The Labour Ward Handbook

Cover
Half Title
Title
Copyright
Dedication
Contents
Preface
Acknowledgements
About the Author
Abbreviations
Glossary
Bleep/crash calls
Part I Approach to care
1 The biopsychosocial approach to care of the woman in labour
1.1 Assessing women’s satisfaction with intrapartum care
2 Communication between care providers
2.1 Early identification and communication of risk
2.2 Handover
2.3 Communication with anaesthetists
3 Documentation
4 Admission to, and discharge home from, the delivery suite
4.1 Admission
4.2 Discharge
5 Learning from clinical incidents
5.1 What is a clinical incident?
5.2 Why do we need clinical incident analysis?
5.3 Reporting clinical incidents
5.4 Learning from clinical incidents
5.5 Confidentiality
6 Transfer of care between professionals
6.1 Background
6.2 Handover by clinical staff
6.3 Transfer of emergencies from primary care
6.4 Transfer between hospitals with the fetus in utero
6.5 Transfer of care between consultants
6.6 Transfer back to the community or GP care
6.7 Transfer to ICU and HDU
6.8 Who is in charge while the woman is in ICU or HDU?
6.9 Return to delivery suite from ICU
7 Reviewing what happened
Further reading for Part I
Part II Normal and Low-Risk Labour
8 Vaginal examination
8.1 Before vaginal examination
8.2 During vaginal examination
8.3 Details to be recorded
9 Intravenous cannulation
10 Management of normal labour
10.1 Criteria for normal labour
11 Prelabour rupture of membranes at term (37–42 weeks)
11.1 Further management
11.2 Expectant management
11.3 Active management
12 Management of the first stage of labour
12.1 Diagnosis
12.2 Monitoring progress of labour
12.3 Birth plans
12.4 Support person
12.5 Positioning
12.6 Nutrition
12.7 Antacids (including H2-receptor antagonists)
12.8 Pain relief
12.9 Entonox (50% O2 and 50% N2O)
12.10 Opioids (pethidine, diamorphine or other)
12.11 Epidural analgesia
12.12 Bladder care
13 Fetal monitoring
13.1 Intermittent auscultation
13.2 Electronic fetal monitoring
13.3 Suspicious or abnormal trace
13.4 Classification of cardiotocograph (Table 13.1)
13.5 Management of suspicious or pathological cardiotocograph
13.6 Management of fetal tachycardia
13.7 Note
13.8 Management of fetal bradycardia
13.9 Schedule
13.10 Reduced variability (2–5 beats/min)
13.11 Late deceleration
14 Fetal scalp blood sampling
14.1 Contraindications to FBS
14.2 Interpretation of pH result
14.3 Scalp blood lactate
14.4 Documentation
14.5 FBS at full cervical dilatation
15 Augmentation of labour
15.1 Artificial rupture of fetal membranes (ARM)
15.2 Augmentation with Syntocinon
15.3 Syntocinon infusion
15.4 Second stage of labour
15.5 Uterine hyperstimulation
15.6 Management
16 Cord-blood sampling
17 Epidural analgesia in labour
17.1 Indications for epidural analgesia
17.2 Contraindications to epidural analgesia
17.3 Coagulopathy
17.4 Therapeutic/prophylactic anticoagulation
17.5 Setting up
17.6 Procedure
17.7 Method of administration
17.8 Epidural infusion
17.9 Epidural top-up
17.10 Protocol for top-ups
17.11 General care of the woman with an epidural
17.12 In the second stage of labour
17.13 Complications of epidural analgesia
17.14 Dural tap
17.15 Local anaesthetic toxicity (IV injection)
17.16 Total spinal
17.17 Dense motor block
17.18 Bladder distension
17.19 Discontinuation of epidural
18 Management of the second stage of labour
18.1 Duration
18.2 Passive phase
18.3 Active phase
18.4 Immediate versus delayed pushing
18.5 Delayed second stage
18.6 Management of delayed second stage
18.7 Calling the paediatrician
19 Criteria for paediatric attendance at delivery
20 Management of the third stage of labour
20.1 Active management
20.2 If the placenta is not delivered within 30 minutes, refer to the obstetrician
20.3 Physiological management
21 Immediate postpartum care
21.1 Care of the mother
21.2 Bladder care
21.3 Care of the baby
21.4 The placenta
21.5 Documentation
22 Care of the newborn
22.1 Skin-to-skin contact
22.2 Prevention of hypothermia
22.3 Vitamin K
22.4 Identification of the baby
22.5 Breastfeeding
22.6 Management of hypoglycaemia
22.7 Preventive care
23 Meconium-stained amniotic fluid
23.1 Risk to baby
23.2 Note
23.3 Meconium-stained fluid in labour
23.4 Meconium-stained fluid at vaginal delivery
23.5 Meconium-stained fluid at caesarean section
24 Neonatal resuscitation
24.1 Principles
24.2 Avoid thermal stress
24.3 Airway
24.4 Evaluation
24.5 Breathing
24.6 Chest compression
24.7 Drugs used in neonatal resuscitation
24.8 Volume replacement
25 Babies born before arrival at hospital
25.1 Mother
25.2 Baby
26 Episiotomy
27 The woman with a history of childhood sexual abuse
27.1 General measures
27.2 Communication
27.3 Physical examination and procedures
27.4 Flashbacks
28 Use of birthing pool
28.1 Inclusion criteria
28.2 Exclusion criteria
28.3 Conduct of labour
28.4 Support in labour
28.5 Indications for asking the woman to leave the pool
28.6 Delivery
28.7 General
Further reading for Part II
Part III Abnormal and high-risk labour
Section 1 Powers, passenger, passage
29 Caesarean section
29.1 Preparations
29.2 Medication to reduce the risk of aspiration syndrome
29.3 Classification of urgency of CS
29.4 Elective CS
29.5 Workplace noise
29.6 Emergency CS
29.7 Surgical procedure
29.8 Prophylactic antibiotics
29.9 High-risk cases
29.10 Delayed elective CS
29.11 Postoperative care
29.12 Thromboprophylaxis
30 Recovery of obstetric patients
31 High-dependency care
31.1 Early warning score
32 Failed intubation drill
33 Instrumental delivery
33.1 Non-operative interventions which reduce instrumental delivery rates
33.2 Avoiding harm
33.3 Indications for instrumental delivery
33.4 Conditions to be fulfilled before instrumental delivery
33.5 Classification of instrumental vaginal delivery
33.6 Communication
33.7 Choice of instrument
33.8 Pre-application assessment: abdominal and vaginal examination
33.9 Vacuum-assisted delivery
33.10 Procedure
33.11 Contraindications to vacuum-assisted delivery
33.12 Forceps delivery
33.13 Checking for proper application of the forceps
33.14 Kjelland forceps
33.15 Trial of instrumental delivery
33.16 The principle of abandonment
33.17 Post-delivery
33.18 Documentation
33.19 Errors in instrumental vaginal delivery
34 Trial of vaginal delivery after a previous caesarean section
34.1 Contraindications
34.2 Action plan for trial of vaginal delivery
34.3 Use of Syntocinon
34.4 Signs of scar rupture or imminent rupture
34.5 Post-delivery
35 Induction of labour
35.1 Methods
35.2 Artificial rupture of fetal membranes
35.3 Prostaglandin induction of labour
35.4 Monitoring following insertion of prostaglandin
35.5 Precautions
35.6 Hyperstimulation
35.7 Syntocinon infusion
35.8 Uterine hyperstimulation
36 Antenatal corticosteroid therapy
36.1 Indications
36.2 Dose
36.3 Contraindications
36.4 Beta-sympathomimetics
36.5 Repeated doses
37 Preterm prelabour rupture of membranes
37.1 Action plan
37.2 Conservative management
37.3 Mode of delivery, in the absence of other complications
37.4 Induction of labour
37.5 Labour
38 Preterm uterine contractions
38.1 Diagnosis
38.2 Action plan
38.3 Fetal fibronectin test
38.4 Management of established preterm labour (when it is too late to suppress labour)
38.5 Suppression of labour
38.6 Contraindications to suppression of labour
38.7 Nifedipine
38.8 Indomethacin (prostaglandins synthetase inhibitor)
38.9 Atosiban
38.10 Magnesium sulphate for neuroprotection
38.11 Monitoring
39 Deliveries at the lower margin of viability
39.1 Pregnancy under 22 weeks
39.2 Pregnancy over 22 weeks
39.3 Post-delivery care if the baby does not survive
39.4 Support group
40 Multiple pregnancy
40.1 First stage of labour
40.2 Second stage of labour
40.3 Delivery of the second twin
40.4 Third stage of labour
40.5 Indications for CS for second twin
41 Abnormal lie in labour
41.1 Intact membranes
41.2 Ruptured membranes
41.3 Caesarean section
41.4 Difficult cases
41.5 Uterodistension
42 Occipito-posterior position
42.1 Persistent occipito-posterior position
43 Malpresentation
43.1 Brow presentation
43.2 Face presentation
43.3 Compound presentation
44 Breech presentation
44.1 Undiagnosed breech in labour
44.2 Preterm breech in labour
44.3 Breech vaginal delivery
44.4 Caesarean section for breech presentation (elective or emergency)
45 External cephalic version
45.1 Risks of ECV
45.2 Contraindications to ECV
45.3 Cautions
45.4 Action plan
46 The woman with genital cutting
46.1 WHO classification of female genital cutting
46.2 Action plan
46.3 Female Genital Mutilation Act 2003
47 The obese woman in labour
47.1 WHO classification of BMI
47.2 Woman who had bariatric surgery
48 Perineal tear
48.1 Classification of perineal tears
48.2 First- and second-degree tears: episiotomy
48.3 Third- and fourth-degree tears
Section 2 Medical conditions
49 Heart disease in labour
49.1 Principles of management
49.2 Action plan
50 Peripartum cardiomyopathy
50.1 Diagnosis
50.2 Risk factors
50.3 Symptoms and signs
50.4 Action plan
51 Pre-eclampsia
51.1 Classification
51.2 Action plan
51.3 Measurement of blood pressure
51.4 Severe pre-eclampsia
51.5 Delivery
51.6 Watch for PPH
51.7 Post-delivery
51.8 Antihypertensive therapy in pre-eclampsia
51.9 Labetalol
51.10 Hydralazine
51.11 Nifedipine
51.12 Anticonvulsant prophylaxis in pre-eclampsia
51.13 Magnesium sulphate blood levels
51.14 Management of magnesium toxicity
51.15 Postpartum
51.16 Post-delivery ward round (days 0–3)
51.17 Fluid management in pre-eclampsia
51.18 Management of oliguria (<80 mL in 4 hours)
51.19 Blood transfusion
52 Eclampsia
52.1 Action plan
52.2 Anticonvulsant treatment (magnesium sulphate)
52.3 Magnesium sulphate blood levels
52.4 Persistent seizures
52.5 Controlling blood pressure
52.6 General management
53 Diabetes mellitus
53.1 Recommended timing of delivery
53.2 Induction of labour by artificial rupture of fetal membranes
53.3 Induction of labour with prostaglandin
53.4 Elective caesarean section
53.5 First stage of labour
53.6 Gestational diabetes, diet-controlled
53.7 Preterm labour
53.8 After delivery
53.9 Care of the neonate
53.10 Maternal hypoglycaemic shock
53.11 Diabetic ketoacidosis
53.12 Presentation
54 Asthma (acute exacerbation in labour)
54.1 Drugs that can cause or aggravate bronchospasm
54.2 Action points
54.3 After delivery
55 Epilepsy
55.1 Management in labour
55.2 Indications for caesarean section
55.3 Management of fits in labour
55.4 After seizure
55.5 After delivery
56 Systemic lupus erythematosus
56.1 Principles
56.2 Action plan
56.3 Neonatal lupus
57 Connective tissue disorders
57.1 Rheumatoid arthritis
57.2 Marfan syndrome
57.3 Ehlers–Danlos syndrome
Section 3 Haemorrhage and haematological disorders
58 The rhesus-negative woman
58.1 Sensitizing events
58.2 At delivery
58.3 Transfusions
59 Thromboembolism prophylaxis
59.1 Thromboprophylaxis for caesarean section
59.2 Low risk
59.3 Moderate risk
59.4 High risk
59.5 Thromboprophylaxis in vaginal deliveries
59.6 Low risk
59.7 Moderate risk
59.8 High risk
59.9 Relative and absolute contraindications to the use of dalteparin
59.10 The use of unfractionated heparin (UFH)
59.11 Regional analgesia
59.12 Regional analgesia and dalteparin
60 Acute venous thromboembolism and pulmonary embolism
60.1 Risk factors
60.2 Clinical features
60.3 Initial investigations
60.4 Suspected DVT
60.5 Suspected PE
60.6 Anticoagulant therapy for DVT and PE
60.7 Duration of treatment
60.8 Labour and delivery
60.9 High risk woman on therapeutic LMWH
60.10 Woman on high dose prophylaxis, twice-a-day regimen
60.11 Induction of labour
60.12 Elective caesarean section
60.13 Third stage of labour
60.14 Epidural or spinal anaesthesia
60.15 Postpartum anticoagulation
61 Major haemoglobinopathy
61.1 Principles of management in labour
61.2 Action plan
61.3 Sickle cell crisis
61.4 Action plan
62 Inherited coagulation disorders: Haemophilia and von Willebrand disease
62.1 Haemophilia
62.2 Von Willebrand disease
62.3 Action plan
62.4 The neonate
63 Immune thrombocytopenic purpura
63.1 Differential diagnoses of thrombocytopenia in pregnancy
63.2 Action plan
63.3 Mode of delivery
63.4 The neonate
63.5 Postnatal care
64 Thrombophilia
64.1 Management in labour
64.2 Epidural analgesia
64.3 Postpartum
65 Gestational thrombocytopenia
66 Antepartum haemorrhage
66.1 RCOG classification of APH
66.2 Differential diagnoses
66.3 Placental abruption
66.4 Assessment
66.5 Minor APH (minimal loss, <50 mL on admission)
66.6 Major APH (significant bleeding, 50–1000 mL but not in shock)
66.7 Massive APH (estimated loss >1000 mL and/or signs of clinical shock)
66.8 Delivery
67 Major placenta praevia
67.1 Action plan
67.2 Cell salvage
68 Placenta accreta spectrum
68.1 Investigation
68.2 Delivery
69 Retained placenta
69.1 Action plan
70 Postpartum haemorrhage
70.1 Action plan
70.2 Retained placenta
70.3 Uterine atony
70.4 Genital tract trauma or undiagnosed bleeding
70.5 Coagulopathy
70.6 Transfusion of blood products
70.7 Compression suture
70.8 Where could things go wrong?
70.9 Documentation
71 Disseminated intravascular coagulopathy
71.1 Investigations
71.2 Treatment
72 Delivery of the woman at known risk of haemorrhage
72.1 If surgery is indicated
73 Standards for administering blood transfusion
73.1 Background
73.2 Obtaining consent
73.3 Collecting a specimen for group-and-save/cross-match
73.4 Checking procedure for blood transfusion
73.5 Documentation
74 Management of the woman who declines blood transfusion
74.1 Antenatal care
74.2 Labour
74.3 Management of haemorrhage
74.4 Communication
74.5 Drugs and infusions
74.6 Hysterectomy
74.7 Management of staff
Section 4 Infection
75 Prophylactic antibiotics
75.1 Caesarean section
75.2 Cardiac disease (see Chapter 49)
75.3 Group B streptococci (GBS)
75.4 Prolonged rupture of fetal membranes
76 Intrapartum sepsis
76.1 Principles
76.2 Action plan
77 Hepatitis B and C
77.1 Action plan
77.2 Immunization
77.3 Breastfeeding
78 Intrapartum antibiotic prophylaxis for Group B streptococci
78.1 Principles
78.2 Risk factors
78.3 Indications for intrapartum GBS prophylaxis
78.4 Intrapartum GBS prophylaxis not indicated
78.5 Action plan
78.6 Neonate
78.7 Useful contact for patients
78.8 Helpline 0330 120 0796 (UK)
79 Genital herpes
80 Human immunodeficiency virus
80.1 Mode of delivery
80.2 Management of vaginal delivery
80.3 Other measures to reduce the risk of vertical transmission
80.4 After delivery
80.5 Breastfeeding
80.6 Preparation for caesarean section
80.7 Prelabour rupture of membranes at term (PROM)
80.8 Preterm prelabour rupture of membranes
80.9 Cord blood
80.10 Care of the baby
80.11 Infection control
81 The woman with COVID-19
81.1 Action plan
81.2 Clinical care
Section 5 Other obstetric emergencies
82 Paravaginal haematoma and cervical tear
82.1 Paravaginal haematoma
82.2 Cervical tear
83 Rupture of the uterus
83.1 Action plan
83.2 Preventive care
84 Shoulder dystocia
84.1 Risk factors
84.2 Risks to mother and baby
84.3 When shoulder dystocia is anticipated
84.4 Turtle sign
84.5 Action plan: ‘HELPERR’
84.6 After delivery
84.7 Documentation
85 Cord prolapse
85.1 Risk factors
85.2 Action plan
86 Anaphylaxis
86.1 Presentation
86.2 World Allergy Organization criteria for diagnosis of anaphylaxis
86.3 Action plan
87 Inverted uterus
87.1 Action plan
87.2 Reduction of the inversion
87.3 Hydrostatic reduction
88 Amniotic fluid embolism
88.1 Differential diagnoses
88.2 Management
89 Sudden maternal collapse
89.1 Possible causes
89.2 Management
89.3 Investigations
90 Latex allergy
90.1 Risk factors
90.2 Care of the woman allergic to latex
90.3 Operating theatre (elective or emergency procedure)
Section 6 Stillbirths and congenital abnormalities
91 Checklist for fetal loss at 13–23 weeks
91.1 Parents
91.2 Communication
91.3 Forms/administration
92 Intrauterine fetal demise
92.1 Principles
92.2 Diagnosis (if not made before admission)
92.3 Action plan
92.4 Investigations
92.5 Induction of labour
92.6 Support group
93 Mid-trimester termination of pregnancy for fetal abnormality
93.1 Investigations
93.2 Prenatal diagnosis of chromosomal abnormality
93.3 Ultrasound scan diagnosis of structural abnormality or external appearance suggestive of aneuploidy
93.4 Scan diagnosis of neural tube defect, with no other malformation or recurrences in family
93.5 Genetic examination of fetuses and samples
93.6 Induction of labour
93.7 Contraindications
93.8 Caution
Further reading for Part III
Appendix
Index