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OBS & GYNAE (Obstetrics & Gynaecology) > Intrapartum Care - Premature Labour > Flashcards

Intrapartum Care - Premature Labour Flashcards

1
Q

What is Premature Labour?

A

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

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2
Q

Resuscitation and Prematurity (3).

A
  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.
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3
Q

Classification of Prematurity.

A
  1. Extreme Preterm : Under 28 Weeks.
  2. Very Preterm : 28-32 Weeks.
  3. Moderate-Late Preterm : 32-37 Weeks.
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4
Q

What is Preterm Birth?

A

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

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5
Q

What is Foetal Fibronectin (fFN)?

A

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

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6
Q

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

A

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.

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7
Q

Risk Factors of Preterm Labour (5).

A
  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).
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8
Q

What can be offered as Prophylaxis of Preterm Labour?

A
  1. Vaginal Gel/Pessary Progesterone.

2. Cervical Cerclage.

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9
Q

Mechanism of Action of Prophylactic Medication in Preterm Labour.

A
  1. Decreases Activity of Myometrium.

2. Prevents Cervical Remodelling in Preparation for Delivery.

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10
Q

Who is this Prophylactic medication offered to?

A

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

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11
Q

What is Cervical Cerclage?

A
  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.
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12
Q

Who is Cervical Cerclage offered to? (3)

A
  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.
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13
Q

When is Rescue Cervical Cerclage offered?

A

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

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14
Q

What is Preterm Prelabour Rupture of Membranes (PPROM)?

A

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

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15
Q

What is SROM?

A

Spontaneous rupture of membranes.

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16
Q

What is PROM?

A

Prelabour rupture of membranes - before onset of labour.

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17
Q

What is long PROM?

A

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

18
Q

How is PPROM diagnosed?

A

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

19
Q

Other Investigations to Confirm Diagnosis of PPROM (4).

A
  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).
20
Q

Management of PPROM (4).

A
  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.
21
Q

Complications of PPROM (2).

A
  1. Foetal : Infection (NEC) and Pulmonary Hypoplasia and Facial/Limb Deformities (Compression).
  2. Maternal : Chorioamnionitis.
22
Q

What is Preterm Labour with Intact Membranes?

A

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

23
Q

Diagnosis of Preterm Labour with Intact Membranes (4).

A
  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).
24
Q

Management of Preterm Labour with Intact Membranes (6).

A
  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).
25
Q

What is Tocolysis?

A

Use of medications to stop uterine contractions and thus labour.

26
Q

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

A
  1. Nifedipine (CCB) - preferred.
  2. Atosiban (Oxytocin Receptor Antagonist) - alternative.
  3. Other : Indomethacin (NSAID), Terbutaline (B2 Agonist), MgSO4.
27
Q

When can Tocolysis be used?

A

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

28
Q

Contraindications to Tocolysis (6).

A
  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.
29
Q

When can Maternal Corticosteroids be offered?

A

Before 36 Weeks.

30
Q

Why can Maternal Corticosteroids be offered?

A

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

31
Q

How can these Antenatal Steroids be offered?

A

2 Doses of IM Betamethasone 24 hours apart.

32
Q

Why is IV Magnesium Sulphate offered?

A

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

33
Q

When is IV Magnesium Sulphate given?

A

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

34
Q

How is IV Magnesium Sulphate given?

A

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

35
Q

Why should mothers with this drug be monitored?

A

Toxicity - check at least 4 hourly -

  1. Observations (Reduced RR and BP).
  2. Absent Tendon Reflexes (e.g. Patella).
36
Q

What is Chorioamnionitis?

A

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

37
Q

Major Risk Factor of Chorioamnionitis.

A

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

38
Q

Management of Chorioamnionitis (3).

A
  1. Prompt Delivery of Foetus.
    2 IV Antibiotics (Sepsis 6).
  2. Admission.
39
Q

Clinical Features of Chorioamnionitis (6).

A
  1. Fever.
  2. Abdominal Pain.
  3. Offensive Vaginal Discharge.
  4. Maternal and Foetal Tachycardia.
  5. Pyrexia.
  6. Uterine Tenderness.
40
Q

What is Prelabour Rupture of Membranes AT TERM?

A

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

41
Q

Prognosis of Prelabour Rupture of Membranes AT TERM.

A

Most women start spontaneous labour within subsequent 24 hours.

42
Q

Management of Prelabour Rupture of Membranes AT TERM.

A
  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.

OBS & GYNAE (Obstetrics & Gynaecology) (73 decks)

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