1. Obstetrics II Phase 3B Bukky Olaitan and Rolla Ibrahim
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2. Aims Normal Labour Complications Emergencies
Multiple Pregnancy
Abnormal fetal presentations
Emergencies
Shoulder dystocia
Cord Prolapse
Amniotic Fluid embolism
Uterine Rupture
Prematurity, postmaturity and puerperium
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3. Normal Labour
Process whereby fetus and placenta are expelled from uterus.
Normally between 37 and 42 weeks gestation
When is diagnosis made?
Painful uterine contractions accompany dilatation and effacement of the cervix.
3 stages
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4. Labour - Anatomy Mechanical factors
Powers – degree of force expelling fetus
Passage – Dimension of pelvis and resistance of soft tissues
Passengers – Diameter of fetal head
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5. Labour - Powers Uterine contractions
Braxton Hicks occur after 30th week and can be palpated.
Causes cervical dilatation (1st stage and then expulsion 2nd and 3rd stages)
Effacement
Incorporation of cervix into lower uterine segment
Poor uterine activity
Nulliparous
Induced labour
Braxton Hicks contractions – painless uterine contractions that occur at intervals from early until late pregnancy.
Intensity of contraction x frequency of contraction (per 10 minutes) proviced measure of uterine activity expressed in Montevideio units, or measured using cardiotocograph.
Pacemaker of uterus is located at junction of Fallopian tube and uterus on one side. Contractions are coordinated with maximal intensity in upper part of uterus, intensit reduces as wave passes down to cervix. Triple descending gradient is when peak of contraction occurs simultaneously in all parts of the uterus.
Intensity and frequency of uterine contractions increases as labour progresses. Uterine activity found to be greater if woman walks about during early labour.
Coordinated contractions od labour cause a permanent shortening of the muscle fibres, maximal in upper part of uterus which causes a distension tension on less muscular lower part – expecially cervix.
Pain of contractions is due to ischaemia developing in myometrial fibres
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6. Labour What is: Effacement? Lie? Presentation? Station? Attitude?
Rotation?
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7. Labour Which three of the following are true? A, B and C are true
A) The lie of the fetus describes the relationship of the fetus to the long axis of the uterus
B) Presentation refers to the part of the fetus that occupies the lower segment of the uterus or pelvis
C) Abnormal lie occurs in 1 in 200 births
D) Preterm labour is less commonly complicated by an abnormal lie than labour at full term
E) Unstable lie in nulliparous women is common
F) In an extended breech the feet are presenting
A, B and C are true
Factors associated with abnormal lie: polyhydroamnios, high parity, fetal and uterine abnormalities and conditions that prevent engagement e.g placenta praevia, pelvic tumours and uterine deformities. In reality, most abnormal or unstable lies occur in multiparous women. Both abnormal lie and breech presentations are more comon in early gestation, and therefore if preterm labour occurs. In an extended breech the legs are extended, so are near the head, whilst the buttocks are presenting.
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8. Labour - passages Bony Pelvis Ischial spine Soft Tissues Inlet
Mid cavity
Outlet
Ischial spine
Used to assess descent (station)
Soft Tissues
Cervical dilatation
Vagina and perineum need to be overcome in second stage
Upper uterine segment – fundus and part of uterus that lies above vesico-uterine fold of peritoneum. Undergoes greatest degree of myometrial hyperplasia and hypertrophy during pregnancy. Provides strong contractions that push the fetus along the birth canal
Lower uterine segment – Lies between vesico-uterine fold of peritoneum superiorly and cervix inferiorly. During pregancy upper part of cervix is incorporated into lower uterine segment, which stretches to accommodate fetal presenting part. In late pregnancy lower segment develops more rapidly and is stretched radially to permit the fetal presenting part to descend. In labour entire cervix becomes incorporated into stretched lower uterine segment.
Cervix becomes softer in late pregnancy due to chemical changes in collagen fibres. Also undergoes dilatation = cervical ripening.
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9. Labour - passages
Regarding the normal bony pelvis: which three of the following are true?
A) The inlet of the pelvis is widest in its AP diameter at about 11cm
B) The mid-cavity is almost round, as the transverse and AP diameter are roughly similar
C) At the outlet, the AP diameter is about 12.5cm
D) Station 0 means the head is at the level of the ischial spines, approximately mid-cavity
E) Station is documented as +/-1, 2, 3; +2 means the head is 2cm above the spines
F) The coccyx may cause obstruction
B, C and D
At the inlet of the pelvis the transverse diameter is widest at 13cm. At the outlet the AP diameter is greatest, the transverse diameter is 11cm. With regard to nomenclature of the stations, +ve numbers are below spines and –ve numbers are above spines. The coccyx does not obstruct labour, although alteration in its position has rarely been associated with pain after birth.
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10. Labour - passages
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11. Labour - Passenger
Attitude and position of the fetal head: which four of the following are true?
A) Attitude is the degree of flexion of the head on the neck. The ideal attitude is maximal extension, keeping the head bowed.
B) Maximal flexion is called vertex presentation and the presenting diameter is 9.5 cm.
C) Extension of 90° results in brow presentation, and a much larger diameter of 13 cm.
D) 120° of extension from the vertex position results in face presentation.
E) The head must normally rotate 90° during labour.
F) The head usually delivers in the occipito-posterior position (OP).
B,C, D and E
B, C, D and E are true. At the pelvic inlet the head will best fit the pelvis with the sagittal suture in the transverse whereas at the outlet the head best fits with the sagittal suture in the midline. A is false as maximal flexion, which will keep the head bowed, is ideal. The head usually delivers in the occipito-anterior position, although in the OP position delivery can also be sometimes achieved. See Chapter 28.
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12. Labour - Passenger
Head is oblong in transverse section and bones not fused yet so moulding can occur.
Attitude
Degree of flexion of head on neck (ideally maximal flexion – vertex presentation)
Extension/flexion
Presentation
Part of fetus that occupies the lower segment or pelvis – head (cephalic) or breech
Moulding – compression of head in pelvis as sutures allow bones to come together, and even overlap slightly. Allowing slight reduction of the head. Caput – localised swelling due to pressure of scalp on cervix or pelvic inlet.
Suboccipito-bregmatic – flexed vertex presentation, 9.5cm
Max presentation – Brow presentation – Mento vertical, diameter 13.0cm
Submento-bregmatic – face presentation 9.5cm
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14. Labour -Passenger Presentation Position: Rotation
Part of fetus that occupies the lower segment or pelvis – head (cephalic) or breech
Position: Rotation
Degree of rotation of head on neck
If sagittal suture is transverse – oblong head will fit pelvic inlet best, but at outlet sagittal suture must be vertical for head to fit, therefore head normally rotates 90 degrees during labour.
Usually delivered with OA (Occiput-anterior), 5% OP more diffuculties in delivery, OT (occiput transverse) implies non-rotation, delivery without assistance is impossible.
Presenting part – lowest part of the fetus palpable on vaginal examination
Lowest part of head or breech
Cephalic can be vertex, brow or face, depending on attitude
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15. Stages of Labour Stages of Labour
Initiation to full cervical dilatation (10cm)
Latent phase – Slow dilation up to 3cm
Active phase – Up to full dilatationAvg 1cm/h (nulliparous), 2cm/hr (multiporous).
Full cervical dilatation to delivery of fetus
Passive - full dilatation till head reaches pelvic floor, woman then feels desire to push
Active – Mother pushing – Beware epidurals!
Delivery of fetus to delivery of placenta
Traditional/expectant or active management
Normally 15 mins
<500mL blood loss normal
Epidurals may remove desire to push and therefore lengthen labour.
Active stage – woman should push with contractions, should not be supine, fetus normally delivered after 40 mins (nulliparous) or 20 mins (multiparous)
Traditional or expectant management
Ulnar border of one hand is places in the uterine fundus and signs of placental separation are awaited. Signs are:
A gush of blood
Fundus rises in the abdomen and becomes spherical
Part of the umbilical cord which can be seen at the vulva, lengthens
IF the fundus is lifted upwards the umbilical cord does not shorten
Active management
IM syntocinon – syntometrine (combination of oxytocin and ergometrine) widely used
Placenta and membrances examined – to make sure no part remains in uterus as can cause bleeding, membranes and cotyledons inspected.
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17. Management of Labour
Progress in labour: problems and their treatment: which two of the following are true?
A) The partogram aids identification of abnormal progress.
B) Cephalo-pelvic disproportion is the most common cause of slow progress in labour.
C) When hyperactive uterine contractions are associated with vaginal bleeding and fetal heart rate abnormalities, tocolysis should be given.
D) In a multiparous woman, if descent is poor in the second stage, an oxytocin infusion should be started and pushing delayed by up to 2 hours.
E) Epidural analgesia is associated with an increased risk of instrumental delivery.
F) Occipito-posterior position in the first stage of labour should be identified so that oxytocin can be given.
A and E
A and E are true. A partogram is a graphic representation of labour progress and of key observations. Use of an appropriate partogram can influence obstetric management and prevents excessive delay and unnecessary intervention. Inefficient uterine action is the most common cause of slow progress in primiparous labour, therefore B is false. Epidural analgesia prevents the normal urge to push; randomized controlled trials have shown that the risk of instrumental delivery is increased. In a multiparous woman slow progress is more likely to be associated with malposition and the uterus is more prone to rupture. Although this management may be considered in a primip, oxytocin in a multip should only be used with great caution and after exclusion of malpresentation. Although oxytocin may be required where there is slow progress with an occipito-posterior position, this is not always the case. C would be an indication for grade I Caesarean section. It is likely to be due to placental abruption, which can cause uterine hyperactivity. Tocolysis is best reserved for where hyperactivity is iatrogenic, e.g. prostaglandin administration.
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18. Management of Labour General care Progress in labour Physical health
Mental health
Progress in labour
Partogram – records progress in dilatation of cervix (+/- descent of head)
Powers
Inefficient uterine action
Hyperactive uterine action
Physical health – standard obs, mobility and delivery positions, hydration, stomach and food (eating discouraged as stomach contents can be aspirated – Mendelson’s syndrome – if GA required) , urinary tract – neglected retention of urine can irreversibly damage detrusor muscle
Mental health – environment, birth attendant, partner/accompanying person. Control
Partogram – dilatation of cervix plotted over time – alert and action lines indicate slow progress.
Inefficient uterine action – most common cause of slow labour. Usually nulliparous women. Encourage mobility, continuous reassurance reduced incidence as reduces anxiety. If persistent treat with augmentation (ARM – artificial rupture of membranes)
Hyperactive uterine action – Excessively strong or prequent or prolonged contractions. Causes fetal distress as placental blod flow diminished and labour may be rapid. Associated with placental abruption, too much oxytocin or SE of prostaglandin administration to induce labour. Treatment depends on cause if no evidence of abruption – tocolutic e.g salbutamol can be given IV or SC, but LSCS usually indicated because of fetal distress.
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19. Management of Labour
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20. Management of Labour Nulliparous Multiparous First stage
Slow progress – Augmentation via ARM/amniotomy or artificial oxytocin. If no full dilatation after 12-16hr then C-section
Passive second stage
Poor descent – oxytocin infusion
Active second stage
If lasts longer than 1hr, spontaneous delivery unlikely due to maternal exhaustion, fetal hypoxia. – Episiotomy, ventouse or forceps.
Multiparous
Unlikely to be problems with powers in first stage, more likely to be problems with fetal head.
Careful with augmentation with oxytocin.
Augmentation – artificial strengthening of contractions in established labour.
Induction – artificial initiation of labour
If ARM fails to further cervical dilatation in 1-2hr, oxytocin indicated.
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21. Management of Labour Problems with Passage
Cephalo-pelvic disproportion – extremely rare
Pelvic variants and deformities
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22. Management of Labour Care of fetus
Intrapartum problems – meconium aspiration, fetal blood loss, trauma, infection (Group B Strep)
Fetal distress = hypoxia that might result in fetal damage or death if not reversed or fetus delivered urgently
Diagnosis – colour of meconium, fetal heart rate auscultation (every 15 mins in 1st stage, every 5 mins in 2nd stage), CTG, Fetal Ecg monitoring, Fetal blood (scalp) sampling
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23. CTG Dr C Bravado Define Risk Contractions per 10 mins (normal <5)
Baseline Rate – normal bpm
Tachycardia – fever, fetal infection or hypoxia (in conjunction with other abnormalities)
Steep, sustained deterioration in rate suggests acute fetal distress
Variability – Variation in fetal heart rate should be >5bpm
Prolonged reduced variablity suggests hypoxia
Accelerations – With movements or contractions are reassuring!
Decelerations – Early, variable and late
Overall assessment
Dr C Bravado
Define Risk
Contractions per 10 mins (normal <5)
Baseline Rate – normal bpm
Tachycardia – fever, fetal infection or hypoxia (in conjunction with other abnormalities)
Steep, sustained deterioration in rate suggests acute fetal distress
Variability – Variation in fetal heart rate should b >5bpm
Prolonged reduced variablity suggests hypoxia
Accelerations – With movements or contractions are reassuring!
Decelerations – Early, variable and late
Early Decelerations – synchronous with contraction, normal
Variable Decelerations – vary in timing, reflect cord compression which causes hypoxia
Late decelarations – Persist after contraction completed – suggest fetal hypoxia
Overall assessment
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24. Check out geekymedics site on how to read CTG: http://geekymedics
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25. Management of labour Fetal Distress Management
Level 1: Intermittent auscultation of fetal heart, if abnormal or indicated proceed to
Level 2: continuous CTG
If sustained bradycardia deliver
If other abnormalities attempt to correct, if fails proceed to
Level 3: Fetal blood sampling. If abnormal
Level 4: Delivery by quickest route
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26. Management of Labour Pain relief in labour
Non medical
Entonox (nitrous oxide and oxygen)
Systemic opiates IM
Can be PCA
Antiemetics needed
Epidural anaesthesia (pros and cons)
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27. Perineal Trauma First degree: Injury to skin only
Second degree: Involving perineal muscles but not anal sphincter
Episiotomy: Equivalent to second degree, may extend to 3rd/4th
Third Degree: Involving anal sphincter
3a: <50% external anal sphincter torn
3b: >50% external anal sphincter torn
3c: Internal anal spincter also involved
Fourth Degree: Involving anal sphincter and anal epithelium
1st and 2nd can be sutured using local anaesthetic, 3rd/4th requires epidural or spinal and physiotherapy.
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28. Multiple Pregnancies
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29. Question 1
Which of the following does NOT increase your risk of multiple pregnancies
FHx of monozygotic twins
Increased maternal age
Induced ovulation
IVF
Japanese Women
Ans: Family history of monozygotic twins
Its family history of dizygotic twins
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30. Multiple Gestation Incidence Predisposing factors
Twins 3/ Triplets 1/10’000
Predisposing factors
FH of dizygotic twins
Increased maternal age
Induced ovulation, IVF
Race – Japanese and Nigerian Yoruba women
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31. Termanology ‘Chorionic’  Placenta ‘Amnionic’  Amniotic sac
Dizygotic/Faternal twins
2/3rds of twins
Derived from 2 different eggs  2 different zygotes
Monozygotic twins
1/250
Occur at constant rate worldwide
Derived from 1 separate egg
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32. Question 2 Name the following ANS: Monoamniotic Monochorionic
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33. Question 3 Name the following ANS: Diamnionic Dichorionic
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34. Multiple Pregnancies Dichorionic twins Monochorionic twins
Thick chorionic intertwin septum
Separated on either side by a thin layer of amnion
Monochorionic twins
Thin midline septum
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35. Complications: the P’s
Puking
Pallor (anemia)
Pre-elampsia
Pressure – compressive symptoms
Preterm Labor, Prolonged Rupture of membranes, Premature Prolonged rupture of membranes
Polyhydramnios
Cord Prolapse
Prematurity
Mal Presentation
Perinatal Morbidity and mortality
Parental distress
Postpartum despression
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36. Complications
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37. Question 4 How often do you ultrasound multiple pregnancies?
Monthly from presentation
Monthly from 20 weeks
Biweekly from 20 weeks
Monthly from 28 weeks
Weekly during last trimester
Ans: Monthly during 20 weeks
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38. Question 5 When would you offer an elective birth? Ans: 37 weeks
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39. Management Ultrasound FBCat 20-24 weeks Monthly US from 20 weeks
11 to 13+6wks
Viability, chorionicity, nuchal translucency, malformation
FBCat weeks
Monthly US from 20 weeks
Refer if
Discordant growth of >25%
Fetal anomaly
Monochronionic Monoamniotic
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40. Question 6 What is the commonest complication of multiple pregnancy
Down’s syndrome
Prematurity
Prolapsed cord
IUGR
Miscarriage
Ans: prematurity
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41. Twin-Twin Transfusion
10% monochorionic twins
Concern if >30% discordance in estimated fetal weight
Etiology
Arterial blood flow form donor goes through placenta to vein of recepient
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42. Complications Donor Twin Recipient IUGR Oligohydramnios Hypovolemia
Hypotension
Anemia
Polyhydramnios
Hypertension
Polycythemia
Oedema
Kernicterus in neonatal period
CHF
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43. Management Doppler analysis flow for diagnosis
Therapeutic amniocentesis to decrease polyhydramnios for recipient
Intra-uterine blood transfusion if needed
Laprascopic occlusion of placental vessels
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44. Obstetric Emergencies
Shoulder dystocia: which three of the following are true?
A The obstruction is at the pelvic outlet.
B The incidence is about 1 in 200 deliveries.
C Can be prevented in the majority of cases.
D Maternal diabetes is a risk factor.
E The most effective treatment is strong, sustained traction on the neck.
F Many affected babies are of normal birth weight.
B, D and F
B, D and F are true. The obstruction is at the pelvic inlet. Although high birth weight is the most important risk factor, most affected babies weigh less than 4.5 kg. Maternal diabetes is an additional risk factor. Prevention is difficult because of the difficulties in determining fetal weight using ultrasound, and elective Caesarean section for large babies of non-diabetic mothers is seldom advised. Excessive traction is pointless and will cause an Erb's palsy from tearing the brachial plexus. This may resolve or be permanent.
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45. Obstetric Emergencies
Shoulder Dystocia
Failure of shoulder to deliver
1 in 200 deliveries
Can cause: Erb’s palsy (Brachial plexus damage), or clavicle or humerus fracture
Risk factors – Large baby, previous socal dystocia, increased maternal BMI, labour induction
Management – Rapid and skilled intervention
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46. Obstetric Emergencies
Shoulder Dystocia
McRoberts position tilts pelvis, orienting symphysis more horizontally to facilitate shoulder delivery, it expands the size of the maternal pelvis by flattening lumbar lordosis and rotating symphysis pubis superiorly.
Rotational maneuvers: Rubin II (two fingers placed behind anterior shoulder, downward pressure applied around arc of rotation, presenting part rotated clockwise for 30-60s) and wood-screw (two fingers placed behind posterior shoulder, upward pressure applied around arc of rotation, presenting part rotated clockwise for 30-60s)
Gaskin Maneuver – Patients rolls onto hands and knees, downward traction applied to deliver posterior shoulder, can repeat above rotational maneuvers if needed), Works by increasing pelvic diameters (TOC, Sagittal)
Last Resort Maneuvers – Deliberate clavicle frature, Zavanelli Maneuver (C-section with cephalic replacement), symphysiotomy, abdominal surgery with hesterotomy.
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47. Obstetric Emergencies
Cord prolapse: which three of the following are true?
A Cord prolapse occurs when the cord is felt through intact membranes.
B Occurs in 1 in 5000 deliveries.
C Risk factors include preterm labour, breech presentation, abnormal lie and twin pregnancy.
D More than half occur at artificial amniotomy.
E Initial management is to elevate the presenting part to prevent cord compression, followed by expedited delivery.
F Is a common cause of intrapartum stillbirth.
C,D and E
C, D and E are true. A describes a cord presentation. Cord prolapse is when, after the membranes have rupture, the umbilical cord descends below the presenting part. Cord prolapse occurs in 1 in 500 deliveries. The diagnosis is usually made when the fetal heart rate becomes abnormal or the cord is palpated vaginally. Instrumental delivery is appropriate if the cervix is fully dilated and the head is low. Because it is relatively rare and usually rapidly managed, it is an unusual cause of intrapartum stillbirth
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48. Obstetric Emergencies
Cord Prolapse
Umbilical cord descends below presenting part
1 in 500 deliveries
Can cause compression or spasm of cord => hypoxia
Risk Factors – preterm labour, breech presentation, polyhydroamnios, abnormal lie, twin pregnancy
Mx – prevent compression of cord. C-section
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49. Obstetric Emergencies
Amniotic fluid embolus: which four of the following are true?
A It can present with sudden dyspnoea, hypoxia or hypotension.
B Occurs in 1 in 80 000 pregnancies and as such is not a significant cause of mortality.
C Disseminated intravascular coagulation, pulmonary oedeema and adult respiratory distress syndrome (ARDS) develop rapidly in those who survive the initial 30 minutes.
D Once the patient is stabilized a hysterectomy is normally performed.
E It can occur at any time during pregnancy.
F It is a cause of postpartum haemorrhage.
A, C, E and F
A, C, E and F are true. Although commonly associated with uterine hyperstimulation in parous women, amniotic fluid embolus can occur at any time in pregnancy. Eighty per cent of affected women with proven emboli will die; therefore B is false. Although the ensuing coagulopathy may cause postpartum haemorrhage, this is best managed medically, at least initially.
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50. Obstetric Emergencies
Amniotic Fluid Embolism
Liquor enters maternal circulation => anaphylaxis with sudden dyspnoea, hypoxia and hypotension, often accompanied by seizures and cardiac arrest.
Causes DIC, pulmonary oedema and ARDS
Rare but high mortality rate
Usually occurs when membranes rupture, can happen at labour, C-section or TOP
DDx – Eclampsia
Mx – Resuscitation and supportive treatment
O2, Fluid, bloods (clotting, FBC, electrolytes, cross-match), blood and FFP. ICU
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51. Obstetric Emergencies
Uterine Rupture
1 in 1500 pregnancies
Causes: de novo, old scar (e.g C-section)
Signs: fetal heart rate abnormalities, constant lower abdo pain, vaginal bleeding, cessation of contractions, maternal collapse
Fetus extruded, bleeding, acute fetal hypoxia, massive internal maternal haemorrhage
Risk Factors: labours with scarred uterus: classical c-section or deep myomectomy, neglected obstructed labout (developing countries)
Mx – Maternal resuscitation, urgent laparotomy for delivery of fetus
High recurrence rate in subsequent pregnancies.
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52. Obstetric Emergencies
Uterine Inversion
Fundus inverts into uterine cavity
From traction on placenta
1 in deliveries
Mx: GA, replacement with hydrostatic pressure, several litres warm saline
Epileptiform seizures
Maternal epilepsy or eclampsia or hypoxia
Clear airway, give O2, diazepam if epilepsy, MgSO4 if ecmlapsia
Local anaesthetic toxicity
Massive antepartum Haemorrhage
Massive Postpartum Haemorrhage
Pulmonary embolus
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53. Postmaturity
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54. Question 1 What is the difference between induction and augmentation?
Induction – artificial initiation of labour
Augmentation – promotes contractions when spontaneous contractions are inadequate
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55. Question 2 What is a ‘ripe’ cervix?
Soft, short, thin, anterior cervix with open OS
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56. Induction of Labour Prerequisites Capability for CS if necessary Fetal
Cephalic lie
Normal fetal heart tracing
Maternal
Soft, short, thin, anterior cervix with open os
If not ripe  prostaglandin vaginal insert, gel, or Foley catheter
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57. Question 3
What are the 5 cervical characteristics of the Bishop Score?
Effacement
Position
Consistency
Dilation
Fetal lie
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58. Indications Post-date pregnancy  >41wks Fetal factors
Fetal demise, IUGR
Any suspecion of fetal jeopardy
Maternal-fetal factors
Premature rupture of membranes, isoimmunization, chorioamnionitis
Maternal factors
Significant medical problem – HTN, eclampsia, renal disease
Sigificant antepartum hemorrhage
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59. Question 4
Which of the following is NOT a contraindication for induction of labour?
Cephalopelvic disproportion
Fetal distress
Cord presentation
Breech presentation
Pelvic tumour
Ans: Breech presentation
Also contraindicated: placenta praevia, previous repair to cervix
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60. Complications Failed induction – 15% Uterine hyperstimulation – 1-5%
Iatrogenic prematurity
Infection
Bleeding
Cord prolapse e.g. high head at amniotomy
CS 22%
Instrumental delivery 15%
Uterine rupture - rare
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61. Methods Cervical ripening Must be done first if Bishop’s score <6
Intravaginal prostaglandin
Foley catheter – manual dilation
Induction
Amniotomy  rupture of membrane
Monitor fetal heart rate
Oxytocin IV with 5% dextrose
If cervix dilated 5cm, more sensitive
Start with 1-4MU/min, increase every 30mins
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62. Question 5 When is misoprostol used? Why?
NICE – after intrauterine death
Why?
Route and dose for labour induction with a live fetus are not known and there are concerns regarding hyperstimulation
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63. Prematurity
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64. Question 1
You see a pregnant woman at 14 weeks gestation. She has a history of preterm pregnancy at 33 weeks. You perform a vaginal swab and its positive for bacterial vaginosis, but she is asymptomatic. What is the appropriate management?
Oral metronidazole
Vaginal clindamycin
No treatment, she’s asymptomatic
Oral tinidazole
IV ceftriaxone
Ans: Oral metronidazole. Significant link between BV and preterm labour. Possible links to miscarriages, low birth weight, and PROM.
Clindamycin cream avoided during 2nd half of pregnancy  premature birth. Metronidazole contraindicated in first trimester.
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65. Question 2 The following is NOT a risk factor for preterm labour
Untreated bacteriuria
Previous abdominal surgery
Single pregnancy
Polyhdramnios
Fetal hydrops
Ans: Single pregnancy
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66. Prematurity Labour occurring between 20 to 37 weeks gestation Etiology
Idiopathic – 40%
Maternal-fetal – PPROM, polyhydramnios, multiple pregnancies, Placenta previa or abruption, placental insufficiency
Fetal – chromosomal abnormalities
Fetal hydrops abnormal build of fluid in 2 or more body areas  sign of underlying disease
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67. Prematurity Maternal causes
Infection – recurrent pyelonephritis, untreated bacteriuria, chorioamnionitis
Infection Genital infection – BV associated with 2X increase risk
Illness – HTM, DM, chronic illness
Previous obs/gyn or abdo surgery
Social factors
Smoking, alcohol, drugs, stress, poor nutirion
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68. Question 3 What is the most important risk factor for preterm labour?
Bacterial vaginosis
Fetal fibronectin
Previous pre-term labour
Cervical length
Ans: Previous preterm labour
All of these are risk factors, but the most important one is previous
Fetal fibronectin – glycoprotein in amniotic fluid. Fx – maintain chorionic-decidual interfase. If present in high amounts and short cervix, pre-term labour likely
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69. Management Initial Suppress labour  Tocolysis
Hydration, bedrest. Avoid repeated pelvic exam – increased risk of infection
Ultrasound – GA, position, placenta, estimate weight
Suppress labour  Tocolysis
Prostaglandin synthesis inhibitors  indomethacin
Calcium channel blockers  Nifedipine
Requirements
Preterm labour
Live, immature fetus, intact membranes, cervical dilatation <4cm
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70. Question 4
Which of the following is NOT an absolute contraindication for tocolytics?
Fetal death
Chorioamnionitis
Pre-eclampsia
Maternal condition close to death
Ans: Pre-eclampsia
Absolute CIs as above
Relative: pre-eclampsia, placenta previa, cervix >4cm, pulmonary oedema, fluid overload
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71. Question 5 Why would a corticosteroid be used in preterm birth?
To help fetal surfactant production
Which one?
Betamethasone or Dexamethasone
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72. Glucocorticoid 28-34 wks  reduce risk of RDS
24-28wks  reduces severity of RDS, overall mortality and rate if IVH
Help close patent ductuses and protect periventricular malacia, which can cause cerebral palsy
Caution:
Systemic infection – TB maternal sepsis, chorioamnionitis
Diabetic
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73. Cervical cerclage
Cervcical sutures at the internal OS. Usually at the end of the first trimester and removed in the third trimester
Indications
Cervical incompetence
Diagnosis
Obstetric hx – silent cervical dilation
Ability of cervix to hold inflated Foley during hysterosonogram
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74. Question 6 – Definitions!
Premature rupture of membranes
Rupture of membranes prior to labour at any GA
Prolonged ROM
>24hrs elapsed between ROM and onset of labour
Preterm ROM
ROM before 37wks
PPROM
Rupture of membranes before 37wks AND prior onset of labour
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75. Breech Presentation
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76. Question 1
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77. Breech Frank breech - 60% Complete breech – 10% Footling breech – 30%
Most common breech presentation to be delivered vaginally
Complete breech – 10%
Footling breech – 30%
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78. Thank you! Bukky: oolaitan1@sheffield.ac.uk
Rolla:
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