Oxford Handbook of Midwifery (79 page)

CHAPTER 18
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• The baby should be classed as high risk for hypoglycaemia (b see Hypoglycaemia, p. 592).
  

  Post-delivery
  

• Continue the insulin pump with 2h measurements of blood sugar levels until a normal diet can be resumed.
  
• When the mother is ready to eat, give subcutaneous insulin as for her
  pre-pregnancy regime, then discontinue the insulin pump after 1h.
  

  Gestational diabetes
  

  Use of the insulin pump and the IV insulin infusion may be discontinued after delivery since the condition usually resolves. Assessment of blood sugar approximately 2h later and during the subsequent morning will exclude an establishing diabetes.
  

  1. National Institute for Clinical Excellence (NICE) (2008).
     Diabetes in Pregnancy, Management of Diabetes and it’s Complications From Preconception to the Post Natal Period.
     Guideline 63. London: NICE. Available at: M
     www.nice.org.uk.
     
  2. The Practice Development Team (2010).
     Jessop Wing Labour Ward Guidelines 2009–2010
     . Sheffield: Sheffield Teaching Hospitals NHS Trust.
     

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  CHAPTER 18
  High-risk labour
  

  342‌‌
  

  Drug and alcohol misuse
  

  Intrapartum care
  

• Most women who are known to be drug or alcohol dependent will have normal labour and deliveries. They should receive the same information and choices in labour as other women.
  

  •
  Ideally the woman should be cared for by a midwife known to her.
  

  On admission
  

• Ensure that you are familiar with any plan for social care and child protection, and inform the appropriate agencies/workers involved of the client’s admission to the delivery suite. Ensure that the plan is documented in the hospital notes.
  
• Inform the obstetrician (although if there are no complications, the obstetrician need not be the lead professional), paediatrician, and SCBU of admission.
  
• A woman with a history of drug addiction may have veins that prove difficult to cannulate. If she is considered to be at risk of bleeding, the anaesthetist may site a cannula early in labour as a precaution.
  

  The methadone programme
  

• Women who have opted for a methadone programme to facilitate withdrawal from their habit should continue this drug according to the dose currently prescribed.
  
• If caring for a woman who is an addict who has withdrawn from treatment, it should be assumed that she is taking drugs. Encourage her to disclose her most recent use. Aim to achieve cooperation and involvement of the woman and partner.
  
• Respect confidentiality.
  
• Do not tolerate illicit drug use on the hospital premises.
  
• Symptoms of withdrawal may occur during labour.
  
• Women with a history of previous addiction may wish to avoid narcotics. However, they are not contraindicated for pain relief. Unless stated otherwise in the management plan, higher doses of opiates may be necessary because of tolerance.
  
• Epidural analgesia can be offered.
  
• Avoid cyclizine, it may increase the effect of methadone and is a central nervous system (CNS) irritant. It is also a misused drug with significant street value.
  

  Infection risk
  ¹
  

  If the woman is, or has been, an IV drug abuser, then she is at risk of carrying HIV and hepatitis B or C (b see Infections, p. 164). If this is a concern, to avoid vertical transmission:
  

• Membranes should not be ruptured
  
• A fetal scalp electrode should be avoided
  
• Fetal blood sampling is contraindicated.
  

  DRUG AND ALCOHOL MISUSE
  

  343
  

  Care
  ¹
  of the fetus and neonate
  ²
  

if there are no other concerns (apart from known drug/alcohol dependency) midwifery-led care protocols (intermittent monitoring of the fetal heart) may be followed.

• Paediatrician
  
• Specialist midwife for drug/alcohol use
  
• Community midwife
  
• Liaison health visitor
  
• Social worker
  
• Specialist midwife for child protection
  
• Supervisor of midwives.
  
  1. Sheffield Teaching Hospitals NHS Trust (2009).
     Jessop Wing, Labour Ward Guidelines 2009–2010.
     

     Sheffield: Sheffield Teaching Hospitals NHS Trust.
     

  2. Martin M (2005).
     Guidelines for Practice, Babies Born to Substance Misusing Mothers
     . Sheffield: Sheffield Teaching Hospitals NHS Trust.
     

     CHAPTER 18
     High-risk labour
     

     344‌‌
     

     Epilepsy
     

     Epilepsy affects about 0.5% of pregnant women. Some experience an increase in fits during pregnancy. This may be because women discontinue their medication or they experience nausea/vomiting. Also, a haemodilu- tion and increased metabolism of anticonvulsant drugs may lead to a fall
     

     in the concentration of the drug in the plasma. Only 1–2% of women with active epilepsy will have a seizure in labour.
     ¹
     

     A brief isolated fit is unlikely to be dangerous to the fetus, only occasionally will a seizure cause morbidity, but status epilepticus is a cause of maternal and fetal death.
     

     Women with epilepsy are frequently anxious and require much reassurance. Ideally they should be cared for in labour by a midwife who is known to them and they should have met the consultant overseeing care.
     

     Prevention of seizures
     

     • The midwife should listen to the woman’s assessment of her own needs. She will be familiar with the factors which stimulate her seizures and she may experience warning of an attack.
       
     • Anticonvulsant medication should be given as normal during labour. Anticonvulsants include:
       
       • Phenytoin
         
       • Primidone
         
       • Sodium valproate
         
       • Carbamazepine
         
       • Phenobarbital.
         

         Missed doses will cause a drop in plasma levels which should be avoided. Malabsorption during labour may also increase risk of a seizure. If excessive nausea and vomiting occurs an IV regimen of phenytoin may be necessary.
         

     • The midwife should help the woman to achieve a good night’s sleep during early labour and prolonged labour should be avoided— exhaustion may cause a seizure.
       
     • Anxiety and stress should be minimized. The midwife can help by encouraging support from the partner and discussing the plan of care fully with the woman.
       
     • Pain or hyperventilation related to pain or stress may cause seizure so adequate analgesia is paramount. The midwife should offer the same range of pain relief (including epidural) as available to other women.
       
     • The midwife should ensure adequate hydration and nutrition since dehydration or hypoglycaemia can trigger seizures.
       
     • The midwife and/or partner should be in attendance throughout the labour.
       

       Signs of epileptic seizure
       

       Epileptic seizures occur in a variety of forms. The most dangerous are tonic clonic seizures.
       

     • Tonic clonic seizure: the woman may experience aura: a strange feeling, taste, or smell. She will suddenly stiffen and if standing fall backwards. She may cry out or bite her tongue. Her muscles will relax and tighten causing the body to convulse. She may be incontinent of urine.
       

  EPILEPSY
  

  345
  

  Her breathing may be laboured. The colour of her skin may change to blue-grey. She cannot hear. The episode may last just a few minutes.
  

  • Following the seizure: the colour of the woman’s skin returns to normal. The woman may feel tired and confused. She may have a headache and want to sleep.