Oxford Handbook of Midwifery (76 page)

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

BOOK: Oxford Handbook of Midwifery
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  • Encourage her to follow consultant guidelines on diet during labour.
    In early labour light snacks and fluids are usually recommended. If prescribed by the anaesthetist give ranitidine 150mg orally, three times a day.
    Established first stage
  • As labour establishes, monitor the fetal hearts continuously, alongside
    uterine contractions.
  • Epidural anaesthesia is often recommended for pain relief. It provides adequate analgesia if intrauterine manipulation of the second twin, forceps delivery, or caesarean is necessary in the second stage. However, be sensitive to individual choice.
  • Whatever the woman’s choice, an infusion of normal saline may help to keep her hydrated and maintain IV access.
  • Make regular assessment of the woman’s blood pressure, pulse, temperature, and fluid balance.
  • If an epidural is in place and if the presenting head of the first twin is well engaged in the pelvis, after obtaining the consent of the woman artificially rupture the membranes, and place a fetal scalp electrode on the first twin, to facilitate monitoring.
  • Care should be taken to ensure the woman’s comfort, regularly easing her position and paying attention to hygiene. Encourage her to choose lateral positions to avoid supine hypotension.
  • Assess progress and keep the obstetric registrar, anaesthetist, and paediatric team informed. If possible, introduce all personnel to the parents.
    Second stage of labour
  • When delivery is imminent, call the obstetric registrar in case manipulation of the second twin is necessary.
  • The anaesthetist on call should be immediately available outside the delivery room.
  • The paediatric team should be present and additional resuscitation equipment prepared to receive both babies.
  • Maintain a calm environment and minimize stress for the parents.
  • A portable ultrasound scanner should be ready.
  • An oxytocin infusion (e.g. oxytocin 5IU added to 250mL of normal saline set to run at 6mL/h) should be prepared to run via a pump. It should be connected to the IV cannula already
    in situ
    by a dual tap. Initially it remains turned off.
  • The woman may prefer not to deliver in the lithotomy position, but the potential for this should be available. An upright position will facilitate pushing and descent of second twin.
  • Proceed with the delivery of the first twin:
    • NEVER give Syntometrine
      ®
      because the second stage is not yet concluded.
    • Episiotomy may not be necessary.
    • Clamp and cut the cord.
    • If the baby is in good condition, encourage the father and mother to hold the baby.
      CHAPTER 18
      High-risk labour
      330
      • Occasionally, but not usually, the first placenta may deliver next.
      • The registrar should remain present while the midwife performs the second delivery. The midwife should:
        • Palpate the abdomen or scan to determine the lie of the second twin, which must be longitudinal
        • Monitor the heart rate continuously
          • With the woman’s consent, gently perform a vaginal examination The midwife will be able to feel the bulging membranes (unless
          the twins are monozygotic) and a cephalic presentation. Confirm descent
        • Leave the membranes intact
        • Encourage the woman to continue pushing and, if necessary, administer the oxytocin infusion to help contractions
        • When the presenting head is well engaged and progressive descent is obvious, the membranes may rupture spontaneously or the midwife may perform ARM
        • The second twin should be delivered within approximately 30min of the first
        • Mark the cord of the second twin with an extra clamp or ligature, to distinguish it from the first.
      • If the babies are well on delivery, encourage skin-to-skin contact between babies and parents. If there is concern on delivery, the paediatric team will assess the babies.
      • Samples of cord blood may be taken for assessment of pH.
        Complications with the second twin
        If the second twin does not take up longitudinal lie following the delivery of the first twin, the obstetric registrar will take over care. With the woman’s consent, the following may be performed.
      • A catheter will be placed
        in situ
        .
      • External cephalic version may be attempted.
      • If not successful, but the fetal heart is reassuring, analgesia is adequate and the second twin is no larger than the first, internal podalic version and breech extraction may be attempted.
      • Internal podalic version is performed by the obstetric registrar. The ultrasound scanner is used to assess the position and locate the feet of the second twin. If the feet are easily accessible vaginally, between contractions the obstetrician should reach into the uterine cavity and grasp the foot through the membranes. At the onset of a contraction the fetal foot is pulled downwards with one hand whilst ARM is performed with the other hand. The fetus should then be longitudinal lie and it should be possible to grasp the other foot and encourage maternal effort to push. A vaginal breech birth should ensue.
      • However, because of the perceived risks of breech birth, protocols recommend emergency caesarean section.
        Third stage of labour
      • Allowing the third stage to progress unaided is not usually recommended because of the risk of excessive blood loss from two placental sites.
        DELIVERY CARE FOR TWINS AND OTHER MULTIPLE BIRTHS
        331
  • Obtain the mother’s consent to proceed to active management of the third stage, and give 1mL of Syntometrine
    ®
    intramuscularly.
  • Once delivered, the placenta should be sent for histological examination.
  • An oxytocin infusion continued for 4h following delivery will help to minimize PPH.
    Rare scenarios with twin pregnancies
    Monoamniotic twins
  • Vascular anastomoses can occur between the placental vessels of the twins.
  • One twin may be small, pale and anaemic and the other large, plethoric and polycythaemic.
  • As a result of twin–twin transfusion, fetal asphyxia can occur in either twin.
  • These twins are usually diagnosed prior to labour and caesarean section performed to avoid the complications of fetal asphyxia.
    Locked twins
  • This situation may arise when the first twin is in the breech position and the second twin is a cephalic presentation.
  • The head of the first twin can become locked above the head of the second.
  • Caesarean section is now recommended for twins with this presentation.
    CHAPTER 18
    High-risk labour
    332‌‌
    Hypertensive disorders
    Definitions of hypertension during pregnancy
    • Essential hypertension
      is raised arterial blood pressure, 140/90mmHg or more, before 20 weeks’ gestation. No proteinuria is present.
    • Gestational hypertension
      (pregnancy-induced hypertension, PIH) is
      blood pressure raised above 140/90mmHg after 20+ weeks’ gestation.
      No proteinuria is present. It can be classified as a blood pressure of 20–25mmHg above the baseline diastolic reading, sustained over 24h.
    • Pre-eclampsia
      is a multisystem disorder. The classification of severity depends on levels of maternal blood pressure and proteinuria: blood pressure, 140/90mmHg; proteinuria, a dipstick reading of 1+, or 0.3g in a 24h urine collection.
    • Eclampsia
      is defined as the occurrence of convulsions alongside signs and symptoms of pre-eclampsia.
      Hypertensive disorders can worsen or flare up suddenly during labour or up to 10 days post natally.
    • All affected women should be considered to be at high risk:
      • Access consultant-led care
      • Deliver at a unit with neonatal facilities.
    • Untreated hypertensive disorders in pregnancy can progress to pre-eclampsia, eclampsia, HELLP syndrome (b see p. 408), DIC syndrome (b see Disseminated intravascular coagulation, p. 410), and fetal/maternal death.
    • Eclampsia is the leading cause of maternal death.
      • Death may occur from acute respiratory distress syndrome (RDS), intracerebral haemorrhage, hepatic, renal, or cardiovascular failure.
      • Fetal death may occur from asphyxia, compromise in labour or placental abruption.
    • The only known cure for worsening pre-eclampsia is delivery of the baby. The decision to deliver depends on the condition of the mother and fetus and the length of gestation.
      Principles of midwifery care
      An experienced midwife should:
    • Provide continuous care to the woman and liaise with all the team.
    • Monitor the maternal and fetal condition closely.
    • Be aware of abnormal clinical findings/complications.
    • Refer changes in maternal and fetal condition immediately to the consultant/senior obstetrician for early treatment.
    • Carry out the obstetrician’s plan of care or assist the obstetrician and multidisciplinary team to perform actions necessary to achieve
      optimum outcome, considering appropriate time and route for delivery of the fetus. Attentive intrapartum care according to a management plan by a consultant obstetrician is paramount.
    • Facilitate communication between all members of the multidisciplinary team, including the senior midwife, obstetrician, anaesthetist, paediatrician, neonatal intensive care and laboratory staff.
      HYPERTENSIVE DISORDERS
      333

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