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Midwifery Emergencies > USE THIS PRETERM > Flashcards

USE THIS PRETERM Flashcards

1
Q

Define preterm labour + what source?

A

Labour between 24 and 37 weeks, with the onset of regular contractions associated with effacement + progressive cervical dilation - may or may not be ROM (MAYES p979)

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2
Q

What is the age of viability?

A

24 weeks but if >23 and estimated >400g and showing signs of life, resus often attempted

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3
Q

What happens in the last few weeks of pregnancy?

A

laying down of brown fat, sucking reflex and lung surfactant

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4
Q

What are late preterm babies at risk of?

A

hypoglycaemia, jaundice and RDS

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5
Q

In 2012 what was the incidence of premature babies?

A

> 52,000

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6
Q

What is the prematurity the biggest cause of?

A

neonatal mortality and morbidity

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7
Q

What are 75% of premature births a concequence of?

A

preterm spontaneous labour or secondary to PPROM

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8
Q

What causes the other 25% ?

A

elective decision to deliver the baby

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9
Q

What is the major long term consequence of premature birth?

A

neurodevelopmental disability

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10
Q

What other things is premature birth associated with?

A

cerebral palsy, chronic lung disease

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11
Q

Behavioural and environmental risk factors 10

A
  • smoking - pprom and iugr
  • recreational drugs, alcohol
  • poor nutritional status/malnourishment
  • low bmi <19
  • physically demanding work e.g. manual work - may be associated with lower socio-economic status
  • prolonged periods of standing ?shift/night work
  • domestic violence
  • abdo injury / trauma
  • stress - catecholamine release
  • cocaine - placental abruption
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12
Q

Demographic risk factors

A
  • low socioeconomic status
  • <17 years or >35 years
  • ethnicity - ethnic minority in a developed country - unknown cause
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13
Q

Medical risk factors

A
  • infection -40%
  • diabetes
  • renal disease
  • cardiovascular disease
  • hypertension
  • antiphospholipid syndrome
  • psychiatric disorders
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14
Q

What is antiphospholipid syndrome?

A

Disorder of the immune system that causes an increased risk of blood clots

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15
Q

What is important about infection and prematurity?

A

It can be the cause of the preterm birth or PPROM - usually assumed over >48 hr PPROM is the cause of infection but it may have caused the PPROM - always do a septic screen

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16
Q

Reproductive risk factors

A

-PPROM
-placental abruption/aph
inadequate antenatal care
-previous preterm labour
-previous >2nd trimester loss
-multiple pregnancy - if MCMA often delivered at 32 weeks to avoid twin to twin transfusion
-cervical abnormalities - sutures, previous lletz
-uterine abnormalities - bicornate, uterus with septum
-polyhydramnios
-IUGR
-history of preterm labour

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17
Q

What is the incidence of PPROM?

A

2%

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18
Q

How can preterm labour be prevented?

A
  • encouraging a healthy lifestyle
  • comprehensive antenatal care
  • on-going risk assessment
  • infection screening in pregnancy
  • routine msu testing
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19
Q

What are the 2 most accurate markers to predict women at risk of preterm labour?

A

transvaginal USS of cervical length, measurement of cervicovaginal fetal fibronectin levels

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20
Q

What is cervicovaginal fetal fibronectin?

A

It is a protein found in amniotic fluid, placental tissue and the extracellular substance of the intervillous space. By 22 weeks, following fusion of chorion and decidua FFN secretion stops. Before labour starts, separation of chorion from decidua releases secretion of ffn. If the test is detected after 22 weeks it is a preterm birth indicator.

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21
Q

What are the results of the ffn test?

A

High negative and low positive

negative = 50ng/ml or less

Positive 50ng/ml or more

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22
Q

What causes ffn to become inaccurate?

A

presence of pprom or vaginal bleeding

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23
Q

What is the transvaginal uss for?

A

To measure cervical length- safe and acceptable test for women

  • The normal average length of cervix at 24 weeks is 35.2mm +/- 8.3mm .
  • in normal low risk pregnancies, the length remains constant until 3rd trimester
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24
Q

How can low socioeconomic status cause preterm labour?

A

associated with increased risk. prevention in this category involves preconception care including education on smoking cessation, better family planning and interpregnancy spacing, and financial support, alleviate poverty, partner education to reduce domestic violence

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25
Q

What is vaginal progesterone?

A

prophylactic treatment - inhibits uterine contractions and cervical ripening which prolongs pregnancy
-has been shown to reduce rates of ptb in women with a singleton pregnancy and hx of previous ptb, a short cx identified on tuss between 19-25 weeks

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26
Q

What is a cervical cerclage?

A

this is a suture placed around the cervix before or during pregnancy to correct structural weakness or defects

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27
Q

What is used when suspected preterm labour to diagnose?

A

Measurement of cervical length, fetal fibronectin

28
Q

What is important in the care of preterm labour?

A

Antenatal corticosteroids - lung maturation
Nifedipine - usually antihypertensive but also tocolytic
Magnesium sulfate- lung surfactant production

29
Q

How is fetal monitoring done for preterm birth?

A

if <28 weeks no ctg - for wellbeing of healthy term babies

30
Q

What is the ideal cord clamping for preterm babies?

A

30 seconds

31
Q

What do corticosteroids do for women at risk of ptb?

A

Reduction in risks of complications of prematurity such as RDS, intraventricular haemorrhage and perinatal death

32
Q

What are the two corticosteroid regimes shown to be effective?

A

Betamethasone 12mg IM, 2 doses, 24 hours apart

Dexamethasone 6mg, 4 doses 12 hourly

33
Q

Which corticosteroid is shown to be more effective?

A

betamethasone - greater reduction in RDS

34
Q

What are tocolytics?

A

Medicines that prevent uterine contractions

35
Q

What tocolytics are offered to women?

A 
Atosiban (oxytocin receptor inhibitor) 
Ritodrine (not often as lot of side effects) 
Betamimetic 
GTN
Indomethacin
Magnesium sulfate
Nifedipine (calcium channel blocker)
36
Q

Does tocolysis improve outcomes?

A

No clear evidence - only indication is to complete full course of corticosteroids

37
Q

What is the most beneficial tocolytic and what is the issue with it?

A

Nifedipine - increased gestational age at birth, fewer NICU admissions and shorter duration of stay

  • Not licensed for use as a tocolytic
38
Q

What is magnesium sulfate used for?

A

Cochrane review showed it reduces the risk of cerebral palsy in preterm infants and reduces the risk of gross motor function disturbances
No significant effect on mortality or other neurological disability.

39
Q

What mag sulf regime do NICE recommend? 2015

A

admission of a bolus dose of 4g, then a maintenance dose of 1g/hour until delivery or 24 hours.

40
Q

When is mag sulf offered?

A

Between 24-29+4 and considered between 30-33+4

41
Q

How do we manage preterm delivery? 10

A
  1. Provide vigilant labour care in line with NICE intrapartum care guidelines
  2. Stop tocolytics
  3. If borderline viability - early MDT involvement
  4. CTG if over 28 weeks
  5. Spontaneous labour for preterm is often rapid
  6. Desicion over LSCS or vaginal delivery depends on gestation, presentation and fetal condition
  7. Instrumental - never ventouse as fetal skull soft - forceps may be used
  8. Epis may be used for easier passage of fragile skull
  9. Important to avoid delay on perineum - high pressure on skull
  10. Ensure all towels and hats etc are pre-warmed and clock is started at birth, begin active resus, paeds and nnu staff ready and present, plastic bag for warmth
42
Q

What are the maternal complications of a ptb?

A
  • Risk of infection following aph, anaemia and increased vulnerability following maternal shock
  • Haemorrhage if placental abruption
  • Psychological trauma/PTSD
  • DIC - secondary to infection or haemorrhage
  • Maternal death
43
Q

Fetal complications of ptb

A
  • complications of prematurity - RDS, poor temp control, hypoglycaemia
  • infection
  • death
  • cerebral palsy
44
Q

Role of the midwife in ptb

A
  • prevention
  • risk assessment
  • early detection- plan in place- mdt
  • liaise with medical staff
  • labour care
  • visit scbu
  • prep parents for delivery
  • keep baby warm - neo wrap
  • encourage expression - reduction of NEC
  • Offer emotional support
  • Direct to financial support - BLISS family fund
45
Q

What reactions can women have to preterm labour?

A
  • complex emotions (guilt, sense of failure)
  • lack of prep time
  • lack of experience
  • fear for wellbeing of baby
  • prolonged disruption to life if baby in scbu
46
Q

What is pprom?

A

Preterm prelabour rupture of membranes

47
Q

What is the incidence of PPROM?

A

2% of pregnancies

48
Q

How many preterm deliveries are associated with pprom?

A

40%

49
Q

What are the complications of PPROM?

A
  • prematurity
  • sepsis
  • pulmonary hypoplasia
  • cord prolapse
  • malpresentatin
  • ?APH
50
Q

How is PPROM diagnosed?

A

-positive if pool of fluid seen in vagina during speculum

  • Microscopic exam which looks for:
  • ferning of crytalline pattern of dried amniotic fluid
  • presence of lanugo hair
  • fetal epithelial cells

-USS for oligo

51
Q

What test is done if no fluid pooling in vagina?

A

Insulin like growth factor binding protein 1 or placental alpha microglobulin 1 test

52
Q

Which test for pprom should you not use and why?

A

nitrazine test - can be innacurate as based on pH which can be altered by vaginal secretions, semen and blood

53
Q

What is the management of PPROM?

A
  • corticosteroids
  • antibiotics
  • inpatient vs home care
  • timing and method of delivery should be decided
54
Q

What antibiotics are given for PPROM?

A

Erythromycin 250mg QDS for 10 days or until labour

55
Q

If unable to take usual pprom antibiotic which one can be given?

A

Penicillin for 10 days or until labout

56
Q

Which antibiotic should not be given for PPROM?

A

Augementin/co-amoxiclav

- increased risk of NEC

57
Q

What is the benefit of giving antibiotics for pprom?

A

Reduction in chorioamnionitis, delivery within 48 hours, reduction in infection, use of surfactant, 02 therapy, abnormal cerebral USS

58
Q

What if someone has GBS and pprom?

A

Take CRP, WCC, commence CTG, expedite delivery, depends on gestation and clinical picture

59
Q

What is the inpatient care for PPROM?

A
  • temp 4 hourly
  • ctg daily
  • CRP and WCC daily
  • USS for liqour volume,, growth and doppler
  • MSU + HVS/LVS
  • ? discharge after 48 hours
60
Q

What is the home care for PPROM?

A
  • temp QDS- report if abnormal
  • no baths, sexual intercourse or tampons
  • give info on concerning signs/symptoms that require further investigation
  • twice weekly review in hospital for CTG, CRP and WCC
  • Fortnightly USS for growth
  • Weekly USS for dopplers
61
Q

What are the advantages of home care?

A
  • 10 fewer hospital days as an inpatient - less hospital costs
  • psychological benefits for mother
  • ? less danger of infection as not in hospital
62
Q

What are the disadvantages of home care?

A
  • deterioration in maternal condition might be missed
  • Fetal monitoring only twice weekly
  • RCOG guidelines for fetal monitoring do not advise home care
63
Q

What is the timing of delivery for PPROM?

A
  • depends on maternal condition
  • depends on presentation - cephalic, breech, transverse
  • NICE 2015 does not make any recommendations regarding delivery gestation
64
Q

What does RCOG 2010 say about timing of delivery for pprom?

A

delivery should be considered at 34 weeks. where expectant management is considered beyond this gestation, women should be informed of the increased risk of chorioamnionitis and the decreased risk of respiratory problems in the neonate

65
Q

What is amnioinfusion?

A

The process of instilling isotonic liquid in the uterine cavity. Studies have shown that a transcervical infusion resulted in improved umbilical artery pH at delivery and reduction in variable decels. Transabdominal infusion resulted in a reduction in NND, pulmonary hypoplasia, puerperal sepsis

66
Q

What is pulmonary hypolplasia?

A

incomplete development of the lungs

Midwifery Emergencies (7 decks)

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