BE PREPAREDIntrapartum emergenciesSession 3

Vanessa Murley MD CCFP

Obstetrical Emergencies

Cord prolapseUterine ruptureAssisted vaginal deliveryShoulder dystociaPPH

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 normalBaby is vertex by Leopold's manoeuvresHer cervix is 2 cm long mid position and soft,

FT dilatedPooling 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 examIntrauterine resuscitation eg. Position changeCall your staffAdminister tocolysis if needed eg. Uterine

tetanyDocument, 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 ProlapseOvert

ROM is prerequisiteDiagnosed 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.

Incidence of cord prolapse 0.17% to 0.4%Overt cord prolapse varies with fetal

presentationLowest with cephalic, highest with transverseMorbidity worsens with increasing time to

deliveryMortality ranges 0.02% to 12.6%

Cord Prolapse – Risk factorsMalpresentation eg. Footling breechPolyhydramniosPreterm gestation, PPROMGrand multip (>5 parity)Placenta Previa or low-lying placentaCPD – narrow pelvis preventing descent of

presenting partMultiple gestations – second twinLong cord

Overt Cord Prolapse - ManagementCall for assistance + neonatal staff: code 333

and 222Pelvic exam effacement and dilatation

Station and presenting part Presence of pulsations in the cord

Maternal Trendelenberg or knee-chest positionHold the presenting part up TocolysisUrgent delivery by C/S or expedited vaginal

birth if C/S is unavailable and Cx is fully dilated

RebeccaRebecca 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 candidatesPrevious incision – horizontal scar in the lower

uterine segment, no extensionType of closure – double layer closure saferInter-birth interval – more risk if less than 18 monthsNon-recurring indication for last C/SHypertensive disorders of preg – greater riskCephalic presentation - optimalAccess to emergency services for C/SNumber 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 rateNumber of previous C/S – more risk after 2 C/SRisk of uterine rupture 1/200Patient must understand and accept the riskIdeally, 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 ruptureAbnormal FHRVaginal bleedingHematuriaMaternal tachycardia, hypotension or

hypovolemic shockEasier abdo palp of fetal partsUnexpected elevation of the presenting partAcute onset of scar pain or tenderness (seldom

masked by epidural)Chest pain, shoulder tip pain and/or sudden SOBChange in uterine activity (uncommon, unreliable)

Management of rupturePrompt identification – call code 333/222Rapid volume expansionImmediate surgical interventionUterine repair or hysterectomyProphylactic ABs

Management of labour in VBACCandidate selection, patient counselingAntepartum OBS consultationContinuous EFM in active labourCareful observation of labour progress and

mat well-beingInduction/augmentation with cautionNo 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?

KimAfter 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 stageConditions which require a shorter 2nd stage

(maternal cardiac/CV disease)Maternal exhaustion (ineffective effort)Evidence of fetal compromise requiring

delivery

Vacuum - ContraindicationsNon-cephalic presentationIncompletely dilated cervixEvidence of CPD (LSCS is treatment)<34 weeksDeflexed attitudeNeed for rotation Fetal Conditions (e.g. bleeding disorder)

AVD video – Dr. O. Hughes

Vacuum- RisksCephalohematoma - appx 10%Subgaleal or other IVH hemorrhage 0.28%Failed deliveryShoulder dystocia/ Brachial Plexus InjuryIncreased maternal lacerations/ blood loss/

urinary retentionNeonatal hyperbilirubinemia

Subgaleal hemorrhageBleeding between the periosteum of the skull and

the aponeurosisCaused by traction on the scalp during delivery4/10,000 SVD or 59/10,000 vacuum-assisted deliveryPotential for massive blood lossSubgaleal space extends from orbital ridges

anteriorly to nape of neck posteriorly to ears laterally

Mortality 12-14%Monitor for diffuse fluctuant swelling of the headRN monitors HC for difficult vacuum deliveries 24-

48 hrs

Vacuum PrerequisitesInformed consentNo contraindicationMembranes rupturedReasonable chance of successAssessment of pelvic adequacyAdequate anesthesiaBladder emptyBACKUP PLANContinuous monitoring

Vacuum - Mnemonic

Classification of AVD

Outlet – scalp visible at introitusLow – head >=+2 stationMid – 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 FNShoulder dystocia video

KimThe 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 - DefinitionAnterior shoulder impaction on symphysis

pubisFetus enters the pelvis with the shoulders in

the AP diameter instead of obliqueInability to deliver shoulders by the usual

methods> 60 sec head to body delivery time(turtle sign, often no spontaneous restitution)

IncidenceOverall 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 FactorsMaternal Abnormal pelvic anatomy Gestational diabetes/pre-existing diabetes Post-dates pregnancy Previous shoulder dystocia Short stature Maternal obesityFetal MacrosomiaLabour related Assisted vaginal delivery (forceps or vacuum) Protracted active phase of first-stage labour Protracted second-stage labour

Risk FactorsInduction 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 BPINNT 443-489 in diabetic mothers

Shoulder Dystocia - Management

AVOID THE 4 “P ’s”

Don’t PULL on headDon’t PUSH on fundusDon’t PANICDon’t PIVOT (i.e. don’t use coccyx as a

fulcrum)

Shoulder Dystocia - MnemonicALARMER (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 injurySignificant risk of PPHDo cord gasesDOCUMENT all maneuvers usedExamine baby for birth injury (peds in

attendance ideally)

Shoulder Dystocia -Maternal Complications

PPH (uterine atony, maternal lacerations) 11%

Uterine rupture3/4th degree tear (2-5.1%), rectovaginal

fistulaSymphyseal separation +/- transient femoral

neuropathy

KimAfter 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 uterine atonyTRAUMA vaginal, cervical, uterineTISSUE retained placentaTHROMBIN underlying coagulopathy

PPH Management

Assess the FUNDUSWhat is normal? What does abnormal feel like?

PPH Management

Don’t forget your ABC’s

Get HELPRN gets the PPH kit from fridge if not there

alreadyHelp includes 1 or 2 extra nurses, possibly the

OB on callMay also include anaesthesia or RACE team if

severeCall anaesthesia early if thinking of need to go

to OR

Post Partum Hemorrhage ManagementIf boggy, external massage and uterotonics

(Oxytocin rapid IV infusion is 1st line)5 U IV push20-40 U/L NS wide open10 U IM if cardiovascular collapse or no IV access

If remains boggy and bleeding persists, Try to deliver the placentaProceed to bimanual massageMay assess for retained products at this time

Post Partum Hemorrhage Management

EMPTY THE BLADDER!A 1 litre bladder may prevent the uterus from

contractingUsed 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 ManagementIf uterus is firm:Explore for trauma – vaginal walls, cervixEnsure adequate analgesiaUndertake surgical repairTemporize 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 preparedStart basic resuscitationKnow your drugs in the PPH kitLow threshold to call for help

KimTwenty 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?

DOCUMENTCheck CBC in the morningConsider iron stores and iron supplementsDebrief with mom and dadDebrief with teamCongratulate self on a job well done!