Complications in Labour Flashcards
Discuss fever in labour
-Definition (2)
-Incidence (1)
-Implications (2)
-Causes (5)
- Definition
-One reading of temperature >38
-Two readings of temperature >37.5 - Incidence
-1:15 women in labour - Implications
-Isolated intrapartum fever associated with poorer neonatal outcomes even if no infection
-Fetal hyperthermia may lead to tissue hypoxia secondary to increased metabolic rate - Causes
-Infection
-Dehydration
-Neuroaxial block
-Prostaglandins
-Increased room temperature
Discuss chorioamnionitis
-Definition (1)
-Incidence (2)
-Risk factors (8)
-Common infectious agents (4)
-Mode of infection (3)
- Inflammation of the amnio-chorionic membrane of the placenta, amniotic fluids, decidua and fetus
- Incidence
-1% of all live births
-30% of all PPROM - Risk factors
-PPROM/PROM
-PTL
-Prolonged labour
-Known GBS
-Nuliparity
-Mec Liquor
-Internal fetal monitoring
-Invasive procedures - Common infectious agents
-Mycoplasma
-Anerobes
-E. coli
-GBS - Mode of infection
-Mostly ascending infection 96%
-Haematogenous dissemination
-Invasive procedures
What are the histological findings seen on placenta from chorioamnionitis (6)
- Polymorphonuclear leucocytes
- Neurophillic inflammation (Acute)
- Lymphocytic inflammation (chronic)
- Necrotising chorio characterised by hypereosinophillia of basement membrane
- Isolated chorio is seen with ascending infection
- Inflammation of the villi and intervillous space are characteristic of haematogenous spread
What are the implications of chorioamnionitis
-To the mother (4)
-To the baby (5)
- Impact to the mother
-Dysfunctional labour
-Increased rate of CS
-Increased risk of PPH
-DIC and ARDS if severe - Impact to the baby
-Infection
-Respiratory distress
-Intraventricular haemorrhage
-Bronchopulmonary dysplasia
-Cerebral palsy RR 2.4
Discuss management of chorioamnionitis (8)
- Chorioamnionitis is an indication to delivery whether the baby is viable or not
- Augment if not in established labour or labour is dysfunctional
- Chorioamnionitis is rarely a cause for CS alone
- Commence broad spec antibiotics
- Reduce pyrexia with paracetamol
- Give IVF
- Continue antibiotic PP if risk factors for ongoing infection
- Avoid FBS in suspected chorioamnionitis
Discuss meconium liquor
-Causes (2)
-Incidence of mec aspiration syndrome (2)
-Issues associated with mec aspiration syndrome (4)
- Causes
-Fetal distress
-Fetal maturity - Incidence of mec aspiration syndrome
-2-10% of babies born in mec liquor
-Accounts for 2% of perinatal deaths - Issues associated with mec aspiration syndrome
-Infection (Unlikely if not concurrent with sepsis)
-Pneumothorax
-Respiratory failure
-Persistent pulmonary HTN
How should babies born in meconium liquor be managed?
- Call paeds if thick mec or thin mec and fetal distress
- Avoid suctioning when head on perineum
- Rourine endotrachael suction is not indicated
- If baby is vigorous can dry and avoid suction and intubation
- If baby not vigorous prioritise effective ventilation. Can suction what you can see
- Monitor neonate for 24 hrs
Discuss GBS in pregnancy
-Number of women colonised with GBS
-Number of babies colonised if mothers are colonised?
-Number of colonised babies who develop early onset neonatal sepsis?
-Number of babies who die from early onset neonatal sepsis?
-Reduction in risk of sepsis of IV antibiotics given in labour
- Number of women colonised with GBS = 10-30%
- Number of babies colonised if mother colonised = 40-50%
- Number of colonised babies who develop early onset neonatal sepsis = 0.4%
- Number of babies who die from GBS sepsis = 14% of those babies who get early onset GSB sepsis. Case fatality 10 fold higher in preterm infants (20%)
- Reduction in risk of sepsis by 80% if treated with IVABx in labour
Discuss the methods for determining GBS status in pregnant women (3)
- Risk factor based (NZ and UK). Treat if
-PPROM
-Rupture of membranes >18hrs
-Maternal fever >38
-Previous infant with GBS sepsis
-GBS bacteruria at any time in pregnancy
-GBS on swab after 35 weeks or earlier if swab not repeated
-Clinical dx of chorioamnionitis - Universal culture based screening (Aus, USA)
-Vaginal and ano-rectal swab done between 35-37 weeks or within 5 weeks of expected delivery
-Needs to be on selective enriched culture media to increase sensitivity and reduce false negatives (50% false negatives on normal media) - POC testing in labour
-Not currently available
Discuss universal screening for GBS
-Advantages (5)
-Disadvantages (5)
- Advantages
- Positive swab at 36 weeks has 91% sensitivity and 89% specificity
-NPV 95-98%
-Doesn’t miss the 30% of women who have GBS but no risk factors
-Reduced early onset GBS sepsis cf. risk based assessment OR 0.45.
-Able to test for erythromycin and clindamycin sensitivities to use as alternative if penecilin allergic - Disadvantages
-Expensive
-Increased medicalisation of labour
-May not be culturally acceptable to all
-High false negative rate if wrong media used
-Unable to screen when in labour
-May need re-screening
Discuss risk based screening for GBS
-Advantages (4)
-Disadvantages (2)
- Advantages
-Less invasive
-Less expensive
-Less unnecessary Abx use
-Can be used for women presenting in labour with limited ANC - Disadvantages
-Misses 30% of women with GBS + but no risk factors
-Bacteria sensitivities unknown
How should GBS in labour be treated?
-Standard regimen
-If penicillin allergy
-If penicillin anaphylaxis
- Standard regimen - 1.2g Ben Pen loading then 0.6g Q4H
- If penicillin allergic - Cefazolin 2g loading then 1g Q8H
- If Penicillin anaphylaxis - Vancomycin 1g Q12H
How should GBS be managed in the following:
1. ELCS (1)
2. PTL with unknown GBS status (1)
3. Term PROM and GSB positive (1)
4. PPROM (5)
5. A previous child affected by GBS sepsis
- ELCS - no antibiotics required
- PTL with unknown GBS status
-Give Abx if in labour. Discontinue if labour stops - Term PROM with GBS
-Offer immediate IOL and Abx - PPROM
-Test for GBS.
-If GBS + give Abx at onset of labour
-Give erythromycin regardless of GBS status
-If <34 weeks and GBS + manage expectantly
-If >34 weeks and GBS + IOL - PROMEXIL trial - A previous child affected by GBS sepsis
-Give ABX regardless of current GBS status
Discuss the management of incidental GBS finding in pregnancy
-GBS on swab (3)
-GBS in urine (3)
- GBS on swab
-Don’t treat. Recurrence rate 67%
-If within 5 weeks of labour give ABx
-If > 5 weeks from labour re-swab or risk factor based approach - GBS in urine
-Always treat regardless of symptoms
-Give Abx at onset of labour.
-GBS in the urine is associated with high colonisation of the genital tract
