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BE PREPARED Intrapartum emergencies Session 3 Vanessa Murley MD CCFP Obstetrical Emergencies Cord prolapse Uterine rupture Assisted vaginal delivery Shoulder dystocia PPH 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? 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 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… How do you interpret this strip? What do you do now? 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 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… NOW WHAT? 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 Cord Prolapse Overt Occult ROM is prerequisite Suspect in all patients with Diagnosed by visualizing the persistent or significant variable decelerations Cord is prolapsed at pelvic inlet, compressed against presenting part. cord through the introitus or palpation of the cord through the vagina 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% Cord Prolapse – Risk factors Malpresentation eg. Footling breech Polyhydramnios Preterm gestation, PPROM Grand multip (>5 parity) Placenta Previa or low-lying placenta CPD – narrow pelvis preventing descent of presenting part Multiple gestations – second twin Long cord 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 Rebecca Rebecca is a healthy 36 yo F who was admitted to the BU in active labor overnight. She is a G2P1 at 40+4 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)? 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 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 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 What do you think? What do you do? 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 What’s going on? 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) Management of rupture Prompt identification – call code 333/222 Rapid volume expansion Immediate surgical intervention Uterine repair or hysterectomy Prophylactic ABs 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 To AVD workshop Kim After a normal pregnancy and spontaneous labour at 39+3 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? After 1 hour Kim is at spines +2, still OA, contracting q 3minutes, mild urge to push, FHR reassuring. What to do? 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!!!! 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 Vacuum - Contraindications Non-cephalic presentation Incompletely dilated cervix Evidence of CPD (LSCS is treatment) <34 weeks Deflexed attitude Need for rotation Fetal Conditions (e.g. bleeding disorder) AVD video – Dr. O. Hughes 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 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 Vacuum Prerequisites Informed consent No contraindication Membranes ruptured Reasonable chance of success Assessment of pelvic adequacy Adequate anesthesia Bladder empty BACKUP PLAN Continuous monitoring Vacuum - Mnemonic Classification of AVD Outlet – scalp visible at introitus Low – head >=+2 station Mid – 0 to +2 station Assess leading edge of skull, not caput 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 Simulated AVD, completion of FN Shoulder dystocia video 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 isn’t good! Anticipate… 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 > 60 sec head to body delivery time (turtle sign, often no spontaneous restitution) Incidence Overall 0.2-2.0% <3500 gm = 0.1% >4000 gm = 4% (15% for GDM) >4500 gm = 10% (42% for GDM) 50% have no predisposing factors or warning SO ALWAYS BE PREPARED Fetal Complications Birth Injuries (Brachial Plexus Palsy, clavicle fracture, humerus fracture) HIE (hypoxic ischemic encephalopathy) Death 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! 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 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 Shoulder Dystocia - Management AVOID THE 4 “P’s” Don’t PULL on head Don’t PUSH on fundus Don’t PANIC Don’t PIVOT (i.e. don’t use coccyx as a fulcrum) Shoulder Dystocia - Mnemonic ALARMER (see next slide) HeLPERR Appx. 50% of shoulder dystocia can be relieved with McRoberts maneuver and suprapubic pressure ALARMER Mnemonic Video 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) 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 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 Post Partum Hemorrhage Definition > 500 cc vaginal delivery > 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 Post Partum Hemorrhage Definition PPH Etiology THINK OF THE 4 “ T’s” TONE TRAUMA TISSUE THROMBIN uterine atony vaginal, cervical, uterine retained placenta underlying coagulopathy PPH Management Assess the FUNDUS What is normal? What does abnormal feel like? PPH Management Don’t forget your ABC’s 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 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 Post Partum Hemorrhage Management EMPTY THE BLADDER! A 1 litre bladder may prevent the uterus from contracting Used for therapeutic and diagnostic purposes Post Partum Hemorrhage Management If uterus is still boggy after placenta is delivered and manual massage – uterus should be explored Consider other medications now 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) If uterus still boggy, or still bleeding you should alert all staff to PPH code 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.) BOTTOM LINE Be prepared Start basic resuscitation Know your drugs in the PPH kit Low threshold to call for help 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? 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!