Intrapartum care for high risk women for nurses and midwifes

1. Prepared and presented by:Prepared and presented by:
Dr. Hashem Yaseen MBBS, 4Dr. Hashem Yaseen MBBS, 4thth
year OGyear OG
KAUH / JUSTKAUH / JUST

2. Before we start ?
•What is the labour?What is the labour?
•Stages of labourStages of labour
•Parameters of progress of labourParameters of progress of labour
•Causes of abnormal labourCauses of abnormal labour

3. The principle of intrapartum care

9. The outlines

10. Urine
• Test for ketones. If ketones are present at a moderate or high level, consider hydration
and contact
• Test for protein.
Blood glucose monitoring
• Type 1 and Type 2 and GDM on insulin 2-hourly
• GDM not on insulin 4-hourly.
•If induction of labour or CS, continue normal insulin until day of procedure, then start
sliding scale in early morning.
• Avoid maternal hyperglycaemia → causes fetal hypoglycaemia.
• If steroids are given for threatened preterm labour, monitor glucose
closely—hyperglycaemia should be anticipated.
• Prepare for the possibility of shoulder dystocia
Diabetes in Pregnancy: ManagementDiabetes in Pregnancy: Management
in Labourin Labour

11. Diabetes in Pregnancy: ManagementDiabetes in Pregnancy: Management
in Labourin Labour

12. Diabetes in Pregnancy: ManagementDiabetes in Pregnancy: Management
in Labourin Labour

13. Diabetes in Pregnancy: ManagementDiabetes in Pregnancy: Management
in Labourin Labour
Intravenous insulin infusion
Suitable for patients requiring intensive therapy and/or poor control on a
sliding scale, for example severe pre-eclampsia. Consult with Diabetes
Physician.
Via syringe pump
• 50 units NovoRapid insulin in 50 mLs of Normal saline
Aim to keep blood glucose level 4-7mmol/L
• Start rate of 1-2 units/hour depending on initial blood glucose level
• If blood glucose level > 7 mmol/l, increase insulin by 1 unit/hour
• If blood glucose level < 4 mmol/l, decrease insulin by 1 unit/hour
• If blood glucose level 4-7 mmol/L, maintain rate.
Note: do not use this regimen for diabetic ketoacidosis.

14. Diabetes in Pregnancy: ManagementDiabetes in Pregnancy: Management
in Labourin Labour
Postpartum
Insulin requirements fall dramatically postpartum
Monitor glucose levels to avoid profound and/or prolonged hypoglycaemia.
Type 1 and Type 2
• blood glucose monitoring within 2 hours of birth then: o QID: fasting and
before each meal
o sliding scale insulin (low dose)
o type 2 women will usually not require insulin in the postnatal period
unless blood glucose levels are consistently elevated
o Oral hypoglycaemic agents are not recommended while breastfeeding
except for low dose metformin.
GDM
• Blood glucose monitoring B.D. for 48 hours
• Insulin is ceased post birth
• If blood glucose levels > 7.0 mmol/L, continue to monitor until discharge -
fasting and 2 hours after meals
• If blood glucose levels are persistently elevated after 72 hours, contact

16. Hypertensive disorders
Blood pressure measurement
• BP must be measured correctly to avoid falsely high or low readings
that may influence clinical management.
• BP should be measured sitting or in the supine position with a
left sided tilt (to avoid compression of the inferior vena cava by
the pregnant uterus, which reduces blood fl ow to the heart and
consequently stroke volume and leads to falsely low BP) with the
upper arm at the level of the heart.
• Use the correct cuff size (a normal adult cuff is usually for an upper
arm of 34cm or less). A cuff too small may lead to a falsely high
reading.
• The diastolic BP should be taken as Korotkoff V (the absence of
sound), rather than Korotkoff IV (muffl ing of sound), which was
previously used, unless the sound is heard all the way down to 0.
Be aware of automated BP monitors. They may under-record BPBe aware of automated BP monitors. They may under-record BP
especially in pre-eclampsia. If unsure, check withespecially in pre-eclampsia. If unsure, check with sphygmomanometersphygmomanometer..

17. Severe pre-eclampsia: managementSevere pre-eclampsia: management
Other management
• Take bloods for FBC, urea
and electrolytes (U&E), LFTs,
and clotting
profile.
• Strict fluid balance chart:
consider a catheter.
• CTG monitoring of fetus
until condition stable.
• Ultrasound of fetus:
• evidence of IUGR, estimate
weight if severely preterm
• assess condition using
fetal and umbilical artery
Doppler.

19. Epilepsy
Intrapartum careIntrapartum care
Pregnant WWE should be counselled that the risk ofPregnant WWE should be counselled that the risk of
seizures in labour is low.seizures in labour is low.
Adequate analgesia and appropriate care in labourAdequate analgesia and appropriate care in labour
should be provided to minimise risk factors for seizures suchshould be provided to minimise risk factors for seizures such
as insomnia, stress and dehydration.as insomnia, stress and dehydration.
Long-acting benzodiazepines such as clobazam can beLong-acting benzodiazepines such as clobazam can be
considered if there is a very high risk of seizures in theconsidered if there is a very high risk of seizures in the
peripartum period.peripartum period.
AED intake should be continued during labour. If thisAED intake should be continued during labour. If this
cannot be tolerated orally, a parenteral alternative should becannot be tolerated orally, a parenteral alternative should be
administered.administered.

20. Epilepsy
Intrapartum careIntrapartum care
Seizures in labour should be terminated as soon as possible toSeizures in labour should be terminated as soon as possible to
avoid maternal and fetal hypoxia and fetal acidosis.avoid maternal and fetal hypoxia and fetal acidosis.
BenzodiazepinesBenzodiazepines are the drugs of choice.are the drugs of choice.
Continuous fetal monitoringContinuous fetal monitoring is recommended in women at highis recommended in women at high
risk of a seizure in labour, and following an intrapartum seizure.risk of a seizure in labour, and following an intrapartum seizure.
Pain relief in labour should be prioritised in WWE, withPain relief in labour should be prioritised in WWE, with
options including transcutaneous electrical nerve stimulationoptions including transcutaneous electrical nerve stimulation
(TENS), nitrous oxide and oxygen (Entonox®), and regional(TENS), nitrous oxide and oxygen (Entonox®), and regional
analgesia.analgesia.
Pethidine should be used with caution in WWE for analgesia inPethidine should be used with caution in WWE for analgesia in
labour.labour. DiamorphineDiamorphine should be used in preference to pethidine.should be used in preference to pethidine.

22. Status epilepticus

23. Subarachnoid haemorrhageSubarachnoid haemorrhage
Outside pregnancy the commonest cause is aOutside pregnancy the commonest cause is a
ruptured berry aneurysm, but arteriovenousruptured berry aneurysm, but arteriovenous
malformations (AVMs) may dilate in pregnancy duemalformations (AVMs) may dilate in pregnancy due
to the effect of oestrogen, resulting in a similarto the effect of oestrogen, resulting in a similar
incidence.incidence.
PresentationPresentation
•• Headache.Headache.
•• Vomiting.Vomiting.
•• Loss of or impaired consciousness.Loss of or impaired consciousness.
•• Neck stiffness.Neck stiffness.
•• Focal neurological signs.Focal neurological signs.

24. Subarachnoid haemorrhageSubarachnoid haemorrhage
•labour is a high-risk time for bleeding, elective CSlabour is a high-risk time for bleeding, elective CS
should be recommended if the lesion isshould be recommended if the lesion is
inoperableinoperable
•• epidural anaesthesia is contraindicated with aepidural anaesthesia is contraindicated with a
recent subarachnoid haemorrhage (SAH) due torecent subarachnoid haemorrhage (SAH) due to
raised intracranial pressureraised intracranial pressure
•• if the lesion has been successfully treated,if the lesion has been successfully treated,
vaginal delivery is recommended (a longervaginal delivery is recommended (a longer
passive 2nd stage with early use of assistedpassive 2nd stage with early use of assisted
delivery may reduce the risk of rebleeding).delivery may reduce the risk of rebleeding).

26. Cardiac disease: managementCardiac disease: management
•Aim for a vaginal delivery usually with a short active 2nd stage (CS isAim for a vaginal delivery usually with a short active 2nd stage (CS is
indicated if aortic root >4.5cm, left ventricular ejection fraction (LVEF)indicated if aortic root >4.5cm, left ventricular ejection fraction (LVEF)
<30%, aortic dissection or aneurysm).<30%, aortic dissection or aneurysm).
•• In labour, maternal cardiac ± invasive monitoring may be requiredIn labour, maternal cardiac ± invasive monitoring may be required
the fetus should be continuously monitored).the fetus should be continuously monitored).
•• Avoid aortocaval compression.Avoid aortocaval compression.
•• Decide on need for endocarditis prophylaxis.Decide on need for endocarditis prophylaxis.
•• Blood loss should be minimized by active management of 3rd stageBlood loss should be minimized by active management of 3rd stage
followed by an infusion of oxytocin, but ergometrine andfollowed by an infusion of oxytocin, but ergometrine and
prostaglandinprostaglandin
F2α (PGF2 α , dinoprost) should be avoided.F2α (PGF2 α , dinoprost) should be avoided.
•• Epidural analgesia may reduce changes in heart rate and BPEpidural analgesia may reduce changes in heart rate and BP
associated with pain (low-dose epidural is usually well tolerated, butassociated with pain (low-dose epidural is usually well tolerated, but
may causemay cause
serious complications with restricted cardiac output).serious complications with restricted cardiac output).
•• Strict fluid balance is mandatory as there is a much higher risk ofStrict fluid balance is mandatory as there is a much higher risk of

28. •Chronic and acute severe asthma should be treated as in
the nonpregnant state (aim for O 2 sats >95% and
administer O 2 if required).
•Asthma attacks are rare during labour; inhaled B -agonists
can be used (there is no evidence that they interfere with
uterine activity).
• Women on long-term oral steroids (prednisolone
>7.5mg/day for >2wks) are at risk of Addisonian collapse
during labour—give hydrocortisone 100mg every 8h.
• PGF2 α should only be used in cases of life-threatening
post-partum haemorrhage → its bronchoconstriction action

31. Haemophilia

32. Thrombophilia
IntrapartumIntrapartum
>Aspirin can be continued until birth
> Low-dose aspirin does not affect the use of regional anaesthesia
during labour
> Send the placenta for histopathology if there is preeclampsia,
IUGR, previous stillbirth or miscarriage/s
PostpartumPostpartum
Drug treatment
Women with a history of previous thrombosis should receive LMWH
or warfarin for 6 weeks postpartum.
Women without previous history of thrombosis who have other risk
factors for venous thrombosis should receive postpartum LMWH
for 5 days.
>For women recommencing warfarin:>For women recommencing warfarin:
>Recommence warfarin treatment on day 2 -3 as ordered for
women on long term warfarin treatment
>Discontinue LMWH when the international normalized ratio (INR) is
> 2.0

34. RENAL FAILURE
Interventions should include catheterization, centralInterventions should include catheterization, central
venous line.venous line.
•• Replace fluid/blood loss but avoid fluid overload as thereReplace fluid/blood loss but avoid fluid overload as there
is a significant risk of pulmonary oedema (accurateis a significant risk of pulmonary oedema (accurate
documentation of input/output.documentation of input/output.
•• Maintain BP at levels that allow adequate renalMaintain BP at levels that allow adequate renal
perfusion.perfusion.
•• Correct hyperkalaemia, coagulopathy, and giveCorrect hyperkalaemia, coagulopathy, and give
antibiotics if infection suspected.antibiotics if infection suspected.

36. Acute fatty liver of pregnancy

37. Acute fatty liver of pregnancy
•• Management should involve:Management should involve:
•• treatment of hypoglycaemiatreatment of hypoglycaemia
•• correction of coagulopathy with IV vitamin K and freshcorrection of coagulopathy with IV vitamin K and fresh
frozen plasma (FFP)frozen plasma (FFP)
•• strict control of BP and fluid balance.strict control of BP and fluid balance.
•• Delivery should follow stabilization (regional anaesthesia isDelivery should follow stabilization (regional anaesthesia is
contraindicatedcontraindicated
in presence of thrombocytopaenia (<80) or deranged clotting).in presence of thrombocytopaenia (<80) or deranged clotting).
•• Bleeding complications are common.Bleeding complications are common.
•• Fluid balance may require central line .Fluid balance may require central line .
•• Following delivery, care is supportive, and most womenFollowing delivery, care is supportive, and most women
improve rapidly after delivery with no long-term liverimprove rapidly after delivery with no long-term liver
damage.damage.

56. Perineal Body

58. PREOPERATIVE PREPARATION
• A thorough visual inspection of the distal vagina,
perineum and anorectum should be performed
following a vaginal delivery to identify and
evaluate the extent of a vaginal tear.
• The apex of the vaginal laceration should always
be identified.
• A rectal examination is performed to exclude
injury to the anorectal mucosa and anal
sphincter.
• Palpation is important to determine whether the
rectal mucosa and anal sphincter are intact.

59. • The rectovaginal examination is accomplished
by:
• Placing an index finger in the rectum.
• The thumb over the anal sphincter.
• Using a pill-rolling motion to assess the
sphincter.
• Of note, the anal sphincter may be disrupted by
shearing forces produced by descent of the fetal
head, and this can occur in women with an
otherwise intact perineum.

71. Retained placenta

72. Retained placenta

73. Prepared and presented by:Prepared and presented by:
Dr. Hashem Yaseen MBBS, 4Dr. Hashem Yaseen MBBS, 4thth
year OGyear OG
KAUH / JUSTKAUH / JUST