Oxford Handbook of Midwifery (80 page)

backwards. Recovery after a tonic seizure is quick.

In the event of an epileptic seizure

Status epilepticus
can occur in any type of seizure. If it happens with tonic clonic seizure it is a serious emergency. If the fit continues the anaesthetist will administer 10mg IV diazepam (Diazemuls
^®
) slowly. A further 10mg diazepam may be given. If seizure control is not then achieved the anaesthetist will induce general anaesthesia.

The baby will be delivered by caesarean.

Immediate postnatal care for epileptic mother and her baby

of haemorrhagic disease of the newborn caused by deficiency in the mother and fetus of vitamin K dependent clotting factors.

1
The Royal College of Obstetricians and Gynaecologists: Scottish Executive Committee (1999).
The Management of Pregnancy in Women with Epilepsy. A clinical Practice Guideline for those involved in Maternity Care
. Aberdeen: Scottish Programme for Reproductive Health.

CHAPTER 18
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346‌‌

Cardiac conditions

Women with cardiac conditions should have individualized plans made for their care by a team including cardiologist, anaesthetist, obstetrician and midwife. All women should be assessed for exercise tolerance and cardiac function prior to labour and birth.

The aim of care is to reduce the risk of cardiac failure. There are a number of haemodynamic changes taking place in the cardiovascular

system during labour and birth which will affect a pregnant woman with significant cardiac disease.

• Increase in cardiac output by 34%.
  
• Rise in blood pressure from early first stage to the end of second stage. There is a marked increase during second stage contractions when this is accompanied by the mother’s pushing efforts.
  

  First stage of labour
  

• Spontaneous labour and vaginal birth are preferable and there is no significant benefit from elective caesarean section.
  
• Epidural analgesia is a good option because it decreases cardiac output by increasing peripheral dilatation and reducing the need for fluid pre- load. Care must be exercised in those with a fixed cardiac output.
  
• Fluid balance requires particular attention and care must be taken not to overload as this may precipitate pulmonary oedema.
  
• Maternal and fetal well-being must be continuously and carefully assessed.
  

  Second stage of labour
  

• The second stage of labour can be shortened by elective instrumental delivery to minimize the dramatic rise in blood pressure observed when the mother is pushing.
  
• In mild heart disease where there have been no antenatal problems it would not be necessary to intervene if progress is rapid and a short second stage anticipated.
  

  Third stage of labour
  

• Ergometrine and Syntometrine
  ^®
  should be avoided as they can cause generalized vasospasm and hypertension resulting in a 500–800mL bolus of blood returning to the venous circulation.
  
• Use of oxytocin infusion avoids the problems of bolus and PPH. However, oxytocin should be used with caution in women with severe disease because it can cause profound hypotension.
  
• Physiological management results in a return of 200–300mL of blood to the circulation. As no oxytocic is given this occurs over a period of minutes rather than during one contraction.
  
• Women with cardiac disease should be closely monitored for at least 24h following birth.
  

  Cardiac conditions classified into groups according to risk
  ¹
  

  Low-risk conditions
  

• Uncomplicated septal defects
  
• Mild or moderate pulmonary stenosis
  

CARDIAC CONDITIONS

347

Conditions with some risk

High-risk conditions

Any case where there is heart failure which is difficult to control. The fetus may be at particularly high risk when maternal cyanosis or heart failure is present.

Some cardiac conditions may require antibiotic cover prophylactically for the prevention of endocarditis, at the onset of spontaneous labour or for obstetric procedures such as induction of labour.

1
Siu SC, Colman JM (2001). Heart disease and pregnancy.
Heart
85
, 710–15.

CHAPTER 18
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Pyrexia

• Pyrexia is defined as a persistent temperature above 38°C.
  
• It is often associated with coincidental maternal infection, such as upper respiratory tract infection, or may be due to chorioamnionitis.
  
• Epidural analgesia is often accompanied by a rise in maternal
  temperature but it cannot always be assumed that this is the cause and
  

  an infective agent must be ruled out.
  

• Fever exceeding 38°C is associated with an increased risk of cerebral palsy in the baby.
  
• Be aware of maternal sepsis developing, especially if there are predisposing factors such as prolonged rupture of membranes, surgical delivery, pyelonephritis (inflammation of the kidney and renal pelvis). Both maternal and fetal infection must be considered.
  

  Women who develop pyrexia should receive the following care.
  

• Sepsis screen: blood culture, catheter specimen of urine and high vaginal, introital, and rectal swabs should be sent for laboratory analysis.
  
• Cooling strategies: use of a fan, paracetamol, and tepid sponging of the skin.
  
• The registrar on call should be informed of the woman’s pyrexia.
  
• Broad-spectrum IV antibiotics will be prescribed as per unit protocol. (e.g. cefuroxime 750mg–1500mg IV 8h and metronidazole 500mg IV 8h)
  
• Be alert for septic shock. It usually presents with pyrexia and hypotension. Inform the obstetrician of any deterioration in the woman’s condition.
  

  A wide variety of organisms have been implicated in septic shock during pregnancy, including
  Escherichia coli
  ,
  Staphylococcus aureus
  , and B-haemolytic streptococcus.
  

  Suspected septicaemia is an indication for transfer of the woman to a high-dependency care facility, and the intensive care medical team, consultant obstetrician, and anaesthetist need to be involved prior to transfer.
  

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  CHAPTER 18
  High-risk labour
  

  350‌‌
  

  Infections
  

  Care of the mother with an infection during pregnancy, labour, and the postnatal period should be individualized according to the needs of the woman and her family. Information shared among carers should be on a need-to-know basis in order to protect the woman’s confidentiality.
  

  Hepatitis B
  

  A woman newly diagnosed during pregnancy should have had the oppor- tunity to discuss her management and been given written information about the condition. The Public Health Laboratory should have been informed of the diagnosis and a full hepatitis B serology obtained.
  

  If the woman is antigen positive, neonatal hepatitis B immunoglobulin is indicated as there is a high risk of neonatal transmission. This can be obtained in advance on a named patient basis.
  

  During labour, if possible:
  

• Do not apply a scalp electrode
  
• Do not perform fetal blood sampling.
  

  Options for analgesia are the same as for the woman who is hepatitis B negative.
  

  Hepatitis C
  

  As for hepatitis B, do not perform fetal blood sampling or attach a fetal scalp electrode.
  

  There is a small risk of transmission to the neonate and the baby will need paediatric follow-up, as detection of transmission may require more than one blood test over a 6–12-month period.
  

  HIV
  

  Make arrangements for the birth in advance and liaise with the infectious disease specialist and pharmacy, who need to know the expected date of delivery in advance in order to ensure enough stock of antiviral therapy.
  

  Most transmission is known to occur around the time of delivery, and elective caesarean delivery before the membranes rupture is known to lower vertical transmission rates compared with emergency section or vaginal delivery.
  ¹
  

• Some women choose to have a vaginal delivery, and for these women do not apply a fetal scalp electrode or perform scalp sampling.
  
• Offer the same analgesia as would be offered to other women in labour.
  
• Zidovudine infusion can be commenced prophylactically during labour, to help prevent maternal–fetal transmission of the virus.
  ²
  
  • A continuous infusion of 2mg/kg over 1h followed by 1mg/kg/h until the umbilical cord is clamped.
    
  • For an elective caesarean section, the infusion can be started 4h prior to the operation at 2mg/kg for 1hr, followed by 1mg/kg/h until the umbilical cord is clamped.
    
• Procedures at birth include obtaining blood samples from the baby, after washing, to test for antibodies and the potential effects of zidovudine treatment during pregnancy.
  

INFECTIONS

351

Herpes

Neonatal herpes is a severe systemic viral infection with high morbidity and mortality. The risks are greatest when a woman acquires a primary infection during late pregnancy, so the baby is born before the develop- ment of protective maternal antibodies.
³