"Game Preparations": What an OB Can and Cannot Tell You About a Baby You've Been Called to Resuscita - PowerPoint PPT Presentation

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"Game Preparations": What an OB Can and Cannot Tell You About a Baby You've Been Called to Resuscita

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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

2
Faculty 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.

3
OBJECTIVES
  • 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

4
GOALS
  • Indentify all newborns who
  • will need neonatal resuscitation
  • Delivery at the appropriate
  • hospital
  • Anticipate risks of intrapartum
  • events
  • Proper communication with
  • neonatal team

5
RISK FACTORS
  • Risk factors associated with the need for
    neonatal resuscitation
  • Maternal medical
  • Obstetric
  • Neonatal characteristics

6
RISK FACTORS
?
7
  • Term gestation?
  • Clear Amniotic fluid?
  • Breathing or crying?
  • Good muscle tone?

8
Called for 3 cesarean deliveries STAT
  • Term
  • Clear fluid

Uterine rupture
Cord prolapse
Fetal distress
9
Called for 3 cesarean deliveries STAT
  • Term
  • Clear fluid

?
Uterine rupture
Cord prolapse
Fetal distress
10
What 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

11
What 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

12
Average DDI by CD Indication

Plt0.05
13
Bloom SL, et al. Obstet. Gynecol., Jul 2006 108
6 - 11
14
Bloom SL, et al. Obstet. Gynecol., Jul 2006 108
6 - 11
Bloom SL, et al. Obstet. Gynecol., Jul 2006 108
6 - 11
15
What 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

16
What 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

17
Category 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

19
Called for 3 cesarean deliveries STAT
  • Term
  • Clear fluid

?
Uterine rupture
Cord prolapse
Fetal distress
20
Cord 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
21
Levy H, Obst Gynecol 1984 64(4)499-502
22
Cord prolapse
?
Uterine rupture
  • h

Fetal distress
23
Uterine 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
24
Uterine Rupture
Uterine RuptureRisks Factors
Landon M, et al Obstet. Gynecol., Jul 2006
108 12 - 20
25
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26
Meconium-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

27
Meconium-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

28
Other intrapartum events
  • Shoulder dystocia
  • 3rd trimester bleeding
  • Abruptio placenta
  • Placenta previa
  • Vasa previa
  • Chorioamnionitis

29
Vasa 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.

30
Vasa Previa
31
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32
Vasa Previa
  • Bleeding when rupturing membranes
  • Associated with fetal heart rate decelerations,
    bradycardia or sinusoidal pattern

EMERGENT DELIVERY
33
Prolonged 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
34
Antepartum Factors
  • Maternal
  • Diabetes
  • Chronic hypertension
  • Preeclampsia
  • Cardiac
  • Renal
  • Pulmonary
  • Thyroid
  • Neurologic

35
Diabetes
  • 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

36
Diabetes
  • EFW suspected LGA
  • Risk of shoulder dystocia
  • Risk of hypoglycemia
  • Near term effect

37
Gestational Diabetes
Crowther et al 2005 352(24)2477-2486
38
Crowther et al 2005 352(24)2477-2486
39
Fetal
  • Preterm delivery
  • Fetal anomalies
  • Fetal anemia
  • Oligohydramnios
  • Polyhydramnios
  • Growth restriction
  • Multiple pregnancies

40
Ascites
41
Fetal Hydrops
  • Immune versus non-immune
  • Fetal anemia
  • Use of middle cerebral artery velocity
  • Fetal heart monitoring

42
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43
MCA Velocity Graph
44
Conclusions
  • 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

45
Conclusions
  • 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

46
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