Oxford Handbook of Midwifery (83 page)

Management of preterm delivery

discussed between obstetric, anaesthetic and theatre, neonatal, senior

midwifery staff, and parents.

• Confirm the fetal lie and presentation
  
• Give an estimated fetal weight
  
• Exclude serious abnormality.
  

  If the fetus is between 22 and 26 weeks’ gestation
  

22 weeks’ gestation. Sometimes it may be that delivery, assessment, and postnatal transfer is more appropriate.

• Follow the agreed management plan when discussing the family’s needs. Be a sympathetic listener and encourage the parents to seek psychological support from family, friends, and other networks.
  
• Help the parents to understand how their baby may look at delivery. Discuss the approximate size, features of prematurity, and possible bruising which may be present after delivery.
  
• The parents should understand the procedure that will be followed. Be prepared to repeat explanations. Distressed and anxious parents may not remember information.
  
• Check that the content of the paediatrician’s discussions with the parents are documented in the woman’s notes.
  
• If the plan is to resuscitate the baby, the parents should understand that the baby’s condition will be continually assessed and care will be provided in the NICU as long as this is appropriate.
  

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upon. It is also sometimes difficult and time consuming to attempt to obtain a continuous trace when the fetus is very preterm.

• Once established, labour may progress quickly. The cervix may not need to dilate to the traditional 10cm before delivery! Early
  

  preparation for delivery and confirmation of availability of personnel will minimize anxiety and help the delivery run smoothly.
  

  •
  Call the paediatrician to attend all births thought to be >22 weeks’ gestation, to assess the condition of the baby at birth and to make a
  

  decision about resuscitation.
  

• At >23 weeks’ gestation the paediatrician and neonatal nurse team should attend the birth, to assess the baby’s condition and resuscitate actively if appropriate.
  
• The response of the baby to resuscitation determines whether the baby is transferred to the neonatal unit for further intensive care and assessment.
  
• If there has been no time to discuss a plan of action with the parents, it is acceptable to offer intensive care ‘provisionally’ pending further assessment and discussion.
  
• The placenta may be sent to histology for examination.
  

  If the fetus is >27 weeks’ gestation
  

• When a diagnosis of preterm labour is made, arrange for the parents to visit a NICU and to discuss the plan of action with the paediatrician and neonatal team.
  
• Ensure that the parents understand what will happen at delivery.
  
• The environment of care is particularly important when labour is preterm. If psychological stress is reduced, the woman may labour more effectively, with better tolerance of pain. The midwife can help provide a peaceful environment by minimizing the numbers of staff, interruptions, intrusive noise, or light.
  

  During the first stage of preterm labour
  

• Monitor the woman as for a normal first stage.
  
• Encourage the intake of light snacks and fluids. (The anaesthetist may suggest oral ranitidine 150mg 6 or 8h as an antacid in the case of emergency anaesthesia.)
  
• Enable the woman to mobilize. This will enhance the normal descent and well-being of the fetus. The woman’s comfort may be improved with mobility. Supine positions may increase the FHR.
  
• If possible, provide one-to-one support with a variety of coping strategies. This may enhance the woman’s experience of labour and reduce her needs for analgesia.
  
  • Choices for analgesia include TENS, Entonox
    ^®
    , and patient- controlled analgesia.
    
  • If opiates must be used for maternal analgesia, explain possible side- effects to the woman: opiates can make the baby slow to breathe at delivery, or sleepy, with limited interest in suckling.
    
• Monitor the fetal heart according to the obstetrician’s recommendations and parents’ preference. When considering continuous monitoring (CTG) remember that the preterm fetus may demonstrate a different heart pattern:
  

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  • The baseline may be higher than 160bpm
    
  • The variability may be reduced
    
  • Bradycardia and variable decelerations may occur more frequently.
    

maternal infection, FBS will be considered.
¹
If performed, provide
support for the mother during the procedure.

• There is a risk of infection to the fetus
  
• Cord compression or prolapse may occur
  
• It may precipitate variable decelerations in the fetal heart.
  

The second stage of labour

This may allow the normal physiological changes to take place and the optimum transfusion of blood via the cord.

The third stage of labour

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• Delayed clamping and cutting may be applied even when the third stage is managed actively. It may reduce anaemia in the preterm neonate and the red cell transfusion requirements. It may also reduce the duration of the baby’s need for oxygen therapy.
  
• The obstetrician may ask the midwife to double clamp the cord so that cord venous and arterial blood samples can be taken for pH analysis.
  

  This provides a baseline and may aid neonatal management.
  

• When clamping and cutting the cord, leave approximately 6cm at the
  

  baby’s end in case of a later need for umbilical catheterization.
  

• Although a baby may be compromised at delivery, it is important to encourage the parents to look at and touch their baby before transfer to the NICU.
  
• Where possible, encourage the maintenance of skin-to-skin contact, since this maintains the baby’s temperature and may reduce the baby’s stress response. It promotes bonding between the mother and baby. These may be important memories for the parents after the baby’s transfer to NICU. It may improve the duration of breastfeeding.
  
• It is the midwife’s responsibility to ensure that baby identity labels are
  

  in situ
  —one on each ankle—before transfer to NICU.
  

• Take surface swabs from ear, axilla, and umbilicus of the baby if the membranes have been ruptured for longer than 72h. These will be sent for culture and determination of antibiotic sensitivity.
  
• Ensure that the neonatal team has access to the mother’s notes.
  
• A photograph may be taken in NICU and given to the parents.
  
• Encourage the parents to visit as soon a mutually acceptable time can be arranged.
  
• The obstetrician may request histological examination of the placenta.
  

  Recommended reading
  

  Written with reference to: The Practice Development Team (2009).
  Jessop Wing Labour Ward Guidelines 2009–2010.
  Sheffield: Sheffield Teaching Hospitals NHS Trust.
  

  1
  National Institute for Health and Clinical Excellence (2001).
  Electronic Fetal Monitoring
  . London: NICE.
  

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  Induction of labour
  

  Definition
  : labour is initiated using mechanical and/or pharmacological methods. The intervention is necessary when the well-being of the mother or baby may be at risk if the pregnancy is continued. The parents should be in agreement and fully informed of procedures.
  ¹
  

  Some indications
  

• Post maturity
  
• PROM (>37 weeks)
  
• PIH, pre-eclampsia
  
• APH
  
• Placental insufficiency and IUGR
  
• Large fetus, twins
  
• Diabetes, renal disease, or other underlying condition
  
• IUD.
  

  Method of induction
  

  Prostaglandin gel is used to soften/ripen the cervix. When this is achieved, the membranes are ruptured (amniotomy) and an oxytocin infusion commenced to stimulate regular uterine contractions and dilatation of the cervix.
  

  Management
  

• If a consultant-booked woman requires induction of labour, always act under the instructions of the obstetric consultant or registrar.
  ²
  
• The obstetric consultant or registrar should authorize the induction and write the indication and method in the woman’s notes.
  
• The woman will be admitted to the delivery suite.
  
• If she is a primigravida and is likely to need induction using vaginal prostaglandin, she may be admitted at 5pm, given treatment, and allowed to progress over night.
  
• A multigravida who may already have a cervix favourable for induction, and may not need prostaglandin before amniotomy is possible, may be admitted at 7am.
  
• Carefully explain the length of time that induction may take and the procedures involved and possible outcomes. This will help to alleviate the prospective parents’ anxiety and enable them to make appropriate arrangements for hospital admission.
  
• Before commencing the induction, ensure that:
  
  • The woman and her partner understand and consent. If induction fails, a caesarean section is indicated. NICE has produced a booklet about induction of labour
    ³
    
  • The rationale for induction is documented and current
    
  • The estimated date of delivery is correct and, if possible, confirmed on early pregnancy scan
    
  • The presenting part is engaged (3/5 palpable abdominally)
    
  • The fetal heart (CTG) has been monitored for 30min and is reassuring
    
  • The obstetric registrar has prescribed the treatment
    
  • The woman is comfortable and has passed urine.
    
• Ensure that the woman’s dignity and privacy are preserved at all times.
  

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  Bishop score
  

  You should be experienced in assessing the state of the cervix.