Obstetrics

What is Gestational trophoblastic diseases (GTD) ? These are a condition occurring when there is abnormal development, usually the over-proliferation of the chorionic villi. GTD can either lead to partial or complete hydatidiform mole. There is viable fetus despite the rising of the hCG in the woman’s urine and blood serum. In other words, GTD is a spectrum of neoplastic disorders originating from placental development. Gestational tissue is present, but the pregnancy is not viable. How common is Gestational trophoblastic disease The incident rate is 1:1, 000 pregnancies in United Kingdom but up to 15 times higher in Asian countries. Types of Gestational trophoblastic diseases  There are two most common types of GTD namely: Risk factors for GTD Signs and symptoms of GTDs GTD is a benign condition which usually manifests in second trimester of pregnancy with the following signs and symptoms: Molar pregnancy/hydatidiform mole Hydatidiform mole is a benign neoplasm of the chorion in which the chronic villi degenerate and become transparent vesicles containing clear, viscid fluid.  Pathophysiology: How molar pregnancy develops Hydatidiform mole is a benign neoplasm of the chorion in which the chronic villi degenerate and become transparent vesicles containing clear, viscid fluid. Hydatidiform mole is classified as complete or partial, distinguished by differences in clinical presentation, pathology, genetics and epidemiology. The complete mole contains no fetal tissue and develops from an empty egg which is fertilized by a normal sperm. The paternal chromosomes replicate resulting in 46 all paternal chromosomes. The embryo is not viable and dies. No circulation is established and no embryonic tissue is found. The complete mole is associated with the development of choriocarcinoma. The partial mole has a triploid Karyotype (69 chromosomes), because two sperm have provided a double contribution by fertilizing the ovum. Types of molar pregnancy/ Hydatidiform mole Hydatidiform mole is classified as complete or partial, distinguished by differences in clinical presentation, pathology, genetics and epidemiology. What are the differences between complete and partial mole? Complete mole Partial mole Generalized trophoblastic hyperplasia Focal trophoblastic hyperplasia Generalized swelling of villous tissue Focal swelling of villous tissue No embryonic  or fetal parts  Embryonic/fetal part is present Chromosomal constituent is usually 46, XY or 46, XX Chromosomal constituent is usually 69, XXY or    60, XXX Contains only paternal genome Contains both paternal and maternal genome Causes of molar pregnancy The exact cause of molar pregnancy is unknown but researchers are looking into a genetic basis. Studies have revealed some remarkable features about molar pregnancies including: How to diagnose Gestational trophoblastic diseases Rapid continuous rise in hCG may be a diagnostic clue for GTD which needs to be confirmed by antenatal ultrasound screening. Diagnosis is made through ultrasound revealing appearance of vesicular molar pattern. Nursing assessment for molar pregnancy The nurse (midwife) plays a crucial role in identifying this condition and notifying obstetrician. Bases on sound knowledge of clinical manifestation and expertise antenatal assessments, clinical manifestation of GTD is similar to those of spontaneous abortion at about 12 weeks of pregnancy. The following symptoms will alert the midwife about GTD. Management of Gestational trophoblastic diseases Treatment of molar pregnancy is by both medical and nursing approaches. Medical treatment for molar pregnancy: Treatment consists of immediate evacuation of uterine content as soon as the diagnosis is made and long-term follows up of the client to detect any remaining trophoblastic tissue that might become malignant. This is then followed by histologic examination of the tissue to enhance accurate diagnosis of molar pregnancy. It is carried out with manual or electrical vacuum aspiration. The tissue obtained is sent for choriocarcinoma. Women with Rhesus negative factor are highly recommended to receive Anti-D immunoglobulin following a molar pregnancy evacuation. This is encouraged until everything stabilizes (hCG being in pregravid state and the woman being fit). Serial levels of hCG help detect residual trophoblastic tissue for 1 year because if any tissue remains, hCG levels will not drop. In 80% of women with a benign hydatidiform mole, serum hCG titers steadily drop to normal within 8 – 12 weeks after evacuation 20% of women with a malignant hydatidiform mole, serum hCG levels begin to rise. Due to increased risk of cancer, the patient is advised to receive extensive follow-up therapy for the next 12 months. While in subsequent pregnancies, hCG levels are meticulously monitored for about 6-8weeks of gestation to confirm that molar pregnancy does not occur again. The following-up protocol for GTD include: Nursing management for molar pregnancy The aims of nursing management are: Preparing the client Once diagnosis is made, immediate evacuation is needed, prepare the client physically and psychologically for the procedure. Providing emotional support Educating the client Complications of GTD If the molar pregnancy is not evacuated on time or does not spontaneously miscarry, it can result in these disorders: Prevention of Molar pregnancy There is no specific way of preventing hydatidiform mole. However, women at higher risk of molar pregnancy are encouraged to embrace contraception. Or if they become pregnancy, the women should endeavour to book for antenatal care on time where ultrasound screening and other supportive investigations would be recommended and performed.

What is Postpartum haemorrhage? Postpartum haemorrhage (postnatal bleeding) is the excessive bleeding from the woman’s genital tract of about 500mls or more following childbirth. Or it can be seen as any amount of bleeding occurring after the birth of the baby which deteriorates the maternal health state following birth of the baby up to 6 weeks after birth Postpartum haemorrhage is the one of the types of obstetric haemorrhage. Remember that obstetric haemorrhage is defined as the blood loss during pregnancy, labour or within the days of pregnancy termination (delivery or abortion). Obstetric haemorrhage accounts 25% of maternal death globally and 90% in developing countries — which are often attributed to DELAY and lack of proper facility for obstetric emergencies. This article would be very lengthy. Hence, consider the table of contents below for quick overview: Signs and symptoms of PPH Causes of Postpartum Haemorrhage (PPH) PPH is caused by 4 “T” s as follows: Tone, Trauma, Tissue and Thrombin. Tone: This is most common cause of post-partum haemorrhage. It is bleeding due to lack of uterine muscle tone, interfering with contraction of the uterus. It is known as uterine atony and predisposing factors are; Trauma: Tissue: Thrombin: Coagulation failure interfering with blood clotting mechanism e.g., DIC Risk factors of PPH Alternatively, PPH is associated with: Before delivery  After delivery How common is postpartum haemorrhage? PPH occurs in less than 1% of all births and constitutes the key leading cause of maternal death. PPH remains one of the major obstetric concerns because of the following:  Types of postpartum haemorrhage (PPH) Post-partum haemorrhage may be primary or secondary. Primary postpartum haemorrhage Primary Post-Partum Haemorrhage is defined as excessive blood loss from genital tract greater than 500ml occurring during third stage of labour till with 24 hours after delivery. It is a haemorrhage occurs during the third stage of labour and within 24hours of delivery Secondary postpartum haemorrhage Secondary PPH is the abnormal or excessive bleeding from the genital tract after 24hours to about 6-8weeks postpartum period. It is an excessive bleeding after 24hours of birth but within 42 days of the puerperium. Secondary postpartum haemorrhage otherwise called puerperal haemorrhage is far more likely to occur within 10-14 days after delivery but tends to be less severe when compared to primary postpartum haemorrhage. Symptoms of secondary postpartum haemorrhage Secondary PPH may be associated with these: Causes of Secondary PPH Note: The cervical os usually remains patent (opened) when something is retained in the uterus. Secondary postpartum haemorrhage management Vulval haematoma Vulval haematoma is a condition where there is a concealed traumatic haemorrhage into the connective tissues of the vulva and vaginal wall.  It is caused by rupture of subcutaneous vessels, which can manifest few hours after delivery. While a small vulval haematoma may be attributed to repair of medio-lateral episiotomy or laceration.   Woman with vulval haematoma usually complains of discomfort and pain in the labia and/or perineum.  The skin of labia becomes thin —making haematoma to bulge into the vagina. How to treat vulval haematoma Complications of Postpartum haemorrhage Principles of management of Postpartum haemorrhage Principles for managing PPH include the following: Resuscitation (and Rapid Assessment) Calling for medical aid is an important first step to take. Once PPH occurs after delivery, send for obstetrician or a doctor while you get everything in control before the arrival of the doctor there is no problem. Reason for sending aid on time is that the woman’s condition may worsen and the woman may lose her life within few hours. If you are in the community, plan to refer the woman to hospital as you take initial measures to stop the bleeding Stop Bleeding:  This involves the following steps: Rub uterus to Contraction: Give uterotonics Empty the uterus Once the uterus is contracted, the midwife ensures that uterus is empty. If the woman is not shock Specific Treatment Treatment depends on the identified. Oxytocin is the drug of choice to administer especially for treating haemorrhage due to uterine atony. Give loading dose of 10IU intramuscularly and 20 – 40 units into infusion to run at the rate of 60 drops per minute maintenance dose of 20IU at 60 drops per unit Second Drug – Ergometrine if oxytocin is not available but is contraindicated in heart problems. Third Drug – Misoprostol General management Rapid Assessment and Resuscitation of the Woman Therefore, there may be need to catheterize the woman. Monitor vital signs every 15 minutes until patient’s condition stabilizes. If the woman is transferred from another place take history of bleeding Note: On no account should a woman in shock be moved before resuscitation and her condition stabilizes. Treatment of the specific cause When the cause of bleeding is identified treat the cause. If it is uterine atony that does not respond to oxytocin do bimanual compression of the uterus. If it is retained placenta – do manual removal of placenta Prevention of Postpartum Haemorrhage Predicting who will have post-partum haemorrhage is not the best approach; rather taking preventive measures can save a lot of lives. Despite efforts of health workers, PPH may still occur, but quick diagnosis and prompt effective treatment can save life. Routine preventive actions should be offered to all women from pregnancy till immediate post-partum period as follows: During Antenatal Care During Labour and Second Stage During Third Stage After Delivery of the Placenta

Shock is among obstetric emergencies that occur when there is sudden fall or collapse of a patient during pregnancy, labour or shortly after delivery. In this condition, the body does not work normally and organs such as the heart, brain, lungs and kidneys are adversely affected due to hypoxia (lack of oxygen). What is obstetric shock? Whenever the circulatory system is unable to maintain adequate perfusion of vital organs or inability of the circulatory system to provide the tissues demands of oxygen and nutrients and to remove metabolic wastes, then shock is said to have occurred.  Obstetric shock is a condition of collapse due to failure of the maternal circulatory system to meet the body’s need for oxygen, nutrients and removal of waste substances. The causes of shock can be either haemorrhagic or non-haemorrhagic. The prompt action of the midwife, her competency and skills are required to reduce the risk of maternal morbidity and mortality related to obstetric shock.  Signs and symptoms of obstetric shock What are early signs of shock? Early stage of shock is characterized by: What are late signs of shock? Late stage of shock is characterized by: What are causes of obstetric shock? Diagnosis of obstetric shock The midwife should always be well-skilled and prepared. He or she should suspect or anticipate shock in the following cases such as: Physiology of obstetric shock There are four stages of shock in which if nothing is done to arrest the condition, the patient would die. Stage I: Initial phase: Here, there is reduction in blood or fluid which lowers the venous to the heart.  This makes the ventricles of the heart to be poorly filled, resulting in a decline in stroke volume and cardiac output. The falling of cardiac output and venous return also result in decline in blood pressure, which adversely affect oxygen supply to tissues and cell function is impaired. Stage II: Compensatory or non-progressive phase: In this phase, the body puts up its effort to maintain adequate blood supply due to reduced cardiac output. This is achieved by sympathetic nervous system stimulating the receptors in the aorta and carotid arteries, causing blood to be redirected to the essential organs with constriction of some vessels in the gastrointestinal tract, kidneys, lungs and skin. This is often characterized by the skin becoming pale and cool, slow-down of peristalsis, reduced urinary output, and impaired gaseous exchange due to reduction in blood flow to the lungs; rapid heart rate in attempt to improve cardiac output and blood pressure; dilation of eye pupils; sweating, moist and clammy skin. Adrenaline (epinephrine) produced by the adrenal medulla, aldosterone produced by the adrenal cortex and anti-diuretic hormone (ADH) produced by the posterior lobe of the pituitary –all unite together to cause vasoconstriction, increase cardiac output and reduce urinary output, thereby making venous return to the heart to improve. However, if nothing is done to replace the lost fluid, the patient’s condition would deteriorate further. Stage III: Decompensatory or progressive phase: When the compensatory effort in phase II      is not maintained by fluid replacement, multisystem organ failures occur as the vital organs no long receive adequate perfusion. There would be more declines in blood pressure and cardiac output with resultant weak or absent pulse. Stage IV: Irreversible/ phase of inevitable death: This phase is characterized by multisystem organ failure and cell destruction and finally death occurs. Types of obstetric shock Haemorrhagic/hypovolemic shock: This is a shock occurring due to excessive blood loss and may be caused by: Anaphylactic shock: This may be caused by sensitivity to drugs (allergic reactions), anaesthestic complications (e.g. Mendelson’s syndrome) or embolism (e.g. amniotic fluid, air or thrombus) Endotoxic shock: This is a shock due to release of toxins (e.g. from septicemia) into the bloodstream thereby disrupting the circulatory system. The toxins released causes generalized vascular disturbance. Cardiogenic shock: This is a form of obstetric shock resulting in inefficient or ineffective contraction of the cardiac muscles, which may be caused by heart failure or myocardial infarction. Neurologic shock: This shock occurs due to painful conditions such as: How to manage obstetric shock What are the roles of midwives in managing obstetric shock What are complications of obstetric shock? Poorly managed shock is associated with these complications:

Uterine contractions are the main forces that facilitate labour and delivery. When there is problem in uterine contractions, labour can be prolonged or obstructed. The strength, frequent, intensity and duration of uterine contraction can either make or mar labour and delivery. According to wikipedia, the uterine smooth muscle contracts during the menstrual cycle and labour, and these are known as uterine contractions. What is abnormal uterine contraction? This is when the uterine contraction is capable of affecting the labour negatively and /or causing harm to either mother or fetus. What are types of abnormal uterine contraction? Abnormal uterine contractions are classified into two groups which are: ·         Hypertonic uterine contractions ·         Hypotonic uterine contractions Hypertonic uterine contractions In hypertonic labour pattern, uterine contractions are of poor quality and occur in latent phase of labour and the resting tone of the myometrium increases. Contractions usually become frequent but their intensity may decrease. The contractions are painful but ineffective in dilating and effacing the cervix and a prolonged phase may result. Effects of hypertonic contractions on the mother Effects of hypertonic contraction on the fetus/neonate How to manage hypertonic uterine contraction Hypotonic Uterine Contractions Hypotonic uterine action occurs in active phase of first stage of labour, though it may come in latent of labour. It is characterized by 2 – 3 or fewer contractions in 10 minutes. Causes of hypotonic uterine contractions Effects of hypotonic uterine contractions on the mother Effects of hypotonic contractions on the fetus/neonate How to manage hypotonic uterine contraction General management of abnormal uterine contractions

Cephalopelvic Disproportion is anatomical disproportion between fetal head and maternal pelvis. It may be as a result of big head, small pelvis or combination of both. It occurs when the head of the fetus does not fit in to the mother’s pelvis or a delivery condition in which the mother’s pelvis is too small or too misshapen to allow the fetal head to pass through. It can be classified as mild, moderate or severe. Causes of CPD These may be divided into maternal and fetal causes. Maternal causes Fetal Causes Contracted Pelvis This is when the one or more pelvic diameters are reduced by1 centimeter or more centimeters. Signs of contracted pelvis Degrees of contracted pelvis Signs of CPD Methods of Determining Cephalopelvic Disproportion Management of CPD

Malpresentations & Malpositions are among the causes of poor progress of labour. Good progress of labour is enhanced when the presenting part is well applied to the cervix. In malpresentation like face presenting part is not well applied resulting to poor progress. Also, in face presentation the face is not compressible for a lesser diameter to pass through the pelvis, like moulding in the vault.  Through vaginal delivery is possible but takes longer. Brow presentation is larger than diameters of pelvis, except hypertension of the neck occurs and face presentation result in.  Shoulder presentation cannot be delivered vaginally. What are risk factors/causes of Malpresentations & Malpositions? How abnormalities of Birth Canal (the Passage) cause Malpresentations & Malpositions The bony pelvis may be the reason for the delay during labour. Abnormalities of uterus and cervix can also delay the progress of labour e.g., fibroid.  Unsuspected fibroid in the lower uterine segment can impede descent of labour. The fetal head cervical dystocia can also cause delay in progress of labour.  Cervical dystocia can also cause delay in progress of labour. Cervical dystocia means non-compliant cervix which effaces but fail to dilate. Poor progress in the Second Stage of Labour Delay in second stage of labour can occur during the latent or active phase of labour i.e., (pelvic or perineal phase). The causes are: The midwife should not encourage the woman to bear down during the latent phase of 2nd stage as this can lead to maternal exhaustion. The second stage may range from 30 minutes to 2 hours for multiparae and 1-3 hours in primiparae. This will not make the midwife to hurry the woman provided both the mother and fetus are in good condition. During the active phase of labour intervention is not needed if the woman and baby are in good condition. If active phase becomes unduely prolonged, obstetrician should be invited to assess the woman instrumental delivery using forceps or vacuum extraction may be used to deliver the baby if risk of prolonging the labour further outweighs this intervention. Operative delivery may also be taken. The Role of the Midwife in caring for a woman in poor progress of labour Thanks for reading.  See you next time.

Trial of labour is conducted in the presence of a minor or moderate degree of cephalopelvic disproportion in an attempt to achieve a vaginal delivery. The factors supporting the achievement of vaginal delivery in trial of labour are: What is trial of labour? Trial of labour is defined as a test given to a woman with mild or moderate cephalopelvic disproportion (CPD) to see if she can deliver her baby vaginally  with least or no harm damage to herself and baby. Factors that influence the prognosis in trial of labour Advantages of trial of labour Trial of labour prevents unnecessary elective caesarean section in cases of minor degree of disproportion. This is particularly vital in developing countries where facilities for maternity service are poorly equipped and patients may not return for antenatal supervision after delivery by Caeserean section. These patients run the great risk of uterine rupture in subsequent pregnancies. Another advantage is the avoidance of premature induction of labour (with its attendant risk) which is used to popularly practised in cases of suspected disproportion. Premature induction of labour refers to the delivery of a baby which may be too big for the maternal pelvis if delivered at term. It’s, however, not without risks. The patient may fail to go into labour and intrauterine infection may result in. if the patient goes into labour, a grossly premature baby may be delivered. Wherever possible, vaginal delivery is to be preferred to an abdominal delivery. If, hence, trial of labour ensures a safe vaginal delivery, so much the better for all concerned. Disadvantages of trial of labour Trial of labour may fail and when it fails, the patient is naturally disappointed; she may have gone via a great deal of psychological trauma. Her failure to deliver per vias naturates (by the natural route) may affect her adversely. She may have consider herself or her baby abnormal and she would think of many reasons why she is unable to do what others women seem to do without much mental or physical trauma. Apart from psychological agony the patient and her attendants go through, if trial of labour has gone on too long, the risk of intrauterine infection with its consequences on both the mother and baby cannot be underestimated. Conditions in which trial of scar is considered These are: Contraindications of trial of labour Trial of labour should not be attempted in the following situations: A trial of scar When a woman has had a scar of Caeserean section or hysterotomy is given chance to deliver vaginally. This trial is given to see if the scar is strong enough to withstand the labour. Like trial of labour it has to be conducted in hospital. A failure of trial scar is indicated by (a) pain and tenderness over the scar (b) slight vaginal bleeding and (c) slight raise in pulse. Vacuum is usually applied in 2nd stage if there is no sign of rupture. Outcome of trial labour When does a trial of labour fails? Trial of labour is said to be successful if the delivery of the baby is accomplished per vagina spontaneously or by forceps or vaccum extractor.  It is only when unfavourable conditions such as fetal or maternal distress or failure to advance after 6-8hours of good contraction make the delivery of the baby by Caeserean section necessary that trial of labour can be said to have failed. The midwife’s duties during a trial of labour Since there is a chance of obstruction during trial of labour, it should only be done in a hospital with facilities for emergency Caeserean section. The midwife should on no account undertake the conduct of trial of labour on her own responsibility without due arrangement for emergency. The following are the roles of midwife during a trial of labour: 1. Duties to the patient:  It is advisable to explain the situation to the patient and forewarn her of possible operative interferences.  The patient should be carefully assessed on admission to determine the following: The physical and the emotional states of the patient are very essential factors in trial of labour so the midwife should endeavour to improve the morale of the patient.  The patient is confined to bed to prevent early rupture of membranes, sedation is administered liberally to promote rest and avoid exhaustion and undue anxiety.  Stay   with   patient,   talk   to   her   have   the   labour   is progressing, and help her to be relaxed. Adequate hydration of the patient is ensured by giving intravenous infusion of 5% glucose. Nothing per oral is allowed since operative interference may be at short notice. The danger of inhalation of vomitus during anaesthesia is hence prevented. However, she may be allowed sips of water. The bladder and rectum should be emptied to facilitate descent of the fetal head. Encouragement of the patient and a friendly attitude on the part of the midwife will go a long way to boost the patient’s morale. Keep her as comfortable and as dry as possible. Strict asepsis is maintained to avoid infection. 2. Assessment of progress of labour:  the progress of labour is monitored by vigilant observations made by the midwife in the constant attendance of the patient. The observations are made on: a. The uterine contractions: They type of uterine contractions (i.e. their frequency, strength and duration) are noted and recorded hourly and half-hourly towards the end of the labour.  The effects of these contractions on the patient and the fetus are also noted. b. The descent of the presentation: The uterine contractions should facilitate the flexion and descent of the head into the pelvis. The descent of the head is determined abdominally hourly. c. The maternal condition:  A half-hourly observation and record are made of the maternal pulse, blood pressure and respiration.  The temperature is recorded hourly and every specimen of urine the patient passes is tested to rule out albuminuria and acetonuria. Fluid chart is also kept and the midwife should inform the doctor at once if the patient can no longer endure the ordeal. d. The