Laborrr 3

1. Laborrr 3 MW II Prepared by Mrs. Raheegeh Awni 113 تشرين الثاني، 14

2. Amniotomy (AROM), • Amniotomy, or artificial rupture of the membranes is usually accomplished by fracturing the membranes with a sterile plastic instrument that is guided between two gloved fingers.

3. Indications • Visualizing the amniotic fluid for quantity and evidence of meconium or blood • Gaining direct access to the fetus for placement of internal fetal monitors • Attempting to induce labor or restore progress in labor • Impending second stage of labor where the provider wants to minimize the risk of exposure to body fluids during the birth.

4. Amniotomy is the only definitive way to visualize the amniotic fluid and to gain direct access to the fetal scalp.

5. complications: • Rupture of a fetal vessel traversing the fetal membranes (vasa previa) at the site of amniotomy is rare but can cause fetal exsanguination. • Prolapse of the umbilical cord • severe fetal compromise unless operative delivery is performed rapidly. • The risk of cord prolapse can be minimized by not performing amniotomy until the head is engaged in the pelvis and is exerting significant pressure against the cervix. • Cord prolapse can also occur with spontaneous rupture of membranes.

6. effects from amniotomy • temporary fetal acidosis, • increased incidence of variable fetal heart rate decelerations, • and increased incidence of caput succedaneum and molding of the fetal skull. • Neonatal outcome in early amniotomy versus late spontaneous rupture has been similar in the majority of studies.

7. Spontaneous Rupture of Membranes • Spontaneous rupture of membranes is often abbreviated to S.R.M. or S.R.O.M.Spontaneous rupture of membranes usually occurs during normal labour – but membranes can rupture before labour also and this can affect progress of labour.

9. pre labour SRM In pregnancies that reach term (37 weeks and over) 10% of women have spontaneous rupture of membranes before labour begins – that is, before contractions commence

10. When the membranes rupture prior to labour, after 37 weeks of pregnancy, most women will go into labour spontaneously.86% of women will have labour within 12-23 hours. 6% of women will not be in spontaneous labour within 96 hours of PROM.

11. management • expectant management’ The mother is asked to wait either at home or in the unit for 24-48 hours to ‘see what happens’, knowing that the majority of women will start to labour without any further intervention. • During this time they will be asked to report back if the color of the fluid changes or they feel unwell.

12. induction of labour as the longer the time interval of ruptured membranes, the higher the risk of infection. antibiotics for prolonged rupture of membranes. • These are usually given orally before labour and intravenously during labour, to reduce the risk of infection. • immediate induction of labour after SRM.

13. preterm pre labour rupture of membranes • This occurs to rupture of the membranes before 37 weeks of pregnancy, prior to labour commencing. • As the baby is not yet fully grown and ready to be born this may be managed differently. :

14. Management depends on: • The length of pregnancy (gestation) • The growth of the baby so far • The condition of the baby at the moment • Any other medical or pregnancy related factors.

15. It is possible that preterm pre labour SRM would be treated with any or a combination of the following: • Expectant management • Antibiotics • Steroid therapy, in the form of injections for the mother, to mature the bay’s lungs • Transfer to a large maternity unit • Immediate delivery

16. Diagnosis • Dx of ruptured membranes may sometimes be visually confirmed by inspection, but it is often necessary to perform a sterile speculum examination to determine the status of the fetal membranes.

17. Using sterile technique, a sterile speculum is inserted into the vagina, and a light source is positioned so the cervix and posterior vagina can be visualized. • Gross pooling of amniotic fluid in the posterior fornix is almost 100% diagnostic of ROM. • Direct transcervical visualization of fetal scalp, feet, umbilical cord, or other fetal parts confirms ruptured membranes.

18. If uncertain about ROM, any fluid pooled in the posterior vaginal fornix is sampled with a sterile cotton swab, smeared on a glass slide, and applied to nitrazine paper. • Ferning of the air-dried fluid under the microscope suggests amniotic fluid. • The alkaline pH of amniotic fluid causes nitrazine paper to turn deep blue, indicating a positive result. • Blood and sometimes urine may cause false-positive results.

19. If bloody amniotic fluid is noted (port-wine fluid), further investigation to rule out abruptio placentae should be undertaken. • The absence or presence of meconium (fetal stool) in the amniotic fluid should be noted. • The incidence of meconium-stained amniotic fluid increases with advancing gestational age. • Although it may be released into the amniotic fluid during hypoxic stress, this is not indication for hypoxemia.

20. Absence of amniotic fluid noted at the time of attempted amniotomy should be considered as evidence for the presence of thick meconium until proven otherwise. • Cultures are obtained when preterm labor or chorioamnionitis is suspected. • With preterm ROM, a sample of amniotic fluid from the vaginal pool can be obtained to evaluate fetal lung maturity.

22. Thank you

24. Admission • Pregnant women should be urged to report early in labor rather than to procrastinate until delivery is imminent for fear that they might be experiencing false labor. Early admittance to the labor and delivery unit is important, especially if during antepartum care the woman, her fetus, or both have been identified as being at risk.