Tn: High Risk Labour And Delivery

Front 1

Preterm Labour Definition

Back 1

regular uterine contractions accompanied by progressive cervical dilation and / or effacement at greater than 20 weeks and less than 37 weeks 0 days’ gestation.

Front 2

Preterm birth definition

Back 2

delivery before 37 weeks 0 days gestation

Front 3

Aetiology of preterm birth

Back 3

• Preterm pre-labor rupture of membranes (PPROM) (30–40% of preterm births)
  
• Spontaneous preterm labor with intact membranes (40–50% of preterm births)
  
• Medically indicated (20–30% of preterm births)
  

Front 4

Maternal/fetal conditions associated with clinically indicated preterm birth?

Back 4

• Pre-eclampsia
  
• Complicated insulin-dependent diabetes mellitus
  
• Abnormal (non-reassuring) fetal surveillance
  
• Intrauterine growth restriction (IUGR)
  
• Abruptio placenta
  
• Intrauterine fetal death (IUFD)
  
• Chorioamnionitis
  
• Monochorionic, Monoamniotic twins
  

Front 5

Risk factors for SPONTANEOUS preterm birth?

Back 5

• Reproductive history
  
• PPROM in current pregnancy
  
• Antepartum bleeding
  
• Cervical uterine factors
  
• Fetal/intrauterine factors
  
• infection
  
• lifestyle
  
• demographics

Front 6

Factors on reproductive history that increase risk of spontaneous preterm birth?

Back 6

• Previous spontaneous preterm birth
  
• Advanced reproductive technologies (ART)
  

Front 7

Cervical/uterine factors that increase risk of spontaneous preterm birth?

Back 7

• Cervical insufficiency (incompetence) /Uterine malformation and fibroids
  
• Excisional cervical treatment for cervical intraepithelial neoplasia
  

Front 8

Fetal/intrauterine factors that increase risk of spontaneous preterm birth?

Back 8

• Fetal anomaly
  
• Multiple pregnancy
  
• Polyhydramnios (uterine overdistension)
  

Front 9

Infectious correlates that increase risk of spontaneous preterm birth?

Back 9

• Chorioamnionitis
  
• Bacteriuria
  
• Periodontal disease
  
• Current Bacterial vaginosis with a prior preterm birth
  
• Malaria (particularly in developing countries)
  

Front 10

Lifestyle issues that increase risk of spontaneous preterm birth?

Back 10

• Illicit drugs
  
• Smoking (>10 cigarettes/day)
  
• Physical abuse
  
• Inadequate prenatal care
  
• Low pre-pregnancy weight (< 55 kilograms)
  
• Poor weight gain in pregnancy
  
• Stress
  
• Obesity
  

Front 11

Demographic factors that increase risk of spontaneous preterm birth?

Back 11

• Low socioeconomic status
  
• Single women
  
• Low level of education
  
• maternal age < 18 and > 35 years
  

Front 12

Clinical features of preterm labour?

Back 12

• regular contractions (2 in 10 min)
  
• cervix >2 cm dilated or 80% effaced or documented change in cervix
  

Front 13

Treatment of preterm labour?

Back 13

STAT:

Steroids

Tocolytics, if indicated

Antibiotics: GBS prophylaxis

Transport

Front 14

Treatment summary (preterm labour)

Back 14

• Diagnose promptly and accurately
  
• Identify and treat underlying cause, if possible
  
• Attempt to prolong pregnancy if indicated
  
• Consider magnesium sulfate therapy under 31 weeks and 6 days’ for neuroprotection
  
• Intervene to minimize neonatal morbidity and mortality
  
• Follow recommendations for antenatal steroid therapy
  
• Give GBS prophylaxis as required
  
• Effect maternal transport as appropriate
  
• Provide anticipatory guidance related to the importance of skin-to-skin care, human milk and breastfeeding, oral immune therapy (OIT) and how to establish lactation
  

Front 15

Premature Rupture of Membranes, definition

Back 15

• PROM or amniorrhexis: rupture of membranes prior to labour at any GA
  
• prolonged ROM: > 24 h elapsed between rupture of membranes and onset of labour
• preterm ROM: ROM occuring before 37 37 weeks gestation (associated with PTL)
• PPROM: rupture of membranes before 37 weeks and prior to onset of labour

Front 16

How to determine membrane status?

Back 16

• pooling of fluid on speculum exam
• increase pH on vaginal fluid (nitrazine test)
• ferning of fluid under light microscopy
• decreased AFV on US

Front 17

PROM maternal risk factors

Back 17

• multiparity
  
• cervical incompetence
• infection (cervicitis, vaginitis, STI, UTI)
• family history of PROM
• low SES/poor nutrition

Front 18

PROM fetal risk factors

Back 18

• congenital anomaly
  
• multiple gestation
  

Front 19

clinical features of PROM?

Back 19

history of fluid gush or continued leakage

Front 20

Is digital pelvic exam recommended when diagnosing PROM?

Back 20

not recommended because of the increased risk of ascending infection and shortening of the latent period.

However, sterile speculum examination is appropriate for confirmation of PROM, assessment of cervical status, and exclusion of cord prolapse

Front 21

Investigations for PROM?

Back 21

1. History

2. Speculum exam (look for pooling in posterior fornix, free flow of fluid, ferning, pH test of fluid)

3. US to r/o fetal anomalies, assess GA and BPP

Note: ferning = high salt in amniotic fluid evaporates

Front 22

What is the L/S ratio?

Back 22

Lecithin: sphingomyelin ratio

Lecithin levels increase rapidly after 35 w gestation, whereas sphingomyelin levels remain relatively constant. L/S ratio is a measure of fetal lung maturity. Less than 2:1 indicates pulmonary immaturity

Front 23

Complications of term PROM?

Back 23

• Fetal/neonatal infection (e.g., RDS, IVH, NEC)
  
• Maternal infection (e.g., Endometritis , Chorioamnionitis , bacteremia)
  
• Umbilical cord compression / prolapsed
  

Front 24

Complications of PPROM?

Back 24

The most significant complication of PPROM is preterm birth and its consequences

• Preterm labor and delivery
  
• Fetal / neonatal infection
  
• Maternal infection
  
• Umbilical cord compression / prolapse
  
• Increased cesarean section rate
  
• Abruptio placenta
  

Front 25

Summary for management of PPROM 34 to 36.6 weeks

Back 25

• Avoid digital cervical exam
  
• Assess for infection: Obtain cultures
  
• Ultrasound assessment of fetal Position , cervical status and fluid volume.
  
• Antibiotics for GBS prophylaxis, if indicated
  
• Consider transfer to a higher level center, if appropriate
  
• Consider induction of labor with oxytocin to reduce the risk of Chorioamnionitis (at the expense of an increase in mild neonatal morbidity - respiratory and metabolic)
  
• Inform women of the benefits and risks of induction of labor compared with Expectant management
  
• if management is expectant assess for infection (monitor maternal pulse and temperature, fetal heart rate, presence of uterine tenderness or irritability, WBC changes),
  
• If Chorioamnionitis is suspected, administer appropriate antibiotics and deliver.
  

Front 26

Management of PPROM 34 weeks or less?

Back 26

• Avoid digital cervical exam.
  
• Assess for infection: Obtain cultures, if indicated
  
• Amniotic fluid may be collected from the vagina to assess fetal lung maturity.
  
• Ultrasound assessment of fetal Position , cervical status and fluid volume.
  
• Glucocorticoids should be given < 32 weeks’ and considered from 32 weeks’ to 34 weeks’ (preferably, betamethasone IM, 12 mg 24hours x 2 doses).
  
• Antepartum antibiotics: consider the administration of erythromycin.
  
• Antibiotics for GBS prophylaxis, if indicated.
  
• Restart GBS prophylaxis at the onset of labor, if indicated.
  
• Consider transfer to a tertiary care center, if appropriate.
  
• Expectant management .
  
• Surveillance for Chorioamnionitis (monitor maternal pulse and temperature, fetal heart rate, presence of uterine tenderness or irritability, differential WBC changes).
  
• Appropriate antibiotics and induction of labor if Chorioamnionitis develops.
  

Front 27

What percentage of women with PROM at 28-34 weeks go into spontaneous labour within 1 week?

Back 27

90%

Front 28

What percentage of women with PROM at < 26 weeks gestational age go into spontaneous labour within 1 week?

Back 28

50%

Front 29

What are complications of PROM?

Back 29

cord prolapse

intrauterine infection

premature delivery

limb contracture

Front 30

What is breech presentation?

Back 30

When the buttocks of the fetus enters the maternal pelvis first

Front 31

Three types of breech presentation?

Back 31

• Complete
  
• Footling/incomplete
  
• Frank
  

Front 32

What is complete breech?

Back 32

10%

flexion at hips and knees

Front 33

What is footling/incomplete breech?

Back 33

10-30%

one or both hips extended, foot or knee presenting

Front 34

What is frank breech?

Back 34

60%

hips flexed, knees extended

Front 35

Epidemiology of breech presentation?

Back 35

occurs in 3-4% of pregnancies at term (25% before 28 wk)

Front 36

Maternal risk factors for breech presentation?

Back 36

• pelvis (contracted)
• uterus (shape abnormalities, intrauterine tumours, fibroids)
• extrauterine tumours causing compression
• grand multiparity

Front 37

Maternal-fetal risk factors for breech presentation?

Back 37

• placenta (previa)
• amniotic fluid (poly-/oligohydramnios)

Front 38

Fetal risk factors for breech presentation?

Back 38

• prematurity
• multiple gestation
• congenital malformations
• abnormalities in fetal tone and movement
• aneuploidy

Front 39

Managaement of breech presentation?

Back 39

ECV: reposition of fetus within uterus under US guidance (65% success rate)

Pre or early labour US to assess type of breech presentation, fetal growth, estimated weight, attitude of fetal head; if US unavailable recommend CS

Trial of labour and elective CS should be presented as options

Front 40

Method for vaginal breech delivery?

Back 40

encourage effective maternal pushing efforts

at delivery of after-coming head, assistant must apply suprapubic pressure to flex and engage fetal head

delivery can be spontaneous or assisted

apply fetal manipulation only after spontaneous delivery to level of umbilicus

Front 41

When is CS recommended for breech?

Back 41

if breech has not descended to perineum in second stage of labour after 2 h

in absence of active pushing

or if vaginal delivery not imminent after 1 h of active pushing

Front 42

contraindications to breech delivery

Back 42

cord presentation

clinically inadequate maternal pelvis

fetal factors incompatible with vaginal delivery

Front 43

Prognosis of breech delivery?

Back 43

regardless of route of delivery, breech infants have lower birth weights and higher rates ofperinatal mortality, congenital anomalies, abruption, and cord prolapse

Front 44

Criteria for breech delivery?

Back 44

• Frank or complete breech, GA >36 wk
  
• EFW 2500-3800 g based on clinical and US assessment
  
• fetal head fixed
  
• continuous fetal monitoring
  
• 2 experienced obstetricians, assistant, and anesthetist present
  
• ability to perform emergency CS within 30 min if required
  

Front 45

What is VBAC

Back 45

Vaginal birth after Cesarean

Front 46

Risk of uterine rupture for VBAC

Back 46

<1%

Front 47

VBAC recommended after what sort of incision

Back 47

Low transverse incision

Front 48

Success rate for VBAC

Back 48

60-80%

Front 49

Contraindications for VBAC

Back 49

• previous classical, inverted T, or unknown uterine incision
• history of hysterectomy
• multiple gestation
• non-vertex presentation or placenta previa
• inadequate facilities or personnel for emergency CS

Front 50

What is prolonged pregnancy?

Back 50

pregnancy beyond 42 wk GA

Front 51

Epidemiology of prolonged pregnancy?

41 week and 42 wk GA

Back 51

• 41 week GA: up to 27%
• 42 week GA: 4-14%

Front 52

Causes of prolonged pregnancy?

Back 52

• most cases idiopathic
• anencephalic fetus with no pituitary gland
• placental sulfatase deficiency - rare

Front 53

Clinical features of prolonged pregnancy

Back 53

Postmaturity syndrome

complications

Front 54

Postmaturity syndrome

Back 54

• fetal weight loss,
• reduction insubcutaneous fat,
• scaling,
• dry skin from placental insufficiency,
• long thin body,
• open-eyed, alertand worried look, long nails, palms and soles wrinkled

Front 55

Complications of prolonged pregnancy?

Back 55

• with increasing GA, higher rates of: intrauterine infection,
  
• asphyxia,
  
• meconium aspirationsyndrome,
  
• placental insufficiency,
  
• placental aging and infarction,
  
• macrosomia,
  
• dystocia, fetaldistress, operative deliveries
  

Front 56

Management of prolonged pregnancy (GA 40-41 wk)

Back 56

• expectant management
  
• no evidence to support IOL or C/S unless other risk factors for morbidity are present (see prognosis)
  

Front 57

Management of prolonged pregnancy (GA > 41 wk)

Back 57

• offer IOL if vaginal delivery is not contraindicated
  
• IOL shown to decrease C/S, fetal heart rate changes, meconium staining, macrosomia, anddeath when compared with expectant management
  

Front 58

What is IOL?

Back 58

Induction of labour

Front 59

Prognosis of prolonged pregnancy?

Back 59

• if >42 wk, perinatal mortality 2-3x higher (due to progressive uteroplacental insufficiency)
• morbidity increased with HTN in pregnancy, DM, abruption, IUGR, and multiple gestation

Front 60

Define intrauterine fetal death

Back 60

Fetal death in utero after 20 week GA

Front 61

Epidemiology of intrauterine fetal death

Back 61

1% of pregnancies

Front 62

Cause of intrauterine fetal death

Back 62

50% are idiopathic

50% secondary to:

• HTN
• DM
• erythroblastosis fetalis
• congenital anomalies
• umbilical cord
• placental complications
• intrauterine infection
• APS

Front 63

Clinical features intrauterine fetal death

Back 63

• decreased perception of fetal movement by mother
  
• SFH and maternal weight not increasing
  
• absent fetal heart tones (not diagnostic)
  
• high MSAFP
  

Front 64

How to diagnose intrauterine fetal demise?

Back 64

absent cardiac activity and fetal movement on U/S required for diagnosis

Front 65

How to determine secondary cause of intrauterine fetal demise?

Back 65

• maternal: HbA1c, Kleihauer-Betke, VDRL, ANA, antibody screens, INR/PTT, serum/urinetoxicology screens, cervical and vaginal cultures, TORCH screen
  
• fetal: chromosomes, cord blood, skin biopsy, genetics evaluation, autopsy
  
• placenta: pathology, bacterial cultures
  

Front 66

Treatment of intrauterine demise?

Back 66

• induction of labor
  
• monitor for maternal coagulopathy (10% risk of DIC)
  
• parental psychological care as per hospital protocol
  
• comprehensive discussion within 3 mo about final investigation and post mortem results, make plans for future pregnancies