Transcript Intrapartum emergencies - V. Murley

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
 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!