intrapartum care Flashcards
initially what qs would you ask the pregnant woman when she comes into hospital
Review the antenatal notes (including all antenatal screening results) and discuss these with the woman.
Ask her about the length, strength and frequency of her contractions.
Ask her about any pain she is experiencing and discuss her options for pain relief.
Record her pulse, blood pressure and temperature, and carry out urinalysis.
Record if she has had any vaginal loss.
what examination would u do in a pregnant woman
Ask the woman about the baby’s movements in the last 24 hours.
Palpate the woman’s abdomen to determine the fundal height, the baby’s lie, presentation, position, engagement of the presenting part, and frequency and duration of contractions.
Auscultate the fetal heart rate for a minimum of 1 minute immediately after a contraction. Palpate the woman’s pulse to differentiate between the heartbeats of the woman and the baby.
what observations of the pregnant woman might trigger you to transfer her to obstetrics
pulse over 120 beats/minute on 2 occasions 30 minutes apart
a single reading of either raised diastolic blood pressure of 110 mmHg or more or raised systolic blood pressure of 160 mmHg or more
either raised diastolic blood pressure of 90 mmHg or more or raised systolic blood pressure of 140 mmHg or more on 2 consecutive readings taken 30 minutes apart
a reading of 2+ of protein on urinalysis and a single reading of either raised diastolic blood pressure (90 mmHg or more) or raised systolic blood pressure (140 mmHg or more)
temperature of 38°C or above on a single reading, or 37.5°C or above on 2 consecutive readings 1 hour apart
any vaginal blood loss other than a show
rupture of membranes more than 24 hours before the onset of established labour (see recommendation 1.15.25)
the presence of significant meconium (see recommendation 1.5.2)
pain reported by the woman that differs from the pain normally associated with contractions
what observations of the unborn baby might trigger you to transfer mother to obstetrics
any abnormal presentation, including cord presentation
transverse or oblique lie
high (4/5–5/5 palpable) or free‑floating head in a nulliparous woman
suspected fetal growth restriction or macrosomia
suspected anhydramnios or polyhydramnios
fetal heart rate below 110 or above 160 beats/minute
a deceleration in fetal heart rate heard on intermittent auscultation
reduced fetal movements in the last 24 hours reported by the woman.
fetal monitoring with a woman in susp or established labour
Use either a Pinard stethoscope or doppler ultrasound.
Carry out auscultation immediately after a contraction for at least 1 minute and record it as a single rate.
Record accelerations and decelerations if heard.
Palpate the maternal pulse to differentiate between the maternal and fetal heartbeats.
options for pain relief/analgesia in labour
- water immersion
- TENS machine
- having a birth partner
Ensure that Entonox (a 50:50 mixture of oxygen and nitrous oxide)
- nauseous
- light‑headed.
IV/IM opiods - pethidine - diamorphine RISKS (drowsiness, nausea and vomiting) and her baby (short‑term respiratory depression and drowsiness which may last several days)
what observations should be done for women with regional analgesia/ epidural
maternal complications
CI
During establishment of regional analgesia or after further boluses (10 ml or more of low‑dose solutions), measure blood pressure every 5 minutes for 15 minutes.
If the woman is not pain‑free 30 minutes after each administration of local anaesthetic/opioid solution, recall the anaesthetist.
Assess the level of the sensory block hourly.
Risks
- epidural abscess
- hypotension
- temporary loss of bladder control/urinary retention
- delayed second stage due to inability to push effectively
- nausea
- headache
- nerve damage
- procedure failure
- inability to move freely
- increased chances of instrumentation delivery
CI
- abnormal bleeding
- skin infection at or near site
- hypovolaemia
- neurological disorders
- CVS disease
- anatomical abnormalities of the vertebral
- pt refusal
- lack of adequately trained staff
when to perform CTG in regional analgesia
least 30 minutes during establishment of regional analgesia and after administration of each further bolus of 10 ml or more.
if rapid analgesia is required which one do u use
combined spinal-epidural analgesia
bupivacaine
fentanyl
epidural v spinal anaesthetic
epidural is inseted into th epotential space that lies between the dura matter and the periosteum lining the inside of the vertebral canal
spinal anaesthesia is induced by injecting small amounts of local anaesthetic is induced by injecting small amounts of local anaesthetic into the CSF after having pierced the dura matter
when to advise continous CTG
maternal pulse over 120 beats/minute on 2 occasions 30 minutes apart
temperature of 38°C or above on a single reading, or 37.5°C or above on 2 consecutive occasions 1 hour apart
suspected chorioamnionitis or sepsis
pain reported by the woman that differs from the pain normally associated with contractions
the presence of significant meconium (as defined in recommendation 1.5.2)
fresh vaginal bleeding that develops in labour
severe hypertension: a single reading of either systolic blood pressure of 160 mmHg or more or diastolic blood pressure of 110 mmHg or more, measured between contractions
hypertension: either systolic blood pressure of 140 mmHg or more or diastolic blood pressure of 90 mmHg or more on 2 consecutive readings taken 30 minutes apart, measured between contractions
a reading of 2+ of protein on urinalysis and a single reading of either raised systolic blood pressure (140 mmHg or more) or raised diastolic blood pressure (90 mmHg or more)
confirmed delay in the first or second stage of labour (see recommendations 1.12.14, 1.13.3 and 1.13.4)
contractions that last longer than 60 seconds (hypertonus), or more than 5 contractions in 10 minutes (tachysystole)
oxytocin use.
when reviewing a CTG trace what should u document
baseline rate
baseline variability
presence or absence of decelerations (and concerning characteristics of variable decelerations* if present)
presence of accelerations.
normal HR for fetus
110-160
abnormal baseline in CTG
Below 100
OR
Above 180
Abnormal baseline variability in CTG
Less than 5 for more than 50 minutes
OR
More than 25 for more than 25 minutes
OR
Sinusoidal
abnormal decelerations seen in CTG
Variable decelerations with any concerning characteristics* in over 50% of contractions for 30 minutes (or less if any maternal or fetal clinical risk factors [see above])
OR
Late decelerations for 30 minutes (or less if any maternal or fetal clinical risk factors)
OR
Acute bradycardia, or a single prolonged deceleration lasting 3 minutes or more
baseline in non reassuring CTG
100 to 109†
OR
161 to 180
non reassuring baseline variability CTG
Less than 5 for 30 to 50 minutes
OR
More than 25 for 15 to 25 minutes
non-reassuring decelerations in CTG
variable decelerations with no concerning characteristics for 90 minutes or more
variable decelerations with any concerning characteristics in up to 50% of contractions for 30 minutes or more
variable decelerations with any concerning characteristics in over 50% of contractions for less than 30 minutes
late decelerations in over 50% of contractions for less than 30 minutes, with no maternal or fetal clinical risk factors such as vaginal bleeding or significant meconium
when is CTG suspicious
1 non-reassuring feature
AND
2 reassuring features
Mx for suspicious CTG
Correct any underlying causes, such as hypotension or uterine hyperstimulation
Perform a full set of maternal observations
Start 1 or more conservative measures*
Inform an obstetrician or a senior midwife
pathological feature criteria in CTG
1 abnormal feature
OR
2 non-reassuring features
Mx of pathological CTG
Obtain a review by an obstetrician and a senior midwife
Exclude acute events (for example, cord prolapse, suspected placental abruption or suspected uterine rupture)
Correct any underlying causes, such as hypotension or uterine hyperstimulation
Start 1 or more conservative measures*
Talk to the woman and her birth companion(s) about what is happening and take her preferences into account
If the cardiotocograph trace is still pathological after implementing conservative measures:
obtain a further review by an obstetrician and a senior midwife
offer digital fetal scalp stimulation and document the outcome
If the cardiotocograph trace is still pathological after fetal scalp stimulation:
consider fetal blood sampling
consider expediting the birth
take the woman’s preferences into account
need fo urgent intervention criteria
Acute bradycardia, or a single prolonged deceleration for 3 minutes or more
Mx for need for urgent intervention
Urgently seek obstetric help
If there has been an acute event (for example, cord prolapse, suspected placental abruption or suspected uterine rupture), expedite the birth
Correct any underlying causes, such as hypotension or uterine hyperstimulation
Start 1 or more conservative measures*
Make preparations for an urgent birth
Talk to the woman and her birth companion(s) about what is happening and take her preferences into account
Expedite the birth if the acute bradycardia persists for 9 minutes
If the fetal heart rate recovers at any time up to 9 minutes, reassess any decision to expedite the birth, in discussion with the woman
concerning characterisitcs of variable decelerations
lasting more than 60 seconds
reduced baseline variability within the deceleration
failure to return to baseline
biphasic (W) shape
no shouldering
conservative measures for heart fetal
encourage the woman to mobilise or adopt an alternative position (and to avoid being supine)
offer intravenous fluids if the woman is hypotensive
reduce contraction frequency by:
reducing or stopping oxytocin if it is being used and/or
offering a tocolytic drug (a suggested regimen is subcutaneous terbutaline 0.25 mg).
when to offer fetal blood sampling
if CTG is stilkl pathological regardless of fetal scalp stimulation
what is fetal blood sampling
measure the level of acid in the baby’s blood, which may help to show how well the baby is coping with labour.
when taking a sample a small scratch may be formed on the baby’s scalp
- small risk of infection
classification of pH of fetal blood
normal: 7.25 or above
borderline: 7.21 to 7.24
abnormal: 7.20 or below
classification of lactate of fetal blood
normal: 4.1 mmol/l or below
borderline: 4.2 to 4.8 mmol/l
abnormal: 4.9 mmol/l or above. [2017]
if fetal blood sample is borderline - no accelerations in response to fetal scalp stimulation
second fetal blood sample no more than 30 minutes later if this is still indicated by the cardiotocograph trace
if fetal blood sample is normal - no accelerations in response to fetal scalp stimulation
second fetal blood sample no more than 1 hour later if this is still indicated by the cardiotocograph trace
what advise should be given to women presenting with prelabour rupture of the membranes
the risk of serious neonatal infection is 1%, rather than 0.5% for women with intact membranes
60% of women with prelabour rupture of the membranes will go into labour within 24 hours
induction of labour[4] is appropriate approximately 24 hours after rupture of the membranes
what observations are recorded during the first stage of labour
half‑hourly documentation of frequency of contractions
hourly pulse
4‑hourly temperature and blood pressure
frequency of passing urine
offer a vaginal examination 4‑hourly or if there is concern about progress or in response to the woman’s wishes (after abdominal palpation and assessment of vaginal loss).
delay in first stage what to take into account
parity
cervical dilatation and rate of change
uterine contractions
station and position of presenting part
the woman’s emotional state
referral to the appropriate healthcare professional.
what aspects should be assessed when diagnosing delay
cervical dilatation of less than 2 cm in 4 hours for first labours
cervical dilatation of less than 2 cm in 4 hours or a slowing in the progress of labour for second or subsequent labours
descent and rotation of the baby’s head
changes in the strength, duration and frequency of uterine contractions.
if delay is established what might be done
amniotomy - rupturing of membranes artificially
repeat vaginal examination 2 hours later whether her membranes are ruptured or intact
what would amniotomy do
shorten her labour by about an hour and may increase the strength and pain of her contractions
role of oxytocine in first stage labour
ncrease the frequency and strength of her contractions and that its use will mean that her baby should be monitored continuously.
vaginal examination 4 hours after stating oxytocin
define passive second stage of labour
the finding of full dilatation of the cervix before or in the absence of involuntary expulsive contractions.
define onset of the active second stage of labour
the baby is visible
expulsive contractions with a finding of full dilatation of the cervix or other signs of full dilatation of the cervix
active maternal effort following confirmation of full dilatation of the cervix in the absence of expulsive contractions.
observations done during the second stage
partogram
half‑hourly documentation of the frequency of contractions
hourly blood pressure
continued 4‑hourly temperature
frequency of passing urine
offer a vaginal examination hourly in the active second stage, or in response to the woman’s wishes (after abdominal palpation and assessment of vaginal loss).
Perform intermittent auscultation of the fetal heart rate immediately after a contraction for at least 1 minute, at least every 5 minutes. Palpate the woman’s pulse every 15 minutes to differentiate between the two heartbeats
duration of second stage of labour in a nulliparous woman
birth would be expected to take place within 3 hours of the start of the active second stage in most women
diagnose delay in the active second stage when it has lasted 2 hour undertake an operative vaginal birth if birth is not imminent
duration of second stage of labour in a nulliparous woman
birth would be expected to take place within 2 hours of the start of the active second stage in most women
diagnose delay in the active second stage when it has lasted 1 hour undertake an operative vaginal birth if birth is not imminent
when to suspect delay in progress in a nulliparous woman second stage
in terms of rotation and/or descent of the presenting part) is inadequate after 1 hour of active second stage. Offer vaginal examination and then offer amniotomy if the membranes are intact
when to suspect delay in progress in a nulliparous woman second stage
(in terms of rotation and/or descent of the presenting part) is inadequate after 30 minutes of active second stage. Offer vaginal examination and then offer amniotomy if the membranes are intact
when to consider oxytocin in the second stage
Consideration should be given to the use of oxytocin, with the offer of regional analgesia, for nulliparous women if contractions are inadequate at the onset of the second stage.
intervention to recuse perineal trauma
Either the ‘hands on’ (guarding the perineum and flexing the baby’s head) or the ‘hands poised’ (with hands off the perineum and baby’s head but in readiness) technique can be used to facilitate spontaneous birth.
what advise to give to women who have had third or fourth degree trauma
current urgency or incontinence symptoms
the degree of previous trauma
risk of recurrence
the success of the repair undertaken
the psychological effect of the previous trauma
management of her labour
if episiotomy has to be performed which method might be recommended
mediolateral episiotomy originating at the vaginal fourchette and usually directed to the right side. The angle to the vertical axis should be between 45 and 60 degrees at the time of the episiotomy
when to offer instrumental birth
baby’s wellbeing or there is a prolonged second stage]]advise the woman to ahve tested effective anaesthesia
if anaesthesia declines offer a pudendal block
assessments that needs to be done when expediting birth
the degree of urgency
clinical findings on abdominal and vaginal examination
choice of mode of birth (and whether to use forceps or ventouse if an instrumental birth is indicated)
anticipated degree of difficulty, including the likelihood of success if instrumental birth is attempted
location
any time that may be needed for transfer to obstetric‑led care
the need for additional analgesia or anaesthesia
the woman’s preferences
define third stage of labour
time from the birth of the baby to the expulsion of the placenta and membranes.
what does active Mx of the third stage of labour involves
routine use of uterotonic drugs
deferred clamping and cutting of the cord
controlled cord traction after signs of separation of the placenta.
shortens the third stage compared with physiological management
is associated with nausea and vomiting in about 100 in 1,000 women
is associated with an approximate risk of 13 in 1,000 of a haemorrhage of more than 1 litre
is associated with an approximate risk of 14 in 1,000 of a blood transfusion.
what does physiological Mx of the third stage involves
Gold standard is active
-no routine use of uterotonic drugs
- IM Injection with oxytocin, usually as birth is taking place
- Cord is clamped and cut, 1-5mins after birth
- Placenta is pulled out by the midwife once it has separated from the wall of the uterus, usually happens within 30 mins
REDUCED risk of PPH, need for blood transfusion and postnatal anaemia
is associated with nausea and vomiting in about 50 in 1,000 women
physiological
- delivery of the placenta by maternal effort.
- no clamping of the cord until pulsation has stopped
is associated with an approximate risk of 29 in 1,000 of a haemorrhage of more than 1 litre
is associated with an approximate risk of 40 in 1,000 of a blood transfusion
when can prolonged third stage be diagnosed
if it is not completed within 30 minutes of the birth with active management or within 60 minutes of the birth with physiological management.
what is recorded in the third stage labour
her general physical condition, as shown by her colour, respiration and her own report of how she feels
vaginal blood loss.
what is injected in active management
administer 10 IU of oxytocin by intramuscular injection with the birth of the anterior shoulder or immediately after the birth of the baby and before the cord is clamped and cut. Use oxytocin as it is associated with fewer side effects than oxytocin plus ergometrine
when to clamp cord
Do not clamp the cord earlier than 1 minute from the birth of the baby unless there is concern about the integrity of the cord or the baby has a heart rate below 60 beats/minute that is not getting faster.
Clamp the cord before 5 minutes in order to perform controlled cord traction as part of active management.
If the woman requests that the cord is clamped and cut later than 5 minutes, support her in her choice
when to perform controlled cord traction
active management only after administration of oxytocin and signs of separation of the placenta.
when do u move from physiological to active Mx
haemorrhage
the placenta is not delivered within 1 hour of the birth of the baby.
shorten the third stage
if placenta is retained
IV access
examine vagina
needs to be removed
antenatal RFs for postpartum haemorrhage
previous retained placenta or postpartum haemorrhage
maternal haemoglobin level below 85 g/litre at onset of labour
BMI greater than 35 kg/m2
grand multiparity (parity 4 or more)
antepartum haemorrhage
overdistention of the uterus (for example, multiple pregnancy, polyhydramnios or macrosomia)
existing uterine abnormalities
low‑lying placenta
maternal age of 35 years or older.
risk factors in labour for postpartum haemorrhage
induction
prolonged first, second or third stage of labour
oxytocin use
precipitate labour
operative birth or caesarean section
Mx of postpartum haemorrhage
all for help
give immediate clinical treatment:
emptying of the bladder and
uterine massage and
uterotonic drugs and
intravenous fluids and
controlled cord traction if the placenta has not yet been delivered
continuously assess blood loss and the woman’s condition, and identify the source of the bleeding
give supplementary oxygen
arrange for transfer of the woman to obstetric‑led care
first line treatment for postpartum haemorrhage
oxytocin (10 IU intravenous) or
ergometrine (0.5 mg intramuscular) or
combined oxytocin and ergometrine (5 IU/0.5 mg intramuscular).
second line treatment for postpartum haemorrhage
repeat bolus of:
oxytocin (intravenous)
ergometrine (intramuscular, or cautiously intravenously)
combined oxytocin and ergometrine (intramuscular)
misoprostol
oxytocin infusion
carboprost (intramuscular).
other treatment for postpartum haemorrhage
tranexamic acid (intravenous)
rarely, in the presence of otherwise normal clotting factors, rFactor VIIa, in consultation with a haematologist
initial assessment of the newborn baby
Record the Apgar score routinely at 1 and 5 minutes for all births.
Record the time from birth to the onset of regular respirations.
mother baby bonding
skin to skin contact
breastfeeding within first hour if possible
observations of baby born due to PROM
(more than 24 hours before the onset of established labour) at term for the first 12 hours of life (at 1 hour, 2 hours, 6 hours and 12 hours) in all settings. Include assessment of:
temperature
heart rate
respiratory rate
presence of respiratory grunting
significant subcostal recession
presence of nasal flare
presence of central cyanosis, confirmed by pulse oximetry if available
skin perfusion assessed by capillary refill
floppiness, general wellbeing and feeding.
observation of the woman after birth
record her temp, pulse, BP
Uterine contraction and lochia.
Examine the placenta and membranes: assess their condition, structure, cord vessels and completeness.
successful voiding of the labour
define first degree
injury to skin only
define second degree
injury to the perineal muscles but not the anal sphincter
define third degree
injury to the perineum involving the anal sphincter complex:
3a – less than 50% of external anal sphincter thickness torn
3b – more than 50% of external anal sphincter thickness torn
3c – internal anal sphincter torn.
define fourth degree
injury to the perineum involving the anal sphincter complex (external and internal anal sphincter) and anal epithelium
what is induction of labour
starting labour artificially.
when will IOL is indicated
prolonged gestation -> between 41-41w
premature rupture of membranes, infection, bleeding
maternal health problems - HTN, pre-eclampsia, diabetes, obstetric cholestasis
fetal growth restiriction or
fetal macrosomia
intrauterine fetal death
previous c section
when to offer IOL in PROM
less than 37 weeks gestation
or
offer expectant management for a maximum of 24 hours
when to offer IOL in P-PROM
<34 weeks’ gestation – delay IOL unless obstetric factors indicate otherwise e.g. fetal distress.
>34 weeks’ gestation – the timing of IOL depends on risks vs benefits of delaying pregnancy further e.g. increased risk of infection.
Absolute contraindications of IOL
Cephalopelvic disproportion
Major placenta praevia
Vasa praevia
Cord prolapse
Transverse lie
Active primary genital herpes
Previous classical Caesarean section
Relative contraindication of IOL
- Breech presentation
- Triplet or higher order pregnancy
- Two or more previous low transverse caesarean sections
main methods of induction
vaginal PGs
amniotomy
membrane sweep
method of vaginal PGs
prepare the cervix for labour by ripening it, and also have a role in the contraction of the smooth muscle of the uterus. They come as either a tablet, gel or a controlled-release pessary:
Tablet/gel regimen: 1 cycle = 1st dose, plus a 2nd dose if labour has not started 6 hours later.
Pessary regimen: 1 cycle = 1 dose over 24 hours.
There is a recommended maximum of one cycle in 24 hours
define amniotomy
membranes are ruptured artificially using an instrument called an amnihook.
releases prostaglandins in an attempt to expedite labour. It is only performed when the cervix has been deemed as ‘ripe’ (see Bishop Score below).
Often, an infusion of artificial oxytocin (Syntocinon) will be given alongside an amniotomy, acting to increase the strength and frequency of contractions. The aim is to start low and titrate upwards until there are 4 contractions every 10 minutes.
when is membrane sweep offered
40 and 41 weeks’ gestation to nulliparous women, and 41 weeks to multiparous women.
procedure is performed by inserting a gloved finger through cervix and rotating it against the fetal membranes, aiming to separate the chorionic membrane from the decidua. The separation helps to release natural prostaglandins in an attempt to kick-start labour.
what is the bishop score
‘cervical ripeness‘ based on measurements taken during vaginal examination. It is checked prior to induction, and during induction to assess progress (6 hours post-table/gel, 24 hours post-pessary):
Score of ≥ 7 – suggests the cervix is ripe or ‘favourable’ – this means that there is a high chance of a response to interventions made to induce labour (i.e. induction of labour is possible).
Score of <4 – suggests that labour is unlikely to progress naturally and prostaglandin tablet/gel/pessary will be required
what must be done prior to IOL
CTG
After initiation of IOL, when contractions begin assess fetal heart rate using continuous CTG until a normal rate is confirmed. Subsequently assess using intermittent auscultation.
complications of IOL
Failure of induction (15%) – offer a further cycle of prostaglandins, or a caesarean section.
Uterine hyperstimulation (1-5%) – contractions last too long or are too frequent, leading to fetal distress. Can be managed with tocolytic agents (anti-contraction) such as terbutaline.
Cord prolapse – can occur at time of amniotomy, particularly if the presentation of the fetal head is high.
Infection – risk is reduced by using pessary vs tablet/gel, as fewer vaginal examinations are required to check progress.
Pain – IOL is often more painful than spontaneous labour. Often epidural analgesia is required.
Increased rate of further intervention vs spontaneous labour – 22% require emergency caesarean sections, and 15% require instrumental deliveries.
Uterine rupture (rare)
what is the optimal head position for delivery
occiput anterior
what is looked for in a vaginal examination
consistency, effacement and dilatation of the cervix
- whether the membranes are intact
- colour of the amniotic fluid
- nature and presentation of the presenting part and its relationship to the ischial spine
- size of pelvic outlet
RFs for GBS mx
Suspected or confirmed infection in another baby in the case of a multiple pregnancy
Parenteral antibiotic treatment given to the woman for confirmed or suspected invasive bacterial infection (such as septicaemia) at any time during labour, or in the 24-hour periods before and after the birth [This does not refer to intrapartum antibiotic prophylaxis]
Respiratory distress starting more than 4 hours after birth
Seizures
Need for mechanical ventilation in a term baby
Signs of shock
