Abnormal labour Flashcards
(37 cards)
What is PPROM (as opposed to PROM) and how is it diagnosed?
-Premature pre-labour rupture of membranes ie <37 weeks
DIAGNOSIS
-Pooling of amniotic fluid seen on sterile speculum
–NB do not perform vaginal examination due to infection risk
-AMNISURE= placental alpha-microglobulin-1 test
What is the probability of spontaneous labour in PPROM vs SROM at term?
PPROM = 80% within 7 days
SROM at term = 90% within 48h
How should PPROM be managed?
Aim is to bide time to delay delivery
-Prophylactic steroids to help with foetal lung maturity (betamethasone 12mg IM, 2 doses 24h apart)
-Antibiotics (erythromycin 250mg QDS for 10 days)
-Intrapartum antibiotic prophylaxis (IAP) should be given during delivery (IM 1.5g Ben-pen)
-Induce labour:
–around 34w if signs of infection
–around 37w if no signs
unless maternal / foetal distress implied
What are the complications of a PPROM before foetal viability?
Absence of amniotic fluid causes the following problems:
-Pulmonary hypoplasie due to reduced ability to ‘practice’ breathing
-Infection risk
-Limb problems due to inability to move
-GI problems - normally foetus ingests fluid and excretes it to keep the oesophagus patent and kidneys functioning
How is breech presentation defined?
-Foetal position in utero oriented so the buttocks are delivered first
-Can be:
–Frank / extended (65%)
–Complete / flexed (10%)
–Incomplete / footling (25%) (pre-term + highest risk)
How should a breech presentation be managed?
1.External cephalic version (ECV)
2. C-section (reduced morbidity and mortality for breeched babies compared to VD)
3. Planned vaginal delivery
(Moxibustion = acupuncture alternative)
What risk factors are there for breech presentation?
-Uterine malformations
-Fibroids
-Placenta praevia
-Polyhydramnios / oligohydramnios
-Foetal abnormality
-Prematurity
What risks are associated with breech presentation?
-Cord prolapse (position creates a less effective ‘plug’ on cervix)
-Difficulty delivering head
-Foetal hypoxia
-Increased foetal morbidity and mortality
What does ECV involve?
-Applying gentle pressure to the abdomen to turn the foetus
-Done at 36-37 weeks (if <36 weeks most will turn spontaneously)
-Tocolytics given to relax uterine muscles, allowing movement
-CTG monitoring pre- and post-procedure
-Success rate = 50%, 5% chance of moving again once successfully rotated
What risks are associated with ECV?
-Foetal distress
-Cord entanglement
-Transient foetal bradycardia
-Pain
-Foeto-maternal haemorrhage (give Anti-D in Rh- patients)
-Placental abruption
What are some contra-indications for ECV in breech presentations?
ABSOLUTE
-Placenta praevia
-Uterine malformations
-Ruptured membranes
-Abnormal CTG
-Multiple pregnancies
RELATIVE
-Previous CS
-Active labour
-Pre-eclampsia
-Oligohydramnios
-Foetal abnormalities
-Hyperextension of foetal head
-Maternal cardiac disease
What is the main factor in determining pregnancy outcome in twins / higher order pregnancies?
-Chorionicity
= whether twins share a placenta or not
What are the 4 types of chorionicity / amnioticity and what do they mean?
Dichorionic / Diamniotic = 2 placentas + 2 sacs (DCDA)
Monochorionic / Diamniotic = 1 placenta + 2 sacs (MCDA)
Monochorionic / Monoamniotic = 1 placenta + 1 sac (MCMA)
Conjoined twins
When are the different cleavage times for pregnancies of different chorionicities?
DCDA = days 1-3
MCDA = days 4-8
MCMA = days 8-13
Conjoined = days 13-15
NB all dizygotic twins are DCDA, monozygotic twins can be any
What do T and lamda signs denote on USS of twin pregnancies?
-Lamda sign = DCDA
-T = MCDA
What maternal complications does a multiple pregnancy carry?
-Hyperemesis gravidarum
-Anaemia
-GDM + G-HTN
-Placenta praevia
-Miscarriage
-Preterm labour and delivery
-Pre-eclampsia
-Antepartum haemorrhage
-Postpartum haemorrhage
-Postnatal depression
What foetal complications does a multiple pregnancy carry?
-Polyhydramnios
-Prematurity
-Malpresentation
-Cord prolapse
-Placental abruption
-Chromosomal / congenital abnormalities (2-3 times higher for monozygotic twins)
-IUGR
-Intrauterine death
What is twin-twin transfusion syndrome?
-Occurs in monochorionic pregnancies
-One foetus dominates over the other, creating an imbalance in placental blood flow to each foetus
-Donor = smaller, fails to thrive, higher risk of intrauterine death
-Recipient = fluid overload, heart failure, more risks postnatally, polyhydramnios, cardiac hypertrophy
-Trocar procedure divides blood vessels to manage this
What additional antenatal care is needed for multiple pregnancies?
-Higher dose folic acid (5mg)
-Aspirin 75mg
-Detailed anatomy and cardiac scans
-Regular growth scans (4-weekly if DCDA, 2-weekly if MC)
-Regular BP and urine checks (pre-eclampsia)
-OGTT at 28 weeks
When and how should twins be delivered?
-DCDA = 37-38 weeks
-MCDA = 36 weeks
-MCMA = 32-34 weeks by CS
-If presenting twin is cephalic –> vaginal delivery
-If presenting twin is breech / transverse –> CS
How is delayed labour diagnosed (1st stage)?
Primigravida = dilatation of <2cm in 4h
Multigravida = dilatation of <2cm in 4h or slowing of progress
What are the 3Ps that influence progress in labour?
POWER - uterine contraction
PASSENGER - foetal position, foetal size
PASSAGE - parity, pelvis
How is slow progress managed in the 1st stage of labour?
-ARM
-Syntocinon infusion
-C-section if all else fails
What does the partogram show?
A pictorial record of labour, showing:
-Cervical dilatation and descent of head
-Frequency of contractions
-Foetal HR
-Colour of liquor
-Maternal obs
-Any drugs / fluids given
