1. COMPLICATIONS OF LABOR
Premature Labor
Divided in two:-
Spontaneous preterm labor
Preterm pre-labor rupture of membranes(PPROM)

2. WHO definition
Preterm labor is the presence of contractions of sufficient strength and frequency to effect progressive effacement and dilatation of the cervix between 20 and 37 weeks’ gestation

3. Preterm labor is considered to be established if regular uterine contractions can be documented at least 4 in 20 minutes or 8 in 60 minutes with progressive change in the cervical score in terms of effacement of 80% or more and cervical dilatation of more than 1cm

4. The leading cause of perinatal morbidity and mortality
Survival rates have increased and morbidity has decreased because of technologic advances

5. Classification Preterm Delivery
Preterm birth: < 37completed weeks
Very Preterm birth: < 32 weeks
Extremely Preterm birth: < 28 weeks

6. Survival by gestational age among live-born resuscitated infants

7. Incidence of preterm births
Preterm birth occurs in 5-12% of all pregnancies and accounts for majority of congenital neurological disability including cerebral palsy

8. Risk Factors for Preterm Birth
Non-modifiable
Previous preterm birth
Age <18 or >40 years
Poor nutrition/low pre pregnancy weight
Low socioeconomic status
Cervical injury or anomaly
Uterine anomaly or fibroid
Premature cervical dilatation (>2 cm) or
effacement (>80 percent)
Over distended uterus (multiple pregnancy,
polyhydramnios)
Modifiable
Cigarette smoking
Substance abuse
Absent prenatal care
Short interpregnancy intervals
Anemia(hemoglobin <10 g/dL)
Bacteriuria/urinary tract infection
Genital infection

9. Risk factors for preterm birth cont..d
Stress
Single women
Low socioeconomic status
Anxiety
Depression
Life events (divorce, separation, death)
Abdominal surgery during pregnancy
Occupational fatigue
Upright posture
Use of industrial machines
Physical exertion
Mental or environmental stress
Excessive or impaired uterine distention
Multiple gestation
Polyhydramnios
Uterine anomaly or fibroids
Cervical factors
History of second trimester abortion
History of cervical surgery
Premature cervical dilatation or effacement
Infection
Sexually transmitted infections
Pyelonephritis
Systemic infection
Bacteriuria
Periodontal disease
Placental pathology
Placenta previa
Abruption
Vaginal bleeding

10. Risk Factors cont..d Fetal factors Congenital anomalies
intrauterine growth restriction
Intrauterine fetal death
Uterine causes
Myomata (particularly submucosal or subplacental
Bicornuate uterus
Cervical incompetence

11. Infections associated with preterm delivery
Genital * Bacterial vaginosis (BV)
* Group B streptococcus
* Chlamydia
* Mycoplasmas
Intra-uterine * Ascending (from genital tract)
* Transplacental (blood-borne)
* Transfallopian (intraperitoneal)
* Iatrogenic (invasive procedures)
Extra-uterine * Pyelonephritis
* Malaria
* Typhoid fever
* Pneumonia
* Listeria
* Asymptomatic bacteriuria 11

12. Ascending intrauterine infections stage I changing flora vagina/cervix, II Microorganism alocated between the amnion and chorion, III intra amniotic infection, IV fetal invation
The preterm parturition syndrome. Multiple pathologic processes can lead to activation of the common pathway of parturition.
In: Creasy, Resnik . Maternal – Fetal Medicine, 2009 12

13. Diagnosis
Documented uterine contractions(4 in 20 minutes or 8 in 60 minutes)
Documented cervical change (cervical effacement of 80% or cervical dilatation of 2cm or more)
Ultrasound examination of cervical length
Fetal fibronectin (fFN) levels detectable in vaginal secretions

14. Management of Preterm Labor
An initial assessment: ascertain cervical length and dilatation and the station and nature of the presenting part
Bed Rest : be place patient in lateral decubitus
Hydration
Sedation

15. Beta 2 adrenergic receptor agonists (Terbutaline)
Tocolytic Therapy
Beta 2 adrenergic receptor agonists (Terbutaline)
Mechanism of action
decreases free intracellular calcium ions
Inhibits actin myosin interaction
Side Effects
Tachycardia, palpitations, hypotension, SOB, pulmonary edema, hyperglycemia
Contraindications
Maternal cardiac disease, uncontrolled diabetes and hyperthyroidism

16. Magnesium Sulfate Mechanism of Action Side Effects Contraindications
Competes with Calcium at plasma membrane
Side Effects
Diaphoresis, flushing, pulmonary edema
Contraindications
Myasthenia gravis, renal failure

17. Calcium Channel Blockers
Example: Nifedipine
Mechanism of Action
Directly block influx of Ca through cell membrane
Side Effects
Nausea, flushing, palpitations
Contraindications
Caution: LV dysfunction, CHF

18. Tocolytic therapy may offer some short-term benefit in the management of preterm labor
A delay in delivery can be used to administer corticosteroids to enhance pulmonary maturity and reduce the severity of fetal respiratory distress syndrome
Can also be used to facilitate transfer of the patient to a tertiary care center

19. Other Drugs Antenatal Steroids Dexamethasone: dosage 6 mg q 12 h
Betamethasone: dosage 12.5 mg q 24 h
Indicated for fetal maturation
Reduces fetal mortality, respiratory distress syndrome and intraventricular hemorrhage in infants between 28 and 34 weeks of gestation
Benefits start at 24 hours and last up to seven days after treatment

20. Antibiotic Therapy
Studies have shown that women who receive antibiotics sustain pregnancy twice as long as those who do not receive antibiotics
A lower incidence of clinical amnionitis.
Poor fetal outcome (death, respiratory distress syndrome, sepsis, intraventricular hemorrhage or necrotizing colitis) occur less frequently in women receiving antibiotics

21. Management during labor and delivery
With modern neonatal care, the lower limit of potential viability is 24 weeks or 500g, although these limits vary with the expertise of the neonatal intensive care unit
Continuous fetal heart monitoring and prompt attention to abnormal fetal heart rate pattern are extremely important
With a vertex presentation, vaginal delivery is preferred.

22. Labor and delivery cont,.d
Use of vacuum extraction and episiotomy to shorten the second stage are advocated.
Cesarean section for delivery of the very low birth weight baby
For the breech fetus estimated at less than 1500g, neonatal outcome is improved by cesarean section

23. Evaluation of patients with preterm labor
History
Evaluate the following symptoms
Uterine contractions
Rhythmic low back pain
Pelvic pressure
Increased vaginal discharge
Vaginal bleeding(bloody show)

24. Physical Examination
Uterine tenderness on abdominal examination
Sterile speculum examination may reveal pooling of amniotic fluid, blood and/or abnormal discharge may be observed
Visual assessment of cervical dilatation
Digital examination should be limited as may stimulate prostaglandins

25. Preterm Pre-labor Rupture of Membranes(PPROM)
Spontaneous rupture of fetal membranes occurring before 37 weeks of gestation(prior to the onset of labor )
Diagnosis
History of sudden escape of watery amniotic fluid
Differentiate it from stress urinary incontinence and profuse normal vaginal discharge

26. Incidence PROM occurs in about 10-15% of all deliveries
PROM is associated with 10% of term deliveries

27. Causes
The cause of PROM is not clearly understood, but is associated with the following factors:-
Trauma
Sexual intercourse (particularly in the late gestational weeks)
--Lax of internal os of uterine

28. Vaginal infection due to bacteria, viruses e. g
Vaginal infection due to bacteria, viruses e.g. Toxoplasmosis, CMV, HPV, HSV
STIs play an important role in the cause of PROM
Increased of intra-uterine pressure (such as multiple pregnancy and polyhydramnios)
Abnormalities in presentation and position

29. Smoking:
The risk of PROM is at lease doubled in women who smoke during pregnancy
Other risk factors for PROM include:-
Prior PROM
A short cervical length
Prior preterm delivery
Bleeding in early pregnancy

30. Manifestations
Fluid passing through the vagina suddenly, and then small amounts intermitently particularly with increased abdominal pressure (cough, sneeze, etc)
Intermittent urinary leakage is common during pregnancy, especially near term
Increased vaginal secretions in pregnancy
Perineal moisture
Increased cervical discharge
Urinary incontinence

31. Diagnosis
A sterile speculum examination confirms that the fluid is coming through the os
Ultrasound examination shows oligohydramnios
Fern test-placing a sample on a microscopic slide, air drying, and examining for ferning
The amniotic fluid does fern
The other fluid do not fern

32. Nitrazine test- uses pH to distinguish amniotic fluid from urine and vaginal secretions, the paper turns dark blue from yellow in response to the amniotic fluid

33. Complications of PPROM
Maternal complications
Preterm delivery
Chorioamnionitis
Placental abruption
Retained placenta
PPH
Endometritis

34. Fetal and neonatal complications
Fetal and neonatal pneumonia
Neonatal respiratory distress syndrome
Neurologic dysfunction
Intracranial hemorrhage
Prolapse of umbilical cord
Abruptio placenta
Prematurity
Pneumonia and early neonatal sepsis
Pulmonary hypoplasia
Fetal death

35. Management of PPROM Correct and prompt diagnosis Surfactant therapy
Conservative management after ruling out cord complications e.g. cord prolapse, cord compression, placental abruption and fetal distress
Antibiotic therapy may prolong the latency period after preterm PROM and improve the perinatal outcome
Corticosteroids given between 24 and 34 weeks gestation to enhance fetal pulmonary maturity

36. Fetal surveillance by non stress test and biophysical profile done daily
Delivery must be planned when:
There is evidence of clinical infection e.g. chorioamnionitis
Non reassuring features on fetal monitoring when pregnancy has reached 34 weeks
PPROM at weeks- induce labor unless fetal lung maturity or gestational age is doubtful

37. If PROM occurs at term(37 weeks’ gestational age or more), awaiting the onset of spontaneous labor for 12-24h should be considered, because spontaneous labor will ensue in 90% of patients within 24 hours
If the time from PROM to the onset of labor exceeds 24h, induction of labor should be considered by oxytocin

38. If the evaluation suggests intrauterine infection or chorioamnionitis, antibiotic and delivery are indicated and the antibiotic prescribed should have a broad spectrum of coverage
If the infant is a preterm breech, and the onset of PROM occurs after 30 weeks’ of gestation, delivery is possibly by cesarean delivery

39. If the gestational age is less 30 weeks’, vaginal delivery should be chosen
If the fetus is significantly preterm with absence of infection, expectant management is generally chosen

40. Patients assessment Uterine tenderness daily
Frequent electronic fetal monitoring
Fetal movement monitoring by the mother
Frequent ultrasound assessment helps to determine amniotic fluid
Frequently WBC counts, usually daily for several days