3.1 PPROM & Prem Labour Flashcards
Preterm labour
Delivery between 20-37 weeks estimated gestational age
Preterm labour is characterised by uterine contractions and cervical dilation/effacement
Preterm labour - risk factors & causes
Risk factors:
Hx of preterm birth
Cervical surgery
Vaginal bleeding, UTI, genital tract infections
Behavioural factors (substance abuse, low maternal BMI, smoking)
Short interpregnancy interval
<18 or >35 years old
Ethnicity (Indigenous are 70% increased risk)
Causes:
Short cervical length (<25mm before 25 weeks gestation)
Multiple gestation
Uterine anomalies
Polyhydramnios/Oligohydramnios
Medical conditions - preeclampsia
Preterm labour - signs/symptoms & complications
Signs & Symptoms:
Irregular uterine activity / contractions
Lower abdominal cramping
Vaginal loss - mucous, blood, fluid, meconium
Lower back pain
Pelvic pressure
Presenting part fixed or engaged, cervical dilation
Increased urinary frequency
Complications:
fFN - US, FBE, CTG, medications (corticosteroids & tocolytics), antibiotics (especially if GBS+)
Preterm labour - assessments
Vitals
Abdominal palpation - look for engagement of heart
Contractions 4:10 (palp, CTG & FHR at >38)
GBS swab @ 36
Vaginal examination
Foetal fibronectin test - a protein that the foetus produces, tells us if labour is imminent, positive means the amniotic sac is not attaching to the uterus. Speculum swab (medical procedure)
Blood & urine test
Preterm labour medical management - Tocolytic therapy (CCBs)
Indication:
Short-term, prolongation of pregnancy within 24-34 weeks
Dose:
Reassess after 30 minutes if still contracting after initial dose, maintenance every 6 hours
Action:
Contraindication:
Hypotension
Preload dependent cardiac lesions (e.g., aortic insufficiency)
Preterm labour medical management - tocolytic therapy (NSAIDS)
Indication:
Short-term, prolongation of pregnancy within 24-34 weeks
Dose:
Action:
Contraindication:
Platelet dysfunction or bleeding disorder
Hepatic dysfunction
GI ulcerative disease
Renal dysfunction
Asthma
Preterm labour medical management - Tocolytic therapy (Beta-adrenergic receptor agonists)
Indication:
Short-term, prolongation of pregnancy within 24-34 weeks
Dose:
Action:
Contraindication:
Tachycardia sensitive maternal cardiac disease
Poorly controlled diabetes mellitus
Preterm labour medical management - Tocolytic therapy (mag sulph)
Indication:
Short-term, prolongation of pregnancy within 24-34 weeks
Neuroprotection of <30 week gestation
Dose:
Action:
Contraindication:
Myasthenia gravis
Preterm labour medical management - progesterone therapy
Indication:
Reduce risk / prevention of preterm delivery. For women with previous preterm birth or short cervical length
Dose:
Action:
Inhibition of cervical ripening, reduction of myometrial contractility, modulator of inflammation
Contraindication:
No evidence of improvement for women with shortened cervix at multiple gestation (can be effective for singletons)
Preterm labour medical management - Cervical clercage
Indication:
Hx of spont preterm birth, short cervix
Dose:
Action:
Contraindication:
Not recommended for hx of cervical surgeries or anomalies, multiple pregnancy
Preterm labour medical management - Corticosteroids
Indication:
Helps mature the foetal lungs to avoid respiratory distress
Dose:
Action:
Contraindication:
>36 weeks
Midwifery care for preterm labour - 24-34 weeks
- Corticosteroids (reduces respiratory distress syndrome, intracranial haemorrhage, death
- Short-term tocolytic therapy (prolongation of pregnancy)
- Magnesium sulphate
Midwifery care for preterm labour - >34 weeks
- Prepare for birth - consult with OB
- Anticipate vaginal birth
- Prepare resus equipment appropriate for gestation
- Counsel woman about what to expect in terms of baby’s condition and care
- Follow up care - counselling, debrief
PPROM - definition & risk factors
The spontaneous rupture of membranes before 37 weeks gestation, without the onset of labour.
Risk factors:
Previous hx of PPROM
Previous hx of preterm birth
Cervical insufficiency
Placental abruption
Uterine distention
Infection - chorioamnionitis
Multiple gestation
PPROM - complications & assessments
Complications:
Preterm birth (respiratory distress, infection)
Cord prolapse
Infection (maternal sepsis)
Placental abruption
Oligohydramnios (limb deformities, cord compression)
Assessments:
Assess liquor - blood, meconium, amount
Don’t drive - call an ambulance if needed
Amnisure - determines if membranes are actually ruptured. Like a covid test swab.
Pack bags - potentially for multiple nights
Chorioamnionitis - purulent or foul smelling amniotic fluid (mec looking), fever, tachycardia. Needs antibiotics (benpen), potentially expedite delivery
Shower and don’t bathe - reduce risk of infection
Monitor for foetal movements
Avoid intercourse
FBE
Send home if: negative fFN, cephalic presentation, low symptoms, weekly scans and CTG monitoring if at home, FBE
PPROM management - <23 weeks
Antibiotic prophylaxis (benzyl penicillin or clindamycin)
Established labour:
Prepare for birth
Provide counselling for woman & family
Not established labour:
Suspected sepsis/chorioamnionitis? Significant antepartum haemorrhage?
Yes - active management IOL
No - continue antibiotics, US examination for FG & wellbeing, weekly high vaginal swab, biweekly FBE & CRP, daily FHR auscultation
PPROM management - 23-34 weeks
Antibiotic prophylaxis (benzyl penicillin or clindamycin)
Established labour:
Aim for in utero transfer when possible - contact PIPER
Tocolysis, corticosteroids, MgSO4 if <30 weeks
Prepare for birth or transfer
Not established labour:
Suspected sepsis/chorioamnionitis? Significant antepartum haemorrhage?
Yes - active management IOL or c-section
No - US examination for FG & wellbeing, continue antibiotics, daily mat observations, weekly HVS, FBE 7 CRP 3x daily then bi-weekly, <28 daily auscultation of FHR, >28 daily CTG
PPROM management - 34-37 weeks
Antibiotic prophylaxis (benzyl penicillin or clindamycin)
Established labour:
Aim for in utero transfer when possible - contact PIPER
Corticosteroids if 37+
Prepare for birth or transfer
Not established labour:
Suspected sepsis/chorioamnionitis? Significant antepartum haemorrhage? GBS+ & >37?
Yes - active management IOL or c-section
No - US examination for FG & wellbeing, await spont labour until 37 weeks, antibiotic prophylaxis during labour, daily CTG
PPROM Maternal & Fetal monitoring
Maternal:
Chorioamnionitis - lower abdominal pain, abdominal vaginal discharge, fever, reduced fetal movements (Lab CRP and FBE)
Antibiotics - reduce chorioamnionitis, prolong latency, improve neonatal outcome
Offer expectant management until 37 weeks - if there are no contraindications
Intrapartum antibiotic prophylaxis for GBS
Fetal:
Non-stress test daily
CTG continuous in labour/delivery
