Labor Complications

Suspected Preterm Premature Rupture of Membranes (PPROM)

26 y/o G2P0101 at 34 WGA with h/o preterm delivery presents s/p a sudden gush of fluid per vagina. Denies sexual intercourse during the previous 24 hours. Pregnancy complications include smoking, gonorrhea, and chlamydia infection. Pooling, cervical dilation/effacement, and fluid discharge through the cervix noted on sterile speculum exam.

• Send GBS swab and gonorrhea/chlamydia cervical swab obtained during exam

• Positive ferning and nitrazine paper test

• Reassuring non-stress test (NST)

• GBS status unknown

  • 5mU penicillin G loading dose followed by 3mU q4h

  • Penicillin allergy: See alternative GBS prophylaxis options, UNC-CH GBS Algorithm

• ≥ 34 WGA: Start induction and plan for delivery

Preterm Labor

26 y/o G2P0101 at 34 WGA with h/o preterm delivery < 18 months prior presents with contractions every 5-10 minutes. Current pregnancy complications include smoking, multiple UTI, gonorrhea/chlamydia, GDMA2, cervical length < 2.5 cm. Completed course of hydroxyprogesterone caproate (Makena) 250mg IM weekly from 16-34 WGA with no missed doses. Cerclage was contraindicated due to multiple gestation. BMI < 20 kg/m^2 with 3 cm cervical dilation and suspected rupture of membranes on sterile speculum exam.

• Labs

  • No intercourse within past 48 hours: Consider fetal fibronectin

  • Perform GBS testing

  • Obtain gonorrhea/chlamydia NAAT urine, urinalysis, and urine culture

• Treatment

  • GBS status presently unknown

    • 5mU penicillin G loading dose followed by 3mU q4h

    • Penicillin allergy: See alternative GBS prophylaxis options, UNC-CH GBS Algorithm

  • Administer two doses betamethasone 12 mg IM 24 hours apart

  • No h/o myasthenia gravis: Administer 6g magnesium loading dose then 2g/hr for tocolysis and CP risk reduction

• Patient encouraged to hydrate PO

GBS Prophylaxis

26 y/o G2P1001 < 37 WGA with h/o positive GBS status during previous pregnancy, GBS bacteriuria during current pregnancy presents in labor. Membranes ruptured > 18 hours ago. Records indicate positive GBS test within previous 5 weeks.

• Start GBS ppx for any of the following:

  • GBS positive during previous pregnancy

  • GBS bacteriuria and/or positive GBS culture during current pregnancy

  • Culture not performed or > 5 weeks from negative culture with any of the following:

    • < 37 WGA

    • ROM ≥ 18 hrs

    • Maternal temperature > 38 C

• Agents in order of preference:

  • Penicillin G 5 million units IV loading dose then 2.5 to 3 million units IV q4 hours until delivery

  • PCN allergy not no h/o anaphylaxis: Cefazolin 2g IV initial dose then 1g IV q8 hours until delivery

  • PCN allergy with h/o anaphylaxis:

    • Sensitive to clindamycin and erythromycin: Clindamycin 900 mg IV q8 hours until delivery

    • Vancomycin 1g IV q12 hours until delivery

• Infant delivers before 36 WGA or before GBS prophylaxis is administered:

  • Obtain newborn CBC, blood cx

  • Observe newborn for 48h prior to discharge

Reference: UNC GBS Algorithm

Intrapartum Fever

26 y/o G1P0 with protracted labor and rupture of membranes > 18 hours develops acute onset intrapartum fever. Reports chills, increased thirst, dyspnea, dysuria. Epidural anesthesia placed recently. Maternal heart rate > 110 bpm, temperature > 38 C, bilateral pulmonary crackles, costovertebral angle tenderness, abdominal tenderness, uterine tenderness, and malodorous amniotic fluid on exam. IUPC and fetal scalp electrode in place with fetal heart rate > 160 bpm.

• Initial Labs

  • Obtain urinalysis to rule out urinary tract infection

  • Influenza season and not appropriately vaccinated: Obtain rapid antigen nasopharyngeal influenza swab

• Temperature > 39 C

  • Obtain confirmatory urine culture regardless of urinalysis results

  • Obtain CBC with differential and evaluate for bandemia indicating acute infection

  • Consider blood cultures

  • Concern for intrauterine infection or inflammation

    • Send amniotic fluid for gram stain, fluid glucose, WBC count, and culture

    • Send placenta for histopathology

• Clinical concern for pneumonia with crackles on exam: Obtain CXR

• Treatment

  • Administer 500 cc LR bolus

  • Unable to rule out intrapartum infection: Start ampicillin 2g q6h and gentamicin 1.5 mg/kg q8h

  • Influenza swab positive: Start oseltamivir 75 mg BID x 5 days

  • CXR positive for PNA

    • Start azithromycin 500 mg x 1 day followed by 250 mg x 4 days

    • Not already on ampicillin/gentamicin: Start ceftriaxone 1 g x 5 days

• Patient counseled that antibiotic therapy reduces risk of neonatal infection

Notes

• Risk factors: Nulliparity, prolonged labor, rupture of membranes > 18 hours

• Etiologies

  • Most common

    • Epidural anesthesia: Should be suspected only if temperature rose immediately following epidural placement, epidural has been in place less than 4 hours, and the patient has no other signs/symptoms of systemic illness

    • Intra-amniotic infection: Consider in setting of uterine tenderness and maternal/fetal tachycardia

  • Respiratory infection

  • Urinary tract infection

• WBC count range for pregnant patients is generally 10,000 to 16,000 and will vary by institution

• Fetal heart rate: Category I tracings do not exclude intrauterine infection

• Pregnant women

Other

• Chorioamnionitis

• Labor dystocia