Prolonged pregnancy & disorders of uterine action

Prolonged pregnancy

Definition: A pregnancy that persist for 42 weeks or more from the onset of the last menstrual period. It is also called postmaturity or postdate.
Incidence: 5-10%. It is more common in primigravidae.

Aetiology: Unknown, but Hereditary, Hormonal & non engagement of the presenting part. Risk of post-term: Placental insufficiency: which may lead to feotal hypoxia or even death. Oligohydraminios: with its sequelae particularly cord compression during labour. Obstructed labour: due to; - Oversized baby, - no moulding of the skull due to more calcification. Increased incidence of operative delivery.

Diagnosis A. Antenatal: History: calculation of gestational age Examination: larger baby size X-ray: large ossification center in the upper end of the tibia. Ultrasonography: can detect Biparietal diameter more than 9.6cm. Increased foetal weight. Oligohydramnios Increased placental calcification. Tests for placental function

B. postnatal: General appearance:

baby looks thin and old. Skin is wrinkled. There is absence of vernix caseosa. Body and the cord are stained with greenish yellow colour.

Baby length: more than 54 cm Baby weight: more than 4.5kg. Skull:
head is hard without much evidence of moulding. well ossified with smaller fontanelles

Finger nails: project beyond finger tips.

 Liquor amni: Scanty and may be stained with meconium.

Placenta: There is evidence of ageing of the placenta manifested by excessive infarction and calcification. Cord: There is diminished quantity of Whartons jelly which may precipitate cord compressions.

Complications Fetal: During pregnancy There is diminished placental function, oligohydramnios and meconium stained liquor. These lead to fetal hypoxia and fetal distress.

1. 2. 3. 4. 5. 6.

7.

During labour: Fetal hypoxia and acidosis. Labour dysfunction Meconium aspiration Risks of cord compression due to oligohydramnios. Shoulder dystocia. Increased incidence of birth trauma due to big size baby and non-moulding of head due to hardening of skull bones. Increased incidence of operative delivery. The main clinical significance of post term pregnancy is dysmaturity or macrosomia.

Following birth: 1. chemical pneumonitis, atelectasis and pulmonary hypertension are due to meconium aspiration. 2. Hypoxia (low apgar scores) and respiratory failure. 3. Hypoglycemia and polycythemia Maternal: there is increased morbidity, incidental to hazards of induction, instrumental and operative delivery. Postmaturity - does not put the mother at risk.

Management
A. Uncomplicated: Termination of labour is indicated which may be by: 1. Induction of labour - if the condition is favourable for vaginal delivery using: Amniotomy + oxytocin, Prostaglandins + oxytocin, 2. Caesarean section: if conditions are not favourable for vaginal delivery, or if induction of labour failed.

B. Complicated group: 1. Elective caesarean section 2. Associated complications likely to produce placental insufficiency pregnancies should not be allowed to go past the expected date induction or CS Management during labour: The labour is prolonged because of big baby and poor moulding of the head. More analgesia is required to relief pain. Possibility of shoulder dystocia to be kept in mind. Careful fetal monitoring is necessary.

Prolonged Labour

Prolonged Labour
The word difficult labour or dystocia suggests that labour has failed to progress normally and is causing difficulties for mother and baby. Delayed progress of labour can be due to various causes. Definition: If the labour doesnt complete within-18 hours in case of the primigravida woman and 12 hours in case of those who have had a prior delivery, it is considered prolongued.

Classification: Prolonged latent phase phase Prolonged active phase

1. Prolonged latent phase phase: The average duration of latent phase in nulliparous woman is 8.6 hours & if it is lasted 18- 20 hrs or more it is considered to be Prolonged latent phase phase.

2. Prolonged active phase:

The active phase is distinguished by an increased rate of dilatation of the cervix, with descent of the presenting part. Slow progress may be defined either in total duration of hours in labour or failure of the cervix to dilate at a fixed rate per hour. A rate or 1 cm per hour is most commonly used. A prolonged active phase is caused by a combination of factors including the cervix, the uterus, the fetus and the mothers pelvis.

Factors causing delayed progress of labour are: Inadequate intensity and frequency of uterine contractions. Over distention of the uterus (in cases like twins or large baby). The position of the baby in uterus is not favorable. Pelvis is not adequate for the passage of the babys head.

 Medications have been given to mother for pain relief to decrease the perception of contractions (epidural anaesthesia) These sometimes have an effect of prolonging labour, particularly the second stage. Urinary bladder is not completely evacuated / bowels, they may rarely cause failure of progress of labour. In most hospital enema is given during the 1st stage of labour.

Diagnosis: Abdominal examination Vaginal examination Intranatal imaging (radiography, CT or MR)

Effects of prolonged labour

The difficulty in progress of labour may lead to: Exhaustion of the mother. Increased post partum bleeding. Increased chances of trauma to the genital tract. Increased chances of operative deliveries like, forceps, vacuum Decreased supply of oxygen to fetus. Increased chances of infection in the uterus

Treatment
a. Prevention Antenatal or early intranatal detection. Use of partograph Selective and judicious augmentation Change of posture in labour other than supine to increase uterine contractions. Avoidance of dehydration in labour and use of adequate analgesia for pain relief.

Actual Treatment: careful evaluation is to be done to find out; 1. Cause of prolonged labour 2. Effect on the mother 3. Effect on the fetus.
In a nulliparous patient primary dysfunctional labour. In multiparous CPD

Definitive treatment: first stage delay: Vaginal examination is done to verify the fetal presentation position and station. Clinical pelvimetry is done. If only uterine activity is suboptimal. Amniotomy and / or oxytocin infusion is adequate. Effective pain relief is given by intramuscular pethidine or by regional epidural) analgesia. Caesarean section is done when vaginal delivery is unsafe (malpresentation, mal position, big baby, or CPD).

Second stage delay short period of expectant management is reasonable provided the FHR (electronic monitoring) is reassuring and vaginal delivery is imminent. Otherwise appropriate assisted delivery vaginal (forceps, ventouse) or abdominal (caesarean) should be done.

Abnormal Uterine Action

Types abnormal uterine contraction Hypertonic uterus: Normal polarity Excessive Contraction: it may lead to obstruction (-) precipitate labour obstruction (+) Tonic ut contractions & retraction (Bandls ring) Uterine inertia (common) - Ineffective uterine contractions

1.

Ineffective uterine contractions: 2. Abnormal polarity (inco-ordinate uterine action): it leads to Spastic lower segment (common) Colicky uterus Asymmetry uterine contraction Constriction ring Generalized tonic contraction Cervical dystocia

Classification 1. Over-efficient uterine action

Precipitate labour: in absence of obstruction Excessive contraction and retraction: in presence of obstruction

2. Inefficient uterine action

Hypotonic inertia Hypertonic inertia
Colicky uterus Hyperactive lower uterine segment

Constriction (contraction) ring

3. Cervical dystocia

ETIOLOGY
Prevalent in first birth specially with advancing age of the mother. Prolonged pregnancy Over distension of the uterus due to twins and/or hydramnios. Psychologic factor Contracted pelvis, malpresentation and deflexed head, full bladder are often associated too.

All these lead to ill fitting of the presenting part into the lower uterine segment. This probably results in inhibition of the local reflex which is needed to produce effective contraction of the upper segment. Injudicious administration of sedatives, analgesics and oxytocics. Premature attempt at vaginal delivery or attempted instrumental vaginal delivery under light anesthesia.

PRECIPITATE LABOUR

PRECIPITATE LABOUR
Definition A labour is called precipitate when the combined duration of the first and second stage is less than two hours. A labour lasting less than 3 hours. Aetiology It is more common in multiparas when there are; strong uterine contractions, small sized baby, roomy pelvis, minimal soft tissue resistance.

Complications Maternal:
Lacerations of the cervix, perineum. Shock. Inversion of the uterus. Postpartum haemorrhage:
no time for retraction, lacerations.

vagina

and

Sepsis due to:

lacerations, inappropriate surroundings.

Foetal:
Intracranial haemorrhage due to sudden compression and decompression of the head. Foetal asphyxia due to:
strong frequent uterine contractions reducing placental perfusion, lack of immediate resuscitation.

Avulsion of the umbilical cord. Foetal injury due to falling down.

Management Before delivery Patient who had previous precipitate labour should be hospitalized before expected date of delivery as she is more prone to repeated precipitate labour.
During delivery Inhalation anaesthesia: as nitrous oxide and oxygen is given to slow the course of labour.

 Tocolytic agents: as ritodrine (Yutopar) may be effective. Episiotomy: to avoid perineal lacerations and intracranial haemorrhage.
After delivery Examine the mother and foetus for injuries.

EXCESSIVE UTERINE CONTRACTION AND RETRACTION

Physiological Retraction Ring It is a line of demarcation between the upper and lower uterine segment present during normal labour and cannot usually be felt abdominally. Pathological Retraction Ring (Bandls ring) It is the rising up retraction ring during obstructed labour due to marked retraction and thickening of the upper uterine segment while the relatively passive lower segment is markedly stretched and thinned to accommodate the foetus.

the thinned lower uterine segment will rupture. The Bandls ring is seen and felt abdominally as a transverse groove that may rise to or above the umbilicus. Clinical picture: is that of obstructed labour with impending rupture uterus. Obstructed labour should be properly treated otherwise otherwise the thinned lower uterine segment will rupture.

HYPOTONIC UTERINE INERTIA

Definition The uterine contractions are infrequent, weak and of short duration. Aetiology Unknown but the following factors may be incriminated: General factors:
Primigravida particularly elderly. Anaemia and asthenia. Nervous and emotional as anxiety and fear. Hormonal due to deficient prostaglandins or oxytocin as in induced labour. Improper use of analgesics.

Local factors:
Overdistension of the uterus. Developmental anomalies of the uterus e.g. hypoplasia. Myomas of the uterus interfering mechanically with contractions. Malpresentations, malpositions and cephalopelvic disproportion. The presenting part is not fitting in the lower uterine segment leading to absence of reflex uterine contractions. Full bladder and rectum.

Types 1. Primary inertia: weak uterine contractions from the start.

2. Secondary inertia: inertia developed after a period of good uterine contractions when it failed to overcome an obstruction so the uterus is exhausted.

Clinical Picture
Labour is prolonged. Uterine contractions are infrequent, weak and of short duration. Slow cervical dilatation. Membranes are usually intact. The foetus and mother are usually not affected apart from maternal anxiety due to prolonged labour. More susceptibility for retained placenta and postpartum haemorrhage due to persistent inertia. Tocography: shows infrequent waves of contractions with low amplitude.

Management
General measures:
Examination to detect disproportion, malpresentation or malposition and manage according to the case. Proper management of the first stage Prophylactic antibiotics in prolonged labour particularly if the membranes are ruptured.

Amniotomy:
Providing that; vaginal delivery is amenable, the cervix is more than 3 cm dilatation and the presenting part occupying well the lower uterine segment.

 Artificial rupture of membranes augments the uterine contractions by: release of prostaglandins. reflex stimulation of uterine contractions when the presenting part is brought closer to the lower uterine segment.

Oxytocin:
Providing that there is no contraindication for it, 5 units of oxytocin (syntocinon) in 500 c.c glucose 5% is given by IV infusion starting with 10 drops per minute and increasing gradually to get a uterine contraction rate of 3 per 10 minutes.

Operative delivery:
Vaginal delivery: by forceps, vacuum or breech extraction according to the presenting part and its level providing that,
cervix is fully dilated. vaginal delivery is amenable.

Caesarean section is indicated in:

failure of the previous methods. contraindications to oxytocin infusion including disproportion. foetal distress before full cervical dilatation.

HYPERTONIC UTERINE INERTIA (Uncoordinated Uterine Action)

Types Colicky uterus: incoordination of the different parts of the uterus in contractions. Hyperactive lower uterine segment: so the dominance of the upper segment is lost.
Clinical Picture The condition is more common in primigravidae and characterised by: Labour is prolonged.

 Uterine contractions: irregular and more painful. The pain is felt before and throughout the contractions with marked low backache often in occipito-posterior position. High resting intrauterine pressure in between uterine contractions detected by tocography (normal value is 5-10 mmHg). Slow cervical dilatation . Premature rupture of membranes. Foetal and maternal distress.

Management General measures: as hypotonic inertia. Medical measures:

Analgesic and antispasmodic as pethidine. Epidural analgesia may be of good benefit.

Caesarean section is indicated in:

Failure of the previous methods. Disproportion. Foetal distress before full cervical dilatation.

CONSTRICTION (CONTRACTION) RING

Definition It is a persistent localised annular spasm of the circular uterine muscles. It occurs at any part of the uterus but usually at junction of the upper and lower uterine segments. It can occur at the 1st, 2nd or 3 rd stage of labour.

Aetiology Unknown but the predisposing factors are: Malpresentations and malpositions. Clumsy intrauterine manipulations under light anaesthesia. Improper use of oxytocin e.g.
use of oxytocin in hypertonic inertia. IM injection of oxytocin.

Diagnosis The condition is more common in primigravidae and frequently preceded by colicky uterus. The exact diagnosis is achieved only by feeling the ring with a hand introduced into the uterine cavity.

Complications Prolonged 1st stage: if the ring occurs at the level of the internal os. Prolonged 2nd stage: if the ring occurs around the foetal neck. Retained placenta and postpartum haemorrhage: if the ring occurs in the 3rd stage (hour- glass contraction).

Pathological Retraction Ring

Constriction Ring

Occurs in prolonged 2nd stage.

Always between upper and lower uterine segments. Rises up. Felt and seen abdominally. The uterus is tonically retracted, tender and the foetal parts cannot be felt.

Occurs in the 1st, 2nd or 3rd stage.

At any level of the uterus. Does not change its position. Felt only vaginally. The uterus is not tonically retracted and the foetal parts can be felt.

Maternal distress and foetal distress Maternal and foetal distress may not or death. be present.
Relieved only by delivery of the foetus. May be relieved by anaesthetics or antispasmodics.

Management Exclude malpresentations, malposition and disproportion. In the 1st stage: Pethidine may be of benefit. In the 2nd stage: Deep general anaesthesia and amyl nitrite inhalation are given to relax the constriction ring:
If the ring is relaxed, the foetus is delivered immediately by forceps.

 If the ring does not relax, caesarean section is carried out with lower segment vertical incision to divide the ring.

In the 3rd stage: Deep general anaesthesia and amyl nitrite inhalation are given followed by manual removal of the placenta.

CERVICAL DYSTOCIA

Definition Failure of the cervix to dilate within a reasonable time in spite of good regular uterine contractions. Varieties Organic (secondary) due to:
Cervical stances as a sequel to previous amputation, cone biopsy, extensive cauterisation or obstetric trauma. Organic lesions as cervical myoma or carcinoma.

Functional (primary):
In spite of the absence of any organic lesion and the well effacement of the cervix, the external os fails to dilate.

This may be due to lack of softening of the cervix during pregnancy or cervical spasm resulted from overactive sympathetic tone.

Complications Annular detachment of the cervix: surprisingly the bleeding from the cervix is minimal because of fibrosis and avascular pressure necrosis leading to thrombosis of the vessels before detachment. Rupture uterus. Postpartum haemorrhage: particularly if cervical laceration extends upwards tearing the main uterine vessels.

Management (i)Organic dystocia:

Caesarean section is the management of choice.

(II) Functional dystocia:

Pethidine and antispasmodics: may be effective. Caesarean section: if
medical treatment fails or foetal distress developed.

Definition: Induction is a method of artificially or prematurely stimulating labour in a woman.

A good labour pattern is established when there are three contractions in 10 minutes, each lasting more than 40 seconds.

Induction of labour means initiation of uterine contractions after the period of viability by any method medical, surgical or combined for the purpose of vaginal delivery. Overall induction rate is 10 percent. Augmentation: is the process of stimulation of uterine contractions that are already present but found to be inadequate.

Why is labor induced?

Labor can be induced for many reasons. Labor should only be induced for valid medical reasons. Preterm induction. Elective induction of labour means termination of pregnancy without any acceptable medical indication.

Common causes for induction include: The baby is believed to be getting too big. Postdate pregnancy, Intrauterine fetal growth retardation (IUGR). There are health risks to the woman in continuing the pregnancy (e.g. pre-eclampsia). Premature rupture of the membranes (PROM)

Premature termination of the pregnancy (abortion). Congenital anomalies of fetus. Fetal death in utero. Oligohydramnios & polyhydramnios Unstable lie

Contraindications
Contracted pelvis & CPD Malpresentation Previous LSCS or hysterectomy Uteroplacental factors: unexplained vaginal bleeding, vasa previa, PP Active genital herpes infection High risk pregnancy with fetal comprromise Heart disease Pelvic tumor Elderly primi gravid with obstetric / medical complication.

Dangers of induction of labour

Maternal: 1. Psychological upset , when there is failure & CS 2. Tendency of prolonged labour due to abnormal uterine action. 3. Increased need of analgesia during labour 4. Increase operative interference 5. Increased morbidity. Fetal: 1. Iatrogenic prematurity 2. Hypoxia

Parameters to assess prior to induction of labour: When induction is considered for fetal interest, one must ensure the gestational age and maturity (pulmonary) of the fetus. However, induction for maternal interest may compel to ignore the fetus. However, the following parameters are to be assessed: Be sure about the indication for induction.

 Exclude the contraindications of IOL Ensure fetal well being. Ensure fetal gestational age and the estimated weight. Assess bishop score (score > 6 favourable). Factors for successful induction of labour: 1.Period of gestation: Pregnancy nearer the term or post-term more the success. 2. Pre induction score: Bishop score > 6 is favourable. Dilatation of the cervix is most important

Score
Parameters Cervix *Dilatation (cm) 0 Closed 1 1-2 2 3-4 3 5+

*Cervical length (cm)

*Consistency

3
Firm

2
Medium

1
Soft

0
-

*Position
Head : Station

Posterior Midline
-3 -2

Anteri or
-1.0

+1, +2

Total Score =13

Favourable score = 6-13 Unfavourable score = 0-5

3. Sensitivity of the uterus: Positive oxytocin sensitivity test is favourable. 4. Case profile: Favourable in parous woman and in cases with PROM. Less responsive in elderly primigraviade or cases with prolonged retention of dead fetus.

METHODS OF INDUCTION

1. Natural Methods of Labor Induction: Many women are turning towards natural methods of labor induction with some success. The most common home induction tricks can include: Nipple Stimulation Castor Oil Sex as Induction Method Stripping the Membranes Relaxation & Visual Imagery Natural Labor Induction

2. Pharmacological Methods/MEDICAL Prostaglandins (PGS) Dinoprostone (PGE2), Misoprostol (PGE1) Dinoprost (PGF2a)

3. Non-Pharmacological Methods /SURGICAL Stripping the membranes

Oxytocin
Steroid receptor antagonists -Mifepristone (RU 486) -Onapristone (ZK 98299) Relaxin

Amniotomy (Artifical rupture of the membranes)

Mechanical dilators, Osmotic dilators (laminaria), Balloon catheter

4. COMBINED: These are used to increase the efficacy of induction by reducing the induction delivery interval.

Cervical Ripening
Cervical ripening is a series of complex biochemical changes in the cervix which is mediated by the hormones. There is alteration of both cervical collagen and ground substance. Ultimately the cervix becomes soft and pliable.

Medical indications

Surgical indications

Combined indications

Intrauterine fetal death Premature rupture of membranes In combination with surgical induction (ARM)

Abrupto placenta Chronic hydramnios Severe preeclampsia eclampsia In combination with medical induction To place scalp electrode for electronic fetal monitoring.

To shorten the induction delivery interval

MEDICAL INDUCTION

OXYTOCIN Use oxytocin with great caution as fetal distress can occur from hyperstimulation and, rarely, uterine rupture can occur. Multiparous women are at higher risk for uterine rupture. Carefully observe women receiving oxytocin. The effective dose of oxytocin varies greatly between women. Cautiously administer oxytocin in IV fluids (dextrose or normal saline),

 gradually increasing the rate of infusion until good labour is established (3 contractions in 10 minutes, each lasting more than 40 seconds). Maintain this rate until delivery. The uterus should relax between contractions. When oxytocin infusion results in a good labour pattern, maintain the same rate until delivery. Monitor the womans pulse, blood pressure and contractions and check the fetal heart rate - If the fetal heart rate is less than 100 beats per minute, stop the infusion. Review for indications.

PROSTAGLANDINS Prostaglandins are highly effective in ripening the cervix during induction of labour. Check the womans pulse, blood pressure and contractions and check the fetal heart rate. Record findings on a partograph. Review for indications. Prostaglandin E2 (PGE2) is available in several forms (3 mg pessary or 23 mg gel). The prostaglandin is placed high in the posterior fornix of the vagina and may be repeated after 6 hours if required.

 Monitor uterine contractions and fetal heart rate of all women undergoing induction of labour with prostaglandins. Discontinue use of prostaglandins and begin oxytocin infusion if: - membranes rupture; - cervical ripening has been achieved; - good labour has been established; - OR 12 hours have passed.

MISOPROSTOL Use misoprostol to ripen the cervix only in highly selected situations such as: - severe pre-eclampsia or eclampsia when the cervix is unfavourable and safe caesarean section is not immediately available or the baby is too premature to survive; - fetal death in-utero if the woman has not gone into spontaneous labour after 4 weeks and platelets are decreasing.

 Place misoprostol 25 mcg in the posterior fornix of the vagina. Repeat after 6 hours, if required; If there is no response after two doses of 25 mcg, increase to 50 mcg every 6 hours; Do not use more than 50 mcg at a time and do not exceed four doses (200 mcg). Do not use oxytocin within 8 hours of using misoprostol. Monitor uterine contractions and fetal heart rate.

Merits & demerits of oxytocin & prostaglandins

Oxytocin Prostaglandins (PGE2 PGE1)

Cost:

PGE2 costly, PGE1 less costly Stability: Needs refrigeration PGE2 needs refrigeration, (may be kept for 1 PGE1 is stable at room month at 30 C) temperature .
Administration:

Cheaper

Intravaginally or orally

intravenous (I.V)
Effectiveness: Less with:

More effective in those cases as it has got more * Low Bishop score collagenolytic properties and * IUFD it also sensitises the * Lesser weeks of pregnancy myometrium to oxytocin.

Side effects: uterine hyperstimulation ( ceases following stoppage of infusion)

Tachysystole may last longer (may need Inj. Terbulatone 0.2 mg s.c).

Systemic side-effects: Systemic side-effects may Less water intoxication be troublesome specially with oral or intravenous infusion. Vaginal route use has got minimal side-effects. Antidiuretic effect (ADH effect): In high dose. No such.

SURGICAL METHODS
1. "Membrane sweep: also known as membrane stripping, or "stretch and sweep" Method: The midwife moves her finger around the cervix to stimulate and/or separate the membranes around the baby from the cervix. This causes a release of prostaglandins which can help to kick-start labour.

Rupture of Membranes

2. Artificial Rupture of Membranes

Note: In areas of high HIV prevalence it is prudent to leave the membranes intact for as long as possible to reduce perinatal transmission of HIV. Types : 1. Low rupture of membranes(LRM). 2. High rupture of membranes(LRM).

Low rupture of the membranes: The membranes below the presenting part overlying the internal os are ruptured to drain some amount of amniotic fluid. High rupture of membranes: The membranes below the presenting part overlying above the internal os are ruptured to drain some amount of amniotic fluid.

Advantages of amniotomy: High sources rate Chance to observe the amniotic fluid for blood or meconium. Access to use fetal scalp electrode or intrauterine pressure catheter or for fetal scalp blood sampling. Limitation: It cannot be employed in an unfavourable cervix (long, firm cervix with os closed). The cervix should be at least one finger dilated.

Contraindications: Intrauterine fetal death, Maternal AIDS, Genital active herpes infection. Immediate beneficial effects of ARM lowering of the blood pressure in preeclampsia-eclampsia. Relief of maternal distress in hydramnios Control of bleeding in APH Relief of tension in abruptio placenta and initiation of labour.

Method
Review for indications Listen to and note the fetal heart rate. Ask the woman to lie on her back with her legs bent, feet together and knees apart. Wearing high-level disinfected gloves, use one hand to examine the cervix and note the consistency, position, effacement and dilatation. Use the other hand to insert an amniotic hook or a Kocher clamp into the vagina

Amniotic hook

Kochers forceps

Kochers forceps

 Guide the clamp or hook towards the membranes along the fingers in the vagina. Place two fingers against the membranes and gently rupture the membranes with the instrument in the other hand. Allow the amniotic fluid to drain slowly around the fingers. Note the colour of the fluid (clear, greenish, bloody). If thick meconium is present, suspect fetal distress.

 After ARM: listen to the fetal heart rate during and after a contraction. If the fetal heart rate is abnormal (less than 100 or more than 180 beats per minute), suspect fetal distress. If delivery is not anticipated within 18 hours, give prophylactic antibiotics in order to help reduce Group B streptococcus infection in the neonate:

 - penicillin G 2 million units IV; - OR ampicillin 2 g IV, every 6 hours until delivery; - If there are no signs of infection after delivery, discontinue antibiotics. If good labour is not established 1 hour after ARM, begin oxytocin infusion. If labour is induced because of severe maternal disease (e.g. sepsis or eclampsia), begin oxytocin infusion at the same time as ARM.

Hazards of ARM: Chance of umbillical cord prolapse the chance is minimized in cases with engaged head or rupture of membranes with head fixed to the brim. Amnionitis Meticulous asepsis during the procedure should be taken.

 Accidental injury: to the placenta, cervix or uterus, fetal parts or vasa-praevia. Care taken during rupture of the membranes minimizes the problem. Early detection of rupture of the vasa praevia can be made by testing the presence of fetal blood.