Immediate Postnatal Care and Fetal Growth Restriction 3

Immediate Postnatal Care

• Oxytocin Administration

  • Drug of choice for active management of the third stage of labor.

  • Dosage: 5 IU IV, followed by another 5 IU IV if post-partum hemorrhage (PPH) occurs.

  • Avoid Ergometrine and Syntometrine as they can acutely raise blood pressure (BP).

• Monitoring

  • Conduct 4-hourly BP observations unless stable for over 24 hours and discussed with a doctor.

  • Maintain at least 4 BP checks per day during inpatient stay.

• Eclampsia Risk

  • Remember that 44% of eclamptic fits occur postpartum, particularly until day 5.

• Antihypertensive Medication Management

  • Women should continue their antenatal antihypertensives unless on Methyldopa.

  • Transition to Enalapril, Amlodipine, or Nifedipine.

• Breastfeeding and Medication

  • Breastfeeding is generally safe, even if most medications are not licensed for BF.

• Hypoglycemic Monitoring

  • Monitor newborns of mothers on Labetalol for hypoglycemia.

• Caution with NSAIDs

  • Caution with NSAIDS, these can increase BP effects and inhibit platelet aggregation.

  Discharge to community

  • There needs to be a post-discharge follow-up plan detailing BP monitoring frequency, required follow-up care, and treatment adjustment criteria.

  • GP appointment should occur at 2 weeks and 6 weeks postpartum.

  • Women should be informed of an increased risk of hypertension and cardiovascular diseases later on in life. Lifestyle changes may be necessary.

  • Women should be aware of an increased risk of recurrent hypertensive disorders in future pregnancies

  • Offer an appointment with obstetrician at 6-8 weeks postpartum for those with severe PET

  • Contraceptive Advice

Fetal Growth Restriction and Doppler Assessment

• Definitions

  • Small for Gestational Age (SGA): Estimated fetal weight (EFW) or abdominal circumference (AC) <10th percentile.

  • Fetal Growth Restriction (FGR): Failing to achieve genetically predetermined growth potential, often indicated by EFW <3rd percentile or abnormal Doppler readings.

• Causes of Small Babies

  • Constitutional: Genetic factors or maternal characteristics.

  • Placenta-mediated: Conditions like hypertensive disorders, renal disease, or autoimmune conditions.

  • Non-placenta-mediated: Genetic abnormalities, fetal infections (e.g., CMV, toxoplasmosis, COVID-19).

    Maternal Uteroplacental Circulation

  • Pre-eclampsia and FGR are associated with inadequate maternal vascular response to placentation, leading to increased impedance in uterine arteries and abnormal Doppler results.

  Assessment Tools to determine fetal wellbeing

  - Biometry:

  • Measurements for head circumference, abdominal circumference, and femur length to calculate EFW and growth velocity.

    Doppler Assessment

    • Umbilical Artery

      Normal umbilical flow should always be from fetus to placenta throughout systole and diastole from 16 weeks.

      • Absent End Diastolic Flow: when the blood flow is absent during diastole. It means decreased blood flow to placenta

      • Reversed End Diastolic Flow: when there is a reversed flow during diastole. This means an increase in resistance in placental blood flow. It is the most severe abnormal umbilical artery Dopplers and associated with significant fetal mortality.

• Middle Cerebral Artery Doppler

  • Monitoring cerebro-placental ratio (CPR). A reduced CPR indicates circulatory redistribution in the fetus (red flag).

• Ductus Venosus Assessment

  • Absence of A-wave in ductus venosus suggests immediate delivery is necessary.

• Computerized CTG with Short-term Variability (STV)

  • Used to assess fetal wellbeing and response to conditions during monitoring periods.