Week 5 part 1 Flashcards
Rupture of membranes (ROM):
The amniotic sac has ruptured.
Spontaneous rupture of membranes (SROM):
The amniotic sac has ruptured spontaneously
Prolonged rupture of membranes (also PROM):
The amniotic sac ruptures more than 18 hours before delivery.
Prematurity
Prematurity is defined as birth before 37 weeks gestation. The more premature the baby, the worse the outcomes
The World Health Organisation classify prematurity as:
- Under 28 weeks: extreme preterm
- 28 – 32 weeks: very preterm
- 32 – 37 weeks: moderate to late preterm
Prophylaxis of Preterm Labour options
Vaginal Progesterone
Cervical Cerclage
Vaginal Progesterone
Progesterone can be given vaginally via gel or pessary as prophylaxis for preterm labour. Progesterone has a role in maintaining pregnancy and preventing labour by decreasing activity of the myometrium and preventing the cervix remodelling in preparation for delivery. This is offered to women with a cervical length less than 25mm on vaginal ultrasound between 16 and 24 weeks gestation.
Cervical Cerclage
Cervical cerclage involves putting a stitch in the cervix to add support and keep it closed. This involves a spinal or general anaesthetic. The stitch is removed when the woman goes into labour or reaches term.
Cervical cerclage is offered to women with a cervical length less than 25mm on vaginal ultrasound between 16 and 24 weeks gestation, who have had a previous premature birth or cervical trauma (e.g. colposcopy and cone biopsy).
“Rescue” cervical cerclage may also be offered between 16 and 27 + 6 weeks when there is cervical dilatation without rupture of membranes, to prevent progression and premature delivery.
Diagnosis of Preterm Prelabour Rupture of Membranes
Speculum examination revealing pooling of amniotic fluid in the vagina. No tests are required.
Management of Preterm Prelabour Rupture of Membranes
Prophylactic antibiotics should be given to prevent the development of chorioamnionitis. The NICE guidelines (2019) recommend erythromycin 250mg four times daily for ten days, or until labour is established if within ten days.
Induction of labour may be offered from 34 weeks to initiate the onset of labour.
Preterm Labour with Intact Membranes
Preterm labour with intact membranes involves regular painful contraction and cervical dilatation, without rupture of the amniotic sac.
Diagnosis of Preterm Labour with Intact Membranes
Clinical assessment includes a speculum examination to assess for cervical dilatation. The NICE guidelines (2017) recommend:
• Less than 30 weeks gestation, clinical assessment alone is enough to offer management of preterm labour.
• More than 30 weeks gestation, a transvaginal ultrasound can be used to assess the cervical length. When the cervical length on ultrasound is less than 15mm, management of preterm labour can be offered. A cervical length of more than 15mm indicates preterm labour is unlikely.
Fetal fibronectin
An alternative test to vaginal ultrasound. Fetal fibronectin is the “glue” between the chorion and the uterus, and is found in the vagina during labour. A result of less than 50 ng/ml is considered negative, and indicates that preterm labour is unlikely.
Tocolysis
Tocolysis involves using medications to stop uterine contractions. Nifedipine, a calcium channel blocker, is the medication of choice for tocolysis. Atosiban is an oxytocin receptor antagonist that can be used as an alternative when nifedipine is contraindicated.
When can tocolysis be used?
Tocolysis can be used between 24 and 33 + 6 weeks gestation in preterm labour to delay delivery and buy time for further fetal development, administration of maternal steroids or transfer to a more specialist unit (e.g. with a neonatal ICU). It is only used as a short term measure (i.e. less than 48 hours).
Antenatal Steroids
Giving the mother corticosteroids helps to develop the fetal lungs and reduce respiratory distress syndrome after delivery. They are used in women with suspected preterm labour of babies less than 36 weeks gestation.
An example regime would be two doses of intramuscular betamethasone, 24 hours apart.
Magnesium Sulfate
Giving the mother IV magnesium sulfate helps protect the fetal brain during premature delivery. It reduces the risk and severity of cerebral palsy. Magnesium sulphate is given within 24 hours of delivery of preterm babies of less than 34 weeks gestation. It is given as a bolus, followed by an infusion for up to 24 hours or until birth.
Magnesium toxicity symptoms
Mothers need close monitoring for magnesium toxicity at least four hourly. This involves close monitoring of observations, as well as tendon reflexes (usually patella reflex). Key signs of toxicity are:
• Reduced respiratory rate
• Reduced blood pressure
• Absent reflexes
The Bishop score
The Bishop score is a scoring system used to determine whether to induce labour.
Five things are assessed and given a score based on different criteria (minimum score is 0 and maximum is 13):
• Fetal station (scored 0 – 3)
• Cervical position (scored 0 – 2)
• Cervical dilatation (scored 0 – 3)
• Cervical effacement (scored 0 – 3)
• Cervical consistency (scored 0 – 2)
What bishop score predicts a successful induction of labor?
A score of 8 or more predicts a successful induction of labour. A score below this suggests cervical ripening may be required to prepare the cervix.
There are two means for monitoring during the induction of labour; what are they?
- Cardiotocography (CTG) to assess the fetal heart rate and uterine contractions before and during induction of labour
- Bishop score before and during induction of labour to monitor the progress
Uterine hyperstimulation
Uterine hyperstimulation is the main complication of induction of labour with vaginal prostaglandins. This is where the contraction of the uterus is prolonged and frequent, causing fetal distress and compromise.
The criteria for uterine hyperstimulation varies slightly between guidelines (always check local policies and involve experienced seniors). The two criteria often given are:
- Individual uterine contractions lasting more than 2 minutes in duration
- More than five uterine contractions every 10 minutes
Uterine hyperstimulation can lead to:
- Fetal compromise, with hypoxia and acidosis
- Emergency caesarean section
- Uterine rupture