Maternal & Fetal Safety in

Labor & Delivery

Laleh Eslamian MD. Associated Prof.

Maternal Fetal Medicine, Shariati hospital, TUMS

Observational studies:

- Fecal incontinence in parous sisters> nulliparous sisters (2 – 3times)

- Urinary incontinence in parous sisters> nulliparous sisters (4 times)

- Among Pre menopausal women: SUI in parous > nulliparous.

- Among Post menopausal women: Hx of pregnancy & child birth: little

impact on SUI (Medications, age …)

- Among Post menopausal women: Hx of at least 1 delivery:

↑ 2 times prolapse – C/R – RVO than nulliparas

ASSOCIATION BETWEEN PFD

&

Pregnancy & Delivery

50% of incontinence, 75% of prolapse

Pregnancy & child birth → pelvic floor injury

Compression

Stretching

Tearing of nerves, muscles & connective tissue

Pelvic floor injury in pregnancy &child birth

are due to

Neural injury:

Anal sphincter injury: Medio lateral episiotomy

Injury to the lavator axis & coccygeus muscles

for occult injuries: Forceps delivery

Prolonged 2nd stage

Medio lateral epi

Neural injury:Descent of fetal head → stretch & compression of

pelvic floor & associated nerves

Risk factors for nerve damage: operative delivery

prolonged 2nd stage

↑ BW

Most resolve after 1st year, some remain >5yr

Denervation injury may accumulate with ↑ parity.

CAN OBTETRICAL CARE BE MODIFIED TO

REDUCE PFD?

1- C/S before labor: no RCT

weak evidence to support preventive role for C/S

(2006 National Institution of Health).

7 should undergo C/S to permit 1 woman from

developing PFD latter in life

2- Changes in labor management

*avoidance of episiotomy (anal sphincter trauma)

*avoidance of operative delivery (FI, pudendal neuropathy)

other factors? CPD – race.

*oxytocin use (no RCT)

*epidural anesthesia (no RCT)

*macrosomia: could influence → OB intervention

PFD

3- Prophylactic pelvic floor muscle exercises:

No effect (during pregnancy & post partum)

4- Limiting Parity:

Risk of prolapse doubles after 1st birth

↑ 10% with each additional delivery

5- Other strategies:

Age – race – smoking – obesity

(non modifiable)

Alternatives to operative vaginal deliveries (OVD)

C/S

Expectant management: delayed pushing

maternal rest

change in mat. position

emotional support

Augmentation with oxytocin

Selected Issues

SUI during pregnancy: The best delivery plan?

some observational studies: SUI are less after C/S

Some do not show this benefit

C/S →↓ SUI by 12% not affected by SUI during

pregnancy

Further studies are needed

Women who have undergone surgical repair.

The best delivery plan: no Consensus

Women with a prior anal sphincter laceration

secondary repair:

Carefully counseled about pregnancy & delivery

Recommendation of experts → planned C/S

Birth injuries of fetus - neonate

• Overall incidence: 2% NVD, 1.1% C/S

• ↑ Risk: macrosomia (>4000g), Mat. obesity, Breech, OVD,

Small mat. size & Mat. pelvic anomalies

• Most common: Soft tissue injuries (bruising – petechiae,

subcutaneous fat necrosis, lacerations)

• Lacerations are the most common injury associated with C/S.

Other Injuries

Extra cranial

Intra cranial

Facial

Fx

Neurologic

Intra abdominal

*Extra cranial: Caputsuccedaneum, cephalohematoma:

resolves spontaneously

*Intracranial: Subgaleal hemorrhage → massive blood

loss → not managed appropriately → shock & death

(4/10.000 NVD vs 59/10.000 vaccum)

ICH: 3.7, 16.2, 17/10.000

*Facial injuries: Nasal septal dislocation (3d)

Ocular injuries: (mild, resolves)

Fx:

Clavicle, humerus, femur, skull: resolve spontaneously

Immobilization (4w)

Neurologic injuries:

Brachial plexus & facial, phrenic & laryngeal nerves

resolve spontaneously

Spinal cord injuries: poor prognosis

Intra abdominal injuries

Rare, rupture & hemorrhage in to the liver,

spleen & adrenal gland.

Neonatal Complications due to OVD:

Short term → head compression.

traction on fetal intracranial structures,

face, scalp

Most serious: ICH

Bruises abrasions, lacerations, facial nerve palsy,

cephalohematoma, retinal hemorrhage, subgaleal

hemorrhage, skull fx.

Most of these occurs in the course of a spontaneous vag.

delivery.

presentation: 10hr

(Continued)

Long term: ICH

(subdural, subarachnoid, IV, intraparencyhmal

& neuromuscular injury)

Vacuum <34w

Vacuum: ↑ neonatal cephalohematoma, ↑ retinal

hemorrhage VS. forceps or spontaneous vag. delivery

Developmental outcomes = equivalant for forceps &

vaccum

Frequency of birth trauma related to mode of delivery cases per 10,000 births

TraumaSpontaneous birthVacuum assistedForceps assistedCesarean no laborCesarean with

labor

Subdural or cerebral hemorrhage

2.98.09.84.17.4

Intraventricular hemorrhage

1.11.52.60.82.5

Subarachnoid hemorrhage

1.32.23.30.01.2

Facial nerve injury3.34.645.44.93.1

Brachial plexus injury

7.717.625.04.11.8

Convulsions6.411.79.88.621.3

CNS depression3.19.25.26.79.6

Feeding difficulty68.572.174.6106.3117.2

Mechanical ventilation

25.839.145.471.3103.2

Adapted from: data in Towner, D, Castro, MA, Eby-Wilkens, E, et al. N Engl J Med 1999; 341:1709.

2nd stage < 3hr 2nd stage > 3hr

NICU admission 4% 8%

Chorioamnionitis 3% 12.5%

Uterine atony 3.5% 7.8%

Dystocia & augmentation Control

Spontaneous delivery 59% 92%

Heavily meconium stained

fluid 13% 8%

PPH 4.02% 2.5%

BW >4000g 19% 14%

Patient safety:

Minimizing error & preventing harm

Reason for errors: Human fallibility

Medical complexity

System deficiencies

Defensive barriers

Strategies to reduce errors:

& subsequent adverse out comes

1- Team & individual training

2- Simulation & drills

3- Development of protocols, guidelines, checklists.

4- Use of informative technology

5- Education.