ABNORMAL MIDWIFERY Or ABNORMAL MATERNITY.pptx

Abnormal midwifery presentation

1. ABNORMAL MIDWIFERY BEN OCHIENG’ BSC.N MOI UNIVERSITY

2. INDUCTION OF LABOUR This is the artificial initiation of labour process from 24 weeks gestation (fetal viability) Full assessment is done to rule out any risk that may be imposed on the mother or the fetus It is only indicated when the vaginal birth is the most appropriate mode of delivery

3. Indications for induction of labour This often applies to cases where there are deviations from the normal physiological processes of childbirth as a result of the maternal or fetal problems.

4. Maternal problems Prolonged pregnancy pg >42 wks Hypertension; pre- eclampsia Diabetes.- increases perinatal mortality, stillbirth and fetal macrosomia . IOL is done prior to 40 weeks Pre- laour rupture of membranes –increases risk of infections Maternal request- physiological or social reasons

5. Fetal prolems Intrauterine growth restrictions Macrosomia –to reduce risk associated with shoulder dystocia Fetal dealth Fetal anomaly not compatible with life

6. Contraindications for IOL Placenta praevia Transverse lie persisting after attempted version Breech presentation Maternal parity Severe acute fetal compromise

7. Methods of induction Cx must undergo some changes to enhance effective uterine contractions in the progressive dilatationa and effacement of the cx, descent of the presenting part and the birth of the baby The bishops scoring system determines the induction of labour (score>8 more favourable ) Abdominal examinations must be done before induction process

8. Bishops scoring system Induciblity features 1 2 3 Dilatation of the cx (cm) <1 1-2 2-4 >4 Consistency of the cx firm firm med soft Cervical canal length (cm) >4 2-4 1-2 <1 Position of cx post mid ant - Station of presenting part -3 -2 -1, 0 +1, +2

9. Membrane sweep The membrane sweep carried out after 40 weeks by an experienced midwife or a doctor reduces the need for further methods to induce labour Benefits include; no pre- labour rupture of membranes, bleeding or maternal or neonatal infections

10. Prostaglandins E2 (PGE 2 ) These are female hormones in the tissues produced in the cx, uterus, decidua and fetal membranes The natural PGE2 is placed in the posterior fornix of the vagina and absorbed by the vaginal epithelium and cx causing relaxation and dilatation of cx muscles and also increases uterine contractions

11. Administration of PGE2 Prostaglandin E2 gel-1mg into the post fornix for a primigravida or 1 mg for multigravida repeated after 6-12 hrs PGE2 gel- 0.5mg into the cx (6-12) hrs PGE2 tabs- 1mg intravaginally 4 hours for 4 doses N/B- with a ripe cx, do not start cyntocinon infusion <6hrs after the last dose of PGE2 50 micrograms can be used for primigravidae intravaginally

12. Risks associated with PGE2 Hypertonic uterus Placental abruption Fetal hypoxia Pulmonary or amniotic fluid embolism Uterine rupture (rare)

13. Artificial rupture of membranes Amniotomy /ARM s preferred when the cx is favorable and the presenting part is fixed in the pelvis. Carry out abdominal exams and VE to rule out cord presentation and vasa praevia The forewaters is ruptured using amnio -hook to release amniotic fluid. Assess the fluid for colour and volume Monitor the fetus and assess the presentation

14. ARM cont’n Longer interval predisposes the mother to chorioamnionitis due to ascending infections from the genital tract Chorion creates a barrier between the amnion and fetus from the vagina and cervix PGDH produced by the chorion breaks down PGE2 hence no changes in the cx therefore preventing pre-term labour

15. oxytocin Synthesized in the hypothalamus then transported to the posterior pituitary gland then released to act on the smooth muscles. The syntocinon ( synthetic form) , apoerful uterotonic agent given by slow IV 5 units oxytocin in one liter ringer’s lactate (15 drops/min) doubled every 30-50 mins Amniotomy should be done incase the membranes have not ruptured Monitor fetal heart and uterine activity using continuous electronic monitoring

16. hyper stimulation and hypertonic uterus may lead to fetal compromise hence need for reduction or discontinuation of the infusion and medical aid summoned The midwife should palpate the uterine contractions for frequency, strength and duration

17. Risk of using IV oxytocin Uterine hyper stimulation Fetal hypoxia and asphyxia Uterine rupture Fluid retention due to effects of antidiuretic effect of oxytocin (vasopressin) Postpartum haemorrhage Amniotic fluid embolism

18. Role of midwife to the mother during labour induction Ensures that the woman and the partner have been fully informed and understand the process and the procedure Promotes care during the antenatal and intrapartum period Document any discussions that take place requests made in maternity notes Document all maternal and fetal observations during the induction Pain management encompassing the choice of type of pain relief