Oxford Handbook of Midwifery (74 page)

Read Oxford Handbook of Midwifery Online

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

BOOK: Oxford Handbook of Midwifery
5.53Mb size Format: txt, pdf, ePub
  • Laxity of uterine and abdominal muscles
  • Placenta praevia
  • Multiple pregnancy
  • Polyhydramnios
  • Uterine abnormality
  • Contracted pelvis
  • Uterine fibroid.
    Diagnosis
  • A transverse lie is usually detected in pregnancy by the appearance of the shape of the abdomen: there is a bulge on each side of the abdomen and the fundus appears very low.
  • On palpation the head and the breech lie in opposite iliac fossae.
  • There is no presenting part descending into the pelvis.
  • Ultrasound may be used to confirm the condition and detect any fetal abnormality.
    Management
  • External version may be attempted, followed by induction of labour if successful.
  • Monitor labour closely by EFM and diligent observation of the maternal condition.
  • Providing normal progress in labour continues, the membranes may be ruptured once the fetal head enters the pelvis.
  • Detect shoulder presentation by abdominal palpation and report this immediately to a doctor.
  • Carry out vaginal examination (if placenta praevia has been previously excluded).
  • LSCS may be the mode of delivery if the lie is persistently oblique or transverse, if there are any complications, or if there is a poor obstetric history.
  • In the case of a second twin in the transverse position, correct the lie immediately by external version, while rupturing the membranes to hasten the birth and maintain the longitudinal lie.
    This page intentionally left blank
    High-risk labour
    ‌
    Chapter 18
    321
    Principles of care for high-risk labour
    322
    Trial of labour for vaginal birth following
    previous caesarean (or other uterine scar)
    324
    Obstructed labour
    326
    Delivery care for twins and other multiple births
    328
    Hypertensive disorders
    332
    Care of the diabetic mother and fetus
    338
    Drug and alcohol misuse
    342
    Epilepsy
    344
    Cardiac conditions
    346
    Pyrexia
    348
    Infections
    350
    Group B haemolytic streptococcus
    352
    Preterm labour
    354
    Induction of labour
    364
    Augmentation of labour: active management
    370
    Measures to assist birth
    372
    Caesarean section
    376
    Breech delivery
    382
    Retained placenta
    388
    CHAPTER 18
    High-risk labour
    322‌‌
    Principles of care for high-risk labour
    Definition
    A ‘high-risk’ pregnancy is one in which the mother, fetus, or newborn is, or will be, at an increased risk of morbidity or mortality before, during, or after delivery.
    On admission to the labour ward each antenatal patient will have
    been assessed to determine any risk factors. A high-risk or complicated pregnancy usually falls into one or more of the following categories:
    1
    • Antepartum, intrapartum, or postpartum complication arising in a previous pregnancy, for example:
      • Stillbirth or neonatal death, subfertility
      • Caesarean section, any uterine scar, i.e. myomectomy, hysterotomy
      • Shoulder dystocia
      • PPH
      • Severe hypertension or eclampsia
      • Thromboembolism
      • Bowel or bladder surgery.
    • Antepartum, intrapartum, or postpartum complication arising in the current pregnancy, for example:
      Antepartum:
    • Suspected small for gestational age fetus
    • Woman suspected of being at risk of cephalopelvic disproportion
    • Oligohydramnios, polyhydramnios
    • APH
    • Placenta praevia
    • Multiple pregnancy
    • Rh or other red cell antibodies
    • Pregnancy-induced hypertension/pre-eclampsia
    • Anaemia—haemoglobin less than 9g/dL
    • Liver disease, e.g. cholestasis of pregnancy.
      Intrapartum:
    • Preterm labour (<37 completed weeks)
    • Preterm rupture of membranes (<37 completed weeks)
    • Post-term labour (>42 completed weeks)
    • Malpresentation, e.g. breech presentation or transverse lie.
    • Maternal pyrexia (greater than 38°C)
    • Known GBS positive
    • Intrapartum haemorrhage
    • Meconium-stained liquor
    • Induced labour
    • Administration of oxytocin infusion to augment labour
    • Regional analgesia (epidural or combined spinal-epidural)
    • Slow progress in first or second stages of labour
    • Suspicious FHR on auscultation
    • Abnormal fetal heart pattern
    • Planned home delivery admitted to hospital
    • Unbooked women or transfers from other hospitals.
      PRINCIPLES OF CARE FOR HIGH-RISK LABOUR
      323
      Always inform the consultant on call if any of the following are anticipated:
  • Emergency ceasarean section
  • Instrumental delivery in obstetric theatre
  • Multiple birth
  • Vaginal breech delivery.
    Postpartum:
  • PPH
  • Third- and fourth-degree tear
  • Postpartum severe pre-eclampsia.
    The woman has a chronic medical disorder; for example any of the following:
  • Diabetes
  • Neurological, e.g. epilepsy, multiple sclerosis, myasthenia gravis
  • Connective tissue disorder, e.g. systemic lupus erythematosus
  • Cardiac disease
  • Renal disease
  • Thyroid, parathyroid, pituitary, or adrenal disease
  • Respiratory disease (other than mild asthma)
  • Coagulation disorder/thrombophilia
  • Inflammatory bowel disease.
    Ensure that all patients defined as high risk:
  • Are treated sensitively, recognizing that women experiencing complications in labour may be extremely stressed and anxious, or have a different interpretation of their pregnancy than the clinically defined view. Give these patients:
    • Full, unbiased explanations
    • The chance to ask questions
    • Adequate support
    • Freedom to make choices in care
  • Receive consultant-led care on admission to the labour ward or are transferred from midwifery-led care to consultant care when the problem arises.
  • Are seen by a registrar as soon as they attend the hospital or the complication arises.
  • Have a birth plan, devised in the antenatal clinic in consultation with a senior doctor, documented in the case notes. Review the notes to
    find plans for labour and delivery. Discuss the plan with the woman to ensure that it is up to date.
  • Are monitored continuously for electronic FHR in labour (unless defined as high risk due to a previous postnatal complication, e.g. third- degree tear). Some instances of referral for high-risk care may require the midwife to inform the hospital clinical risk manager.
    1
    The Practice Development Team (2010).
    Jessop Wing Labour Ward Guidelines 2009–2010
    . Sheffield: Sheffield Teaching Hospitals NHS Trust.
    CHAPTER 18
    High-risk labour
    324‌‌
    Trial of labour for vaginal birth following previous caesarean (or other uterine scar)
    A woman may request VBAC because:
    •
    She wishes to avoid the stress of abdominal surgery and a longer hospital stay and recovery
    • Vaginal deliveries have less risk of infection or haemorrhage
    • She would like a satisfying experience of birth.
      It is the responsibility of the obstetrician to ensure that a plan for delivery is made antenatally. However, the midwife should be aware of the risks and benefits of VBAC so that she/he can support the family in their choice of care.
    • Most women who opt for VBAC do deliver vaginally.
      1,2
    • Rare complications can occur—uterine rupture is increased with VBAC: 1:10 000 (repeat caesarean), 50:10 000(VBAC).
      1
    • Intrapartum fetal death is rare, about the same risk for a primigravida, but increased compared to planned repeat caesarean (1:10 000).
      1
    • If the trial of labour includes induction there is a further increased risk of uterine rupture, especially if prostaglandins are used.
      Because of these risks precautions are recommended:
    • Admission to a regional unit with access to emergency caesarean and blood transfusion should this be required
    • Continuous EFM during labour
    • Careful use of prostaglandins for induction.
      XHowever, a woman has the right to choose home birth or water birth after caesarean section and needs accurate information to make a choice appropriate for her needs. During the antenatal period the supervisor of midwives should be involved: discussion, planning, and documentation are paramount.
      When admitting a woman anticipating VBAC to the delivery suite:
    • Recognize the psychological distress that may have been caused by a previous long labour and emergency caesarean. Give clear
      explanations, positive support, and discuss in detail the plans for the birth.
    • Admit as for ‘high risk’ care:
      • Inform the woman’s consultant obstetrician
      • Have a management plan documented in the hospital notes
      • Be aware of signs of uterine rupture (b see Uterine rupture, p. 398).
    • Obtain consent from the woman to monitor the fetal heart continuously in established labour, ensuring the woman’s comfort and being flexible about maternal position. Review for variable and late decelerations and bradycardia.
    • Site IV access, take and dispatch blood samples from the mother for group and save (G&S) and FBC.
    • Monitor maternal blood pressure and pulse half hourly in established labour.
    • In consultation with the anaesthetist and the woman, discuss what food and drink would be acceptable in labour. Total fasting is not
    TRIAL OF LABOUR
    325
    now recommended under normal circumstances. It can lead to poor progress.
    3

Other books

Slack tide by Coxe, George Harmon, 1901-
Way Down Dark by J.P. Smythe
Llévame a casa by Libertad Morán
Mutiny on Outstation Zori by John Hegenberger
Fury by Koren Zailckas