Intrapartum Care - Premature Labour

Question 1

What is Premature Labour?

Answer 1

Onset of regular uterine contractions and cervical changes occurring before 37 weeks gestation.

Question 2

Resuscitation and Prematurity (3).

Answer 2

1. Non-Viable : Below 23 Weeks.
2. Do Not Resuscitate Babies Between 23-24 with No Signs of Life (10% survival).
3. Resuscitate fully after 24 weeks onwards.

Question 3

Classification of Prematurity.

Answer 3

1. Extreme Preterm : Under 28 Weeks.
2. Very Preterm : 28-32 Weeks.
3. Moderate-Late Preterm : 32-37 Weeks.

Question 4

What is Preterm Birth?

Answer 4

Delivery of a baby after week 20 gestation but before 37 weeks gestation.

Question 5

What is Foetal Fibronectin (fFN)?

Answer 5

The glue between the chorion and uterus - it is found in the vagina during labour.

Question 6

What screening test is used to assess the risk of preterm delivery?

Answer 6

fFN Test, offered to assess the risk of preterm delivery after the onset of preterm labour - if negative, low risk of delivery within next 7-14 days.

Question 7

Risk Factors of Preterm Labour (5).

Answer 7

1. Conditions that cause overstretching of uterus (Multiple Pregnancy, Polyhydramnios).
2. Conditions where foetus is at risk (PET, IUGR, Placental Abruption).
3. Uterine/Cervix Structural Abnormalities (Fibroids, Congenital, Short/Weak Cervix, Previous Uterine/Cervical Surgery).
4. Infections (Chorioamnionitis, Maternal/Neonatal Sepsis, STIs, GBS, BV, rUTIs).
5. Maternal Co-Morbidity (HTN, Diabetes, Renal Failure, Thyroid Disease).

Question 8

What can be offered as Prophylaxis of Preterm Labour?

Answer 8

1. Vaginal Gel/Pessary Progesterone.

2. Cervical Cerclage.

Question 9

Mechanism of Action of Prophylactic Medication in Preterm Labour.

Answer 9

1. Decreases Activity of Myometrium.

2. Prevents Cervical Remodelling in Preparation for Delivery.

Question 10

Who is this Prophylactic medication offered to?

Answer 10

Cervical Length Less than 25mm on Vaginal US between 16-24 Weeks Gestation.

Question 11

What is Cervical Cerclage?

Answer 11

1. Insertion of a stitch in the cervix to keep it closed and support it, using spinal/general anaesthesia.
2. Remove when term or in labour.

Question 12

Who is Cervical Cerclage offered to? (3)

Answer 12

1. Cervical Length Less than 25mm on Vaginal US between 16-24 Weeks Gestation.
2. Previous Premature Birth.
3. Cervical Trauma e.g. Colposcopy and Cone Biopsy.

Question 13

When is Rescue Cervical Cerclage offered?

Answer 13

Between 16 and 27+6 Weeks with Cervical Dilation without rupture of membranes to prevent progression and premature delivery.

Question 14

What is Preterm Prelabour Rupture of Membranes (PPROM)?

Answer 14

The amniotic sac ruptures releasing amniotic fluid before the onset of labour in a preterm pregnancy (before 37 weeks).

Question 15

What is SROM?

Answer 15

Spontaneous rupture of membranes.

Question 16

What is PROM?

Answer 16

Prelabour rupture of membranes - before onset of labour.

Question 17

What is long PROM?

Answer 17

Prolonged rupture of membranes - more than 18 hours before delivery.

Question 18

How is PPROM diagnosed?

Answer 18

Speculum Examination : Pooling of Amniotic Fluid in Posterior Vaginal Vault.

Question 19

Other Investigations to Confirm Diagnosis of PPROM (4).

Answer 19

1. IGFBP-1 (Insulin-Like Growth Factor Binding Protein) - found in high concentrations in amniotic fluid so test vaginal fluid.
2. PAMG-1 (Placental Alpha Microglobin) - similar to IGFBP-1.
   * not necessary
3. US - Oligohydramnios.
4. DRE - AVOID (Infection).

Question 20

Management of PPROM (4).

Answer 20

1. Admit and Regular Observations.
2. Prophylactic Antibiotics (against Chorioamnionitis) - use Oral Erythromycin 250mg QDS for 10 Days or until Labour is established if within 10 Days.
3. Induction from Week 34 (Trade-Off Between Increased Risk of Maternal Chorioamnionitis & NRDS).
4. Antenatal Corticosteroids.

Question 21

Complications of PPROM (2).

Answer 21

1. Foetal : Infection (NEC) and Pulmonary Hypoplasia and Facial/Limb Deformities (Compression).
2. Maternal : Chorioamnionitis.

Question 22

What is Preterm Labour with Intact Membranes?

Answer 22

Preterm Labour with intact membranes involves regular painful contraction and cervical dilation without rupture of the amniotic sac.

Question 23

Diagnosis of Preterm Labour with Intact Membranes (4).

Answer 23

1. Speculum Examination : Cervical Dilation.
2. If Before Week 30 : Clinical Assessment.
3. If After Week 30 : Transvaginal US to Assess Cervical Length - only manage if cervical length is less than 15mm (likely preterm labour).
4. Use fFN as alternative to TVUS (only manage if above 50ng/ml).

Question 24

Management of Preterm Labour with Intact Membranes (6).

Answer 24

1. Foetal Monitoring (CTG/Intermittent Auscultation).
2. Tocolysis.
3. Maternal Corticosteroids.
4. IV Magnesium Sulphate.
5. Delayed Cord Clamping/Cord Milking.
6. IV Antibiotics - Penicillin (if evidence of GBS in current/previous pregnancy).

Question 25

What is Tocolysis?

Answer 25

Use of medications to stop uterine contractions and thus labour.

Question 26

What medications can be used for Tocolysis? (3).

Answer 26

1. Nifedipine (CCB) - preferred. 2. Atosiban (Oxytocin Receptor Antagonist) - alternative. 3. Other : Indomethacin (NSAID), Terbutaline (B2 Agonist), MgSO4.

Question 27

When can Tocolysis be used?

Answer 27

Between 24 and 33+6 weeks to delay delivery and buy time for further foetal development (short-term measure - < 48 hours).

Question 28

Contraindications to Tocolysis (6).

Answer 28

1. Above Week 34. 2. CTG, Fatal Foetal Anomaly, IUD Risk. 3. IUGR or Placental Insufficiency. 4. Dilation > 4cm. 5. Chorioamnionitis. 6. Maternal Co-Morbidities.

Question 29

When can Maternal Corticosteroids be offered?

Answer 29

Before 36 Weeks.

Question 30

Why can Maternal Corticosteroids be offered?

Answer 30

To reduce neonatal morbidity and mortality - development of foetal lungs (reduce RDS after delivery).

Question 31

How can these Antenatal Steroids be offered?

Answer 31

2 Doses of IM Betamethasone 24 hours apart.

Question 32

Why is IV Magnesium Sulphate offered?

Answer 32

Protection of foetal brain during premature delivery to reduce risk and severity of cerebral palsy.

Question 33

When is IV Magnesium Sulphate given?

Answer 33

To the Mother Before Week 34 within 24 hours of delivery of preterm babies of less than week 34 gestation.

Question 34

How is IV Magnesium Sulphate given?

Answer 34

Bolus followed by an infusion for up to 24 hours or until birth.

Question 35

Why should mothers with this drug be monitored?

Answer 35

Toxicity - check at least 4 hourly - 1. Observations (Reduced RR and BP). 2. Absent Tendon Reflexes (e.g. Patella).

Question 36

What is Chorioamnionitis?

Answer 36

A medical emergency - result of ascending bacterial infection of the amniotic fluid, membranes or placenta.

Question 37

Major Risk Factor of Chorioamnionitis.

Answer 37

PPROM - exposure of normally sterile environment of uterus to potential pathogens.

Question 38

Management of Chorioamnionitis (3).

Answer 38

1. Prompt Delivery of Foetus. 2 IV Antibiotics (Sepsis 6). 3. Admission.

Question 39

Clinical Features of Chorioamnionitis (6).

Answer 39

1. Fever. 2. Abdominal Pain. 3. Offensive Vaginal Discharge. 4. Maternal and Foetal Tachycardia. 5. Pyrexia. 6. Uterine Tenderness.

Question 40

What is Prelabour Rupture of Membranes AT TERM?

Answer 40

Rupture of amniotic membranes before onset of labour after week 37.

Question 41

Prognosis of Prelabour Rupture of Membranes AT TERM.

Answer 41

Most women start spontaneous labour within subsequent 24 hours.

Question 42

Management of Prelabour Rupture of Membranes AT TERM.

Answer 42

1. Induction of Labour Offered or Monitor for Chorioamnionitis if Declined. 2. If Infection : Immediate Induction and Broad-Spectrum Antibiotics. 3. If Foetal Compromise : C-Section. 4. Close Observation following Delivery for 12 hours.