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Lothian NHS Board = Waverley Gate 2-4 Waterloo Place Edinburgh EH1 3EG = 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 E:\sites\intranetfiles\admin_new\dcaspfileupload01\uploads\$ASQCaesarian Section.doc Page 1 of 2 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 E:\sites\intranetfiles\admin_new\dcaspfileupload01\uploads\$ASQCaesarian Section.doc 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 A Page 3 of 6 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. A Page 4 of 6 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. A Page 5 of 6 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 A Page 6 of 6 2 DMT 3 PSD 4 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 I 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 A Page 1 of 1 3 4 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 I Page 1 of 2 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 I Page 2 of 2 3 4 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. I Page 1 of 2 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 I Page 2 of 2 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. A Page 1 of 12 Management of Hyperemesis Gravidarum Guideline ............................................................................. 3 Management of Hyperemesis Gravidarum Flow chart............................................................................ 9 Moderate Risk Guidelines in Nutrition – Hyperemesis.............................................................................. 10 SCRH Observation Chart............................................................................................................................... 11 A Page 2 of 12 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. P 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. P 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. P 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). P 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 P 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? P 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. I 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. I 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. I 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) I 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. I 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. I Page 1 of 3 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. I 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 P Page 1 of 1