O+G

ResponseO+G

• Placental abruption
• Ovary - cyst/torsion
• Braxton hicks contractions
• HELLP syndrome
• Round ligament pain

Other

• Surgical - Appendicitis
• GIT - Gastroenteritis
• Genitourinary - Cystitis/UTI/Pyelo/Renal colic

ResponseIdiopathic (most common)
Previous miscarriage, multiple pregnancy
Uterine abnormalities - Fibroids, bicornate uterus
Cervical abnormalities - Cervical incompetence, short cervix
Polyhydramniois
PROM
Antipartum haemorrhage
Infection (Chorioamnionitis, UTI, significant infection from any source)
Age <18 or >40
Poor antenatal care
Smoker, stimulant use
Low socioeconomic status, Ethnicity - African, asian, indigenous

ResponseRupture of membranes - pooling amniotic fluid in vagina/history of sudden gush of fluid
Regular contractions - progressive intensity
Increasing lower back/pelvic pain

ResponseVital signs inc symphysis fundal height
Abdo examination - foetal lie and engagement
Sterile spec - degree of cervical dilation, PV bleeding, amniotic fluid leak/pooling
Fetal descent into pelvis
Bedside U/S - confirm FHR and lie
Hint: its the same as any assessment of labour

ResponseCTG trace showing contractions/foetal wellbeing
POCUS - foetal wellbeing
Ferning of amniotic fluid on microscopy - This seemed very important in ROSH MCQ’s
Vaginal pH ?6.5
Fetal fibronectin level on PV swab (Negative = 98% no delivery within 7 days)
Formal U/S ? Cervical length (>3cm usually excludes pre term labour, <1.5cm suggestive of labour)

ResponseFoetal Fibronectin on vaginal swab - If not detected labour very unlikely with next 1-2 weeks
NPV >99% (highly sensitive)

ResponseThink PASTED
Meds
Oxytocin 10U IM, Betamethasone 11.4 mg IM, tocolytics (Salbutamol nebs, Nifedipine 20 mg Q30 min to 3 doses), Antibiotics (Given PROM - amp/gent)
Equipment
Delivery pack + cord clamps, resuscitaire + neopuff (PPV device), U/S ?FHR, towels, suction, prayers

ResponseThis will almost certainly be in a rural centre - Retrieval!
Tocolytics - effective in delaying delivery 24-48 hours (in 80% of cases)

• Nifedipine 20 mg PO Q20-30 min (Max 60 mg) if contractions persist, then QID
• Terbutaline 0.25mg s/c
• Salbutamol 5mg neb or IV infusion (Poorly tolerated, don’t use together with nifedipine)
• GTN
• ?NSAIDS - Ketorolac/Indometacin

Steroids - glucocorticoids promote foetal lung maturity if gestation <37/40

• Betamethasone IM 11.4mg

Antibiotics - ? chorioamnionitis established (Infection most common cause - Treat!)

• Amp/gent/metro

Neuroprotection - foetal neuroprotection

• MgSO4 4g over 20 mins

Continuous foetal monitoring
Prepare for labour!
Transfer to obstetric centre/urgent O+G consult. Will need paeds support/NICU if preterm +++

ResponseGestation >34 wks
Fetal death in utero
Fetal malformation where pal care only is planned
Suspected fetal compromise (US or CTG) requiring urgent delivery
Placental abruption
Chorioamnionitis
Preeclampsia

ResponseActive labour >5cm cervical dilation or baby on view
Absent FHR or bradycardia
Unstable mother
Unable to transfer safely (Eg: no safe escort/skilled staff)
Cord prolapse