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Cord prolapse is an obstetric emergency with a high risk of perinatal mortality. Selective transvaginal scanning in women with high-risk factors such as a transverse lie, malpresentation (e.g. footling or lexed breech) or high presenting part of fetus, may be useful. Amniotomy is contraindicated if the cord is palpable below or by the side of the presenting part during vaginal examination. Women with prelabour (prolonged) rupture of membranes (PROM) should be offered a speculum examination irrespective of the period of gestation. A digital vaginal examination indicates the presence of PROM or preterm PROM (PPROM) with cardiotocograph (CTG) abnormalities such as variable decelerations, prolonged decelerations and bradycardia and a suspicion of cord prolapse. Emergency caesarean section (CS) is frequently needed but assisted or operative vaginal delivery may be possible if the cervix is fully dilated. Post-delivery debriefing and counselling of parents and risk-management discussions are needed.
Remifentanil's safety profile in neonates combined with rapid onset and offset means that it offers potential not only as a labor analgesic, when administered as patient-controlled analgesia (PCA), but also as an adjunct to general anesthesia, particularly in high-risk obstetric patients. An ideal intravenous opiate should have an onset and offset that can match the time course of uterine contractions, while preserving uterine contractility and a reassuring cardiotocograph (CTG). The analgesia experienced should be considered worthwhile and there should be minimal maternal and neonatal effects, allowing administration up to and during delivery. Remifentanil can offer sedation and analgesia for the anxious patient without the risk of persistent opioid effects. Systemic opioids are the mainstay of managing discomfort during epidural anesthesia for cesarean section. High doses of remifentanil with general anesthesia have unpredictable neonatal effects, making attendance by a physician trained in neonatal resuscitation mandatory.
Electronic fetal monitoring (EFM) primary screening test is a highly sensitive test detecting a disease with a low prevalence. The fetal heart rate (FHR) trace or cardiotocograph (CTG) has five recognisable features: uterine activity, baseline FHR, baseline variability, accelerations and decelerations. The National Institute for Health and Clinical Excellence guidelines on EFM recommend that a CTG or FHR trace is classified into one of three groups: normal, suspicious or pathological based on the presence of reassuring and non-reassuring features. Fetal blood sampling (FBS) is used to identify compromised fetuses that need immediate delivery from those that are fine. There is a need for a monitoring system with a high specificity and sensitivity for detecting fetal acidosis and allowing timely and appropriate intervention without putting the fetus at risk. Currently, systems being researched include fetal ECG analysis and fetal oxygen saturation monitoring.
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