CBL 1_PROM and Early Labour Flashcards
How often does Term PROM occur?
8-10 % of all people
How many of Term Prom people go into labour on their own? (2)
-Over 50 % in active labour within 1 day
-95 % in active labour in 3 days
Difference bw PPROM and PROM?
PROM isn’t pathologic in itself while PPROM carries significant increased risks
Risks of P(reterm)PROM? (3)
-clinically evident intra-amniotic infection with histological chorioamnionitis
Fetal risks:
umbilical cord compression
ascending infection.”
How often does intra-amniotic infection occur in PPROM?
15-25 % of all birthers
How often does histological chorio occur in PPROM?
51 % of all birthers
Risk factors of PPROM? (13)
-Disorders of the cervix, either iatrogenic (e.g., operative), or not (e.g., insufficiency) · PPROM in a previous pregnancy ·
-Prior preterm labour/delivery ·
-Chronic placental abruption ·
-Polyhydramnios
-Multiple pregnancy ·
-Short interpregnancy interval of less than 6 months ·
-Cigarette smoking ·
-Sexually transmitted infection ·
-Low socioeconomic status ·
-Amniocentesis ·
-Periodontal disease
-Gestational Diabetes Mellitus
-Bacterial vaginosis (BV)
How long no ctx with ROM to be considered PROM?
1 hour
What is prolonged ROM?
ROM for more than 18 hours with ctxs (kind of an arbitrary number)
How many exp. managed Term PROM will be in active labour within 1 day?
Over 50 %
How many exp. managed Term PROM will be in labour within 3 days?
95 %
How many people with leaking fluid have PROM?
95 %
What should be asked with Query PROM? (9)
- Presence of leaking fluid
- Amount
- Timing
- Odor
- Persistance
- Colour
- FM
- Cx
- fever?
When should IOL be offered with PROM for GBS neg/unknown?
12-24 hours or immediately if client wants
When should IOL and abx be offered for PROM GBS +?
Both immediately SOGC
PROM care plan for GBS + (AOM)?
Ideally prenatal discussion.
- Give SOGC reccomendation: Immediate IOL and Antibiotic prophylaxis
- discuss research gap regarding most effective approach to preventing EOGBSD
- Acknowledge and proceed depending on client preferences and values
- If client choses expectant management at this time, remind client of recommendation for medical IOL for PROM at18hrs & antibiotics at start of labour
Pelvic precautions for PROM? (5)
-Nothing in vagina
-Blot rather than wipe
-Change pad often
-Take temp q4 hours when awake
-Page if temp 38 degrees C or higher
PROM Assessment Care plan? (2)
-Prompt assessment if any abnormal findings/unclear re history
-Assessment Within 24 hours if history is clear, signs/symptoms are normal, and they choose a period of exp. mgmt.
What should be assessed in person to confirm query PROM?(4)
- Sterile spec
- GBS swab if none done yet
- Nitrizine
- Ferning sample
What is looked at in sterile spec? (4)
- Fluid pooling in posterior fornix
- Free flow of fluid from cvx
- Cord prolapse
- Dilation, effacement, position
How do you collect a ferning specimen? (4)
-Obtain fluid from posterior fornix
-Place on glass slide
-let air dry for 10 mins
-look under microscope
What is ferning?
Crystallization of sodium chloride = presence of amniotic fluid
What can cause false positive with nitrizine amniotic fluid assessment? (4)
- Blood
- Alkaline vag infections (BV)
- Alkaline urine
- Semen.
What can cause false negative with amniotic fluid assessment?
Prolonged ROM with little residual fluid
What colour does positive nitrizine turn?
Dark Blue from yellow, with pH above 6.5
How accurate is nitrizine?
Sensitive but not specific
Often says ‘positive’
What is the normal pH of pregnancy vag?
4.5 -6.0
What is pH of amniotic fluid?
7.1-7.3
What can cause a false positive with ferning (4)?
Antiseptic solution
Semen
Fingerprints
cervical mucus
Is ferning a conclusive test?
No, it’s supportive rather than conclusive in non-labouring clients with non-specific vaginal fluid loss
What won’t cause a false positive with ferning? (3)
Blood
Mec
Vaginal secretions
(don’t ask me what the difference bw from vag secretions and cervical fluids is…)
What is a more specific and sensitive test for AF?
Amnisure – more expensive
(placental alpha microglobulin-1)
The sensitivity ranges from 94.8 to 98.9% and the specificity from 87.5 to 100%;
Is it reasonable for someone to stay home with PROM?
Yes, if IOL is declined and VEs avoided.
All else: of course they can but higher risks
Recommendations for Expectant Mgmt PROM ALARM? (7)
-avoid VEs
-observe infection:
monitor maternal pulse and temperature
FHR
uterine tenderness
-give abx and IOL ifchorioamnionitis develops
-educate to report signs of infection or decreased FM
-FM/FHR evaulatued every 24 hours
-when in labour after term PROM > 24 hours, EFM in labour is recommended (AOM differs)
-asymptomatic healthy term babies born after 24 hours of PROM should be observed for the first 12 hours for signs of infection (AOM routine pp care)
What is the CD rate in BC in BC 2021?
37.8 % )
What is the CD rate for nulips with spontaneous labour in BC 2021?
24.3 %
What is Term PROM?
Term ROM with no ctx for more than 18 hours (which is an arbitrary number)
What is the CD rate for nulips with IOL in BC 2021?
52.6 % (2x higher than nulips w spont. labour)
What is Prolonged ROM?
ROM in with ctx for greater than 18 hours
What are the risks of prolonged ROM?
Increased chance of infection for mom and bb
How to monitor prolonged ROM?
Increased surveillance of temp (q2 hours)
No Mec/risk factors = IA is fine
What causes spontaneous labour?
Not fully known, activated by fetus and caused by cascade of positive feedback loops
VAL WISDOM: wow so complex and mysterious, our job = don’t mess with it
What is the risk of misidentifying early labour?
Mistaking Early L for Active L can contribute to unnecessary interventions related to ‘failure to progress’
Non pharm strategies for coping in early labour?
- Coping strategies prenatally and education around long early labour can be
- Continuous support from a support person
- Staying at home/home like environment
- Focused breathing/meditation
- Heat, cold
- TENS machine
- Intuitive, upright positions
- Distracting activities
- Positioning:
OP position is associated with longer labours, increased back pain, increased need for pain management, dystocia, and adverse conditions and outcomes
Support optimal fetal positioning by encouraging clients to get into positions such as hands and knees and side-lying
Hands and knees position and sterile water injections can also relieve back pain associated with OP fetal positioning (1,2,3,5)
Early labour pharm methods? (4)
-Tylenol and gravol
-IM morphine and gravol
-IV hydration
-IM gravol (hb)
Triaging PROM? (10)
Hx
GBS status
red flags
fluid
amount
time
fetal well-being -movement and fetal presentation last time you saw them
contraction pattern
coping
‘are you feeling well’,
Options to confirm PROM?(5)
Sterile spec and pooling
Nitrizine - not accurate, kind of crap - needs to be up in the cervix (not when it’s trickled down the vagina with mucus, blood, and urine)
Ferning
US - not diagnostic, but info that could be relevant
“Amnisure” - placental alpha microglobilin test (expensive) (but what is this cost compared to induction - Val wisdom)
Can you have baths with PROM
No baths till active labour
What is the likelihood of chorio with PROM and no VEs?
Low
When is ideal IOL for term PROM?
There is a research gap
What does the evidence say about IOL vs exp mgmt. for PROM?
Low Risk term PROM =
evidence to support safety of IOL or expectant mgmt
What are the issues with TERM PROM RCT?(3)
- Overly broad defn around chorio
- More VE for exp mgmt than IOL group
- No screening/treating GBS
What are abnormal findings where IOL may be a good choice for TERM PROM? (5)
Mec
Bad smelling fluid
Active vag bleeding
Fever above 38
Decreased FM
What is the biggest risk factor for infection of birther and babe with low risk term PROM?
Frequent VES before active labour
How much does AOM recommend for PROM timing?
96 hours
How much does ACOG recommend for PROM timing?
12-24 hours
How much does NICE recommend for PROM timing?
24 hours
What should be included in monitoring of exp mgmt PROM?(2)
- When/how to page
- Daily in person assessments (birthing person’s VS, FHR, FM)
Are daily NSTs evidence based for low-risk Term PROM?
Not if we don’t view PROM as a pathology (VAL HOT TAKE)
What does SOGC recommend with fetal monitoring in labour for PROM?
CEFM if PROM greater than 24 hours
What doess AOM recommend for PROM timing and FHS? (evidence based)
IA is reasonable if no risk factors present (AOM) (no mec or fever)
What does WHO say the ideal CD rate should be?
(WHO recommends ideal CD rate 10-15%
What is Prolonged early labour?
Latent phase lasting over 14 hours in multip/20h in nullip
Risks of prolonged early labour?
Dehydration
Exhaustion
Non-pharmacological early labour support?
Continuous support person
Staying home; music; relaxed breathing; massage; counter pressure; TENS
Use of water
Intuitive movement, upright position; birth ball, etc
Encourage rest, eating, hydration
Emotional support and reassurance
Fetal position impacts labour: encourage hands and knees; side-lying for OP
Sterile water injections
GBS stats for ICD?
15-40% of pregnant ppl are GBS pos
40-70% of babies born to GBS pos birther will be colonized if untreated
1-2% of colonized NB will develop infection if untreated
5% of NB who develop infection will die
