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Year 4k: Obs and Gynae > Prematurity and normal labour > Flashcards

Prematurity and normal labour Flashcards

1
Q

What are neonatal risks of prematurity?

A
  • Neonatal death
  • Respiratory distress syndrome
  • Chronic lung disease
  • Intraventricular haemorrhage
  • Necrotising enterocolitis
  • Sepsis
  • Retinopathy of prematurity
  • Hypothermia
  • Feeding problem
  • Jaundice
  • <28 weeks: physical disabilities, learning disabilities, behavioural problems, visual and hearing problems
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2
Q

What is Prematurity?

A

Infants born before 37 weeks gestation.

  • Extremely preterm <28 weeks (<1% in UK but 51% of infant deaths)
  • Very preterm 28-32 weeks
  • Moderate to late preterm 32-36+6
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3
Q

What are implications of Prematurity?

A
  • Single biggest cause of neonatal mortality and morbidity.
  • High rate of neonatal and infant morbidity increasing with decreasing gestational age. Major long-term concerns are neurodevelopmental disabilities
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4
Q

What are risk factors for Preterm prelabour rupture of membranes (PPROM)?

A
  • Smoking (especially <28 weeks gestation)
  • Previous PROM/pre-term delivery
  • Lower genital tract infection
  • Polyhydramnios
  • Multiple pregnancy
  • Cervical insufficiency
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5
Q

What are clinical features of PPROM?

A
  • Gush of fluid from vagina
  • Leaking of vaginal fluid
  • Increased watery discharge
  • Concern or uncertainty about urinary incontinence
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6
Q

What are examinations and investigations for PPROM?

A

Examination

  • Sterile speculum examination (avoid digital vaginal examination due to infection risk) - pool of fluid seen and if no fluid seen and unsure then ActimPROM or AmniSure

Investigations

  • FBC
  • CRP
  • HVS
  • Ultrasound – may show oligohydramnios
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7
Q

What is ActimPROM?

A

Antibodies that bind to IGFBP-1

  • Insulin-like growth factor binding protein-1 produced by decidual cells and presents in high amounts in amniotic fluid and is not normally found in vagina.
  • High sensitivity and specificity
  • Can use at any gestational age
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8
Q

What are foetal and maternal complications of PPROM?

A

Foetal

  • Prematurity
  • Infection
  • Pulmonary hypoplasia
  • Cord prolapse

Maternal

  • Chorioamnionitis (can affect up to 5% of all pregnancies)
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9
Q

What is Chorioamnionitis?

A
  • Potentially life-threatening condition to both mother and foetus and is therefore considered a medical emergency.
  • Results from an ascending bacterial infection of the amniotic fluid/membranes/placenta.
  • Major risk factor in this scenario is the PPROM (however, it can still occur when the membranes are still intact) which expose the normally sterile environment of the uterus to potential pathogens.
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10
Q

How is Chorioamnionitis managed?

A

Mainstay initial treatment: Prompt delivery of the foetus (via caesarean section if necessary) and administration of IVantibiotics

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11
Q

How is PPROM managed?

A

Admission

  • Regular observations to ensure chorioamnionitis is not developing for at least 48h-72h. Inform NICU and SCBU
  • Oral erythromycin given for 10 days.
  • CRP, WBC, temperature, maternal and foetal heart rate monitored
  • Antenatal corticosteroid should be administered to reduce risk of respiratory distress syndrome if between 24-33+6 weeks
  • Expectant management until at least 37 weeks if no other risk factors
  • Delivery considered at 34 weeks of gestation if GBS suspected– trade-off between increased risk of maternal chorioamnionitis with decreased risk of respiratory distress syndrome as the pregnancy progresses
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12
Q

What is Pre-term labour?

A

Labour/regular contraction resulting in changes in cervix before 37 weeks.

  • Leading causes of perinatal death and disability
  • Psychosocial and emotional effect on the family. Also has Increased cost for health services
  • 75% of preterm births are spontaneous labour, remainder elective
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13
Q

What are risk factors for Pre-term labour and how are they managed?

A

Risk factors are: Spontaneous preterm birth, Mid-trimester PPROM, Cervical trauma

Management:

  • Increased Transvaginal ultrasounds to monitor cervical length
  • High vaginal swabs (for bacterial vaginosis)
  • If shortening between 16-24 weeks, can give prophylactic vaginal progesterone or perform cervical cerclage
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14
Q

How is a patient with Pre-term labour assessed?

A

History

  • Menstrual-like cramping
  • Mild irregular contractions
  • Low back ache
  • Pressure sensation in vagina or pelvis
  • Vaginal discharge of mucus which may be clear, pink or slightly bloody

Examination:

  • Abdomen: assess firmness, tenderness, foetal size and foetal postion
  • Contractions: frequency, intensity, duration
  • Review foetal heart rate
  • Speculum: estimate cervical dilation and assess for blood or fluid

NICE recommends treatment for women under 30 weeks without investigations and to investigate if over 30 weeks.

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15
Q

What are tests for Pre-term labour?

A
  • Gold Standard: Ultrasound. If Transvaginal USS for cervical length shows:
    • >15mm – unlikely pre-term labour
    • <15mm – confirmed preterm labour and offer treatment
  • Bedside test
    • Foetal fibronection – NICE recommended
    • ACTIM-PARTUS – not NICE validated
      • Uses phosphorylated IGFBP-1. Leaks into cervix when decidua and chorion detach. Good NPP
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16
Q

How is Preterm labour managed?

A
  • Admission: liase with neonatology
  • Tocolysis: slow down contractions with nifedipine or atosiban. Allow time for administration of steroids or transfer
  • Lung Maturity: corticosteroids if <34 weeks
  • Rescue Cerclage: if dilated cervix with exposed foetal membranes but less than 28 weeks, no PPROM, no infection, no contractions
  • In Labour: neuroprotection with magnesium sulphate for <34 weeks. Antibiotics given and continuous monitoring
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17
Q

What is an amniotic fluid embolism?

A
  • When foetal cells/amniotic fluid enters the mother’s bloodstream and stimulate a reaction which may be immune mediated
  • Majority of cases present in labour but also can occur in caesarean section and after delivery in immediate postpartum period
18
Q

What is the clinical presentation of Amniotic Fluid Embolism?

A
  • Symptoms include: chills, shivering, sweating, anxiety, and coughing
  • Signs include: cyanosis, hypotension, bronchospasms, tachycardia, arrhythmias, and myocardial infarction

Clinical diagnosis of exclusion. Critical care unit by an MDT. Management is mostly supportive.

19
Q

What is Post-Term Pregnancy?

A

Pregnancy that has extended to or beyond 42 weeks

20
Q

What are complications of Post-Term Pregnancy?

A

Neonatal

  • Reduced placental perfusion
  • Oligohydramnios

Maternal

  • Increased rates of intervention including forceps and c-section
  • Increased rates of labour induction
21
Q

How is a bishop score interpreted?

A
  • Score of <5 indicates that labour is unlikely to start without induction
  • Score of >9 indicates that labour will most likely commence spontaneously
22
Q

What is the indication for induction of labour?

A
  • Prolonged pregnancy e.g. > 12 days after estimated date of delivery
  • Prelabour premature rupture of the membranes, where labour does not start
  • Diabetic mother > 38 weeks
  • Rhesus incompatibility
23
Q

What are methods of inducing labour?

A
  • Membrane sweep
  • Intravaginal prostaglandins
  • Breaking of waters
  • Oxytocin
24
Q

What is labour?

A

Onset of regular and painful contractions associated with cervical dilation and descent of the presenting part

25
Q

What are factors that affect labour?

A
  • Passage: Pelvis and Soft tissues
  • Powers: Fundal dominance of the contractions. Contractions are rhythmic and occur every 3-4 minutes in early labour and every 2-3 minutes in advanced labour.
  • Passenger: Lie and presentation
  • Denominator: Part of the fetus used as reference point to describe the position in the maternal pelvis
  • Position: Relationship of the fetal denominator to the maternal pelvis
26
Q

What makes up the pelvis and soft tissues passage?

A
  • Pelvis: has Pelvic Inlet, Mid-cavity and Pelvic Outlet. It rarely causes obstruction unless bone disease or trauma
  • Soft tissues: Lower uterine segment, cervix, vagina, vulva, pelvic floor and perineum. It rarely causes obstruction unless in cases of FGM, cervical treatment
27
Q

What is the Lie and Presentation?

A
  • Lie**: Relationship of fetal long axis of the baby to that of the mother (long, oblique and transverse).
  • Presentation: the part of the foetus lowermost in the uterus (cephalic, vertex, brow, face, breech, shoulder). There are grades of skull transformations
28
Q

What are signs of labour?

A
  • Regular and painful uterine contractions
  • A show - shedding of mucous plug)
  • Rupture of the membranes (not always)
  • Shortening and dilation of the cervix
29
Q

What are stages of labour?

A

Stage 1: From the onset of true labour to when the cervix is fully dilated. In a primigravida, it can last typically 10-16 hours. At this stage there are 3-4 contractions every 10 minutes and 3-4cm dilated.

Stage 2: from full dilation to delivery of the foetus

Stage 3: from delivery of foetus to when the placenta and membranes have been completely delivered

30
Q

What is the typical presentation of the baby in Stage 1 labour?

A
  • 90% of babies are vertex.
  • Head enters pelvis in occipito-lateral position. Head normally delivers in an occipito-anterior position
31
Q

What are phases of Stage 1 Labour?

A
  • Latent phase = 0-3 cm dilation normally take 6 hours
  • Active phase = 3-10 cm dilation normally 1cm/hr
32
Q

What are causes of Delay of Stage 1 Labour?

A
  • Foetal malpresentation
  • Issues with Uterine contraction
  • Cervical Dystocia or stenosis
  • Cephalopelvic disproportion
33
Q

What is the management of Stage 1 Labour?

A
  • Artificial rupture of membranes if already not broken
  • Regular vaginal examinations advised
  • Oxytocin drip with epidural and electronic monitoring
34
Q

What occurs in Stage 2 of Labour?

A
  • ‘Passive 2nd stage’ refers to 2nd stage in the absence of pushing.
  • ‘Active 2nd stage’ refers to active process of maternal pushing. This stage often less painful compared to first.
  • Can last approximately 1 hour but if longer than this, consider Ventouse extraction, forceps delivery or caesarean section
  • 2nd stage is associated with transient foetal bradycardia
35
Q

What are the stages the foetus goes through when in labour to expulsion?

A
  • Engagement
  • Flexion
  • Descent
  • Internal rotation
  • Extension
  • External Rotation (if this doesn’t happen, can be a sign of shoulder obstruction)
36
Q

What maternal monitoring is done during labour?

A
  • Maternal pulse rate assessed every 60min
  • Maternal BP and temp should be checked every 4 hours
  • Contractions assessed every 10 min, cervical dilation and descent of presenting part
37
Q

What is the management of the mother during labour?

A
  • Analgesia
  • Antacids
  • Bladder care – voiding regularly, catheter
  • 3rd stage – active management, oxytocics and controlled cord traction. Check perineum post delivery
38
Q

What is the foetal monitoring for labour?

A
  • Fetal Heart Rate (FHR) monitored every 15min (or continuously via CTG).
  • Colour of liquor checked as well
  • VE should be offered every 4 hours to check progression of labour
39
Q

What is Cardiotocography?

A

Measures pressure changes in uterus using internal or external pressure transducers. Normal foetal heart rate varies between 100-160/min

  • CTG has high sensitivity and high specificity
  • Confirm by foetal acid-base status
  • If unable to perform, deliver by the speediest route
40
Q

What are guideline that indicate continuous monitoring?

A
  • Suspected chorioamnionitis or sepsis, or a temperature of 38°C or above
  • Severe hypertension 160/110 mmHg or above
  • Oxytocin use
  • The presence of significant meconium
  • Fresh vaginal bleeding that develops in labour - this was a new point added to the guidelines in 2014
  • 2 temperature readings of 37.5

Year 4k: Obs and Gynae (19 decks)

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