PPH, C/S, LBAOUR, ROM Flashcards
what are some of the investigations done for PPH
- Hb
- Ultrasound
- Clotting time
- Blood clotting screen
- CTG for differential diagnosis/fetal wellbeing
- Blood gases
- Check renal function
- PV to assess cervix if diagnosis certain for AP, NO PV for PP
When does preterm labour occur and preterm rupture of membranes
before 37 weeks
Diagnosis:
* Regular painful contractions with cervical changes with/without ROM.
* Threatened preterm labour if only uterine contractions
what are come of the cause preterm labour and preterm rupture of membranes
- Infection: chorioamnionitis, genital tract infection e.g. group B strep
- Maternal pyrexial illness: pyelonephritis, RTI
- Cervical incompetence
- Multiple pregnancies
- Polyhydramnios
- Placenta praevia
- Abruptio placenta
- IUGR
- Uterine abnormalities
- Fetal abnormalities
what are the risk factors associated with preterm labour and preterm rupture of membranes
- Previous preterm labour
- Unbooked
- Lower SES
- Smoking, alcohol
- Malnutrition
what investigations are done in the event of preterm labour
- Midstream urine MC&S
- High vaginal swab
- CTG
- Ultrasound
what are some of the contraindications to tocolytic drugs
- Fetal distress
- Pre-eclampsia
- Lethal fetal abnormality
- Chorioamnionitis
- IUGR
- APH
what are tocolytics
they are drugs that are used to suppress labour in order to administer steroids to enhance fetal lung maturity. only continued for 48 hours.
brief summary on Calcium channel blockers
- E.g. Nifedipine (drug of first choice) Adalat®
- Dose: initially 30mg orally then 20mg after 90 minutes and if contractions persist,
20mg every 6 hours - Side effects: headache, flushing and nausea
- Contra-indications: hypovoleamia, cardiac conditions
brief summary on Β2adrenergic agents
- E.g. Salbutamol (Ventolin®) uterine smooth muscle relaxant
- Dose: 250mcg diluted in 9.5mls water as a slow IV bolus
- Side effects: maternal and fetal tachycardia, hyperglycaemia
- Contra-indications: stenotic valvular heart lesions, shock, diabetes, thyrotoxicosis
brief summary on Prostaglandin antagonists
- E.g. Indomethacin (blocks the conversion of arachidonic acid to prostaglandin E2 and
F2α) - Dose: 100mg rectally 12 hours apart for 48 hours
- Side effects: GIT irritation, renal failure, suppression of platelet function, premature
closure of fetal ductus arteriosus - Contra-indications: thrombocytopaenia, peptic ulcer disease, fetal gestation> 32
weeks
brief summary on steroids
Enhance fetal lung maturity, prevent intraventricular haemorrhage and necrotizing enterocolitis.
Betamethasone 12mg intra-muscularly 24 hours apart (2 doses)
Usually only a single course given but a rescue course may be given if the initial dose is given at a very early gestation e.g. 27 weeks.
brief summary on antibiotics
Use of antibiotics is controversial
The ORACLE II trial showed no benefit except in those patients in whom membranes had also ruptured
* In South Africa, we do not routinely screen for infections such as Group B Strep infection, but patients with clinical signs and symptoms suggestive of Group B Strep (such as preterm labour, PROM, PPROM), should receive intravenous Ampicillin to protect the baby.
* Identified infections such as pyelonephritis should be treated with appropriate antibiotics - based on microbiological culture results.
preterm rupture of membranes
Confirm membrane rupture by history, examination & special investigations.
Perform a sterile speculum examination. Liquor observed draining from the cervical os confirms the diagnosis. The patient can be asked to cough is liquor is not initial evident. If fluid is observed pooling in the posterior fornix, a specimen should be taken aspirating liquor with the plastic cannula of a jelo/IV catheter.
how is the diagnosis of preterm rupture of membranes made
- Litmus lesting: Liquor is alkaline and turns red litmus blue.
- “Ferning can be observed under a microscope if liquor is placed on a slide and left to dry.
Amnisure: Is used for the detection of PAMG-1 (placental alpha macroglobulin 1) in amniotic fluid using test strips. Expensive test therefore use litmus as initial test and Amnisure only in uncertain cases.
Highly sensitive and specific for amniotic fluid. - Fetal fat cells stain orange with 1% Nile blue sulphate (after 30 weeks)
what is the management of preterm rupture of membranes before 34 weeks
- Admit the patient and counsel about risks of preterm labour.
- Avoid vaginal examination unless prolapsed cord suspected because of abnormal fetal heart rate.
- Administer antibiotics Azithromycin 500mg daily for 3 days
- Administer Betamethasone 12mg IMI 12 hourly x 2 doses
- Midstream urine to exclude urinary tract infection
- Twice weekly white cell counts
- Use of sterile pads
- Growth ultrasound
- If labour supervenes, consider tocolysis for 48 hours to administer steroids
- If there are signs of infection such as maternal pyrexia, uterine tendernes or fetal tachycardia or rising white cell count, induce labour urgently regardless of the gestational age.
what is the management of preterm rupture of membranes above 34 weeks
Expedite delivery after 24 hours of rupture of membranes if not in labour either with Prostaglandins (eg. Misoprostol) or Oxytocin. Most patients will go into labour spontaneously within 24 hours (85-90%). If any signs of infection or other obstetric indication for delivery, induce labour earlier and do not wait for 24 hours.
Note: if patient is HIV+ with an unsuppressed viral load, augment or induce labour after 4 hours of rupture of membranes if not in labour. All patients
should receive IV antibiotics in labour to protect the baby against Group B Strep
- Ampicillin 1g 6 hourly intravenously. Alternatively, Clindamycin 600mg intravenously 8 hourly for patients who are allergic to penicillin.
Induction of labour
The initiation of labour artificially before the spontaneous onset of labour.
what are the maternal indications for induction of labour.
- Pre-eclampsia/eclampsia
- Prolonged rupture of membranes after 34 weeks of gestation
- Chorioamnionitis
- Maternal medical conditions eg. diabetes at term, hypertension at
term etc. - Previous unexplained stillbirth
- Previous precipitate labour
- Previous abruptio placentae
- Antepartum haemorrhage of unknown origin
- Polyhydramnios with risk of cord prolapse
what are the fetal indications for induction of labour.
- Intra-uterine death
- Growth restriction with concern for fetal wellbeing
- Prolonged pregnancy
what is the Bishop score
it is an assessment made prior to the commencement of induction of labour, an assessment of the ripeness of the cervix is made. this will assist the choice of method of indiction
Bishop score > 9 = favourable cervix
Bishop score <9 = unfavourable cervix. needs to be ripened.
Bishop score looks at
- Dilation
- Effacement
- Consistency
- Station
- Position
Misoprostol
- Is asynthetic Prostaglandin E1 analogue (Cytotece) currenty regsitered for
use in inhibition of gastric acid secretion and protection against NSAID associated ulceration. - It is inexpensive.
- It is stable drug at room temperature and does not require refrigeration therefore widely used.
- CTG monitoring essential before and after administration of drug
- Available as 200mcg tablets (administered as 200mcg tablet dissolved in 20mls water given in divided doses)
- Side effects: GIT side effects (nausea/vomiting, diarrhoea), fever, shivering
- Dose for IOL at term: 25mcg as a test dose followed by 25 mcg half hour later (if CTG reactive) then 150mcg in 3 divided doses (CAUTION: do not give Misoprostol if patient is contracting as may cause uterine hyperstimulation and uterine rupture)
- Contra-indicated in multiparous patients (parity ≥ 5) and patients who have had a previous Caesarean section or myomectomy.
- Contra-indicated in patients with abruptio placentae (increased risk of uterine rupture).
Dinoprostone - Prandin Gel
- Prostaglandin E2 vaginal gel (1mg/2mg)
- Applied vaginally in the posterior fornix every 6 hours (maximum 3 doses)
To be used with caution in multiparous patients and patients who have a previous Caesarean section (with an IUD) - Expensive and needs to be refrigerated.
- May also result in uterine hyperstimulation and uterine rupture.
Dinoprostone - Prepidil gel
- Prostaglandin E2 vaginal gel (0.5mg) inserted intra-cervically
- Expensive and rarely used.
- Side effects include uterine hyperstimulation and rupture.
Oxytocin
correct dose is that which causes physiological type contractions. Dose is
therefore titrated against contractions (until 3-4 strong contractions achieved in
10 minutes).
- Continuous CTG monitoring is mandatory during oxytocin infusion
- Dose: 12 units in 200mls normal saline via a volumetric pump (IVAC)
commencing at 2mls/hour increasing dose by 2mls/hour every half an hour. (Max
12mls/hr)
- Contraindications: multiparous, previous c/s, CPD.
- Caution: pre-eclampsia, cardiac patient
- Side effects: tetanic contractions, hypertonic uterus (>/= 5 contractions in
10mins), fetal distress and water intoxication
SURGICAL INDUCTION
Performed when cervix is favourable, and the patient is HIV negative. If patients are HIV positive, they must have a suppressed VL.
Amniotomy:
- Methods:
* Amnio-hook - Risks:
* Trauma to cervix or fetal head
* Infection, especially HIV maternal-fetal transmission
* Cord prolapse - Precautions:
- Aseptic technique
- Lithotomy position preferable
- Exclude cord presentation
- Controlled rupture of membranes, suprapubic pressure if high head or poly-hydramnios present
- Do CTG before and after
Assess colour of liquor (clear/meconium/blood-stained)
MECHANICAL METHODS OF INDUCTION
a. Stretch and Sweep
* Stretching the cervix and sweeping membranes off cervix and lower segment-causes local release of prostaglandins resulting in onset of labour in 50% percent of cases.
b. Intracervical Catheter (ICC)
* Can at times be used to ripen the cervix in a setting where the waiting list for IOL/monitored induction beds is long
* Catheter with a 30ml bulb is placed into the cervix extra-amniotically
* Either placed on traction or with extra-amniotic saline infusion (EAS!)
Contraindications to induction of labour
- Multiparous (>4)
- Previous c/s
- Contraindication of specific methods
- Vaginal birth not possible
- Abnormal lie, presentation
- Pelvic fracture
- Previous 3rd/4th degree vaginal tear - HIV status for ROM
Fetal - Preterm unless needed
- Abnormal lie, presentation
- Twins, leading twin Nb
- Big EFW
indications for a C/S
Maternal Indications:
* Placenta praevia
* Previous classical CS
* Previous uterine surgery, e.g. CS, myomectomy
* Cervical carcinoma
* Serious medical conditions
* Bearing down efforts contraindicated, eg. cerebral aneurysm
* Uterine rupture
* Previous vaginal repair or surgery for urinary incontinence
Fetal Indications:
* Fetal distress
* Prolapsed cord with live baby
* Abruption placenta with live baby
* Breech presentation
* Transverse lie
OXYTOCIN receptor antagonist
Atosiban
- blocks oxytocin receptors on the uterus
- expensive with few side effects but not given in the state sector.
causes of prelabaour premature rupture of membranes
- infection
- incompetent cervix
- complication of external cephalic version
- a complication of amniocentesis
- multiple pregnancy (over distension of uterus, this can also be seen in polyhydramnios)
