Title: "Game Preparations": What an OB Can and Cannot Tell You About a Baby You've Been Called to Resuscita
1"Game Preparations" What an OB Can and Cannot
Tell You About a Baby You've Been Called to
Resuscitate?
- Mildred M. Ramirez, MD
- University of Texas Health Science Center,
Houston - October 10th, 2008
2Faculty Disclosure Information
- In the past 12 months, I have no relevant
financial relationships with the manufacturer(s)
of any commercial product(s) and/or provider(s)
of commercial services discussed in this CME
activity. - I do (or) do not intend to discuss an
unapproved/investigative use of a commercial
product/device in my presentation.
3OBJECTIVES
- Identify risk factors associated with the need
for neonatal resuscitation - Anticipate the need for more complex
resuscitation - Discuss new definitions of FHR terminology
- Identify situations of increased risk for
perinatal asphyxia
4GOALS
- Indentify all newborns who
- will need neonatal resuscitation
- Delivery at the appropriate
- hospital
- Anticipate risks of intrapartum
- events
- Proper communication with
- neonatal team
5RISK FACTORS
- Risk factors associated with the need for
neonatal resuscitation - Maternal medical
- Obstetric
- Neonatal characteristics
6RISK FACTORS
?
7- Term gestation?
- Clear Amniotic fluid?
- Breathing or crying?
- Good muscle tone?
8Called for 3 cesarean deliveries STAT
Uterine rupture
Cord prolapse
Fetal distress
9Called for 3 cesarean deliveries STAT
?
Uterine rupture
Cord prolapse
Fetal distress
10What can I tell you?
- Fetal distress is an imprecise terminology and
does not correlate with the risk of neonatal
depression - Requires prompt delivery to reduce risk of
neonatal asphyxia/ death - 29 of deliveries are by CD
- 2.5-5 of CD are emergent
11What can I tell you?
What can I tell you?
- ACOG recommends capability of beginning a CD
within 30 min - Compliance with recommendations varies
- Limited data correlating outcome with
decision-to-delivery - Some indications may mandate more expeditious
delivery
12Average DDI by CD Indication
Plt0.05
13Bloom SL, et al. Obstet. Gynecol., Jul 2006 108
6 - 11
14Bloom SL, et al. Obstet. Gynecol., Jul 2006 108
6 - 11
Bloom SL, et al. Obstet. Gynecol., Jul 2006 108
6 - 11
15What about the Fetal Monitoring?
- Recent workshop on intrapartum electronic FHR
monitoring (2008) - Definitions
- Interpretation
- Category I (Normal)
- Category III- (Abnormal)
- Category II- Equivocal/ Indeterminate
- Research guidelines
16What about the Fetal Monitoring?
- 1. Are there FHR accelerations?
- Presence of FHR accelerations RELIABLY predict
absence of fetal metabolic acidemia - 2. Is there documented FHR moderate variability?
- Presence of moderate variability RELIABLY
predicts absence of fetal metabolic acidemia
17Category III FHR Pattern
- Absent baseline FHR variability and any of the
following - Recurrent late decelerations
- Recurrent variable decelerations
- Bradycardia (baseline lt 110 bpm)
- Sinusoidal pattern
18?
- Nonreassuring FHR
- terminology should not
- be used
19Called for 3 cesarean deliveries STAT
?
Uterine rupture
Cord prolapse
Fetal distress
20Cord Prolapse
- 1.1 of emergent CD due to cord prolapse
- Risk of cord prolapse is 1/400
- 1 in 5 can be prevented
Check Fetal Heart Rate
21Levy H, Obst Gynecol 1984 64(4)499-502
22Cord prolapse
?
Uterine rupture
Fetal distress
23Uterine Rupture
- 0.9 of women undergoing a trial of labor will
experience a uterine rupture - ACOG Guidelines VBAC should be attempted in
institutions equipped to respond to emergencies
with physicians immediately available to provide
emergency care - Significant neonatal morbidity occurred when 18
minutes elapsed between the onset of prolonged
deceleration and delivery
Leung et al Am J Obstet Gynecol. 1993
Oct169(4)945-50
24Uterine Rupture
Uterine RuptureRisks Factors
Landon M, et al Obstet. Gynecol., Jul 2006
108 12 - 20
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26Meconium-stained Amniotic Fluid
- Occurs in approximately 12 of pregnancies
- Incidence of meconium-stained amniotic fluid
rises with increasing gestational age - The relationship between fetal hypoxemia/acidemia
and meconium-stained amniotic fluid remains
highly controversial - Meconium is a sign not a disease
27Meconium-stained Amniotic Fluid
- Recent changes in the management of
meconium-stained amniotic fluid - Routine amnio-infusion is not recommended
- Routine De Lee in the perineum is not recommended
28Other intrapartum events
- Shoulder dystocia
- 3rd trimester bleeding
- Abruptio placenta
- Placenta previa
- Vasa previa
- Chorioamnionitis
29Vasa Previa
- Not all blood is maternal in origin
- Vasa previa is rare 13000, but is lethal if not
diagnosed. Perinatal mortality 50-60 just
from cord compression - High level of suspicion needed
- Defined as velamentous insertion of the cord in
the lower uterine segment such that cord vessels
course unsupported through the membranes in
advance of the fetal presenting part and often
across the cervical os.
30Vasa Previa
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32Vasa Previa
- Bleeding when rupturing membranes
- Associated with fetal heart rate decelerations,
bradycardia or sinusoidal pattern
EMERGENT DELIVERY
33Prolonged second stage?
- Table 2. Neonatal Data for Overall Group and
Patients With or Without a Prolonged Second-Stage
Labor - Group 1 (second stagelt 120 min) Group 2
(second stage gt120 min) P - Birth weight (g) 3135 677 3398
584 .001 - Sex ( male) 51.1 56.3
.029 - 5-min Apgar lt 7 () 1.9
2.7 .351 - Umbilical artery pH 7.23 0.08
7.22 0.09 .994 - Meconium-stained fluid () 13.0
16.1 .059 - NICU admission () 3.9
3.6 . .416 - Perinatal death 1.3
0.8 .523 - ( corrected for lethal anomalies)
.
Miles Santolaya Obst Gynecol 2003102(1)52-58
34Antepartum Factors
- Maternal
- Diabetes
- Chronic hypertension
- Preeclampsia
- Cardiac
- Renal
- Pulmonary
- Thyroid
- Neurologic
35Diabetes
- Good glycemic control reduces the risk of
maternal and neonatal adverse outcome - Risk of preterm delivery in Type I DM can range
from 20-30 - CD gt 65
- Perinatal mortality 14-22/1000
- Use of APGAR score as a surrogate of neonatal
outcome
36Diabetes
- EFW suspected LGA
- Risk of shoulder dystocia
- Risk of hypoglycemia
- Near term effect
37Gestational Diabetes
Crowther et al 2005 352(24)2477-2486
38Crowther et al 2005 352(24)2477-2486
39Fetal
- Preterm delivery
- Fetal anomalies
- Fetal anemia
- Oligohydramnios
- Polyhydramnios
- Growth restriction
- Multiple pregnancies
40Ascites
41Fetal Hydrops
- Immune versus non-immune
- Fetal anemia
- Use of middle cerebral artery velocity
- Fetal heart monitoring
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43MCA Velocity Graph
44Conclusions
- With proper evaluation of risk factors many of
the cases that need neonatal resuscitation can be
anticipated before delivery - Communication with the neonatal team is paramount
- Not all events can be anticipated or prevented
- Response to catastrophic intrapartum events needs
to be expedient and well coordinated
45Conclusions
- Obstetrical simulations of rare events may reduce
neonatal morbidity and mortality - The interactions between maternal, fetal and
intrapartum risk factors needs to be assessed in
future studies
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