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Ростовский Государственный Медицинский Университет
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Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2899_Библиотеки_им_академика_М_И_Перельмана

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Table61.5Postnatalmanagementandmonitoringofhypertensivedisordersof pregnancy
Chronic hypertension
Gestationalhypertension Pre-eclampsia
PostnatalBP monitoring
CheckBPdailyforfirst2days CheckBPatleastoncebetweendays 3–5 CheckBPwheneverAHTis modified
Ifpatientdidn’tuseAHTin pregnancy:
Atleast4×/daywhileinpatient At least once between days 3–5 postpartum On alternate days until normal if abnormalatdays3–5postpartum
IfpatientusedAHTinpregnancy:
Atleast4×/daywhileinpatient Every 1–2 days for up to 2 weeks untiloff AHT andnormotens ive
Askwomenaboutsevereheadache andepigastricpainateachBP measurement
Starting, stopping,and continuing postnatal AHT
KeepBP <140/90mmHg— continueAHTif necessaryto achievethis
ContinueAHTifstillneeded ReduceAHTifBP<130/80mmHg StartAHTifBP>150/100mmHg
StartAHTifBP≥150/100mmHg IfalreadyusingAHT,continueafter birth and consider reducing when BP<140/90mmHg
Outpatient reviewand follow-up
Reviewat2weeks, thenagainat6–8 weeks
Reviewat2weeks,thenagainat6– 8weeks Provide community staff with a clear plan for follow-up including frequency of monitoring and thresholdsforstoppingtreatment
Check platelets, creatinine, and transaminases 48–72 hours after birth—does not need repeating if normal Transfer to community care when asymptomatic, BP (treated or untreated) <150/100mmHg, and bloodsstableorimproving Reviewat2weeks,thenagainat6– 8weeks Do urinalysis at 6–8 weeks, if ≥1 proteinuria then reassess kidney function at 3 months. If abnormal, refertospecialist Provide community staff with a clear plan for follow-up including frequency of monitoring and thresholdsforstoppingtreatment
Specialconsiderations
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Breastfeeding
Treatment options for breastfeeding patients include enalapril, nifedipine, amlodipine, atenolol, andlabetalol. ManyAHTs canpassintobreastmilkat verylowlevels.They areunlikelytohaveanyclinical effect ConsidermonitoringtheBPofthebaby(especiallyifpre-term)iftheyhavesymptomsoflowBP inthefirstfewweeksoflife Parentsshouldmonitorbabiesfordrowsiness,lethargy,pallor,coldperipheries,andpoorfeeding
Furtherreading
1.NICE(2016).PlGF-basedtestingtohelpdiagnosesuspectedpre-eclampsia(TriagePlGFtest,Elecsys immunoassay sFlt-1/PlGF ratio, DELFIA Xpress PlGF 1-2-3 test, and BRAHMS sFlt-1 Kryptor/BRAHMS PlGF plus Kryptor PE ratio) (DG23). Available at:
https://www.nice.org.uk/guidance/dg23
2.ThangaratinamS,AlloteyJ,MarlinN,etal.(2019).PREP-S:riskofcomplicationsinearly-onsetpre­eclampsia.Availableat:https://www.evidencio.com/models/show/1038
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Chapter62
Intrapartumcare
Guideline: This chapter was based on: NICE CG190(Intrapartum care for
healthy women and babies): https://www.nice.org.uk/guidance/cg190/, updated2017.Sincethechapterwaswritten,theguidelinehasbeenupdated to NICE CG190 (Intrapartum care for healthy women and babies):
www.nice.org.uk/guidance/cg190/, updated December 2022. NICE have
updated the recommendations on monitoringduringlabour and transferred them to the new guideline NICE NG229 (Fetal monitoring in labour):
https://www.nice.org.uk/guidance/ng229.NICEhavealsowithdrawncontent
onfetalbloodsampling.
OUPdisclaimer:OxfordUniversity Press makesno representation, express or implied, that the drugdosagesarecorrectand thatthe recommendations are an exclusive or mandatory course of care. All health professionals readingthistexthavearesponsibilitytoevaluateitsappropriatenessandtake theindividualneedsofthepatientintoaccount.
Localtrustguidelines:pleaserefertoyourlocalguidelinesasnecessary.
Overview
This chapter deals with standard care during labour for pregnancies where the birth is takingplaceatterm(between37and42weeks).
Initialassessmentofawomaninlabour
Start by reviewing antenatal notes and relevant investigations such as bloods and screeningresults.
History
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Contractions:length,strength,andfrequency Pain:fullhistory,anddiscussanalgesiaoptions(Table62.1) Vaginalloss:bleeding,liquor,discharge Fetalmovementsoverthepast24hours:anychange?
Examination
Observations:pulse,bloodpressure,andtemperature Abdomen:fundalheight,fetallie,fetalpresentation,fetalposition,engagementofpresentingpart. Assesscontractionsifrelevant Vaginalexamination:performifinestablishedlabour,orconsiderifthediagnosisisuncertain.
Investigations
Urinalysis.
Fetalmonitoring—shouldcontinueforthedurationoflabour
Fetalheartauscultation(withPinardstethoscopeorDopplerultrasound):
For1minuteimmediatelyafteracontraction Feelthewoman’spulsesimultaneouslytodifferentiate Ifabnormalitiesaresuspected,useCTG
CTG:
IfthepatienthasanyoftheriskfactorsinBox62.1whichmeantheyshouldhaveobstetric-led care,usecontinuousCTG If fetalheartauscultationsuggestsabnormalities,useCTGfor20 minutesandthenreturnto intermittentauscultationifnormal CTG can be offered to low-risk women if they are not yet in established labour but they should be aware ofthe risks andbenefitsand that it may require them to be transferred to obstetric-ledcare.
Box62.1Transfertoobstetric-ledcare
Thepatientshouldbetransferredtoobstetric-ledcare(iftheyarecurrentlybeingcared forbyamidwife)ifanyofthefollowingarenoted:
Signsofpossiblepre-eclampsia(seeChapter61)
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Systolic blood pressure≥160mmHg OR ≥140mmHg ontwo consecutivereadings,30 minutes apart Diastolicbloodpressure≥110mgOR≥90mmHgontwoconsecutivereadings,30minutesapart ≥2+ proteinuria WITH EITHER systolic blood pressure ≥140mmHg OR diastolic blood pressure≥90mmHg Maternalcollapseorseizure.
Signsofpossiblesepsis(seeChapter66)
Pulse>120bpmontwooccasions,30minutesapart Temperature≥38°COR≥37.5°Contwoconsecutivereadings,1hourapart Suspectedchorioamnionitisorsepsis.
Otherconcerns
Painthatisnotconsistentwithnormalcontractions Contractions>60seconds >5contractionsin10minutes Useofoxytocin Wishforregionalanalgesia Antepartumhaemorrhage(seeChapter58) Ruptureofmembranes>24hoursbeforeonsetofestablishedlabour Significantmeconium Reducedfetalmovementsinlast24hours Cordprolapse Delayedfirstorsecondstageoflabour Anyabnormalpresentationincludingtransverseorobliquelie Highorfree-floatingheadinanulliparouswoman Suspectedfetalgrowthrestrictionormacrosomia Anhydramniosorpolyhydramnios Fetalheartrate<110bpmor>160bpm Decelerationsonintermittentauscultation.
Postpartumcomplications
Needforneonatalresuscitation Postpartumhaemorrhage(seeChapter65) Third-orfourth-degreetear(see‘Perinealtrauma’).
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Table62.1Painreliefoptionsinlabour
Non-pharmacological Breathingandrelaxationtechniques,massage,music,useofwaterorpool
Pharmacological Advantages Disadvantages
Entonox (50:50oxygen:nitrous oxide)
Inhaledrouteonly Availableinallbirthsettings
Nausea,vomiting,light-headedness
Opioids (pethidineor diamorphine)
Availableinallbirthsettings IMsingleinjection Lasts2–4hours Onlytakes20minutestowork
Requiresconcurrentadministrationofantiemetic Maternal:nauseaandvomiting,drowsiness, interfereswithbreastfeeding Fetal:short-termrespiratorydepressionand drowsiness
Regionalanaesthesia (epiduralorcombined spinalepidural)
Moreeffectiveanalgesia Doesnotincreaseriskof caesareansection Doesnotincreaseriskoflonger firststageoflabour
Onlyavailableinobstetricunits RequiresIVaccessandcontinuousfetalmonitoring somobilitymaybereduced Associatedwithlongersecondstageoflabour Associatedwith↑chanceofinstrumentalbirth
Generalpointswhichapplythroughoutlabour
Encouragethewomantomobilizeanduseanypositionshefindscomfortable Documentifmeconiumispresentatanypoint Encouragethewomantodrinkduringlabour,preferablyisotonicdrinks Thewomanmayeatalightdietunlessshehasreceivedopioidsor islikelytorequireageneral anaesthetic.
Fetalmonitoringduringlabour
Low-riskwomen:intermittentauscultation
Auscultate immediately after a contraction for 1 minute, at least every 15 minutes, and palpate maternalpulsehourly.Increasemonitoringifconcerned If thereare definiteconcerns,summonhelp, transfer toobstetric care,and undertakecontinuous CTG.
High-riskwomen:CTG
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Assessanddocumentthefollowingfeatures:
Contractions Baselinefetalheartrate Baselinefetalheartratevariability Presence of accelerations (abrupt increase >15bpm in baseline fetal heart rate for >15 seconds) Presence of decelerations (abrupt decrease >15bpm in baseline fetal heart rate for >15 seconds):
Early: startwhenuterinecontraction begins,recover when uterinecontractionstops— physiological Variable: rapid fall in baseline fetal heartrate with variable recovery phase—may suggestpressureontheumbilicalcord Late:startatpeakof uterinecontraction,recover after uterinecontraction stops—fetal hypoxia Prolonged:>3minutes
InterprettheCTGaccordingtoTable62.2.
CategorizingCTGtraces(seeTable62.2)
Normal:allfeaturesarereassuring Suspicious:onenon-reassuringANDtworeassuringfeatures Pathological:oneabnormalORtwonon-reassuringfeatures.
Ifnormal—continueusualcare Ifsuspicious:
Repeatmaternalobservations Correctunderlyingcause,e.g.hypotension Startconservativemeasures,e.g.mobilization,alternativepositions,IVfluids,reduceorstop oxytocin,tocolysistoreducecontractions Informanobstetricianorseniormidwife
Ifpathological:
Aspersuspicious Excludeacuteeventse.g.cordprolapse,placentalabruption,uterinerupture Ifnoimprovement,offerfetalscalpstimulation IftheCTGremainsabnormal,considerfetalbloodsamplingandexpeditingthebirth
Ifacutebradycardiaordecelerationlasting≥3minutes:
Urgentinterventionisrequired Aftercorrectingunderlyingcauseandstartingconservativemeasures,ifbradycardiapersists for>9minutesoranacuteeventisconfirmed,prepareforurgentdelivery.
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Table62.2ClassificationofCTGreadings
Baselinefetal heartrate
Baseline variability
Decelerations
Reassuring 110–160bpm 5–25bpm None
OR
Early OR Variable<90minutes
Non­reassuring
100–109bpm OR 161–180bpm
<5bpmfor30–50 minutes OR >25bpmfor15–25 minutes
Variable≥90minutes OR Variablewithconcerningfeaturesinupto50%of contractionsfor≥30minutes OR Variablewithconcerningfeaturesin>50%contractionsfor <30minutes OR Latein>50%contractionsfor<30minuteswithno significantclinicalriskfactors
Abnormal <100bpm
OR
>180bpm
<5bpmfor>50 minutes OR >25bpmfor>25 minutes OR Sinusoidal
Variablewithconcerningfeatures>50%contractionsfor >30minutes OR Latefor30minutes OR Acutebradycardia OR Decelerationlasting≥3minutes
Fetalbloodsampling
Involvestakingasmallsampleofbloodfromthebaby’sscalpduringavaginalspeculum examination.ResultsareclassifiedasperTable62.3.UseeitherpHorlactate.
Table62.3Classificationoffetalbloodsamplingresults
pH Lactate Action
Normal ≥7.25 ≤4.1mmol/L Repeatsamplewith1hourifCTGremainspathological
Borderline 7.21–7.24 4.2–4.8mmol/L Repeatsamplewithin30minutesifCTGremainspathological
Abnormal ≤7.20 ≥4.9mmol/L Expeditebirth
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Firststageoflabour
Typicallylasts8–18hoursforprimiparouswomanand5–12hoursformultiparouswoman
Latentstage:painfulcontractionsandcervicaleffacementanddilatationupto4cm Establishedstage:regularpainfulcontractionsandprogressivecervicaldilationfrom4cmuntil fullydilated(10cm)
Completeapartogramtomonitorprogression.Document:
Frequencyofpassingurine Frequencyofcontractionsevery30minutes Hourlypulse 4-hourlytemperature 4-hourlybloodpressure
4-hourlyvaginalexamination(orifthereisclinicalconcern) Delayintheestablishedfirststage:cervicaldilation<2cmin4hoursinanypatientORslowing of progress if multiparous. If membranes are intact, offer amniotomy and obstetric review to consideroxytocinaugmentation.
Secondstageoflabour
Passive stage: where the cervix is fully dilatated before the commencement of involuntary
contractionsoractivematernaleffort Activestage:babyvisibleORexpulsivecontractionsORactivematernaleffortatfulldilatation Document:
Frequencyofpassingurine
Frequencyofcontractionsevery30minutes
Hourlybloodpressure
Hourlyvaginalexamination
4-hourlytemperature Fetalauscultationshouldbedoneafteracontractionatleastevery5minutes Delay in the second stage: if active stage >2 hours (nulliparous) or >1 hour (multiparous). Arrange obstetric review to decide if oxytocin augmentation, instrumental birth, or caesarean sectionisnecessary Encouragethewomantoadoptanycomfortablepositionthatisnotlyingdownorsittinginbed.
Thirdstageoflabour
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Definition:timefromthebirthofthebabytotheexpulsionofplacentaandmembranes Managementcanbeactiveorpassive Active management: 10IU oxytocin IM after birth, deferred cord clamping (1–5 minutes), and controlled cord traction. There is a higher risk of nausea and vomiting compared to passive management Passive(physiological)management:waiting untilthecord stopspulsing beforeclamping,and natural delivery of the placenta. There is a higher risk of haemorrhage and requiring a blood transfusioncomparedtoactivemanagement Activemanagementisrecommendedduetothesignificantreductionintheincidenceofpostpartum haemorrhage(seeChapter65) Prolongedthirdstage:>30minutes(activemanagement)or>60minutes(passivemanagement). SecureIVaccessandconsiderifexaminationunderanaestheticisrequiredintheatreforpossible manualremovalofretainedplacenta.
Postpartum
Document pulse, temperature,blood pressure, uterinecontraction,andlochia (vaginaldischarge afterbirth) Assessthattheplacentaandmembranesarecomplete Thewomanshouldhaveurinatedwithin6hoursofthebirth.
Specialconsiderations
Perinealtrauma
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