CBL 3 – PTL and IPV Flashcards
Definition of PTL?
Labour occurring before 37 wks GA
Early PTL <33 wks GA
Late PTL 34-36+6 wks GA
How can the causes of PTB be organized? (3)
- PPROM
- Spontaneous PTL
- Medically induced PTL
Incidence of PTL?
8%
What could be considered in preventing PTL for someone with higher risk? (4)
- Screening and treating BV
- Screening and treating asymptomatic bacteriuria
- Cervical cerclage (shortened cervix before 24 wks GA and history of PTB)
- Progesterone
What’s the deal with fetal fibronectin?
fFN found in vagina before 34 wks GA is associated with PTB
Strong negative predictive value, so can be reassuring when someone is presenting with threatened PTL
But it has false positives
What are some reasons for indicated/induced PTL? (5)
IUGR
Pre-eclampsia
Insulin managed GDM
Chorioamnionitis
Monomono twins
Pre-existing risk factors of PTL? (6)
- Previous PTL
- Low SES, low education
- Uterine malformations
- Obesity, low BMI
- <6 mo bw pregnancy
- <18 >35 yo
Pregnancy risk factors of PTL? (17)
- Assisted reproduction
- Drug use
- Smoking
- Physical abuse
- Inadequate prenatal care
- PPROM
- Cervical insufficiency
- Antepartum bleeding
- Multiple gestations
- Fetal anomalies
- Infection (chorioamnionitis, BV)
- Poor nutrition
- Stress
- Insulin managed GDM
- Hypertensive disorders of pregnancy
- Placenta previa
- Polyhydramnios
Etiology of PTL? (5)
Still some unknowns (50% have no known risk factors)
Infection
Decidual hemorrhage
Excessive uterine stretch
Maternal/Fetal stress
What are indications of consult/TOC for midwives and PTL?
Consulty Late Preterm 34+0 – 36+6 weeks
(Usually shared care)
Transfer >34 wks TOC
Where are the best places to transfer PTB?
Level 3 centres
Babes born in transit have the worst outcomes
How should midwives talk about IPV? (6)
- ENSURE SAFE SPACE
- GENERAL QUESTIONS
- IF APPROPRIATE, TARGETED QUESTIONS
- BE SPECIFIC WHEN DESCRIBING ASSUALT
- RECOGNIZE FEAR SOMEONE MAY HAVE OF MEDICAL PROFESSION/OWN BIAS
- OTHER CHILDREN IN HOME? ANY SIGNS OF VIOLENCE?
What should you ask someone phoning about PTL?
When did contractions/cramps start? are they regular?
How would she describe the sensation/pain/discomfort?
Any pelvic/vaginal sensations?
Any PV loss? Or S&S of PPROM?
Any backpain? Any pain down legs?
Fetal movement?
Any risk factors for PTL?
What should be included in a PTL assessment? (8)
- Ensure accurate dating
ROUTINE
* client vital signs
* fetal heart rate (EFM)
* contraction pattern (w palpation)
PTL
* urinalysis/ culture and sensitivity
* sterile spec exam/ferning/amnisure etc
* With or without fFN (if not obvious labour etc) and under 35w
* swabs for infection (chlamydia, gonorrhea, GBS, BV)
* cervical dilation
* Ultrasound for cervical length
When should you NOT transport for PTL? (5)
Unstable client
Abnormal FHR
Birth is imminent
No trained person to travel w client
Hazardous weather
What can be considered for PTL depending on clinical context?
Tocolytics
Glucocorticoid therapy
Antibiotics (if delivery imminent)
Magnesium sulphate
Why would tocolytics be used?
To delay birth for 48 hours for:
Transport or glucocorticoids
When could tocolytics be considered?
<34 wks
What is the reason for corticosteroid therapy?
Helps with lung maturation and decreases likelihood of death
Corticosteroid dose?
-Betamethasone 12 mg IM every 24 hours x 2 doses OR
-Dexamethasone 6 mg IM every 12 hours x 4 doses
When corticosteroids should be given for PTL?
24+0 to 33+6
When should GBS abx be given in PTL?
If birth imminent – GBS + or GBS status unknown
Why is magnesium sulphate given in PTL?
Reduce risk of cerebral palsy/death
ALARM PTL recommendations?
Diagnose promptly/accurately
Identify underlying cause, treat if possible, prolong preg if indicated
Consider MagSulph
STAT
S steroids
T tocolytics
A Abx
T transport
Why are preterm infants more likely to have jaundice/hyperbilirubinemia? (4)
- immature gastrointestinal tracts and hepatic systems
- slower passage of meconium
- immature liver
- immature feeding
When do late preterm infants bili levels peak?
5-7 days instead of 3-5 in term
Why are later preterm babes at risk for poor weight gain/poor feeding?
- Immature suck/swallow/breathe/coordination (1)
- Low muscle/oromotor tone (1)
- Immature feeding cues (1)
- Poor regulation of state behaviour (1)
- Excessive sleepiness (1)
- Getting tired easily during feeds (1)
- Ineffective milk transfer (1)
- Insufficient feeding frequency/breastmilk availability/supplement volumes (1)
Preterm babes delayed cord clamping?
<37 wks delaying 60-120 s
When should Mg sulph be given for PTL?
Up to 33+6 wks
What is ok for waterbirth?
Term, Low risk, GBS is fine
When is waterbirth contraindicated?
-<37 wks
-multiple gestations
-water is not clean
- epidural/fentanyl/Morphine (3 hours)
-SSRIs
-Colonized with Abx resistant organisms (MRSA)
-HSV active infection
-No provider experienced in waterbirth
-Mec (maybe increased respiratory
-Changes in FH status, birther health status
-Increased risk of shoulders or PPH
Birther physical signs of IPV?
Hx of PTL, miscarriages, or terminations of pregnancy
Repetive urinary tract infections, STIs, yeast infections
Chronic pain
Injuries
Chronic physical disorders
Newborn signs of IPV?
Poor weigh gain
Injuries
Older kids – somatic complaints, GI disorders
Persistent crying in a calm infant
Sleep difficulties
Factors that can increase chance of family violence? (7)
- Recent separation
- New partner
- Financial stress
- Loss of employment
- Relocation
- Young age
- Hx of IPV/violence
Key points on PTL? (5)
- Accurate dating is key
- Know your level of service, when to transfer
- Counsel clients about paging early to maximize options
- Prepare for resus
- Anticipate ++feeding support
Key points for IPV?
- Screen EVERYONE
- TIC
- Understand role as midwife/limits of role
- Know community resources
- Know BCCNM policy duty to report
What does research say on safety of waterbirth?
Lower initial apgars but no difference in long term sequelae
When do midwives have a duty to report family violence?
When children are involved
