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MRCOG PART 2 SBAs and EMQs

MRCOG Part 2, MRCOG 2

Course PAID
notes	336
EMQ	1502
SBA	2115

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ESSAY 167 - SROM AT TERM

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		Posted by Rani M. Fri Aug 12, 2005 02:16 pm
Prolonged pregnancy is associated with increased incidence of meconium staining of liquor & intrapartum fetal hypoxia.perinatal mortality rates almost double with delivery at 42 weeks as compared with delivery at 37-41 weeks. Prelabour rupture of membranes increases the risk of ascending infection & chorioamnionitis which may lead to neonatal infection, maternal infection and risk of endometritis. Meconium staining of liquor is associated with higher perinatal morbidity and mortality which is mainly due to meconium aspiration syndrome. Management of this woman is done keeping above factors in mind. History is taken regarding duration since leaking and since when she noticed greenish colour of liquor ( perinatal infection rates increases with increasing interval between membrane rupture and onset of labour);whether she has labour pains, for symptoms suggestive of choriomanionitis such as fever or foulsmelling discharge. Her antenatal notes are perused to confirm gestational age from a dating scan,and to note any associated medical or obstetric complications. She is examined for fever, tachycardia , uterine tenderness or foulsmelling discharge which will suggest chorioamnionitis.Abdominal examination is done to confirm fetal presentation, lie and heart rate and uterine contractons.Per speculum examination is done to grade the meconium staining ( Thick or thin ,and whether liquor is scanty or seems coming freely ),to rule out foulsmell. H.V.S is taken for bacterial vaginosis and LVS & urethral swab for Group B streptococcus.Vaginal examination is done to note cervical dilatation , effacement and to calculate bishop score if she is not in labour.C.T.G. is done to assess the fetal condition.F.B.C & mid stream sample of urine are taken. Patient is advised admission and offered induction of labour if she is not in labour, if there is no contraindication to vaginal delivery and there is no immediate fetal distress . Canadian Term PROM trial showed that immediate induction with oxytocin is associated with lower risk of neonatal and maternal infection, shorter hospital stay , is more cost effective and was not associated with increase in cesarean sections. Similarly there is evidence that routine induction of labour at 41 weeks+ is associated with lower perinatal mortalitywith no increase in cesarean sections.If the cervix is unripe prostaglandin may be used to ripen the cervix though induction with prostaglandin may be associated with marginally higher risk of infection, increase in interval to delivery and may need additional oxytocin in nearly half of women.In a study only 30 % of women preferred expectant management in favour of induction.Induction is associated with increase pain and increase requirent of maternal analgesia.In case of GBS positive, immediate induction reduces rates of neonatal sepsis. If the woman refuses induction after informed counselling, she should still be admitted in lieu of meconium staining.The discussion is documented in the notes and she is kept under close observation by regular CTG. 90% of women may go into labour with in 4 days of rupture of membranes.The major limitation of this management is,there is no appropiate method of fetal surveillance, no consensus what should be the frequency of surveillance.Amniotic fluid index or liquor volume will not be reliable in this woman due to SROM.Doppler has not been found to be useful either.She need to be monitored for symptom and signs of choriomanionitis also. Regular WBC counts and CRP are done. Delivery will need to be expedited if there is evidence of fetal compromise,of features of chorioamnionitis( leucocytosis, rising CRP, fever, uterine tenderness, foulsmelling liquor) There is no evidence that cesarean section prevents meconium aspiration syndrome(MAS). Neonatologist is informed when she is admitted to the hospital and again when she is in labour.Continous electronic fetal monitoring is done preferably with an internal electrode due to high incidence of intrapartun fetal distress. Threshold for cesarean is lower especially if meconium is thick as these fetuses tolerate asphyxia poorly. Risk of MAS is about 19 % if meconium is thick versus 3% in case of thin meconium.Epidural analgesia is preferred especially in cases of induced labour . Suction of throat after delivery of head and prior to delivery of body is done though evidence in favour of this conflicting.Neonatologist attends the delivery. If baby cries immediately and is active nothing more than routine care is required. But if baby is depressed, endotracheal suction prior to resuscitation is necessary. Baby is taken care of in NICU till stable.Follow up visits will discuss the issue of recurrence rates which are about 30 % for both prolonged pregnancy and 20 % for PROM .
		Posted by Nitin P. Fri Aug 12, 2005 08:16 pm
The risks of intervention have to be balanced against the risks awaitin event in this case. The risks of continuation of pregnancy are chorioamnionitis and beyond 42 weeks of increased perinatal mortality due to placental insufficiency. Meconium stained liquour is also a risk factor for meconium aspiration syndrome. The dates are confirmed on history. The duration since rupture of membranes will give an indication of the time available for conservative management, if desired by the patient. Regular contractions may already have set in, indicating spontaneous onset of labour. On examination, the temperature and pulse are checked for evidence of maternal infection. The lie, presentation and size of the pregnancy is checked. Breech presentations are associated with early meconium passage. Frequent V/E s are avoided. At initial presentation a speculum examination to check for the colour and amount of liquour draining is justified. Fresh, thick meconium with scanty liquour suggests fetal distress. Whereas, thin meconium would not be unexpected at this gestational age. A vaginal examination is done to confirm the absence of cord prolapse and check for cervical dilatation. Maternal blood is checked for infection with leucocyte count and CRP. However, pregnancy causes a physiological leucocytosis, making interpretation difficult. CRP is a non-specific indicator of any infection. In case of foul smelling liquour, high vaginal swab is taken at the time of the speculum examination. A CTG is done to confirm fetal well being. There is no role of Doppler or Ultrasound to predict fetal well being at this gestational age. The timing and mode of delivery depend upon maternal wishes, the cervical favourability, presence of infection and fetal well being as confirmed by the CTG. The risks and benefits of awaiting events and induction are explained to the woman. In the presence of a reassuring CTG and absence of signs of infection, conservative management may be followed. The best method of monitoring is not known, but a twice daily CTG, four hourly maternal temp and pulse, daily maternal WBC, and watch on amount and nature of draining liquour is appropriate. The benefit of conservative management is that 90% of women after spontaneous rupture will labour within 96 hours. The risk is of infection and increased operative interventions at 41+ weeks. On the other hand, induction reduces the risk of infection and perinatal mortality rates which rise with rising gestational age. Also there is no rise in the rates of intervention. Prostaglandins or oxytocin may be used for induction and both are equally effective after rupture of membranes. However, PGs are associated with better maternal satisfaction rates and delivery within 24 hours. If the CTG is non-reassuring at any time a Fetal scalp blood sample is obtained to rule out fetal acidosis. FBS may be technically difficult in the absence of sufficient cervical dilatation. A pathological CTG at any time, warrants early delivery by an emergency caesarean section. Intrapartum antibiotics prophylaxis against GBS is given if rupture of membranes is greater than 18 hours. There should be continuous fetal monitoring in labour. There is insufficient evidence regards the role of amnioinfusion to reduce the risks of intrapartum fetal distress and meconium aspiration syndrome. Neonatologist should be present at the time of delivery, and the oro pharynx should be cleared of meconium before the first breath. Postpartum, whatever the mode of delivery, there is a risk of endometritis and febrile morbidity associated with prolonged rupture of membranes.
		Posted by uma M. Fri Aug 12, 2005 10:37 pm
Meconium stained liquor is common finding(40-50%) in this gestational age.But presence of meconium is assosiated with increased incidence of intra partum stillbirths, distress, Neonatal death, acidosis,low APGAR .These are more common if meconium is thick .If meconium is old and diluted risk is comparitively less than if it is thick ,fresh and associated with oligoamnios.this increases perinatal mortality by 5-7 fold.These should be taken into account while deceiding managemant aspects.SROM itself increase risk of infection to mother and fetus Initially note history regarding duration of rupture of membranes,any pain abdomen suggestive of labour ,fever &rigors suggestive of infection , and her appreciation of fetal movemants.Review AN record for any risk factors that are missed and allowed pregnancy to continue till 41 weeks like IUGR,PIH ETC and also confirm dating from early scans. Examine the woman - record PR,BP,TEMP, P/A any tenderness,contractions to note if she is in labour,presentation , Record fetal heart.If contractions are prasent note strength,duration of contractions. P/S examination to note liquor wether thin or thick meconium stained VE to note cervical findings(effacement ,dilatation), Bishop score to assess favourability for induction if not in labour. Fetal wellbeing assessed by CTG . HVS is taken and LVS & urethral swab for Group B streptococcus. WCC,CRP to note if there is any infection as evidence of infection needs immediate delivery. Further management depends on fetal condition , maternal condition (she is in labour or not, cervical findings,)mother\'s wishes. She is admitted ,explain her risk associated with her situation. Patient\'s wishes considered. If there is evidence of fetal compromise ,infection, immediate delivery is advocated by quickest route possible based on examination findings.Most often it would be caesarean section unless women is already in late labour.Mal presentations require C.S If women is in established labour and fetal condition is satisfactory on initial CTG assessment, labour is allowed to progress. continous EFM is recommended till delivery as these fetuses are at risk of hypoxia.If CTG trace is abnormal then FBS is done if feasible . Ph <7.2 needs immediate delivery by quickest route possible , If > 7.2 labour is allowed to progress.Monitor progress of labour, plot partogram, if necessary augmentation can be considered with syntocinon . If woman is not in labour ,fetal condition reassuring then consideration should be given for induction of labour.This is favourable to expectant management is this woman with MSAF , as IOL is assosiated with lower rates of maternal and neonatal infection, no increase in C.S RATE.Infection further increases the risk assosiated with meconium.Oxytocin is preferrable as use of PG\'s is assosiated with increase in MATERNAL &neonatal infectioN. IOL if not acceptable by the mother respect her wishes , document , and subject her for surveillance. COntinous EFM , 4 th hrly temp,PR. Uterine tenderness .Most woman 92% of woman get into spn labour within 48 - 96 hrs.Deliver if fetal compromise ,e/o infection. Amnio infusion with saline ,will reduse meconium concetration, relieve cord compression ,there by reduse fetal gasping. Cochrane review has showed that there is significant reduction in C.S rates specifically due to fetal distress, reduse incidence of MAS and so is beneficial to fetus.This shuold be considered if thick meconium assosiated with oligoamnois. Intrapartum avoid events that precipitate hypoxia .eg - hyperstimulation, supine hypotension. Neonatologist informed.Paediatrician be present at the time of delivery.Suctioning of oropharynx,is done gentle at delivery of head,before first breath.Unproven value of splinting of shoulders,adn routine suctioning of trachea. Watch for development of MAS. All events and discussions well documented as a risk management strategy.
		Posted by Mangala sundari R. Sat Aug 13, 2005 06:52 pm
The perinatal morbidity and mortality is considerably increased due to the presence of meconium stained liquor. She should be admitted to the labour ward without any delay and senior midwife should be informed about the findings. Her antenatal notes are reviewed for confirmation of dates, any risk factors, like,multiple pegnanacy, macrosomia, IUGR, Gestatioanl diabetes, PIH, or autoimmune disorders . Any recent ultrasound report is verified for the estimated fetal weight, liquor , Doppler studies,placental localization is noted. History is taken about the time of ruptured membranes,onset of labour pains,any foul smelling, colour ( flakes of meconium or old green coloured), any fever, presence or sluggish or absent fetal movements. Examination includes, patients ( height & weight from patients AN card), temp, Pulse, BP,Per abdominal examination to see for tenderness, uterine contractions, presentation, position for engagement of the presenting part, approximate size of the baby and fetal heart sounds. Per vaginal examination is done to see the dilatation and effacement of cervix, position and station of the presenting part, the adequacy of the pelvis, colour whether it is thin or moderately thick meconium stained liquor. Fetal scalp electrode is applied( if no contraindication like, herpes,HIV, Coagulopathies) . This patient needs continuous monitoring by CTG. IV hydartion is started and collecting blood for FBC, group and cross matching. CRP. HVS is collected and antibiotics started. Partogram is important to know the progress of labour and the need for interference. Patient is informed about the findings and the progression of labour. As she is already term and with meconium stained liquor she should be actively amanged for good perinatal out come. Neonatologist and SCBU should be kept informed. CTG with uterine contractions are noted.If there is adequate contractions with dialation ( approximately 1.5 cm per hour) without any decelerations and thin meconium stained liquor, labour is allowed to progess without any interference. Patient monitored in left lateral position, analgesia can be given either i.m.opiates, or epidural anesthesia. If the menbaranes have ruptured for more than 14 hours it is better to augment the labour to prevent chorioamnionitis and to reduce perinatal morbidity and mortality. Labour can be augmented with oxytocin ,increments according to the units protocol. Should avoid hyper stimulation which will precipitate hypoxia and decelerations. Any decelerations to be taken seriously for interference. If in the event that patients progress is not satisfactory or with FH decelarations ( variable, delayed, or sinusoidal pattern) patient should be reassessed for any cephalopelvic disproportion and early recourse to cesarean section is advised. The findings of CTG should be substantiated with Fetal blood sampling before the decision of C Section ( if the facility is available) Neonatologist should be available during delivery for resuscitation and to prevent meconium aspiration. Patient will be kept informed about the progress in labour and the decision is taken with her consent.
		Posted by manjula C. Mon Aug 15, 2005 12:01 am
The incidence of prolonged pregnancy is about 5-10% and is considered as high risk , as there is an increased perinatal morbidity and mortality due to placental insufficiency.There is also an increased rate of operative deliveries and caesarean section adding to the maternal morbidity.Though the definition by itself is 294 days or 42wks,according to rcog it is ideal to induce labour in the woman if she is arround 41 wks of gestation. The woman who presents at 41wks with ruptured membranes and meconium stained liquor is at risk, eventhough meconium stained liquor is a common finding at this gestational age.Meconium stained liquor is found to be associated with increased intrapartum stillbirth and neonatal mortality due to the risk of aspiration.A thorough evaluation of her antenatal records is essential to detect if there is any factor suggesting an increased likelihood of fetal compromise like IUGR,SGA.,preeclampsia,oligohydramnios,which will decide about the mode of delivery(C.S) She should be asked about pain abdomen suggestive of labour,bleeding p.v,any reduced fetal movements and the duration of leak.An abdominopelvic examination is done to know the the uterine activity,presenting part,Bishops score and station of the presenting part.The liquor is checked whether it is thick or with particulate matter,which may increase the pulmpnary complications if aspirated. An admission test is taken,to know the baseline fetal heart rate,variability,and to detect decelerations if any. Keeping all these above factors in mind the woman is counselled about the intended mode of delivery .She is also told about the risks to the fetus like meconium aspiration ,birth asphyxia, will be high.Postnatal complications like pulmonary atelectasis,hypoglycaemia,hypocalcemia, hyperbilirubimemia and a prolonged stay in SCBUare detailed about.Also she is reassured that all measures will be taken to reduce these complications by involving a senior obstetrician and a neonatologist during delivery. Meconium stained liquor by itself,unless accompanied by ominous changes in CTG is not associated with hypoxia or acidosis.However it is likely to cause meconium aspiration syndrome if aspiraterd,which could happen even during C.S.C.S may even increase the respiratory distress due to the transient tachypnoea of the newborn which is common following c.s. Management of labour either conservative or c.s has to be explained in detail to her and an informed consent is taken after the decision is made. If there are obvious risks for vaginal delivery like IUGR,breech presentation she should be ideally managed by c.s.If the ctg is ominous showing bradycardia, loss of variability,late and variable decelerations,high station of the presenting part,poor Bishops score in the presence of thick meconium, she should be delivered by c.s. . If there are no factors needing immediate delivery of the fetus,the labour can be managed like any other highrisk labour, by keeping the lady in left lateral position to avoid further hypoxia due to supine hypotension.Hypotension due to epidural analgesia has to be watched for and managed appropriately..The labour has to be monitored by continuos electronic fetal monitor ing. A partogram has to be plotted to know the progress of labour. .A course of prophylactic antibiotic either erythromycin or ampicillin has to be given as it is likely to reduce maternal and fetel infectious morbidity Theatre staff, anaesthetist , neonatologist and a senior midwife have to be alerted.A consultant obstetrician shoud be involved in decision making if there are abnormalities in ctg during labour.A neonatologist has to be informed in advance and should be present at delivery. Neonatal resuscitation set has to be checked for functioning. Ther e are studies suggesting that amnioinfusion , normal saline transcervically,in cases of meconium stained liquor have found to be useful .It dilutes the meconium and also relieves the cord compression thereby reducing the aspiration pneumonitis. The most crucial event either during c.s or vaginal delivery is throat suctioning as soon as the head is delivered,before the first breath.This is likely to reduce the risk of aspiration,however if it is very vigorous it may cause bradycardia and byitself may stimulate a breath and cancel the very purpose.There may be a necessity to do a laryngoscopy following delivery to check whether the meconium is found below or above the vocal cords,where in if it is found below the cords the risk of meconium aspiration syndrome is high. If during labour any abnormalities in CTG arise like prolonged bradycardia,late and variable decelerations ,FBS has to be made after explaining it to the mother and seeking informed consent.IF it shows a PH of<7.2 delivery by c.s should be done within 30min.However it can be repeated again after 30min, if it is normal but CTG being abnormal and if there is a satisfactory progress in labour. The mother is encouraged about breast feeding if there are no complications during delivery.She should be encouraged to visit the SCBU to see the progress made by her baby.