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acute tocolysis in labour

Acute Tocolysis in Labour

Occurrence of Hypertonus

Management

Occurrence of Hypertonus

Hypertonus may occur in:

Spontaneous normal labour

With concurrent abruption

After prostaglandin use for induction of labour

After inadvertent administration of ergometrine, especially prior to delivery of the second twin

During oxytocin infusion

Multigravidas more than primigravidas

It may cause acute fetal compromise and the mother will often complain of constant lower abdominal pain.

If a continuous electronic fetal monitor is in use, the tocograph may show:

Sustained contractions

Frequent contractions with little break in between

Management

Commence continuous electronic fetal monitoring if not already used

Call for help: Pink Alert

Obstetric registrar and RMO, Midwife, and/or consultant on-call

Intra-uterine resuscitative measures:

Discontinue IV Oxytocic if being used

Change maternal position to lateral recumbent - usually works best on LHS, but if no response, reasonable to try RHS

O2 via face-mask - but prolonged face mask O2 maybe harmful to the fetus and should be avoided

Rapid infusion of IV fluid particularly if BP low or patient dehydrated

If despite these simple measures, the FHR pattern is abnormal in association with hypertonus, OR if there is a uterine scar, Acute Tocolysis should be considered using:

Terbutaline:

250 micograms IV or SC: Recommended at the Royal Women's Hospital

The ampoule comes as 500mcg/1ml. The volume to be given is therefore 0.5ml IV if there is already IV access, or 0.5ml SC if there is not.

IV Salbutamol:

100 micrograms IV

Make up 1 ampoule of salbutamol sulphate for injection 500 µg (NOT Ventolin Obstetric), to 10 ml in normal saline (final concentration 50 µg/ml)

Administer 100 µg (2 ml of the preparation, above) over 1-2 minutes

May be repeated after 5 minutes if hypertonus sustained

Sublingual GTN spray:

400 µg

Product in form of sublingual spray (Nitrolingual ®)

One metered spray (=400 µg) administered under the tongue

If response is inadequate, repeat the dose after 5 minutes

If FHR tracing is non-reassuring, and tocolysis (as above) ineffective and:

The patient is not fully dilated, a code green should be called (i.e. immediate caesarean section).

The patient is fully dilated and all conditions fulfilled for assisted vaginal delivery, this should be expedited and a paediatrician should be requested to attend the delivery

Royal Women's Hospital Clinical Practice Guidelines (CPGs) are intended to provide guidance to health care professionals, based on a thorough evaluation of research evidence, on the practical assessment and management of specific clinical issues or situations. The guidelines allow some flexibility on the part of the health care professional based on the needs of the specific patient for whom they are caring.

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