Complications in Labour Flashcards

1
Q

Discuss fever in labour
-Definition (2)
-Incidence (1)
-Implications (2)
-Causes (5)

A
  1. Definition
    -One reading of temperature >38
    -Two readings of temperature >37.5
  2. Incidence
    -1:15 women in labour
  3. Implications
    -Isolated intrapartum fever associated with poorer neonatal outcomes even if no infection
    -Fetal hyperthermia may lead to tissue hypoxia secondary to increased metabolic rate
  4. Causes
    -Infection
    -Dehydration
    -Neuroaxial block
    -Prostaglandins
    -Increased room temperature
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2
Q

Discuss chorioamnionitis
-Definition (1)
-Incidence (2)
-Risk factors (8)
-Common infectious agents (4)
-Mode of infection (3)

A
  1. Inflammation of the amnio-chorionic membrane of the placenta, amniotic fluids, decidua and fetus
  2. Incidence
    -1% of all live births
    -30% of all PPROM
  3. Risk factors
    -PPROM/PROM
    -PTL
    -Prolonged labour
    -Known GBS
    -Nuliparity
    -Mec Liquor
    -Internal fetal monitoring
    -Invasive procedures
  4. Common infectious agents
    -Mycoplasma
    -Anerobes
    -E. coli
    -GBS
  5. Mode of infection
    -Mostly ascending infection 96%
    -Haematogenous dissemination
    -Invasive procedures
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3
Q

What are the histological findings seen on placenta from chorioamnionitis (6)

A
  1. Polymorphonuclear leucocytes
  2. Neurophillic inflammation (Acute)
  3. Lymphocytic inflammation (chronic)
  4. Necrotising chorio characterised by hypereosinophillia of basement membrane
  5. Isolated chorio is seen with ascending infection
  6. Inflammation of the villi and intervillous space are characteristic of haematogenous spread
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4
Q

What are the implications of chorioamnionitis
-To the mother (4)
-To the baby (5)

A
  1. Impact to the mother
    -Dysfunctional labour
    -Increased rate of CS
    -Increased risk of PPH
    -DIC and ARDS if severe
  2. Impact to the baby
    -Infection
    -Respiratory distress
    -Intraventricular haemorrhage
    -Bronchopulmonary dysplasia
    -Cerebral palsy RR 2.4
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5
Q

Discuss management of chorioamnionitis (8)

A
  1. Chorioamnionitis is an indication to delivery whether the baby is viable or not
  2. Augment if not in established labour or labour is dysfunctional
  3. Chorioamnionitis is rarely a cause for CS alone
  4. Commence broad spec antibiotics
  5. Reduce pyrexia with paracetamol
  6. Give IVF
  7. Continue antibiotic PP if risk factors for ongoing infection
  8. Avoid FBS in suspected chorioamnionitis
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6
Q

Discuss meconium liquor
-Causes (2)
-Incidence of mec aspiration syndrome (2)
-Issues associated with mec aspiration syndrome (4)

A
  1. Causes
    -Fetal distress
    -Fetal maturity
  2. Incidence of mec aspiration syndrome
    -2-10% of babies born in mec liquor
    -Accounts for 2% of perinatal deaths
  3. Issues associated with mec aspiration syndrome
    -Infection (Unlikely if not concurrent with sepsis)
    -Pneumothorax
    -Respiratory failure
    -Persistent pulmonary HTN
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7
Q

How should babies born in meconium liquor be managed?

A
  1. Call paeds if thick mec or thin mec and fetal distress
  2. Avoid suctioning when head on perineum
  3. Rourine endotrachael suction is not indicated
  4. If baby is vigorous can dry and avoid suction and intubation
  5. If baby not vigorous prioritise effective ventilation. Can suction what you can see
  6. Monitor neonate for 24 hrs
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8
Q

Discuss GBS in pregnancy
-Number of women colonised with GBS
-Number of babies colonised if mothers are colonised?
-Number of colonised babies who develop early onset neonatal sepsis?
-Number of babies who die from early onset neonatal sepsis?
-Reduction in risk of sepsis of IV antibiotics given in labour

A
  1. Number of women colonised with GBS = 10-30%
  2. Number of babies colonised if mother colonised = 40-50%
  3. Number of colonised babies who develop early onset neonatal sepsis = 0.4%
  4. Number of babies who die from GBS sepsis = 14% of those babies who get early onset GSB sepsis. Case fatality 10 fold higher in preterm infants (20%)
  5. Reduction in risk of sepsis by 80% if treated with IVABx in labour
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9
Q

Discuss the methods for determining GBS status in pregnant women (3)

A
  1. Risk factor based (NZ and UK). Treat if
    -PPROM
    -Rupture of membranes >18hrs
    -Maternal fever >38
    -Previous infant with GBS sepsis
    -GBS bacteruria at any time in pregnancy
    -GBS on swab after 35 weeks or earlier if swab not repeated
    -Clinical dx of chorioamnionitis
  2. Universal culture based screening (Aus, USA)
    -Vaginal and ano-rectal swab done between 35-37 weeks or within 5 weeks of expected delivery
    -Needs to be on selective enriched culture media to increase sensitivity and reduce false negatives (50% false negatives on normal media)
  3. POC testing in labour
    -Not currently available
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10
Q

Discuss universal screening for GBS
-Advantages (5)
-Disadvantages (5)

A
  1. Advantages
    - Positive swab at 36 weeks has 91% sensitivity and 89% specificity
    -NPV 95-98%
    -Doesn’t miss the 30% of women who have GBS but no risk factors
    -Reduced early onset GBS sepsis cf. risk based assessment OR 0.45.
    -Able to test for erythromycin and clindamycin sensitivities to use as alternative if penecilin allergic
  2. Disadvantages
    -Expensive
    -Increased medicalisation of labour
    -May not be culturally acceptable to all
    -High false negative rate if wrong media used
    -Unable to screen when in labour
    -May need re-screening
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11
Q

Discuss risk based screening for GBS
-Advantages (4)
-Disadvantages (2)

A
  1. Advantages
    -Less invasive
    -Less expensive
    -Less unnecessary Abx use
    -Can be used for women presenting in labour with limited ANC
  2. Disadvantages
    -Misses 30% of women with GBS + but no risk factors
    -Bacteria sensitivities unknown
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12
Q

How should GBS in labour be treated?
-Standard regimen
-If penicillin allergy
-If penicillin anaphylaxis

A
  1. Standard regimen - 1.2g Ben Pen loading then 0.6g Q4H
  2. If penicillin allergic - Cefazolin 2g loading then 1g Q8H
  3. If Penicillin anaphylaxis - Vancomycin 1g Q12H
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13
Q

How should GBS be managed in the following:
1. ELCS (1)
2. PTL with unknown GBS status (1)
3. Term PROM and GSB positive (1)
4. PPROM (5)
5. A previous child affected by GBS sepsis

A
  1. ELCS - no antibiotics required
  2. PTL with unknown GBS status
    -Give Abx if in labour. Discontinue if labour stops
  3. Term PROM with GBS
    -Offer immediate IOL and Abx
  4. PPROM
    -Test for GBS.
    -If GBS + give Abx at onset of labour
    -Give erythromycin regardless of GBS status
    -If <34 weeks and GBS + manage expectantly
    -If >34 weeks and GBS + IOL - PROMEXIL trial
  5. A previous child affected by GBS sepsis
    -Give ABX regardless of current GBS status
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14
Q

Discuss the management of incidental GBS finding in pregnancy
-GBS on swab (3)
-GBS in urine (3)

A
  1. GBS on swab
    -Don’t treat. Recurrence rate 67%
    -If within 5 weeks of labour give ABx
    -If > 5 weeks from labour re-swab or risk factor based approach
  2. GBS in urine
    -Always treat regardless of symptoms
    -Give Abx at onset of labour.
    -GBS in the urine is associated with high colonisation of the genital tract
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