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Childbirth at Risk


Childbirth at Risk The Perinatal and Intrapartal Period Previa Cause: unknown; 1:200 preganacies Risk factors: multiparity,increasing age, accreta, prior c/s, smoking ... – PowerPoint PPT presentation

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Title: Childbirth at Risk

Childbirth at Risk
  • The Perinatal and
  • Intrapartal Period

  • Describe the mental illness that women are at
    greatest risk for during the perinatal period
  • Critically assess and evaluate the cluster of sx
    indicative of the most prevelant mental illness
    in women
  • Explore the nurses role

Flying Below the Radar Screen Mental Illness in
the Perinatal Period
  • Describe the mental illness that women are at
    greatest risk for during the perinatal period
  • Critically assess and evaluate the cluster of sx
    indicative of the most prevelant mental illness
    in women
  • Explore the nurses role

Care of the Woman at Risk Because of
Psychological Disorders
  • Prevalence of psychological disorders of adults
    in the U.S. is 26.2
  • 44 million women meet the diagnostic criteria for
    mental illness in any given year.
  • Represents 4 of the leading 10 causes of
    disability in the U.S.
  • Alteration in thinking, mood or behavior

  • Perinatal mood and anxiety disorders
  • Depression
  • Anxiety or Panic Disorder
  • OCD
  • PTSD
  • Psychosis
  • Bipolar
  • These disorders can affect people at any
    time during their lives. However, there is a
    marked increase in prevalence of these disorders
    during pregnancy and the postpartum period.

Risk Factors for PMADs
  • Previous PMADs family history, personal history,
    symptoms during pregnancy
  • History of Mood Disorders Personal or family
    history of depression, anxiety, bipolar disorder,
    eating disorders or OCD
  • Significant Mood Reactions to hormonal changes
    puberty, PMS, hormonal BC, fertililty treatment.

PMAD Risks
  • Endocrine Dysfunction hx of thyroid imbalance,
    fertility issues, diabetes
  • Social Factors inadequate social, familial, or
    financial support
  • Teen pregnancy

Its not all about Hormones.
  • Biological/Physiological risks
  • Psychological risks
  • Social/Relationships
  • Myths of Motherhood

Myths of Motherhood
  • Getting pregnant
  • Becoming a mother
  • Being pregnant
  • Labor Delivery
  • Breastfeeding
  • The baby sleep all the time
  • Superwoman/wife/mother
  • Happy all the time
  • Media images

Postpartum Psychological Physiological Changes
  • Focus on baby/forming attachment
  • Fatigue/sleep deprivation
  • Loss of freedom, control, and self-esteem
  • Hormonal changes
  • Birth not going as expected
  • Learning new skills
  • Role transitions
  • Dreams and expectations

Psychological and Physiological Changes of
  • All about the new mom
  • Hormonal changes
  • Prenatal classes
  • Preparing for parenthood
  • Dreams and expectations
  • Watching the Baby Channel
  • Not always happy, glowing time
  • Planned vs. unplanned

Why Moms Suffer in Silence
  • Stigmas associated with mental illness
  • Barriers to treatment
  • Shame

Effect on Labor
  • Unable to concentrate/process info from
    healthcare team
  • May begin labor fatigued or sleep deprived
  • Labor process may overwhelm the woman physically
    emotionally-no energy
  • May appear irritable or withdrawn due to
    inability to articulate feelings of hopelessness
    or unworthiness of motherhood

Why should we care about PMADs?
  • Tragic consequences Affecting Society
  • Marital problems/divorce
  • Disability/Unemployment
  • Child neglect abuse
  • Developmental delays/behavioral problems
  • Infanticide/Homicide/Suicide
  • P. Boyce, University of Sydney Hospital, Nepean
    Hospital, Penrith NSW Australia

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Myths About Postpartum Depression
  • Its only postpartum and its only depression
  • It means I dont love my baby/want to kill my
  • Its all about crying
  • Andre Yates drowned her 5 kids
  • Itll go away on its own
  • Anxiety and depression dont happen during
  • Physical/Mental Illness

PMAD (Perinatal Mood and Anxiety Disorders)
  • Depression and Anxiety Disorders can occur
    anytime in pregnancy or the first year postpartum
  • PMAD is a new term replacing the narrow
    definition of PPD.

PMADs Underdiagnosed and Under-treated
  • Depression/Anxiety in Pregnancy It is estimated
    that 15-20 of pregnant women will experience
    moderate to severe symptoms of depression and/or
  • Postpartum Depression Approximately
  • 15 (Marcus, 2009)

Exacerbating Factors for PMADs
  • Complications in pregnancy, birth, or
  • Age-related stressors adolescence

  • perimenopause
  • Climate Stressors seasonal depression or mania
  • Perfectionism/high expectations/Superwoman

Possible Exacerbating Factors
  • Pain
  • Lack of sleep
  • Abrupt discontinuation of breastfeeding
  • Childcare stress/Marital stress
  • Losses-miscarriage, neonatal death, stillborn,
    selective termination, elective abortion
  • History of childhood sexual abuse

Possible Exacerbating Factors
  • Culture shock career vs motherhood
  • Whos the dad?
  • Death of someone close
  • Building a new home or moving

Barriers to Treatment
  • Distinguishing normal adjustment versus
  • Absence of education, screening, and diagnosis
  • Absence of professional education and treatment
  • Symptoms denied, ignored or minimized

More Barriers
  • Social and cultural expectations
  • Stigma of mental illness
  • Myths of motherhood
  • Shame, embarassment
  • Lack of information and advocacy
  • Cost of treatment and medications
  • Fear of medications
  • Transportation

  • More women are affected than men
  • CNS imbalance in serotonin other
  • Unable to process information
  • Unable to concentrate
  • Fatigue, sleep deprivation
  • Overwhelmed by labor process
  • Unworthy of motherhood
  • Hopelessness

Perinatal Depression Syndrome
  • Sadness, crying
  • Suicidal thoughts
  • Appetite changes
  • Sleep disturbances
  • Poor concentration/focus
  • Irritability and anger
  • Hopelessness and helpless
  • Guilt and shame

Perinatal Depression SX(continued)
  • Anxiety
  • Lack of feelings toward the baby
  • Inability to take care of self or family
  • Loss of interest, joy, or pleasure
  • This doesnt feel like me.
  • Mood swings

Baby Blues the Non-Disorder
  • Affects 60-80 of new moms
  • Symptoms include crying, feeling overwhelmed with
    motherhood, being uncertain
  • Due to the extreme hormone fluctuations at the
    time of birth
  • Last no more than 2 days to 2 weeks
  • Acute sleep deprivation
  • Fatigue

Postpartum bluesNot a mild form of depression
  • Features tearfulness, lability, reactivity
  • Predominant mood happiness
  • Peaks 3-5 days after delivery
  • Present in 50-80 of women, in diverse cultures
  • Unrelated to stress or psychiatric history
  • Posited to be due to hormone withdrawal and/or
    effects of maternal bonding hormones

Anxious Depression
  • High co-morbidity between depression and anxiety
    symptoms in perinatal women.
  • (Moses-Kolko EL et al. JAMA 2005 293 2372-2383
    Anderson L et al, American Journal Obstetrics
    gynecology 2003 189 148-152)

Depression/Anxiety in Pregnancy
  • Rates vary by studies up to 51 in low SES
    women (average is 18)
  • Depression During Pregnancy, Overview Clinical
    Factors, Bennett, H. et al., Clinical Drug
    Investigations 2004 24 (3) 157-179

Anxiety Symptoms
  • Agitated
  • Excessive concern about babys or her own health
  • Appetite changes-often rapid weight loss
  • Sleep disturbances (difficulty falling/staying
  • Constant worry
  • Shortness of breath
  • Heart palpitations

Anxiety Disorders
  • Panic disorder, OCD,PTSD, generalized anxiety
    disorder, phobias
  • Cause a wide range of sx in the laboring woman
    terror, SOB, CP, weakness, faintness, dizziness
    (exclude other dx)
  • Labor may trigger flashbacks, avoidance behavior,
    anxiety sx.
  • Severe sx to vague feeling something is wrong

Panic Symptoms
  • Episodes of extreme anxiety
  • Shortness of breath, CP, sensations of choking or
    smothering, dizziness
  • Hot or cold flashed, trembling, rapid heart rate,
    numbness or tingling sensations
  • Fear of going crazy, losing control or dying
  • Beyond the Blues by Indman and Bennett (2006)

OCD Classic Symptoms
  • Cleaning
  • Checking
  • Counting
  • Ordering
  • Obsession with germs, cleanliness
  • Checking on baby
  • hypervigilence

  • Intrusive, repetitive thought-ususally of harm
    coming to baby
  • Tremendous guilt and shame
  • Horrified by these things
  • Hypervigilence
  • Moms engage in behjaviors to avoid harm or
    minimize triggers.
  • Educate mom that thought does not equal action.

Perinatal PTSD
  • An anxiety disorder after a terrifying event or
    ordeal in which grave physical harm occurred or
    was threatened.
  • Its in the eye of the beholder.
  • Beck, CT (2004). Birth Trauma In the Eye of the
    Beholder, Nursing Research, 53, 28-35.

Postpartum PTSD Themes
  • Perception of lack of caring
  • Feeling abandoned
  • Stripped of dignity
  • Lack of support and reassurance
  • Poor communication
  • Moms feel invisible
  • Feeling powerless
  • Betrayal of trust
  • Dont feel protected by staff
  • Do the ends justify the means?
  • Healthy baby justifies traumatic delivery?

  • Postpartum Hemorrhage
  • Emergency C/S
  • Any birth complication for mom or baby
  • Previous PTSD
  • Previous Sexual Abuse

  • Intrusive re-experiencing of a past traumatic
    event-anxiety attacks with flashbacks
  • emotional numbing
  • Hyperarousal/hypervigilence

PTSD due to traumatic labor delivery
  • Incidence
  • Full PTSD in 0.2 - 3 of birth
  • Partial symptoms in about 25 of birth
  • Creedy et al 2000 Czamocka et al 2000,
    Mounts K. Screening for Maternal Depression in
    the Neonatal ICU. Clinical Perinatology 2009
    36 137-152.

PTSD due to traumatic labor delivery resultant
  • Avoidance of aftercare
  • Impaired mother-infant bonding
  • PTSD in partner who witnessed birth
  • Sexual dysfunction
  • Avoidance of further pregnancies
  • Exacerbation in future pregnancies
  • Elective c/s in future pregnancies

PTSD in NICU moms
  • Risk factors
  • Neonatal complications
  • Lower gestational age
  • Greater length of stay in NICU
  • Stillbirth
  • Prominent symptoms
  • Intrusive memories of infants hospitalization
  • Avoidance of reminders of childbirth

Perinatal Psychosis
  • It was the seventh deadly sin. My children
    werent righteous. They stumbled because I was
    evil. The way I was raising them they could
    never be saved. The were doomed to perish in the
    fires of hell.
  • Andrea Yates,
    mother of Noah, John, Luke, Paul and Mary

Psychosis Prevalence
  • 1-2 in 1,000 postpartum women will develop PPP
  • Of those women5 suicide
  • 4 infanticide
  • Onset usually within first 3 weeks after delivery

  • Delusions (eg baby is possessed by a demon)
  • Hallucinations (eg. Seeing someone elses face
    instead of the babys face)
  • Insomnia
  • Rapid mood swings
  • Waxing and waning (can appear and feel normal for
    stretches of time between psychotic symptoms

Bipolar Disorder
  • Higher risk of suicide
  • Women with a previous diagnosis of bipolar
    depression are at greater risk for developing a
    mood disorder in the postpartum period
  • Postpartum psychosis is more common in women with
    bipolar disorder 20 out of 30 postpartum women
    with bipolar disorder experience a psychotic
    episode. 70 of women with bipolar disorder will
    relapse within the first 6 months postpartum

Clinical Therapy
  • Provide support
  • Decrease anxiety
  • Orient to reality
  • Sedatives/analgesia (decrease pain may decrease
    psychological sx)
  • Psychiatric support

Can PMADS Be Prevented
  • Prevention is the great challenge of
    postnatal illness because this is one of the few
    areas of psychiatry in which primary prevention
    is feasible.
  • Hamilton and Harberger (1992)

Primary Prevention Model
  • Risk factors are known
  • Feasible to identify high-risk mothers
  • Screening is inexpensive and educational
  • Many risk factors are amenable to change
  • Known effective, reliable treatments exist

Does prevalence of perinatal depression warrant
  • YES !
  • By comparison
  • 4.8 have gestational diabetes
  • 5 have hypertension in pregnancy

Who Should Screen?
  • All healthcare professionals that have contact
    with pregnant or postpartum women
  • Primary care providers
  • OB/GYN providers
  • Pediatricians
  • NPs, CNMs, CSWs
  • WIC programs
  • Hospitals

Key Points
  • Provide privacy during screening
  • Give brief explanation
  • Edinburgh Postnatal Depression Scale EDPS ( most
    thoroughly validated, free, designed for
    perinatal use, easy to administer score)

Breastfeedingto wean or not to wean
  • The decision to breastfeed is not, however,
    always so simple, especially for women who suffer
    from depression and are taking psychotropic

3 Choices
  • Expose the baby to medicatoni through the breast
  • Expose the baby to the adverse effects of
    untreated depression in the mother
  • Take antidepressant medications and dont
    breastfeed the baby

Dads and Partners RoleEducation of Parnters
  • Often first to realize something is wrong
  • Often required to intervene in an emergency
  • Best positioned to monitro treatment on a daily
  • Often required to assume more responsibility for
    wellbeing of family
  • Have the most at stake in her getting well

  • Abnormal labor pattern
  • Problem with the 3 Ps
  • Most common problem is dysfunctional uterine
    contractions resulting in prolonged labor
  • Friedman curve 4cm in active labor-1cm/hr for
    primips, 1.5 cm/hr for multips
  • Variations protracted labor arrest of labor
    (no change for 2 hours)

Hypertonic Labor Pattern
  • Ineffectual uterine contractions of poor quality
    occur in the latent phase and resting tone of the
    myometrium increases
  • Painful, ineffective contractions become more
    frequent prolonging latent phase
  • Management bed rest and sedation to promote
    relaxation and reducpain
  • Nursing comfort measures position change,
    hydrotherapy, mouthcare, linen change, relaxation
    exercises, education

Clinical Management
  • Consider CPD (station) out of the pelvis
  • If no CPD, consider amniotomy and Pitocin

Active vs Expectant Management
  • AMOL amniotomy, timed cervical checks,
    augmentation of labor with IV pitocin
  • Expectant management Labor considered a normal
    process and allowed to progress without automatic

Nursing Care and Management
  • VS
  • Labor pattern
  • Cervical progress
  • Fetal status
  • Vtx pressing down on cx without descent caput,
    caput increases with no progress
  • Maternal hydration I O
  • Monitor for infection

Precipitous Labor and Birth
  • L D occurs within 3 hours
  • Maternal risks abruptio placenta, lacerations,
  • Fetal risks oxygenation may be poor-meconium
    stained AF may be aspirated, low Apgar scores,
  • Know hx, assess laboring woman for rapid

Postterm Pregnancy
  • Extends beyond 42 completed weeks of pregnancy
  • 7 of all pregnancies in the U.S.
  • Cause unknown, wrong dates
  • ? Dates early sono
  • Maternal risks labor induced, LGA, macrosomia,
    forceps, vacuum, perineal damage, hemorrhage, c/s
    doubled (endometritis, hemorrhage, thromboembolic

Postterm Pregnancy
  • Fetal risks placental changes, increased
    perinatal mortality, oligohydramnios, if
    decreased placental perfusion-SGA
  • IF no compromise-LGA or macrosomic, birth trauma,
    shoulder dystocia, prolonged labor, hypoglycemia
    seizures, respiratory distress, meconium

Management of Postterm Pregnancy
  • Starting at 40 wks NST, BPP, AF index NST
    usually twice weekly
  • In labor, ongoing assessment, continuous EFM,
    note AF,

Fetal Malposition - POP
  • Early labor 15, at birth 5
  • Maternal risk intense back pain til rotation,
    3rd or 4th degree laceration if born OP, higher
    incidence of operative deliveries (60 of women
    will have a c/s)
  • Nursing assessment back pain, abdominal
    depression, protracted labor, FHR heard laterally
  • Nursing care Position change! pelvic rocking

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Face presentation. Mechanism of birth in
mentoposterior position. Fetal head is unable to
extend farther. The face becomes impacted.
Types of cephalic presentations. A, The occiput
is the presenting part because the head is flexed
and the fetal chin is against the chest. The
largest anteroposterior (AP) diameter that
presents B, Military (sinciput) presentation. C,
Brow presentation.D, Face presentation.
  • Overall incidence 4, directly related to
    gestational age
  • Frank breech most common 50-70(term)
  • Single or double footling breech 10-30 (preterm)
  • Complete breech 5

Frank breech
Incomplete (footling) breech
, Complete breech
On vaginal examination, the nurse may feel the
anal sphincter. The tissue of the fetal buttocks
feels soft.
  • Associated with placenta previa, oligo,
    hydrocephaly, anencephaly,multiples
  • Higher incidence of cord prolapse, neonatal
    infant mortality, mec aspiration
  • Entrapment, head trauma, spinal injury
  • ECV (external cephalic version) attempted at 37-
    38 weeks
  • Passage of mec normal in vag breech

Transverse Lie
  • Common in mutliples
  • More common in multips
  • Many convert to cephalic or breech by term
  • If still transverse ECV may be done
  • Persistent transverse lie requires a c/s after
    determining fetal lung maturity

Transverse lie. Shoulder presentation
  • More than 4500 g. (differs according to ethnic
  • Obese women 3-4 times more likely
  • Association with pregestational and gestational
  • Distention of uterus, overstretching leads to
    dysfunctional labor increased PPH
  • Increased risk perineal trauma, PPH, infections,
    forceps, vacuum

Shoulder Dystocia
  • ID macrosomic infant infant in labor
  • McRoberts maneuver, lower moms head, apply
    suprapubic pressure
  • Recognize slow descent, turtle sign, excessive
  • After the birth examine for cephalhematoma,
    Erbs palsy, fractured clavicle. Neuro/cerebral

McRoberts maneuver. A, The woman flexes her
thighs up onto her abdomen
B, The angle of the maternal pelvis before
McRoberts maneuver. C, The angle of the pelvis
with McRoberts maneuver.
  • Twins 3.2 of all pregnancies
  • Triplets and higher 1.8
  • 33 monozygotic twins genetically
    identical-highest risk for fetal demise, cord
    entanglement, twin-to-twin transfusion
  • 25 of all twins are lost before the end of the
    first trimester
  • Higher incidence of preterm birth

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Complications Common with Multiples
  • Spontaneous abortion
  • Gestational diabetes
  • Hypertension or preeclampsia 2.6x
  • Acute fatty liver (severe coagulopathy,
    hypoglycemia, hyperammonemia
  • Pulmonary embolism 6x
  • Maternal anemia
  • Hydramnios
  • PROM, incompetent cx, IUGR
  • Labor cx PTL, uterine dysfunction, abn
    presentations, operative delivery (forceps, c/s)

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  • Goals promote normal fetal development,
  • prevent maternal complication, prevent PTD,
    diminish fetal trauma
  • US frequent surveillance
  • PTL prevention cervical checks start at 28 wks
    cervical measurements, fetal fibronectin
    equivocal. Bed rest and hospitalization to
    prevent PTL not supported by EBP
  • Expect fundal height greater than wks gestation
  • Auscultate 2 heart beats
  • Wt gain 35-44
  • Diet 135g protein 1mg folic acid

Labor Management of Multiples
  • c/s if presenting twin is not vertex
  • External monitor A B
  • Internal monitor A external monitor B
  • Correctly identify A B
  • Anticipate PPH

Nonreassuring Fetal Status
  • O2 supply insufficient to meet physiological
    demands of fetus
  • Causes cord compression, uteroplacental
    insufficiency, maternal/fetal disease
  • Most common initial signsmeconium stained AF
    (vertex) changes in FHR( late, severe variable
    decelerations rising baseline)

  • Change mothers position
  • Increase rate of IV infusion
  • O2 via mask at 6-10 L/min
  • Continuous EFM
  • D/C pitocin if running
  • Provide emotional support to woman, her partner,
    family-explanations unexpected c/s

Placental Problems
  • Abruptio placenta
  • Placenta previa
  • Accreta

Abruptio Placentae
  • Premature separation of a normally implanted
    placenta 0.5-2
  • Risk factors smoking, PROM, HTN, previous
    abruptio10x higher risk
  • Cause unknown maternal HTN(44), trauma (
    2-10),fibroids, cocaine, high parity, short cord
  • Marginal, Central (concealed bleeding), Complete
  • Retroplacental clot, blood invades myometrium,
    uterus turns blue couvelaire uterus- hysterectomy
  • Large amts of thromboplastin are released
    triggering DIC, fibrinogen plummets

Abruptio placentae. A, Marginal abruption with
external hemorrhage. B, Central abruption with
concealed hemorrhage. C, Complete separation
  • Risk of DIC- evaluate coagulation profile
  • In DIC fibrinogen and platelet counts are
    decreased, PT and PTT are normal to prolonged,
    fibrin split produces rise with DIC
  • IV access (16 or 18 gauge), continuous EFM, c/s
    usually safest, T and X-M at least 3 units of
    blood, treat hypofibrinogenemia with cryo or FFP
    before surgery, may need CVP monitoring.
  • Consider 2 IV lines, watch I O, worrisome if
    output below 30 mL/hour
  • Clot observation test at bedside (red top tube)
    if clot fails to form in 6 minutes fibrinogen
    level of less than 150 mg/dL is suspected, clot
    not formed in 30 minutes fibrinogen less than 100

Placenta Previa
  • The placenta is improperly implanted in the lower
    uterine segment. Implantation may be on a
    portion of the lower uterine segment or over the
    internal os.
  • As the lower uterine segment contracts and
    dilates in the later weeks of pregnancy, the
    placental villae are torn from the uterine wall.

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  • Cause unknown 1200 preganacies
  • Risk factors multiparity,increasing age,
    accreta, prior c/s, smoking, recent abortion
    spontaneous or induced, large placenta
  • Total placenta previa internal os covered
  • Partial placenta previa internal os partly
  • Marginal placenta previa edge of placenta is at
    the margin of the os
  • Low-lying placenta implanted in the lower
    segment but does not reach the os

Placenta previa. A, Low placental implantation.
B, Partial placenta previa. C, Total placenta
  • Vasa previa fetal vessels course thru the
    amniotic membranes and are present at the
    cervical os
  • Women present with bleeding, review records, get
    us, no vag exams (unless double set-up), consider
    cervical bleeding
  • If less than 37 weeks first bleeding
    episode-expectant management
  • No vag exams
  • Bed rest with BRP
  • Monitor bleeding, pain , UC, vs, FHR
  • Labs Rh, hh urinalysis
  • IV
  • 2 units blood available
  • Betamethasone to facilitate fetal lung maturity

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Prolapsed Cord
  • An umbilical cord that precedes the fetal
    presenting part cord falls or is washed down
    thru the cervix into the vagina and becomes
    trapped between the presenting part and the
    maternal pelvis
  • Usually occult cord prolapse
  • Risks breech, shoulder presentations, LBW,
    multips with 5 or more births, multiples,

Prolapse of the umbilical cord
Prolapsed Cord
  • Mom c/s, fetal death
  • Fetus bradycardia, variable decel
  • Relieve the pressure by pushing back the
    presenting part, O2, EFM, IV, fill bladder,
    Trendelenberg,knee-chest, delivery
  • Women at risk not engaged SROM or AROM, bed
    rest if ROM and not engaged

  • Occurs when a bolus of amniotic fluid enters the
    maternal circulation and then the maternal lungs
  • Cause unknown
  • Mortality 60-80
  • 10 of all maternal deaths in the U.S.

Vigorous contractions in a woman having her
first baby can led to circumstances in which AFE
is likely to develop.-Williams Obstetrics
  • Cytotec causes unusually strong contractions, AFE
    is a known risk of using cytotec on a pregnant

  • WE know that the rate of women dying around the
    time of birth has been increasing in the US for
    25 years
  • What about the rate of AFE?
  • Evidence suggests that AFE related deaths are
    increasing as well with a clear connection with
    increasing use of uterine stimulant drugs

  • Wild West medicine
  • Maternal mortality going up
  • Slight decrease in perinatal mortality due not to
    a decrease in of babies who die before they are
    born but rather to a slight decrease in the rate
    of babies who die shortly after birth owing to
    our Neonatal intensive care.

  • DES approved by FDA without testing
  • 1947-1971 wonder drug 5 million US women take
  • Popular regime 125 mg 700 bcps
  • 1962 declared ineffective for preg but used as a
    morning after pill
  • 1971 alarming rates of vaginal cancer seen in DES

  • off-label
  • Not approved by

Letter from Searle Warning Doctors Against
Cytotec Birth Inductions
  • August 23, 2000
  • Important drug warning concerning
    unapproved use of intravaginal or oral
    misoprostal in pregnant women for induction of
    labor or abortion
  • Dear Health Care Provider
  • The purpose of this letter is to remind
    you that Cytotec administration by any route is
    contraindicated in women who are pregnant because
    it can cause abortion. Cytotec is not approved
    for the induction of labor or abortion.
  • Cytotec is indicated for the prevention
    of NSAID (nonsteroidal anti-inflammatory drugs,
    including aspirin)-induced gastric ulcers in
    patients at high risk of complications from
    gastric ulcer, e.g., the elderly and patients
    with concomitant debilitating disease, as well as
    patients at high risk of developing gastric
    ulceration, such as patients with a history of
  • The uterotonic effect of Cytotec is an
    inherent property of prostaglandin E1(PGE1), of
    which Cytotec is stable, orally active, synthetic
    analog. Searle has become aware of some instances
    where Cytotec, outside of its approved
    indication, was used as a cervical ripening agent
    prior to termination of pregnancy, or for
    induction of labor, in spite of the specific
    contraindications to its use during pregnancy.

  • Serious adverse events reported following
    off-label use of Cytotec in pregnant women
    include maternal or fetal death uterine
    hyperstimulation, rupture or perforation
    requiring uterine surgical repair, hysterectomy
    or salpingo-oophorectomy amniotic fluid
    embolism severe vaginal bleeding, retained
    placenta, shock, fetal bradycardia and pelvic
  • Searle has not conducted research
    concerning the use of Cytotec for cervical
    ripening prior to termination of pregnancy or for
    induction of labor, nor does Searle intend to
    study or support these uses. Therefore, Searle is
    unable to provide complete risk information for
    Cytotec when it is used for such purposes. In
    addition to the known and unknown acute risks to
    the mother and fetus, the effect of Cytotec on
    the later growth, development and functional
    maturation of the child when Cytotec is used for
    induction of labor or cervical ripening has not
    been established
  • Searle promotes the use of Cytotec only
    for its approved indication.
  • Further information may be obtained by
    calling 1-800-323-4204.
  • Michael Cullen, MDMedical Director,

  • Polyhydramnios
  • Over 2000mL of amniotic fluid
  • Often occurs in cases of major congenital
    anomalies, malformations that affect swallowing,
  • Diabetes, Rh sensitization, infections (syphilis,
    toxoplasmosis, cytomegalovirus, herpes, rubella)

  • Largest pocket of amniotic fluid is 5 cm or less
    on ultrasound
  • Postmaturity, IUGR, renal malformations in the

  • Cephalopelvic Disproportion
  • Contracture of the bony pelvis or the maternal
    soft tissues
  • Contractures of the inlet, outlet, midpelvis
  • Labor is prolonged and protracted

Retained Placenta
  • Retention of the placenta beyond 30 minutes after
    birth of the baby
  • Manual removal

  • Bright red bleeding cx, vagina
  • Risks nullip, epidural, forcps, VAD, epis
  • Firstdegree limited to fourchette, perineal
    skin and vaginal mucous membrane
  • Second-degree perineal skin, vaginal mucous
    membrane, fascia, muscles of the perineal body
  • Third-degree involves anal sphincter and may
    extend up the anterior wall of the rectum
  • Fourth-degree extends thru the rectal mucosa to
    the lumen of the rectum.

Placenta Accreta
  • Chorionic villi attach directly to the myometrium
    of the uterus
  • Increta myometrium is invaded
  • Percreta myometrium is penetrated
  • Causes maternal hemorrhage
  • Tx may be abdominal hysterectomy