth within
No birth within next hour
Parous: active second
1 hour
(total active second stage
stage = 1 hour
= 2 hours)
Diagnosis of delay in the second stage
Assessment and ongoing
review every 15-30 mins by
obstetrician.
Do not start oxytocin
Consider instrumental birth if
concern about fetal well being or
for prolonged second stage.
Good progress:
Advise CS if vaginal birth not
Second stage
possible.
Birth expected to take place within
3 hours of start of active second
stage for Nulliparous women and
within 2 hours for parous women
Consider instrumental birth if
concern about fetal well being or
for prolonged second stage.
Birth:
Advise CS if vaginal birth not
Third stage
possible.
Birth expected to take place within
3 hours of start of active second
stage for Nulliparous women and
within 2 hours for parous women
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Non-Rotational Forceps Delivery
A
Abdominal palpation
Ask for consent – document this
Adequate analgesia
Ask for help
B
empty the Bladder
C
full Cervical dilatation
D
Define the station and position
remember the risk of shoulder Dystocia
E
check the Equipment
F
apply the Forceps and check its application
G
Gentle traction (Pajot’s manoevre)
H
lift the Handles as the occiput clears the pubic arch
I
Incision – use an episiotomy
J
when you can reach the Jaw, remove the blades
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Ventouse Delivery
A
Abdominal palpation
Ask for consent – document this
Adequate analgesia
Ask for help
B
empty the Bladder
C
full Cervical dilatation
D
Define the station and position
remember the risk of shoulder Dystocia
E
check the Equipment
F
apply the cup to the posterior Fontanelle
G
Gentle traction
H
Halt
if the cup avulses 3 times
if there is no descent over 3 contractions
if the head has not delivered in 20 minutes
I
Incision – consider using an episiotomy
J
when you can reach the Jaw, remove the cup
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References
Albers L, Schiff M, Gorwoda J (1996) The length of active labour in normal pregnancies.
Obstet Gynecol 87: 355-359.
Carroli G, Belizan J (2002) Episiotomy for vaginal birth.
Cochrane Database of Systematic
Reviews, Issue 4.
De Leeuw JW
et al (2001) Risk factors for third degree perineal injuries during delivery.
BJOG 108: 383-387.
Gardosi J, Hutson N, B-Lynch C (1989) Randomised controlled trial of squatting in the second
stage of labour.
Lancet 2: 74-77.
Gardosi J, Sylvester S, B-Lynch C (1989) Alternative positions in the second stage of labour:
a randomized controlled trial.
BJOG 96: 1290-1296.
Johanson R (1997) Choice of instrument for vaginal delivery.
Curr Opin Obstet Gynecol 9: 361-365.
Johanson RB
et al (1999) Maternal and child health after assisted vaginal delivery: five year
follow up of a randomised controlled study comparing forceps and ventouse.
BJOG 106: 544-
549.
Johanson RB, Menon V (2002) Soft versus rigid vacuum extractor cups for assisted vaginal
delivery.
Cochrane Database of Systematic Reviews, Issue 4.
Menticoglou SM
et al (1995) Perinatal outcome in relation to second stage duration.
Am J
Obstet Gynecol 173: 906-912.
NICE Intrapartum Guidelines
O’Grady JP, Pope CS, Patel SS (2000) Vacuum extraction in modern obstetric practice: a
review and critique.
Curr Opin Obstet Gynecol 126: 475-480.
Parsons JE, Hedayati H, Crowther CA (2002) Rectal analgesia for pain from perineal trauma
following childbirth.
Cochrane Database of Systematic Reviews, Issue 4. Saunders N, Paterson C, Wadsworth J (1992) Neonatal and maternal morbidity in relation to
the length of the second stage of labour.
BJOG 99: 381-385.
Tufnell D
et al (1989) Simulation of cervical changes in labour: reproducibility of expert
assessment.
Lancet 2: 1089-1090.
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CHAPTER 7 - THIRD STAGE OF LABOUR
7.1
DEFINITIONS ...................................................................................................85
7.2
MANAGEMENT OF THIRD STAGE .................................................................85
7.3
PHYSIOLOGICAL THIRD STAGE OF LABOUR ..............................................86
7.4
TREATMENT OF WOMEN WITH A RETAINED PLACENTA...........................87
7.5
THE MORBIDLY ADHERENT PLACENTA.......................................................89
7.6
PLACENTAL HISTOLOGY ...............................................................................90
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7.1 DEFINITIONS
Definition of the third stage
For the purposes of this guideline, the following definitions are recommended:
• The third stage of labour is the time from the birth of the baby to the expulsion of the
placenta and membranes
• Active management of the third stage involved a package of care which includes all of
these three components:
- Routine use of uterotonic drugs
- Early clamping and cutting of the cord
- Controlled cord traction
• Physiological management of the third stage involved a package of care which
includes all of these three components:
- No routine use of uterotonic drugs
- No clamping of the cord until pulsation has ceased
- Delivery of the placenta by maternal effort
Prolonged third stage
The third stage of labour is diagnosed as prolonged if not completed within 30 minutes
of the birth of the baby with active management and 60 minutes with physiological
management.
7.2
MANAGEMENT OF THIRD STAGE
Observations by a midwife of a woman in the third stage of labour include:
• Her general physical condition, as shown by her colour, respiration and her own report
of how she feels
• Vaginal blood loss
In addition, in the presence of haemorrhage, retained placenta or maternal collapse, frequent
observations to assess the need for resuscitation are required.
Physiological and active management of the third stage
Active management of the third stage is recommended, which includes the use of oxytocin (10
international units [IU] by intramuscular injection), followed by early clamping and cutting of
the cord and controlled cord traction.
Women should be informed that active management of the third stage reduces the risk of
maternal haemorrhage and shortens the third stage.
Women at low risk of postpartum haemorrhage who request physiological management of the
third stage should be supported in their choice.
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Changing from physiological management to active management of the third stage is
indicated in the case of:
• Haemorrhage
• Failure to deliver the placenta within 1 hour
• The woman’s desire to artificially shorten the third stage
Pulling the cord or palpating the uterus should only be carried out after administration of
oxytocin as part of active management.
In the third stage of labour neither umbilical oxytocin infusion nor prostaglandin should be
used routinely.
If the placenta is not delivered within 30 minutes
The midwife should:
• Check for signs of separation
If the placenta appears to be separated try to effect delivery by:
• Emptying bladder by voiding or catheterisation
• Encourage maternal effort pushing, squatting, without CCT
• Put baby to the breast if woman agreeable
• Record maternal observations of pulse and blood pressure
• Bear in mind that excessive CCT and / or excessive fundal pressure may cause uterine
inversion
7.3
PHYSIOLOGICAL THIRD STAGE OF LABOUR
Third stage management should be planned antenatally and documented in the notes.
Advantages
Physiological third stage offers continuation of the normal physiological process of labour.
There is no evidence of clinically significant increased morbidity for low risk women.
Disadvantages
In comparison to active management, a larger blood loss may be anticipated when managing
the third stage physiologically and the length of third stage is likely to be longer.
Mechanisms of physiological management of the third stage of labour
See figure 2.
Good practice points
• the midwife needs to be competent in caring for a woman during expectant management
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• the woman should never be left unattended
• pulse and blood pressure should be recorded every 30 mins
• the woman needs to be kept warm. This will reduce her risk of PPH
• leave the cord unclamped and uncut until the placenta separates
• the woman should adopt an upright position if possible
• if estimated blood loss exceeds 500ml, resort to active management and seek assistance
• if the woman has not delivered her placenta after 60 minutes refer to medical staff
7.4
TREATMENT OF WOMEN WITH A RETAINED PLACENTA
Intravenous access should always be secured in women with a retained placenta.
Intravenous infusion of oxytocin should not be used to assist the delivery of the placenta.
For women with a retained placenta oxytocin injection into the umbilical vein with 20 IU of
oxytocin in 20 ml of saline is recommended, followed by proximal clamping of the cord.
If the placenta is still retained 30 minutes after oxytocin injection, or sooner if there is concern
about the woman’s condition, women should be offered an assessment of the need to remove
the placenta. Women should be informed that this assessment can be painful and they
should be advised to have analgesia or even anaesthesia for this assessment.
If a woman reports inadequate pain relief during the assessment, the healthcare professional
must immediately stop the examination and address this need.
If manual removal of the placenta is required, this must be carried out under effective regional
anaesthesia (or general anaesthesia when necessary).
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Diagnosis of delay in the third stage
>30 min after birth with active
> 1 hour after birth with
management
physiological management
Revert to active management:
Give 10 IU oxytocin IM and apply
controlled cord traction
Secure IV access
Placenta delivered
OXYTOCIN
Injection of 20 IU in 20 ml of saline into the
umbilical vein, proximal cord clamping
No IV oxytocin infusion
Oxytocin
Oxytocin not effective
effective
Within 30 mins
Placenta delivered
Use analgesia or anaesthesia for
assessment
If women reports inadequate pain
relief, stop assessment and address
this need
Use effective regional or general
anaesthesia for manual removal of
placenta
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7.5
THE MORBIDLY ADHERENT PLACENTA
The diagnosis of placenta accreta classically is based upon histological investigations rather
than clinical findings or antenatal imaging. There are three histological grades:
•
accreta
villi attached to the myometrium
•
increta
villi extending into myometrium
•
percreta
villi penetrating myometrial wall
The condition arises in between 1:2000 and 1:7000 pregnancies, the incidence rising in recent
years. Associations have been described with placenta praevia, previous caesarean section
and myomectomy but placenta accreta may also arise in women without these risk factors.
Antenatal imaging
Placenta accreta cannot be diagnosed with confidence by ultrasound but its presence may be
inferred when the normal hypoechoic interface between the placenta and myometrium is lost.
Venous lakes may also be found in association with the condition. Some reports suggest that
magnetic resonance imaging can improve antenatal assessment but this has yet to find a
place in routine clinical practice. If the diagnosis is suspected antenatally, counselling should
cover the topics of surgical and conservative management at delivery and consider tertiary
referral.
Surgical management
Suspicion of placenta accreta often arises only when a placenta cannot be removed by
standard manoeuvres and a clear plane of cleavage cannot be found by digital exploration at
caesarean or during examination under anaesthesia after vaginal birth. Excavation of the
placental tissue from deep within the myometrium should be avoided as this is likely to lead to
haemorrhage. The Consultant Obstetrician should be informed and will wish to confirm the
findings.
The traditional management of placenta accreta is to perform a hysterectomy. When this is
undertaken promptly, a reduction in maternal mortality can be demonstrated. If the placenta
has already been removed and heavy bleeding is encountered, tamponade may be attempted
using gauze or an inflatable Cooke Catheter. Ligation of the internal iliac arteries is unlikely to
control bleeding sufficiently well to enable preservation of the uterus. Wedge resection of the
placental bed has also been described but is not presently recommended.
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Conservative management
Rather than perform a hysterectomy or attempt piecemeal removal of the placenta, in the
absence of haemorrhage, the cord may be cut short and the placenta left in situ. If the
morbidly adherent placenta is identified during caesarean, the uterus should then be closed in
the standard fashion. A Foley catheter should be inserted and generous intravenous access
gained.
A uterotonic drug such as 800 mcg rectal misoprostol should be given in addition to broad
spectrum antibiotics (eg) co-amoxyclav for 10 days. Methotrexate is not recommended as it
does not appear to alter clinical outcome.
If the woman is going to experience post partum haemorrhage this is most likely to arise over
the next 24 hours so over this time, regular observation of pulse, blood pressure, fundal height
and vaginal bleeding should be maintained on Delivery Suite.
Follow up after discharge from hospital must be agreed with the Consultant but may include
daily follow up by the Community Midwife and weekly review in antenatal clinic or on MAU. In
addition to history and general examination at weekly follow up, a full blood count and β-hCG
level should be checked. A well maintained Hb concentration and progressively falling β-hCG
suggest that the placental tissue is involuting. Ultrasound is not routinely required.
Reports suggest that morbidly adherent placenta managed in this way can be completely
resorbed into the maternal circulation. Occasionally, placental tissue is expelled from the
uterus spontaneously after a variable time interval. A second surgical procedure aiming to
remove placental tissue should however be carried out if secondary post partum haemorrhage
arises with the placenta still in situ. In such cases, hysterectomy is likely to be required.
7.6 PLACENTAL
HISTOLOGY
The placenta should be saved and sent for histology in the following circumstances.
• multiple pregnancy (if babies the same sex)
• pre-term
delivery
• intrauterine growth retardation
• Apgar under 7 at 5 minutes
• fetal
abnormality
• suspected
chorioamnionitis
• fetal death, regardless of request for post mortem
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figure 1
active management of the third stage of labour
discuss - consent - document
ensure the bladder is empty
give syntocinon 10 iu im
with the anterior shoulder
or as soon after the birth of the baby as possible
clamp and cut the cord
skin to skin contact where the mother agrees
observe for external signs of separation
cord lengthening, small trickle of fresh blood, uterus firm and rising in the abdomen
then try
controlled cord traction
if signs of separation have not been recognised
after 4 minutes
carefully check uterus is firm and well contracted
then try
controlled cord traction
abandon if the cord tears or snaps
try maternal effort alone
then
seek medical help
seek medical help if the placenta is not delivered within 30 minutes of birth or if estimated
blood loss of more than 500 ml arises before delivery of the placenta
check the placenta for completeness
exclude active bleeding
confirm that the uterus is firm and well contracted
estimate the blood loss and document
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figure 2
physiological management of the third stage of labour
discuss – consent – document
normal first and second stages of labour
no additional risk factors
omit oxytocic agent
offer skin to skin contact
consider putting the baby to the breast
do not clamp or cut the cord until palsations have stopped
do not palpate the uterus
keep the mother warm and encourage an upright posture
record her pulse and BP every 30 minutes
deliver the placenta and membranes by
maternal effort and gravity
check the placenta for completeness
exclude active bleeding
confirm that the uterus is firm and well contracted
estimate the blood loss and document
if
estimated blood loss over 500ml
length of the third stage over 60 minutes
concerns regarding maternal condition
then
seek medical assistance
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References
Armstrong CA, Harding S, Dickinson JE (2004) Clinical aspects and conservative
management of placenta accreta.
The Obstetrician and Gynaecologist 6: 132-37.
Austin J (2003) An audit of third degree perineal tears.
Br J Midwifery 11: 649-654.
Begley C (1990) A comparison of active and physiological management of the third stage of
labour.
Midwifery 6: 3-17.
Carroli G, Bergel E (2004) Umbilical vein injection for management of retained placenta. In:
The Cochrane Library, Issue 2, 2004. Chichester, UK: John Wiley & Sons, Ltd.
Fleming N (1990) Can the suturing method make a difference in postpartum perineal pain?
J
Nurse Midwifery 35: 30-33.
McDonald S, Prendiville W, Elbourne D (1999) Prophylactic syntometrine versus oxytocin for
delivery of the placenta.
The Cochrane Library of Systematic Reviews, Issue 4.
Metcalfe A
et al (2002) A Pragmatic tool for the measurement of perineal tears.
Br J Midwifery 10: 412-417.
NICE Intrapartum Guidelines
Prendiville WJ
et al (1988) The Bristol Third Stage Trial: active versus physiological
amangement of the third stage of labour.
BMJ 297: 1295-1300.
Rogers J
et al (1998) Active versus expectant management of the third stage of labour: The
Honchinbrooke randomised controlled trial.
Lancet 351: 693-699.
Sanaullah F, Moran P, Loughney AD (2002) The role of ultrasound in intrapartum care.
BMUS
Bulletin 10: 23-27.
Walsh D (2000) Perineal care should be a feminist issue.
Br J Midwifery 8: 125-129.
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CHAPTER 8 - PERINEAL REPAIR
8.1
PERINEAL REPAIR ..........................................................................................95
8.2
CLASSIFICATION OF PERINEAL TRAUMA ....................................................95
8.3
ANALGESIA......................................................................................................95
8.4
SECOND DEGREE TEARS..............................................................................95
8.5
THIRD AND FOURTH DEGREE TEARS..........................................................96
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8.1 PERINEAL
REPAIR
Whenever possible the person delivering a woman should undertake perineal assessment and
any necessary repair, under experienced supervision if necessary, with minimum delay. This
should be done by vaginal and rectal examination, using the finger lift technique, under
adequate light. Lithotomy position is not usually needed.
8.2
CLASSIFICATION OF PERINEAL TRAUMA
1st degree
-
fourchette, superficial perineal and vaginal tissues
2nd degree -
the above, plus muscles of perineal body
3rd degree
-
the above, plus partial or complete disruption of the anal sphincter
3a
-
under 50% of the external anal sphincter involved
3b
-
over 50% of the external anal sphincter involved
3c
-
internal anal sphincter torn
4th degree
-
the above, plus anal epithelium
8.3 ANALGESIA
Adequate analgesia is essential. For local infiltration, 1% lignocaine may be used up to a total
of 20 ml, this total including any lignocaine infiltrated prior to episiotomy. If perineal analgesia
remains inadequate, the duty anaesthetist should be informed.
8.4
SECOND DEGREE TEARS
The management of a second degree tear is usually surgical since functional outcome after
conservative management is unclear – there is little clear evidence to guide a woman so that
she can make an informed choice. When a decision is made
not to suture, the reasoning
should be documented and the notes signed by the attending midwife.
In suturing a second degree tear, the aims are to achieve:
♦ Anatomical
re-alignment
♦ Haemostatis
♦ Healing by first intention
Thereby reducing the risk of infection and restoring normal function.
Suture material
Vicryl and Vicryl Rapide are the suture materials of choice as they cause less perineal pain
than other materials. Of the two, Rapide is absorbed more quickly (42 days versus 90 days),
but there is no clear evidence to show that either one has a clinical advantage over the other.
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Suture to the vaginal wall
As there is no firm evidence to inform practice, the vaginal wall may be closed with either a
locking or a non-locking continuous suture.
Suture to the perineal body
Either continuous or interrupted sutures may be used to appose the disrupted muscles of the
perineal body, moving from deep to superficial tissues in order.
Suture to the skin
The use of a subcutaneous suture on the perineal skin is associated with less short-term pain
than interrupted sutures and is the technique of choice. The incidence of dysparunia after 3
months is similar in both groups. Non-closure of perineal skin is equally effective but offers no
particular benefit in terms of healing or pain.
Diclofenac sodium
A 100 mg diclofenac sodium rectal suppository may be offered at the end of the procedure.
Operator skill
Practitioners should be appropriately trained and supervised to ensure a consistent high
standard of perineal repair.
Documentation
The repair should be documented in full on an operative procedure sheet. Needles,
instruments and swabs should be counted and documented at the beginning and at the end of
the procedure. The operator is responsible for safe sharp disposal.
8.5
THIRD AND FOURTH DEGREE TEARS
Recognition and initial response
Any tear causing partial or complete disruption of the anal sphincter is a third degree tear
while involvement of the anal / rectal mucosa is fourth degree. The Consultant should be
informed if the middle grade obstetrician is not experienced / trained.
♦ Consultant
Obstetrician
♦ Experienced
SpR
After repair, complete an adverse event form and the audit form and inform the consultant
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Repair
This should be undertaken in theatre with adequate
♦ Exposure of tissues
♦ Light
♦ Analgesia (spinal or epidural)
The following sutures are suggested:
Mucosa
interrupted or continuous subepithelial 3/0 vicryl
Sphincter
internal
end to end anastamosis with 3/0 PDS
external
overlapping or end to end anastomosis with 3/0 PDS
Vagina
continuous suture with 2/0 vicryl or vicryl rapide
Perineal body
continuous or interrupted 2/0 vicryl or vicryl rapide
Perineal skin
continuous subcuticular 2/0 vicryl or vicryl rapide
Although there is no clear evidence of benefit, a stat IV dose of 750 mg cefuoxime and 500
mg metronidazole should be administered in theatre. A 100 mg diclofenac sodium rectal
suppository may be given for analgesia at the end of the procedure if it is not otherwise
contraindicated.
A Foley catheter should be considered after the repair of a third or fourth degree tear.
Postnatal Care
Antibiotics
A seven day oral course of cefalexin and metronidazole is currently
recommended although clear evidence of benefit is lacking.
Analgesia
Oral analgesia should be adequate but preparations containing codeine
should be avoided as they are constipating. See postnatal ward
analgesia guidelines.
Laxatives
To discourage straining, good hydration should be maintained and
Docusate sodium 200 mg bd or prophylactic lactulose or fybogel may be
given for 7-10 days.
Review
Patients should be reviewed daily on the postnatal ward. The patient’s
own consultant should be informed if this has not already occurred.
Exercises
The woman may commence gentle pelvic floor exercises in the days
after sustaining a third or fourth degree tear. These may be of long term
benefit and there is no evidence to suggest that they are detrimental to
healing.
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Repair breakdown Under no circumstances should a broken down repair be re-sutured.
Expert opinion must be sought from Mr Matar.
Follow up
All women should be offered a follow up in her own consultant’s
antenatal clinic approximately 6 weeks after delivery to discuss the
events surrounding delivery. Follow up at the urogynaecology clinic
should also be offered after 6-9 months.
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References:
Austin J (2003) An audit of third degree perineal tears.
M J Midiwf 11:
Blaisdell P (1940) Repair of the incontinent sphincter ani.
Surg, Gynecol Obstet 70: 692-697.
Draper J, Newell R (1996) A discussion of some of the literature relating to history, repair and
consequences of perineal trauma.
Midwifery 12: 140-145.
Fleming n (1990) Can the suturing method make a difference in post partum perineal pain?
J
Nurse Midwif 35: Gee H
et al (2001) Management of third and fourth degree perineal tears following vaginal
delivery. RCOG Clinical Green Top Guideline No 29, RCOG Press, London, UK.
Gordon B
et al (1998) The Ipswich Childbirth Study 1: A randomised evaluation of two stage
postpartum perineal repair leaving the skin unsutured.
BJOG 105: 435-440.
Johanson FR
et al (2002)
Methods of repair for obstetric anal sphincter injury.
Cochrane
Database of Systematic Reviews Issue 4.
Kettle C
et al (2002) Continuous versus interrupted perineal repair with standard or rapidly
absorbed sutures after spontaneous vaginal birth: a randomised controlled trial.
Lancet 359: 2217-2223
Kettle C, Johanson RB (2002) Absorbable synthetic versus catgut suture material for perineal
repair.
Cochrane Database of Systematic Reviews Issue 4.
Kettle C, O’Brien PMS (2004) Methods and materials used in perineal repair. RCOG Clinical
Green Top Guideline No 23, RCOG Press, London, UK
Metcalfe A
et al (2002) A pragmatic tool for the measurement of perineal tears.
BJM 10: Parks AG, McPartlin JF (1971) Late repair of injuries of the anal sphincter.
Proc Roy Soc Med
64: 1187-1189
Parsons JE, Hedayati H, Crowther CA (2002) Rectal analgesia for pain from perineal trauma
following childbirth.
Cochrane Database of Systematic Reviews Issue 4
Sultan AH
et al (1999) Primary repair of obstetric anal sphincter rupture using the overlap
technique.
BJOG 106: 318-323
Walsh D (2000) Perineal care should be a feminist issue.
BJ Midwif 8:
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CHAPTER 9 - BREECH
9.1
ANTENATAL CONSIDERATIONS....................................................................101
9.2
ECV...................................................................................................................101
9.3
ELECTIVE CAESAREAN SECTION.................................................................101
9.4
PLANNED VAGINAL BREECH DELIVERY ......................................................101
9.5
TERM BREECH DIAGNOSED IN LABOUR .....................................................103
9.6
PRE-TERM BREECH .......................................................................................103
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9.1 ANTENATAL
CONSIDERATIONS
Before labour, breech presentation may be suspected on abdominal palpation but diagnosis
rests with abdominal ultrasound. Once breech presentation has been confirmed at 36+0
weeks gestation, options for management should be discussed and documented in the notes:
• attempted external cephalic version
• elective caesarean section at 39+0 weeks gestation or later
• planned vaginal delivery
Antenatal counselling should include reference to the Term Breech Trial:
• planned vaginal delivery is associated with significantly higher rates of neonatal morbidity
and mortality than planned caesarean section
• planned vaginal delivery is associated with no difference in rates of maternal morbidity and
mortality than planned caesarean section
• two year follow up demonstrated no continued benefit after caesarean section but firm
conclusions could not be drawn as the original study was not designed to measure long
term outcomes.
9.2 ECV
1.
A detailed ultrasound scan should be performed at some time prior to the procedure.
2.
The procedure should be performed on Delivery Suite.
3.
Ultrasound scanning should be available for the duration of the procedure.
4.
CTG should be performed after the procedure whether or not it was successful.
5.
Tocolysis may be indicated. Nifedipine 20 mg orally 30 minutes prior to the event.
6.
There should be a maximum of three attempts at version. This can be repeated one
week later.
7.
The patients who are Rhesus negative should have Anti D administered.
9.3
ELECTIVE CAESAREAN SECTION
This may be carried out beyond 39+0 weeks gestation.
Prior to elective caesarean, the surgeon should confirm that the baby is still presenting by the
breech by portable ultrasound. In the event of spontaneous cephalic version, the decision to
cancel or continue with the caesarean should be based on other obstetric factors but must
also take into consideration the wishes of the woman. The duty Consultant must be kept
informed.
9.4
PLANNED VAGINAL BREECH DELIVERY
First stage of labour
On admission to the Delivery Suite in spontaneous labour:
• confirm that antenatal counselling has been adequate
• confirm that the woman wishes to proceed with vaginal delivery
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• document this discussion on the partograph
• gain IV access
• full blood count plus group and save serum
• inform the duty consultant
Thereafter:
• monitor the fetal heart continuously
• assess progress 4 hourly or more frequently if clinically indicated
• epidural should be considered but is not mandatory (WCH only)
Augmentation of labour with syntocinon is uncommon and should only be undertaken with
good evidence of inadequate uterine activity, after discussion with the duty Consultant.
Second stage of labour
When full dilatation has been confirmed, inform:
• the lead midwife on Delivery Suite
• the anaesthetist / ODA and theatre team
• SCBU
• the obstetric SpR and the duty Consultant
Allow sixty to ninety minutes for the breech to descend spontaneously if the fetal heart rate
features remain reassuring. Check the position and the station of the breech after this time.
Conduct of the delivery
Delivery should be supervised by the SpR or the duty Consultant. The fetal heart rate should
be monitored throughout. Good practice points follow:
• lithotomy
position
• empty the bladder
• ensure adequate analgesia
• allow spontaneous descent of the breech
As the maternal perineum stretches, consider episiotomy with careful guarding of fetal tissues.
The breech should then be allowed to descend with maternal effort alone (‘hands off the
breech’) with the sacrum lateral / anterior. Baby’s legs may be swept laterally or allowed to
deliver spontaneously and the arms may be delivered spontaneously, by sweeping medially
across the chest or by Lovsett’s manoeuvre. For the head:
• allow descent until the occiput is visible, then use…
• non-rotational forceps, or…
• Mauriceau-Smellie-Veit (but do
not place a finger in the baby’s mouth)
MODIFIED MARICEAU SMELLIE VEIT MANOEUVRE TO DELIVER THE HEAD.
Everything about this manoeuvre is designed to promote flexion.
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Place the other hand beneath the baby: put two fingers over the baby’s maxillae.
Deliver the head by flexing it through the pelvis – maternal effort, the occipital finger, pressure
to the maxillae and raising the body of the baby through a large arc. When the baby’s body is
vertical, an assistant can hold the feet. Application of suprapubic pressure by an assistant to
flex the head through the pelvis may also be used.
9.5
TERM BREECH DIAGNOSED IN LABOUR
When breech presentation is first suspected in labour, the SpR should be informed. He / she
should palpate the abdomen, perform a vaginal examination, then confirm presentation with
portable ultrasound. All relevant information should be recorded on the partogram, such as:
• parity
• maternal
height
• previous delivery details
• cervical
dilatation
• progress in labour to date
• membranes intact or ruptured
• clinically or ultrasonically estimated weight of this baby
• station of presenting part
• flexion or extension at the baby’s knees
• flexion or extension at the baby’s neck
Continuous fetal heart rate monitoring should be instituted on the diagnosis of breech. Unless
delivery is imminent, counselling should be based on the findings of the Term Breech Trial in
the absence of more accurate data. This work presents data regarding the outcome of
planned vaginal delivery in a subset of women who were not induced or augmented:
• planned vaginal delivery has a relative risk of serious fetal morbidity or mortality of 2.05
compared to planned caesarean section (1.6% vs 3.3%)
• no figures are given on maternal morbidity
• previous obstetric history has not been accounted for in this calculation
An algorithm for practice has been included. ECV may be attempted if an experienced
practitioner is available and the clinical scenario allows - good analgesia, high breech, intact
membranes, maternal consent. Tocolysis with terbutiline (0.25 mg sc) may be a useful step.
9.6 PRE-TERM
BREECH
Breech presentation is an independent risk factor for neonatal morbidity and mortality in pre-
term birth. Although data are sparse, there is no conclusive evidence that a blanket policy of
delivery by caesarean for a labouring pre-term breech reduces either morbidity or mortality.
Findings of the Term Breech Trial cannot be applied to this population. Management of the
pre-term labouring breech should therefore be discussed with the duty Consultant, with
reference to the principles detailed in Chapter 12.
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Breech diagnosed in labour
Ë
Ì
Delivery
Delivery
thought
to
be
not
thought
to
be
imminent
imminent
È
È
SpR
consider ECV
or
Consultant
È
to attend
delivery experienced
practitioner
?
favourable USS assessment ?
normal CTG ?
consent ?
Ë
Ì
yes
no
theatre counsel
epidural
for CS
tocolysis
È
Ë
Ì
if vaginal
success failure
delivery
È
È
requested
monitor
counsel
SpR
È
for CS
or Consultant
aim for
È
to
attend
vaginal
if vaginal
delivery
delivery
delivery
requested
SpR
or Consultant
to attend delivery
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References
Hannah M, Hannah W (1996) Caesarean section or vaginal birth for breech presentation at
term.
BMJ 312: 1433-4.
Hofmeyr GJ, Hannah M (2002) Planned caesarean section for term breech delivery.
Cochrane
Database of Systematic Reviews Issue 4.
Young PF, Johanson RB (2001) The management of breech presentation at term
. Curr Opin
Obstet Gynaecol 13: 589-593.
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CHAPTER 10 - MULTIPLE PREGNANCY
10.1
HIGH ORDER MULTIPLE PREGNANCY .........................................................107
10.2
INITIAL ASSESSMENT OF TWIN PREGNANCY.............................................107
10.3
FIRST STAGE OF LABOUR.............................................................................107
10.4
SECOND STAGE OF LABOUR ........................................................................108
10.5
THIRD STAGE OF LABOUR ............................................................................109
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10.1 HIGH ORDER MULTIPLE PREGNANCY
The principles of care involved in managing high order multiple pregnancies are the same as
those discussed below for twin pregnancy. The optimal mode of delivery in a high order
multiple pregnancy should be determined by the consultant obstetrician. The most frequent
mode of delivery is caesarean section.
10.2 INITIAL ASSESSMENT OF TWIN PREGNANCY
Each woman with a twin pregnancy should have a plan for delivery documented in her
antenatal notes. If none can be found, a full history should be taken, abdominal and vaginal
examination performed and the abdomen should be scanned to confirm presentation. The
decision to plan for vaginal delivery or caesarean section will be based upon several factors:
• presentation – if the first twin is a breech at full term, caesarean is usually recommended
although there is little evidence to guide practice in this respect. Presentation of the
second twin does not often have a major influence on the planned mode of delivery
• growth – poorer outcomes after labour are more common if there is evidence of growth
restriction in either twin, particularly if the growth is discordant
• chorionicity and amnionicity – there is no evidence to suggest that all mono chorionic twins
should be delivered by caesarean but mono amniotic twins should not be subjected to
labour
• gestation – caesarean section is not necessarily beneficial for very preterm twins in
spontaneous labour, whether the first twin is cephalic or breech, unless there is evidence
of fetal compromise
• the plan for delivery should be formulated in conjunction with the duty Consultant.
• maternal preference – this will be the final arbiter in planning mode of delivery for term
twins and will influence your management of preterm twin delivery
10.3 FIRST STAGE OF LABOUR
On admission to Delivery Suite in spontaneous labour:
• confirm that antenatal counselling has been adequate
• confirm that the woman wishes to proceed with vaginal delivery
• document this discussion on the partogram
• gain IV access, full blood count, group and save serum
• inform the duty Consultant
Poor quality CTGs are common in twin labours but effort should be made to ensure that both
babies are monitored continuously throughout labour. This may be achieved with dual
abdominal transducers or with a combination of scalp electrode (first twin) and abdominal
transducer (second twin).
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• assess progress 4 hourly or more frequently if clinically indicated
• epidural should be considered but is not mandatory – clear evidence of benefit is lacking
(WCH only)
Augmentation of labour with syntocinon should only be undertaken after discussion with the
duty Consultant and with good evidence of inadequate uterine activity.
10.4 SECOND STAGE OF LABOUR
When full dilatation has been confirmed, inform:
• the
anaesthetist
• SCBU / Paediatrics as required
• the senior obstetric SpR (if appropriately experienced) or the duty Consultant
• the senior midwife on Delivery Suite
• theatre
team
The following equipment and drugs should be readily accessible throughout the second stage,
either in the delivery room or in the adjoining corridor:
• portable ultrasound scanner
• forceps
trolley
• ventouse
• IV syntocinon for augmentation of contractions (10 iu in 50 ml n/saline)
• ergometrine
• IV syntocinon for infusion in the event of PPH (40 iu in 1000 ml n/saline, 250 mls per hr)
Staff present at the birth
Two midwives should be available throughout the birth of twins.
The Obstetric SpR and / or duty Consultant should also be present in the delivery room if
either twin is thought to be non cephalic, if there are concerns about the progress of labour or
if the wellbeing of either twin is in doubt. The Obstetric team should otherwise be available on
the Delivery Suite in case assistance is requested.
The need for the paediatric on call team should be determined on a case by case basis.
Delivery of the first twin
After spontaneous labour, the aim is to deliver both twins vaginally, in a safe manner, without
unnecessary intervention. The descent and delivery of the first twin should therefore follow
standard second stage guidelines as long as the second twin maintains a normal CTG. Use of
forceps or ventouse should be based upon standard parameters but may also occasionally be
carried out in order to gain access to the second twin.
Delivery of the first twin should be carried out by the midwife if its presentation is cephalic and
if the birth is unassisted. The Obstetric SpR or the duty Consultant will usually deliver the first
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twin if forceps or ventouse are to be used or if it is not cephalic. In some circumstances
however, the duty Consultant may allow the attending midwife to deliver a breech first twin
under his/her direct supervision if there are no additional clinical concerns.
Delivery of the second twin
After delivery of the first twin, the presentation of its sibling should be confirmed on
abdominal palpation by the attending midwife. The Obstetric team should be asked to confirm
presentation by ultrasound scan in cases of doubt. Thereafter, if presentation is cephalic,
descent of the presenting part should be awaited in the usual way. Syntocinon may be infused
if uterine activity is thought to be inadequate 5 to 10 minutes after delivery of the first twin, with
infusion rates following the standard regimen. Amniotomy is recommended once the head
reaches the ischial spines and assisted delivery thereafter should only be offered using
standard Obstetric parameters.
If the lie of the second twin is transverse, external cephalic version may be attempted.
Once the fetal head is above the pelvis, the lie should be stabilised externally while syntocinon
infusion is commenced. Amniotomy should then be undertaken once the head descends into
the pelvis. As an alternative, internal podalic version may be used in the management of a
transverse second twin. One or both heels are grasped, preferably through intact membranes,
and brought through the cervix and vagina onto the perineum. Breech extraction follows, the
membranes rupturing spontaneously during the process. This must only be attempted by
appropriately trained personnel.
If the lie of the second twin is breech, either external cephalic version or assisted vaginal
breech delivery may be undertaken. Management should be determined by the most senior
Obstetrician attending the birth. In some circumstances, the duty Consultant may allow the
attending midwife to deliver a breech second twin under his/her direct supervision if there are
no additional clinical concerns. Breech extraction may also be considered in experienced
hands if concerns arise regarding fetal wellbeing.
On average, as the length of time between delivery of the twins increases, the outcome for the
second twin worsens. This does not mean that artificially shortening the delivery interval will
necessarily improve the outcome for the second twin, but it illustrates the need for careful
CTG monitoring and intervention if the second twin shows any evidence of compromise.
10.5 THIRD STAGE OF LABOUR
For active third stage management give Syntometrine (unless ergometrine is contraindicated)
with the anterior shoulder or soon after the birth of the second twin. Label the umbilical cords
as 'twin 1' and 'twin 2' and take cord gases from both placentae. In the case of same sex
twins, the placenta should be sent for histological examination after it has been clinically
inspected. The placenta from discordant sex twins should only be sent if there are other
concerns.
Syntocinon and saline should be ready in the room to make up into an infusion if PPH arises,
but this should not be given routinely as a prophylactic measure.
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References
Bakker M
et al (2004) Quality of intrapartum cardiotocography in twin deliveries.
AJOG 2004:
191: 2114-2119.
Blickstein I, Louis KG (2003) Outcome of triplets and high-order multiple pregnancies.
Curr
Opin Obstet Gynecol 15: 113-117.
Chanhan SP
et al (1995) Delivery of the nonvertex second twin: breech extraction versus
external cephalic version.
Am J Obstet Gynecol 173: 1015-1020.
Feng TI, Swindle RE Jr, Huddleston JF (1995) A lack of adverse effect of prolonged delivery
interval between twins.
J Mat Fet Invest 5: 222-225.
Greig PC
et al (1992) The effect of presentation and mode of delivery on neonatal outcome in
the second twin.
Am J Obstet Gynecol 167: 901-906.
Hartley RS, Hitti J (2005) Birth order and delivery interval: analysis of twin perinatal outcomes.
J Mat Fet Med Neonatal Med 17: 375-380.
Houlihan C, Knuppel RA (1996) Intrapartum management of multiple gestations.
Clin Perinatol 23: 91-116.
Jones HW (2003) Multiple births: how are we doing?
Fertil Steril 79: 17-21.
McDonald S
et al (2004) Prophylactic ergometrine-oxytocin versus oxytocin for the third stage.
Cochrane Review.
Miller DA
et al (1996) Vaginal birth after caesarean section in twin gestation.
Am J Obstet
Gynecol 175: 194-198.
Pons JC
et al (2002) Delivery of the second twin:
comparison of two approaches
. Eur J Obstet
Gynecol Reprod Biol 104: 32-39.
Rabinovici J
et al (1987) Randomized management of the second nonvertex twin: vaginal
delivery or Caesarean section.
Am J Obstet Gynecol 156: 52-56.
Sansregret A
et al (2003) Twin delivery after a previous caesarean: a twelve-year experience.
J Obstet Gynaecol Can 25: 294-298.
Scher AI
et al (2002) The risk of mortality or cerebral palsy in twins: a collaborative population-
based study.
Pediat Res 52: 671-681.
Smith CS
et al (2005) Mode of delivery and the risk of delivery related perinatal death among
twins at term: a retrospective cohort study of 8073 births.
BJOG 112: 1139-1144.
Zhang J
et al (2004) Delayed interval delivery interval and infant survival: population based
study.
AJOG 191: 470-476.
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CHAPTER 11 - SHOULDER DYSTOCIA
11.1
DEFINITION......................................................................................................112
11.2
ANTICIPATION .................................................................................................112
11.3
HELPERR .........................................................................................................112
11.4
SYMPHYSISIOTOMY .......................................................................................112
11.5
ZAVANELLI’S MANOEUVRE............................................................................113
11.6
HARD PULL......................................................................................................113
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11.1 DEFINITION
Shoulder dystocia is the impaction of the anterior shoulder against the symphysis pubis after
the fetal head has been delivered. It may be recognised clinically as a failure to deliver the
shoulders with ‘normal traction’.
11.2 ANTICIPATION
Although as many as 50% of cases arise in a ‘low risk’ population, some risk factors have
been recognised:
• previous history of shoulder dystocia
• large baby on abdominal palpation
• baby over 4 kg on ultrasonic estimation
• delay in the first stage of labour
• delay in the second stage of labour
• assisted
delivery
• head retreating from perineum during pushing (‘bobbing’)
If shoulder dystocia is anticipated, the following steps should be taken during delivery:
• inform the lead midwife and the obstetric SpR
• get a second midwife into the room to assist
• remove surplus furniture from the room
• empty the bladder
• explain to the parents what they may be asked to do
11.3 HELPERR
This mnemonic will help you to remember how to manage shoulder dystocia although the
order in which manoeuvres are performed may vary in practice – the mnemonic should be
used in conjunction with good clinical practice. Rotational enter manoeuvres and removal of
the posterior arm are for example interchangeable. The most experienced clinician present
should co-ordinate the team’s efforts but any doctor or midwife trained in the techniques
employed may actually deliver the baby.
During the birth, contemporaneous notes should be kept. Following delivery complete the
summary sheet to SD, see page 96. After the birth, the notes should be completed. These
steps can help to avoid confusion in the recall of events.
11.4 SYMPHYSISIOTOMY
If the baby cannot be delivered despite working through all of the HELPERR manoeuvres, the
Consultant Obstetrician may consider symphysisiotomy. The procedure should take place in
the operating theatre under general anaesthetic unless a dense regional block is already in
place. The woman should be placed in the lithotomy position, but each of her legs should
receive additional supported from a member of staff. The abdomen and vagina should be
prepped, the legs draped then a rigid catheter run into the urethra and palpated with the left
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hand through the anterior vaginal wall. The catheter should be rolled laterally away from the
midline, then the symphysis incised. Delivery of the baby may then be attempted by
downwards traction, by suprapubic pressure or by internal rotation / Woods Screw. Repair of
the symphysis is not normally necessary.
A Foley’s catheter should be passed and left in place for a minimum of 7 days after this
procedure and oral antibiotics should be continued for one week.
11.5 ZAVANELLI’S MANOEUVRE
This should only be considered by the Consultant Obstetrician after failure of all of the
HELPERR manoeuvres and in the continued presence of a discernible fetal heart rate. The
woman should be given 0.5 mg sc terbutiline for tocolysis then transferred to the operating
theatre. A general anaesthetic should be administered unless a dense regional block is
already in place. The fetal head is then rotated on the perineum to an OA position, flexed,
then returned to the uterus with pressure from the flat of the hand on the baby’s occiput. The
bladder should then be catheterised, the abdomen prepped in the usual way and a caesarean
section performed. After delivery of the placenta, the uterus and cervix should be examined
carefully to exclude visceral trauma. At the end of the procedure, the vagina, perineum, anus
and rectum should be examined and repaired in the usual way.
The catheter should remain in place for a minimum of 72 hours after this procedure and oral
antibiotics should be continued for one week.
11.6 HARD
PULL
Throughout the shoulder dystocia, normal traction should be applied (ie) the amount of
traction you would normally apply when delivering a baby without a shoulder dystocia.
However, if:
• standard HELPERR manoeuvres have failed to deliver the baby
• you are unable to carry out a symphysisiotomy or Zavanelli’s manoeuvre for any
reason
• you have clear evidence that the baby’s life is in jeopardy, such as fetal bradycardia
…then you should pull as hard as is necessary to deliver the baby. In doing this it is accepted
that the baby is likely to suffer brachial plexus and bony injury. It is also accepted that the
injuries suffer may cause long-term disability. The alternative of death or damage due to
prolonged hypoxia are however even less desirable.
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H
Help
call for help obstetric SpR
paediatrician
senior midwife
additional midwife and a support worker
consider calling the Obstetric Consultant
inform the anaesthetist
E
Episiotomy
evaluate for an episiotomy
may be deferred until after McRobert’s
L
Legs
place legs in McRobert’s position
hyperflexed at the hips, slightly adducted
attempt to deliver for 30 seconds
P
Pressure
constant suprapubic pressure
behind the anterior shoulder
attempt to deliver for 30 seconds
rocking suprapubic pressure
behind the anterior shoulder
attempt to deliver for 30 seconds
E
Enter
finger behind the anterior shoulder
push the anterior shoulder into oblique
attempt to deliver ± two handed technique
finger behind the posterior shoulder
push the posterior shoulder into oblique
Woods screw manoeuvre
continue rotation a further 180o
attempt to deliver
R
Remove
remove the posterior arm by grasping the
posterior forearm and sweeping it across the chest
attempt to deliver
R
Roll
roll the woman onto all fours
attempt to deliver
If all of these measures fail, start again while awaiting the consultant’s attendance.
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MANAGEMENT OF SHOULDER DYSTOCIA
- file this in the notes after use -
Time Personnel
Order
Head delivered
H – Help called
E – Evaluate for episiotomy
L – Legs into MacRoberts
P – Pressure - suprapubic
E – Enter manoeuvres (detail)
R – Remove posterior arm
R – Roll &/or repeat (detail)
Additional manoeuvres (detail)
Baby delivered
State which shoulder impacted right
Left
State amount of traction
normal
increased
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References
Gherman RB (2003) New insights to shoulder dystocia and brachial plexus palsy
. Obstet
Gynecol Survey 58: 1-2.
Gherman RB (2002) Shoulder dystocia: an evidence-based evaluation of the obstetric
nightmare.
Clin Obstet Gynecol 45: 345-362.
Lam MH, Wong GY, Lao TT (2002) Reappraisal of neonatal clavicular fracture. Relationship
between infant size and risk factors.
J Reprod Med 47: 903-908.
Robinson H
et al (2003) Is maternal obesity a predictor of shoulder dystocia?
Obstet Gynecol 101: 24-27.
Sandmire HF, DeMott RK (2002) Erb's palsy without shoulder dystocia.
Int J Gynaecol Obstet
78: 253-256.
Spellacy WN (1999) Shoulder dystocia risks.
Am J Obstet Gynecol 180: 1047.
Zelig CM, Gherman RB (2002) Modified Zavanelli manoeuvre for the alleviation of shoulder
dystocia.
Obstet Gynecol 100: 1112-1114.
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CHAPTER 12 - PRE-TERM LABOUR
12.1
INITIAL ASSESSMENT ....................................................................................118
12.2
EXTREME PREMATURITY ..............................................................................118
12.3
FIBRONECTIN SWABS....................................................................................119
12.4
TOCOLYSIS .....................................................................................................120
12.5
ANTIBIOTICS ...................................................................................................122
12.6
STEROIDS........................................................................................................123
12.7
TEMPERATURE CONTROL AT BIRTH ...........................................................123
12.8
SURVIVAL AND MORBIDITY CHARTS ...........................................................124
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12.1 INITIAL
ASSESSMENT
A full history should be taken from any woman presenting to Delivery Suite with suspected
preterm labour. This should be recorded in the patient’s notes - annotation of the partogram is
not sufficient unless labour is well established. The information should include:
• previous obstetric history
• previous medical history
• history of present pregnancy to date including an estimate of gestation
• present history of contractions or other pain
• present history of vaginal loss of blood or liquor
• urinary
symptoms
• symptoms of systemic illness
On abdominal examination, the fundal height should be estimated and the presenting part
determined. The presence of uterine or renal angle tenderness and the presence of palpable
uterine contractions should also be recorded.
A speculum examination should then be performed by the SHO or SpR in order to:
• assess cervical effacement and dilatation
• obtain an endocervical swab, chlamydial swab, HVS and low vaginal swab
• determine whether or not the membranes remain intact
Digital examination should be avoided if at all possible as this may increase the risk of
infection. Pelvic examination need not be repeated when a woman has been transferred from
another hospital if the above steps have already been taken.
The following investigations should be performed:
• FBC
• group and save serum
• CRP
• urine dipstick analysis
• MSU
• urine microscopy if indicated by the history and examination
Portable ultrasound
Abdominal portable ultrasound examination may be used by a trained operator to assess fetal
viability, presentation, estimate fetal weight, measure the liquor volume and determine the
placental site. It is also occasionally possible to determine cervical dilatation by ultrasound.
12.2 EXTREME
PREMATURITY
If a women is admitted in labour < 26 weeks the Consultant Obstetrician should be informed of
her presence.
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12.3 FIBRONECTIN
SWABS
Fibronectin swabs may help to guide management in suspected preterm labour, when a
woman has:
• contractions at least once every ten minutes, but…
• intact membranes, and…
• cervical dilatation below 3 cm
There are some circumstances in which a swab is not helpful:
• proven rupture of the membranes
• antepartum
haemorrhage
• sexual intercourse within the last 24 hours, which gives a high false positive rate
The sample should be collected before digital examination is carried out. First, a speculum is
passed without prior lubrication. Next, the sterile swab provided in the fibronectin kits is
rotated around the posterior fornix of the vagina for 10 seconds. Subsequent steps to be taken
in performing the assay are explained clearly in the literature attached to each fibronectin kit.
Negative swab
It is reasonable to withhold tocolysis and steroids if the fibronectin swab is negative. Instead,
the woman should be observed until contractions settle and the results of other investigations
have been obtained.
Positive swab
A symptomatic woman with a positive swab has an increased chance of giving birth before full
term. Steroids and tocolysis should be offered in such cases, even when cervical dilatation is
below 3 cm and the membranes are intact.
Test result
Probability
of Risk of RDS at Rate of RDS at NNT *
birth within 10 32 weeks’
32 weeks’
days of test (%) gestation
gestation (%)
No test
4.5
0.53
2.0
109
Test
positive
20.6 0.53 11.0 17
Test negative
1.0
0.53
0.4
509
* NNT - Number of women needed to treat with steroids to prevent one case of RDS.
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12.4 TOCOLYSIS
The SpR may sanction the use of tocolytic drugs. Tocolysis has the following aims:
• delay
delivery
• allow steroid administration
• allow time for transfer to another unit when SCBU has no available cots
Suppression of uterine activity is not usually recommended however, in the presence of:
• fetal gestation greater than 33+6 weeks
• antepartum
haemorrhage
• clinical evidence of chorioamnionitis
Nifedipine
Nifedipine is generally safe and may have a tocolytic efficacy similar to that of atosiban. One
of the commonest regimens currently used is:
•
30 mg slow release nifedipine (adalat retard) stat, followed by…
•
20 mg slow release nifedipine (adalat retard) 8 hourly for 48 hours
If nifedipine is used for tocolysis, monitoring should be instituted for at least the first 2 hours:
• maternal BP every 15 minutes
• CTG
Nifedipine is not currently licensed for use in preterm labour however adverse fetal and
maternal outcomes have been reported in the literature, so it should only be used when
sanctioned by the Consultant Obstetrician. Caution is particularly advocated with:
•
maternal cardiac disease
• maternal
hypertension
• pre
eclampsia
•
evidence of pre existing fetal compromise
Atosiban (Tractocile)
Atosiban, an oxytocin receptor antagonist, is the only current tocolytic that is licensed for the
treatment of preterm labour. It has few side effects but treatment costs are high, so it should
only be used if there is clear evidence of preterm labour. If the membranes are intact and the
cervix 3 cm or less dilated, this evidence should include the presence of a positive fibronectin
swab. The drug administration regimen is shown overleaf.
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Atosiban dose regimen
prerequisites
regular uterine contractions lasting 30 seconds at a rate of ≥ 4 in 30 minutes
cervical dilation of 0 to 3 cm
gestation from 24+0 to 33+6 weeks
a normal fetal heart rate
Atosban may be administered even if other tocolytics have already been administered
it is administered intravenously in three successive stages
(1)
give a bolus dose of 6.75 mg
dilute a 0.9 ml vial of atosiban for injection with 10 ml n/saline
inject iv over 1 minute
then
(2)
give a continuous high dose infusion at a dose of 18 mg / hr for 3 hours
remove 10 ml fluid from a 100 ml bag of n/saline
add two 5 ml vials of atosiban for infusion, giving a total of 75 mg in each bag
infuse at a rate of 24 ml / hr
then
(3)
give a continuous low dose infusion at a dose of 6 mg / hr for up to 45 hours
reduce the rate of infusion above to 8 ml / hr
The bolus, high dose and low dose infusion bottles are all clearly labelled. Please follow
the manufacturer’s instructions carefully.
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12.5 ANTIBIOTICS
The ORACLE Trial
Women in preterm labour who have clear evidence of infection should be offered antibiotics
(see Section 20). Results of The ORACLE Trial suggest that between 24 and 36 weeks
gestation, where there is no clear clinical evidence of infection:
preterm labour with intact membranes
erythromycin has no definite role
see
GBS
guidance
below
preterm labour with ruptured membranes *
erythromycin may reduce neonatal
infection after birth
preterm, prelabour rupture of the membranes *
erythromycin may reduce neonatal
infection after birth
* Prescribe erythromycin 250 mg qds orally for 10 days.
Augmentin should
not be used in women at risk of delivering before term as this drug
increases the incidence of neonatal necrotising enterocolitis.
Neither Erythromycin nor Augmentin has a discernible effect on the incidence of maternal
infection or chorioamnionitis.
Antibiotics for GBS
When a woman goes into preterm labour, her baby is at an increased risk of developing early
onset GBS sepsis after birth. Even without clear evidence of infection, antibiotic prophylaxis
with iv penicillin or clindamycin should therefore be offered.
Prematurity under 37 weeks
Risk of early onset GBS infection in the neonate without IAP is 1:400
Risk of early onset GBS infection in the neonate with IAP is 1:2186
Prematurity under 35 weeks
Risk of early onset GBS infection in the neonate without IAP is 1:286
Risk of early onset GBS infection in the neonate with IAP is 1:1253
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12.6 STEROIDS
Women who seem likely to give birth between 24+0 and 33+6 weeks gestation should be
offered betamethasone to reduce the risk of neonatal intraventricular haemorrhage,
respiratory distress syndrome (RDS) and death. The evidence for a course of steroids, 34-36
weeks, is therefore weaker but may be appropriately given. Since most literature relates to IM
administration - there is little information regarding the efficacy of oral steroids – a dose of 12
mg betamethasone IM should be given with a second identical dose 24 hours later. There is
no evidence to support an accelerated second dose, say after 12 hours, even if rapid delivery
seems likely.
•
before 34+0 weeks, treatment of 5 women with steroids will prevent one case of RDS
•
from 34+0 to 35+6 weeks, treatment of 94 women will prevent one case of RDS
•
most benefit occurs when steroids are given between 24 hours and 7 days before birth
In general, a single course of steroids is recommended.
If a second course is considered discuss with the Consultant. If the risk of preterm delivery
remains high some time after administration of the first course however, a second course of
betamethasone may occasionally be given 14 days later.
Evidence for a second course is very limited however. A second course of steroids should
only be countenanced by a consultant obstetrician.
Administration of betamethasone should be avoided if there are clear signs of systemic
maternal sepsis. In the presence of definite evidence of chorioamnionitis, the administration of
betamethasone should first be discussed with the on call consultant and its relative merits and
potential adverse effects discussed.
12.7 TEMPERATURE CONTROL AT BIRTH
When a baby is born before 33+6 weeks gestation, neonatal hypothermia may arise. This is
worth preventing as hypothermia is a major risk factor for morbidity and mortality in preterm
infants (CESDI 27/28 project
www.cesdi.com). Babies lose heat through different mechanisms
- convection, evaporation, conduction and radiation. The first two of these account for most
heat loss but their effect can be countered by placing any preterm baby in a specially provided
plastic bag for initial resuscitation after delivery. These are available on the Delivery Suite and
should be used as follows:
Preparation prior to delivery
Standard resuscitation equipment should be ready. Environmental factors should be optimised
(eg) doors and windows closed to prevent drafts, overhead heater turned on and warm towels
provided. A plastic temperature control bag then be placed on the resuscitaire to warm.
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At delivery (the neonatal team will lead on this)
The baby should be placed immediately into the bag – do not waste time drying the baby. The
standard ABC procedure should then be followed. All resuscitation procedures, including
cardiac massage if needed, can be performed with the bag
in situ. A hole can be cut in bag to
access the umbilicus if necessary.
Transfer to SCBU
The baby should be transferred on the resuscitaire while still wearing its bag. On admission to
SCBU the baby will be placed in / on a pre-warmed incubator / platform. Once the incubator
side doors have been closed, the plastic bag will be removed through the portholes prior to
measure axilla temperature. If nursed on a platform the plastic bag will remain in place.
12.8 SURVIVAL AND MORBIDITY CHARTS
Birth weight (g)
96
99
3000
73-100
94-100
97
99
99
2750
89-100
91-100
95-100
90th percentile
97
98
98
2500
94-99
94-100
96-100
10th percentile
97
96
97
98
2250
96-99
92-99
96-99
97-100
98
81
93
96
98
98
2000
97-99
98-91
89-97
95-99
97-99
98-100
97
73
90
95
97
98
98
1750
97-99
56-86
84-94
93-97
96-99
97-99
98-100
96
32
86
85
92
95
97
98
99
1500
95-98
12-82
49-80
79-90
90-95
94-97
96-98
97-99
9-100
92
57
77
87
92
94
96
97
98
1250
91-94
43-70
71-83
85-90
90-94
93-96
94-98
96-99
97-100
76
20
41
60
73
80
84
87
90
94
97
1000
73-79
14-33
33-60
55-66
69-77
77-84
84-88
84-91
87-94
89-96
92-100
32
8
12
28
38
46
50
54
59
67
80
93
750
28-37
5-14
13-23
24-34
34-44
40-53
43-59
44-64
47-70
51-81
56-94
82-100
3
2
4
5
7
8
8
9
500
2-6
1-5
2-7
3-10
4-13
4-16
3-18
3-22
250
7
15
29
47
65
79
88
93
96
97
98
0
4-11
11-20
25-34
43-52
61-69
76-82
86-90
92-95
95-97
97-99
97-100
22 23 24 25 26 27 28 29 30 31 32
Gestation (weeks)
Draper’s Charts: Predicted survival (%) of infants alive at the onset of labour
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Morbidity data
Newcastle 1994-8 (booked)
Gestation
23 24 25 26 27 28 29 30 31
(weeks)
Survival (%) 33 25 50 42 82 98 96 98 98
Disability in - - - - - - - - -
survivors
(%)
Northern Region 1990-91
Gestation
23 24 25 26 27 28 29 30 31
(weeks)
Survival
16 24 51 50 76 79 91 92 96
(%)
Disability in 50 37 21 15 26 15 11
6
5
survivors
(%)
UK (Epicure 1995)
Gestation
23 24 25 26 27 28 29 30 31
(weeks)
Survival
20
33
52
- - - - - -
(%)
Disability in 35
29
24
- - - - - -
Survivors
(%)
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References
Baud O
et al (1999) Antenatal glucocorticoid treatment and cystic periventricular
leukomamacia in very premature infants.
NEJM 341: 1190-1196.
Besch NJ, Perlstein PH, Edwards NK, Keenan WJ, Sutherland JM (1971) The transparent
baby bag. A shield against heat loss.
NEJM 284: 121-124.
Bortolus R
et al (2000) Nifedipine administered in pregnancy: effect on the development of
children at 18 months
BJOG 107: 792-794.
Brodman ML
et al (1994) Wide-band transabdominal cerclage for a foreshortened,
incompetent cervix.
Obstet Gynecol 84: 704-706.
Crowley P (2002) Prophylactic corticosteroids for pre-term birth.
Cochrane Database of
Systematic Reviews Issue 2.
Draper ES, Manktelow B, Field DJ, James D (2003) Tables for predicting survival for preterm
births are updated.
BMJ 327: 872.
Groom KM and Bennett PR (2004) Tocolysis for the treatment of preterm labour – a clinically
based review.
The Obstetrician and Gynaecologist 6 (1): 4-12.
Honest H
et al (2002) Accuracy of cervicovaginal fibronectin test in predicting risk of
spontaneous preterm birth: systematic review.
BMJ 325: 301-311.
Hughes RG, Brocklehurst P, Stenson B (2004) Prevention of early onset neonatal group B
streptococcal disease. RCOG Green Top Guideline Number 36, RCOG Press, London, UK.
Kenyon SL, Taylor DJ, Tarnow-Mordi W (2001) Broad-spectrum antibiotics for preterm,
prelabour rupture of fetal membranes: the ORACLE I randomised trial.
Lancet 357: 979-988.
Kenyon SL, Taylor DJ, Tarnow-Mordi W (2001) Broad-spectrum antibiotics for spontaneous
preterm labour: the ORACLE II randomised trial.
Lancet 357: 989-994.
King JF
et al (2002) Calcium channel blockers for inhibiting preterm labour.
Cochrane
Database of Systematic Reviews Issue 4.
Le Flore JL
et al (2002) Association of antenatal and postnatal dexamethasone exposure with
outcomes in extremely low birth weight neonates.
Paediatrics 110: 275-279.
Lowe M
et al (2004) Prospective randomized controlled trial of fetal fibronectin on preterm
labor management in a tertiary care center.
Am J Obstet Gynecol 190: 358-362.
Lyon AJ, Stenson B (2004) Cold comfort for babies.
Arch Disease Childhood: Fetal &
Neonatal Edition 89.
McDonald IA (1957) Cervical suture.
J Obstet Gynaecol Br Empire 3: 346-350.
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Moutquin JM
et al (2000) Double blind, randomised controlled trial of atosiban and ritodrine in
the treatment of preterm labour: a multicenter effectiveness and safety study.
Am J Obstet
Gynecol 182: 1191-1199.
Papatsonis DN
et al (2000) Neonatal effects of nifedipine and ritodrine for preterm labor.
Obstet Gynecol 95: 477-481.
Penney GC and Cameron MJ (2004) Antenatal corticosteroids to prevent respiratory distress
syndrome. RCOG Green Top Guidelines: Guideline Number 7. RCOG Press, London, UK.
Shirodkar (1955) Cervical suture.
The Antiseptic 52: 299-300.
Vohra S, Frent G, Campbell V, Abbott M, Whyte R (1999) Effect of polyethylene occlusive skin
wrapping on heat loss in very low birth weight infants at delivery: a randomized trial.
J
Pediatrics 134: 547-551.
Zaveri V
et al (2002) Abdominal versus vaginal cerclage after a failed transvaginal cerclage: a
systematic review.
Am J Obstet Gynecol 187: 868-872.
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CHAPTER 13 - FETAL HEART RATE MONITORING
The guidelines presented in this section are compatible with the RCOG / NICE Guidelines on
Electronic Fetal Monitoring published in 2001.
13.1
FETAL HEART RATE MONITORING ...............................................................129
13.2
DEFINITIONS ...................................................................................................129
13.3
RISK ASSESSMENT ........................................................................................130
13.4
ANTENATAL FETAL HEART MONITORING....................................................131
13.5
THE DAWES / REDMAN CRITERIA AS USED BY THE OXFORD SONICAID
SYSTEM ...........................................................................................................132
13.6
ADMISSION CTG .............................................................................................132
13.7
INTERMITTENT AUSCULTATION ...................................................................133
13.8
CONTINUOUS MONITORING..........................................................................133
13.9
CATEGORISATION OF FETAL HEART RATE FEATURES ............................134
13.10
CTG CLASSIFICATION ....................................................................................134
13.11 SUSPICIOUS CTG ...........................................................................................134
13.12
PATHOLOGICAL CTG......................................................................................135
13.13
FETAL SCALP BLOOD SAMPLING .................................................................135
13.14
DR C BRAVADO...............................................................................................136
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13.1 FETAL HEART RATE MONITORING
Cardiotocograph (CTG) machines use doppler to detect movement in the mother’s abdomen,
including movement of the fetal heart. Before this can be displayed on the monitor, extraneous
‘noise’ (such as movement in the mother’s blood vessels) has to be filtered out by the
machine. This is usually achieved successfully but sometimes a ‘trace’ can be displayed on
the machine even after fetal death has occurred. In these cases, the signal is derived from
maternal tissue movement. To guard against this, the Medical Devices Agency recommends:
• the fetal heart should identified by auscultation with a Pinnard before the CTG is attached
• if a problem is encountered in identifying the fetal heart, ultrasound should be used to
confirm the presence of a heart beat
• the time and date should be checked on the monitor whenever a CTG is commenced
• the maternal pulse should be recorded on the CTG trace and on the partogram regularly
• if the maternal and fetal heart rates are similar and the maternal heart beat seems to be
synchronious with the sound coming from the monitor, the presence of a true fetal heart
beat must be confirmed by other means (such as ultrasound or fetal scalp electrode)
• anyone making management decisions based on a CTG should sign both the trace and
the subsequent action plan recorded in the notes
13.2 DEFINITIONS
Baseline rate
The mean heart rate over 5 minutes
Baseline variability
Variation in the baseline rate excluding accelerations and
decelerations
Acceleration
A rise in the heart rate of at least 15 bpm for at least 15 seconds
Deceleration
A transient decrease in the heart rate of 15 bpm lasting for 15
seconds or more. Shallower decelerations may also be significant
however from a baseline with reduced variability
Early deceleration
The nadir of the deceleration mirrors the peak of the contraction and
recovery occurs within the contraction
Variable deceleration The timing of the deceleration is variable in relation to the peak of the
contraction. Depth and duration may also be variable
Late deceleration
The nadir of the deceleration consistently occurs after the peak of the
contraction
Shouldering
Small accelerations before and / or after decelerations
All CTG’s should be assessed and categorised as normal, suspicious or pathological.
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13.3 RISK
ASSESSMENT
On first admission to Delivery Suite, women in labour should be assessed and allocated low
or high risk status. High risk status will be conferred when any one of a number of conditions
affecting fetal or maternal wellbeing are identified. The following list is not exhaustive:
Maternal
• placenta
praevia
• antepartum
haemorrhage
• isoimmunisation - Rhesus or other antibodies
• previous caesarean section
• pre
eclampsia
• HIV / Hep B
• diabetes
Fetal
• breech
presentation
• multiple
pregnancy
• thick
meconium
• polyhydramnios
• oligohydramnios
• congenital
abnormalities
• gestation under 37 weeks
• baby under 2.5 kg estimated weight
Intrapartum
Transfer to high-risk status should be precipitated by:
• pyrexia
• use of syntocinon
• intrapartum
haemorrhage
• fetal heart rate abnormalities
• fetal capillary blood sampling
• prolonged rupture of the membranes
• any other concern about the woman’s wellbeing
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13.4 ANTENATAL FETAL HEART MONITORING
Purpose
To record the fetal heart rate pattern where the gestational age is 26 weeks or more, over a
period of time between 10-60 minutes in order to assess the well being of the fetus.
Instruction
The midwife will explain the purpose for and the procedure to the women.
The midwife will palpate the abdomen, measure the fundal – symphysis height and auscultate
the fetal heart with a pinards prior to the CTG.
The midwife will apply tocograph and ultrasound transducers.
The fetal activity button will be given to the women with instructions for use.
The CTG will last 20-60 minutes when visually interpreting and 10-60 minutes when using the
Dawes / Redman computerised fetal heart rate monitor.
On completion of the trace the midwife will explain the findings to the women.
The appropriate medical staff will be summoned in the event of an abnormal trace, (duty rota
and bleep numbers available).
The CTG will be repeated as indicated for each individual women (see Maternity Assessment
Unit Guidelines). The midwife will arrange any further antenatal follow-up care required.
At all times maintain clear and accurate documentation.
Key Points
All CTG tracings must be clearly marked with woman’s name.
Maternal pulse rate
The woman’s DOB
The gestational age
The date and time the trace took place
The signature of the midwife commencing and terminating the trace
When using the Sonicaid Team Monitor the Dawes / Redman Criteria will be used in
conjunction with the visual analysis of the raw data.
3.1
Refer to guideline ultrasound scans in the case of an abnormal CTG.
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13.5 THE DAWES / REDMAN CRITERIA AS USED BY THE OXFORD
SONICAID SYSTEM
What parameters does the system analyse
It measures the heart rate in beats per minute and fits a baseline. From this computed
baseline it is then able to: -
Measure accelerations and decelerations
Measure the overall variation of the fetal heart rate around the baseline when
decelerations have been excluded
Measure the short-term variation (STV)
Identify episodes of high and low variations
Identify signal loss
Count
contractions
Count fetal movement per hour as recorded by the woman
The Criteria
The baseline heart rate must be > 115 < 160bpm
There must be no large decelerations (of >20 lost beats)
There must be at least 1 fetal movement of 3 accelerations
The overall variation should be >=22ms
The
STV>=3ms
At least 5 out of 6 consecutive minutes of high variation
If the criteria is not met inform medical staff.
13.6 ADMISSION
CTG
The admission CTG is only recommended for women in the high risk category. It consists of a
20 minute trace in which both the fetal heart rate and contractions are clearly recorded and
should be assessed as normal, suspicious or pathological (see below).
Women whose labours have been classified as low risk may occasionally request an
admission CTG. Although admission CTG’s are of no proven benefit in such cases, the trace
may still be performed after appropriate counselling as part of the woman’s choice.
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13.7 INTERMITTENT
AUSCULTATION
This is the method of choice for fetal heart rate monitoring in low risk labours. It is defined as
the auscultation of the fetal heart rate for one minute after a contraction:
• at least once every 15 minutes in the first stage of labour
• at lest once every 5 minutes in the second stage of labour
The rate should be recorded contemporaneously on the partograph. Either a Pinnard or a
hand held doppler can be used, depending upon the experience of the midwife and the wishes
of the labouring woman.
If circumstances lead to reclassification of the labour as ‘high risk’, continuous monitoring
should be commenced. Conversion to continuous monitoring should also be expedited if:
• the baseline rate is below 110 bpm
• the baseline rate is above 160 bpm
• a deceleration is heard after a contraction
13.8 CONTINUOUS MONITORING
Women assessed as high risk on admission, who become high risk during labour or who have
a suspected fetal heart rate abnormality on intermittent auscultation should be monitored
continuously. A woman thought to be at low risk of complications may request continuous
monitoring, but this should only be commenced after counselling:
• no proven benefit to the woman
• no proven benefit to the baby
• increased risk of operative intervention during the labour
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13.9 CATEGORISATION OF FETAL HEART RATE FEATURES
Figure 1
RCOG/NICE Categorisation of FHR Features
Feature
Baseline
Variability
Decelerations
Accelerations
Reassuring 110-160
>5
none
present
non-reassuring 100-109
<5 for
early;
?
161-180
40 to 90 min
typical variable;
prolonged <3 min
abnormal
< 100
< 5 for
atypical variable; ?
> 180
over 90 min
late;
sinusoidal
prolonged >3 min
absence of accelerations in an otherwise normal trace is of unknown
significance
13.10 CTG CLASSIFICATION
See figure 1. This includes the formulation of an action plan.
13.11 SUSPICIOUS CTG
This is the presence of one non-reassuring feature, but no more than one. No abnormal
features should be present. The attending midwife should alert the midwife in charge of
Delivery Suite. When there is continued concern the SHO and / or SpR should be informed.
• check the quality of the trace
• consider using a fetal scalp electrode if the quality is suboptimal
• ensure the mother is not supine - encourage her to adopt the left lateral position
Hyperstimulation (also see Section 4)
• reduce or stop Syntocinon if it is in use and if contractions are occuring > 5:10 minutes
• consider tocolysis with 0.25 to 0.5 mg sc terbutiline
Maternal tachycardia or pyrexia (also see Section 20)
• stop tocolytics if in use
• consider blood cultures and triple swabs
• consider intravenous antibiotics
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If the trace remains suspicious over a prolonged period of time, although no additional active
intervention may be required, all other clinical considerations should be taken into account
before coming to this conclusion. The woman and her CTG should be observed closely and
medical review should take place hourly as a minimum. A written entry should be made in the
women’s partogaph by the medical staff on an hourly basis in these circumstances.
13.12 PATHOLOGICAL CTG
This is the presence of two or more non-reassuring features on the CTG, or one abnormal
feature. In most cases, a fetal scalp blood sample will be required to exclude acidaemia. If a
sample cannot be obtained, delivery should then be expedited. Occasionally, delivery should
be undertaken without recourse to fetal scalp blood sampling:
• baseline variability under 2 bpm together with late fetal heart rate decelerations
• prolonged fetal bradycardia lasting for more than 3 minutes with no sign of recovery
• technically very difficult or impossible to obtain a fetal scalp blood sample
In such cases, intervention may be postponed if clear evidence emerges of recovery of the
CTG to a normal pattern prior to delivery.
13.13 FETAL SCALP BLOOD SAMPLING
Ensure patient and partner understand procedure
Position the patient and prepare the equipment
• usually left lateral position
• if the cervix is less than 3cm dilated then consider using lithotomy position
• select an amniscope and lubricate it with gel or cream
• use standard pre-heparanised 55 mcl capillary tubes
Visualise and prepare the fetal scalp
• insert the amniscope
• clean the baby’s head with a small gauze pledget then spray the scalp with ethyl chloride
• spread a very thin layer of petroleum jelly on the scalp
Collect the sample
• prick the baby's head firmly with the blade
• if an additional prick is required this should be at right angles to the first
• wait for blood to collect as a drop on the scalp then collect it with the capillary tube
Aim to completely fill capillary tube, anything less than 70% full is likely to fail to give a pH
result. Any air bubbles are likely to lead to a ‘non-homogenous’ failure. Take 3 samples if
possible.
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Sample analysis
The capillary tube should be rocked gently to avoid clotting. Only those midwives trained in
the use of the blood gas analyser should undertake this task. At the machine the caps should
be removed and the opposite end to that used for taking the sample introduced into the ‘clot
catcher’ and inserted into the blood gas analyser.
The commonest reasons samples are rejected are:
• sample
clotted
• insufficient
sample
• non-homogenous sample, i.e. air bubbles
We should achieve 70% success rate
pH
Subsequent
Action
≥ 7.25
FBS should be repeated if the abnormality persists
Frequency of sampling determined by the SpR or Consultant
7.21-7.24
Repeat FBS within 30 minutes or consider delivery if there has been a
rapid fall since the last sample was obtained
≤ 7.20
Delivery is indicated
13.14 DR C BRAVADO
This mnemonic may help you to remember the features of the CTG.
D
Define the Risk
R
C
Contractions
B
Baseline RAte
R
A
V
Variability
A
Accelerations
D
Decelerations
O
Overall assessment
formulate an action plan based on the overall assessment
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References
Amer-Wahlin
et al (2001) CTG only versus CTG plus ST analysis of the fetal ECG for
intrapartum fetal monitoring: a Swedish randomised controlled trial.
Lancet 358: 534-538.
Ayres de Campos D
et al (1999) Inconsistencies in classification of cardiotocograms and
subsequent clinical decisions.
BJOG 106: 1307-1310.
Goodwin TM
et al (1994) Elimination of fetal scalp blood sampling in a large clinical service.
Obstet Gynecol 83: 971-974.
Greene KR (1991). Scalp blood gas analysis in antepartum and intrapartum fetal assessment.
Obstet Gynecol Clin North Am 26: 641-656.
Hagberg B
et al (2001) changing panorama of cerebral palsy in Sweden VIII. Prevalence and
origin in the birth period 1991-1994.
Acta Paediatr 90: 271.
Hagberg B
et al (2001) Cerebral palsy in west Sweden 1954-1994.
Acta Paediatr 90: 277.
Hakon Noren
et al (2003) Fetal ECG in labour and neonatal outcome: data from the Swedish
RCT on intrapartum fetal monitoring.
Am J Obstet Gynecol 188: 183-192.
Hofmeyr GJ, Kulier R (2002) Tocolysis for preventing fetal distress in second stage of labour.
Cochrane Database of Systematic Reviews,
Issue 4.
Impey L
et al (2003) Admission cardiotocography: a randomised controlled trial.
Lancet 361:
465-70.
Johnstone FD, Campbell DM, Huges GJ (1978) Has continuous intrapartum fetal monitoring
made any impact on fetal outcome?
Lancet 1: 1298-1300.
Larsen JF (1996). Why has conventional intrapartum cardiotocography not given the expected
results?
J Perinat Med 24: 15-23.
MacDonald D
et al (1985) The Dublin randomised controlled trial of intra partum fetal heart
rate monitoring.
Am J Obstet Gynecol 152: 524-539.
Neilson JP (2003) Fetal ECG for fetal monitoring in labour (Cochrane Review). In: The
Cochrane Library, Issue 2. Oxford: Update Software.
Nelson KB, Ellenberg JH (1986) Antecedents of cerebral palsy.
NEJM 315: 81-86.
Rosen KG, Isaksson O (1976) Alterations in fetal heart rate and ECG correlation to glycogen,
creatine phosphate and ATP levels during graded hypoxia.
Biol Neonate 30: 17-24.
Saling E (1996) Comments on the past and present situation of intensive monitoring of the
fetus during labour
. J Perinat Med 24: 7-13.
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Surveillance of cerebral palsy in Europe (2000). A collaboration of cerebral palsy surveys and
registers.
Dev Med Child Neurol 42: 816-824.
Thacker SB
et al (1995) Efficacy and safety of intrapartum electronic fetal monitoring: an
update.
Obstet Gynecol 86: 613-620.
Umstad MP
et al (1995) Litigation and the intrapartum cardiotocography.
BJOG 102: 89-91
Westgate JA
et al (1993) Plymouth randomised trial of CTG only versus ST waveform plus
CTG for intrapartum monitoring in 2400 cases.
Am J Obstet Gynecol 169: 1151-1160.
Westgate JA
et al (1999) Antecedents of neonatal encephalopathy with fetal acidaemia at
term.
BJOG 106: 774-782
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CHAPTER 14 - ANTEPARTUM HAEMORRHAGE
14.1
INTRODUCTION...............................................................................................140
14.2
GENERAL MANAGEMENT ..............................................................................140
14.3
MANAGEMENT OF SEVERE HAEMORRHAGE IN THE COMMUNITY..........141
14.4
PLACENTA PRAEVIA.......................................................................................142
14.5
PLACENTAL ABRUPTION ...............................................................................143
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14.1 INTRODUCTION
Antepartum haemorrhage is the loss of blood from any part of the genital tract, after the point
of fetal viability but before delivery of the baby. The origin of the blood loss may be:
• vulval
• vaginal
• cervical
• uterine, not involving the placental bed
• uterine, involving the placental bed
In practice, blood loss from the uterine cavity, involving the placental bed, is the form of
antepartum haemorrhage most commonly associated with maternal and fetal clinical
sequelae. These conditions form the subject matter for this section:
• placenta
praevia
• placental
abruption
14.2 GENERAL MANAGEMENT
Women with minor antepartum haemorrhage will usually be seen by the midwives and
medical staff on the Maternity Assessment Unit in the first instance then referred to Delivery
Suite if needed. Women with heavy bleeding may be admitted directly to the Delivery Suite,
however.
Whenever a woman with antepartum haemorrhage arrives on the Delivery Suite, the following
measures and investigations should be instituted if not already in place:
• intravenous access gained with two large bore cannulae
• intravenous infusion started with normal saline or Hartmann’s solution
• full blood count
• clotting
screen
• crossmatch of at least 2 units of blood – refer to Section 15.
• cardiotocography
• consider
Kleihauer
The senior SpR or Consultant must be informed about any patient with bleeding sufficient to
cause clinical concern. Pelvic examination should not be performed until this contact has been
made and the case discussed.
Anti-D should be given within 72 hours of bleeding.
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14.3 MANAGEMENT OF SEVERE HAEMORRHAGE IN THE COMMUNITY
When SEVERE bleeding occurs at HOME the midwife is sometimes contacted by telephone.
In these circumstances the midwife should:
1. Obtain details of the woman’s general condition, amount of blood loss, any associated
pain, and when she delivered.
2. Obtain details of her name, address, telephone number and GP.
3. Request a paramedic ambulance on 999 to admit to the consultant Unit.
4. Notify the GP and request attendance if it is felt necessary.
5. A midwife MAY be available to go to the house. Consider each situation individually on
the severity of the haemorrhage, the availability of supporting staff and the location of
the woman.
6. If a midwife goes to the home she should, if possible, take an infusion set, Hartmanns
Solution, a community bag and oxytocic drugs, i.e. ergometrine 0.5 mg. Ergometrine
may be required postnatally.
ACTION BY THE MIDWIFE IN THE HOME OR IN THE MATERNITY UNIT
a) Transfer the woman in an ambulance with a doctor and/or midwife.
b) A GP should be requested urgently.
c) Monitor the woman’s condition throughout – BP, pulse, respiration, pallor, blood loss, level
of consciousness. Do not give any oral fluids.
CONTINUE WITH FLOW CHART ON MANAGEMENT OF POST-PARTUM HAEMORRHAGE
(See Chapter 15.8)
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14.4 PLACENTA
PRAEVIA
This occurs in 0.4 to 0.8 % of pregnancies. There are many risk factors, including:
• maternal age over 35 years
• smoking
• high
parity
• previous caesarean section
• multiple
pregnancy
Presentation tends to be with painless bleeding and a high presenting part or malpresentation,
though these features are variable. Diagnosis rests with vaginal or abdominal ultrasound, and
will usually already be clearly indicated in the antenatal notes. Ultrasound diagnosis on the
Delivery Suite may only be made by an appropriately experienced clinician.
Bleeding placenta praevia, not in labour
Women with bleeding placenta praevia who are not in labour may occasionally be treated
conservatively, for example to allow steroid administration to a preterm infant. Conservative
management should always be sanctioned by the Consultant Obstetrician. As a prerequisite,
conservative management will rely upon a stable fetal and maternal condition.
When there is evidence of fetal or maternal compromise but the Consultant Obstetrician on
call is attending from home, delivery should not usually be delayed. The attending SpR should
commence a caesarean section after discussion with the duty Consultant, who will give
assistance upon her / his arrival if necessary.
Bleeding placenta praevia, in labour
When a woman with bleeding placenta praevia arrives on the Delivery Suite in labour, delivery
will
usually be by caesarean section.
• inform the Consultant Obstetrician
• inform the on call anaesthetist
• inform the haematology lab
• obtain venous access with two large bore cannulae (16G or larger)
• cross match a minimum of 2 units of blood
• check the full blood count and clotting screen
• transfer to theatre without delay for caesarean section
Exceptions to the principle of delivery by caesarean section may arise when the leading edge
of the placenta is more than 2.5 cm from the cervical os and there is no evidence of maternal
or fetal compromise. The decision not to perform a caesarean section in these circumstances
can only be made by the on call Consultant.
In common with non-labouring women, when there is evidence of fetal or maternal
compromise but the Consultant Obstetrician on call is attending from home, delivery should
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not usually be delayed. The attending SpR should commence a caesarean after discussion
with the duty Consultant, who will give assistance upon her / his arrival if necessary.
14.5 PLACENTAL
ABRUPTION
This occurs in approximately 1.0 % of pregnancies. There are many risk factors, including:
• maternal age over 35 years
• high
parity
• smoking
• trauma
• hypertension
Classically, women with placental abruption attend with abdominal pain and bleeding. They
may appear unwell, with tachycardia and hypotension. A tender, rigid uterus is common but
not universal. Although none of these features is wholly reliable, the diagnosis remains
primarily clinical. A negative ultrasound scan cannot exclude the diagnosis.
Management of placental abruption
Women with suspected placental abruption may occasionally be treated conservatively
whether in labour or not, for example when there is an element of doubt in the diagnosis and
the maternal and fetal conditions are stable. Any plan for conservative management should be
sanctioned by a consultant and should include elements of Section 14.2.
When there is clear evidence of fetal or maternal compromise but the Consultant Obstetrician
on call is attending from home, delivery should not usually be delayed. The attending SpR
should commence delivery after discussion with duty Consultant, who will respond
immediately and attend as soon as possible and provide assistance upon her / his arrival if
necessary.
Management of suspected placental abruption
• inform the Consultant Obstetrician
• inform the anaesthetist
• inform the G Grade midwife co-ordinating Delivery Suite
• inform the on call haematologist if the maternal condition is giving concern
(1)
with no evidence of fetal or maternal compromise
and
a decision to try for vaginal delivery
continuous FH monitoring
IV access, FBC, clotting status, Kleihauer, cross match blood
amniotomy
(2)
with clear evidence of maternal or fetal compromise
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deliver by
Grade 1 caesarean section
or
assisted vaginal delivery
without delay
continuous FH monitoring where possible
IV access, FBC, clotting status, Kleihauer, cross match blood
(3)
with fetal demise or imminent fetal demise
such as prolonged profound bradycardia with no previously recorded normal FH
manage with maternal wellbeing exclusively in mind
for example
aim for vaginal delivery if the mother is clinically stable
consider caesarean section if the mother is not clinically stable
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References
Ananth CV
et al (2003) The effect of placenta
previa on neonatal mortality: a population-based
study in the United States, 1989 through 1997.
Am J Obstet Gynecol 188: 1299-1304.
Fiaz AS, Ananth CV (2003) Etiology and risk factors for placenta
previa: an overview and
meta-analysis of observational studies.
J Mat Fetal Neonat Med 13: 175-190.
Kayani SI
et al (2003) Pregnancy outcome in severe placental abruption.
BJOG 110: 679-683.
Neilson JP (2003) Interventions for treating placental abruption
. The Cochrane Database of
Systematic Reviews.
Neilson JP (2003) Interventions for suspected placenta
praevia.
The Cochrane Database of
Systematic Reviews.
Sheiner E
et al (2003) Placental abruption in term
pregnancies: clinical significance and
obstetric risk factors.
J Mat Fet Neonat Med 13: 45-49.
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CHAPTER 15 - POSTPARTUM HAEMORRHAGE
15.1
BACKGROUND ................................................................................................147
15.2
MANAGEMENT OF SEVERE HAEMORRHAGE IN THE COMMUNITY..........147
15.3
MANAGEMENT OF MAJOR PPH.....................................................................148
15.4
THE ROLE OF STAFF DEALING WITH PPH...................................................151
15.5
SECONDARY PPH ...........................................................................................152
15.6
BLOOD TRANSFUSION...................................................................................153
15.7
RECOMBINANT FACTOR VIIA ........................................................................156
15.8
INITIAL MANAGEMENT OF MASSIVE HAEMORRHAGE – ORGANISING THE
TEAM ................................................................................................................158
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15.1 BACKGROUND
Primary postpartum haemorrhage (PPH) loss of over 500 ml blood within 24 hours of delivery.
It occurs after approximately 1:10 births, but is not always clinically significant.
Major postpartum haemorrhage loss of over 1500 ml blood postpartum. It may occur
immediately, but occasionally does not become apparent for several hours. It arises after
approximately 1:500 births.
Secondary postpartum haemorrhage loss of over 500 ml blood between 24 hours and 6
weeks after delivery. It occurs after approximately 1:100 births.
The causes of postpartum haemorrhage may be remembered as - TTTT
• Tone
uterine
atony
• Trauma
genital trauma, including damage to vulva, vagina, cervix or uterus
• Tissue
retained
placenta
• Thrombin
coagulopathy
• Infection
secondary PPH may be caused by or associated with endometritis
Major PPH remains one of the commonest causes of maternal morbidity and mortality, so it
requires prompt recognition and effective management.
• be prepared to manage major PPH after any delivery
• liaise with colleagues
• use the major PPH drill
15.2 MANAGEMENT OF SEVERE HAEMORRHAGE IN THE COMMUNITY
When SEVERE bleeding occurs at HOME the midwife is sometimes contacted by telephone.
In these circumstances the midwife should:
1 Obtain details of the woman’s general condition, amount of blood loss, any associated
pain, and when she delivered.
2 Obtain details of her name, address, telephone number and GP.
3 Request an ambulance on 999 to admit to the consultant Unit.
4 Notify the GP and request attendance if it is felt necessary.
5 A midwife MAY be available to go to the house. Consider each situation individually on the
severity of the haemorrhage, the availability of supporting staff and the location of the
woman.
6 If a midwife goes to the home she should, if possible, take an infusion set, Hartmanns
Solution, a community bag and oxytocic drugs, i.e. ergometrine 0.5 mg.
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ACTION BY THE MIDWIFE IN THE HOME OR IN THE MATERNITY UNIT
a) Transfer the woman in an ambulance with a doctor and/or midwife.
b) A GP should be requested urgently.
c) Monitor the woman’s condition throughout – BP, pulse, respiration, pallor, blood loss, level
of consciousness. Do not give any oral fluids.
CONTINUE WITH FLOW CHART ON MANAGEMENT OF POST-PARTUM HAEMORRHAGE
15.3 MANAGEMENT OF MAJOR PPH
The major PPH drill (below) provides a guide to resuscitative measures that should be taken
when managing major primary or secondary PPH. In addition to the common initial steps, the
specific causes of PPH should be assessed in each individual and action taken accordingly.
Tone
• expel clot from the vagina and uterine cavity with fundal pressure
• bimanually compress the uterus
• IV ergometrine 500 mcg
Over 1500 ml loss and still bleeding?
• inform the anaesthetist and the Consultant Obstetrician
• consider IM carboprost 250 mcg every 15 minutes - maximum 8 doses (2 mg)
• consider 600 – 800 mcg rectal misoprostol
• transfer to theatre for EUA / laparotomy
• consider intra myometrial carboprost 250 mcg
• once bleeding has been controlled and the circulating volume restored, set up an infusion
of IV syntocinon 40 iu in 1000 ml normal saline for 4 hours. There is no evidence for a
reducing regimen.
• Administer high flow O2 at 8 litres per minute
Trauma
• apply pressure over the bleeding point if it is easily identified
• suture in the delivery room if the bleeding point is easily identified
• transfer to theatre if not
• examine the anus, vulva, vagina, cervix under direct vision
• manually explore the uterine cavity to exclude trauma or retained placental tissue
• consider
laparotomy
• if the uterus has been explored, give IV co amoxyclav 1.2 gm stat
if the uterus has been explored, set up an infusion of IV syntocinon 40 iu in 1000 ml normal
saline for 4 hours. There is no evidence for a reducing regimen
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Tissue
• IV Augmentin 1.2 gm
• manually remove placenta in the delivery room if epidural is dense enough
• manually remove placenta in theatre if additional analgesia is required
once bleeding has been controlled and the circulating volume restored, set up an infusion of
IV syntocinon 40 iu in 1000 ml normal saline for 4 hours. There is no evidence for a reducing
regimen.
Thrombin
Risk factors for the development of coagulopathy include pre-eclampsia (particularly HELLP
syndrome) and APH (particularly placental abruption). It may also complicate PPH due to
other causes (Tone, Tissue, Trauma). The diagnosis should be suspected when bleeding
continues despite the presence of an empty, well contracted uterus and in the absence of
genital trauma. Management (cryoprecipitate, FFP, platelets, rVIIa) will be determined on an
individualised basis after liaison with the on-call haematologist.
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MAJOR POSTPARTUM HAEMORRHAGE
1500 ml blood loss and still bleeding
HELP
Midwife SpR SHO Anaesthetist Anaesthetic Nurse Senior Midwife
Health Care Assistant Consultant Obstetrician
b
POSITION
rub-up contraction lie flat facial oxygen dynamap pulse oxymeter
b
IV ACCESS
2 x 16 (grey) gauge cannulae FBC clotting UE cross-match blood
colloid infusion under pressure blood transfusion
b
VE
empty bladder expel clot determine cause
Tissue
Trauma
Tone
Thrombin
retained placenta
genital trauma
uterine atony
abnormal clotting
↓
↓
↓
↓
analgesia
compress wound bimanual
liaise with
↓
↓ compression
haematologists
manual removal
analgesia
↓
↓ IV
ergometrine
repair
↓
IM carboprost or misoprostil
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15.4 THE ROLE OF STAFF DEALING WITH PPH
Resuscitation of women experiencing PPH is the joint responsibility of her attending midwife,
senior labour ward midwife, Obstetric SpR and SHO and the anaesthetist. Liaison between all
staff members is essential. Demarcation of roles in advance is often impractical, but the
following sections suggest areas in which each member of staff might be best employed:
Midwife
• call for help
• lie the woman flat
• rub up a contraction
• high flow oxygen @ 8L / minute
• administer ergometrine 500 mcg IV
• set up a colloid infusion
• record P, BP, SAO2 every 5 minutes
• record fluid in / out
• record administration of drugs
• support the family
Lead Midwife
• ensure all appropriate staff attending
• ensure blood products being retrieved
• liaise with SpR, anaesthetist and Consultant Obstetrician if necessary
Health Care Assistant / Support worker
• retrieve blood products from Blood Bank / Theatres
• support the family
SHO
• site two large bore venflons (16G or larger)
• FBC, clotting, UE, cross-match blood
• liaise with SpR, anaesthetist and blood bank
SpR **team leader**
• call for help
• bimanual
compression
• Foleys
catheter
• assess TTTT and initiate response specific to cause of haemorrhage
• estimate and record blood loss
• determine need for transfusion
• contact Consultant Obstetrician if blood loss over 1500 ml or theatre being considered
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Anaesthetist
• maintain the airway
• maintain
breathing
• maintain
circulation
• arterial blood gases
• estimate and record blood loss
• determine need for transfusion
• consider need for CVP
• liaise with Consultant Anaesthetist where appropriate
Anaesthetic nurse
• run fluid through
• get pressure bag
• get blood warmer
• get monitoring stack
15.5 SECONDARY
PPH
In the event of secondary PPH arising in a woman at home up to 6 weeks post partum,
ambulance transfer should be arranged for admission directly to Women’s Services rather
than A&E. MAU review is usually appropriate but transfer to the Delivery Suite may be
arranged directly if the woman is bleeding heavily.
When managing secondary PPH, bear in mind that infection is likely to complicate the clinical
picture. Retained products are common and may lead to both uterine atony and coagulopathy.
Initial resuscitation may follow the scheme set out in the Major PPH Drill. Assessment should
include abdominal palpation and speculum examination, at which time a high vaginal swab is
worthwhile. If the uterus is atonic and the cervical os is gaping, retained products are likely.
Abdominal ultrasound performed by a trained operator may show tissue in utero or delineate
an irregular cavity. A negative scan does not completely exclude retained products however.
Treatment with intravenous antibiotics is advisable before any attempt is made to empty the
uterine cavity:
• co amoxyclav 1.2 gm IV tds
Major haemorrhage may require evacuation of the uterus under anaesthetic without delay but
in a woman who is clinically stable, it is reasonable to delay uterine evacuation for up to 24
hours to allow the antibiotics to take effect.
Post-operative treatment for 5 days with 375 mg oral co amoxyclav is recommended.
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Evacuation of retained products of conception
Written consent should be obtained for examination under anaesthetic and evacuation of
retained products. The following risks should be documented, but balanced against the risks of
no intervention:
• infection
• trauma to uterus
• bleeding
• perineal breakdown and resuturing
The anaesthetist should be informed and will determine the form of analgesia to be used after
discussion with the patient.
Evacuation retained products should be by an experienced or supervised.. Digital examination
of the uterine cavity should first be attempted. Exploration of the cavity with a blunt curette or
ovard forceps may be required however.
Treatment with drugs such as ergometrine or rectal misoprostol at the end of the procedure
may be useful if the uterus is atonic but treatment is at the discretion of the obstetrician.
15.6 BLOOD
TRANSFUSION
The decision to transfuse blood or other blood products, the volume of transfusion and the
urgency required will be based upon several factors:
• estimated and measured blood loss to date
• ongoing
bleeding
• clinical
condition
• response to colloid / crystalloid
• intercurrent illness
• last recorded haemaglobin
A decision to use blood products should weigh the potential benefits against the potential
complications of transfusion, including:
• transfusion
reaction
• bactorial, viral or prion infection
• adult respiratory distress syndrome
The attending SpR or Consultant Obstetrician and the anaesthetist should discuss these
factors and the outcome of this discussion should be recorded in the patient’s notes.
If the use of FFP, cryoprecipitate or platelets is being considered, the SpR or anaesthetist
should liaise directly with the on-call haematologist and the Consultant Obstetrician should be
made aware of the situation.
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Urgency of blood requirement
The table below represents a reasonable response when dealing with PPH in a woman
weighing 60 kg at booking. Note that small women and women with pre-eclampsia are less
tolerant of blood loss than other women.
Estimated blood loss (ml) Degree of urgency
Request
over 1000, bleeding
Urgent (1 hour)
Urgent cross-match 4
controlled
units
over 1000, actively
Very Urgent (30 minutes)
Type-specific 6 units
bleeding
Over 2500
Emergency (15 minutes)
O Rh negative 2-4 units,
then Type-specific as
required
Transport of blood in an emergency
• If blood required urgently the lead midwife should ensure that a appropriately trained
member of staff is dispatched to retrieve it from the blood bank
• Between 0900 hrs – 1700 hrs either an appropriately trained member of staff or a porter
should be asked to retrieve the blood urgently.
• After 1700 hrs a porter must be asked to retrieve the blood urgently
• Blood products should be transported in the red box available
• All blood products collected must be used immediately and not stored on unit or in the red
box
Safety issues
• transfusion of each unit of blood should begin within 30 minutes of retrieval from the fridge
• transfusion of each unit of blood should be complete within 4 hours of issue
• blood warmers should be used
• unused blood should be returned to Blood Bank within 30 minutes, otherwise it is
discarded
The Blood Fridge
BLOOD MUST NOT BE STORED IN ANY OTHER FRIDGE OTHER THAN THE BLOOD
BANK FRIDGE
• the blood fridge is situated in Path Lab, Lower Ground Floor, CIC
• the blood fridge is situated at the end of the corridor leading to outpatients at WCH
Any blood removed from the fridge should be signed out
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More about O Rhesus negative blood
• ensure that a pre-transfusion specimen of blood for group and cross match has been
taken from the patient even when O Rhesus negative blood is going to be administered
• if you are considering giving a woman with red cell antibodies some O Rhesus negative
blood, inform blood transfusion because haemolytic reactions can occur
Refusal of blood products
• see Chapter 16
• the Consultant Obstetrician should be informed when any woman who will refuse blood
transfusion is admitted in labour
• labour should be managed routinely, by an experienced midwife, in the first instance
• if caesarean section is needed, this should be performed by the Consultant Obstetrician
wherever possible
• syntometrine should be given when the baby is delivered, with controlled cord traction and
guarding for the third stage. In the first hour after delivery, the midwife should not leave the
woman unattended
• if haemorrhage occurs, detection and resuscitation should be prompt. The threshold for
intervention should be lower than in other cases. Blood loss should be quantified as
carefully as possible throughout
• standard management should be commenced using the PPH drill but in addition the
Consultant Obstetrician, Consultant Anaesthetist and Consultant Haematologist should be
informed at an early stage
• colloid and crystalloid (but not Dextran) should be used in place of blood in the
resuscitation process
• In very exceptional circumstances it may be appropriate to discuss the use of recombinant
factor VIIa (rVIIa) with the haematologist as explained below. This expensive drug may
only be used as directed by the haematologist in exceptional circumstances.
• when bleeding continues, the prothrombin time should be checked. An attempt may be
made to correct this with vitamin K if abnormal, after discussion with the haematologist
Vitamin K Infusion
Abnormal prothrombin time ?
↓
Dilute 5 mg konakion MM in 50 ml 5% glucose
↓
up to 25mg in 24 hours
Slow IV bolus over 5 minutes
↓
Repeat prothrombin time after 3 hours
• early recourse to laparotomy, internal iliac artery ligation and subtotal or total hysterectomy
should be considered.
• post-operative recovery will normally be on the Intensive Care Unit and the use of
erythropoietin, parenteral iron, protein supplements and hyperbaric oxygen should be
considered in cases of severe anaemia
• the use of tranexamic acid, desmopressin and methylprednisolone should be considered if
the patient continues to bleed post-operatively
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Trust policy for the medical treatment of Jehovah’s Witnesses
The Trust’s general statement of policy in treating Jehovah’s Witnesses has been included in
these Guidelines as an Appendix. This deals with the legal issues of competence and
consent.
15.7 RECOMBINANT FACTOR VIIA
Recombinant factor VIIa may be a useful treatment in patients with severe haemorrhage
despite attempts to correct coagulopathy and optimal surgical management. It is only
appropriate to consider rFVIIa use when the following general points apply:
Severe haemorrhage from multiple sites particularly bleeding from large raw areas despite
attempting local measures to control.
Severe haemorrhage despite attempts to correct coagulopathy with fresh frozen plasma,
cryoprecipitate and platelets. In particular attempts to raise the fibrinogen level to >1g/l and
platelets >20x109/l should have been undertaken prior to rFVIIa use.
Continued brisk bleeding despite correction of coagulopathy and optimal surgical
management.
General management of patient is optimal – including correction of hypothermia.
For maximum benefit, rVIIa should be given prior to the onset of the complications associated
with massive transfusion. Do not use rFVIIa if overall outlook is so poor that arresting
haemorrhage is unlikely to improve outcome.
Specific indications for the use of rFVIIa
Surgical
Severe peri or post operative haemorrhage refractory to conventional
management
Coagulopathy
Non-surgical haemorrhage associated with coagulopathy refractory to
conventional managment
Obstetric
Severe obstetric haemorrhage requiring consideration of internal iliac artery
ligation, uterine artery embolisation or hysterectomy.
or
Severe obstetric haemorrhage in women refusing blood products, when
exsanguination appears possible.
Neonatal
Massive neonatal haemorrhage
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Specific contra-indications for the use of rFVIIa
rFVIIa may occasionally be associated with thrombosis. It should be used with caution if there
is evidence of established disseminated intravascular coagulation.
Authorisation and dose
The use of rFVIIa should be approved by the duty Consultant Haematologist. As many of
these patients are seriously ill early involvement of the duty ITU consultant is essential.
rFVIIa; NovoSeven 90ug/kg rounded up to the next whole vial (1.2 + 2.4mg vials), repeated at
3hrs if indicated. If there has been no response after 2 doses, further doses should not be
administered. To facilitate availability, a stock of rFVIIa will be held in hospital blood banks.
Assessment of response
Response should be assessed on clinical grounds, including reduction or cessation of
haemorrhage and the need for further blood product support pre/post rFVIIa administration.
Assessment of safety
A coagulation screen and D-Dimers should be checked immediately before and 15 minutes
after rFVIIa administration. All patients should undergo bilateral lower limb ultrasound to check
for DVT 3-5 days following rFVIIa administration
Audit
A central register of patients who receive rFVIIa is held and prospective audit of the protocol is
undertaken to assess the appropriateness and safety of rFVIIa use. The details of all patients
who receive rFVIIa as well as any comments about this protocol should be sent to Dr John
Hanley, Consultant Haematologist, RVI (Tel: 24170; email:
xxxx.xxxxxx@xxxx.xxx.xx).
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15.8
INITIAL MANAGEMENT OF MASSIVE HAEMORRHAGE –
ORGANISING THE TEAM
HEAD
• Check
AIRWAY
• Check
BREATHING
• Administer
OXYGEN
• Lie
FLAT
• Note time of relevant EVENTS
• Reassure
woman
(& partner)
ARMS
Check PULSE and BP
• Establish LARGE BORE IV ACCESS x2
• Check FBC, CLOTTING, X-MATCH 4-6 units
• Start FLUID RESUSCITATION (initially x2L
crystalloid)
• Give
DRUGS:
1. ERGOMETRINE 500microg IV/IM
2. SYNTOCINON IV INFUSION (10U/hour)
3. CARBOPROST or PGF2α [‘HEMABATE’]
250microg IM – repeat after 15mins (maximum
x 8 doses- if > 2 doses should consider moving
to operating theatre)
4. Consider MISOPROSTOL 800microg PR
UTERUS
START HERE - CALL FOR HELP (ensure adequate and appropriate)
• RUB-UP
CONTRACTION
• CO-ORDINATE:
o Helper 1 at ‘HEAD’
o Helpers 2 & 3 at ‘ARMS’
• IF BLADDER FULL or PALPABLE - CATHETERISE
• IF ATONY PERSISTS – APPLY BIMANUAL COMPRESSION
• REVIEW OTHER CAUSES – 4 ‘T’s (Tone, Trauma, Tissue, Thrombin)
• MOVE EARLY TO OPERATING THEATRE IF BLEEDING PERSISTS
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References:
Better blood transfusion – Appropriate use of blood. DoH National Guidance HSC 2002/009.
Better blood transfusion website WWW.DOH.GOV.UK/BLOOD/BBT.HTM
B-Lynch C
et al (1997) The B-Lynch surgical technique for the control of massive postpartum
haemorrhage: and alternative to hysterectomy? Five cases reported.
BJOG 104: 372-375.
Drife J (1997) Management of primary post partum haemorrhage.
BJOG 104: 275-277.
Ferguson JE, Bourgeois FJ (2000) B-Lynch suture for postpartum haemorrhage.
Obstet
Gynecol 95: 1020-1022.
Johanson R
et al (2001) Management of massive postpartum haemorrhage: use of a
hydrostatic balloon catheter to avoid laparotomy.
BJOG 108: 420-422.
Moscardo F
et al (2001) Successful treatment of severe intra abdominal bleeding associated
with disseminated intravascular coagulation using recombinant activated Factor VII.
Br J
Haematol 113: 174-176.
Sokolic V
et al (2002) Recombinant factor VIIa (rFVIIa) is effective at massive bleeding after
caesarean section -–a case report.
Coll Antropol 26: 155-157.
Zupancic SS
et al (2002) Successful use of recombinant factor VIIa for massive bleeding after
caesarean section due to HELLP syndrome.
Acta Haematol 108: 162-163.
Roger Neuberg & Kim Hinshaw - ALSO(UK) © – February 2005
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CHAPTER 16 - MANAGEMENT OF WOMEN REFUSING BLOOD
TRANSFUSION
16.1
BOOKING .........................................................................................................161
16.2
ANTENATAL CARE ..........................................................................................161
16.3
LABOUR ...........................................................................................................161
16.4
HAEMORRHAGE..............................................................................................161
16.5
POSTNATAL CARE..........................................................................................162
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16.1 BOOKING
1.
At the booking clinic all women are normally asked their religious beliefs. If a woman is a
Jehovah’s Witness, or it is felt that she is likely to refuse transfusion, she should be
asked for her views and these noted in the case notes.
2.
If she asks about the risk of refusing blood transfusion she should be given all relevant
information in a non-confrontational manner. She should be referred to a consultant
obstetrician for discussion.
16.2 ANTENATAL
CARE
3.
The woman’s blood group and antibody status should be checked during pregnancy in
the usual way. The haemoglobin and serum ferritin, if indicated, should be checked as
normal. There is no indication to routinely give haematinics.
4.
There is no extra reason to identify the placental site in the last trimester.
5. There are well-described procedures for elective surgery in those refusing blood
transfusion. Some people will donate blood before surgery for subsequent auto-
transfusion if necessary, though others consider that this too is forbidden by their
religion. Blood storage should not be suggested to pregnant women, as the amounts of
blood required to treat massive obstetric haemorrhage are far in excess of the amount
that could be donated during pregnancy
6. If any signification complication is noted during the antenatal period, the consultant
obstetrician must be informed.
16.3 LABOUR
7. The consultant obstetrician should be informed when a woman who will refuse blood
transfusion is admitted in labour. Consultants in other specialities need not be alerted
unless complications occur.
8.
The labour should be managed routinely by experienced staff.
9.
Oxytocics should be given when the baby is delivered. The woman should not be left
alone for an hour after delivery.
10. If Caesarean section is necessary it should be carried out by a consultant obstetrician if
possible.
11. When the mother is discharged from hospital she should be advised to report promptly if
she has any concerns about bleeding during the puerperium.
16.4 HAEMORRHAGE
12. The principle of management of haemorrhage in these cases is to avoid delay. Rapid
decision-making may be necessary, particularly with regard to surgical intervention.
13. If unusual bleeding occurs at any time during pregnancy, labour or the puerperium, the
Consultant Obstetrician should be informed and the standard management should be
commenced promptly. The threshold for intervention should be lower than in other
patients. Extra vigilance should be exercised to quantify any abnormal bleeding and to
detect complications, such as clotting abnormalities, as promptly as possible.
14. Consultants in other specialities, particularly anaesthetics and haematology, are normally
involved in the treatment of massive haemorrhage. When the patient is a woman who
has refused blood transfusion the consultant anaesthetist should be informed as soon as
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possible after abnormal bleeding has been detected. The consultant haematologist
should also be notified, even though the options for treatment may be severely limited.
15. Dextran should be avoided for fluid replacement because of its possible effects on
haemostasis. Intravenous crystalloid and artificial plasma expanders, such as
Haemocoel, should be used.
16. In cases of severe bleeding, Vitamin K should be given to the woman intravenously.
Other drugs which have been recommended include Desmopressin, Methylprednisolone
and Fibrinolytic Inhibitors, such as Aprotinin (Trasylol) and Tranexamic Acid. The advice
of the haematologist should be sought before considering the use of Heparin to combat
disseminated intravascular coagulation.
17. The woman should be kept fully informed about what is happening. Information must be
given in a professional way, ideally by someone she knows and trusts. If standard
treatment is not controlling the bleeding, she should be advised that blood transfusion is
strongly recommended. Any patient is entitled to change her mind about a previously
agreed treatment plan.
18. The doctor must be satisfied that the woman is not being subjected to pressure from
others. It is reasonable to ask the accompanying persons to leave the room for a while
so that the doctor (with a midwife or other colleague) can ask her whether she is making
her decision of her own free will.
19. If she maintains her refusal to accept blood or blood products, her wishes should be
respected. The legal position is that any adult patient (i.e. 18 years old or over) who has
the necessary mental capacity to do so, is entitled to refuse treatment, even if it is likely
that refusal will result in the patient’s death. No other person is legally able to consent to
treatment for that adult or to refuse treatment on that person’s behalf.
16.5 POSTNATAL
CARE
20. The staff must maintain a professional attitude. They must not lose the trust of the
patient or her partner as further decisions, i.e. about hysterectomy, may have to be
made.
21. If the woman survives the acute episode and is transferred to an intensive care unit, the
management there should include Erythropoetin, parenteral iron therapy and adequate
protein for haemoglobin synthesis.
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References:
Busuttil D, Copplestone A (1995), Management of Blood Loss in Jehovahs Witness – BMJ
311: 1115 – 1116
Department of Health 91996) – The Treatment of Obstetric Haemorrhage in women who
refuse blood transfusion. Report in Confidential Enquiries into Maternal Deaths in UK – 1991
– 1993, HMJO P 44 – 47
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CHAPTER 17 - THROMBOSIS AND THROMBOPROPHYLAXIS
17.1
CHECKLIST FOR WOMEN NEEDING THROMBOPROPHYLAXIS.................165
17.2
CAESAREAN SECTION IN WOMEN TAKING THERAPEUTIC DOSES OF
CLEXANE .........................................................................................................167
17.3
THROMBOPROPHYLAXIS FOR LABOUR ......................................................168
17.4
LABOUR IN WOMEN TAKING THERAPEUTIC DOSES OF CLEXANE ..........168
17.5
WARFARIN.......................................................................................................169
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17.1 CHECKLIST FOR WOMEN NEEDING THROMBOPROPHYLAXIS
On admission to the delivery suite in labour, the women’s risk status should be assessed and
written in the box on Page 2 of the yellow notes. If there are no risk factors on admission,
please write “none” in the “other” box on Page 2. (This enables all carers to see the
assessment has been done).
NB: For personal past history of VTE or thrombophilia see below. With family history use
clinical judgement e.g. DVT in an elderly relative following major surgery should not be
regarded as a risk factor, but DVT in a sister on oral contraception should be. If in doubt, ask
medical staff or include as a risk factor.
Following delivery please tick all boxes on Page 19 that are relevant. These together with any
risk factors identified on admission will determine whether thromboprophylaxis is required.
Again if there are no risk factors please write “none”.
1.
Thromboprophylaxis in Vaginal Deliveries
Patients with two or more risk factors will require thromboprophylaxis in the form of
Enoxaparin.
After delivery add the risk factors from the box on Page 19 of the yellow delivery notes and if
the patient has two or more risk factors (total from both page 2 and 19), give
thromboprophylaxis.
2.
Thromboprophylaxis for Caesarean section
Elective C/S: These patients should have thromboprophylaxis if one or more risk factors
present. See checklist on Page 2 and Page 19 for risk assessment.
Emergency C/S: All patients undergoing emergency Caesarean section should have
thromboprophylaxis.
Caesarean section in patients already taking prophylactic clexane
At least twelve hours should elapse between the administration of prophylactic clexane and
the use of regional anaesthesia. If elective caesarean section is being performed, the
morning’s clexane should be omitted and the patient should be fitted with compression
stockings. The ante natal dose of clexane should be administered after closure of the uterus
although it may be delayed for up to four hours on clinical grounds if requested by the
surgeon. Once daily prophylaxis will then usually be continued for six weeks postpartum. In
the event of an emergency caesarean, if clexane has been administered within twelve hours
of the surgery, general anaesthesia will usually be necessary.
3.
Personal past history of VTE and/or Thrombophilia
Ideally a plan should have been made antenatally for these patients. If not, these patients
should have thromboprophylaxis in the form of Enoxaparin injections for six weeks postnatally.
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DOSE OF ENOXAPARIN:
Body weight <50 kg
20 mg once daily s.c.
Body weight 50-90 kg
40 mg once daily s.c.
Body weight > 90 kg
40 mg twice daily s.c.
DURATION
Patients with two risk factors should have Enoxaparin until day 5 postnatal or discharge,
whichever earlier.
Patients with three or more risk factors should have Enoxaparin for at least three days if early
discharge or until day 5 if still an in-patient.
Patients with a past history of VTE and/or thrombophilia should have Enoxaparin for six weeks
postnatally or as otherwise determined by Consultant or Haematologist.
DOCUMENTATION
CAESAREAN SECTION OR INSTRUMENTAL DELIVERY:
Medical staff must ensure the post operative instructions (Page 17) are completed
immediately following the procedure.
Contraindications to clexane
Clexane (and other forms of heparin) should not be used in the following circumstances:
• previous systemic allergic reaction to any heparin
• abnormal liver function leading to deranged clotting
• abnormal renal function leading to deranged clotting
• thrombocytopenia with platelet count below 20 x 109 /l
When a woman in whom clexane is contraindicated needs caesarean section, compression
stockings should be fitted in addition to Flowtron or sequential compression stockings. These
may be obtained from Main Theatres. Pay careful attention to hydration post operatively.
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17.2 CAESAREAN SECTION IN WOMEN TAKING THERAPEUTIC DOSES
OF CLEXANE
Emergency caesarean section
If a woman has had a recent thromboembolism, she may require an emergency caesarean
section despite having recently taken a high dose of clexane (175 units /kg /day). Such
women are at an increased risk of intra operative and post partum haemorrhage. In these
circumstances:
• omit any further clexane due to be administered prior to or during surgery
• fit compression stockings
• site a large bore cannula
• check her full blood count, APTT and anti Xa assay
• cross match 4 units of blood
Inform:
• Consultant
Obstetrician
• Consultant
Anaesthetist
•
Haematologist on call
It is unlikely that regional anaesthesia will be available to the woman in these circumstances,
but the anaesthetist will determine this.
In the event of haemorrhage during or after surgery, standard measures should be taken but
close liaison with the on call haematologist is mandatory. Protamine may be given after
discussion with the on call haematologist. This will reverse approximately 90 % of the anti IIa
activity of the heparin but will only reverse about 60-85 % of its anti Xa activity.
Clexane should be reinstituted at the full therapeutic dose according to its previous schedule
or four hours after completion of the caesarean section, whichever is the later. The woman
should be encouraged to continue to wear her compression stockings for six weeks post
partum.
Elective caesarean section
If a woman taking therapeutic clexane is to have an elective caesarean, an individualised plan
of care will be available in her antenatal notes. For example, on the day of surgery:
• she may be commenced on an infusion of unfractionated heparin with dose adjustment
according to APTT assay, then have the infusion stopped shortly before surgery, or…
• she may simply have her clexane omitted on the day of surgery.
Compression stockings should be fitted and good hydration maintained.
The full therapeutic dose of clexane should be recommenced according to its previous
schedule or four hours after completion of the caesarean third stage, whichever is the later.
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17.3 THROMBOPROPHYLAXIS FOR LABOUR
Labour in women already on prophylactic doses of clexane
The obstetric notes will include a plan of action for management in labour. This will usually
involve fitting compression stockings on arrival and omitting any clexane due to be given
during labour. Therapy should be recommenced four hours after delivery or four hours after
removal of the epidural catheter, whichever is later. The subsequent planned duration of
therapy will be documented in the notes. It is not necessary to check the APTT in labour.
Induction of labour in women taking prophylactic doses of clexane
The principles outlined above apply. Clexane should be omitted on the first day of induction
and compression stockings fitted. Any clexane due to be given once labour has established
should also be omitted. Prophylactic clexane should be recommenced four hours after
delivery or four hours after removal of the epidural catheter, whichever is the later.
Epidural anaesthesia will not be available for at least twelve hours after the administration of a
prophylactic dose of clexane.
17.4 LABOUR IN WOMEN TAKING THERAPEUTIC DOSES OF CLEXANE
If a woman has had a recent thromboembolism, she may present in labour while taking higher
doses of clexane (175 units /kg /day). Such women are at an increased risk of intra partum
and post partum haemorrhage. In these circumstances:
• omit any further clexane due to be administered during labour
• fit compression stockings
• site a large bore cannula
• check her full blood count, APTT and anti Xa assay
• cross match 4 units of blood
Inform:
• Consultant
Obstetrician
• anaesthetist on call
• haematologist on call
It is unlikely that regional anaesthesia will be available to the woman in these circumstances,
but the anaesthetist will determine this.
In the event of haemorrhage, standard measures should be taken but close liaison with the on
call haematologist is mandatory. Protamine may be given after discussion with the on call
haematologist. This will reverse approximately 90 % of the anti IIa activity of the heparin but
will only reverse about 60-85 % of its anti Xa activity.
Clexane should be reinstituted at the full therapeutic dose four hours after completion of the
third stage of labour or four hours after removal of the epidural catheter, whichever is the later.
The woman should also be encouraged to continue to wear her compression stockings for 6
weeks post partum.
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Induction of labour in women taking therapeutic clexane
If a woman taking therapeutic doses of clexane is being induced, an individualised plan of
care will be available in her antenatal notes. For example:
• she may be commenced on an infusion of unfractionated heparin with dose adjustment
according to APTT assay, then have the infusion stopped when labour is established, or…
• she may be given a reduced dose of clexane (50 units /kg /day) during the initial stages of
the induction process then have her clexane omitted in active labour
• compression stockings should be fitted and careful attention paid to maintaining mobility
and good hydration
• the full therapeutic dose of clexane should be recommenced four hours after completion of
the third stage or four hours after removal of the epidural catheter, whichever is the later.
17.5 WARFARIN
Few women taking warfarin will attend in labour. If this does occur however, a large bore
cannula should be used to gain venous access, FBC and INR should be checked and
repeated twelve hourly, or more frequently in the event of haemorrhage, and four units of
blood should be cross-matched. Warfarin should be withheld from the onset of labour and until
six hours post delivery. Regional anaesthesia will not normally be offered to women taking
warfarin.
In addition to the Consultant Obstetrician, the Haematology Consultant must always be
contacted if a woman on warfarin attends Delivery Suite in labour. Treatment will depend upon
the INR and the presence or absence of bleeding, but all such women are at high risk of
bleeding. In general, the haematologist will recommend one or other of the following:
• vitamin K (iv preparations are preferred to oral preparations in labouring women)
• FFP
• prothrombin complex concentrate (Beriplex)
These should not be prescribed until a discussion has taken place with the haematologists.
Traumatic obstetric delivery should be avoided to safeguard the baby. All ventouse deliveries
and rotational forceps deliveries are contraindicated while gentle non-rotational forceps should
only be attempted if the fetal head lies in an occipito anterior position, at least 2 cm below the
ischial spines.
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References
Bates SM, Ginsberg JS (2002) How we manage venous thromboembolism during pregnancy.
Blood 100: 3470-3478.
Crowther MA
et al (2002) Mechanisms responsible for the failure of protamine to inactivate
low molecular weight heparin.
Br J Haematol 116: 178-186.
Ellison J, Walker ID, Greer IA (2000) Antenatal use of enoxaparin for prevention and
treatment of thromboebolism in pregnancy.
BJOG 107: 1116-1121.
Greer IA, Thompson AJ (2001) Thromboembolic disease in pregnancy and the puerperium:
acute management. RCOG Clinical Green Top Guidelines, RCOG Press, London, UK.
Hainer JW
et al (2002) Dosing in heavy weight / obese patients with the LMWH, clexane: a
pharmacokinetic study.
Thromb Haemost 87: 817-823.
Horlocker TT, Wedel DJ (1998) Neuraxial block and low molecular weight heparin: balancing
perioperative analgesia and thromboprophylaxis
. Regional Anaesthesia and Pain Medicine 23: 164-177.
Nelson-Piercy C (2004) Thromboprophylaxis during pregnancy, labour and after vaginal
delivery. RCOG Clinical Green Top Guidelines, RCOG Press, London, UK.
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CHAPTER 18 - CAESAREAN SECTION, VAGINAL BIRTH AFTER
CAESAREAN SECTION AND LAPAROTOMY
The guidelines presented in this section are compatible with the RCOG / NICE Guidelines on
Caesarean Section published in 2004. Hard copies of the RCOG NICE document are located
on the Delivery Suite.
18.1
ELECTIVE CAESAREAN SECTION.................................................................172
18.2
EMERGENCY CAESAREAN SECTION ...........................................................174
18.3
THE PROCEDURE ...........................................................................................176
18.4
ANALGESIA AFTER CAESAREAN SECTION .................................................179
18.5
CAESAREAN SECTION FOR PLACENTA PRAEVIA ACCRETA ....................180
18.6
CAESAREAN SECTION WITHOUT HEALTH INDICATIONS ..........................181
18.7
LAPAROTOMY .................................................................................................181
18.8
FEMALE STERILISATION................................................................................182
18.9
RECOVERY......................................................................................................182
18.10
VAGINAL BIRTH AFTER PREVIOUS CAESAREAN SECTION.......................183
18.11
PROPHYLACTIC ANTIBIOTICS FOR CAESAREAN SECTION ......................186
18.12
THROMBOPROPHYLAXIS IN PATIENTS RECEIVING SPINAL OR EPIDURAL
ANAESTHESIA .................................................................................................186
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18.1 ELECTIVE CAESAREAN SECTION
These guidelines are provided to ensure that this operation is carried out in as safe a manner
as possible.
Indications for an elective caesarean section
Elective caesarean may be performed for one or more of a number of different reasons, such
as:
• placental
praevia
• breech
presentation
• transverse or unstable lie
• previous caesarean section
• previous third degree tear after vaginal delivery
This is not an exhaustive list and the conditions listed are relative rather than absolute
indications for caesarean.
Booking an elective caesarean section
The decision to perform an elective caesarean is most commonly made or confirmed in
antenatal clinic at about 20 or 36 weeks gestation. It should always be made by the
Consultant Obstetrician.
There are 2 slots available on each caesarean section list. If the list is already fully booked
please discuss with Consultant Obstetrician.
Except where clinically otherwise indicated, elective caesareans should be booked to take
place no earlier than 39 +0 weeks gestation, based upon ultrasound dating.
The woman’s details should always be recorded in the planned delivery diary, including her
name, ID number, parity, gestation and the indication for caesarean.
In the Antenatal Clinic the woman should be given a patient information leaflet confirming the
date of her caesarean section.
Pre Op Fasting Guidelines
(See Chapter 19.6)
Consent for the operation
The clinician performing the caesarean section should obtain written consent on
NHS Consent
Form 2. The following should be discussed and clearly documented:
• the indication for the procedure
• the intended benefits
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• serious or frequently occurring potential complications, including complications that can
occur after vaginal birth but that are more likely after caesarean section, including:
• haemorrhage
• blood
transfusion
• possible requirement for return to theatre
• infection- wound infection or UTI
• thromboembolism
• visceral injury, notably bladder trauma
• cut to the baby (approximately a 2 % risk)
Women considering having a caesarean should be told that they are likely to have more
abdominal pain but less perineal pain than women giving birth vaginally. It may also be more
difficult to establish breast feeding after caesarean but once established, birth by caesarean
leads to no ongoing disadvantage. Finally, the average length of hospital stay is longer after
caesarean section than after vaginal birth.
The emphasis of this discussion will vary with the previous clinical history and present clinical
circumstances.
Consent for anaesthesia
The clinician booking a caesarean section and obtaining initial consent should explain that in
most cases, the operation is performed under regional anaesthesia. An anaesthetic review will
however be performed either in the pre operative assessment clinic or after the woman’s
admission to hospital, prior to her operation.
General anaesthesia is occasionally required, for example:
• major placenta praevia
• anatomical abnormalities of the lumbar spine
Booking elective caesarean sections from the antenatal ward
Occasionally the decision to perform an elective caesarean section is made while a woman is
resident on the antenatal ward. In this case, the responsibilities of the medical staff remain
unchanged. The midwife allocated to the woman’s care will liaise with delivery suite to ensure
that the workload diary is completed appropriately.
Organising the elective caesarean section list
Elective caesarean sections should be performed within the confines of existing elective
caesarean section lists unless these are fully booked. If they are fully booked the best time to
add extra cases must be discussed with the Anaesthetic Department secretary and Lead
Midwife on Delivery Suite.
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Trust Policy on Consent
The Trust Policy on Consent is available on the Trust Intranet at
http://nww.northcumbriahealth.nhs.uk/link.asp?pid=4272&id=11638
18.2 EMERGENCY CAESAREAN SECTION
All emergency caesareans should be graded by the attending Obstetrician in conjunction with
the attending midwife according to the scheme below. The grade should be recorded clearly
on the partogram and on operative delivery note. In each case, the form of anaesthesia will be
determined by the Anaesthetist after direct discussion with the attending Obstetrician:
Grade 1 - Emergency
Immediate threat to the life of mother or fetus
This may occur because of a number of reasons. The following list is not exhaustive:
♦ cord
prolapse
♦ uterine
rupture
♦ pH
≤ 7.20 on fetal scalp sampling
♦ ante partum haemorrhage with evidence of maternal or fetal compromise
♦ pathological CTG when FBS is inappropriate such as profound prolonged bradycardia
If the decision to delivery time is > 30 minutes please generate an adverse incident form.
Grade 2 - Urgent Maternal or fetal compromise not immediately life threatening
This may occur because of a number of reasons. The following list is not exhaustive:
♦ failed instrumental delivery
♦ ante partum haemorrhage without evidence of maternal or fetal compromise
♦ pathological CTG when FBS would be appropriate but is not possible (but see above)
♦ failure to progress in the second stage of labour
If the decision to delivery time is > 60 minutes please generate an adverse incident form
Grade 3 - Scheduled
No maternal or fetal compromise but needs early delivery
This may occur because of a number of reasons. The following list is not exhaustive:
♦ abnormal biophysical score with a normal CTG (care individualised by fetal medicine)
♦ failure to progress in the first stage of labour with no evidence of fetal compromise
♦ malpresentation in labour with no evidence of fetal compromise
Grade 4 - Elective Delivery Time to suit women and staff
This encompasses elective procedures.
Decision
In most cases, the decision to perform an emergency caesarean will be made by the
Specialist Registrar after discussion with the Consultant on call and the time of the decision
should be recorded clearly on the partogram. Only in very urgent cases should the decision
not be discussed with the Consultant first. In such cases another member of the Delivery Suite
staff may be delegated to contact the on call Consultant.
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Consent
In most cases there will be sufficient time to obtain informed consent in the manner described
above. Verbal consent alone is only acceptable in exceptional circumstances.
Transfer to theatre
This can take place as soon as the decision has been made to perform the caesarean section
and the various personnel have been informed. For some women with an epidural (WCH),
the anaesthetist may prefer to top up the epidural in the delivery room prior to transfer to
theatre.
Responsibilities of personnel
Surgeon
responsible for obtaining consent and performing the operation.
The surgeon should confirm the swab count.
Assistant
role is to ensure good venous access is gained prior to the
procedure, to obtain full blood count, to group and save serum or
cross match blood where needed and to assist at the procedure.
Scrub nurse
responsible for the operative equipment, for the instrument
count, for the swab count and for maintaining the sterility of the
operative field.
Midwife
responsible for the woman’s care up to the point of surgery, for
the safety and conduct of the birth partner, for care of the infant
unless the paediatrician is present. The midwife is also
responsible for the care of the placenta after delivery - for the
cord gas analysis, taking of appropriate Rhesus bloods and
possible histology referral.
Support worker
aids the scrub nurse with the operative count, providing her / him
with equipment, swabs and sutures as required.
Anaesthetist
responsible for the anaesthetic and the immediate medical care
of woman. She / he will determine when the procedure may
commence.
Anaesthetic nurse/ODA
assists the anaesthetist in providing adequate anaesthesia for
the procedure. Is responsible for setting up adequate patient
monitoring for the anaesthetic, and drawing up relevant
anaesthetic drugs.
Paediatrician
responsible for the immediate resuscitation of the baby where
requested to attend. It is her / his responsibility to check that the
resuscitaire and its associated equipment is working properly.
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18.3
THE
PROCEDURE
This Guideline does not aim to be prescriptive in determining operative technique. Good
practice points follow however.
Bladder drainage
• emergency caesarean section…
• elective caesarean section with regional block…
• insert a 14 French gauge Foley
This may be passed into the bladder at any time before the caesarean – often after insertion
of the spinal anaesthetic, but occasionally in the delivery room following vaginal assessment.
For an elective caesarean under GA, in-out catheterisation alone prior to surgery is
acceptable but please ensure that such women pass urine within 6 hours of completion of the
procedure. If not, fit a Foley.
Foley catheters should be left
in situ for at least 16 hours.
Lateral tilt
Lateral 15o tilt is recommended as it reduces the incidence of maternal hypotension. It is of no
proven benefit to the baby.
Skin incision
Most caesareans are performed through a transverse abdominal incision 3 cm above the
symphysis pubis even if a longitudinal uterine incision is being contemplated. An alternative
approach should only be used by appropriately trained surgeons where clinically indicated.
Abdominal entry
Joel Cohen’s approach is the preferred option in most cases with blunt dissection of the
tissues, using scissors rather than a knife if any sharp dissection is required.
Uterine incision
Usually the uterine incision will be transverse in the lower segment. After uterine entry in the
midline, blunt lateral dissection is encouraged if the lower segment is well formed as this may
reduce blood loss. If necessary, this incision may be extended by sharp proximal dissection
from one angle to leave a J-shaped scar.
Classical incision of the uterus comprises a longitudinal incision in the upper segment. This
may be contemplated by an appropriately experienced surgeon in the management of anterior
placenta praevia or in the presence of a fibroid uterus.
A vertical De Lee incision in the lower segment may be employed in the delivery of a fetus
under 28 weeks gestation. Consultant help should be available in such cases. If this incision is
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extended into the upper uterine segment to facilitate delivery, it should be regarded as a
classical caesarean section scar in future pregnancies.
Care should be taken on final entry into the uterine cavity in order to avoid fetal injury. The use
of Bonney scissers or similar rather than a scalpel is acceptable for final entry for this reason.
Difficulty in delivering the head
This can occur because of cephalic impaction or in contrast, because of poor cephalic
engagement. The former may be remedied by an additional assistant pushing the fetal head
up via the vagina but if this is undertaken, a 5 day course of co amoxyclav or an alternative
broad spectrum antibiotic should then be prescribed. In the latter case, direct application of
Neville Barnes, Wrigley’s forceps may help.
Delivery of the placenta
Manual removal of the placenta at caesarean section may lead to postnatal endometritis and
so should be avoided.
Use of blunt needles
Blunt needles are less likely to perforate the operator’s, the assistant’s and the scrub nurse’s
gloves than atraumatic needles. As a result, they significantly reduce needle stick injuries and
should be considered by all surgeons performing caesarean sections. With practice they are
no more difficult to use than sharp needles.
Uterine closure
There is some evidence that single layer uterine closure is associated with less intra operative
blood loss than two layer closure.
Bladder injury
If the bladder wall in incised or torn during caesarean section. Repair will be with 2-0 vicryl,
employing a 2 layer closure. Free drainage of the bladder should be maintained for a
minimum of 10 days with a Foley catheter post operatively and follow up arranged.
The peritoneum
Non closure of visceral and parietal peritoneum shortens operative time and may be
associated with more rapid reperitonisation of the abdomen than suturing. If peritoneal closure
is thought necessary, the choice of technique lies with the surgeon.
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Use of drains
The surgeon should consider leaving a drain
in situ when:
• intraoperative haemostasis has been difficult to achieve
• the uterine incision has been extended at delivery
• the woman has had multiple previous caesarean sections
• previous births have been attended by massive haemorrhage
• the indication for caesarean section was placenta praevia or abruption
Drains should be removed at the discretion of the surgeon, usually 12 – 24 hours after
significant drainage has ceased.
Fat closure
Routine closure of subcutaneous fat is not recommended. There is some evidence to suggest
however that when this layer is greater than 2 cm in depth, closure of the subcutaneous tissue
with an absorbable suture reduces the risk of wound infection.
Skin closure
The suture material for skin closure will usually be prolene or vicryl. Staples reduce glove
perforation and needle stick injuries but they have significant cost implications.
Antibiotic prophylaxis
The likelihood of infection rises up to 20 fold after caesarean birth compared to vaginal birth,
and may complicate as many as 10 % of caesarean wounds unless intra operative antibiotics
are administered. To reduce infection rates a single dose of co amoxyclav 1.2 gm IV is known
to be effective. This is given following delivery of the baby. It is the responsibility of the
Obstetrician to ensure antibiotics are presented and given. This will usually be carried out by
the Anaesthetist. For penicillin allergic women, an alternative broad spectrum antibiotic, e.g.
Gentamicin 5mg/kg + Clindamycin 600 mg, should be given.
Thromboembolic prophylaxis
Patients undergoing caesarean section are at high risk of developing postnatal venous
thrombosis. The first dose should be given within 6 hours of surgery then continued for at
least five days on a once daily basis. Longer periods of prophylaxis should be considered for
women who remain immobile beyond this time. The dose varies with the patient’s weight at
initial booking in pregnancy:
• at 8 am each morning, give…
• 3500 iu for women who are 60-100 kg
• 50 iu / kg for women below 60 kg or above 100 kg.
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Birth partner
One birth partner may accompany a woman in theatre when she is having a caesarean under
regional block. Interpreters should be allowed into theatre in addition to the birth partner. The
birth partner should be shown where to change into appropriate scrubs and shoes. If the birth
partner causes disruption, he / she should be escorted from theatre by the attending midwife.
Skin to skin
Early skin-to-skin contact should be encouraged between mother and baby. This does not
need to be delayed until the caesarean has been completed. To achieve this take the
following steps:
•
maternal discussion and consent
•
the abdominal drape is fastened to an IV stand each side of the woman.
•
baby born caesarean section
•
cord clamped and cut by surgeon
•
midwife wearing gown and gloves lifts baby from table
•
midwife places baby skin to skin under drapes
• dries
baby
•
clean towel placed on top of baby
18.4 ANALGESIA AFTER CAESAREAN SECTION
Prescribed by anaesthetist. Reviewed as indicated (minimum daily) by obstetric medical ward
staff for side-effects or complications please.
1.
MORPHINE Usually needed for first 24 hours only
IM 10-15 mg 3 hourly PRN (+ antiemetic prescribed).
2.
DICLOFENAC
i.
100 mg PR on completion of Caesarean
ii.
50 mg oral tds for up to 5 days. First dose after first solid food.
CAUTION: Contradinications include history of GI bleeding, anticoagulant treatment and
sensitivity to other NSAIDs including aspirin.
3.
PARACETAMOL
1 Gm 5 hourly for up to 5 days. First dose as soon as oral fluids are tolerated.
4. CODEINE
30 – 60 mg 4 hourly PRN up to 240 mg / day.
Regular codeine should be given to patients in whom diclofenac is contraindicated.
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18.5 CAESAREAN SECTION FOR PLACENTA PRAEVIA ACCRETA
Placenta praevia accreta is an indication to consider transfer to tertiary care.
Consent and plan of action
When placenta praevia accreta is suspected in a pregnant woman, possible clinical sequelae
should be made apparent to her at an early stage and a clear plan of management set out in
the medical records. Wherever possible, this plan of management should be conveyed to all
Obstetric and Anaesthetic Consultants in the hospital in advance of the likely date for delivery.
Issues to be discussed with the woman should include those relating to:
♦ surgical
management
♦ anaesthetic
management
♦ haematological
interventions
♦ paediatric
interventions
Anaesthetic considerations
♦ general
anaesthesia
♦ central venous access
♦ arterial
line
♦ flowtron boots and TED stockings
Withhold enzaparin until six hours after the procedure then give 50 iu/kg booking weight for a
minimum of 5 days.
Additional theatre equipment
♦ B Lynch suture
♦ hysterectomy tray
♦ Cooke
catheter
♦ cystoscope and imaging
♦ pigtail stents and size 4 and 6 infant feeding tubes
Surgery
♦ Consultant Obstetrician and Gynaecologist should perform the procedure
♦ try to ascertain the availability of a Consultant Vascular Surgeon before surgery
commences
♦ low transverse incision is adequate in most cases
♦ placental invasion of the bladder should be assessed before the uterus is incised
♦ inspection of the uterus may help to determining the best site for uterine incision
♦ classical incision over the uterine fundus may be required
♦ B-Lynch and cervical compression sutures may reduce bleeding after placental delivery
If haemostasis is then inadequate proceed to hysterectomy. Note that early recourse to
hysterectomy and bladder repair should be considered if the placenta accreta involves the
bladder.
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Blood availability
A Consultant Haematologist should be aware that the operation is being carried out. It would
be reasonable to request:
♦ cross matched blood in theatre
♦ FFP in theatre
♦ recombinant factor VIIa in theatre
Liaison with Paediatrician
This is essential as many of these procedures are carried out before full term and the neonate
may suffer blood loss during surgery, prior to birth.
18.6 CAESAREAN SECTION WITHOUT HEALTH INDICATIONS
When a caesarean section is requested by a woman without clear physical or psychological
health indications, there is no compulsion upon the part of the Consultant Obstetrician to
accede to the request. The relative risks and benefits of the procedure must be discussed with
the patient and a decision reached based upon the merits of each case separately.
Where doubt remains regarding the optimal management of any particular case, the opinion of
a second Consultant Obstetrician or other professional such as a Consultant Psychiatrist may
be helpful.
18.7 LAPAROTOMY
Laparotomy on the Delivery Suite is a relatively uncommon event, but when it occurs, it
usually follows prior caesarean section. The commonest indications are wound pathology and
suspicion of intra abdominal haemorrhage.
Wound pathology
The decision to return to theatre because of wound dehiscence, wound haematoma or
retention of a drain should be taken in the final instance by a consultant obstetrician.
Intra operatively, the sheath should always be examined to ensure its integrity. The skin will
normally be closed with non occlusive sutures such as staples. Broad spectrum antibiotics
should be given intra and post operatively.
Haemorrhage
Please refer to the massive haemorrhage guidelines in Section 15. The Consultant
Obstetrician and a senior Anaesthetist must be informed and involved early in the
resuscitation of any woman suspected of having intra abdominal haemorrhage after
caesarean section. Before return to theatre is contemplated, attention must be made to
adequate resuscitation, including:
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• venous
access
•
intra-vascular volume expansion
•
cross-matching of blood
Consent must be obtained for all conceivable eventualities including hysterectomy.
In the unusual event of massive secondary post partum haemorrhage requiring laparotomy,
main theatres may be a more suitable venue for surgery than the obstetric theatres because
of the increased likelihood of hysterectomy or the presence of intra abdominal adhesions.
18.8 FEMALE
STERILISATION
Occasionally, a woman contemplating an elective caesarean section asks will request
sterilisation. It is the RCOG’s recommendation that:
• discussion should take place at least one week prior to the caesarean section
• consent should be obtained at that time
• consent should be confirmed immediately prior to the caesarean section
• the procedure should be described as irreversible
• the failure rate should be quoted as 1 in 200 or possibly worse
• failure could result in ectopic pregnancy
In the event of a baby being born with an unexpected complication (eg requiring resuscitation,
a suspicion of Down’s Syndrome), the sterilisation should be deferred.
Sterilisation should not be offered to women having an emergency caesarean section. It
should only be considered if a clear plan has been made in the antenatal period for
sterilisation.
18.9 RECOVERY
CIC - Post-operative recovery is the joint responsibility of the midwife and the anaesthetic
nurse.
WCH – Post-operative recovery is the responsibility of the recovery nurse.
The following observations should be made:
• pulse every 5 minutes, extending to 20 minutes depending upon clinical
condition
• BP
every 5 minutes, extending to 20 minutes depending upon clinical
condition
• SAO2 continuously
• block every 15 minutes
• lochia within 30 minutes of delivery, thereafter depending upon clinical
condition
• wound within 30 minutes of delivery, thereafter depending upon clinical
condition
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Medical review
Women with a medical condition pre dating delivery that may affect recovery should have
formal obstetric medical review within 1 hour. Such conditions include:
• pre-eclampsia
• placenta
praevia
• diabetes
• renal
failure
• cardiac
disease
Immediate obstetric medical review must be sought when any of the following arise:
• the woman feels or looks unwell
• systolic BP falls below 100 mm Hg
• maternal pulse rises to over 120 bpm
• significant clots of blood are passed vaginally
• a persistent ooze of blood is noted vaginally
• bleeding is noted from the wound
• maternal temperature is recorded ≥ 38 oC
• haematuria is noted
• oliguria is noted – under 30 ml in the first hour on the recovery area
• analgesia appears to be inadequate
Feeding the patient post operative delivery
There is no clear consensus regarding the safe time interval that should pass between the
end of a caesarean section and the resumption of oral diet. Little hard evidence is available to
guide practice although starvation for more than one day after surgery appears to slow
recovery and may interfere with breast feeding.
18.10 VAGINAL BIRTH AFTER PREVIOUS CAESAREAN SECTION
These notes have been adapted from the Regional Guideline and the RCOG/NICE
Caesarean Section Guidelines dealing with trial of vaginal birth after previous lower segment
caesarean section. The measures suggested here should be applied to all labours after a
previous caesarean, even if successful vaginal delivery has subsequently been achieved.
Management of individual cases may vary and should be discussed with senior staff.
1. Antenatal
Counselling
♦ Review old notes pertinent to the previous LSCS – directly or by correspondence
with other hospital
♦ Initial discussion with patient (review the labour that resulted in LSCS; discuss
outcomes for VBAC – offer appropriate information leaflet, plan VBAC for majority)
♦ Record final agreed plan for delivery in antenatal record (Senior Staff should be
involved in the decision) this may be nearer term
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2.
Induction of Labour Cases in VBAC
The risk of uterine rupture is increased in induced labour compared to spontaneous labour
and this increase in more marked if both prostaglandin (PG) and oxytocin are used.
Therefore:
1 Induction of labour should only be undertaken for valid obstetric indications. Offer
membrane sweep at 41 weeks
2 The preferred method of induction is by forewater amniotomy (ARM) with judicious
oxytocin augmentation (as per unit guideline)
3 PG priming should be kept to a minimum – an experienced obstetrician (at least SpR
status) should assess the need for PG. If PG is necessary, one 3mg tablet should only be
used and must be administered on the delivery suite. Further doses of PG should only be
used after discussion with Senior Staff
4 Oxytocin infusion should not be started for 6 hours following PG prostoglandin
administration. The maximum dose should not exceed 32 mU.min.
3.
Management of Labour for VBAC
Management of labour
The midwife should provide normal midwifery care throughout labour. The medical staff must
however ensure that they are kept informed of progress in labour. Labouring women with a
previous caesarean section should be reviewed on the twice daily ward round as a minimum
and at the request of the attending midwife whenever clinical concern arises.
At the onset of labour:
♦ site a large bore venflon
♦ check FBS, Group & Save
♦ perform a vaginal examination
♦ inform the SpR
First stage of labour:
♦ monitor the fetal heart and contractions throughout labour on the CTG
♦ perform a vaginal examination 4 hourly up to 7cm dilatation
♦ perform a vaginal examination 2 hourly after 7 cm dilatation
♦ expect 1 cm dilatation per hour in established labour
♦ inform the SpR if progress is slower than this
Syntocinon augmentation
:
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This may only be sanctioned by the SpR or Consultant. Before syntocinon is prescribed, a full
medical review should take place first including:
♦ history of contractions noted to be less than 4 in 10 minutes
♦ abdominal palpation performed to confirm that the fetal head is engaged in the pelvis
♦ vaginal examination should be performed to confirm position and station
Augmentation may then take place following the guidelines detailed in Section 4.
Second stage of labour, if there are no maternal or fetal concerns:
♦ allow up to 1.5 hours for passive descent of the fetal head if this appears to be required
♦ allow up to 1.0 hours of active pushing
♦ obtain medical review if delivery is not then imminent
If instrumental delivery is then required:
♦ the delivery should be attended by the SpR or consultant
♦ if the vertex is higher than 1 cm below the ischial spines, consider delivery in theatre
♦ if transfer to theatre is required, the Consultant Obstetrician on call should be informed
Please also refer to the Guidelines Section 6 dealing with instrumental delivery.
Third stage of labour:
♦ the integrity of the uterine scar does not need to be checked routinely
♦ if clinically indicated, the integrity of uterine scar should be formally checked in theatre
♦ the Consultant on call should be informed if third stage abnormalities arise
4. Special
Points
Length of Labour (VBAC)
Inform Senior Staff when appropriate oxytocin
augmentation does not correct progress of
labour
Intrauterine Pressure (IUP) monitoring routine use of IUP does not improve obstetric
outcome or reduce scar rupture rate
Scar & dehiscence & rupture
incidence 0.5% (this is not increased by careful
augmentation)
Symptoms and Signs of impending rupture
include:
Rising maternal pulse rate (MAY BE THE ONLY
SIGN
Acute fetal heart rate abnormalities
Sudden cessation of contractions
Continuous scar pain (still occurs with epidural)
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Vaginal bleeding
Haematuria
Retraction of presenting part (on vaginal
assessment)
ALL STAFF must be aware of these symptoms
and signs
They may occur for the first time in the
SECOND
STAGE
Subsequent Labours
The scar rupture rate
increases with each
subsequent labour: women with previous LSCS
should have
ALL subsequent labours managed as described above
18.11 PROPHYLACTIC ANTIBIOTICS FOR CAESAREAN SECTION
Augmentin 1.2 g intravenously after delivery of the baby. It is the responsibility of the
Obstetrician to ensure that the antibiotics are prescribed and given. This will usually be carried
out by the Anaesthetist.
In cases where an allergy to Augmentin is known or suspected, than Clindamycin 900 mgs
should be substituted.
18.12 THROMBOPROPHYLAXIS IN PATIENTS RECEIVING SPINAL OR
EPIDURAL ANAESTHESIA
The objective is to try to ensure that spinal/epidural block, or removal of epidural
catheters, is performed when anticoagulant activity is at its lowest.
Low Molecular Weight Heparin (LMWH) e.g. Clexane, can safely be given the evening before
surgery before 2000 hours.
No patient should be given LMWH or Standard heparin (SH) on the day of surgery before
going to theatre if there is any likelihood of them receiving a spinal or epidural block. The
anaesthetist will take responsibility for ensuring that appropriate thromboprophylaxis is given.
If a patient is given LMWH or SH by mistake, the anaesthetist MUST be informed before the
patient goes into the anaesthetic room.
Thromboprophylaxis is not contraindicated in patients with epidural catheters in place, such
catheters, however, need to be removed at a safe time. This should be:-
Standard Heparin
4 hours after a dose with an interval of at least 1 hour before the
next dose.
LMWH
12 hours after a dose with an interval of at least 4 hours before the
next dose.
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Heparin infusions, epidural catheters should not be removed whilst a patient is on IV Heparin.
Do not remove an epidural catheter from a patient who has abnormal bleeding or abnormal
laboratory tests of coagulation.
If a patient has been on standard Heparin for more than four days, regular platelet counts are
recommended, the platelet count MUST be checked before an epidural catheter is removed in
these patients.
If there is any uncertainty consult a senior anaesthetist.
If a patient who has had a spinal or epidural block, or has an epidural catheter in-situ,
develops any new focal neurological signs, especially numbness or weakness in the legs or
perineum, faecal or urinary incontinence, or severe back or sciatic pain, notify a senior
anaesthetist as soon as possible.
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References
Chua S
et al (1990) Augmentation of labour: does internal tocography result in better obstetric
outcome than external tocography?
Obstet Gynecol 76: 164-167.
Hema KR, Johanson R (2001) Techniques for performing caesarean section
. Best Practice
Res Clin Obstet Gynaecol 15: 17-47.
Induction of labour – NICE Inherited Guideline D (2001). National Institute for Clinical
Excellence, London.
Caesarean Section Clinical Guideline (2004) Published on behalf of RCOG and NICE, RCOG
Press, London , UK.
James D (2001) Caesarean section for fetal distress.
BMJ 322: 1317-1317.
Lydon-Rochelle M
et al (2001) Risk of uterine rupture during labor among women with a prior
Cesarean section.
NEJM 345: 3-8.
Mackenzie IZ, Cooke I (2001) Prospective 12 month study of 30 minute decision to delivery
intervals for “emergency” caesarean section.
BMJ 322: 1334-1335
Mangesi L, Hofmeyr GJ (2002) early compared with delayed oral fluids and food after
caesarean section.
The Cochrane Database of Systematic Reviews Issue 3: CD003516.
Smaill F, Hofmeyr GJ (2003) Antibiotic prophylaxis for caesarean section. Cochrane Review.
In: The Cochrane Library Issue 4.
Steer PJ, Carter MC, Beard RW (1984) Normal levels of active contraction area in
spontaneous labour.
BJOG 91: 211.
Thomas J, Paranjothy S (2001) for the Royal College of Obstetricians and Gynaecologists
Clinical Effectiveness Support Unit. National Sentinel Caesarean Section Audit Report. RCOG
Press.
Tuffnell DJ, Wilkinson K, Beresford N (2001) Interval between decision and delivery by
caesarean section - are current standards achievable? Observational case series.
BMJ 322:1330-1333.
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CHAPTER 19 - ANALGESIA AND ANAESTHESIA
19.1
PRE DELIVERY ASSESSMENT OF ANALGESIC / ANAESTHETIC PROBLEMS
..........................................................................................................................190
19.2
PRESENCE AND ROLE OF ANAESTHETIST .................................................191
19.3
EPIDURAL ISSUES ..........................................................................................191
19.4
URGENT ANAESTHESIA.................................................................................196
19.5
PHARMACOLOGICAL PAIN RELIEF IN LABOUR...........................................196
19.6
PREOPERATIVE FASTING GUIDELINES .......................................................197
19.7
FEEDING IN LABOUR......................................................................................197
19.8
ANTACID REGIMEN.........................................................................................197
19.9
WOMEN ON ANTITHROMBOTIC TREATMENT..............................................198
19.10
COMPLICATIONS OF THE THIRD STAGE .....................................................198
19.11
POST-OPERATIVE CARE................................................................................199
19.12
TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION (TENS) .............200
19.13
THE ADMINISTRATION OF HOMEOPATHIC OR HERBAL SUBSTANCES ...200
19.14
FAILED INTUBATION DRILL............................................................................200
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19.1 PRE DELIVERY ASSESSMENT OF ANALGESIC / ANAESTHETIC
PROBLEMS
Women who may need specialised anaesthetic input should be referred during the antenatal
period. Conditions precipitating referral include:
• heart disease, especially congenital heart disease
• severe respiratory disease
• musculo-skeletal problems (e.g.) spina bifida or a history of muscle disease
• previous back surgery or problems (e.g.) injuries or disc prolapse
• neurological problems (e.g.) intracerebral conditions or multiple sclerosis
• clotting problems or those on long-term anticoagulant therapy
• previous anaesthetic problems (e.g.) difficult intubation or suxamethonium apnoea
• previous complaint relating to anaesthetic management
• structural facial or neck abnormalities
• previous major head or neck surgery
• BMI of 45 kg/m2 or greater at booking
The above list is not intended to be complete. There may be women who fall outside the
above categories in whom anaesthetic assessment may be beneficial.
CIC
- Alert Dr Stride / Dr Kennedy or Consultant Anaesthetist on call at CIC, who will
either review immediately or suggest an appropriate course of action if this is not
possible.
WCH - Complete anaesthetic referral form
Women should be referred in (or before) pregnancy to a cardiologist
• Patients with significant or symptomatic valvular disease
• Significant maternal congenital heart disease
• Cardiomyopathy
• Ischaemic heart disease
• Left ventricular dysfunction from any cause
• Pulmonary
hypertension
• Family history of young sudden cardiac death e.g. HOCMs,
prolonged QTs, etc
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19.2 PRESENCE AND ROLE OF ANAESTHETIST
Urgent anaesthetic assistance should be summoned in cases of collapse, cardiac arrest. The
emergency call system (extension 2222) may be used. The duty Anaesthetist should also be
informed in the following circumstances:
• severe
pre-eclampsia
• breech presentation on admission and when pushing
• multiple pregnancy on admission and when pushing
• trial of forceps when vaginal delivery seems uncertain
• admission of woman with cardiac disease or sickle cell disease
• admission of woman who would refuse blood transfusion
• request for epidural analgesia (WCH only)
• caesarean section required
• where specified in the case notes
• BMI >40 (this may have implications for the theatre table)
19.3 EPIDURAL ISSUES (WCH ONLY)
GUIDELINES FOR THE MANAGEMENT OF EPIDURALS
Aim
The aim of modern epidural analgesia during labour is to safely provide a significant degree of
analgesia labour in those labouring women who wish to employ this technique, following
suitable discussion with the midwifery and anaesthetic staff.
Request For Epidural
The midwife responsible for the patient should contact the duty anaesthetist when an epidural
is requested and will be expected to provide the following information:
♦ Name of patient
♦ Stage and progression of labour
♦ Any other relevant information to the placement of an epidural, such as a history of pre-
eclampsia, the diastolic blood pressure or problems with previous regional techniques.
Consent For Epidural
Following discussion with the anaesthetist of the major recognised possible complications,
explicit verbal consent for the epidural
must always be given by the patient in the presence of
a midwife and recorded legibly in the clinical notes by the anaesthetist. Evidence-based
complications to be explicitly mentioned:
1. The potential low risk for incomplete epidural block or even failure to site.
2. The potential low risk of post-dural puncture headache.
3. Likely hypotension and the need for an IV cannula.
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CONDITIONS AND EQUIPMENT REQUIRED
1.
The patient must have a large bore intravenous cannula, securely sited prior to epidural
placement and an IV infusion of crystalloid initiated.
2.
Following aseptic placement of the epidural, a test dose (usually 3ml of 1% lignocaine) is
employed to exclude sub-dural siting of the catheter.
3.
Establishment of the epidural analgesia is subsequently achieved using a slow bolus of
the standard pre-prepared mix of
0.1% marcaine and 2 mcg/ml fentanyl.
4.
The epidural should be dressed with a transparent dressing so that the catheter skin
puncture site is visible.
5.
Following establishment of epidural analgesia with the bolus dose, an epidural infusion is
to commenced using the pre-prepared epidural mix and the automated delivery system
at a prescribed rate by the anaesthetist (an infusion rate range is to be prescribed e.g.
6-
15 mls per hour).
6.
The midwifery staff may vary the infusion rate within this range according to level of block
tested to fine touch, i.e. gentle stroking of skin if inadequate or too high (in increments of
+ 3 mls per hour).
7.
The anaesthetist will complete the epidural record form.
8.
The midwifery staff are responsible for ensuring that the pre-prepared epidural 250 ml
mix bags are available on the labour ward and loading them into the automated delivery
system (presently an IMED) when prescribed.
9.
Once prescribed the midwifery staff may connect the infusion system to the epidural and
commence the infusion. Immediate observations should be recorded as outlined on the
epidural regime form.
10. Once the epidural is sited the patient
must not be managed for any significant time
either flat on her back or in a non-tilted position when semi-reclined.
Either of these
positions can lead to rapid cardiovascular collapse and poor placental perfusion dur to
either caval or aortic compression.
OBSERVATIONS REQUIRED
1.
Every 30 minutes;
♦ Ask if pain relief is adequate, record pulse and blood pressure.
♦ Record height of block to fine touch (gentle stroking of skin) in relation to sternal
notch, xiphisternum and umbilicus.
♦ Can the bladder be felt? If a large bladder is palpable and no desire to void urine,
consider placement of urinary catheter.
2.
Every 60 minutes also record maternal temperature.
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REMOVAL OF EPIDURAL CATHETER
1.
Cease epidural infusion and remove the catheter only after the placenta is completely
delivered and any necessary suturing completed.
2.
Having taken off the dressings, the catheter is removed by gently pulling on the catheter
until fully withdrawn and checking that the catheter is complete. If this does not work
then repeat the manoeuvre after leaning the patient forward to mimic the insertion
position. If this fails contact the duty anaesthetist
3.
After catheter removal place a small sterile dressing over the insertion site.
POTENTIAL PROBLEMS AND THEIR MANAGEMENT
♦
INADEQUATE PAIN RELIEF
1.
Is the level of block adequate? Increase infusion rate by 3ml/hr and reassess in 15
minutes.
2.
Is there a “missed segment”? Turn the patient onto the side of the painful region (or
sit if perineal pain), increase infusion rate and reassess in 15 minutes.
3.
If neither of these work contact the duty anaesthetist.
4.
Top up boluses are only to be given by anaesthetist staff.
♦
HYPOTENSION (systolic BP <90mmhg)
1.
Ensure that the patient is not lying or sitting without a significant degree of lateral tilt.
2.
If sitting, then move the patient to a more horizontal left lateral position and increase
intravenous fluid infusion rate until BP acceptable.
3.
If there is no rapid improvement in BP:
i.
Give high flow Oxygen by face mask (12-15 litres per minute)
ii.
Increase the Intravenous fluid rate to maximal.
iii.
Switch off epidural infusion having recorded level of sensory block to ice.
iv.
Turn patient to left lateral.
v.
Contact Anaesthetist and Obstetric SHO to confirm/exclude potential causes of
low BP.
vi.
Assume major haemorrhage in process until medical staff in attendance.
♦
HIGH EPIDURAL BLOCK
1.
If level of block to fine touch (gentle stroking of skin) reaches xiphisternum cease
infusion for 30 minutes and then re-commence at lower rate.
2.
If patient describes difficulty in breathing, stop infusion and contact duty anaesthetic
staff immediately.
♦
DURAL TAP
1.
If a dural tap is achieved during placement of an epidural DO NOT consider
converting to a spinal catheter regime and withdraw needle and catheter.
2.
Attempt to re-site epidural one space above and direct catheter away from likely
dural puncture site.
3.
Continue with labour management as normal.
4.
Inform patient and record event in clinical notes at time of puncture.
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5.
Ensure anaesthetic consultant review within 24-hours or earlier if symptomatic
headache develops.
♦
POST DURAL PUNCTURE HEADACHE
1.
If a headache is severe within 5 days after placement or attempted placement of an
epidural and not responding to simple analgesia contact the duty anaesthetist to
review the patient and confirm diagnosis.
2.
Re-commence IV infusion of N/Saline (1 litre, 12 hourly), encourage oral fluids and
initiate strict supine bed rest for a minimum of 24 hours and oral analgesics.
3.
If symptoms persist overnight or more than 24 hours then the duty consultant
anaesthetist should consider more invasive treatment, such as an epidural blood
patch.
HYPOTENSION IN POST SPINAL/EPIDURAL PATIENTS
• For patients with an
Epidural, the prescription is on the front of the pain prescription chart
and is valid once the anaesthetist has signed for the Epidural.
• For patients with a
Spinal the prescription should be written up on the patient’s white
prescription chart before discharge to the ward.
• The anaesthetist will determine the lowest acceptable systolic BP and will record this on
the prescription chart.
• Ephedrine 30 mgs in 1 ml is diluted with 9 mls of Normal Saline in a 10 ml syringe (=3
mgs/ml)
• Administer the Ephedrine via a venflon where an IVI is fast running.
A IF TARGET SYSTOLIC BP FALLS BY 10-15 mmHg
1. Give oxygen 35% via a mask for 3 litres via a nasal sponge.
2. Check wound and drain for excessive bleeding. (Hypovolaemia).
3. Check for urine output or excessive dryness of patients mouth (Hypovolaemia)
4. Administer 500 mls Gelofusin/Haemacel stat (intravenous colloid)
5. Re-check BP after 3 – 5 minutes
6. If the target systolic remains below the acceptable level ADMINISTER EPHEDRINE
3MGS IV
7. Re-check the BP in 3-5 minutes
8. Repeat the 3 mg bolus every 3-5 minutes until the acceptable level has been
reached (limit the number of doses to 3, failure to reach the target after 3 doses
must be reported to medical staff).
9. Inform medical staff IMMEDIATELY if there are signs of excessive bleeding.
B IF TARGET SYSTOLIC BP FALLS BY MORE THAN 15 mmHg OR BELOW 80 mmHg
1. Give oxygen 35% via a mask or 3 litres via a nasal sponge
2. Check wound and drain for excessive bleeding (Hypovolaemia)
3. Check urine output and excessive dry mouth (Hypovolaemia)
4. Administer 500 mls Gelofusin/Haemaccel stat.
5. Administer Ephedrine 6 mgs IV once only
6. Inform medical staff IMMEDIATELY who will then administer further 6 mg boluses if
necessary
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• Once the target systolic has been achieved the patients BP must be checked
every 15 minutes for 1 hour.
• If the BP falls again revert A or B according to the patients BP and inform
medical staff immediately.
• NB Persistent Hypotension or repeated episodes may be due to Hypovolaemia
and bleeding must be ruled out.
MANAGEMENT OF SECOND STAGE WITH EPIDURAL DEPARTMENTAL POLICY
1.
If a routine v.e. is done and the patient is found to be fully dilated follow the chart below:-
PRIMIP WITHOUT
WITH OXYTOCIN FULLY
MULTIP FULLY DILATED
OXYTOCIN FULLY DILATED
DILATED
WAIT 1
HOUR
V.E.
PUSH
PROGRESS
NO
PUSH
PROGRESS
30 MINUTES
EXPECTANT
OXYTOCIN
1 HOUR
MANAGEMENT
1 HOUR
UPTO
THEN PUSH
1
HOUR
ACTION
SEE 4
2.
Do not alter the epidural infusion rate (unless pushing inhibited by a dense block).
3.
If an operative delivery is required, the management of the epidural should be discussed
with the consultant anaesthetist on duty.
4. Reminders:
A) After one hour pushing (primips) or 30 minutes pushing (multips), the registrar on
duty should assess the patient with a view to delivery.
B) Deliveries from anything other than the occipito anterior position should be
discussed with the consultant on duty beforehand.
C) Consider risk factors
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19.4 URGENT
ANAESTHESIA
In an emergency situation the Obstetric SpR or Consultant and the Consultant Anaesthetist on
call Consultant should agree the urgency with which the patient should be delivered by means
of a direct conversation. The final decision in relation to mode of anaesthesia rests with the
Anaesthetist. The Obstetric Anaesthetists Association suggest:
Grade 1
Immediate threat to life of woman or fetus
Grade 2
Maternal or fetal compromise not immediately life threatening
Grade 3
Needing early delivery but no immediate maternal or fetal compromise
Grade 4
At a time to suit patient and team
This grading system has now been adopted by the NC Delivery Suites.
19.5 PHARMACOLOGICAL PAIN RELIEF IN LABOUR
Pharmacological methods can be offered. However labour pain can only be partially relieved
by the use of analgesic drugs such as Diamorphine, morphine, Meptid, pethidine and entonox.
Women need access to good information in order to be able to make informed choice and this
should ideally take place in the antenatal period as pharmacological methods of pain relief all
have side-effects.
Attendance at antenatal classes is also associated with a reduction in the use of
pharmacological pain relief during labour. Available options can be discussed addressing
personal experiences and circumstances, which may influence the woman’s ability to cope.
However, if this has not happened and been recorded, the midwife on the labour ward must
take responsibility for offering it.
Changes to medicine legislation, which came into effect in August 2000, clarify the law in
relation to the supply or administration of medicines under Patient Group Directions (PGD’s).
Guidance supplied by the relevant government health department regarding implementation of
PGD’s should be followed. Patient Group Direction is a written instruction for the supply or
administration of medicines to groups of patients/clients who may not be individually identified
before presentation for treatment. PGD’s are drawn up locally by doctors or, if appropriate, by
dentists, pharmacists or other health professionals. Midwives currently offer the following
Pethidine, Diamorphine, Meptid and Entonox covered by Patient Group Directions for North
Cumbria Acute Hospital NHS Trust (2005). All registered midwives must adhere to the
principles for safe administration of medicines and should exercise their professional
accountability in the best interests of their patients (NMC 2004).
Whilst Pethidine maybe the most commonly used opiate in labour, there are doubts about it’s
effectiveness, and concerns about its maternal, fetal and neonatal side effect. These include
depression of neonatal respiration, lassitude, drowsiness and depression of reflexes including
impaired suckling. Side effects to the mother include nausea, vomiting, dizziness, dysphoria
and drowsiness. There appears to be benefits to the use of diamorphine as the opiate in
labour as they found a higher level of pain relief, less maternal vomiting and a lower incidence
of low one minute Apgar scores. As yet no convincing research to show that alternative
opioids are better.
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19.6 PREOPERATIVE FASTING GUIDELINES
To avoid aspiration of gastric contents, patients should not eat or drink immediately prior to
anaesthesia wherever possible.
The following North Cumbria Trust guidelines follow AAGBI recommendations, which are
based on the American Society of Anaesthesiologists (ASA) guidelines. There is little
evidence regarding the effects of solid food ingested preoperatively but the fasting time for
clear fluids is evidence based.
•
6 hours for solid food
•
2 hours for clear non-particulate and non carbonated fluids
•
2 hours for chewing gum
Oral pre-medication can be taken with up to 75 ml of water 1 hour before anaesthesia.
Patients who have had bowel preparation and breastfeeding mothers may require intravenous
fluids prior to surgery.
Adults having emergency surgery after trauma may have delayed gastric emptying,. The
guidelines above should be followed for non-life threatening conditions but an empty stomach
cannot be guaranteed.
19.7 FEEDING IN LABOUR
The following guidelines are suggested:
• light snacks such as ‘toast’ may be taken in early uncomplicated labour and…
• fluids may be taken throughout labour but..
• if surgical intervention is anticipated, fluid and snacks should be stopped…
• and substituted with small sips of water only
• the amount of fluid taken should be recorded and fizzy drinks should not be given
• oral medicines are always permitted if necessary
Women awaiting a scheduled operation should have no solid food for 6 hours and no
liquid for two hours before the procedure. These restrictions should also be applied to
women awaiting an event that has a high chance of leading to anaesthesia. The
Anaesthetist will make a judgement if there is a need to empty the stomach.
19.8 ANTACID
REGIMEN
Women at risk of operative intervention should be given 150 mg Ranitidine orally every 6
hours during labour after appropriate explanation of its purpose if problems are anticipated.
Oral Ranitidine is prescribed for mothers undergoing elective caesarean section. The
Anaesthetist’s reply / instructions should be brought to the attention of the Anaesthetist on
call.
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19.9 WOMEN ON ANTITHROMBOTIC TREATMENT
The Consultant Anaesthetists have agreed to provide regional analgesia to women on anti
thrombotic treatment as follows:
Aspirin
Epidural is not contraindicated when a woman is taking 75 mg aspirin daily.
Warfarin
Clotting status (INR, APTT and platelet count) should be checked. In general terms however,
an epidural is contra-indicated.
Low Molecular Weight Heparin
The introduction of low molecular weight heparin to clinical practice poses a potential problem
when regional analgesia is requested.
For patients on once daily prophylactic enoxaparin regional blocks should only be considered
once twelve hours have elapsed since the last dose. No further heparin should be given
during labour and the heparin should not be restarted until at least four hours after the
epidural catheter has been removed or after the spinal was performed.
For patients on treatment doses of enoxaparin, 24 hours must elapse before instituting a
regional block and again a four hour window post block should ensue before restarting the
heparin.
A high index of suspicion should be maintained when regional blocks are given to patients on
low molecular weight heparin. Back pain, new onset weakness and numbness are the cardinal
features of an epidural haematoma. If an epidural haematoma occurs, rapid investigation with
MRI scanning and neurosurgical evacuation within 8 hours are essential.
19.10 COMPLICATIONS OF THE THIRD STAGE
Retained Placenta
In the presence of effective epidural analgesia, an immediate attempt at manual removal of
the placenta is permissible in the delivery room by the SpR. If this is ineffective arrangements
should be made to transfer to theatre.
Massive haemorrhage
The Consultant Obstetrician and senior anaesthetic staff should be made aware of massive
primary PPH (immediate blood loss >1500ml and continuing to bleed) whether or not
operative intervention is required. Please refer to Chapter 15.
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19.11 POST-OPERATIVE CARE
All women undergoing a surgical procedure need time to recover and this will usually take
place recovery area adjacent to the Obstetric Theatres. A handover will take place from the
Anaesthetist to an appropriately trained midwife / recovery nurse, giving details of the
operation, anaesthetic and current status of the patient. Instructions will be given for the
management of pain, intravenous fluids and other ongoing therapy.
Electronic monitoring of pulse, blood pressure and pulse oximetry should be used together
with clinical observations. Constant attendance is mandatory until the mother is fully awake
after general anaesthesia or a regional block has regressed below T10.
Pain relief
A rectal diclofenac suppository may be offered to women with no contraindications to NSAID
therapy.
Most women will need to stay in recovery (at WCH) or on Delivery Suite (at CIC) for a
minimum of 2 hours. The block height to cold spray should be at or below T10 (umbilicus)
before discharge to a ward. Prior to transfer out, both obstetric and anaesthetic factors need
to be considered. The patient should be fully awake with stable vital signs, effective analgesia
in place and with no signs of haemorrhage. Instructions regarding analgesia must be relayed
to the postnatal ward. If pain relief is inadequate, contact the anaesthetist. There may be a
simple cause (e.g.) full bladder.
If a woman wishes she can have small volumes of non-carbonated oral fluids 2 hours after her
operation.
After 2 hours oral medicines can be restarted or instituted.
After 6 hours a light diet can be allowed.
Bladder management
In women who have had a caesarean section under general anaesthesia an indwelling
catheter is commonly used but is not mandatory. If spontaneous voiding does not ensue
management is along the same lines as after normal delivery. If caesarean has been
performed under regional anaesthesia the catheter should be removed when the urine is clear
and at least 500 mls has been passed.
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19.12 TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION (TENS)
MECHANISM OF ACTION
TENS applies controlled mild electrical stimulation to the skin via a series of electrodes.
Stimulating peripheral nerve endings in this way seems to inhibit the transmission of painful
impulses at the dorsal horn of the spinal column and activates some of the descending pain
inhibiting systems above the spinal level.
Exclusion criteria
• women with pacemakers
• where continuous monitoring required
• TENS cannot be used in the birthing pool
Women planning to use TENS in labour should make their own arrangements to hire the
apparatus. Midwives should have no involvement applying the TENS, although there is no
evidence that TENS can harm the mother or baby.
19.13
THE ADMINISTRATION OF HOMEOPATHIC OR HERBAL
SUBSTANCES
Homeopathic and herbal medicines
are subject to the licensing provisions of the Medicines
Act 1968. Those already on the market when that Act became operative however (which
applies to most of these substances now available) received product licences without any
evaluation of their efficacy, safety or quality. You should ensure that you are familiar with the
requirements of Rule 41 (1) (The Midwife’s Rules and Code of Practice, 1998) in relation to
the administration of medicines. It is necessary, however to respect the right of individuals to
self-administer substances of their choice. The use of such substances should always be
recorded on the partogram.
19.14 FAILED INTUBATION DRILL
This is included overleaf.
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Failed Intubation Drill
1.
abandon attempts to intubate quickly and implement drill
2.
inform surgeon of difficulty and call for anaesthetic help
mask
ventilation
ventilation
transtracheal jet
failed
LMA or
ventilation via
intubation
Combitube
impossible
impossible
cricothyroidotomy
mask
ventilation
possible
ventilate with
allow patient
cricoid pressure
to awaken
non emergency
fetal
or
maternal
consider
emergency
awake intubation
or
regional anaesthesia
consider LMA
or
complete
continue mask ventilation
the
surgery
continue cricoid pressure
LMA = Laryngeal Mask Airway
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observation.
Midwifery 9: 136-145.
Priest J, Rosser J (1991) Pethidine - a shot in the dark.
MIDIRS Midwifery Digest 1:373-375
Roberts RB, Shirley MA (1976) The obstetrician’s role in reducing the risk of aspiration
pneumonitis. With particular reference to the use of oral antacids.
Am J Obstet Gynecol 124: 611-617.
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CHAPTER 20 - INFECTION
20.1
INTRAPARTUM FEVER ...................................................................................204
20.2
GROUP B STREPTOCOCCAL INFECTION.....................................................204
20.3
HERPES SIMPLEX...........................................................................................207
20.4
HIV ....................................................................................................................208
20.5
HEPATITIS B AND HEPATITIS C.....................................................................210
20.6
ANTIBIOTIC PROPHYLAXIS FOR CAESAREAN SECTION ...........................211
20.7
ANTIBIOTIC PROPHYLAXIS FOR INFECTIVE ENDOCARDITIS....................211
20.8
MRSA................................................................................................................212
20.9
INFECTION CONTROL ....................................................................................212
20.10
INFECTION CONTROL FOR HIV/ HBV / HCV POSITIVE WOMEN ................213
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20.1 INTRAPARTUM
FEVER
Women in labour whose temperature is recorded as 37.8 oC or more on two occasions, 20
minutes apart, should be investigated to identify a possible source of infection.
• blood
cultures
• MSU
• HVS and LVS where possible
• additional swabs / cultures depending upon clinical circumstances
The organisms most likely to infect the genital tract and cause pyrexia in labour are
β haemolytic streptococci and
E Coli. A triple regimen of IV antibiotics should therefore be
given to labouring women with sustained pyrexia:
• amoxicillin
• cefuroxime
• metronidazole
If therapy is to be continued orally after delivery of the baby, co-amoxiclav should be given as
a single agent or change according to the culture and sensitivity results if available.
Allergy to Penicillin
• If gastroinstestinal symptoms only proceed with penicillin
• If history of anaphylaxis or rash after penicillins or cephalosporins use clindamycin 900
mgs IV 8 hourly, changing to 300 mgs orally qds when delivered and apyrexial. Continue
with oral therapy until fully apyrexial for 48 hours
Clyndamycin does not give gram neg cover i.e. E Coli may need to use something like
gentamicin and change as soon as sensitives are available.
Seek microbiological advice if patient collapsed or septicaemic.
The paediatricians should be informed and the baby reviewed if the babies condition causes
concern at any time.
20.2 GROUP B STREPTOCOCCAL INFECTION
Background
Early onset Group B streptococcal (GBS) sepsis occurs at a rate of 0.5 – 1.5 per 1000 live
births. Between 5 and 10 % of affected babies will die as a result of the infection, while others
survive with significant neurological impairment. Predicting which babies are likely to develop
the disease is difficult however, because although around 25 % of women are colonised with
GBS, less than 1 % of their babies become infected.
Although US based studies have shown that intrapartum antibiotic prophylaxis (IAP) given to
women with risk factors for GBS infection is effective in preventing neonatal disease, there is
currently insufficient evidence to recommend routine screening for all pregnant women. This is
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partly due to the fact that the sensitivity of a single vaginal swab taken during pregnancy in
detecting GBS is under 50 %. Only a combination of lower vaginal and rectal swabs using
selective microbiological media can raise this sensitivity to over 90 %. Even where optimal
swabs are used, the positive and negative predictive values of swabs taken more than 5
weeks before delivery are low. This means that you cannot rely on swabs taken under current
clinical practices to exclude the possibility of maternal intrapartum carriage.
Recommendations
Bearing the above notes in mind, current recommended practice is based upon the RCOG
Green Top Guidelines (2004) and PHLS recommendations (2003), supplemented with data
from CDCP Guidelines (MMWR 2002).
Women
In the following cases, triple antibiotics detailed in Section 20.1 should be given as this will
cover possible GBS infection:
• chorioamnionitis diagnosed or suspected clinically
• fever in labour of unknown cause
In the absence of fever or suspected chorioamnionitis, women should be offered penicillin
prophylaxis for GBS in the following situations:
• GBS infection in a previous baby
• GBS detected in the vagina at any time in the current pregnancy
• GBS detected in the urine at any time in the current pregnancy
Penicillin prophylaxis for GBS should also be considered in the following situations, but is not
mandatory:
• preterm labour with absent or intact membranes
• prolonged rupture of the membranes over 18 hours at term, once established in labour
The following data may be used to counsel women:
Rupture of membranes over 18 hours at term
Risk of early onset GBS infection in the neonate without IAP is 1:476
Risk of early onset GBS infection in the neonate with IAP is 1:8351
Prematurity under 37 weeks
Risk of early onset GBS infection in the neonate without IAP is 1:400
Risk of early onset GBS infection in the neonate with IAP is 1:2186
Prematurity under 35 weeks
Risk of early onset GBS infection in the neonate without IAP is 1:286
Risk of early onset GBS infection in the neonate with IAP is 1:1253
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In the absence of infection the onset of labour of should be awaited before giving IAP, this
includes pre-labour, SROM in patients who are GBS carriers.
Babies
Some babies will always require antibiotics (inform the paediatrician):
• babies of any gestation with signs of sepsis
• multiple births where one baby is diagnosed with GBS sepsis
Consider giving antibiotics to the following babies (inform the paediatrician or SCBU):
• babies born to mothers who should have received IAP but who did not
• babies born to mothers who received the first dose of antibiotics under 4 hours before birth
• preterm babies whose mothers received IAP
• babies born to mothers who required broad spectrum antibiotics in labour
• prolonged rupture of the membranes (see below)
• need for active resuscitation at birth
• antenatal concerns about fetal wellbeing
Treatment regimens
There is a small risk of adverse reaction to any antibiotic. In addition, the absolute risk to
babies with some risk factors such as prolonged rupture of the membranes at term is small.
Therefore a decision
not to treat may sometimes be made. In this respect, maternal wishes
should be sought and a contemporaneous entry made in the case notes.
The aim is to achieve at least 4 hours of IAP prior to delivery, so the first dose should be given
as soon as labour commences:
• Benxylpenicillin 3 g (5 mU) iv initially, then 1.5 g every 4 hours until delivery, or…
• Clindamycin 900 mg iv every 8 hours until delivery if allergic to penicillin
Prolonged rupture of the membranes
Almost all babies with early onset GBS sepsis develop signs of infection before 24 hours of
age. Women who give birth having had prolonged rupture of the membranes should be
advised that a paediatrician will want to review the baby after delivery, whether or not IAP was
administered. Observations will then be carried out for at least 24 hours, even if antibiotics are
not prescribed. In the presence of other risk factors for sepsis, the paediatrician may wish to
take blood cultures from baby and to give a 48 hour course of iv antibiotics.
The birthing pool
Women carrying GBS or whose babies are at increased risk of developing GBS may still use
the birthing pool for labour and delivery
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Monitoring in labour
Women whose babies are at risk of developing GBS do not always require continuous
monitoring. The decision to use a CTG should be based on other clinical factors such as
prematurity or fever.
20.3 HERPES
SIMPLEX
Primary infection in the first and second trimester
Management should be in line with the woman’s clinical condition and may involve the use of
oral or intravenous Acyclovir in standard doses. In general, the pregnancy may be managed
expectantly and vaginal delivery anticipated. Prophylactic Acyclovir in the last 4 weeks of
pregnancy may reduce the risk of recurrence at term and hence the need for caesarean
section.
Primary infection in the third trimester
Caesarean section should be considered for all women having a first attack of herpes simplex
in the third trimester, particularly those with symptoms within 6 weeks of delivery because the
risk of viral shedding in labour is high. If vaginal delivery is unavoidable then both mother and
baby should be treated with Acyclovir.
Recurrent herpes
For all women with recurrent genital herpes the mode of delivery in the event of a recurrent
infection during labour should be discussed antenatally and recorded in the notes.
When a woman with a history of recurrent genital herpes simplex present to the Delivery Suite
in labour, speculum examination should be performed
• to identify active lesions
• to identify whether the membranes have ruptured
In the absence of active lesions at that time, vaginal delivery should be safe
Traditionally in the presence of active lesions, caesarean section has been recommended to
guard against neonatal opthalmia. The risk of this is small however and the 2004 NICE
Caesarean Section Guideline advises that caesarean section should not now be offered for
this indication unless as part of a research study.
There appears to be no benefit in obtaining specimens for culture before or after delivery in
women with recurrent herpes, whether lesions are present or not.
Please keep the paediatricians informed in these cases.
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20.4 HIV
Duty of care and confidentiality
All doctors and midwives have a duty to provide necessary care. A refusal to care for a mother
with HIV infection is professionally unacceptable.
A woman’s right to confidentiality is not altered by her HIV status. Before discussing her
circumstances with members of other services her consent must be obtained. Those cases
where breach of confidentiality are regarded as necessary are exceptional and midwives
should take advice from their Midwifery Manager.
The following advice has been obtained from RCOG Guidelines dealing with the management
of HIV in pregnancy.
Delivery by elective caesarean section
Delivery by elective caesarean section near term is recommended for HIV positive women:
• the anti viral regimen will be documented in the woman’s management plan
• this should be prescribed on the Trust drug Kardex on the night before delivery
• the prescribed regimen should be commenced before surgery, as stipulated in the notes
o Zidovudine infusion 2 mg/kg current body weight for the first hour, then…
o continuous infusion of 1 mg/kg per hour until birth of the baby
• oral medication should be resumed after delivery
The benefit of caesarean is clear for women with a detectable plasma viral load. One meta
analysis demonstrated a vertical transmission rate 50% lower in women who underwent
caesarean before labour or rupture of the membranes. In subsequent work, women with a
plasma viral load of <1000 around delivery were found to have a vertical transmission rate of 1
% when using anti retroviral therapy compared to 9.8% if no treatment was being used.
Multivariate analysis showed transmission to be lower with anti retroviral therapy, caesarean
section, greater birth weight and higher CD4 count. These data suggest that caesarean still
reduces transmission when plasma viral load is <1000 copies/ml. Whether caesarean reduces
transmission in women whose plasma viral load is undetectable using current assays (<50
copies/ml), particularly in those taking HAART, is unknown.
Some studies have suggested that postoperative complications are increased in HIV infected
women compared with uninfected women, with complication rates related to the level of
immunocompromise. In one RCT however, elective caesarean was not associated with
increased morbidity or mortality compared with vaginal delivery.
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Management of women presenting with HIV in labour, prior to full antenatal
assessment
When a woman presents with HIV late in pregnancy or in labour, rapid immunological and
virological assessment may not be possible. Such women should be treated with anti
retrovirals including zidovudine, lamivudine and nevirapine (HAART regimen). Zidovudine
should be given intravenously intrapartum and HAART should be continued postpartum until
the results of the CD4 T-lymphocyte count and plasma viral load are known.
Vaginal delivery
A woman with no detectable plasma viraemia (<50 copies/ml) and who has an uncomplicated
obstetric history may express a preference for vaginal delivery, particularly if she is planning to
return to a country with limited medical resources in the future:
• experienced personnel should care for the woman
• staff should wear theatre scrubs, impervious fluid repellent gowns and plastic aprons
• masks, goggles or visors and double gloves should be worn for the birth
• open footwear should be avoided – Wellingtons are best for the birth
• protective clothing should be removed and hands washed before leaving the clinical area
• all contaminated waste should be disposed of as clinical waste
• blood spillages should be treated with 10 000 ppm chlorine
• an anti viral regimen should be give, usually:
o Zidovudine infusion 2 mg/kg current body weight for 1 hour, then…
o Zidovudine 1 mg/kg per hour continuous infusion until the baby’s birth
• fetal scalp electrodes should not be used
• fetal blood sampling should not be performed
• amniotomy should be delayed
Emergency caesarean should be performed for the usual indications, particularly aiming to
avoid a traumatic vaginal delivery and prolonged rupture of membranes. This is because
prolonged rupture of the membranes has been associated with a 2% incremental increase in
mother to child transmission risk for every hour of ruptured membranes up to 24 hours.
Term pre labour rupture of the membranes
Caesarean section or stimulation of labour should be considered without delay – see above.
Pre term rupture of the membranes
In pre term rupture of the membranes the risk of HIV transmission with prolongation of the
pregnancy should be set against the risks of prematurity. Preterm babies are more likely to be
infected with HIV because of immature immune function, incompetent mucosal barriers and
low levels of acquired maternal antibody. Chorioamnionitis is common after preterm rupture of
the membranes in this group. Steroids may be used to promote fetal lung maturation.
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• contact the consultant obstetrician for advice
• mode of delivery will depend upon viral load
• see hospital notes for individualised management plan, where already available
Induction of labour
This is uncommon – an individualised care plan will be found in the notes. In general, Prostin
tablets may be preferable to amniotomy for induction of labour as vertical transmission
increases with the length of time membranes have been ruptured.
Postpartum management
In the UK, HIV positive women are advised not to breastfeed as this increases mother to child
transmission by 14% for women infected with HIV before birth and by 30% in mothers infected
postnatally. Women who choose to breastfeed against medical advice should be advised to
do so exclusively, avoiding artificial milk top ups.
20.5 HEPATITIS B AND HEPATITIS C
Duty of Care
All doctors and midwives have a duty to provide necessary care. A refusal to care for a mother
with HBV or HCV infection is professionally unacceptable.
Hepatitis B Surface Ag Positive Women
Only women who are hepatitis surface antigen positive are an infection risk for staff. They
should be cared for in a single room using universal procedures. Care should be given by staff
known to be Hepatitis B immune: all midwives and obstetricians should be vaccinated against
Hepatitis B and should retain documentary evidence of seroconversion. This can be arranged
through Occupational Health.
Postnatal care
Normal care should be offered but gloves must be worn whenever contact with blood is
possible. The baby’s cord should be left dry and the mother encouraged to clean the cord
herself if necessary.
The infant
The infant should be regarded as sero positive for Hepatitis B antigen and precautions taken
as for the mother. The paediatrician will decide whether passive and / or active immunisation
is indicated, for example with a course of Hepatitis B vaccine. Breastfeeding is not
contraindicated.
Hepatitis C
All women who have HCV should be regarded as an infection risk for staff. They should be
cared for in a single room using universal procedures. Breastfeeding is not contraindicated.
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20.6 ANTIBIOTIC PROPHYLAXIS FOR CAESAREAN SECTION
Antibiotic prophylaxis should be given to every woman having a caesarean section after the
cord has been clamped:
•
Augmentin 1.2 gm IV or…
•
Gentamicin 5mg/kg + Clindamycin 600mg IV if the patient is penicillin sensitive
20.7 ANTIBIOTIC PROPHYLAXIS FOR INFECTIVE ENDOCARDITIS
The new national guidelines for the prevention of endocartitis recommends prophylaxis only in
caesarean section, not in vaginal delivery.
•
Amoxicillin 1 gm IV + gentamicin 1.5 mg/kg IV given at induction
•
Teicoplanin 400 mg IV + Gentamicin 1.5 mg/kg IV
Patients who should have antibiotic prophylaxis for endocarditis who are having caesarean
section are
• Prosthetic heart valve
• Previous infective endocarditis
• Complex cyanotic congenital heart disease
• Transposition of great arteries
• Fallot’s
tetralogy
• Gerbode’s defect (complete AV septal defect)
• Surgically constructed systemic pulmonary shunts or conduits
• Mitral valve prolapse with clinically significant (severe) mitral regurgitation or thickened
valve leaflets
• Any patient believed to have foreign material in the heart of great vessels
• Any other variety of arterial switch surgery
The following patients do not require antibiotic prophylaxis
• Acquired valvular heart disease e.g. rheumatic heart disease
• Aortic
stenosis
• Aortic
regurgitation
• Mitral regurgitation, unless severe and accompanied by myxomatous degeneration of
the mitral valve
• Other structural cardiac defects e.g. VSD
• Bicuspid aortic valve
• Atrial septum primum defect
• Patent ductus arteriosis
• Aortic root replacement
• Coarctation of aorta
• Arterial septa aneurysm / patent foramen ovale
• Hypertrophic obstructive cardiomyopathy
• Subaortic
membrane
• Uncomplicated pulmonary stenosis
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20.8 MRSA
Handling MRSA positive women on delivery suite
MRSA positive women should be placed in standard isolation while on Delivery Suite. Anyone
examining an MRSA positive woman must wear an apron and gloves. These should be
discarded after the examination and a hand wash undertaken immediately.
Any medical equipment coming into contact with an MRSA positive women should be cleaned
after use. Alcohol wipes should be used to clean BP cuffs, stethoscopes, chairs and couches.
Scan probes should be cleaned with hibiscrub or T-spray. Where possible, disposable
equipment such as disposable BP cuffs should be used then discarded.
After an MRSA positive woman leaves her delivery room, give the room a terminal clean.
Handling the baby of an MRSA positive woman
When a baby is born to an MRSA positive woman, the paediatricians should be informed
together with the on call microbiologist. Occasionally they will request MRSA swabs from the
baby. If so, this should be done within 48 hours of birth.
20.9 INFECTION
CONTROL
It is essential that all midwives, nurses and doctors develop and maintain high standards of
hygiene and safety in their clinical practice to minimise the risk of accidental exposure to
infection. In the event of a needle stick injury Occupational Health should be contacted as
soon as possible if during working hours, otherwise contact A&E for advice.
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20.10 INFECTION CONTROL FOR HIV/ HBV / HCV POSITIVE WOMEN
Admit patient directly to a single room
Essential Equipment only in room of delivery
Wash hands before and after contact with patient and after removing gloves
Delivery Room
Theatre
Delivery Bed
Theatre bed
Equipment for VE’s del.
Fridge on small trolley
Sharps Box
Anaesthetic machine
CTG machine
Resuscitation/intubation trolley
Drip stand
C/S tray and trolley
Entonox equipment - disposable
Mayo stand
O2 equipment
Dip Bowls
Resuscitation equipment for Baby
Mop stand
Small trolley containing sutures &
extra mops, dressing required for
operation
Diathermy machine
Baby’s cot
Epidural Trolley
Resuscitaire
Vaginal Examination
Protection - apron and double latex gloves.
If amniotomy is undertaken, follow the precautions for ‘Labour and Vaginal Delivery’
Injections
Protection - double latex gloves.
Extreme care must be taken to avoid needle stick injury. The person who administers the
injection is responsible for discarding the needle and syringe as a complete unit following use.
Please refer to the Trust 10 point plan towards the prevention of needlestick injuries.
Epidural
Double latex gloves, apron under fluid repellent gown, masks and goggles or visor
The anaesthetist is responsible for the safe disposal of the sharps.
Cannulation
Protection - double latex gloves and apron
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Venepuncture
Protection - double latex gloves and apron
Blood Samples should be double bagged and all sections of the forms to be labelled with a
biohazard label and the air tube system is not to be used to send bloods to the labs.
Entonox
Preferably a disposable system should be used. Re-usable systems should be sent to the
Sterile Services Department for processing.
Operative Deliveries/Procedures Carried Out in Lithotomy
All procedures carried out in lithotomy position carry an increased risk of inadvertent exposure
to blood.
Instrumental Delivery
The use of forceps is recommended rather than ventouse. Protection - double latex gloves,
cap, mask and goggles or visor, full length apron beneath a fluid repellent gown and
wellington boots are recommended for operators and immediate assistants. Disposable
under-buttock drapes with collection pouch for fluid are available. Perineal Repair - performed
only by an experienced midwife/doctor.
Caesarean section
Essential equipment and personnel only to be in theatre. The use of disposable caesarean
section drapes with collection pouch is recommended, as is the use of blunt needles.
Placenta
CIC
- Place in a clinical waste bag and into a single use placenta bin. Blue cable tie,
label with date, time and place of origin then place in designated cart for
anatomical waste.
WCH - Place in yellow clinical waste bag, self seal it then place directly into sulo bin.
Sterile Services Equipment
Place in Sterile Services box. If out of hours, place safely in sluice until collection next day.
(This is the Midwife in charge of the case’s responsibility.)
Blood Gases
The fetal blood sample (FBS) machine may be used. Following use, clean down with 70%
alcohol. Inform/leave a message on the FBS machine for the technician that it has been used
for an infected specimen.
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Linen
CIC -
All linen contaminated with blood or body fluids must be disposed of as infected
linen, placed in a hot water soluble red alginate bag then placed in a clear plastic
laundry bag.
WCH – All linen contaminated with body fluids and blood must be placed in the sulo bin for
disposal.
Waste
CIC
- Waste contaminated with blood or body fluids must be disposed of as clinical
waste. It should be swan necked, fastened with a black tag, labelled with date,
time and place of origin.
WCH – All contaminated waste must go in the sulo bin.
Sharps Boxes
Sharps should be disposed of via the normal route (placed in a ‘Sharps’ disposal box) locked
and collected after the patient episode is completed.
Cleaning of Room and Equipment
It is the responsibility of the senior nurse/midwife in charge of case/theatre to ensure terminal
cleaning is carried out appropriately. Personnel must always use universal precautions i.e.
latex gloves and an apron. Blood spills must be cleaned up immediately with hypochlorite
solution.
Ensure adequate ventilation - open windows if possible. If any curtains are contaminated with
blood/body fluid they should be removed and treat as infected linen.
In the Event of Needle Stick Injury
Don’t panic!
Bleed it with a gentle pressure
do not suck the injury
Wash with soap and water
Cover with waterproof dressing
If the event of exposure to mucous membranes rinse with copious amounts of water
Report immediately to Occupational Health (taking details of the source patient) or A&E if out
of hours.
Complete an incident form
See Trust code of practice for innoculation injury on the intranet
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studies.
NEJM 340: 977–987.
The International Perinatal HIV Group (2001) Duration of ruptured membranes and vertical
transmission of HIV-1: a meta-analysis from 15 prospective cohort studies.
AIDS 15: 357–368.
Towers CV
et al (1998) A "bloodless cesarean section" and perinatal transmission of the
human immunodeficiency virus.
Am J Obstet Gynecol 179: 708–714.
Gould FK,
et al. Guidelines for Prevention of endocarditis; report of working party of the British
Society for Antimicrobia Chemotherapy
journal of Antimicrobial Chemotherapy (2006) 57,
1035-1042
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CHAPTER 21 - ECLAMPSIA AND PRE-ECLAMPSIA
21.1
CRITERIA FOR INCLUSION ............................................................................219
21.2
ANTICONVULSANT GUIDELINES...................................................................219
21.3
FURTHER NOTES ON THERAPY WITH MAGNESIUM ..................................220
21.4
ANAESTHETIC GUIDELINES ..........................................................................221
21.5
ANTIHYPERTENSIVE THERAPY GUIDELINES..............................................221
21.6
MAINTENANCE THERAPY FOR BLOOD PRESSURE CONTROL .................223
21.7
SIMPLIFIED FLUID GUIDELINES ....................................................................224
21.8
SUMMARY OF CARE......................................................................................225
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21.1 CRITERIA FOR INCLUSION
Any woman with severe proteinuric hypertension,
when the decision has been made to deliver
her baby and when one of the following criteria is met (either A, B or C):
A) Hypertension
( ≥ 140/90 mm Hg) with proteinuria ( ≥ 0.3 g / day or ≥ 2+ on urinalysis)
and
at least one of the following:
• Headache, visual disturbance, epigastric pain
• Clonus
(
≥ 3 beats)
• Platelet count < 100 x 109, ALT > 50 IU / litre
B) Severe
hypertension
(systolic ≥ 170 mm Hg or diastolic ≥ 110 mm Hg) with proteinuria
( ≥ 0.3 g / day or ≥ 2+ on urinalysis)
C) Eclampsia
In these circumstances, the patient should be managed according to the following guidelines
irrespective of mode of delivery or method of analgesia.
Whenever a patient is commenced on the protocol, ensure:
1.
Consultant on call is aware
2.
Anaesthetist on call for Delivery Suite is aware.
21.2 ANTICONVULSANT GUIDELINES
Magnesium sulphate is the drug of choice for the prophylaxis and treatment of eclamptic
seizures. All women who meet the inclusion criteria should be treated with magnesium.
Initial Treatment
Dilute 4g (8ml) Mg SO4, in 40 mls normal saline in 50 ml syringe
(Loading Dose)
= 48 ml. Give as IV bolus dose over 5-10 minutes by doctor
.
Maintenance Dose
follow by an infusion of 1 g per hr
5 g MgSO4 (10 ml) in 40 ml normal saline for 24 hours = 5 g in 50
ml solution, i.e. 1 g per hr is 10 ml /hr
Contraindications
with severe cardiac disease or acute renal failure - use 10 mg
Diazemuls then 2.5 mg / hr maintenance
Duration of Infusion
while patient is on Delivery Suite (i.e.) 24-48 hrs
Monitoring
Clinical: hourly patellar reflexes after the loading dose. Use arm
reflexes in presence of an epidural.
ECG / Pulse Oxymetry: ECG is mandatory during and for 1 hour
after loading dose. Pulse oxymetry is needed throughout while on
MgSO4.
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Magnesium Levels
MgSO4 administered according to this regimen can be used
safely without the need to monitor Mg levels. Mg is excreted by
the kidneys and toxicity is more likely however if there is oliguria
(urine output < 100 ml / 4 hrs) or urea > 10 mmol / L.
Measurement of Mg levels may facilitate care if there are signs of
toxicity.
Toxicity
Signs of toxicity are extremely uncommon and correlate with
magnesium levels.
Mg level (mmol/L)
Therapeutic
Range
2-4
loss of tendon reflexes, weakness, nausea, feeling of
5
warmth, flushing, somnolence, double vision, slurred speech
muscle paralysis, respiratory arrest
6-7.5
cardiac arrest
> 12
21.3 FURTHER NOTES ON THERAPY WITH MAGNESIUM
Loss of patellar reflex
Stop maintenance infusion
If
possible,
check
Mg
level
Withhold further Mg until patellar reflexes return or Mg levels
known. Once tendon reflexes return, if Mg level < 4 mmol /L
restart maintenance dose at 0.5 g / hr and recheck levels in 3
hours.
Oxygen saturation
Commence O2, check patellar reflexes, inform anaesthetist
persistently < 92%
If patellar reflexes present, exclude other causes (eg) opiates,
pulmonary oedema
If patellar reflexes absent, see above
Cardiorespiratory arrest
Stop maintenance infusion
Institute
CPR
Administer 10 ml Calcium gluconate IV
Intubate immediately and manage with assisted ventilation until
resumption of spontaneous respirations
If possible, check Mg levels
If Mg level <2.0 mmol / L restart maintenance dose at 2 g / hr
Seizure on Magnesium
Treat seizure with a further bolus of Mg 2 g over 5 minutes
If possible check Mg levels prior to this
If further seizures despite this, consider:
Diazemuls 10 mg IV bolus then infusion
Thiopentone infusion on ITU
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21.4 ANAESTHETIC
GUIDELINES
To be determined by obstetric anaesthetist:
CRITERIA FOR TRANSFER TO ITU:
1. Recurrent seizures
2. MAP > 125 mg Hg inspite IV hydrallazine and labetolol
3. Persistant oliguria with normal / high CVP
4. Pulmonary oedema with oliguria
5. Compromised myocardial function
21.5 ANTIHYPERTENSIVE THERAPY GUIDELINES
CALCULATION OF MAP
CALCULATION OF MAP
DBP + (SBP- DBP)
(DBP x 2) + SBP
or
3
3
Above a MAP of 140 mm Hg, a previously normotensive woman will lose cerebral
autoregulation and is at increasing risk of cerebral haemorrhage. MAPs > 140 mm Hg
constitute an obstetric emergency.
Automated oscillometric devices may underestimate blood pressure.
The drug of choice should be labetolol. Give bolus dose of 20 mg and repeat every 20
minutes as per flowchart overleaf until MAP is less than 125 mm or maximum dose of 200 mg
is given.
Hydralazine is first line therapy for the treatment of hypertension for women with asthma.
• Dilute 20 mg of hydralazine in 20 ml of 0.9% saline = 1 mg in 1 ml of dilute
• Give 5 mg by slow (1 mg / per minute) IV bolus
• Check BP every 5 minutes for 30 minutes or until BP is stable at MAP < 125 mg, then
every 15 minutes for a further 60 minutes
• Acute treatment may be repeated every 15 minutes until 15 mg of hydralazine is given
Both drugs can precipitate fetal distress and therefore continuous fetal heart rate monitoring is
mandatory.
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MAP > 140 mmHg
MAP ≥ 125 mmHg
Recheck BP every 5 minutes
Recheck BP every 15 minutes
If sustained over 15 minutes
If sustained over 45 minutes
Labetolol
20 mg IV
Recheck MAP
MAP < 125 mm Hg
after 20 min
MAP ≥ 125 mm
Recheck BP
every 15 min
Repeat labetalol
in escalating
doses 40 mg, 60 mg, 80 mg
every 20 min up to a
maximum of 200 mg
If MAP remains ≥ 125 mmHg, discuss with consultant. Consider intra arterial monitoring /
transfer to ITU
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21.6 MAINTENANCE THERAPY FOR BLOOD PRESSURE CONTROL
Subsequent episodes of hypertension can be managed with intermittent boluses of IV
labetolol or hydralazine but if these are needed more than hourly, consider using an
infusion:
Labetolol infusion
In a 50 ml syringe, draw up 2 ampoules of labetolol (1 ampoule contains 100 mg). This will
give you 200 mg in 40 ml.
Use a syringe driver to commence your labetolol infusion at 40 mg (8 ml) /hr
Double this every 30 minutes until you get a satisfactory response (ie) MAP < 125 mmHg
The maximum dose you can give is 160 mg (32 ml) /hr
Hydralazine infusion
In a 50 ml syringe, make 40 mg hydralazine up to 40 ml with n/saline
Use a syringe driver to commence your hydralazine infusion at 10 mg (10 ml) /hr
Double this every 30 minutes until you get a satisfactory response (ie) MAP < 125 mmhg
The maximum dose you can give is 40 mg (40 ml) /hr
Side effects include headache, flushing and dizziness - consider using labetolol if these occur
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21.7 SIMPLIFIED FLUID GUIDELINES
infuse 85 ml Hartmann’s solution /hr
if
urine output
under 100 ml in 4 hours
check UE, FBS and clotting studies
ensure significant hypovolaemia due to blood loss or DIC
has been corrected with packed cells and/or other blood products
if
still oliguric
antecubital long line
CVP
check the position with a CXR
<
4
mmHg
4-8
mmHg
>8
mmHg
give 500 ml colloid
manage expectantly
check O2 sats
over
5
minutes
auscultate
chest
if
urine
output look
at
the
CXR
if urine output
under 200 ml
under 25 ml
in the next 8 hours
no
pulmonary
in
the
next
hour
pulmonary
oedema
give
200
ml
colloid
oedema
discuss
with
over
5
minutes
frusemide
20
mg
consultant obstetrician
and anaesthetist
if urine output if
no
diuresis
under
25
ml
individualised care
in the next hour
frusemide 40 mg
recheck
the
UE
if
no
diuresis
discuss
with
discuss
with
consultant obstetrician
consultant obstetrician
and
anaesthetist
and
anaesthetist
individualised
care
individualised
care
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21.8
SUMMARY OF CARE
Only women with severe pre-eclampsia / eclampsia should be managed according to
this guideline.
All women will remain on the delivery suite for a minimum of 24 hours after giving birth.
Ensure that when the woman is transferred to the post natal ward, ward staff are made
aware of the need for strict fluid balance for at least 48 hours.
Aspects of Care Maternal Observations: These should be filled in hourly. Record the hourly fluid intake
(iv & oral), urine output & fluid balance, BP, oxygen saturation & reflexes while on iv
magnesium. Remember to document important events such as administration of
antihypertensive treatment, epidural insertion, top ups, delivery and mark delivery
blood loss.
BP measurements
: BP measurements should be made and recorded every 15
minutes. Inform medical staff if there are two consecutive readings with MAP >125 mm
Hg or one reading >140 mm Hg.
Fluid intake: The standard IV fluid regime is 85 ml/hour, including the 20 ml of MgSO4
each hour. Once oral fluids are established the hourly oral intake needs to be
subtracted from the IV input (if a women is drinking 50 ml/hr, she needs 35 ml/hr IV).
Urine output: This is measured hourly using calibrated urometers. Inform medical staff
if the output is <100 ml over a four hour period.
MgSO4:
This is given by IV infusion. The first signs of toxicity are loss of tendon
reflexes & respiratory depression. Throughout the infusion, hourly recordings must be
made of:
• Patellar and/or biceps reflex. If you fail to detect a reflex or are unhappy about the
method of testing you must let the medical staff know immediately.
• Oxygen saturation. Inform the medical staff if this is persistently < 92%.
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References
Belfort MA
et al (2003) A comparison of magnesium sulfate and nimodipine for the prevention
of eclampsia.
NEJM 348: 304-311.
Collaberative Eclampsia Group (1995) Which anticonvulsant for women with eclampsia?
Evidence from the Collaborative Eclampsia Trial.
Lancet: 345; 1455-1463.
Dekker G, Sibai B (2001) Primary, secondary and tertiary prevention of pre-eclampsia.
Lancet 357: 209-215.
Douglas KA, Redman CW (1994) Eclampsia in the United Kingdom.
BMJ 309: 1395-1400.
Duley L, Henderson-Smart DJ (2004)
Cochrane Database of Systematic Reviews Issue 3.
Magee L
et al (2003)
BMJ 327: 955-60.
Scardo JA
et al (1999)
Am J Obstet Gynecol 181: 862-6.
The Magpie Collaborative Group (2002) Do women with pre-eclampsia, and their babies,
benefit from magnesium sulphate? The Magpie Trial: a randomised placebo-controlled trial.
Lancet 359: 1877-1890.
Witlin AG (1999) Prevention and treatment of eclamptic convulsions
. Clin Obstet Gynecol 42: 507-518.
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CHAPTER 22 - DIABETES
22.1
GENERAL NOTES FOR OBSTETRIC STAFF ON THE MANAGEMENT OF WOMEN
WITH INSULIN-TREATED DIABETES .............................................................228
22.2
MANAGEMENT OF PREGNANT WOMEN WITH INSULIN-TREATED DIABETES
FOLLOWING EMERGENCY ADMISSION .......................................................229
22.3
MANAGEMENT OF STEROIDS IN PREGNANT WOMEN WITH DIABETES ..230
22.4
REGIMEN FOR ELECTIVE CAESAREAN SECTION, INDUCTION OF LABOUR OR
SPONTANEOUS DELIVERY............................................................................230
22.5
MANAGEMENT FOLLOWING DELIVERY .......................................................234
22.6
ADDITIONAL POINTS FOR THE CARE OF THE MOTHER WITH DIABETES
AFTER DELIVERY............................................................................................235
22.7
HYPOGLYCAEMIA IN MATERNITY PATIENTS ..............................................236
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22.1 GENERAL NOTES FOR OBSTETRIC STAFF ON THE MANAGEMENT
OF WOMEN WITH INSULIN-TREATED DIABETES
• When a woman with diabetes is admitted to the Maternity Unit please inform the
Diabetes team (01228 814780 / 814140, 01946 523010), Dr. H or S Sawers and the
diabetes specialist midwife (Angela Bell, Bernadette Bowness).
•
There is no official out of hours diabetes on-call service but it is always worth calling Dr
Sawers’ offices (01228 814139 or 01946 523002). The diabetes SpR may be on
medical call, but failing that the medical registrar should be asked for advice if required.
•
Depending on the clinical status and reason for admission it may be appropriate for the
woman to remain fully responsible for insulin dosing and administration, but a record of
her blood sugars and insulin doses given should always be available for inspection
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22.2 MANAGEMENT OF PREGNANT WOMEN WITH INSULIN-TREATED
DIABETES FOLLOWING EMERGENCY ADMISSION
•
Obstetric problems will be complicated if blood sugars are too low or too high. High
blood sugars may result from infection or steroid injections. Low blood sugars may result
from unplanned fasting.
Some
practical tips on the management of diabetes:
1. Pregnant women with diabetes are at high risk of developing diabetic
ketoacidosis. Ketoacidosis occurs if there is deficiency of insulin or
carbohydrate.
2. Ketoacidosis is a condition with 2% mortality in young people and is life-
threatening to the baby
3. Insulin must not normally be stopped and will need to be increased if there is
intercurrent infection or steroid administration (both of which increase insulin
resistance) (see 22.3)
4. Check for ketones by urine testing on admission. Thereafter on each
specimen if the patient is
♦
unwell,
♦
vomiting / not able to eat, or
♦
pre-meal sugars are above 10mmol/l
5. If more than a trace of ketones is detected request an urgent lab check of urea
and electrolytes as well as bicarbonate (all on a venous sample). Bicarbonate
needs to be specifically requested. A reduced bicarbonate means acidosis is
developing and the medical registrar needs to be alerted immediately. What
happens next will depend on the severity of the metabolic decompensation.
6. When insulin and dextrose are being infused always use a y-connector with
anti-reflux valve.
7. Remember that intravenous insulin disappears from the system within minutes
of being switched off. When switching back to subcutaneous insulin from an
i.v. regimen carry on with insulin infusion until 30 min
after first subcutaneous
injection of conventional rapid acting insulin (e.g. Humulin S or Actrapid) has
been given or until 15 min
after first subcutaneous injection of rapid acting
insulin analogue (e.g. Novorapid or Humalog)
8. Hypoglycaemia in a patient should be corrected as per guideline and should
not normally result in subsequent insulin being withheld (see 22.7).
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22.3 MANAGEMENT OF STEROIDS IN PREGNANT WOMEN WITH
DIABETES
1.
Corticosteroids are used during pregnancy when delivery is anticipated prior to 36 weeks
gestation, in order to accelerate fetal lung maturation and prevent respiratory distress
syndrome. The use of steroids in patients with diabetes is associated with a significant
worsening of their glycaemic control for up to 48 h after steroid administration, the peak
effect usually being between 4 h and 10 h.
2. Admission is planned for such patients and intramuscular betamethasone is
administered (12 mg repeated after 12 h). If possible avoid starting the regimen on a
Friday or Saturday as there is not likely to be any diabetes team support when the
decision to discontinue the regimen is being made.
3.
Following admission the patient continues to administer her usual subcutaneous insulin
regime without any change of dosage and follows her usual dietary programme.
4.
In addition, immediately prior to the first steroid injection, a supplementary, variable dose
intravenous insulin infusion is started and adjusted according to hourly blood glucose
measurements. The initial dosage regimen (A, B, C or D) is determined according to her
current total daily s.c. insulin requirement (see table).
5.
If blood glucose levels are too high on the initial regimen (glucose greater than
10.1 mmol/l for 2 consecutive hours) the dosage regimen is moved up to the next level
(e.g. if started on B move up to C, etc.). If the blood glucose level has dropped to less
than 4 mmol/l on any regimen, immediately reduce by one level (e.g. if on C move down
to B, etc.). Note: Whichever regimen is in use no i.v. insulin is given until the blood
glucose rises to 6.1 mmol/l or above.
6. The supplementary insulin infusion is continued for
at least 12 h after the second steroid
injection. (Do not discontinue it if more than an average of 2 units of extra insulin per
hour has been required over the previous 4 hours)
22.4 REGIMEN FOR ELECTIVE CAESAREAN SECTION, INDUCTION OF
Total daily s.c
Up to 40 U/day
40-80 U/day
81-120 U/day Over 120 U/day
Insulin requirement
The insulin is delivered via a syringe driver containing 50 units
Actrapid made up to 50 ml by adding 49.5 ml N Saline
Intravenous insulin infusion rate (units/hr)
Hourly blood glucose
A B
C
D
(mmol/l)
Less than 6.1
0
0
0
0
6.1-7.0 0.5
1
2
3
7.1-8.0 1
2
3
5
8.1-9.0 1.5
3
4
7
9.1-10.0 2
4
6
10
More than 10
3
6
8
13
Table modified from Kaushal, K., Gibson, J. M., Railton, A., Hounsome, B., New, J. P. & Young, R. J. -
A protocol for improved glycaemic control following corticosteroid therapy in diabetic pregnancies
Diabetic Medicine 20 (1), 73-75. Jan 2003
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LABOUR OR SPONTANEOUS DELIVERY
Women with gestational diabetes will be treated in
the same way as other women in labour unless they
are currently insulin treated
General principles:
♦
Induction of labour should be carried out using standard guidelines. Ideally the woman
should be admitted to hospital on the evening prior to induction, even if there is no plan
to give prostaglandins. Timing of admission may be individualised.
♦ Elective caesareans should be booked into morning lists wherever possible, with
admission to hospital on the previous evening
♦ Both hypoglycaemia and diabetic ketoacidosis need to be avoided, aiming to maintain
blood glucose as near normal as possible.
♦ The woman should remain on subcutaneous insulin and continue eating until either
1.
labour is established or
2.
pre-operative fasting is required
♦
At the time of the first missed dose of insulin / missed meal or snack simultaneous
infusion of Glucose 10%
AND Actrapid in N. Saline needs to be set up
Elective morning CS
• For
an
elective morning CS reduce by 30% the previous night’s dose of any long-acting
insulin (eg Lantus)
•
Omit breakfast and morning dose of subcutaneous insulin
•
Check blood glucose with a meter; ensure that recent U and E’s results are available
•
Before 7.30 a.m. set up i.v. infusion of:
Glucose 10% + 0.15% KCl through a counter at 100ml/hr
omit KCl if
potassium level
AND
over 5 mmol/l
50 units Actrapid in 50ml N. saline via a syringe driver
• These
must go through a y-connection incorporating anti-reflux valve (PCA giving
set)
•
Choose a sliding scale regime (see below) and check blood glucose levels hourly during
labour or section and adjust insulin (or glucose) to maintain levels between 4-7 mmol/
• The insulin and glucose regime will provide sufficient insulin and carbohydrate, but
prolonged use (more than 24 hrs), in the absence of other fluid intake, will result in
hyponatraemia unless sodium requirements are separately addressed by infusion.
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• Any other fluids which are required (e.g. blood, colloid or N Saline) should be given
through a
separate line.
Pre-delivery sliding scale
The basic scale delivers more glucose and more insulin than ‘usual’ sliding scales in standard
peri-op regimen because pregnant patients are insulin resistant
Blood glucose
Insulin rate
Hints
mmol/l
ml or units/hr
Less than 4
0 and inform
Deal with low blood sugar by extra glucose
doctor
infusion (eg 100-150 ml 10% glucose) and
aim to get insulin restarted as soon as
possible, with a reduced sliding scale if
necessary
4-5 1
5.1-7 2
7.1-10 3
10.1-15
4
Check ketones….. if positive check bicarb,
check infusion system is working, consider
increasing sliding scale
More than 15
6 and inform
Check ketones….. if positive check bicarb,
doctor
adjust scale
1. Before starting sliding scale as above consider whether it is likely to be appropriate for
the particular patient and, if not,
adjust it at the outset.
2. Assess this by working out the patient’s current total daily insulin dose and divide by 24.
This should roughly correspond to the number of units to be infused if the blood sugar is
in the target range (shaded above).
e.g. if the total daily dose is 80 units per day the above infusion rates may need to be
increased by approximately 50% each
3. The key to success is to reassess the appropriateness of the regimen frequently. Blood
glucose should be checked hourly and, if there is concern about blood glucose control,
monitor more frequently to allow changes to be made to optimise the regimen.
4. Low bicarb (less than 20) and heavy ketones suggests diabetic ketoacidosis urgent
medical help required! Contact the diabetes team or the on-call medical team.
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Notes
1. For elective CS in the afternoon: give usual short-acting insulin before breakfast and at
10.00 h set up i.v. glucose and insulin regimen.
2. For induction: the woman will continue on subcutaneous insulin until labour is
established. Set up i.v. glucose and insulin regimen prior to first missed dose of insulin
/ missed meal or snack
3. For admission in established labour set up i.v. glucose and insulin regimen unless
delivery is imminent
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22.5 MANAGEMENT FOLLOWING DELIVERY
• The aim of management immediately post-partum is to avoid hypoglycaemia and to
maintain pre-prandial blood glucose levels between 4 and 12 mmol/l
• Insulin requirements drop immediately after delivery so switch to the regimen below
at
the point of delivery, individualising it as necessary
Post-delivery sliding scale
Blood glucose
Insulin rate
mmol/l
ml or units/hr
Hints
Deal with low blood sugar by extra glucose
infusion (eg 100-150 ml 10% glucose) and
0 and inform
Less than 4
aim to get insulin restarted as soon as
doctor
possible, with a reduced sliding scale if
necessary
4-5.1 0.5
5.1-7 1
7.1-10 2
10.1-15 3
Check ketones….. if positive check bicarb,
15.1-20 4
check infusion system is working, consider
increasing sliding scale
6 and inform
Check ketones….. if positive check bicarb,
More than 20
doctor
adjust scale
♦ Check blood sugars hourly to inform adjustments to insulin infusion rate
♦ Once stable and tolerating diet restart subcutaneous insulin in
pre-pregnancy doses,
reducing these by a third if breast-feeding is planned.
♦ Remember that intravenous insulin disappears from the system within minutes of being
switched off. When switching back to subcutaneous insulin from an i.v. regimen carry on
with insulin infusion until 30 min
after first subcutaneous injection of conventional rapid
acting insulin (e.g. Humulin S or Actrapid) has been given or until 15 min
after first
subcutaneous injection of rapid acting insulin analogue (e.g. Novorapid or Humalog)
♦ Once back on s.c. insulin check blood sugars pre-meals and pre-bed and consider
checking through the night if breast feeding. Also check if there is concern about low
sugars or the women is unwell.
Women with gestational diabetes
Those who have been insulin treated in pregnancy will not normally require any
insulin post-delivery. Simply monitor blood sugar before meals until discharge and
alert diabetes team if pre-prandial blood sugars are above 7 mmol/l.
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22.6 ADDITIONAL POINTS FOR THE CARE OF THE MOTHER WITH
DIABETES AFTER DELIVERY
1. Remind the mother that control of blood sugars must not be too tight because of the
unpredictable demands of the baby, particularly if breast feeding. Sugars of 7-10 before
meals are very satisfactory.
2. Remind the mother about the desirability of planning any future pregnancy so that pre-
conception care can be given (drug review, folic acid 5mg/day, good HbA1c etc)
3.
All those with gestational DM defined by WHO criteria (whether or not insulin treatment
was given) should have OGTT performed at 6 weeks postnatal, conducted under strict
conditions by the Community Team.
Implementing lifestyle changes can reduce the risk of development of later diabetes so all
those identified as having gestational diabetes should be offered dietetic input post-
delivery to reinforce this.
They should also have annual screening for development of diabetes mellitus thereafter
and reassessment prior to planned subsequent pregnancy.
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22.7 HYPOGLYCAEMIA IN MATERNITY PATIENTS
1. Hypoglycaemia is often a problem in the first trimester as women try and tighten up
control. It is important not to let blood sugar fall too low in order to preserve
hypoglycaemic awareness. Women are asked to regard a blood sugar of less than 4 as
too low.
2. A low blood sugar requires:
♦ Corrective action to restore blood sugar level
♦ Analysis to decide whether it can be explained…
If so, avoidance tactics for next time
If not, reduce the dose of the responsible insulin next time
3. A high glucose product will raise blood sugar quickly but have no sustaining power so
needs to be followed by long-acting carbohydrate (starchy food)
So,
start with:
Cups of sugary tea take
50-100 ml lucozade or
too long to make and cool
3-6 Dextrose sweets or
Diet drinks won’t work
1 tube of Glucogel
Once she is beginning to feel better
follow on with: 2 slices bread or
Cereal bar or
Plain biscuit and glass of milk or
Large banana
Or the next meal if that was due. Inject any insulin due with that meal after the meal.
Do not omit insulin after a hypo unless recovery has not taken place
4. Some hypos may result in impaired consciousness. For these use glucagon 1mg i.m.
or
s.c., or if there is venous access through a large vein use 50 ml 20% glucose (repeated if
necessary)
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References:
NICE Guidelines – Antenatal Care
NICE Guidelines, 15, Type 1 diabetes: diagnosis and management of Type 1 diabetes in
adults
Diabetes UK Care Recommendations for the management of pregnant women with diabetes
Kaushal, K., Gibson, J. M., Railton, A., Hounsome, B., New, J. P. & Young, R.J. - A protocol
for improved glycaemic control following corticosteroid therapy in diabetic pregnancies.
Diabetic Medicine 20 (1), 73-75. Jan 2003
Scott DA, Loveman E, McIntyre L, Waugh N. Screening for Gestational Diabetes: a
systematic review and economic evaluation. Health Technol Assess 2002;6(11)
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CHAPTER 23 - LATEX ALLERGY
23.1
BACKGROUND ................................................................................................239
23.2
LATEX IN THE HOSPITAL ENVIRONMENT ....................................................239
23.3
IDENTIFICATION OF THE PROBLEM .............................................................240
23.4
PROVISION OF A LATEX-FREE ENVIRONMENT ..........................................240
23.5
TREATMENT OF ANAPHYLAXIS ....................................................................241
23.6
LATEX ALLERGY BOX.....................................................................................241
23.7
FURTHER INFORMATION...............................................................................242
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23.1 BACKGROUND
Latex allergy is an increasingly common problem. Two scenarios may be encountered:
Contact hypersensitivity
Most often, contact hypersensitivity is seen as a localised eczematous skin reaction. It is
common in people regularly exposed to latex, such as is found in medical gloves. Avoidance
is the most important measure to take. For example, affected staff must have access to latex-
free gloves at work. It is rare for contact hypersensitivity to precede a more severe reaction.
Acute anaphylaxis
Acute immediate (Type I) allergic reactions to latex are uncommon, but are often difficult to
recognise and manage. Swelling may affect the lips, tongue and throat, leading to stridor.
Bronchospasm, hypotension and loss of consciousness, abdominal pain, vomiting and
diarrhoea may also occur. Only 50 % will have an urticarial rash. Latex anaphylaxis may be
found in association asthma, eczema, hay fever or food anaphylaxes.
23.2 LATEX IN THE HOSPITAL ENVIRONMENT
Products used in the hospital setting will often contain latex, as shown below. Latex-free
alternatives are available for most products, however, while some products can effectively be
neutralised by covering them with other materials.
BP cuffs
Cover thoroughly with a stockinette. You can’t get Latex Free
ECG dots
Contain Latex – use Latex Free in box
venflons
Contain Latex – use Latex free in box
giving sets
Contain Latex – use Latex Free in box
syringes
Contain Latex – use Latex Free in box
gloves
Use Latex Free in box. If Latex Gloves have been worn, hands must be
thoroughly washed and at least one hour must pass before you have
contact with a Latex allergic patient
tourniquets
Contain Latex – do not use these. Use someone else’s hand
catheters
Contain Latex – use an ‘in and out’ catheter. If caesarean is being
performed leave the ‘in and out’ in place until after the operation
epidural packs
These are okay but discard the resistance syringe. Use a glass syringe
from the Latex Allergy Box
oxygen masks
Green Masks (UFE Care) are ok but remove elastic strapping. Face
masks contain Latex so use clear masks instead. For Entonox use a
plastic mouthpiece
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ET tubes
Use Mallinckroft tubes.
laryngeal masks Okay
elastoplast
Contains Latex. Use Mefix instead
venfon dressings Contain Latex. Use Mefix instead
theatre table
Contain Latex. Double cover with Baxters drapes / green sheets
table supports
Contain Latex. Double cover with Baxters drapes / green sheets
drugs
Drugs that need mixing (eg) antibiotics – remove the rubber bung prior to
mixing. Use syringes from the Latex Allergy Box
diathermy plates
Do not use as prepared. Use the plate available in the Latex Allergy Box,
then secure with Mefix
The list is never ending. Please use your common sense. Think about all the products
that you are using. Do they contain Latex? 23.3 IDENTIFICATION OF THE PROBLEM • When a routine clinical history is being taken, the patient should be questioned directly
about latex allergy in addition to drug and other allergies.
• Latex allergy should be suspected in a patient presenting with anaphylaxis who
deteriorates despite treatment after reaching hospital.
• Latex allergy should be considered as part of the differential diagnosis for any in-hospital
episode of anaphylaxis, and for any ‘anaesthetic’ reactions.
• Any patient with a severe allergy who has been seen in the Department of Immunology will
usually wear a Medic-Alert bracelet. These should always be inspected if present.
23.4 PROVISION OF A LATEX-FREE ENVIRONMENT Hospital staff with hand eczema related to latex should consult Occupational Health for
advice. Advice about obtaining latex-free gloves is available from the Department of
Immunology.
Patients with severe systemic reactions to latex must be treated in a latex free environment as
far as possible. Particular care should be taken when exposing the patient to gloves, airways,
masks, iv lines, rubber bungs on drug ampoules, couches and bed liners. A pack of latex free
emergency equipment is available on the Delivery Suite in theatre. If you have been wearing
latex gloves, you must scrub your hands thoroughly before handling a patient with known
severe latex reactions.
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When a patient is being admitted for an elective procedure, identification of severe latex
reactions should prompt an assessment of the risk of exposure in the planned procedure.
Latex free alternatives will be required, discuss with theatres.
In general, drugs in glass snap ampoules, tablets and capsules are safe. Any drug in an
ampoule with a rubber bung should be assumed to be unsafe unless specifically identified as
safe by Pharmacy (some bungs are made of synthetic rubber with no latex component).
Terumo syringes are known to be safe.
In an emergency, specific advice can be obtained from the on-call Immunologist (contact RVI
switchboard).
23.5 TREATMENT OF ANAPHYLAXIS
• Stop administration of drug(s) likely to have caused the anaphylaxis.
• Call for urgent help.
• Maintain airway: Give 100% Oxygen (in non-latex mask)
• Lay patient flat with feet elevated
• Secure large bore, intravenous access
• Give
adrenaline:
Either: IM, 0.5 mg to 1 mg (0.5 to 1.0 ml of 1:1,000) every 10 – 15 mins take pulse and
blood pressure
Or:
IV, 50 to 100 ug slowly (0.5 to 1.0 ml of 1:10,000) every 1 min take pulse and
blood pressure
• Start intravascular volume expansion with crystalloid or colloid (large IV cannula needed)
• Administer hydrocortisone 200 mg IV
• Consider chlorpheniramine 10 mg IV
For anaphylaxis in areas other than theatres and medical wards, the on-call medical registrar
for the site should be contacted for further advice via the switchboard.
23.6 LATEX ALLERGY BOX
The latex allergy box is situated in the anaesthetic room
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23.7 FURTHER
INFORMATION
The Regional Department of Immunology at the RVI can provide additional information and
advice on request - Department extension 25517
Providing care for the latex sensitive woman
latex sensitive women must be cared for in a single room
or
a multi bedded room that has been unoccupied for at least one hour
all staff preparing the room
and
all staff subsequently caring for the woman
must
wash hands and face and brush hair
change into a clean set of clothes or uniform
to prepare the room
completely remove all equipment that contains latex
do not simply store this in a cupboard in the room
take care to remove small items like erasers and rubber gripped biros
damp dust all remaining equipment and all surfaces
replenish the room with latex free alternatives
take care not to introduce latex into the room
when administering drugs
particularly
drugs stored in bottles with rubber bungs
if in doubt, check with pharmacy
inform the post natal ward about the woman’s arrival
so that
suitable post natal accommodation can be arranged
advise the woman to bring in latex free teats if she is planning to bottle feed her baby
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References
Ayeko MO, Smith NJ (1999) Coexisting allergies to latex and to muscle relaxants in a
primigravida.
Hospital Med (London) 60: 311.
Chen FC
et al (1999) Atopy, the use of condoms, and a history of cesarean delivery: potential
predisposing factors for latex sensitization in pregnant women.
Am J Obstet Gynecol 181: 1461-1464.
Eckhout GV Jr, Ayad S (2001) Anaphylaxis due to airborne exposure to latex in a
primigravida.
Anesthesiol 95: 1034-1035.
AAGB&I, 2003 - Suspected Anaphylactic Reactions
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CHAPTER 24 - SUBSTANCE ABUSE
24.1
AIMS .................................................................................................................245
24.2
INTRAPARTUM CARE .....................................................................................245
24.3
ANALGESIA IN LABOUR OR PRIOR TO CAESAREAN SECTION ................245
24.4
IMMEDIATE NEONATAL CARE .......................................................................246
24.5
NEONATAL WITHDRAWAL .............................................................................246
24.6
BREAST FEEDING...........................................................................................247
24.7
INFECTION ISSUES.........................................................................................247
24.8
THE IMPACT OF SUBSTANCE USE ON THE INFANT...................................248
24.9
USEFUL CONTACTS .......................................................................................249
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24.1 AIMS
• To provide an inclusive non-judgmental service within mainstream intrapartum care
• To maintain confidentiality and engender trust
• To improve maternal and neonatal outcome, minimising the impact of substance use
• To encourage engagement with relevant support services where appropriate
• To establish close liaison between professionals through a multidisciplinary approach
• To encourage continuing contact with drug services after birth
24.2 INTRAPARTUM
CARE
With few exceptions, intrapartum care is little different in these women. Notes should be
reviewed for details of:
• substance
use
• alcohol
use
• evidence of IUGR
• child protection issues
24.3 ANALGESIA IN LABOUR OR PRIOR TO CAESAREAN SECTION
When a woman taking methadone attends Delivery Suite to give birth, her own supply of
methadone should be stored in the controlled drugs cupboard and the relevant documentation
should be completed. In labour, methadone should be administered to the woman in a
delivery room, under the direct supervision of an attending midwife. Every effort should be
made to confirm that the dose requested by the women concurs with the dose prescribed or
agreed for labour antenatally. This information will be available in the antenatal notes.
Any additional analgesia may be requested by the woman. Her options should not be
restricted because of her substance use. The anaesthetist should be informed and involved in
the decision making process. Remember:
• opiate analgesia may be less effective than usual because of saturation of opiate
receptors
• an epidural may be preferable because of this
When a woman taken Subutex attends Delivery Suite to give birth, analgesia should be non-
opiate, i.e. Meptid or Entonox.
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24.4 IMMEDIATE NEONATAL CARE
Naloxone given to the neonate may precipitate acute withdrawal and is
contraindicated
Inform the paediatric team when the baby is born.
The baby’s first feed should be within 5 hours and further feeds should be at no greater than 5
hourly intervals. A nursing intervention score sheet should be started for neonatal withdrawal
symptoms after the first feed.
The baby’s first urine sample should be collected in a 10 ml universal container and:
• sent to biochemistry for a toxicology screen if the maternal drug history is uncertain. The
result will be available in approximately 48 hours
• stored a –4 0C when the maternal drug history is known, in case signs of neonatal
withdrawal develop at a later stage
Maternal consent is not required for the storage of urine.
Separation of mother and infant should only occur for legal or medical reasons.
24.5 NEONATAL
WITHDRAWAL
A third of babies born to opiate using mothers require drug treatment. The onset and severity
of withdrawal symptoms is difficult to predict however. For example, opiate withdrawal
typically occurs within 72 hours but may be later with methadone while benzodiazepine
withdrawal may not present for up to 10 days. Because of this, women should be discouraged
from leaving hospital prior to the 4th postnatal day. A nursing intervention score sheet is
available to monitor symptoms and provide nursing advice. Classicaly, affected babies are
hungry but feed ineffectually. The following are scored 4 hourly or PRN 30-mins after each
feed:
• convulsions
• tremor when undisturbed
• non-stop high pitched cry
• sleep <1hr following good feed
• watery
stools
• projectile
vomiting
• Pyrexia
>38oC & Tachypnoea
• Yawning and hiccoughs
• Sweating and dehydration
• Hypertonicity
Every infant is scored for at least 72 hours. If treatment is required, the score sheet is
continued for 72 hours after discontinuation of treatment.
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Transfer to SCBU is based on medical grounds, such as vascular collapse or the occurrence
of convulsions. If sedation is required it may be possible for babies to be kept on the postnatal
ward and brought to SCBU for their medication
24.6 BREAST
FEEDING
The only absolute contraindication is maternal HIV. Other women should be encouraged to
breast feed in the short term. This is thought to reduce the incidence of sudden infant death
and may reduce the severity of neonatal withdrawal syndrome.
Women taking over 80 mg methadone per day may be discouraged from long term breast
feeding but this issue will be raised by the multidisciplinary team in the antenatal period.
24.7 INFECTION
ISSUES
Hepatitis B
Breast feeding is not contraindicated.
If the maternal status is unknown, temporary infant protection is provided with gamma globulin
given within 12 hours of birth. Once maternal status is confirmed, further neonatal protection
can be given if necessary with Hepatitis B vaccine. Consent for immunisation will be required.
Hepatitis C
Breast feeding is not contraindicated.
An estimated 30% of substances users are Hepatitis C positive, and infant testing for Hepatitis
C is unreliable before 1 year.
HIV
Breast feeding is contraindicated.
Prior to discharge, liaise with community midwife/ GP/ GUM team / Consultant Obstetrician/
Health Care Worker/ Social Services/ drug services as appropriate. Discuss contraception and
sexual health needs.
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24.8 THE IMPACT OF SUBSTANCE USE ON THE INFANT
In pregnancy, women using substances have an increased incidence of early pregnancy loss,
prematurity, low birth weight and stillbirth. Neonatal death and sudden infant death syndrome
are also more common. The aetiology is multifactorial and includes socioeconomic factors and
smoking.
Substance
Direct effects and treatment aims
Opiates
IUGR, in-utero withdrawal (presents as increased fetal
(heroin, DF118, movements occurs ~30 min after maternal symptoms). Meconium
methadone,
aspiration. Neonatal withdrawal in 1 in 3. Aim is for stabilisation
buprenorphine,)
with methadone, possible reduction or abstinence.
Cocaine and crack Complications related to increased vascular resistance:
spontaneous abortion, abruption (risk x10) PROM, and fetal
GU,CNS sequelae. No neonatal withdrawal. Aim for abstinence.
Benzodiazepines
Facial clefts (possible risk). Neonatal withdrawal, typically at
maternal doses >30 mg/day. Aim for stabilisation, with a slow
reduction to abstinence.
Amphetamines
Maternal hypertension and cardiac arrhythmia. Cleft palate
(possibly), fetal thrombocytopenia (rare). Neonatal withdrawal.
Aim for abstinence.
Cannabis
Low birth weight (tobacco related). No neonatal withdrawal. Aim
for abstinence.
Ecstasy
No neonatal effects demonstrated. Aim for abstinence.
Alcohol
Fetal alcohol syndrome (IUGR, microcephaly, craniofacial
abnormalities). There is no clear dose relationship.
Solvents
Microcephaly, neonatal withdrawal. Aim for abstinence.
LSD
Increased risk of spontaneous abortion. No neonatal effects
demonstrated. Aim for abstinence.
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24.9 USEFUL
CONTACTS
Cumbria Drug and Alcohol Services
113-117 Botchergate
CARLISLE
Cumbria
Tel: 01228 882299
Straightline – Drug and Alcohol Services for under 19 years
113-117 Botchergate
CARLISLE
Cumbria
Tel: 01228 882299 (Mobile: 0788 777 3898)
Fast-track – Immediate access to someone in drug and alcohol services
John Plaskett (Mobile: 0787 963 0512) - Available Monday – Friday
CADAS (Cumbria Alcohol and Drug Advisory Service)
Tel: 01228 544140
Signpost – 24-hour telephone helpline for drug/alcohol users, family or friends
Tel: 0800 0838449
DRUG AND ALCOHOL MIDWIFE CONTACT;
Vanessa Kelly (Mobile: 0777 0999 0038)
Named Nurse Child Protection – Shelagh Dixon
Work: 01228 814160 (pager #6461)
Mobile 0779 522 3912
Named Midwife Child Protection – Linzi Musgrave
Howgill: 01946 62681
Mobile: 07867 553483
WCH: 01946 693181 ext 4253
CASUMS (Child and Adolescent Substance Use / Misuse Service)
Tel: 01228 603033
Turning Point – Drug and Alcohol Services - Workington
Tel: 01900 65737
Turning Point – Family Support Group - Workington
Tel: 01900 604086
NCABS – North Cumbria Addictive Behaviour Service
Carlisle Office
– Tel 01228 603020
Whitehaven Office – Tel 01946 599413
Penrith Office
– Tel 01768 861280
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Reference
Hepburn M, Personal Communication, Nov 2003
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CHAPTER 25 - MATERNAL COLLAPSE AND ACUTE MEDICAL
PROBLEMS
25.1
MATERNAL COLLAPSE AND ACUTE MEDICAL PROBLEMS .......................252
25.2
TRANSFER TO THE INTENSIVE CARE UNIT.................................................254
25.3
UTERINE RUPTURE ........................................................................................256
25.4
MATERNAL STEROID COVER FOR DELIVERY.............................................256
25.5
MANAGEMENT OF HAEMOGLOBINOPATHIES.............................................256
25.6
SCREENING FOR HAEMOGLOBINPATHIES IN PREGNANCY .....................256
25.7
THALASSAEMIA SYNDROMES.......................................................................257
25.8
HAEMOGLOBIN VARIANTS – SICKLE CELL SYNDROMES ..........................257
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25.1 MATERNAL COLLAPSE AND ACUTE MEDICAL PROBLEMS
Acute Collapse
Sudden unexpected maternal collapse before, during or after delivery constitutes a medical
emergency. When faced with this ….
approach patient
ensuring that
you yourself are safe
Responsive
shake and shout at the patient
Leave the
woman in the
not responsive
position you
Shout for help
found her
ensure the airway is open
Go for help
head tilt
chin lift
Breathing
check for evidence of breathing
Put in the
recovery
not breathing
position
Go for help
give 2 effective rescue breaths
check the carotids for signs of a pulse
Pulse present
no pulse
Continue
rescue breaths
until
commence CPR
spontaneous
breathing
15% left sided pelvic tilt
resumes
2 breaths to 30 chest compressions
continue until senior help arrives
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Additional help should always be summoned when faced with maternal collapse:
♦ Midwife in charge of Delivery Suite
♦ Senior House Officer
♦ On call SpR
♦ On call anaesthetist SpR and anaesthetic consultant
♦ On call consultant obstetrician
During the resuscitation procedure:
♦ Gain IV access – 2 x 16g cannulae if possible
♦ Give facial oxygen at up to 15 litres / minute
♦ Check the blood pressure – attach to a dynamap
♦ Check the oxygen saturation – attach to an oxygen saturation monitor
By now you should be trying to determine the cause for the collapse. Consider:
♦ Bleeding – revealed or concealed
♦ Thromboembolism
♦ Amniotic fluid embolism
♦ Myocardial
infarction
♦ Total spinal anaesthesia
♦ Hypotension
Investigations will be guided by the clinical circumstances but might usefully include:
♦ Hemacue and / or haemoglobin
♦ Clotting screen including fibrinogen
♦ Arterial blood gases
♦ Chest
x-ray
♦ ECG
♦ Urgent cross match of 4 units of blood
Further management will be planned after discussion with the consultants on call for
Obstetrics and Anaesthesia. This discussion will involve the on call haematologists and
general physicians where appropriate.
Consider caesarean section, primarily to assist maternal resuscitation:
♦ Gestation > 24 weeks
♦ Cardiac arrest > 4 minutes
♦ No anticipated immediate response to alternative measures such as volume replacement
for acute blood loss
Perimortem caesarean section should be considered in any woman who presents in cardiac
arrest or is apparently dead at gestation > 24 weeks, even when there is no anticipation of
restoring maternal life. The chance of intact neurologic status is related to the time interval
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from cardiac arrest to delivery, varying form 98% with delivery in 0-5 minutes, to 25 % with
delivery at 26-35 minutes post arrest.
Cardiac Arrest
The cardiac arrest team may be able to offer assistance when urgent medical assistance is
required. The on call consultant obstetrician should be made aware that the arrest team is
being called however, usually before assistance is requested.
The number to call is:
♦ Arrest team is on:
CIC ext 2222
WCH ext 2222
Breathing
♦ Respiration rate under 8 and over 30 per minute
♦ Oxygen saturation under 90% despite 60% inspired O2
♦ Arterial
PaO2 under 8 kPa despite 60% inspired O2
♦
Discuss with obstetric anaesthetist and obstetrician
Circulation
♦ Pulse under 40 bpm
♦ Sinus rhythm over 130 bpm
♦ PH under 7.2
♦ Bicarbonate under 20
♦
Discuss with obstetric anaesthetist and obstetrician
Renal
♦ Urine output under 90 ml in 3 hours
♦ Excluding
pre-eclampsia
♦ Excluding
PPH
♦
Discuss with obstetric anaesthetist and obstetrician
Central Nervous System
♦ Patient does not respond to commands
♦
Discuss with obstetric anaesthetist and obstetrician 25.2 TRANSFER TO THE INTENSIVE CARE UNIT
The initial investigation and management of any acutely ill obstetric patient should be co-
ordinated by the SpR who must liaise with senior obstetric and anaesthetic staff. Review by
the Consultant Obstetrician should be requested at the earliest opportunity. Please refer to
Trust Policy ‘Safe Transfer of the Critically Ill Patient’ Policy Transfer to the Intensive
Treatment Unit at Cumberland Infirmary, Carlisle or West Cumberland Hospital, Whitehaven
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should only be undertaken however after full consultation with the Consultant Obstetrician, for
example:
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♦ after respiratory arrest
♦ deteriorating respiratory function potentially necessitating ventilation
♦ after cardiac arrest
♦ deteriorating cardiac function potentially requiring specialist intervention
♦ after massive haemorrhage with ongoing cardiovascular compromise
♦ after major, previously unplanned surgery
♦ organ failure outwith normal obstetric practice
♦ GCS under 12, or under 14 and falling
♦ Anaphylaxis
25.3 UTERINE
RUPTURE
If uterine rupture is suspected then the consultant on call must be informed and attend for
delivery and repair. At least 4 units of blood should be cross-matched. The paediatrician
should be present if delivery not yet taken place.
25.4 MATERNAL STEROID COVER FOR DELIVERY
Women taking maintenance steroids antenatally (usually in the form of Prednisolone, 10 mg
or more per day) should be given steroid cover in labour. The plan of action should be
detailed in the antenatal notes but will commonly take the form of parental hydrocortisone:
♦ Hydrocortisone 100 mg IM or IV
♦ Six hourly throughout labour
♦ Continued postpartum until a light diet can be tolerated
25.5 MANAGEMENT OF HAEMOGLOBINOPATHIES
These are inherited defects of Haemoglobin resulting from:
1.
Impaired globin synthesis (thalassaemia syndromes), or
2.
Structural abnormality of globin (Hb variants)
With the increased stress of haemopoiesis during pregnancy the clinical effects of these
haemoglobin defects, even in the heterozygote state may complicate obstetric management.
Prenatal diagnosis of a fetus at risk of a serious Hb defect is possible.
25.6 SCREENING FOR HAEMOGLOBINPATHIES IN PREGNANCY
1. The important haemoglobinopathies, which should be screened for at Booking are
Thalassaemia and Sickle Cell Disease.
2. The Haematology Laboratory will follow the recommendations of the British Committee
for Standards in Haematology / General Haematology Task Force. They will
automatically screen for Thalassaemia if the Hb is low, MCH is low the MCHC is
normal.
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Any blood count that has an MCH less than 27 pg will have a ferritin assay done followed by
electrophoresis if it is normal.
Any persistent microcytosis should have Hb electrophoresis requested.
3. The midwifery staff will incorporate in the list of booking questions the enquiry as to the
ethnicity of the patient. If there is any chance of black African or Afro-Caribbean
ancestry, the patient’s blood should be screened for Sickle Cell Disease. From
knowledge of the patient’s family, it may be appropriate for the midwife to omit this
question. This must be on the Midwife’s responsibility and at her own discretion.
25.7 THALASSAEMIA
SYNDROMES
Either the alpha or the beta globin chain synthesis is depressed.
Beta Thalassaemia
Major Beta Thalassaemia
¾ Avoid iron
¾ Give folate
¾ Regular transfusions for anaemia
¾ Screen partner and consider counselling and prenatal diagnosis if trait/minor
Minor/trait Beta Thalassaemia
¾ Give folate
¾ Oral, not parenteral iron if low ferritin
¾ Transfusion for anaemia
¾ Screen partner and consider counselling and prenatal diagnosis if trait/minor
Alpha Thalasseamia (Minor)
¾ Give folate
¾ Transfusion for severe anaemia
¾ Screen partner and consider counselling and prenatal diagnosis if positive
There are no specific management plans indicated in labour or postnatally for thalasseamia
patients.
25.8 HAEMOGLOBIN VARIANTS – SICKLE CELL SYNDROMES
Pre-pregnancy
¾ Counsel against conception until disease status optimised, assess renal and liver
function.
¾ Avoid IUCD
¾ Counsel re. Risks of pregnancy
¾ Screen partner and if trait or positive counsel regarding prenatal diagnosis.
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Antenatal
¾ Hb electrophoresis screening of whole population or high risk groups
¾ Screen partner and consider counselling and prenatal diagnosis if trait or disease
¾ Regular transfusions to maintain Hb at 9-12 g/dl with 60-70% Hb A. Discuss
management with National Centre (via Fetal Medicine at RVI).
¾ Prompt treatment of crises (adequate hydration, oxygen, screen for infection) may
include exchange transfusions
¾ Avoid tourniquets
¾ Fetal surveillance for fetal well being
¾ Screen for : Urinary infection
Hypertension/pre-eclampsia
Renal and liver function
SFD and Umbilical artery Dopplers
Labour
Ensure adequate hydration
¾ Avoid hypoxia
¾ Continuous CTG
Postnatal
¾ Consider use of prophylactic antibiotics
¾ Maintain good hydration and oxygenation especially for the first 24 hours
¾ Contraceptive counselling
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Reference
Browne I
et al (2003) Sickle cell disease in pregnancy – Eurpoean Journal Anas. 20: 75-76
Rees DC (2003) Guidelines for management of the acute painful crisis in sickle cell disease –
British Journal Haematology – 120; 744-752
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CHAPTER 26 - PREGNANCY LOSS AND MATERNAL DEATH
26.1
BACKGROUND ................................................................................................261
26.2
THREATENED MISCARRIAGE........................................................................261
26.3
TERMINATION OF PREGNANCY FOR FETAL ABNORMALITY.....................261
26.4
INTRAUTERINE DEATH ..................................................................................262
26.5
SUPPORT NETWORK .....................................................................................262
26.6
TOPICS FOR DISCUSSION AND CONSIDERATION......................................263
26.7
MANAGEMENT OF PREGNANCY LOSS ........................................................264
26.8
FETUS OVER 24 WEEKS (NO POST MORTEM) ............................................266
26.9
FETUS OVER 24 WEEKS (FOR POST MORTEM)..........................................267
26.10
FETUS UNDER 24 WEEKS (NO POST MORTEM) .........................................269
26.11
FETUS UNDER 24 WEEKS (FOR POSTMORTEM) ........................................270
26.12
CYTOGENETIC SAMPLES TRANSPORT ARRANGEMENT...........................271
26.13
TWINS ..............................................................................................................272
26.14
CHAPLAINCY ...................................................................................................272
26.15
BAPTISM ..........................................................................................................272
26.16
REGISTRATION OF DEATHS AND STILLBIRTH ............................................273
26.17
PROCEDURE FOR CARE OF THE PRE-VIABLE BORN INFANT ..................273
26.18
MANAGEMENT OF STILLBIRTH INCLUDING DELIVERY, POSTNATAL CARE AND
LAYING OUT ....................................................................................................273
26.19
PROCEDURE FOR USE OF THE CRADLE ROOM.........................................275
26.20
HAND AND FOOT PRINTS ..............................................................................276
26.21
BEREAVEMENT COUNSELLORS ...................................................................276
26.22
POSTNATAL REVIEW......................................................................................277
26.23
MATERNAL DEATH .........................................................................................277
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26.1 BACKGROUND
Failure to produce an expected live, healthy baby may lead to a sense of failure, shame or
guilt. The resultant low self-esteem makes it more difficult for parents to express their needs,
leaving them feeling out of control. The gestation at which pregnancy loss occurs makes little
difference to the patients: it is their baby irrespective of gestational age. Fundamental
changes have taken place recently in our attitudes to pregnancy loss. We know now that the
provision of physical comfort, good communication skills, attention to spiritual needs,
maintenance confidentiality and participation in decision making are necessary for the grieving
family. The provision of a designated, customised room for parents’ use is also
recommended. While poor practice can have a detrimental effect on a woman’s recovery,
good management can help to restore dignity.
26.2 THREATENED
MISCARRIAGE
Women with a threatened miscarriage who are less than 16 weeks pregnant are admitted to
the Early Pregnancy Assessment Unit or the on call gynaecologist.
Women with a threatened miscarriage who are 16 weeks and over are admitted to the
Maternity Assessment Unit. Management thereafter will be determined by:
• The presence or absence of a fetal heart beat
• The woman’s blood group. Rhesus negative women should have their Kleihauer
checked and will normally be given anti-D 250 iu by Intramuscular injection.
26.3 TERMINATION OF PREGNANCY FOR FETAL ABNORMALITY
The Antenatal Clinic will liaise with Delivery Suite in arranging admission at a time to suit the
parents. The procedure for termination and appropriateness of investigations should be fully
explained.
They may choose either to stay in the hospital until the day of termination or to return home.
Whichever choice is made, the relevant personnel should be informed and a network of
support initiated. Good communication between professionals is essential.
If the parents wish to return home prior to the termination they should be informed that they
can return to hospital at any time for any reason, if they choose to do so.
Teardrop stickers should be attached to the front covers of the Obstetric and handheld notes.
They should be applied before discharge home and the date of delivery late added.
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26.4 INTRAUTERINE
DEATH
Diagnosis may be made by ultrasound in any of the Directorates clinical areas. The parents
will then need time to come to terms with this bad news before management can be
discussed. This will help them take on board the information they have been given and will
enable them to express their feelings worries and doubts.
A list has been designed to help the parents think about issue surrounding the labour and
delivery. The procedure for induction of labour and the appropriateness of investigations
should be fully explained. Arrangements should be made for induction to take place at an
appropriate time to suite the parents.
Teardrop stickers are now available, for attachment to the front covers of both Obstetric and
Handheld notes. They should be applied at the time of diagnosis and the date of delivery
added later.
Arrangements should be made for the Obstetric notes to be sent to or kept on Delivery Suite.
26.5 SUPPORT
NETWORK
Diagnosis
Allow time
Discussion and choices
HOME
AND / OR
HOSPITAL
Support network:
Inform and offer visit by:
Delivery suite, 24 hour service
Community Midwife
Community Midwife
Chaplain
Counsellors Counsellors
Inform GP
Inform GP
48 hour return appointment
Gradual giving of information
Information Leaflets
Formulation of birth plan with midwife
Time to formulate birth plan with family
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26.6 TOPICS FOR DISCUSSION AND CONSIDERATION
Oral mifepristone
36-48 hours later, commence 3 hourly misoprostol orally or vaginally
analgesia
delivery
if / when to see their baby
momentoes:
Photographs: digital x 2 and Polaroid for obstetric notes
own
camera
Hand and footprints
Lock of hair (if possible)
Identification bands and cot card
Certificate of birth (babies under 24 weeks)
Registration and Stillbirth certificate (babies of 24 weeks and over)
Memory boxes – WCH
Caring & memory booklet - WCH
Outfit for the baby
Gift or toy for baby
Blessing and funeral
Support:
Hospital Midwife
Community
Midwife
Chaplain
Bereavement
Counsellor
Investigations, maternal and baby
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26.7 MANAGEMENT OF PREGNANCY LOSS
Caution must be exercised when prescribing Mifepristone and Misoprostol. The dosage is
dependent upon the gestational age.
Pregnancy Under 24 weeks
All women should be offered 200 mg oral Mifepristone priming unless contraindicated. This is
given in the hospital, but the woman can be allowed home 30 minutes after administration.
She should be told to contact Delivery Suite if vomiting occurs within 2 hours, to enable the
medication to be repeated. The possible side effects of faintness, headache, nausea and
vomiting and skin rashes must be explained.
Admission to Delivery Suite should be arranged for 36-48 hours later. Misoprostol should be
given on admission to hospital (see guideline 4.8). Side effects include diarrhoea, nausea,
vomiting, hot flushes, dizziness, chills and headaches.
Consultant review is mandatory if the patient has not delivered within 24 hours.
Continued use of prostaglandins at the present dose may be considered with or without a
delay of 24 hours. Rarely, physical methods of uterine evacuation may be employed.
See Chapter 26.8 ‘Procedure following pregnancy loss under 24 weeks’ for care of the baby
following delivery.
Pregnancy of 24 Weeks and Over
All women should be offered Mifepristone priming with a single oral dose of 200 mg, unless
contraindicated. This is given in the hospital, but the woman can be allowed home 30 minutes
after administration. She should be told to contact the Delivery Suite if vomiting occurs within
2 hours, to enable the medication to be repeated. The possible side effects of faintness,
headache, nausea and vomiting and skin rashes must be explained.
Admission to Delivery Suite should be arranged for 36-48 hours later. Misoprostol should be
given on admission to hospital (see guideline 4.8). Side effects include diarrhoea, nausea,
vomiting, hot flushes, dizziness, chills and headaches.
Consultant review is mandatory if the patient has not delivered within 24 hours.
Continued use of Misoprostil at the present dose may be considered with or without a delay of
24 hours.
See Chapter 26.9 ‘Procedure following pregnancy loss at 24 weeks and over’ for care of the
baby following delivery.
Relative contraindications to Misoprostol
• Uterine
scar
• Chronic Pulmonary Disease
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• Chronic Cardio-Vascular Disease
• Chronic Renal Compromise
In such cases the use of Misoprostol must be discussed with the patient’s Consultant or the
Consultant on call for Delivery Suite.
Intrauterine death at term – Initiation of Labour
Pre-treatment with Mifepristone 200 mg orally should be given to help shorten the delivery
process.
Because of the theoretical risk of causing uterine hypertonicity, prostin tablets
may be used to
induce labour instead of Misprostol, at gestations beyond 37 weeks. This is particularly useful
when a woman has any additional risk factors for uterine rupture.
• Prostin 3 mg tablet as per induction guideline (Chapter 4.5)
• Side effects include diarrhoea, nausea and vomiting, hot flushes, dizziness and
headaches.
The membranes should not be artificially ruptured until delivery is imminent, except in unusual
circumstances, e.g. clinically significant antepartum haemorrhage. If the membranes rupture
spontaneously before labour is established, further management should be discussed with the
senior SpR or the Consultant. It would then be reasonable to commence intravenous
syntocinon, depending on the stage of labour and the woman’s parity.
Consultant review is mandatory if the patient has not delivered within 24 hours.
Continued use of prostin tablets at the present dose may be considered with or without a
delay of 24 hours. Alternatively, misoprostol may be then be used at a dose of 100 mcg 3
hourly or rarely, physical methods of uterine evacuation may be employed.
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26.8 FETUS OVER 24 WEEKS (NO POST MORTEM)
Gestation of the fetus over 24 weeks – Not to be sent to the Centre of Life
Ensure Investigation checklist for late pregnancy loss and stillbirth is completed.
CORRECT SAMPLES FOR CHROMOSOME ANALYSIS (CYTOGENETICS)
Biopsy: Skin and Muscle:
Approximately 1 cm of skin and muscle is taken from the back of the thigh and placed in
sterile saline solution.
Biopsy: Placental and Membrane:
When a biopsy of the placenta is taken please include membrane in the specimen and place
in sterile saline.
Please keep all specimens in the fridge until it is collected for transport.
Forms to accompany samples to include:
• Consent forms for chromosome (Cytogenetic) analysis after Pregnancy Loss or
Termination
• Cytogenetics form must be completed and be secured with specimen
Samples sent to:
FAO Dr Carol English
Institute of Human Genetics
International Centre for Life
Central Parkway
Newcastle-Upon-Tyne
NE1 3BZ
Tel: 0191 241 8796 (Direct Line)
NOTE – Please phone to notify the samples are going to be sent
Samples:
• To be stored in the cradle room
• Not to be sent over weekend as Centre closed. Samples to arrive during week prior to
1630 hrs as Centre closes at 1700 hrs.
• Arrange next day delivery with TNT, Tel 0800 100 600
• Fill out transport label
BABY
•
(CIC) Telephone Mr Tremble regarding the baby. Tel: 01228 594831 / 711543
•
(WCH) Telephone E Kegg, Ext 2816
• If there are any unusual requests by parents for cremation / burial contact
Bereavement Counsellor to ensure correct procedures are carried out.
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Forms to accompany fetus for disposal
(for Funeral Director)
• Certificate of Medical Practitioner in Respect of Fetal Remains – over 24 weeks
• Baby Internment Details Form
• Medical Certificate of Stillbirth (Death Certificate – blue book)
• Burial Certificate (obtained from the Registrar of Births, Marriages and Deaths)
• Funeral arrangement form (Stillbirth and neonatal death form)
• Cremation – if parents want cremation, fill in cream coloured cremation form and notice
of cremation (pink form)
• Ensure information leaflet on registering deaths and stillbirths are given to parents.
26.9 FETUS OVER 24 WEEKS (FOR POST MORTEM)
Gestation of the fetus over 24 weeks – Not to be sent to the Centre of Life
Ensure Investigation checklist for late pregnancy loss and stillbirth is completed.
CORRECT SAMPLES FOR CHROMOSOME ANALYSIS (CYTOGENETICS)
Biopsy: Skin and Muscle:
Approximately 1 cm of skin and muscle is taken from the back of the thigh and placed in
sterile saline solution.
Biopsy: Placental and Membrane:
When a biopsy of the placenta is taken please include membrane in the specimen and place
in sterile saline.
Please keep all specimens in the fridge until it is collected for transport.
Forms to accompany samples to include:
• Consent forms for chromosome (Cytogenetic) analysis after Pregnancy Loss or
Termination
• Cytogenetics form must be completed and be secured with specimen
Samples sent to:
FAO Dr Carol English
Institute of Human Genetics
International Centre for Life
Central Parkway
Newcastle-Upon-Tyne
NE1 3BZ
Tel: 0191 241 8796 (Direct Line)
NOTE – Please phone to notify the samples are going to be sent
POST MORTEM
CIC: Mr Tremble (Funeral Director), Tel: 01228 594831 / 711543 will take the samples to the
Centre of Life and then take the fetus and dry placenta to the RVI.
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WCH: E Kegg, Ext 2816
Fetus (and if requested) Placenta to go to RVI (Placenta – dry)
Samples sent to:
FAO Chris Wright (Pathologist)
Pathology Department
RVI
Queen Victoria Road
Newcastle Upon Tyne
NE2 4LP
NOTE – Please contact Chris prior to sample being sent – RVI Pathology
Forms to accompany fetus
• Request for a Perinatal Post Mortem Examination – ensure arrangements to return
baby is completed on form
• Consent to the post mortem examination of a baby
Forms to accompany fetus for disposal
(for Funeral Director)
• Certificate of Medical Practitioner in Respect of Fetal Remains – over 24 weeks
• Baby Internment Details Form
• Medical Certificate of Stillbirth (Death Certificate – blue book)
• Burial Certificate (obtained from the Registrar of Births, Marriages and Deaths)
• Funeral arrangement form (Stillbirth and neonatal death form)
• Cremation – if parents want cremation, fill in cream coloured cremation form and notice
of cremation (pink form)
• Ensure information leaflet on registering deaths and stillbirths are given to parents.
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26.10 FETUS UNDER 24 WEEKS (NO POST MORTEM)
Gestation of the fetus under 24 weeks – To be sent to the Centre of Life
Ensure Investigation checklist for late pregnancy loss and stillbirth is completed.
CORRECT SAMPLES FOR CHROMOSOME ANALYSIS (CYTOGENETICS)
Fetus:
The fetus should be wrapped in a clean sheet and stored in the cradle room. To be sent
intact. If parents refuse for baby to be sent but consent to skin and muscle to be taken, place
1 cm of skin and muscle in sterile saline solution
Biopsy: Placental and Membrane:
Placenta is sent dry and complete. If a biopsy is taken please include membrane in the
specimen and place in sterile saline.
Please keep all specimens in the fridge until it is collected for transport.
Samples sent to:
FAO Dr Carol English
Institute of Human Genetics
International Centre for Life
Central Parkway
Newcastle-Upon-Tyne
NE1 3BZ
Tel: 0191 241 8796 (Direct Line)
NOTE: Please phone to notify the samples are going to be sent
Not to be sent over the weekend as the Centre is closed.
Samples to arrive during week prior to 1630 hrs as the Centre closes at 1700
hrs.
Forms to accompany samples for Chromosome Analysis to include:
• Consent forms for chromosome (Cytogenetic) analysis after Pregnancy Loss or
Termination
• Cytogenetics form must be completed and be secured with specimen
Forms to accompany fetus for disposal
(for Funeral Director)
• Certificate of Medical Practitioner in Respect of Fetal Remains
• Baby Internment Details Form
• Funeral arrangement form (Stillbirth and neonatal death form)
• Cremation – if parents want cremation, fill in cream coloured cremation form and notice
of cremation (pink form)
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26.11 FETUS UNDER 24 WEEKS (FOR POSTMORTEM)
Gestation of the fetus under 24 weeks – To be sent to the Centre of Life
Ensure Investigation checklist for late pregnancy loss and stillbirth is completed.
CORRECT SAMPLES FOR CHROMOSOME ANALYSIS (CYTOGENETICS)
Fetus:
The fetus should be wrapped in a clean sheet and stored in the cradle room
Biopsy: Placental and Membrane:
Placenta to be sent dry and complete. If a biopsy of the placenta is taken please include
membrane in the specimen and place in sterile saline.
Placenta:
Please keep all specimens in the fridge until it is collected for transport.
Samples sent to:
FAO Dr Carol English
Institute of Human Genetics
International Centre for Life
Central Parkway
Newcastle-Upon-Tyne
NE1 3BZ
Tel: 0191 241 8796 (Direct Line)
NOTE – Please phone to notify the samples are going to be sent
Forms to accompany samples to include:
• Consent forms for chromosome (Cytogenetic) analysis after Pregnancy Loss or
Termination
• Cytogenetics form must be completed and be secured with specimen
POSTMORTEM
CIC;
Mr Tremble (Funeral Director), Tel: 01228 594831 / 711543 will take the samples to
the Centre of Life and then take the fetus and dry placenta to the RVI. Placenta (dry
– put in tube - then put tube in bubble wrap box)
WCH; E Kegg, Ext 2816
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Samples sent to:
FAO Chris Wright (Pathologist)
Pathology Department
RVI
Queen Victoria Road
Newcastle Upon Tyne
NE2 4LP
NOTE – Please contact Chris prior to sample being sent – RVI Pathology
Forms to accompany fetus
• Request for a Perinatal Post Mortem Examination – ensure arrangements to return
baby is completed on form
• Consent to the post mortem examination of a baby
Forms to accompany fetus for disposal
(for Funeral Director)
• Certificate of Medical Practitioner in Respect of Fetal Remains – over 24 weeks
• Baby Internment Details Form
• Funeral arrangement form (Stillbirth and neonatal death form)
• Cremation – if parents want cremation, fill in cream coloured cremation form and notice
of cremation (pink form)
TRANSPORT OF FETUS / INFANT UNDERTAKER
Every fetus / infant going for investigation at Newcastle (RVI / Centre For Life) must be
transported by the undertaker.
CIC; John
Tremble
WCH;
E Kegg, Ext 2816
37 Church Street
CARLISLE
Cumbria
Tel: 01228 594831 / 711547
Fax: 01228 536080
26.12 CYTOGENETIC SAMPLES TRANSPORT ARRANGEMENT
TNT have the contract to transport Cytogenetic samples to Newcastle, to arrange for
collection telephone 0800 777222 and ask for collection (next day service).
Account No. 0440069009
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26.13 TWINS
1.
If a twin dies in utero, no matter what gestation and the other twin is born over 24 weeks
gestation, the fetus has to be registered as a stillbirth.
2.
The Registrar will only accept a Stillbirth Certificate if it has a sex on it.
3. Parents are required to register the fetus and return the disposal certificate to the
Maternity Ward. Alternatively, forms can be given to the Community Midwife to bring
back to the Maternity Ward.
4. The doctor who sees the fetus should, if possible, state the sex of the baby. If not
obvious he / she must ask pathology. If pathology are not sure of the sex the parents of
the fetus can be asked to choose a sex.
5.
See “Information for Parents after Stillbirth” for information regarding burial or cremation
of fetus.
26.14 CHAPLAINCY
Some members of the Chaplaincy Team carry pagers and can therefore be contacted more
quickly than by telephone, contact pagers via switchboard.
An on-call rota for alternative religions is available via switchboard.
26.15 BAPTISM
1.
Parents permission should be obtained and the clergyman of the appropriate
denomination contacted.
2.
Ensure the correct name for the baby.
3.
Set a small trolley in the mothers room with a Christening bowl and spoon and flowers.
4.
Escort the minister to the room when he arrives and give him time to wash his hands.
5.
The midwife should be present to support the parents throughout the service.
6.
Ensure Baptismal Book is completed and signed by the Minister who will extract
relevant information for his records. The book is kept on SCBU.
7.
Hospital Baptism Certificate is given to parents.
8.
If death is imminent the midwife may perform the Baptism.
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26.16 REGISTRATION OF DEATHS AND STILLBIRTH
•
The death / stillbirth must be registered within 5 days
•
Please phone Registrar (01228 607430 or 607433) to inform of stillbirth
•
These parents do not need notification of birth sheet
•
The parents must be given the death certificate issued by the doctor
•
The registrar will, on registering the stillbirth will issue a Certificate of Burial or
Cremation. If a hospital burial or cremation the certificate should be bought back to the
maternity ward. Funeral Directors will collect it. If for private funeral the certificate
should be given to the undertaker of choice.
•
Registration can be arranged by an appointment system if wished.
26.17 PROCEDURE FOR CARE OF THE PRE-VIABLE BORN INFANT
If the baby is born before 24 weeks gestation and active measures to preserve life are taken
and the baby subsequently dies, please follow normal neonatal death procedure.
If the birth is so premature that an abortion is expected, this baby may breathe at birth and live
for a matter of minutes or hours.
a) If the paediatrician wishes, the baby should be transferred to an incubator in SCBU, or
b) With the agreement of the paediatrician, the baby should be wrapped up and placed in a
Moses basket.
If the parents wish, the baby may stay in the room with the parents until breathing
ceases.
If the parents do not wish this to happen, the baby may be transferred in the Moses
basket to the nursery.
The baby can be returned to the parents at any time should they so wish.
Photographs may be taken on the infant in the Moses basket.
26.18
MANAGEMENT OF STILLBIRTH INCLUDING DELIVERY,
POSTNATAL CARE AND LAYING OUT
Labour
If the mother and her partner know that their baby is going to be stillborn, an opportunity
should be made while she is in early labour to discuss with her and her next of kin, who, if
anyone, she would like to be present at the delivery and to introduce the idea of her holding
her stillborn infant when it is born.
The first answer must not necessarily be accepted as the right answer and supportive
discussion will need to take place to help the parents to come to a decision.
A midwife should not be expected to take charge of the case if she has never witnessed a
stillbirth before.
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Ideally, this midwife should be encouraged to be involved as the 2nd midwife in the providing
care.
The mother should be given adequate analgesia and if in doubt about how much she can be
given, medical advice should be sought.
Delivery
The baby should be delivered into a baby wrap and wrapped in blankets.
If the mother an / or father wish to hold their infant, the baby should be given to them as soon
as possible whilst the baby still feels warm.
If they do not wish to hold their infant, the baby should be placed in the cot and later taken to
another room. Under no circumstances should the baby be placed on the delivery trolley.
If it has been an unexpected stillbirth, the paediatrician will probably be present at delivery and
will be able to sign the stillbirth certificate. If it is an IUD and there is no doctor present, the
registrar should be bleeped to see the baby as soon as possible.
Any arrangements the parents wish to discuss can be done so through the midwife in charge
of the case.
Postnatally
Usually the parents will remain on the Delivery Suite until discharge home.
Ensure the checklist is completed including the date and time for the parents to return to
discuss the case at a later date when any test results will be available.
Ensure all paperwork is filled out correctly and that specimens are collected and dispatched
appropriately according to the guidelines.
The mother and her partner should be allowed open visiting for family and friends should the
parents wish this.
The SANDS booklet should be offered to the parents prior to discharge. The parents may
also find comfort in receiving footprints of their baby and / or hat and bootees the baby was
dressed in.
The SANDS are also offering a small pair of teddy bears for the parents. The first bear to be
buried with the baby and the second bear to be kept by the parents as a keepsake.
The discharge letter should be completed and sent to the GP and midwife through the postal
system.
At a suitable time, inform the parents of the various arrangements to be made. If the parents
cannot make any decisions prior to discharge the Community Midwife can liaise with the ward.
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Laying Out the Baby
1.
Clamp the cord with a Hollister Clamp
2.
Gently wash off any excess blood or meconium if the skin is not too macerated.
3.
Label the baby with a namelet on the ankle.
4.
Complete details as requested on checklist sheet and on Investigation of Perinatal Death
sheet.
5.
Dress or wrap the baby in a suitable way. The parents may wish the baby to be dressed
in clothes that they provide.
6.
A digital photo to be taken and put in the notes. Then take some photos for the parents.
The parents may wish for photos holding the fetus.
7.
A completed cot card must accompany the baby for identification purposes.
8.
When all interested parties have seen the baby, wrap the baby in an outer sheet, seal
with tape and transfer to the cradle room.
9. In cases where the parents do not wish to see or hold the baby immediately after
delivery, the baby should be placed in the cradle room.
26.19 PROCEDURE FOR USE OF THE CRADLE ROOM
1. When parents have had the time they wish with their baby the midwife from Delivery
Suite will put the baby in the fridge in the cradle room and complete the record book,
which is kept on top of the fridge.
2.
If the baby is for post mortem write this in the record book in the cradle room.
3. The midwife is to inform the mortuary of any baby put in the cradle room for post
mortem.
4.
When the baby goes for post mortem the midwife should escort the porter to the cradle
room to collect the baby. Both should sign the book. When the baby is returned the
porter is to sign the book and inform staff of the return.
5.
The fridge temperature should be at 4oC and checked daily by a nursing assistant.
6. When babies are in the cradle room please write their names on the Maternity Ward
board.
7.
A progress report to be given at each changeover of staff, e.g. if baby has gone for post
mortem or not.
8. Undertakers to liaise with the midwife in charge of Maternity Ward before removing
babies from the Hospital and sign the record book.
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26.20 HAND AND FOOT PRINTS
This is a two person job.
Equipment: Wipes
Sensitised certificates or labels
White
envelopes
1.
Ensure the child’s feet are clean and dry.
2.
The first person, using the wipe, gently wipes the child’s hand / foot. NOTE – the wipe
may feel dry – this is normal.
3.
The second person, holds the certificate / label while the first person positions the child’s
foot gently, but firmly, press to make a good print.
Be very careful as the wipe will also coat your fingers and if you touch the sensitised
certificate, your fingerprint will also appear.
It will take at least 30 seconds for the print to appear a pale lavender colour.
4.
Repeat the process for the other hand / foot.
5.
If the wipe is not used immediately, please store in a cool dry place, away from the light,
and ensure that the bag remains sealed and airtight.
6.
Place the prints in a white envelope to protect them from fading.
Your Manager can re-order wipes and sensitised paper as required from:
Ontiles
Ltd
7 Brockwell Park Row
LONDON
SE2
2YH
26.21 BEREAVEMENT COUNSELLORS
Please ensure that bereaved parents have contact number for Bereavement Counsellor or
Co-ordinator before discharge. If possible arrange for the parents to meet the before
discharge.
If there are any special requests by parents for cremation / burial please contact Bereavement
Counsellor so that she can ensure the correct procedures are put in place.
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26.22 POSTNATAL REVIEW
The Consultant who is responsible for the patients care should be informed about the stillbirth
or neonatal death before the patient leaves the hospital. The SHO or SpR on call at the time
death is responsible for this communication.
The midwife discharging the patient is responsible for making arrangements for counselling.
This will be via the Obstetrics Secretary, usually about 6-8 weeks after the event.
26.23 MATERNAL DEATH
Maternal death is a death that occurs during or within a year of pregnancy childbirth or
abortion. It can be classified as directly related to pregnancy, indirectly related, late or
coincidental:
Direct - Deaths resulting from obstetric complications of the pregnant state [pregnancy, labour
and puerperium], from interventions, omissions, incorrect treatment or from a chain of events
resulting from any of above
Indirect - Deaths resulting from previous existing disease or disease that developed during
pregnancy and which was not due to direct obstetric causes, but which was aggravated by the
physiologic effects of pregnancy e.g. Epilepsy, diabetes, cardiac disease
Late - Deaths occurring between 42 days and 1 year after abortion miscarriage or delivery
that are due to
Direct or
Indirect maternal causes
Coincidental [Fortuitous] - Deaths from unrelated causes, which happen to occur in
pregnancy or in the puerperium e.g. road traffic accident.
The responsibility for notifying the Public Health Director that a maternal death has occurred
should rest with the Consultant Obstetrician or the Head of Midwifery.
Appendix
In the event of the baby dying in-utero the following should be considered:
Definition of a stillbirth does not include the removal of a dead baby from its dead mother at
post mortem in order to ascertain cause of death. Therefore registration of a baby, in these
circumstances, over 24 weeks gestation, as a death is not legally required.
If the baby is delivered during Maternal resuscitation, the baby will be registered as either live
birth or stillbirth
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Checklist
ACTION YES
NO
DATE,
TIME,
SIGNATURE
COMMENTS
Notify immediately:
Consultant on call
Midwifery Manager on
call
Head of Midwifery
Supervisor of Midwives
on call
Next of kin informed by
Senior Medical Staff
Ensure all documentation is
completed
Mortuary informed
Pathologist informed by
Consultant
Post mortem consent
completed.
In case of unknown cause
Coroner can undertake this
without consent
Issue of Death Certificate
Chaplain to be informed
Inform following within
normal working hours:
Patients Consultant
General Practitioner
Community Midwives
Health Visitor
Chief Executive
LSA Midwifery Officer
Coroners Office
Public Health Director
Tel:603500
Director of Nursing
Clinical Director
Medical Director
CEMD Regional
Coordinator
CEMD National Coordinator
Documentation
Ensure all documentation is
complete
Complete Trust Incident
Report Form
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Phototcopy notes at earliest
opportunity
Copy Maternal Death
Certificate into notes
If referred to Coroner,
please state clearly
Stillbirth
Use stillbirth checklist in
separate folder
NB If death
occurs in-utero, please
refer to Appendix
Serious Untoward
Incident to be reported, in
line with Trust Untoward
Incident Reporting
Policy [see policy in Risk
Management Folder]
Support
Family Support,
bereavement counselling
Staff support & meetings
Debriefing
Statement writing
Critical Incident Review
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References:
Bourne S, Lewis E (1984) Pregnancy after stillbirth or neonatal death.
Lancet 289: 31-33
Peppers LG, Knapp RJ (1980) Maternal reactions to involuntary fetal / infant death.
Psychiatry 43: 155-159
Robb F (1999) Congenital malformations: breaking the bad news.
Br J Midwifery 7: 28-31
Estok P, Lehman A (1983) Perinatal Death: Grief support for families.
Birth 10: 17-25
Forrest GC, Standish E, Baum JD (1982), Support after perinatal death: a study of support
and counselling after perinatal bereavement.
BMJ 285: 1475 – 1479
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CHAPTER 27 - CORD PROLAPSE
27.1
CORD PROLAPSE ...........................................................................................282
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27.1 CORD
PROLAPSE
Definition:
Cord presentation is the presence of the fetal umbilical cord in advance of any other fetal part.
This may occur with or without rupture of the membranes.
Cord prolapse is the protrusion of the cord through the cervical os. This usually only occurs in
the absence of membranes.
Incidence of cord prolapse:
Between 0.2% and 0.4 %, but may be higher in ‘at risk’ pregnancies.
Risk Factors:
♦ Pre-term
♦ Small for gestational age
♦ Malpresentation
♦ Transverse
lie
♦ Breech presentation (particularly flexed breech and footling breech)
♦ Face
presentation
♦ Brow
presentation
♦ Oblique
lie
♦ Twins
♦ Polyhydromnios
♦ Amniotomy
Consequences:
Prolapse of the cord may result in:
♦ Cord
compression
♦ Vasospasm
Consequences for the fetus relate to the acute interruption of blood flow in the cord.
♦ Acute fetal hypoxaemia
♦ Acute
acidaemia
♦ Tissue
hypoxia
♦ Low arterial cord pH
♦ Apgar score at 5 minutes under 7
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Sometimes leading to:
♦ Fitting
♦ Long term cerebral dysfunction
♦ Death
Management:
When faced with cord prolapse, the aim of management is to:
♦ Keep pressure off the cord
♦ Keep the cord warm
♦ Delivery of the baby …
♦ Without jeopardising the mother’s safety
See the algorithm (figure 1)
(Figure 1)
Cord Prolapse
Stay calm
Call for help
Anaesthetist & anaesthetic nurse paediatrician
Senior SpR / Consultant Senior Midwife Auxiliary
use the fingers of your examining hand to apply
pressure
to the presenting fetal part
if the cord is lying outside the vagina
replace
it gently into the vagina
then
roll
the woman onto all fours
and
transfer
her to theatre
deliver her by
caesarean section
If the fetal heart is still audible
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Vaginal delivery in the presence of cord prolapse:
In some circumstances, vaginal delivery may be preferable despite cord prolapse. For
example, in the presence of a dead fetus the prolapsed cord will not obstruct delivery
vaginally. Attention must simply be paid to any associated fetal malposition.
When the fetus is alive, vaginal delivery may be considered if:
♦ The cervix is fully dilated
♦ A senior SpR or Consultant is present
♦ It
is
likely that vaginal delivery can be achieved rapidly …
♦ Without traumatising the cord
These conditions may be met for example in the delivery of a second twin presenting by
breech. Following delivery, the operator must always document the reasons for attempting
vaginal delivery rather than performing a caesarean section.
Filling the bladder
By filling the bladder rapidly with 500 ml normal saline at room temperature, pressure can be
taken off the cord effectively. This technique may be employed
instead of rolling the patient if
facilities are directly to hand, but transfer to theatre should not be delayed.
In brief, a litre of normal saline is run through a giving set and hooked up to a Foley’s catheter.
The catheter is passed through the urethra into the bladder and 500 ml saline is run through
rapidly. The balloon of the bladder is inflated, the catheter clamped and the bag of saline
removed.
The anaesthetic should be administered and the patient prepped for surgery with the bladder
full, but the clamp should be removed to allow the bladder to drain when the skin is being
incised. The operator must take particular care to avoid the bladder during the caesarean
section.
ARM with a high head:
This procedure will normally be performed by the SpR or the Consultant.
When an ARM is to be performed in the presence of a high head (3/5 or more palpable
abdominally), the operator should be ready to deal with cord prolapse. Therefore, the
anaesthetist and Senior Midwife should be ‘made aware’ and the operating theatre should be
available for use. The operator may choose to have available a litre of normal saline run
through a giving set, together with a Foley catheter.
Gentle pressure should be applied to the fetal head above the pubis by an attending midwife
while the membranes are ruptured with an amnihook. The operator’s hand should remain in
the vagina until the fetal head has descended low enough to prevent cord prolapse. If
syntocinon is to be used, this should be commenced at 0.6 ml / hr without delay.
A further vaginal examination is advisable 1 hour later to confirm the absence of cord. Vaginal
examination is mandatory if any fetal hear rate abnormalities arise after performing the ARM.
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References:
Prabulos AM, Philipson EH (1998) Umbilical cord prolapse. Is the time from diagnosis to
delivery critical?
J Reprod Med 43: 129-32.
Runnebaum IB, Katz M (1999) Intrauterine resuscitation by rapid urinary bladder instillation in
a case of occult prolapse of an excessively long umbilical cord.
Eur J Obstet Gynecol Reprod
Biol 84: 101-2.
Usta IM, Mercer BM, Sibai BM (1999) Current obstetrical practice and umbilical cord prolapse.
Am J Perinatol 16: 479-84.
Uygur D
et al (2002) Risk factors and infants outcomes associated with umbilical cord
prolapse,
Int J Gynaecol Obstet 78: 127-30.
Newcastle Hospitals NHS Trust, Delivery Suite Guidelines,
Sept 2004
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North Cumbria Delivery Suite Guidelines
CHAPTER 28 - PAEDIATRIC INVOLVMENT ON DELIVERY
SUITE
Please also refer to the Paediatric Guidelines ‘Management of Babies at Delivery and
on the Postnatal Wards’
28.1
CASES IN WHICH A PAEDIATRIC PROBLEM HAS BEEN IDENTIFIED
ANTENATALLY
......................................................................................................................2
89
28.2
URGENT INTRAUTERINE TRANSFER REQUESTS: THE HOT LINE
PROCEDURE
......................................................................................................................2
89
28.3
PAEDIATRIC ALERT DURING LABOUR
......................................................................................................................2
89
28.4
PAEDIATRIC PRESENCE AT DELIVERY (WCH ONLY)
......................................................................................................................2
89
28.5
RESUSCITATION OF NEONATES BY MIDWIVES (CIC ONLY)
......................................................................................................................2
90
28.6
URGENT CALL FOR PAEDIATRIC ASSISTANCE
......................................................................................................................2
90
28.7
MATERNAL ADVICE
......................................................................................................................2
91
28.8
ROUTINE MANAGEMENT OF THE BABY
......................................................................................................................2
91
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28.9
DELIVERY IN THEATRE
......................................................................................................................2
91
28.10
MANAGEMENT OF BABY AT BIRTH WITH MECONIUM STAINED LIQUOR
......................................................................................................................2
91
28.11
SKIN-TO-SKIN & HYPOTHERMIA GUIDELINES
......................................................................................................................2
92
28.12
HYPOGLYCAEMIA OF THE NEWBORN -
......................................................................................................................2
95
28.13
UNEXPECTED ABNORMALITY OR DEATH
......................................................................................................................2
99
28.14
HAEMOLYTIC DISEASE OF THE NEWBORN
......................................................................................................................2
99
28.15
GROUP B STREPTOCOCCUS INFECTION
......................................................................................................................2
99
28.16
CHILD ABDUCTION – PROCEDURE FOR STAFF
......................................................................................................................2
99
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28.1 CASES IN WHICH A PAEDIATRIC PROBLEM HAS BEEN
IDENTIFIED ANTENATALLY
Occasionally, a baby that may need paediatric involvement at or shortly after delivery is
identified antenatally. For example:
• congenital
abnormality
• previous cot death
• family history of disease
When this happens, the paediatric services can be notified in advance by discussing the
case with the paediatrician of the week at CIC or WCH.
28.2 URGENT INTRAUTERINE TRANSFER REQUESTS: THE HOT
LINE PROCEDURE
Details are included in Chapter 1.
28.3 PAEDIATRIC ALERT DURING LABOUR
In some circumstances it is helpful to notify the duty paediatrician where a mother is in
labour. This may enable the paediatrician to speak to the parents in advance of the
delivery or to be aware of issues that may be relevant to the delivery or care of the baby
following delivery. These may include:
• Multiple pregnancy <35/40
• Suspected fetal abnormality
• Preterm
labour
• Maternal
Pyrexia
• When specific instructions have been given on the case notes, e.g. on an alert
form
• Mother with Rhesus and / or other antibodies
28.4 PAEDIATRIC PRESENCE AT DELIVERY (WCH ONLY)
The duty Paediatrician should be present at delivery in the following circumstances:
• Caesarean section performed as an emergency for prolonged fetal distress
• Multiple births <35/40
• Thick fresh meconium staining of liquor
• Assisted delivery because of concerns about fetal wellbeing
• Mother with antibodies whose labour has been induced on fetal grounds
• Growth retardation where babies weight is < 2kg
• Delivery < 36 weeks gestation
• Prolonged fetal bradycardia
• Cord
prolapse
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28.5 RESUSCITATION OF NEONATES BY MIDWIVES (CIC ONLY)
The baby's condition at birth and the method or resuscitation, including Apgar scoring,
will be written in the baby's notes. Consultants should be called to be present at the
following problem deliveries:
• Premature births at gestation 34 weeks or less; intra-uterine growth retardation
where the baby's size is equivalent to 34 weeks or less than 2 kg.
• Multiple pregnancy less than 35 weeks.
• Significantly prolonged fetal distress.
• Thick meconium noted in labour.
• Known congenital abnormality; please discuss with the consultant on duty.
• Cord
prolapse.
Difficulties encountered during resuscitation
Midwives trained in advanced neonatal resuscitation should be in attendance.
If a midwife has no response to resuscitation at 5 minutes, the consultant should be
called urgently. The switchboard must be requested to urgently page the Consultant
Paediatrician. Out of hours, request switchboard to page and telephone Consultant's
home number and request to attend Delivery Suite urgently. Switchboard will confirm to
Delivery Suite they are on way. If possible, it is preferable for obstetrician or midwife to
discuss the case directly with the paediatrician.
Ventilation of the baby by the midwife continues as long as needed, or until the
consultant arrives. Cardiac massage is given if the heart rate remains below 60 /
minute. This requires an assistant for the midwife until the consultant is present.
There will continue to be unexpected asphyxiated neonates, some of whom will not
respond well to adequate resuscitation by a skilled resuscitator. We should be well
prepared to deal with this unfortunate situation by having trained resuscitators on site.
28.6 URGENT CALL FOR PAEDIATRIC ASSISTANCE
The paediatrician should be called urgently in the following situations:
• An unexpectedly unresponsive baby
• Thick particulate meconium staining of the liquor not previously diagnosed
• Any other cause for concern
If a midwife has no response to resuscitation at 5 minutes or it is evident that the
condition of the baby suggests that urgent paediatric involvement is needed the
consultant should be called. In these circumstances switchboard should be requested
to urgently page the duty consultant and if out-of-hours to also phone the consultant at
home informing the consultant that their immediate presence is required on LDRP. The
switchboard should be asked to confirm to LDRP that the consultant is on his / her way.
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28.7 MATERNAL
ADVICE
It is helpful to warn mothers that some otherwise healthy babies will usually be taken to
Special Care for a period of assessment:
• Gestation <34 weeks
• Weight < 1.8 kg
• Term babies with weight under the 3rd centile (not all admitted to SCBU)
28.8 ROUTINE MANAGEMENT OF THE BABY
The baby should be labelled and weighed in the delivery room and may be put to the
breast at an opportune time according to the mother’s wishes.
28.9 DELIVERY IN THEATRE
If birth takes place in the operating theatre, parental interests should not be neglected.
When spinal / epidural anaesthesia is used, both parents may have the opportunity to
see and touch the baby. If general anaesthesia is given the father should see the baby
as soon as possible.
28.10 MANAGEMENT OF BABY AT BIRTH WITH MECONIUM STAINED
LIQUOR
Most babies born from meconium stained liquor have not inhaled any particulate
material into the lower respiratory tract. If they have not done so as a result of anoxic
gasping before birth, they will very rarely do so at birth. However, be aware that
participate material in the trachea can cause obstruction and may need removing.
If thick meconium is present at birth and the baby makes no respiratory effort
• Avoid tactile stimulation
• Inspect the larynx using neonatal laryngoscope
• Under direct vision aspirate the trachea to confirm they have not aspirated any
meconium below the cords.
Material thick enough to cause obstruction cannot be sucked up by a catheter small
enough to pass down an ET tube; if possible whole ET tube should be used as the
suction catheter.
There is no evidence to suggest that upper airway suction during delivery reduces the
number of babies with symptomatic aspiration pneumonia needing Oxygen after birth
and some evidence to show it can do more harm.
A BABY BORN SCREAMING HAS AN OPEN AIRWAY
A FLOPPY BABY ------------ HAVE A LOOK
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28.11 SKIN-TO-SKIN & HYPOTHERMIA GUIDELINES
♦ All mothers should be actively encouraged to hold their babies in skin-to-skin contact
as soon after delivery as is practical, regardless of intended method of feeding.
♦ Skin-to-skin contact must be offered within an unhurried environment with no
pressure to cease as long as both mother and baby are well. (Literature suggests
this could last 90 minutes.)
♦ The baby should be dried with a pre-heated towel.
♦ When skin-to-skin contact is initiated both mother and baby should be covered
together. The baby can also wear a hat if the room temperature is sub optimal or if
the baby is small.
♦ According to the parent’s wishes the baby should be weighed either immediately
post delivery or after skin-to-skin contact has ceased. In this way the contact
between the mother and the baby is not interrupted.
♦ Early feeding should be encouraged.
♦ Most babies are particularly alert and want to feed within the first two hours after
delivery. Signs that he/she is ready for a feed can be pointed out.
♦ The midwife should offer help with this first feed.
♦ Special attention needs to be addressed with regards to the safety of the infant if the
mother has recently been sedated, received opiate analgesia or general
anaesthesia. In this situation either the birth partner or a Health Care Professional
should remain with the pair whilst the baby is in bed with the mother. This is an ideal
time for positive family interaction.
♦ When the mother has decided to cease skin-to-skin contact, the baby can be
identified, checked over, weighed and washed. The baby’s father can be offered
skin-to-skin contact. If he declines or is unable, the baby can be wrapped in a pre-
heated blanket until the mother is able to have the baby back skin-to-skin.
♦ The baby and mother will be transferred to Maternity Ward skin-to-skin. A blanket
should be wrapped around them both.
♦ If the mother wishes she can keep the baby skin-to-skin on Maternity Ward, ensuring
she is not too sedated (see above)
♦ The mother should be offered assistance again with feeding during this early
postnatal period.
♦ All help and skin contact will be documented on the
Audit Sheet and the care plan.
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♦ During the postnatal period, regardless of the chosen feeding method, women
should be encouraged to retry skin-to-skin contact as a way of settling their babies.
♦ Should the baby’s temperature be low at any time skin-to-skin contact must be
encouraged as the optimum method of bringing it up to normal levels.
(See
attached Appendix 1 – Flow chart)
Benefits of Skin-to-Skin Contact
♦ Maintains / regulates the baby’s body temperature.
♦ Calms the baby thus teaching the mothers a way to soothe their baby, making
rooming in easier.
♦ If left undisturbed in skin-to-skin contact with their mothers after delivery babies
exhibit such behaviour as:-
Salivating
Rooting
Crawling to the breast
All of which enable the first feed.
♦ Early contact leading to an early feed boosts maternal confidence, which leads to
easier subsequent feeds.
♦ Early breastfeeding can increase uterine activity so reducing the risk of post-partum
haemorrhage.
♦ Early breastfeeding appears to help promote gut maturity and aids the passage of
meconium in the baby and so lessens the incidence of mucousy babies and
neonatal jaundice.
♦ Mothers are overwhelmingly positive about their experiences of skin-to-skin contact
and often claim that the sight, feel and smell of their baby encouraged powerful
feelings of love and protectiveness.
♦ Demand feeding is encouraged, it can be used to stimulate the sleepy baby.
♦ Settling the fractious baby is easier making the need for soothers less likely.
Benefits for the Pre-term Baby
♦ Regulates heartbeat and breathing
♦ Helps maintain temperature
♦ Promotes longer more restful sleep
♦ Encourages breastfeeding
♦ May enhance weight gain and possibly lead to a shorter hospital stay
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Flowchart for Management of Hypothermia
S.G.A. & Pre-term
Term
Temperature 36.5 & below
Temperature 36.2 & below
♦ Skin to skin contact with
♦ Skin to skin contact with
mother
mother
♦ Ensure both are covered
♦
Ensure both are
with a blanket
covered with a blanket
♦ Ensure the baby feeds
♦ Ensure the baby feeds
adequately
adequately
♦ The baby will need a hat
♦ Ensure a warm thermal
environment
Check temperature after 1 hour
If no improvement
♦
Check blood glucose
♦
Inform Paediatrician
If improved
If improved
♦ Encourage skin to skin
♦ Encourage skin to skin
as much as possible
as much as possible
♦ Monitor temperature 2-4
♦ Monitor temperature 4-6
hourly until stable
hourly until stable
♦ Monitor
feeds
♦ Monitor feeds until
temperature stable
When in cot
When in cot
♦ Extra
clothes
♦ Extra
clothes
♦ Extra
blankets
♦ Extra
blankets
♦ Extra
mattress
♦ Hat
♦ Sheepskin
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North Cumbria Delivery Suite Guidelines
28.12 HYPOGLYCAEMIA OF THE NEWBORN -
GUIDELINES FOR PREVENTION AND MANAGEMENT
Well Term Babies
Infants born at term (>37 completed weeks) who are
appropriate for gestational age
and who are
well do not require routine glucose monitoring. These babies are able to
produce alternative fuels in the form of ketone bodies so the blood glucose level per se
is less relevant and harder to interpret (1). The healthy term newborn does not develop
“symptomatic” hypoglycaemia as a result of simple underfeeding (2). If there are
symptoms to suggest low blood glucose, the infant must be reviewed to look for an
underlying cause.
Hypoglycaemia and hypothermia are often associated and although there is no
established causal link it is important that the baby’s temperature is maintained from
birth.
There is little data on how often a newborn infant needs to feed but feeding early after
delivery is recommended. It may be four times or less in the first day of life increasing in
frequency from day two (3).If a baby is unwilling to feed or has not woken up for a feed
within twelve hours of birth he or she may be ill in this case the baby should be clinically
assessed “feed – check – review” see below. Clinical observation and physical
examination are more valuable than isolated blood glucose monitoring in establishing
whether there is an underlying problem. These infants will then have appropriate
investigations and treatment without delay.
If there are no signs of illness, but the infants feeding pattern is causing concern,
guidelines recommend a policy of “feed – check – review” (4), and compliance with the
Healthy Term Baby flow chart management.
♦
Feed - Offer milk frequently either breast or E.B.M. or formula if the infant is
artificially fed. Initiate Skin-to-Skin contact and encourage feeding by massage and
stimulation.
♦
Check - Observation of vital signs – temperature, heart rate and respirations.
♦
Review -
Well baby = continue: Symptoms or concern = need medical review.
Jitteriness is a rapid symmetrical tremor of the limbs. It is common in the first few days
and can be stopped by handling the baby and flexing it’s limbs. It is never accompanied
by physiological changes e.g. heart rate or apnoea – this could be indicative of a
seizure. Jitteriness in a healthy term baby is often a benign finding. In a high risk baby
hypoglycaemia should be considered.
Page 295 of 302
North Cumbria Delivery Suite Guidelines
Well Term Baby (Flowchart)
At Birth
Feeding is not initiated
♦ Dry the baby well
♦ Establish Skin-to-Skin
♦
Maintain or re-establish
♦ Offer a feed as soon as the
skin-to-skin
baby is ready
♦ Observe for infant cues and
offer feeds
♦ Teach hand expressing
Feeding is initiated
Well baby but feeding not
♦ Baby is a symptomatic
initiated or woken up by 12
♦ Offer 2nd feed within 6 hours
If cause for
hours
♦
Continue with demand feeding
concern
unless any clinical cause for
concern
Follow policy of
♦ Teach hand expressing within 1st
“Feed, Check, Review”
and 24 hours if breastfeeding
♦ Exclude
clinical signs of
Hypoglycaemia
see below
Normal examination and
♦ Monitor vital signs
A symptomatic
♦ Continue
Feed-Check-Review
♦ Encourage
Skin-to-Skin
Abnormal examination
and / or Symptomatic
♦ Blood Glucose estimation
Blood Glucose
2.6 mmol/l or Ç above
♦ Continue Feed-Check-Review
Blood Glucose
♦ Repeat blood glucose prior to next
2.6 mmol/l or below
feed only if concerned.
♦ Feed – breast, EBM or
formula if A/F or no EBM
Any Baby
♦ Repeat Blood Glucose 1
Who is Symptomatic
hour after feed
♦ Must be referred to a paediatrician
immediately
♦ Blood glucose must be done
Blood Glucose
Blood Glucose
♦ Keep the baby warm
2.6 mmol / l or above
Below 2.6mmol/l
Symptoms Include
♦ Offer 3 hourly feeds
♦ Inform the staff
• Jitteriness
♦ Repeat pre feed blood
on NNU
• Irritability,
Cold
glucose until 2 consecutive
• Apnoea
readings are Ç 2.6mmol/l
• Colour
Changes ♦ Then demand feeding
• Hypotonia
• Convulsions
Jitteriness is rapid generalised symmetrical tremor of the limbs.
•
Altered
It is common in the first few days and can be stopped by
Consciousness
handling the baby and flexing the limbs. It is never accompanied
by physiological changes, e.g. raised heart rate or apnoea this
Any Baby
would be indicative of a seizure. Jitteriness in a healthy baby is
often a benign finding. In a high risk baby hypoglycaemia should
Whose Blood Glucose is È
1
be considered. (Textbook of Neonatology Eds., Robertson &
mmol/ l refer immediately to
Bernie, 3rd Edition, Churchill Livingston, 1999)
paediatrician
Page 296 of 302
High Risk Babies
All babies in the at risk group (see over) should be identified clearly at birth and the
Hypoglycaemia Guidelines flow chart followed, feed chart commenced and subsequent
care documented and discussed with the parents.
Hypoglycaemia is a low blood sugar concentration, which may result in permanent
neurological dysfunction. A “normal” range for the neonate has not yet been properly
defined and values are influenced by birth weight, gestational age, feeding method and
postnatal age.
At Risk babies have an increased incidence of hypoglycaemia, and an appropriate
metabolic response may be absent placing them at greater risk. Infants in these at risk
groups should be fed early and reviewed frequently as they may have an impaired
counter regulatory response i.e. be unable to synthesise glucose adequately or mobilise
alternative cerebral fuels. Therefore blood glucose monitoring is appropriate for such
babies even when asymptomatic.
Consensus is that for at risk neonates who do not show abnormal clinical signs the
blood glucose concentration should be maintained above 2.5 mmol/l.
In at risk neonates hypoglycaemia is more likely to occur in the first 24 hours of life
hypoglycaemia that presents after this time, is recurrent, or persistent, does not
necessarily mean inadequate feeding, but could be a sign of illness.
Colostrum or breast milk appears to promote ketogenesis. There is evidence that
suggests formula fed babies have lower blood glucose measurements than those who
are breastfed. Therefore colostrum or breastmilk should be given when available.
If at any stage any infant develops symptoms of hypoglycaemia, becomes unwell or has
a blood glucose of less than 1.0 mmol/l
urgent referral must be made to the
Paediatrician. If more than 2 blood glucose measurements are less than 2.6 mmol/l
conformation by the lab is indicated.
Symptoms of hypoglycaemia include jitteriness, apnoea, pallor, abnormal cry,
floppiness, tachyapnoea, feeding difficulties, coma and convulsions.
Page 297 of 302
High Risk Babies (Flowchart)
At Risk Babies
♦ Weight È 3rd centile
i.e. 37 weeks – 2220 g
At birth
At birth
38 weeks – 2400 g
39 weeks – 2600 g
The baby who is able to feed
The baby who is
40+ weeks – 2790 g
unable to feed
♦ Look “wasted” e.g. loose skin folds on upper
♦ Dry the baby well
arms, thighs, abdomen and scapular
♦ Keep the baby warm, skin-to-
♦ Dry the baby well
regions
skin
♦ Keep the baby warm, as
♦ Encourage an early feed on
much skin-to-skin as baby’s
♦ Pre-term less than 37 weeks
labour ward (within 1 hour).
condition will allow
♦ Baby of a diabetic / gestational mother
Give E.B.M. if a breastfeeding
♦ Transfer the baby to NNU
♦ Baby who is hypothermic
baby will not feed.
♦ Baby who has apgar È 7 at 5 mins
♦ Low cord pH
♦ Baby who is clinically ill
The Second Feed
If the Blood Glucose is Low
If the Blood Glucose
♦ Maternal medication e.g. beta blockers
2-3 hours after first
È 2.6 mmol/l
is still low
È 2.6 mmol/l or the baby is
Any Baby Who Is
♦ Keep the baby warm
♦ Feed the baby
quickly, at
symptomatic
Symptomatic
♦ Encourage the baby to have a
the breast or give EBM or
good feed, (if the baby is to
high calorie formula if the
♦ Inform the paediatrician
♦ Must be referred to a paediatrician
be breastfed and will not feed,
mother is formula feeding
♦ Admit to NNU and follow
immediately
give E.B.M. as much as can
♦ Check a post feed blood
their guidelines
♦ Blood glucose must be done
be hand expressed, by cup or
glucose 1 hour after the feed
♦ Keep the baby warm
syringe)
is completed
♦
Check a pre-feed blood
Symptoms Include
glucose
If the Blood Glucose
If at any time the blood glucose is low
is Normal
- Jitteriness
- Colour changes
2.6 mmol/l or Ç
- Irritability
- Hypnotonia
- Cold
- Convulsions
Third and Subsequent Feeds
Jitteriness is rapid generalised symmetrical tremor of the limbs. It is common
- Apnoea
- Altered consciousness
in the first few days and can be stopped by handling the baby and flexing the
♦ Feed in 2-3 hours with pre-feed blood
limbs. It is never accompanied by physiological changes, e.g. raised heart
Any Baby
rate or apnoea this would be indicative of a seizure. Jitteriness in a healthy
glucose for this feed
baby is often a benign finding. In a high risk baby hypoglycaemia should be
♦ Monitor blood glucose prior to feeds until
Whose blood glucose is È 1 mmol/l refer
considered. (Textbook of Neonatology Eds., Robertson & Bernie, 3rd Edition,
there are 3 consecutive pre-feed blood
immediately to paediatrician
Churchill Livingston, 1999)
glucose readings of 2.6 mmol/l or Ç
Page 298 of 302
28.13 UNEXPECTED ABNORMALITY OR DEATH
In cases of unexpected major fetal abnormality the duty paediatrician should always be
informed. After stillbirth or early neonatal death, senior medical staff should be informed as
soon as possible in order to investigate the cause of death, begin bereavement counselling
and complete certification. Under all of these circumstances the consultant obstetrician
responsible for the cause should be informed at the earliest opportunity.
28.14 HAEMOLYTIC DISEASE OF THE NEWBORN
In HDN, the attending midwife should take cord blood at delivery. The role of the duty
paediatrician is to:
• Meet the parents prior to delivery and outline a plan of management
• Ensure that blood is available in the transfusion laboratory in case it is needed
• Ensure that cord blood is sent urgently for Hb, group and Coombs + cross match
• Ensure that results are retrieved
• Take part of the cord blood sample to measure PCV and Bilirubin
28.15 GROUP B STREPTOCOCCUS INFECTION
This topic has been dealt with in Chapter 19.
28.16 CHILD ABDUCTION – PROCEDURE FOR STAFF
When any baby has a legal status then that baby cannot be moved from the hospital by a
parent or unauthorised person, therefore all staff at ward level will need to know.
Order of Procedure
1.
CIC - Ring 3434 to close all exits and check CCTV
2.
WCH – Ring switchboard to close all exits and check CCTV
3. Inform midwife / nurse in charge of ward area
4. Contact the police as they are the only people who have got detaining power, Tel 9999
5. Immediately search the entire unit. Time is critical (do a head count of all infants).
Question the mother of the infant suspected to be missing as to other possible
locations of the child within the facility.
6. The Social Services to be contacted. Outside 0900 hrs – 1700 hrs there is an
emergency service. Switchboard have the number.
7. Inform the Midwifery Manager bleep holder and Head of Midwifery and Supervisor of
Midwives.
8. Inform the Business Manager – Maternity, Obstetrics & Paediatrics Services.
Page 299 of 302
9. Ask switchboard to inform the Chief Executive and / or Director of Nursing and Quality,
and Security Officer.
10. Midwife / nurse to move mother to a single room and stay with her.
11. Mother’s belongings not to be moved. The area where abduction occurred must be left
untouched as the police may require forensic evidence from the area.
12. Midwife / nurse in charge of ward should explain the situation to each mother while the
mother and infant are together. (Mothers should not hear the news from the media or
the police).
NOTE:
“Legal Status” implies – An Emergency Protection Order or a Ward of Court
order. Both can be placed on the baby and confer legal status.
NB: Midwifery or nursing staff must not liaise with press or public.
Nurse Managers / Supervisors should be sensitive to the fact that the nursing staff may suffer
post-traumatic stress disorder (PTSD) as a result of the abduction and hold a group
discussion session in which all hospital personnel affected by the abduction are required to
attend. Such a session will allow health care personnel a forum for expressing their emotions
and help them deal with the stress resulting form the abduction.
Page 300 of 302
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