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BE PREPARED Intrapartum emergencies Session 3 Vanessa Murley MD CCFP

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Title: Management of Labour Author: Dave Millar Last modified by: Whitehead, Kristine Created Date: 7/9/2006 7:01:24 AM Document presentation format – PowerPoint PPT presentation

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Title: BE PREPARED Intrapartum emergencies Session 3 Vanessa Murley MD CCFP


1
BE PREPARED Intrapartum emergencies Session
3 Vanessa Murley MD CCFP
2
Obstetrical Emergencies
  • Cord prolapse
  • Uterine rupture
  • Assisted vaginal delivery
  • Shoulder dystocia
  • PPH

3
Sarah
  • Sarah is a 35 year old G1P0 with an uncomplicated
    pregnancy. You are the resident on call, asked
    to see her in triage due to PROM at term. She is
    having some mild contractions. She is GBS .
  • What is your next step?

4
  • VSS, physical exam are normal
  • Baby is vertex by Leopold's manoeuvres
  • Her cervix is 2 cm long mid position and soft, FT
    dilated
  • Pooling of clear fluid is seen in the posterior
    vaginal vault, the specimen tests positive for
    ferning
  • FHR is normal baseline 145-150 bpm, accels,
    no decels

5
  • IV PenG is started for GBS prophylaxis, she
    continues to have mild irregular contractions and
    induction is undertaken by IV oxytocin. When she
    reaches 6 mU/min you are called in to see her
    because

6
How do you interpret this strip? What do you do
now?
7
  • Stop oxytocin!
  • Perform a vaginal exam
  • Intrauterine resuscitation eg. Position change
  • Call your staff
  • Administer tocolysis if needed eg. Uterine tetany
  • Document, discuss with family

8
  • Oxytocin is stopped and vaginal exam reveals the
    presenting part at stn -3 with cx still 2 cm long
    and FT dilated. No palpable cord prolapse.
    Nurse turns her to left lateral and the FHR
    returns to normal. Her contractions continue on
    their own.
  • 6 h later you are called to reassess her because

9
NOW WHAT?
10
  • Vaginal exam is again performed. She is 4-5 cm
    dilated, cervix is thin, stn -1. The obstetrical
    team is consulted. Decision is made to proceed
    with emergent LTCS. Incision of the uterus
    reveals an occult prolapsed cord.
  • Baby is vigorous with apgars of 9 and 9

11
Cord Prolapse
  • Overt
  • ROM is prerequisite
  • Diagnosed by visualizing the cord through the
    introitus or palpation of the cord through the
    vagina
  • Occult
  • Suspect in all patients with persistent or
    significant variable decelerations
  • Cord is prolapsed at pelvic inlet, compressed
    against presenting part.

12
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13
  • Incidence of cord prolapse 0.17 to 0.4
  • Overt cord prolapse varies with fetal
    presentation
  • Lowest with cephalic, highest with transverse
  • Morbidity worsens with increasing time to
    delivery
  • Mortality ranges 0.02 to 12.6

14
Cord Prolapse Risk factors
  • Malpresentation eg. Footling breech
  • Polyhydramnios
  • Preterm gestation, PPROM
  • Grand multip (gt5 parity)
  • Placenta Previa or low-lying placenta
  • CPD narrow pelvis preventing descent of
    presenting part
  • Multiple gestations second twin
  • Long cord

15
Overt Cord Prolapse - Management
  • Call for assistance neonatal staff code 333
    and 222
  • Pelvic exam effacement and dilatation
  • Station and presenting part
  • Presence of pulsations in the cord
  • Maternal Trendelenberg or knee-chest position
  • Hold the presenting part up
  • Tocolysis
  • Urgent delivery by C/S or expedited vaginal
    birth if C/S is unavailable and Cx is fully
    dilated

16
Rebecca
  • Rebecca is a healthy 36 yo F who was admitted to
    the BU in active labor overnight. She is a G2P1
    at 404 weeks gestation. She delivered her first
    baby by c/s because of a breech presentation but
    is hoping to deliver vaginally this time.
  • Does she require continuous fetal monitoring? An
    iv?
  • How do you assess whether or not she is an
    appropriate candidate for vaginal birth after c/s
    (VBAC)?

17
Selection of candidates
  • Previous incision horizontal scar in the lower
    uterine segment, no extension
  • Type of closure double layer closure safer
  • Inter-birth interval more risk if less than 18
    months
  • Non-recurring indication for last C/S
  • Hypertensive disorders of preg greater risk
  • Cephalic presentation - optimal
  • Access to emergency services for C/S
  • Number of previous C/S slightly more risk after
    2 C/S

18
VBAC/TOLAC (Trial of labor after C/S)
  • Success rate 50-85
  • Obesity associated with lower success rate
  • Number of previous C/S more risk after 2 C/S
  • Risk of uterine rupture 1/200
  • Patient must understand and accept the risk
  • Ideally, spontaneous onset of labor with
    favorable cx

19
  • Rebecca makes slow progress over the course of
    the morning. She gets an epidural and her
    contractions space out. You consult OBS to
    inquire about augmenting the labor with oxytocin
    and they agree to use of the low dose protocol.
    The patient is aware of the increased risk of
    uterine rupture with augmentation but would like
    to proceed. FHR has been normal with baseline
    140-150 bpm, moderate variability, some accels,
    infrequent uncomplicated variables
  • You get called to her room because of concerns
    about the fetal tracing after about 3 hours

20
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21
  • Rebecca is comfortable with her epidural. She
    has been slightly hypotensive since her epidural
    was inserted and her HR is 120 bpm.
  • You examine her and are unable to palpate the
    presenting part
  • Whats going on?

22
Uterine rupture
  • Abnormal FHR
  • Vaginal bleeding
  • Hematuria
  • Maternal tachycardia, hypotension or hypovolemic
    shock
  • Easier abdo palp of fetal parts
  • Unexpected elevation of the presenting part
  • Acute onset of scar pain or tenderness (seldom
    masked by epidural)
  • Chest pain, shoulder tip pain and/or sudden SOB
  • Change in uterine activity (uncommon, unreliable)

23
Management of rupture
  • Prompt identification call code 333/222
  • Rapid volume expansion
  • Immediate surgical intervention
  • Uterine repair or hysterectomy
  • Prophylactic ABs

24
Management of labour in VBAC
  • Candidate selection, patient counseling
  • Antepartum OBS consultation
  • Continuous EFM in active labour
  • Careful observation of labour progress and mat
    well-being
  • Induction/augmentation with caution
  • No contraindication to epidural

25
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26
  • To AVD workshop

27
Kim
  • After a normal pregnancy and spontaneous labour
    at 393 weeks, Kim a 32 year old G1P0 is fully
    dilated, FHR normal, presenting part is at stn 0
    direct OA with minimal caput. She has an epidural
    but has some urge to push.
  • Should she start pushing?

28
  • After 1 hour Kim is at spines 2, still OA,
    contracting q 3minutes, mild urge to push, FHR
    reassuring.
  • What to do?

29
Kim
  • After 2 hours of pushing, head has descended to
    station 3, mild caput, perineum is swelling.
    FHR normal
  • Kim says she is exhausted and begs you to TAKE IT
    OUT!!!!

30
Vacuum - Indications
  • Failure to deliver spontaneously in 2nd stage
  • Conditions which require a shorter 2nd stage
    (maternal cardiac/CV disease)
  • Maternal exhaustion (ineffective effort)
  • Evidence of fetal compromise requiring delivery

31
Vacuum - Contraindications
  • Non-cephalic presentation
  • Incompletely dilated cervix
  • Evidence of CPD (LSCS is treatment)
  • lt34 weeks
  • Deflexed attitude
  • Need for rotation
  • Fetal Conditions (e.g. bleeding disorder)

32
AVD video Dr. O. Hughes
33
Vacuum- Risks
  • Cephalohematoma - appx 10
  • Subgaleal or other IVH hemorrhage 0.28
  • Failed delivery
  • Shoulder dystocia/ Brachial Plexus Injury
  • Increased maternal lacerations/ blood loss/
    urinary retention
  • Neonatal hyperbilirubinemia

34
Subgaleal hemorrhage
  • Bleeding between the periosteum of the skull and
    the aponeurosis
  • Caused by traction on the scalp during delivery
  • 4/10,000 SVD or 59/10,000 vacuum-assisted
    delivery
  • Potential for massive blood loss
  • Subgaleal space extends from orbital ridges
    anteriorly to nape of neck posteriorly to ears
    laterally
  • Mortality 12-14
  • Monitor for diffuse fluctuant swelling of the
    head
  • RN monitors HC for difficult vacuum deliveries
    24-48 hrs

35

36
Vacuum Prerequisites
  • Informed consent
  • No contraindication
  • Membranes ruptured
  • Reasonable chance of success
  • Assessment of pelvic adequacy
  • Adequate anesthesia
  • Bladder empty
  • BACKUP PLAN
  • Continuous monitoring

37
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38
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39
Vacuum - Mnemonic
40
Classification of AVD
  • Outlet scalp visible at introitus
  • Low head gt2 station
  • Mid 0 to 2 station
  • Assess leading edge of skull, not caput

41
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42
Vacuum - Management
  • Communicate with family and team at all times
  • Make sure appropriate team members are there
    (e.g. RN, paeds, anesthesia if necessary)
  • DOCUMENT afterwards

43
  • Simulated AVD, completion of FN
  • Shoulder dystocia video

44
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45
Kim
  • The head is delivered with vacuum assistance.
  • As you remove the vacuum, the head rests tightly
    against the perineum.
  • You have difficulty checking for a cord
  • This isnt good! Anticipate

46
Shoulder Dystocia - Definition
  • Anterior shoulder impaction on symphysis pubis
  • Fetus enters the pelvis with the shoulders in the
    AP diameter instead of oblique
  • Inability to deliver shoulders by the usual
    methods
  • gt 60 sec head to body delivery time
  • (turtle sign, often no spontaneous restitution)

47
Incidence
  • Overall 0.2-2.0
  • lt3500 gm 0.1
  • gt4000 gm 4 (15 for GDM)
  • gt4500 gm 10 (42 for GDM)
  • 50 have no predisposing factors or warning
  • SO ALWAYS BE PREPARED

48
Fetal Complications
  • Birth Injuries (Brachial Plexus Palsy, clavicle
    fracture, humerus fracture)
  • HIE (hypoxic ischemic encephalopathy)
  • Death

49
Shoulder Dystocia -Fetal Complications
  • NB - monkey models show pH decreasing by
    0.04/minute when cord is completely occluded.
  • No significant linear relationship between head
    to body delivery time and fetal acid-base
    balance.
  • Do NOT cut a nuchal cord in presence of a
    suspected shoulder dystocia!

50
Risk Factors
  • Maternal
  • Abnormal pelvic anatomy
  • Gestational diabetes/pre-existing diabetes
  • Post-dates pregnancy
  • Previous shoulder dystocia
  • Short stature
  • Maternal obesity
  • Fetal
  • Macrosomia
  • Labour related
  • Assisted vaginal delivery (forceps or vacuum)
  • Protracted active phase of first-stage labour
  • Protracted second-stage labour

51
Risk Factors
  • Induction of labour does not prevent shoulder
    dystocia nor does it prevent brachial plexus
    injury.
  • Ultrasound is not an accurate predictor of fetal
    macrosomia.
  • C/S for indication of fetal macrosomia (4-4.5kg
    EFW)
  • NNT 2,345-3,695 to prevent one permanent BPI
  • NNT 443-489 in diabetic mothers

52
Shoulder Dystocia - Management
  • AVOID THE 4 Ps
  • Dont PULL on head
  • Dont PUSH on fundus
  • Dont PANIC
  • Dont PIVOT (i.e. dont use coccyx as a fulcrum)

53
Shoulder Dystocia - Mnemonic
  • ALARMER (see next slide)
  • HeLPERR
  • Appx. 50 of shoulder dystocia can be relieved
    with McRoberts maneuver and suprapubic pressure

54
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55
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56
ALARMER Mnemonic
57
  • Video

58
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59
Shoulder Dystocia - Management
  • Significant risk of maternal injury
  • Significant risk of PPH
  • Do cord gases
  • DOCUMENT all maneuvers used
  • Examine baby for birth injury (peds in attendance
    ideally)

60
Shoulder Dystocia -Maternal Complications
  • PPH (uterine atony, maternal lacerations) 11
  • Uterine rupture
  • 3/4th degree tear (2-5.1), rectovaginal fistula
  • Symphyseal separation /- transient femoral
    neuropathy

61
Kim
  • After 2 minutes (failed McRoberts, successful
    roll-over) delivery of a 4100 g baby boy is
    accomplished. Apgars 6 and 9. Neonates in
    attendance. You then deliver the placenta
    spontaneously. You discuss the delivery with the
    family.
  • 5 minutes later, while you are charting, the
    nurse alerts you to brisk vaginal bleeding

62
Post Partum Hemorrhage Definition
  • gt 500 cc vaginal delivery
  • gt 1000 cc cesarean section
  • clinically any blood loss that has the ability to
    cause hemodynamic instability is PPH
  • See Active management of the third stage of
    labour prevention and treatment of postpartum
    hemorrhage SOGC, No.235, Oct. 2009

63
Post Partum Hemorrhage Definition
64
PPH Etiology
  • THINK OF THE 4 Ts
  • TONE uterine atony
  • TRAUMA vaginal, cervical, uterine
  • TISSUE retained placenta
  • THROMBIN underlying coagulopathy

65
PPH Management
  • Assess the FUNDUS
  • What is normal?
  • What does abnormal feel like?

66
PPH Management
  • Dont forget your ABCs

67
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68
  • Get HELP
  • RN gets the PPH kit from fridge if not there
    already
  • Help includes 1 or 2 extra nurses, possibly the
    OB on call
  • May also include anaesthesia or RACE team if
    severe
  • Call anaesthesia early if thinking of need to go
    to OR

69
Post Partum Hemorrhage Management
  • If boggy, external massage and uterotonics
    (Oxytocin rapid IV infusion is 1st line)
  • 5 U IV push
  • 20-40 U/L NS wide open
  • 10 U IM if cardiovascular collapse or no IV
    access
  • If remains boggy and bleeding persists,
  • Try to deliver the placenta
  • Proceed to bimanual massage
  • May assess for retained products at this time

70
Post Partum Hemorrhage Management
  • EMPTY THE BLADDER!
  • A 1 litre bladder may prevent the uterus from
    contracting
  • Used for therapeutic and diagnostic purposes

71
Post Partum Hemorrhage Management
  • If uterus is still boggy after placenta is
    delivered and manual massage uterus should be
    explored
  • Consider other medications now

72
Post Partum Hemorrhage Management
  • Misoprostol 800 mcg pr 1 dose
  • If not able to give rectally also may use 200mcg
    orally with 400mcg sublingual
  • Fever with oral dose
  • OR
  • Hemabate /Carboprost 250 mcg IM or IMM
  • Dosing q 15 minutes, Max total dose 2 mg
  • Careful with asthma
  • OR
  • Ergonovine .2 to.25mg IM/IV Q 2-4 H to total of
    6 doses
  • CONTRAINDICATED in HDP (CVA/hypertensive crisis)
  • Not compatible with HIV meds
  • OR
  • Carbetocin 100 mcg IM or IV bolus over 1 minute
    (shown to reduce bleeding from atony in C/S only)

73
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74
Post Partum Hemorrhage Management
  • If uterus is firm
  • Explore for trauma vaginal walls, cervix
  • Ensure adequate analgesia
  • Undertake surgical repair
  • Temporize with packing or ligation
  • If bleeding is originating from a firm uterus
  • Evaluate for an acquired coagulopathy
  • Prepare for OR (exploration, ligation,
    hysterectomy etc.)

75
  • BOTTOM LINE
  • Be prepared
  • Start basic resuscitation
  • Know your drugs in the PPH kit
  • Low threshold to call for help

76
Kim
  • Twenty five minutes later, her uterus is
    contracted firmly, the bleeding has stopped, her
    vaginal laceration has been repaired, her vitals
    are stable, her baby is pink and in no distress.
  • What next?

77
  • DOCUMENT
  • Check CBC in the morning
  • Consider iron stores and iron supplements
  • Debrief with mom and dad
  • Debrief with team
  • Congratulate self on a job well done!

78
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