Download Lothian NHS Board

Lothian NHS Board
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Waverley Gate
2-4 Waterloo Place
Edinburgh
EH1 3EG
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Telephone: 0131 536 9000
www.nhslothian.scot.nhs.uk
Date:
Our Ref:
20/01/2015
4944
Enquiries to :
Bryony Pillath
Extension:
35676
Direct Line:
0131 465 5676
[email protected]
Dear
FREEDOM OF INFORMATION – LABOUR WARD PROTOCOLS
I write in response to your request for information in relation to labour ward protocols and guidance
used in NHS Lothian in 2007.
I have been provided with information to help answer your request by Mr Niall Blackie, Clinical
Effectiveness Facilitator, Reproductive Health, NHS Lothian.
Question:
We would be obliged by you kindly providing us with the management labour ward
guidelines or protocol at your hospital as at 1 December 2007.
Answer:
I have enclosed the guidelines listed below. These are taken from the archived guidelines
which have approval and review dates indicating that they were in use in December 2007.
As archiving of these guidelines did not begin until 2013, it cannot be guaranteed that this is
a complete list of guidelines in place in the labour ward at this date.
Information which may identify individual members of staff has been redacted from the
documents. Since we do not have their consent to release this data from their records, the
information is exempt under section 38 of the Freedom of Information (Scotland) Act, as to
provide it would breach the 7th Principle of the Data Protection Act 1998.
-
Fetal Blood Sampling – Issued June 05, Review Due March 2010
Preterm Labour Management – Issued January 07, Review Due January 2010
Post Dates Monitoring – Issued May 2006, Review Due May 2007
Labour in a Patient with a Previous Caesarean Section/Previous Uterine Surgery
Issued August 05, Review Due March 2010
Management of Twin Labour – Issued January 07, Review Due January 2010
Shoulder Dystocia – Issued January 07, Review Due January 2010
Venofer for Post-Partum Anaemia – Issued August 06, No review date
Umbilical Artery Doppler – Issued May 06, Review Due November 08
Stillbirth – Issued June 05, Review Due March 10
Management of Uterine Hypertonus or Hyperstimulation – Issued November 06,
Review Due July 07
4944 Labour Ward Protocols January 2015
-
Iron Intravenous (Dextrose and Sucrose) – Issued September 05, Review Due
September 07
Reduced Fetal Movement – Issued May 06, Review Due November 08
Perineal Care – Issued January 06, Review Due January 08
Maternal Collapse; Resuscitation of the Pregnant Patient – Issued August 05,
Reviewed January 07
Caesarean Section – Issued March 07, Review Due March 10
Inversion of the Uterus – Issued January 07, Review Due January 2010
Fetal Anomaly Scans for High Risk Women – Issued December 05, Review Due March
2010
Instrumental Vaginal Delivery – Issued June 06, Review Due June 07
Management of Hyperemesis Gravidarum – Issued April 05, Review Due April 07
Management of Post Partum Hypertension – Issued August 06, Review Due August 08
Obstetric High Dependency Protocol – Issued January 07, Review Due January 10
Cardiotocograph – Issued March 06, Review Due April 07
Eating in Labour – Issued January 07, Review Due January 10
I hope the information provided helps with your request.
If you are unhappy with our response to your request, you do have the right to request us to review
it. Your request should be made within 40 working days of receipt of this letter, and we will reply
within 20 working days of receipt. If our decision is unchanged following a review and you remain
dissatisfied with this, you then have the right to make a formal complaint to the Scottish Information
Commissioner.
If you require a review of our decision to be carried out, please write to the FOI Reviewer at the
address at the head of this letter. The review will be undertaken by a Reviewer who was not
involved in the original decision-making process.
FOI responses (subject to redaction of personal information) may appear on NHS Lothian’s
Freedom of Information website at:
http://www.nhslothian.scot.nhs.uk/YourRights/FOI/Pages/default.aspx
Yours sincerely
ALAN BOYTER
Director of Human Resources
and Organisational Development
Cc: Chief Executive
Enc.
Page 2 of 2
Caesarean Section
1. ELECTIVE
• Decision is made by Obstetric Registrar/Consultant- indication must be
clearly documented in notes
• ICP should be started, and consent should be obtained in the clinic
• Full details to be entered in the Labour ward diary (phone 22544) Generally a
date should be given for 39 weeks unless medical or obstetric reasons for
earlier delivery.
• FBC and G & S are to be sent within 7 days of the CS date
• The CS list is typed and faxed to BTS at 3pm on the previous afternoon by
the LW co-coordinator or theatre midwife
• The patient attends 0730 on day of surgery, fasted from midnight to triage
and assessment and will be transferred to the postnatal ward on arrival
• If the section is for breech USS to confirm presentation is in Day Assessment
Unit at 0830.
• In cases involving suspected intrauterine growth retardation, diabetic or HIV
positive mothers, multiple pregnancy or if the fetus is premature, the neonatal
paediatricians should be given as much notice as possible.
• The post natal staff will prepare the patient for theatre and surgeon and
Anaesthetist on the ward will review her. FBC result should be noted. 150mg
oral Ranitidine should be given and EMLA cream applied to hand as soon as
possible after arrival.
• BTS should be phoned EXT 27501 to confirm patient eligible for electronic
issue. If not eligible a repeat specimen must be sent urgently to BTS. The
patient cannot leave for theatre until BTS confirm specimen received. All
women for elective caesarean section are eligible for electronic blood issue
except those with irregular antibodies and those requiring a cross match e g.;
placenta praevia.
• If patient third on the list consider siting a venflon and starting IV crystalloid at
100ml/hr until theatre.
2. EMERGENCY
Some cases demand true emergency caesarean section, e.g. Umbilical cord prolapse, acute
severe fetal distress and severe antepartum haemorrhage. For this reason and due to
severely delayed gastric emptying, women in established labour are not given food to eat but
clear fluids are encouraged. Emergency caesarean section is performed by the most senior
obstetrician present, with the patient under rapidly induced general anaesthesia or regional
block by experienced Anaesthetist. 50mg ranitidine diluted to 20ml with normal saline given
over 3 minutes IV is used in this situation.
More commonly, it is possible to predict the need for caesarean section some hours before it
is required. This allows time to be sent for group and save, 50 mg I.M ranitidine given,
consideration of the use of epidural anaesthesia and discussion with the paediatricians.
The decision to undertake any emergency caesarean section is made by the obstetric
registrar after discussion with Consultant Obstetrician or SpR4/5. It is important that the
anaesthetist is made aware of the degree of urgency required for delivery so that the
appropriate anaesthetic can be given, and the use of regional techniques maximised. The
mode of anaesthesia is the decision of the anaesthetist. The section should be categorized
according to the RCO/OAA/CESDI criteria as follows and this should be documented in the
notes:
1. Immediate threat to the life of woman or fetus
2. Maternal or fetal compromise that is not immediately life threatening
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3. Needing early delivery but no maternal or fetal compromise
4. At a time to suit patient and maternity team
Category 2 should have a decision to incision time of no more than 30 minutes (OAA)
•
•
•
THE FETUS MUST BE CONTINUOUSLY MONITORED DURING EPIDURAL OR
SPINAL SITING
Consider High flow facial oxygen
Left lateral tilt
Patients undergoing emergency caesarean section who require blood cross matched include
those with placenta praevia, known irregular antibodies and anticipated difficult caesarean
section ( >2previous CS, fibroids ) at the discretion of the surgeon.
A paediatrician experienced in neonatal resuscitation should be present at all deliveries by
emergency caesarean section.
A partner or close relative or friend may only be present in theatre when caesarean section
is conducted under regional anaesthesia. The obstetrician performing the operation and the
anaesthetist must both agree to their presence and the partner may be asked to leave at
any time if complications develop and especially if GA is required.
THE BLADDER SHOULD BE CATHETERISED EVEN IN CASES OF FETAL DISTRESS AS
A FULL BLADDER CAN IMPEDE ACCESS. Ideally this is done after regional anaesthesia
sited.
Prophylactic antibiotics ( 750mg cefuroxime I.V ) should be administered with all caesarean
sections after clamping of the cord. Alternative antibiotics should be used in those with a
history of allergy to cefuroxime. See Antibiotic prophylaxis protocol.
Cord pH measurements must be performed and recorded on the operation note.
Ref No Repromed 088
Issue date Mar 2007
Review Date Mar 2010
Published by Labour suite management committee Level 1 2
3 4
Ratified By Clinical Director
Issuing Officer: D.I.M. Farquharson
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Page 2 of 2
SIMPSON CENTRE FOR REPRODUCTIVE HEALTH
ROYAL INFIRMARY of EDINBURGH
Clinical Protocol
CARDIOTOCOGRAPH
Cardiotocograph Antenatal ..................................... Error! Bookmark not defined.
Interpretation of Antenatal Cardiotocograph Recording .........Error! Bookmark not
defined.
How to Perform A Cardiotocograph On A Twin Pregnancy Using A Twin Monitor
............................................................................... Error! Bookmark not defined.
Ref No Repromed 043 Issue date March 2006 Review Date April 2007
Published by Antenatal clinic management committee
Level: 1
Ratified By
TB
CEF
Issuing Officer: Dr D Farquharson
Reviewed by Dr E S Cooper May 2006
A
Page 1 of 6
2
DMT
3
PSD
4
A
Page 2 of 6
CARDIOTOCOGRAPH - Antenatal
Definition
Continuous electronic recording combining fetal cardiograph and maternal tocograph,
to ascertain fetal wellbeing. ( Essential Midwifery – Henderson & Jones 1997)
Indications:
1. Reduced fetal movements
2. Post dates
3. Intrauterine growth retardation
4. Diabetes
5. Raised blood pressure
6. Multiple pregnancy
7. Poor obstetric history
8. Cholestasis
Procedure:
1. Ensure the woman is aware of the reason for performing the test.
2. Ensure privacy and comfort,
3. Palpate the abdomen, estimate fundal height.
4. For optimum position the woman should be upright, or lateral – not supine. Apply
cardiotocograph; ensure good contact.
5. Instruct the woman to note any fetal movements, using the mark button on the
cardiotocograph machine.
6. Write name, date and time on the cardiotocograph at the beginning of the trace.
7. Record Maternal pulse on the graph paper.
8. The trace should be performed for a minimum of 20 minutes. The following
criteria should be reached
Baseline 110-150 bpm
Variability 5-10 bpm
3 accelerations associated with movements or uterine activity.
No decelerations
Document findings in the notes:
Any abnormal findings should be reported to the medical staff
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INTERPRETATION OF ANTENATAL CARDIOTOCOGRAPH RECORDING
Non-stress ante-natal cardiotocograph - an objective assessment of the fetal
condition.
A reactive test would satisfy the following criteria:
1.
2.
3.
4.
5.
Baseline 110 - 150.
Baseline variability of 5 - 10 bpm.
No decelerations.
At least three accelerations of the fetal heart associated with fetal movement
or contractions in any 20-minute period.
An acceleration should last for at least 15 seconds, with an amptitude of more
than 15bpm.
Gestational age should be taken into account when assessing a CTG as few
accelerations occur prior to 28 - 30 weeks gestation, and short icicle/transient
decelerations are normal at the same gestational period.
Indications For Referral To Medical Staff
Absence of accelerations after 1 hour.
Baseline heart rate 100 - 110 or 150 - 170 bpm.
URGENT - Heart rate less than 100 bpm OR more than 170 bpm.
Poor baseline variability, i.e. less than 5 bpm.
Decelerations.
Sinusoidal pattern, i.e. less than two cycles per minute.
If after one hour, a trace remains unreactive despite palpation or food.
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HOW TO PERFORM A CARDIOTOCOGRAPH ON A TWIN PREGNANCY USING
A TWIN MONITOR
Explanation and preparation as for a singleton pregnancy
Palpation to determine presentation and lie of both fetus
Place 3 belts around the woman’s back
Write the woman’s name, unit number, date and time on the graph paper and
document the maternal pulse.
Place a small amount of contact gel on both cardiotocographs
Switch on machine
Locate the fetal heart of twin1 using a pinnard and then apply lead 1, locate twin2 in
the same way and apply the 2nd lead.
Place the tocograph at the fundus and secure with a belt
Care should be taken to ensure that 2 clear fetal signals are recorded
Although both fetal hearts are visible on the trace, only 1 heartbeat is audible at a
time. To identify the fetus being heard take note of which speaker light is on. To hear
the other fetus, press the volume key on the other channel.
To separate the twin traces – When twins are being monitored it can be difficult to
distinguish traces with a similar baselines. It is possible to separate these traces and
make them easier to interpret by , using the twin offset feature. The trace of
ultrasound 1 is elevated by 20bpm.
To separate the traces press and release “F” button to display 20
The signal quality indicator will show Red if the traces are not separated and Green if
the traces are separated.
Press + or – button to change the setting
Press “F” button until you return to the normal display.
NB The fetal heart rate on the graph for ultrasound 1 will be elevated by 20bpm
Ultrasound 1 traces in a dark bolder ink.
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Ultrasound 2 traces in a lighter ink.
Look carefully at the 2 traces to ensure that they are from 2 babies. The machine will
mark the graph if there is a period on the paper when it detects that similar fetal heart
rates have been detected. The paper will be marked with a ?.
Continue the trace until a satisfactory recording from each baby is obtained
Document in notes
Any abnormal traces should be reviewed by the medical staff
To switch off the twin offset facility use the “F” button the – button and the “F” button
again.
Ref No Repromed 043 Issue date March 2006 Review Date April 2007
Published by Antenatal clinic management committee
Level: 1
Ratified By
TB
CEF
Issuing Officer: Dr D Farquharson
Reviewed by Dr
May 2006
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Page 6 of 6
2
DMT
3
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SIMPSON CENTRE FOR REPRODUCTIVE HEALTH
ROYAL INFIRMARY of EDINBURGH
Clinical Protocol
EATING IN LABOUR
Women in the early/latent phase should be encouraged to enjoy a light diet. High
carbohydrate, low residue foods such as cornflakes, toast with jam or honey, plain
biscuits etc, provide rapidly absorbed sources of energy, Enkin (2000).
Enforced fasting in labour is unpleasant, is no guarantee of an empty stomach and
may be hazardous to mother and possibly baby.
In later, more active labour, when gastric emptying is slower, choice of diet should
take into account factors which impact on gastric emptying eg. Opioid administration.
It is suggested that solid foods are restricted but the following fluids encouraged: tea,
soups, squash drinks, non acidic fruit juices, low fat yoghurt drinks and water.
To reduce amount and acidity of stomach contents.
Boggod DG (1995) Gastric emptying and feeding in labour Current Anaesthesia
and Critical Care 6:224-8
Enkin M, Keirse MJNC, Neilson J Crowther C, Duley L, Hodnett E Hofmeyr J.
2000 (3rd Edition) A Guide to Effective care in Pregnancy and Childbirth Oxford
University Press Oxford
Pickett J, Oppenteimer C, May A (1996) Does midwifery led intrapartum care require
anaesthetic services? International Journal of Obstetric Anaesthesia. 5:152-5
Whitehead EM (1993) An evaluation of gastrine emptying times in pregnancy and the
puerperium. Anaesthetic 48:53-7
Ref No: Repromed35
Issue date Jan 2007
Published by Practice Development Midwives
Level: 1
Ratified By
TB
CEF
DMT
PSD
Issuing Officer: Dr D Farquharson
Midwifery Guidelines
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Page 1 of 1
Review Date: Jan 2010
2
3
4
SIMPSON CENTRE FOR REPRODUCTIVE HEALTH
ROYAL INFIRMARY of EDINBURGH
Clinical Protocol
FETAL ANOMALY SCANS FOR HIGH RISH WOMEN
A fetal anomaly scan (18-20 week ultrasound) may not be offered to all women.
However it may be offered to women who fall into one of the following categories:
•
Raised AFP on serum screening
•
Diabetics
•
Epileptics
•
Multiple Pregnancy
•
Significant (teratogenic) prescribed/non prescribed drug history.
•
Past history of abnormality detectable on ultrasound.
•
First degree family history of abnormality detectable on ultrasound
•
Seroconversion following contact with infectious disease (CMV, Parvovirus,
Rubella, Syphilis, Toxoplasmosis, Varicella)
•
Fetal abnormality or increased nuchal translucency noted at booking
•
Post amniocentesis / CVS
•
Intracytoplasmic sperm injection (ICSI)
•
Women booking too late for serum screening, i.e. after 20 weeks
Ref No Repromed 098
Issue date December 2005
Review Date Mar 2010
Published by Antenatal management committee Level 1 2
Ratified By Clinical Director
Issuing Officer: D.I.M. Farquharson
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SIMPSON CENTRE FOR REPRODUCTIVE HEALTH
ROYAL INFIRMARY of EDINBURGH
Clinical Protocol
FETAL BLOOD SAMPLING
INDICATION
Fetal blood sampling is used to confirm (or refute) a diagnosis of fetal acidosis made
on the basis of an abnormal fetal heart rate, as described in the fetal monitoring
protocol:
• late decelerations with normal or low baseline variability
• mixed late/variable decelerations with decreased baseline variability
• variability of <5bpm for >40 minutes
• sinusoidal pattern
• arrythmias
CONTRAINDICATION
• maternal infection with HIV, Hepatitis B or C, active genital Herpes
• face presentation
• fetal bleeding disorder suspected or diagnosed e.g. mother is haemophilila
carrier or has I.T.P.
• preterm <34 weeks
• clear evidence of fetal compromise e.g. bradycardia >3 minutes duration
PROCEDURE
(Ensure that the pH meter is calibrated before sampling begins).
The patient should either be in the left lateral position or in lithotomy with a left sided
wedge to prevent aort-caval compression during the process. Use the scalp sampling
sterile pack. Insert the largest diameter of amnioscope
FETAL BLOOD SAMPLING
TECHNIQUE FOR BG3
To process a sample properly you must follow these simple steps:1
Make sure there is enough blood in the tube.
2.
Make sure there are no air bubbles in the sample.
3.
Make sure the sample is agitated to make sure of mixing the heparin with
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the blood in the pre heparinized tube.
4.
Make sure machine is in the ready mode.
5.
Lift sampler.
6.
Present sample with blood at the end of the tube. Make sure that the
blood is AT THE END OF TUBE. (This machine does not like air).
7.
PRESS MICRO-SAMPLE ONLY.
8.
It will then tell you to lower the sampler.
9.
It will then ask you to put in data. Make sure the SM No is put in and
proper blood type (ie from
10.
vein or artery).
Press enter and the machine will give you a print out. Make sure you
collect a second print out for storage, (put in drawer under machine).
11.
Manual Aspiration is possible with small sample, but you have to be very
careful when doing so, (if in doubt ask o.d.p., to do so).
IF IN DOUBT PLEASE SEEK HELP THESE SAMPLES ARE EXTREMLY
IMPORTANT A BABY’S WELL BEING MAY DEPEND UPON THE RESULT.
Normal Values of Scalp pH
pH above 7.25
- normal
pH from 7.20 to 7.25 - borderline - requires either delivery or very
close observation
pH below 7.20
- acidotic - requires immediate delivery
All PH results should be attached to maternal case records.
Borderline values warrant repetition within 30-60 minutes, particularly if the fetal
heart recording remains abnormal.
Ref No Repromed 002
Issue date June 2005
Review Date Mar 2010
Published by Labour suite management committee Level 1 2
Ratified By PSD
Issuing Officer: D.I.M. Farquharson
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SIMPSON CENTRE FOR REPRODUCTIVE HEALTH
ROYAL INFIRMARY of EDINBURGH
Clinical Protocol
OBSTETRIC HIGH DEPENDENCY PROTOCOL
Admission Criteria:
The requirement for nursing/midwifery care and clinical monitoring not available
elsewhere in the labour or postnatal areas. Either obstetric or anaesthetic medical
staff may require the admission of a patient to the HDU. The non- admitting
speciality must always be informed.
Conditions requiring HDU care:
• Preclampsia / eclampsia.
• Haemorrhage – significant APH, PPH or other major haemorrhage.
• Post abruption.
• Placenta praevia.
• Recovery from anaesthesia when more than 1 hour of recovery time is
required.
• Coexisting medical disorders that require the patient to be closely monitored.
On Admission to HDU:
The consultant obstetrician on the day of admission will assume responsibility for the
patient’s care throughout their stay in HDU. Patients admitted under a non obstetric
consultant (e.g. weekend) will have their care transferred to the first subsequent
obstetric consultant on call. The responsible anaesthetist will be the consultant on
call for labour ward.
Documentation:
• The patient should have an admission clerking with a brief summary of events
and reason for admission.
• An examination should be documented in the notes together with a fluid
balance.
• The anaesthetist should document the fluid balance from theatre if
appropriate and any invasive monitoring being used.
• The patient’s medication should be reviewed and documented on admission.
Baseline bloods should be taken and a plan agreed for the timing of the next
sample.
• A HDU monitoring chart should be commenced.
• Urinary catheter and urine volumes monitored hourly.
Routine monitoring may include:
• Urine output
• Oxygen saturation
• Invasive arterial pressure
• Central venous pressure
• Respiratory rate
• Conscious state
• Tendon reflexes
• Monitoring of intravenous infusions – antibiotics, antihypertensives, heparin,
and magnesium.
The midwife looking after the patient should have undergone competency based
training in HDU care.
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Review:
08.30 and 17.30
• Senior obstetric and anaesthetic joint review.
• Clinical examination.
• Review of all monitoring.
• Review of investigations.
12.30 and 13.00
• Lab results and progress review
22.00
• Anaesthetic and obstetric registrar formal review
• Documented examination and plan for overnight
The labour ward obstetric and anaesthetic team should make it clear to the midwife
looking after the patient who to contact for which aspects of the patient’s
management.
Admission to HDU Beyond 24 Hrs.
Daily review by the consultant responsible for their care.
Daily registrar review and examination to include:
• Fluid balance over the 24 hrs.
• Review of medications.
• Inspection of invasive lines for infection and the dressings changed.
• Blood results reviewed and documented on the flow sheet.
• Liaison with ITU considered if patient’s condition does not improve,
deteriorates and/or develops two or more organ failure.
Discharge:
The responsible consultant should be informed of the discharge of the patient from
HDU.
1
Ref No Repromed 014
Issue date Jan 2007
Review Date Jan 2010
Published by Labour suite management committee Level 1 2
Ratified By PSD
Issuing Officer: D.I.M. Farquharson
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3 4
University Hospitals Division
Departments of Obstetrics ,Gynaecology,
Dietetics & Pharmacy,
Simpson Centre for Reproductive Health
Royal Infirmary of Edinburgh
Guidelines For The Management Of Hyperemesis Gravidarum
Version 2
Release April 2005
Document control
Issued to:
Serial No: ref 052
Date :review April 2007
This is a controlled document.
It is your responsibility to keep this manual safe.
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Management of Hyperemesis Gravidarum Guideline ............................................................................. 3
Management of Hyperemesis Gravidarum Flow chart............................................................................ 9
Moderate Risk Guidelines in Nutrition – Hyperemesis.............................................................................. 10
SCRH Observation Chart............................................................................................................................... 11
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Management of Hyperemesis Gravidarum Guideline
1
Introduction
Hyperemesis gravidarum (HG) is defined as persistent vomiting and severe nausea occurring
for the first time in the first trimester or usually before the 20th week of pregnancy causing an
inability to maintain hydration, fluid and electrolyte balance and nutritional status. It occurs
in 3-10 per 1000 pregnancies and needs to be distinguished from nausea and vomiting of
pregnancy (Morning sickness) which can affect 50 to 70% of pregnant women. Other
causes of nausea and vomiting such as UTI, Addison’s disease, peptic ulcer or pancreatitis
must also be excluded. This condition is usually poorly managed, sometimes because staff
underestimate the physiological and psychological morbidity associated with protracted
vomiting in pregnancy. Prompt treatment is advised. Poor maternal nutritional status has a
major impact on fetal outcome such as an increased risk of low birth weight (LBW) delivery,
neonatal death and long term medical and developmental problems. National guidelines
are not available for the management of HG . These guidelines have been developed by a
multidisciplinary (senior obstetricians, pharmacists, dietician and midwives) group based on
current local clinical practice and evidence from the literature to encourage a more
consistent approach to patient care (see appendix 1 for flow chart).
2
•
•
•
A
Indications for admission
Women who are unable to maintain hydration status
Ketotic
Prescribed anti emetics are ineffective
3
Symptoms and Severity
3.1
Investigations may reveal hyponatraemia, hypokalaemia, low serum urea,
ketonuria,metabolic hypochloraemic alkalosis, abnormal liver function tests (LFTs) (in
about 50% patients) and abnormal thyroid function tests (TFTs) (in about 66% of
patients).
3.2
Rarely severe hyponatraemia producing pontine demyelination (central pontine
myelinolysis) which can result in pyramidal tract signs, spastic quadriplegia and
altered levels of consciousness. Do not correct hyponatraemia rapidly as rapid
correction is associated with risk of central pontine myelinolysis. If sodium less than
110 mmol/l aim to increase sodium by 0.5mmol/hour.
3.3
Wernicke’s encephalopathy, as a result of acute nutritional thiamine (vitamin B1)
deficiency, can develop in severe cases. Thiamine replacement is required
following a prolonged period of vomiting (1-2weeks). Wernicke’s encephalopathy
may also be precipitated by dextrose-containing fluids (oral or IV). Avoid dextrose
infusion for fluid replacement especially in presence of abnormal LFTs.
3.4
Peripheral neuropathy and megaloblastic anaemia are also possible, and are a
result of deficiencies in pyridoxine (Vitamin B6) and cyanocobalamin (Vitamin B12).
3.5
Fetal IUGR has been reported. There is little information on long term fetal effects in
those treated with antiemetics.
Page 3 of 12
4
Management
4.1
Monitoring
Nausea score (Use Observation Chart, see appendix 2)
Height and pre-pregnancy weight(if known) or current weight
Weight (twice a week)
Pulse, Temperature and BP (daily)
Urinalysis (daily)
Biochemistry [Na, K, HCO3, Urea, Creat, LFTs, serum Glucose, (daily while requiring IV
fluids)
MSU (if proteinurea)
)to exclude other
Thyroid function tests (on first admission only) ) causes of hyperemesis
USS to confirm gestation and exclude molar pregnancy and multiple pregnancy as
both can produce higher HCG levels and are associated with more severe HG.
4.2
Fluid and electrolyte replacement (titrate to daily Na and K and fluid)
Initially aggressive hydration with 1000ml administered over 2 hours. During this period
medical staff should review U&Es and further fluids prescribed usually 500ml over 2-4 hours
alternating type of fluid see below. If hypokalaemic, fluids containing potassium should be
prescribed.
NB Refer to consultant any women with renal or cardiac failure or complex congenital heart
disease as aggressive hydration is contraindicated.
4.2.1 Appropriate sodium containing fluids:Sodium chloride 0.9% (150mmol/L sodium)
Hartmann’s solution (Compound Sodium Lactate)(131 mmol/L sodium)
4.2.2 Appropriate potassium containing fluids:Sodium chloride 0.9% 500ml + 20mmol potassium
Sodium chloride 0.9% 500ml + 40mmol potassium
4.2.3
Avoid dextrose-containing fluids (see Section 3.3 Symptoms/severity)
4.3
Thromboprophylaxis
These women are likely to have been dehydrated and immobile prior to admission and are
at risk of thromboembolism. Women who are immobile for more than 24 hour require to be
fitted with above the knee TED stocking. If immobile for more than 48 hours, medical staff to
prescribe enoxaparin 40mg daily. See thromboprophylaxis policy.
4.4
Dietary Management-
4.4.1
Initial assessment
On arrival measure weight, height, BMI(kg/m2) and establish pre-pregnancy weight to assess
weight change. Keep a record of food intake on the fluid balance chart, also record
emetic events (use nausea and vomiting scores).
4.4.2
Food and Drink
Introduce drinks starting with sips of water and gradually increase, then try other drinks such
as fruit juice, lemonade or milk. Small frequent meals (2-3 hourly) should then be introduced.
Avoid foods which trigger or aggravate nausea and vomiting. Suitable foods include
bread, toast or sandwiches, breakfast cereals, ginger containing foods, rice, pasta,
potatoes, yoghurts, bananas. See moderate risk nutrition guidelines (appendix 3).
4.4.3
A
Nutritional Supplements
Page 4 of 12
If after following the moderate risk guidelines (Appendix 3) for 48 hours and there is no
improvement. Please contact the Dietician (call 26924, bleep 8017) who will assess and
advise on nutritional care.
4.4.4
Nasogastric/Nasoduodenal/Parenteral nutrition
If admitted with severe HG and there has been no intake for more than 5 days and
nutritional supplements are not tolerated then artificial nutritional support should be
considered. Nasogastric or nasoduodenal enteral feeding (contact dietitian bleep 8017)
should be considered before total parenteral nutrition (TPN) as it seems to be more
successful for women in whom nausea and vomiting are linked to consumption of food.
Enteral feeding is contraindicated in women with acute vomiting due to the risk of aspiration.
If nasogastric enteral feeding is contraindicated or unsuccessful then TPN should be
considered (consult nutrition sister bleep 8039 and clinical pharmacist bleep 2256 for more
information on TPN).
4.5
Complementary Care
All women need emotional support, frequent reassurance and encouragement. Encourage
bed rest and counsel about eating habits and precipitating factors. Previous history is an
important consideration. Some success has been reported with acupuncture, sea-bands,
hypnosis and herbal remedies such as ginger (consult drug information or clinical
pharmacist for more information). A few women may require psychiatric referral.
4.6
Vitamins replacement
4.6.1 Oral- Give oral thiamine and folic acid to all in-patients with HG lasting over 2 weeks.
Review need for continued use prior to discharge.
Thiamine 100mg daily
Folic acid 5mg daily
4.6.2
Parenteral vitamins (consult pharmacy)
Pabrinex IV High Potency : Half of the content of each pair of ampoules once weekly.
Higher doses may be need in severe cases. Add to 100ml sodium chloride 0.9% and infuse
by short infusion over 30 minutes.
• Serious allergic adverse reactions can occur during or shortly after thiamine/Pabrinex .
Facilities for treating anaphylaxis should be available.
• Check serum magnesium concentration as response to thiamine is poor in
hypomagnesaemia.
4.7
Antiemetics
Antiemetics can reduce the frequency of nausea in early pregnancy. Use regular, rather
than when required until vomiting has stopped. A detailed medication history must be
taken. Start with 1st line agent unless patient’s drug history shows that this was not effective
or there was particular success with an alternative agent. Avoid cyclizine if there are
concerns about drug abuse. Use other agents only if symptoms have not improved after at
least two therapeutic doses. Avoid agents where there is known hypersensitivity. REMEMBER
THAT DYSTONIC REACTIONS can occur (in particular with metoclopramide and very rarely
with prochlorperazine and domperidone). Use benzatropine (IM/IV) 1-2mg and repeat if
symptoms reappear.
1st line
A
cyclizine 50mg IM
control achieved.
8 hourly switch to cyclizine 50mg orally 8 hourly once
Page 5 of 12
Side effects are drowsiness, dizziness, insomnia, blurred vision, dry mouth,
constipation, tachycardia (rarely) and urticaria.
Stop and then try 2nd and/or 3rd line agents.
2nd line
3rd line
prochlorperazine 25mg PR initially 12 hourly increasing to 8 hourly if required
or prochlorperazine 12.5mg IM 6 hourly for up to 3 days.
Switch to 10mg oral/PR three times a day once control achieved. Reduce to
5mg dose if possible.
and add if needed
domperidone 30-60mg PR 8hrly switch to 10-20mg oral three times a day
once control achieved. Start at higher oral dose then reduce.
or
metoclopramide 10mg IM 8 hourly switch to metoclopramide 10mg orally 8
hourly once control achieved.
Side effects of prochlorperazine are extrapyramidal symptoms, drowsiness,
antimuscarinic symptoms, hypotension, and rarely cardiac arrhythmias. Side
effects of metoclopramide are extrapyramidal symptoms especially dystonic
reactions, these are less likely with domperidone. Avoid prochlorperazine in
women with severe liver or renal impairment or epilepsy.
4th line
ondansetron 8mg IV 12hourly for 2 doses then orally 8mg 12 hourly for up to 5
days. Careful assessment of risk and benefit is essential prior to use. (Safety
data limited).
Side effects are constipation, headache, flushing/warmth sensation, hiccups.
4.8
Histamine-H2 Antagonists
Ranitidine 50mg IV or IM 8 hourly or 150mg orally 12 hourly, may be useful in addition to any
antiemetic agents in some women. An alternative is Omeprazole, again assessment of risks
and benefits is essential as safety data limited.
4.9
Corticosteroids only for cases refractory to above treatments
The decision to start corticosteroids must be made by a consultant.
Use is based on the rational that HG may be the result of adrenocortical insuffiency.
Efficacy is based on the few anecdotal case reports. The appropriate dosage and duration
of treatment is still unclear; several weeks of treatment is usually required so risks and benefits
analysis is essential. Predisposition to NIDDM, increased risk of infection, osteoporosis and
rarely aseptic necrosis of hip are just a few problems associated with chronic corticosteroid
use. Chronic exposure to fetus to high doses may cause fetal adrenal suppression and
developmental concerns. Careful consideration should be taken before starting
corticosteroids in pregnancy at < 10weeks gestation, a critical period for cleft palate
formation as there is a small risk with high dose steroids.
Response is usually dramatic and occurs within 12 hours. Continued treatment for at least 4
weeks after control of symptoms (usually for up to 6-17 weeks) has been necessary or until
gestation at which hyperemesis would have stopped and in severe cases up to delivery.
Withdraw very slowly (1mg weekly may be required) and titrate to symptoms as rapid
withdrawal can result in reappearance of symptoms.
4.9.1 Parenteral
Hydrocortisone 50mg by slow IV every 12hours (double dose if necessary) for 24-48hrs.
Change to an equivalent oral prednisolone dosage as soon as oral route is tolerated. Avoid
prescribing second dose after 6pm as risk of insomnia.
A
Page 6 of 12
4.9.2 Oral (use oral whenever possible and if no improvement after 72 hours then start IV)
Prednisolone 10-20mg 12 hourly (up to 60mg/daily have been tried). Reduce to lowest
effective dose over 2 weeks then gradually reduce by 1-2mg per week thereafter.
The guideline was ratified by:
......................................................................
Dr
Lead Clinician
..................................................................
/
, Lead Directorate
Pharmacists
.............................................................
..................................................................
,
Lead therapist in adult dietetics
A
, Principal Midwife
Page 7 of 12
A
5
References
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
Lancet 1993; 341: 185 (letter) ondansetron
Lancet 1992; 340: 1223 (letter) ondansetron
Am J Obstet Gynecol 1996; 174:1565-8
ondansetron vs promethazine
American Pharmacy 1995; 35(10): 25Treatment of Pregnancy Related Illness
Br J Obste. Gynaecol 1994; 101:1013-1015
steroids
QJ Med 1996; 89: 103-107
steroids
Br J Obstet Gynaecol 1995; 103: 478-480
steroids
Postgrad Med J 1996; 72 (853): 688-9
ondansetron
Am J Obstet Gynaecol 1995; 172 (5): 1585-1591
vitamins
BMJ 1992; 305: 517-518
thiamine
Martindale 31st Edition
thiamine
Report on Confidential Enquiries into Maternal Deaths in UK 1991-93
D&T Bulletin: Management of Alcoholics
thiamine
Hospital Pharmacy Practice 1993, Sept-Oct
case study
Koda-Kimble Ch. 68
antiemetics
Pharmacotherapy (Di Piro) Ch. 32
antiemetics
Data Sheets
antiemetics
Pharmaceutical Journal 1994; 253: 57-60 (July) antiemetics
Drugs in Pregnancy and Lactation, Briggs 4th Edition
antiemetics
Bellshill Maternity Hospital
chlorpromazine
Sanofi Winthrop
domperidone
Rhone-Poulenc Rover
prochlorperazine
Handbook of Obstetric Practice
general management
1st J Med Sci 1994; 30(3): 225-8
Obstet Gynaecol 1986; 68(4): 563-571
TPN & pregnancy
Obstet Gynaecol 1988; 71(1): 102-107
TPN & HG
Obset Gynaecol 1996; 88(3): 343-346
NG & HG
JPEN 1984; 9(2): 212-215
Hyperalimentation
JPEN 1988; 12(1): 72-80
Intravenous Nutritional Support
JPEN 1990; 14(5): 485-489
Peripheral Parenteral Nutrition
Drugs 2000;59(4): 781-800 ( Risk and benefit analysis, good recent review)
Teratology 1998;58:2-5 (Risk of cleft palate with steroids)
Br J Obstet Gynaecol 2004;111:940-943 ondansetron
Aliment Pharmacol Ther 2005; 21:269-275 proton pump inhibitors
Page 8 of 12
Management of Hyperemesis Gravidarum Flow chart
(To be used in conjunction with the guidelines)
INDICATION FOR ADMISSION
Unable to maintain adequate hydration
Ketotic
Prescribed anti emetics are in effective
•
•
•
•
•
•
•
•
INVESTIGATIONS
Na, K, HC03, Urea, creatinine, LFTs, serum glucose Daily while requiring I.V.Fluids (NOT FBC)
Mg if severe - repeat weekly
MSU (if protein present),
Thyroid function tests - to exclude other causes
USS to confirm gestation and exclude molar or multiple
pregnancy
COMPLEMENTARY CARE
All women need
emotional support and
encouragement
•
•
•
•
•
•
•
•
•
•
•
•
FLUID AND ELECTROLYTE REPLACEMENT
Aggressive hydration=1000ml over 2 hrs
Prompt treatment is advised
Sodium Chloride 0.9%
Hartmann’s solution
Sodium chloride with 20mmol or 40mmol
potassium
DO NOT USE 1.8% NACL.
AVOID DEXTROSE CONTAINING FLUIDS
Observations
Nausea score
Height at initial assessment
Weight + BMI twice weekly
Refer to moderate risk guidelines
Pulse, Temperature & BP - daily
Urine analysis - daily
Record oral intake both food
and fluids
THROMBOPROPHYLAX
IS
If immobile for 24 hrs =
TED stockings +
ANTIEMETICS
ADD
Ranitidine
50mg
8hrly
IV/IM
or
150mg orally BD
DIETARY CARE
• Use full menu
• Refer to Moderate
Risk Guidelines
Contact dietician after
48hrs. Bleep 8017
Establish anti emetic history prior to referral
Give regularly until vomiting has stopped. Try at least 2 doses of 1st
line then go to 2nd line.
• 1st LINE - Cyclizine 50mg IM 8hrly then oral once control
achieved
Stop Cyclizine prior to
• 2nd LINE - Prochlorperazine 25mg PR 12hrly initially-increase to 8
hrly if required for maximum of 3 days OR 12.5 mg IM 6 hrly.
When control achieved give 10 mg orally/PR 3 times per day
reduce to 5 mg if possible
and add if needed
• 3rd LINE - Domperidone 30-60mg PR 8hrly. When control
achieved 10-20mg oral 3 times per day
or metoclorpramide 10mg IM 8hrly. Change to oral when
stable
REMEMBER DYSTONIC REACTIONS CAN OCCUR,
benztropine 1-2mg is the antidote
REFRACTORY CASES
Consultant’s decision for treatment
Use oral when possible
• Hydrocortisone 50mg IV 12hrly for 24-48
hours.
• Prednisolone 10-20mg 12hrly (up to
60mg/day)
Reduce to lowest effective dose over 2 wks then
by 1-2mg per week thereafter
A
•
•
•
•
Page 9 of 12
4th LINE
Use only if at
least two regular
doses of 1st-3rd
line antiemetics
have failed.
Ondansetron
8mg IV 12 hourly
for 2 doses then
8mg
12
hrly
orally for up to 5
days
REFRACTORY CASES
Reassess NUTRITIONAL STATUS by dietician
Consider nasogastric / nasoduodenal
feed
TPN Contact nutrition sister Bleep 8029
and Pharmacist Bleep 5880/2256
Remember thiamine is still needed.
Moderate Risk Guidelines in Nutrition – Hyperemesis
Introduce drinks starting with sips of water & gradually increase volume. Try fruit juice, lemonade or
milk.
Introduce small frequent meals, which are low in fat and high in carbohydrate. Avoid foods that
trigger and aggravate nausea. Suitable foods include bread, toast, sandwich, breakfast cereals,
ginger biscuits, rice, pasta, potatoes, yoghurts, bananas and other fruits/vegetables.
•
•
•
•
Fortify dishes at meal time.
Breakfast: Cereal with Full Cream Milk. Toast with butter, jam or honey.
Lunch and Dinner: Add Margarine/Butter to potatoes and vegetables or add grated
cheese. For dessert try Milk Puddings such as custard, rice pudding or yoghurts.
Have a cup of Full Cream Milk. Try 2 to 3 cups per day.
Try 1 to 2 sachets/day, of Build up / Complan each made with 200mls Full Cream Milk. This
will provide an extra 300-600 kcals energy & 15-30g protein per day.
Have a nourishing Snack at mid afternoon and supper e.g. Bread + butter/jam/marmalade,
Biscuits, Crackers + butter and cheese, Yoghurts or Breakfast cereal + Full Cream Milk. Hot
cross bun, Teacake, Malt loaf, sponge, fruit or fairy cakes.
If admitted into hospital patients can be offered the following (via the ward hostess):
•
•
•
•
•
Fortified soups and puddings can be ordered for a patient via the ward hostess (providing
extra 400kcal + 10g protein approx.)
Higher energy options can be ordered from the menu, coded HE.
Patient can be offered extra glasses of full cream milk.
Patient could have full cream milk on porridge/cereals and butter added to potatoes.
Extra sandwich, cheese and biscuits and/or yoghurts can be ordered from menu.
Please keep a food record chart and weigh patient twice weekly.
A
Page 10 of 12
Ketones
A
Protein
Glucose
BOWEL MOVEMENT
Indicate Y or N daily
URINALYSIS:
Daily till stable
B/P
Daily till stable
Temperature & Pulse
Daily till stable
WEIGHT/BMI
Twice weekly
NAUSEA SCORE:
0 = No nausea
1 = Mild nausea
2 = Nausea &/or vomiting
3 = Persistent vomiting
O/A
Page 11 of 12
indicate R/A in red if re-admission
DATE & TIME indicate R/A
in red if re-admission
Date/time
Nausea score
Date/time
Height on admission:
Pre pregnancy weight:
for women with
HYPEREMESIS GRAVIDARUM:
SCRH Observation Chart
DOB:
Ref no:
Address:
Or Name
Addressograph label
Issue date April 2005
A
Issuing Officer: D.I.M. Farquharson
Ratified By Clinical Director
Page 12 of 12
3 4
Review Date April 2007
Published by Labour suite management committee Level 1 2
Ref No Repromed 052
Initial:
BLOODS TAKEN FOR
BIOCHEMESTRY
Daily while on I.V.Fluids
Departments of Obstetrics, Anaesthesia and Pharmacy
Lothian Maternity Services SCRH
Management of Post Partum Hypertension
Protocol for the Management of Post Partum Hypertension
Introduction
Blood pressure in normal pregnancy falls immediately after delivery and then rises again, often reaching a
peak 3 or 4 days post partum. Women with hypertension during pregnancy may become hypertensive again
within the first week post partum, even though they are normotensive immediately following delivery.
Methlydopa, although the anti hypertensive of choice in early pregnancy, has side effects including
depression, sedation and postural hypotension and should be discontinued after delivery.
Well established beta blockers, angiotensin converting enzyme (ACE) inhibitors, calcium channel blockers
and diuretics are considered moderately safe to use in a woman who is breastfeeding. Information on newer
drugs is sparse.
Thiazide diuretics are considered moderately hazardous, they may be less well tolerated and cause
excessive thirst if the mother is breastfeeding and may reduce milk production.
Pre-existing /Chronic Hypertension
•
Stop methyldopa after delivery.
•
Recommence the anti hypertensive treatment regime the woman was receiving prior to pregnancy
before discharge. If this was a diuretic, consider using a beta-blocker (unless asthmatic requiring regular
inhalers) or calcium channel blocker instead. Ask patient about known adverse reactions to
antihypertensives
•
Review by an SpR or consultant prior to discharge
•
Discharge to GP/community midwife. If suspected pre-existing hypertension is diagnosed for the first
time in pregnancy (ie BP raised <20 weeks of pregnancy) this must be clearly communicated to the GP
and initial treatment is as for PIH/PET (see below)
Pregnancy Induced Hypertension/ Pre-eclampsia
•
Stop methyldopa after delivery.
•
Continue monitoring fluid balance, U&E’s, platelets and LFT’s following delivery until normalising. Urate
does not require monitoring.
•
If not on medication BP>150/100 requires regular treatment.
•
Ibuprofen may be introduced once normotensive if not other contraindication
Medication can be reduced in increments if BP consistently <140/90. NB most women will require to go
home still on treatment. Consider stopping if doses have been withheld due to low blood pressure
•
Discharge to GP/community midwife. If the BP is <140/90 by 2 weeks post partum, therapy should be
decreased/stopped. Antihypertensives can usually be discontinued within 2-6 weeks.
Reproductive Health Directorate
NHS Lothian – University Hospitals Division
Date prepared: August 2006
Review Date: August 2008
Departments of Obstetrics, Anaesthesia and Pharmacy
Lothian Maternity Services SCRH
Management of Post Partum Hypertension
Suggested Antihypertensive Regimes for Post Partum Hypertension
st
1 Line
Labetalol may have been used orally antenatally or peripartum. This can be continued postpartum with dose
adjustment according to BP. Consider changing labetalol to atenolol if long-term antihypertensive treatment
anticipated, as it is a once daily regimin.
nd
2 Line
Atenolol 50mg or 100mg once daily (ensure there is no history of asthma)
If this is inadequate, add in:
rd
3 Line
Nifedipine Modified Release - Prescribe Adalat LA 20mg or 30mg once daily unless currently has a supply
of Adalat Retard which is prescribed as 10mg or 20mg twice a day.
If a beta-blocker and calcium channel blocker together fail to control the blood pressure ask for cardiology
review and check renal function is normal prior to considering commencing an ACE inhibitor (enalapril is
preferable if breast feeding).
______________________Date__________
Consultant Fetomaternal Medicine
_____________________Date__________
Clinical Manager
__________________Date________
Lead Pharmacist, Reproductive Health
Reproductive Health Directorate
NHS Lothian – University Hospitals Division
Date prepared: August 2006
Review Date: August 2008
SIMPSON CENTRE FOR REPRODUCTIVE HEALTH
ROYAL INFIRMARY of EDINBURGH
Clinical Protocol
INSTRUMENTAL VAGINAL DELIVERY
Incidence is approximately 12%1
Indications
In the second stage
• Nonreassuring fetal status (cord pH<7.20, deterioration in CTG).
• Maternal exhaustion &/or lack of maternal effort.
• Delay.
Special indications where Valsalva is to be avoided e.g.
• Severe pre-eclampsia
• Some cases of cardiac, cerebrovascular and respiratory diseases & previous
neurosurgery
• Past history of detached retina
• Unconscious patient e.g. diabetic coma
Prerequisites
• Full cervical dilatation.
• Head should not be palpable abdominally and maximum diameter of the fetal
head should have entered the pelvic inlet
(The station and position of the head should be assessed both by abdominal and
vaginal assessment so that true station could be accurately determined; caput and
moulding should be assessed).
• Adequate analgesia. Instrumental vaginal delivery is associated with severe pain
(pudendal block and perineal infiltration could be sufficient for low cavity delivery,
after discussion with the patient while regional anaesthesia is generally preferred in
the others). Requires spinal/epidural top with 0.5% bupivicaine- bag mix is NOT
strong enough.
• Empty maternal bladder.
• Informed consent.
• Known position
• Operator experience with the chosen instrument
• Indication must be documented in the notes.
Contraindications
• Unengaged head
Extra contraindications for ventouse
• possible or diagnosed fetal coagulopathy
• face presentation
• Below 36 weeks of gestation2
I
Page 1 of 3
In view of the reduction of maternal injuries the vacuum has been considered to be the
instrument of first choice2. A five-year follow-up of women enrolled in one of the RCTs
did not show any significant differences in long-term outcome between the two
instruments for either the mother or the child3.
It is important that the operator uses the instrument with which he or she has the
greatest experience.
Ventouse delivery
Good maternal effort is essential
•
•
•
•
•
•
•
With the suction off apply the centre of the cup to the occiput 3cm anterior to the
posterior fontanelle in the midline (flexion point)4.
A ventouse cup is applied to a pressure of 0.8kg/cm2 checking that no cervical or
vaginal tissue is trapped
Cup Choice
o Silicone- well flexed, OA/OT, minimum caput
o Anterior Metal Cup- long 2nd stage, OA, moderate caput
o Posterior Cup-OP/OT position
o KIWI- any position, in room, minimal analgesia, certain vaginal delivery AVOID USE WHEN PATIENT HAS SPINAL ANAESTHETIC (as
associated with insufficient maternal effort)
Descent should be evaluated after each contraction (no descent consider CPD)
If cup comes off summon SpR4/5 or consultant and only reapply once.
Aim should be to achieve delivery in a maximum of 3 pulls over a maximum of 3
contractions preferably within 15 minutes of cup application. Use finger of non-pulling
hand to apply counter pressure to the cup.
Traction is in pelvic axis until head on perineum and then taken through an upward
arc of 90o. Evaluate for episiotomy
Pull out Forceps delivery
•
•
Position of fetal head should be determined not only before but also after
application of the forceps blades.
When checking the application the sagittal suture should be perpendicular to the
plane of the shanks throughout the length.
Rotational forceps (always in theatre)
Consent for trial of forceps +/-Caesarean Section
• Adequate station
Head should be engaged. No head or 1/5th of the head should be palpable abdominally
and the vertex should be at least at the ischial spines.
• Adequate analgesia
Should be done under regional anaesthesia (either a spinal or epidural top up for CS)
pudendal block is not sufficient.
• Spr4/5 or consultant supervision is essential.
• Rotation should be attempted only when the uterus is relaxed.
I
Page 2 of 3
•
•
Should be done in theatre with a low threshold to abandon if the forceps blades
cannot be easily applied or the handles do not easily approximate or rotation is not
easily effected with gentle traction.
Indwelling Foley catheter for at least 6 hours after.
Manual rotation may be used alone or in conjunction with instrumental birth with little or
no increased risk to the mother or the baby.
It is essential to be prepared to abandon the procedure if the progress is not as planned.
The baby should be delivered within three contractions with maternal and operator effort.
Routine episiotomy is not essential for every instrumental vaginal delivery.
Risks increase significantly amongst babies who are exposed to attempts at both
vacuum and forceps delivery.
If in doubt, prepare for a trial of instrumental delivery in theatre so that an appropriate
assessment can be made in theatre with appropriate analgesia and the mother is
prepared for caesarean section (should be done or supervised by spr4/5 or the
consultant). Remember to continue to monitor the fetus during the preparation. Send G
& S, give 50mg IV ranitidine and consent as for CS.
•
•
•
Per rectal examination should be done after all instrumental vaginal deliveries
especially following repair of the perineal tear or episiotomy.
Documentation of instrumental vaginal delivery in the notes is very important
including the findings, choice of instrument, procedure, anaesthesia, personnel
present, complications and cord ph.
Analgesia paracetamol 1g 4 hourly, voltarol 100mg
References
1. Simpson Centre for Reproductive Health Delivery data 2004.
2. Royal College of Obstetricians and Gynaecologists.Instrumental Vaginal delivery.
Guideline No 26.London:RCOG;2000.
3. Johanson RB Menon BK. Vacuum extraction versus forceps delivery for assisted
vaginal delivery. Cochrane Database Syst Rev 2000(2).
4. Bird GC. The importance of flexion in vacuum extractor delivery. Br J Obstet
Gynecol 1976;83:194-200.
Ref No Repromed 081
Issue date June 2006
Review Date June 2007
Published by Labour suite management committee Level 1 2
Ratified By Clinical Director
Issuing Officer: D.I.M. Farquharson
I
Page 3 of 3
3 4
SIMPSON CENTRE FOR REPRODUCTIVE HEALTH
ROYAL INFIRMARY of EDINBURGH
Clinical Protocol
INVERSION OF THE UTERUS
Incidence 1:2000 deliveries
Signs
•
•
•
•
•
Severe lower abdominal pain in the third stage
Haemorrhage (94% cases)
Shock out of proportion to the vaginal blood loss
Uterine fundus not palpable per abdomen
Mass palpable per vaginam
Aetiology – very rarely if misapplied pressure has been used on the uterine fundus or
traction of the non-separated placenta especially in the multiparous woman, the uterus
can dimple and invert. This very traumatic event can lead to the fundus turns inside out
and goes through the cervix and into the vagina.
Management
• Do not attempt to remove the placenta if still attached
• Emergency call 222 asking for the Obstetric Team
• Urgently call the consultant Obstetrician and Obstetric Anaesthetist
• Commence resuscitation
o Facial oxygen 10litres/minute
o 2 grey venflon
o IV fluid replacement – crystalloid then colloid
o Send FBC, clotting and 6 unit x-match
o Continuous BP, heart rate, respiratory rate, O2 saturation
o Transfer to theatre
o Unless working epidural in situ, proceed to GA
• Early Replacement will be more likely to work
Replacement – try in this order
1. Try manual replacement ASAP then remove the placenta
2. May require tocolysis – ritodrine 0.15mg IV bolus
3. O’Sullivan’s Hydrostatic process- using silicone ventouse cup to block the
vaginal outlet, instil 2-4 litres of warm saline rapidly via an intravenous giving set
into the vagina.
4. Laparotomy
a. Huntingdon’s Procedure- Allis forceps are placed in the dimple and
upward traction is applied, then the clamp is removed and replaced
advancing the fundus by the least bit out back first method.
b. Haultain’s Procedure – incise the cervical ligament with a
longitudinal incision and reattempt Huntingdon’s procedure.
I
Page 1 of 2
Once replaced and the placenta removed with care, then administer 500µg IM
ergometrine bolus. and oxytocin 40iu in 500ml normal saline at 125ml/hr. also give
prophylactic antibiotics – Cefuroxime 1.5g IV bolus and Metronidazole 500mg IV
bolus.
Reference:
1. Watson P, Besch N, Bowes WA. Management of acute and subacute
puerperal inversion of the uterus. Obstet gynecol 1980;55:12-16.
Ref No Repromed 090
Issue date Jan 2007
Review Date Jan 2010
Published by Labour suite management committee Level 1 2
Ratified By Clinical Director
Issuing Officer: D.I.M. Farquharson
I
Page 2 of 2
3 4
Department of Obstetrics, Pharmacy
and Haematology
Total Dose Iron Dextran (Cosmofer ) Infusion for Iron Deficiency Anaemia in 2ndand 3rd trimester of Pregnancy
Patient Name - ………………………………
Patient’s Weight (current) .......................... kg
Date of Birth - ………………………………..
Hb (pretreatment)
Unit Number - …………………………………
(use addressograph)
Cosmofer required
............................mls
(Must prescribe in ONCE ONLY section of Medicines Chart)
............................g/L
Indications
ONLY for iron deficiency anaemia in pregnant women. It is not suitable for women requiring iron replacement for blood loss. Oral
iron should not be commenced until 5 days after an iron dextran infusion. Recheck Hb in 6 weeks.
Inclusion Criteria
- haemoglobin less than 80g/L
- severe anaemia related symptoms
- unable to tolerate oral therapy
- on recommendation of consultant haematologist
and/or obstetrician
Contraindications (exclusion criteria)
- 1st trimester of pregnancy
- non-iron deficiency anaemia
- history of asthma, eczema or other atopic allergy
- liver cirrhosis or hepatitis
- acute or chronic infection
- active rheumatoid arthritis
- acute renal failure
Dosage
Values shown in table below is the dosage (ml) of Cosmofer (iron dextran) 50mg/ml ) to reach target Hb 110g/L
For * in table calculate dosage (ml) of Cosmofer using equation 0.4ml/kg(20mg/kg)
Further dilution is essential prior to administration (discard after 24 hour after dilution).
Body
Weight (kg)
40-45
50-59
*
46-50
*
*
19
17
51-55
*
*
20
18
56-60
*
24
21
18
61-65
*
25
22
19
66-70
*
26
23
20
71-75
*
28
24
20
76-80
*
29
25
21
81-85
34
30
26
22
86-90
35
31
27
22
Pretreatment haemoglobin concentration (g/L)
60-69
70-79
80-89
*
18
16
Preparation of Infusion of iron dextran
Draw up required volume (see Table) of Cosmofer or calculate dosage (ml) for * patients and add to 500ml bag of Sodium
Chloride 0.9%. This is used for both the test dose and infusion. It is also compatible with glucose 5%
Administration
(i)
Test Dose of 25mg iron dextran (using infusion solution) over 15 minutes. Administered test dose to all patients.
Volume of Test Dose (V ) mls = 250 ÷ dosage (ml) Cosmofer added to 500ml bag = ………………..ml
Rate of Infusion of test dose (ml/hr) = (V)................ x 4
=............... (ml/hr)
(ii)
Remaining Dose
If test dose tolerated, increase rate of infusion by 10ml/hr every 15 minutes up to maximum rate of 160ml/hr.
Once maximum rate is reached continue infusion until completed
A
Page 1 of 6
Iron Dextran ( Cosmofer ) for Iron Deficient Anaemia in Pregnancy cont.
Monitoring
During test dose patient should receive one-to-one nursing due to small risk of anaphylactic reaction. Emergency drugs
must be available, including Adrenaline, Chlorpheniramine and Corticosteroids.
Pulse, BP and RR should be monitored every 30 minutes.
Patient must be monitored for ONE hour after infusion completed before being discharged.
Observe and record details on chart below every 15 minutes until maximum infusion rate(160ml/hr) reached. Thereafter
record details every 30 minutes.
Infusion Observation Chart
Type of infusion pump –
Infusion pump No –
Commenced by midwife Checked byDate
Time
Site
check
(tick)
Infusion
rate
(signature)
(print)
(signature)
(print)
Estimated
volume infused
(visual check)
Volume cosmofer added to 500ml bag(mls)=
Test dose volume(mls)=
Test dose rate(ml/hr)=
Actual
volume infused
(Pump check)
Midwife
(Sign and print)
RATIFICATION
__________________________
____________________________
____________________
Consultant Fetomaternal Medicine
Clinical Manager
Principal Midwife
__________________________
Lead Pharmacists, Reproductive Health
A
____________________________
Consultant Haematologist
Page 2 of 6
Ref No Repromed 094
Issue date September 2004
Review Date September 2006
Published by Department of Obstetrics, Pharmacy and Haematology Level 1 2
3 4
Ratified By Clinical Director
Issuing Officer: D.I.M. Farquharson
A
Page 3 of 6
Produced Date: Sept 2005
Review Date: Sept 2007
Department of Obstetrics, Pharmacy
and Haematology
Parenteral Iron Sucrose (Venofer ) for Iron Deficiency Anaemia in 2nd and 3rd trimester of Pregnancy
Patient Name - …………………………………
Patient’s Weight (current) .......................... kg
Date of birth - …………………………………..
Hb (pre-treatment)
Unit Number -…………………………….
(use addressograph)
Number of injections of 200mg required……………..
Number of injections of 100mg required……………..
(Must prescribe in ONCE ONLY section of Medicines Chart)
............................g/L
Indications
ONLY for iron deficiency anaemia in pregnant women. It is not suitable for women requiring iron replacement for blood loss. Oral
iron should not be commenced until 5 days after an iron sucrose course is completed. Recheck Hb in 6 weeks after commencing
treatment.
Inclusion Criteria
- haemoglobin less than 80g/L
- severe anaemia related symptoms
- unable to tolerate oral therapy
- on recommendation of consultant haematologist
and/or obstetrician
A
Contraindications (exclusion criteria)
- 1st trimester of pregnancy
- non-iron deficiency anaemia
- history of asthma, eczema or other atopic allergies
- liver cirrhosis or hepatitis
- acute or chronic infection
- active rheumatoid arthritis
Page 4 of 6
Produced Date: Sept 2005
Review Date: Sept 2007
Dosage
Repeated doses of 200mg up to three times a week. Values shown in table below is the number injections of 200mg
Venofer (iron sucrose) 20mg/ml ) to reach target Hb 100g/l
Body
Weight (kg)
40-45
46-50
51-55
56-60
61-65
66-70
71-75
76-80
81-85
86-90
Pre-treatment haemoglobin concentration (g/L)
60-69
70-79
80-89
4x200mg+
3x200mg+
5x200mg
4x200mg
1x100mg
1x100mg
4x200mg+
3x200mg+
5x200mg
4x200mg
1x100mg
1x100mg
5x200mg +
4x200mg+
3x200mg+
4x200mg
1x100mg
1x100mg
1x100mg
5x200mg +
3x200mg+
5x200mg
4x200mg
1x100mg
1x100mg
4x200mg+
3x200mg+
6x200mg
5x200mg
1x100mg
1x100mg
5x200mg +
4x200mg+
3x200mg+
6x200mg
1x100mg
1x100mg
1x100mg
6x200mg+
5x200mg +
4x200mg +
4x200mg
1x100mg
1x100mg
1x100mg
6x200mg+
6x200mg
5x200mg
4x200mg
1x100mg
7x200mg
6x200mg
5x200mg
4x200mg
50-59
7x200mg
6x200mg
5x200mg
4x200mg
Administration
By short IV infusion
First dose – test dose must be administered
Add two 5ml ampoules i.e.10ml( 200mg of iron) to 100ml sodium chloride 0.9% and mix well
Test Dose 12.5ml (25mg iron) of diluted solution should be infused over 15 minutes i.e 50ml/hour for 15minutes
Remaining Dose
If no adverse reactions occur during this time give the remaining dose over approximately 30 minutes i.e. at a rate of
175ml/hr
Parenteral Iron Sucrose ( Venofer
) for Iron Deficient Anaemia in Pregnancy cont.
Subsequent doses
Add two 5ml ampoules i.e.10ml (200mg of iron) to 100ml sodium chloride 0.9% and mix well. Infuse at a rate of 175ml/hr (this would
give an infusion for 34 minutes).
For 100mg dose only add 5ml to 100ml sodium chloride 0.9% and infuse at same rate.
Monitoring for test dose
During test dose patient should receive one-to-one nursing due to small risk of anaphylactic reaction. Emergency drugs
must be available.
Pulse, BP and RR should be monitored every 5 minutes of the first 15 minutes.
Observe and record details on chart below every 15 minutes .
Side effects
The most frequently reported adverse drug reactions (ADRs) of Venofer® in clinical trials were transient taste perversion,
hypotension, fever and shivering, injection site reactions and nausea, occurring in 0.5 to 1.5% of the patients. Non-serious
anaphylactoid reactions occurred rarely. In general anaphylactoid reactions are potentially the most serious adverse reactions
Paravenous leakage at the injection site may lead to pain, inflammation, tissue necrosis, sterile abscess and brown discolouration of
skin.
Infusion Observation Chart
First dose
Test dose =12.5mls over 15 minutes ( 50ml/hr for 15 minutes)
5ml or 10ml specify ……… of Venofer added to
Remaining dose= 175ml/hr until finished approx 30minutes
A
Page 5 of 6
100ml sodium chloride 0.9%
Type of infusion pump –
Infusion pump No –
Commenced by midwife -
(signature)
(print)
(signature)
(print)
Checked by -
Date
Time
Site
check
(tick)
Infusion
rate
ml/hr
RATIFICATION
K Dundas
__________________________
Consultant Fetomaternal Medicine
S Wright/J Carson
___________________________
Lead Pharmacists, Reproductive Health
Estimated
volume infused
(visual check)
Susequent doses
Rate of infusion =175ml/hour
Actual
volume infused
(Pump check)
Y Clark
___________________________
Clinical Manager
L Horn
___________________________
Consultant Haematologist
Midwife
(Sign and print)
M Wilson
______________________
Director of Midwifery
Maternity/Gynae
Ref No Repromed 099
Issue date September 2005
Review Date September 2007
Published by Labour suite management committee Level 1 2
3 4
Ratified By Clinical Director
Issuing Officer: D.I.M. Farquharson
A
Page 6 of 6
SIMPSON CENTRE FOR REPRODUCTIVE HEALTH
ROYAL INFIRMARY of EDINBURGH
Clinical Protocol
MATERNAL COLLAPSE
RESUSCITATION OF THE PREGNANT PATIENT
Call for help
222 stating ‘obstetric emergency in eg. Labour ward’
Individual pages:
Obstetricians
1622, 1616, 4000, 4001
Anaesthetists
2204
Paediatricians
1611
ODP
2276
Call consultant obstetrician & anaesthetist
Consider the likely causes of collapse in pregnancy:
• Haemorrhage
• Pulmonary Embolism – thrombus, air, amniotic fluid
• Myocardial infarction
• Eclampsia
• Drug toxicity
• Anaphylaxis
• High regional anaesthetic
• Vasovagal attack
• Diabetic hypo/hyper – glycaemia
Whatever the diagnosis apply principles of Advanced Life Support (Airway, Breathing
and Circulation) but REMEMBER:
Effective maternal life support will optimise fetal outcome:
If conscious – 02 via Hudson mask @ 15L/min
If unconscious:
Airway
Breathing
Circulation
I
Increased risk of aspiration in pregnancy-early intubation with
cricoid pressure
Splinting of diaphragm by large uterus occurs in late pregnancyHigher inflation pressures necessary for effective ventilation
Aorto caval compression must be relieved by:
• Placing pillows or a wedge under patients right flank
• Manual displacement of uterus to the left
• Left lateral tilt if on operating table or long spine board
Maternal blood volume is greater in pregnancy & occult
haemorrhage may cause hypovolaemic arrest
• Take blood for cross matching, FBC, coagulation and glucose
and start early IV fluids
• Early surgical intervention to stop haemorrhage may be
necessary
Page 1 of 2
Monitoring
Delivery
(Transfer to HDU/theatre)
• ECG
• Pulse oximetry
• NIBP
• Urinary output
• Arterial line (take blood gases)
After 5 minutes of unsuccessful resuscitation, delivery of fetus by
emergency Caesarean Section is indicated (relieves aorto caval
compression and improve survival chances for both fetus and mother).
Continue Advanced Life Support during and after surgery if necessary.
Ref No Repromed 097
Issue date August 2005:
Reviewed Jan 2007:
Published by Labour suite management committee Level 1 2
Ratified By Clinical Director
Issuing Officer: D.I.M. Farquharson
I
Page 2 of 2
3 4
Review Date Jan 2008
SIMPSON CENTRE FOR REPRODUCTIVE HEALTH
ROYAL INFIRMARY of EDINBURGH
Clinical Protocol
PERINEAL CARE
Of those women having a vaginal delivery the majority will sustain perineal trauma
requiring suturing, and a fifth of these women will have long-term pain and
dyspareunia. This can, of course, affect self-image, her sexuality, and her
relationship with her partner and her baby in the immediate postnatal period as well
as in the long-term. It can also disrupt breastfeeding.
AETIOLOGY
Incidence of trauma: 85% of women in the UK having a vaginal delivery will have
some degree of genital trauma, (Albers et al 1999) and 60-70% of these women will
require suturing (Premkumar 2005). Two-thirds of women will have 1st or 2nd degree
tears, and half will have outer vaginal tears (e.g. labial tears).
PERINEAL TRAUMA SEQUELAE
23-42% will have pain/discomfort for 10-12 days
7-10% will have long-term pain (3-18 months)
23% superficial dyspareunia at 3 months
3-10% will report faecal incontinence at 3 months
Up to 24% will have urinary problems
(Kettle 2004)
Obviously, this is an issue that can cause long-term morbidity. Any interventions that
prevent or minimise perineal trauma would benefit large numbers of women.
Preventing trauma has true time and cost benefits: suturing, drugs and analgesia.
RISK FACTORS FOR PERINEAL TRAUMA
Nulliparous
Increasing birth weight
Operative vaginal deliveries
Maternal weight gain
Fetal malpositions (Albers 2003)
Striae gravidarum
Epidural
Position for birth
Place of birth
The rates of trauma by age, ethnicity and social status are unclear.
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Page 1 of 7
ANTENATAL PREPARATION
PERINEAL MASSAGE
Shipman et al (1997) found a reduction of 6.1% in 2nd and 3rd degree tears and
episiotomies, affecting those women who undertook perineal massage. Tear rates
were 75% in the control group and 69% in the massage group. A much larger benefit
was seen in those aged over 30, a smaller benefit in the under 30’s. The
researchers also noted a reduction in the instrumental delivery rate from 40.9 to
34.6% in the massage group.
Labreque et al (1999) in Quebec noted a 76% trauma rate compared to 85% in the
control group. No significant effect was noted for multips. The difference was not
very large but was statistically significant. Intact perineum rates were 24.3% v.
15.1% (61% higher).
The theory behind perineal massage is that it increases the stretch in the tissues and
also educates the woman as to the sensations she will experience during the birth, to
keep her relaxed during crowning.
How to perform perineal massage
Scrub hands and file nails! Sit, spreading legs in a semi-sitting birthing position. A
mirror may be helpful initially. Use massage oil, vitamin E oil, almond or olive oil, or
a lubricant, but not mineral oils, Vaseline, cocoa butter or undiluted essential oils.
Insert thumbs as deeply as possible inside the vagina and spread your legs. Press
the perineal area down towards the rectum and towards the sides. Gently continue
to stretch the opening until a slight burn or tingling is felt.
Hold the stretch until the tingling subsides and gently massage the lower part of the
vaginal canal back and forth.
While massaging, hook the thumbs onto the sides of the vaginal canal and gently
pull these tissues forwards, as the baby’s head would do (not all masseurs suggest
this).
Finally, massage the tissues between the thumb and forefinger back and forth for
about a minute.
Being too vigorous could cause bruising and swelling, and pressure on the urethra
should be avoided.
This should be done weekly from 34 weeks, and should take 5-10 minutes.
Evening primrose oil has been recommended for women with previous episiotomies
for massaging into the scar tissue (not research validated).
Continuing with antenatal preparation, raspberry leaf tea has been associated with a
reduction in the length of the second stage of labour, and also on reducing the rate of
instrumental deliveries (Simpson et al 2001), so could have an indirect role in
preventing perineal trauma.
As malpositions are a risk factor for trauma, optimal fetal positioning could also form
a part of antenatal preparation.
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Page 2 of 7
Pelvic Floor Exercises
A Norwegian randomised controlled trial of the effect of pelvic floor exercises in
pregnancy demonstrated a reduction in numbers of women having a second stage of
labour lasting longer than an hour. While the operative delivery rate was unaffected
there was a lower rate of episiotomies, in a country where episiotomy rates are high:
51% compared to 64% (Salveson and Morkved 2004). Women in the exercise group
were encouraged to do Kegel squeezes twice a day from around 28 weeks, and had
physio input once a week. The authors suggest pelvic floor exercises could reduce
“prolonged” 2nd stage of labours for 1 in 8 women.
INTRAPARTUM CARE
“Not only do practitioners bring personal attitudes, beliefs and technical skills to their
conduct of a birth, but they also influence the woman’s bearing down efforts and
position for birth” (Roberts 2002).
Hands on or poised?
The HOOP trial (Hands Off Or Poised) was greatly anticipated, and found that the
only significant differences were more mild pain at 10 days in the “hands poised”
group. There were more episiotomies in the hands-on group, but the rate of manual
removal of placenta was higher in the hands-poised group. Mayerhofer et al (2002)
confirmed these findings, of no statistical difference in overall perineal injury in 2
groups, but increased rate of episiotomy and 3rd degree tears in the “hands on”
group.
The practice of delivering the anterior shoulder first by downward traction has been
questioned. It has been observed that left alone, the posterior shoulder will deliver
first, not the anterior.
“Ironing” the perineum
The practice of massaging or “ironing” the perineum during the birth has been
challenged. The RCM Evidence-based guidelines state that there is no evidence to
support these practices. Albers et al (1996) noted that the use of oils or lubricants on
the perineum increased the risk of lacerations by 70%.
Continuous support
Continuous support in labour could avoid the cascade of interventions associated
with epidural anaesthesia including instrumental deliveries and the perineal morbidity
associated (Caton 2002).
The hypothesis is that labour support enhances labour physiology and mothers’
feeling of control and competence, reducing reliance on medical interventions. The
decreased stress response may enhance passage of the fetus through the pelvis and
soft tissues, and may reduce the likelihood of operative birth and subsequent
complications, and enhances women’s feelings of control and satisfaction with their
childbirth experiences (Hodnett 2002).
Emotional support, information and advice, comfort measures, and advocacy may
reduce anxiety and fear, and their associated adverse effects during labour.
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Page 3 of 7
Episiotomy
Episiotomy is associated with increased pain and blood loss, slower healing
compared to spontaneous lacerations, and does not prevent urinary incontinence or
sexual dysfunction (Klein et al 1994). There is no evidence of short term or long-term
maternal benefit to support the use of liberal episiotomy (Carroli and Belizan 2004).
Episiotomy is associated with a higher frequency of 3rd and 4th degree lacerations
(Eason et al 2000, Renfrew et al 1998, Albers et al 1999). When a restrictive policy
was instituted in an American hospital the episiotomy rate dropped from 37-17%, and
the anal sphincter laceration rate dropped by 55% (Clemons et al 2005).
Women report increased pain and discomfort after episiotomy that interferes with the
experience of early motherhood (RCM 2005). Mean time from birth to bonding with
the baby was longer in women who had episiotomies (Martin et al 2001). Restrictive
use of episiotomy results in less posterior perineal trauma, less suturing and fewer
healing complications (Caroli 2004). Allowing a longer 2nd stage (and potentially
avoiding perineal trauma) has not been shown to be associated with adverse
perinatal outcomes (Menticoglan 1995). The practice should be restricted mainly to
fetal indications (Sleep 1990).
The most common reasons for performing episiotomies are to expedite delivery in
cases of fetal distress, and to prevent a bad tear, especially in instrumental
deliveries. Other indications may include primip breech and shoulder dystocia.
Epidural anaesthesia significantly increases the risk of episiotomy for prims, although
there does not appear to be an increase in spontaneous lacerations (Bodner-Adler et
al 2002).
Infiltrating the perineum may be sufficient to allow further advance of the vertex,
perhaps because women have more control in pushing when the perineum is painfree.
Birthing Pool
There are fewer episiotomies and more intact perineum in waterbirths (Schorn 1993,
Garland and Jones 2000). In a prospective study of more than 200 waterbirths in
Switzerland (Geissbuhler and Eberhard 2001), the episiotomy rate for pool labours
was 13% compared to 33% on the bed, where 3rd and 4th degree tears were more
common: rates of 1st or 2nd degree lacerations were not noted. In another study a
reduction in episiotomy rates and vaginal wall tears were observed, but no change in
perineal tear rates (Bodner et al 2002).
Forceps or Ventouse?
Episiotomy is always required in a forceps delivery but less so with ventouse.
Ventouse deliveries are associated with lower maternal morbidity than forceps.
Forceps are associated with a ten-fold increase in anal sphincter trauma, compared
to SVD (Christianson et al 2003). One study found an association with faecal
incontinence and forceps delivery but not with ventouse (MacArthur et al 2001).
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Page 4 of 7
Position for birth
Left lateral had the highest number of intact perineums (66%) in Shortens (2004)
retrospective study. Squatting had the least favourable result (42%). Left lateral may
slow the delivery of the head, especially where the second stage is progressing
rapidly. And if the oxygenation is improved then there may be fewer indications of
fetal stress in which episiotomy may be considered. Albers et al (1996) noted an
increase in perineal trauma when in lithotomy position (12.5% compared to 16.4%)
but birthing chairs appear to show a reduction in perineal tears compared to semirecumbent (Hillan 1985).
Pushing Technique
Women who push spontaneously have a higher chance of having an intact perineum,
and less likely to have episiotomies and 3rd or 4th degree tears (Sampselle and Hines
1999). Slow descent of the fetal head with spontaneous pushing may be more
protective of perineal tissues
Early direction to push, upon full dilation found a higher incidence of forceps
deliveries and perineal trauma. The valsalva type of pushing is well known for
shortening the length of labour, but increasing fetal heart decelerations: does this
increase the odds of having an episiotomy for “fetal distress”?
Place of birth
Meta-analysis of the safety of homebirth shows a lower frequency of severe perineal
lacerations (Olsen 1999, Turnbull 1996). In the homebirth setting 30% of women
have some degree of perineal trauma, compared to 80% nationally (Murphy 1998).
Could a more home-like environment in the labour ward also have an impact on
perineal trauma by facilitating alternatives to the “traditional” position? The Cochrane
review of “Home-like versus conventional institutional settings for birth” noted an
increase in the vaginal/perineal laceration rate but a decrease in the episiotomy rates
for those in a home-like environment (Hodnett et al 2005).
Hot/Cold Pads
Albers et al (1996) noted a 4% increase in the number of intact perineums when
warm compresses were applied to the perineum.
Suturing
To suture or not to suture? The policy on the SCRH labour ward is for all tears to be
sutured, including 1st degree tears unless the woman declines. This policy is based
on the RCOG (2004) guidelines that state that unsutured tears have longer healing
times, and no difference in short-term discomfort.
The recommended technique at SCRH is “non-stop”, which entails using a
continuous non-interlocking suture and sub-cuticular stitching to the skin. This
means that there should be less suture material used and only two knots in total.
Vicryl rapide is the suture material, as it is associated with less perineal pain,
analgesia, dehiscence, resuturing, and reduction in suture material (RCOG 2004).
This technique will be taught at suturing workshops.
Interesting developments may come from the use of tissue adhesives in place of
traditional suture material. This technique appears to be faster and less painful to
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Page 5 of 7
administer, and has demonstrated favourable results so far, in small trials (Rogerson
et al 2000, Bowen and Selinger 2002).
POSTNATAL CARE
Perineal healing requires an adequate supply of nutrients: proteins, calories and
vitamins (especially vitamin C). Additional factors that may adversely affect wound
healing include hypoxia, dehydration, a fall in wound temperature, and haematoma.
Smoking also delays wound healing.
Applying icepacks may give short term relief by numbing tissues, but the
accompanying vasoconstriction may delay wound healing, due to hypoxia and drop
in temperature (Sleep and Grant 1988). There is no strong evidence to avoid
icepacks altogether but caution would appear wise. Maternity gel pads were more
effective in alleviating perineal trauma and were more highly rated by women than
icepacks. (Steen et al 1999).
Complementary therapies in common use are aromatherapy oils, and homeopathy.
Lavender oil and tea-tree oils are commonly added to bath water: both oils are
thought to have antiseptic properties, and lavender is associated with analgesic and
anti-inflammatory properties. Witchhazel and calendula compresses are also used
topically.
The use of arnica is not supported by vigorous clinical trials, beyond a placebo effect.
However the studies that have been conducted have had methodological flaws (Ernst
and Pittler 1998) and practitioners of homeopathy have expressed concern that the
researchers did not understand the fundamentals of homeopathy: that too large a
dose could be as ineffective as too small.
Using a hairdryer is no longer recommended as the excessive drying can interfere
with healing and may cause infection. While ring cushions are rarely used now, the
NCT hires out Valley Cushions, which are supposed to avoid the problems of
oedema and numbness. Pelvic floor exercises are commonly recommended, not only
to improve pelvic floor tone and bladder control, but also to increase the circulation to
the damaged and healing tissues.
SUBSEQUENT BIRTHS
There appears to be no consensus as to what mode of delivery is recommended for
women who had serious perineal trauma/ pelvic floor damage. Repeat SVD may
worsen incontinence: women who have sustained significant anal sphincter damage
during birth are at greater risk of further damage and faecal incontinence with
subsequent deliveries (Fitzpatrick and O’Herlihy 2000). An American retrospective
study compared the outcomes of subsequent births of women who had previous 3rd
or 4th degree tears to those without such a history. Women with a history of previous
severe perineal trauma were at more than twice the risk of having repeat severe
damage, the highest risk for those who had instrumental and/or episiotomy (Peleg et
al 1999): in this category 11% had repeat severe perineal trauma, compared to 6.5%.
As episiotomies are associated with increased risk of 3rd degree tears, do they have
a role in preventing subsequent severe lacerations?
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Page 6 of 7
SUMMARY
Measures that influence the risk of perineal trauma include perineal massage, place
and position for birth, and appropriate use of episiotomy.
The Royal College of Midwives have published “Evidence based guidelines for
midwifery–led care in labour”, one section of which is dedicated to perineal care.
Ref No Repromed 040
P
Issue date January 2006
Review Date January 2008
Page 7 of 7
SIMPSON CENTRE FOR REPRODUCTIVE HEALTH
ROYAL INFIRMARY of EDINBURGH
Clinical Protocol
POST DATES MONITORING
Definition
Uncomplicated Pregnancy beyond term + 10days
Risk Factors
If any of the following risk factors are present monitoring should be commenced
earlier in pregnancy as clinically indicated e.g.
Uncertain dates
Small for dates
Raised Blood pressure
Maternal age> 40yrs
Management
Antenatal examination to include abdominal palpation, urinalysis and Blood pressure
Cardiotocograph - to assess fetal wellbeing
Measure AFI (normal > 5cm)
Document findings in the case notes
Arrange further day assessment visits if required prior to labour or induction X 3 per
week.
If induction of labour is indicated liase with the labour suite 225.35.
Advise woman to monitor fetal activity and report any change
If any abnormality on the CTG or if liquor volumes significantly reduced discuss with
medical staff
Ref No Repromed 060
Issue date May 2006
Review Date May 2007
Published by Antenatal clinic management committee Level 1 2
Ratified By PSD
Issuing Officer: D.I.M. Farquharson
Reviewed by Dr
A
12
May 2006
Page 1 of 2
3 4
A
Page 2 of 2
SIMPSON CENTRE FOR REPRODUCTIVE HEALTH
ROYAL INFIRMARY of EDINBURGH
Clinical Protocol
PRETERM LABOUR - MANAGEMENT
Guideline for the Management of Suspected Pre term labour......................2
Management Between 24 - 34 Weeks Gestation ........................................3
Management At 34-36 Weeks Gestation......................................................3
Management at 23 weeks to 23weeks+6 days.............................................3
I
Page 1 of 4
Guideline for the Management of Suspected Pre term labour
The purpose of this document is to provide guidance in the management of pre-term
labour with a view to avoiding unnecessary use of betamethasone and tocolytic
drugs. It is not a substitute for clinical judgement or expertise but hopefully a useful
adjuvant.
The majority of these patients will not be in labour.
Obtain history including risk factors for pre term delivery. Accurately establish current
gestation.
Assess baseline pulse, blood pressure and temperature.
Assess uterine activity by palpation
Perform CTG if 26 weeks gestation or greater.
OBJECTIVE ASSESSMENT
This should be performed by SHO3/SPR if the SHO is inexperienced.
1. Perform sterile speculum examination.
If there is evidence of ruptured membranes follow preterm rupture of membranes
protocol at the end of this document.
If no evidence of ruptured membranes visualise the cervix.
If the membranes are visibly bulging it is possible that the cervix is significantly
dilated i.e. more than 4cm dilated.
2.Perform a LOW vaginal swab. Send for urgent gram stain (if in normal working
hours) and for culture. Send with MSSU. Perform Fetal Fibronectin Test as per
instructions on the pack.
3.Perform digital assessment of cervix and note effacement and dilatation. DO
NOT PERFORM A DIGITAL EXAMINATION in the presence of ruptured
membranes.
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Page 2 of 4
Management Between 24 - 34 Weeks Gestation
These patients should all be seen by or discussed with the on-call senior SPR. If
in doubt please discuss with the labour ward consultant.
1. If in labour i.e. contracting, cervix effaced and greater than 2cm dilated
LEAVE MEMBRANES INTACT
COMMENCE STEROID THERAPY betamethasone 12mg i.m. 24 hours apart.
Ensure presentation is known by scan
If GBS positive commence prophylaxis.- see protocol please.
Inform NNU and ask paediatrician to review.
2.
If cervix uneffaced and less than 2cm dilated observe uterine activity over next
2 hours.
Administer steroids according to clinical impression of RISK in view of past
history, current uterine activity, multiple pregnancy etc. Not all of these
women will require steroids.
Management At 34-36 Weeks Gestation
Steroids not indicated but cases should be considered on an individual basis- liase
with paeds if unsure.
Inform paeds if remains on labour ward.
IN-UTERO ACTIVITY
At times of high activity in the neonatal ICU in utero transfer may be require to
another centre. This must be discussed with the on call consultant obstetrician at
SCRH to ensure the mother’s fitness for transfer.
Management at 23 weeks to 23weeks+6 days
The neonatal mortality risk after birth before 24 weeks is extremely high and very few
of the survivors are free from disability. Because of this, the management of labour at
this gestation should be planned with the patient after detailed discussion with both a
consultant obstetrician and a consultant neonatologist. In many cases, where the
assessment of gestation is secure, a decision will be made not to monitor the woman
or to provide active treatment to the baby if born alive. Under these circumstances a
paediatrician will not usually attend the delivery. If a decision is made antenatally that
active treatment will be given after birth then it is appropriate to consider
administering antenatal steroids and using fetal monitoring.
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Page 3 of 4
After consultant review, if a plan to manage the pregnancy as potentially viable has
been agreed, the following should be implemented.
1. 12mg im betamethasone, two doses 24 hours apart
2. Fetal CTG monitoring. No operative Obstetric intervention is made on the basis of
the CTG but this provides information for the Neonatal team as to fetal well being
during the labour.
3. The neonatal team are informed of the second stage of labour and will attend to
assess the baby.
Fetal death during labour is quite likely and CTG monitoring may be distressing to the
parents. It may be appropriate to turn down the volume of the machine and turn it
away from the patient so that the trace is not immediately visible.
1
Ref No Repromed 024
Issue date Jan 2007
Review Date Jan 2010
Published by Labour suite management committee Level 1 2
Ratified By PSD
Issuing Officer: D.I.M. Farquharson
I
Page 4 of 4
3 4
SIMPSON CENTRE FOR REPRODUCTIVE HEALTH
ROYAL INFIRMARY of EDINBURGH
Clinical Protocol
LABOUR IN A PATIENT WITH A PREVIOUS CAESAREAN SECTION/
PREVIOUS UTERINE SURGERY
All women with a previous caesarean section or other uterine surgery e.g. myomectomy1
• Management plan must be agreed in the antenatal period with the woman’s
Consultant or SpR4/5 and clearly documented in the woman’s notes (In most cases
where the reason for caesarean section is non recurrent, a trial of labour will have
been decided)
• It is preferable in such cases that the onset of labour is spontaneous
• The use of prostaglandin and oxytocics is kept to a minimum
o prostaglandin use increases rupture risk OR2.9 and oxytocic use increases
rupture risk OR2.42.
o SEE INDUCTION/AUGMENTATION OF LABOUR GUIDELINE
Management in labour
• Intravenous access should be obtained once labour is established
• blood sent for electronic issue
• The duty Registrar should be involved in the management of such women. It is
acceptable for the attending midwife to perform the initial vaginal examination.
• Continuous CTG monitoring during labour is recommended, regardless of the
reason for previous caesarean section
Risk of uterine rupture <0.7%2
Symptoms
• severe abdominal pain (not usually masked by epidural, unless bupivicaine
0.375% has been used when pain block is very dense)
• vaginal bleeding
• profound fetal distress
• maternal shock – See separate protocol for uterine rupture
Signs
• maternal tachycardia
• cessation of uterine contractions
• loss of presenting part on VE
•
If suspected inform senior medical staff immediately
Any variation from this protocol needs to be discussed with a Consultant Obstetrician and
this discussion should be documented in the notes.
References
1. Confidential enquiry into Stillbirths and Deaths in infancy. 5th AnnualReport. London;
Maternal and Child Health Research Consortium 1998
2. Landon MB, Hauth JC, Leveno KJ et al. Maternal and perinatal outcomes associated
with a trial of labour after a prior caesarean delivery. N Eng J Med 2004;351:2581-9.
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Page 1 of 2
Ref No Repromed 082
Issue date August 2005
Review Date Mar 2010
Published by Labour suite management committee Level 1 2
Ratified By Clinical Director
Issuing Officer: D.I.M. Farquharson
I
Page 2 of 2
3 4
SIMPSON CENTRE FOR REPRODUCTIVE HEALTH
ROYAL INFIRMARY of EDINBURGH
Clinical Protocol
REDUCED FETAL MOVEMENTS
Definition
A noticeable reduction from the normal amount of fetal movements felt.
Ref: A guide to effective Care in Pregnancy and Child Birth 2nd ed. Enkin, Keirse,
Renfrew and Nelson 1996
Management
History
Palpation
Fundal height
27 weeks gestation onwards perform a Cardiotocograph
24- 27 weeks gestation perform ultrasound scan to demonstrate fetal movements
If the Cardiotocograph is satisfactory and movements are felt midwife can discharge
home with a kick chart. If the cardiotocograph is satisfactory but no fetal movements
are felt perform an ultrasound scan to demonstrate the presence of fetal movements.
If movements seen discharge home with a kick chart.
Any abnormal findings should be reviewed by the medical staff.
Document findings in the notes.
Ref No Repromed 057
Issue date May 2006
Review Date Nov 2008
Published by Antenatal clinic management committee Level 1 2
Ratified By PSD
Issuing Officer: D.I.M. Farquharson
Reviewed by Dr
A
1
Nov 2008
Page 1 of 1
3 4
SIMPSON CENTRE FOR REPRODUCTIVE HEALTH
ROYAL INFIRMARY of EDINBURGH
Clinical Protocol
SHOULDER DYSTOCIA
Definition is a condition requiring special manoeuvres to deliver the shoulders
following an unsuccessful attempt to apply downward traction1. The most common
type is impaction of the anterior shoulder against the symphysis pubis after delivery
of the fetal head.
Shoulder dystocia cannot be reliably predicted and most strategies to prevent it are
either ineffective (early induction) or lead to excessive intervention (elective
caesarean section)2,3. The presence of known risk factors should trigger advanced
preparations to deal with the situation before it arises.
•
•
•
Incidence is increased with increasing birth weight, although >50% occur in
babies of normal birth weight. Factors leading to increased birth weight
should be considered e.g. maternal diabetes, elevated BMI, multiparity and
post-dates pregnancy
Poor progress in labour is a poor predictor, although failure of descent and
mid-cavity forceps deliveries are associated factors4,5
Overall recurrence rates are 10-15%
Early diagnosis allows prompt intervention and 90% of cases will be successful with
McRoberts manoeuvre and suprapubic pressure, without requiring the internal
manoeuvres described below.
ALSO mnemonic H.E.L.P.E.R.R6
With each manoeuvre the delivering practitioner should exert no more than 15
seconds of moderate traction
H
Call for help
Senior midwife to help with McRoberts Position
222 for Obstetric Team and Paediatrician
Co-ordinator should call the Obstetric Consultant
Scribe
E
Evaluate for Episiotomy
Episiotomy should be generous allows room for manoeuvres.
L
Legs – McRoberts manoeuvre
Involves flexing the maternal thighs up onto the maternal abdomen, which
increases the pelvic inlet diameter. This flattens the lumbo-sacral curve,
lessening any obstruction from the sacral promontory. It simultaneously
flexes the fetal spine and often pushes the posterior shoulder over the sacral
promontory, allowing it to fall into the hollow of the sacrum.
P
Suprapubic Pressure (Rubins I)
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Page 1 of 3
Fetal lie should be determined and using a stance similar to cardiopulmonary
resuscitation, pressure is exerted obliquely in a rocking motion on the
posterior aspect of the anterior shoulder. This adducts and encourages
rotation of the shoulders into the oblique.
E
Enter – rotational manoeuvres
•
•
•
Rubins II. With external pressure as before, place hand posteriorly in
the vagina to the posterior aspect of the anterior shoulder and apply
pressure to rotate.
Woodscrew Manoeuvre. As above but simultaneously applying
pressure on the anterior aspect of the posterior shoulder thus rotating
to the oblique position.
Reverse Woodscrew. If unsuccessful attempt rotation in the opposite
direction without external pressure. Fingers of the hand used for
Rubins II are placed on posterior aspect of posterior shoulder.
R
Remove posterior arm
The hand is passed vaginally to the anterior aspect of the fetus and the
posterior humerus identified. The fetal elbow is flexed and forearm flexed
across the fetal chest, wrist grasped and the posterior arm delivered. The
anterior shoulder can then be delivered in the usual manner.
R
Roll mother onto hands and knees (Gaskin Manoeuvre)
The posterior shoulder (in relation to the mother) is delivered first then
anterior.
If these actions fail other measures should only be attempted when a consultant is
present. CONSIDER MOVE TO THEATRE
• Deliberate fracture of the fetal clavicle
• Symphysiotomy
Insert a urethral catheter and move urethra to one side digitally.
2 assistants are required each to hold a hip. Incomplete incision of the
symphyseal joint is made.
•
Zavanelli’s manoeuvre
This is abdominal replacement of the fetal head under tocolysis. Give
2 puffs GTN spray sublingually (stored in cupboard theatre 3/LW drug
cupboard) and then attempt upward placement of the head from the
vagina followed by caesarean section under general anaesthesia.
Accurate scribing of actions and timings is essential.
Following delivery, it is essential that all the details surrounding the delivery are
accurately recorded both in notes and on the audit sheet. This includes interval
between delivery of the head and shoulders and timing of the above stages. Parents
should be adequately de-briefed following delivery.
References
1.Resnik R. Management of shoulder girdle dystocia. Clin Obstet Gynecol
1980;23:559-64.
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Page 2 of 3
2.Combs et al. Elective Induction versus spontaneous labor after the sonographic
diagnosis of fetal macrosomia. Obstet Gynecol 1993;81:492-6.
3.Baskett TF, Allen AC. Perinatal implications of shoulder dystocia. Obstet
gynecol1995;8614-17.
4.Keller J, Lopex-Zeno J, Dooley S, Socol M. shoulder dystocia and birth trauma in
gestational diabetes: a five year experience. Am J Obstet Gyneco 1991;165:928030.
5. Boekhuizen et al. Vacuum extraction versus forceps delivery: indications and
implications, 1979-84. Obstet Gynecol 1987;69:338-42.
6.Gobbo R, Baxley E. Shoulder Dystocia. In:Damos JR etc. ALSO Course Manual.
4th ed. Leawood, KS:American Association of Family Physicians;2000. p1-13.
Ref No Repromed 085
Issue date Jan 2007
Review Date Jan 2010
Published by Labour suite management committee Level 1 2
Ratified By Clinical Director
Issuing Officer: D.I.M. Farquharson
I
Page 3 of 3
3 4
SIMPSON CENTRE FOR REPRODUCTIVE HEALTH
ROYAL INFIRMARY of EDINBURGH
Clinical Protocol
STILLBIRTH
(Use in conjunction with Induction of Labour with oral mifepristone and misoprostol)
If intrauterine death is suspected, the diagnosis must be confirmed or excluded using
prompt ultrasound examination by two skilled operators. If the woman presents at
night and a sufficiently skilled ultrasonographer is not available, one should be
summoned from home (either consultant Obstetrician or Radiologist).
It is not acceptable to wait for the ultrasound department to open at 9am.
Check maternal observations
• pulse, BP, temperature,
• urinalysis and baseline bloods of FBC, Clotting, G & S and U and Es.
The woman must be seen by the duty Registrar. If the Registrar is not immediately
available, the SR or Consultant should be summoned. In all cases the duty SR and
Consultant should be informed about the case and the woman’s own Consultant
notified as soon as reasonably possible.
Delivery will usually be vaginal. Any patient with a previous caesarean section must
be discussed with a consultant Obstetrician. In rare cases an elective Caesarean
Section may be appropriate. Induction of labour will usually commence immediately
with oral mifepristone although in a well patient without evidence of bleeding or
sepsis a small delay of 24-48 hours is acceptable in cases where the couple feel this
is better. SEE PROTOCOL FOR Induction of Labour with oral mifepristone and
misoprostol. Amniotomy should be avoided due to risk of sepsis
If intrauterine death has occurred more than four weeks previously, clotting problems
can occur and these should be investigated. Clotting problems may also result in
more recent intrauterine death particularly in relation to large antepartum
haemorrhage and this should be borne in mind. Epidural is not contraindicated
providing that clotting is normal. However PCA may be appropriate for sedative affect
and many women find advantageous.
Administration of mifepristone 200mgs 36hours prior to induction should be
considered. This is especially useful before 34 weeks if there has been no uterine
activity. Understandably many women are reluctant to accept the perceived delay
until delivery but the resultant significant reduction in length of labour should be
emphasised. Mifepristone should be administered even if it is planned to proceed
directly to induction of labour 12 hours must elapse between mifepristone
administration and misoprostol.
It is important to make strenuous efforts to establish the cause of all perinatal deaths
including stillbirths. The nature and extent of investigations will vary with individual
circumstances.
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Autopsy by an experienced perinatal Pathologist is invaluable. A senior
Obstetrician must always request autopsy. It must be recognised that this is a painful
decision for parents to make and the matter must be raised with sensitivity. A small
number of couples will have religious objections and it is wrong to pressurise them,
however, a limited examination may be acceptable to parents instead. The placenta
should always be sent to the Pathology department for histological and
bacteriological studies and chromosomal studies in some cases.
Other routine investigations are shown below. These are especially important when
intrauterine death occurs unexpectedly and without any immediately obvious
explanation.
It is vital that medical staff not only pursue the cause of perinatal deaths, but also
recognise the pain of bereavement which is experienced by the parents. The
provision of informed care and of kindness can greatly ease the recovery after such
an event. Encouraging the parents to confront the pain rather than avoiding events
which bring back memories of the baby may facilitate grieving. Physical reminders
such as a lock of hair or a photograph are helpful. Parents should be encouraged to
hold and name their dead child. See booklet “information for parents following
the stillbirth of their baby”.
The ritual importance of a funeral should not be underestimated. Religious and
spiritual support should be offered. Explanations are often not understood by parents
in a state of shock shortly after the event. They require to be repeated on a later
occasion, preferably in an unhurried interview with the Consultant in charge some six
weeks later.
Autopsy information (if performed may be discussed then, as may be the prospects
for future pregnancies. Referral to another specialist, e.g. for genetic counselling,
may be arranged when appropriate. Irrational feelings of guilt are common, and these
should be elicited and dispelled. All parents will be sent information about services of
the bereavement counselling sevice. Contact with an organisation such as The
Stillbirth and Neonatal Death Society (SANDS) may provide ongoing support. Some
parents experience very prolonged grief.
All perinatal deaths are discussed at a monthly meeting during the Monday lunchtime
programme. This is an important part of training and all junior medical staff are
expected to attend.
A check list to ensure that important steps are not accidentally missed and a
comprehensive folder has been devised for each patient with medical and midwifery
checklists. This should be filed in the patient’s notes.
INVESTIGATIONS AFTER PERINATAL LOSS
INVESTIGATION
I
PURPOSE
INDICATION
Page 2 of 3
SAMPLE
REQUIRED
Autopsy
Detect fetal
anomalies
All deaths
Fetus and placenta
Detect maternal
glucose
intolerance
Detect fetomaternal
haemorrhage
Detect
Antiphospholipid
Syndrome and
clotting disorders
All deaths
Red tube to
biochemistry
All deaths
Blue BTS tube
All deaths
3 green tubes and
red tube sent
urgently with
porter to
haematology dept,
perform in working
hours
White tube to
immunology
Maternal blood
HbA1C
Kleihauer test
Lupus
anticoagulant
Anticardiolipin
antibodies
Thrombophilia
screen
Anticardiolipin
antibodies
All deaths
Group and
antibody screen
Detect
isoimmunisation
All deaths
Blue BTS tube
Virology screen
TORCH and
parvovirus B19
All deaths
White tube to
microbiology
LFTS, bile salts,
urate
All deaths
Brown tube to
biochemistry
Thyroid function
tests
All deaths
Brown tube to
biochemistry
Blood culture
bottles to
microbiology
Fetal blood - cord
or cardiac
Piece of placenta
MUST BE SENT
EARLY IF TO BE
ANALYSED
Blood cultures
Detect Listeria
All deaths
Cytogenetic
analysis (WGH)
Detect abnormal
karyotype
Placental swab
Detect intrauterine
infection
Fetuses with
congenital
malformation or
dysmorphism,
fetuses with no
obvious cause for
death
Suspected
chorioamnionitis
Ref No Repromed 086
Issue date June 2005
Review Date Mar 2010
Published by Labour suite management committee Level 1 2
Ratified By Clinical Director
Issuing Officer: D.I.M. Farquharson
I
Page 3 of 3
3 4
Swab to
microbiology
SIMPSON CENTRE FOR REPRODUCTIVE HEALTH
ROYAL INFIRMARY of EDINBURGH
Clinical Protocol
MANGEMENT OF TWIN LABOUR
Introduction
Vaginal delivery of twins is only considered after discussion with consultant Obstetrician in a
diamniotic twin pregnancy where twin I is cephalic. Higher order multiples, monoamniotic and
pregnancies where twin I is non cephalic should be delivered by caesarean section.
Management
1st Stage
1
Care is in the main labour suite corridor.
2
Obstetric Registrar must review patient on admission to labour suite and perform USS to
ensure two separate fetal hearts and presentation of twin I.
3
Continuous CTG monitoring is essential. Use the split (+20 BPM) facility if two FH rates are
similar. Apply FSE to twin I once membranes ruptured to establish accuracy, unless perfect
racings available abdominally.
4
Early anaesthetic assessment is arranged because of risk of intervention, especially in twin II.
Epidural insertion is encouraged.
5
Amniotomy should be performed once in established labour to allow FSE application. FSE
should not be applied to <34 weeks gestation.
6
IV access, FBC, G&S should be done on admission in established labour
7
Oral ranitidine 150mg 8 hourly must be administered
8
Inform paediatric team if <36 weeks
9
CTG abnormalities in twin 1- do FBS, twin 2 - do CS. If any difficulties with monitoring
consider CS
10
First stage arrest – Syntocinon (oxytocin) for augmentation may only be used after
consultation with SpR 4/5 or consultant Obstetrician. Refer to Induction guideline
11
Prepare for 2nd STAGE Syntocinon (use oxytocin infusion chart and label clearly).
11.1 Oxytocin 90mU/ml for augmentation: Add 10iu (1ml) of oxytocin into 100ml 0.9% sodium
chloride and shake well to mix. Set up infusion and run through an Alaris pump before pushing
begins as this may be required for augmentation between twins. Commence oxytocin infusion
90mU/ml at 2ml/hr (or 3mU/min), increasing every 30 minutes as required. Max dose 8ml/hr (or
12mU/min)
11.2 Oxytocin 80mU/ml for postpartum haemorrhage: Add 40iu (4ml) of oxytocin into 500ml
sodium chloride 0.9% and shake well to mix. Set up and run at 125ml (10iu) / hr through an Alaris
pump in anticipation of postpartum haemorrhage if required.
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Page 1 of 2
2nd Stage
Twin patient is more prone to aorto-caval compression therefore extreme care is required with
positioning of parturient after regional anaesthesia is required especially in second stage.
1
Two or three midwives are required to conduct/deliver, stabilise second twin and
take each twin
2
Obstetric registrar and USS machine in room
3
SpR 4/5 or consultant Obstetrician, anaesthetist, ODP and paediatrician x2 all in labour suite
until end of third stage. If <32 weeks also neonatal unit facilitator
4
Midwife epidural top up should be administered before onset of pushing
5
Deliver twin 1 as if singleton. Ensure separate identifications for cords 1 and II are organised.
6
An experienced midwife must palpate and stabilise twin 2 as twin 1 delivers, to help ensure a
longitudinal lie. After twin 1 delivered Obs Reg must confirm by palpation and USS the
lie/presentation of twin2. Inform SpR 4/5 or consultant if transverse to allow attempt at ECV
to be considered.
7
Inter twin delivery time has no upper limit if CTG reassuring. However, if >30 minutes has
lapsed a consultant Obstetrician must assess the situation.
8
Perform amniotomy when twin 2 has longitudinal lie with presenting part in pelvis and regular
contractions have resumed.
9
If no contractions 15 minutes after twin 1 delivered commence 2nd stage oxytocin Syntocinon
(10iu in 100ml) at 2ml/hr (3mU/min) for augmentation.
ADOPT A LOW THRESHOLD FOR TRANSFER TO THEATRE
FOR ANY OPERATIVE DELIVERY OR OTHER OBSTETRIC COMPLICATIONS.
3rd Stage
Active management of the third stage should be employed
After delivery of placenta commence the infusion of Syntocinon (40iu oxytocin in 500ml sodium
chloride 0.9%) at 125ml (10iu)/hr
Internal podalic version
Only to be undertaken by experienced practitioner as an alternative to ECV. Recognise a heal
through intact membranes and gently pull to lower into pelvis. Perform amniotomy as late as
possible.
Ratification in collaboration with Labour Suite Management Committee
, Consultant Obstetrician_____________________
, Principal
Midwife______________________
, Consultant Anaesthetist______________________________
, Clinical
Manager___________________
, Lead Directorate Pharmacist_____________________
Ref No Repromed 072
Issue date Jan 2007
Review Date Jan 2010
Published by Labour suite management committee Level 1 2
Ratified By PSD
I
3 4
Issuing Officer: D.I.M. Farquharson
Page 2 of 2
SIMPSON CENTRE FOR REPRODUCTIVE HEALTH
ROYAL INFIRMARY of EDINBURGH
Clinical Protocol
UMBILICAL ARTERY DOPPLER
Definition
The examination of the umbilical artery with colour and spectral Doppler and the
measurement of the resistance index to assess placental circulatory reserve
Indications
AC<5th Centile for gestation
Static Growth on Centile chart
Oligohydramnios with intact membranes
Follow up of established IUGR (AC<5th Centile) – monitor as requested by
Consultant Obstetrician
Procedure
• Explain the purpose of the examination and obtain verbal consent
• Select a free loop of cord, away from the fetus if possible, and preferably during a
period when it is not breathing
• Press colour flow button
• Place Doppler cursor over umbilical artery (UA). Ideally choose a portion in which
the flow is directly to or from the transducer, i.e. minimise the angle of
interrogation
• Freeze the spectral Doppler trace and measure resistance index(RI)
• If end diastolic flow poor/absent/reversed, repeat the examination a further 2
times attempting to select a different portion of the cord and/or improve the angle
of interrogation
• Take images of the measurements
• Report: state indication for the examination. Give UARI and comment if it is
normal or increased for the gestation. If end diastolic flow (EDF) is absent or
reversed comment on it.
NB. If some loops have reduced EDF and others have absent EDF comment, “there
is reduced EDF” i.e. always give the better result – technical factors may account for
the poorer one
• Agree an action plan with a senior obstetrician in those women in whom a
Doppler examination has been performed
Note :
Due to the higher acoustic output used during Doppler examinations there may
be thermal effects that may result in fetal tissue being heated if exposed.
Because of this it should only be used when there is clear indication for the
examination, Umbilical artery Doppler studies should not be performed for fetal
assessment in post dates pregnancies or for the assessment of reduced fetal
movements.
A
Page 1 of 2
References:
Neilson JP and Alfirevic z . Doppler ultrasound for fetal assessment in high risk
pregnancies (cochrane review) from the cochrane library issue 2 2004-06-18
Kenyon AP et al 2002. Obstetric cholestasis, outcome with active management: a
series of 70 cases. BJOG 109 282-8
Nelson-Piercy C Handbook of Obstetric Medicine 2nd edition 2002
BMUS Safety Guidelines and Safety statement. British Medical Ultrasound Society
Bulletin August 2000
Signature
Consultant Obstetrician
Consultant Radiologist
Ref No Repromed 061
Issue date May 2006
Review Date Nov 2008
Published by Antenatal clinic management committee Level 1 2
Ratified By PSD
Issuing Officer: D.I.M. Farquharson
Reviewed by Dr
A
Nov 2007
Page 2 of 2
3 4
SIMPSON CENTRE FOR REPRODUCTIVE HEALTH
ROYAL INFIRMARY of EDINBURGH
Clinical Protocol
MANAGEMENT OF UTERINE HYPERTONUS OR HYPERSTIMULATION
Introduction
Uterine hypertonus and hyperstimulation are well recognised and rare complications of induction of
labour using dinoprostone and oxytocin (Syntocinon). The risk can be minimised by use of lowest
effective dose. Careful monitoring is mandatory after sequential combined use (NICE Guideline
Induction of labour 2001, www.nice.org.uk).
Definition
Uterine hypertonus is defined as more than 5 painful and palpable uterine contractions lasting at least
30 seconds in 10 minutes, almost always associated with CTG abnormalities (NICE guideline on
induction of labour 2001).
Management
1
2
If the woman is on oxytocin (Syntocinon), stop infusion.
Ensure the woman is in the left lateral position. Consider facial oxygen if there is any sign of fetal
distress.
3 Inform Obstetric registrar
4. Administer terbutaline (Bricanyl) which must be prescribed on the Prescription and Administration
Record
Dose: 250micrograms (0.5ml) subcutaneously of a 500microgram/ml solution.
5. Always consider fetal well being as delivery may be required.
Contra-indications
Known hypersensitivity to any constituent, diabetes, severe cardiac disease and untreated
hyperthyroidism
Adverse Effects
Serious side effects are dose related. Common side effects include fine tremor (especially hands),
palpitations, muscle cramps, tension, headaches and flushing. Hypokalaemia, tachycardia and
arrhythmias can occur. Hypersensitivity reactions include paradoxical bronchospasm, angiooedema,
urticaria, hypotension and collapse. Rarely, pulmonary oedema has occurred with high doses.
Drug Interactions
Beta blockers, corticosteroids and sympathomimetics amines,
References see SCRH website and (NICE Guideline Induction of labour 2001, www.nice.org.uk).
I
Version 2.1
Page 1 of 2
Prepared: November 2006
Review date: July 2008
Ratification in collaboration with Labour Suite Management Committee
Consultant Obstetrician ---------------------------------
(Principal Midwife) ------------------------------------
(Consultant Anaesthetist) ---------------------------------
(Lead Directorate Pharmacist)--------------------------
(Clinical Manager)-------------------------------------------
Ref No Repromed 03
Issue date November 2006
Review Date July 2007
Published by Labour suite management committee Level 1 2
3 4
Ratified By Clinical Director
Issuing Officer: D.I.M. Farquharson
I
Version 2.1
Page 2 of 2
Prepared: November 2006
Review date: July 2008
SIMPSON CENTRE FOR REPRODUCTIVE HEALTH
ROYAL INFIRMARY of EDINBURGH
Clinical Protocol
VENOFER for POST-PARTUM ANAEMIA
Intravenous iron may be indicated if a patient is anaemic, the severity of which would
normally require transfusion but
• the patient is intolerant of oral iron
• the patient refuses transfusion
Administration
• Venofer can be given in the ward as well as HDU but if in the ward, a
doctor must be in the vicinity for 20 mins.
• Monitoring is needed for the first dose. This includes pulse oximetry which
will give both SaO2 and pulse rate, and NIBP. This needs to be done for
the first 20 mins of infusion. Thereafter, if all observations are satisfactory,
monitoring is unnecessary. No monitoring is necessary for the second
dose provided the first dose was uneventful.
• The dose is 200 mg on day 1 and 2.
• Add 2 ampoules of Venofer (20mg/ml) to 100 mls N.Saline. Run through
Alaris pump.
• Site Venflon (20G or 22G)
• Run pump at 100 mls/hr.
• At end of infusion, flush Venofer in giving set through with another 100 ml
bag of N.Saline but this need only be run until the giving set is clear.
• Note that a few patients may complain of a burning sensation in the hand.
This can be reduced either by slowing the infusion down to 50 mls/hr or
giving a bolus of 2 mls 1% lignocaine directly into the Venflon to
anaesthetise the vein.
VC/AC
August 2006
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