Delivering Babies: It’s Not Always Over When The Baby is Out Larry Veltman, MD, FACOG 4 th Annual...

Delivering Babies:It’s Not Always Over When The

Baby is Out

Larry Veltman, MD, FACOG

4th Annual SCPS Colloquium

January 19, 2012

From This:

To This:

Before Delivery: Antenatal Care

Life Style• Diet• Exercise• Smoking• Alcohol

We don’t go here…

Or here…


Ultrasound• Nuchal translucency, second trimester screening• Fetal growth, amniotic fluid volume, placental

abnormalities


Genetics• Ethnic genetic screening• Chorionic Villus Sampling (CVS), amniocentesis,

maternal blood analysis


Labs• Maternal Serum Alpha Fetoprotein Test (MSAFP)• Cystic Fibrosis Screening (CF) “It is important that CF

screening continues to be offered to women of reproductive age. It is becoming increasingly difficult to assign a single ethnicity to individuals. It is reasonable, therefore, to offer CF carrier screening to all patients. Screening is most efficacious in the non-Hispanic white and Ashkenazi Jewish populations.”

Source: The American College of Obstetricians and Gynecologists (ACOG), “Update on Carrier Screening for Cystic Fibrosis,” ACOG Committee Opinion No. 486, Obstetrics and Gynecology, Vol. 117, 2011, pp.1028-31.


• HIV testing: Say it right!” 25% to 2%– “Testing for HIV and syphilis exposures is a

routine part of the prenatal laboratory panel because treatment during pregnancy can prevent transmission of these infections to the fetus. We test all of our patients unless they decline to be tested.”

Source: California Perinatal Quality Care Collaborative (CPQCC), Perinatal HIV Prevention Toolkit, 2008.

Getting Closer: Antepartum

• Liberal use of antepartum testing– NST, U/S, CST, FAS

• Gestational age: a critical factor in determining non-medically indicated delivery

During Labor and Delivery

• Monitoring – Electronic Fetal Monitoring (EFM)• Second stage traps• Delivery – Operative Vaginal Delivery (OVD),

Forceps, Cesarean• Assembling a resuscitation team (“R” team)• Handing off the baby to the baby’s physician &

team

EFM – Benefit or not?

Second Stage Seduction

• “She was a multip.”• “She was going to deliver soon.”• “They were variables and returned to baseline.”• Apgars 4,5,5• pH 6.685, BE -22

Optimal Second Stage Management

• Standard of care during 2nd stage is the same as during 1st stage

• Aggressive, coached closed-glottis pushing is avoided until urge is present

• Allow laboring down for women with epidurals

• Management based on fetal status

• Oxytocin is maintained at rate to simulate a physiologic second stage

• Discontinue oxytocin for non reassuring pattern

• Historical use of arbitrary time frames avoided

• Only indicated operative deliveries

Sequential Instruments

“The highest risk of fetal injury was reported for those infants who were delivered with combined forceps and vacuum extraction…”

Source: Towner D, Castro MA, Eby-Wilkens E, Gilbert WM. Effect of mode of delivery in nulliparous women on neonatal intracranial injury. N Engl J Med 1999;341:1709–1714.

After the Baby’s Out

• The perinatal handoff• Avoiding birth trauma• Handling the newborn

– Safety vs. “the experience” (low Apgars, cold, no resuscitation)

– Underwater birthing– Skin to skin - breast is

best video

• The “R” team policy• Neonatal Resuscitation

Guidelines (NRP) -2012

• Going to the Nursery• Management of Bad

Results• Humane circumcision • The obstetrician’s role

in breastfeeding

The Perinatal Handoff:

Mother’s Caregiver to Baby’s Caregiver

• May begin during pregnancy if issues arise– Anomalies, maternal diseases impacting newborn,

refusal of Vitamin K, eye phophylaxis, etc.

• Should be a routine part of every delivery

Source: Provence St. Vincent Medical Center, Portland, OR

OB to Peds Handoff Form

Antepartum issues: Fetal abnormality on

ultrasound Genetic issue IUGR Maternal Diabetes Isoimmunization Group B streptococcus

positive Other

Intrapartum/immediate postpartum concerns: Temperature during labor of > = 100.4 F (38C) not

treated with antibiotics Antibiotics for suspected chorioamnionitis Group B streptococcus prophlylaxis for < 4 hours

before delivery Other Group B streptococcus prophylaxis concerns Other

Uneventful pregnancy = Routine Notification to baby care providerNote: Routine notification = name of baby, birth time, gestational age and birth weight.

Note: PHS guidelines for routine well baby care state that the baby’s care provider is to see the newborn within 24 hours of birth.

OR

Include the following concerns with initial notification of baby care provider

Please ask the baby’s care provider to call me to discuss the case

Other: __________________________________________________

Infant Vacuum Follow-up

Delivering Practitioner: • Inform infant care providers of vacuum delivery.• All infants should be observed for a minimum 4

hours after a vacuum birth

Source: Michael Ross, “Vacuum Delivery: What Can Go Wrong,” The 27th Annual Conference on Obstetrics, Gynecology, Perinatal Medicine, Neonatology and the Law, Boston University, January, 2011.

Infant Vacuum Follow-upInfant Care Provider:• Monitor infant vital signs, color behavior.• Do not place cap on infant’s head for 24 h. • Measure newborn head circumference at birth, and at hourly

intervals x 4 hours. • Examine newborn for scalp swelling consistent with caput,

subgaleal hematoma or cephaplohematoma.• Should physical signs demonstrate possible newborn

compromise, notify physician monitor blood pressure and heart rate and vital signs appropriately

• Check newborn hematocrit.

Source: Michael Ross, “Vacuum Delivery: What Can Go Wrong,” The 27th Annual Conference on Obstetrics, Gynecology, Perinatal Medicine, Neonatology and the Law, Boston University, January, 2011.

Mandatory “R” Team Attendance

• Preterm birth• Placental abnormalities

(placenta previa, vasa previa, abruption)

• Multiple gestation• Non reassuring fetal heart

tracing• Malpresentation• Operative vaginal delivery• Prolapsed cord• Meconium stained fluid

• Fetal anomalies (e.g., skeletal dysplasia, pulmonary hypoplasia, gastroschesis)

• Maternal medical conditions (e.g., Idiopathic thrombocytopenic purpura (ITP), addiction)

• Emergency cesarean• Isoimmunization, hydrops• OB provider or nurses

discretion

Resuscitation

• “At every delivery, there should be at least one person whose primary responsibility is the newborn and who is capable of initiating resuscitation, including positive-pressure ventilation and chest compressions.”

• “Either that person or someone else who is immediately available should have the skills required to perform a complete resuscitation, including endotracheal intubation and the use of medications.”

Source: American Academy of Pediatrics and The American College of Obstetricians and Gynecologists, Guidelines for Perinatal Care, Sixth Edition, American Academy of Pediatrics, Elk Grove Village, IL, The American College of Obstetricians and Gynecologists, Washington DC, 2007, pp. 205.

Neonatal Resuscitation Guidelines 2012

Changes for Delivery• Delayed cord clamping• Routine neonatal suctioning• Skin to skin contact

A Lingering Controversy

Should NRP Certification Be Required of Everyone with Obstetrical

Privileges?

Benefits of Delayed Cord Clamping• Neonatal blood volume increased up to 50%• 50-80% of this transfusion occurs in the 1st minute

after delivery (WHO recommends 3 mins)• Benefits preterm infants most

– Decreased IVH– Decreased sepsis– Decreased transfusions– Decreased mechanical ventilation and surfactant– Improved hemoglobin initially and long term– Improved BP and cerebral oxygenation

Source: C. M. Chaparro and C. Luther, Beyond Survival: Integrated Delivery Care Practices for Long-Term Maternal and Infant Nutrition, Health and Development, Pan American Health Organization (PAHO), Washington, D.C., December 2007.

Benefits of Delayed Cord Clamping

• Term Infants– Increased neonatal blood volume and iron stores– Increased HCT and iron stores at 2-4 months of age

• Equivalent to 3.5 months of neonatal iron supplementation

– Increased iron stores are associated with improved cognition

• Maternal– Shortened second stage of labor– Decreased incidence of retained placenta


Effects of Delayed Cord Clamping: Old News

Sources: A. Yao, M. Hirvensalo and J. Lind, “Placental Transfusion-Rate and Uterine Contraction,” Lancet, Vol. 1, 1968, pp. 380-3; A. Yao, M. Moinian and J. Lind, “Distribution of Blood between Infant and Placenta after Birth,” Lancet, Vol. 2, 1969, pp. 871-3.

Where should the baby be?


DON’T Delay Cord Clamping if….

• You are cutting through the placenta at cesarean section

• If the infant appears depressed• Twins• The uncommon clinical situation where in your

judgment delaying cord clamping would place the infant at risk

Routine Neonatal Suctioning

• Not necessary in active crying infants• Not the same as DON’T SUCTION• Suction if there is obvious obstruction to

spontaneous breathing, or you think it is necessary

• Simply wiping the face with a towel will be adequate in many cases

• This applies to meconium too

Neonatal Suctioning Risks

• Neonatal bradycardia• Trauma

Skin to Skin Contact Benefits

• Infant – Improves breastfeeding initiation– Reduces time to effective infant suckling– Maintains temperature– Improves cardio-respiratory stability in preterm infants– Increases breastfeeding duration

• Maternal – Improves bonding– Decreases engorgement

Putting It All Together

• Cord clamping is delayed 60 seconds• Delivery room attendant will hit time and call out

times at 10 sec intervals• After vaginal delivery the infant is placed on a

warm towel on lower maternal abdomen or provider’s lap

• After cesarean section infant is placed between mother’s legs until clamping

Putting It All Together cont.

• Assess and dry infant while waiting to clamp the cord

• Wipe off the face and suction if necessary, but not as a routine

• After cord clamping, place the infant directly on maternal chest skin to skin

• Cover with a warm blanket• Continue assessing

Born On Land!

American Academy of Pediatrics

“ The safety and efficacy of underwater birth for the newborn has not been established. There is no convincing evidence of benefit to the neonate but some concern for serious harm. Therefore, underwater birth should be considered an experimental procedure that should not be performed except within the context of an appropriately designed RCT after informed parental consent.”

Source: Committee on Fetus and Newborn, 2004–2005, D. G. Batton, L. R. Blackmon, D. H. Adamkin et al., “Underwater Births,” Commentary, Pediatrics, Vol. 115, No. 5, May1, 2005, pp. 1413-14.

Underwater Birth Safety Checklist

In house legal review, strategic planning regarding initiation of services

Dedicate resources for space and equipment. – Allowing outside equipment, tubs etc

Establish criteria for inclusion and exclusion Write specific consents with risks and benefits Write specific policies and procedures governing underwater

birthing at the institution. – Distinguish between hydrotherapy during labor and actual birthing

underwater, who and how many can be in the pool, how long the baby stays underwater, criteria for moving the mother out of the pool, monitoring temperature, monitoring the fetus, staffing ratios, NRP attendance, contraindications, medication use and limitations

Underwater Birth Safety Checklist

Establish the technology to perform intrauterine fetal monitoring in water

Interact with various departments that will interface with equipment – Infection control, Biomed, Housekeeping, OSHA

Develop protocols and simulation training for potential emergencies occurring in the water birth environment, for example,

– Shoulder dystocia, Hemorrhage, Need for neonatal resuscitation including water inhalation, Maternal collapse, Moving patients out of the tub, prevention of falls

Develop a program of occupational health for professionals who work in the environment with regard to infection protection, musculoskeletal work related injuries associated with delivery, moving patient etc.

ACOG & Breastfeeding

• Breastfeeding is the preferred method of feeding for newborns and infants.

• Health professionals have a wide range of opportunities to serve as a primary resource to the public and their patients regarding the benefits of breastfeeding and the knowledge, skills and support needed for successful breastfeeding.

• The American College of Obstetricians and Gynecologists strongly supports breastfeeding and calls upon its Fellows, other health professionals caring for women and their infants, hospitals and employers to support women in choosing to breastfeed their infants.

Source: American College of Obstetricians and Gynecologists (ACOG), Executive Board Statement on Breastfeeding, Approved by the ACOG Executive Board September 1994, Amended and reaffirmed July 2003.

The Four A’s Of Humane Circumcision

Anesthesia

Ancillary

Measures

Appropriate

Technique

Analgesia

The Management of Bad Results: A Specific Way of Interacting with Patients

• Part of one’s skill set

• Geared to help the

patient and family

through the crisis

• Manages surprise and

new emotions

• Shows that you are a

caring physician

• Shows you are genuinely

sorry about the outcome

• You will be accountable

and follow them through

this

• Does not shoot oneself or

any one else in the foot

• May leverage against

accusation of negligence

What Do Our Patients Want?

• I would want to be told as soon as it was discovered - 98.8%

• I would want to know that something was being done about it to make sure that it didn’t happen again – 98.7%

• I would want to be told in person rather than over the phone – 90%

• I would want the doctor to tell me that he or she was sincerely sorry – 87.8%

Source: Kathleen M. Mazor, Steven R. Simon, Robert A. Yood, et al., “Health Plan Members' Views about Disclosure of Medical Errors,” Annals of Internal Medicine, Vol. 140, March 16, 2004, pp. 409-18.

The Management of Bad Results

For the patient:• Get expert help early on with the process• Meet with the healthcare team including risk

management specialists• Capitalize on your relationship• Meet with patient and family

– “Should I apologize?”– “How and how much should I disclose?”

• Consider appropriate write-offs– Be careful what you say

• Give meticulous follow-up

Conversations to Diffuse Anger

• What do I say to the family when a disagreement on management between a doctor and a nurse occurred in front of the patient and was accompanied by a bad outcome?

• What do I say when a patient’s interpretation of a poorly managed case is correct?

• How should I respond when a patient or family member directs his or her anger at me for a bad outcome that I may have been responsible for?

• What do I say when under the influence of fatigue, I am short-tempered with a family member and then something bad happens?

Should I Apologize?• Apology is important in our society• Get expert help early on with the process• Necessary, especially with a bad result

– You are very sorry this happened– You regret very much that this occurred– You realize that this must have caused much pain,

angst, lost work, and life change– You are committed to being there and seeing them

through this• Be careful about admitting fault• Be sincere; It is easy to recognize a phony

apology

Source: California Evidence Code, Section 1160.

California’s Apology Law

NursesObstetriciansPediatricians

PerinatologistsNeonatologists

Pediatric NeurologistsPediatric Neuroradiologists

Communications With Other Professionals

Poor Communication Can Lead To This Neonatologist’s Note:

Neonatologists note:

Poor Communication Can Lead To This:

Go Into the Nursery!“I think…. the obstetrician (should) have a face to face meeting with the baby's doctor as soon as possible after the event.....There are typically many nuances of obstetrical care that are not at all apparent to the pediatric/neonatal staff. Additionally there may be historical factors that the obstetrician is aware of that are either not in the chart or are missed (e.g. recent illness, decreased fetal movement, unusual finding on U/S, etc.).

I would also encourage the Ob to check in daily with the pediatrician/neonatologist...best in person. This again helps to clarify information, show concern, etc. Source: Interview with Dr. John McDonald, Neonatologist, Director of Newborn Services, Providence St. Vincent Medical Center, Portland, Oregon, 2009.

Newborn Issues and the Obstetrical Team:Why You Should Care?• Universal bilirubin screening of normal newborns• Neuroradiology and timing of an insult• Brain anomalies may mimic Hypoxic-Ischemic

Enephalopathy (HIE) birth trauma• Genetic disorders may mimic Cerebral Palsy (CP)• Antenatal stroke• Head or body cooling• Fetal Inflammatory Response Syndrome (FIRS)

Why You Should Care?

Source: The Law Offices of Dr. Bruce G. Fagel & Associates, “Brain Cooling,” n.d., http://www.fagellaw.com/Information_Center/Brain_Cooling.aspx, 12/16/2011.

It’s Not Always Over When The Baby’s Out

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