4.2 Complex Intrapartum Care

Question 1

Indications for IOL

Answer 1

Induction of labour - Artificial commencement of labour before spontaneous onset for the purpose of birthing the baby

Indications for IOL:
- When risk to mother/foetus outweighs the benefits of continuing pregnancy
- Maternal: Prolonged pregnancy between 41-42 weeks, PPROM, previous c-section (risk of uterine rupture), breech presentation, BMI >50 between 38-39 weeks
- Fetal: severe congenital abnormalities, severe Rhesus isoimmunisation, fetal death, potential fetal compromise (FGR, oligo, placental insufficiency, non-reassuring fetal surveillance)
- Cervix shows favorability for labour (VE & Bishop’s score)
–> Bishop’s score considers the cervix length, position, consistency, dilation, and station to see if it is favourable or unfavourable for induction, and if prostaglandins are required to stimulate ripening of the cervix for labour

Question 2

Prostin

Answer 2

Vaginal gel. Promotes cervical ripening (softening and effacement) and stimulates myometrial contractions

Unfavourable cervix of <6 Bishop score as this increases likelihood of successful induction and spontaneous vaginal birth. Will work quicker than Cervidil.

Woman has an empty bladder, lithotomy position, inserted into posterior fornix of the vagina, wait laterally for 30 minutes after insertion

Must not be inserted into the cervical canal
Uterine hyperstimulation can be reduced through NOT using oxytocin (after 6 hours) and ARM (after 4 hours) . Tachysystole

Question 3

Cervidil

Answer 3

Continuous release of vaginal pessary. Promotes cervical ripening (softening and effacement) and stimulates myometrial contractions

Unfavourable cervix of <6 Bishop score as this increases likelihood of successful induction and spontaneous vaginal birth

Woman has an empty bladder, lithotomy position, remove pessary from foil packaging. Tear the foil top and gently pull out of the sachet. Insert high into the posterior vaginal fornix, using a small amount of lubricant and not in the cervical canal. Tuck any excess tape into vagina, remain in lateral position for 30 minutes

Must not be inserted into the cervical canal.
Uterine hyperstimulation can be reduced through NOT using oxytocin within 30 minutes of removal and ARM whilst in situ

Question 4

Syntocinon

Answer 4

Unfavourable cervix <6. If head is too high do synt before ARM.

Standard volume infusion, oxytocin 10 units, sodium chloride 0.9% chloride, CTG

Ensure CTG remains stable

Question 4

Balloon

Answer 4

Mechanical cervical ripening (softening and effacement), apply pressure on the internal os of the cervix, increase release of endogenous prostaglandins

Less likely to cause hyperstimulation in comparison to Cervidil or Prostin. Can take out whenever.

16F or 18F Foley single balloon catheter, sterile speculum approx. 60mls on each side if the cervix and light source, and ring forceps are used.

GDM - baby is fragile/placenta is not functioning effectively

Question 5

ARM

Answer 5

Favourable cervix, past history of rapid labour, grand multiparity, previous c-section, maternal preference

An amniotomy hook is used to manually rupture the membranes (amnion & chorion)

If baby’s head is high and mobile - could cause cord prolapse

Question 6

Membrane sweep

Answer 6

40-41 weeks during a vaginal examination

Examining finger passing through the cervix to rotate against the wall of the uterus, to separate chorionic membrane from the decidua

Discomfort and pain, potential for bleeding post-procedure

Question 7

Maternal risk factors for IOL

Answer 7

Uterine rupture
PPH
Requiring an epidural
Requiring an operative vaginal birth
Requiring a c-section
Uterine hyperstimulation

Question 8

Fetal risk factors for IOL

Answer 8

Cord prolapse - avoid amniotomy id the baby’s head is high and mobile
Abnormal CTG

Question 9

Uterine hyperstimulation

Answer 9

• Excessive uterine activity (either tachysystole or uterine hypertonus)
• Presence of fetal heart rate abnormalities

Midwifery management:
- Continuous CTG
- Reducing or ceasing oxytocin infusion
- Maternity staff remaining with woman until normal uterine activity is observed
- Consideration of tocolysis
- Consideration of urgent delivery
- Consider fetal scalp lactate

Tocolytic regimens:
- Salbutamol 100 mcg IV
- Terbutaline 250 mcg IV or subcutaneous
- CTN spray 400 mcg sublingually

Question 9

Excessive uterine activity

Answer 9

Excessive uterine activity:
- More than 5 active labour contractions in 10 minutes for 2 consecutive intervals, reducing fetal oxygenation (tachysystole)

Or

• Contractions lasting longer than 2 minutes duration therefore uterus is not relaxing enough in between contractions, causing fetal distress + contractions occurring within 60 seconds of each other (hypertonus)

All without fetal heart rate abnormalities

Midwifery management:
- Continuous CTG
- Consideration of reducing or ceasing oxytocin infusion
- Maternity staff remaining with woman until normal uterine activity is observed
- Consideration of tocolysis - however not indicated in the absence of fetal compromise

Question 10

Occipito-posterior position physiology

Answer 10

• Fetal occiput is positioned in the posterior aspect of the pelvis
• Fetal head is not fully flexed (deflexed/military) - anterior fontanelle is directly over the internal os, large diameter of head on the pelvic brim, fetal spine faces the forward curve of the maternal lumbar spine
• Occipito-frontal diameter presenting at 11.5cm
• Ovoid in shape
• Kicks will be outwards to front of belly rather than higher

Question 11

Occipito-posterior position characteristics of labour

Answer 11

• Prolonged and more painful due to inefficient uterine action (weak hypotonic contractions or incoordinate uterine activity - uneven pressure applied to the cervix)
• Uneven presenting part at the cervix (11.5cm) → risk for early rupture of membranes
• Increased risk of maternal and fetal morbidity
• Early urge to push before full dilation → swollen cervix / obstructed labour → c-section
• Backache - pressure on posterior pelvis and maternal spine

Question 12

OP Birth/Labour outcomes

Answer 12

A. Long anterior rotation - baby will go into OA and be born normally
B. Short posterior rotation - no flexion throughout descent, sinciput is the presenting part (11.5cm) and rotates ⅛ towards the sunny side, ‘face to sun’ delivery or towards pubic bone
C. Short anterior rotation - Fetal head has begun long internal rotation but there is insufficient flexion to complete the process. Labour becomes obstructed

Question 13

OP spontaneous vaginal birth - Midwife role

Answer 13

• Posturing women for comfort - hands and knees, lateral position, sims position on same side of fetal spine, upright forward position, TEMS, massage, water immersion
• Focused breathing, inhalation analgesia
• Midwifery support - ensuring she remains hydrated and nourished, enough rest and comfortable resting positions, keeping bladder empty, mobilisation for uterine efficiency and fetal descent,
• Pain management for the back ache - water injections (redirects pain in back and lasts approx. 4 hours), warm shower & forward leaning

Question 14

Indications for assisted birth

Answer 14

• If necessary to expedite the birth of the baby
• Concerns with fetal heart rate in labour (stressed)
• Prolonged pushing with minimal progress in fetal head moving down the birth canal
• Maternal exhaustion from a long labour
• Maternal medical condition (e.g., heart disease) limits ability to push safely and effectively

Question 15

Methods of assisted birth - forceps

Answer 15

• Inserted into the vagina and placed around the fetus’ head - gentle traction is applied to help guide the fetus’ head out of the birth canal as the woman continues pushing
• Cervix must be fully dilated - no exceptions
• Fewer neonatal injuries such as retinal haemorrhage and cephalohematoma
• Higher success rate
• May be quicker delivery

Question 16

Methods of assisted birth - Ventouse

Answer 16

• A suction cup with a handle attached - placed into the vagina and applied to the top of the fetus’ head, traction is used to guide the fetal out of the birth canal
• Cervix must be fully dilated - although have some exceptions
• Easier to place than forceps
• Associated with less maternal perineal trauma
• Less traction that forceps
• Increased risk of cephalohematoma, retinal haemorrhage, and jaundice

Question 17

Assisted birth - role of the midwife

Answer 17

• Supporting mother & father + scribing (documenting time of each pull & reminding at pull 5, communicating fetal heart)
• Setting up the trolleys - epis, ventouse or forceps, drape, birth trolley
• Managing increased risk of PPH
• Managing increased risk of thromboembolism stemming from prolonged labour/immobility/assisted delivery - thromboprophylaxis
• Pain management
• Ensure bladder functions - timing and volume of the first urine void should be monitored. FBC for forceps for at least 24 hours. Catheter if indicated.
• Managing PTSD - referrals, debriefs
• Monitoring baby for risks - bleeding, hypothermia, shoulder dystocia

Question 18

Epidural analgesia pathophysiology

Answer 18

• Opioids/local anaesthetic injected into the epidural space → opioids bind to opioid receptors in the dorsal horn of the spinal cord → complete blockage of transmission of pain in the brain
• E.g., fentanyl, morphine, hydromorphone

Question 19

Epidural analgesia - midwifery care

Answer 19

1. Prepare the space (epidural trolleys, declutter, woman in position on the bed)
2. Encourage the woman to void prior to insertion
3. IV access is patent/fluids commenced (as epidural causes hypotension therefore 500ml bolus is given)
4. CTG in progress
5. Maternal BP, RR, pulse, and fetal heart is monitored - 5 minutely for 20 minutes & document
6. Assist to semi-recumbent position
7. Explain risk for falls - get assistance when needing to mobilise
8. Stop syntocinon if on
   9.Pressure care/mobilising 2 hourly
9. Pain assessments / bromage scores / dermatomes hourly & assessing demands for bolus
10. Monitor catheter / urine output
11. Educate - if you feel metallic taste in mouth let the midwife know, sit up if she can’t breathe & stop the epidural & then call anaesthetist