Oxford Handbook of Midwifery (85 page)

CHAPTER 18
High-risk labour

368

• Monitor the fetal heart
  
  • Continuously following the procedure
    
  • For 60min when the induction is in a low-risk woman; thereafter the fetal heart should be monitored intermittently (each 15min) until contractions occur regularly or IV oxytocin is commenced.
    
• If the woman is not experiencing regular contractions, administer an
  oxytocin regimen:
  
  • Immediately after ARM for all primigravidae and multigravidae with
    

    urgent indication for induction, such as pre-eclampsia
    

  • 2h after ARM if regular contractions have not commenced and if multiparous and non-urgent indication for delivery.
    

    Complications of ARM
    

• Prolapsed cord may occur if the fetal head is not engaged when the membranes are ruptured, or if it has not been recognized that the cord is presenting prior to the procedure.
  
• Non-reassuring fetal heart pattern may occur following ARM. This may be due to compression of the fetal head or placenta. It should settle to normal soon after.
  
• Increased infection risk once the membranes have been ruptured. It is important that effective progress in labour is achieved.
  

  Intravenous oxytocin
  

• Syntocinon
  ^®
  is a synthetic oxytocin. It is effective in stimulating uterine activity and promoting dilatation of the cervix.
  
• Before commencing Syntocinon
  ^®
  , ensure that:
  
  • The drug is prescribed by the registrar
    
  • The woman understands the procedure for administration, the restriction it will place on her mobility, and the analgesia available
    
  • 6h have elapsed since the last administration of vaginal prostaglandins
    
  • Spontaneous rupture of membranes is certain or that ARM has been performed
    
  • You are fully conversant with client’s obstetric history, since extreme caution is indicated in clients with a uterine scar or grand multiparity
    
  • You are aware of the current state of maternal observations, contractions, and cervical dilatation as a baseline
    
  • The fetal heart is monitored continuously and is reassuring.
    
• Check the medication with a colleague: it can be given via IV infusion using an Alaris
  ^®
  pump and a dilution of 5IU of Syntocinon
  ^®
  in 250mL of normal saline.
  
• Siting of an IV cannula is a good time to take FBC/platelets and G&S in case of later need. A double Luer catheter will allow an infusion of 1000mL normal saline to be sited to run slowly alongside 250mL of
  

  normal saline/5IU of Syntocinon
  ^®
  via an Alaris pump. The initial dose is 6mL/h. Titrate the dose against uterine activity.
  

• The aim is to achieve three or four regular contractions in 10min. There should be 1min relaxation between each contraction. To achieve this, the dose may be increased every 30min as shown in Table 18.3.
  

  INDUCTION OF LABOUR
  

  369
  

  

  Table 18.3
  Syntocinon
  ^®
  regime
  

  2mU/min 6mL/h
  

  4mU/min 12mL/h
  

  8mU/min 24mL/h
  

  16mU/min 48mL/h
  

Risks/complications of Syntocinon® administration

You should remain in attendance, ensuring the safety of mother and fetus, and observe for the following:

1. Arulkumaran S, Symonds IM, Fowlie A (2004).
   Oxford Handbook of Obstetrics and Gynaecology
   . Oxford: Oxford University Press.
   
2. The Practice Development Team (2009).
   Jessop Wing, Labour Ward Guidelines 2009–2010
   . Sheffield: Sheffield Teaching Hospitals NHS Trust.
   
3. National Institute for Health and Clinical Excellence (2001). Induction of labour. Inherited Clinical Guideline D. London: NICE. Available at M www.nice.org.uk.
   
4. Boulvain M, Fraser WD, Marcoux S,
   et al
   . (2001). Stripping/sweeping the membranes for inducing labour or preventing post-term pregnancy (Cochrane review). In:
   Cochrane Library
   , Issue
   

   3. Oxford: Update Software.
   

5. National Institute for Health and Clinical Excellence (2003). Antenatal care guideline 6. London: NICE. Available at: M
   www.nice.org.uk.
   

   CHAPTER 18
   High-risk labour
   

   370‌‌
   

   Augmentation of labour: active management
   

   A variety of protocols exist which are aimed at avoiding a long labour and maternal exhaustion and achieving delivery of the baby within 12–18h.
   

   Augmentation of labour may be initiated if the normal progress of
   labour appears slow. You may consider active management in a normal
   

   labour without previous obstetric or antenatal complications if:
   

   • The woman is definitely in established labour (changes in the cervix demonstrating progressive effacement and dilatation) but is making slow progress because the uterine activity appears limited
     
   • The woman states that she understands the concept, interventions, and mobility restraints and prefers active management
     
   • You have discussed the plan and obtained the agreement of the delivery suite coordinator and the obstetric registrar.
     

     Management
     

   • Careful observation of maternal and fetal condition is necessary.
     
   • Accurate documentation of the interventions on the partogram is essential.
     
   • Monitor the FH continuously.
     
   • Monitor the length, strength, and number of uterine contractions.
     
   • Site an IV infusion.
     
   • If the membranes are intact, following abdominal assessment, perform a vaginal examination and ARM. This may shorten the ARM delivery time if used in conjunction with an oxytocin infusion. Remember, however, that hydrostatic pressure no longer cushions the placenta. There is a higher risk of fetal cardiac irregularities. There is also a risk of infection to the fetus.
     
   • Note the current cervical dilatation, state of descent of the presenting part, and colour of the liquor.
     
   • Some authorities suggest a cervicograph guide may be used to measure progress. Action is recommended if cervical dilatation is 2h behind the cervicogragh curve. The oxytocin regimen may be commenced as for induction of labour (b see Induction of labour, p. 364).
     
   • Vaginal examination (using a sterile procedure) may be performed at regular intervals, for example 2–3h, to ascertain progress.
     
   • Assess maternal blood pressure and pulse half hourly.
     
   • Monitor maternal temperature and urine output 2h.
     
   • Encourage the woman to take fluids and light snacks. However, narcotics used for analgesia in labour seem to delay stomach emptying.
     
   • Be guided by the woman’s choice for analgesia. Assist the woman to use upright positions and some non-pharmacological methods of pain relief. However, contractions augmented by oxytocin may be experienced as more painful than those of spontaneous labour.
     
   • If a normal delivery is not achieved within the set time frame, inform the obstetric registrar.
     

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     CHAPTER 18
     High-risk labour
     

     372‌‌
     

     Measures to assist birth
     

     The midwife may be required to assist the obstetric team when an instru- mental (ventouse or forceps) or caesarean delivery is necessary.
     

     When caring for a woman in labour, the midwife should report the following to the obstetric registrar:
     

     •
     FHR irregularities or abnormalities of the CTG occurring in the first or second stage of labour. The registrar may request FBS
     

   • Delay in the first or second stage when the labour does not respond to oxytocin
     
   • Deterioration in the woman’s condition.
     

     It may be necessary to deliver the baby quickly. Caesarean section will be necessary to expedite birth in the first stage, after full dilatation ventouse or forceps delivery may be possible. If there is doubt about achieving delivery by forceps, trial in theatre may be arranged, with the anaesthetist and theatre team present. Caesarean section can follow immediately if forceps delivery fails.
     

     Instrumental delivery: forceps
     

     The decision to deliver by forceps is made by the registrar or consultant. Indication for forceps delivery, explanation of the procedure, and pos- sible problems should be discussed with the parents, and their consent obtained. Provide support for the woman during the delivery by further explanation, prompting her as appropriate, and monitoring her needs.
     

     Indications for forceps delivery include:
     

   • Delay in, or no progress during the second stage, related to limited maternal expulsive effort and exhaustion
     
   • Absence of the urge to ‘push’ because of epidural administration
     
   • When excessive pushing may worsen pre-eclampsia or cardiac conditions
     
   • When CTG is non-reassuring, the fetal head is below mid-cavity and delivery can be more quickly achieved with forceps
     
   • If there is suspected mild malposition or asynclitism which might be corrected and delivery facilitated.
     

     The obstetric registrar will want to know the following:
     

   • Does the fetus feel, on abdominal palpation, to be a normal size? Could there be disproportion present? Is the fetal head ‘well down’? Is there
     

     <1/5 fetal head palpable above the pelvic brim?
     

   • On vaginal examination, is the cervix fully dilated? Is the station of the head below the spines (+1cm)? Is the moulding or caput minimal? Is the position occipito-anterior (OA)? Is the liquor clear and the FHR reassuring?
     
   • Does the woman experience strong and sustained regular uterine contractions which achieve some descent of the head with maternal ‘pushing’ effort?
     
   • Does the woman have adequate pain relief? Is the epidural effective? Is a pudendal block needed?
     

     Preparation for the delivery:
     

   • The birthing bed needs preparation, with facility for lithotomy position
     
   • Delivery pack
     

MEASURES TO ASSIST BIRTH

373