Unit 4 Labour Complications, Breastfeeding Task 1 Speaking In pairs make a list of 5 complications that may arise in labour. Are they life-threatening? Task 2 Ten Common Labour Complications Written by Lori Smith BSN MSN CRNP, Published: Wednesday 9 March 2016 http://www.medicalnewstoday.com/articles/307462.php Most often, the labour and birth process is uncomplicated. However, there are times in which complications arise that may require immediate attention. Complications can occur during any part of the labour process. Complete the text below with the phrases A to J: A) Pressing the mother's thighs against her belly B) The baby not receiving enough oxygen C) Other indicators include vaginal bleeding, irregular contractions and lasting pain between contractions. D) babies affected by the condition at birth may present signs such as poor skin colour, low heart rate, weak muscle tone, gasping, weak breathing or meconium-stained amniotic fluid. E) Slow cervical dilation F) A uterus that contracts efficiently and strongly G) Placental abruption H) Small or abnormally-shaped maternal pelvis. I) Prior uterine surgeries J) Lying sideways: lying horizontally across the uterus as opposed to vertically 1. Failure to progress Labour may be described as prolonged or having failed to progress when it lasts for an abnormally long period of time. For first time mothers, failure to progress is described as labour lasting over 20 hours, whereas in mothers who have previously given birth, it is described as labour lasting more than 14 hours. Prolonged labour can occur in any phase of labour; however, it is most concerning during the active phase. Causes of prolonged labour include: * (1) ……………………………….. * A large baby * A small birth canal or pelvis * Delivery of multiple babies · Emotional factors, such as worry, stress and fear · Pain medications can also be a contributing factor by slowing or weakening uterine contractions. In cases of labours that fail to progress, women may be given labour-inducing medications or require a C-section. Depending on the stage of labour, it may be recommended that a woman tries relaxation techniques, walking, sleeping, bathing or positional changes, such as side lying, standing or squatting. 2. Foetal distress Foetal distress, now referred to as non-reassuring foetal status, is a term that is used to describe when a foetus does not appear to be doing well. Causes of foetal distress include: * (2) ……………………………………………….. * Anaemia * Low levels of amniotic fluid (oligohydramnios) * Pregnancy-induced hypertension (PIH) * Post-date pregnancies of 42 or more weeks gestation * Intrauterine growth retardation (IUGR) * Meconium-stained amniotic fluid. During episodes of non-reassuring foetal status, it may be recommended that women change position, increase their hydration, maintain oxygenation, undergo amnioinfusion (the instillation of fluid into the amniotic cavity) or tocolysis (temporary stoppage of contractions) and receive intravenous hypertonic dextrose. To confirm the presence of foetal distress, a foetal blood acid base study may be performed; at times, delivery via C-section may be warranted. 3. Perinatal asphyxia Perinatal asphyxia (birth asphyxia) is a condition which can occur before, during or immediately following birth and is caused from inadequate oxygenation. This condition can result in blood abnormalities in the baby including hypoxemia (low oxygen levels) and acidosis (excessive acid in the blood). Babies who are not yet born may show symptoms of perinatal asphyxia by way of a low heart rate and lower than normal pH levels; (3) ………………………………………………….. . Treatment of perinatal asphyxia can include maternal oxygenation, C-section, mechanical breathing or medication. 4. Shoulder dystocia Shoulder dystocia is an unpredictable condition in which the baby's head is delivered vaginally, only for their shoulders to remain stuck within the mother. In the presence of shoulder dystocia, health care providers may employ several manoeuvers to release the shoulders: * Pressure to the abdomen * Manually turning the baby's shoulders * Performing an episiotomy to make room for the shoulders * (4) …………………………………………………………… Complications from shoulder dystocia are typically treatable and temporary. However, there are cases of significant injury. Maternal complications include uterine, vaginal, cervical or rectal tearing and heavy postpartum bleeding. 5. Excessive bleeding On average, women lose 500 ml during the vaginal delivery of a single baby. During a C-section for a single baby, the average amount of blood lost is 1,000 ml. Approximately 4% of women will experience postpartum haemorrhage - excessive bleeding following the delivery of a baby. The most common cause of postpartum haemorrhage is uterine atony, in which the uterine contractions are too weak to provide adequate compression to the blood vessels at the site of where the now-expelled placenta was attached to the uterus. Maternal blood pressure, shock and death can result from postpartum haemorrhage. Certain medical conditions can increase a woman's risk for developing postpartum haemorrhage: * (5) ………………………………… * Placenta previa * Uterine overdistention * Prolonged labour * Infection * Obesity * Labour-inducing medications or medications to stop labour * Forceps or vacuum-assisted delivery * Use of general anaesthesia. Additional medical conditions increasing the risk of postpartum haemorrhage include cervical, vaginal or uterine blood vessel tears, hematoma of the vulva, vagina or pelvis, blood clotting disorders, placenta accreta, increta or percreta and uterine rupture. Treatment for postpartum haemorrhage includes the use of medication, uterine massage, removal of retained placenta, uterine packing, tying off bleeding blood vessels and surgery - a laparotomy or hysterectomy. 6. Malposition Certain baby positions can make vaginal delivery more difficult, including breech and horizontal positions. Not all babies will be in the best position for vaginal delivery. Although facing downward (occiput anterior) is the most common foetal birth position, babies can be in other positions. At times, these positions can raise certain challenges. Other positions that babies may find themselves in include: * Facing upward: (occiput posterior) * Breech: buttocks first (frank breech) or feet first (complete breech) * (6) ………………………………………………………………………… Depending on the position of the baby and situation, health care providers may decide upon manual position changes, the use of forceps, episiotomy or C-section to deliver the baby. 7. Placenta previa When the placenta covers the opening of the cervix, this is referred to as placenta previa. In cases if placenta previa, a C-section is typically performed to deliver the baby. Risk factors for developing placenta previa include: * (7) …………………………………………………. * Prior deliveries or placenta previa * Multiple gestation pregnancy * Age 35 or older * Smoking * Cocaine use. The main symptom of placenta previa is bleeding during the second half of pregnancy, ranging from light to heavy. Bleeding during pregnancy can lead to severe bleeding during labour and preterm birth. If placenta previa bleeding is light, rest is typically recommended. Severe bleeding may be treated by supervised rest in hospital, blood transfusion or C-section - particularly if the bleeding does not stop. 8. Cephalopelvic disproportion When a baby's head is too large in relation to the maternal pelvis and unable to fit through it, a diagnosis of cephalopelvic disproportion (CPD) is made. According to the American College of Nurse Midwives, cephalopelvic disproportion occurs in 1 in 250 pregnancies. Causes of CPD may include: * Presence of a large baby * Abnormal foetal positions * (8) …………………………………………………….. Most often, babies with cephalopelvic disproportion are delivered via C-section. 9. Uterine rupture If someone has previously had a baby delivered by C-section, there is a chance that the scar could tear open during future labour. Although infrequent, this can be dangerous to an unborn baby, putting them at risk of oxygen deprivation. If a C-section scar begins to tear during labour, another C-section will be required to deliver the baby. Due to the potential risk, it is recommended that women trying for a vaginal birth who have previously had a C-section delivery should aim to have their baby delivered at a health care facility with access to an operating room and blood transfusion service. The most common sign of uterine rupture is the baby having an abnormal heart rate. (9) ………………………………………………………………………………….. . Ultrasound scanning can also be used to determine the thickness of the C-section scar. Uterine rupture is estimated to affect 2 out of every 1,000 babies delivered via vaginal birth after a C-section. 10. Rapid labour Together, the three stages of labour typically last for 6-18 hours. However, some instances of labour can last for 3-5 hours. Such instances are referred to as rapid labour or precipitous labour. The chances of rapid labour are increased by: * A smaller than average baby * (10) ……………………………………………………………….. * A compliant birth canal * A history of rapid labour. Rapid labour can be preceded by a sudden series of quick, intense contractions that leave little time in between for rest, to the extent that they feel as though they are one continuous contraction. Rapid labour can be problematic for the mother as it can leave them feeling out of control and not leave them with enough time to get to a health care facility. The condition can also increase the risk of tearing and laceration to the cervix and vagina, haemorrhage and postpartum shock. For the baby, rapid labour can lead to the aspiration of amniotic fluid and increase the risk of infection due to the possibility of being born in an unsterile location. In the event of the onset of rapid labour, a doctor or midwife should be contacted, and the use of breathing techniques and calming thoughts can help people to feel slightly more in control of their situation. Remaining in a sterile place and lying down on either the back or side can also help. Task 3 Episiotomy Read the answers a midwife gives to a woman who has learnt she is going to have episiotomy. Match the questions with the answers below. 1. ……………………………………………………………? It is a cut through the skin and muscles to widen the opening of vagina. It runs from the vagina towards the rectum. 2. …………………………………………………………….. ? It´s necessary because the pushing phase is taking too long and the baby is at risk. His head is stuck. If you continue pushing, you may badly tear. Episiotomy seems to be the best thing to do. It´s safer for you and the baby. 3. ………………………………………………………………? I´ll give you a shot to numb the skin and then the doctor will make the incision when the contraction comes. It will be alright. 4. ………………………………………………………………..? No, we will use dissolvable ones. They get absorbed after a few weeks. 5. ………………………………………………………………….? Well, it´s a simple procedure and I´m sure it will be done properly. It´s rather unpleasant but we can´t put the baby´s life at risk. a) Will I need to have the stitches removed? b) Why does it have to be done? c) Will it hurt? d) What is episiotomy? e) Is it risky? Task 4 Caesarean section A) What are the most common indications for a caesarean delivery? Write a list with a partner. B) The text below is an explanation given to a patient who is going to undergo a C-section. Guess the missing words, the first letter is given as a prompt. 1. As the labour is not p …………………., we have to carry out a C-section to get the baby out of your womb. 2. You are fully d………………., but the baby´s head is too big for your pelvis and cannot be born in a natural way. 3. We cannot wait any longer because the baby is d……………… as he is not getting enough o…………….. . 4. Caesarean section is a safe p……………… and there is no need to be afraid. 5. The s……………. will take about 45 minutes but we will get the baby out within the first 10 minutes. 6. You will get an extra dose of e…………… because there is no need to give you general a……………….. . 7. The cut will be across your a…………… just below your bikini line. 8. After the baby is born and the placenta removed, the wound will be closed with s………. . Task 5 Breastfeeding - Vocabulary Read the breastfeeding instructions and choose the correct option in each sentence. 1. The best moment to start breastfeeding is shortly after birth. Putting the naked baby on the mother´s bare skin (skin-to-skin contact) makes him/her search/grab for the nipple and stimulates/ makes milk production. 2. To start any feed, it is important to take/ find a comfortable position. 3. First bring/ take the baby´s nose to your nipple. 4. Tilt his/her head a little to make / cause the baby´s upper lip touch the nipple. 5. When the baby opens the mouth, push all your nipple deep into his mouth, gently squeezing/ spreading the breast. 6. Your nipple should reach/ achieve the baby´s soft palate. The baby´s mouth should cover / include not just the nipple but most of the bottom of the areola and some of the top. 7. Throughout the feed, support/ push the baby´s upper back and neck with your hand or forearm. 8. A sign of good latch is pulling sensation on the breast as the baby is licking/ sucking. Task 6 Problems with breastfeeding Match solutions with problems. latching pain inverted nipples blocked milk ducts breast engorgement low milk supply cracked nipples mastitis baby sleeping at breast leaking breasts thrush (yeast infection) Problem Solution 1. Check the baby´s position and adjust it if necessary. Spread a few drops of breast milk over the nipple at the end of each feed. Always allow your nipples dry before putting on a bra. Wash the nipples with plain water, no soap. Apply lanolin ointment on the cracks. 2. Feed the baby more often. Start the feeding from the tender breast. Put a warm compress on the breast to help the milk flow. When breastfeeding stroke the lump in your breast towards the nipple to direct the milk flow. Express milk if the baby doesn´t empty the breast completely. 3. Take antibiotics as prescribed from the doctor. Apply hot compresses to your breast. Express milk to empty the breast. Continue breastfeeding. If an abscess forms, a surgical intervention may be necessary. 4. Use nursing pads. Don´t use a breast pump as it stimulates milk production. 5. Apply the antifungal medication on your nipple and inside the baby´s mouth as prescribed by the doctor. 6. Reposition the baby: the baby´s mouth should cover more of the areola below the nipple rather than above, the baby´s nose and chin should touch the breast. 7. Start feedings at the fuller breast. When the baby stops sucking, stimulate him/her by rubbing the back or tickling the feet to keep him/her awake. 8. Use a breast pump to get the milk flowing before you latch the baby. Use nipple shields to make it easier for the baby to latch. 9. Feed the baby more often to stimulate the milk production. Pumping during the day may also be helpful. Drink herbal teas e.g. fennel that stimulate milk production. 10. Before feeding put a warm compress on the breast and express some milk to soften the breast and make it easier for the baby to latch. Feed the baby on demand. Put ice packs on the breasts between feeds to reduce the swelling. (adapted from Czubak, M., Hansen, E. English for Midwives. MediPage, 2015.)