Prepared and presented by: Prepared and presented by: Dr. Hashem Yaseen MBBS, 4Dr. Hashem Yaseen MBBS, 4thth year OG year OG

KAUH / JUSTKAUH / JUST

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

The principle of intrapartum care

The outlines

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 glucoseclosely—hyperglycaemia should be anticipated.• Prepare for the possibility of shoulder dystocia

Diabetes in Pregnancy: Management Diabetes in Pregnancy: Management in Labourin Labour

Diabetes in Pregnancy: Management Diabetes in Pregnancy: Management in Labour in Labour

Diabetes in Pregnancy: Management Diabetes in Pregnancy: Management in Labour in Labour

Diabetes in Pregnancy: Management Diabetes in Pregnancy: Management in Labour in 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.

Diabetes in Pregnancy: Management Diabetes in Pregnancy: Management in Labour in 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

Hypertensive disordersBlood pressure measurement

• BP must be measured correctly to avoid falsely high or low readingsthat may influence clinical management.

• BP should be measured sitting or in the supine position with aleft sided tilt (to avoid compression of the inferior vena cava bythe pregnant uterus, which reduces blood fl ow to the heart andconsequently stroke volume and leads to falsely low BP) with theupper arm at the level of the heart.

• Use the correct cuff size (a normal adult cuff is usually for an upperarm of 34cm or less). A cuff too small may lead to a falsely highreading.

• The diastolic BP should be taken as Korotkoff V (the absence ofsound), rather than Korotkoff IV (muffl ing of sound), which waspreviously used, unless the sound is heard all the way down to 0.

Be aware of automated BP monitors. They may under-Be aware of automated BP monitors. They may under-record BPrecord BPespecially in pre-eclampsia. If unsure, check with especially in pre-eclampsia. If unsure, check with sphygmomanometersphygmomanometer..

Severe pre-eclampsia: managementSevere pre-eclampsia: management

Other management• Take bloods for FBC, urea and electrolytes (U&E), LFTs, and clottingprofile.• 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.

EpilepsyIntrapartum careIntrapartum care

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

EpilepsyIntrapartum careIntrapartum care

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

Status epilepticus

Subarachnoid haemorrhageSubarachnoid haemorrhage

Outside pregnancy the commonest cause Outside pregnancy the commonest cause is a ruptured berry aneurysm, but is a ruptured berry aneurysm, but arteriovenous malformations (AVMs) arteriovenous malformations (AVMs) may dilate in pregnancy due to the may dilate in pregnancy due to the effect of oestrogen, resulting in a effect of oestrogen, resulting in a similar incidence.similar 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.

Subarachnoid haemorrhageSubarachnoid haemorrhage

•labour is a high-risk time for bleeding, labour is a high-risk time for bleeding, elective CS should be recommended if elective CS should be recommended if the lesion is inoperablethe lesion is inoperable• • epidural anaesthesia is contraindicated epidural anaesthesia is contraindicated with a recent subarachnoid haemorrhage with a recent subarachnoid haemorrhage (SAH) due to raised intracranial pressure(SAH) due to raised intracranial pressure• • if the lesion has been successfully if the lesion has been successfully treated, vaginal delivery is treated, vaginal delivery is recommended (a longer passive 2nd recommended (a longer passive 2nd stage with early use of assistedstage with early use of assisteddelivery may reduce the risk of delivery may reduce the risk of rebleeding).rebleeding).

Cardiac disease: Cardiac disease: managementmanagement

•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 isindicated 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 required In 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 stagefollowed by an infusion of oxytocin, but ergometrine and followed by an infusion of oxytocin, but ergometrine and prostaglandinprostaglandinF2α (PGF2 α , dinoprost) should be avoided.F2α (PGF2 α , dinoprost) should be avoided.• • Epidural analgesia may reduce changes in heart rate and BP Epidural analgesia may reduce changes in heart rate and BP associated with pain (low-dose epidural is usually well tolerated, but associated with pain (low-dose epidural is usually well tolerated, but may causemay causeserious 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 ofpulmonary oedema the fi rst few days post-partum.pulmonary oedema the fi rst few days post-partum.

•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

Haemophilia

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 PostpartumPostpartumDrug 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

RENAL FAILURE

Interventions should include catheterization, Interventions should include catheterization, central venous line.central venous line.• • Replace fluid/blood loss but avoid fluid Replace fluid/blood loss but avoid fluid overload as there is a significant risk of overload as there is a significant risk of pulmonary oedema (accurate pulmonary oedema (accurate documentation of input/output.documentation of input/output.

• • Maintain BP at levels that allow adequate Maintain BP at levels that allow adequate renal perfusion.renal perfusion.

• • Correct hyperkalaemia, coagulopathy, and Correct hyperkalaemia, coagulopathy, and give antibiotics if infection suspected.give antibiotics if infection suspected.

Acute fatty liver of pregnancy

Acute fatty liver of pregnancy• • Management should involve:Management should involve:• • treatment of hypoglycaemiatreatment of hypoglycaemia• • correction of coagulopathy with IV vitamin K correction of coagulopathy with IV vitamin K and fresh frozen plasma (FFP)and fresh frozen plasma (FFP)• • strict control of BP and fluid balance.strict control of BP and fluid balance.• • Delivery should follow stabilization (regional Delivery should follow stabilization (regional anaesthesia is contraindicatedanaesthesia is contraindicatedin presence of thrombocytopaenia (<80) or in presence of thrombocytopaenia (<80) or deranged clotting).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 Following delivery, care is supportive, and most women improve rapidly after delivery with no women improve rapidly after delivery with no long-term liver damage.long-term liver damage.

Perineal Body

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.

• 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.

Retained placenta

Retained placenta

Prepared and presented by: Prepared and presented by: Dr. Hashem Yaseen MBBS, 4Dr. Hashem Yaseen MBBS, 4thth year OG year OG

KAUH / JUSTKAUH / JUST