Obstetrics

What is Antepartum haemorrhage? Antepartum refers to existing or occurring before birth. Hence, antepartum haemorrhage (APH) is defined as vaginal or genital  bleeding during pregnancy after the 28th week’s gestation. Another name  for antepartum haemorrhage (APH)  is called pre-partum haemorrhage.  How common is antepartum haemorrhage? APH as one of obstetric haemorrhages affects 3-5% of all pregnancies and accounts for 27% of all maternal deaths.  Antepartum bleeding is associated with increased perinatal morbidity and mortality and can occur at any time until completion of the second stage of labour . Antepartum haemorrhage causes The aetiology of APH are multifaceted and may include: Risk factors of antepartum haemorrhage The predisposing factors for APH are: Types of Antepartum haemorrhage APH can be divided into two based on duration or period of its occurrences. These are: Bleeding in early pregnancy This occurs when a pregnant woman experiences vaginal bleeding or bleeding from genital tract before the 20th week of gestation. Its causes are cervical erosion, cancer of cervix, abortion/miscarriage and ectopic pregnancy.  However, major causes of bleeding in early pregnancy are ectopic pregnancy and abortion —whether spontaneous or induced.  Bleeding before 24 weeks of pregnancy denotes miscarriage. Bleeding in late pregnancy This is the vaginal blood loss  that occurs during 24th or 28th weeks of pregnancy. This type of antepartum haemorrhage  is associated with increased maternal and perinatal morbidity and mortality. Placenta praevia and placental abruption are major causes of vaginal bleeding in late pregnancy.   Vaginal bleeding often dark in colour and accompanied by pain during pregnancy indicates  abruptio placenta. While bright vaginal bleeding during  pregnancy which is painless denotes placenta praevia. What are the signs and symptoms of antepartum haemorrhage? Antepartum haemorrhage symptoms are: Diagnosis of antepartum haemorrhage Apart from detailed history from the woman and examining her vaginally with aid of speculum, antepartum ultrasound helps to diagnose and confirm the actual cause of bleeding in pregnancy. Prenatal ultrasound is a safe and painless test which can be performed during the first, second, or third trimester based on what the health care provider is looking for. Note: Experienced midwife knows that bright vaginal blood loss which is painless is associated with placenta praevia while that which is dark in colour and accompanied with pain suggests placental abruption. Complications of antepartum haemorrhage These complications can be grouped into: Maternal complications Fetal complications Antepartum haemorrhage management Management for bleeding in pregnancy depends on the causative factor (s), stage of pregnancy, degree of haemorrhage and maternal and fetal conditions. What is the prevention of antepartum haemorrhage? No specific ways you prevent antepartum haemorrhage. However, encouraging early booking, regular antenatal care, early detection of high risk cases and early referral to a higher center help in preventing bleeding in pregnancy. The patient is encouraged to get adequate bed rest, avoid intercourse and limit physical activity. Those at higher risk of APH are advised on the use of contraceptives in order to prevent subsequent pregnancy. Aspirin  at doses of 75-100mg can be used before 16 weeks of pregnancy to prevent pre-eclampsia which is also effective at preventing antepartum bleeding. While pregnant women who have suffered bleeding during should be referred to higher facilities where there are good facilities for cesarean section and availability of blood banks so as to improve maternal and perinatal outcomes.

When a pregnancy is prolonged beyond the usual period of gestation, it is considered to be postmature or overdue. Before the midwife can diagnose postmaturity, he or she should know the accepted average duration of pregnancy and should also be able to calculate the expected date of delivery.  The average duration of a normal pregnancy is 280 days or 10 lunar months. The expected date of confinement is calculated from the first day of the last menstrual cycle. This is done by adding days to the date of the first day of the last menstrual cycle and adding nine calendar months. What is prolonged pregnancy? Prolonged pregnancy is the elongation of pregnancy beyond term or beyond the normal duration (38-42 weeks) counting form the first day of the last normal menstrual period. A pregnancy that has gone beyond 280 days is known as postmature or prolonged. Usually, in the absence of other complications, the obstetrician waits until the pregnancy is 290 days or more before action is taken. What are causes of prolonged pregnancy? Post-term pregnancy is associated with the following factors: Ways of estimating the gestational age How to diagnose prolonged pregnancy The diagnosis of postmaturity is based on the following: Nursing diagnosis of a woman with prolonged pregnancy Management of postmaturity The midwife should always refer all suspected cases of prolonged pregnancy to the doctor.  The patient is usually admitted to hospital at 10 to 12 days past the expected date of delivery.  After ascertaining that the pregnancy is overdue or prolonged, induction of labour is often performed at about 42 weeks of gestation.  In view of accurately diagnosing postmaturity, every effort must be made to ascertain the duration of pregnancy before induction is carried out lest a premature baby is delivered.  The date of quickening if remembered by the patient may aid in the estimation of the duration of pregnancy.  As a general rule, 20 weeks are added to the date of quickening to obtain a rough estimate of the expected date of confinement. After induction, supervision of the patient in labour is of   vital importance.  It should be noted that the infant may be severely asphyxiated at birth. The paediatrician should be informed long before the baby is delivered and arrangements should be made for the transfer of the newborn to the special baby care unit. How does postmature baby look like? After delivery, suggestive evidence of postmaturity may be obtained from the birth weight and overall length of the baby.  If the baby’s weight exceeds 4kg, postmaturity may be suspected.  This is, however, not conclusive.  A length of 54cm or more is also highly suggestive of postmaturity. It is necessary to impress on the midwife that some cases of postmaturity are due to cephalopelvic disproportion. This should be done ruled out before induction of labour is carried out.  The postmature baby sometimes has a typical appearance.  It looks old and wizened.  Its skin is wrinkled and inelastic (dry peeling skin).  The skull bones are usually harder than those of a mature newborn baby. Complications of post-maturity/prolonged pregnancy There are two major hazards associated with prolonged pregnancy or postmaturity.  It is a known fact that placental function begins to wane from the 38th to 40th weeks of pregnancy. After the 41st week of pregnancy the longer the fetus remains in-utero the worse the prognosis because of the risk of intrauterine hypoxia.  This risk, which is due to diminution in placental function, may be aggravated by pregnancy complications such as pre-eclampsia, hypertension, chronic nephritis and antepartum haemorrhage. When pregnancy is prolonged beyond 41st weeks, the baby’s size may increases in the absence of placental insufficiency and the increase in fetal head size may cause a difficult labour.  This may lead to obstructed labour with all its ugly sequelae. Hence, two main hazards are recognized in postmaturity: Both of these conditions may bring about an increase in intrauterine death or perinatal mortality rate.

Gestational diabetes mellitus (GMD) or diabetes complicated by pregnancy is far common in temperate countries than in tropics.  In the pre-insulin days, diabetic women failed to menstruate and conception was usually ruled out. With the advent of insulin, pregnancy occurs in the presence of diabetes.  Sometimes, diabetes is noticed for the first time in pregnancy.  Pregnancy is believed to unmask the signs and symptoms of diabetes in women with latent diabetes. Gestational diabetes mellitus needs multidimensional approaches to ensure the safety of both mother and baby. The prediabetic state should be suspected in women who give the following history: Such women should be referred to by the midwife to a big hospital where facilities are available for dealing with such cases. What is gestational diabetes mellitus? Gestational diabetes mellitus (GDM) is a metabolic disorder of carbohydrate intolerance resulting in hyperglycaemia of variable severity with its onset or first recognition during pregnancy. The midwife should suspect diabetes in women who give this type of history as well as women who show evidence of the following: Diagnosis of gestational diabetes mellitus All such patients are referred to the doctor. The diagnosis is confirmed in the hospital by estimating the fasting blood sugar level which is usually high in diabetics (about 120mg per 100ml of blood or more. The normal fasting blood sugar level is 80—100mg per 100ml).  The glucose tolerance test is also used to confirm the diagnosis when a typical diabetic curve is obtained. Types of diabetes mellitus The two types of diabetes usually described are: Risk factors of gestational diabetes mellitus Nursing diagnosis of a woman with Gestational diabetes mellitus (GDM) How to manage gestational diabetes mellitus All cases of diabetes require dietary control. The diabetic physician and dietician are always consulted in all cases of pregnancy complicating diabetes. The mother is advised on taking mild exercises, avoiding too much carbohydrate and increasing intake of fruits and vegetables. If the hyperglycaemia fails to be controlled, the woman may be placed on insulin injection which is also safe during pregnancy. The diabetic baby The diabetic baby is usually fat, flabby and oedematous, weighing 4 to 4.5kg or over.  Despites its enormous size, it is a premature or immature baby that needs the same special care and attention as  a full-term baby weighing about 1.5kg.  The first 48 hours of the life of a diabetic baby are fraught with hazards and the baby runs the risk of respiratory complications often caused by poor expansion of the lungs, inhalation of stomach contents and hyaline membrane disease. As the oedema subsides, the baby loses weight very rapidly and tends to chill very easily. Nursing diagnosis for a baby born by a woman with Gestational diabetes mellitus (GDM) Nursing care of diabetic baby At birth, the airways must be adequately cleared and a stomach tube passed to empty the stomach and prevent regurgitation and subsequent aspiration of stomach contents. If the baby has a lot of mucus, it should be put on its side with a slight head-down tilt or allow for the drainage of mucus. The airways should be aspirated at regular intervals and the baby closely monitored.  Oxygen by mask or nasal catheter is administered as often as necessary. The baby is watched for signs of cyanosis and respiratory embarrassment. Feeding is managed as that of a premature baby. Where the baby is ill or disinclined to suck, spoon feeding may be employed. Over-feeding is avoided so as to prevent regurgitation and subsequent aspiration of stomach contents. Precautions are also taken to prevent infection. Metabolism of carbohydrate in pregnancy /effect of pregnancy on diabetes Pregnancy is diabetogenic in the sense that insulin and carbohydrate metabolism is altered in order to make glucose readily available to the fetus. There is progressive hyperplasia of the pancreatic beta cells resulting in the secretion of 50% more insulin (hyperinsulinaemia) by the third trimester. This is due to increasing levels of oestrogen, progesterone and prolactin. There is reduction in effectiveness of insulin due to the presence of insulin antagonists (progesterone, human placental lactogen, and cortisol) and also there is diminished tissue responsiveness to insulin. Collectively, these result in blood glucose levels that are higher aftermath and remain raised for longer periods than in the non-pregnant state.   Glucose is therefore more readily available to the feto-placental unity. This is considered to be a glucose-sparing mechanism (diabetogenic effect of pregnancy). This mechanism enables the large quantities of glucose to be taken up by the maternal circulation and transferred to the fetus through the placenta.  These take place by the process of facilitated diffusion.  Pre-pregnancy insulin sensitivity is restored immediately is delivered due to reduction in insulin resistance. Gestational diabetes is most likely to emerge during the third trimester when the extra demands on the pancreatic beta cells precipitate glucose intolerance.   If the mother is diabetic, she does not have the capacity to increase insulin secretion due to altered carbohydrate metabolism in the maternal and fetal system. Complication of gestational diabetes mellitus The effects of diabetes on pregnancy and on the fetus if not well controlled can never be underestimated. These may be divided as follow: Effect of diabetes on pregnancy Effects of Gestational diabetes mellitus on the fetus The bottom line Gestational diabetes mellitus tends to endanger the lives of both mother and foetus. However, if the woman is a booked patient in the hospital who attends her antenatal care regularly, those complications are far more likely to be prevented. Women who are overweight or obese should endeavour to achieve a healthy weight before getting pregnant. This helps to lower the risk of gestational diabetes mellitus.

Intrauterine death refers to the death of the fetus occurring after 28th weeks of gestation resulting in a macerated stillbirth.  If the fetal death occurs before the 28th, the term “missed abortion” is used. 24 hours after the death of the fetus, aseptic degeneration called maceration occurs. Blisters first form on the skin which peels off easily. The rest of the body also undergoes degeneration later. what is intrauterine death? intrauterine death is defined as the death of baby in-utero which occurs after 28th weeks of gestation leading to a macerated stillbirth. It is a disheartening condition to both the mother and her partner. Signs of Intrauterine fetal death(IUFD) The midwife should be guided by the following findings in diagnosing intrauterine death: The following are other radiographic signs suggestive of intrauterine demise: Causes of intrauterine death of the fetus Intrauterine deaths occurring just before delivery are usually caused by accidents in labour such as cord prolapse, delay in second stage of labour or a generally prolonged and obstructed labour. Such intrauterine deaths result in the delivery of a fresh stillborn baby with no signs of maceration. Sometimes, fresh stillbirth is also seen in in the presence of toxaemia of pregnancy and all other conditions mentioned above in which the extra strain of a difficult labour precipitates fetal death in-utero. The distinction between macerated and fresh stillbirth is essential. it enables the midwife to separate deaths occurring in-utero long before the onset of labour, as a result of a preventable  antenatal causes, form those occurring in labour. It must, however, be emphasized that certain deaths occurring during labour may show maceration if labour is prolonged and unassisted. Maceration can take place within 12 to 24 hours after the fetal death. Management of intrauterine death All cases of intrauterine fetal death must be referred to the doctor. Usually is done until confirmatory x-ray diagnosis has been performed. In the hospital, the patient is given medical induction of labour in the form of oil, enema, and bath followed by Pitocin (oxytocin) infusion or a high dose of quinine. Some obstetricians believe in giving a high dose of stilboestrol to sensitize the uterus to the action of oxytocins. Surgical induction is NEVER CARRIED OUT in the presence of intrauterine death. Quite apart from the fact that the patient may fail to go into labour, artificial rupture of membranes in the presence of intrauterine death of the fetus is a highly dangerous procedure which may cause severe infection with anaerobic organisms resulting in gas gangrene and maternal death. If medical induction fails at first, the doctor waits a few days and then tries again. In most cases, spontaneous labour occurs two or three weeks after the fetal death. Complication of intrauterine death An important cause for anxiety in cases of intrauterine fetal demise is the possibility of profuse haemorrhage from hypofibrinogenaemia.  This is usually does not occur until four week or more after fetal death and is not very common. prevention of intrauterine death There are no specific way to prevent fetal death in-utero. However, encouraging mother to attend antenatal care regularly, improving in her nutrition and strictly takes the prescribed routine drugs can improve the fetal wellbeing and overall health of the mother. Every mother should try to utilize facility-based delivery where emergency obstetric care is readily available.